Author(s): Liz Langley. Published on January 4, 2016.

State of Independence

As more Americans choose to grow old in their own homes,
the healthcare and responder communities design strategies
to reach them where they live.
BY LIZ LANGLEY

NANCY BUTTY IS NOT ONE to miss a teachable moment about fire safety.

Butty, the public education specialist for the fire department in Rochester Hills, Michigan, near Detroit, had heard about a recent blaze at a condominium housing development. The fire occurred in a single-story unit occupied by an older couple. No one was injured or killed in the incident, but the higher-than-normal incidence of emergency calls originating from the area led Butty to suspect there were a number of senior citizens in the development, a characteristic that could put it at higher risk of additional fires.

Butty’s hunch turned out to be right, even though there were no no “senior living” or “retirement” designators in the name of the development, terms that would identify it as housing specifically designed for seniors. The development’s older demographic was instead a natural phenomenon produced by a range of factors—what social services practitioners and first responders increasingly refer to as “naturally occurring retirement communities,” or NORCs. The Older Americans Act defines NORCs in part as housing, in a single building or in a geographic area, where 40 percent or more of the individuals are “older”—the term leaves some wiggle room, but 65 and up is generally considered “senior”—and the residence cannot be designated as institutional care, long-term care, or as an assisted living setting.

Butty wasted little time contacting the homeowners’ association to do a talk on fire safety. She brought a dramatic prop with her: a plugged vent pipe from a clothes dryer, which had been identified as the cause of the fire. “I had this nasty, terribly corroded pipe that was full of gunk, and the visual was amazing,” Butty says. “People were aghast that they could have that fire hazard in their home.”

Firefighter comforting older woman.
​Even in residences identified as senior housing, responders can sometimes be taken by surprise by the number of residents with mobility issues, which can complicate and slow evacuation in an emergency. ​Photograph: Brian van der Brug/Los Angeles Times via Getty Images

Butty’s brand of proactive education is a good model for how safety advocates need to address the proliferation of senior housing living options, NORCs included, driven by peoples’ desire to live independently as they grow older. Purpose built senior living options and NORCS are everywhere, and their numbers will likely increase as the country’s population ages. A recent U.S. Census Bureau estimate put the number of people 65 and older in the U.S. in 2014 at 44.7 million, or 14.1 percent of the population. By 2060, the bureau projects there will be 98.2 million people 65 and older, or nearly a quarter of all U.S. residents. Of those, nearly 20 million will be 85 or older.

Senior housing presents a challenge for an array of NFPA stakeholders, from public health practitioners to building inspectors to public safety departments. First responders, who must consider the needs and characteristics of an older population when conducting incident pre-planning, must be aware of a range issues, including residents’ mobility, the presence of home medical equipment, and attendant problems like hoarding. “When you look at your most at-risk populations, it’s the very elderly and the very young,” says Otto Drozd, fire chief of Orange County, Florida. People increasingly want to grow old in their own homes, rather than nursing homes or assisted living facilities, Drozd notes, but those homes may not include features such as wider doorways to facilitate the easier access of walkers or wheelchairs.

Housing built specifically for seniors can offer “an operational advantage” in the event of an emergency, Drozd says. “But we have a lot of elderly here who don’t have that.”

Older & Everywhere

It isn’t just retirement hotbeds like Central Florida that are experiencing a surge of seniors living independently—the phenomenon is taking place across the country in communities large and small. Whether it’s deliberate, like a senior condominium development, or organic, like a building or neighborhood that over time takes on a higher proportion of older people, the concerns and challenges associated with this trend are the same.

NORCs present the added challenge of not being readily identifiable. They can take shape when young people move out of rural areas, leaving a high senior population behind, or when seniors migrate into urban areas with easy access to transportation and culture, according to NORCBlueprint.org, a United Hospital Fund website that helps people facilitate health and social services for NORCs. Most NORCs, though, are the result of people simply staying in their homes, also known as “aging in place.” For many older people, that may not be a matter of choice; while they may prefer senior housing designed to meet their needs, the expense of assisted-living facilities can be well beyond the means of many older Americans living on fixed incomes.

Baby boomers, the generation born between 1946 and 1964, seem especially determined to stay in their homes, or at the very least live independently. A 2014 AARP study found that 87 percent of adults 65 and older wanted to remain in their current homes and communities as they aged. Boomers are also inclined to see themselves as more adventurous and durable than seniors of the past. “The thinking is often, ‘Hey, I lived through the 1970s, so I can do anything,” says Karen Berard-Reed, senior project manager in NFPA’s Public Education Division, of the boomer hubris.

That can present problems, including seniors minimizing or ignoring their aging-related needs. Many of those issues were addressed at the “Summit on Safe, Independent Living,” held in Orlando in November and sponsored by the Fire Protection Research Foundation. Among the speakers was Robert Mayer, founder and president of the Hulda B. and Maurice L. Rothschild Foundation, a Chicago-based philanthropy for improving the lives of elders in long-term care communities. Mayer addressed the problem of what he called “Peter Pan housing”—hazard-filled homes embraced by aging people who seem to believe they will never grow old. On a more positive note, Berard-Reed adds that boomers’ desire to tick adventures off their bucket lists rather than sit at home often encourages them to take a more active interest in their health and safety.

Older couple sitting in living room.
​A strong desire to remain independent can create problems for older people who may need extra help with daily activities. ​Photograph: Shutterstock

Hubris aside, age catches up with everybody. Aging can bring problems with hearing, vision, memory, cognition, and mobility, all of which can present problems in residential settings that lack senior-specific safety features. Falls account for more than 55 percent of deaths from unintentional injuries for people 65 years and older, according to the Centers for Disease Control. NFPA data show that older people are twice as likely as the general population to be killed or injured by fires.

Responder Concerns

First responders in smaller communities often know where the pockets of seniors are in their neighborhoods based on the frequency of emergency calls received from those areas. In larger cities, though, where responders may not have such an intimate knowledge of the demographic landscape, those areas may not be known until an emergency situation occurs. “The fire department gets there and the building is full of seniors or people with otherwise severe mobility impairments,” says Robert Solomon, division manager of Building and Life Safety at NFPA. “It may not be until that moment that they realize, ‘We knew we had older residents here, but we didn’t know they constituted 80 percent of the building’s population.’”

In those situations, a number of variables enter the response equation. Stephen Hrustich, assistant chief at Gwinnett County Fire and Emergency Services in Lawrenceville, Georgia, says when the fire service responds to incidents at residential board and care facilities, they know more or less what to expect. “Residents will require additional assistance in getting out,” Hrustich says, “or there will be a slower evacuation time because of the age and mobility of the residents.” With NORCs, and even with senior developments, though, responders often don’t get that kind of heads-up. Buildings that weren’t designed to facilitate seniors getting out in a hurry can pose significant problems for firefighters, Hrustich says. “We have to worry about not only fighting the fire, but also protecting in place,” in which residents wait for emergency responders to come and get them rather than exiting on their own.

While the plan is often a good one, he says, it can also depend on the safety features in the building and whether or not residents are viable to escape on their own. In older buildings, Hrustich says, fire doors may not close properly and penetrations through fire-rated walls made over time can allow fire and smoke travel throughout the building. Alarm and suppression systems, if provided, are more likely to fail through lack of inspection and maintenance, and residents’ mobility problems may hinder the evacuation process.

Problems can arise even when the presence of seniors is known. In December, 2014, a fire in a high-rise senior living apartment building in San Antonio, Texas, killed five people. Firefighters were surprised by the number of residents with significant mobility issues; as many as 120 of the 700 residents had to be carried out of the building, according to media reports.


First responder helping woman into stretcher.
​The importance of having an emergency home evacuation plan. ​Photograph: Richard Eaton/Demotix

The culture of aging itself can complicate emergency response. Lisa Garforth, a paramedic and community educator for the City of Madison Fire Department in Madison, Mississippi, says she finds seniors can be hesitant to call in an emergency for fear they may be removed from their homes. “They’re afraid,” Garforth says. “They don’t want to put a burden on us and they’re afraid we may call human services or their families.” People will sometimes wait for hours to call in an emergency situation, she says. “It’s heart-breaking to go in and find somebody laying on the hard floor,” which can lead to further injury, she says. She conducts follow-up visits to make sure people understand that they can contact her at any time.

Knowledge & Prep

Addressing safety issues starts with identifying NORCs themselves, or any area with a high concentration of seniors, a challenge that is drawing more research interest.

In 2014, for example, Takashi Yamashita, a sociologist at the University of Nevada at Las Vegas, co-authored a study in The Journals of Gerontology that used geographical information systems, or GIS, to identify NORCs. His team used census block data to track NORCs in Ohio from 2000 to 2010, showing NORC hotspots and population shifts. “Knowing the number, and percentage, of older populations in the areas would be helpful to prepare and allocate resources to manage emergency situations,” Yamashita says. “That includes how much and what kind of medical supplies may be needed, as well as how many people may have mobility problems.”

Older woman using walker to exit shower.

Older woman cooking on electric oven.

​Falls in bathrooms, along with cooking-related fires, are common sources of injuries for seniors in their home and are the focus of programs like NFPA's Remembering When. ​Photographs: Shutterstock

In any area with a high concentration of seniors, an important step is to determine the best tools to help keep people in that particular community safe. Many communities have elder support services, where a non-profit group typically coordinates health, recreational, and volunteer activities according to members’ needs, with an emphasis on consistent home-safety checks and safety education. A recent survey conducted by the Denver-based Jewish Family Services illustrated how effective these programs can be. The organization surveys all seniors who receive services through a program before the services start and again six months later. In one survey of 60 residents, well over half reported fewer emergency room visits, and three-quarters of the residents reported fewer hospital visits.

The fire service can be instrumental in mitigating safety hazards for seniors in their homes, Hrustich says. In addition to evaluating the locations of frequent 911 calls to identify possible NORCs, fire departments can work with communities or building managers on smoke alarm programs and assist with emergency planning. Wildfires in California last year provided a wake-up call for making sure emergency evacuation plans include provisions for the elderly and disabled, since they may be unable to respond to emergency alerts or may not be aware of them. The Los Angeles Times reported that, in Calaveras County, where the Butte Fire began in September, an estimated 20 percent of residents are seniors, the highest proportion in the state, according to census data. Both fatalities in the Butte fire were seniors.

The emerging areas of fire-based community paramedicine and mobile integrated healthcare also represent key ways to monitor and serve older residents in their homes. Community paramedicine, which typically utilizes fire department paramedics and emergency medical technicians, is designed to address patients’ non-acute medical incidents in their own homes, thus reducing the pressure on hospital emergency departments and freeing emergency health assets in the event of actual emergencies. It is also designed to provide patients with education and strategies to maintain their health.

Codes and standards, too, factor into the broad discussion on senior housing options. Newly constructed apartment buildings, for example, are already required to have sprinkler systems, fire alarms, and egress components, says Solomon. But persuading jurisdictions to adopt those same sprinkler provisions for existing buildings remains a challenge. So is providing temporary housing and relocation options for building residents in order to retrofit old buildings with sprinkler systems, as well as figuring out who’s going to pay for it. Costs are often passed on to the consumer, but many older people live in senior housing apartments because it’s what they can afford—and it’s where they want to be.

Sometimes the building features are more utilitarian. Safety features like grab bars in showers, improved lighting, and handrails in hallways can help prevent falls and accidents. Solomon also points to emerging technologies such as heat-limiting cooktops, which automatically turn off stove-top burners when they get too hot—home cooking devices are the leading cause of home structure fires in the U.S.—and expanded use of arc fault circuit interrupters, which help prevent electrical fires and shocks, as technologies that could also be considered for broader use as a matter of policy or code mandate. An Apartments for the Elderly Task Group, which reports to the Technical Committee on Residential Occupancies as part of the NFPA Safety to Life Project, is looking at some of these issues, Solomon says, but so far the group has not made any formal recommendations to change the code.

Most important, though, is the recognition among stakeholders that all manner of senior residences, as well as NORCs, are more common than we think, and are proliferating—“there’s no place like home” is quickly becoming our collective approach to how we plan to grow old. “This is how we want it,” says Solomon. “Now we just have to figure out how to do it safely.” 

LIZ LANGLEY is a writer in Orlando, Florida. Top Illustration: James Steinberg