消除“老有所居”的结构性老龄歧视，确保“老有所居”

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Ageing in place. A phrase familiar to so many and one we rarely question. Ageing in place counters mass institutionalisation and secures the bond between person and home. Or does it? Ageing in place is a popular ideal, a concept used in research, and a policy directive employed widely around the world. Nonetheless, ageing in place, as it used today, ageing in place obscures several ageist precepts and is increasingly out of place in today's world. Behind ageing in place lie a complex set of judgements, myths and misunderstandings that potentially diminish the health and well-being of older people.

老龄化到位。一个很多人都熟悉的短语，一个我们很少质疑的短语。就地养老可以抵制大规模机构化，并确保人与家庭之间的联系。是吗？就地老龄化是一个流行的理想，是一个研究中使用的概念，也是世界各地广泛采用的一项政策指示。然而，“就地养老”，正如今天所使用的，“就地养老”掩盖了一些老龄主义观念，在当今世界越来越不合时宜。就地养老的背后是一系列复杂的判断、神话和误解，可能会损害老年人的健康和福祉。

The fundamental notion of ageing in place rejects the ageist notion that older people are so needful that they cannot and should not live in homes that suited them in younger years. So far, so good. But consider ageing in place from the obverse perspective. Do we think of being young in place? We do, only so far as to assure that children and youth reside in a home supported by adults who provide them parental oversight. Beyond youth, many communities and societies encourage younger people to reach beyond their childhood homes to establish themselves as adults. The risk of drawing a parallel between childhood and elderhood creates permission to infantilize older people, suggesting old age connotes the universal need for pseudo-parental oversight in later life from younger people.

就地养老的基本概念拒绝了年龄歧视的概念，即老年人是如此的需要，以至于他们不能也不应该生活在年轻时适合他们的家庭中。到目前为止，一切顺利。但从正面的角度考虑就地老龄化。我们在原地想年轻吗？我们这样做，只是为了确保儿童和青少年居住在一个由成年人支持的家庭，由成年人对他们进行父母监督。除了青年人之外，许多社区和社会鼓励年轻人走出童年的家，成长为成年人。将童年和老年相提并论的风险为将老年人婴儿化创造了条件，这表明老年意味着在晚年生活中普遍需要年轻人的假父母监督。

Critically, ageing in place emphasises ideals of nuclear and extended families, underscoring familial obligation to care for elder members with little or no external support. The need for oversight and care in later life that ageing in place implies belies a myth and a mistake. The myth is that, after childhood, only older people need care and support. We, as nurses and commonly as caregivers in our own families and communities, know that people need care and support at different times and for different reasons throughout their lives. The mistake is to presume that family members are always capable of and in a position to provide care to the person in need. The rising popularity of the terms ‘kinless elders’ or ‘kinless seniors’ as well as the derogatory ‘elder orphans’ underscores this mistaken belief system about who provides care in later life. An elder who has no children or life partner is no more likely bereft of social connections than is an elder, surrounded by an extensive family network, assured of the right sort of care and support.

至关重要的是，就地老龄化强调核心家庭和大家庭的理想，强调家庭有义务在很少或没有外部支助的情况下照顾老年人。原地老龄化意味着晚年生活需要监督和照顾，这掩盖了一个神话和错误。有一种说法是，童年过后，只有老年人需要照顾和支持。我们作为护士，通常作为我们自己家庭和社区的照顾者，知道人们在一生中不同的时间和不同的原因需要照顾和支持。错误的做法是假定家庭成员总是有能力和有能力为有需要的人提供照顾。“没有亲属的老人”或“没有亲属的老年人”以及贬义的“老年孤儿”一词的日益流行，凸显了这种关于谁在晚年提供照顾的错误信念体系。没有子女或生活伴侣的老年人并不比被广泛的家庭网络所包围的老年人更有可能失去社会联系，并确保得到适当的照顾和支持。

An individual's capacities, preferences and needs change markedly over the life course. Over decades, networks of family members—those related both by blood and by affiliation—along with friends, neighbours, co-workers, community members and professionals shift in their composition, connection and support. For example, teachers are part of that network in early life but, paradoxically given what we know about the value of lifelong learning, not in later life. Ageing in place presages a contraction of an individual's network to family members who are then supported by a select group of professionals (only in some instances given the family resources). In most societies, those professionals hold roles in health care and, secondarily, in social care. They step into elder's lives apropos health crises, typically those involving what are seen as older people's functional failures—a fall, declining memory or a severe illness.

一个人的能力、偏好和需求在一生中会发生显著变化。几十年来，家庭成员（血缘关系和从属关系）以及朋友、邻居、同事、社区成员和专业人士的网络在组成、联系和支持方面发生了变化。例如，教师在早年是这一网络的一部分，但矛盾的是，鉴于我们对终身学习价值的了解，教师在晚年却不是。就地老龄化预示着个人的关系网收缩到家庭成员，然后由一批特定的专业人员提供支助（只有在某些情况下，家庭资源有限）。在大多数社会中，这些专业人员在保健方面发挥作用，其次在社会护理方面发挥作用。他们步入老年人的生活，与健康危机有关，通常是那些被视为老年人功能障碍的疾病跌倒、记忆力衰退或严重疾病。

Gerontechnology is integral to contemporary scientific interpretations of ageing in place. Many gerontological nurses and other gerontologists recognise harm found in the common sequence represented by ageing in place until a health or functional crisis and then introduce professional and paraprofessional support services to target the putative causes of the crisis. Investigation of myriad personal and home technologies—from alarm systems to smart watches and beyond—to support ageing in place are widely conducted and often excitingly reported. Nonetheless, gerontechnology solutions pose two significant disadvantages. Many devices and systems are technically or financially out of reach, and most are devoid of human interaction. These disadvantages are fatal flaws considering what we know about financial security in later life and the critical need for social connection as we age. Gerontechnology can often make ageing in place in a current home possible for some over in specific situations, but it cannot replace being in the right home, the home that matches the person's preferences and needs.

老年人技术是当代科学解释就地老龄化的组成部分。许多老年病护士和其他老年病学家认识到，在健康或功能危机之前，以原地衰老为代表的常见序列中发现了危害，然后引入专业和准专业支持服务，以针对危机的假定原因。对无数个人和家庭技术从报警系统到智能手表等等支持就地养老的调查被广泛进行，并经常有令人兴奋的报道。尽管如此，gerontechnology的解决方案仍存在两个明显的缺点。许多设备和系统在技术上或经济上都是遥不可及的，而且大多数都缺乏人类交互。考虑到我们对晚年经济保障的了解以及随着年龄的增长对社会联系的迫切需求，这些缺点是致命的缺陷。老年人技术往往可以使一些人在特定情况下在目前的家中就地养老，但它不能取代在正确的家中，即符合个人喜好和需要的家中养老。

Employing ageing in place, and with it the innovations of gerontechnology, offers implicit licence for substandard institutional care. When ageing in place is the policy imperative, care over the longer term that requires a place that is not home—a nursing or care in most societies—takes second place. Second place means fewer resources and less attention, creating an undesirable option at best and a risk laden forced choice at worst. Contemporary standards for social care stress that consigning children and younger people to live in institutions is broadly unacceptable. Yet the idea that older people can expect to live in an institution at some point in their elderhood is widely accepted in many parts of the world. The implicit sequence is then to age in place until a crisis occurs forcing relocation to a nursing home. This cascade is personally and financial costly. Despite being blatantly unacceptable given those costs, this succession of events is common, accepted despite the distress and despair it typically causes.

就地养老，以及随之而来的老年技术创新，为不合格的机构护理提供了隐性许可。当就地养老成为政策的当务之急时，需要一个非家庭场所的长期护理（大多数社会中的护理或照料）就退居其次。第二名意味着更少的资源和更少的关注，充其量是一个不受欢迎的选择，最坏的情况是一个充满风险的被迫选择。当代社会照料标准强调，将儿童和青少年送到收容机构生活是普遍不可接受的。然而，世界许多地方都广泛接受老年人在其老年时期的某个时候可以预期住在养老院的想法。隐含的顺序是在原地老化，直到危机发生，迫使搬迁到养老院。这一连串的事件对个人和财政都是很昂贵的。尽管考虑到这些代价，这一系列事件显然是不可接受的，但这是常见的，尽管它通常会造成痛苦和绝望，但人们还是接受了这一点。

Ageing in place is a 20th century notion, one that runs counter to the most critical threat to ageing well in the 21st century: the climate crisis. Telling millions of older people around the world to age in place is to generate the possibility of a crisis as or more threatening than a fractured hip or a diagnosis of dementia. The climate crisis is widely acknowledged as inherently discriminatory, disproportionately affecting elders, children, people of colour, women and those with limited social and economic capital. For many older people, especially those in low- and middle-income countries at high risk for climatological disasters and those residing in housing stock unsuited to rapidly changing climate conditions, ageing in place actually risks serious injury and death. Despite current analyses of such risk, few efforts at robust planning for projections of the worsening climate crisis with attention to the needs of older populations are evident.

就地老龄化是20世纪的一个概念，它与21世纪老龄化面临的最严重威胁背道而驰：气候危机。告诉全世界数百万老年人就地养老，可能会产生一场危机，其威胁性甚至超过髋骨骨折或痴呆症的诊断。气候危机被广泛认为具有内在的歧视性，对老人、儿童、有色人种、妇女以及社会和经济资本有限的人造成了不成比例的影响。对许多老年人来说，特别是那些生活在气候灾害高风险低收入和中等收入国家的老年人，以及那些居住在不适应迅速变化的气候条件的住房中的老年人，就地养老实际上有严重伤害和死亡的风险。尽管目前对这种风险进行了分析，但显然没有作出什么努力，对日益恶化的气候危机进行强有力的规划预测，同时注意老年人口的需求。

Rethinking ageing in place for the 21st century is essential for safety, health and well-being. The deleterious consequences of ageing in place do not simply affect a small group of older people. They affect us all in our families, neighbourhoods and communities now and as we age. Critical analysis of ageing in place requires individual and structural actions. Structural actions require reconceptualization, policy analyses and new models of investigation, especially in implementation science. Most directly, ageing in place needs to be rephrased. Ageing in the right place is a start but the complexity of current understandings of ageing in place merit a careful unpicking of meaning, associations and implications. Supporting people to live in homes that are right for them—meeting their needs and attending to their preferences—is right at any age. That support is especially important in later life when ageist understandings subjugate preferences in favour of parent-like supposition that diminish personhood.

重新思考21世纪的老龄化问题对安全、健康和福祉至关重要。就地养老的有害后果不仅仅影响到一小部分老年人。它们现在和随着我们年龄的增长影响到我们所有人的家庭、邻里和社区。对老龄问题进行批判性分析需要采取个人和结构性行动。结构性行动需要重新构思、政策分析和新的调查模式，特别是在执行科学方面。最直接的是，就地养老需要重新措辞。在适当的地方老龄化是一个开始，但目前对老龄化的理解十分复杂，值得仔细分析其含义、联系和影响。支持人们住在适合他们的房子里满足他们的需求和喜好在任何年龄都是正确的。这种支持在以后的生活中尤其重要，因为年龄歧视的理解会压倒偏好，而倾向于家长式的假设，从而削弱人格。

I look towards a time when nursing homes are reclassed as nursing hospitals where people of all ages come to stay, receiving intensive nursing care for a variety of conditions and rehabilitation that helps them return home or find a new residence that better suits their ongoing needs. Similarly, I imagine a burgeoning class of homes which draw together people to ensure a sense of home that meets their needs arising from functional and social changes. But as nurses, we hold the power to help individuals, families, and even some communities act far ahead of those and many more structural changes.

我期待着有一天，养老院被重新归类为护理医院，所有年龄段的人都来这里住宿，接受各种条件和康复的重症护理，帮助他们回家或找到一个更适合他们持续需求的新住所。同样，我设想一个新兴的家庭阶层，它把人们聚集在一起，以确保有一种家的感觉，满足他们因功能和社会变化而产生的需要。但作为护士，我们有能力帮助个人、家庭，甚至一些社区在这些和更多的结构性变化之前采取行动。

In our roles as nurses and in our own lives, families, and communities, we possess knowledge and skills relevant to aid people age in the right place for them. We, especially in partnership with our social worker and allied health colleagues, can help people plan and prevent. We can all plan more robustly for what might become a reality by learning more, modifying our homes and habits, and better using tools and technologies. Planning goes must include advance directives and similar devices to express wishes and preferences but must go far beyond those foundations to be effective. And start earlier in life.

在我们作为护士的角色中，在我们自己的生活、家庭和社区中，我们拥有相关的知识和技能来帮助人们在适合他们的地方变老。我们，特别是与我们的社会工作者和专职医疗人员合作，可以帮助人们计划和预防。我们都可以通过学习更多的知识、改变我们的家庭和习惯、更好地使用工具和技术，为可能成为现实的事情做更稳健的计划。规划必须包括预先指示和类似的手段来表达愿望和偏好，但必须远远超出这些基础，才能有效。在生命中早点开始。

In nursing, planning and prevention are central to our perspective and our practices. Gerontechnology prompts us to think about health literacy, inclusive of both electronic and mobile health literacy, and making use of devices like smart watches to help with personal safety. But other ‘low tech’ planning strategies offer tremendous benefits we often neglect. Consider pairing a fitness program that includes advanced balance training with a focus foot, ankle, and hip flexor strength and mobility with in-home mobility aids. Even less common are conversations about advantages of relocating to a home that offers more social connections and available services in advance of a health crisis. The examples of how we can help people plan to age well and to prevent health crises are innumerable. The benefits extend from the person though their family to their communities, a beacon for what later life might be.

在护理中，计划和预防是我们观点和实践的核心。Gerontechnology促使我们思考健康素养，包括电子和移动的健康素养，以及利用智能手表等设备来帮助个人安全。但其他“低技术”规划策略提供了我们经常忽视的巨大好处。考虑将包括高级平衡训练在内的健身计划与家庭助行器相结合，重点是足部、踝关节和髋关节屈肌的力量和灵活性。更不常见的是关于搬迁到一个在健康危机之前提供更多社会联系和可用服务的家庭的好处的谈话。我们如何帮助人们计划健康地变老和预防健康危机的例子不胜枚举。这些好处从个人通过家庭延伸到社区，成为今后生活的灯塔。

We, as nurses and neighbours, offer so much to help individuals age in the right place as we lead dismantling the ageism of ageing in place. Let us use what our resources, working together to make 2023 the year of ageing in the right place.

我们，作为护士和邻居，提供了这么多帮助个人在正确的地方变老，因为我们领导拆除老年歧视的地方。让我们利用我们的资源，共同努力，使2023年成为适当的老龄年。

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