The phone number listed yesterday for the Alexandria Area Agency on Aging should have been 838-0920; for the National Institute on Aging, 496-1752.
"Someone told me my wife died," the small, bent-over man whispered to nurse Cheryl Bluestein, as he stood and looked down at the floor of his room.
"Yes," Bluestein responded gently, stroking his cheek. "She died two weeks ago, of a heart attack . . . . You went to the funeral."
"I guess some things you don't want to remember," sighed the 92-year-old man, who had been an accomplished musician.
With his wife gone, the once confident man was alone and confused and needed more care and supervision than he had just a short time before.
His wife -- more than 20 years his junior -- had been able to care for him in their apartment, with the help of extensive services where they lived -- meals, housekeeping and nursing staff on duty.
When she died, he was transferred into the five-story nursing care center that is part of the same complex, so he could get around-the-clock supervision in a small private room with a single hospital bed.
The couple had planned for this eventuality. They had chosen to live out their lives in a "continuing care" or "life-care" community that promises to provide all levels of personal and nursing services as people need them.
This increasingly popular concept of life-care has developed over the past decades, along with other housing arrangements and in-home services designed to keep older people as independent as possible for as long as possible.
Older people say overwhelmingly they do not want to go live with their children, voicing fears of being a burden. But in the past there were few options besides living on one's own, living with an adult child or going to a nursing home.
That has changed as demand has grown for alternatives, particularly as people live longer and have more of the chronic health problems that restrict activities but do not require intensive medical care.
"We want to help establish a continuum of care in the community," said Carol Fraser Fisk, acting director of the U.S. Administration on Aging. "We have seen some filling in of the continuum . . . . The press of the numbers [of older people] is driving it."
That continuum now includes these options:
*In-home services for people who can stay where they are as long as they get help. This may include meals, housekeeping, daily routines such as dressing or more intensive personal and medical care.
*Adult day care, primarily used by older people who live with working children and cannot be left alone.
*Shared apartments with shared homemaker services.
*Apartment buildings that come with a range of personal services.
*Group homes for the elderly who need continual supervision but not skilled medical care.
A majority of older Americans, 60 percent, lived in homes they owned free and clear at the last census, and another 15 percent owned a home with a mortgage, while 25 percent were renters. In the Washington region, as in other urban areas, the percentage of renters was considerably higher than the national average -- 41 percent locally.
Most people stay in their own homes, whether bought or rented, as long as they can, and administrators report that those seeking admission to the various types of assisted-living arrangements generally are in their eighties.
When they decide to move, it usually is either because their homes have become too large or difficult to maintain or because they no longer can take care of themselves. Group Homes
In Alexandria, in a two-story brick house that looks like others in the neighborhood, a group of elderly women gathered around a table recently, cutting out paper ornaments.
A white-haired, neatly dressed woman began a conversation conventionally enough, with pertinent remarks on the weather and on her paper cutouts. But it soon became obvious that she was not quite aware of her circumstances. She talked about how she had decided to buy the home where she is, though actually she does not own it, and how nice it is to have a school for the children nearby, though all her children are grown and do not live there.
She was physically fit but sometimes confused. Because of that, she came to live at Cameron Knolls, a privately owned group home on Mount Vernon Avenue.
Pearl Dunn, 87, like some others who come to the group home, is completely alert but no longer felt comfortable living alone after she had hip surgery.
"It's the nearest thing to home you want to know," said Dunn.
"The residents are not candidates for a nursing home, but they can't live by themselves in an apartment," said Alexa Hymes, who owns and operates the group home. "We can catch some of the people who fall between the cracks." Clustered Apartments
Lillian Hyman, 86, lived with her son and daughter-in-law for five years but then fell down the stairs and broke both arms. The family and doctors decided she needed to live somewhere without stairs. Since 1979 she has lived in a sunny, two-bedroom apartment on upper Connecticut Avenue with a roommate she met through the Jewish Council on Aging, and the two of them share the services of a trained homemaker with four other elderly people in the apartment building.
The $750-a-month cost, sometimes subsidized by the agency, includes rent at the North Cleveland Park building, utilities, telephone, housecleaning and food. An agency social worker goes by once a week to see how they are doing.
A sharing arrangement still has its drawbacks and may be particularly hard to get used to for those who have had large homes to themselves. For some, it is simply a bit better than available alternatives.
"I think that people in places like this, they have to reach a state of acceptance," said one 82-year-old woman in the program, who did not want to be named. "You don't go running to it like you would go running for a train."
For those who are generally healthy and independent but require some minimal support services like community meals and emergency call systems, there are government-subsidized rental apartments at places like the 199-unit Friendship Terrace in Northwest Washington. Built under the federal government's Section 202 program for the elderly, the building has a population with a median age of 79 1/2.
"We try to help residents maintain as much independence as possible, but it is the first step where there is a measure of security," said Norman L. Owens, adminstrator of Friendship Terrace. "The meal acts as a check, we count noses."
The National Caucus and Center on Black Aged, with $7 million in federal money, in 1981 opened its first apartment house on upper 14th Street for elderly of limited means. The 174-unit building, where residents can buy a cafeteria-style meal, is full and has a waiting list, an NCBA spokesman said.
Privately owned, unsubsidized apartment complexes with services are available as well. These can be expensive, even without intensive medical care. The cost of renting a studio apartment at the Westwood garden apartments in Bethesda is $2,300 a month, for example.
The price includes three meals a day, maid service and a nurse on duty at all times. The rooms, which are carpeted and decorated, are kept unlocked, and most residents are checked on periodically by staff. When residents become incontinent or no longer can walk to meals, they must be transferred to a facility with a higher level of care.
A more traditional type of old-age home is the Episcopal Home in Georgetown, where the maximum charge for a small room with half bath and three meals a day is $1,200 a month, with the church subsidizing the charges for many residents. The setting on 32nd Street NW is quiet with a large garden area, but the rooms are sparse and on a recent visit the common areas were dark and unused. Life-Care Communities
The most comprehensive housing arrangement for the elderly is the life-care or continuing-care community, which is expensive but gives residents the security of knowing that any level of care they need can be provided right there.
One such place is the Hermitage, a mid-rise facility near Shirley Highway and Seminary Road in Alexandria, owned and operated by Virginia United Methodist Homes Inc. Residents pay an entrance fee plus monthly rent, live in one- or two-room apartments and get their meals and any personal assistance they need. If they need medical care, short-term or long-term, they can be moved into the nursing center in a separate wing.
"This is the last move a person will ever make," said the Rev. Seneca Foote, the Hermitage's administrator.
If the residents get sick or become too frail or confused to live in their apartments, they go into the five-story nursing center where the rooms, most of them private, are like those in a hospital. The level of contentment varies from room to room at the nursing center.
One patient, a Roanoke native who came to Washington in the late 1930s, chatted cheerfully about the machine being used on her swollen knee, the same type Redskins quarterback Joe Theismann had, she said. On a higher floor, another resident was celebrating her 85th birthday, but made it clear she wanted to be elsewhere: "I'd escape, but I have no place to go."
Originally, the life-care concept started out as a plan for older people to pay a large lump sum up front and be guaranteed food and shelter and all the health care they need for the rest of their lives. But the inflation of the 1970s and underestimates of how long the residents would live combined to create several tragic situations where bankruptcies left older people without the homes and care they had been promised, according to experts on aging and housing.
Two life-care communities in Northern Virginia, the Virginian and the Washington House, went into bankruptcy court but managed to survive after the residents agreed to modify their contracts and pay higher rates.
The concept has been modified now, and most have entrance fees plus monthly fees that can escalate annually. But the idea remains of providing all levels of support services and health care as people need them.
At the Asbury Methodist Village complex in Gaithersburg there are three levels of living arrangements, starting with apartments for independent people who pay an entrance fee and a monthly fee that covers a meal a day but not health care. Entrance fees range from $24,300 for studios to $50,700 for a two-bedroom unit, plus monthly fees of $418 to $690.
Another building contains suites for people who need help with bathing, dressing and housekeeping. A third building provides nursing care.
Herbert Doggett, Asbury Village director of development, said there are about 1,400 people on the waiting list for the independent apartments, meaning a wait of about five to eight years. The wait is about two years for the assisted living units, where the average age of admission is 83, he said.
In the past, most of the communities have had religious, nonprofit sponsors, but more for-profits are entering the field now. Marriott Corp., for example, has plans to open three life-care communities during the next four years, including in the Washington area.
Experts caution that people must be careful about the financial arrangements, particularly refund policies, involved in this kind of community. But they also say there is some initial evidence that people at such communities live longer, possibly because emergency care is so near and because residents worry less about their future. The arrangement can be affordable for homeowners with large amounts of equity.
"Life-care communities are becoming very popular. I'm going to look at it myself when I get older," said Fernando Torres-Gil, staff director of the House Aging Committee. At the same time, he said, the industry remains largely unregulated, and there have been cases where people have not been allowed to stay after their resources are gone, he said.
The state of Maryland does regulate continuing care communities and reviews financial viability before one is allowed to open. There now are 22 in the state, several with long waiting lists, and eight new communities in the planning stages, said Violet Sloat, Maryland Office of Aging program officer. Local Government Plans
Local governments are responding to the needs of a growing elderly population by sponsoring more housing programs and services.
In the Washington area, officials are experimenting with housing programs with various levels of support services. Some area officials said they have taken on more responsibility since federal programs for elderly housing have declined to the creation of fewer than 100 units a year for the entire Washington metropolitan area.
In Arlington County, where 30 percent of the elderly live alone, the county board in December approved a new program of support services at two apartment complexes, one a senior citizens building and the other a regular apartment building, said Terri Lynch, director of the Arlington Area Agency on Aging.
Montgomery County recently started developing a number of semi-independent housing options under Maryland's subsidized "sheltered housing" program for persons needing supervision and help with some daily activities.
The county last year licensed its first four group homes especially for elders under the program. Between five and eight elderly people live together and get three meals a day, housecleaning and personal care, at a cost of around $1,000 a month.
Most local jurisdictions now sponsor day-care centers for both well and frail elderly. While some are designed primarily for companionship and activities, others are geriatric centers for those who are physically or mentally impaired.
Arlington County 10 years ago started its Madison Adult Center, operating on weekdays and now serving about 60 older persons with varying degrees of impairment, with an average age of 80, said Ruth Ullom, the center's director. Full cost is $22 a day for county residents, but there is a sliding fee scale so those with less income pay less or nothing. In-Home Services
The choice that appeals most to many people is staying right where they are as long as they can. Local governments and nonprofit organizations are trying to help more there, as well, with delivered meals, transportation, telephone checks and homemakers to do chores.
"We are seeing an increasing demand for those in-home services. That is the greatest need," said Veronica Pace, director of the D.C. Office on Aging.
When a frail parent lives in one city and a child in another, arrangements can be more difficult. Seeing an unfilled need for long-distance help, two local social workers formed a company in Bethesda called the Aging Network to link people with services for elderly relatives.
"Children like the idea of a surrogate, the parents don't," said Barbara Kane, one of the firm's founders. It may go over better if the children go with the social worker or aides and explain to the parent that this is someone being brought in to help the family as a whole, Kane said.
When Iris Littig, a social worker herself, needed to find help for her 80-year-old mother in New York, she contacted the Aging Network. For a charge of about $275, the company found the proper services for her mother, who has an arthritic condition and increasing confusion: two nurses' aides, a social worker, a woman who helps with shopping and chores, and cleaning help.
The arrangement "puts a limit on the amount of feeling guilty" about not being able to be there herself, Littig said. Littig's mother was lucky in having the resources to pay for all the care she needed -- and it is expensive, costing about $700 a week.
Effie Eldridge, 78, could not afford those kind of services for her condition: She is bedridden with severe rheumatoid arthritis and a serious bedsore that will not heal. But her husband, Jerry Eldridge, 76, a former United Press International editor, is there to help care for her. He has given up his worldwide camping trips, they have sold their vacation condo in Arizona, and he stays at home.
With assistance from the Visiting Nurses Association, a nonprofit group, they are managing. They bought a bright corner co-op apartment across the street from the Watergate about 20 years ago, and they have retirement income. They cannot afford the full-time companion her doctor recommended, however, because it would cost $350 a week.
"The doctor asked how our financial status was," said Effie Eldridge, who appears frail, with gnarled hands. "I said it's stable and adequate for the moment -- but it wouldn't be if I had to pay someone $350 a week."
The Visiting Nurses Association bases its charges on a sliding scale depending on a family's income level, but the full cost is $54 for a visit by a nurse and $41 per visit by a home health aide.
The nonprofit Homemaker Health Aide Service of the National Capital Area, which gets some government subsidies, charges according to income as well, said executive director Miriam Felder.
"It is hard to find people to do this type of work at what we are able to pay them," Felder said. "Howard Johnson's is now paying more."
Even expensive, private home-care services are often found wanting, according to several who have used these services.
Elma Holder of the National Coalition of Nursing Home Reform said she arranged care for an 80-year-old friend named Violet, who died last year, and she hired help from a home care agency.
"I have been an advocate of home care and still am, but I experienced it for the first time this year," Holder said. "It was awful."
Violet had 11 nurses in a five-month period until her death from cancer. She had been a social worker involved with home care herself, but still could not find consistent quality care, Holder said. Violet had wanted to die at home but in the end died in hospital, where she was taken by ambulance when the home care aide due that day failed to show up.
For those who deal with the sick or confused elderly all the time, the quality of the end stages of life becomes a vivid daily issue.
"It has affected me . . . . I see the people here and say, 'If this is all I've worked for, then what the heck,' " said Ullom, of the Madison center. "I have to step back and say this is only a small percentage of the elderly. You have to think about all the elderly people you know who are just fine."