Aging in Place: Maintaining Quality of Life for Older Persons at Home
The US population is rapidly aging, a long-anticipated, transformational demographic event. The post-World War II generation, born in the mid-twentieth century, is now reaching the milestone of 65 years and beyond. There are currently 45 million Americans aged 65 or older, which will increase to 73 million by 2030 (US Census Bureau 2018). Aging can result in chronic illness and functional decline (St. John et al. 2019), which pose threats to individual independence and the possibility of placement in an institutional setting. Without question, individuals would prefer to lead long, active, and meaningful lives in their own homes and communities as they age, without worry of disease or disability (AARP 2018). Nations also have every reason to want their older citizens to be part of a vibrant society – to be healthy, happy, self-sufficient, and sharing their accumulated wisdom and life experiences with their younger counterparts (WHO 2015).
Key Research Findings
Aging in place has been the subject of a large, complex literature over the past four decades (Vasunilashorn et al. 2012). Aging in place represents an aspiration for continuity and comfort as one ages, by remaining in a familiar residential environment over the long term. The meaning of place has undergone a change in focus, from an individual at home to an individual within a community (Thomas and Blanchard 2009). Aging in place as a concept has changed from a simple goal to a dynamic process of successfully adapting to medical and functional challenges over a lifetime (Ahn 2017). Scharlach and his collaborators have proposed a developmental model with six components: continuity, compensation, control, connection, contribution, and challenge/comfort (Scharlach and Diaz Moore 2016).
Researchers have sought to enrich academic definitions of aging in place, by including older persons’ perceptions of what is most important to them. Grimmer led a qualitative study in Southern Australia in which 42 older participants living in the community were interviewed about aging in place. Resilience, adaptability, and independence were considered to be essential individual attributes. Health, information, practical assistance, finance, activity (physical and mental), company (family, friends, neighbors, pets), transport, and safety were identified as important components (Grimmer et al. 2015). Stafford conducted interviews with ten participants between the ages of 88 and 100 years in four states (Iowa, Minnesota, New Jersey, and Rhode Island), to characterize the experiences of people aging in place; she singled out seven adaptations that they made: maintaining lifestyle with modifications, change in the use of assistive devices and technology, behavior, outsourcing, relationships, attitude, and environment (Stafford 2017). In another small qualitative study, low-income elderly homeowners in Greensboro, North Carolina, named the following key elements: support from family and neighbors; ready access to shopping, education, transportation, and medical care; and a safe, quiet residential environment (Lee et al. 2017).
Understanding trends in the population over time is critical, but there have been few large longitudinal studies on aging in place. Kendig et al. conducted a prospective cohort study in Australia, from 1994 to 2010. One thousand persons 65 years of age and older, residents of Melbourne, underwent interviews every 2 years. Multivariate analysis determined negative predictors (age greater than 75, female gender, and being a private renter) and positive predictors (home modifications). Independence was not a predictor, except when controlling for age. Those who owned their homes, rather than renters, were more likely to want to remain at home (Kendig et al. 2017). In his conclusions, Kendig underscored the need for additional longitudinal studies.
Studies have recently considered the risk of vulnerable older adults who remain in suboptimal, unsafe environments and the need for relocation in some circumstances (Oswald et al. 2011; Golant 2015) (See “Aging in Right Place”). Oswald et al. (2011) in a study of 381 community-dwelling individuals uncovered clear differences between the “young-old” and “old-old,” with the younger group showing more satisfaction with their indoor physical environment. For the older group, neighborhood quality and outdoor place attachment were more important. Golant points out that isolation, chronic illness, disability, financial stress, and simple frailty might make relocation imperative. Different options could include naturally occurring retirement communities with supportive service programs, senior villages (e.g., in Boston and Washington, DC), continuing care retirement communities, assisted living, and board and care. Such environments may help individuals to achieve “residential normalcy,” which encompasses both residential comfort and mastery, and achieve a better emotional fit with where they live (Golant 2015). A systematic review of frail older persons in Canada, and how they make housing decisions, revealed that the process is extremely complex, with 88 factors involved. These factors were classified in six dimensions of the meaning and experience of home (psychological and psychosocial, socioeconomic and health, social, economic, time and space-time, and built and natural environment dimension). Fifty-two factors of influence, representing all six dimensions, impacted housing decisions in at least 60% of the studies reviewed (Roy et al. 2018). Older persons living at home may consider the availability of services to be essential to their independence. A disparity in access to services between those living in public housing, compared with residents of continuing care retirement communities, was reported in a recent study of persons 50 years of age and older in upstate New York (Ewen et al. 2017).
Health status can impact the quality of life of older persons at home and their ability to age in place (See “Aging in Place and Quality of Life”). A cross-sectional study measured health-related quality of life (HRQL) in 634 functionally independent individuals, with a mean age of 74.8 years, living in Gipuzkoa, Spain (population, 708,000). Sensory impairment, lack of engagement in cognitively stimulating activities, lack of engagement in group social activities, a low level of social support, and obstacles in the home environment showed a significant association with a poor self-rating for HRQL (Machón et al. 2017). Vanleerberghe et al. performed a systematic review of quality of life of older persons aging in place. They found that measurements of quality of life are rarely reported and noted the absence of a standardized instrument. The instruments employed were too narrow, focused primarily on physical function and health, without considering important domains such as home, neighborhood, and autonomy (Vanleerberghe et al. 2017).
Examples of Application
Nongovernmental organizations advocating for older persons have embraced the idea of aging in place, not simply in a home, but within a welcoming, well-conceived, age-friendly community. In its 2005 report, Beyond 50.05: A Report to the Nation on Livable Communities: Creating Environments for Successful Aging, AARP recommends communities be adapted for older persons to help them to age well – to create “livable communities” (See “Age-friendly Cities and Communities”). A “livable community” is defined as “…one that has affordable and appropriate housing, supportive community features and services, and adequate mobility options, which together facilitate personal independence and the engagement of residents in civic and social life” (AARP 2005) (See “Accessible Age-Friendly Environments”). AARP made recommendations for (1) promoting community engagement, including volunteering, membership in organizations, and participation in community decision-making; (2) affordable, plentiful, and properly designed housing which meets individuals’ physical needs; (3) safe, inclusive communities, for individuals of all ages and abilities, with access to shopping, community services, and adequate coordination with area agencies on aging; (4) an optimal driver environment, availability of driver education, and promotion of safe driving; (5) public transportation and transportation for people with special needs; and (6) available areas to walk and bicycle (See “Access to Transportation for Older Adults”) (AARP 2005). AARP has worked to promote these objectives through its Livable Communities Initiative, a program offering education and expertise to local governments and officials, grants, and an annual conference (AARP 2019). The World Health Organization has also advocated the creation of age-friendly cities worldwide (WHO 2007).
There are new models for older persons living together, where support services are provided: Naturally Occurring Retirement Communities with Special Support Programs (NORC-SSPs), villages, and campus-affiliated communities (See “Retirement Villages”). Bookman studied each setting qualitatively. NORCs were heterogeneous in structure and ethnically and economically diverse and had advantageous relationships with community organizations and health-related programs and peer support. Villages placed older persons in active leadership and decision-making roles, fostered strong social relationships among members, and offered additional support services financed by dues. Campus-affiliated communities were located close to academic institutions, where residents could take courses and be engaged in life-long learning, access needed medical and hospice care, attend cultural programs, and establish intergenerational connections (Bookman 2008). NORCs may fall short in the extent of the services they offer (Greenfield 2015). Villages have organizational and financial shortcomings that pose challenges to their long-term success (Scharlach et al. 2011).
Effective health programs have been developed specifically for older people living in the community. In the Community Aging in Place, Advancing Better Living for Elders (CAPABLE) trial, 300 older adults residing in Baltimore, Maryland, 65 years of age and older, were enrolled. They were cognitively intact, with deficits in one or more activities of daily living or two or more instrumental activities of daily living, and randomized to a control or intervention group. Those in the intervention group were visited by occupational therapists, nurses, and home modifiers (“handymen”), for as many as ten visits over a 5-month period, with the objective of improving function or making home modifications. After 5 months, individuals in the intervention group had disability scores that were 30% lower, compared with the control group. They saw the program positively, noting that it made their lives easier, facilitated self-care, and improved their confidence in addressing challenges (Szanton et al. 2019). In the multi-year Independence at Home Demonstration Project of the Center for Medicare and Medicaid Services, teams led by physicians and nurse practitioners in 18 home care practices cared for older adults at home, who had reduced hospitalizations and emergency room visits and high satisfaction scores (US Department of Health and Human Services 2018). Legislation has been introduced in the US Congress in April 2019 to disseminate the program nationally.
As a group, US Veterans are aging rapidly. They number 20 million, with 9 million “baby boomers,” born in the years 1946–1964 (US Department of Veterans Affairs 2018). There are 4.8 million Veterans 65–74 years of age and 4.2 million 75 years of age and older (US Census Bureau 2017). Veterans cared for in the VA Healthcare System have a high prevalence of multiple chronic conditions and have poorer health status compared with the general population (Balbale et al. 2016). There is a limited literature on successful aging in Veterans (Pruchno 2016) and no good studies on aging in place.
The Veterans Health Administration of the Department of Veterans Affairs has designed and implemented programs which can be helpful to Veterans who strive to age in place successfully at home (See “Veterans Care”). The Home-Based Primary Care (HBPC) Program, started in the 1970s, employs an interdisciplinary team of professionals in medicine, nursing, social work, nutrition, psychology, physical therapy, and pharmacy to care collaboratively for those Veterans who cannot easily travel to an outpatient clinic. Since its inception, HBPC has increased from a handful of pilot programs to 430 programs throughout the United States. Veterans enrolled in HBPC are older and often have multiple comorbid conditions and functional deficits. HBPC focuses not only on medical management and reducing healthcare utilization but also on function, quality of life, and psychological and social support, thereby allowing older Veterans remain at home. Veterans enrolled in the program have access to other support services, including home health aides, home improvement grants, durable medical equipment, and transportation (Beales and Edes 2009; Edes et al. 2014; Jayes and Kaiser 2017).
The VA has residential options which may benefit the aging Veteran population. The Medical Foster Home (MFH) Program is designed to give Veterans the choice of residing in a home-like setting in the community (See “Adult Foster Homes”). A maximum of three Veterans may live in an MFH, which is managed by a private caregiver and inspected by the VA MFH Director. It provides an environment for Veterans who require assistance but may not have a spouse or family member who can fill that role. It is a relatively low-cost option for Veterans who would otherwise need placement in a larger institutional setting. All Veterans enrolled in MFH automatically receive medical care through the HBPC program. MFH has been disseminated throughout the VA Healthcare System (Levy and Whitfield 2016).
Future Directions of Research
There are aspects of aging in place that deserve further exploration. There are few longitudinal studies, particularly in the United States, and future studies could explore the determinants of aging in place in diverse populations and residential settings, and Veterans, who are underrepresented in such research, need to be included. A limited evidence base exists for the newer residential models, such as NORCs, villages, campus-affiliated retirement communities, and VA Medical Foster Home. Studies could catalog their common characteristics in greater detail, measure their effectiveness, and suggest how they could be redesigned, improved, and disseminated. Further research could examine which groups of older persons are most vulnerable if they remain in environments that cannot be adequately modified and develop standard criteria for relocation. Research must also address quality of life, by developing a common instrument and collecting and analyzing data that can offer a better day-to-day assessment of how well older persons are living at home. Assessment of assistive technologies can produce data that guides utility and choice (See “Home Health Technologies”).
The US population is rapidly aging. Individuals would prefer to “age in place,” to be able to lead long, active, and meaningful lives in their own homes and communities over the long term, without worry of disease or disability. Aging in place as a concept has changed from a simple goal to a dynamic process of successfully adapting to medical and functional challenges over a lifetime. Older persons have identified resilience, adaptability, and independence as valuable attributes to aging in place; health, information, practical assistance, finance, activity (physical and mental), company (family, friends, neighbors, pets), transport, and safety were perceived to be important components. In a large longitudinal study, age greater than 75, female gender, and being a private renter were negative predicators, and home modification was a positive predictor. Frail older persons, with chronic illness, disability, and financial stress, might need to forgo home modification and consider relocation. There are models for older persons living together, where support services are provided: Naturally Occurring Retirement Communities with Special Support Programs (NORC-SSPs), villages, campus-affiliated communities, and the VA Medical Foster Home. Health programs such as the CAPABLE intervention and the VA Home-Based Primary Care Program provide effective medical care through interprofessional home care teams. Further research, including longitudinal studies, outcomes research, high-risk groups, criteria for relocation, and technology assessment are warranted.
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