LIVING ARRANGEMENTS

Factors that determine living arrangements over the course of late life are diverse and complex. Living arrangements have important implications for an older adult's emotional, financial, and physical health, and historical changes in elderly living arrangements, the range of housing options available, and factors that predict living arrangements all have consequences for the well-being of older adults.

Historical perspective

Over the course of the twentieth century, living arrangements changed dramatically for older adults. In the early 1900s, the majority of older adults lived with one of their adult children. In 1910, only 12 percent of widows age sixty-five or older lived alone. Following World War II, there was a dramatic increase in the percentage of elderly people living alone. In the 1990s, most older adults either lived with their spouses or, if not married, alone.

Today, the majority of males age sixty-five and over live with a spouse (72 percent) while 20 percent live alone or with nonrelatives. Only a small proportion of older men live with other relatives (8 percent). On the other hand, most women age sixty-five and over tend to live alone or with nonrelatives (43 percent), and another 40 percent live with a spouse. A small percentage of older women (17 percent) live with other relatives.

Types of living arrangements

Various housing choices are available for independent, semi-independent, and dependent older adults. These categories provide rough approximations of the ability of housing types to support older persons with differing functional abilities.

Housing choices for independent older persons. In the United States, most independent older persons with few or no problems related to self-care, activities of daily living (ADLs), or instrumental activities of daily living (IADLs) reside in conventional homes or apartments. Those who choose this living arrangement tend to be younger, married, have a spouse present, have children living in the home or nearby, and own their own home.

Over three-quarters (77 percent) of older adults in the United States own their own homes. While rates of home ownership decrease with advancing age, 67 percent of older adults over age eighty-five still own their own homes. Nationally, more than 5 million elderly households rent their housing. In comparison to owners, renters tend to have lower incomes and to be women or minorities who live alone.

In government-subsidized housing, the federal government provides housing for low-income older persons by financing housing for the elderly and providing rent subsidies. Approximately 1.7 million older persons live in federally subsidized housing nationwide. The largest program serving low-income older persons is public housing, in which approximately 500,000 elderly reside, primarily in special housing for the elderly. Another program benefiting older adults is Section 202 housing, which has provided funds for non-profit sponsors to develop about 325,000 units in which over 387,000 tenants live (as of 2001).

Accessory apartments, created within single-family homes, are complete living units, including a private kitchen and bath. Elder cottage housing opportunities (ECHO) provide private housing arrangements adjacent to single-family housing. These two options can encourage economic and personal support between households, while at the same time allowing privacy. The number of older adults living in these types of housing is unknown, but is generally considered small. The growth of these options has been very slow, partly due to consumer reluctance, the physical difficulty of placing units in areas such as inner cities and inner suburbs, and restrictive zoning codes.

Retirement communities are designed for persons sixty years of age or older and provide a variety of social and recreational opportunities. While retirement communities exist in Australia, Japan, and Europe, they are more prevalent in the United States (Liebig). These communities target independent older adults and generally provide a minimum of supportive services. It is estimated that 7 percent of seniors in the United States live in this type of housing. These communities tend to be concentrated in metropolitan areas and in the southeast and western regions of the United States. The likelihood of moving to these types of communities decreases if there is an adult child available who lives less than an hour away. One study found that healthy, non-Hispanic white individuals tend to favor this living arrangement.

Another study, however, found that older adults with moderate disability are also attracted to retirement communities. The probability of moving to a retirement community increases as one's degree of difficulty performing IADLs (meal preparation, shopping, using the telephone, managing money, doing housework) changes from mild to moderate, but declines as such disabilities become severe. Although services are not provided by these communities, older adults may view this move as an opportunity to live among other older adults who can provide informal support. Silverstein and Zablotsky suggest that one move can serve two different needs: the desire for amenities and the need for support with daily tasks.

Housing for semi-independent older persons

Various housing options exist for semi-independent older adults who require some assistance with daily tasks. These options, which provide a supportive setting linked with services, can take place either in the home or in housing built for the expressed purpose of providing services.

Aging in place. Since most older adults prefer to remain in their own homes despite increasing frailty, bringing services into the home is an option for semi-independent older adults. Home care describes a situation in which an older person receives help in his or her home from an organization or another individual who is not a family member. As of March 2000, there were about 20,000 home care providers serving approximately 8 million individuals of all ages nationwide.

Persons preferring home care tend to have difficulties with ADLs or IADLs. This arrangement tends to be favored by persons who are divorced, separated, or widowed. The presence of children nearby decreases the likelihood of choosing home care.

A second option for receiving assistance within the home is shared housing, an arrangement in which two or more unrelated people share a house or apartment. Each person usually has his or her own sleeping quarters, with the rest of the house being shared. Members of the household can benefit from the potential for mutual assistance with chores and tasks. Surveys suggest that 2.5 percent of older adult households have at least one nonrelative living in their home, and almost 20 percent of older adults would consider living with someone they did not know. This living situation may occur naturally when individuals decide to form a household, through matches facilitated by an agency, or in small group-type homes operated by nonprofit or private organizations.

Older adults who have difficulties with activities of daily living, instrumental activities of daily living, and those without children living nearby tend to favor a shared arrangement. Divorced, separated, widowed, and persons who have never married are more likely to live in shared housing than married persons. Minorities, especially blacks and Asians, are also more likely to choose this arrangement.

Supportive housing. Frail older persons are likely to need a more physically supportive dwelling unit, greater supervision (e.g., with medications), more services, or more companionship than can be efficiently provided in conventional homes or apartments. While these options require older adults to relocate, they can offer the benefits of a built environment that is physically supportive and linked with services. These housing types tend to attract older adults and those who do not have children living nearby. Persons with difficulties climbing stairs are also more likely to select supportive housing. Supportive housing options include congregate housing, board and care homes, assisted living, and continuing care retirement communities.

Congregate housing refers to a wide range of multi-unit living arrangements for older persons in both the private and public sector. Older persons who live in this type of housing generally have their own apartments that include kitchens or kitchenettes and private bathrooms. Most of this housing has dining rooms and provides residents with at least one meal a day, which is frequently included in the rent. The housing also has common spaces for social and educational activities and, in some cases, provides transportation.

Congregate housing generally does not offer personal-care services or health services, and therefore attracts older persons who can live independently. It especially appeals to older persons who no longer want the responsibility of home maintenance and meal preparation, and who positively anticipate making new friends and engaging in activities.

Board and care homes are residential facilities that generally offer on-site management, supervision, a physically accessible environment, meals, and a range of services for physically or mentally vulnerable older people, as well as younger disabled people who experienced difficulties living independently in their previous residences. In facilities that primarily serve seniors, the average age of older persons in these settings is approximately eighty-three, about eight years older than residents of government-assisted housing.

Studies suggest that over 30,000 board and care homes exist in the United States, more than double the number of nursing homes. However, owing to their smaller size (usually between 5 and 20 dwelling units), board and care facilities house only about 400,000 residents (one-fourth the number of residents in nursing homes) and include about 200,000 persons under age sixty-two.

Assisted living is a housing option prevalent in the U.S. and northern Europe (Regner and Scott) that involves the delivery of professionally managed supportive services and, depending on state regulations, nursing services in a group setting that is residential in character and appearance. During the 1990s, assisted living was the fastest growing segment of the senior housing market. It has the capacity to meet unscheduled needs for assistance and is managed in ways that aim to maximize the physical and psychological independence of residents.

In 1999, there were approximately 30,000 to 40,000 assisted-living facilities in the United States, housing approximately one million individuals. A variety of services can be provided, including meals, housekeeping, transportation, medication management, laundry services, and recreation activities. Assisted living is intended to accommodate physically and mentally frail elderly people without imposing on them a heavily regulated, institutional environment. For many residents, assisted living has served as an alternative to nursing homes.

Also referred to as life care communities, continuing care retirement communities (CCRCs) are unique in that they offer various levels of care within one community to accommodate residents who have changing needs. Most CCRCs offer independent living areas, assisted living, and skilled nursing care. A variety of services are offered, including transportation, meals, housekeeping, and physician services. While some communities provide most of their own services, others obtain many of them through contracts with outside organizations.

By 1992, there were approximately 1,000 CCRCs in the United States, housing approximately 350,000 to 450,000 older persons. Each community houses between 400 and 600 older persons, often in campus-type settings. CCRCs generally require, as a condition for entry, that new residents be in reasonably good health.

The growth of housing types for semi-independent older adults provides increasing options for older adults who face increasing frailty in later life. In addition, home-care agencies, which provide needed assistance with household tasks and personal-care needs coupled with environmental modifications, can enable older adults to remain in their own homes.

Dependent older adults

Nursing homes provide an option for older adults whose functional limitations and chronic needs are severe. These facilities provide skilled nursing care and rehabilitation services to the elderly as well as younger individuals who are disabled or mentally ill. These are generally stand-alone facilities, but some are operated within a hospital or retirement community. There were approximately 1.56 million nursing home residents in the United States in 1996.

Those living in nursing homes tend to be women (72 percent), over age eighty-five (49 percent), white (89 percent), and widowed (60 percent). A vast majority of residents receive help with three or more ADLs, such as bathing, dressing, toileting, transfers, feeding, and mobility. The majority of residents also tend to have some form of memory loss (71 percent). The most frequently occurring health conditions for nursing home residents over age sixty-five are dementia (51 percent), heart disease (48 percent), and hypertension (40 percent)

Relocation effects

There has long been concern that relocation to a nursing home may adversely affect physical and mental health due to the disruption of daily routines and connections to family and friends. Recent research has demonstrated higher mortality rates among those who have recently relocated to a nursing home, compared with persons remaining at home. This problem has been labeled relocation stress syndrome, defined as physiological or psychosocial reactions resulting from transfer from one environment to another. Symptoms include anxiety, apprehension, confusion, depression, and loneliness. Acceptance to institutionalization generally begins within six to eight weeks, and adjustment is usually complete within three to six months.

It could be argued that it is not the relocation itself that leads to a greater likelihood of mortality, but the admission of largely high-risk persons who are already near death. However, one study found that those institutionalized for reasons other than poor health also experienced an increase in mortality immediately following admission to a nursing home (Aneshensel et al., 2000), suggesting that there are factors inherent in the relocation itself that elevate the postadmission mortality rate.

There are a range of housing types available to older adults, and the factors that influence moves seem complex. Most research has focused on predictors of relocation to different geographical areas (to be closer to or with family members), or to institutions. Future research needs to explore predictors of relocation into specific housing types, such as assisted living or CCRCs. The rapid growth of the older adult population necessitates an understanding of determinants of living arrangements and its implications for the elderly.

Christy M. Nishita Jon Pyroos

See also Aging in Place; Assisted Living; Board and Care Homes; Congregate Housing; Continuing Care Retirement Communities; Coresidence; Government Assisted Housing; Home Care and Home Services; Housing; Migration, Geographic Mobility and Distribution; Nursing Homes; Retirement Communities.

BIBLIOGRAPHY

AARP. Understanding Senior Housing into the Next Century: Survey of Consumer Preferences, Concerns, and Needs. Washington, D.C.: AARP, 1996.

Aneshensel, C. S.; Pearlin, L. I.; Levy, S. L.; Schuler, R. H. "Transition from Home to Nursing Home Mortality among Persons with Dementia." Journals of Gerontology Series B 55B, no. 3: S152–S162.

Assisted Living Federation of America. The Assisted Living Industry 1999: An Overview. Fairfax, Va.: ALFA, 1999.

Bean, F. D.; Myers, G. C.; Angel, J. L.; and Galle, O. "Geographic Concentration, Migration, and Population Redistribution of the Elderly." In Demography of Aging. Edited by L. G. Martin and S. H. Preston. Washington, D.C.: National Academy Press, 1994.

Joint Center for Housing Studies. Housing America's Seniors. Boston, Mass.: JCHS, Harvard University, 2000.

Kane, R. A., and Wilson, K. B. Assisted Living in the United States: A New Paradigm for Residential Care for Frail Older Persons? Washington, D.C.: AARP, 1993.

Kramarow, E. A. "The Elderly Who Live alone in the United States: Historical Perspectives on Household Change." Demography 32 (1995): 335–352.

Krauss, N. A., and Altman, B. M. Characteristics of Nursing Home Residents 1996. Rockville, Md.: Agency for Health Care Quality and Research, 1996.

Manion, P. S., and Rantz, M. J. "Relocation Stress Syndrome: A Comprehensive Plan for Long-term Care Admissions." Geriatric Nursing 16, no. 3 (1995): 108–112.

National Association of Home Care. World Wide Web document, 2001. www.nahc.org.

Schafer, R. Determinants of the Living Arrangements of the Elderly. Boston, Mass.: Joint Center for Housing Studies, Harvard University, 1999.

Silverstein, M., and Zablotsky, D. L. "Health and Social Precursors of Later Life Retirement-Community Migration." Journal of Gerontology: Social Sciences 51B, no. 3 (1996): S150–S156.

Sirrocco, A. Nursing Homes and Board and Care Homes. Hyattsville, Md.: National Center for Health Statistics, 1994.

Wolinski, F. D.; Stump, T. E.; and Callahan, C. M. "Does Being Placed in a Nursing Home Make You Sicker and More Likely to Die?" In Societal Mechanisms for Maintaining Competence in Old Age. Edited by S. L. Willis, K. W. Schaie, and M. Hayward. New York: Springer, 1997. Pages 94–130.

U.S. Department of Housing and Urban Development, Office of Policy Development and Research. The Challenge of Housing Security: Report to Congress on the Housing Conditions and Needs of Older Americans. Washington, D.C.: HUD, 1999.

LIVING WILL

See Advance directives for health care