16.4 Living Environments and Aging in Late Adulthood

Aging in Place and Caregiver Support

When you think of living environments in older age, you might imagine institutional settings such as assisted living or nursing home facilities. Currently, however, fewer than 5 percent of U.S. adults aged sixty-five years and older live in an institutional setting (Hallstrom, 2023). Most older adults live at home.

The effort to live safely and comfortably at home while maintaining as much independence as possible is known as aging in place, and older adults generally prefer it; around eight in ten say they prefer to grow old in their home and community (AARP, 2021).

The primary motivations for wanting to age in place are maintaining daily independence and control of personal space (Ahn et al., 2017). There may also be measurable benefits. For example, aging in place is associated with better cognitive ability, less depression, and greater independence and functional ability than is found among nursing home residents (Marek et al., 2005). Older adults rate living at home as the optimal environment for very old adults (ages eighty years and older), including those with health problems, difficulty dressing, and mobility limitations (Kasper et al., 2018).

Research has typically considered two types of functional ability in older age: activities of daily living and instrumental activities of daily living. An activity of daily living (ADL) is an everyday self-care task, such as feeding yourself, bathing, and moving around your environment (Katz, 1983; Zawaly et al., 2022). People having difficulty performing ADLs require assistance from someone in their environment on a regular and consistent basis, typically several times a day (Figure 16.15).

Figure 16.15 Most older adults are independent and able to take care of daily activities such as (a) food preparation and (b) household cleaning. (credit a: modification of work “Grandma Cooking” by Chris/Flickr, CC BY 2.0; credit b: modification of work “How to sweep the floor” by Kim Siever/Flickr, Public Domain)

There are some tasks that are considered more complex than ADLs, such as using the phone, shopping, preparing meals, doing laundry, managing medications, and dealing with finances (Lawton & Brody, 1969; Pashmdarfard & Azad, 2020). A task like this is referred to as an instrumental activity of daily living (IADL). Someone who’s struggling with one or two IADL tasks may need help occasionally but not every day.

Is aging in place an option for individuals with ADL and IADL limitations? Possibly, because there are many resources to make this possible. One of the most common is the help of a caregiver. A caregiver is an individual who looks after and helps someone with health problems and difficulty performing ADLs and IADLs. Some are paid and trained, but many are just relatives or friends of the person in need.

Caregivers play a highly valuable role, but the work can be stressful, especially when informal caregivers undertake the task (Figure 16.16). Informal caregivers, such as spouses and adult children, are the most common unpaid caregivers to older adults (Avent, 2019). It’s difficult to accept the reality of a loved one experiencing declining health and loss of independence, especially when that also means assuming the responsibility for that individual’s well-being, daily needs, and health care. Undertaking the caregiving role has thus been associated with poorer health and more anxiety and depression (del-Pino-Casado et al., 2021; Haley et al., 2020; Ho et al., 2009; Schulz et al., 2020).

Figure 16.16 Many older adults can stay at home with the help of caregivers. (credit: modification of work “helping” by Harland Spinks/Flickr, CC BY 2.0)

Some health consequences may be directly related to caregiving responsibilities, such as back pain caused by lifting or moving the care recipient. Other research suggests that the chronic stress associated with caregiving is a source of health problems like high blood pressure and decreased immune system functioning (Haley et al., 2020; Schulz et al., 2020; Vitaliano et al., 2004). These risks are serious; individuals reporting demanding caregiving responsibilities had higher mortality rates than noncaregivers and caregivers with less demanding roles (Perkins et al., 2012; Schulz et al., 2020). These health problems can cause caregivers to end up needing care themselves, complicating the situation for everyone.

Caregiving situations can differ, often in complex ways, based on gender and cultural factors like race, ethnicity, and country of origin. Women are more likely to assume the role of primary caregiver and engage in more intense caregiving activities than men (Haley et al., 2020; Kim & Woo, 2022; Schulz et al., 2020). Women also devote more hours to caregiving and have greater mental and physical health declines associated with the role than men (Haley et al., 2020; Pinquart & Sörensen, 2006; Schulz et al., 2020). Within the United States, cross-cultural research has often, but not universally, demonstrated that Black caregivers report less burden and depression than White caregivers, potentially due to more positive appraisals of the caregiving relationship and an emphasis on religion as a source of comfort. Hispanic caregivers, on the other hand, tend to report high levels of caregiving-related distress as well as difficulty accessing services due to language barriers (Haley et al., 2020; Liu et al., 2021). Cultural factors may intersect with SES to influence the accessibility of services, especially for families with low incomes who disproportionately tend to be people of color.

The care recipient’s specific medical condition is another potential factor in caregiving. Caring for a family member with dementia can be especially difficult, for example, because of the progressive nature of the decline and the need for caregivers to manage ADLs, IADLs, and possibly behavior problems as well. Only one in ten older adults receiving caregiving at home has dementia, yet 41 percent of unpaid caregiving hours are devoted to dementia caregiving because it’s such an intense and demanding task (Haley et al., 2020; Kasper et al., 2015; Liu et al., 2021; Schulz et al., 2020). The negative consequences associated with dementia caregiving may again vary by culture. For example, because East Asian culture regards dementia as a form of mental illness and also regards mental illnesses as shameful, dementia caregivers of East Asian and East Asian American descent often report high levels of distress, specifically due to the stigma associated with the care recipient’s condition (Lim et al., 2020).

Another common resource for aging in place is home health aides. A home health aide is a professional who travels to clients’ homes and assists with health care, ADLs, and IADLs. Home health aides can help older adults continue to live at home instead of relocating to long-term care. While most home health aides report a high level of fulfillment and job satisfaction, they’re also financially vulnerable due to the low pay of the position (Bercovitz et al., 2011). Also, in the United States, naturalized citizens and legal noncitizen immigrants make up 26 percent of the nation’s home health aides, despite representing only 12 percent of the general workforce population. Thus, changes in their ability to work in the United States may negatively impact care resources for older adults and those who have disabilities (Zallman et al., 2019).

Some resources promoting aging in place are located outside the home. At adult daycare centers, older adults participate in supervised activities that provide physical and cognitive stimulation as well as opportunities for social interaction. This also gives informal caregivers a break and enables them to run errands, go to work, or just relax. This resource is most frequently used for older adults who have dementia, which can limit their ability to be at home alone (Cohen-Mansfield et al., 2001; Tuohy et al., 2023).

Perhaps the most rapidly growing resource to support aging in place is technology. Social media, cell phones, and software such as guided mindfulness training apps can contribute to mental well-being by providing opportunities for social engagement, staying in touch with loved ones, and managing anxiety. Physical well-being can be enhanced through technologies such as fitness trackers, medication reminders, and online exercise options such as YouTube videos, and alarms and notification devices can call for assistance if there’s a medical emergency or injury (Fang et al., 2016; Ollevier et al., 2020). More recently, technology applications and personal assistants have been found to help older adults access information, emergency contacts, and entertainment (O'Brien et al., 2019). Technologies have also expanded that support people with hearing or vision loss such as AI or personal assistants for visual support or applications that transcribe conversations for those who need auditory support. Apps that connect people to services such as food delivery and transportation can also be beneficial to older adults with IADL difficulties.

Independent Living Communities

While many people choose to age in place, some relocate to independent living communities designed for older adults. These are not considered institutional settings. Residents are completely independent, can come and go as they please, and enjoy the same freedom as all other adults. The only distinction is that the community is specifically intended for older adults (Figure 16.17). Typically, the living spaces have been customized with such aids as handrails for support and wheelchair accessibility ramps. Many age-restricted communities take care of all outside maintenance such as lawn work and snow removal, making the residence easier to maintain. They also tend to be located near transportation, health care, shopping, and other services (Chen et al., 2020). Older adults often report that they enjoy the amenities and the increased opportunities for socialization in these living situations (Bekhet et al., 2009).

Figure 16.17 Independent living environments can help older adults maintain autonomy with assistive tools such as (a) ramps amenable to walkers and wheelchairs and (b) kitchens designed to accommodate the physical changes that occur with age so individuals can remain. (credit a: modification of work “Animo” by Sarah Stierch/Flickr, Public Domain; credit b: modification of work “UDLL-handicap-accessible-kitchen-sink” by Joffre Essley/Flickr, CC BY 2.0)

Some older adults with IADL limitations may require additional assistance. Living in congregate housing can offer more access to assistance than typical independent living communities while also maintaining residents’ independence. Congregate housing arrangements are often similar to college dormitories in that there are private living areas and common spaces, such as dining areas or lounges. These facilities often have services such as a shuttle to help older adults with transportation, but they typically do not provide any medical services (Chum et al., 2022).

Using an intergenerational model, some European countries have developed innovative living options for older adults. In the Netherlands and France, there’s a significant shortage of affordable housing for young adults, so young adults are matched with older adults and then move into their home, either a private dwelling or an older adult community. There are ground rules for the young adult to follow, such as requirements for socializing with the older adults, in return for the housing (Arentshorst et al., 2019; Labit & Dubost, 2016).

Germany and Denmark have more single older adults and few all-day childcare resources so in these countries intergenerational living often pairs older adults and families with children in designated buildings or complexes (not preexisting neighborhoods or buildings that just happen to have people of different generations as neighbors). The older adults often become surrogate grandparents. The communities may be managed by local governments, churches, nonprofit organizations, or even the residents themselves (Beck, 2019; Labit & Dubost, 2016). All these options have the potential to benefit their residents of all ages by enhancing social and emotional functioning as well as providing practical support (Beck, 2019).

Assisted Living and Nursing Homes

While many older adults prefer aging in place or independent living situations, in some cases these options may not be feasible or safe, and relocating to an institutional setting is necessary. Here “institutional setting” means a monitored facility in which residents typically lack the freedom to come and go as they please. Two types of institutional living environments primarily serve older adults, depending on the person’s care needs:

• An assisted living facility is for individuals with physical and/or cognitive limitations that prevent them from living at home. Here they have access to many services such as meals and housekeeping. They also get assistance with IADL and ADL, such as help using the restroom, bathing, and taking medications.
• A nursing home is like an assisted living facility but also addresses medical care needs. It provides twenty-four-hour supervision that includes skilled nursing care and services such as occupational therapy, speech therapy, and physical rehabilitation. Nursing homes are the most common institutionalized living environment for older adults.

Both assisted living and nursing home settings also generally have dedicated areas for residents with dementia. These are frequently referred to as memory care units and provide specific supervision and cognitive stimulation for residents who may be confused, disoriented, or unaware of their surroundings (National Institute on Aging, 2023).

Only 2.5 percent of U.S. adults sixty-five years of age and older reside in nursing homes, but the likelihood of needing this type of environment increases with age (Bom et al., 2023; Hallstrom, 2023). Data suggest that 16.9 percent of nursing home residents in the United States are under age sixty-five years, 19.5 percent are sixty-five to seventy years of age, 27.2 percent are seventy-five to eighty-four years of age, and 36.4 percent are age eighty-five years or older (Sengupta et al., 2022). Not all are there for the long term, however. Some people need short stays for rehabilitation after a serious health event such as surgery or a stroke. Others might remain for a short period while their homes are modified to accommodate physical limitations, such as adding wheelchair accessibility. The percentage of older adults residing in nursing homes varies from country to country (Figure 16.18) (Bom et al., 2023; Dyer et al., 2020).

Figure 16.18 The top bar for each country shows the percentage of its residents aged eighty years and older who live in nursing homes. The bottom bar shows the percentage aged sixty-five years and older who live in nursing homes. Across all countries shown, a much higher percentage of nursing home residents are eighty years of age or older. (attribution: Copyright Rice University, OpenStax, under CC BY 4.0 license)

Figure 16.18 represents only affluent nations, largely in Europe and North America. Many lower-income nations, including in Africa and Central and South America, are experiencing aging societies as well and are seeing even larger increases in their older adult populations (Committee on Population, & National Academies of Sciences, Engineering, and Medicine, 2015; Velkoff & Kowal, 2007). Data about long-term care use and other health-care needs of older adults in these countries are less available, but most research suggests that the level of relliance on informal care provided at home by family members will not sustain the health needs of rapidly growing older populations (Kalideen et al., 2022; Robledo et al., 2022).

In some countries, a typical path for individuals unable to live independently would transition first to an assisted living facility, and then to a nursing home facility if their health worsens. Making several moves into different communities may be less than ideal, however, and a rapidly growing trend is to move to older adult housing compatible with a variety of needs. This type of facility is known as a continuing care community. Continuing care communities typically have a section dedicated to independent living, consisting of freestanding homes or apartments. If residents’ needs increase, some services such as transportation or meal preparation may be available, as in congregate housing environments. If more assistance is required, residents can move into assisted living or nursing home environments located on the same campus (National Institute on Aging, 2023). This allows older adults to maintain their independence as long as possible and have access to increasing levels of assistance without needing to relocate to different communities.

Financial and Safety Considerations of Different Settings

Care of older adults can be a large expense that requires planning and access to resources. Even when someone is aging at home, hiring home health aides and making home modifications like installing wheelchair ramps costs money. Although Medicare may pay for some types of at-home services such as physical therapy and other skilled care (Medicare.gov, n.d.), homemaker and home health services cost an average of about $5,000 per month (Kaldy et al., 2024).

Informal caregiving isn’t without cost either because informal caregivers are likely to quit their jobs or reduce their work hours to accommodate their caregiving, reducing income. Women are particularly likely to encounter this situation because they typically take on more caregiving responsibilities than men (Lee & Tang, 2015; Schulz et al., 2020). A recent study found that loss of income was one of the most consistent challenges expressed by caregivers (Nadash et al., 2023). Programs operated by Medicaid and other agencies aim to reduce the financial burden for individuals who leave the workforce to care for a loved one. Many of these programs have been criticized, however, for having rigid requirements, limits on enrollment, and long waitlists.

Congregate housing and independent living communities, while a potential alternative to both home and institutional care, have their own obstacles to financial access. In the United States, congregate housing programs are typically available only for residents of federally subsidized housing (United States Department of Housing and Urban Development, n.d.), meaning that some people may have income too high to qualify for this option but too low to make other options feasible. Independent living communities tend to be expensive—the median cost in the United States is about $3,000 per month (Shuman, 2024)—and these aren’t typically covered by insurance because they don’t provide medical services.

In the United States, the cost of living in long-term care facilities can be extremely high. The average cost of staying in a private room at a nursing home is $9,000 per month, and assisted living costs about half that. Medicare doesn’t typically cover nursing home living, though it may cover up to 100 days of rehabilitation services or skilled nursing care. Some options such as long-term care insurance can help cover these expenses, but these policies are expensive, must be purchased while you’re still independent and in good health, and aren’t available for people with certain health conditions, such as muscular dystrophy (Kaldy et al., 2023).

Most individuals don’t or can’t adequately prepare for long-term care in later life, and 80 percent of U.S. adults cannot afford it, making Medicaid the primary option. To qualify, however, typically an individual must first demonstrate they have no assets. If a person doesn’t have enough assets to pay for care themselves but has too much to qualify for Medicaid, they must spend all their assets, including selling their house and depleting all savings and retirement funds until they are considered impoverished. This “spending down” must occur at least five years before attempting to qualify for Medicaid (National Council on Aging, 2023; Ng et al., 2010; Potter & Bowblis, 2021).

Apart from the low level of income needed to qualify for support, there are other centers with Medicaid. For example, not all long-term care facilities accept it. Also, facilities that do accept Medicaid generally operate on a much smaller per-person budget than more expensive options, meaning they have fewer amenities. Research suggests that nursing homes with a high percentage of Medicaid-qualifying residents also score lower on overall quality than those serving primarily residents with private insurance. Medicaid-accepting facilities are much more likely to serve a higher percentage of people of color and to be located in low-income neighborhoods. Research identifying differences in quality of care based on SES, race, and ethnicity suggests that these discrepancies have been increasing over time (Konetzka et al., 2021).

The financial aspects of nursing home care can vary considerably among countries along dimensions such as how the care is financed, how much of the country’s gross domestic product (GDP) is spent on long-term care costs, whether people must meet a certain income threshold to qualify for government assistance, and what percentage of total costs is paid for out of pocket by the resident or their family. The Netherlands, where eligibility for support is not based on income, spends four times as much of its GDP on health care as the United States does, and its residents pay less than half as much out of pocket. In Japan, all adults over age forty years are required to purchase long-term care insurance. While the United Kingdom and the United States both have income requirements to qualify for government assistance with health-care costs, the level to qualify is fifteen times higher in the United States as compared with the United Kingdom (Gruber & McCarry, 2023; Lee et al., 2023; Rau, 2023). Overall, these data suggest that nursing homes and other long-term care are often paid for with a complicated combination of government assistance, private and public insurance, and out-of-pocket costs.

While aging in place is desirable for many reasons, safety is an important consideration with this option. Many houses don’t include accessibility features, and a person who starts needing help transferring on and off the toilet and can’t afford to install grab bars risks falling. This also produces safety concerns for informal caregivers, who may not have been trained in safe lifting procedures and could injure themselves while helping the care recipient.

An important concern in these types of living environments is elder abuse, which is the mistreatment or neglect of an older adult. It is not an uncommon problem; one in ten older adults in the United States is believed to be a victim of elder abuse at some point in their lives (National Council on Aging, 2024). Global data across twenty-eight countries indicate that one in six older adults worldwide experienced some form of abuse within the past year (World Health Organization, 2024).

Elder abuse can take many forms, including the physical, sexual, and emotional abuse and neglect seen in other populations. Other forms are more common among this older age group. For example, financial abuse occurs when people take money from an older adult without their knowledge. This can happen when family members exploit their relatives’ financial resources or if professionals overcharge for services. Financial abuse is thought to be the most common form of elder abuse (Figure 16.19) (Weissberger et al., 2019).

Figure 16.19 Financial elder abuse is by far the most common type of elder abuse. (attribution: Copyright Rice University, OpenStax, under CC BY 4.0 license)

Elder abuse in institutional settings such as nursing homes tends to get a lot of attention, but a recent study examining nearly 2,000 reported cases revealed that family members and friends/acquaintances were the most common perpetrators, accounting for 47 and 25 percent of cases, respectively (Figure 16.20) (Weissberger et al., 2019). Informal caregivers often have no training in managing the emotional or physical aspects of caregiving and have an increased risk of social isolation and distress caused by caregiving, meaning they may perform their caregiving duties with little supervision or support and thus be at greater risk for engaging in abusive behavior. Generally, vulnerable older adults, such as those with poor health and those dependent on the perpetrator for care and assistance, are more likely to experience abuse. Caregivers who are financially dependent on the older adult or report psychological problems such as depression and burnout are more likely to perpetrate abuse (Storey, 2020).

Figure 16.20 Contrary to popular belief, perpetrators of elder abuse are more likely to be family members and friends than health-care workers. (attribution: Copyright Rice University, OpenStax, under CC BY 4.0 license)

The CDC and other resources indicate elder abuse can be prevented through improving our understanding of the challenges of aging, being aware of signs of abuse and how to report it, and checking in on older loved ones through regular visits (CDC, 2024). Additionally, if you are helping a loved one choose a caregiving facility, look for facilities that have educated staff, low turnover, opportunities for continued independence of residents, and clear care and kindness for residents (Maryville, 2024). If caregiving is provided at home, ensure that those providing care are provided with the social and emotional support they need to reduce caregiver stress and provide them with financial and tangible resources to provided adequate care such as education and training on the needs of the person under their care (APA, 2024).