Aging in Place:: Are We Prepared?

While aging in place is preferred by the vast majority of adults and can bring a host of psychological and physical benefits, older adults require community support in order to age in place safely and with dignity. In this commentary, we review the demographic changes and characteristics of older adults nationally and in Delaware, highlight some of the benefits and challenges to aging in place, and discuss the individual and system-level strategies that are needed to help older adults successfully age in place. Finally, we provide an overview of one creative solution that addresses instrumental and social needs among individuals aging in place with chronic illness.

Aging in the United States

The United States is facing a “gray tsunami” as the baby boomer generation ages and fertility rates decline. In 2010, there were 40.3 million Americans over 65, a number that is expected to grow to 80 million by 2030. Delaware is not isolated from this trend: it is predicted that the Delaware over-65 population will increase 48.6% between 2020 and 2050, from 183,822 to 273,105. For many older adults, managing a chronic disease will be a central part of the aging experience. Nationwide, 78% of adults over 55 have a chronic condition (e.g., arthritis, asthma, cancer, cardiovascular disease, chronic obstructive pulmonary disease, or diabetes), a rate that swells to 85% in adults over 65. In Delaware, four of the top five leading causes of death are chronic diseases.

As the age and health status of the population shift, we are also seeing changes in family systems and dynamics. Increasingly, older adults in the U.S. are unlikely to live with extended family or even to live less than one hour away from family members who provide at least intermittent care. While proximity to adult children can be a source of support for many, 15.2 million older adults have no children, and 22% of adults are or will be on their own in old age. With research showing that at least half of older adults 65 or older can expect to be in need of care during their older years, the availability of caregivers is an important consideration.

Aging in Place

Aging in place is defined as remaining in a community-based dwelling during one’s late years in life. The home may be one where an individual spent most of their adulthood, perhaps rearing a family and establishing deep roots, or it may be a “downsized” space, such as an apartment, mobile home, or condo, that offers the appeal of independent living without the maintenance, expense, and potential dangers of remaining in a larger home. For some, aging in place may even mean moving in with a family member or friend to maintain some independence while also enjoying the benefits - and supports - of co-housing.

According to the AARP in 2021, if given the choice, 77% of adults over 50 would prefer to age in place. This personal preference is reflected in the data: in the past 20 years, the number of community-dwelling adults in traditional housing has increased, while those living in nursing homes has declined, and in 2020 only 1.2 million adults over 65 were nursing home residents. In Delaware, public nursing home utilization has been declining since 2011 and private nursing home utilization began declining in 2020. As nursing homes are less utilized, the burden of care is shifted to community-based caregivers, both paid/formal and unpaid/informal. In the United States in 2020, there were approximately 53 million informal caregivers, which translates to one in five American adults. While caregivers provide critical support to allow an individual to age in place, this unpaid care can have deleterious effects on the caregiver’s own health, finances, and emotional wellbeing.

Aging in Place: The Benefits

With so many individuals choosing to age in place, it is undeniable that there are many perceived benefits. The advantages, however, may not be as understood and documented as one might expect. Many older adults associate “aging in place” with positive attributes such as maintaining one’s autonomy and independence in a community that offers social connections and access to services. When an individual is able to age in their own home, they are granted a daily sense of familiarity, whether that consists of morning greetings from a household pet, contact with neighbors, or the ability to surround themselves with physical objects that represent cherished memories.

A familiar environment and place can contribute to an older adult’s sense of identity, can promote successful utilization of neighborhood services, and can help one remain socially connected thanks to the proximity of friends. Research indicates that higher satisfaction with one’s social network and neighborhood integration is directly correlated with decreased feelings of loneliness. In addition, perceived safety and sufficiency of neighborhood services is also linked to an older adult’s experience of loneliness. It is important to note that the opposite may also be true - if a person is less satisfied with their social network, is less engaged with neighborhood resources, and feels generally less connected to their surroundings, a person may actually feel more isolated and lonely and less satisfied with their aging in place experience.

Health and financial considerations may also factor into the perceived benefits of aging in place. For many, the perceived financial advantages of aging in place are a motivator to delay or avoid institution-level care. While the costs of all forms of long term care are undeniably increasing, research does suggest that providing care at home to those aging in place may be a more cost-effective option. Research also shows that millions of health care associated infections occur in long-term care facilities in the U.S. each year. Aging in one’s home can provide an alternative to nursing homes or long-term care facilities, therefore protecting older adults from health care associated infections that could negatively impact their health and/or shorten their lifespan.

Aging in Place: The Challenges

Despite the noted preference among adults for aging in place, barriers to doing so safely do exist. One of the key components of aging in place, one’s home, tops the list. A 2020 report estimated that only 10% of American homes are “aging ready,” with a step-free entryway, a bedroom and bathroom on the first floor, and at least one bathroom accessibility feature. While home modifications that could enable individuals to age in place safely do exist, they are often not known about or are out of reach financially for older adults on a limited budget. With roughly one third of adults over the age of 65 experiencing a fall each year and up to two thirds of these falls taking place in and around the home, the importance of appropriate home modifications to reduce fall risk cannot be understated.

For older adults aging in place, the safety and accessibility of one’s neighborhood is also of paramount importance. While exercise is recognized as important for physical and social health, activities such as walking outdoors can produce anxiety due to concerns about sidewalk safety and corresponding fall risks. Research indicates that older individuals are 18% more likely to be mobile when their community environment is accessible. In addition to concerns about safety and accessibility in their neighborhoods, older adults who are continuously exposed to built environments with fewer support services (ex: pharmacies, senior centers) and more businesses like fast food restaurants and liquor stores, are more likely to self-report poor health.

A lack of transportation options can also be a barrier to aging in place. Transportation-disadvantaged older adults experience social isolation and obstacles to accessing a variety of goods and services essential to quality of life. The most-used form of transportation among American adults is the private vehicle. As individuals age and lose the ability to drive, they must rely upon other forms of transportation to access essential services. Alternatives such as walking, public transportation, ridesharing and paratransit services do not come without their pitfalls such as accessibility, effectiveness, and efficiency.

While aging in place may be more affordable than institutional care, it remains expensive and can be inaccessible to some. It is found that the wealthiest of Americans are able to afford care and the poorest are able to receive some degree of subsidized care. It is middle class Americans, then, who often struggle the most: they may be unable to afford adequate care and may be ineligible for public assistance to supplement the costs.

Many older adults share that one of their greatest concerns in regard to aging in place is the lack of someone to make a social call to check on them. More than one third of adults over 45 report feeling lonely, and research suggests that social isolation and loneliness are associated with increased rates of mortality, dementia, heart disease, stroke, anxiety, depression, and suicide. For older adults, loneliness may increase due to mobility and transportation changes that come with age and which impact one’s ability to engage in the community.
Aging in place affects not only the individuals choosing to remain in their homes but also the informal support systems they rely upon as they age and their health declines. The United States is increasingly depending on informal caregivers to deliver essential support to older adults aging in place: it is estimated that the value of care provided by informal caregivers is $470 billion annually. While many individuals enjoy aspects of caring for an aging loved one, the potential threats to caregivers’ health and wellbeing are real. Research demonstrates that spousal caregivers reporting associated strain are nearly two thirds more likely to die within four years than non-caregivers. Yet, without a support system that provides direct assistance (such as with transportation, housekeeping, organizing pills, sometimes even bathing), care coordination (scheduling appointments and facilitating communication between providers), and patient advocacy (ensuring the individual receives the care and resources they need), aging in place can quickly become fraught with challenges, if not outright dangers.

Aging in Place: Strategies

A variety of strategies - both on individual and community levels - can be implemented to create a supportive environment conducive to aging in place. The foundational aspects of these strategies include improving education, advocacy, and infrastructure to foster independence for the aging population. In considering community efforts, literature suggests that programs and policies directed toward mitigating physical barriers, such as creating a built environment that promotes connectedness and providing transportation supports, are beneficial in supporting an aging population within a community. Community-wide strategies to address accessibility, mobility, and supportive services that are linked with financial support from local and national governments along with continuous advocacy are most likely to produce lasting change.

Successful and dignified aging in the home is not brought about only by an individual’s surroundings - how one interacts with their community is equally important. Educational initiatives for older adults that aim to increase awareness of what supportive services are available and how to use them are integral to aging in the community setting. It is also essential to consider the social determinants of health and how they impact each individual and for the voices of those actually affected to be heard. When the citizens of an aging community are involved and passionate in advocacy efforts, change is more easily instigated.

Many communities and organizations are working to creatively address some of the challenges facing those striving to age in place. From home repair programs, to home-based care teams, to senior centers, to Meals on Wheels, to Villages, and more, these initiatives are making aging in place a more realistic option for some. Nevertheless, a more unified statewide and national approach as well as further research on the effectiveness of existing programs and areas of opportunity are needed to support a growing older adult population’s goal to age in place with dignity and independence.

Intergenerational Service Learning: A Unique Approach

Intergenerational service learning is one promising solution to the challenges facing older adults aging in place. Research suggests that intergenerational service learning not only improves young people’s attitudes towards aging and the older generation, but also has a positive impact on the older adult participants’ quality of life, physical health, generativity, and a lessening of depressive symptoms. Lori’s Hands is a Delaware-based community health service learning nonprofit that jointly aims to improve the wellbeing of community-dwelling adults with chronic illness while also preparing a next-generation health care workforce to care for an aging population. Established as a student club at the University of Delaware in 2009, Lori’s Hands is now a 501(c)3 nonprofit organization spanning three states (Delaware, Maryland, and Michigan).

Lori’s Hands’ unique intergenerational model addresses many of the challenges faced by older adults and individuals with chronic illness who are aging in place. Lori’s Hands trains and equips college student volunteers to make weekly visits to help community members with day-to-day tasks (such as grocery shopping, organizing a closet, or running the vacuum cleaner) that can be made challenging by chronic disease. While improving clients’ independence, students also provide essential social support, increasing community connectedness and reducing loneliness. As clients experience these benefits, they educate students about their experiences living with chronic illness, navigating the health care system, aging, and more, providing a real-world education to pre-health professionals.

Lori’s Hands’ services are available to adult community members living with chronic illness in Newark, DE, Baltimore, MD, and Metro Detroit, MI. Among the most common client diagnoses are arthritis, diabetes, hypertension, pulmonary disease, cancer, depression or anxiety, and stroke. Eighty-three percent of clients live with multiple chronic conditions. Thirty one percent of clients are people of color, 76% are female, and 88% are over the age of 65. The majority (61%) of clients are single or widowed. While Lori’s Hands has no income eligibility criteria, 63% of clients report having “not enough” or “just enough” money left over at the end of each month.

Lori’s Hands student volunteers are currently enrolled in an undergraduate or graduate course of study. While the majority of student volunteers are preparing for a career in health care, participation is open to students from any academic major. The most frequently reported barrier to participation for students is in regard to transportation to client homes. Currently, students must find their own means of transportation to make client visits. To attempt to reduce this barrier, Lori’s Hands always pairs students together to make client visits, guaranteeing at least one student has a vehicle and students can carpool. Due to issues like limited public transportation, high gas prices, and less frequent car ownership in urban environments, Lori’s Hands is continuing to develop creative solutions to reduce barriers to participation for prospective student volunteers.

The benefits of participation in Lori’s Hands to both students and clients have been documented through both internal and independent evaluation. Benefits for clients include decreased loneliness, emotional fulfillment and connection, intergenerational understanding, and assistance with daily tasks. Among students, reported benefits include solidifying career interests, a deepening knowledge of chronic illness, and intergenerational understanding. Since Lori’s Hands’ inception, more than 1500 student volunteers and 400 community members have benefited from participation. Lori’s Hands has developed partnerships with more than 13 colleges and universities to create meaningful service learning opportunities across its three locations. In 2020, Lori’s Hands received federal funding from the Administration for Community Living’s Community Care Corps to support program expansion. Intergenerational service learning programs like Lori’s Hands have tremendous potential to deliver impactful support to community members aging in place while also preparing a next-generation health care workforce to deliver care with empathy, insight, and creativity.

Conclusion

As the number of older adults in the United States continues to increase and the aging in place movement maintains popularity, we must take a critical look at how our communities are equipped to support this growing population. Many factors should be considered when we assess the suitability of both our built and social environments for aging in place, recognizing that these elements can have a direct effect on physical and social health and wellbeing. Creative solutions do currently exist to address some of the needs of those who are aging in place. Additional research needs to be conducted to more fully understand the challenges and benefits of aging in place and to guide efforts to continue to support the aging community’s independence, health, and wellbeing.