Aging in Place: Issues Facing

Manitoba Seniors

Juliette E. Cooper, PhD, OT(C), FCAOT

Professor Emeritus, Department of Occupational Therapy

University of Manitoba

Centre on Aging27th Annual Spring Research Symposium

May 3, 2010

‘Mid pleasures and palaces though we may roam, be it ever

so humble, there’s no place like home…John Howard Payne, ca 1823

What I Will Cover

• home and aging

• a model and some determinants

• environmental competence and housing

• Aging in Place – some considerations

• Canada’s seniors – living arrangements, income, cost

of accommodation

• extrapolation to Manitoba

What is “Home”?

• is it a physical space?

• is it a social construct?

• is it a state of mind?

Meaning of “Home”“A home fulfills many needs: a place of self-expression, a vessel of memories,

a refuge from the outside world, a cocoon where we can feel nurtured and let

down our guard.”

“As we change and grow throughout our lives, our psychological

development is punctuated not only by meaningful emotional relationships

with people, but also by close affective ties with a number of significant

physical environments…”

“Those of us fortunate enough to own or rent a home that fits our needs

may never realize the depth of its emotional significance until we lose it,

through divorce, natural disaster, or old age.”

“For many people, the longer they live their lives in one place, the more they

become attached to it – particularly if the time spent in that place included

fulfilling human relationships.”(Marcus, 1995, pp. 4,221,244)

Aging and the Concept of “Home”• growing old in familiar surroundings with familiar faces and familiar

routines can provide contentedness

• moves associated with growing old can be positive; improved housing can

improve quality of life, there may be an increased sense of security

• for some, aging in place means “rootedness”, for others “rigidity”

A study using the data from the English Longitudinal Study of Ageing and

the Health Survey for England found:

• residential mobility declined as age increased

• rates of residential mobility were slightly higher for those who had a

greater number of functional limitations

• the majority of individuals who had spent most of their adult life in their

current home reported feeling “part of the area”, regardless of the

socioeconomic status of the area

• age and aging in place contributed to a feeling of belonging, but not

necessarily to feelings of well-being

• well-being may contribute to feeling of belonging, not the other way

around(Gilleard et al., 2007)

Aging and the Concept of “Home”

In the United States, Golant (2008) stated that a familiar dwelling:

• provides comfort

• gives rise to feelings of control and independence

• allows seniors to maintain continuity with the past

• home and community were seen as the most desirable settings for coping

with changes in health and function

• assistance provided in the home setting ranged from IADLs (housekeeping,

shopping, banking) to ADLs (bathing, dressing, medication management) to

skilled nursing care to behaviour monitoring

• most of these services (88%) were provided by family members (spouses,

daughters)

Sense of Well-being

Feeling of Belonging

Sense of Connectedness

(Gilleard et al., 2007)

Aging and the Concept of “Home”

“Home” provides a:

Person-Environment-Occupation Model

(Law et al., 1996)

PERSON ENVIRONMENT

OCCUPATION

Definitions

What is “Person”?

“…a unique being who assumes a variety of roles simultaneously. These

roles are dynamic, varying across time and context in their importance,

duration and significance.”(Law et al., 1996, pp. 15-16)

What is “Environment”?

“Environments are…those situations which occur outside individuals

and elicit responses in them.”(Law, 1991, p. 175)

Environments can include the built environment (dwelling,

neighbourhood, community), climate, as well as domains such as

cultural, social, socio-economic and political environments.

What is “Occupation”?

“Groups of activities and tasks of everyday life, named, organized, and

given value and meaning by individuals and a culture.

Everything people do to occupy themselves…(CAOT, 1997, p.181)

Person-Environment-Occupation Model

(Law et al., 1996)

PERSON ENVIRONMENT

OCCUPATION OCCUPATIONAL

PERFORMANCE

What is “Occupational Performance”?

Occupational Performance is:• the result of a dynamic, interwoven relationship between

persons, environment and occupation over a person’s lifespan;

• the ability to choose, organize, and satisfactorily perform

meaningful occupations that are culturally defined and age

appropriate for looking after oneself, enjoying life, and

contributing to the social and economic fabric of a community.

(CAOT, 1997, p. 181)

PERSONENVIRONMENT

A Change in Any Element of the P-E-O

Can Affect Occupational Performance

ENVIRONMENT

OCCUPATION OCCUPATIONAL

PERFORMANCE

Focusing on the

Physical Environment…

Key Determinants of Health

1. Income and social status

2. Social support networks

3. Education and literacy

4. Employment/working conditions

5. Social environments

6. Physical environments

7. Personal health practices and coping skills

8. Healthy child development

9. Biology and genetic endowment

10. Health services

11.Gender

12.Culture(Public Health Agency of Canada, n.d.)

In the built environment,

factors related to housing,

indoor air quality, and the

design of communities and

transportation systems can

significantly influence our

physical and psychological

well-being.

Determinants of Active Aging

Gender

Social

determinants

Culture

Economic

determinants

Active

Ageing

Health and

social services

Behavioural

determinants

Personal

determinants

Physical

environment

(Adapted from WHO, 2007, p.5)

What Does “Active Aging” Mean?

The ability to maintain control over one’s immediate surroundings

and to function freely in an environment that is safe, secure and

appropriate is linked on the one hand to the characteristics of the

individual (physiological, psychological) and on the other hand to the

characteristics of the environment in which that individual lives

(economic, social and housing).(Maltais, Trickey & Robitaille, 1989)

Active ageing is the process of optimizing opportunities for health,

participation and security in order to enhance quality of life as people

age.(WHO, 2007, p.5)

Housing is Obviously a Critical

Component of the Physical Environment

PERSONENVIRONMENT

A Change in Any Element of the P-E-O

Can Affect Occupational Performance

ENVIRONMENT

OCCUPATION OCCUPATIONAL

PERFORMANCE

“Environmental Competence”

Time

• physical capacity changes as a person ages

• this change affects a person’s ability to interact with the environment

• “environmental competence” declines

Environmental Competence

Evolution of the Thinking About

Housing for Seniors

(Filion et al., 1992)

Environmental Competence

Traditional Home/Institution Approach

Time

Home

Institution

(e.g., nursing

home, chronic

care hospital)

Environmental Competence

(Filion et al., 1992)

Environmental Competence

Continuum of Adjustment Perspective

Time

Environmental Competence

(Filion et al., 1992)

Institution

Home

Adapted

Housing

Environmental Competence

Maximization of Choice Perspective

Time(Filion et al., 1992)

1.= Shelter Housing

2.= Granny Flats

3.= Support Services

4.= Design Alterations

Environmental Competence

Institution

Home

2.

3.

1.

4.

Environmental Competence

Aging in Place Perspective

Time

Home

(Filion et al., 1992)

Support

Services &

Design

Alterations

Institution

Environmental Competence

So, what is Aging in Place?

Definitions of Aging in Place

• …not having to move from one’s present residence in order to secure

necessary support services in response to changing needs.(Pastalan, 1990)

• Aging in place refers to living where you have lived for years, typically not

in a health care environment, using products, services, and conveniences

which allow you to remain home as circumstances change.”(aginginplace.com, n.d.)

• Staying in one’s home and community.

• Moving to a new community with the intent of remaining there for as long

as possible.(Wick & Zanni, 2009)

• “…opportunity to remain in one’s community…”(Manitoba Government, n.d.)

What are Housing Options for Aging in

Place?

• single detached house

• apartment

• condominium

• co-op housing

• movable dwelling (mobile home)

• garden suite/granny flat

• dedicated seniors’ housing – apartments, homes

• sheltered housing

• congregate housing

• assisted living facility

• stand alone facilities work best if they provide services at both ends of the

continuum – low levels of need and high levels of need.

• the ideal solution would be to provide assisted living amenities within the

confines of residential living.(Bhushan, 2010)

Interior Design Elements Support Aging

in Place

“Habitability” (Demirbilek & Demirkan, 1998)

• minimum number of levels to decrease need for stairs

• good lighting and contrast of surfaces

• furnishings and flooring to decrease risk of falls

• hand rails for stairs – properly installed

• lever door handles, taps

• illuminated lighting controls

• wall switches and outlets within reach of upper limb

• alarm system – auditory and visual, monitored

• rounded corners – counters, furniture

• furniture at correct height

Universal Design• the design of products and environments to be usable by all people, to the

greatest extent possible, without the need for adaptation or specialized

design.

• accessible, adaptable, aesthetic, affordable(Mace, n.d.)

Examples of Universal Design

http://www.intheworks.biz/graphics/universal_kitchen_movable.jpg

Examples of Universal Design

http://www.nahbmonday.com/capsco/editor_images/Universal_Design_Demonstration_House_in_VA_for_e-issue.jpg

Community Design Elements Support

Aging in Place

“Age-Friendly Community”• transportation - flexible, affordable, available

• parking - handicap

• mobility – sidewalks (in good repair, cleared of ice and snow), access to

public buildings, traffic control

• safety – outdoor lighting, personal safety in all environments

• opportunities to maintain or establish meaningful social relationships

• social activities – affordable, accessible, appropriate

• communication systems – telephone, media, internet, emergency

contact(Menec et al., 2007)

Elements to Consider in Community

Housing Accessibility in both indoor and outdoor environments

• layout and design features of living space

• maintenance of living space

• removal of ice and snow outdoors

• access to local services – transportation, bank, grocery, pharmacy, medical

care, community centre

Safety and security

• design promotes safety, privacy

• help is available when needed – community and formal support services

• provision for dealing with cognitive impairment

Choice - of housing options

Affordability

• equal access to housing options

• affordable

Communication and connection

• ability to maintain family connections, participate in community life

Equality and dignity

• ability to be equal, respected participants in the community, to maintain

self-esteem, self-worth(Gnaedinger & Doyle, 1999; Manitoba Government, n.d., WHO, 2007)

Aging in Smaller Urban Areas• availability of appropriate housing, for all income ranges

• options for and flexibility of transportation – shuttle bus to grocery,

volunteer drivers, Handi-van

(Menec et al., 2007)

“Service-rich”communities:• have an array of formal services (acute care, home care, long-term care)

• have appropriate and affordable housing

• have recreation/volunteer-based activities

• have appropriate, affordable transportation

• provide services available “at the right time, at the right place, for the right

duration” (p. e154)

• provide services that are accessible (no waiting lists), affordable for all, are

coordinated, on a continuum, seamless

• have environments that meet peoples’ economic, health, cultural and

spiritual needs

• support independence

• provide quality of life for seniors(Davenport et al., 2009)

Aging in Rural Areas

Rural SaskatchewanAbility to access services is affected by:

• weather and state of roads

• limited availability of public transportation

• availability of health professionals

• lack of trained service providers(MacKenzie, 2001)

Atlantic Canada• there has been an out-migration of younger families from rural areas in

Atlantic Canada because of loss of jobs. One consequence has been the

seniors in Atlantic Canada are moving from rural to urban areas to be closer

to primary health care and other formal services, amenities and informal

support.

• the value of housing in rural areas is less than that in urban areas. This can

preclude a senior moving from a rural home to an urban centre. (Davenport et al., 2009)

Key Considerations for Aging in Place

Collins (2002), using the Aging in Manitoba database to investigate

the predictors of relocation of seniors, found that the key predictors

were:• older age

• renter status

• increased dependency in instrumental activities of daily living

• decreased participation in socially oriented leisure activities

• concerns about adequacy of income

Implications of these findings for service needs:• meal preparation

• laundry

• shopping

• managing finances

• housekeeping

• yard work

• home maintenance and repairs

• home modifications

• home structural repairs

• transportation

• senior centres

• recreation facilities

• recreation activities

• visitation

• financial assistance

• financial alternatives

• safe, accessible, affordable housing

Canada’s Seniors: Can they Afford to Age in Place?

Canada’s Seniors

2004 – 4.1 million persons age 65 or older

Living Arrangements (2001 Census)

• 93% in private dwellings, 7% in collective dwellings (primarily nursing homes,

hospitals)

• of those who live in private dwellings, 69% are in houses, 29% in apartments,

1% in mobile homes

• housing preferences shift with aging - of private householders aged 85+, 58%

are in houses, 41% are in apartments (rental or condominium)

• 45% live with spouse/partner, 27% live alone, 18% with children/grandchildren,

7% in an institution, 3% with others.

• institutional residency is 2% for those age 65-74, 32% for those age 85 and

over

• rate of institutionalization has declined in last 30 years – home care

programs and community support allows seniors to stay in their homes longer.

• health status and functional abilities are key considerations in choice of living

arrangements(Clark, 2005)

Canada’s Seniors – Income (2003 dollars)

Median After-tax Income of Seniors, 2003

Canada Manitoba

Couples $36,500 $36,700

Unattached Females $18,200 $17,700

Unattached Males $20,200 $19,600

Percentage of Seniors’ Income Allocated to Accommodation, 2003

Age 55-64 Age 65-74 Age 75 +

Couples 22.9% 23.7% 28.1%

Unattached Females 31.4% 28.6% 33.9%

Unattached Males 33.3% 35.4% 32.9%

(Turcotte & Schellenberg, 2007)

Cost of Housing - Affordability• cost of housing includes

• rent/condominium fees, mortgage/loan payments for the dwelling

• electricity

• heating fuel

• water, other municipal services

• property taxes

• repairs, upkeep

• “Housing Affordability Problem” is defined as: 30% or more of before-tax

household income is spent on shelter

• in 2001, housing affordability problems affected:

•18% of Canadian seniors

• seniors with the lowest household income

• seniors who lived alone

• seniors from visible minority groups, recent immigrants living in large

cities

• owners of high-value homes (taxes, utilities, municipal fees)(Clark, 2005)

Cost: A Challenge for Seniors Housing in

Winnipeg

Canadian Elder Standard - “typical” cost of basic needs in 5 Canadian

cities (Halifax, Montreal, Toronto, Calgary, Vancouver) in 2001 (adjusted to 2008

values using city-specific CPI)

Monthly rent for single person, couple:Halifax = $687, $704 Montreal = $569, $588 Toronto = $1020, $1029

Calgary = $886, $878 Vancouver = $855, $857(MacDonald et al., 2010)

Examples of ranges for monthly rent for Winnipeg seniors housing (1 bedroom):

• “rent geared to income”

• “27% of gross income”

• $3450(Age and Opportunity, 2009)

Median annual income in Manitoba, 2006:

55-64 years $28,620 ($2385/month), $644/mo available for rent

65+ years $20,605 ($1717/month), $464/mo available for rent(derived from Ryan & Blandford, 2009)

Do We Have a Problem?

But…There’s No Place like Home

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