Well-being among elderly community dwellers and assisted living residents: A comparative analysis Sara Carmel, Hava Tovel, Zinovi Shraga The Center for Multidisciplinary Research in Aging Faculty of Health Sciences Ben-Gurion University of the Negev Supported by: The Israel Ministry for Senior Citizens The Abraham and Sonia Rochlin Foundation

Quality of life and subjective well-being – societal needs and challenges  Decreased quality of life is one of the phenomena accompanying prolonged life, with significant implications for the elderly, their families, and society as a whole.  Finding the best social solutions for this relatively vulnerable population group has become a challenge to all nations.

Purpose of the study   The leading worldwide approach for maintaining successful aging is to enable older people to "age in place" – in their homes and communities.   The purpose of this study was to question this dominant approach by comparing subjective well-being (SWB) of assisted-living residents (ALR) to that of community dwellers (CD).

Assisted living (AL) in Israel In Israel, AL sites (also called “sheltered housing”) are run by for-profit and non-profit organizations. Both provide high quality services. (165 sites/21,000 units) Services provided: - Personal safety arrangements - 24-hour availability of medical services - Immediate assistance for any need - Restaurant services - Home cleaning and repairs - A variety of social, cultural and physical activities The degree of use of each service depends on the resident.

Method Structured home interviews were conducted with two groups of people aged 75+, living in 3 major Israeli cities - Tel-Aviv, Beer-Sheva, Haifa. 1. An ALR group, based on agreement to participate in the study from 8 large facilities (n=215) 2. A CD group - of elderly matched for age, gender, family status, economic status, ADL, and IADL (n=215)

Comparison between CD and ALR on health, function, and socio-demographic characteristics t  2 df p ALRCD  2 =.30, df=1, p=.58 FemaleMaleFemaleMale Gender 161(75%)54 (35%)156 (73%)59 (27%)  2 =1.66, df=1, p=.198 noyesnoyes Spouse 147 (69%)67 (31%)135 (63%)80 (37%) t=-.100, df=428, p= (5.38)83.9 (4.19) Age (M/SD) t=.515, df=428, p= (.84)3.13 (.94) Health (M/SD ) t=1.25, df=426, p= (.55)1.39 (.55) IADL (M/SD ) HighlowHighlow Education 114 (53%) 78 (37%) 21 (10%) 101 (47%) 98 (46%) 15 (7%)  2 =4.85, df=2, p=.089 Very good goodbadVery good goodBad Economic status 45 (21%) 154 (72%) 16 (7%) 28 (13%) 171 (80%) 16 (7%)

Comparison between CD and ALR on indicators of SWB t ALR M (SD) CD M (SD) Well-being -3.24, p= (.61)3.45 (.68)Life satisfaction (Neugarten) -3.57, p< (.55)3.96 (.66)Life satisfaction (Carmel) -2.65, p= (1.62)7.58 (1.83)Successful aging (subjective) -2.72, p= (1.12)4.71 (1.25)Loneliness (high score = low loneliness ) -1.85, p= (1.03)5.29 (1.26)Happiness -2.21, p= (.52)2.85 (.64)Morale (Lawton et al.).105, p= (.72)3.43 (.88)Will to live -2.53, p= (2.99)11.18 (3.42)GDS (high score = low depression) -2.86, p= (1.12)3.72 (1.19)Fear of dying 2.37, p= (.63)1.55 (.81)Fear of death

Antecedents of different aspects of well-being (  ) Fear of death Fear of dying GDSWill to live Morale Happin- ness Loneli- ness Success- ful aging LS-CLS-N * *.108*.119**.099*Gender * ** *-.167**Spouse *.139**Econo. status **-.247**-.291**-.398**-.266**-.125*-.358**-.313**-.331**Health status *-.246** * **-.146**-.134**IADL -.100*.143**.104* **.109**.150**.138**Resid- ence.02*.08**.22**.10**.26**.11**.24**.25**.26** R2R2 LS-N – Life satisfaction (Neugarten et al., 1961), LS-C – Life Satisfaction Carmel, 1997 Morale – Philadelphia Geriatric Center Moral Scale (Lawton, 1975), Loneliness – Hughes et al., 2004, Happiness – Lyubomirsky et al., 1999, GDS – Geriatric Depression Scale (Zalsman et al., 1998).

Addressed needs and satisfaction in AL Degree of addressed needs in AL (on a scale of 0-5): A high degree of response to needs with average scores from 4.84 (SD=.44) to 4.34 (SD=1.38). Exception – reference to meals (3.00, SD=2.2) due to great variability in use. A high degree of response to needs with average scores from 4.84 (SD=.44) to 4.34 (SD=1.38). Exception – reference to meals (3.00, SD=2.2) due to great variability in use. The highest scores were given for: ability to manage an independent life, to continue life as usual, feeling comfortable in the apartment, physical security, accessibility of medical services, and privacy. The highest scores were given for: ability to manage an independent life, to continue life as usual, feeling comfortable in the apartment, physical security, accessibility of medical services, and privacy. Satisfaction with relocation to AL was high – 87% responded as very satisfied. 87% responded as very satisfied.

Experienced changes in AL What are the 3 most important changes for you with relocation? (% out of all responses in each category) Positive (202 out of 215 responded – 365 responses): - Social life - 29% - Release from household - Personal security - 22% duties - 7% - Leisure activities- 13%- Easier life- 7% - Personal tranquility - 9%- Medical security - 5% - Housing conditions - 5% Negative (83 out of 215-responded, 23 responded - no negative change, altogether only 49 responses): - Condition of neighbors 22% - - Adjustment difficulties - 10% - Housing conditions - 22% - Loss of neighborhood - 10% - Loss of privacy - 8%- Faraway from town - 6% - Lacking pets - 4% - Other issues - 16%

Summary of results   The two groups were similar in socio-demographic characteristics, self-rated health, ADL, and IADL.   ALR ranked themselves significantly and systematically higher than CD on indicators of well-being including: Satisfaction with life (two measures) Self-perceived successful aging Happiness Morale Fear of death (inverse direction) Depression (inverse direction) Loneliness (inverse direction) (8 out of 10) ALR ranked themselves worse regarding fear of dying. In

Summary of results (cont.)   The best predictors of SWB across 10 different measures, in order of importance, were: - self-evaluated health status - type of residence - IADL - gender - having a spouse - self-evaluated economic status. Most of the responses to needs addressed in AL and changes with relocation indicated a high level of satisfaction with relocation

Conclusions   Type of residence plays an important role in influencing older adults' SWB, assisted living being preferable.   The residence effect is stronger than age, gender, economic status, having a spouse, and IADL.   These findings and their practical implications shatter the currently dominant beliefs and practices regarding best residence solutions for elderly people.   Replications of this study in Israel and other countries are needed in order to ascertain these findings and the derived implications.   We must continuously promote evidence-based best responses to the needs of older adults and society.

Life is beautiful

Comparison between CD and ALR on indicators of SWB Men only (n=113) t ALR M/SD CD M/SD Well-being -2.32, p= (.59)3.41 (.71)Life satisfaction (Neugarten) -2.06, p< (.55)3.93(.73)Life satisfaction (Carmel) -1.69, p= (1.72)7.43 (1.83)Successful Aging (subjective) -2.59, p= (1.11)4.50 (1.35)Loneliness (high score = low loneliness ) -1.64, p= (1.16)5.21 (1.32)Happiness -1.00, p= (.50)2.89 (.70)Morale (Lawton et al.) -.650, p= (.54)3.56 (.82)Will to live -1.75, p= (2.75)11.17 (3.84)GDS (high score = low depression) -2.16, p= (1.12)3.72 (1.19)Fear of dying.380, p= (.74)1.51 (.70)Fear of death

Comparison between CD and AR on indicators of SWB Women only, n=317 t ALR M/SD CD M/SD Well-being -2.37, p= (.61)3.46 (.67)Life satisfaction (Neugarten) -2.89, p< (.56)3.97 (.63)Life satisfaction (Carmel) -2.04, p= (1.60)7.64 (1.74)Successful Aging (subjective) -1.56, p= (1.13)4.80 (1.21)Loneliness (high score = low loneliness ) -1.13, p= (1.00)5.32 (1.25)Happiness -1.93, p= (.53)2.84 (.61)Morale (Lawton et al.).366, p= (.77)3.39 (.89)Will to live -1.91, p= (3.01)11.18 (3.26)GDS (high score = low depression) -1.94, p= (1.11)3.85(1.16)Fear of dying 2.49, p= (.59)1.56 (.86)Fear of death