Presentation

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ELDERLY LIVING ARRANGEMENTS LIFE SPAN

Do Elderly in Nursing Homes Have Higher Mortality Than Home-Assisted Elders?

Abstract

As the world's population ages, identifying the best living situation for elderly people is essential to enhancing longevity and well-being. This longitudinal observational study compared the mortality of elderly nursing home patients to those receiving home-based assistance. The mediating variables are psychological well-being, social support, and medical care access. The study will follow 50 participants at least 65 years old—25 from nursing homes and 25 from homecare in Florida — over 12 months. Data will be collected at baseline and quarterly intervals using the WHOQOL-OLD, Geriatric Depression Scale (GDS-15), structured demographic surveys, and medical record reviews. The primary outcome is the death rate, evaluated using Kaplan-Meier survival curves. Cox proportional hazards regression will then be used to assess the effect of psychological and medical variables on mortality. This study addresses gaps in geriatric research regarding outcomes with subjective and objective determinants of well-being and survival, which reveal how care environments affect elderly mortality. Such findings may provide information that may help develop healthcare policies and caregiving practices around the living conditions that are conducive to prolonged and meaningful lives among older adults.

Introduction

Globally, the elderly population is rapidly increasing. While growing old, the individual suffers from the deterioration of the time-dependent physiological functions vital to survival and fertility. Such complications raise concerns about the best way to ensure longevity and a good life. Some elderly individuals are looked after within the confines of their homes through "in-home care" facilities that enable them to stay within the confines of their homes, along with the help of family, friends, or professional care providers. However, other individuals requiring greater medical attention are admitted to nursing homes that ensure 24/7 care within a specific center. The option often relies upon the patient's medical condition and the degree of care that the patient requires.

A new crucial question about geriatric care is whether older patients who are living in nursing homes are likely to die quicker than patients who are receiving home care. Physical well-being, social contacts, mental health, and access to medical care are some of the determinants that influence mortality in the elderly. Medical necessity, economic constraint, and family circumstances are the determinants that are typically employed to admit an older patient to a nursing home or to provide home care. There has been limited agreement about whether older patients living in care facilities are likely to live a reduced lifespan than patients receiving home care.

Worldwide, millions of older adults reside in nursing homes, and the percentage is growing along with life expectancy. In the US, the CDC (2020) reports that there are over 15,300 nursing homes, 70.3% of which are for-profit. The nursing homes collectively represent 1.6 million licensed beds and are home to approximately 1.3 million residents. The large percentage of for-profit facilities raises concerns about the standard of care and the priority placed on finances within long-term care. The World Health Organization (WHO) reports that quality of life is multidimensional and founded upon objective and subjective determinants encompassing social support, economic stability, and mental well-being (WHO, 2021).

Research has indicated that older adults who live in nursing homes are less independent and are more likely to develop depression, which causes higher mortality (Šare et al., 2021). Šare et al. (2021) focused on the social and psychological outcomes of institutionalization through cross-sectional designs based on self-reported measures such as the Patient Health Questionnaire and the Generalized Anxiety Disorder Scale. The crucial variables are deinstitutionalization, self-esteem, anxiety, and depression conceptually operationalized as an individual's residence type, how one feels about oneself, constant concern, and constant sadness, respectively. The strengths of the research that has been undertaken are the identification of inequalities in mental health, whereas the limitations are small sample sizes, non-random selection, and the unavailability of longitudinal data.

Similarly, Brent (2021) studied the impact of nursing home (NH) residents on life expectancy through a 13-year parametric survival model. The study showed that the life expectancy of the residents was largely lower—41 months, controlling for conditions such as dementia. The residence location (NH or home care) and life expectancy are the primary variables. The large sample size and longitudinal design are the strengths. The possible unmeasured confounders, such as heterogeneity in the quality of the NH and family support, are the limitations.

Another study done by Zhou et al. (2018) looked at the relationship between the living situation and the psychological well-being (PWB) of older adults in China using a large sample (N=16,020) from the Chinese Longitudinal Healthy Longevity Survey. The researchers found that older adults living in an institution or with family had higher PWB than older adults living alone but that financial dependence was negatively correlated with PWB. The crucial variables are the living situation (institutional, family, or alone) and the PWB (measured using six indicators). The strengths are that the research has a longitudinal design and large sample size that enhances the generalizability. The research does not cover direct mortality analysis and does not account for cultural variations in caregiving.

On the other hand, Brajković et al. (2009) discovered that older adults residing in nursing homes indicated a greater quality of life than older adults residing at home, which indicates that organized care environments enhance well-being. The research employed a small sample (N=60) and self-report measures to decrease the possibility of generalizing the findings. The primary variables are the quality of life (measured in physical, psychological, social, and environmental aspects) and self-reported health. This research did not measure mortality rates. The strengths are the use of standardized measures, but the selection bias and lack of tracking are the weaknesses.

Whereas the current research puts a strong emphasis on the role that care environments play in mental well-being and life quality, some of the gaps remain unaddressed. Most research targets short-term outcomes rather than long-term mortality rates, limiting the knowledge regarding how the care environments influence mortality over time. Unaddressed are also variations in care within family structures and culture, despite the potential that these can influence the life of the elderly within nursing homes versus home care. Unaddressed are also the direct consequences that psychological well-being has upon mortality, where further research regarding both the objective and subjective outcomes is essential. Another crucial gap that has to be filled through extensive longitudinal research is the availability of confounding variables such as underlying medical conditions, family support, and the socioeconomic status that influence both the care environments and mortality. The closing of the mentioned gaps will enable one to gain a clearer understanding of how the care environments influence the lifespan and the well-being of the elderly.

Purpose of the Study and Research Questions

The purpose of this study is to explore the impact of living arrangements on mortality among the elderly. The objective is to determine if the mortality rate of the elderly living in nursing homes is greater than those receiving care at home with assistance.

Research Questions:

1. Do elderly individuals in nursing homes have a shorter life expectancy compared to those receiving home-based care?

2. How do psychological well-being and social support influence mortality rates in different living arrangements?

3. What role does medical care play in prolonging life for elderly individuals in nursing homes versus those at home?

Method

Sample

Fifty participants aged 65 and older will be recruited in both home care and nursing home facilities in Florida, twenty-five from each setting. The inclusion criteria require participants to be cognitively capable of providing consent and living in a nursing home or receiving care at home. Recruitment will be carried out in collaboration with nursing home managers and home care agencies and through outreach at hospitals, churches, and senior centers. Healthcare professionals will inform family members or legal representatives. Interested participants will be invited to attend an information session outlining the study's purpose, procedures, confidentiality measures, and voluntary participation procedures. Participants will be free to withdraw at any time without penalty.

Instruments

Psychological well-being and quality of life will be assessed with the World Health Organization Quality of Life Instrument-Older Adults Module (WHOQOL-OLD) that assesses sensory abilities, autonomy, activities, social participation, death and dying, and intimacy on a 5-point Likert (Díaz et al., 2024). The Geriatric Depression Scale (GDS-15), a 15-item validated yes/no instrument, will be used to screen for depression. With the permission of the participant and facility managers, medical records will be abstracted to record health conditions, medications, and hospitalization (Henriques et al., 2023). Demographic data, including age, gender, socioeconomic status, and living situation, will be determined with a structured survey. Trained research assistants will read questions to individuals with visual or cognitive impairment and mark responses.

Design

The research employs a longitudinal observational design, where participants are followed up over 12 months with data collection at baseline and every three months. The Independent variable is the living environment (nursing home vs. home care), and the dependent variable is the death rate within the study period. Additional variables, psychological well-being, social support, and availability of medical care will be explored to evaluate the effect on death outcomes. Data will be collected through in-person and phone interviews on psychological measures and medical record review. Informed consent will be given before participation, with consideration of rights and voluntary participation.

Procedure

The study will begin with an orientation session in which the participants will be briefed on the study's purpose, procedures, and confidentiality measures. They will then be asked to sign an informed consent and undergo a baseline assessment. Follow-up assessment will be taken every three months through in-person or telephone interviews by trained research assistants. A periodic review of medical records will be carried out for any significant change in health, hospitalization, or death. If death occurs, family or caregivers will report contextual information on the cause and context of death.

Survival analysis (Kaplan-Meier estimator) will be applied at the end of the study to examine data and contrast the mortality rates across groups. The impact of psychological well-being, social support, and medical care on survival will be assessed using a Cox proportional hazards regression model (Smith et al., 2021). Results will be interpreted within the overall context of care in elderly patients, and recommendations will be provided on improving elderly care practices. Participants will be invited to a debriefing session where preliminary results will be presented, as well as mental health and elderly care information. Participants requesting personal assessment results will be provided with a summary and recommendations on further medical or psychological follow-ups.

References

Brajković, L., Godan, A., & Godan, L. (2009). Quality of life after stroke in old age: Comparison of persons living in nursing home and those living in their own home.  Croatian Medical Journal, 50 (2) 182-8.  https://doi.org/10.3325/CMJ.2009.50.182

Brent, R. (2021). Life expectancy in nursing homes.  Applied Economics, 54, 1877 - 1888.  https://doi.org/10.1080/00036846.2021.1983138

Centers for Disease Control and Prevention. (2020). FastStats - Nursing Home Care. National Center for Health Statistics. https://www.cdc.gov/nchs/fastats/nursing-home-care.htm

Díaz, C., Anguiano-Morán, A. C., Valtierra-Oba, E. R., Lemus-Loeza, B. M., Galván-Villalobos, G., & Alaín Raimundo Rodríguez-Orozco. (2024). Psychometric Properties of the World Health Organization Quality of Life Scale for Older Adults (WHO-QoL-Old) in a Mexican Population. Geriatrics, 9(5), 134–134. https://doi.org/10.3390/geriatrics9050134

Henriques, S., Pérez‐Sáez, E., Carvalho, J. O., Bobrowicz-Campos, E., Apóstolo, J., Otero, P., & Vázquez, F. (2023). Reliability and validity of the geriatric depression scale in a sample of portuguese older adults with mild-to-moderate cognitive impairment. Brain Sciences, 13(8), 1160–1160. https://doi.org/10.3390/brainsci13081160

Šare, S., Ljubičić, M., Gusar, I., Čanović, S., & Konjevoda, S. (2021). Self-esteem, anxiety, and depression in older people in nursing homes. Healthcare, 9(8), 1035. https://doi.org/10.3390/healthcare9081035

Smith, T. B., Workman, C., Andrews, C., Barton, B., Cook, M., Layton, R., Morrey, A., Petersen, D., & Holt-Lunstad, J. (2021). Effects of psychosocial support interventions on survival in inpatient and outpatient healthcare settings: A meta-analysis of 106 randomized controlled trials. PLOS Medicine, 18(5), e1003595. https://doi.org/10.1371/journal.pmed.1003595

World Health Organization. (2021). WHOQOL - Measuring Quality of Life. World Health Organization. https://www.who.int/tools/whoqol

Zhou, Z., Mao, F., J., Hao, S., Qian, Z., Elder, K., Turner, J., & Fang, Y. (2018). A longitudinal analysis of the association between living arrangements and health among older adults in China.  Research on Aging, 40, 72 - 97.  https://doi.org/10.1177/0164027516680854