Functional status, assistance, and the risk of a community-based move

Do Health and Housing Attributes Motivate Residential Moves Among Older Chinese Adults? Evidence From an 8‑Year Follow‑up Study

Background and Objectives

Despite the widespread belief in aging-in-place as the preferred housing arrangement for older adults, they are increasingly embracing moving. The person-environment fit theory explains that environmental changes due to residential moves can pose health risks, discouraging older people from moving. However, it also suggests that moves may be suitable when living conditions no longer meet their physical needs. The correlation between older people's health, housing, and their subsequent moving or staying actions in China remains underexplored.

Research Design and Methods

Using alternative operating variables of key concepts and the China Family Panel Studies 2012-2018 data sets, this study examines the effects of health and housing status on older people's residential moves in China. The study outlines changes in health indicators and housing characteristics during multiple moves, as well as examines the relationship between the health and housing status of older adults and moving over a relatively long period of time using both regression models with lagged explanatory variables and fixed effects binary choice models.

Results

The results reveal that: (1) higher rates of subsequent moves were observed among older adults with better self-rated health, positive self-rated health changes, and no ADL impairment, but no significant associations were found between most health variables and moving; and (2) the correlation between older persons' house ownership/type and their residential moves was significant and consistent over time, steady and lasting.

Discussion and Implications

Potential mechanisms explaining the association between specific housing types and ownership statuses on moving are discussed. The findings encourage a focus on the positive benefits of moving in later life and how to provide additional housing options for older individuals.

[Influencing factors for nursing home admission in case of pre-existing need of care - a systematic review]

INTRODUCTION

Knowledge about predictors of nursing home placement is highly relevant. If they are known, targeted interventions such as counselling can help prevent or delay relocation to a nursing home. Above all, preventive and structural measures can target influenceable predictors. The aim of the review was to map predictors of nursing home admission and thus the permanent stay in inpatient long-term care for the target group of people with a pre-existing need for care.

METHODS

A systematic literature search in the databases The Cochrane Library, PubMed, CINAHL, GeroLit and CareLit® was conducted in September 2017. Longitudinal studies with quantitative analyses were included. The methodological quality was assessed using the Newcastle-Ottawa Scale.

RESULTS

45 cohort studies were included. 21 studies examined study populations with need for care, in 24 studies the care status was unclear. A variety of predictors of nursing home admission with at least one-and-a-half times higher risk for both study populations could be identified, including higher age, dementia, underweight, higher age of caregiver, psychiatric symptoms, smoking status, ethnicity, challenging behaviour in people with dementia, higher number of hospitalizations and lower level of life satisfaction.

DISCUSSION

All the predictors identified are relevant to people in need of care. No predictors for the study population with need of care could be identified that are particularly important in contrast to persons with an unclear care status. However, the quality of studies among people with care and support needs is limited compared to studies targeting people with unclear care status.

CONCLUSIONS

Many factors seem to predict the admission to a nursing facility. For the first time, these factors are listed in this systematic review for the target group of people in need of care. Interventions or preventive measures based on known influenceable predictors can help prevent or delay nursing home admission.

When Frail Older People Relocate in Very Old Age, Who Makes the Decision?

Background and Objectives

Older people are likely to transition to a new home closer to family who can provide assistance or to long-term residential care as their health declines and their care needs increase. A minority choose to move to "age-friendly" housing before the onset of disability, but the majority prefer to "age in place" and defer moving until health crises compel a transition. Older people living with dementia are likely to move into residential care, but not much is known about the role they play in decision making around these moves. This qualitative study addresses this gap in knowledge by examining how a rare cohort of "older old" people, most with some level of cognitive impairment, were involved in decisions surrounding assistance seeking and moving to a care home.

Research Design and Methods

Thematic analysis of qualitative interview data from Cambridge City over-75s Cohort (CC75C) study participants aged 95 years and older, who had moved in later life, and their proxy informants (n = 26).

Results

Moves at such an old age were made due to a complexity of push and pull factors which had layered dynamics of decision making. In most cases (n = 22), decision making involved other people with varying degrees of decision ownership. Only four older people, who moved voluntarily, had full ownership of the decision to move. Many relatives reported being traumatized by events leading up to the move.

Discussion and Implications

"Older old" people are sometimes unable to make their own decisions about moving due to the urgency of health crisis and cognitive decline. There is a need to support relatives to discuss moving and housing options at timely junctures before health crises intervene in an effort to optimize older people's participation in decision making.

Short- and Long-Term Impacts of Neighborhood Built Environment on Self-Rated Health of Older Adults

Background and Objectives

Proximity to health care, healthy foods, and recreation is linked to improved health in older adults while deterioration of the built environment is a risk factor for poor health. Yet, it remains unclear whether individuals prone to good health self-select into favorable built environments and how long-term exposure to deteriorated environments impacts health. This study uses a longitudinal framework to address these questions.

Research Design and Methods

The study analyzes 3,240 Americans aged 45 or older from the Panel Study of Income Dynamics with good self-reported health at baseline, and follows them from 1999 to 2013. At each biennial survey wave, individual data are combined with data on services in the neighborhood of residence (defined as the zip code) from the Economic Census. The analysis overcomes the problem of residential self-selection by employing marginal structural models and inverse probability of treatment weights.

Results

Logistic regression estimates indicate that long-term exposure to neighborhood built environments that lack health-supportive services (e.g., physicians, pharmacies, grocery stores, senior centers, and recreational facilities) and are commercially declined (i.e., have a high density of liquor stores, pawn shops, and fast food outlets) increases the risk of fair/poor self-rated health compared to more average neighborhoods. Short-term exposure to the same environments as compared to average neighborhoods has no bearing on self-rated health after adjusting for self-selection.

Discussion and Implications

Results highlight the importance of expanding individuals' access to health-supportive services prior to their reaching old age, and expanding access for people unlikely to attain residence in service-dense neighborhoods.

Health and Its Relationship with Residential Relocations of Older People to Institutions versus to Independent Dwellings

Research into older people’s relocations to independent dwellings has largely remained separate from research into moves to institutions. Yet, both types of moves could be a response to health problems and to a certain extent they could be substitutes for each other. Using Litwak and Longino’s model of moves of older people, this study assesses the extent to which three commonly used health measures (limitations in activities of daily living [ADL], self-rated health, and the prevalence of [limiting] chronic conditions) predict older people’s moves to subsidized care institutions and elsewhere, in one multinomial logistic regression model. The data were derived from the POLS survey for the Netherlands (N = 8306) enriched with administrative data on subsequent moves. In line with Litwak and Longino’s model, the findings indicate that older people’s moves to institutions were more likely among those with more severe health problems, whereas moves elsewhere were more likely among those with moderate health problems. Among the three investigated health measures, limitations in ADL had the strongest predictive value, and was the only one for which the difference in effect between relocations to care institutions and relocations elsewhere was statistically significant.

Functioning, Forgetting, or Failing Health: Which Factors Are Associated With a Community-Based Move Among Older Adults?

OBJECTIVE

To examine whether the health and functioning of middle-aged and older adults are associated with an increased likelihood of community-based moves.

METHOD

Biennial data from adults aged 51 and older in the Health and Retirement Study (HRS) and discrete-time survival models were used to assess the likelihood of community-based moves from 2000 to 2010 as a function of 11 measures of health and functioning.

RESULTS

Respondents diagnosed with heart disease, stroke, hypertension, lung disease, and psychiatric problems were more likely to move during the study period than those with no such diagnosis. Changes in activities of daily living and instrumental activities of daily living functioning, cognitive impairment, and falls were also related to a greater likelihood of moving during the study period. Cancer and diabetes were not related to overall moves, although diabetes was associated with an increased likelihood of local moves. For the most part, it was longstanding not recent diagnoses that were significantly related to the likelihood of moving.

DISCUSSION

Although some health conditions precipitate moves among middle-aged and older adults, others do not. This work has important implications for understanding the role of different aspects of health and functioning in the likelihood of migration among older adults.

Older Adults' Residential Proximity to Their Children: Changes After Cardiovascular Events

OBJECTIVES

To assess changes in family residential proximity after a first cardiovascular (CV) event among older adults and to identify families most likely to experience such moves.

METHOD

Using a nationally representative longitudinal study of older adults in the United States, we identified respondents with no prior diagnosis of CV disease (CVD). We examined subsequent development of stroke, heart attack, and/or heart failure among these older adults and examined changes in their residential proximity to their closest child before and after the CV event. We then compared the likelihood of changes in proximity between families with and without CV events. Finally, we determined which types of families are most likely to relocate following a CV event.

RESULTS

Having a first CV event increases the 2-year predicted probability of children and adult parents moving in with and closer to each other (relative risk ratio = 1.61 and 1.55, respectively). Families are especially likely to move after a first CV event if the older person experiencing the event is spouseless or has a daughter.

DISCUSSION

CVD is a leading cause of disability, which in turn creates a significant need for personal care among older adults. Assessment of changes in family residential proximity responding to CV events is important to fully understand the consequences of older adults' CV events including the cost of caregiving.

Does fall history influence residential adjustments?

PURPOSE OF THE STUDY

To determine whether reported falls at baseline are associated with an older adult's decision to make a residential adjustment (RA) and the type of adjustment made in the subsequent 2 years.

DESIGN AND METHODS

Observations (n = 25,036) were from the Health and Retirement Study, a nationally representative sample of community-living older adults, 65 years of age and older. At baseline, fall history (no fall, 1 fall no injury, 2 or more falls no injury, or 1 or more falls with an injury) and factors potentially associated with RA were used to predict the initiation of an RA (i.e., moving, home modifications, increased use of adaptive equipment, family support, or personal care assistance) during the subsequent 2 years.

RESULTS

Compared with those with no history of falls, individuals with a history of falls had higher odds of making any RA. Among those making an RA, individuals with an injurious fall were more likely than those with no history of a fall to start using adaptive equipment or increase their use of personal care assistance.

IMPLICATIONS

The higher initiation of RAs among fallers may indicate proactive steps to prevent future falls and may be influenced by interactions with the health care system. To optimize fall prevention efforts, older adults would benefit from education and interventions addressing optimal use of RAs before falls occur.

Health Trajectories Among Older Movers

Objective: To examine health trajectories among older migrants by reason for move. Method: Data from the 1992 to 2006 Health and Retirement Study (HRS) are used to model trajectories of self-rated health and activity of daily living (ADL) limitations that occurred prior seven types of moves. Results: There are substantial differences across the reason-for-move groups in initial levels of self-rated health. Declines in self-rated health among nursing home movers are more than two times steeper than the other reason-for-move groups. Employment, comfort, economic security, life crisis, and affiliation movers have low initial levels of ADL limitations and slow increases in ADL limitations. Health and nursing home movers have higher initial ADL limitations and increases in ADL limitations that are three and seven times higher respectively than the other groups. Discussion: The results are consistent with the predictions of Litwak and Longino’s (1987) typology of later-life migration and the extant literature on later-life migration. Implications for communities are considered.

Migration and psychological well-being among older adults: a growth curve analysis based on panel data from the Health and Retirement Study, 1996-2006

PURPOSE

A vibrant body of research examines migration among older adults. Existing research, however, grants scarce attention to the implications of later-life migration for the migrants themselves. Our research focuses on the impacts of migration on depressive symptomatology among older U.S. adults.

METHODS

Our analysis employs six waves of panel data from the Health and Retirement Study, 1996-2006. Growth curve modeling techniques are employed.

RESULTS

Net of other stressful life events, migration effects appear to vary significantly across persons. Findings highlight the particularly depressive impact of moves motivated by negative life events or circumstances. Results further suggest that later life moves may be especially stressful for women and as individuals age.

DISCUSSION

The stress of moving late in life may depend on social integration at destination. Further research should pursue this issue. Study limitations and additional directions for further research are delineated.

Contribution of residential relocation and lifestyle to the structure of health trajectories

OBJECTIVE

Underlining ecological theories of aging, we assessed the impact of relocation, residential type, and individual lifestyle factors on the structure of health status overtime.

METHODS

From the data of Longitudinal Study on Aging II, we included older adults aged 70 and older (N = 5,294). To analyze individual longitudinal trajectories of health outcomes, Latent Growth Curve Modeling (LGCM) was employed.

RESULTS

LGCMs supported that older adults' residential relocation and health-related lifestyles were important in preserving better health outcomes. Multiple structural equations corroborated the causal chains in the multidimensionality of health structure.

DISCUSSION

These findings suggest a necessity to design policies for older adults to create a synergy between housing and health care and to translate meaningful health-related lifestyles into diverse long-term care settings.

Predictors of non-local moves among older adults: a prospective study

OBJECTIVES

The goal of this article was to test a series of established predictors of the hazard of moving for persons primarily in their 50s and 60s. We tested demographic covariates, resources, travel experience, and community and person ties using a prospective design.

METHODS

We employed data from the Health and Retirement Study, 1994 to 2002, based on a representative sample of households containing at least one member aged 51 to 61 in 1992. We employed measures available in the Health and Retirement Study to construct a series of Cox proportional hazards models that examined the causes of non-local moves.

RESULTS

Community and person ties emerged as important predictors of non-local moves.

DISCUSSION

Travel experience, when measured by regular vacationing and second homes, may increase community ties to a destination. The life-course model must be modified in its explanation of the importance of community and person ties, and of life transitions, as motivators of migration.

Early identification of relocation risk in older adults with critical illness

One aspect of an evidence-based practice (EBP) guideline on managing relocation in cognitively intact older adults is elaborated upon in this article. The older population is at particular risk for needing to relocate to a new permanent home following hospitalization for a critical illness, but planning for these moves is often done in crisis mode. The purpose of this article is to sensitize nurses to risks for relocation in critically ill older persons and to encourage application of the EBP guideline in practice. Recommendations for risk assessment are made including using existing and supplementary assessment methods and data. Implementing EBP guidelines such as this is one key element in providing quality care to critically ill older adults.

Health and motivation of elderly relocating to a suburban area in Japan

In Japan, few studies have investigated the effects of moving residence among the elderly, despite the fact that Japanese elderly will be increasingly required to switch residence in the future. Here, we used representative sampling to examine the characteristics of elderly persons who had moved residence to a Tokyo suburb and compared results with those of non-moving residents of the suburb. Movers aged 65 years old or older who had relocated within the previous 2 years (movers) and residents aged 65 years old or older and had lived in the area longer than 5 years (non-movers) were surveyed by mail in 2004, with a focus on health and psychosocial measures. Compared with non-movers (N=117), movers (N=97) were more depressed, socially isolated, and fulfilled less active social roles among family members. The majority of movers had moved to find affordable housing or to live with or near family. Two factors preceded co-residence with family, namely retirement and imminent loss of functional independence. Our findings suggest that movers require community support to prevent social isolation, dependency and health declines.

The effect of frailty on residential/nursing home admission in the Netherlands independent of chronic diseases and functional limitations

The aim of this study was to determine the effect of frailty on the risk of residential/nursing home admission independently of chronic diseases and functional limitations. Frailty consists of multisystem decline and is considered to be a consequence of changes in neuromuscular, endocrine and immune system functioning that occur as people age. Frailty is a combination of multiple impairments in functioning that might lead to functional limitations and disability but it is not clear whether frailty has an independent effect on residential/nursing home admission. Data were used from the Longitudinal Aging Study Amsterdam. The respondents participated at both T₁ (1992/1993) and T₂ (1995/1996), lived independently at T₂, and were aged 65 and over (n=1,503). Nine frailty markers were assessed at two cycles (T₁ and T₂). The frailty markers were defined in two ways: low functioning at T₂ (static frailty); and change in functioning between T₁ and T₂ (dynamic frailty). The outcome variable was residential/nursing home admission between T₂ and T₄ (2001/2002). Cox proportional hazard analyses were used adjusting for chronic diseases, functional limitations, care received, partner status, income, age and sex. Static (RR 1.93, 95%CI 1.36-2.74) and dynamic frailty (RR 1.69, 95%CI 1.19-2.39) were associated with institutionalization in both men and women independently of the effect of chronic diseases and functional limitations. Additional analyses of the total number of both sets of frailty markers present revealed an increased risk of institutionalization when the number increased. In conclusion, frailty is associated with institutionalization, independently of the effect of chronic diseases and functional limitations.

The Effects of Residential Mobility on ADL and IADL Limitations Among the Very Old Living in the Community

OBJECTIVES

We attempt to understand the influence of residential mobility on changes in objective activity of daily living (ADL) and instrumental ADL (IADL) limitations, while taking into account the subjective reason for the move.

METHODS

We examine noninstitutionalized adults aged 70 and older who are in the Longitudinal Study of Aging. We use bivariate regression to identify differences between nonmovers and various types of movers in 1988 and 1990 ADL and IADL limitations. Multivariate residualized regression models estimate the effect of residential mobility on the changes in limitations between 1984-1988 and 1988-1990. We give particular attention to the timing and reason for the move.

RESULTS

Controlling for demographic, social support, health status, and social integration characteristics, we find that residential mobility is associated with a short-term increase in ADL and IADL limitations. However, an additional analysis reveals that this short-term increase in limitations is only experienced by older adults who move for subjective health reasons. Compared with nonmovers, movers do not have significantly different changes in limitations over the long term.

DISCUSSION

Older adults and service providers need to be concerned with short-term increases in objective ADL and IADL limitations that accompany residential relocations, especially for those who move for subjective health reasons. However, from a long-term perspective, residential relocation may serve as a mechanism for accommodating age-related changes that threaten effective functioning.

Estimating hip fracture morbidity, mortality and costs

OBJECTIVES

To estimate lifetime morbidity, mortality, and costs from hip fracture incorporating the effect of deficits in activities of daily living.

DESIGN

Markov computer cohort simulation considering short- and long-term outcomes attributable to hip fractures. Data estimates were based on published literature, and costs were based primarily on Medicare reimbursement rates.

SETTING

Postacute hospital facility.

PARTICIPANTS

Eighty-year-old community dwellers with hip fractures.

MEASUREMENTS

Life expectancy, nursing facility days, and costs.

RESULTS

Hip fracture reduced life expectancy by 1.8 years or 25% compared with an age- and sex-matched general population. About 17% of remaining life was spent in a nursing facility. The lifetime attributable cost of hip fracture was $81,300, of which nearly half (44%) related to nursing facility expenses. The development of deficits in ADLs after hip fracture resulted in substantial morbidity, mortality, and costs.

CONCLUSION

Hip fractures result in significant mortality, morbidity, and costs. The estimated lifetime cost for all hip fractures in the United States in 1997 likely exceeded $20 billion. These results emphasize the importance of current and future interventions to decrease the incidence of hip fracture.

Competing risk of household expansion or institutionalization in late life

OBJECTIVES

The purpose of this study was to evaluate predictors of change in household size and institutionalization in late life.

METHODS

The Duke Established Populations for Epidemiologic Studies of the Elderly cohort (n = 3730) was assessed annually (1986-1996). Independent variables included home ownership, income, cognitive and functional ability, chronic illness, mood, household size, social support, and stressful life events. Competing risk of household expansion or institutionalization was modeled using (a) hazard of either event and (b) odds of household expansion or institutionalization among elders who experienced an event.

RESULTS

Hazard of either event was associated with younger age, Black race, lower income, cognitive problems and stability, functional abilities and deterioration, low chronic illness burden, being unmarried, having more living children, and recent life events. Among those who reported either event, odds of institutionalization (vs. household expansion) were associated with older age, White race, cognitive and functional problems, high chronic illness burden, being married, having fewer living children, smaller household size, social isolation, and exits of nonspouse coresidents.

DISCUSSION

Modeling separate effects of whether there was a household expansion or institutionalization, and if so, which type of event occurred, and taking into account acute and evolving states, enabled more precise understanding of the complex mechanisms involved in determining continued community residence or institutionalization.

What impact do setting and transitions have on the quality of life at the end of life and the quality of the dying process?

PURPOSE

The aim of this article was to identify major research needs related to quality of life at the end of life and quality of the dying process for vulnerable older people at home, in assisted living facilities, in skilled nursing facilities, and in prisons.

DESIGN AND METHODS

Review and analysis of the literature was used.

RESULTS

The science is generally weak in relationship to what is known about quality of life at the end of life and quality of dying for vulnerable older adults in different settings. Few studies address actively dying patients and the reasons for transfers between home and other settings. Existing studies are primarily anecdotal, descriptive, have small samples, and involve a single setting. Participant decisional capacity is a barrier to conducting research in these settings.

IMPLICATIONS

Research recommendations for each setting and across settings are provided. The National Institutes of Health should clarify criteria for enrollment of persons with diminished, fluctuating, and absent decisional capacity in research.

Old age mortality in Japan: does the socioeconomic gradient interact with gender and age?

OBJECTIVES

There is limited knowledge concerning how the effects of socioeconomic status (SES) on mortality interact with gender and age. In addition, current studies are largely based on data from the Western nations. The validity of prior observations needs to be further evaluated. This research examines socioeconomic inequalities in old age mortality in Japan, with a special emphasis on how inequalities interact with gender and age.

METHODS

Data came from a 5-wave panel study of a national probability sample of 2,200 elderly Japanese conducted between 1987 and 1999. Hazard rate models involving time-varying covariates were used to ascertain the direct and indirect effects of SES. In addition, interaction effects involving SES variables with age and gender were evaluated.

RESULTS

In contrast to prior findings from the Western developed nations, there is an educational crossover effect on mortality among older men, in that, at advanced age, those with less education live longer than those with higher education. On the other hand, there is some evidence that educational differences in the risk of dying tend to converge in the 70-79 age group. More interestingly, there is a crossover in the effect of education among the 80 and older age group.

DISCUSSION

The observation that educational crossover exists only among elderly men may be because of gender and SES differences in causes of death, morbidity, and health behavior. On the other hand, possible explanations for age differences in the educational crossover include selective survival and cohort effects.

Living arrangements and health status in later life: a review of recent literature

The living arrangements of older persons play a key role in their use of formal and informal care, as well as in their health and well-being. Nurses engaged in primary care, discharge planning, and home care are strategically positioned to contribute to an optimal fit between older persons and their home environment. This article describes the demographic significance of late-life living arrangements and proposes a model for organizing the complex web of factors associated with household composition and late-life migration. The article then summarizes qualitative and quantitative evidence in support of the proposed model. Key areas for nursing research and strategies for applying available research are identified.

Disability outcomes of older Medicare HMO enrollees and fee-for-service Medicare beneficiaries

OBJECTIVES

To investigate whether older Medicare beneficiaries enrolled in Medicare risk health maintenance organizations (HMOs) have different rates of disablement than fee-for-service (FFS) beneficiaries.

DESIGN

Secondary analysis of annual functional status transitions using the Medicare Current Beneficiary Survey, 1991 to 1996.

SETTING

Telephone interviews.

PARTICIPANTS

Forty-four thousand seven hundred and sixty-five person-years of annual functional status transitions for noninstitutionalized older Medicare beneficiaries who were either risk HMO enrollees or FFS beneficiaries with or without private supplementary insurance.

MEASUREMENTS

Five multinomial logit models were estimated as single-state transition models, with five functional states, death, and censored as outcomes. The probability of being in a certain functional state the following year was specified as a function of individual risk factors and HMO versus FFS supplementary insurance status.

RESULTS

Among functionally independent beneficiaries, the odds of becoming disabled in activities of daily living (ADLs) within a year were lower among FFS individuals with supplementary insurance (odds ratios (OR) = 0.67, P <.01) and HMO enrollees (OR = 0.58, P <.01). Among older people who were functionally impaired, neither HMO enrollment nor private supplementary insurance affected the risk of further functional decline or functional improvement. Supplementary insurance, but not HMO enrollment, was associated with lower mortality risk among beneficiaries with functional limitations (OR = 0.65, P <.05) or moderate ADL disability (OR = 0.72, P <.05).

CONCLUSION

Medicare risk HMO enrollment and FFS private supplementary insurance convey similar benefits of slowing functional decline and extending life span for nonseverely disabled older people. That no association was found between adverse functional status outcomes and risk HMO enrollment has favorable implications regarding the quality of care of managed care plans.

Environmental press and adaptation to disability in hospitalized live-alone older adults

PURPOSE

This study examined the ability of personal competency variables at the time of hospital discharge to predict primary instrumental activities of daily living (IADLs) and secondary outcomes (living arrangements) in a sample of 194 urban, live-alone, older adults who had a new onset disability.

DESIGN AND METHODS

Consecutively admitted medical rehabilitation patients, 72% women and 85% African American, participated in the study. Using path analysis, three of the four competency variables collected at the time of hospitalization (cognition, medical burden, activities of daily living) predicted IADLs at 3 and 6 months after hospitalization (e.g., cooking, telephone use, money management). IADLs, in turn, predicted living arrangements at 3 and at 6 months after hospitalization.

RESULTS

The findings provided strong support for the importance of assessing a broad range of competency variables when investigating adaptation to disability.

IMPLICATIONS

The increased understanding of adaptation in live-alone older adults with a new-onset disability is particularly timely given the increase in live-alone older adults and the dire consequences associated with change in living arrangement (i.e., mortality and morbidity) in this group.