2.1▓Quality of Life of elderly people
In view of aging population increasing projections, the world strives to improve the health and quality of life (QOL) of seniors. Though, it probably involves diverse factors such as the social, political and physical environment. Active aging is the process of optimizing opportunities for health. World Health Organization defined health as, “a state of complete physical, mental and social well-being, not just simply the absence of disease or injury.” Thus, in order to achieve good quality of life and good health, one of the key elements is health promotion. Promoting good health requires a system such as income, supportive neighbors and friends, remaining active, responsive community services, access to amenities, and public transportation that supports seniors in their ability to meet various age-related challenges with comparable resources (Bryant et al., 2002). The system refers to the broader political, social and economic context in which seniors live. These seniors identified issues were possibly important contributors to quality of life. The needs of the senior are complex. The care provided shall accommodate their needs and also focus on quality of life and their well-being.
Quality of Life Research Unit, University of Toronto (2011) suggested, QOL may be conceived as either a desired outcome of health promotion practice, or as a determinant of health among seniors, that is, differentiating between pathological, normal and optimal functioning among seniors. It appears to be a part of the public health planning and practice.
The Quality of Life profile: Seniors version had been developed (Refer to Table 2-1).
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Table 2-1▓Quality of Life profile: Seniors version
Physical Being Being physically able to get around my home and neighborhood
Good nutrition and eating the right foods Psychological Being Being able to have clear thoughts
Coping with what life brings Being
Spiritual Being Feeling that my life is accomplishing something
Participating in religious or spiritual activities Physical Belonging Having a space for privacy
Living in a place especially equipped for seniors Social Belonging Being able to count on family members for help
Having neighbor’s I can turn to Belonging
Community Belonging
Being able to get dental services
Going to places in my neighborhood (stores, etc.)
Practical Becoming The caring I do for a spouse or other adult
Doing work around my home (cleaning, cooking)
Leisure Becoming Having hobbies (gardening, knitting, painting, etc.)
Participating in organized recreation activities Becoming
Growth Becoming Improving or keeping up my thinking and memory skills
Adjusting to changes in my personal life
Source: The Quality of Life Research Unit, University of Toronto (2011), http://www.utoronto.ca/qol/concepts.html
Quality of life is important not only because of the increasing aging population but also the quality care of the elderly people; and as an indicator of well-being or satisfaction of life.
There were over 100 definitions and models of QOL (Cummins, 1997), and more than 1000 measures of various aspects of QOL (Hughes and Hwang, 1996). There were senior version of quality of life developed by The Quality of Life Research Unit, University of Toronto which mainly measures the functional status or their ability to participate (refer Table 2-1).
However, our study utilized the WHOQOL-BREF which was shorter and easier for the elderly people to accomplish compare to the WHOQOL-100 questionnaire.
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The quality of life divided into several domains and it is a multi-dimensional broad concepts. There are factors including age, gender, marital status, depression, physical illness, functional status determined to the quality of life. For instance, occurrence of disability and its effects on living conditions are two of the major factors that determine the quality of life of elderly people (Wenger & Burholt, 2003). However, there are other factors would affect the quality of life such as depressive symptoms, number of chronic conditions, military rank for the veterans, and social support (Chang, 2010). Social isolation and loneliness in old age are linked to a decline in both physical and mental well-being. Kondo et al. (2007) found that a higher level of engagement was associated with greater functional capacity, especially social role performance, which means that they have a higher quality of life.
The policymakers not only provide the shelter for the elderly people but also the community support. The elderly people commonly would still face the loneliness, helplessness and boredom no matter they are living with their loving family or in the nursing home. The degree of loneliness depends on the situation. The loneliness is the failure of the social systems. Therefore the social or family support systems are crucial for the well-being of the elderly.
Depression is common in the later life especially in the aged nursing home. Prevalence rates could be range from 2% to 61% (Jongenelis, et al., 2003). In Taiwan, older people who live in nursing homes suffer from more depressive symptoms than those in community dwellings (Chong, 2010). There was another study analyses indicated that men residing within an institution in Canada were significantly more depressed than those residing within detached homes and significantly more depressed than women in both situations (Vallain &
Furac, 1993). Lin, Wang & Huang (2007) study had discovered that the length of residency, number of chronic conditions, perceived health status and the amount of social support from their family and relatives could explain 38.8% of the total variances in depressive symptoms.
The coping strategies such as seeking support from family could help adapting to difficulty aroused from the disability (Hsu & Tung, 2011).
The knowledge such as the causes of health and illness remain relatively unknown to the public including the senior groups and Bryant et al. (2002) suggested the seniors should be
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increased the awareness of developing positive attitudes to life. These involved and increased their social activities (Schroll, Jonsson, Mor, Berg, Sherwood, 1997), and improved outreach efforts to older adults who live alone. Equally important was the need to provide information about aging and retirement. Besides, the filial piety is one of the factors affecting the willingness of children to take care of their elderly parents in the future. However, a decreasing birthrate, rising numbers of women pursuing careers, work pressures, tensions between parents and children, and a weakening in traditional filial piety mores have changed Taiwanese society in recent years (Liu & Huang, 2009). Moreover, there is less possible for the only child or employed children to take care of their parents especially disabled parents.
Such changes may result in poorer levels of family care. Thus, education with emphasis of filial piety should be implemented.
2.2▓Living arrangements and care of elderly people
Elderly people live in a wide range of housing settings-from single family homes, to full-service retirement communities, to nursing facilities. There are several types of senior housing or retirement home options for elderly people to choose including active adult retirement communities, independent living retirement homes, and assisted living facilities, long term care services in apartment, nursing home or hospital. The utilization rates of the different type of the senior housing or institution in Taiwan were shown in table 2-2.
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Table 2-2▓Number of the people >65 years living in different types of senior housing, Taiwan
Year/ Type of senior housing Number of senior housing
The size of the senior housing
The number of the people living in the senior housing Long-term Care Institutions
Nursing home
Source : Department of Social Affairs, MOI and County and City Government (2010), http://www.moi.gov.tw/stat/news_content.aspx?sn=5209
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As stated in table 2-2, the Department of Social Affairs, Minister of Interiors, Taiwan has divided the senior housing into three types with the low level of care to high level of care.
1. The long term care services (Ministry of Interior-Department of Social Affairs, 2011) includes caring institution, long term care institutions, nursing home or hospital. The designed not only to provide accommodation, but also meals, cleaning and laundry, assistance with showering and dressing, nursing care including medication management, social activities services. The caring institution are designed for the seniors who needs low level care or none of the family member are able to take care of these seniors. Then, they are eligible to apply for the caring institution in Taiwan (refer table 2-2). The long term care institutions are setting up for the chronic conditions elderly people with 24 hours nursing care needed. Nursing homes mainly serve frail elders with chronic diseases, urinary catheters appliances, tube feeding, disabilities, either physical or mental (mainly dementia) or both. These facilities usually provide health care, meals, which can be characterized as the highest level of care.
2. Active adult retirement communities: These communities could be closed off or gated.
They may also have on-site security and even health care. Typically, they are associated with amenities appealing to the newly retired. In Taiwan, the resources from the communities are utilized to set up the housing for the widow or senior who live alone.
There are only 9 retirement communities set up in Taiwan as shown in Table 2-2. However, in other country such as Canada, a country club, golf course, trails, swimming pool, tennis courts, spas, fitness centers and/or a variety of clubs features might be included in the community. Active adult community residences may be suites or condominiums in a tower, detached units, town houses, or bungalows. These are also known as resort communities, 55 plus or adult lifestyle communities (Senior Advisor Care-Comfort Life, 2011). These are ideal for seniors moving through the first phase of their retirement, also well-suited to those who want to leave their retirement options open.
3. Independent living retirement homes: Independent living comes in many different shapes and forms. Housing arrangements can include suites or apartments in a tower, townhouse complexes, mobile homes, standard subdivision complexes, bungalow style single residences or “cluster housing” (Senior Advisor Care-Comfort Life, 2011). Five senior
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apartments were set up in Taiwan (refer table 2-2). These homes are ideal for active, healthy, and low care requirement seniors. Usually, there will be a communal area but the size of this may vary greatly. Each unit will almost certainly include its own kitchen, even though the residence may offer communal meals. Independent living retirement homes are most often rentals but they can include subsidized housing. The cost of renting can vary widely depending on real estate costs in the region we are considering as well as services offered. In some cases, we may have the option of purchasing our home. While seniors in independent living homes take care of the majority of their own needs, they may also be provided with meals, laundry services, and linen delivery and planned activities. Many independent living communities provide some form of transportation service to community members.
Independent living communities do not necessarily exclude the option of medical assistance.
Residents may be allowed to hire in their own medical help. Many homes may include assistive technologies such as pull cords and handrails. In general, though, residents are in good health and as implied, they need no help from other people.
The assisted living retirement homes are ideal for seniors who need help with some daily activities such as meal preparation, laundry, shopping and medication but who are not in need of full time care. Other activities include bathing, dressing, toileting or diapering, grooming and other hygiene, meal preparation or cooking, eating, getting around the house, getting around town, housekeeping.
Board and care homes, supervised care facilities, personal care homes, residential care facilities, domiciliary care, supervised care facilities are called assisted living retirement homes (Senior Advisor Care-Comfort Life, 2011). Residents may have problems with memory, incontinence or only mobility. Assisted living can be a more sensible alternative to home health care. On a continuum of retirement care, assisted living offers more independence than continued care or traditional nursing homes. It is also less costly than those options. Assisted living care will cost in the range of $2000 CAD per month in most places such as in Canada but costs can be much higher for people with high needs. Assisted living attract residents with a perceived combination of security, personal care services, less restrictive homelike environments and emphasis on independence, privacy and personal dignity.
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The senior apartment in Kaohsiung City comprises of 180 beds and the Ren-Ai institution-based home consists of 80 beds. Both offer single room or shared rooms only for couples. The current residents in apartment are 130 people and 78 in Ren-Ai home. The building is owned by government and managed by the Buddhist organization-Fo Guang Shan Compassion Foundation. Senior apartment is an independent retirement home. The home is mainly for the active and healthy elderly people. However, the residents are provided with meals, and planned activities. Three meals are provided and the nutritionist will give consultation once a weeks. A special diet could be prepared with the special ordered by the residents due to their conditions such as the vegetarian, soft food. The extra services include the laundry, showering, housekeeping, taking around the medical visit could be provided with the arrangement of the social workers. The assisted living will implied with the extra cost.
The activities including 27 courses to attend per week, the birthday celebration and outdoor activities every two month, is free for the residents to participate. They are encouraged involved with all these activities. A family doctor will come every Thursday. The nurse in the working hours will assist with the blood pressure, temperature measures and simple nursing care. To promote the ageing in place, when the higher level of care is needed, the carer could be employed for daily living assistance without any medical or nursing care.
The institution-based home, caring institution which mainly designed for healthy elderly people but they have no family member or their family members have no ability to take care of them. The setting of the Ren-Ai home is similar to the senior apartment in Kaohsiung City.
There is single or shared room available to be chosen. They have about four regular courses or activities organized per week. The nurse will be in working hours to assist with the elderly people. The family doctor and the doctor from the division of endocrinology and metabolism will come once a week. The hospital, nursing home and long term care institution is situated next door. The setting of the institution combines the personal care services, less restrictive homelike environments and emphasis on independence, and privacy.
The home-dwelling elderly people that participate in our study could stay with family member, next of kin or live alone. They participate in the activities at least in a week organized by the community.
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Table 2-3 summarized the difference between the home, apartment and institution-based home. With the right choice of the type of housing or type of care provided should help to reduce certain expenditure. Moreover, the most important is to stay with the enjoyment and freely.
Table 2-3▓The difference between the home, apartment and institution-based home
Level of care/ Meal provided/ Cost
Home-dwelling Independently or with informal and/or formal care (including domestic help and home nursing).
Home health care provided
Prepare own meals
Cost: Low compare to senior apartment or nursing home Senior apartment Assistance can be provided for some basic activities of
daily living, including assistance with the laundry, showering, housekeeping, taking around the medical visit could be provided with the arrangement of the social workers. Usually, most care in residential homes is provided by nursing aides and personnel with little or no training.
Three meals provided
Cost between the home-dwelling and institution-based home (13,800 NTD per month)
Low level of care
Institution-based home Providing assisted living care such as activities of daily living and mobility, psychosocial and personal care, paramedical care, such as physiotherapy and occupational therapy, nutritional care. Limited assistance with appliances such as urinary catheters.
Three meals provided (including special meals such as tube feeding, liquidity food)
High cost expenditure (15,000-24,000 NTD per month)
Low level of care
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2.3▓Hypothesis questions
As the aging population increasing dramatically, the higher expectation of the “good life” within societies, has led to the great interest of achievement healthy aging with enjoyment of life, seeking satisfaction or meanings of life for the elderly people. In exploring the importance of QOL domains, Evans et al. (2005) found that family, finances, social life, leisure, health and living arrangements were considered important to over 80% of the elderly people studied. In WHOQOL-BREF the environment domain include the conditions such as noise, pollution, attractiveness, traffic. The perceived quality of neighborhood, facilities such as social leisure, health services, rubbish/liter, cleanliness, transport, closeness to the shop and safety home environment (Beaumont & Kenealy, 2004) are also an important determinant to the quality of life (QOL). The fit between individual’s and their surroundings environment is relevant in planning future residential strategies for the promotion of good quality of later in life (Kalfoss & Halvorsrud, 2009).
H1: The quality of life is different across institution-based home, senior apartment or staying at home with the different living arrangements.
The prevalence of the old age depression is high especially the residents staying in nursing home (Abrams, Teresi, Butin, 1992). Health events such as physical illness (53.9%) appeared to be the most common and the most widely experienced caused of depression. It then followed by the death of someone with close ties (13.5%), events connected with relationships with children and family members (9.2%), with matters related to money or possessions (6.2%) (Chong, 2001). Health events is highly correlated with the depression state and nursing home (low ADL) has the higher prevalent of depression compare to independent living retirement home (high ADL).
H2: The disability (Barthel Index of ADL), emotional state (Taiwan Depression Questionnare TDQ), are significant different in the home-dwelling, institution-based home or in the senior apartment.
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Improvements in assistive technology and environmental accomadation may be enabling persons with more severe disabilities to remain at home as there was a study showed the rates of basic disabilities among American community-dwelling adults aged 65 and older increased 9% between 2000 and 2005 (Fuller-Thomson et al., 2009). Disability is one of the good quality-of-life indicators as it captures both diseased and no diseased person. When institutionalized elders were included, basic Barthel Index of Activities of Daily Living (ADL) disability rates were stable among man but increased among women. In addition, functional mobility and independence level of the nursing home residents were higher than the home-dwelling elderly, but they had more depressive symptoms, and their level of QOL was lower (Karakaya, et al. 2009). Table 2-3 summarized the theoretical model of our study.
H3: The disability (Barthel Index of ADL) and emotional state (depression scale) contribute to the quality of life despite the different living arrangement?
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Table 2-4▓Theoretical model of the study
Home Apartment Institution-based home
Depression Symptoms
Medium
(Achterberg W, 2006)
Low (For active retirement life)
High (Abrams RC, Teresi JA, Butin DN., 1992, Snowdown, J., 2010 ) Disability Medium
(Fuller-Thomson, E., et al., 2009)
Low (For active retirement life)
High (Rothera, I., Jones, R., Harwood, R., et al., 2003) Quality of Life Medium
(Karakaya, MG., et al., 2009)
High (For active retirement life)
Low
(Karakaya, MG., et al., 2009)
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Living Arrangement
Age
Gender Marital Status
Gender Marital Status