Journal of Gerontology: SOCIAL SCIENCES 1990. Vol. 45. No. 3. S95-I0!
Copyright 1990 by The Gerontological Society of America
Functional Capacity and Living Arrangements of Unmarried Elderly Persons Jacqueline Lowe Worobey1 and Ronald J. Angel2 'Institute for Health, Health Care Policy, and Aging Research, Rutgers University, department of Sociology, The University of Texas at Austin.
care for the aged is an issue of increasing LONG-TERM ' concern among policy makers and researchers as the number of unmarried elderly persons at high risk of institutionalization grows (Harris, 1986; Somers, 1982). As we near the end of the 20th century the processes that demographers have termed the "demographic transition," characterized by both low fertility and low mortality, have resulted in a dramatic increase in the proportion of the population in the oldest age ranges. These two processes have created a situation in which increased longevity is coupled with a smaller number of potential caretakers. Individuals now aging in the United States have fewer children to provide for their welfare than was the case in earlier centuries or than is the case in the developing world today (Siegel and Taeuber, 1986). These demographic processes have had important economic and political consequences for the welfare of elderly persons, as well as for public funding of the dependency burden they represent. By and large, responsibility for care of elderly persons has shifted from the immediate family and local community to the state (Myles, 1984). What is perhaps most surprising is the extent and speed of the shift in the attitudes of both the elderly and their children concerning responsibility for the economic security of dependent older persons. Opinion polls consistently indicate that since the passage of the Social Security Act of 1936, the attitudes of both older and younger persons have shifted from the expectation that children should bear the major responsibility for the care of aging parents to the near universal expectation that the care of older persons is the state's responsibility (Crystal, 1982). These changes in attitudes have paralleled changes in public policy. Since the turn of the century, the roles that the family and government play in the care of elderly persons have changed considerably. Historically, the family assumed economic responsibility for functionally dependent
elderly persons (Shanas et al., 1968). In the contemporary United States the basic resources and assistance needed by older adults are increasingly provided by the state. Yet it is clear that, if they are available, family members provide a great deal of help, often making it possible for elderly people to avoid institutionalization. As of yet, however, we know little about how older single persons cope with the loss of functional independence in the absence of kin. Older persons who have few children or those whose children live far away may not have immediate sources of instrumental aid. For such individuals, there may be few alternatives to institutionalization. A complex set of factors, then, including declining fertility and mortality, the rise of the paternalistic old-age welfare state, the increased availability of housing, and an apparent widespread preference for solitary living arrangements has led to dramatic changes in the living arrangements of elderly persons. In years to come the aggregate dependency burden on society is likely to increase dramatically as a result of these trends (Crystal, 1982; Shanas, 1962). In this study we examined the impact of physical decline on the living arrangements of older persons. We focused on unmarried individuals and those who live alone and examined the changes in living arrangements that they experience when they suffer declines in physical capacity. Older persons who live alone are at elevated risk for institutionalization or of dependency upon others in the event of diminished health. Before proceeding it might be useful to summarize the options in living arrangements available to an older person who is living alone and who becomes incapacitated. These include, (a) continuing to live alone; (b) moving into another person's household or including someone in his or her household; or (c) entering a nursing home. The factors determining which of these options an individual exercises are complex and depend on economic, cultural, and personal factors. In this analysis we will examine how options in
S95
Downloaded from http://geronj.oxfordjournals.org/ at University of Birmingham on August 21, 2015
This analysis employed the 1986 Longitudinal Study of Aging (LSOA) to examine the impact offunctional capacity, gender, race and ethnicity, and various socioeconomic characteristics on changes in living arrangements among unmarried elderly persons over a two-year period. The results reveal that a decline in functional capacity greatly increases the likelihood that an elderly person will move in with others or become institutionalized. Nonetheless, even when they experience significant declines in health, most single elderly persons who were living alone at the initial interview continued to live alone two years later. Multivariate analyses show that women who suffer declines in functional capacity are somewhat less likely than men who experience declines to live alone at Time two. In contrast, Blacks who suffer declines are more likely than Whites who experience declines to continue living alone at follow-up.
S96
WOROBEY AND ANGEL
living arrangements are affected by race, social class, and gender. The major objective of this analysis is to determine the extent to which declines in functional capacity lead to greater dependency on others and to institutionalization.
METHODS
This analysis employed the Longitudinal Study of Aging (LSOA), a supplement to the 1984 National Health Interview Survey (Fitti and Kovar, 1987). Information on the functional capacity and living arrangements of a national sample of 4,112 individuals aged 70 or older in 1984 who were still alive in 1986 is provided by the survey. This analysis employs a subsample of that group, comprising 2,498 unmarried elderly men and women who were alive and for whom information was available at the follow-up. With these data the impact of such factors as gender, race, and income on changes in health and living arrangements between 1984 and 1986 can be estimated. This survey is particularly appropriate for our purposes since it contains individuals of advanced age who are at elevated risk of experiencing changes in both functional capacity and living arrangements. In addition, the sample was stratified in order to ensure the representation of the oldest old and Black elderly. Although two years is a relatively short time, because of the advanced age of this sample significant decrements in health were common. These data, then, permit us to begin to unravel the dynamics of the formation and dissolution of households among elderly persons and to determine how changes in health status affect that process. The analysis consists of an examination of the probability of a change in living arrangement as a function of a change in functional capacity between the initial interview and the follow-up. Our focus, then, is on net changes in health and living arrangements between the initial interview and the follow-up. Although it is possible that an individual's health status and living arrangements changed more than once during this period, the study provides information only for the two time points. Once again, however, although the two-year period is long enough to observe significant change, it is short enough so that dramatic changes in status that result in no observable net change are probably not common. In the descriptive tables that follow, data are weighted to adjust for the age-race-sex stratification of the sample. Weights are not used in the multivariate analyses because our models include the major stratification variables as controls and because our objective is to examine associations between predictors and outcome variables and not to make population inferences. Analyses The dependent variable in the following analyses refers to an individual's living arrangement at the time of the followup interview and consists of a trichotomy: (a) living alone; (b) living with others (family and nonrelatives); and (c) entering an institution. In our conceptualization each category reflects an increasing amount of dependency upon others, with institutionalization representing an extreme of
Downloaded from http://geronj.oxfordjournals.org/ at University of Birmingham on August 21, 2015
Previous Findings Most married elderly persons live with their spouses and maintain independent households. However, since World War II the trend toward independent living arrangements for those without a living spouse has increased substantially (Wolf and Soldo, 1988). Unmarried individuals are at increased risk of institutionalization because they are both at high risk of illness and often do not have family nearby to provide help with activities of daily living. Social scientists who study elderly persons concur that one of the most significant determinants of living arrangements is health. Individuals who require help with activities such as bathing, dressing, and eating are more likely to live with others than those who can function independently (Bishop, 1986; Soldo, Sharma, and Campbell, 1984; Wolf and Soldo, 1988). Unfortunately, with few exceptions (Schwartz, Danziger, and Smolensky, 1984; Tissue and McCoy, 1981), these findings are based on cross-sectional samples. This makes it impossible to determine whether disability precedes the formation of joint households or whether other background characteristics influence choices in living arrangements. The interaction of physical capacity with other variables that influence living arrangements is poorly understood. Several potential interactions are of interest. For example, mortality differentials between men and women are such that among the oldest age ranges women outnumber men by approximately two to one (Rosenwaike, 1985). Given their longer life spans, women suffer more protracted but less often fatal disabilities than men (Manton, 1988; Verbrugge, 1985). Illness, then, may be a greater factor in determining the living arrangements of women than of men in the later stages of the life course. Another factor that may interact with health to influence living arrangements is race. A common observation reported in the literature is that minority group elderly are more likely to live in multiperson households than to live alone because of group norms and economic need. In her ethnographic account of survival in a ghetto Black community, for example, Stack (1974) observed that poor urban Blacks adapted to poverty through the maintenance of three-generation households. Such multigenerational households facilitate the exchange of goods and services and strengthen bonds of obligation, alliance, and dependence among family members. Because most community samples contain relatively few Blacks or other minority group members, little is known concerning the impact of race or ethnicity on extended living arrangements, and the evidence that exists is often contradictory (Bachrach, 1980; Bishop, 1986; Wolf, 1984; Wolf and Soldo, 1988). Although previous research has documented the association between health and living arrangements crosssectionally, there are few studies of the impact of changes in health on changes in living arrangements over time. In particular, the question of the extent to which sociodemographic variables affect the living arrangements of unmar-
ried older persons who experience diminished functional capacity remains unanswered. Until recently there were few national, representative, longitudinal surveys of the aged with which to investigate these issues. Many of these shortcomings are overcome in the present study because of unique aspects of the longitudinal data employed.
S97
LIVING ARRANGEMENTS, UNMARRIED ELDERLY
Family income. — Total family income consists of earnings, Social Security, and other sources, e.g., unemployment payments, public assistance, interest, and dividends. Unfortunately, the LSOA provides no information on the respondent's individual income. Family income is a noncontinuous variable, and for the present analysis we collapsed it into three levels: low income, $0 through $6,999; middle income, $7,000 through $ 19,999; and high income, $20,000 or more. Health. — The operationalization of functional capacity consists of questions concerning one's ability to carry out activities of daily living (ADLs) as measured by the Katz ADL scale (Katz et al., 1963). Respondents were asked how much assistance they required in seven domains of physical functioning: bathing, eating, dressing, walking, toileting, going outside, and getting in and out of a chair. Each ADL is weighted by the degree of severity that includes four levels — none, some, a lot, or unable to perform the activity at all. In order to summarize the data concerning a respondent's degree of physical disability, the seven ADLs are summed into a global measure of disability. This scale ranges from 0 to 21, and a higher score reflects greater functional incapacity. Other independent variables included in the analysis capture aspects of culture, sociodemographics, region, and urban/rural residence that are likely to influence options in living arrangements. Two variables tap dimensions of culture, race, and Hispanic ethnicity (coded as dichotomies).
Age, coded continuously, is included because it is associated with functional dependency. Gender, a dichotomy, is included because females live longer than males and may have more opportunity to live with others. Previous marital status (divorced/separated and never married, with widowed as a reference category) is included as a control since it may have an impact on present living arrangements. The analysis includes the number of living children because having children increases the likelihood of living with family. Education, coded continuously, is included since it is associated with different preferences for living arrangements. Two aggregate level variables, region of the country and rural/ urban residence, are introduced to control for differences in housing and the availability of long-term care facilities. RESULTS
Table 1 presents basic sample characteristics. The sample consists primarily of non-Hispanic White, female widows but also includes a substantial number of elderly men, Blacks, and rural residents. In addition, half of the sample is at least 80 years or older. Forty percent of the study group report low income. In 1984, two thirds of the unmarried
Table 1. Baseline Characteristics of the Sample Characteristics Sex Male Female Age Mean
Unweighted Percent
Weighted Percent
N
17.8 82.2
18.7 81.3
503 2,324
79.6
78.2
2,827
Race/Ethnicity Non-Hispanic White Black Hispanic
85.6 12.0 2.5
87.7 9.7 2.6
2,419 338 70
Prior marital status Di vorced/Separated Never married Widowed
8.1 8.6 83.3
9.0 9.2 81.8
229 244 2,354
Level of completed education Grade school or less High school College or more
45.0 38.1 16.9
42.3 39.5 18.3
1,244 1,053 467
Family income Low (0-$6,999) Middle ($7,000-519,999) High ($20,000 or more)
45.3 42.1 12.6
41.4 41.1 17.5
980 911 272
Region of country North Central East South West
25.9 24.1 33.5 16.5
25.3 25.1 32.5 17.1
733 680 948 466
Size of residence SMSA cities and towns Non-SMSA suburbs Rural towns (
Copyright 1990 by The Gerontological Society of America
Functional Capacity and Living Arrangements of Unmarried Elderly Persons Jacqueline Lowe Worobey1 and Ronald J. Angel2 'Institute for Health, Health Care Policy, and Aging Research, Rutgers University, department of Sociology, The University of Texas at Austin.
care for the aged is an issue of increasing LONG-TERM ' concern among policy makers and researchers as the number of unmarried elderly persons at high risk of institutionalization grows (Harris, 1986; Somers, 1982). As we near the end of the 20th century the processes that demographers have termed the "demographic transition," characterized by both low fertility and low mortality, have resulted in a dramatic increase in the proportion of the population in the oldest age ranges. These two processes have created a situation in which increased longevity is coupled with a smaller number of potential caretakers. Individuals now aging in the United States have fewer children to provide for their welfare than was the case in earlier centuries or than is the case in the developing world today (Siegel and Taeuber, 1986). These demographic processes have had important economic and political consequences for the welfare of elderly persons, as well as for public funding of the dependency burden they represent. By and large, responsibility for care of elderly persons has shifted from the immediate family and local community to the state (Myles, 1984). What is perhaps most surprising is the extent and speed of the shift in the attitudes of both the elderly and their children concerning responsibility for the economic security of dependent older persons. Opinion polls consistently indicate that since the passage of the Social Security Act of 1936, the attitudes of both older and younger persons have shifted from the expectation that children should bear the major responsibility for the care of aging parents to the near universal expectation that the care of older persons is the state's responsibility (Crystal, 1982). These changes in attitudes have paralleled changes in public policy. Since the turn of the century, the roles that the family and government play in the care of elderly persons have changed considerably. Historically, the family assumed economic responsibility for functionally dependent
elderly persons (Shanas et al., 1968). In the contemporary United States the basic resources and assistance needed by older adults are increasingly provided by the state. Yet it is clear that, if they are available, family members provide a great deal of help, often making it possible for elderly people to avoid institutionalization. As of yet, however, we know little about how older single persons cope with the loss of functional independence in the absence of kin. Older persons who have few children or those whose children live far away may not have immediate sources of instrumental aid. For such individuals, there may be few alternatives to institutionalization. A complex set of factors, then, including declining fertility and mortality, the rise of the paternalistic old-age welfare state, the increased availability of housing, and an apparent widespread preference for solitary living arrangements has led to dramatic changes in the living arrangements of elderly persons. In years to come the aggregate dependency burden on society is likely to increase dramatically as a result of these trends (Crystal, 1982; Shanas, 1962). In this study we examined the impact of physical decline on the living arrangements of older persons. We focused on unmarried individuals and those who live alone and examined the changes in living arrangements that they experience when they suffer declines in physical capacity. Older persons who live alone are at elevated risk for institutionalization or of dependency upon others in the event of diminished health. Before proceeding it might be useful to summarize the options in living arrangements available to an older person who is living alone and who becomes incapacitated. These include, (a) continuing to live alone; (b) moving into another person's household or including someone in his or her household; or (c) entering a nursing home. The factors determining which of these options an individual exercises are complex and depend on economic, cultural, and personal factors. In this analysis we will examine how options in
S95
Downloaded from http://geronj.oxfordjournals.org/ at University of Birmingham on August 21, 2015
This analysis employed the 1986 Longitudinal Study of Aging (LSOA) to examine the impact offunctional capacity, gender, race and ethnicity, and various socioeconomic characteristics on changes in living arrangements among unmarried elderly persons over a two-year period. The results reveal that a decline in functional capacity greatly increases the likelihood that an elderly person will move in with others or become institutionalized. Nonetheless, even when they experience significant declines in health, most single elderly persons who were living alone at the initial interview continued to live alone two years later. Multivariate analyses show that women who suffer declines in functional capacity are somewhat less likely than men who experience declines to live alone at Time two. In contrast, Blacks who suffer declines are more likely than Whites who experience declines to continue living alone at follow-up.
S96
WOROBEY AND ANGEL
living arrangements are affected by race, social class, and gender. The major objective of this analysis is to determine the extent to which declines in functional capacity lead to greater dependency on others and to institutionalization.
METHODS
This analysis employed the Longitudinal Study of Aging (LSOA), a supplement to the 1984 National Health Interview Survey (Fitti and Kovar, 1987). Information on the functional capacity and living arrangements of a national sample of 4,112 individuals aged 70 or older in 1984 who were still alive in 1986 is provided by the survey. This analysis employs a subsample of that group, comprising 2,498 unmarried elderly men and women who were alive and for whom information was available at the follow-up. With these data the impact of such factors as gender, race, and income on changes in health and living arrangements between 1984 and 1986 can be estimated. This survey is particularly appropriate for our purposes since it contains individuals of advanced age who are at elevated risk of experiencing changes in both functional capacity and living arrangements. In addition, the sample was stratified in order to ensure the representation of the oldest old and Black elderly. Although two years is a relatively short time, because of the advanced age of this sample significant decrements in health were common. These data, then, permit us to begin to unravel the dynamics of the formation and dissolution of households among elderly persons and to determine how changes in health status affect that process. The analysis consists of an examination of the probability of a change in living arrangement as a function of a change in functional capacity between the initial interview and the follow-up. Our focus, then, is on net changes in health and living arrangements between the initial interview and the follow-up. Although it is possible that an individual's health status and living arrangements changed more than once during this period, the study provides information only for the two time points. Once again, however, although the two-year period is long enough to observe significant change, it is short enough so that dramatic changes in status that result in no observable net change are probably not common. In the descriptive tables that follow, data are weighted to adjust for the age-race-sex stratification of the sample. Weights are not used in the multivariate analyses because our models include the major stratification variables as controls and because our objective is to examine associations between predictors and outcome variables and not to make population inferences. Analyses The dependent variable in the following analyses refers to an individual's living arrangement at the time of the followup interview and consists of a trichotomy: (a) living alone; (b) living with others (family and nonrelatives); and (c) entering an institution. In our conceptualization each category reflects an increasing amount of dependency upon others, with institutionalization representing an extreme of
Downloaded from http://geronj.oxfordjournals.org/ at University of Birmingham on August 21, 2015
Previous Findings Most married elderly persons live with their spouses and maintain independent households. However, since World War II the trend toward independent living arrangements for those without a living spouse has increased substantially (Wolf and Soldo, 1988). Unmarried individuals are at increased risk of institutionalization because they are both at high risk of illness and often do not have family nearby to provide help with activities of daily living. Social scientists who study elderly persons concur that one of the most significant determinants of living arrangements is health. Individuals who require help with activities such as bathing, dressing, and eating are more likely to live with others than those who can function independently (Bishop, 1986; Soldo, Sharma, and Campbell, 1984; Wolf and Soldo, 1988). Unfortunately, with few exceptions (Schwartz, Danziger, and Smolensky, 1984; Tissue and McCoy, 1981), these findings are based on cross-sectional samples. This makes it impossible to determine whether disability precedes the formation of joint households or whether other background characteristics influence choices in living arrangements. The interaction of physical capacity with other variables that influence living arrangements is poorly understood. Several potential interactions are of interest. For example, mortality differentials between men and women are such that among the oldest age ranges women outnumber men by approximately two to one (Rosenwaike, 1985). Given their longer life spans, women suffer more protracted but less often fatal disabilities than men (Manton, 1988; Verbrugge, 1985). Illness, then, may be a greater factor in determining the living arrangements of women than of men in the later stages of the life course. Another factor that may interact with health to influence living arrangements is race. A common observation reported in the literature is that minority group elderly are more likely to live in multiperson households than to live alone because of group norms and economic need. In her ethnographic account of survival in a ghetto Black community, for example, Stack (1974) observed that poor urban Blacks adapted to poverty through the maintenance of three-generation households. Such multigenerational households facilitate the exchange of goods and services and strengthen bonds of obligation, alliance, and dependence among family members. Because most community samples contain relatively few Blacks or other minority group members, little is known concerning the impact of race or ethnicity on extended living arrangements, and the evidence that exists is often contradictory (Bachrach, 1980; Bishop, 1986; Wolf, 1984; Wolf and Soldo, 1988). Although previous research has documented the association between health and living arrangements crosssectionally, there are few studies of the impact of changes in health on changes in living arrangements over time. In particular, the question of the extent to which sociodemographic variables affect the living arrangements of unmar-
ried older persons who experience diminished functional capacity remains unanswered. Until recently there were few national, representative, longitudinal surveys of the aged with which to investigate these issues. Many of these shortcomings are overcome in the present study because of unique aspects of the longitudinal data employed.
S97
LIVING ARRANGEMENTS, UNMARRIED ELDERLY
Family income. — Total family income consists of earnings, Social Security, and other sources, e.g., unemployment payments, public assistance, interest, and dividends. Unfortunately, the LSOA provides no information on the respondent's individual income. Family income is a noncontinuous variable, and for the present analysis we collapsed it into three levels: low income, $0 through $6,999; middle income, $7,000 through $ 19,999; and high income, $20,000 or more. Health. — The operationalization of functional capacity consists of questions concerning one's ability to carry out activities of daily living (ADLs) as measured by the Katz ADL scale (Katz et al., 1963). Respondents were asked how much assistance they required in seven domains of physical functioning: bathing, eating, dressing, walking, toileting, going outside, and getting in and out of a chair. Each ADL is weighted by the degree of severity that includes four levels — none, some, a lot, or unable to perform the activity at all. In order to summarize the data concerning a respondent's degree of physical disability, the seven ADLs are summed into a global measure of disability. This scale ranges from 0 to 21, and a higher score reflects greater functional incapacity. Other independent variables included in the analysis capture aspects of culture, sociodemographics, region, and urban/rural residence that are likely to influence options in living arrangements. Two variables tap dimensions of culture, race, and Hispanic ethnicity (coded as dichotomies).
Age, coded continuously, is included because it is associated with functional dependency. Gender, a dichotomy, is included because females live longer than males and may have more opportunity to live with others. Previous marital status (divorced/separated and never married, with widowed as a reference category) is included as a control since it may have an impact on present living arrangements. The analysis includes the number of living children because having children increases the likelihood of living with family. Education, coded continuously, is included since it is associated with different preferences for living arrangements. Two aggregate level variables, region of the country and rural/ urban residence, are introduced to control for differences in housing and the availability of long-term care facilities. RESULTS
Table 1 presents basic sample characteristics. The sample consists primarily of non-Hispanic White, female widows but also includes a substantial number of elderly men, Blacks, and rural residents. In addition, half of the sample is at least 80 years or older. Forty percent of the study group report low income. In 1984, two thirds of the unmarried
Table 1. Baseline Characteristics of the Sample Characteristics Sex Male Female Age Mean
Unweighted Percent
Weighted Percent
N
17.8 82.2
18.7 81.3
503 2,324
79.6
78.2
2,827
Race/Ethnicity Non-Hispanic White Black Hispanic
85.6 12.0 2.5
87.7 9.7 2.6
2,419 338 70
Prior marital status Di vorced/Separated Never married Widowed
8.1 8.6 83.3
9.0 9.2 81.8
229 244 2,354
Level of completed education Grade school or less High school College or more
45.0 38.1 16.9
42.3 39.5 18.3
1,244 1,053 467
Family income Low (0-$6,999) Middle ($7,000-519,999) High ($20,000 or more)
45.3 42.1 12.6
41.4 41.1 17.5
980 911 272
Region of country North Central East South West
25.9 24.1 33.5 16.5
25.3 25.1 32.5 17.1
733 680 948 466
Size of residence SMSA cities and towns Non-SMSA suburbs Rural towns (
