This study examined the self-perceived health vulnerability of older adults who are living alone in the community and as well as exploring their perceptions about aspects in the community, including services that they need and are a priority to them. We discuss the extent of vulnerability, the issue on advance medical care plans and the perceived needs and priorities of older people living alone in light of the previous literature published on elder orphans and solo ageing.
Vulnerability
Our findings show that in this cohort of older adults, even though they are still able to cope living alone in the community, 21.4% were considered vulnerable and at risk of health decline. This aligns with the elder orphan profile identified in earlier literature reviews, as a group of older people who have stable health status yet have a higher likelihood of physical and functional disability, and loneliness which can then affect self-rated health (Carney et al., 2016; Montayre et al., 2019a). The growing body of literature on the profile of elder orphans indicates the primary risk factors, which include childlessness and single marital status such as being widowed, divorced, or never marrying (Valerio et al., 2021). They are more likely to be female, and have low income (Margolis & Verdery, 2017; Schrempft et al., 2019), have a higher likelihood of chronic conditions such as cardiovascular disease resulting in coronary heart disease and stroke (Golaszewski et al., 2022), compromised immune functioning (Powell et al., 2021) and mobility issues (Philip et al., 2020). The risk toward cognitive decline including loneliness and depression is also high (Kervin et al., 2021; Powell et al., 2021; Roofeh et al., 2020), which can then contribute to low perceptions about their health (Raymo & Wang, 2022; Zhang et al., 2021). These risk factors affecting physical and psychological wellbeing contribute to vulnerability where the older person is at increased susceptibility for an adverse outcome, injury and admission to a nursing home or hospitalisation (Culo, 2011; Perseguino et al., 2022).
In addition to the vulnerability, we found that most participants had no knowledge of an organisation or agency that could assist them with health appointments or visits (n = 304 or 97.1%). The lack of information available to older adults on services that are available to them coupled with poor healthcare access, affordability and social isolation can make it harder to access healthcare which can negatively affect health and wellbeing (Kotval-K et al., 2020). Navigating the healthcare system is difficult for older adults, especially for elder orphans with no social support system in place. Literature discusses approaches to improve access to healthcare through initiatives such as trained volunteer companions such as Medical Visit Companions (MVCs) or patient navigators, where a person engages with a patient to determine barriers to care and provides information and care coordination to ensure older adults have adequate access to community-based supports and services to enable them to maintain their independence at home (Budde et al., 2021; Budde et al., 2022; Peart et al., 2018). The programmes assist patients to access healthcare by addressing transport help, and accompaniment to medical visits (Sheehan et al., 2021). Community transport help services which offer transportation to medical appointments are also geared to helping older adults and those living with disabilities after they cease to drive, and include public transit, paratransit, taxis, rideshare services, and volunteer drivers (Kotval-K et al., 2020; MacLeod et al., 2015). Existing patient navigator programmes typically focus on cancer care, transitional care for helping an older patient on discharge from hospital or care for vulnerable or disadvantaged populations such as migrants, homeless or uninsured people (Budde et al., 2022). Considering the profile of an elder orphan and that the results for this study indicated that a percentage of elder orphans may be considered vulnerable, policy makers introducing patient navigator programmes in a community would contribute to improve elder orphan’s access to healthcare utilisation.
Advance medical care plan
Another important finding of this study was that two thirds of older adults did not have or did not know if they had an advanced medical care plan (n = 176 or 66.2%). While many elder orphans can live independently, they are at risk of becoming “unbefriended” or without an advocate, if they lack a completed advance healthcare directive or a surrogate decision maker who will take over as a fiduciary and advocate for them at any point if they are not able to speak for themselves (Chamberlain et al., 2020; Farrell et al., 2021; Pope, 2015). This can potentially lead to issues of poor quality of life and end of life care for the individual (Chamberlain et al., 2020). An advance medical care directive can play an important role in effectuating the medical wishes of an incapacitated person. Unbefriended older adults in need of advocates are frequently encountered in both healthcare inpatient and outpatient settings and research indicates that this number is escalating (Babb et al., 2021; Farrell et al., 2021; Kim & Song, 2018). A possible explanation for why community-dwelling elder orphans lack advance medical care directives is discussed in literature. If they are fit and well, there are no thoughts of completing advance medical care directives and there is no family to influence them in making these decisions (Bernard et al., 2020; Montayre et al., 2019b; Thaggard & Montayre, 2019). Furthermore, some elder orphans may not be able to identify a health care proxy if they are socially isolated and have no one that they feel they can trust to advocate for them if they are incapacitated (Carney et al., 2016). Other barriers include medical doctors not initiating discussions about future medical care decisions or not educating the elder orphan with patient-friendly materials about the importance of advance care planning, which is potentiated if there is a barrier to healthcare access (Bernard et al., 2020; Sager et al., 2019).
Elder orphans have a need to have an advance medical care directive in place while they are still relatively well and healthy, to ensure their future medical needs and wishes are met (Carney et al., 2016). If an elder orphan has not been able to identify a health care proxy, then a public guardian or a surrogate decision maker can be appointed by a court to make legal and personal decisions on behalf of an incapacitated individual, however this process can be lengthy and expensive. Clinicians in hospitals often use best judgement on how to proceed if a timely decision is required but there lies the risk of clinician biasness and unmet care needs for the individual occurring (Farrell et al., 2017). Clinicians, attorneys, and policymakers should collaborate to improve early detection and to meet the advance medical care directive needs of this vulnerable population (Farrell et al., 2021).
Needs and Priorities
Our study showed that access to healthcare in the community is considered a top priority, followed by affordability and social involvement, with the preservation of one’s culture considered a last priority. It is not surprising that this study identified healthcare access (35.8%, n = 77), affordability (35.8%, n = 77), followed by social involvement (16%, n = 16) as first priorities that elder orphans thought what mattered the most as they live in the community. Each of these priority needs identified are not completely independent of each other. They are interactive and become barriers that can contribute to elder orphans’ vulnerability and hinder their quality of life. This is consistent with previous literature which describes affordability presenting a financial barrier to accessing healthcare if the older adult has poor or no health insurance coverage, and low income (Jacobson et al., 2021). The financial constraints people face as they reach old age reduces the possibility of owning a private vehicle and driving independently to access healthcare. Many older adults are advised to stop driving due to decreasing physical and mental conditions and if there is no social network support for the older adult, then transport services are needed to be relied upon, however affordability and accessibility can then impact the ability to utilise public transit options (Kotval-K et al., 2020). Lack of social support such as family, friend or a caregiver to act as an accompaniment to appointments or to assist with information exchange and dissemination also influences the ability to access healthcare (Sheehan et al., 2021; Watson & DeRenzo, 2019).
A lack of social involvement and participation can lead to social isolation. Factors influencing this include poor health, loss of social contacts, lack of finances and appropriate transport, perceived danger in the neighbourhood or the fear of being exploited. Social isolation can lead to anxiety and depression which can lead to an older adult developing a range of fears that may leave them feeling ashamed to ask for help, or fearful to admit they are not coping (Goll et al., 2018). Maintaining strong social networks is essential for successful ageing and can be achieved with interventions that meet an individual’s requirement. They can include social activity groups, the use of befriending and peer-coaching programmes, or the use of digital technology for connectivity with other people and the outside world (no one & Yang, 2021), including social network sites such as Facebook (Francis, 2022).
Providing initiatives such as supportive environments for older adults to socialise with people, learn new skills such as in the use of digital technology, as well as educating them about “how” to ask for help in a safe manner would be beneficial. Health care providers should educate patients about the importance of social connection for their mental wellbeing, as well as screening for their vulnerability of social isolation (Garcia & Jordan, 2022).
To improve access to healthcare utilisation, as mentioned earlier, initiatives such as patient navigators or trained volunteer MVCs would address transport and social support barriers, and assist with care coordination (Sheehan et al., 2021) for these older adults who are kinless and living alone. Therefore, in this community-dwelling group, it is critical to identify and cater for their specific health care needs and priorities at an early stage while they are still manageable.