Which of the following is true about continuity in the lives of older adults?

An elderly Tibetan woman holding a prayer wheel demonstrates the continuity theory. Despite their age, older adults generally maintain the same traditions and beliefs.

The continuity theory of normal aging states that older adults will usually maintain the same activities, behaviors, relationships as they did in their earlier years of life. According to this theory, older adults try to maintain this continuity of lifestyle by adapting strategies that are connected to their past experiences.

The continuity theory is one of three major psychosocial theories which describe how people develop in old age. The other two psychosocial theories are the disengagement theory, with which the continuity theory comes to odds, and the activity theory upon which the continuity theory modifies and elaborates. Unlike the other two theories, the continuity theory uses a life course perspective to define normal aging.

The continuity theory can be classified as a micro-level theory because it pertains to the individual, and more specifically it can be viewed from the functionalist perspective

History[edit]

The continuity theory originated in the observation that a large proportion of older adults show consistency in their activities, personalities, and relationships despite their changing physical, mental, and social status. In 1968, George L. Maddox gave an empirical description of the theory in a chapter of the book Middle Age and Aging: A Reader in Social Psychology called "Persistence of life style among the elderly: A longitudinal study of patterns of social activity in relation to life satisfaction". The continuity theory was formerly proposed in 1971 by Robert Atchley in his article "Retirement and Leisure Participation: Continuity or Crisis?" in the journal The Gerontologist. Later, in 1989, he published another article entitled "A Continuity Theory of Normal Aging, in The Gerontologist in which he substantially developed the theory. In this article, he expanded the continuity theory to explain the development of internal and external structures of continuity. In 1999, Robert Atchley continued to strengthen his theory in his book Continuity and Adaptation in Aging: Creating Positive Experiences.

Elements[edit]

The theory deals with the internal structure and the external structure of continuity to describe how people adapt to their situation and set their goals. The internal structure of an individual such as personality, ideas, and beliefs remain constant throughout the life course. This provides the individual a way to make future decisions based on their internal foundation of the past. The external structure of an individual such as relationships and social roles provides a support for maintaining a stable self-concept and lifestyle.

Criticisms and weaknesses[edit]

The major criticism for the theory is its definition of normal aging. The theory distinguishes normal aging from pathological aging, neglecting the older adults with chronic illness.

The feminist theories criticise the continuity theory for defining normal aging around a male model.

Another weakness of the theory is that it fails to demonstrate how social institutions impact the individuals and the way they age.[citation needed]

Although Australia's population is ageing (Australian Bureau of Statistics ), older people are not a homogeneous group. Government policy and the popular media tend to focus on the so-called baby-boomer generation born after the Second World War and who officially reached the traditional onset of old age, 65 years, during 2010 (Kinsella and Velkoff ; McCracken and McCracken ). Yet, the major demographic change has been a gradual worldwide increase in very old people, those aged 85 and over. Between 1950 and 2000 their numbers swelled from one-tenth to one-sixth of the world's 65 and over population (Clark and Quinn ; Hardy ). Improved longevity will see this group continue to outpace its younger counterparts. By the mid-21st century, this group will comprise over a quarter of all older persons while its proportion of the total population will double from 1.8 per cent in 2010 to 5.1 per cent by 2050 (Australian Bureau of Statistics ).

People in their sixties and seventies are typically healthy and most continue to live independently. By comparison, the independence of those in their eighties and above is typically prone to increasing frailty and susceptibility to illness and disability (Austad ; Buchner and Wagner ). These individuals may be just ‘one serious illness away from institutional care’, according to Abraham et al. (: 269). Irrespective of physical decline during old age, most people prefer to continue living in their own homes among their own communities (Fricke and Unsworth ), and they do not regard transition to a form of institutional residential care as a natural or desirable progression (Becker ; Hammer ; Krothe ; Mack et al. ; McGee et al. ; O'Hanlon et al. ). For these individuals, residential care is their ‘choice of last resort’ (McAuley and Blieszner ) or worse, an ‘an evil to be avoided at all costs’ (Wilson ).

What drives this enduring attachment to living independently? Research supports a general positive correlation between ageing in familiar surroundings with a deeper sense of satisfaction and contentedness (Wilmoth ). Recognising this general preference for independent living, the Australian federal government policy response since the early 1990s has been to expand progressively funding and service options to support older people to remain at home for as long as possible. Recent aged-care sector reform under the federal government's 2011 Living Longer Living Better policy framework aims to empower older people with access to a greater range of service support choices to live independently. Nevertheless, it is still predicted that a third of all men and half of all women over the age of 65 will enter permanent residential care at some point (Australian Commonwealth Department of Health and Ageing ). Moreover, many older adults will continue to have little decisional influence in their relocation to institutional care, as family or professionals decide on their behalf, but not necessarily at their behest (Minichiello ).

Despite the expansion of social policy, the literature tells us comparatively little about the actual lived experiences of older people who live independently and their preferences. Most qualitative and quantitative research has taken place within institutional settings (e.g. Wigdor and Ploufee ), and tends to focus on the psychological wellbeing of older individuals after relocation. There is considerably less research into the subjective experiences of very old people still living at home, and this serves as a key motivation for this study. Utilising salient psychological theories of ageing to provide a conceptual framework for enquiry, the specific goal of this study was to achieve an understanding of the lived experiences of very old people committed to staying at home rather than entering residential care.

Psychology of ageing: theoretical perspectives on ageing

One single theory of ageing cannot encompass the rich diversity and essence of human experience, as individual variation is the rule, not the exception (Zajicek ). Some post-modern thinkers, disputing the relevance of mainstream theories of ageing (Belsky ), prefer to address specific aspects of ageing, rather than construct grand, universal theories. Mindful of the paradigm shift away from unifying psychological theories of ageing, this study examined the unique ways in which its participants narrate and understand their own experience of ageing (Cohen, Kahn and Steeves ).

Successful ageing: developmental approaches

While growing very old may be experienced as a sequence of losses leading to a natural process of disengagement, for example through the death of a close relative (van Baarsen ), it may also be seen in a more positive light (Dittmann-Kohl ). This notion is based on the concept of continual development (Walker ). Erikson's seminal theory of the psycho-social stages of ageing offers a developmental perspective of old age as a phase in the lifecourse of human development; a time for reflecting on one's life with either satisfaction, or despair over one's losses (Erikson ). It may also be a time of generativity (Neugarten ), of productivity and creativity rather than stagnation (Hinck ; Terrill and Gullifer ).

Erikson's early work has influenced theories suggesting that physical decline in old age can be psychologically transcended (Reed ; Tornstam ). Erikson and Erikson () have shown that integrity and wisdom acquired throughout life can enable strength in old age and the capacity to live in the present as well as the past and future.

Selective optimisation with compensation (SOC) offers another developmental conception of psychological ageing (Baltes and Baltes ; Baltes and Smith ). Effective adaptation to increasing physical and cognitive decline begins by limiting efforts in endeavours of high personal priority, and using external aids to compensate for losses (Baltes and Smith ). Older people may, for example, choose to relinquish the more laborious tasks in their gardens and concentrate their energy on small flower beds that prosper in response to the increased attention.

Adaptive theories like SOC form key components of the broader psychological paradigm known as successful ageing (Gingold ; Rowe and Kahn ). Jutta Heckhausen and Richard Schulz's lifespan model (Heckhausen and Schulz ) offers an important theoretical example. Its main strategy involves honing performance in essential areas of life, judicious use of external aids (Heckhausen and Schulz ), and pursuing activities that support belief in one's ability to perform goal-oriented behaviours and enhance feelings of control (Schulz and Heckhausen ). This interesting variation on SOC suggests that a sense of control is critical in enabling people to age successfully in place (Lachman ).

Control theories

The lifespan model of successful ageing distinguishes between concepts of primary and secondary control (Blanchard-Fields and Chen , ; Heckhausen and Schulz ). Primary control signifies one's ability to influence the external environment via direct, instrumental action, whereas secondary control allows feelings of helplessness to be lessened by adopting an accepting attitude to irreversible physical limitations and realities (Brandtstadter and Renner ; Brandtstadter and Rothermund ). Practical home modifications such as shower rails and ramps are an adaptive, compensatory mechanism involving primary control (Heckhausen and Schulz 1995; Smith, Marsiske and Maier ). Secondary control might involve the cognitive acceptance of physical limitations and avoidance of possible psychological sequelae such as depression (Oswald et al. ).

A sense of personal control appears crucial to the psychological wellbeing of very old individuals facing environmental changes, transition stress and other losses, whether inevitable or not (Bandura ; Bertrand and Lachman ; Brandstadter and Greve ; Chowdary ; Clarke-Plaskie and Lachman ; Heckhausen ). However, a sense of control has been found to decrease in very old age as dependence on others increases (Brandstadter and Rothermund ; Cerrato and Fernandez de Troconiz ). When decreased perceptions of control include lack of choice about living environments, depression, withdrawal and feelings of helplessness often result (Parmelee and Lawton ).

Continuity within a familiar environment has been identified as a crucial factor in the desire to remain at home (Wahl ). Continuity theory interprets ageing in place as an adaptive strategy employed to support ‘inner psychological continuity as well as outward continuity of social behaviour and circumstances’ (Atchley : 183). This theory offers a useful description of the ways adults draw on their past to conceive of their future and respond to the changes of normal ageing (Atchley ). To older people loss of continuity suggests volatility in their life and environment (Fry ; George ; Moen, Erickson and Dempster-McClain ). It is reasonable to suppose that when attachment to home and community is permanently ruptured by entry to permanent residential care, the continuity that nourishes their sense of identity will be threatened (French, Gekoski and Knox ; Pretty, Chiuper and Bramston ; Wilmoth ).

Attachment to place

Very old people, perhaps more than any other age group, feel strong attachment to their homes; not only to the physical setting but to the things, experiences, memories and expectations embodied therein (Hidalgo and Hernandez ; Marcus ; Rowles ; Rubinstein ), and to its community of location and socio-cultural milieu. Home provides older people with a sense of autonomy and independence (Hearle, Prince and Rees ), of control over daily activities and events, body, individuality and social status (Golant ). Home enables independence ‘by defining a space that is controlled by and is uniquely the domain of the individual’ (Kontos : 286). Thus ‘home’ means more than the structure in which a person lives; home represents the independent self and enables independent life (Sixsmith ). In the broader sense, ‘home’ refers to the constellation of both the built and social community within which the individual resides. Hence attachment to place will vary according to the unique interwoven elements of the older person's physical place of residence, the social and constructed community, and the tenure of the individual within that community. Arguably, it is likely that there is a positive correlation between length of time a person has lived in the one house, the quality and number of meaningful relationships and social supports the individual has developed within the neighbouring community, and their subjective sense of attachment to home.

Sixsmith and Sixsmith () explored the meaning of ‘independence’ for very old people in the context of home. Surveys of people moving into residential aged-care found that by comparison, at home they felt physically self-reliant, more able to exercise self-direction or control, and were free of feelings of obligation. Home offered them historical continuity, a sense of being settled. It preserved the elements of life, personal projects, activities and memories that maintain one's self-concept or identity during the later years (Mitchell and Piggott ).

Home and preservation of self-identity

Self-identity involves making distinctions between oneself and significant others; it extends to objects and things and the spaces and places in which they are found (Altman and Low ; Proshansky, Fabian and Kaminoff ). Home's contribution to personal identity is critical (Aberg et al. ). Home provides more than just a physical shelter for older people (Pastalan ). Home nourishes their sense of self, provides continuity of history and support in times of change (Altman and Low ; Gullifer and Thompson ), and connects older people with their younger selves to their current physical and psychological status (Coulthard, Walker and Morgan ; Cuba and Hummon ; Evans, Kantrowitz and Eshelman ; Fried ; Rowles, Oswald and Hunter ; Rubinstein and De Medeiros ). If ageing in place provides the positive outcomes suggested above, physical dislocation may adversely affect older people's psychological and emotional wellbeing.

Home versus residential aged-care

The transition from home to residential care has been described in gerontological literature as one of loss and regret (Groger ). Losing one's home can be extremely painful for older individuals and for their families. Hepworth (: 94) notes that home is ‘a prominent narrative turning point in stories of ageing’. Research comparing community-dwelling very old people with residents of care facilities offers objective evidence for the negative effects of this transition (Antonelli, Rubini and Fassone ).

Community-dwelling older adults tend to enjoy more intimate relationships and positive self-evaluations, are more interested in others, and suffer less depression than residents of care facilities (Sampson ). Similarly, research in the field of environmental gerontology indicates that people living in their own homes cope better with widowhood (Baldwin ; Rothermund and Brandstadter ), loss of mobility (Krothe ) and sub-optimal housing (Crystal and Beck ) than residents of care facilities. The preference to cope with the challenges of ageing (Wahl ) at home does not necessarily mean withdrawal from society. A refusal to accept the ‘truth’ about their vulnerability at home may puzzle or frustrate family members, yet this seemingly recalcitrant behaviour may be a strategy that allows the older person to retain their sense of themselves and their place in the world (Macdonald and McDermott ).

The foregoing research indicates that older people are drawn to the home for affirmations of self-identity, security, familiarity and new ways of interacting with the community. Examining the psychological constructs reviewed thus far may suggest that the meanings of home to older people – autonomy, independence, security and continuity of self-identity, create strong preferences for ageing in place and continuing to live in one's own home (Coulthard, Walker and Morgan ).

Research based on a holistic and nuanced understanding of older peoples' refusal to leave their home for residential aged-care, despite compelling health and safety concerns, is therefore essential. Home as a place for ageing well is often imagined in ideal terms, but whether this ideal reflects the lived reality of very old adults requires further qualitative research (Bordo, Klein and Silverman ; Perkins and Thorns ).

Methodology

Most prior studies investigating links between psychological processes of ageing and attachment to place have used quantitative methodologies (Fried ; Kendig et al. ), while most qualitative research has focused on residents in aged-care settings rather than very old people living independently (Altman and Low ; Oswald and Wahl ; Rowles and Chaudhury ). Research so far has largely emphasised observable phenomena such as deterioration in cognitive abilities, and conceived of ageing as a progressive, inevitable phase of senescence (George ). Qualities such as contentment, compassion and integrity may elude capture by the tools of quantitative research, whereas deficit-based, quantitative research tends to reinforce the ageist view that older people pose a burden to society (Ranzijn ).

The present study, based on experiential research, seeks to offer deeper insights into the way older people think and feel about living independently, and the ways in which their self-concept and identity intersect with their struggle to remain there. The primary goal of this study was to generate a comprehensive description of the experiences of community-dwelling very old people, as told by them (Kerschner and Pegues ). This methodology was chosen for its salutogenic perspective (Macdonald and McDermott ); that is, it explores gains as well as losses during old age, health rather than merely ill health, and strengths alongside weaknesses.

While this study aims to conceptualise the experiences of very old (aged 85 plus) individuals living independently at home, it also seeks to assist health-care professionals in informing the development of appropriate interventions to support ageing in place, and reduce the risk of adverse psychological consequences for older people who may, at some point, need to enter residential care.

A key strength of qualitative research is the emphasis on individual experience. From a psychological perspective it is necessary to understand the changes and psychological conditions that may accompany old age (Bryant, Corbett and Kutner ) and that current research on age-related changes does not neglect the individual experience. Giving primacy to individual experience (Holloway and Todres ) and the lived experiences of reality, in order to understand the phenomenon under research (Holloway ; Kruger ; McLeod ; Maypole and Davies ; Robinson and Reed ) resonates with Interpretative Phenomenological Analysis (IPA) (Smith and Osborn ) and is therefore the appropriate research method for this study.

IPA offers a path to understanding how very old community-dwelling adults make sense of their social world, interpret their own life experiences and assign meaning to independent living. IPA allows an understanding of the ways in which older people's unique characteristics affect their desire to remain at home (Benner and Wrubel ; Koch ). It does not require a predetermined hypothesis on the researcher's part; it aims to explore the personal lived experiences of a phenomenon of interest, rather than produce an objective statement of the event or object itself (Davidson ; Jones ).

Participants

A total of 23 men and women aged at least 85 years who live independently in rural Australia took part in this study (19 women, four men, with a mean age of 90.7 years, range 85–101 years). Of the 19 women, eight were widows who lived alone, seven lived with their partners and four were never married, also living alone. The four men were widowers and lived alone. Twenty lived in rural towns located in the state of Victoria with populations of less than 10,000 residents, with three residing in a larger provincial city with a population of approximately 100,000.

Most participants owned their own home, had lived in their current home and community for over 15 years, with five having lived in the same rural community for their entire life. Four participants lived in government-subsidised housing and were classified as experiencing a higher level of financial hardship. Eighteen participants were in receipt of either a full federal aged-care pension as their sole income, with five participants receiving a partial government pension to supplement their superannuation income (annuity payments from private investment). Fifteen participants required some sort of aid to assist their independent mobility, such as a walking frame, with two requiring a wheelchair to ambulate. Sixteen participants required some form of personal care support to provide either direct physical support or supervision for hygiene care (showering). The participants were screened from inclusion if a medical condition such as a diagnosis of dementia impaired their legal capacity to give consent. Only three of the participants were born outside Australia, and they had all emigrated during their early adult life during the post-Second World War immigration programmes promoted and sponsored by the Australian Government.

Table 1. Participant characteristics

Procedure

Institutional ethics board approval was gained from Charles Sturt University, School of Psychology. Voluntary participation in the research was extended to older clients of a large not-for-profit, community service organisation, Villa Maria Society, who operate a range of government-funded residential aged-care facilities, community-based health and disability care projects across the state of Victoria. Potential participants were presented with information about the nature and objectives of the research project, with careful screening of people who had a significant cognitive or psychiatric condition that impaired their legal capacity to consent to participate in the research.

Interviews took place during May and June 2010 and were conducted by the first author (DS) in the participants' homes. The interview with each participant lasted approximately one hour and was guided by the level of fatigue and willingness of the participant. An interview schedule (see the Appendix) was used that broadly covered domains of experience concerned with living at home, identity, independence and resilience. All interviews were audio recorded and subsequently transcribed verbatim, enabling interpretations to be supported. Words and phrases of native language were captured phonetically when they were different from standard English to reflect the meaning within the language accurately (Mishler ; Sandelowski ). Vocalisations such as laughter or crying were added during transcription. The transcripts were then compared with the audio recordings for accuracy, and finally, consensual validation was obtained with six participants who read and confirmed their own transcripts.

Analytic method: reflections on the process of qualitative inquiry

Preliminary interpretation began during interviews and transcription. More formal analysis and interpretation commenced as each transcript and field note was read in order to obtain an overview of the interview. In line with the idiographic approach to analysis, which begins with particular examples and slowly works up to more general categorisation or claims (Smith and Osborn ), the initial overview was expanded with careful re-reading, in detail and from different perspectives (Cohen, Kahn and Steeves ), before moving on to examine each one, case by case.

Each piece of data suggesting a separate unit of meaning (Aronson ; Braun and Clarke ; Hayes ) was coded. These coded units of data across multiple cases were clustered into proto-themes for further development as the analysis proceeded (Hayes ). The proto-themes were then funnelled into a group of consistently emerging themes reflecting the key areas of interest. Interpretation focused on comparison of similarities and variations, not just frequency of themes. Within- and across-case comparisons continued throughout the interpretive process as transcripts were re-read.

Distinctions were drawn between readily accessible semantic themes, and latent themes at the interpretative level of content analysis (Braun and Clarke ). The final themes developed were integrated with literature (Aronson ). In keeping with the cyclical, non-linear nature of qualitative research (Hayes ), a second review of the literature took place.

Findings

Drawing together the participants' reflections on the importance of living independently, four interrelated themes emerged:

1. 1. Beholden to no one: home affords maximum autonomy and privacy.

2. 2. Residential aged-care is stagnation of the self whereas home sustains self-identity.

3. 3. Home, a warehouse of memories connecting the past and present self.

4. 4. Attachment to place: independent living has relational utility and gives purpose to life.

Evident within the themes were participant descriptions of the way home mediated their connections to people and events in their past. To them home meant constancy in the face of change and loss: sticking it out together ‘to the end’, whether the end meant their death or the end of their tenure at home. Their narratives revealed key factors that sustained their desire to live at home for as long as possible.

The participants expressed satisfaction in the knowledge that they were living independently and often alone in their homes, taking care of their homes and themselves. Living at home rather than in residential care gave them a sense of freedom to do as they pleased. Satisfaction in devising their own daily activities – suiting themselves – was especially notable among participants who lived alone. This sense of freedom was sometimes qualified by a certain frustration that the routines of home-care workers attenuated that freedom.

In the following description of the component themes, data examples demonstrate the relationships among the component phenomena. The personal–social context of the component phenomena is addressed. Finally, the limitations and implications of this research are considered in terms of the study's aims.

Theme 1: Beholden to no one: home affords maximum autonomy and privacy

This theme describes how the participants linked their sense of personal autonomy to their independent living status. Autonomy means independence and determination of one's own life; the ability to resist social pressures to think or behave in a particular way; to evaluate one's life by internal standards (Ryff , ). The participants expressed consistent satisfaction at being in control in the privacy of their own homes where they could exercise their personal preferences, rather than comply with those of others as indicated in the following comments:

I don't have to bow to anybody else. (Richard)

Yes umm, I can make my own decisions without having to be told by others what to do … and I can have my own privacy. (Max)

More control over everything really … and at our age you have less control over a lot of things. (Olivia)

Control in daily life, the freedom to choose activities, decline assistance and do things for themselves, symbolised autonomy. Even when independence in self-care was tested following a setback in health, participants associated independent living with the capacity for autonomous decision making. Virginia described modifications to her routines that enabled her to maintain her independence:

I want to do as much as possible for myself … like when they offered to have the district nurses coming in to organise your pills. I have one of those Webster packs. And it's all laid out for me instead. (Virginia)

Virginia's determination to perform her own daily tasks reflects an association between mental and physical competence that was woven throughout the narratives.

Most participants wished to manage their own care tasks. Yet when increasing frailty presented them with a stark choice between assistance at home and entry to residential care, they accepted services. Their change of heart supports research suggesting that older people retain a sense of personal control by adapting to crises that threaten their functional equilibrium (Nygren, Norberg and Lundman ), as demonstrated in the following extracts:

Oh, I don't mind other people doing these things … it allows me to be able to be at home instead of in hospital or a hostel… (Jane)

Well, I'd rather not have to have them [home-care help] … but it's a sort of trade off … I get to keep independence longer. (Olivia)

Yeah, like just because I get some things [home-care assistance] doesn't mean I've let go of the reins up here [pointing to her head]. (Winnifred)

The decision to relinquish absolute independence for a degree of support allowed these participants to remain at home despite significant physiological decline; they maintained a sense of decisional control even as their capacity for direct instrumental control diminished. Their strategy reflects prior research suggesting that secondary control usage increases with age (Grob, Little and Wanner ; Heckhausen and Schulz ). In the following samples, participants reveal the nuanced ways they distinguished assistance with general tasks from those essential to their personal dignity:

You've got to have some self-respect … I would struggle to stay on top of some things like my meals … and yes, my own, you know, washing … bathing… (Richard)

Oh … I don't really mind, after all [referring to home-care assistance]. I need some things done so you just have to accept it… (Virginia)

Interviewer:Climbing over baths is a classic way to get into trouble, isn't it?

Kaley: …but there's nothing like a good bath…

Interviewer: …a choice to accept a little less safety for the sake of your preference…?

Kaley: Yes, really I have, I suppose.

These vivid reflections demonstrate the internal, lived conflict participants feel as they strive to continue living independently. Switching from a primary to secondary mode of control (i.e. Schulz, Wrosch and Heckhausen ) – from the actual ‘doing’ of self-care to ‘holding the reins’ – was not a simple matter:

Selena: Well I need them [home-care assistance] so there is no point complaining.

Interviewer: What would you complain about?

Selena: Just having to rely on others to do what I could do before.

Sort of like big brother is watching … [referring to personal safety pendant]. So, I resent it sometimes. Then again, I suppose it beats falling over and not having anyone to help… (Jane)

In trying to understand the source of the resentment for Jane, a clue may be found in the comment from Felicity, who resisted relinquishing her laundry:

Some of them want to come in and do the [clothes] washing, and I won't let them … (laughing). It's probably what's kept me going past 90! (Felicity)

Felicity alludes to the importance of doing things in order to keep her authentic self alive. She defends against the loss of self-integrity by engaging secondary control strategies (Brandstadter and Greve ), thus bridging the dissonance between help-accepting behaviour and the opposing belief that self-integrity requires total self-reliance. The use of adaptive strategies to manage changes associated with physical disability and preserve their wellbeing at home is explained by the life-span model of successful ageing (Heckhausen and Schulz 1995).

Theme 2: Residential aged-care represents stagnation of the self whereas home sustains self-identity

This theme describes the unanimous expressed aversion to the idea of residential care, on the basis that a care facility would erode their autonomy and self-identity (Macdonald and McDermott ), as expressed in the following comments:

Going into care … it's like the final handover of what bit … of control we've got left. (Olivia)

Selena:I've seen other friends go in … and within 12 months they've just died.

Interviewer: You mean physically died? Or they died in their heads?

Selena:Both. You go and see them, and each visit they are just that much worse.

Yes you see these older ones I know … at the retirement village and they are like … shells. (Jane)

Selena's view reflects the story referred to in Ignatieff (: 99) in which residential care signifies the imminent, literal and metaphorical death of the person. The participants' hostility towards residential care appears to have been shaped by their own experiences and those of their friends. Their antagonism sometimes appeared to exceed their attachment to home. Norma, a centenarian who had endured humiliating and patronising treatment during a period in respite care (short-term stay in an aged-care facility), reiterated her abhorrence of residential care 14 times during the interview:

I won't go. I'd never go and I wouldn't advise anyone to go. (Norma)

The strength of participants' attachment to home may not have been exclusively due to an affective bond of attachment to that home (Atchley ; Sixsmith ). The phenomena of psychological attachment espoused by attachment theory does not fully account for the negative factors, even profound fears that keep very old people at home. Only one participant, Virginia, appeared sanguine about the prospect of residential care. Otherwise, a consistent narrative throughout the interviews was that residential care meant stagnation of life, while home represented the preservation of the self.

The participants' reluctance to enter residential care reflected their sense that home was where they could be themselves, as illustrated by Sixsmith and Sixsmith (). Jane and Felicity described how home preserved their authentic selves:

…it's the only place you can just be yourself… (Jane)

At home it's just so much easier to be yourself. In fact, home is like part of who you are. (Felicity)

Interviewer: …how do you feel about these things in your house?

Max:They come … altogether. I mean … the whole house … like an old friend … I'm never lonely.

Even the language used to describe the home is one of personhood. Over time, home blends with the older person's self-identity (Belsky ), becomes ‘an old friend’. The home and the personal objects in it nourish the individual's self-concept by enabling and embodying the authentic self (Gullifer and Thompson ). This helps us to understand why an older person facing the prospect of residential care may fear disconnection from their authentic self (Antonelli, Rubini and Fassone ) and becoming a living ‘shell’, as described by Jane.

The participants often said that they felt no different from their younger selves, despite their changing bodies. Continuity theory (Atchley ) suggests that the individual's ability to preserve their enduring self in the face of unavoidable changes depends on successful adaptation to those changes. By integrating continuity theory with attachment to place, we propose that the participants in this study equated independent living with continuity of the independent self, in all its struggles. Consider Felicity's comments:

Felicity: I'm a fighter [talking about her bouts of cancer].

Interviewer: You see it as a battle to be won.

Felicity:To fight on … yes.

Interviewer: The house is part of that?

Felicity:Yes, the only way I leave this box is in a little long box! (laughing)

At the semantic level, Felicity's self-identification as a ‘fighter’ describes her struggles with her health and her resolve to remain at home; latently it may suggest a respect for strength. When contemplated within the psychological framework of lifespan development (Bertrand and Lachman ), life's ‘fights’ or battles, including the struggle to remain at home at almost any cost, represent continuity with values essential to the older person's self-identity. In this narrative of fight and battle, the house is the participant's friend ageing with her, in harmony:

I'm so glad I've been able to stay put here … It's like part of me I suppose after this long … well I haven't changed much except for getting older and the house neither. (Norma)

Yeah, like we've got past the point of no return is how you could put it! (Dorothy)

That bond between ageing body and ageing house may reflect a way of coping with a constantly changing outer world (Fry ). Home becomes a last bastion, a bulwark of resistance against unwelcome change, and the losses that accompany it.

Winnifred: They're all gone now, everyone's gone now, I reckon…

Interviewer: But you and this house?

Winnifred:We are going to keep going to the end!

Interpreting the data in this theme integrates and augments theories of continuity (Atchley ), attachment to place (Sixsmith and Sixsmith ) and lifespan development (Heckhausen ). Continuity at home is believed to be desirable because of the affective bond formed. But fear of the alternative is equally powerful. Home, as a companion and a witness to the past, enables the enduring, present self to face and manage environmental change, while preserving and protecting one's self-identity. (Fry ; Wilson ).

Theme 3: Home, a warehouse of memories connecting the past and present self

This theme explores the significance of living at home with the preservation of self-identity in a temporal sense. Participants described the importance of having a presence in the present as well as in the past, and the central role home plays in enabling them to do this. Being present in the present meant full engagement in important moments such as meeting one's grandchildren (Nygren, Norberg and Lundman ); being present in the past meant gathering strength from personally significant memories (Cavanaugh and Blanchard-Fields ).

Participants offered thoughtful reflections on both the sad and joyful times in their long lives and those memories often involved deceased loved ones. Many participants had experienced the loss of a spouse. Some had suffered the loss of children. Regardless of the intervening years, they referred to their deceased family members in the context of their current life at home:

I had a little girl, the first, and she was born a blue baby … and she couldn't walk from here to the next room – I'd have to carry her. (Selena)

The death of my son it left a big gap in my life, and he still lives with me no matter what or where he is. (Jane)

Evident in both Selena's and Jane's comments are that home held memories of shared experiences with deceased spouses, and feelings of comfort, grief and vulnerability associated with the loss of loved ones. Personal memories strengthened the attachment to home, as demonstrated by Kaley who had lived on the same rural property for approximately 70 years:

Interviewer: Do your feelings about living at home relate to these links you have to the past…?

Kaley:Oh yes … I see them as connected … this house here has been a silent witness to my own life and all those memories.

The participants' efforts to preserve objects of personal significance confirm research suggesting that attachment to home includes objects within it; intimate possessions and intangible phenomena such as ideas, beliefs and values of importance to the individual (Cookman ). Objects and ideas, even those ‘past their prime’, from the perspective of others, were tenaciously protected:

Fancy saying that's got to come down! [referring to a suggestion that an old garden shed should be demolished]. He [husband] had a place, like … in it … tools! … Yes, all laid out properly … mind out if the kids messed it up. And a beautiful garden. Oh, all vegetables, an’ that … it was beautiful. (Winnifred)

I still darn my socks, but the younger people throw everything away. (Dorothy)

These glimpses of the participants' earlier lives and those of their deceased loved ones show attachment not just to the object but also to the beliefs, values or ideas it encapsulates, such as their generation's thriftiness. Younger people might discard old things but the participants attributed durability to certain objects, to good memories of shared effort and even the simple continuing utility of the object. These struggles to save an object or old building may also reflect a fear of being discarded themselves (Cookman ).

Theme 4: Attachment to place: independent living has relational utility and gives purpose to life

Relationships with family and friends, including those who had passed away, emerged as central to the participants' sense of an enduring self. Home, besides mediating their need for autonomy, privacy and authentic self, offered a platform for connecting with others (Hearle, Prince and Rees ). Olivia offered this insight:

I … need to have my own place to go back to. It's where I can be me … and if people come over I can relax with them here.

In the participants' homes they could be themselves to others; give a performance of the self, either openly or unconsciously; recreate personal experience for public expression (Cavanaugh and Blanchard-Fields ). The implication is that older individuals can reveal their personhood in their own home, but not in a residential aged facility. Home allows continuing connectedness with the broader community:

I can still be a part of the world … It's like I'm still alive … at home is still part of the town you know, like always. (Annaliese)

Connection with others confirms Annaliese's sense of self, and satisfies her need to be known as the same vital being she was when she was younger (Altman and Low ). The self can be seen as a collection of relationships interwoven with various values into an overall and biographical sense (Erickson and Erickson, ). The self emerges from relationships as contextual, relational and interdependent.

Research suggests family members often pressure older people to enter residential care. This study therefore took a particular interest in family members' role in supporting the participants' independent living arrangements. Of the 23 participants, only Richard had experienced direct pressure – from a community nurse – and he dealt with this threat to his autonomy by asserting control: by ‘digging my heels in and paying no attention until she let it go’.

Noteworthy was that participants in this study indicated that their family members supported their desire to stay at home:

I know that a lot of elderly people have to put up with being bossed … I have seen it but just been so incredibly lucky not to have it with our children, or from anyone else. (Olivia)

Participants' homes also allowed them to continue important roles which formed part of their self-identity:

I won't be here forever … but with Ivan [son] to look after, and he looks after me, it's better at home. (Virginia)

And when I have it here sometimes [steak and kidney pie] I say to him [referring to Winnifred's son Kevin], ‘Where are you working, … I have some steak and kidney pie’. And he says, ‘Oh, good mum. I'll be down’. (Winnifred)

The relational dimensions involved in the participants' commitment to living at home cannot be reduced to the simple presence or absence of coercion. If adult children suggested changes to household routines after a parents' health setback, a subtle power struggle for control sometimes ensued. The resistance was stronger when the freedom under threat held special importance for the older person:

I love baking and that. ‘No Mum, you might spill something or you slip or something and that.’ He was goin’ on, you know … So, they got me a microwave, you know… [and placed a marble slab over the gas hotplate]. Oh, my son used to say, ‘That looks awful Mum, all the stuff [groceries] you put on the stove’. And I said ‘I'm going to pile it on till you eat it all!’ … Yep, if they block off the stove with that thing so I can't use it then I'll be sneaky and load it up with stuff so that they worry about all that and maybe take it away! (Gerta)

Even though Gerta's two adult sons supported her desire to live at home, she saw their attempts to prevent her using the gas stove as restricting her freedom, responding with mild sabotage. Her defiance, even when the battle was all but lost, demonstrates the psychological strategy of secondary control (Clarke-Plaskie and Lachman ). The older person, while accepting the erosion of her freedom, still asserts her feelings about the matter. This belief in continued competence may be as vital to her self-concept as her objective degree of independence in self-care.

Perhaps most surprising were examples of coercion in the reverse direction: that is, coercion employed by the older person, rather than the family carers, to use the situation at home to achieve relationship goals:

To be honest I don't mind having someone in the family do a bit … it means I get to see my granddaughter a lot more. (Kaley)

Home enables older people to sustain relationships with friends, the broader community and family – and participants attributed this quality specifically to home. The ability to nourish long-term and newer relationships from home supports a sense of self-image, personal competence and self-worth (Aberg et al. ) and the integrity of the self interacting with the environment.

Participants drew a distinction between the physical and psychological dimensions of ageing and distanced themselves from their counterparts in residential care:

Well, I'm old and I don't act old … I'm interested in things, where they [residents of nursing homes] … They sort of pulled down the shutters. (Kaley)

I think you've got to keep being interested in things … some of my friends, before they died, they weren't near as old as me, but they never read a paper or anything like that. (Norma)

Participants associated staying young in outlook with continued engagement in the world. Some were helping family and friends as much as they could and their pleasure in giving pleasure brought positive psychological rewards. Remaining active in spite of physical disability often stimulates opportunities for more mental activities and interests – an essential characteristic of successful ageing (Gullifer and Thompson ; Ranzijn ; Terrill and Gullifer ) – and participants clearly demonstrated this. In various ways, they described the act of keeping their bodies fit as a form of caring for themselves and meeting the challenges of ageing.

Some participants stressed the importance of taking one day at a time subject to their levels of energy or lethargy. This desire to do things at their own pace may have played a part in their aversion to the more regimented timetables of residential care.

A positive mental outlook towards age-related problems contributed to the contentment that most participants felt at home:

Some people spend too much time worrying about things they can't change which I see absolutely no point to … I'm just grateful for what I have … I also think you've got to have something to do each day. (Richard)

I live one day at a time. If I get too crook well I'll have to leave here I suppose … it will be sad and God knows how they will put up with me in the nursing home! If they let me do the things I like it might not be so bad. (Selena)

… I think you need to be prepared to think about it [relocation to residential care] … though I hope it will never happen. (Jane)

The importance of confronting adversity without giving up emerged throughout the texts, suggesting that participants drew strength from their personal struggles. This sophisticated strategy enabled them to cope in a resilient manner with inevitable changes (Rowe and Kahn ). Notwithstanding the profound commitment they felt towards remaining at home, these final data extracts reveal the participants' conscious psychological preparation for the possibility of an unwelcome though necessary relocation to residential care in the future.

The foregoing narratives provide examples of ‘good ageing’ with growth and wisdom instead of despair and disdain (Erikson and Erikson ). Erikson and Erikson describe trust as a shield against hardship in life, but add that it would be difficult to survive without mistrust because through physical decline, ‘elders are forced to mistrust their own capabilities’ (1997: 107). Yet the very old people in this study seemed to meet that decline by cultivating faith in others, including family and formal care workers, rather than mistrust.

Discussion

In summary, the themes derived from the participant narratives revealed that home allowed them to maintain valued roles essential to their self-identity and position in life (Ryff, Kwan and Singer ). The themes represented their inner strengths as generativity (Berg et al. ): the oldest old are still active and using their bodies, while performing mental activities inspired by the body's inactivity. Remaining the same yet accepting new realities gave the participants the stability and strength to accept and adjust to altered circumstances and contemplate the possible end of their tenure at home, whether through a future move to residential care, or death.

The risk of having to relinquish home and enter residential care connects the themes in this study. All participants regarded institutional care as posing at least some threat to their self-autonomy and to life itself (Becker ; Golant ; Hammer ; Krothe ). The depersonalising qualities they attributed to residential care contrasted with the other concept discernible through their comments: that the familiar sphere of home enables continuity of self and nurtures personal control and expression of individuality. This phenomenon concurs with the experiences of older people reported elsewhere and reviewed above (Aberg et al. ; Atchley ) and with prior findings that levels of autonomy and environmental mastery do not necessarily diminish during old age (Ryff, Kwan and Singer ).

The researchers positioning among the data endeavoured to preserve the wholeness, or gestalt of the participants' experience (Stainton Rogers ), while attempting to discern latent narratives within the accounts. Although elements of the participants' experiences have been presented separately in this study for the purposes of illustration, in reality a constant inter-relationship exists between the themes, for example when Kaley describes her preference for taking a bath rather than the safer option of showering. During thematic analysis this was rendered as her positive assertion of being in control (theme 1) – of needing to do tasks for herself – rather than stubborn opposition to the concerns held by others for her safety. Yet, within the same account we see the theme of continuity of self (theme 2) – the desire to enjoy activities that have long held subjective significance, in this particular case one of sensory pleasure ‘…there's nothing like a good bath…’

Furthermore, the interconnected themes yield an insight into the personal meanings underlying the participants' behaviour that single theme analysis does not afford. For example, gaining insight into the emotional function or purpose of bathing instead of showering, namely validation of the participant's self-identity (theme 2), informs our understanding of what it means to continue ‘to do things for myself’, a subset of the primary concept of autonomy (theme 1). Consequently, this vignette leads to a super-ordinate narrative constituted by both themes which could be summarised as: risk-reduction strategies (e.g. showering versus bathing) might help maintain physical independence at home, but what is the point of independence if features essential to the older person's self are sacrificed in the process?

The participants' confidence in their ability to cope with health problems, bereavement and the maintenance of their home epitomises the lifespan human development theory of psychological ageing in which generativity and strength are derived from successfully managing life's difficulties (Erikson and Erikson ). Although not explicit in their observations, the participants conveyed a deep sense of contentment to the researchers as they sat among their family photos, keepsakes and mementos and, in some cases, within the walls where they had raised their children and lived out their lives. The thought of having to relinquish their personal space and history, as well as their privacy and autonomy, would cause them a grievous sense of loss.

Finally, living in the place where they could best be themselves – their own homes – was fundamental to all component themes. At home, the participants could keep busy, care for themselves and pursue specific interests because they had the right supports at hand and the space to act as they intended. At home they need bow to no-one. Undertaking tasks for themselves and having a purpose in life sustained them because they focused their daily lives on short-term, practical goals. The participants' accounts yield narratives of dynamic competence within the constraints and deficits of old age; they demonstrate attitudes and behaviours characteristic of successful ageing (Abraham and Hansonn ; Diener and Suh ; Gingold ; Heckhausen and Schulz ).

This study's principal objective was to gain insight into the subjective experiences of a small group of very old individuals committed to living at home. Thematic analysis confirmed that remaining at home is an important value even when age-related health problems create major challenges to independent self-care and home care. Participants had adapted their environment and their everyday practices to accommodate their desired activities. When asked how they felt about the possibility of residential care, the majority saw it as a profound threat to their personal autonomy and privacy.

The purposive sampling employed for this study attracted participants still actively engaged in their community and deeply committed to living at home, thus excluding those who may feel more socially isolated. Likewise, there were other dimensions of the participants' living context beyond their immediate home that due to the study limitations were not fully explored. Principally, the rural residential setting of the participants in all likelihood is an operant factor in the construction of their desire to remain at home, perhaps due to some cultural resilience or sense of independence emerging from a rural context. The individual residential biographies and lifecourse trajectories around place and home were key constituents of the participant's strong commitment to continuing to live independently, especially for participants who had resided for long periods in their current home and community. For example, the participant Richard, who was suffering progressively deteriorating visual functioning, had lived as a bachelor for his entire life within the one small country town (population 1,000), with most of his adult life in the same house in a street with long-term and supportive neighbours. It is quite probable that his spatial commitment to staying in his current home at all costs, despite living alone with severe sensory impairments, would be different had his residential biography been different and more mobile.

Other external factors that could affect the participants' experience of living at home, and compromise their independence, could include significant changes to their family structure such as loss of a spouse, disruptions to accessing support from family carers, and the availability of social service infrastructure. These important variables were present throughout the participants' reflections, but admittedly were not adequately explored in this study, presenting further opportunity for further research. Notwithstanding these limitations, the basic findings of this study add knowledge about successful ageing in place, and inform the second study aim of improving intervention strategies for community aged-care services.

The thematic findings suggest that professionals involved in either assisting older people to stay at home, or move to residential aged care, need to understand the unique meanings their clients may assign to their homes, and their likely preconceptions about residential care. This research suggests that older people's unique circumstances, personal history, existing resources and psychological outlook will influence their commitment to remaining at home. Accordingly, assessment and planning processes that health-care professionals undertake to facilitate delivery of either home-based care services, or transitioning from home to residential aged-care, will be more effective if they explore the subjective psychological and emotional drivers of individual behavioural responses to interventions. Kaley's example above adequately demonstrated this. Unnecessary conflict, and misdirected resource allocation, can be avoided if a professional assessor seeks to appreciate the latent psychological dimensions to Kaley's preference for taking baths, and the unintended psychological harm caused by failing to comprehend these and focusing only on the more tangible physical safety risks and persuading Kaley to exchange bathing for showering. This research suggests that current home-care assessment approaches (and standardised assessment tools) could be enhanced by incorporating measures to gauge the psychological and emotional functions of individual preferences in self-care, dietary, social and home-care. Unfortunately, at present, many standard home-care assessment approaches adopt a dualistic stance that separates domains of functioning into separate physical and psychological categories (i.e. conceptualising the ‘how you function – physical’ and the ‘how are you feeling – psychological’ as important but nevertheless disconnected, discrete components of living). If there is one overarching insight from this limited research for health-care personnel involved in supporting older people to live at home, it is the worthiness of sensitively appraising the intrinsic psychological value of preferred activities and routines for an individual, rather than leaping straight from problem identification to paternalistic service response.

Likewise, it was apparent that participants defined their capacity to live at home by their abilities to function and retain control rather than by their limitations to do so. Information about home services and safety interventions may therefore be more effective if it reinforces rather than challenges the older person's desire for self-sufficiency and decisional control. Understanding older people's needs and desires is vital in providing them with health and community care services that will nurture inherent psycho-social resources acquired over a lifetime. Any consideration of a move from home to residential care should take into account the rich meanings, histories and significance of older people's attachment to their home, and the potential disruption of paternalistic interventions (McDaniel ; Wilson ), such as that experienced by participant Richard. Insight into the deep bond between Richard's self-identity and his struggle to manage at home (despite severe vision difficulties) should motivate professionals to find ways to help him stay at home. Staying at home despite difficulties is a substantial part of who Richard is, not a ‘risk factor’ to be neutralised by the comparative safety of residential care. Such a forced relocation would pose the biggest safety risk to Richard's self-identity.

Such person-centred approaches could augment the many qualities acquired over a lifetime, and show genuine respect for older people's autonomy: a fundamental ethical position easily embraced in principle, but more difficult to support when an older person's physical safety is threatened. Winnifred's story demonstrates this in theme 1. Despite progressive health problems, Winnifred knew what living meant for her and still saw herself as the good cook she had always been. Continuing to cook was not primarily, for her, about nutrition. It signified her own robust, continuous self-identity, reinforced externally by other people's appreciation of her skills. This insight, applied to practice, would respect Winnifred's autonomy and promote successful ageing by offering her assistance to continue cooking rather than receive pre-prepared food.

Prior research (Sixsmith ) suggests that older people's preference for ageing in place is based on deep attachment bonds to home, formed over time. However, this study found considerable variability in that attachment. In many cases, aversion to residential care seemed to play as significant a part in the desire to remain at home as positive affective attachment factors per se. Although this study's methodology does not permit comparisons or conclusive statements about the motivations underlying the participants' preference for ageing in place, it may be that some older people feel vulnerable or lonely at home, but remain there because of untested fears of residential aged care.

Accordingly, additional research could explore whether older people experience genuine dis-attachment distress when absent from home, or whether their psychological state reflects a fear that the culture of residential care will subsume their sense of self. Research into this question could assist the development of strategies to support transition from home to residential care, especially when transition becomes unavoidable due to increased health and safety risks. Such strategies could include organising short-term respite to allow older people to test their preconceived assumptions about residential care; providing detailed information about the facility's dedication to encouraging individual preferences and autonomous decision making; the allocation of psychological resources to support the transition experience; and opportunities for older people to remain vitally connected to their community of origin.

The perspective of this unique group aged over 85 offers a basis for developing interventions to help them remain at home as long as possible (Thornton and Tozer ). With one exception, overt family or professional pressure to enter residential care was conspicuously lacking from the participants' experience. Instead, complex relationship dynamics with family carers were evident, particularly with adult children, with the home best placed for preserving reciprocal caring relationships. This suggests that very old people see themselves as active supporters of others rather than passive recipients of care services – an insight that should encourage care providers to nurture, not diminish, interactions and relationships in which older adults play a supportive role. More extensive qualitative research would help evaluate existing community aged-care policy settings, which at present tend to isolate people from their socio-cultural context, downplaying the valued role of family care-givers.

In conclusion, this study gave voice to the concerns and feelings of a group of participants who, although they represent the fastest growing segment of our ageing population (85+ years), have not been well represented in studies about the psychology of ageing. We are only beginning to explore the largely un-narrated experiences of very old people – a field that offers opportunities for community aged-care service policy to harness the generative psychological capacities of older people (Cutchin ; Gitlin ). The lived experience of our participants expands our knowledge of the meanings and forms of growth experienced by older people living at home, and their amazing capacity for positive growth rather than disengagement.

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