Issues for people living alone
The proportion of people living alone in Australia increased from 7% of the population in 1986 to 9% in 2001. This is projected to increase from 1.8 million in 2001 to between 2.8 million and 3.7 million by 2026, representing an increase of between 57% and 105%. [1] It has also been projected that in 2021 between 20% to 24% of people living alone will be older Australians (aged 75 years and over), and of these about three-quarters will be women. [2]
The changing nature of living alone
With the changing demographics of the family (less inter-generational cohabitation) and increased migration (families living interstate or overseas) the opportunity to have informal care provided by an extended family member is diminished. [3, 4] More recent social trends such as declining fertility, delays in having a family, increased divorce rates and increasing life expectancy, has also contributed to the decrease in the availability of younger carers. For many older people, informal care support is provided by an elderly spouse.
Trends over the past 30 years have seen more women in the workforce with financial and social independence and less reliance on a husband as wage earner. It is also now more socially acceptable not to marry or have a family (for both men and women). Many people prefer living alone without family pressures and demands on time, as work and/ or life-long learning demands are increasing. [5] As the population increases, so do the number of those living with chronic illness, many of whom are elderly. This may mean being alone at home with less capacity in terms of function, mobility and access to social activities.
In the past elderly widows were those more commonly found living alone, but adults in their middle years are now beginning to increasingly live alone, and although the majority of younger people still live in family households, the number of people aged 20-29 years living alone has almost doubled in the past 30 years. [5]
Likely Common Issues for people living alone
A report produced in 2002/3 by the Department of Families, Housing, Community Services & Indigenous Affairs entitled ‘The lone person household demographic: Trends and implications’ [5] highlights common issues with implications for health and ultimately for palliative care. Living alone appears to be correlated with lower levels of social and economic participation, along with a higher prevalence of mental health disorders, than other household types. Of those living alone and not in the work force over 70 per cent were aged 65 years or more. Bray, in his analysis of financial stress and hardship in Australia, describes lone person households as experiencing higher than average levels of financial stress and multiple hardship. [6]
With increasing life expectancy many people are outliving spouses, friends and other family members.
Fewer social supports are likely to exist as people get older, especially if they are living alone. Isolation and loneliness can be co-existing problems and will differ according to gender or to cultural differences. Some older people will withdraw from social contacts through their own choice, and either way there are less support mechanisms for these people when they are ill or dying which often means increased hospital admission as and when problems arise.
End-of-life issues
Many people if asked would say they would like to die at home. The question of place of care and place of death is often posed when people are well, and not always raised again as an illness progresses. Some people may change their mind as their circumstances change. Being cared for and dying at home cannot always be realised, especially where there are implications for end-of-life care such as access to 24 hour care. [7] Not everyone wants to die at home with some looking for a more supportive environment, possibly as the implications of dying at home could mean dying alone. [8] The ability to participate in decision making is paramount, and a home death should not be inappropriately encouraged nor should it be necessarily seen as a marker of a quality death. [9,10]
Much of the literature in Australia and overseas in relation to place of death cites living alone (with no informal carers) as a factor associated with decreased likelihood of a home death despite any choices that have been made. [8, 11, 12] In their study of 40 (healthy) UK citizens aged 80 and over Lloyd-Williams and colleagues found many stating their wishes not to have to move from their current home before dying. [13] This is a common theme with the emphasis that living alone significantly predicts admissions for symptom control and an increased likelihood of death at an institution. [14,15] In their study in the UK, Grundy and colleagues found that cancer patients who live alone report more distress, poorer adjustment to diagnosis and have a poorer quality of life than those living with others. [4]
Those without a caregiver need considerably more practical assistance and liaison regarding care, with additional time spent per visit providing support tasks. [15] Relationships with friends and family become significant in place of death, with those living alone reliant on such outside support, which can take many forms (eg, providing emotional comfort, financial assistance or practical help). Some people if able, will move in with family, or others will have relatives helping at home staying with them overnight as needed. [4] The health of family and friends as potential support people for those wishing to die at home will then also be a consideration. [4,12]
A study in the UK looked at characteristics of patients as a marker to predict the likelihood of a home death and found older patients and women were less likely to die at home, with cancer patients in higher socio-economic groups more likely to die at home. [16] Brazil and colleagues in Canada also found that dying at home was associated with GP visits at home. [17] A review of the literature on social and cultural determinants by a group in the US found other variables that may impact on the site of death as functional status, length of time since diagnosis, pain and symptom management, causes of rehospitalisation and patient wishes.
Others living alone will not have family or close friends, managing sometimes with the help of neighbours or local community resources such as community health services, local councils and the church, or sometimes with no help at all. Some individuals have a strong need to maintain their independence and will often have the resilience to manage by themselves for long periods of time. [11] Some will refuse all offers of help, however there are often safety implications in these choices for the health professionals who interact with them.
Policies and Resources
References
- Australian Bureau of Statistics. Future living arrangements, 2006; ABS cat. no. 1301.0.
- Australian Bureau of Statistics. Household and family projections, Australia 1996 to 2021. 2006; ABS cat. no. 3236.0.
- Davies E, Higginson IJ. Better palliative care for older people. Copenhagen: World Health Organization; 2004.
- Grundy E, Mayer D, Young H, Sloggett A. Living arrangements and place of death of older people with cancer in England and Wales: a record linkage study. Br J Cancer. 2004 Aug 31;91(5):907-12.
- Clark D. Australian Social Policy 2002 - 2003. The lone person household demographic: Trends and implications [Internet]. Canberra: Commonwealth of Australia; 2004 [Updated 2009 Apr 24; cited 2009 Nov 9]
- Bray JR. Hardship in Australia: An analysis of financial stress indicators in the 1998-99 Australian Bureau of Statistics Household Expenditure Survey. Occasional Paper no. 4. Canberra: Department of Family and Community Services; 2001.
- Houttekier DA, Cohen J, Bilsen J, Deboosere P, Verduyckt P, Deliens L. Determinants of the place of death in the Brussels metropolitan region. J Pain Symptom Manage. 2009 Jun;37(6):996-1005. Epub 2009 Apr 5.
- Cohen J, Bilsen J, Hooft P, Deboosere P, van der Wal G, Deliens L. Dying at home or in an institution Using death certificates to explore the factors associated with place of death. Health Policy. 2006 Oct;78(2-3):319-29. Epub 2005 Dec 15.
- Australian and New Zealand Society of Palliative Medicine (ANZSPM). Caring for people at the end of life: Submission to the National Health and Hospitals Reform Commission. Braidwood, NSW: ANZSPM; 2009.
- Hudson P. Home-based support for palliative care families: challenges and recommendations. Med J Aust. 2003 Sep 15;179(6 Suppl):S35-7.
- Aoun S, Kristjanson LJ, Oldham L, Currow D. A qualitative investigation of the palliative care needs of terminally ill people who live alone. Collegian. 2008;15(1):3-9.
- Brink P, Frise Smith T. Determinants of home death in palliative home care: using the interRAI palliative care to assess end-of-life care. Am J Hosp Palliat Care. 2008 Aug-Sep;25(4):263-70. Epub 2008 Jun 11.
- Lloyd-Williams M, Kennedy V, Sixsmith A, Sixsmith J. The end of life: a qualitative study of the perceptions of people over the age of 80 on issues surrounding death and dying. J Pain Symptom Manage. 2007 Jul;34(1):60-6. Epub 2007 May 25.
- Gyllenhammar E, Thoren-Todoulos E, Strang P, Strom G, Eriksson E, Kinch M. Predictive factors for home deaths among cancer patients in Swedish palliative home care. Support Care Cancer. 2003 Sep:11(9):560-7. Epub 2003 Jul 3.
- Aoun S, Kristjanson L, Currow D, Skett K, Oldham L, Yates P. Terminally-ill people living alone without a caregiver: an Australian national scoping study of palliative care needs. Palliat Med. 2007Jan;21(1):29-34.
- Grande GE, Addington-Hall JM, Todd CJ. Place of death and access to home care services: are certain patient groups at a disadvantage? Soc Sci Med. 1998 Sep;47(5):565-79.
- Brazil K, Bedard M, Willison K. Factors associated with home death for individuals who receive home support services: a retrospective cohort study. BMC Palliat Care. 2002 Mar 25;1(1):2.
This page was created on 05 April 2012*