Defining Aging in Place: The Intersectionality of Space, Person, and Time

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Abstract

Aging in place (AIP) is a term that is commonly used and defined in a plethora of ways. Multiple disciplines take a different stance on the definition of AIP, and its definition has evolved over time. Such diverse ways to define AIP could be a barrier to reach a shared expectation among multiple stakeholders when formulating research studies, making policy decisions, developing care plans, or designing technology tools to support older adults. We conducted a scoping review for the term AIP to understand specifically how it has been defined across time and disciplines. We collected exemplary definitions of AIP from 7 databases that represent different fields of study; namely, AgeLine, Anthropology Plus, Art and Architecture Source, CINAHL, PsycINFO, PubMed, and SocINDEX. We conducted a thematic analysis to identify the common concepts that emerged across the definitions identified in the scoping review. We developed 3 main categories from the themes: space, person, and time to illustrate the root of meaning across the definitions. Intersectionality across the categories yielded a comprehensive understanding of AIP, which does not constrain its definition to a place-related phenomenon. We propose that AIP be defined as “One’s journey to maintain independence in one’s place of residence as well as to participate in one’s community.” With this shared understanding of the term AIP, policymakers, researchers, technology designers, and caregivers can better support those who aim to age in the place of their choice.

Translational Significance: The term “aging in place” is used widely but not defined consistently across disciplines or contexts. We reviewed the use of the term in research contexts to develop a shared definition inclusive of space, person, and time. Our interdisciplinary review revealed the importance of considering the intersectionality of these components. A broader, consistent definition of aging in place can guide interdisciplinary research and design collaborations between environmental gerontology and other related fields. A shared understanding will expand future design programs, tools, technologies, services, and policies to support aging in place.

A well-known and clearly documented phenomenon is the aging of the world population (World Health Organization, 2018). There are more people older than the age of 60 than ever before and the trend is continuing. Where do most older of these older adults live? The idea that people want to remain in their own original home may seem obvious on the surface, but is it really true for everyone? Older people in their 60s and 70s may move to downsize, move to a different climate, an over-55 community, to be nearer to family, or to invest in a continuing care retirement community. On theme of these moves is choice—older adults today have many options about where to live as they grow older. In other cases, the older person may have to move due to illness or injury, finances, physical limitations, or cognitive challenges. The motivations may differ, but there are options for the person to consider and to choose from.

The term “aging in place (AIP)” is used widely in research articles, public policy documents, government information websites, commercial advertisements, business names, and more. However, it is not always clear what the intended meaning is in these different contexts, or even if the term is being interpreted similarly for the different usages.

Most commonly, the intention appears to be that older adults want to remain in their own—sometimes long-time or original—homes as they age. For example, Beidler and Bourbonniere (1999, pp. 34–35) defined AIP as a term that is “used in long-term care discussions to describe the desire of older people to remain at home,” whereas Bigby (2008, p. 77) focused on AIP as the enabler for people to “remain in familiar surroundings, close to family and friends, to retain personal belongings, and avoid institutionalization.” These two definitions favored the home as the setting for AIP to follow older adults’ desire to stay in their familiar environment with their family and friends. However, these definitions did not take into account older adults’ ability to maintain their independence in conducting their everyday activities. As people age, they experience cognitive and functional capacity changes that may interfere with their ability to stay in their current environment. As evidenced by the person–environment fit theory (Lawton & Nahemow, 1973), it is important to consider the personal capacity to provide sufficient environmental support for successful adaptation in old age. The experience of living in a familiar environment may not be enough if individuals’ ability to successfully engage with their activities of daily living is sacrificed. This perspective may be overly constraining, which might result in negative connotations and limit opportunities for older adults (Weil & Smith, 2016).The term AIP gets used a short hand and how individuals, families, communities, and societies think about where older adults should want to live. But words matter. Assuming that all older adults want to remain in their current living situation for the foreseeable future is limiting. Moreover, forgetting that people who do not live in traditional homes still need environmental supports that enhance their quality of life does them a disservice.

When specific AIP definitions are provided, they vary widely. To illustrate:

“This aging-in-place philosophy means residents will have to relocate to a new settings less often.” (Chapin & Dobbs-Kepper, 2001, p. 43)

“Implicit in the current ‘aging in place’ movement is the assumption that people develop an attachment, affinity, or familiarity for a place, and maintaining this connection to home and environment is adaptive.” (Kovach, 1998, p. 33)

“The concrete strategy of ‘ageing in place’ is to provide the elderly and the disabled with care services in their own community.” (Chen, 2008, p. 183)

“The term “aging-in-place” denotes the process of cohort transition to increasing age and residential inertia.” (Graff & Wiseman, 1978, p. 382)

“The demographic processes involved in the numerical growth or decline of the elderly population over a fixed time period include both net migration and natural increase.” (Lichter et al., 1981, p. 481)

“… aging-in-place is not only a demographic or political issue, but is also an emotional and lived experience that inherently involves the broader place or residence.” (Coleman & Kearns, 2015, p. 206)

These examples exemplify the range of concepts included in AIP definitions as well as the goals for using the term. Sometimes the definition assumes intentions on the part of older individuals; other times it provides guidance for measurement and defines a scope of research.

As researchers, it is crucially important to define the terms that guide our paths of inquiry. Based on the review of common concepts and constructs that are associated with AIP, Weil and Smith (2016) suggested the reevaluation of the AIP concept to highlight and to incorporate a wider diversity in its definition beyond the matter of “place.” Moreover, as was clear from Weil and Smith’s (2016) examples, AIP has been used ambiguously with limited empirical support. Our goal in this project was to understand how AIP has been defined—and hence explored in the research literature. We conducted a scoping review to trace AIP definitions over time and across disciplines to understand the parameters of use, themes, distinctions, and trends. Ultimately, we wanted to broaden the utility of the term to encompass the needs and preferences of older adults.

Research Design and Method

The purpose of a scoping review is to “map” the evidence to convey a summary that captures the breadth and depth of a field (Levac et al., 2010). To understand the changing AIP meaning and context of use, we searched multiple databases for evidence of the AIP concept, definition, and development in different fields of study. We selected a comprehensive set of disciplines that would be most likely to investigate concepts related to AIP: social, medical, behavioral, gerontological, and architectural.

Data Collection

Literature screening was the initial step to collect various definitions of AIP. We conducted the search in seven databases to represent multiple disciplines: medicine, psychology, nursing, gerontology, sociology, anthropology, and architecture. These databases were recommended by the university librarian as the best avenue to gather articles that are representative of the disciplines we had selected. The list of databases with a short content description is provided in Table 1 .

Table 1.

Databases Included in the Scoping Review

Notes: Database descriptions were adapted from the database websites. Relevance scoring methods determined from EBSCOConnect, 2020; Fiorini et al., 2018; National Library of Medicine, 2020; ProQuest Support Center, 2020.

The data were collected from June to December 2019. We used the search terms “aging in place,” “aging-in-place,” “ageing in place,” and “ageing-in-place” under titles, abstracts, keywords, and subject category in every database during the initial literature screening. Articles other than research articles, books, and book sections that appeared on the search were excluded from the pool. The process of article search and screening is shown in Figure 1 .

Flowchart of article search and inclusion criteria.

We identified 2,529 items through the initial screening of seven databases. To make a detailed review of the definitions feasible, we selected a subset of the articles that were most relevant to our goals. We thus conducted a separate search for each decade: before the 1960s, 1960–1969, 1970–1979, 1980–1989, 1990–1999, 2000–2009, and 2010–2019 to differentiate the number of items that were published in each decade. Then, we sorted the search results using the “sort by relevance” feature of the database for each decade to select the top five articles in a specific time period. Some of the databases only had a few (i.e., less than 2) articles for some decades, whereas other databases had many articles (i.e., more than 50) in a decade. We decided to select the top five relevant articles to have a relatively balanced number of articles that are most relevant as determined by the database. The detail of relevance scoring method in each database is explained in Table 1 .There were 108 articles after the secondary screening. We reviewed the full text from this pool for specific AIP definitions. We excluded 32 articles that did not have an explicit AIP definition in the body of text; note that this represents 30% of articles that used the term without explicitly defining it, assuming it must be self-explanatory. There were 76 articles remaining to be assessed for eligibility with the criterion that the definition included in the article must be the original citation for that definition. Ten articles that used or cited definitions from other articles were replaced with the original article from which it cited the AIP definition. Some items appeared in multiple databases. Following the redundancy check, we removed 12 articles that showed up more than once and only retained the ones that appeared in the earlier database search. The order of the search was alphabetical: AgeLine, Anthropology Plus, Art and Architecture Source, CINAHL, PubMed, PsycINFO, and SocINDEX. After this entire process, we were left with 60 article definitions to analyze thematically.

Two research team members extracted the AIP definitions from the 60 articles. One researcher extracted definitions from CINAHL, PsycINFO, and PubMed, whereas the other researcher extracted the definitions from AgeLine, Anthropology Plus, Art and Architecture Source, and SocINDEX. The definitions were copied and combined in a matrix. Once the definition extraction was completed, thematic analysis was conducted separately by two researchers. Each researcher coded the definitions separately to find themes that emerged from the data. Subsequently, the researchers met to discuss the themes and the words used to explain them. If necessary, similar themes were reworded to ensure that every team member was using similar wording. When there was a disagreement on themes, the team discussed to reach an agreement on the code definition. From this process, we created a database that had the theme definitions and similar words or phrases that would fall under the same codes. This thematic analysis was done iteratively until a comprehensive and well-defined coding scheme was constructed, and all the definitions were coded using the latest version of coding schemes.

Once the themes were finalized, the research team grouped them subjectively into higher-level categories of space, person, and time ( Table 2 ). Themes that concerned the place-related issue were grouped into the “space” category. Themes related to the personal capacity, preference, and relations were classified under the “person” category. Lastly, themes related to periodical moments were combined under the “time” category. A single definition could be coded with multiple codes if it is related to more than one category. Some definitions had only space or person-related themes in the definitions, whereas others had multiple categories represented in the AIP definition. After grouping the themes, the team then counted how many times each category appeared throughout the definitions. Counting the category appearance among AIP definitions was the foundation to understand how AIP has been defined and changed over time. The results of the thematic analysis were then analyzed to synthesize the history and utilization of the AIP terminology across disciplines.

Table 2.

Coding Scheme of Themes Identified From the Aging in Place Definitions