Retirement villages have expanded rapidly, now housing one in eight people aged 75 and over. Little is known though about residents, including their health status and needs. To remedy this, Dr Joanna Broad of the University of Auckland led a study of the residents of 33 villages in Auckland. The result is a rare snapshot of who residents are, their unmet needs and the opportunities for better managing their chronic conditions.
Here, Dr Broad tells Eldernet what surprised her about the results, and the big issues the study highlights for the future of retirement villages and aged care in New Zealand.
What prompted the study and what is its purpose?
Four times during 30 years, our University of Auckland research team studied the health of older people living in residential long-term care. These are people who need to have care available 24/7. In 2010 we found that although numbers had increased, the rates were falling over time, so we asked why this was?
It could be that older people were a whole lot healthier than they had been 10 or 20 years before. While theoretically possible, that seemed doubtful. We concluded there were two main reasons. First, home-based supports were much more available to those who needed them than before, so people could stay at home longer. And second, that some with low need for care, who before might have moved into low-level long-term care, instead moved into villages anticipating supports would be available there.
We looked for studies of people living in retirement villages in New Zealand to tell us about their health, but could find few. If people moving into retirement villages were looking for support as they aged, then it is important to know the size and nature of their needs, especially given the fast growth in the village sector.
So, we designed a study to ask who the residents were and to describe their needs, how their health needs tracked over time, and whether we could intervene to delay or avert health decline that meant moving to residential aged care or led to unplanned hospital admissions.
Did you have any difficulties recruiting suitable people for the survey?
Yes indeed we did. Perhaps we had underestimated the protection and security roles villages offer, for a number of villages declined to allow our nurse-interviewers to enter the village, or even to outline the study to residents so they could decide for themselves. Then, when the village agreed to allow our researchers in, in some villages locked doors prevented access, meaning we could not door-knock to recruit people randomly to obtain a representative sample.
But we did recruit a mix of sampled residents and volunteer residents, a total of 578 people from 33 villages. Only 27% were men, half were older than 82 years, 44% were widowed, 96% self-identified as European, and 98% had previously owned a home; in these respects the volunteers and the sampled respondents were similar. But those who were sampled were more likely to live alone and they used the internet less.
What findings do you consider most significant?
One of the questions we asked was why they moved into the village. The most common responses were to downsize and reduce maintenance (77%) and to have a less stressed lifestyle (63%). The next most common was for assistance with current/future health issues.
We also collected information about medical diagnoses and unmet needs. High blood pressure was reported by over one in two residents. Heart disease, arthritis and reflux disorder were reported by over one in three. In terms of health needs that were unmet, half the residents were identified as having conditions of the heart, circulation or breathing that could be better managed, and almost that number had inadequately managed pain. The number with unmet health needs or who moved into a village partly to obtain assistance with health issues suggests villages could provide greater support for unmet health needs, such as monitoring cardiovascular conditions or assisting with pain management through advice, education or referrals.
It was also important to understand the implications of having many health conditions. In the last three months, 94% had seen their GP and 9% had an overnight hospital stay, while some reported they needed an appointment but did not have one.
Any big surprises in what the survey showed?
Yes, we were surprised that even among those living in a unit as “independent”, at least one in three received home-based supports – in all, 34% housework and 10% personal care.
We were also surprised that people reported so many ongoing medical conditions. Health studies often list conditions that are known to be common and ask only about them. Because we included conditions described in free text, i.e. not from a list, other conditions were picked up that were common but not often surveyed. These included for example atrial fibrillation, osteoporosis, diverticular disease and thyroid disorder, all with over 5% prevalence. While we expected to find most residents having two or more ongoing conditions, and three or more by the age of 85, the wide range was a surprise.
One in five respondents said they provide daily support for others – what are the implications of this?
Where the respondent is living with another person, that person is probably the one being cared for, i.e. a spouse or partner, but not always – other family members or neighbours are likely. For a couple it may indicate that years of cohabitation mean an interdependence, a “looking out for each other”, with one taking some roles and responsibilities and the other partner adopting others. It indicates the importance of considering an individual’s circumstances when treating, managing or providing for their care. Illness or incapacity in one partner may mean that both, not just one, will need support. We need to better understand the implications.
What are the limitations of the study?
Having villages decline to participate, and then numbers of residents also declining, could mean the study is not representative of all village residents. However, those who were sampled and the volunteers were similar in many respects, so it is unlikely there is much bias.
Two other aspects of the study’s conduct could limit how applicable it is to all New Zealand village residents. Firstly, it was conducted in Auckland villages only. Secondly, under the ethics approval, people with dementia or even mild cognitive impairment could not be included. This means we are unable to report the extent that people with diminished cognitive function live in villages, or to describe the impact on their ongoing activities and health needs.
Do you think it points up any major issues for the future of retirement villages and aged care in NZ? For example, the predominance of residents who identify as European and formerly owned their own home – how will we create village-like spaces for other ethnicities and levels of wealth?
There is evidence from overseas that, in general, people who move into retirement villages fare better health-wise than similar people who do not. While this study cannot prove or disprove that for New Zealand, the fact that in our study 93% say they are satisfied or very satisfied with the village does support that impression.
We found fewer people than expected who did not identify as NZ European or other European. Maybe non-Europeans are less likely to own a home whose sale allows them to move into a village, or maybe they choose not to move in because they prefer to live among their own people, or in an environment more sympathetic to their own culture /lifestyle. We do not know. Certainly it does seem that there is a need for villages with rental-type accommodation and for culturally diverse options, but we are researchers, not economists or business people; the responsibility to develop different models lies with developers and providers.
This survey is the first part of a larger study – what else is to come?
We have two other main areas of investigation in this study. In 2021 the longitudinal study will report trajectories in health service use and outcomes, to identify factors that might lead to improved health. In addition, results of our randomised trial aiming to reduce or delay key health events in village residents will be known.
What do you see as the big gaps in research into NZ’s older population?
There is still a great lack of clarity why some people access medical care and health services more easily than others, and why some are better managed. Increasingly, databases that routinely record health conditions are used to describe health and health outcomes in order to better understand the relationships between health conditions, risk factors and health outcomes. Approved studies may anonymously access these data relatively cheaply, to answer research questions and provide helpful new knowledge about healthcare. There is so much we do not yet understand about common health conditions including atrial fibrillation and reflux disorder.