Skip to main content

Advertisement

SpringerLink
Log in

Association of Living Alone and Hospitalization Among Community-Dwelling Elders With and Without Dementia

  • Original Research
  • Published:
Journal of General Internal Medicine Aims and scope Submit manuscript

ABSTRACT

BACKGROUND

Older persons account for the majority of hospitalizations in the United States.1 Identifying risk factors for hospitalization among elders, especially potentially preventable hospitalization, may suggest opportunities to improve primary care. Certain factors—for example, living alone—may increase the risk for hospitalization, and their effect may be greater among persons with dementia and the old-old (aged 85+).

OBJECTIVES

To determine the association of living alone and risk for hospitalization, and see if the observed effect is greater among persons with dementia or the old-old.

DESIGN

Retrospective longitudinal cohort study.

PARTICIPANTS

2,636 participants in the Adult Changes in Thought (ACT) study, a longitudinal cohort study of dementia incidence. Participants were adults aged 65+ enrolled in an integrated health care system who completed biennial follow-up visits to assess for dementia and living situation.

MAIN MEASURES

Hospitalization for all causes and for ambulatory care sensitive conditions (ACSCs) were identified using automated data.

KEY RESULTS

At baseline, the mean age of participants was 75.5 years, 59 % were female and 36 % lived alone. Follow-up time averaged 8.4 years (SD 3.5), yielding 10,431 approximately 2-year periods for analysis. Living alone was positively associated with being aged 85+, female, and having lower reported social support and better physical function, and negatively associated with having dementia. In a regression model adjusted for age, sex, comorbidity burden, physical function and length of follow-up, living alone was not associated with all-cause (OR = 0.93; 95 % CI 0.84, 1.03) or ambulatory care sensitive condition (ACSC) hospitalization (OR = 0.88; 95 % CI 0.73, 1.07). Among participants aged 85+, living alone was associated with a lower risk for all-cause (OR = 0.76; 95 % CI 0.61, 0.94), but not ACSC hospitalization. Dementia did not modify any observed associations.

CONCLUSION

Living alone in later life did not increase hospitalization risk, and in this population may be a marker of healthy aging in the old-old.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Figure 1

Similar content being viewed by others

REFERENCES

  1. DeFrances CJ, Lucas CA, Buie VC, Golosinskiy A. 2006 National Hospital Discharge Survey. US Centers for Disease Control and Prevention National Health Statistics Reports. 2008;5:1–20.

    Google Scholar 

  2. US Centers for Disease Control and Prevention National Hospital Discharge Survey. Atlanta: Centers for Disease Control and Prevention; Data highlights- selected tables; number and rate of discharges by sex and age; 2012 Aug 28. Available from: http://www.cdc.gov/nchs/nhds/nhds_products.htm. Accessed April 16, 2014.

  3. Jiang HJ, Wier LM, Potter D, Burgess J. Potentially Preventable Hospitalizations among Medicare-Medicaid Dual Eligibles, 2008: Statistical Brief #96. In: Healthcare Cost and Utilization Project (HCUP) Statistical Briefs. Rockville (MD): Agency for Health Care Policy and Research (US); 2006. Available at: http://www.ncbi.nlm.nih.gov/books/NBK52652/. Accessed April 16, 2014.

  4. Pfuntner A, Wier LM, Stocks C. Most Frequent Conditions in U.S. Hospitals, 2010: Statistical Brief #148. 2006. Available at: http://www.ncbi.nlm.nih.gov/books/NBK127490/. Accessed April 16, 2014.

  5. Phelan EA, Borson S, Grothaus L, Balch S, Larson EB. Association of incident dementia with hospitalizations. JAMA. 2012;307(2):165–172.

    Article  PubMed  CAS  PubMed Central  Google Scholar 

  6. Bindman AB, Grumbach K, Osmond D, et al. Preventable hospitalizations and access to health care. JAMA. 1995;274(4):305–311.

    Article  PubMed  CAS  Google Scholar 

  7. Billings J, Zeitel L, Lukomnik J, Carey TS, Blank AE, Newman L. Impact of socioeconomic status on hospital use in New York City. Health Aff (Millwood). 1993;12(1):162–173.

    Article  CAS  Google Scholar 

  8. Ingold BB, Yersin B, Wietlisbach V, Burckhardt P, Bumand B, Büla CJ. Characteristics associated with inappropriate hospital use in elderly patients admitted to a general internal medicine service. Aging (Milano). 2000;12(6):430–438.

    CAS  Google Scholar 

  9. Murphy BM, Elliott PC, Le Grande MR, et al. Living alone predicts 30-day hospital readmission after coronary artery bypass graft surgery. Eur J Cardiovasc Prev Rehabil. 2008;15(2):210–215.

    Article  PubMed  Google Scholar 

  10. Di Iorio A, Longo AL, Mitidieri Costanza A, et al. Characteristics of geriatric patients related to early and late readmissions to hospital. Aging (Milano). 1998;10(4):339–346.

    Google Scholar 

  11. Lett HS, Blumenthal JA, Babyak MA, Strauman TJ, Robins C, Sherwood A. Social support and coronary heart disease: epidemiologic evidence and implications for treatment. Psychosom Med. 2005;67(6):869–878.

    Article  PubMed  Google Scholar 

  12. Schmaltz HN, Southern D, Ghali WA, et al. Living alone, patient sex and mortality after acute myocardial infarction. J Gen Intern Med. 2007;22(5):572–578.

    Article  PubMed  PubMed Central  Google Scholar 

  13. Tennstedt SL, Crawford S, McKinlay JB. Determining the pattern of community care: is coresidence more important than caregiver relationship? J Gerontol. 1993;48(2):S74–83.

    Article  PubMed  CAS  Google Scholar 

  14. Chappell NL. Living arrangements and sources of caregiving. J Gerontol. 1991;46(1):S1–8.

    Article  PubMed  CAS  Google Scholar 

  15. Lund R, Due P, Modvig J, Holstein BE, Damsgaard MT, Andersen PK. Cohabitation and marital status as predictors of mortality–an eight year follow-up study. Soc Sci Med. 2002;55(4):673–679.

    Article  PubMed  Google Scholar 

  16. DiMatteo MR. Social support and patient adherence to medical treatment: a meta-analysis. Health Psychol. 2004;23(2):207–218.

    Article  PubMed  Google Scholar 

  17. Haslbeck JW, McCorkle R, Schaeffer D. Chronic illness self-management while living alone in later life: a systematic integrative review. Research on Aging. 2012;34(5):507–547.

    Article  Google Scholar 

  18. Carmel S, Anson O, Levin M. Emergency department utilization: a comparative analysis of older-adults, old and old-old patients. Aging (Milano). 1990;2(4):387–393.

    CAS  Google Scholar 

  19. Albert SM, Costa R, Merchant C, Small S, Jenders RA, Stern Y. Hospitalization and Alzheimer’s disease: results from a community-based study. J Gerontol A Biol Sci Med Sci. 1999;54(5):M267–271.

    Article  PubMed  CAS  Google Scholar 

  20. Bynum JPW, Rabins PV, Weller W, Niefeld M, Anderson GF, Wu AW. The relationship between a dementia diagnosis, chronic illness, Medicare expenditures, and hospital use. J Am Geriatr Soc. 2004;52(2):187–194.

    Article  PubMed  Google Scholar 

  21. Zhao Y, Kuo T-C, Weir S, Kramer MS, Ash AS. Healthcare costs and utilization for Medicare beneficiaries with Alzheimer’s. BMC Health Serv Res. 2008;8:108.

    Article  PubMed  PubMed Central  Google Scholar 

  22. Natalwala A, Potluri R, Uppal H, Heun R. Reasons for hospital admissions in dementia patients in Birmingham, UK, during 2002–2007. Dement Geriatr Cogn Disord. 2008;26(6):499–505.

    Article  PubMed  Google Scholar 

  23. Nourhashemi F, Amouyal-Barkate K, Gillette-Guyonnet S, Cantet C, Vellas B. Living alone with Alzheimer’s disease: cross-sectional and longitudinal analysis in the REAL.FR Study. J Nutr Health Aging. 2005;9(2):117–120.

    PubMed  CAS  Google Scholar 

  24. Miranda-Castillo C, Woods B, Orrell M. People with dementia living alone: what are their needs and what kind of support are they receiving? Int Psychogeriatr. 2010;22(4):607–617.

    Article  PubMed  Google Scholar 

  25. Tierney MC, Snow WG, Charles J, Moineddin R, Kiss A. Neuropsychological predictors of self-neglect in cognitively impaired older people who live alone. Am J Geriatr Psychiatry. 2007;15(2):140–148.

    Article  PubMed  Google Scholar 

  26. Tierney MC, Charles J, Naglie G, Jaglal S, Kiss A, Fisher RH. Risk factors for harm in cognitively impaired seniors who live alone: a prospective study. J Am Geriatr Soc. 2004;52(9):1435–1441.

    Article  PubMed  Google Scholar 

  27. Larson EB, Kukull WA, Teri L, et al. University of Washington Alzheimer’s Disease Patient Registry (ADPR): 1987–1988. Aging (Milano). 1990;2(4):404–408.

    CAS  Google Scholar 

  28. Kukull WA, Higdon R, Bowen JD, et al. Dementia and Alzheimer disease incidence: a prospective cohort study. Arch Neurol. 2002;59(11):1737–1746.

    Article  PubMed  Google Scholar 

  29. Saunders KW, Davis RL, Stergachis A. Group Health Cooperative. In: Pharmacoepidemiology. 4th ed. Hoboken: Wiley; 2005:223–240.

    Google Scholar 

  30. Culler SD, Parchman ML, Przybylski M. Factors related to potentially preventable hospitalizations among the elderly. Med Care. 1998;36(6):804–817.

    Article  PubMed  CAS  Google Scholar 

  31. McCall N, Harlow J, Dayhoff D. Rates of hospitalization for ambulatory care sensitive conditions in the Medicare + Choice population. Health Care Financ R. 2001;22(3):127–146.

    Google Scholar 

  32. Teng EL, Hasegawa K, Homma A, et al. The Cognitive Abilities Screening Instrument (CASI): a practical test for cross-cultural epidemiological studies of dementia. Int Psychogeriatr. 1994;6(1):45–58.

    Article  PubMed  CAS  Google Scholar 

  33. Jorm AF, Korten AE. Assessment of cognitive decline in the elderly by informant interview. Br J Psychiatry. 1988;152:209–213.

    Article  PubMed  CAS  Google Scholar 

  34. Folstein MF, Folstein SE, McHugh PR. Mini-mental state.” A practical method for grading the cognitive state of patients for the clinician. J Psychiatr Res. 1975;12(3):189–198.

    Article  PubMed  CAS  Google Scholar 

  35. McKhann G, Drachman D, Folstein M, Katzman R, Price D, Stadlan EM. Clinical diagnosis of Alzheimer’s disease: report of the NINCDS-ADRDA Work Group under the auspices of Department of Health and Human Services Task Force on Alzheimer’s Disease. Neurology. 1984;34(7):939–944.

    Article  PubMed  CAS  Google Scholar 

  36. Davis MA, Neuhaus JM, Moritz DJ, Segal MR. Living arrangements and survival among middle-aged and older adults in the NHANES I epidemiologic follow-up study. Am J Public Health. 1992;82(3):401–406.

    Article  PubMed  CAS  PubMed Central  Google Scholar 

  37. Kasper J. Aging alone: profiles and projections, a report of the Commonwealth Fund Commission on Elderly People Living Alone. Washington: Commonwealth Fund; 1988.

    Google Scholar 

  38. Klinenberg, E, Torres, S, Portacolone, E. Aging alone in America: a briefing paper prepared for the Council on Contemporary Families for Older Americans month May 2012. 2012. Available at: http://www.contemporaryfamilies.org/wp-content/uploads/2013/10/2012_Briefing_Klinenberg_Aging-alone-in-america.pdf. Accessed April 16, 2014.

  39. Walker AE. Multiple chronic diseases and quality of life: patterns emerging from a large national sample, Australia. Chronic Illn. 2007;3(3):202–218.

    Article  PubMed  Google Scholar 

  40. Magaziner J, Cadigan DA, Hebel JR, Parry RE. Health and living arrangements among older women: does living alone increase the risk of illness? J Gerontol. 1988;43(5):M127–133.

    Article  PubMed  CAS  Google Scholar 

  41. Worobey JL, Angel RJ. Functional capacity and living arrangements of unmarried elderly persons. J Gerontol. 1990;45(3):S95–101.

    Article  PubMed  CAS  Google Scholar 

  42. Putnam KG, Buist DSM, Fishman P, et al. Chronic disease score as a predictor of hospitalization. Epidemiology. 2002;13(3):340–346.

    Article  PubMed  Google Scholar 

  43. Landi F, Onder G, Cesari M, et al. Comorbidity and social factors predicted hospitalization in frail elderly patients. J Clin Epidemiol. 2004;57(8):832–836.

    Article  PubMed  Google Scholar 

  44. Inouye SK, Zhang Y, Jones RN, et al. Risk factors for hospitalization among community-dwelling primary care older patients: development and validation of a predictive model. Med Care. 2008;46(7):726–731.

    Article  PubMed  PubMed Central  Google Scholar 

  45. Jacobs JM, Rottenberg Y, Cohen A, Stessman J. Physical activity and health service utilization among older people. J Am Med Dir Assoc. 2013;14(2):125–129. doi:10.1016/j.jamda.2012.10.023.

    Article  PubMed  Google Scholar 

  46. Fishman PA, Goodman MJ, Hornbrook MC, Meenan RT, Bachman DJ, O’Keeffe Rosetti MC. Risk adjustment using automated ambulatory pharmacy data: the RxRisk model. Med Care. 2003;41(1):84–99.

    Article  PubMed  Google Scholar 

  47. Sloan KL, Sales AE, Liu C-F, et al. Construction and characteristics of the RxRisk-V: a VA-adapted pharmacy-based case-mix instrument. Med Care. 2003;41(6):761–774. doi:10.1097/01.MLR.0000064641.84967.B7.

    PubMed  Google Scholar 

  48. Huntley AL, Johnson R, Purdy S, Valderas JM, Salisbury C. Measures of Multimorbidity and Morbidity Burden for Use in Primary Care and Community Settings: A Systematic Review and Guide. Ann Fam Med. 2012;10(2):134–141. doi:10.1370/afm.1363.

    Article  PubMed  PubMed Central  Google Scholar 

  49. Wang L, Larson EB, Bowen JD, van Belle G. Performance-based physical function and future dementia in older people. Arch Intern Med. 2006;166(10):1115–1120.

    Article  PubMed  Google Scholar 

  50. Cohen S, Mermelstein R, Kamarck T, Hoberman H. Measuring the functional components of social support. In: Sarason IG, Sarason BR, eds. Social support: Theory, research, and application. The Hague, Holland: Martinus Nijhoff; 1985.

    Google Scholar 

  51. Martire LM, Schulz R, Mittelmark MB, Newsom JT. Stability and change in older adults’ social contact and social support: the Cardiovascular Health Study. J Gerontol B Psychol Sci Soc Sci. 1999;54(5):S302–311.

    Article  PubMed  CAS  Google Scholar 

  52. Andresen EM, Malmgren JA, Carter WB, Patrick DL. Screening for depression in well older adults: evaluation of a short form of the CES-D (Center for Epidemiologic Studies Depression Scale). Am J Prev Med. 1994;10(2):77–84.

    PubMed  CAS  Google Scholar 

  53. Ferrer A, Badia T, Formiga F, et al. Frailty in the oldest old: prevalence and associated factors. J Am Geriatr Soc. 2013;61(2):294–296.

    Article  PubMed  Google Scholar 

  54. Balardy L, Voisin T, Cantet C, Vellas B. Predictive factors of emergency hospitalisation in Alzheimer’s patients: results of one-year follow-up in the REAL.FR Cohort. J Nutr Health Aging. 2005;9(2):112–116.

    PubMed  CAS  Google Scholar 

  55. Caspi E, Silverstein NM, Porell F, Kwan N. Physician outpatient contacts and hospitalizations among cognitively impaired elderly. Alzheimers Dement. 2009;5(1):30–42.

    Article  PubMed  Google Scholar 

  56. Boult C, Dowd B, McCaffrey D, Boult L, Hernandez R, Krulewitch H. Screening elders for risk of hospital admission. J Am Geriatr Soc. 1993;41(8):811–817.

    PubMed  CAS  Google Scholar 

  57. Billings J, Dixon J, Mijanovich T, Wennberg D. Case finding for patients at risk of readmission to hospital: development of algorithm to identify high risk patients. BMJ. 2006;333(7563):327. doi:10.1136/bmj.38870.657917.AE.

    Article  PubMed  PubMed Central  Google Scholar 

  58. Billings J, Blunt I, Steventon A, Georghiou T, Lewis G, Bardsley M. Development of a predictive model to identify inpatients at risk of re-admission within 30 days of discharge (PARR-30). BMJ Open. 2012;2(4). doi:10.1136/bmjopen-2012-001667

  59. Bottle A, Aylin P, Majeed A. Identifying patients at high risk of emergency hospital admissions: a logistic regression analysis. J R Soc Med. 2006;99(8):406–414. doi:10.1258/jrsm.99.8.406.

    Article  PubMed  PubMed Central  Google Scholar 

  60. Howell S, Coory M, Martin J, Duckett S. Using routine inpatient data to identify patients at risk of hospital readmission. BMC Health Serv Res. 2009;9:96. doi:10.1186/1472-6963-9-96.

    Article  PubMed  PubMed Central  Google Scholar 

  61. Michael YL, Berkman LF, Colditz GA, Kawachi I. Living arrangements, social integration, and change in functional health status. Am J Epidemiol. 2001;153(2):123–131.

    Article  PubMed  CAS  Google Scholar 

  62. Nihtilä E, Martikainen P. Why older people living with a spouse are less likely to be institutionalized: the role of socioeconomic factors and health characteristics. Scand J Public Health. 2008;36(1):35–43.

    Article  PubMed  Google Scholar 

  63. Manton KG. Recent declines in chronic disability in the elderly U.S. population: risk factors and future dynamics. Annu Rev Public Health. 2008;29:91–113.

    Article  PubMed  Google Scholar 

  64. Aging In Place: A State Survey of Livability Policies and Practices - AARP. AARP. Available at: http://www.aarp.org/home-garden/livable-communities/info-11-2011/Aging-In-Place.html. Accessed April 16, 2014.

Download references

Acknowledgements

ACT is supported by NIA grant UO1 AG 06781 (Principal Investigator: Dr. Larson).

Conflicts of Interest

Dr. Larson receives royalties from UptoDate®. All other authors declare that they do not have a conflict of interest.

Author information

Authors and Affiliations

  1. Department of Health Services, School of Public Health, University of Washington, Box 357230, Seattle, WA, 98195, USA

    Stephanie K. Ennis MS, MPH, Eric B. Larson MD, MPH, Christian D. Helfrich PhD & Elizabeth A. Phelan MD, MS

  2. Division of Gerontology and Geriatric Medicine, School of Medicine, University of Washington, Seattle, WA, USA

    Elizabeth A. Phelan MD, MS

  3. Group Health Research Institute, Seattle, WA, USA

    Eric B. Larson MD, MPH, Louis Grothaus MS, Steven Balch MA & Elizabeth A. Phelan MD, MS

  4. VA Puget Sound Health Services Research & Development, Seattle, WA, USA

    Christian D. Helfrich PhD

Authors
  1. Stephanie K. Ennis MS, MPH
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Eric B. Larson MD, MPH
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Louis Grothaus MS
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Christian D. Helfrich PhD
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Steven Balch MA
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Elizabeth A. Phelan MD, MS
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Stephanie K. Ennis MS, MPH.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Ennis, S.K., Larson, E.B., Grothaus, L. et al. Association of Living Alone and Hospitalization Among Community-Dwelling Elders With and Without Dementia. J GEN INTERN MED 29, 1451–1459 (2014). https://doi.org/10.1007/s11606-014-2904-z

Download citation

  • Received:

  • Revised:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s11606-014-2904-z

KEY WORDS

Search

Navigation