Aging-in-Place versus Long Term Care Conflicts Experienced by Older Adults

Background:

Aging-in-place versus living in long-term care communities can be one of the most consequential decisions that older adults make in their lifetime.^1,2 Because of its significance, family members are often involved in and influence the decision-making process.³ Even though well-intentioned, family support can cause conflict, increasing stress rather than providing relief.⁴ Most conflict statements can be categorized within the interest-right-power (IRP) framework, which is widely used in negotiation literature and can be leveraged to resolve disputes. Interests statements delineate the reasons behind a particular position; Rights refer to the perceived fairness; and Power statements use authority to defend a position. Successful negotiations redirect rights or power-focused arguments to ones that are interests-based. We aimed to describe the conflicts that older adults experience surrounding their living arrangements and determine the frequency of IRP statements.

Methods:

As part of a study on decision-making about aging-in-place versus moving into long term care communities, we are longitudinally following a cohort of older adults with surveys every 6 months for 18 months. Subjects are asked specifically to describe any conflicts that have occurred about their living situation. Subject responses were transcribed and coded using constant comparative analysis examining type, content, and whether statements were based on interests, rights, or power. Compound conflict statements could map to more than one category.

Results:

We enrolled 293 subjects (mean age 73.5 yrs, SD 5 yrs, 40.4% non-white; 94.5% retention rate) and 124 conflicts were reported over 18 months. Thematic analysis revealed three types of conflicts:1.) Interpersonal (subcategories: spouse, intergeneration, other) (e.g., my son comes from Florida and tries to tell me what to do), 2.) Task (e.g., up-keeping of the place), 3.) Value-based (e.g., living in a condo versus a more open area). Content was coded into 6 themes (Figure 1): 1.) Location change (e.g., my sister says I can be incapacitated and I should go live in senior housing.), 2.) Home maintenance issues (e.g., My son insisted I put in a new lower tub and I didn’t want to.), 3.) Different ways of completing tasks (e.g., It is about my children and the way we do things. I don’t take my time, and I don’t eat the same stuff.), 4.) Safety (e.g., Neighbor’s boyfriend kicked in the door and destroyed our property.), 5.) Financial (e.g., I discovered that my spouse secretly met his attorney and changed his will so I would get nothing.), 6.) Health-related (e.g., The family next door is always having bonfires which messes with my asthma. we’ve argued). In mapping the statements to the IRP frameworks, coders identified statements as interests-based 46.1% (n=94), rights-based 13.6% (n=28), power-based 3.9% (n=8), and 1.9% (n=4) had insufficient context to identify the type (Table 1).

Figure 1.

Types of Conflicts Older Adults Face When Making Decisions about Living Arrangements

Table 1.

Definitions of the three types of conflict statements with selected examples from participants.

Power	— Uses threats — Pressures someone to do something they would not otherwise do
	•   “The neighbor’s boyfriend kicked in the door and destroyed our property”   •   “When my soon to be ex-husband was asked to leave there was a big argument.”
Rights	— Refers to fairness, past issues, or events — Brings up health and safety laws
	•   “Usually it’s about some repair he wants to do but isn’t safe for him, like get on a ladder.”  •  “We get our food delivered now since the dining room is closed and the quality of the food is terrible. The building management has taken away our freedom. They say “seniors you must do this...”, they talk to us very dictatorial and mean. They said this is how they have to talk to seniors”
Interests	— Understands underlying needs, desires, concerns — Explores reasons for resistance
	•   “Usually, it’s rather if we need to relocate to avoid some of the maintenance. It’s more a long-term decision, we have to think about do we want to stay here as we age vs focusing on what we like about the house”  •  “He is ready to leave and get to Florida and I have put it off because I have friends and family in Chicago.”

Discussion:

Our results are the first to describe the types of conflicts older adults face when making decisions about their living arrangements. Most often they experience interpersonal conflicts with family members about moving from their homes into long-term care communities. Older adults in our cohort made mostly interests-based statements – denoting their ‘why’ position behind the conflicts – and secondly, rights-based statements – or perceived fairness. Identifying interests is vital to resolving conflicts as negotiators facilitate agreements by addressing those concerns. While subjects may have felt comfortable revealing their interests to researchers – who were neutral third parties – healthcare providers could serve a similar role in resolving disagreements between patients and families. Providers could help redirect conversations away from rights or power-based arguments toward shared interest-based solutions. Previous work has demonstrated that providers value negotiation training when addressing conflicts with older patients.⁵ Future research could evaluate the effectiveness of training providers to mediate conflicts regarding aging-in-place.

One limitation of this study is that conflicts were viewed from the older adult’s perspective only. Caregivers may have had a different interpretation of the same event. Future research could examine conflicts about aging-in-place from the caregiver’s viewpoint. Such knowledge could inform negotiation strategies to benefit both older adults and their supporters.

Older adults experience a wide range of conflicts pertaining to aging-in-place. They report interpersonal conflicts with caregivers about aging in place versus moving to long-term care communities. Equipping providers, patients, and caregivers with skills to negotiate housing transitions could alleviate these conflicts.