Housing characteristics of low and moderate income older adults with and without disabilities

Abstract

Housing is relevant to quality-of-life for older adults with and without disabilities, particularly those with limited financial resources. Among 4,898 low- and moderate-income community-living National Health and Aging Trends Study respondents, we describe and examine differences in housing characteristics of older adults with (n=2744) and without disability (n=2124). Next, among those with disability (self-care, household-activity, or mobility limitations), we examine associations of housing characteristics with adverse consequences due to unmet care needs, including soiling oneself or having to stay inside. In descriptive analyses, those with disability (vs without) more commonly rented, lived in subsidized housing, lived in apartments or mobile homes, and with home disorder, home disrepair, and street disorder. In adjusted logistic regressions among the subgroup with disability, several housing characteristics were statistically significantly associated with adverse consequences. Policy, programmatic, and clinical interventions that account for housing as an important social determinant of older adult quality-of-life should be advanced.

Introduction

Aging in one’s home and community (also referred to as “aging in place”) is preferred by most older Americans and is supported by programs and policies at the federal, state, and local levels. ¹ It is understood that characteristics of the home are central to whether older adults are able to successfully age in place. ²

A systematic review and meta-ethnography of qualitative studies of the experiences of aging in place in the United States identified the following constructs related to the topic of “home” as an important “place” for aging: positive experiences of place while aging in place (e.g., home as personal, home as private); threats to sense of place (e.g., issues with home upkeep, financial concerns, problems with neighborhood environment); approaches to threats to sense of place (e.g., making adaptations to home and routine); and consequences of unmitigated threats to sense of place (e.g., experiencing place as unsafe or no longer private). ² Despite the centrality of homes to older adults’ efforts to successfully age in place, there are a limited number of quantitative studies that characterize the homes of community-living older Americans. ³

Characteristics of the home, including the physical and economic aspects of one’s housing, ⁴ are particularly important to successful aging in place of older adults living with disability (those who need assistance with one or more daily activities). Characteristics such as: clutter, tripping hazards, and evidence of other interior housing problems (referred to in this study as interior home disorder); exterior signs of disrepair such as broken windows or roof problems; and litter or graffiti near the home (referred to in this study as street disorder), may contribute to disability-related outcomes among older adults by placing excessive environmental demands on the older adult and their care network relative to capacity. ⁵ Other housing characteristics, including housing tenure (e.g., rental/ownership status) and living in subsidized housing, may be related to disability outcomes via their reflection of and/or contribution to an older adult’s available financial resources to obtain necessary care services. The physical and economic aspects of one’s housing are interrelated; there is typically a higher price to pay for high quality, accessible housing, located near service amenities. Understanding the relationship between housing context and the experiences of older adults with disability could signal at-risk populations and modifiable housing-related risk factors to target with intervention, thus informing the development of new programs or expansion of current programs that address housing-related needs of older adults— particularly for those aging with a disability.

For older adults living with disability, an important quality-of-life outcome is whether a person’s care needs are being met, or conversely whether they experience adverse (i.e., harmful) consequences due to their needs not being met. Adverse consequences due to unmet care need can be dire, and extend from going without eating to soiling oneself. ⁶ Adverse consequences are an important outcome to study because they are an indicator of whether a person living with disability has sufficient supports at the interpersonal, community, and health services levels. For example, from family and friends, or home care services. ⁷

In addition to affecting quality-of-life, unmet care needs may mediate the association of disability with other important outcomes. For example, previous research has found that adverse consequences due to unmet care need are associated with increased mortality, ⁸ hospitalization, ⁹ and transfer to a nursing home. ¹⁰ While housing factors such as housing cost burden¹¹ and housing of inadequate quality^12–14 have been associated with accidental falls, ¹³ the ability to perform self-care activities, ¹⁵ and transition to a nursing home¹⁶ among older adults with disabilities, the impact of housing on quality-of-life and daily care experiences has not garnered much research attention. With the overwhelming majority (>80%) of older adults with disabilities living in community, as opposed to institutional settings (e.g., nursing homes or long term care), ¹⁷ it is crucial to determine what housing characteristics are linked with older adults’ ability to meet their care needs.

The relationship between housing and adverse consequences due to unmet care needs are especially relevant to people with disability because the difficulty of getting to the bathroom or obtaining or preparing food in the house, for example, can be lessened or worsened by the physical conditions of the home, as well as by financial resources that are available for housing, food, and paid support services. Further, the relationship between housing and unmet care needs may be particularly important for older adults who are socioeconomically disadvantaged. Not only are these individuals more likely to have disabilities but also they are more likely to experience more housing-related risk and are less likely to have a home that accommodates their daily care needs. ^12,18,19

The purpose of this study is twofold. First, we examine the prevalence of key housing characteristics among a representative sample of U.S. low- and moderate-income community-living older adults, comparing the characteristics of older adults with and without disabilities (those who need assistance with one or more daily activities). Second, we examine the association of housing characteristics with adverse consequences due to unmet care needs among the subset with disabilities. We consider older adults with both low and moderate incomes, because of evidence that older adults with moderate incomes also struggle to secure housing and paid support services in the present configuration of the U.S. housing and social welfare context (i.e., available housing subsidies, social and health insurance programs and financing). ¹⁸ We hypothesize that housing characteristics differ by disability status. We further hypothesize that housing characteristics (exposures of interest) are associated with odds of experiencing adverse consequences due to unmet care needs (outcome of interest), among older adults with disabilities.

Material and Methods

Sample

We draw on the 2015 National Health and Aging Trends Study (NHATS), a population-based national survey of older adults (≥65 years) and their households on topics of health and disability, conducted via a two-hour in-home interview. ²⁰ Data from the 2015 round of NHATS was chosen because, of the most recent round of NHATS data available at the time of the study, it included the largest sample. Details of the study design and procedures for NHATS have been published previously. ²¹ Briefly, the sampling frame for NHATS consisted of Medicare enrollees aged 65 years or older living in the contiguous United States. African Americans and persons with greater age were oversampled to facilitate analyses in these populations. The initial NHATS cohort was enrolled in 2011, and the sample was replenished in 2015 to replace those in the youngest age group (65–69 years) and those who had died or been lost to follow-up. NHATS measured individual sociodemographic, financial, household, activity and disability characteristics and experiences. A brief interviewer-completed rating of participants’ home environments was also conducted. For this study, we included 7070 NHATS participants who responded to the 2015 survey and lived in community settings (not nursing home or assisted living). We excluded 581 participants who did not have a home visit by an interviewer to collect information about their home environment. We further excluded 1591 participants who had annual incomes in the highest 25^th percentile. Our analytic sample was 4898 low and moderate income (defined as those in the bottom 75% of income, or an annual income <$60,000) ¹⁶ community-living NHATS respondents. This sample is representative of 24.2 million Medicare beneficiaries 65 years of age and older.

Measures

Housing characteristics

We included the following self-reported housing characteristics: living in a retirement community (“is your home part of a retirement community or a senior housing community?”); living in subsidized housing (“is this home in Section 8 public housing or housing for low-income seniors?”); renting or owning their home; and living in an apartment or mobile home vs. a house. ²² Items from an interviewer-completed checklist of the participants’ home environment was used to capture the presence of the following characteristics (binary measures): interior home disorder refers to broken furniture or lamps, flooring in need of repair, tripping hazards, clutter, peeling or flaking paint, or evidence of pests; exterior home disrepair refers to broken or boarded up windows, crumbling foundation, missing bricks or siding, roof problems, or uneven walking surfaces or broken steps; and street disorder refers to litter, graffiti, or vacant houses. ²³

Sociodemographic characteristics

Other measures include sociodemographic characteristics: age (categorized as 65–74, 75–84, and ≥85 years), sex, racial/ethnic status, and educational attainment. Racial/ethnic status were categorized as White non-Hispanic, Black non-Hispanic, Hispanic, and “other” an NHATS category that includes American Indian, Asian, Native Hawaiian, and Pacific Islander. Three income categories were created based on sample tertile (<$17,000, $17,001-$32,000, and $32,001-$60,00). We classified participants as having financial hardship if they reported skipping a meal during the previous month because there was not enough food or money to buy food, or if they reported not having enough money to pay for medical expenses, the rent or mortgage, or utility bills during the previous year. ²⁴

Disability status

We identified older adults with self-care, household task, and mobility limitations. NHATS asks participants about how they perform self-care (eating, bathing, dressing, toileting), household tasks (doing laundry, shopping for groceries, preparing meals, managing bills and banking), and mobility (getting around inside the housing, outside of the house, transferring in and out of bed). For each activity, older adults are asked whether they receive help, and the level of difficulty if they performed the activity with or without assistance. If participants reported performing the activity without assistance, they were asked how difficult it was to do the activity alone. These measures of difficulty with self-care, household, and mobility activities have been found to acceptably valid and reliable. ²⁵ We considered respondents to have a disability if they reported that they had assistance with a self-care, household, or mobility activity due to health or function reasons, or they reported that they performed an activity themselves with difficulty.

Adverse consequences due to an unmet care need

Outcomes for this study include specific adverse consequences due to unmet self-care, household, and mobility needs. Participants who reported receiving help or having difficulty completing an activity (classified in this study as having a disability) were asked whether they experienced, in the past month, an adverse consequence due to no one being there to provide help or the activity being too difficult for them to complete on their own. Adverse consequences included the following: went without eating; went without showering/taking a bath/washing up; wet or soiled self; went without getting dressed; went without clean laundry; went without groceries or personal items; went without a hot meal; went without handling bills and banking matters; made a mistake in taking prescribed medicines; had to stay inside; did not go to places inside the home; had to stay in bed. ²⁶ We created binary summary measures that indicated whether the participant experienced zero vs ≥1 adverse consequences due to an unmet care need experienced by the participant overall as well as by activity domain (self-care, household, and mobility). This measure of adverse consequences of unmet need has been used in prior research within the NHATS and is consistent with previous approaches to measuring unmet need. ^6,7,27

Social Support Indicators

We included indicators of social support because social support may confound the association between housing characteristics and adverse consequences due to unmet care needs.^7,28 Living arrangement refers to living alone, with a spouse, or with others who are not a spouse. Social isolation draws on a measure developed by Cudjoe and colleagues: ²⁹ participants received 1 point (total score range 0–4) for each of the following: living with ≥1 other person, talking to ≥2 people about important matters in the past year, attending religious services in the past month, and participating in other activities (clubs, classes, or other organized activities) in the past month. Participants were classified as follows: 0 severely socially isolated; 1 socially isolated; and ≥2 socially integrated.

Analysis plan

To test our first hypothesis that housing characteristics differ by disability status, we compared disability status in relation to sociodemographic, support, and housing characteristics among low-to-moderate income community dwelling older adults using x² tests. Next, we tested our second hypothesis that housing characteristics are associated with odds of experiencing adverse consequences due to unmet care needs among the subsample of older adults with disabilities. We first computed unadjusted logistic regression models to see if each of the housing characteristics were associated with adverse consequences due to unmet care needs in each category of disability (self-care, household, and mobility) and any adverse consequence across all three categories. We then computed multivariable logistic regression models adjusting for sociodemographic and social support indicators.

We applied complex survey design weights for all analyses, where survey weights accounted for nonresponse, oversampling of subgroups, incomplete interviews and further adjustments relative to cohort replenishment of the original sample. ²⁰ All analyses were conducted using Stata v17.0. ³⁰

Results

The unweighted sample for this study comprises 4,898 community-living older adults with low or moderate annual incomes; 2,124 without self-care, household, or mobility disability (weighted percentage of 48.6) and 2,744 with disability (weighted percentage of 51.4) (Table 1). Older adults with (versus without) disability were more commonly older, with lower education achievement, and with lower income and financial hardship. Older adults with disability more commonly lived with others and were more often socially isolated. Housing characteristics differed between older adults with (versus without) disabilities. Those with disabilities were more likely to rent vs own, live in subsidized housing, live in apartments or mobile homes (vs houses), and to experience interior home disorder, exterior home disrepair, or street disorder.

Table 1.

Characteristics of Low- and Moderate-Income Community-Living Older Adults Overall and by Disability Status (n=4898)

	Overall n=4898	No disability n=2124 n (weighted %)	With disability n= 2774 n (weighted %)
Weighted estimate	24,202,201	11,774,110 (48.6)	12,428,091 (51.4)
Sociodemographic				P value
Age				<.001
65 to 74	1674 (51.9)	901 (58.8)	773 (45.5)
75 to 84	2050 (34.4)	910 (33.2)	1140 (35.5)
≥85	1174 (13.7)	313 (8.0)	861 (19.0)
Female	3082 (61.4)	1242 (58.8)	1840 (63.8)	<.01
Education
Above High School	2001 (44.4)	985 (49.7)	1016 (39.4)	<.001
High School	1547 (32.3)	691 (31.6)	856 (33.0)
Below High School	1350 (23.3)	448 (18.8)	902 (27.6)
Race
White non-Hispanic	3126 (75.0)	1457 (78.3)	1669 (71.9)	<.01
Black non-Hispanic	1224 (10.5)	459 (9.1)	765 (11.8)
Hispanic	385 (10.0)	145 (8.9)	240 (11.1)
Other	163 (4.5)	63 (3.7)	100 (5.2)
Income
$32,001-$60,000	1593 (38.4)	864 (45.7)	729 (31.5)	<.001
$17,001-$32,000	1628 (32.7)	710 (32.1)	918 (33.3)
$0-$17,000	1677 (28.9)	550 (22.2)	1127 (35.2)
Financial Hardship	474 (9.7)	136 (5.9)	338 (13.2)	<.001
Social Support Indicators
Living arrangement, lives:				<.001
Alone	1800 (34.9)	822 (36.6)	978 (33.2)
With spouse	1914 (45.6)	943 (48.7)	971 (42.6)
With others	1184 (19.6)	359 (14.6)	825 (24.2)
Social Isolation/integration:
Severely isolated	452 (10.0)	179 (9.5)	273 (10.4)	<.01
Isolated	1234 (26.8)	506 (24.7)	728 (28.7)
Integrated	3212 (63.3)	1439 (65.8)	1773 (60.9)
Housing
Retirement Community	401 (7.4)	155 (6.6)	246 (8.1)	0.10
Subsidized Housing	319 (5.3)	99 (3.4)	220 (7.0)	<.001
Rent vs own	1532 (28.9)	518 (23.1)	1014 (34.5)	<.001
Apartment or mobile home (vs house)	885 (17.7)	330 (14.8)	555 (20.4)	<.001
Interior Home Disorder	1620 (32.0)	598 (27.7)	1022 (36.1)	<.001
Exterior Home Disrepair	857 (16.6)	331 (15.1)	526 (18.0)	0.02
Street Disorder	689 (12.2)	243 (9.9)	446 (14.4)	<.001

Note. Data are from the National Health and Aging Trends Study (NHATS) (2015).

^aP values of tests of difference using χ² tests between participants who did and did not report a self-care, household, or mobility disability.

Approximately 32% (an estimated 4 million) of low-and moderate-income community-living older adults with disability experienced an adverse consequence due to an unmet self-care, household, or mobility need (Table 2). Supplemental Table 1 includes details of the prevalence of specific disabilities and related adverse consequences in the study sample. Among older adults with disability of low or moderate income, living in subsidized housing (OR 1.82, 95% CI: 1.30, 2.55), renting (vs. owning) (OR 1.57, 95% CI: 1.28, 1.94), living in an apartment or mobile home (vs. house) (OR 1.31, 95% CI: 1.05, 1.63), and living in a home with interior disorder (OR 1.25, 95% CI: 1.05, 1.51) were most highly associated with experiencing one or more adverse consequences due to unmet care needs in unadjusted logistic regressions (Table 3). When we adjusted the models for sociodemographic (age, gender, education, racial/ethnic status, income, financial hardship) and support characteristics (living arrangement and social isolation/integration), the magnitude, direction, and confidence intervals for results were similar to unadjusted models (Table 4). Results support our hypothesis that housing characteristics are associated with odds of experiencing adverse consequences due to unmet care needs, among older adults with disabilities.

Table 2.

Housing characteristics of Low- and Moderate- Income Community-Living Older Adults with Disabilities by Adverse Consequences of Unmet Self-care, Household, or Mobility needs (n=2774)

		Adverse Consequences due to:
	No Adverse Consequences n=1835 n (weighted %)	Any Adverse Consequences n= 939 n (weighted %)	Unmet self-care needs n=357 n (weighted %)	Unmet household needs n=380 n (weighted %)	Unmet mobility needs n=553 n (weighted %)
Weighted estimate	8,406,942 (67.6)	4,021,149 (32.4)	1,436,939 (11.6)	1,871,927 (15.1)	2,368,172 (19.1)
Retirement Community	157 (7.7)	89 (9.0)	36 (10.2)	42 (9.0)	32 (5.5)
Subsidized Housing	124 (5.7)	96 (9.9)	47 (13.9)	45 (11.9)	51 (9.0)
Rent (vs. own)	612 (31.1)	402 (41.5)	172 (46.3)	161 (42.8)	241 (43.7)
Apartment or mobile home (vs house)	346 (18.9)	209 (23.4)	87 (27.7)	97 (26.8)	104 (21.3)
Interior Home Disorder	655 (34.4)	367 (39.7)	143 (39.6)	141 (38.2)	223 (41.6)
Exterior Home Disrepair	331 (17.7)	195 (18.6)	69 (18.9)	85 (20.8)	120 (19.5)
Street Disorder	276 (13.4)	170 (16.3)	70 (17.8)	70 (17.1)	104 (16.9)

Note. Data are from the National Health and Aging Trends Study (NHATS) (2015). Column percents.

Table 3.

Unadjusted associations of Housing Characteristics With Odds of Experiencing one or more Adverse Consequences of Unmet Self-care, Household, or Mobility Needs Among Low- and Moderate- Income Community-Living Older Adults with Disabilities (n=2774)

	Adverse consequences due to:
	Any unmet needs n=939	Unmet self-care needs n=357	Unmet household needs n=380	Unmet mobility needs n=553
	OR (95% CI)	OR (95% CI)	OR (95% CI)	OR (95% CI)
Retirement Community	1.18 (0.82, 1.68)	1.33 (0.92, 1.94)	1.13 (0.73, 1.76)	0.61 (0.36, 1.01)
Subsidized Housing	1.82 (1.30, 2.55)	2.47 (1.61, 3.79)	2.07 (1.37, 3.12)	1.40 (0.88, 2.22)
Rent (vs. own)	1.57 (1.28, 1.94)	1.75 (1.37, 2.24)	1.51 (1.12, 2.04)	1.62 (1.25, 2.10)
Apartment or mobile home (vs house)	1.31 (1.05, 1.63)	1.58 (1.17, 2.13)	1.54 (1.13, 2.09)	1.07 (0.79, 1.46)
Interior Home Disorder	1.25 (1.05, 1.51)	1.18 (0.87, 1.60)	1.11 (0.83, 1.48)	1.33 (1.05, 1.68)
Exterior Home Disrepair	1.06 (0.82, 1.38)	1.07 (0.76, 1.51)	1.24 (0.92, 1.68)	1.14 (0.87, 1.48)
Street Disorder	1.25 (0.99, 1.59)	1.34 (0.98, 1.85)	1.28 (0.86, 1.91)	1.27 (0.96, 1.69)

Note. Data are from the National Health and Aging Trends Study (NHATS) (2015). Odds ratio (OR) and 95% confidence interval (CI) from logistic regressions.

Table 4.

Adjusted Associations of Housing Characteristics With Odds of Experiencing one or more Adverse Consequences of Unmet Self-care, Household, or Mobility Needs Among Low- and Moderate- Income Community-Living Older Adults with Disabilities (n=2774)

	Adverse consequences due to:
	Any unmet needs n=939	Unmet self-care needs n=357	Unmet household needs n=380	Unmet mobility needs n=553
	aOR (95% CI)	aOR (95% CI)	aOR (95% CI)	aOR (95% CI)
Retirement Community	1.16 (0.78, 1.73)	1.28 (0.85, 1.91)	0.98 (0.62, 1.56)	0.62 (0.37, 1.03)
Subsidized Housing	1.80 (1.26, 2.57)	2.37 (1.46, 3.87)	1.72 (1.10, 2.68)	1.39 (0.86, 2.24)
Rent (vs. own)	1.40 (1.12, 1.75)	1.40 (1.07, 1.84)	1.48 (1.07, 2.05)	1.33 (1.01, 1.75)
Apartment or mobile home (vs house)	1.26 (1.02, 1.57)	1.49 (1.10, 2.02)	1.33 (0.97, 1.81)	1.04 (0.76, 1.41)
Interior Home Disorder	1.22 (1.01, 1.48)	1.12 (0.80, 1.55)	1.01 (0.76, 1.34)	1.29 (1.01, 1.65)
Exterior Home Disrepair	1.04 (0.81, 1.33)	1.00 (0.70, 1.42)	1.28 (0.95, 1.74)	1.08 (0.84, 1.40)
Street Disorder	1.11 (0.89, 1.39)	1.12 (0.79, 1.59)	1.23 (0.84, 1.80)	1.05 (0.77, 1.42)

Note. Data are from the National Health and Aging Trends Study (NHATS) (2015). Adjusted odds ratios (aOR) and 95% confidence intervals (CI) from adjusted logistic regressions. A separate negative logistic regression model for each characteristic was adjusted for sociodemographic and support characteristics: age, gender, education, racial/ethnic status, income, financial hardship, living arrangement and social isolation/integration.

Discussion

This national study compared housing characteristics of low- and moderate- income community-living older Americans by disability status and, among those with disabilities, documented the relationship between housing characteristics and experiencing adverse consequences of unmet care needs. Housing characteristics differed notably by older adults’ disability status. Older adults with disability were more likely to live in rental housing (including subsidized housing), apartments or mobile homes, and in dwellings that exhibit interior disorder and exterior disrepair, and in locations characterized by street disorder. Most of the housing characteristics examined (living in subsidized housing, renting, living in an apartment or mobile home, and interior home disorder) were associated with experiencing adverse consequences due to unmet self-care, household, and mobility needs among low- and moderate-income older adults with disabilities. Our findings highlight differences in the housing characteristics of older adults with vs without disabilities, and the relevance of housing characteristics to the quality of community-based long-term services and supports (LTSS). Our results are a launching point for further research on the relationship between housing and quality-of-life outcomes for older adults with disabilities, and suggest possible targets of assessment and intervention to advance health equity within this group. These findings build on the existing aging-in-place literature by documenting the housing characteristics associated with adverse consequences due to unmet care needs among a population of low- and moderate-income older adults with disabilities, who have disproportionately higher rates of nursing home admission than their peers. ³¹

Our findings confirm correlations between disability and socioeconomic disadvantage identified in previous literature; older adults with disability are more likely to have lower incomes, less education, and less likely to be married (which is commonly a source of increased financial security).^32-36 Such disadvantage, within our current social welfare system, is associated with more hospitalizations, nursing home admissions, and earlier mortality.^31,37,38 Housing characteristics are closely related to socioeconomic position and the risk of disability, and thus may be a mediator of life course social position and disability outcomes.^32-35,39,40 As such, housing characteristics of older adults in later life are a promising target for attempts to lessen the negative effects of social disadvantage in later life. ⁴¹

Our study found that the presence of interior home disorder was associated with higher odds of experiencing an adverse consequence due to unmet care needs. Because older adults of lower socioeconomic position are more likely to live in poorer quality housing, which has been found related to other outcomes such as falls, physical capacity/performance, and poor sleep, improving housing conditions is a relevant target for future interventions. ^13,24,42

In the U.S., subsidized housing programs are the primary social welfare strategy that considers housing for socioeconomically disadvantaged older adults. Federal subsidized housing programs provide affordable housing and free up financial resources for some low-income older adults, but only around 36.5% of eligible older adults have access. ⁴³ Interestingly, we found that older adults with disabilities living in subsidized housing had higher odds of experiencing adverse consequences due to unmet care needs. This was unexpected because subsidized housing is, by definition affordable and commonly offers accessible options and is subject to housing quality standards, suggesting that it would be protective against adverse consequences. ^44,45 There are at least three potential reasons for this finding. First, our results may reflect limitations of ascertainment of whether participants lived in subsidized housing in this study, as it has been found that participants underreport participating in subsidized housing programs in other surveys. ⁴⁶ The wording of the NHATS survey question may have led to the undercounting of older adults who are participating in other subsidized housing programs besides Section 8 and subsidized senior housing (e.g, USDA or state multifamily housing). Second, these findings may also reflect that those living in subsidized housing differ in their disability-related needs and/or access to help in a way that results in residual confounding. Finally, these results may also suggest that housing meeting legal accessibility requirements may not, in fact, sufficiently meet the needs of all people with disabilities, resulting in unmet care gaps for older adults reliant on subsidized housing.

Over one-third of older adults with disability in our sample were renters. For decades the vast majority of older Americans have owned their homes, but this is changing with demographic growth and increasing socioeconomic heterogeneity of older populations. ^11,39 Along with the trends in increasing older adult renters, are the realities that many rental homes are not accessible to older adults with mobility problems and other disabilities. In a recent report 12% of renters aged 65–79 and 23% of renters age 80 and over reported having such housing challenges in 2019. ³⁹ Universal design features such as walk-in showers, lever-style door handles, bathrooms on entry floors, and no-step entrances in and out of the building, would contribute to the ability for older adults to complete their daily activities and reduce the occurrence of adverse consequences. ³⁹ Efforts to equip older adult homes with low and no-cost accessibility modifications are growing, but are not adequate. While programs exist to support small landlords to fund modifications and repairs of their rental properties, ⁴⁷ renters are typically excluded from directly accessing these funds. Thus existing programs typically afford decisional authority to landlords rather than renters. Although the Fair Housing Act grants the right to reasonable modifications to many renters with disabilities, these rights are not accompanied by funding and there is a need for programs and policies that provide access to funds to low-and moderate income older adult renters with disabilities to make their homes more accessible. ⁴⁸

This study has strengths and limitations. This study benefits from a nationally-representative sample and in-depth survey that included personal characteristics that allow for the definition of important subgroups (e.g., disability characteristics, annual income) as well as objective measures of participants home and street environments. Limitations are as follows. First, this observational study relies on data from more than 8 years ago (2015). Housing and financial challenges for low- and middle-income older adults have worsened since the COVID-19 pandemic, bringing urgency to needs to advance equity in long term services and supports and related well-being outcomes. Future studies are needed to evaluate whether the Emergency Rental Assistance Program and eviction moratoriums initiated during the COVID-19 pandemic improved well-being outcomes for low- and middle-income older adults with disabilities. Second, the cross-sectional design of this study does not provide information about the directionality of the relationships between housing characteristics and adverse consequences due to unmet care needs. Third, this study is limited by its heavy reliance on self-reported measures, although for the primary outcomes of adverse consequences of unmet care needs perception is arguably the most important indicator of participant experience. Finally, this survey-based study does not include extensive detail about older adults’ housing situation and the complex social relationships between housing and well-being: qualitative studies in a similar population will provide valuable information to guide the development of effective interventions.

Conclusion:

In this study, we find that half of community-living older adults with low- and moderate-incomes have a self-care, household, or mobility disability. Housing characteristics differed between older adults with and without disability. This is likely related, in part, to the greater socioeconomic disadvantage of the subgroup with disability. Among older adults with disability, we found housing characteristics (e.g., living in subsidized housing, renting, living in an apartment or mobile home, living with interior home disorder) to be associated with increased odds of experiencing adverse consequences due to unmet self-care, household, and mobility needs--an important quality-of-life outcome. Our findings highlight the relevance of housing characteristics, a domain that has previously been under-studied, to the well-being of older adults with disabilities, and suggest that policy, programmatic, and clinical interventions that account for housing as an important social determinant of older adult function and quality-of-life should be advanced.