Relocation in older adults: a concept analysis

Abstract

Background/aims

Aging is commonly paired with a series of physical, psychological, social, and spiritual changes in life and these conditions might cause temporary relocation in older adults. This study aimed to analyze and define the concept of relocation in older adults.

Methods/design

Walker and Avant’s approach was used for concept analysis. Electronic text searches were performed using valid databases with “relocation in older adults” keywords. The research included quantitative and qualitative studies related to relocation in older adults published between 1974 and 2024 in English and Persian. Out of 85 obtained articles, 14 met the inclusion criteria.

Results

The authors identified understanding relocation conditions, preparing and planning for relocation, receiving adequate emotional and socioeconomic support, maintaining individual-family involvement, and managing physical and mental conditions are the attributes of the determinants of relocation in older adults. Antecedents were divided into two categories, including the physical conditions of the elderly person and the main factors related to their health and illnesses. The consequences were also identified as both positive (e.g. independency) and negative (e.g. isolation).

Discussion

This study explained the defining attributes of relocation in older adults and its various applications in the related literature in order to provide a comprehensive definition to operationalize and measure this concept.

Conclusions

The results of the concept analysis of relocation in older adults revealed a comprehensive insight into this concept. Successful relocation in the older adults is achieved by considering the physical, personal, social, economic, and psychological aspects, and the preparation and planning of the older adults.

Background

The rise in life expectancy together with mortality decline over recent years has occurred thanks to numerous advances in healthcare services and technologies as well as improved living conditions [1, 2]. In view of that, the world’s population is aging so quickly [3]; for instance, the share of the population aged 60 and over (viz., the elderly population) was about 1 billion in 2020, accounting for 13.5% of the total world’s population, namely, a growth by 2.5 times as compared to that in 1980 (i.e., 382 million people). This is estimated to reach 1.2 billion people by 2050, and the maximum (approximately 70%) is to come about in developing nations [4]. According to international standards, a society is assumed to be old if the population aged 60 and over exceeds 10% or that is more than 7% of the total population [5]. Iran, located in Western Asia, is no exception in this respect, as it ranks second in the world with population trend changes following reduced fertility and increased life expectancy. It is predicted that by 2050, the population aged 60 and older will constitute about 31% (29 million people), the population aged 65 and older about 22% (more than 20 million), and people aged 80 and above 3.8% (about 3.5 million people) of the total Iranian population [6].

Aging is commonly paired with a series of physical, psychological, social, and spiritual changes in individuals, thereby leading to many health status changes, a higher risk of physical and mental illnesses, disabilities and functional disorders, lower survival rate, and mortality [7, 8]. Such conditions might cause temporary relocation in older adults from home to healthcare and rehabilitation centers. In this context, long-term relocation to nursing homes may also ensue for some reason, including dependence on others to perform the activities of daily living (ADLs), cognitive impairments, much need for specialized healthcare services not provided in community-based settings, no social support networks, or the inability of family members or others to care for them at home [9]. Here, the key concept of relocation comes into being, but the older adults have their own limitations to cope with this significant phenomenon as a common event [10]. Relocation has been already described as movement from one environment to another [10, 11]. In accordance with this definition, there are four types of relocation experience in the elderly population, representing internal and external transition, viz., intra-organizational, inter-organizational, residential, and organizational [12].

Over and above relocation that occurs in living places, aging is considered as a life stage with transition from middle to old age, accompanied by some more changes in different life aspects. In keeping with the Transitional Care Model, relocation is a situational transition, characterized by movement from one state to another, which contains a chain of variations in roles and responsibilities, relationships, abilities, and behavioral patterns [13]. Along with relocation, there are also many changes in one’s identity as well as the development of new roles and support strategies [14]. In the present study, this concept denotes changes in elderly period, changes in identity, acceptance of new roles, and changes of living place.

Relocation is thus a gradual process that can be accelerated as a result of innumerable factors, such as illnesses. This experience further affects life quality and satisfaction in the older adults [15] plus their functional status, self-care behaviors, independence, and the ADLs. From this perspective, it is of utmost importance to devote much attention to emotional, physical, cognitive, familial, and sociocultural needs during aging [16]. Relocation can thus yield adverse consequences, such as loneliness, social withdrawal, dependence, confusion, anxiety, and depression, which might vary in each elderly person. They may accordingly present a myriad of physical symptoms (viz., heart palpitations, vomiting, and anorexia nervosa) and psychological ones (namely, behavioral changes, fatigue, and anxiety) [17]. As evidenced, attending preparation programs can help them increase their perceptions of quality of life and relieve relocation-induced stress [17, 18]. On the other hand, it has been argued that people respond to relocation in different ways in older adults, so this phenomenon might have even positive consequences [19], e.g., making better decisions, having a sense of control over one’s life, and reaching more morale and better physical health in those viewing relocation optimistically [10].

In general, aging is one of the evolutionary periods of every person’s life. Today, we are facing a trend of increasing elderly population in various societies., which has turned out to be a global phenomenon in recent years. Population aging can have many consequences, such as a sudden rise in diseases, some changes in social roles and family relationships, retirement, and many mental health challenges. Therefore, developing effective low-cost programs and strategies to tackle the problems facing the older adults make a difference [20]. In this regard, investigating the ways individuals experience relocation for the period of aging can significantly contribute to healthcare systems in all societies. The bulk of definitions proposed for relocation among the older adults populations have to date laid much focus only on the concept of transition and movement from one physical environment to another [3, 10, 11, 19, 21]. The consequences and conditions raised in relocation have thus merely referred to transfer from home to healthcare or nursing centers and vice versa, and the definitions utilized for this concept have shed light on “moving from one environment to another for various reasons” [10].

Given the diverse views of relocation and some ambiguities not yet addressed in this domain, understanding this concept seems to be demanding. As there is still no precise, comprehensive, and clear definition of relocation, specifically in the older adults, it is not possible to achieve a deep understanding of its identification and management without some general definitions. To better appreciate the defining attributes of relocation and its impacts on all life aspects in older adults, it is necessary to identify this concept in a comprehensive and accurate manner. Accordingly, by considering the understanding and readiness of the older adults and paying attention to available support resources, arrangements can be made for successful relocation in older adults. The aim of this study was to analyze the concept of Relocation in older adults. In fact, identifying the defining attributes, model and contrary cases, antecedents, consequences and empirical referents of a concept, increases our understanding and helps to develop tools for measuring the concept.

Methods

The Walker and Avant (W&A) approach (2019) was practiced to analyze relocation as the key concept in this study. The eight steps taken according to the W&A approach were as follows. As the first step, there was an attempt to choose a concept, so relocation was preferred as the desired one due to its importance in the elderly populations. The reason for picking this concept was the big challenges and many needs facing this age group after going through the aging process and entering old age. The second step was to determine the main purpose of analyzing relocation to develop a clear theoretical definition to understand this concept. As the third step, all the uses of this concept were distinguished by an extensive literature review. The fourth step was to identify the defining attributes of the given concept, as the focal point of concept analysis in the W&A approach. To this end, the repeated characteristics of this concept were mined. The fifth step was also to identify the model case, which encompassed all the defining attributes of the concept. As the sixth step, there were attempts to spot the related and contrary cases, wherein the former was an example of its related concept but did not cover all the defining attributes and the latter was an obvious example once the intended concept did not exist. Both cases could be thus found in real environments, obtained through a literature review, or created by researchers. The seventh step was to identify the antecedents and consequences of the concept of interest and the eighth step was to specify its empirical references. To do so, it was required to review the relevant literature systematically [22].

Data sources

To retrieve the maximum number of the related articles on aging and relocation, obtain valuable sources to determine the defining attributes as well as the antecedents and consequences to start the concept analysis, a comprehensive systematic search was conducted, using some terms about relocation on online databases, including Scopus, CINAHL, the Cochrane Library, PubMed, Embase, ScienceDirect, and the Google Scholar search engine for the studies in English, via the keywords of “relocation”, “aging”, and “elderly OR elderly people OR elder people OR older adults” and the Scientific Information Database (SID) and Magiran for the Persian ones, with reference to the equivalent keywords of “relocation”, “aging process” and “older adults OR elderly people”. To check the definition for the concept of relocation, a search was further made on the valid dictionaries. Of note, the search for the articles had no time limitations in order to gain more access to every part of previous research (Table 1).

Table 1.

Search strategy

Research Title	Relocation in older adults
Research strategy	Keywords/Concepts: Relocation AND older adults	Synonyms/alternative words: 1. Relocation AND older adults 2. Relocation AND elderly 3. Relocation AND elder people 4. Relocation AND aging
Limitations and criteria	Full-Text articles in Persian and English without time limitation
Databases and search resources	1.Scopus 5. Science direct 2.CINAHL 6. Embase 3.Cochrane library 7. SID 4.PubMed 8. Magiran
Search Sample in PubMed	“relocation“[Title] AND (“older adults“[Title] OR “elderly“[Title] OR “elder people“[Title] OR “aging“[Title])

The titles, abstracts, and keywords of the retrieved articles were initially searched for the key concepts related to relocation, aging, older adults and the elderly. The studies were then saved with regard to their author (s), publication year, and titles to ensure their non-duplication. The reference lists of the given articles were further reviewed and the relevant ones on relocation in older adults were examined to find more studies missed during the online search. The inclusion criteria for article selection were the studies, in English or Persian, on relocation during aging, containing a definition of relocation, providing a general description of this concept or its dimensions, or discussing the history of this concept, relocation in the older adults populations, as well as the relationship between relocation and its consequences. Of note, the articles that had investigated relocation in other age groups were excluded.

All through the initial search on the related literature, 113 articles were obtained, but 85 studies were selected for further analysis upon removing the duplicates and reducing those on relocation and aging. Then, they were evaluated in terms of meeting the inclusion criteria and 14 articles finally remained (Fig. 1). Accordingly, all the studies that dealt with the concept of relocation and aging and matched the research objectives were selected.

Fig. 1.

Diagram of the articles selection process

Results

Relocation was originally defined in 1960 as an appropriate legal reasoning for the cases related to transfer from one place to another [11]. It has been further described as movement from one situation to another for various reasons [23]. Different definitions have been to date proposed for relocation, each one giving emphasis to a different aspect of this concept, e.g., relocation during natural crises [24], transfer from one’s living place to somewhere else [25], and movement from one situation to another [13].

Considering the concept of aging as a social phenomenon, the way it is perceived and practiced might be thus influenced by some cultural issues, social expectations, and life experiences. Aging is commonly defined through government policies upon creating a chronological age to represent an elderly person [26]. According to its dictionary definition, aging refers to the gradual changes in any organism that lead to an increased risk of weakness, disease, and death. Actually, it denotes the organic changes caused by age [27]. As evidenced on PubMed, the Medical Subject Headings (MeSH) defines aging as gradual irreversible changes in the structure and function of an organism that occur over time [28]. Therefore, reaching elderly is the time associated with poor health conditions and disabilities and the period of withdrawal or non-participation in many interactions and social activities, in line with the Theory of Isolation [26]. Besides, aging is characterized by losses and illnesses. In view of that, the health status of the elderly has been among the major challenges facing healthcare systems across the world [29].

As declared in the Activity Theory, aging is the time when the elderly adjust, redefine, and replace their roles and activities to maintain their sense of self. After a while, such premises have been rejected and positive theories focused on health and activities at some point in aging have been presented [26]. In this regard, some concepts such as successful, active, healthy, positive, and productive aging have emerged in the aging literature [30]. For example, productive aging means the elderly should remain active and productive through participation in non-social activities in order to minimize their dependence on social services. The newer concept of healthy aging has been further defined as “living a long, productive, and meaningful life and enjoying a high quality of life” to maximize the physical, social, and mental well-being of the elderly populations to promote their independence [26].

Given the significance of aging and the way people enter this life stage, dedicating much attention to the special conditions of those subjected to relocation in older adults is one of the main aspects within healthcare services. Although relocation is stressful at any age, it may bring more stress in people aged 65 and over due to their physiological changes and limited coping resources [31]. Hence, the defining attributes of relocation were discussed below based on the review of the selected articles on relocation and aging.

Defining attributes

Reflecting on the defining attributes of relocation was the core of this concept analysis. There was thus much attempt to find a set of features, mostly related to the given concept, and reach wider insights. The major characteristics, called defining attributes, could help name this particular phenomenon, as distinct from other similar or related ones, which could alone bring this concept to the mind. Of note, there were multiple meanings during collecting the examples, but deciding which one was the most useful depended on the analysis objectives [22]. The review of the selected articles here made it possible to identify the key defining attributes associated with relocation in the older adults (Table 2), i.e (1)., understanding relocation conditions (2), preparing and planning for relocation (3), receiving adequate emotional and socioeconomic support (4), maintaining individual-family involvement, and (5) managing physical and mental condition.

1. Understanding Relocation Conditions

   The first defining attribute of relocation in older adults is to understand a person’s condition and realize the aging occurrence. The main factors that come up first, while facing relocation, are an individual’s perception and acceptance of relocation [33, 34]. The elderly’s interpretation and satisfaction with relocation can be thus effective in their participation in optimal planning and successful relocation [33]. To accomplish it, informing the elderly people about aging and relocation seem mandatory [32].

2. Preparing and Planning for Relocation

   One other defining attribute of relocation is preparing and planning for relocation. In view of that, making the elderly prepared for relocation by considering the available choices for life ahead during aging and enhancing their knowledge of relocation and aging can be among the defining attributes of relocation in older adults. Accordingly, there is much focus on a systematic, preliminary and individual-based planning with respect to their preferences [21, 31, 34, 35]. In addition, there is strong evidence that successful relocation is associated with adequate preparation ahead of time [36]. In fact, individuals can predict many events after relocation, do better planning, and make good decisions for older adults by preparing for relocation [37]. Aging can thus form gradually; in other words, it is naturally a process. Successful relocation cannot be spontaneously achieved with no planning, but it is guided by the individual’s choices and actions in a way that it is the upshot of the previous life stages [38].

3. Receiving Adequate Emotional and Socioeconomic Support

   Another defining attribute of relocation in older adults is receiving adequate emotional and socioeconomic support. From this perspective, the aging people deprived of support from their family, friends, and the society for any reason, are more likely to have successful and favorable relocation. Accordingly, screening for adequate emotional and socioeconomic support can be done by inquiring about death, divorce, retirement, loss of caregivers, or movement to a new home in the past years [31, 32]. In this line, the people who receive adequate support from those around can enjoy better outcomes at long last [36].

4. Maintaining Individual-Family Involvement

   The participation of the elderly in relocation and their preparation can improve this process [21, 31, 34]. Getting involved in relocation throughout aging thus minimizes its negative consequences [36]. The active participation of an elderly person in life is also one of the main characteristics under this category, and it is generally related to the need to assume roles and responsibilities and maintain various ADLs according to individual abilities and then avoid inactivity and isolation [19]. Thus, having a hand in one’s life affairs, such as business, leisure time [38], social activities, housework, care for family members, and personal development, in order to maintain individual-family involvement, had been highlighted in the relevant articles [29].

5. Managing Physical and Mental Conditions

   Among the defining attributes of desirable relocation, some favorable physical and mental conditions are associated with the degree of a person’s independence in taking care of oneself and performing the ADLs. In view of that, dependent people in life are more likely to undergo inappropriate relocation in older adults [33]. Managing physical conditions, such as practicing self-care behaviors related to health as well as the conditions of a person in performing the ADLs can be under this category [32]. Although relocation is a stressful condition at any age, it can have more manifestations in the elderly populations due to their limited resources to cope with stress and anxiety caused by this phenomenon [33]. Besides, the occurrence of acute illnesses and subsequent hospitalization lead them to unwanted relocation [29]. As a result, managing the physical and mental conditions of the elderly is one of the defining attributes of relocation.

Table 2.

Literature characteristics

number	References	country	Attributes	Antecedents	Consequences
1	McAuslane and Sperlinger 0.1994 [21]	UK	the provision of relocation preparation programs, voluntary (rather than involuntary) relocations, a systematic, preliminary and individual-based planning with respect to their preferences, The participation of the elderly in relocation and their preparation	age, poor physical and mental health and cognitive impairment,	changes in behavioral dependency or the number of problem behaviors
2	Kirst and Peck. 2010 [32]	-	informing the elderly people about aging and relocation, Involving the patient’s family, available community resources, functional status, such as self-care behaviors associated with health and hygiene needs (activities of daily living [ADLs]), as well as abilities to remain independent enhance positive thinking		boost quality of life and satisfaction and adjustment
3	Naseh et al.,2024 [29]	Iran	physical, psychological and social health, non-dependence on others, active and continuous participation in life, social participation, housework, care for family members, and personal development, in order to maintain individual-family involvement	Positive personal characteristics including younger age, literacy, higher educational attainment, living with a spouse or partner, income, favorable socioeconomic status, maintaining a healthy lifestyle and sticking to favorable health habits,	Improving the quality of life
4	Hertz, et al. 2008 [31]	-	a systematic, preliminary and individual-based planning with respect to their preferences, advanced planning, adequate emotional and social support, The participation of the elderly in relocation and their preparation	frequent hospitalization, sensory disorders and using hearing aids and glasses, cognitive impairment such as Alzheimer’s disease, chronic conditions associated with confusion, and acute illnesses, poor health habits (e.g., lack of exercise, smoking, and alcohol use, health problems and chronic illnesses such as heart disease and diabetes, rented housing, and living alone, rural areas, divorce
5	Komatsu and Hamahata.2014 [33]	-	Understanding of relocation, the degree of a person’s independence in self-care and the ADLs, mental conditions	Age, sex, physical disorders, frequent hospitalization, no proper financial support and health insurance	no motivation for performing the ADLs, isolation, crying or angry, feel dependent on other people in doing their ADLs
6	Marion and Beaver 0.1979 [34]	USA	individual’s perception and acceptance of relocation, The participation of the elderly	health problems	Stress, Adjustment
7	Meehan, et al.2001 [35]	Australia	the preparation and planning before relocation, adequate support		aggressive behaviour
8	Meehan, et al.2004 [36]	Australia	adequate preparation, Engaging patients in the relocation process		enough time for their leisure activities following retirement, increased independence, mprovements in quality of life, access to community-based activities
9	Mirotznik and Kamp. 2000 [37]	USA	preparing for relocation		decline in physical health, stress
10	Zanjari, et al.2016 [38]	Iran	Planning, having a hand in one’s life affairs, such as business, leisure time	personality traits, such as optimism, positive mood, self-efficacy, humor and happiness, resilience, problem-solving skills, high self-esteem, and spiritual and moral capitals, viz., faith and spirituality
11	Brand & Smith. 1974 [19]	South Korea	The active participation of an elderly person, cognitive/mental/physical function, the social interaction	poor health, sex	psychological adaptation, life satisfaction
12	Solhi, et al.2022 [39]	Iran	preparing for relocation, Mental health and Stress management	increasing age, the female gender, being single or living alone, women, those living alone, elderly widows or divorcees	loneliness and isolation
13	Koppitz, et al.2017 [40]	Switzerland	participation in the decision-making		severe health consequences (anxiety, emotional distress, increased confusion, depression, and feelings of loneliness), decreased social communications, stress, aggressive behaviors
14	Anthony, et al. 1987 [41]	UK			confused behaviors and wandering e.g., the symptoms of depression, crying, and loss of appetite

Antecedents

Identifying the antecedents and consequences of relocation were the next steps in this concept analysis. Antecedents refer to the events or incidents that could happen or existed before the occurrence of the given concept [22]. According to the reviewed articles, the physical conditions of the elderly person and the main factors related to their health and illnesses are considered as the antecedents of relocation. Some conditions, including frequent hospitalization, sensory disorders and using hearing aids and glasses, cognitive impairment, such as Alzheimer’s disease, chronic conditions associated with confusion, and acute illnesses also affect their relocation. Some health problems together with poor health habits (e.g., lack of exercise, smoking, and alcohol use) are also connected with the risk of inappropriate relocation during aging. Moreover, the elderly who suffer from chronic illnesses, such as heart disease and diabetes, are at greater risks for the negative consequences of relocation [31, 34]. As established in previous studies, poor physical condition along with mental and cognitive problems could lead to the relocation of the elderly, between their living environments and healthcare centers, thereby binging negative effects to relocation in elderly [21]. On the other hand, the key factors linked to favorable health status are the positive perceptions of one’s health status, acceptable physical, sensory, and cognitive performance, and the practice of health protection strategies, e.g., maintaining a healthy lifestyle and sticking to favorable health habits as the prerequisites for entering successful healthy aging [29].

One of the other antecedents of relocation for the duration of aging is individual conditions. In this respect, someone with positive personal characteristics, including younger age, literacy, higher educational attainment, living with a spouse or partner, income, favorable socioeconomic status [29], and personality traits, such as optimism, positive mood, self-efficacy, humor and happiness, resilience, problem-solving skills, high self-esteem, and spiritual and moral capitals, viz., faith and spirituality [38], can go through desirable relocation during aging and have a more successful elderly ahead.

However, increasing age, the female gender, being single or living alone [39], rented housing, and unfavorable socioeconomic status have been mentioned in the related literature as the antecedents of relocation all through aging [31]. Accordingly, those at the age of over 80 face more physical disorders and thus frequent hospitalization, so they are more exposed to the stress caused by relocation if there is no proper financial support and health insurance [33]. Of note, women are likely to have more negative views of aging than men due to their worries and fears of loneliness and physical disabilities [39]. As well, those living alone, elderly widows or divorcees, and the individuals residing in rented houses [39] and villages [33] are exposed to inappropriate relocation.

Therefore, some factors related to health and illnesses (including hospitalization, cognitive and sensory status, acute and chronic diseases, lifestyle, and health habits) and individual conditions (viz., age, gender, marital status, educational attainment, housing, socioeconomic status, personality traits, and spirituality) can be the antecedents of relocation in older adults.

Consequences

Consequences represent the events or incidents that can occur as a result of relocation during aging [22]. There are thus many positive and negative consequences as people are likely to show unique reactions under different conditions and each person’s view of aging can vary according to the antecedents and defining attributes of relocation [10, 19]. The results of numerous studies in recent decades have demonstrated that relocation has an impact on someone’s well-being and brings various consequences, with regard to their physical conditions as well as mental and cognitive problems [21, 32, 33].

Among the negative consequences of relocation are decreased social communications, which is short-term and seems to improve over time [40]. However, it is by itself stressful for the elderly and makes them face some consequences [34, 40]. This can further occur due to sensory (viz., hearing and vision loss) and cognitive disorders or a new environment (i.e., hospital or nursing home) [37]. Other negative consequences are no motivation for performing the ADLs, limited interactions and social activities, and isolation, mainly attributed to sensory, cognitive, and physical disorders and their homelessness [33]. Furthermore, relocation might exacerbate aggressive behaviors, which are expected to decrease after some time. Preparing someone for relocation and having a plan to do so, by developing intervention strategies, have been thus among the ideas that moderate such negative consequences [40]. Other consequences might be raising some feelings, such as crying or getting angry [33]. Many elderly people also experience confused behaviors and wandering after relocation, e.g., the symptoms of depression, crying, and loss of appetite. As a whole, the intensity of such symptoms is lower in people who prepare for relocation [41]. In some cases, dependence can be one of the consequences; in other words, the elderly might feel dependent on other people in doing their ADLs [33].

In the elderly who are not physically dependent and have enough time for their leisure activities following retirement, increased independence has been documented as one of the positive consequences upon entering old age [36]. The experience of relocation in someone with positive personal characteristics and good health status can thus boost their life quality and satisfaction. Gaining an understanding of the meanings associated with relocation might also have positive impacts on their aging adjustment. Therefore, developing interventions to strengthen positive thinking and cultivate learned resources might help such individuals have favorable responses to relocation [32, 34]. Figure 2 illustrates the antecedents, defining attributes, and consequences of relocation.

Fig. 2.

Relocation to elderly: antecedents, defining attributes and consequences

Model case

A model case is a good example of the use of the desired concept to show its defining attributes. That is, the model case is a pure or paradigmatic example or even an instance. It thus comes first in the concept analysis, develops simultaneously with the defining attributes, or may appear after such features have been empirically determined. Model cases might be accordingly real-life examples cited in the related literature or constructed by researchers. Of note, the model case is or is not a nursing sample [22].

M.A., a 62-year-old female case, and her husband, who turned 65 last week, are retired and have no financial problems. For years, when their last child got married and left home, this couple had been preparing for aging and living their life without children. First, they changed their home, which used to be on the second floor of a three-story apartment with no elevator, and moved to a villa in a town with a 24-hour security guard near their daughter’s home. Needless to say, their son and daughter always visit their parents on weekends and inquire about their conditions by phone calls during the week. Physically, Mrs. M.A. and her husband are independent and able to do their ADLs, but their daughter is still sending her housekeeper to help her mother one day a week to for house chores. Mrs. M.A. has been suffering from diabetes for about five years and her husband is challenged by hypertension, and both are taking oral medications. They thus visit their family doctor every six months for checkups. They have been also dieting for years because of their old age. Their blood sugar and pressure are under control thanks to the regular use of medications. As they have a glucometer and a blood pressure monitor at home, they check their health conditions repeatedly. Every morning after having breakfast, they go for a walk to the park nearby. For some months, they have made friends with some people of their same age, and thus spend an hour talking and sometimes playing chess after walking. Interestingly, Mrs. M.A. is also actively involved in reading books and dedicates hours a day to do so for herself and her husband. They now feel satisfied with their conditions, experience a good-quality life, and have adjusted to aging. Both have fully prepared themselves and planned for aging.

Related case

Related cases are the ones associated with the given concept, but covering not all defining attributes. They are similar to the concept under study and interrelated in some way [22].

Mr. F.C., a 68-year-old male case, is a farmer, who lives on a farm in a small village. Even though it has been a few years he has entered old age, he does not consider himself a weak or ill and old person at all, but wakes up early, works on the farm, and takes care of the livestock. He is busy on the farm as well as the garden until evening. Last month, he suddenly lost his wife due to a heart attack and now lives with his only daughter, but the loss of his beloved wife, who was always by his side and helped him on the farm, has affected Mr. F.C. His daughter insists that he should also reduce his work and take more care of his physical condition following her mother’s heart attack. Mr. F.C. no longer works on the farm as before and has hired a full-time worker to do so. He regularly visits the hospital nearby for checkups under the supervision of a doctor. He has further started dieting and doing exercises, taking the medications prescribed by the doctor regularly, and has even quitted smoking. Although he feels alone after his wife’s death, his life quality has improved due to his daughter’s support plus some changes in his lifestyle and health habits.

Contrary case

Contrary cases can be the clear examples of the given concept. They are often of use to researchers because it is easier to decide what a concept is not than what a concept is [22].

Mr. N.J. is a 73-year-old male case, whose wife passed away two years ago, and his only son lives in another city (living conditions) and visits him twice a year (support). He has been suffering from diabetes, hypertension, and hyperlipidemia for years (disease). Since he lives alone (living conditions), he forgets to take his medications on time, and does not do his diet properly. He has also increased smoking to eight cigarettes per day (health habits). Previously, his wife always reminded him to take medications, do checkups periodically, and follow his diet. Since he lost his wife, he no longer cares about these issues. He used to be an independent person and was able to do his ADLs (managing physical conditions), but he had a cerebrovascular accident last month and lost one’s ability to move the right half of his body (disease). Due to his limited mobility, he is now unable to take care of himself and needs help to take a bath and go to the restroom (managing physical conditions). To do his personal work, he hired a nurse at home (support), but he was not able to pay for it and the healthcare services. Therefore, he has hired a part-time nurse to reduce costs a little (economic situation). Before his illness, even though he was 70, he did not consider oneself an old and disabled person because he was living alone and had independence, so he could not perceive aging and its special conditions (understanding conditions and preparation). Now that he has suddenly faced his disability and aging due to the cerebrovascular accident complications, his loneliness and living situation have put much pressure on him. Since he is home-bound, he is very unhappy with his living conditions. He does not go for the physiotherapy and rehabilitation sessions on time and regularly. As prescribed by his doctor, he should undergo a long rehabilitation period due to his aging, to reach some improvements in his body movements. He currently feels isolated and depressed. Sometimes he becomes very aggressive and gets angry at his nurse (consequence).

Empirical indicators

Determining the empirical references for the defining attributes of relocation in older adults was the last step in this concept analysis. Upon completing the analysis, the question raised was “How is the concept measured or its existence in the real-life world is determined?” In this line, empirical references are the key categories of this phenomenon to show its occurrence. In many cases, the defining attributes and empirical references can be the same. However, there are times when the concept under analysis and its defining attributes are very abstract; thus, empirical references are essential. Of note, empirical references are not tools for evaluating concepts, but tools through which the defining attributes can be identified or measured. Therefore, they are directly related to the defining attributes, not the concept itself. Empirical references, once identified, are accordingly very useful in tool development because they are clearly associated with the theoretical basis of the given concept. Furthermore, they contribute to the content and construct validity of any new tool [22].

A review of the selected articles revealed that, despite the rich research background on relocation and aging as two key concepts, few studies had measured them using some specific tools. Thus far, there have been some tools for examining different aspects of relocation in the elderly, such as adjustment and coping with relocation. According to the defining attributes presented in this study, these tools have not been comprehensive enough to investigate relocation in the elderly. Here, relocation adjustment refers to the ability of the elderly people to cope with different demands and reach stabilization as the members of the society. The Index of Relocation Adjustment was thus a tool, first developed by Prager (1986) [42], and then evaluated in terms of its psychometric properties by Beckett and Zauszniewski (2014) for the American elderly transferred to retirement communities. This tool contained six components, viz., geographic location, control and independence, psychosocial integration, goal realization, mental well-being, and need fulfillment. It was accordingly a screening criterion for the early diagnosis of poor adjustment among the elderly after moving to new places. As established, such an evaluation was significant for nurses to identify poor adjustment and early interventions and then prevent depression and mortality among relocated elderly people [43]. This tool could just evaluate relocation adjustment as applied in Davison et al. [44]. The 32-item Relocation Self-Efficacy Scale (SERS), developed by Rossen and Gruber (2007) [45], was one other tool with three dimensions of engagement efficacy, daily living efficacy, and transition management efficacy. It had already been administered by Seila and Wieseke (2012) [46] and Teti et al. (2014) [47]. Considering the magnitude of relocation in older adults, there has been much attention to this concept across the world, but providing a comprehensive operational definition can be effective in designing more accurate tools to examine it, with much emphasis on movement from one environment to another or a specific consequence, such as adjustment.

Proposed operational definition

Relocation is a process that may occur at any aging stage. It varies from one elderly person to another with regard to the individual and sociocultural contexts, so it may be realized correctly or have negative consequences. By definition, “relocation in older adults is a process that begins with the person’s perception of aging and relocation conditions, so it requires preparing and planning for maintaining individual-family involvement and receiving adequate emotional and socioeconomic support.” Of note, it is more cost-effective for the elderly to manage their physical and mental conditions. To meet these conditions, health-related factors and illnesses along with the individual characteristics of the elderly are of utmost importance, so they can lead to independence, increased life satisfaction, higher life quality, and adjustment to aging if fulfilled positively, or cause loneliness, depression, stress, and aggressive behaviors if not properly realized.

Discussion

The present study was to extract the defining attributes of relocation in older adults and its various applications in the related literature in order to provide a comprehensive definition to operationalize and measure this concept. As a whole, it was concluded that the definitions of the given concept were gradually evolving from the objective ones, focused on moving between two environments, such as home to hospital or nursing centers and vice versa or mere attention to disabilities and illnesses to subjective definitions driven toward well-being, social participation, and adjustment thanks to the expansion of the studies on aging and relocation. This concept is currently represented by a wide range of biological, psychological, sociocultural, and environmental factors. In fact, relocation cannot be limited to an objective and specific structure, but it is a relatively broad concept experienced by the older adults one way or another.

To sum up, population aging has drawn much interest in the health issues of the elderly and thus many views have been centered on the quality of aging and its related concepts, such as relocation. Based on the present concept analysis, relocation in older adults is a process. Once a person approaches aging or in spending it, they first seek to understand this life stage and the relocation conditions. Then, the involvement of the older adults and their family should be maintained by receiving adequate emotional and socioeconomic support, so they can manage their physical and mental conditions in order to prepare and plan based on individual needs for relocation systematically. To meet these conditions, health-related factors and illnesses along with the individual characteristics of the elderly are of great value. When an elderly person has positive personality traits and a desirable lifestyle, with an optimistic realization of relocation, they can achieve independence, increase one’s life satisfaction and quality, and reach aging adjustment. If the defining attributes of relocation in older adults are not realized properly due to the underlying diseases, frequent hospitalization, and negative personal characteristics, it can result in loneliness, depression, stress, and aggressive behaviors.

Therefore, the study results revealed that the defining attributes of relocation included understanding relocation conditions, preparing and planning for relocation, receiving adequate emotional and socioeconomic support, maintaining individual-family involvement, and managing physical and mental conditions. Some factors related to health and illnesses (including hospitalization, cognitive and sensory status, acute and chronic diseases, lifestyle, and health habits) and individual conditions (viz., age, gender, marital status, educational attainment, housing, socioeconomic status, personality traits, and spirituality) could be thus the antecedents of relocation in older adults. The positive consequences of relocation could be increased independence, life quality and satisfaction, and adjustment, and the negative ones were limited interactions, social activities, and communications as well as isolation, dependence, stress, depression, aggressive behaviors, and confusion.

The ultimate objective of relocation is thus to improve independence, life quality and satisfaction, and adjustment in the older adults. To generate favorable conditions for the older adults, relocation with proper preparation and planning is actually needed. In order to develop such conditions, there is a need to fully understand the given concept and its defining attributes.

The operational definition of relocation in older adults, proposed in this study, reflects on various physical, psychological, and socioeconomic aspects in the elderly populations as well as the conditions of their family and the society. In the previous definitions, relocation had been generally depicted and mostly focused on the transition of someone to a nursing home and physical and mental aspects [48–50].

Because of, the length of hospital stays is being shortened, and there is a move toward home-based care, older people have to undergo relocation between hospitals, care facilities, and home, depending on their condition [33]. With a growing ageing population, relocation of the elderly to long-term care facilities appear to evolve as a key future trend in the care of the elderly. Supporting the elderly and their families towards making a peaceful and smooth transition is of considerable importance to health and well-being [1]. Relocation to a new environment can be a stressful situation. Acute illness and hospitalization may “push” an older person into relocating [31].

These studies considered relocation as simply moving from one place to another and focused on elderly people with acute and chronic illnesses who, under the influence of this relocation, may experience disorders such as stress and anxiety. While relocation is a situational transition that can occur in various situations. In addition to the elderly moving from their permanent residence to a hospital or care center, relocation and situational transitions may also include changes in life situations and conditions such as illness, widowhood, and changing professional roles [13].

In many studies, the negative consequences of relocation, its defining attributes, and the way this process could occur in the elderly had not been further discussed [19, 36]. However, the present study was an attempt to take a comprehensive look at this key concept for the period of aging with an extensive review of the related literature. The new definition was accordingly presented regarding the different aspects of relocation among the elderly, considering the conditions before, during, and after this phenomenon.

To define the desired concept precisely, relocation was divided into some components. The concept analysis was thus formed under the influence of different views and aspects of individuals, their family, and the society, so the definition proposed in this particular field can be applied by a multidisciplinary team, consisting of nurses, doctors, physiotherapists, occupational therapists, and social workers at bedside and in research works. Of note, the analysis of this concept can contribute to the development of the Middle-Range Clinical Theories. Besides, identifying the defining attributes helps evaluate relocation, particularly in the elderly exposed to this phenomenon, and improve their conditions. It also aids nurses and other healthcare professionals in contact with the elderly populations to plan and perform interventions by identifying the aspects of relocation not yet developed well, thereby boosting the positive consequences of relocation in older adults and preventing many complications after improper relocation [33].

The proposed definition has implications for nursing research, especially geriatric nursing, to develop nursing knowledge. To reach a properly integrated concept, the operational definition can be further applied for constructing an evaluation tool. Identifying the defining attributes, antecedents, and consequences of relocation thus distinguishes this concept from other similar ones. From a conceptual perspective, relocation refers to a feeling or a condition experienced by an elderly person; therefore, clinical practice is promoted with a correct understanding of the feelings and experiences of relocation in the elderly populations. This concept analysis was to define relocation in older adults through an extensive review of the related literature on social sciences, medical sciences, and health in English and Persian. One of the limitations facing this review was the exclusion of the articles other than both languages mentioned. In addition, the desired concept was dynamic and there might be some changes in its defining attributes, antecedents, and consequences under different conditions, such as the provision of more suitable healthcare services and optimal health management over time, so it is suggested to analyze it with other methods, e.g., Rogers’ evolutionary method of concept analysis.

Conclusion

This concept analysis provided a comprehensive insight of relocation in older adults, as a key concept which includes physical, personal, social, and psychological support along with awareness in the elderly. The defining attributes, antecedents, and consequences delineated in this study can thus help better understand this concept and its different dimensions, and pave the ground for planning to fulfill it. A theoretical foundation was further established for future research in this line. More information was also offered to nurses and other healthcare professionals in terms of identifying and improving relocation in the elderly as well as developing accurate assessment tools and designing appropriate interventions in this domain. With regard to the dependence of the concept of relocation to sociocultural background and the unique contexts of different societies, it was suggested to develop suitable evaluation tools with much emphasis on sociocultural background to determine relocation during aging in each society. It should be noted that all the attributes and consequences can be develop to a suitable tools.

Authors’ contributions

All authors have agreed on the final version and meet at least one of the following criteria: (1) substantial contributions to conception and design, acquisition of data or analysis and interpretation of data and (2) drafting the article or revising it critically for important intellectual content.

Funding

This study was financially supported by Guilan University of Medical Sciences.

Data availability

No datasets were generated or analysed during the current study.

Declarations

Ethics approval and consent to participate

This study was ethically approved by the Ethics Committee of Guilan University of Medical Sciences (IR.GUMS.REC.1403.038).

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.