“I’m Not Terribly Lonely”: Advancing the Understanding of Intimacy Among Older Adults

Abstract

Background and Objectives:

Intimacy, a social relationship component, continues to be essential in later life, including for older adults in long-term care such as assisted living. Yet, no previous study has conceptualized how individuals experience intimacy holistically (i.e., broadly defined) and within the context of later life, health decline, and long-term care. The purpose of this analysis was to provide an in-depth understanding of intimacy in the lives of older adults in assisted living.

Research Design and Methods:

Using grounded theory methods, we analyzed data from the “Convoys of Care” (Kemp, PI: R01AG044368) longitudinal, qualitative research project. Data consisted of 2,224 hours of participant observation and interviews with 28 assisted living residents (aged 58–96), and their care partners (n=114) followed over two years from four diverse assisted living communities.

Results:

Residents’ experience with intimacy was a process involving four dimensions: emotional, intellectual, spiritual, and physical. Intimacy occurred in platonic or romantic forms and was dynamic over time alongside residents’ intimacy needs. Residents engaged in an ongoing process requiring that they manage their needs while negotiating intimacy opportunities and constraints.

Discussion and Implications:

Our findings expand the current conceptualization of intimacy in later life, specifically in the context of long-term care. Findings indicate the need for an approach to long-term care that addresses individuals’ intimacy needs and preferences.

There is a well-established positive association between social relationships and well-being across the life course; research confirms social support benefits physical and mental health, specifically in older age (Antonucci et al., 2009; Cohen, 2004). Social isolation and lack of social relationships contribute to higher mortality rates (Holt‐Lunstad et al., 2010; Saphire‐Bernstein & Taylor, 2013). Prior research shows that older adults who experience various social relationships, especially close social ties with family and friends, are more likely to be active and exhibit better moods than those who do not (Fingerman et al., 2019). This pattern appears in assisted living (AL), where positive relationships with co-residents, staff, and others indicate higher life satisfaction (Street et al., 2007) and subjective well-being (Street & Burge, 2012). Research also demonstrates that social activity in later life is essential for better physical and mental health (Fingerman et al., 2019).

Later life can involve frailty, loss of dependence, and the need for formal long-term care, including residential care communities such as AL (Khatutsky et al., 2016). Relative to the medical model underlying nursing homes, ideally, AL promotes a care model that encourages residents’ personal choice, socialization, and engagement rather than merely attending to health care needs (Kane & Kane, 2001). Residents frequently move in at advanced ages and with considerable care needs, including the demand for medical services (Kemp et al., 2018). These trends represent potential challenges regarding the implementation of social care models. AL staff and residents’ families regularly over-emphasize meeting residents’ physical care needs rather than social and emotional ones (Kemp et al., 2019). Indeed, these needs are under-investigated and not well-understood.

Intimacy between individuals is a product of social relationships and an interpersonal process (Reis, 1990). A central challenge in studying intimacy includes the absence of a definition that encompasses an inclusive definition of intimacy capturing a full range of relationships and contexts. Researchers suggest that intimacy in romantic relationships consists of distinct components: commitment, interdependence, emotional intimacy, and physical intimacy (Blieszner & de Vries, 2001). However, intimacy is not always romantic, exists in various relationships, and is experienced with non-romantic partners. Giddens defines intimacy as a process that allows individuals stability in their interpersonal relationships (1991;1992). Intimacy is more than just sexual behavior. Instead, intimacy involves a full spectrum of relations such as family, kinship, and friendship (Giddens, 1991).

In western cultures, friendships tend to be less obligatory than family relationships (Wood & Robertson, 1978), yet have a more substantial positive effect on well-being (Walen & Lachman, 2000) even as one ages (Fiori et al., 2006). For older adults, close friendships influence an individual’s concept of an authentic self, access to interpersonal activities, and direct care (de Vries, 2018). Noteworthy gender differences among older age friendships include the fact that women typically have more intimate friendships and place greater emphasis on intimacy relative to men (Felmlee & Muraco, 2009). Regardless of gender, older married persons are more likely to have same-gender friendships than cross-gender friendships (Akiyama et al., 1996). For older cohorts, a norm hindering friendships between older men and women includes the view that cross-gender friendships are always romantic (Adams, 1985), leading many to reject such associations out of fear of others’ romantic interpretations (van den Hoonaard, 2006). However, other research proposes that current cohorts have more favorable views of cross-gender friendships and hold values of close ties, including shared norms of trust, commitment, and respect (Felmlee & Muraco, 2009), indicating a shift towards more cross-gender friendships in later life.

Pertinent to understanding AL residents’ intimacy experiences is the “Convoys of Care” model (Kemp et al., 2013a). This model proposes an evolutionary collaboration of those who provide support, including formal and informal social network members, and the care recipient. Older adults typically arrive at AL with pre-existing care convoys of family and friends that expand to include formal care workers and potentially co-residents. Convoys of care encompass the assembly of care providers, including those providing social and emotional support.

AL offers the potential for intimacy between co-residents, including among married (Kemp, 2008, 2012) and dating couples (Kemp, 2016), as well as friends and enemies (Kemp et al., 2012). Residents also develop relationships with AL staff, volunteers, and others in the setting (Ball et al., 2009). Good relationships between direct care workers and residents positively influence care interactions (Kemp et al., 2010), residents’ subjective well-being (Street & Burge, 2012), and life satisfaction (Street et al., 2007). Typically, family members provide residents‗ social support (Perkins et al., 2013); residents also depend on their friends, former neighbors, ministers, fraternity brothers, sorority sisters, volunteers, and co-residents (Kemp et al., 2018).

Despite ageist societal assumptions of older adults as non-sexual, many individuals remain sexually active well into later life (Lindau et al., 2007) and there is considerable within-group variation (Bradway & Beard, 2015). Older adults’ sexual behaviors, desires, and interests are consistent with those of the general population (Hillman, 2008). Research on older adults in long-term care demonstrates restrictions on intimate relationships (Barmon et al., 2016). Bender et al. (2017) found romantic intimacy and sexual behavior scarce in AL, and residents frequently negotiated a lack of intimate relationships. Here, the term intimacy emerged from residents to describe their romantic or sexual feelings and encounters. Barriers to intimacy included the availability or access to partners, limited privacy, and perceived or enforced social rules. AL residents negotiate a lack of intimacy by providing excuses, supplying justifications, and dismissing their needs (Bender et al., 2017).

Current research provides insight into older adults’ social relationships, sexual behavior, and potential lack of intimacy. Existing research is primarily cross-sectional and focused on static notions of intimacy (see Kemp, Marshall, & Cutchin, 2013), missing the potential dynamism of intimacy in older life. No known study has conceptualized intimacy, including how individuals experience intimacy holistically (i.e., broadly defined to incorporate multiple domains of the lived social experience) and within the context of later life, frailty, health decline, and formal care. Thus, our aims are to: (a) provide an in-depth understanding of intimacy derived from a longitudinal study of older adults’ daily lives and care experiences; and (b) identify how and why intimacy experiences vary for older adults and with what outcomes.

Design and Methods

Data for this analysis come from the qualitative, longitudinal study, “Convoys of Care: Developing Collaborative Care Partnerships in AL.” The overall goal was to learn how to support informal care and care convoys in AL in ways that support residents’ ability to age in place with optimal resident and caregiver quality of life. Principles of grounded theory methods guided this study, including a constant comparison approach during which data collection, hypothesis generation, and analysis co-occur (Corbin & Strauss, 2015). Georgia State University’s Institutional Review Board approved the study. We used pseudonyms to protect the research sites’ and participants’ anonymity.

Settings and Sample

The first author analyzed data collected between 2013 and 2015 in four diverse AL communities in Atlanta, Georgia. Researchers chose these communities to maximize variation (Patton, 2015) by size, location, fee structure, ownership, resident characteristics, and other factors researchers believed might influence care arrangements (Kemp et al., 2017). Oakridge Manor, the largest community, was licensed for over 90 residents, corporately owned, and located in an urban area; nearly all residents identified as African American or Black, and many knew each other before AL. Privately-owned Garden House was licensed for about 50 residents and located in a small town. Most residents were white. Feld House was a not-for-profit with a capacity for nearly 50 residents and set in a suburban area. All residents were white, and most were Jewish. Hillside was family-owned, licensed for about ten residents, and located in a rural mountain area. All residents and staff were white.

Researchers recruited and purposively selected 28 residents across these four care communities based on gender, race, age, religion, education, socioeconomic status, functional abilities, and cognitive function. Seventeen of the 28 residents were women; 11 were men. Ten identified as African American or Black and 18 as white. They ranged in age from 58 to 96 years old, with an average of 84 years. Most were widowed; three were married, three divorced, and two were never married. Eleven had Alzheimer’s Disease or related dementia. Most residents used a mobility device such as a walker or wheelchair, while three walked unassisted.

Following resident enrollment, researchers recruited their informal and formal convoy members. A total of 114 convoy participants, including 65 informal convoy members, participated. Of the informal convoy members, residents’ adult children were the most common informal care partners. Spouses, siblings, daughters/sons-in-law, aunts/uncles, grandchildren, and friends also participated. Formal convoy members included AL staff in addition to outside paid providers. Researchers interviewed 29 AL personnel covering a wide range of residents’ care and support activities and 20 care professionals from the external community who provided care within the AL setting.

Data Collection

A team of gerontology researchers collected data using multiple methods, including formal and informal in-depth interviews, participant observation, and review of residents’ AL records. Data collection began with participant observation and in-depth interviews with each community’s executive director(s) to understand the AL culture and learn about residents and staff. Next, researchers interviewed residents and convoy members. Researchers asked residents about their lives, transition to AL, informal and formal care, and experiences residing in AL. Questions about intimacy included: “Tell me about any friends, former neighbors, or other important people in your life?”, “How do you feel about the contact you have with your family and friends?” and “Are you ever lonely?” Researchers conducted a total of 142 qualitative interviews with residents, executive directors, direct care workers, health care professionals, residents’ families and friends, and AL volunteers.

Where possible, researchers visited residents weekly and followed them and their convoys for two years or as long as they remained in the home. We aimed for twice-monthly contact with informal convoy members. Between 2013 and 2015, researchers made 809 site visits logging 2,224 observation hours and informal conversations. Researchers recorded observations in detailed field notes and created resident case profiles. Profiles documented resident and convoy characteristics and tracked continuity and change in residents’ lives over time (see Kemp et al., 2019).

Data Analysis

We used NVivo 11 to store and help facilitate the management, coding, and qualitative data analysis. The principles of Grounded Theory were used for analysis as it allows us to answer our research questions as grounded theory centers commonly on social processes or actions, including the interpretation of what and how people interact (Aldiabat & Navenec, 2011). Convoys of care’s researchers contributed to an initial coding of the data utilizing housekeeping codes that organized broad concepts such as “convoy properties,” “resident needs,” and “care interactions” with care partners. Housekeeping codes highlighted various concepts relative to residents’ care experiences, care partners, and lives in AL. Researchers created and identified initial housekeeping codes to code all data to discover how convoys organized and operated. Data collection and coding analysis co-occurred, and all authors participated in data collection, coding, and analytical discussions in bi-weekly team meetings. Researchers describe details of the broader study’s methods and analytic approach elsewhere (Kemp et al., 2019).

We followed Corbin and Strauss’s (2015) three-stage coding process. The first author began by open-coding, which consists of line-by-line coding of information, particularly data pertinent to residents’ intimacy. She also open-coded the housekeeping codes: “resident characteristics,” “resident needs,” and “socioemotional care.” Open-code examples included: “engagement,” “lacking intimacy,” and “intimacy strategies.” Coding was guided by sensitizing concepts from the literature and new themes identified in the data.

Following open-coding, the first author and co-authors engaged in axial coding (Corbin & Strauss, 2015), linking initial open-coding categories and subcategories. During axial coding, they identified factors that influenced residents’ intimacy needs and experiences. During the final analysis stage, selective coding, the authors collaborated to refine and unite the categories around the core category, which characterizes intimacy as a multi-dimensional process involving “managing needs and negotiating opportunities and constraints.” The core category connects subcategories in describing intimacy as an ongoing process that includes managing intimacy needs while simultaneously negotiating opportunities and constraints involved to realize them.

Results

Our core category, “managing needs and negotiating opportunities and constraints,” characterizes intimacy as a process (see Figure 1). Participants experienced intimacy as a multi-dimensional intra- and interpersonal process involving feelings of closeness, familiarity, affection, trust, and vulnerability, entangled in the relationship and interaction contexts. Intimacy was simultaneously a personal and interpersonal process shaped by residents’ needs and access to intimacy, influenced by multiple resident-, relationship partner-, and AL-factors over time.

Figure 1.

Managing needs and negotiating opportunities and constraints.

Participants accessed intimacy physically through touch, and created and sustained emotional, spiritual, and intellectual intimacy through conversations. Residents experienced intimacy platonically, romantically, sexually, and processed intimacy inwardly, with another, or within a group. Our holistic definition reflects the myriad of areas in which AL residents experienced or lacked intimacy. It also implies that intimacy dimensions can be associated with different relationship partners not solely from one partner.

Intimacy Types

Emotional Intimacy

Emotional intimacy was the most common intimacy dimension residents experienced. Many residents maintained emotional intimacy with a range of partners, including spouses, romantic partners, adult children, other family members, and friends living inside and outside AL. Ethel, an 87-year-old white widowed resident, was asked about the people who provide for her emotionally or listen when she needs to talk. She identified her niece, daughter, and friends, exhibiting variations in emotional intimacy partners. Residents also experienced emotional intimacy through visits, phone and video chats, text messages, letters, emails, and social media, including geographically distant family and friends.

Some residents established emotional connections with co-residents, including co-residents with whom they shared each meal. These tablemates sometimes prove key sources of intimacy, especially for longer-tenured residents and those who had grown emotionally close. Moira, an 80-year-old white widow, characterized co-resident connections, “That is very Important…I now have some social support. That is why I play bingo, and I am learning mahjong. There are some people that I find very… what is the word, the same as I am?” Like Moira, many residents recognized the importance of social support in their lives. Her words suggest perceived commonality as a potentially critical factor influencing intimacy.

Other residents formed close connections with AL staff. Captured in field note data, Peter, an 87-year-old white widower, spoke about his close relationship with Patricia, who was in her 40s, Black, and a manager at the home:

Peter said that the two of them were very close. He said that she was a manager, but she did everything. He said that helping him shower “was not her job, but she did it anyway.” Peter said that she would often come into his room during her shift and lie down on his bed and chat… She told him about her life and all the places she has lived.

While speaking about being a “good resident,” Peter shared one of his approaches, “building relationships with the people who care for” him, indicating the potential importance of resident-staff relationships. Peter and Patricia had an ongoing friendship, but she left to pursue other opportunities during the study. Peter discussed the difficulties of creating, maintaining, and achieving a close relationship, only to have it change or end.

Peter’s concerns regarding intimate connections in later life included limited control over change. This common scenario illustrates that residents valued familiarity and consistency; both influence intimacy and the challenges of sustaining relationships in care and later life contexts.

Some residents had unmet emotional intimacy needs related to an imbalance between needs and desires. The following field note describes the perceived social support of Sadie, who was 95-years old, white, and widowed:

Sadie felt well supported except for someone to have a good time with…Her children and grandchildren provide most of her emotional support except for her friend Eva, her confidant. Sadie says they tell each other everything…and they talk twice a week.

Despite close relationships with her family and having a long-time confidant, Sadie had unmet intimacy needs, expressing loneliness throughout the study.

Physical Intimacy

Physical intimacy expressions varied, yet residents viewed touch as an essential display of closeness, familiarity, and comfort. Most residents expressed physical intimacy through handholding/touching, touching the shoulder or arm, hugs, and kisses with spouses, romantic partners, family members, and friends.

Touch in AL routinely concerned the provision and receipt of care. Direct care workers (DCW), critical providers of residents’ daily care needs, indicated the importance of touch. One care worker said that providing quality care involves, “Touch, the slightest touch, just put your hand on their back, to show them you care.” DCWs were integral to residents’ care, assisting with personal care tasks such as bathing, dressing, hair brushing, toileting, and feeding. During intimate care exchanges, staff consistency and familiarity influenced residents’ feelings of comfort and acceptance of care. Ronald, an 85-year-old Black widower, described the importance of trust when he received assistance with bathing, “It’s a manner that says to me, do you trust this person? I trust them by the way they touch me, the way they touch my arm, the way it feels.” However, touch alone was not indicative of intimacy. Residents specified differences between task-orientated touch, such as in care encounters, and physical intimacy. Touch residents interpreted as intimacy tended to coincide with other intimacy expressions such as emotional intimacy.

Residents often identified physical intimacy as lacking in their lives. However, some residents were fortunate to forge close companionships in AL that included or centered around physical intimacy. Greg, a 90-year-old white widower, began a relationship with Sarah, a white woman in her sixties and paid art instructor at the home. The following field note explains how Angela, an AL administrator, characterized their relationship and its positive impact on Greg:

Angela said, “There’s Greg” and told me about “[his]date with Sarah.” She said that Greg told her he wouldn’t be back until the morning. Angela proceeded to talk about their affectionate ways. Angela said that she’d gone into Greg’s room, and they were holding hands, and another time Sarah was “lying across his bed with her pants pulled up to her knees and he was massaging her feet and legs.” Angela then said, “I don’t know the nature of the relationship, and it doesn’t matter. It’s good companionship, and I think it’s great.”

During his AL tenure, Greg was his wife’s caregiver, became widowed, and developed a new romantic relationship. His experience demonstrates dynamism in AL residents’ social and intimacy careers, influenced by his preferences and partner availability.

Residents looked to their co-residents for physical intimacy and touch as well, which is captured in this field note excerpt:

Mindy would reach for Cora’s hand, commenting on how cold her hands were. Cora would smile and tell Mindy that her warm hands felt good.

There was potential for physical closeness and intimacy among co-residents who were able to empathize with each other and had compassionate relationships.

Intellectual Intimacy

Intellectual intimacy ranged from political debates to speculating about life’s meaning. Residents attained intellectual intimacy through conversations and sharing ideas, experiences, or life history. Some residents prioritized intellectual intimacy; doing so was necessary and correlated with their experiences and identity. Intellectual intimacy involves shared interests, such as past careers and book or film discussions. In the three larger homes, staff organized book clubs or discussion groups, providing a potential intellectual exchange space and opportunities to engage intellectually. Gloria, AL activity director, also reached out to residents individually for discussions, demonstrating the influence of potential care partners’ willingness and ability to engage and address residents’ intimacy needs.

For some residents, intellectual exchange had been an essential component throughout their lifetime. Isaac, an 84-year old Black man, had an advanced degree in linguistics and was one of the few residents observed using a computer frequently. He spoke several languages, had traveled the world, and enjoyed analytical discussions about the origin and history of names. While Isaac often engaged in such conversations with others in AL, he engaged in intellectual intimacy through frequent and lengthy phone calls with friends from across the world. For him, intellectual activities and discussions had been frequent in his life, and maintaining intellectual intimacy was essential for his self-identity and contentment.

Many residents reminisced about life before AL, processing and sharing these feelings. Some shared their thoughts with whoever would listen. Others, more reserved, shared deep conversations only with intellectual intimacy partners. For some residents, end-of-life discussions were essential to their sense of self and “wrapping up” their lives.

Spiritual Intimacy

Spiritual intimacy encompassed feelings shared and experienced with another person and, for many, a sense of connection beyond themselves, including relationships with their deity. For some, spiritual intimacy consisted of prayer, bible study, attending AL devotion activities, and a worship site when feasible. When asked about her mother’s spirituality, a daughter said, “she’s more interested in going to services now than ever before.” Over time, her mother increased her attendance of AL activities centered around her faith.

For some residents, spirituality interfaced with emotional support; for example, Bobbie, an 86-year-old white widow with dementia, whose son explained:

I think her primary source for emotional support is her religion. She is a woman of devout faith, and the whole time I was growing up, anytime she was stressed, she would read the bible. She would always think that she could open the bible to whatever the right answer for her was…[and] always has been and continues to be her primary source of support.

Individuals’ personal histories influenced their intimacy outlets and preferences. Typically, residents maintained the intimacy habits acquired and used throughout their lives. For many, their spiritual practices helped preserve their sense of self and identity.

In AL, religion and spirituality were central to creating feelings of home and community, providing the basis for daily activities and closeness between residents and, frequently, staff and persons outside the facility. At Oakridge Manor, residents were primarily Protestant and Black, including Delores, a 78-year-old widow who ran the morning devotional study four days a week. Delores played the piano, sang hymns, and led bible study. Her ever-popular events were significant to co-residents with limited mobility or options for transport. Such programming allowed residents to seek spiritual intimacy from spiritual exchange onsite and within a group. Delores also visited ill or frail residents who were unable to attend devotional activities. Together, they practiced spiritual intimacy, a benefit for both. Residents forged spiritual intimacy individually, within a dyad, or a collective of individuals, such as a prayer group, providing further illustrations of AL’s potential intimacy opportunities.

Platonic, Romantic, and Sexual Intimacy

Residents’ intimacy experiences were primarily platonic, characterized by familiarity or closeness between co-residents, family, friends, and others. However, some residents experienced romantic or sexual intimacy. Married residents often had one partner with higher care needs than the other or more than their spouse could manage. This challenge landed them together in assisted living or apart, with one in AL and the other at home. Diana, an 83-year-old white resident with dementia, was married to Tom, who lived nearby and frequently visited. Diana did not always recognize her husband but enjoyed his attention. Researchers observed Tom and Diana regularly holding hands, kissing, and proclaiming love to each other. Nevertheless, their relationship transformed over time. Their daughter noted:

My dad is my mom’s white swan, and I think right now, at her stage, I’m not sure she really knows that he’s her husband, but he still thinks she does. I think she believes—I think she knows he’s someone that cares for her, and she cares for him, and that she loves. I’m not sure that, in her present state of mind that she really realizes that he is her husband.

Diana and Tom’s relationship illustrates how intimacy can change over time, especially within the context of dementia. Despite these deviations, they maintained a positive intimate relationship that brought them joy and emotional support during the two years of study.

Residents interested in romantic intimacy sought various potential romantic partners in and outside their facility. They found meaning in these relationships, which helped improve their mood and emotional outlook. Captured in field notes, Mavis, a white 80-year-old widow, discussed her relationship with co-resident Anthony to a researcher:

Mavis said Anthony wants the relationship more than she does but that he makes her feel attractive as a woman, and they have lots of good times together… Mavis said some of Anthony’s family had met her, and that just makes it more meaningful… Mavis said this is the first time she has felt free, saying, “I have everything I need taken care of…I am relearning to be content at this point in my life.” She mentioned that Anthony has some dementia but does not let that bother her.

Mavis adjusted some of her needs and desires for romantic intimacy. Their relationship demonstrates the availability and possibility of intimacy for those experiencing dementia. Additionally, Mavis appreciated the connection with Anthony’s family as additional social support.

Other residents yearned for more romance in their lives, missing what they had lost, sensing they would never have it again. Admittedly “happy” and with “a lot to be grateful for,” Peter described missing physical, romantic intimacy with his wife, noting, “I have a great family and great support. I have a place to live. My health is reasonably good, minus some problems. But, I miss my wife. I miss kissing her. I miss her perfume, touching her, and being intimate.” Peter yearned for the romantic intimacy he had with his wife and compensated by centering emotional and intellectual intimacy with family and facility staff.

Intimacy Factors: Opportunities and Constraints

Resident Factors

Residents’ life history, experiences, and preferences influenced their intimacy process and opportunities. Some individuals wished for more intimacy; others had few needs. Gender imbalance meant limited opportunities for women to have cross-gender relationships and men to have same-gender relationships, including friendships. One’s physical and cognitive function also potentially hindered intimate encounters, especially romantic ones. When asked about any onsite dating potential, Hannah, 85 years old, Black, and widowed, said that the facility’s men needed more help than she was willing to offer. Other women complained about a “lack of men” in the home. Some men expressed desired opportunities to have closer friendships with other men or ruminated about friendships and past relationships.

Marital status limited or provided intimacy. Most residents were widowed and, like Peter, reminisced about lost loves. Dorothy, an 86-year-old Black widow, described her experience:

I do get lonely, but not terribly lonely. There’s always somebody I could communicate with or something I can do… No, I don’t really get lonely, but I miss [George], my husband. I just miss him - just an empty place in my life.

Dorothy’s quote exemplifies how one might feel many gradations of loneliness, from very lonely to “not terribly lonely,” indicating the potential to decrease feelings of loneliness. Other residents spoke about maintaining intimacy with spouses, family members, or friends who had died, a shared experience among widows and widowers.

Most residents had multiple health issues, including incontinence, dementia, mental health, sight, hearing, and mobility. These conditions frequently affected co-resident relationships. One resident who used an oxygen tank lamented, “I’m so afraid to be around people because the oxygen makes so much noise, ” causing her to self-isolate and limit peer connections. Residents with better physical and cognitive function were more likely to congregate and form social bonds than those with more significant care needs. Hearing loss was a factor that residents, staff, and family members felt limited residents’ engagement and intimacy potential. A son noted his mother’s challenges with Parkinson’s disease, and before wearing hearing aids, “Between not having the hearing aids and her shaking, she feels like she cannot participate, she cannot be involved.” After she began wearing hearing aids, her participation and engagement improved her overall sense of happiness.

Health conditions sometimes confined residents to the facility and even their room, making them less likely to engage with others. When asked about her connection with others, Deanna, a 64-year-old Black divorcee, responded, “I used to do all the things, but now, with my brain aneurysm, I don’t see anybody,” indicating her isolation from others.

Residents who experienced the death of a friend at the facility were cautious about connecting with co-residents to avoid such a loss again. The following field note captures Peter’s hesitation:

Peter said that it is hard when you see people you care about because you never know if it will be the last time…Peter said, ‗I am very aware that this is the type of place people come to die.’ He then talked about not wanting to get too close to anyone.

To protect himself from possible emotional pain, Peter strategized and limited his attempts at intimate relationships with co-residents. His closest connections included staff, such as Patricia, and younger family members, indicating the importance of intimate partner factors.

Partner Factors

The main partner factors that influenced residents’ intimacy included the relationship with the resident, their availability, and interest in an intimate relationship. Residents, staff, and family members considered some relationships inappropriate, such as romantic or even emotionally intimate connections with staff, volunteers, or even co-residents. An intimacy partner’s availability and proximity also were influential as few residents had the technological skills or transportation to engage in and maintain physically distant relationships. Furthermore, intimacy partners needed to show interest in such a relationship.

For example, despite having feelings of loneliness, Dorothy had many friends who visited and kept her involved. In the following field note excerpt, we can see that she cherished and appreciated the effort her friends made to visit:

Dorothy told me she was doing “fantastic” as she had just had a lovely visit with some friends. She said she feels so fortunate that her friends come to visit her and spend time with her, and she really enjoys the time they spend together…. she was adamant that she really appreciated their efforts to keep her entertained and engaged.

AL Home Culture, Policies, & Practices

Facility policies and practices shaped the culture and residents’ availability and access to intimacy. AL communities influenced residents’ experiences with collective spaces, communal meals, formal activities, and engagement encouragement. Here, a daughter explained how AL addresses more than just her father’s health needs:

His wants and needs are few in terms of what he asks for. I think [AL] is a big part of that because he has people checking on him daily. [The director] is always in there engaging with him. If he was in a place that didn’t necessarily have that kind of structure to it… I would feel like I needed to daily provide him a lot more of those things. While I do talk to him daily, I don’t feel like I have to be out there every couple of days.

At Oakridge Manor, members of the community were frequently involved in residents’ lives, including some who had known each other for years. These long-lasting relationships provided residents opportunities for intimacy with old friends, students, and fraternity and sorority members, indicating the importance of community connection for residents. For example, Marvin, who was 85 and Black, spoke to researchers about the positive relationships he continued to have with former students and his fraternity brothers who took him out and checked in with him.

Reconciling Intimacy Needs with Opportunities

Facility life created opportunities and constraints in residents’ intimacy process. Residents successful in creating and achieving intimacy displayed more fulfillment than those who did not. When asked, the majority of residents said they were not lonely. Yet, for those who desired but lacked intimacy, feelings of loneliness often ensued. Jacob, an 89-year-old white widower, explained, “I get lonely. I’d have to define loneliness as more of a desire than anything else. That sometimes is physical desire, an emotional desire, even a spiritual desire.”

Particular residents who lacked intimacy actively sought out opportunities in the facility. They looked to co-residents, staff, health care professionals, volunteers, and their family and friends for increased intimacy in their lives. Residents’ strategies for improving intimacy with co-residents ranged from circulating the dining room during meals, leaving their door open to the hallway, attending activities and events, and distributing mail to co-residents. Field note data captured a researcher’s discussion with Michael, an 87-year-old white widow. He wished for more opportunities for co-resident connections: “I am trying to get them to have a coffee area at Garden House. So, we can sit and talk…we can sit down and have lunch or a coffee and talk.”

Discussion

We aimed to provide an in-depth, holistic understanding of older adults’ intimacy experience(s) and identify how and why such intimacy experiences vary in long-term care communities. Findings show that intimacy is an ongoing process influenced by managing one’s needs while negotiating intimacy opportunities and constraints. Most AL residents experienced intimacy in their daily life.

Using grounded theory methods, including a constant comparison approach during which data collection, hypothesis building, and analysis co-occur (Corbin & Strauss, 2015), the Convoys of Care model provided a “sensitizing concept” for our current analysis (Charmaz, 2007). As researchers, we were collaborative participants in the analysis process, ensuring no co-researcher was likely to be pressured into a specific theoretical point (Glaser, 1992). Furthermore, grounded theory methods are decolonizing methodologies for enabling the creation of new knowledge in the context of equal power amongst researchers (Redman & Mills, 2017).

Our findings are congruent with Reis and Shaver’s (1988) and their “interpersonal process model of intimacy,” where intimacy is a reciprocal process between two individuals developing and sharing a connection. Yet, this process also involved managing intimacy needs (type, frequency, and partners), negotiating them within existing opportunities and constraints.

Our conceptual model presents the factors influencing older adults’ intimacy experiences in AL, including their history, preferences, health, frailty, and access to potential partners. Modifiable factors affecting residents’ intimacy experience in AL include home culture, availability of activities and shared spaces, and openness to intimate partnerships. Residents experienced intimacy internally, within a dyad, and within groups. While some residents felt their intimacy needs remained unmet, others were strategic in increasing intimacy opportunities in their lives.

One explanation for the variability of intimacy in AL includes individuals’ diverse intimacy experiences. Older adults arrived at AL communities with an intimacy history, including individual preferences, abilities, and needs. AL may expand their intimacy involvement for some older adults by connecting potential intimacy partners such as co-residents, staff, and volunteers. Our findings regarding older widows’ experiences regarding the intimacy of past relationships as central rather than seeking a current relationship or when intimacy opportunities are limited are consistent with Bender et al.’s (2017) research of intimacy in AL and recent research that centers on continuing bonds in older adults’ convoys (Steman, 2020). We found that residents in better cognitive and physical health were more likely to socialize with others in similar health, a finding consistent with previous research regarding social relationships in AL (Sandhu et al., 2013).

Previous research shows how ageist social norms and internalized ageism decrease the likelihood of older adults’ intimate behavior in AL (Bender, Burgess, & Barmon, 2017). Here, researchers found that residents often ignored their needs and desires to better align with the present opportunities, or rather, lack of opportunities for intimacy in AL. We, too, found that ageist assumptions about older adults’ intimacy process limited one’s internalized intimacy expectations. However, many residents sought and achieved intimacy with an array of potential partners and with variation and consistency over time, showing the potential for a dynamic intimacy process in later life.

Staff-resident relationships were variable, and for many, care workers were pivotal to residents’ intimacy process. These staff and residents differed on various background characteristics, including income, education, and race. At times this led to a power imbalance that influenced these relationships. For example, on occasion, white residents displayed (both blatant and subtle) racism toward Black staff members. Thus, race may be a factor in intimacy and forming intimate connections between residents and care workers. Previous research shows that residents’ racism and discrimination towards Black workers is common across long-term care settings (Kemp et al., 2010; Ryosho, 2011). Despite these problematic interactions, most care workers identify their relationships with residents as the most rewarding part of their job (Kemp et al., 2010). In our research, we found race to be a potential mitigating factor hindering the potential for more intimate relationships between residents and care workers. In co-resident relationships, residents were more likely to be close to residents with similar backgrounds, including race. However, most residents in the homes were of the same race (i.e., Oakridge Manor, most of the residents were Black, and at Hillside, all the residents were white).

It might appear counter-intuitive for intimacy to be scarce within a communal living environment like AL. Yet, many residents lacked intimacy in their lives. Residents who found it challenging to make intimate connections in AL sought opportunities elsewhere or downplayed the significance of intimacy in their lives. Other residents managed their needs with limited prospects by implementing strategies to increase their intimacy opportunities. Findings point to the importance of identifying and addressing residents’ intimacy needs. A comprehensive care model would meet individuals’ physical care needs and attend to their range of intimacy needs. Therefore, it is essential to understand the modifiable factors that can promote intimacy in AL, such as culture, policies, and staff training. AL-organized activities and areas to socialize increased intimacy opportunities for residents.

Despite the rich data and the diversity in residents’ experiences captured by the study, there were limitations. First, the convoys study was not explicitly designed to investigate intimacy but rather to understand care needs and arrangements in AL. Next, although researchers selected sites and residents to optimize variation, only so much can be found in four AL communities from a single geographic location. Further research is needed to obtain more knowledge of older adults’ intimacy experiences, including the involvement of care workers, family, and friends. Additional research would enhance understanding of how care partners impact older adults’ intimacy processes and possibly identify new factors, such as race and culture, shaping resident experiences. Despite limitations, our analysis provides a more nuanced understanding of intimacy in AL than previously existed.

Practitioners can improve older adults’ well-being by involving their care convoys to help strengthen AL intimacy opportunities to a given residents’ optimal level. Our research has implications for how professionals in AL can create and foster intimacy opportunities for residents and how researchers should continue to study the role of intimacy in older peoples’ lives. Our work has implications for how researchers approach intimacy and older adults, especially those receiving long-term care, underscoring the need to conceptualize and study intimacy as a multi-dimensional process that unfolds dynamically over time and is embedded within and shaped by care contexts and relationships and settings.

• Assisted living residents’ experience with intimacy was a process involving four dimensions: emotional, intellectual, spiritual, and physical.

• Assisted living residents’ intimacy experiences occurred platonically, sexually, or romantically, and was dynamic over time alongside their intimacy needs.

• Assisted living residents engaged in an ongoing intimacy process requiring that they manage their needs while negotiating intimacy opportunities and constraints.

• Individual, intimacy-partner, and assisted living communites’ factors influenced older adults’ intimacy experience(s).