Exploring the Normality of the Complexities of Later Life in Aged Homes: A Review

The Traditional ‘Home’ as a Public Setting

The traditional ‘home’ provides a sense of familiarity and is a living environment filled with meaning. The traditional home is the space shared by elderly couples that mirrors their relationship with objects, habits implied and emotions inured, created while they live together (Kane, 2001). Relocating to an aged care home introduces uncertainty into every aspect of the life of older adults, which requires them to get used to their new environment. Their housing needs gradually become intertwined with their personal care needs and overall well-being (Martin et al., 2015). They form a new life pattern within the aged care home, which is also widely accepted as their new second home with similar qualities as their former home but without their family (Lee et al., 2002).

Undoubtedly, most older adults prefer to continue living in their own homes till the end of life. However, this desire is often hindered by the lack of proper infrastructure within the traditional ‘home’ environment to support their needs and health deterioration (Tobi et al., 2017). Within an aged care setting, the traditional ‘home’ is regarded as a public space where the frailty of an older adult is often exposed and an individual’s power diminished (Willcocks et al., 2005). Studies have suggested that for some older adults, home is a negative space that they may bear unpleasant memories of (Castle, 2001). When elderly couples move from their home into an aged care facility, this creates an opportunity for them to develop new profound experiences without feeling detached from their former living environment, as the two environments share similar functions and qualities.

Inhabiting a familiar place promotes a sense of attachment that allows elderly couples to adapt to the change in environment (Domènech, 2016), living in a ‘home’ shared with other residents and staff members (Hughes, 2004). In a similar vein, for older adults with diseases such as Alzheimer’s or dementia, living as part of a small group of people could potentially contribute to a variety of positive outcomes, including a higher level of communal support, lowered decline rate in daily activity, sustained interest in the environment and reduced anxiety, aggressiveness and depression (Fleming et al., 2008; Sjögren et al., 2017). Additionally, interactive care-giving and supportive group activities could include intergenerational interactions involving both the old and young, to enable the sharing of knowledge, feelings or experiences (Tey et al., 2016). This integration of intergenerational interactions combined with appropriate philosophies of good aged care practices could contribute towards establishing a united Malaysian identity that transcends ethnic differences (Hoffman et al., 2020; Tey et al., 2016).

The fundamental impression of an aged care home is commonly as a site with dynamic settings of social, physical, cultural, psychological and emotional security for older adults (Andrews et al., 2007; Wiles, 2003). However, staff members accessing their rooms on a regular basis to provide care makes it difficult for elderly couples to maintain a sense of normalcy, often resulting in the loss of privacy (Domènech, 2016; Eyers et al., 2012). Their rooms become their sole private space, usually equipped with personal and familiar possessions such as photo albums (Rubinstein, 1989). Likewise, elderly couples who share a room get to spend quality time together in a new living environment manifested as a place to be filled with new memories and still are reminded of their past identities and the relationship (Domènech, 2016). Elderly couples endow the home with personal meaning that reinforces a sense of individuality and ownership (Kane, 2015; Willcocks et al., 2005).

Relationships and Togetherness

One of the biggest fears about relocating to an aged care home for an older adult is leaving their spouse behind, or being removed from their own home (Castle, 2001; Granbom et al., 2016; Nay, 1995). The fear of being separated, if they were to move into aged care homes, lingers in the minds of most elderly couples (Rahn et al., 2017). The theme of ‘togetherness’ emerged suggests that it is essential that elderly couples continue sharing their lives to ensure their well-being (Rahn et al., 2017). Previous studies suggest that there is an increase in the number of older adults who prefers ageing in place and provide care for their spouses till the end-of-life despite being burdened by their illnesses and disabilities (Eyers et al., 2012; Turner et al., 2016).

After relocating to an aged care home, an older adult goes through the process of renegotiating meanings, identities and relationships (Cook et al., 2015). In addition, as already mentioned, the relocation to an unfamiliar living environment may pose a threat to their ontological security, disrupting their identity and affecting their ability to be themselves around new people (Castle, 2001; Wiles et al., 2009). In what may be the most apparent need to deal with unfamiliarity, social support in the form of both emotional and practical support can help them cope with the diminishing family support when they move into an aged care home. There is growing evidence that ageing affects different people differently (de Hond et al., 2019; Steptoe et al., 2013; Zaid et al., 2019). According to Peace and Holland (2001, p. 404), ‘some residents build stronger relationships with caregivers compared to their bond with other residents’.

The thought of living within a controlled environment and adjusting to rigid routines can be daunting for older adults (Kane, 2001). Previous studies on elderly couples relocating to an aged care home together have documented that some institutions actively separated partners (Bauer et al., 2013; Rahn et al., 2017), a common practice, and imposed regulations on residents to keep their doors open, with staff entering the room without knocking (Bauer, 1999; Hughes, 2004). The present study points to the possibility that the restrictions and environment in aged care homes make it challenging for elderly couples to maintain their relationship and fulfil their desire to live a normal life with their spouse till the end of life (Castle, 2001). The ability to continue spending quality time together, physical affection, laughter, feelings of love, shared experiences, friendship and playfulness were deemed important essentials for elderly couples (Mahieu & Gastmans, 2015), whereby consistent and positive interaction has a direct correlation to relationship satisfaction (Mahieu et al., 2017).

Towards the End of Life

Despite spending a lifetime together before relocating to aged care homes, some older adults found it challenging to express their thoughts about end-of-life care and refrained from discussing it with their spouse (Cook et al., 2015; Kane, 2015; Turner et al., 2016). Providing care in old age is understood as a necessity among older adults, as part of their responsibility to look after their spouse as a form of commitment to their marriage (Turner et al., 2016). Most people aim to provide care for their spouse while dealing with physical and emotional stress and fatigue (Turcotte et al., 2015; Turner et al., 2016). Willingness to care is tempered by an older adult’s ability to care, as studies suggest that older adults nearing the end of life may suffer from at least three or more chronic conditions, which increases as they head towards later life (Barnett et al., 2012).

Elderly couples in aged care homes will want to provide care for their spouse and retain a sense of normalcy in their everyday lives (Seamark et al., 2014; Turner et al., 2016). In a study, Adamek (2003) described how a group of aged care residents responded to a standard question to rate their mental health, with the answers reflecting dismal outcomes for life. Caregiving is pervasive in later life where the duration of care provided is unpredictable and filled with unforeseen circumstances (Morris et al., 2015; Payne et al., 2012). Older adults who wish to care for their spouse till the end of life will have to empower themselves with resilience to deal with crises, due to the limited support available (Payne et al., 2012; Poirier et al., 2017).

Institutionalization and Its Impact on Privacy and Dignity

Before elderly couples relocate to aged care homes, they share a life with each other and form a cultural association with home, including several aspects such as autonomy, familiarity, history, relationships, privacy and dignity. Older adults may have a different set of expectations and perception of the quality of and what constitutes an excellent aged care home environment (Castle, 2001; Lotvonen et al., 2017). The types of activities carried out in Malaysian aged care systems are usually managed under a single authority. One of the central characteristics of aged care homes is that older adults are at risk of losing their identity and autonomy, which may result in their feeling like a liability in old age (Soares, 2014). One of the most common problems associated with institutionalization is the need for person-centred infrastructure and services that older adults may require to meet their individual needs. The most obvious response to this problem is to employ interactive care-giving methods to support the physical, mental, social and emotional well-being of older adults (Al-Shaqi et al., 2016).

It has conclusively been shown that the restriction of aged care residents’ privacy is also commonly perceived as a trait of institutionalization (Domènech, 2016; Evangelista et al., 2014; Hoe et al., 2018; Hughes, 2004). Privacy in aged care refers to the valued respect for an older adult’s individuality, which is also an indicator of one’s quality of life (Kane, 2015), while dignity refers to older adults’ need to perceive that their dignity is preserved and respected (Degenholtz et al., 2008). Physical privacy in aged care centres refers to the extent to which the body is physically accessible, denoting personal space and the marking of territory (Leino-Kilpi et al., 2001). The role of the body in understanding privacy in gerontology could be taken for granted when caretakers who touch the private parts of older adults’ bodies that may cause uneasiness for their spouses and themselves (Twigg, 2002; Hughes, 2004).

Caretakers are permitted access to older adults’ room and negotiate access to their private space shared with their spouse in order to provide care (Bauer, 1999; Rahn et al., 2017). To facilitate privacy effectively, aged care home staff members need to comprehend their role as a caretaker and ensure that elderly couples can maintain a sense of identity and dignity to prevent any unwanted emotion of being threatened (Domènech, 2016; Willcocks et al., 2005). In order to maximize older adults’ privacy and instil dignity (Hughes, 2004), aged-care providers must look into developing spaces of care that progressively adapt to older adults’ growing demands and be open to alter the traditional approach to the delivery of personal care and territory. This view is supported by Domènech (2016), who writes that the change in approach towards institutionalized boundaries of care spaces will help older adults develop new skills and a new way of experiencing life in aged care together with their spouse.

Bed as the ‘Last Resort’

Expressions of physical affection can influence the quality of a relationship and partner satisfaction, which in turn may affect the health and well-being of either partner (Rahn et al., 2017). Bedrooms in aged care homes are intimate spaces manifested from the objects within the place, with wardrobes, mirrors and photo frames contributing to remind older adults about themselves and their lives before relocating to the aged care facility (Gosling et al., 2002; Nettleton et al., 2018; Villar et al., 2015). Research has indicated that the arrangement of beds and adjustment made to beds affect the choice of actions of older adults and activities conducted within the space (Jacobs & Merriman, 2011; Nettleton et al., 2018). The bed is a material object constituted for therapeutic purposes (Nettleton et al., 2018) that becomes a place of ‘last resort’ for older adults in aged care homes (Townsend, 1981).

Elderly couples in aged care homes who share a bed recognize it as a comforting experience, which contributes significantly to their desire to maintain the relationship (Bauer et al., 2013). Armstrong (1998, p. 447) stated that ‘a building of bricks and mortar, wards, kitchens, laundries, halls and corridors, but at the very core of its physical presence is the bed’. The bed can never be wholly private space, but it serves a ‘hub of the therapeutic, investigative, administrative and financial network’ (Prior, 1992, p. 68). For elderly couples who are separated and placed in different rooms, time together remains important for them to express love and physical affection, for example, through holding hands, kissing, massaging, cuddling and affectionately squeezing (Mahieu & Gastmans, 2015). Nevertheless, elderly couples are aware that although bed curtains allow visual privacy, they do not prevent overhearing of private conversations (Kane, 2015; Zwi, 2017). Some couples may prefer to sleep separately on different beds, but some may be involuntarily asked to sleep in different rooms due to health circumstances (Simpson et al., 2017; Zeiss & Kasl-Godley, 2001).

Barriers to Intimacy and Sexuality in Later Life

Old age and relocation to an aged care facility do not deter elderly couples from yearning for intimacy (Gott, 2004). Older adults’ needs related to sexuality and intimacy have been absent from ageing and care policy (Garrett, 2014; Hafford-Letchfield, 2008). Consequently, this leads to an elderly couple having inadequate privacy and reduces their likelihood to remain intimate with each other (Bauer et al., 2014; Villar et al., 2015). Physical intimacy needs a high degree of privacy to be maintained in their relationships (Merryn et al., 2003). The need for both intimacy and sexuality is vital and is part of human existence (Mahieu et al., 2017). Sexual activity for older adults often get dismissed as being extremely reserved or fully inactive due to the misconception that sexual activity is only limited to youths (Mahieu et al., 2017).

Previous research findings suggested that older adults’ needs relating to intimacy and sexuality were overshadowed by the concern to prolong physical independence (Simpson et al., 2017). Although there are elderly couples who choose to remain sexually active, caretakers and family members often perpetuate ageist notions to dismiss an older adult’s sexual desires and presume them to be asexual (Bauer et al., 2014). Provision for intimacy is often viewed as falling outside the jurisdiction of primary caretakers, because intimacy is considered too private or personal (Bauer, 1999; Bauer et al., 2014). Physical contact has been proven to help elderly couples regulate emotions, reduce stress hormones, promote health and well-being and foster long-term survival and quality of life in the amount of time left and spent with their spouse (Rahn et al., 2017; Rancourt et al., 2017). Health problems may have a direct correlation with the redefinition of sex (Mahieu & Gastmans, 2015), but the perseverance of intimacy among elderly couples in aged care homes remains important until the end of life.