Exploring the Predictors of Well-Being and Advance Directives Among Elder Orphans: A Mixed Methods Study

Background/Purpose: Elder orphan is a term popularized by the media to describe the more than 22% of community-dwelling US adults aging with little to no social support. Although elder orphans are a population with masked risks due to their current stable status, they are at risk of outliving caregivers, being isolated in later adulthood, and being susceptible to multiple chronic health issues. They also may have a general lack of awareness and preparedness for adversity in late life. Elder orphans who have not initiated advance directives are at risk of becoming unbefriended—having no able or willing family or friends to make medical decisions for them during acute injury or medical crisis. The purpose of this explanatory sequential mixed-methods study was to understand the determinants of well-being and advance care planning among a sample of elder orphans.

Method: This study employed a sequential mixed methods design. In the first phase a 93-item survey was administered. A hierarchical regression was conducted to identify which life course events or experiences, if any, were significant predictors of well-being among a sample of elder orphans. A hierarchical binary logistic regression was conducted to predict the likelihood of the possession of advance directives based on elder orphan’s perceived risk of incapacitation and well-being. The quantitative phase was followed by an interpretative phenomenological analysis of in-depth interviews with (n = 6) volunteer participants.

Results: Hierarchical regression revealed income, adverse childhood experiences, discrimination, social network, and multiple health issues were significant predictors of well-being among elder orphans, whereas mid-life events were not significant predictors. Unexpectedly, higher levels of well-being increased the likelihood of having advance directives while perceived risk of incapacitation did not. The qualitative analysis revealed four subordinate themes: (1) the road to elder orphanhood: making meaning of the past; (2) a sudden halt: caregiving experiences and consequences; (3) connecting and trying to connect; and (4) barriers and future concerns

Conclusions/Implications: This study has significant implications for practitioners and policymakers engaged in efforts to develop community-based prevention models and legislative pathways for elder orphans at risk for becoming unbefriended. An understanding of the factors throughout the life course that influence current levels of well-being and advance care planning is critical to developing health behavior change interventions that are holistic in nature and acknowledge the unique perceptions and beliefs of elder orphans. Furthermore, elder orphans provide a unique opportunity to reduce the overall number of unbefriended older adults in the United States. Elder orphans may share many of the same characteristics as unbefriended older adults but continue to have the capacity to make medical decisions. This study represents a unique and precious opportunity to examine an under-studied group of older adults, who are often unrecognizable to health care professionals.  By building awareness of the pressing issues facing individuals aging alone, findings from this study can also be used to develop appropriate screening and assessment tools that help identify at-risk elder orphan populations.