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Patty Ormsby: 2 Solutions for the aging population. 

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Patty Ormsby: 2 Solutions for the aging population. 

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Two solutions to the challenges of population aging

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Aging populations pose a challenge to the fiscal and macroeconomic stability of many societies due to increased government spending on pension, healthcare, and social benefits programs for the elderly. In a new blog, Milena Nikolova poses two possible solutions to relive some of these fiscal pressures.

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Maria Calder

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Current Gerontology and Geriatrics Research - An Open Access Journal

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Current Gerontology and Geriatrics Research aims at scientists, geriatricians, health professionals interested in molecular, cellular, organismal aspects of gerontological research and in diagnosis, treatment, evaluation and educational aspects of geriatrics research. The journal also highlights new discoveries, approaches as well as technical developments in basic, clinical and discovery driven translational research.

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Mindful Sustainable Aging: Advancing a Comprehensive Approach to the Challenges and Opportunities of Old Age | Nilsson | Europe's Journal of Psychology

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Mindful Sustainable Aging: Advancing a Comprehensive Approach to the Challenges and Opportunities of Old Age

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Emily Kolb

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https://www.karger.com/Article/Fulltext/369962

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https://cops.usdoj.gov/html/cd_rom/inaction1/pubs/MisuseAbuseof911.pdf

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https://www.hindawi.com/journals/cggr/2016/4723250/

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https://www.psychologytoday.com/blog/living-single/201610/elder-orphans-real-problem-or-new-way-scare-singles

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look deeper

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Abstract

Social connections are important for individual well-being ( Pavot & Diener, 1993). People with closer social relations tend to be more optimistic about their future, and they are healthier ( Antonucci, 2001; Cohen & Janicki-Deverts, 2009). Social relations also affect subjective well-being (SWB) by providing the individual with the opportunity for participation ( Berkman, Glass, Brissette, & Seeman, 2000) and activities in a social context.

Participating in social activities has been noted as particularly important for older people and has been coined a key factor in successful aging ( Rowe & Kahn, 1997). A number of studies support the idea that the level of activity engagement in general improves SWB and health in older adults ( Adams, Leibbrandt, & Moon, 2011; Chen & Fu, 2008; Fernández-Ballesteros, Zamarrón, & Ruíz, 2001; Menec, 2003). Informal social activities have been identified as being the domain of activities that has the strongest association with SWB ( Adams et al., 2011; Litwin & Shiovitz-Ezra, 2006). Recently, Huxhold, Fiori, and Windsor (2013) have demonstrated that informal social activities in older adults (65 and older) are associated with a number of key aspects of successful aging over and above network structure and social support potential. Engaging in social activities is particularly beneficial for older adults if they perceive themselves as agentic during their performance ( Herzog, Franks, Markus, & Holmberg, 1998).

However, activity engagement requires self-regulatory and emotional effort ( Hess, Emery, & Neupert, 2012; Hess & Ennis, 2012; Sonnentag & Jelden, 2009). If this effort exceeds individual resources, social activities could be detrimental for well-being and health ( Segerstrom, 2008; Windsor, Anstey, & Rodgers, 2008). Furthermore, a key aspect of social activities relates to the context of the particular social relation they are performed within. It has been demonstrated that social relation may not only have positive, but also have negative aspects ( Newsom, Rook, Nishishiba, Sorkin, & Mahan, 2005; Rook, 1984). Therefore, this study will focus on the effects of the type of social relations (i.e., family members vs. friends) with which social activities are performed with indicators of individual well-being.

Differential Effects of Social Interactions With Family and Friends

Social relationships within the family are the main source of support and social integration in later life and therefore central to older adults' SWB ( Antonucci, Jackson, & Biggs, 2007; Katz, 2009; Koropeckyj-Cox, 2002; Lowenstein, 2007; Silverstein & Bengtson, 1994). In a related vein, friendship relations are also a significant source of enjoyment and socializing ( Pinquart & Sörensen, 2000). Thus, good relationships with family members and with friends are important for older adults and have a positive influence on their SWB. SWB is a crucial indicator of successful aging ( Freund & Baltes, 1998), and numerous studies document beneficial effects of SWB on health, the occurrence of critical life events, and mortality ( Diener, 2012).

However, it has also been proposed that the influences of social interactions on SWB differ if they are performed with family members or with friends ( Dupertuis, Aldwin, & Bosse, 2001; Rook & Ituarte, 1999). For example, although both family and friend relations provide emotional support, they differ with regard to instrumental support, which is more prominent in family relations, whereas companionship, social integration, and reaffirmation of self-worth are more characteristic of friendship relations ( Messeri, Silverstein, & Litwak, 1993). A recent study showed that the effects of support on well-being depended on the source of support and the quality of the relationship between provider and recipient ( Merz & Huxhold, 2010): Instrumental support provided by family members increased NA and impaired PA if the relationship quality was low. In contrast, instrumental support from friends was associated with higher PA and lower NA regardless of the relationship quality.

Social interactions with kin or nonkin can also have additive effects. Dupertuis and colleagues (2001) found that older men with high perceived support from family sources alone experienced more depressive symptoms than their peers who received support both from their families and friends. In a related vein, Fiori, Antonucci, and Cortina (2006) have demonstrated that family-focused personal networks are associated with lower mental health than networks that include family and friend relationships (i.e., diverse networks). However, they also found that family-focused and diverse networks did not differ in terms of their affects on physical health.

Social interactions with family members or friends differ with regard to relationship structure. Although family relations are more or less predetermined, friendship relations are formed on a voluntary basis and with peers who share characteristics, cohort experiences, and lifestyles ( Chen & Fu, 2008). Probably because of this voluntary nature, relationships with friends require more maintenance effort than with family relations ( Roberts & Dunbar, 2011). They are also more based on reciprocity than family relations ( Dupertuis et al., 2001). This structural difference might also explain the finding that the perceived quality of family relations tends to be lower than friendship relations, as family obligations increase the likelihood of perpetual negative interaction, and unsatisfying family relations are more difficult to dissolve than unsatisfying relations with friends ( Birditt, Jackey, & Antonucci, 2009; Krause & Rook, 2003). Moreover, according to Rook and Ituarte (1999) friendship relations are a better source of companionship than family relations, which implies that they may also be more important for informal social activities.

Do the Effects of Informal Social Activities Change With Age?

On average, the frequency of informal social activities decreases with advancing age, which is probably a consequence of age-related declines of functional status ( Huxhold et al., 2013). This decline might apply even more informal social activities with friends because friendship relations require more investment of resources ( Roberts & Dunbar, 2011).

Socioemotional selectivity theory predicts that the limited future time perspective of older adults is associated with a focus on emotionally meaningful social interactions ( Carstensen, Isaacowitz & Charles, 1999), which further underlines such effects. In a related vein, the strength and vulnerability model assumes that older adults avoid negative social interactions in particular ( Charles, 2010). Thus, both perspectives would predict that informal social activities that have low emotional meaning or could trigger negative emotions are likely to be reduced. As a consequence of this floor effect, the effects of informal social activities may become more positive in older ages. In contrast to this assumption, empirical studies on this moderating effect of age on the relationship between activities and well-being found ambiguous results ( Adams et al., 2011). One reason for these findings might be that family relations are more difficult to cease than voluntary friendship relations ( Birditt et al., 2009; Krause & Rook, 2003, Litwak, 1981). Therefore, it is plausible to predict that informal social activities with friends, but not with family, will be more positively associated with SWB in older adults than in younger adults. Previous studies that have shown that the association of social support provided by friends with SWB increases with increasing age suggest this assumed age effect ( Li, Fok, & Fung, 2011; Stafford, McMunn, Zaninotto, & Nazroo, 2011), but differential effects of age and relationship structure have not yet been examined.

Aims and Hypotheses

Although there is a good rationale to assume that the effects of informal social relations on SWB may not be uniformly positive (see argumentation earlier), the literature on activities in older adults reports mainly positive associations with SWB. A potential reason for these findings may be that the relationship between activities and well-being might be bidirectional, as high well-being has been shown to increase activity engagement ( Fredrickson & Branigan, 2005). This study therefore uses a methodology that can account for this bidirectional relationship, latent change modeling ( McArdle, 2009). We examine age-differential effects of family and friend activities on three different facets of SWB, namely PA, NA, and life satisfaction, which goes beyond previous research. This study tests three hypotheses in particular:

H1: Older adults perform less informal social activities than middle-aged adults, and this age effect is particularly pronounced in activities with friends.

H2: Informal activities are on average positively related to SWB, but informal activities with friends have a stronger effect on SWB than activities with family members.

H3: There are age differences in that the association between informal social activities with friends and SWB is stronger in older adults than in middle-aged adults. No age differences are expected for informal social activities with family members.

Sample

Data for this study were drawn from the German Aging Survey (DEAS), an ongoing population-based, representative survey of community-dwelling individuals in Germany between 40 and 85 years with in-home interviews and questionnaires. DEAS has a cohort-sequential design and national probability sampling with three survey waves in an interval of 6 years (1996, 2002, and 2008; Engstler & Motel-Klingebiel, 2010). The base samples of 1996 ( N = 4,838) and 2002 ( N = 3,084) were reassessed in subsequent waves. In this study, we use longitudinal data of individuals from 2002 (T1) and 2008 (T2) because these measurement points assessed all meaningful control variables. The final sample consisted of N = 2,032 older adults (65 and older, mean age 73.73 years, 47.9% female participants, 64% with partner) and 2,830 middle-aged adults (40 and older, mean age 53.30, 49.2% female participants, 86.4% with partner). Of these, 665 older adults and 1,327 middle-aged adults took part in T1 and T2. Drop out analyses suggest that follow-up participants were on average younger, healthier, better educated, and had higher incomes than the baseline sample. Effect sizes of the differences between participants who dropped out of the study and those who remained in the study did not exceed d = 0.5 in both age groups, indicating a small-to-medium selectivity effect ( Lindenberger, Gilberg, Pötter, Little, & Baltes, 1996). We accounted for sample attrition by using the full information maximum likelihood (FIML) procedure in MPlus.

Measures

To examine longitudinal associations across domains, measures at both time points were T-standardized ( M = 50, SD = 10) using the mean and standard deviation at T1 (2002) of the respective age group, all other analyses were performed using the raw scores.

Social activities.

Participants were asked to report their engagement in various social activities in the year preceding the interview on a list of nine items: (a) inviting or visiting friends, (b) visiting cultural events, (c) visiting sport events, (d) courses or lectures, (e) going for walks, (f) sports, (g) artistic work, (h) board games, and (i) regular meetings with a certain group of people. Except for item one, participants were asked whether they had performed this activity together with their partner or other relatives (family activities) or with friends, other people, or in a club or association (friend activities). The frequency of every activity was measured ranging from one (< once per month) to five (daily). Time invested in family or friend activities was derived by summing these answers over all family and friend activities.

Subjective well-being.

Life satisfaction was assessed with the Satisfaction With Life Scale ( Pavot & Diener, 1993) on five items using a 5-point scale from 1 ( strongly disagree) to 5 ( strongly agree; Cronbach's α T1/T2 = 0.84/0.85). Emotional well-being was assessed with the Positive and Negative Affect Schedule ( Watson, Clark, & Tellegen, 1988). Participants indicated on a 5-point scale from 1 ( never) to 5 ( very often), how often they experienced 10 positive and 10 negative affective states in the last month (Cronbach's α T1/T2 = 0.87/0.99).

Control variables.

All analyses were controlled for age, sex, partner status at T1 (1 = having a partner, 0 = no partner), health status, and socioeconomic status (SES), as these factors relate to social interactions and network characteristics ( van Groenou & van Tilburg, 2003). SES was indicated by education assessed by the international standard classification of education (ISCED; UNESCO, 1997). Health was indicated by self-rated health (single item; "How would you rate your present state of health?" with answers from 1 ( very bad) to 5 ( very good) and functional health assessed with the physical functioning subscale of the SF-36 ( Ware & Sherbourne, 1992; Cronbach's α T1/T2 = 0.94/0.93).

Statistical Analyses

We used latent change score (LCS) models (McArdle, 2009) to predict changes in SWB between T1 and T2 from social activities at T1. The three facets of SWB (life satisfaction, PA, and NA) were indicated with two parcels of items each (means from the overall items). Social activities (time spent on social activities with family members or friends) were entered into the model as manifest variables.

To evaluate measurement invariance within and across age groups, we performed comparative fit index (CFI) difference tests, which are more apt to detect invariance than the conventionally used chi-square difference tests especially with large sample sizes (Cheung & Rensvold, 2002).

LCS decomposes the score of a T2 variable into the T1 level and between T1 and T2. This LCS carries all advantages of latent variables, such as being free from measurement error, and it can be related to other variables in the model. To examine our main hypotheses, we regressed change in the different facets of well-being on the T1 levels of social activities (β parameters in the model) and additionally controlled both baseline and change variables for age, sex, partner status, education, and subjective and functional health (controlling for functional and subjective health at T2 in the model changed the path coefficients of interest only marginally but worsened the model fit tremendously. Thus, they were left out of the analysis). Differential effects between time spent on family versus friend social activities were examined using nested model comparisons. Figure 1 shows a generic LCS model (not specific to well-being aspect). We regressed changes in well-being on changes in social leisure activities on but only in order to increase the statistical power to detect directional associations. Associations between changes are merely cross-sectional. Therefore, we will refrain from interpreting the associations between changes in the discussion. Instead, we focus on the associations of levels of social leisure activities at T1 with changes in well-being.

Age Group Differences in Informal Social Activities

Overall, middle-aged adults performed more social activities than older adults (Δχ ² = 366.97, df = 4, p < .05). Across both measurement occasions, there were larger differences between younger and older adults in activities with friends than in activities with family members (Δχ ² = 10.45, df = 2, p < .05). We did not find an age group by time point interaction with respect to informal activities with friends (Δχ ² = 0.16, df = 1, p > .05). In contrast, we found a significant interaction of age group by time point with respect to activities with family (Δχ ² = 7.60, df = 1, p < .05). This indicates that older adults reduced their informal social activities between the two time points with family members more than their activities with friends ( Figure 2).

Differential Effects of Informal Social Activities on Changes in SWB

Contrasts in CFI statistics suggested measurement invariance between the measurement points (equal factor loadings resulted in CFI losses of 0.01 and less; Cheung & Rensvold, 2002). However, we were not able to set the variances of the changes to be equal across groups. Thus, we could not contrast the regression weights of predictions of changes between groups directly.

We examined if levels of informal social activities predicted changes in the three facets of well-being separately in both age groups. We contrasted a model with the respective regression paths set to zero to a model in which activities with friends and activities with family members were set to predict changes in one facet at equal strength. In the second step, we contrasted the regression weights of informal social activities with friends with informal social activities with family members by releasing the equality constraint. These contrasts are possible because interindividual differences in levels of activities were standardized to T-scores within each age group.

The overall model fit of the final LCS model was good (χ ² = 809.59, df = 223, root mean square of approximation = 0.032, CFI = 0.98). All latent changes had significant variances. In the following, we will report only the effects of levels of informal social activities at T1 on changes in SWB (directional effects). All other directional regression weights are depicted in Table 1. Path coefficients reported in Table 1 and in the following sections represent standardized beta coefficients from the respective models.

Middle-aged group (40-64 years).

High levels of informal social activities at T1 were associated with increases or maintenance in PA (β = 0.08, Δχ ² = 10.01, df = 1, p < .05) and life satisfaction (β = 0.08, Δχ ² = 9.95, df = 1, p < .05) across 6 years. Levels of activity were unrelated to NA (β = 0.01, Δχ ² = 0.19, df = 1, p >.05). Contrasts indicated no significant differences in effects if informal social activities were performed with friends or with family members ( p > .05 in all contrasts).

Older age group (65 years and older).

Social activities positively predicted changes in PA (β = 0.09, Δχ ² = 5.96, df = 1, p < .05). The regression weights did not differ between activities with friends and activities with family (Δχ ²= 1.58, df = 1, p > .05). Predicting changes in life satisfaction from social activities with friends and with family members fixed to equal regression weights improved the model fit significantly if contrasted to a model, in which the association between levels of social activities and changes in life satisfaction were set to zero (Δχ ² = 4.67, df = 1, p < .05). Releasing the equality constraint improved the model fit further (β friends = 0.14, β family = 0.02, Δχ ² = 3.86, df = 1, p < .05), which indicates that only social activities with friends predicted changes in life satisfaction. In contrast, if social activities from both sources were fixed to predict changes in NA with equal strength, the increase in model fit was not significant (Δχ ² = 0.01, df = 1, and p >.05). Estimating the regression weights freely resulted in a further significant increase in model fit (Δχ ² = 5.48, df = 1, p < .05). Examining the regression weights, we found that the associations of social activities with friends and of social activities with family members nullified each other (β friends = −0.08, β family = 0.08, Δχ ² = 5.48, df = 1, p < .05). In this age group, activities with family at T1 were associated with increasing NA across time, whereas high levels of activity with friends at T1 were predictive of decreases in NA.

Discussion

All three hypotheses were only partly confirmed. As expected, older adults engaged in less informal social activities than middle-aged adults. On average, they also engage in more informal activities with their families than with their friends. Surprisingly, with increasing age, older adults seem to reduce their level of informal social activity with their family members more than the activities with their friends.

Our results imply that in middle age, engaging in informal social activities is generally beneficial for SWB. High levels of activity predicted increasing levels of PA and life satisfaction but were unrelated with NA. In this age group, it seems not to matter with whom informal social activities are performed with. In the older age group, however, the specific company seems to play a role (albeit not with respect to changes in PA): Only informal social activities with friends were associated with increases or maintenance of life satisfaction. In addition, informal social activities with friends were associated with reductions in NA, but social activities with family members were even associated with increases in NA in this age group.

H1: Older adults perform less informal social activities than middle-aged adults, and this age effect is particularly pronounced in activities with friends.

Our analyses contrasted the frequency of informal social activities with friends and with family members between the middle-aged and the older age groups. Older adults performed less social activities than their younger counterparts even after controlling for interindividual differences in health, education, and partner status. In comparison with the middle-aged adults, the older group showed disproportionately less activities with their friends. These findings are in line with the argumentation that engaging in informal social activities is resource demanding. Older adults are, on average, not only less healthy than middle-aged adults but also have less cognitive and motivational resources that may enable them to get involved in effortful activities ( Hess et al., 2012; Hess & Ennis, 2012). Friendship relations require more investing effort than family relations ( Roberts & Dunbar, 2011). This may explain why older adults differ from middle-aged adults in particular in informal social activities with friends. However, older adults reduced their social activities with friends less than their activities with their family members across the 6-year interval. This finding can neither be explained by a resource-driven perspective nor is it likely to be a consequence of participants losing their romantic partner, as the number of persons bereaved between 2002 and 2008 was very small. One potential explanation could be that the major reductions in activities with friends had taken place before the age of 65. Friends who remain in the network in older ages may be selected in accordance to the emotional needs of the aging individual ( Carstensen, Isaacowitz & Charles, 1999; Charles, 2010) and thus remain in the network for a longer time. The nature of activities with family members could also change with increasing older ages, as the family mostly is the primary source of support for older adults ( Antonucci et al., 2007). Advancing into old age, social support from the family may become more important for older adults than informal social activities with their family members.

H2: Informal activities are on average positively related to SWB, but informal activities with friends have a stronger effect on SWB than activities with family members.

Our results suggest that in middle age, it is beneficial to perform leisure activities together with social partners. It can help to maintain or even increase feelings of fun, interest, and general satisfaction with one's life circumstances. Accordingly, in middle-aged adults, it did not matter whether social activities were performed with family members or friends. Therefore, we could not find evidence that supports the second part of our hypotheses that activities with friends are more beneficial for SWB than activities with family members. In older adults, however, the picture seems to be different.

H3: There are age differences in that the association between informal social activities with friends and SWB is stronger in older adults than in middle-aged adults. No age differences are expected for informal social activities with family members.

Our analyses revealed that age differences in the associations between informal social activities and SWB differed with regard to the particular facet of SWB under observation.

High levels of social activities were associated with increases or maintenance in PA in older adults with similar effects as in the middle-aged group, and it seems to make no difference whether the activities were performed with friends or family members.

Social activities were unrelated to NA in middle-aged adults. In the older age group, however, informal social activities with family members were associated with increases or maintenance of NA, but high levels of social activities with friends were associated with decreases in NA. Engaging in informal social activities may require effort and may sometimes be frustrating if conflicts arise with the social interaction ( Hess et al., 2012; Rook, 1984). In older age, motivational and cognitive resources that may play a role in shared leisure activities decline ( Hess et al., 2012). Therefore, engaging in social activities with friends may become more demanding. Moreover, it has been shown that conflicts within the family are relatively stable across the life span ( Krause & Rook, 2003). According to the strength and vulnerability model ( Charles, 2010), older adults are better than younger adults in navigating their social environment. At the same time, older adults suffer more than younger adults if negative social interactions cannot be avoided. Older adults may have generally less opportunities to use their social skills in their family relations because these relationships have a strong normative component ( Litwak, 1981). Combining these two arguments, it seems plausible to assume that familial conflicts that occur within shared leisure activities may particularly affect the SWB of older adults because they are more vulnerable to negative social interactions.

Our finding is in contrast to previous research arguing that informal social activities are generally beneficial for SWB ( Adams et al., 2011). In our view, only specific analyses, such as in this article, allow to detect the association between high levels of social activity and increases in NA because the LCS approach takes into account reciprocal influences. Adams, Leibbrandt, and Moon (2011), for example, argue that high levels of well-being may sometimes be more important for performing activities than the influence of activities on well-being. We controlled for the effects of T1 SWB and for the concurrent reciprocal influences between activities and SWB across the 6-year interval by regressing changes in SWB on changes in social activities. Detrimental effects of activities can only be examined by controlling for these reciprocal influences. In contrast to the negative influence of social activities with the family, informal social activities with friends were associated with decreases in NA. Silverstein and Parker (2002) found that leisure activities buffer against the negative effects of functional impairment, widowhood, and lack of social support but did not differentiate with whom the activities were performed with. The socioemotional selectivity theory ( Carstensen, Isaacowitz & Charles, 1999) and the strength and vulnerability model ( Charles, 2010) predict that older adults will let go of social relations that are emotionally meaningless or even increase the likelihood of negative interactions. Due to the voluntary nature of friendship relations, it might be easier to be selective with friends than with family members ( Krause & Rook, 2003). This expectation of differential selectivity is in line with our finding that age group differences were on average greater for social activities with friends than with activities with family members. In light of this reasoning, it is plausible to assume that activities performed with friends that remain in the social network of older adults after an emotionally driven selectivity process are particularly helpful. Consequently, our findings add to the results from the study by Silverstein and Parker (2002) that only social activities with friends may act as a buffer against the negative consequences of aging and are therefore associated with decreases in NA.

The finding that social activities with family members were only beneficial for life satisfaction in middle-aged adults but not in the older age group might seem puzzling at first sight, and we can only speculate about the reasons. It could be that the role of the family changes in older ages, as social support becomes increasingly important for older adults as a buffer against various negative effects of age-related decline (Bierman & Statland, 2010). The primary provider of social support in older ages is the family (Antonucci, 2001). This may have consequences on how older adults evaluate the relationships with friends and family members: Friends could remain the main source of companionship, for which it is important to perform activities together, whereas family members might increasingly be perceived as crucial providers of social support rather than interaction partners for informal social activities. Consequently, social activities with family members may be less important for life satisfaction of older adults than of younger adults. The changing role of the family may also be the reason why older adults in our sample decreased their activities with their family members more than their activities with their friends during the 6-year period.

Limitations and Strengths

All measures were self-reported and related to potentially long recall periods. This might imply that the recall of activities could be subject to under- or overestimation based on current affective status. However, our results controlled for baseline differences in SWB. This suggests that effects on long-term SWB changes are independent of baseline differences. The limitation to two measurement points with a time difference of 6 years might mask more complex interacting dynamics between higher SWB and social interactions, in particular with regard to PA and NA, which have been shown to fluctuate over shorter time spans and as a result of various life events ( Diener, 2012). We interpret our results as indicating changes in affect dispositions rather than short-term fluctuations, but the possibility that affect measures change as a result of short-term influences needs to be born in mind. Future studies might target these dynamic interactions using more measurement points in shorter time intervals. Moreover, with the data set at hand, we were unable to distinguish between different relationships within the family. It has been shown, however, that relationships with a partner or with children are evaluated quite differently and show different developmental trajectories ( Birditt et al., 2009).

Moreover, our measures of informal social activities broad measure of social integration of older adults. Our analyses did not consider the quality of the relationships with friends or with family members. Merz and Huxhold (2010), for example, have shown that the negative impact of instrumental support provided by family members is moderated by the relationship quality. Thus, future analyses should investigate if the consequences of performing informal social activities with family members with whom the older adult shares a high-quality relationship differ from the effects of performing social activities in the context of low-quality family relations.

Implications and Conclusion

Our study shows that it makes a difference in terms of NA and life satisfaction with whom one engages in social activities for older adults but not for middle-aged adults. These differential effects might be due to the structural and functional differences between family-based and friend-based social networks that influence the emotionally driven selectivity process in older ages. Informal social activities with friends are beneficial for all three aspects of SWB in older adults. Future research might want to examine mediators of these effects, in particular the role of individual expectations with regard to activity outcomes. Our results have strong implications for mental health promotion in older adults, as they suggest supporting older adults in building and maintaining friend-based social networks, for example, by encouraging volunteering in old age in elder-helping-elder programs ( Butler & Eckart, 2007) or programs aiming at increasing informal social interactions, such as cultural programs ( Cohen et al., 2006), university programs ( Fernández-Ballesteros, Molina, Schettini, & Del Rey, 2012), or occupational therapy programs ( Hay et al., 2002).

This work was supported by the German Federal Ministry for Family Affairs, Senior Citizens, Women and Youth (BMFSFJ).

References

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Benefits of Having Friends in Older Ages: Differential Effects of Informal Social Activities on Well-Being in Middle-Aged and Older Adults | The Journals of Gerontology: Series B | Oxford Academic

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Objectives.It has been considered a fact that informal social activities promote well-being in old age, irrespective of whether they are performed with friends or family members. Fundamental differences in the relationship quality between family members (obligatory) and friends (voluntary), however, suggest differential effects on well-being.

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on the fence.  You are correct Emily this is not a primary source.  It would be considered a blog or editorial article which can help serve as a jumping off point for research.

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"With self-reflection and increased wisdom comes the realization that we really should maximize the amount of good relationships we have and not spend so much time on the ones that aren't good." -Andrea Bonior, Ph.D

Few things in life have as big an impact on our happiness as good times spent with friends. And numerous studies show that close relationships with friends - but not necessarily with family - are vital to our physical health, too, with loneliness linked to reduced life expectancy and a host of health issues.

But what if the number of people you count as friends is shrinking, or you find yourself wanting to spend less time socializing - is that just a normal part of aging?

When a recent study showed that as monkeys grow older, the patterns of their friendships change, we decided to investigate.

Changing Patterns of Friendship

Our primate cousins, it turns out, grow pickier about which monkeys to count as "friends" as they age and invest less time in hanging out socially. The study's researchers point out that humans also become choosier about how we spend our time and with whom.

We asked Geoffrey Greif, Ph.D., a professor at University of Maryland's School of Social Work and the author of two books on friendship, to tell us more.

"People begin to value their time more as they age," he said. "But people also have more time, so there are two conflicting vectors. If I don't have much time, I'm certainly going to want to shepherd it well and spend it with my closest friends. But, if I'm retired and sitting around the house looking for things to do, or people to be with, I may be less selective."

Complicating that further, it turns out, is that the differences between men's and women's relationships may affect how we view friendships as we grow older.

Grief's book "Buddy System," which is is based on his research with more than 300 men and 100 women, found that across their lifespans, men's friendships tend to be "shoulder-to-shoulder encounters" - men might watch a game together and catch up during commercials - while women generally construct friendships around face-to-face encounters. Because women share more emotional content in person, these friendships require more maintenance. Demanding relationships that aren't fulfilling can take a hit as we age.

If our tendency as aging humans is to weed out friendships that aren't emotionally fulfilling because we know time is running out, what about the Barbary macaques that the monkey researchers studied? After all, they're not counting down the years.

"Older monkeys might spend less time socializing because they find social interactions increasingly stressful and therefore avoid them," the study lead, Julia Fischer, suggests. The same, she says, may be true for humans.

Licensed clinical psychologist Dr. Andrea Bonior, a professor of psychology at Georgetown University who writes the Washington Posts's Baggage Check column and is the author of " The Friendship Fix," says that as we age, we don't need to waste our time on friendships that cause us stress or make us feel badly.

"With self-reflection and increased wisdom comes the realization that we really should maximize the amount of good relationships we have and not spend so much time on the ones that aren't good," she says.

Most people have friends who are life-stage specific - friends made at college, through our children's activities or at work. Once children are grown or we retire, some of these friendships endure, but many do not. And that's okay, because it would be overwhelming to continue relationships with every friend we ever make. But while some friendships fade out naturally as we experience the life transitions of our later years - retirement, losing a spouse, developing health problems - we also tend to tell ourselves, 'I deserve to have friendships that are fulfilling, that sustain me, and not waste my time,' Bonior says.

The result: Fewer friends and, as a result, less time spent with friends.

It's natural, but if we don't make new friends, it can be a problem.

Friends With Health Benefits

We're social creatures. We've lived in groups since the beginning of civilization - tribes, clans, villages, towns and cities. Friends meet our need for a support system beyond what our families provide. Even better, we get to choose our friends. They're not defined by blood ties or neighborly proximity. Our friend circles are unique to us.

As C.S Lewis said: "Friendship is born at that moment when one person says to another, 'What! You too? I thought I was the only one.'"

True friendship offers a unique feeling of connection that protects us from stress. Studies have shown that social ties reduce our risk of disease by lowering blood pressure, heart rate and cholesterol. University of Chicago professor and neuroscientist John Cacioppo studies loneliness as a health risk. His findings show that loneliness is associated with the progression of Alzheimer's disease, obesity and lower immunity.

The Nurses' Health Study from Harvard Medical School found that the more friends women had, the less likely they were to develop physical problems as they aged. The results were so significant, the researchers concluded that not having close friends is as detrimental to our health as smoking or obesity.

Recently, researchers who followed nearly 1,500 older people for ten years found those with a large network of friends outlived those with fewer friends by more than 20 percent.

In that study, close relationships with family had almost no effect on longevity.

Making New Friends

We asked our experts to share their best tips for making new friends later in life. Both recommend getting involved in activities you enjoy and not only staying open to making new friends as you participate, but also being yourself.

Greif says we need to believe we can make new close friends at any age. "As our oldest friends either move far away or die, if you believe you can't have close friends that you meet when you're 50, 60, 70 or 80, you're going to be more isolated."

But it's not so easy. Making new friends in later life can be intimidating. People think, "Oh I don't have that many friends! Something's wrong with me," Bonior says. Her advice: Don't over-personalize it. View making new friends as a concrete goal.

"It's very funny," Bonior says, "Because with romantic relationships we would never expect to partner for life with the first person we ever went out on a date with. But if a friendship doesn't get off the ground, we automatically wonder what we did wrong. We think, maybe it wasn't a good match. You have to put forth the effort continually, remembering it's a numbers game."

Facebook Friends

How about Facebook? Older adults are now the fastest growing demographic segment on the social network, and it can make finding and reconnecting with friends we've lost touch with and getting to know new ones much easier.

Bonior says Facebook is a double-edged sword. "I think for older people, especially if there are issues with mobility or health, then it's a godsend to be able to still feel connected and engaged when maybe you're not getting many in-person visitors." But, for some people, Facebook is taking the place of real social engagements. "Is it a nice supplement, or have you stopped going to brunch or book club?" Observe how you feel about yourself after being online. "Some folks get trapped in a cycle of constantly looking at Facebook, looking at Facebook, looking at Facebook, and still are feeling empty afterward."

A Friends Survey

I asked my Facebook friends whether they think friendships change over time. Here are some of their answers - and interestingly, only women replied:

"My first inclination is to say, "Definitely!" - but then I say, "Sort of." Now that I'm retired, my best friends are those who are active, like I am, and like DOING things and creating new experiences." -Susan

"I've been semi-retired for two years now. My existing friendships have just gotten better since then. With age comes wisdom, and we can usually just cut to the heart of any issue rather quickly without engaging in a lot of small talk. I also renewed an old friendship from college via Facebook and I'm so glad I made the effort. We had drifted apart due to our busy lives and a little distance geographically, but the heart of our friendship still remains." -Cathy

"My friendships mean a lot more to me now than they ever did when I was younger. I have more time to develop a closer relationship with those friends." -Sandie

"I don't think you can ever have the same relationships with newer friends as you do with the friends you grew up with. So in that respect, I do think they are different. I have lived alone for most of my adult life and made friends mostly at work. Now that I am older, and still living alone, I don't really feel a need to make new friends. I enjoy my alone time and I have friends to hang out with whenever I want to. I talk to my neighbors and people I meet at classes I take, but I don't encourage any kind of real friendship." -Bonnie
Have your friendships changed with age? What are your best tips for making new friends?

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"With self-reflection and increased wisdom comes the realization that we really should maximize the amount of good relationships we have and not spend so much time on the ones that aren't good." -Andrea Bonior, Ph.D Few things in life have as big an impact on our happiness as good times spent with friends.

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http://www.apa.org/pi/aging/resources/guides/older.aspx

Older Adults

Health and age-related changes

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Long Term Care Facilities

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When a person requires someone else to help him with his physical or emotional needs over an extended period of time, this is long-term care

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Abstract

Background:

The elderly population is large in general and growing due to advancement of health care education. These people are faced with numerous physical, psychological and social role changes that challenge their sense of self and capacity to live happily. Many people experience loneliness and depression in old age, either as a result of living alone or due to lack of close family ties and reduced connections with their culture of origin, which results in an inability to actively participate in the community activities. With advancing age, it is inevitable that people lose connection with their friendship networks and that they find it more difficult to initiate new friendships and to belong to new networks. The present study was conducted to investigate the relationships among depression, loneliness and sociability in elderly people.

Materials and Methods:

This study was carried out on 55 elderly people (both men and women). The tools used were Beck Depression Inventory, UCLA Loneliness Scale and Sociability Scale by Eysenck.

Results:

Results revealed a significant relationship between depression and loneliness.

Conclusion:

Most of the elderly people were found to be average in the dimension of sociability and preferred remaining engaged in social interactions. The implications of the study are discussed in the article.

Keywords: Depression, Loneliness, Old age, Sociability

Aging is a series of processes that begin with life and continue throughout the life cycle. It represents the closing period in the lifespan, a time when the individual looks back on life, lives on past accomplishments and begins to finish off his life course. Adjusting to the changes that accompany old age requires that an individual is flexible and develops new coping skills to adapt to the changes that are common to this time in their lives (Warnick, 1995).

The definition of 'health' with regard to old age is a subject of debate. There is consensus that health in old age cannot meaningfully be defined as the absence of disease because the prevalence of diagnosable disorders in elderly populations is high. Instead, health is considered to be multifaceted: The diagnosis of disease should be complemented by assessment of discomfort associated with symptoms (e.g., pain), life threat, treatment consequences (e.g., side effects of medication), functional capacity and subjective health evaluations (Borchelt et al., 1999). Furthermore, Rowe & Khan (1987) suggested that the health of subgroups of older adults be defined in terms of their status relative to age and cohort norms.

There is a growing body of evidence that suggests that psychological and sociological factors have a significant influence on how well individuals age. Aging research has demonstrated a positive correlation of someone's religious beliefs, social relationships, perceived health, self-efficacy, socioeconomic status and coping skills, among others, with their ability to age more successfully.

Depression or the occurrence of depressive symptomatology is a prominent condition amongst older people, with a significant impact on the well-being and quality of life. Many studies have demonstrated that the prevalence of depressive symptoms increases with age (Kennedy, 1996). Depressive symptoms not only have an important place as indicators of psychological well-being but are also recognized as significant predictors of functional health and longevity. Longitudinal studies demonstrate that increased depressive symptoms are significantly associated with increased difficulties with activities of daily living (Penninx et al., 1998). Community-based data indicate that older persons with major depressive disorders are at increased risk of mortality (Bruce, 1994). There are also studies that suggest that depressive disorders may be associated with a reduction in cognitive functions (Speck et al., 1995).

Though the belief persists that depression is synonymous with aging and that depression is in fact inevitable, there has been recent research which dispels this faulty notion. Depression has a causal link to numerous social, physical and psychological problems. These difficulties often emerge in older adulthood, increasing the likelihood of depression; yet depression is not a normal consequence of these problems. Studies have found that age isn't always significantly related to level of depression, and that the oldest of olds may even have better coping skills to deal with depression, making depressive symptoms more common but not as severe as in younger populations.

When the onset of depression first occurs in earlier life, it is more likely that there are genetic, personality and life experience factors that have contributed to the depression. Depression that first develops in later life is more likely to bear some relationship to physical health problems. An older person in good physical health has a relatively low risk of depression. Physical health is indeed the major cause of depression in late life. There are many reasons for this, which include the psychological effects of living with an illness and disability, the effects of chronic pain; the biological effects of some conditions and medications that can cause depression through direct effects on the brain; and the social restrictions that some illnesses place upon older people's life style resulting in isolation and loneliness.

There are strong indications that depression substantially increases the risk of death in adults, mostly by unnatural causes and cardiovascular disease (Wulsin et al., 1999). Some population-based studies did find that this independent relationship does exist in later life, while others did not.

Loneliness is a subjective, negative feeling related to the person's own experience of deficient social relations. The determinants of loneliness are most often defined on the basis of 2 causal models. The first model examines the external factors, which are absent in the social network, as the root of the loneliness; while the second explanatory model refers to the internal factors, such as personality and psychological factors.

Loneliness may lead to serious health-related consequences. It is one of the 3 main factors leading to depression (Green et al., 1992), and an important cause of suicide and suicide attempts. A study carried out by Hansson et al. (1987) revealed that loneliness was related to poor psychological adjustment, dissatisfaction with family and social relationships.

As people grow old, the likelihood of experiencing age-related losses increases. Such losses may impede the maintenance or acquisition of desired relationships, resulting in a higher incidence of loneliness. Many people experience loneliness either as a result of living alone, a lack of close family ties, reduced connections with their culture of origin or an inability to actively participate in the local community activities. When this occurs in combination with physical disablement, demoralization and depression are common accompaniments. The negative effect of loneliness on health in old age has been reported by researchers (Heikkinen et al., 1995). The death of spouse and friends and social disengagement after leaving work or a familiar neighborhood are some of the ubiquitous life-changing events contributing to loneliness in older people. Those in the oldest age cohort are most likely to report the highest rates of loneliness, reflecting their increased probability of such losses.

A study by Max et al. (2005) revealed that the presence of perceived loneliness contributed strongly to the effect of depression on mortality. Thus, in the oldest old, depression is associated with mortality only when feelings of loneliness are present. Depression is a problem that often accompanies loneliness. In many cases, depressive symptoms such as withdrawal, anxiety, lack of motivation and sadness mimic and mask the symptoms of loneliness.

Sociability and old age

Sociability plays an important role in protecting people from the experience of psychological distress and in enhancing well-being. George (1996) summarized some of the empirically well-supported effects of social factors on depressive symptoms in later life, and reported that increasing age, minority racial or ethnic status, lower socioeconomic status and reduced quantity or quality of social relations are all associated with increased depressive symptom levels. Social isolation is a major risk factor for functional difficulties in older persons. Loss of important relationships can lead to feelings of emptiness and depression. "Persons involved with a positive relationship tend to be less affected by everyday problems and to have a greater sense of control and independence. Those without relationships often become isolated, ignored, and depressed. Those caught in poor relationships tend to develop and maintain negative perceptions of self, find life less satisfying and often lack the motivation to change" (Hanson & Carpenter, 1994).

Having few social contacts or living alone does not assure a state of loneliness (Mullins, Johnson, & Anderson, 1987). In fact, for elderly people the time spent with family may be less enjoyable than a visit to a neighbor or someone of their age group. This can be attributed to the fact that relationships with family tend to be obligatory whereas those with friends are a matter of choice. This further emphasizes the need for a perceived internal locus of control over social interaction as a means of alleviating loneliness.

Posner (1995) points out that older people tend to make friendships predominantly with those within the same age cohort. Thus with advancing age, it is inevitable that people lose their friendship networks and that they find it more difficult to initiate new friendships and to belong to new networks. However, those with more physical, material and intellectual resources also have more social "capital," which allows them to continue to seek out new relationships and forms of social involvement.

The number of older people is increasing throughout the world. As individuals grow older, they are faced with numerous physical, psychological and social role changes that challenge their sense of self and capacity to live happily. Depression and loneliness are considered to be the major problems leading to impaired quality of life among elderly persons. At the same time, old age can also be an opportunity for making new friends, developing new interests, discovering fresh ways of service, spending more time in fellowship with God. It can be happy and winsome or empty and sad - depending largely on the faith and grace of the person involved. Therefore, the present study was undertaken with the main purpose of studying the relationships among depression, loneliness and sociability in a group of elderly people and also to determine gender differences with respect to the above relationships of variables.

Objectives of the study

Examine the relationships among loneliness, depression and sociability in elderly persons

Study gender differences with respect to sociability, loneliness and depression among elderly persons

Hypotheses

There will be a positive relationship between loneliness and depression in old age.

There will be a negative relationship between sociability and loneliness in old age.

There will be a negative relationship between sociability and depression in elderly persons.

There will be gender differences with respect to the variables sociability, loneliness and depression in elderly persons.

MATERIALS AND METHODS

Sample

The sample comprised of 55 elderly persons (35 men and 20 women) in the age group of 60-80 years. The mean age of the sample population was 67 years. The subjects for the sample were selected from the older adults of a Delhi-based region residing in the housing societies. These elderly persons were contacted personally, and the questionnaires were administered to them.

Measures

The revised UCLA (University of California, Los Angeles) loneliness scale (Russell et al., 1980)

The UCLA Loneliness Scale includes 10 negatively worded and 10 positively worded items that have the highest correlations with a set of questions that are explicitly related with loneliness. The revised version of the scale has high discriminative validity. The revised loneliness scale also has a high internal consistency, with a coefficient alpha of 0.94.

Beck depression inventory (Beck et al., 1961)

The Beck Depression Inventory (BDI) is a 21-item self-report scale measuring supposed manifestations of depression. The internal consistency for the BDI ranges from 0.73 to 0.92, with a mean of 0.86. The BDI demonstrates high internal consistency, with alpha coefficients of 0.86 and 0.81 for psychiatric and nonpsychiatric populations, respectively. The scale has a split-half reliability coefficient of 0.93.

Sociability subscale of Eysenck personality profiler (Eysenck & Eysenck, 1975)

Eysenck Personality Profiler (EPP V6) is a multidimen sional modular personality inventory for 3 dimensions: Extroversion, emotionality (neuroticism) and adventurous ness (psychoticism). Each dimension has 7 subscales.

The sociability subscale of extroversion used in this study consists of 20 questions. The response category is either 'yes' or 'no.' There are 10 positive items and 10 negative items. The factorial validity of the EPP V6 holds across different cultures and age groups, with a high equivalent factor structure among these different samples.

Procedure

Initially the participants were personally contacted and rapport was established with them. The participants completed the questionnaires given to them. Standard instructions were written on top of each questionnaire, and the participants were asked to rate themselves under the option they felt relevant to them. It was made clear to the participants that there were no right and wrong answers. If they had any difficulty, they were encouraged to ask questions. After finishing the entire set of questions, they were asked to return the questionnaires. The test administration took about 45minutes.

RESULTS

Table 1 shown above reveals that there are no significant gender differences in elderly men and women with respect to loneliness and depression. Elderly men, however, were found to be more sociable as compared to elderly women.

Table 2 shows a significant positive correlation between depression and loneliness, which is significant at the 0.01 level, i.e., there is an increase in the level of depression with an increase in loneliness among elderly men and women. A negative, though insignificant, relationship was found between sociability and loneliness. No significant relationship was found between sociability and depression.

Table 3 reveals that in the male elderly persons, a significant positive correlation was found between depression and loneliness. Sociability and loneliness were negatively correlated, though not significantly.

Female elderly persons manifested a significant positive correlation between depression and loneliness, as can be seen in Table 4 .

DISCUSSION

The health and well-being of older adults is affected by the level of social activity and the mood states. Researchers have reported the negative effects of loneliness on health in old age (Heikkinen et al., 1995). Loneliness, coupled with other physical and mental problems, gives rise to feelings of depression in the elderly persons. Gender differences have been reported in the prevalence of health problems in elderly persons (Arber & Ginn, 1991). Results in Table 1 reveal that there are no significant gender differences in the elderly persons with respect to loneliness and depression, i.e., both the male and female elderly persons equally experience feelings of loneliness and depression. On the dimension of sociability, men were found to be more sociable as compared to their female counterparts. This may have been due to the fact that all the elderly men belonged to the working group, i.e., they were employed in government jobs before retirement and were less hesitant in socializing as compared to their female counterparts who were housewives and were spending their lives at home and finding pleasures by engaging in daily chores. Having both the intellectual and social resources allows elderly men to continue to seek out new relationships. Lack of significant gender differences on loneliness reflects the fact that since both the groups contained elderly married couples, with both partners being alive, the chances of their feeling lonely were low. Moreover, most of the couples were staying with their children and grandchildren, which did not allow them to stay lonely for long. Lack of significant gender differences on depression is contrary to the often held belief and research reports that elderly women are more prone to depression as compared to elderly men (Kessler et al., 1993). This result is not in line with what has been reported in literature. The findings of no significant gender differences with respect to depression may be attributed to the fact that all the women were nonworking ladies before they attained 60 years of age. Hence for them, the transition into old age was less associated with a change in life style associated with a break in ties with others or a sudden loss of power and status. The transition was very gradual, which prevented any abrupt change in mood states.

A positive correlation between loneliness and depression [Tables ​[Tables2 2 - 4 ] is in accordance with the results obtained in literature with regard to both male and female elderly persons (Green et al., 1992). No significant relationship between loneliness and sociability [ Table 2 ] reveals that despite being sociable, they experienced increased feelings of loneliness. Possible explanation for this may be that feeling lonely not only depends on the number of connections one has with others but also whether or not one is satisfied with his life style. An expressed dissatisfaction with available relationships is a more powerful indicator of loneliness (Revenson, 1982).

Lack of significant relationship between depression and sociability [ Table 2 ] confirms the fact that depression is multicausal, i.e., it arises due to a host of factors, like declining health, significant loss due to death of a spouse, lack of social support. Also most of the elderly persons had moderate connections with their friends and family members, and they participated in daily activities.

On the basis of obtained findings, the following conclusions can be made:

1. A significant positive correlation exists between loneliness and depression.

2. No significant relationship was found between loneliness and sociability; depression and sociability.

3. Men are found to be more sociable than women.

4. A significant correlation was found between loneliness and depression in both men and women.

There were certain limitations in the study:

1. The sample size was restricted to few elderly persons. Hence in future, a similar study needs to be conducted on a larger section of the elderly population.

2. For determining gender differences, both male and female constituents of the sample should be equivalent in all respects.

3. Moreover, no formal diagnosis of depression was made in the sample used in the study. Self-report inventory was used for determining the level of depressive symptoms in the elderly persons.

Keeping in view the above limitations, longitudinal studies on a larger group of elderly men and women are needed in future.

Footnotes

Source of Support: Nil

Conflict of Interest: None declared

REFERENCES

4. Bruce M. L, Seeman T, Merrill S. S, Blazer D. G. The impact of depressive symptomatology on physical disability: MacArthur Studies of successful aging. American Journal of Public Health. 1994;84:1796-1799. [[ PMC free article] [ PubMed] Google Scholar]

7. Diener E, Suh E. M, Lucas R. E, Smith H. L. Subjective well-being: Three decades of progress. Psychological Bulletin. 1999;125:276-302. [ Google Scholar]

16. Mullins L. C, Johnson D. P, Anderson L. Danish Medical Bulletin. Special Supplement Series, No. 6, October. 1988:26-29. [ Google Scholar]

19. Revenson T. A. Predictable loneliness of Old Age: Dispelling the Myth. Paper presented at the Annual Convention of the American Psychological Association (90th Washington, DC, August 23-27, 1982) 1982 [ Google Scholar]

Articles from Industrial Psychiatry Journal are provided here courtesy of Wolters Kluwer -- Medknow Publications

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Loneliness, depression and sociability in old age

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The elderly population is large in general and growing due to advancement of health care education. These people are faced with numerous physical, psychological and social role changes that challenge their sense of self and capacity to live happily. Many ...

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Depression in older nursing home residents: The influence of nursing home e...: OneSearch: Books, Articles, Videos and more

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During the 20th century, the number of persons in the United States under age 65 has tripled. At the same time, the number aged 65 or over has jumped by a factor of 11! Consequently, the elderly, who comprised only 1 in every 25 Americans (3.1 million) in 1900, made up 1 in 8 (33.2 million) in 1994.

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good source for final

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DOAJ is an online directory that indexes and provides access to quality open access, peer-reviewed journals.

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Pew Research Center's Social & Demographic Trends Project

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The Pew Research Center's Social & Demographic Trends project studies behaviors and attitudes of Americans in key realms of their lives.

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Does your state outrank others in population growth? Has it been losing people? Is it in the top or bottom in population size or somewhere in the middle?

Hover over any state on the interactive map below and get an instant look at how your state and every state's population has changed from April 1, 2010, to July 1, 2017. Move the cursor down to the bars and see how your state compares to others. Slide over to the graphic lines on the right and follow the change in population every year since 2010 for every state, the District of Columbia and the United States.

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Texas Added the Most People but California Still Most Populous

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Does your state outrank others in population growth? Has it been losing people? Is it in the top or bottom in population size or somewhere in the middle? Hover over any state on the interactive map below and get an instant look at how your state and every state's population has changed from April 1, 2010, to July 1, 2017.

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Centers for Medicaid & Medicare Services

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The Skilled Nursing Facility Value-Based Purchasing Program (SNF VBP)

What's the Skilled Nursing Facility Value-Based Purchasing Program (SNF VBP)?

The SNF VBP Program rewards skilled nursing facilities with incentive payments for the quality of care they give to people with Medicare.

When does the SNF VBP Program start?

The SNF VBP Program starts in fiscal year 2019.

Why's the SNF VBP Program important?

The SNF VBP Program promotes better clinical outcomes for skilled nursing facility patients and makes their care experience better during skilled nursing facility stays.

How will the program work?

We'll pay participating skilled nursing facilities for their services based on the quality of care, not just quantity of the services they provide in a given performance period.

Section 215 of the 2014 Protecting Access to Medicare Act (PAMA) started the SNF VBP Program and gives details about:

The readmission measures specified for the Program

How facility performance will be scored

What the performance standards and periods are

How facilities can review their scores

How facility performance will be reported to the public

Every year, the SNF Prospective Payment System (PPS) rules outline what's required of the SNF VBP Program for that year.

Since October 2016, we have been providing SNFs with quarterly confidential feedback reports containing information regarding their performance on the readmission measure specified for the SNF VBP Program. These quarterly reports are disseminated to SNFs via the QIES system.

October 2017 Update: SNF VBP Baseline Performance Data Are Now Available.

Performance data from the baseline year of the SNF VBP program are now available here. This includes SNFs' performance on the Skilled Nursing Facility Readmission Measure (NQF# 2510) from Calendar Year (CY) 2015.

What types of SNFs are included in the SNF VBP Program?

All SNFs paid under the SNF PPS are included in the SNF VBP Program and are eligible for payment incentives based on their performance on the program's measure.

What measures will be used in the SNF VBP Program?
Skilled Nursing Facility 30-Day All-Cause Readmission Measure
The Skilled Nursing Facility 30-Day All-Cause Readmission Measure (SNFRM) is used in the SNF VBP Program. The SNFRM estimates the risk-standardized rate of unplanned readmissions within 30 days for:

People with fee-for-service Medicare who were inpatients at PPS, critical access, or psychiatric hospitals.

Any cause or condition.

We finalized the SNFRM in the SNF PPS Final Rule for FY 2016. This fact sheet contains important information you should know about SNFRM.

This technical report and technical report supplement provide additional detail on the SNFRM.
Skilled Nursing Facility 30-Day Potentially Preventable Readmission Measure
The Skilled Nursing Facility 30-Day Potentially Preventable Readmission Measure (SNFPPR) estimates the risk-standardized rate of unexpected, potentially preventable readmissions (PPRs) within 30 days for people with fee-for-service Medicare who were inpatients at PPS, critical access, or psychiatric hospitals. The SNFPPR will replace the SNFRM measure in the SNF VBP Program as soon as is practicable.

We finalized the SNFPPR in the SNF PPS Final Rule for FY 2017. This Final Measure Specification provides additional detail on the SNFPPR.

What are the baseline and performance periods affecting payment determination in FY 2019 for the SNF VBP Program?

For each year that the SNF VBP Program affects payment determination, SNFs are scored based on their performance during the applicable baseline period and performance period.

The baseline period affecting payment determination in FY 2019 is calendar year (CY) 2015 (January 1, 2015 through December 31, 2015).

The performance period affecting payment determination in FY 2019 is CY 2017 (January 1, 2017 through December 31, 2017).

How will SNF's performance be scored under the SNF VBP Program?

SNFs will earn a SNF VBP Performance score (0 to 100) and ranking which is calculated based on that SNF's performance on the measure specified for the Program during the performance period and the baseline period. The SNF VBP performance score is equal to the higher of the achievement score and improvement score.

SNFs will be awarded points for achievement on a 0-100-point scale and improvement on a 0-90-point scale, based on how their performance compares to national benchmarks and thresholds.

For more in-depth information on SNF VBP performance scoring, we refer you to the FY 2018 SNF PPS final rule.

Where can I learn more about the SNF VBP Program?
Find out about the SNF VBP Program's updates:

Accessing your Confidential Feedback Quarterly Reports tutorial slides.
Find out how to get your Confidential Feedback Quarterly Reports:

Skilled Nursing Facility Value-Based Purchasing Program FY 2018 Final Rule Call slides.

You can also read our MLN article or contact us for more information.

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The SNF VBP Program rewards skilled nursing facilities with incentive payments for the quality of care they give to people with Medicare. The SNF VBP Program starts in fiscal year 2019. The SNF VBP Program promotes better clinical outcomes for skilled nursing facility patients and makes their care experience better during skilled nursing facility stays.

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The United States Social Security Administration | SSA

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Official website of the U.S. Social Security Administration.

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America spends more money per person than any other advanced nation on health care. Yet compared with other industrialized nations, we consistently rank either near or at the bottom on health care access and quality, and on key measures of a healthy life. Spending on a health care system that is neither efficient nor equitable means we can't afford to invest adequately in education, housing and other factors that keep us healthy.

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By working across sectors, we have the opportunity to create the kind of health system everyone in our nation deserves: one that couples care with compassion, rewards value over volume, and places health at the center of every aspect of life.

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America spends more money per person than any other advanced nation on health care. Yet compared with other industrialized nations, we consistently rank either near or at the bottom on health care access and quality, and on key measures of a healthy life.

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