Advancements in the Understanding of What Wellbeing at Very Old

Age Is: An Exploratory Study

Cosmina Paul

, Magda Velciu

and Luiza Spiru

Ana Aslan International Foundation, Spatarului nr 3, Bucharest, Romania

Keywords: Old Older Adults, Well-Being, Belonging, Aging Well, Care Support.

Abstract: With increasing number of old older adults worldwide, understanding and promoting wellbeing become a

priority. The state of wellbeing is a multifaceted phenomenon that refers to an individual’s subjective

perception and, therefore, exploring perspectives of old older adults for ageing well is developing to be a

relevant area of research, along the general topic of aging well regardless of age. The purpose of this article

was to explore perspectives of wellbeing among old older adults from Romania and Portugal. A comparative

perspective to a sample of older adults in the context of testing Wellbeing of Older People Survey was

employed. Three major themes were identified: a) with age, the relevance of physical and mental health fade

for the old older adults’ perspective, hence the importance of preserving their wellbeing, b) belonging

transform from independence and feeling useful into social contacts and c) the most important things with age

is making ends meet and the satisfaction towards the living situation. This study contributes to get a better

insight concerning old older adults’ perspectives on wellbeing and aging well. Enhancing support in care and

designing age friendly cities which support participation in social activities, living situation are all

contributing factors to aging well. Vital factors are to be considered in developing strategic health and

rehabilitative plans for promoting aging well among older adults.

1 INTRODUCTION

Subtle but massive societal changes, such as

demography and aging, call for social awareness and

vision towards our elderly. Health and care sectors, as

well as businesses and politics, needs to embed

sustainability and resilience in facing an aging

population. But that is not possible without truly

understanding what well-being at very old age is.

The understanding of old elderly’s well-being

bears relevance because it reverberates on the topic of

the already existing and gauging crisis in health and

care sector and, more, on the increasing impact of

health and social care services for older people which

are intended at improving well-being rather than

health alone (Himmler et al, 2022).

More, Covid-19 impact merely showed the

societal crisis in a nutshell. And it revealed how

vulnerable elderly are and how fragile the care

ecosystem is. After 2020, the overreaching themes of

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well-being, quality of life and independence,

flourished. There are more studied in the last 3 years

that in 20 years before the pandemic.

The aim of this study is to shed light on the effects

of a concept mapping strategy regarding wellbeing

for the population aged 80 and over. For this reason,

we look at what wellbeing is from the perspective of

elderly themselves.

All these approaches have their stake because

research showed that prevention can support aging at

home and reduce costs on health and care. According

to a systematic review and meta-analysis of 89 trials,

complex interventions can help elderly people to live

safely and independently, and could be tailored to

meet individuals’ needs and preferences (Beswick et

al, 2008). Complex interventions are combinations of

interdisciplinary teamwork for health and social

problems. The review found that interventions

reduced the risk of not living at home, nursing-home

admissions, hospital admissions, and falls, and

284

Paul, C., Velciu, M. and Spiru, L.

Advancements in the Understanding of What Wellbeing at Very Old Age Is: An Exploratory Study.

DOI: 10.5220/0012730300003699

Paper published under CC license (CC BY-NC-ND 4.0)

In Proceedings of the 10th International Conference on Information and Communication Technologies for Ageing Well and e-Health (ICT4AWE 2024), pages 284-290

ISBN: 978-989-758-700-9; ISSN: 2184-4984

improved physical function in elderly people.

However, more understanding is needed to identify

the optimal components of complex interventions for

elderly people.

Hence, we have started asking ourselves: What

precisely oldest old wellbeing is? What are the

effects of the oldest old lack of wellbeing? What we

are aiming at through our social vision? To what

extent would age-friendly cities improve the

wellbeing of the oldest old?

However, the measure is foremost a subjective

one and older adults represent a heterogeneous group,

which could explain the contradictory results found in

the literature. After concept mapping, we employ a

gerontographics perspective to categorize the older

adults in their views on wellbeing (Moschis, 2019).

Generally, to the older adults, wellbeing stays as

a multidisciplinary concept, which comprises

overlapping terms such as: independence, quality of

life, mental health, dignity, self-determination, or

mobility (Ravulaparthy et al, 2016; Pantelaki et al,

2021; Bechtold et al, 2021; Marques et al, 2020).

1.1 Well-Being and Independence

When analysing well-being as the importance of

promoting and maintaining the independence, also

concepts such as utility and social connectedness of

elderly people for their well-being and quality of life

are strongly related (Siobhan, 2012; Hadeel et al,

2018).

Independence for elderly means having the ability

to live autonomously and with dignity, while

maintaining physical and mental well-being.

Independence can have different meanings for

different older people, depending on their abilities

and preferences, but some common aspects are:

having the freedom to make choices and decisions

about one’s own life, such as daily routines, activities,

and personalization of one’s space.

The feeling of utility for elderly is the sense of

being useful and productive, and having a purpose

and meaning in life. It is related to the concept of

generativity, which is the desire to contribute to the

well-being of others and the society. The feeling of

utility can have positive effects on the mental and

physical health of older people, such as increasing

their self-esteem, happiness, and life satisfaction, and

reducing their depression, anxiety, and cognitive

decline. The feeling of utility can help older people

cope with the challenges and losses of aging, and

maintain a sense of identity and dignity.

1.2 Well-Being and Health

Other authors, discuss well-being from the mental

health perspective, hence, the influence of

psychological factors, such as positive emotions, self-

esteem, life satisfaction, and purpose in life, on the

health and well-being of elderly people is presented

(Bar-Tur, 2021, Hadeel et al, 2018, Siobhan et al ,

2012).

The frameworks so far refer to a variety of

variables, such as biological, psychological, and

social factors that affect the health and well-being of

older adults, such as chronic diseases, cognitive

function, social engagement, and life satisfaction.

Other works look at the psychological interventions

that aim to enhance well- being in healthy older

adults. It categorizes the interventions into four types:

cognitive-behavioral, mindfulness-based, positive

psychology, and existential. It evaluates the

effectiveness, mechanisms, and limitations of each

type of intervention, and provides recommendations

for future research and practice (McClintock et al,

2016; Iwano et al, 2022).

1.3 Well-Being and Lifestyle Factors

Besides independence and mental health, well- being

has been also considered from the role of lifestyle

factors, such as physical activity, healthy eating, and

cognitive stimulation, in preventing or reducing the

risks of physical and mental decline in elderly people.

literature review on the relationship between

memory, cognitive development, and aging linked

with longevity. The review determined that there are

psycho-cultural aspects that have a decisive influence

on the increase in longevity, such as the performance

of activities with positive mental states, positive

emotions and experiences, and the level of studies

(Maldonado et al, 2020).

1.4 Well-Being and the Care Ecosystem

Family relationships affect the well-being of parents,

adult children, and grandparents. Factors that

influence the quality and quantity of family

interactions, such as life course transitions,

geographic distance, and cultural norms are inquired

along the benefits and challenges of family

relationships for well-being, such as social support,

intergenerational solidarity, and conflict (Thomas and

Umberson, 2017).

1.5 Wellbeing and Society

Elderly well-being is also seen from a social

perspective, where the need for appropriate and

Advancements in the Understanding of What Wellbeing at Very Old Age Is: An Exploratory Study

285

accessible services, opportunities, and support for

elderly people to cope with the challenges and losses

of aging and to enhance their vital involvement and

active engagement in life.

This perspective also informed a more practical

approach where positive aging concepts and

strategies to enhance well-being in the elderly are

translated into practical approaches for Positive

Aging. Drawing upon positive psychology and

positive aging research and tools, programs are

designed to help older adults improve their well-being

by acquiring skills and strategies to cope with present

and future challenges (Bar-Tur, 2021).

Making ends meet and living situation are both

economic and social dimensions of elderly well-

being. Economic dimensions refer to the material

resources and income that affect the quality of life and

opportunities for older people. Social dimensions

refer to the interpersonal relationships and social

networks that provide support and belonging for older

adults (Reuben and Lim-Soh, 2021). Making ends

meet and living situation are related to both economic

and social dimensions, as they influence and are

influenced by the financial security and social

integration of older people. For example, making

ends meet can affect the ability to afford adequate

housing, health care, and leisure activities, as well as

the level of stress and satisfaction with life. Living

situation can affect the availability and quality of

social contacts, the sense of autonomy and privacy,

and the risk of isolation and loneliness. Therefore,

both making ends meet and living situation are

important aspects of elderly well-being that involve

both economic and social factors.

1.6 Wellbeing Mapped in Age-Friendly

Cities

But making ends meet and living situation are related

to age-friendly cities. Age-friendly cities are cities

that promote healthy and active ageing and improve

the quality of life for people over 60. One of the

aspects of age-friendly cities is to provide affordable

and accessible housing options for older people, as

well as adequate public services and infrastructure to

support their daily needs. Making ends meet and

living situation are both influenced by the availability

and affordability of housing, as well as the social and

economic opportunities that the city offers.

Besides care support, age-friendly cities have

been another point of focus recently for promoting

wellbeing. They aim to create age-friendly cities that

promote active aging, social inclusion, and well-

being (Gibney et al, 2020; Nieboer et al, 2018; Steels,

2015). Hence, in-depth understanding of what

wellbeing is has implications for designing care

support and age-friendly cities.

Therefore, age-friendly cities can help older

people to have a better living situation and make ends

meet, as well as to enjoy a more fulfilling and

dignified life: a) Having the resources and support to

cope with the challenges and changes of aging, such

as mobility, health, finances, and social connections.

Having the opportunity to pursue one’s interests,

hobbies, and goals, and to contribute to one’s family,

friends, and community. b) Having the self-esteem

and confidence to feel valued and respected as an

individual. c) Independence for elderly is important

because it can enhance their quality of life, happiness,

and resilience. It can also prevent or reduce the risks

of depression, isolation, hopelessness, and stress.

Independence can be promoted and maintained by

providing older people with appropriate and

accessible services, such as home wellness solutions,

home-delivered meals, assistive devices, and

transportation. It can also be supported by

encouraging older people to stay active, engaged, and

connected with others, and by respecting their wishes

and preferences (NET4Age, 2022, 2024).

Lack of independence, utility, and social

connections can have negative effects on the health

and well-being of elderly people. Some of the

possible effects are: a) Increased risk of physical and

mental conditions, such as high blood pressure, heart

disease, obesity, weakened immune system, anxiety,

depression, cognitive decline, and Alzheimer’s

disease; b) Reduced quality of life, happiness, and life

satisfaction. c) Lowered self-esteem, confidence, and

sense of identity. d) Increased feelings of isolation,

loneliness, hopelessness, and stress. e) Decreased

ability to cope with the challenges and losses of aging.

To prevent or reduce these effects, it is important

to promote and maintain the independence, utility,

and social connectedness of elderly people. This can

be done by providing them with appropriate and

accessible services, opportunities, and support, and

by respecting their choices and preferences.

2 METHODOLOGY

We have started from a newly developed Well- being

of Older People measure (WOOP) which has been

elaborated based on older people's own views on what

is important to their well-being (Hackert et al, 2020;

Bowling et al., 2013; Bowling and Stenner, 2011),

instead of expert opinion regarding relevant well-

being domains.

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We will compare data discussed in the study

performed by Hackert et al (2020) with data obtained

from the field trials in Portugal and Romania at the

beginning of the field trial: Hackert et al (2020)

WOOP vs A4A WOOP, within the framework of the

project “From Smart Home to Care Home – AAL4All

(A4A)”, co-funded by the European Programme AAL

(Active Assisted Living – ICT).

When discussing the limitations of the study/

sample, Hackert et al (2020) emphasize that greater

insight is needed in the performance of the WOOP in

older people with more severe physical and mental

health problems, which were underrepresented in

their sample. We aim to overcome this by employing

a larger range of older adults with various mental and

health conditions, and levels of fragility.

The study undertaken by Hackert et al (2020) is

the first quantitative validation of the Well-being of

Older People measure (WOOP). It is an online

survey, where data was collected between December

2017 and January 2018. A sampling agency recruited

1113 respondents aged 65 years and older in the

Netherlands, approximately representative of this

population in terms of age, sex and level of education.

2.1 WOOP Description

WOOP comprises 9 items which cover the central

aspects of well-being that respondents mentioned

when describing what well-being meant to them.

On each item, respondents can indicate the

severity of their health problems using five response

levels. The minimum score is 9 (1 –worst imaginable,

1 for each item cumulates 9), while the maximum

score is 45 (5 – best imaginable, 5 for each item

cumulates 45 points).

Table 1: The items of the Wellbeing for the Old People

Measure according to Hackert et al (2021).

OOP’s Items

1. Physical health

2. Mental health

3. Social contacts

4. Receive support

cceptance and resilience

6. Feeling useful

7. Independence

8. Making ends meet

9. Living situation

2.2 A4A WOOP Population

As Hackert et al (2020) mentioned when discussing

the limitations of their study, the older population

investigated has some particularities which would

rather ascribe the data to an older population who is

generally physically and mentally well. The

population targeted for the testing A4A Solution is

rather more fragile, living alone and benefitting from

care, and can be seen rather physically or

psychologically unwell.

In the case of Hackert et al (2020) sample, older

people in the highest age groups, and those with low

levels of well-being and (physical and mental) health

was underrepresented.

Dependent older adults on health and social care

(e.g., living in a nursing home), might be missing

from the sample. people in poor well-being states,

scoring low on the WOOP items, remains low.

older persons with a non-western background,

Older people with low computer

literacy have not been reached

In the case of A4A WOOP study, a face-to-face

survey was employed and data was collected in the

first stage of the field trials between June 2023 and

August 2023. Both in Romania and Portugal, a total

number of 33 respondents aged 60 years and older

was recruited. Respondents completed a

questionnaire asking about their well-being, health

and several background characteristics. Information

was gathered on respondents' age, sex, number of

children and grandchildren.

Participation was voluntary, based on informed

consent and could be terminated at any point.

A4A WOOP results may differ from those

presented by Hacker et al. (2021) because of the

background specific characteristics of the older adults

interviewed.

2.3 Descriptive Characteristics of the

A4A WOOP

Descriptive characteristics of the General WOOP

(Hackert et al, 2020). Both sexes were equally

represented, and 65% of the respondents were

married or living together. Respectively, 40%, 33%

and 27% had attained a low, middle, and high

education. Almost all were retired (89%), and 28%

indicated material deprivation in at least one of the

indicated expense categories. 61% reported two or

more health problems on the Comorbidity Index,

10% received informal care, and 29% received at

least one type of formal care.

Comparative to the General WOOP sample, in the

case of A4A, respondents on average were 76 years

old, with 40% being 80 years or older. The age range

was also wider, because people with various care

needs were included (such as those coming back from

the hospital and being under recovery, serious health

issues). Thus people 60 + were included. The well-

being also differs because respondents are living

alone. All of them reported health issues.

Advancements in the Understanding of What Wellbeing at Very Old Age Is: An Exploratory Study

287

In the case of A4A WOOP, about 40% were over

80 years old, while in the Hackert study only 19%.

More, some were post hospitalized and had severe

physical limitations in A4A Survey.

We have aimed at including in our sample a wide

range of vulnerabilities, be them structural or

personal. Therefore, people from Southern Europe

have been included and people with less education

and technological familiarity.

In conclusion, if Hackert study rather comprised

People Physically and Mentally Well, A4A WOPP

included either physically or mentally unwell.

Differences in descriptive characteristics of the

population of the Hackert et al WOOP (2020) and A4A

WOOP.

Table 2: Participants description in WOOP tested by

Hackert et al (2021) and A4A Project, 2022-2024.

WOOP

(Hacker et al,

2021)

WOOP

A4AProject, 2022-

2024

Inclusion 65+ 60+

Age average 74 78

Sex Even More women (67%)

Education High 50% elementary

Digital Literacy High 43% no smartphone

Western origin

Yes

40%South European

Marital status

Most married

All living alone

+ formal care Low 65%

+ informal care Low 90%

3 RESULTS

Due to the inclusion criteria, we may notice that on a

scale from 7 to 45, the variance for the A4A WOPP

is very wide. Mental health dropped to half, due to the

same wide of population characteristics.

Interestingly enough, small differences can be

noted in the perception of making ends meet and

living situation. That leads us to the belief that

individual characteristics in setting the expectations is

much more important than the socio-economic

realities out there.

However, socio-economic realities still have their

toll as they appear as determinants to the mental and

physical health where the differences are 50% larger

for the first group in scoring well.

Table 3: Scoring in the population of the old adults (Hackert

et al, 2020) and very old adults (A4A, 2022-2024).

Well-being measures

WOOP

(Hacker et al,

2021)

WOOP A4A

Solution –

General WOOP

scores

High

Average 34,

mode 36

Mental health

90%

reat 41%

reat

Physical health

65%great&goo

30%great&goo

Making ends meet

60% great&goo

64%great&goo

Living situations 88% great&goo

75% great&goo

The following ranges were used to classify

correlation strength: less than 0.10, trivial; 0.10–0.29,

small; 0.30–0.49, moderate; 0.50–0.69, high; 0.70–

0.89, very high; and 0.90 or higher, (nearly) perfect

(Hopkins, 2002).

In the study performed by Hackert et al (2021),

the WOOP general score is mildly to highly

correlated to physical health, and (very) highly with

(mental) health and well-being measures.

In A4A study, the WOOP has a (very) weak

correlation with physical health, while it mildly

correlates to mental health and (very) highly with

other well-being measures. To assess the association

between the WOOP items, Spearman correlations

were calculated.

Table 4: Spearman correlation within A4A WOPP Measure.

Item WOOP A4A Project

Physical health .17 Weak

Mental health .38 Moderate

Social contacts .73 Very high

Receive support .64 High

Acceptance and

resilience

.50 Moderate/High

Feeling useful .52 Moderate/High

Independence .62 High

Making ends meet .76 Very high

Living situation .75 Very high

Hence, we confirm the initial statement that once

age advances, the focus is on improving/ preserving

well-being rather than health (alone).

4 DISCUSSION

The first cluster represents Self-care agency. The

variables’ correlation to general wellbeing is weak,

due to advanced age, high fragility, and limited

capabilities. Hence, what we thought to be key

aspects of well-being became less relevant.

ICT4AWE 2024 - 10th International Conference on Information and Communication Technologies for Ageing Well and e-Health

288

Table 5: Well-being at an advanced age and implications in

designing care and age-friendly cities.

Domain Item

Well-being

Impact at

advanced age

Impact

Socio-

economic

needs

Making ends

mee

Very high Care support

Living

situation

Very high Age-friendly

cities

Belonging Social contacts Very high Age-friendly

cities

Receive

support

High

Age-friendly

cities

Independence High Care suppor

Feeling useful Moderate/ High

Care support

Self-care Acceptance

and resilience

Moderate/

High

Mental health Moderate -

Physical health

Weak

The second cluster is dedicated to ‘Belonging’.

The items here are strongly correlated to

‘Independence’ and with the ‘feeling of being useful’

and social dimensions, such as social contacts and

receiving support. It is a bit counter-intuitive to relate

independence to the need for feeling useful, though

they are strong dimensions of social inclusion.

The correlation between the feeling of being

independent and that of being useful are present and

indicate that these needs stay fundamental to one

general well-being regardless of age.

Regarding potential overlap between the WOOP

items, the results from the regression analyses may

suggest that the content of ‘social contacts’ is also

captured indirectly through other WOOP items. In

particular, ‘social contacts’ and ‘receive support’

were highly correlated. This warrants further

investigation.

We may hypothesise that with age and (either)

physical and psychological deterioration, the overlap

between WOOP items increases suggesting the

following: Generally, the feeling of being

independent is highly correlated to the feeling of

being useful and to social contacts, but when age and

disease advance, social contacts remain solely the

expression of ‘belonging’.

5 CONCLUSION

This study gives in-depth understanding of what well-

being means for the old older adults.

Findings contribute to get better insight about

older adults’ perspectives on aging well. At the very

old age, wellbeing is positively influenced by making

ends meet, living situation and social contacts, while

for young or middle aged-older adults, staying

independent and the feeling of being useful, in

addition to being socially engaged and enjoying good

physical and mental health, all contribute to the

wellbeing. Enhancing a physically The vital factors

are to be considered in developing strategic care

support and age friendly environments for

promoting aging well among older adults.

Moreover, we argue that emotional health and

human dignity are adversely affected by increasing

reliance on technology. Therefore, while we agree

that the benefits provided by new technologies in the

process of caring are doubtless, we also argue that

they may affect emotional health in ways not entirely

understood.

We have mapped the relevance of the related

concepts to wellbeing for the old older adults in

relation to the usage of the same concepts for the old

adults.

Table 6: Well-being related concepts.

Related concepts to well-

being for older adults

The relevance of related

concepts to well-being

olde

adults

Inde

endence Decreasin

Health Decreasin

Lifestyle factors Decreasing

Care ecos

ste

Increasin

Societ

Increasin

Age-friendl

cities Increasing

Hence, we note that as we age the ecosystems became

more and more important and drive our sense of well-

being.

ACKNOWLEDGEMENTS

This work was performed in the frame of the EU project

AAL4All (AAL-2021-8-164-CP) funded by the AAL

Programme and co-funded by the European Commission

and the National Funding Authorities of the partner

countries and A4A.

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