Planning for Aging and Frailty: A Qualitative Study on Older Adults’ Perceptions, Facilitators, and Barriers

Abstract

Aging is often accompanied by health events that may disrupt older adults’ desires to age in place. Understanding older adults’ perceptions of planning for their aging process was a priority to identify how planning behaviors occur. Our study explored how people perceive the concept of planning for aging and frailty, and identified the facilitators and barriers involved in the planning process. Using conventional qualitative content analysis, we used the data from semi-structured interviews of twenty community-dwelling older adults aged 50–80 years old. Demographic information was obtained, followed by the participant interviews. Seventeen code categories surfaced including six categories in the perception domain (i.e., internal, external, and future-oriented), seven categories in the facilitators domain (i.e., internal, external, and systems), and four categories in the barriers domain (i.e., internal, and systems). The emergent categories included understanding one’s perception of planning through a holistic lens, the importance of experiences with self/others as facilitators, and the physical/cognitive/emotional factors that serve as barriers within a larger sphere of societal influence. Planning for aging and frailty is an innovative concept that normalizes the aging process and promotes planning through an awareness of aging across the life-course domains. Future research is warranted for intervention development to help older adults recognize and actively plan for aging and to address the barriers involved.

1. Introduction

In later life, older adults often fear health events and a loss of autonomy [1] while wanting to age in place, but they do not necessarily consider factors such as planning to make this a reality [2,3,4]. Indeed, many older adults believe that they have little control over their future quality of life [5]. Simultaneously, policymakers and leaders in aging organizations express the need to reframe and expand the conceptualization of aging in a positive light [6]. This reframing involves visualizing aging as a continuous process involving both opportunities and challenges; however, negative assumptions and connotations about aging persist within the public arena [7]. Too often, for both individuals and society, a fear of decline and dependency contributes to a “fatalistic stance” that nothing can be accomplished to improve the outcomes in aging [7] (p. 8). In order to counter these fatalistic beliefs, anticipatory planning has been recommended [8].

Anticipatory planning, also known as planning for aging and frailty, is in keeping with the recent recommendations from the World Health Organization (WHO) which stress the need to shift from a reactive, disease-based model to a proactive, health-based model that emphasizes an intrinsic capacity (i.e., the composition of a person’s physical and mental capacities) throughout the life course [9]. This shift may promote increased efforts by healthcare systems and society towards helping older adults understand their bodies as they age by advancing research towards the development of a frailty-ready healthcare system [10]. This is particularly critical given the current confluence of the population level aging demographics and longer individual lifespans which lead to an increased risk for chronic conditions and frailty. Planning for aging and frailty also meets the goals of reframing efforts which call for better planning for the end-of-life and for healthcare systems to be proactive about the eventualities that will confront almost every person who reaches an advanced age [11].

Our previous conceptual work on planning for aging and frailty promoted an upstream approach in planning by turning a comprehensive lens on how older adults actually plan ahead and their readiness to plan by elucidating five domains that change as a direct result of aging [12]. These domains include: (1) communication/socialization, (2) environmental, (3) financial, (4) physical care, and (5) cognitive status. This work is built upon assumptions that recognize aging challenges while also creating an awareness that opportunities can empower older adults to determine their own direction and retain meaning in the final stages of life, which contributes to a sense of well-being [13]. This conceptualization supports the recent literature which suggests that planning activities help older adults to achieve positive developmental outcomes and maintain well-being [14]. In order to help support and promote planning, a necessary first step is to capture older adults’ perceptions of such planning and to identify the ways that planning behavior change is encouraged or prevented.

Exploration of planning for aging and frailty using a qualitative methodology is vital for capturing older adults’ voices, considering the dearth of research. In the three extant studies found, one explored patterns of preparation related to the planning of women living in three countries, and revealing four preparation styles within three social-structural contexts [15]; a second explored how future care needs are thought of and discussed by frail older adults related to their present home environment, noting a priority in current emotional well-being over preparation due to avoidance [16]; and the third explored seniors’ perceptions and planning towards advanced life events that may impact their ability to remain in their own home, identifying a lack of planning and the inability to conceive of the life events occurring to them [17]. Given the significant gaps in the science, Kahana et al. called for qualitative approaches to provide an in-depth exploration of the lived experiences of older adults on the barriers, facilitators, and consequences of proactive adaptations that include planning for the future [13]. Therefore, the purpose of this study was to explore how people perceive the concept of planning for aging and frailty, and to identify the facilitators and barriers involved in planning efforts. This study was part of the first author’s dissertation [18].

2. Materials and Methods

2.1. Design

This study was a cross-sectional, exploratory analysis aiming to understand how older adults prepare and plan for aging and frailty and to gain an insight that might lead to the development of interventions to facilitate the process of proactive planning (i.e., enhance facilitators and mitigate barriers). We conducted 1:1 semi-structured interviews with older adults. The Consolidated Criteria for Reporting Qualitative Studies (COREQ) [19] was used to report the findings (Supplementary S1: COREQ). The study was approved by the Vanderbilt University Institutional Review Board (IRB# 21032).

2.2. Participants and Setting

Participants were purposively sampled from a single senior’s center and two YMCA sites located in a southeastern metropolitan area. The recruitment strategies included flyers posted at each site and online recruitment through email listservs and social media platforms. The participants were included if they were aged 50–80 years old, community-dwelling, and had a phone and email address. Exclusion criteria included residing in an assisted-living facility, long-term care facility, or continuing-care retirement community. Individual interviews were scheduled at times convenient for the participants and occurred between 21 June 2021 and 1 July 2021. The participants were offered a USD 25 gift card for each interview.

2.3. Data Collection

Participants indicated their willingness to be contacted by the PI (E.F.) for a phone interview after the completion of an electronic survey which inquired about one’s level of planning according to the transtheoretical model stages of change and one’s personal experiences and experience with others in planning (as was reported in a prior publication). Demographic data was collected to characterize the sample and included: age, sex, ethnicity, race, language spoken at home, education, marital status, living situation, and household income.

Qualitative data was collected via phone at scheduled dates/times by the PI using an interview guide comprised of open-ended questions in three specific domains (i.e., perceptions of planning, facilitators, and barriers) with specific probes and prompts about planning for aging and frailty (Supplementary S2: Interview Guide). In addition to earlier written informed consent, a verbal assent was obtained at the time of the interview which was then audio-recorded and professionally transcribed. The transcriptions were imported into Microsoft Excel for coding and analysis. The interviews continued until data saturation was reached, that is, the participants provided no new information regarding the concepts of planning for aging and frailty [20].

2.4. Data Analysis

Descriptive statistics were conducted using IBM SPSS Statistics, version 27. The interview transcripts (n = 20) were analyzed using conventional content analysis [21]. Two independent coders (E.F. and A.D.) coded the data, by first examining the data deductively through the domains of perceptions of planning, facilitators, and barriers, and then inductively, by building categories and subcategories [22]. Each investigator independently coded the transcripts then met weekly to review the generated codes, develop a provisional coding framework, and ensure the intercoder reliability and agreement process [23]. The two sets of codes were compared to resolve discrepancies and create a coordinated and matched set of codes. A third member of the research team (C.M.) resolved any discrepancies. The codes were grouped by common subject matter and the categories were defined according to the three domains (i.e., perceptions of planning, facilitators, and barriers), producing a codebook-guided thematic analysis [24] (Supplementary S3: Codebook). Axial coding was used to identify the emergent relationships and themes within the domains related to the perceptions of facilitating factors, and barriers involved in planning for aging and frailty [25]. For example, within the internal category of the perceptions domain, the subcategories of “this is me” and “acceptance” enhanced the properties and dimensions of the category. An illustration of the coding process is depicted in Supplementary S4: Coding Process).

2.5. Rigor

The rigor and trustworthiness of the data collection and analysis, such as for the description of participants, interview instructions, interview question guides, and coding techniques to gather the data, ensured the credibility of the study. Triangulation was facilitated with member checking, allowing the desired participants to verify the accuracy and resonance with their experience [26] and with a peer examination of the coding/results with the research team. An audit trail documenting the steps of the interview process, data collection, and interpretation process was maintained to ensure transferability. The PI served as the sole interviewer in the study promoting the reliability of the data collection and dependability of the process. Two coders conducted analyses of all the qualitative transcripts to ensure inter-coder reliability. A third member of the research team ensured a congruence among the two coders, contributing to the confirmability with the accuracy, relevance, and meaning of the data.

3. Results

3.1. Characteristics

Participant characteristics. The participants (n = 20) had a median age of 67.50 (with an interquartile range of 63.25 and 69.75), and identified primarily as female 75% (n = 15), and White, 83.3% (n = 15). Seventy percent of the participants (n = 14) were married or in a domestic partnership. See Table 1 for additional demographic data.

Table 1. Summaries of demographic characteristics (n= 20).

Characteristic
	n	Median	IQR
Age (years)
		n	%
50–59		3	15
60–69		12	60
70–79		5	25
80		0	0
		n	%
Gender
Female		15	75
Male		5	25
Other		0	0
Ethnicity	18
Hispanic, Latino, or Spanish origin		1	5.6
Not		17	94.4
Race	18
American Indian or Alaska Native		0	0
Asian		0	0
Black or African American		2	11.1
Native Hawaiian or Other Pacific Islander		0	0
White		15	83.3
Multi-race *		1	5.6
Language spoken at home
English		19	95
Spanish		1	5
		Median	IQR
Years of Education		16	(12, 18)
		n	%
Marital Status
Single, never married		1	5
Married or domestic partnership		14	70
Widowed		2	10
Divorced		3	15
Separated
Live with
Live alone		5	25
Live with one other person		14	70
Live with multiple others		1	5
Household income	19
USD 10,000–USD 25,000		1	5.3
USD 25,000–USD 60,000		10	52.6
USD 60,000–USD 100,000		3	15.8
USD 100,000–USD 149,000		4	21.1
USD 150,000+		1	5.3

* Multi-race included American Indian or Alaska Native and Black or African American and White (n = 1).

Data set characteristics. The interviews lasted approximately 14 min each (with a minimum of 9 and a maximum of 18 mins). When transcribed, this resulted in a total of 3030 lines of text for the analysis, and 152 lines on average per transcript.

3.2. Analysis

An overview of the categories and subcategories/codes by domain (i.e., perceptions, facilitators, and barriers) according to the aim of the study is outlined in Supplementary S5: Figure S1. This figure provides a conceptual model of the results of our analysis, reflecting that effective planning for aging and frailty is influenced by cognitive prerequisites [27]. Briefly, overall, there were 17 categories of codes of which 6 were elicited when the participants were asked about their perceptions of planning, 7 were elicited when they were questioned about facilitators, and 4 arose when questioned about barriers. The six categories in the perception domain could be conceptualized as internal perceptions (1–3), external perceptions (4–5), and future-oriented perceptions of planning (6). The seven categories in the facilitators domain appeared to fall along a continuum from micro to macro facilitators (internal 1–4; external 5–6; systems 7) to planning. Finally, the four categories in the barriers domain could be grouped into internal (1–3) and system (4) barriers to planning. The categories are discussed in detail below, while the categories, subcategories, and representative quotations are also included in Table 2, Table 3 and Table 4.

Table 2. Categories and subcategories with representative quotations of perceptions.

Overarching Category	Representative Quotation
Category
Subcategory
Internal
This is me
Acceptance	“Begun thinking about getting older because apparently I’m not going to stay young. I thought that was the case. It isn’t. I have to admit, as a very young baby boomer, I think we’re a lot better off than previous generations at our age.” (P1)
	“Still feels like something that happens to other people and not me.” (P5)
Denial	“You don’t think that anything’s going to happen to you. You think, or this is what I thought in my mind, that if it does it’s going to be in the 80s or 90s. You don’t think of something happening to you which could affect your aging ability and later.” (P71)
	“I’m 64, not 84.” (P25)
In the moment	“I think it’s something that people don’t think about until they get there.” (P5)
Facing your own aging and mortality	“You have a buffer there with all your grandparents and your parents and everybody else, but as you get older and they die you’re next in line.” (P16) “Yes, I’m getting older, and I can feel it. There are things I can’t do that I used to do. I’m still in very good shape for somebody who’s going to be 70 next year. But there are things I can’t do anymore.” (P11)
My body
Self-inventory/life-review	“I’m not retired yet, and I probably won’t retire until another year and a half.” (P24)
Evaluation of life now	“Outside, I have a pretty big yard and I’ve tried to pare down.” (P93)
Home	“My husband and I already begun to realize, we’re probably going to have to sell our house that we currently live in.”(P33)
Support System	“Importance of having support groups, be it organizations, nonprofits, or just one another.” (P27)
	“Being out in the country so far away, I’m pretty isolated.” (P16)
Finances	“I think people need to think about it and have a plan, especially on the financial aspects of it, what are you going to do if you don’t have family. I think it’s important for people to think about.” (P189)
Values/beliefs/attitudes
Independence	“I’m extremely independent.” (P25)
	“I don’t have to rely on anyone for anything.” (P93)
Control	“Have everything in place where it won’t be any confusion, no one can change anything for you.” (P131)
Reflections	“This survey made me realize, that people do not think they’re going to age that quickly or even need any type of assistance when they get older. I just think it’s a denial of some type.” (P71)
	“I’m 66, I still feel like a kid.” (P149)
	“It is important topic.” (P18)
Importance	“Right now, it’s very important to me. I’m 57-year-old.” (P33)
	“Made me stop and think about what’s going to happen to me in the future?” (P24)
Stages of change	“At the age I am and my wife too, we are thinking about the next steps that we’ll be.” (P18)
External
Experiences
Self	“The worst thing anybody could ever have happen is to lose a spouse.” (P24)
Others	“My husband and I did not plan, because my parents died at age 62 and 65, and maybe had they lived I would have thought more about it.” (P150)
	“I was personally the caregiver for my mom. I oversaw everything for her and helped her along her journey.” (P131)
Caregiver role	“The crisis as I have faced as a primary caregiver for my husband who is 78.” (P36)
Role in society	“I think people are really getting clobbered as they get sicker and older due in large part to the apathy or downright meanness of, again, the people that are supposed to be helping them.” (P1)
Ageism
	“Need to use elderly people more.” (P16)
Purpose	“Nobody talked about it when I was growing up. Just didn’t happen.” (P150)
Generational differences	“We are younger than they were at the same age.” (P1)
Preparedness in aging	“I think word does have to get out there maybe even in the high schools. You know how high schools teach sex education now, and a lot of things that weren’t there when I went to school? I think planning for aging should be taught some place in school.” (P150)
Future-oriented
Future needs
Anticipated problems	“I don’t know whether I will be able to be oriented in certain times, you don’t never know what’s going to happen to you.” (P131)
	“In our case we had always hoped to live near our daughter, but we’ve come to realize as we’ve gotten older that’s not realistic because she needs to live in a big city to do her work.” (P21)
	“We’ve done some things in our household to be prepared, but it also kind of shocks me to think that there is so much that I cannot prepare for.” (P21)
Planning in uncertainty	“Get maybe some solutions in line before we have to do a crisis reaction. When you react out of a crisis mode, you’re not going to have information. You’re not going to know what’s available.” (P36)
Proactive vs. Reactive
	“My wills and things are, and my beneficiaries are, and executors of my wills and stuff are all informed and up to date.” (P41)
Formal planning and end-of-life	“I’ve got it set up right now, don’t resuscitate me.” (P131)

Table 3. Categories and subcategories with Representative Quotations of Facilitators.

Overarching Category	Representative Quotation
Category
Subcategory
Internal
Identity
Youthful spirit	“I guess right now, since I’m in such good health, it’s kind of hard to think about getting older and getting frail, and everything else.” (P24) “I’m a two-year cancer survivor right now. But the fallout from all the aggressive treatment has done a great deal of damage to me physically and emotionally and financially. There’s just a lot of health problems that keep occurring.” (P16)
Listening to my body
Life Experience	“I guess my background, knowing that it was important to have advance directives and have wills, that... Just because of my exposure to aging through my work, that I think was pretty obvious to me as something that we needed to do and have in place, so we did take care of that.” (P21)
Personal	“My dad had cancer and died of it too. We had some time when we had to be very helpful for my mom and just being there to be helpful and help him get around before he passed away.” (P11)
Family/Friends	“I think like most people you have to prioritize. What is it that is your concern? Some people, their main concern would be financial. So they need to know where are the appropriate senior housing, subsidized housing. They need to know what the informal supports that won’t cost them.” (P36)
Financial planning	“There are certain things that we do have in place as far as all of our legal documents and healthcare. Those are the major steps that we’ve taken so far.” (P18)
	“I’ve really given a lot of thought to pre-planning my funeral.” (P93)
Proactive planning
Taking action
Anticipating needs
External Role models	“My brother and I were executors. My father passed in, let me see, 1972. And he was a planner. He had everything planned out for him and mom, and then my brother and I became co-executors of the trusts and stuff for mom.” (P41)
	“Just seeing my family and friends and what they’re facing. I don’t know if that’s helpful in a good way, because now that I have that information, I’m still not sure how to make it better.” (P1)
Learning from others’ mistakes	“They didn’t plan…the family was, and especially their children are saddled with the arrangements and with the expense of the funeral and I really didn’t want that. I didn’t want my children have to worry about that.” (P93)
	“And I also took care of my own mother when she got where she couldn’t take care of, do certain things. So in learning, in traveling that journey, I saw what a lot of other people... I learned from other people’s mistakes.” (P131)
Systems
Educational resources
Formal	“I had joined the local senior center.” (P1)
	“AARP, here in my town, the senior citizens’ organizations and the local faith organizations and some of the city services have all been helpful and important resources for information.” (P27)
Informal	“A lot of my information is word of mouth, talking from other people and learning from their experience.” (P131)
	“I read up on it, I go online.” (P131)

Table 4. Categories and subcategories with Representative Quotations of Barriers.

Overarching Category	Representative Quotation
Category
Subcategory
Internal
Mindset
Denial	“As far as I know I’m getting older. I feel myself being able to do less and less, but I don’t believe it’s real yet.” (P5)
Procrastination	“There’s things like putting the house and trust so that the kids get it if something happens to my husband and I, that kind of thing, and just haven’t gotten around to it.” (P34)
Fear and Negativity	“It’s just I feel like if I do a lot of this stuff, it’s almost looking at a certainty kind of thing.” (P93)
	“I definitely see it and I feel it, and it’s not pleasant at all. I was always an extremely active, strong... I was always the go to person when anybody ever needed anything, and I just can’t do it anymore. I guess you could say that leads into the psychological part of a lot of my self-worth has just gone to hell.” (P27)
Optimism and Positivity	“To me, age is a number. I think you can make yourself be an old 65, or you can make yourself be, in your mind, a 20-years-old 65. So I think it’s all in how you perceive yourself. I don’t feel, I mean, I don’t think of myself as being a 65-year-old woman. I don’t know. My mind still goes back to the days when I was in my 30s, and my mind still feels that way.” (P24)
	“It’s seasons of life. It’s just...it’s kind of is what it is.” (P18)
Taking it in stride	“I’m either going to get older or I’m going to die. I assume I will get older.” (P25)
An aging body	“That’s the only time I think of myself as being old other when I’m trying to get up from kneeling down in the garden or the lawn.” (P41)
Physical limitations	“I don’t like admitting it, but yeah. There were things that I did 5 or 10 years ago that I might think about doing now, but it’s not going to happen.” (P189)
	“I just don’t think it’s fair that my children would have to take care of me. It’s not their place. I just don’t want them to do it. My daughter is an RN, and she has said to me, “Mom, you’ll never go to a nursing home or a long-term care facility. I will take care of you.” And after putting up with my husband, I would never do that to her.” (P150)
Care needs	“When my first marriage ended in divorce because he left, I’ve always been affected financially by that.” (P71)
	“My financial situation and the denial of thinking that I didn’t need it because I had a good retirement. You think if you’ve got a good retirement, you don’t need to plan for aging. After all, I’m never going to get old, right.” (P71)
Finances
Lack of financial resources
Systems
Service needs of older adults
Healthcare	“I’ve requested to put that on my medical record so that if I go in an emergency somewhere and I don’t seem to be responding appropriately that they don’t assume that I have dementia [has hearing loss].” (P21)
Broken system	“I think a lot of people don’t... Maybe would not have the resources, would not know where to turn, would not know to whom they would ask for help, would not be able to... Maybe would have great difficulty in accessing resources that are available in the community.” (P18)

3.3. Overarching Category 1: Perceptions

Items which were elicited in the perceptions of planning domain reflected the states of awareness, interpretation, and mental impressions about the topic. The perceptions about planning for aging and frailty were varied, from first time ponderings to serious considerations about the topic. The individual categories which arose from the data included: this is me, self-inventory/life-review, values/beliefs/attitudes, experiences, role in society, and future needs.

Internal perceptions

This is me. The participants voiced discernment, recognizing the complexities of self within the grounded reality of their existence at this moment in their lives in this category. The subcategories of acceptance, denial, in the moment, facing your own aging and mortality, and my body emerged, capturing the holistic self-identities of the participants. While some participants commented about a moment of ‘arrival’ within their lifespan recognizing their aging self, this contrasted with some participants’ disbelief of their current age and physical limitations.

Acceptance

“I’m trying to understand and accept that I’m not going to be younger in these years.”

50 y/o man

Denial

“When you’re younger, it seems like you’re immortal, that this is not going to happen to you, and you don’t understand, you don’t plan properly, you don’t believe that eventually your body is going to catch up with you, and you don’t believe that you contract these horrible diseases, and surprise, surprise, it happens.”

69 y/o woman

My Body

“I realized I’m getting older when I tried to drag the lawnmower back up the hill, and it just about exhausted me.”

69 y/o man

Self-inventory/life review. The language related to self-inventories and life reviews of their current situations and nostalgia for past events emerged as a salient category. The subcategories included evaluations of life now, home, support systems, and finances as the participants reflected on their lives, their environment, and those around them.

Evaluation of life now

“I’m a widow at my age, I have to think about, what’s going to happen should I develop cancer or a heart condition, or something, and who will take care of me?”

65 y/o woman

Home

“We have done some things over the years to make the home we’re in a bit more accessible for us.”

68 y/o man

Support System

“We don’t have children that will necessarily be around to help us, so we realize that we are each other’s support and that if something bad were to happen that we would have to hire outside help.”

69 y/o woman

Finances

“What’s really sad to me is the fact that I have enough money for one year.”

72 y/o woman

“I have no debt. I have sufficient investments and retirement funds incoming that have, well beyond my lifetime.”

77 y/o man

Values/beliefs/attitudes. The participants shared their sense of individuality, motivations, and personal characteristics influencing their perceptions of planning for aging and frailty. The subcategories of independence, control, reflections, importance, and stages of change surfaced in the data.

Independence

“I would like to live independently as long as well. Until I die really.”

71 y/o woman

Control

“I want my wishes carried out. I want it in writing, what I want to do, who I want to be over making decision for me.”

68 y/o woman

Reflections

“I actually told my son where the important papers were the other day because of that.” (i.e., the study).

66 y/o woman

Self-thoughts

“In my earlier days back when I was 30, I never thought I’d live to see the turn of the century. And of course, here I am.”

77 y/o man

Within the subcategory of importance, 16 of the 20 participants commented on the importance of planning despite many indicating that they had not thought about getting older. Amidst the reflections on the importance of planning, many participants engaged in decision-making, thus following the transtheoretical model of health behavior change, advancing in the stages of behavior change from precontemplation/contemplation to preparation and/or action/maintenance.

Important

“Hugely important topic that is absolutely under considered.”

60 y/o woman

“I think it’s very important that we have everything lined up so that there won’t be any confusion…everything will be in place.”

68 y/o woman

Stages of change

“It made me think that I hadn’t done any planning for my aging.”

66 y/o woman

External perceptions

Experiences. The life experiences of self, others, and as a caregiver emerged as subcategories, leaving a direct impact on one’s thoughts, actions, and behaviors.

Self

“I’ve been a home health aide for years, so I’ve seen people get old and frail. I’ve seen what life is like when that happens.”

63 y/o woman

Others

“I went through dealing with my mother-in-law and eventually my mother, putting them in assisted living.”

66 y/o woman

Caregiver Role

“[I] Take care of my mother-in-law and grandchildren at the same time.”

64 y/o woman

Role in society. In this category, the participants reflected on their identity in society and role at this stage in their life in this category. The subcategories of ageism, purpose, generational differences, and preparedness in aging emerged in the data.

Ageism

“I know it’s because of my age I didn’t get either job.”

69 y/o woman

Purpose

“I still have so much to offer and so much to give, and it’s like I feel because I look and because I walk bent over now and I need a cane and all that, but my brain is still there…That hasn’t gone away, but it’s like…it just makes you feel like it’s not worth anything.”

69 y/o woman

Generational differences

“Possibly this generation is planning better than our parents did.”

69 y/o woman

Preparedness in Aging

“In this country, we don’t teach about aging to the young, and I think that’s where it should start. There’s such a gap in knowledge, whether it’s within academia or the health industry or certainly within the senior population of the importance of planning, really planning and doing so on an informed basis.”

70 y/o man

Future-oriented perceptions

Future needs. The participants expressed concerns about their future needs through the subcategories of anticipated problems, planning in uncertainty, proactive vs. reactive planning, and formal planning and end-of-life. These future needs encompassed concerns of physical and cognitive decline whether through falling or mental incapacity, or through being proactive across one’s lifespan with a natural segue of planning for aging and frailty to end-of-life planning.

Anticipated problems

“But I think as time passes on, I will not be able to use the basement anymore because the steps are really steep.”

71 y/o woman

Planning in uncertainty

“I looked at what I had done to prepare and I also sort of came with a bit of a revelation that you can’t always prepare for everything.”

66 y/o woman

Proactive vs. Reactive

“Even though my health is excellent right now, I have to think about what I am going to do and how do I want my kids to handle making decisions for me.”

65 y/o woman

Formal planning/End-of-life

“One of the biggest things that I encourage people to do is to have a will in place, have a health plan in place.”

68 y/o woman

3.4. Overarching Category 2: Facilitators

Facilitators describe the factors that promote or enable a given phenomenon. The facilitators about planning for aging and frailty encompassed elements from a micro to macro level encompassing oneself and others and extending to community level. The individual categories illuminated from the data included: identity, life experience, financial planning, proactive planning, role models, learning from others’ mistakes, and educational resources.

Internal facilitators

Identity. The participants’ own identities raised awareness about the need to plan with the subcategories of youthful spirit and listening to my body emerging.

Youthful spirit

“When I get to be 65…Oh I forget, I’m almost 65.”

64 y/o woman

“I don’t think so much about me getting older because I feel like everyone is depending on me right now.”

64 y/o woman

Listening to my body

“When I trip, or if I have to get down on the floor for something it’s a lot harder to get up, and mostly just getting tired, like if I’m in a shop and say, I mean, I could use to go all day but now I go to two or three places and I’m ready to go home and sit down. I just don’t have the stamina that I used to and that reminds me.”

67 y/o woman

Life experiences. Life experiences through the subcategories of personal and family/friends served as facilitators and triggers in planning for aging and frailty.

Personal

“I worked with, as a social worker for the blind, for the state, most of my clients were elderly.”

68 y/o woman

Family/Friends

“I think one of the triggers is the reality of losing friends as we age. So that makes me a step back and say, “Do I have my financial affairs in order, other legal things in order?”

70 y/o man

Financial planning. The participants described financial resources as a facilitator in their planning efforts.

“We are fortunate that we do have some resources, financial resources that we can draw upon, and that’s a big thing for I think any stage of life.”

68 y/o man

Proactive planning. The participants asserted their belief in a forward-thinking approach with proactive planning represented in the subcategories of taking action and anticipating needs. In the subcategory of taking action, the participants shared actions they have taken including the completion of legal documents, debt removal, changes in the home environment, and strategies to cope with memory changes.

Taking action

“In the home environment to try to not have any kind of obstacles that I can trip over, and the exercise is important, and drinking a lot of water in the diet.”

67 y/o woman

Anticipating needs

“I’m looking at home health care. I don’t require it at this point, but I have been mindful…looking at some of the local nursing healthcare facilities here.”

70 y/o man

External facilitators

Role models. Many participants spoke about their mutual experiences in either having others inspire and influence their planning as a role model, or their lack of a lead figure in their lives.

“We do have our parents and some siblings that are somewhat older than us that have done this planning too, so they’ve maybe inspire us to think about those things.”

68 y/o man

Learning from others’ mistakes. Numerous participants spoke about their gain of knowledge observing the mistakes of their family members.

“She just couldn’t accept the fact that her hair was white and that…You know, she didn’t use a walker, but she could have been, she should have been. Just seeing her, I hope to be more cognizant of my aging and the fact that maybe that near miss I just had on the road is because I shouldn’t be driving anymore.”

69 y/o woman

Systems-level facilitators

Educational resources. Many participants shared beneficial educational knowledge they had obtained through a formal process whether through their workplace, community, or a national organization, i.e., AARP, or through an informal process through friends and community gatherings.

Formal

“I took a part of that class at the Senior Citizens center…the class was supposed to teach you how to be more mobile and things you could do to decrease…falls.”

71 y/o woman

“I pay a lot of attention like to the AARP magazines and the newsletters that come out, and I have delivered prescriptions in the past.”

67 y/o woman

Informal

“Talking with the elderly, some of my elderly friends, they also gave me advice about certain things I need to have done.”

68 y/o woman

3.5. Overarching Category 3: Barriers

Barriers describe the factors that prevent or obstruct a phenomenon. The barriers related to planning for aging and frailty were assorted in nature, from a strong influence of an individual’s mindset related to the topic, to overarching societal issues that have caused obstacles. The categories that arose from the data included: mindset, an aging body, finances, and the service needs of older adults.

Internal barriers

Mindset. The participants’ mentality towards planning for aging and frailty acted as a hindrance in several subcategories including denial, procrastination, and fear and negativity.

Denial

“My unwillingness to admit that I’m getting older.”

69 y/o woman

Procrastination

“I know that these things are, in all probability, will happen and I really should be planning and not waiting until the last minute.”

71 y/o woman

Fear and negativity

“Fear to me, is the biggest negative life situation for concerning the future that I can think of.”

57 y/o woman

In contrast, the subcategories of optimism and positivity and taking it in stride surfaced as the participants maintained a hopeful and adaptive frame of mind about aging.

Optimism and positivity

“I just still think I’m young and vibrant.”

66 y/o woman

“I’m still able to enjoy life and I don’t have to depend on anyone.”

68 y/o woman

Taking it in stride

“I think I keep it in perspective. I’m going to get old and I’m going to die, but I don’t think it’s necessary to sit around and think about, oh my God, I’m getting old. Oh my God, I’m going to die.”

64 y/o woman

“I’m realistic about it but I’m not depressed about it. I know it’s coming. I watched my parents become frail and I know it’s coming. But I’m not happy about it but I’m not depressed or anything like that. I’m accepting of it.”

67 y/o woman

An aging body. The subcategories of physical limitations and care needs revealed the participants’ recognition of the limits of their own body and anticipated necessities from a holistic perspective including exercise, healthy eating, social connection, home structure, and caregiver support.

Physical limitations

“I don’t have the strength I used to. It’s really hard to get anything open anymore. I carry scissors with me everywhere I go. And that’s just been frustrating because I was a mail carrier for 30 years and I had to be strong. And since I’ve retired, I’ve really lost a lot of strength.”

67 y/o woman

Care needs

“But now I actually enjoy the stretching part of the exercise and that is because I am realizing well, I’m not in my twenties, I’m now 50 years old.”

50 y/o man

“I realize now eating healthier is big on my list.”

65 y/o woman

Finances. The participants relayed their lack of financial resources as an obstacle in their planning.

“Because of the way the finances are engineered in this country, and my husband’s extensive healthcare needs in the last seven or eight years, it has wiped me out financially. I’m maxed out. I’m living on social security and that’s difficult, but it’s not unique to me.”

72 y/o woman

Systems-level barriers

Service needs of older adults. The subcategory of healthcare incorporated the participants concerns of an impediment in their planning through insurance, healthcare staff, and lack of patient-centered care.

“What’s not helpful, and this is from more of a macro-perspective, is the uncertainty of the Medicare program and the rising cost of medications and just the whole national debate on healthcare. And for me, it needs to be a greater discussion of the healthcare service needs of seniors.”

70 y/o man

The emergence of the subcategory of a broken system surfaced as the participants identified issues affecting older adults through a lack of services and connections.

“I think there should be more outreaches out there to help the elderly. Especially, I think people forget about the elderly. A lot of people can’t afford certain things, and I think certain services should be set up for the elderly.”

68 y/o woman

4. Discussion

The purpose of this study was to explore how people perceive the concept of planning for aging and frailty, and to identify the facilitators and barriers involved in their planning efforts. This study is the first step to capture older adults’ perceptions of planning for aging and frailty and to provide a description of the facilitators and barriers to planning.

First, our study revealed that planning or a lack of planning entails a personal understanding for each individual. We know from past studies that people have to feel competent in self-management in order to invest in their future as they age [28]. Similarly, having a more positive outlook in one’s future as an older person may lead to more age-related preparatory activities [29]. Our findings reveal that the perceptions of planning arise from the depth of the participants’ identities. The participants revealed their thoughts about planning through their personality, value and belief system, physical body, life experiences, and their place in the world, whether through an introspective assessment of their personal life, role in society, and future needs as an aging adult. Nearly all the participants endorsed the concept of planning for aging as important, whether in the present or future. This supports the need for triggers, resources, and interventions that prompt people to “stop and think,” about the need to plan in a sobering, serious, and reflective manner. The discussions about planning also resulted in a level of nostalgia in the reminiscence of younger years and a reflection response filled with emotional memories. This suggests that reminiscence or life-review interventions might be adapted to result in dual outcomes (i.e., improved depression and a plan for aging and frailty).

Second, the participants in our study uniquely identified the influence of life experiences with self and others as facilitators of planning, often serving as role models and also learning from others’ mistakes. These experiences allowed them to gain wisdom to prepare themselves for aging, and often served as a learning opportunity to act differently with their aging process. Similar to the literature that notes dispositional characteristics, such as optimism and demographic factors including education, may facilitate proactive adaptations [30], our study notes self-identity with a youthful spirit and acknowledging physical changes in a positive light, as facilitators to planning. Financial planning as a means to allow for planning, as well as the availability of educational resources both emerged as facilitators, which are consistent with Sorenson’s statement that for intention to change to action, there is a need for sufficient internal and external resources to exist [14].

Third, our study revealed barriers in planning for aging and frailty that comprise multiple domains of one’s physical, cognitive, and emotional state, in addition to their socioeconomic status and service needs within healthcare and the community. One’s mindset and framing of planning for aging and frailty with negative connotations through denial, procrastination, and fear are consistent with other research revealing why adults don’t plan, including an “experiential avoidance”, where thinking about future dependency and a need for care is avoided [31] and the protection of short-term well-being, outweighs the benefits of preparation [32]. Similarly, in Gould et al.’s (2017) study, older adults were found to optimize their present emotional well-being by avoiding thoughts about future risks [16]. Some participants were able to reframe this awareness and acknowledgement of aging into a positive light by taking aging in their stride. From a physical domain, the participants voiced their limitations in their body and their future care needs. While past research notes a delay of planning for future care until a certain level of disability is reached [15], several of our participants experienced some physical deficits but still could not initiate behavior change in their consideration of planning. A lack of financial resources as a barrier in planning is consistent within the literature [17]. Uniquely, the participants in our study shared concerns of service needs with healthcare, voicing concerns of the Medicare system with rising costs of medications, and a lack of patient-centered care experience in clinical settings. The participants also revealed a lack of resources in the community, and a difficulty in the navigation of these.

4.1. Implications for Practice and Research

Implications for translation to clinical practice suggest the natural progression of planning for aging and frailty as an upstream initiative to prepare the way for later advanced-care planning. This allows clinicians to practice lifespan planning within their established clinician–patient relationships that could eventually lead to planning in end-of-life discussions. Considering the significant contribution that life experiences had in this study on one’s perception and as a facilitator to planning, clinicians might inquire about past family/friend aging experiences to prompt discussions.

While there is a need for interventions to help older adults recognize and actively plan for aging, there is also a need for interventions to address the barriers to planning. Further research should also examine planning not only from the individual level, but also from the systems level, as it requires societal attention, local and national government involvement, and a collaboration amongst various societal industries [33]. The need for collaboration in public health organizations and the sectors of business, education, transportation, and housing all should be examined [34]. Transforming the concept of planning from a micro to macro level allows for a deeper understanding of the influence of social determinants of health on planning, in addition to the need for further exploration within a lens focused on diversity, equity, and inclusion issues.

4.2. Strengths and Limitations

A strength of the study is in capturing the voice of the individual using semi-structured interviews with probes and prompts which allowed for an in-depth understanding of the participants’ lived experiences. The use of two independent coders in the data analysis allowed for objectivity in the data.

The study had limitations, including a new and untested interview guide, and the use of phone interviews rather than in-person interviews which may have prompted a greater connection with the interviewer. In addition, the interviewees had taken a larger survey on planning for aging and frailty prior to the qualitative interview which may have primed their awareness and ideation and led to a prior reflection in the interviews. Our study is also limited in its generalizability since our sample lacked diversity and reflected a middle to higher socio-economic status. Moreover, the participants were recruited from a senior center and YCMA sites which are locations where people seek out social connection, education learning, and physical health which may not provide an accurate depiction of other older populations.

5. Conclusions

This is the first study, to our knowledge, to solely focus on the perceptions, facilitators, and barriers about planning for aging and frailty among community-dwelling adults aged 50–80 years old. To advance a public conversation about planning for aging that normalizes the process, societal attention and public health messaging is imperative. Recognition of the positive and negative aspects of aging on one’s well-being is essential, including understanding the influence of public policy and societal structures on one’s planning behaviors. Interventions are needed to overcome the barriers involved in the avoidance of planning for aging and frailty, and to encourage facilitators. Gaining momentum with the process of planning for aging is essential to the promotion of a greater well-being for older adults across all spectrums.