Living arrangements of the elderly and the sociodemographic and health determinants: a longitudinal study

ABSTRACT Objectives: to describe the sociodemographic characteristics and the number of morbidities in the elderly, according to the dynamics of living arrangements and evaluate the sociodemographic and health determinants of the living arrangements. Methods: this is a household longitudinal survey (2005-2012), carried out with 623 elderly people. Descriptive statistical analysis and multinomial logistic regression were performed (p<0.05). Results: there was predominance of elderly living alone, accompanied and with change in the living arrangements, females, age range between 60├ 70 years, 1├ 4 years of study and with income between 1├┤ 3 minimum wages. During the development of this research, it was identified an increase in the incidence of elderly with 1├┤3 minimum wages. The number of morbidities increased in the three groups throughout the study, with the highest rates observed among the elderly with change in the dynamics of living arrangements. It was found that elderly men showed less chance of living alone (p=0.007) and having change in the living arrangements compared to women (p = 0.005). Incomes less than a minimum wage decreased the chances of change in the living arrangements compared to incomes above three salaries (p=0.034). Conclusion: the determining factors of the living arrangements were sex and income, and the variables functional capacity and number of morbidities were not associated with the outcome analyzed.

. In this version, the cutoff point was set as 12/13 and scoring less than 12 (8) indicated cognitive impairment. In 2012, it was used the MMSE version translated and validated in Brazil (9) , which is composed by questions regarding to orientation, immediate and evocation memory, concentration, calculation, language and spatial domain.
That year, it was considered that score could vary and the cut-off point was set according to the education level of the elderly: 13 for illiterates, 18 for 1 to 11 years of study and 26 for more than 11 years of study (9) . This change was implemented because the researchers considered the validated instrument and the cutoff score (9) more suitable for the case.
To characterize the sociodemographic data, the morbidity and functional capacity, it was used part of the questionnaire Older Americans Resources and Services (OARS), developed by Duke University (1978) and adapted in Brazil by Ramos (1987), with the designation of Brazilian version of Older Multidimensional Functional Assessment Questionnaire (BOMFAQ) (10) .
Regarding the morbidities assessment, the questionnaire contains 26 items investigating whether the individual presents morbidity (10) . The number of morbidities reported by the elderly was accounted for data analysis.
Regarding the functional capacity assessment, the questionnaire comprises 12 activities of daily living, by which the elderly tells the difficulty level to perform  self-care activities (unable to do, little difficulty, much difficulty and no difficulty) (10) . For statistical analysis, it was calculated the score of functional capacity that corresponds to the sum of the scoring of activities of

Results
The study population consisted of 623 elderly people interviewed during the study, divided into three groups according to the dynamics of living arrangements: 34 (5.5%) remained alone, 475 (76.2%) lived accompanied and 114 (18, 3%) presented change in the living arrangements.
In all three groups, most elderly were women, and those who lived alone accounted for the highest percentage (82.4%); unlike observed among men, among which predominated (35.2%) those who lived accompanied (Table 1).
In 2005, most of this population were aged between 60├ 70 years, and in this age group, the highest percentage corresponded to people living accompanied (61.3%). Among those aged between 70├ 80 years, those with changes in the living arrangements predominated (33.6%). Elderly aged 80 years or over represented the highest percentage among those living alone (9.1%) ( Table 1).
Regarding schooling, there was a predominance of elderly with 1├ 4 years of study, followed by those with no schooling, in the three groups. Among those with no schooling, there was a prevalence of individuals who experienced changes in the living arrangements (23.9%); among those with 1├ 4 years of study, those living alone (67.6%); and among those with more than five years of study, the ones living accompanied (23.2%) ( Table 1). The distribution of the educational level did not change during the study.  (Table 2).   and 51% less chance to change the living arrangements compared to women (p=0.005) ( Table 3).
The income bracket was another determinant of change in the living arrangements. To earn less than a minimum wage decreases by 72%, approximately, the chances of change in the arrangement in relation to individuals with more than three minimum wages (p = 0.034) ( Table 3).
It is emphasized that the functional capacity and the number of morbidities were not associated with living alone and the change in the living arrangements ( Table 3).
The determining factors of the living arrangements of the elderly are listed in Table 3, as shown below. In contrast, other studies have found that elderly with lower level of education lived alone (14,16) . It is believed that there are differences in the relation between education level and living arrangements, according to the cultural characteristics of each region.
In some Latin American countries such as Brazil, the proportion of elderly living accompanied, specifically with their sons, increases among individuals with higher levels of education (18) , corroborating the present study.
There was a predominance of a higher income among elderly living alone, which confirmed a study conducted in São Paulo (6) . However, a survey performed at international level showed a predominance of elderly with lower incomes living in this type of living arrangement (16) . Elderly with higher incomes tend to live alone as way to preserve their privacy and independence (6) . In addition, the economic availability can offer a greater purchasing power, providing easier access to health services, as well as a more adequate social cover (6,12,20) -essential aspects to live on their own. In contrast, many elderly with higher incomes reside with their families because of the economic needs of their sons, who make use of their housing and financial resources (7) .
The high incidence of diseases among elderly with change in the living arrangements corroborates a study carried out in the municipality of Campinas, which revealed that the number of morbidities was among the determining factors of the type of family configuration of

Discussion
In this investigation, the predominance of elderly women living alone was, probably, due to their greater longevity (5) , which increases their chances of becoming widows (12) . In addition, if men become widowed, they often marry again, unlike women (13) . Investigations carried out in China and Ribeirão Preto -SP also found a higher percentage of elderly women in single person households, (67.2%) (14) and (71.4%) (15) , respectively.
In a study performed in the United States, it was also observed the predominance of younger elderly living accompanied. Most individuals aged between 65 and 69 lived with someone else (73.0%) (16) . However, conflicting results have been found in other studies conducted at international level (17)(18)(19) . The differences in the results of these studies may be explained by the dual relationship between age and living arrangements. The course of aging can make the elderly live alone because of the loss of their spouses, but it also increases the chances of the elderly cohabit as a result of a greater physical dependence (5)(6) .
Some authors suggest that physical dependence in the elderly is intensified from 80 years of age (15) . In this way, the fact that a higher percentage of octogenarian individuals remained living alone during the follow-up demonstrates, on the one hand, a satisfactory finding, since it is inferred that they are experiencing a successful aging process. However, on the other hand, this is a matter of concern, since these elderly may face some impasses in the use of health services, and have trouble to perform everyday tasks, which are exacerbated in the absence of a family member.
Regarding schooling, the results of this study differ from others conducted in China (18) . This study demonstrates that higher levels of education increase the proportion of elderly living alone (18) . This may be Rev. Latino-Am. Enfermagem 2016;24:e2737.
the elderly (7) . This finding may be related to the need for physical aid, causing many to live with their families and not in single person households (15) .
It is important to point out that cohabitation, by itself, does not mean support in times of difficulty.
Several theories on the family system and types of living arrangements, historically emphasize the protective role of the family on the living conditions of the elderly, especially in societies whose assistance policies for this population are still not consolidated (21) .
However, the results of recent studies at international level are contradictory; some corroborate these hypotheses (16)(17)22) , whereas others suggest a contrary perspective (1,14,21) , which indicates the need of further analysis of the situation by means of research.
In the analysis of the determinants of the living arrangements, the association between female gender and living alone differs from a study conducted with Japanese elderly, which revealed a higher proportion of men living alone compared to women (p = 0.049) (22) .
Other research conducted with Indian elderly also found divergent results, revealing that sex had no statistically significant effect on the other variables (p=0.959) (18) .
On the other hand, the findings of international studies corroborate the present investigation (14,17,19) . These studies found a higher proportion of elderly women living alone compared to men (14,17,19) .
The female sex was also associated with higher chances of change in the living arrangements in a study of elderly in the state of Rio Grande do Sul (12) .
This result is not surprising, considering that it is known that women have longer life expectancy and therefore higher chances of becoming widows (12) . The longer life expectancy in women has been one of the concerns highlighted by the World Health Organization, since the elder elderly women may have more disabilities as well as other multiple health problems (23) . Added to this, with the course of aging, women are more vulnerable to health problems, social isolation and emotional disorders (24) .
Thus, social policies should consider the situation of elderly women, especially the most vulnerable groups such as those living in single person households (17) .
In this study, income was another determining factor of the living arrangements. High income can function as facilitator of independent living arrangements, since it results in a greater purchasing power for the purchase of consumer goods, as well as more adequate social and health coverages (6,12,20) , proving that elderly with high socioeconomic level generally prefer a more independent lifestyle (6) . These aspects possibly contribute to the establishment of single person households among elderly population. In opposition to these arguments, economic independence has been considered an aspect that favors cohabitation because family members often live with the elderly in an attempt to take advantage of the available financial resources (18) . Despite this, a study carried out in Ribeirão Preto -SP found that income was not among the reasons that influenced the living arrangements of the elderly (15) .  (7) .
It is noteworthy that the determinants of the living arrangements differ according to the cultural, socioeconomic and social differences between countries (5) . In this way, this study allowed to bring the knowledge on these aspects to the Brazilian context,

Conclusion
This study identified the characteristics of the living arrangements and their sociodemographic and health determinants. It was found that, among female elderly aged 80 or over, those who live alone accounted for the highest percentage during the follow-up. The number Bolina AF, Tavares DMS.
of morbidities increased in the three groups during the study, and the highest rates were observed in the elderly group who presented change in the dynamics of living arrangements. Sex and income were determining factors of the living arrangements, but the health variables were not associated with the outcome analyzed.
It is believed that the findings of this study may contribute to the planning and management of health and social policies that aim to assist the elderly in different contexts in terms of the living arrangements.
There is an urgent need to consider the most vulnerable elderly like those living alone, females, with older ages,