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published online 30 January 2013Biol Res NursHeidi H. Ewen and Jennifer Kinney

Application of the Model of Allostasis to Older Women's Relocation to Senior Housing  

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Application of the Model of Allostasis to OlderWomen’s Relocation to Senior Housing

Heidi H. Ewen, PhD1 and Jennifer Kinney, PhD1

AbstractObjectives: Adjustment to senior housing entails significant lifestyle changes and is a stressful process. The adaptation process isdynamic and has yet to be studied using the conceptual model of allostasis. This article presents exemplars of women whoseprofiles represent three allostatic states: successful adaptation (homeostasis), ongoing adaptation (allostasis), andmaladaptation (allostatic load). Method: Older women who had relocated to senior housing participated in three interviewsand monthly saliva sample collection over a 6-month period. Saliva was assayed for diurnal cortisol secretion. Triangulation ofmixed methods was used to analyze data, and psychosocial data were mapped onto the cortisol graphs to illustrate changes instress reactivity and well-being. Results: Coping abilities, perceptions of stressors, and cortisol measures provide a detailedpicture of the interplay among events and perceptions and the effects of both on well-being. Discussion: The case exemplarsprovide detailed information on the complexity of psychosocial and physiological components of the model of allostasis. Thisstudy also fills a gap in knowledge on negative relocation outcomes using the allostatic model.

Keywordsaging, coping, adaptation, health outcomes, allostatic model

Adults face stressful life events and transitions during the

course of the aging process. Residential relocation may be par-

ticularly stressful due to the need to adapt to a new physical and

social environment while adjusting to the loss of previous

social ties, community, and a well-established home (Krout

& Wethington, 2003; Mallick & Whipple, 2000; Walker,

Curry, & Hogstel, 2007). Relocation may also be associated

with other life transitions including declines in health and phys-

ical ability, death of a spouse, dispersion of adult children, and

loss of social networks (Krause, 1999; Krout, Moen, Holmes,

Oggins, & Bowen, 2002). Despite the potential stress of

residential relocation, research on the process, especially with

respect to physiological indicators, has been limited. Increasing

our understanding of the elements of successful adaptation to

the stress of significant life events such as residential relocation

in later life is essential to the development of appropriate inter-

ventions, support systems, and policies.

The model of allostasis conceptualizes a dynamic system

that ensures physiological stability (McEwen, 2000, 2003;

Sterling & Eyer, 1988). The model emphasizes the process of

establishing stability through change and facilitates the inte-

grated study of an individual’s physiological and psychological

attempts to manage stress. Typically, researchers define a stres-

sor as any event that an individual appraises as threatening her

or his mental, emotional, and/or physical well-being (Aldwin &

Werner, 2007). Physiological responses to stress can be both

triggered and tempered by internal individual characteristics

such as personality, temperament, and lifelong learning as well

as external factors such as social support and life events (Mroc-

zek & Almeida, 2004). The perception of danger, whether

physical or psychological, activates the sympathetic nervous

system, initiating a cascade of physiological reactions. The

hypothalamic–pituitary–adrenal (HPA) axis, a complex endo-

crinological feedback loop, regulates the secretion of stress

hormones that mobilize the fight-or-flight response (Juster,

McEwen, & Lupien, 2010).

Homeostasis occurs when there is a balance among systems,

the ultimate physiological goal. If homeostasis is achieved, an

individual’s fight-or-flight reaction is ameliorated and her cog-

nitive perception of the situation becomes congruent with her

beliefs. Allostasis is the process of negative feedback that

attempts to bring systems into adjustment. Allostasis differs

from homeostasis in its emphasis on dynamic rather than static

biological set points, consideration of the brain’s role in feed-

back regulation, and view of health as a whole-body adaptation

to contexts (Juster et al., 2010; Schulkin, 2003). In the process

of trying to stabilize the system during stressful periods, the

adrenal gland produces excess cortisol in order to mobilize

1 Department of Sociology and Gerontology, Scripps Gerontology Center,

Miami University, Oxford, OH, USA

Corresponding Author:

Heidi H. Ewen, PhD, Miami University, 396 Upham Hall, 100 Bishop Circle,

Oxford, OH 45056, USA.

Email: ewenhh@muohio.edu

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efforts to deal with the stressor. Physiological dysregulation

ensues when normal homeostatic functioning shifts toward

abnormal ranges via the prolonged secretion of stress hormones

and the subsequent maladaptations this strain exerts on interde-

pendent systems. Allostatic load is the cumulative biological

burden of adapting to life’s demands and is often expressed

as disease onset or exacerbation and even death (Juster et al.,

2010; McEwen, 2000, 2003; Schulkin, 2001; Seeman, Singer,

Rowe, & McEwen, 2001).

Despite the application of the model of allostasis to a range

of stressful life events such as competition, challenges within

social hierarchies, financial strain, and employment instability

(Lantz, House, Mero, & Williams, 2005; McEwen, 1998,

2003), researchers have not used it widely within the geronto-

logical literature. The majority of aging-related research that

uses the model of allostasis focuses on allostatic load (Juster

et al., 2010; Karlamangla, Singer, McEwen, Rowe, & Seeman,

2002; McEwen, 2002; Seeman, McEwen, Rowe, & Singer,

2001). We began to address this gap using the model of

allostasis in a mixed-methods longitudinal study of older

women’s adaptation to relocation to congregate senior housing.

Small-sample, longitudinal, mixed-methods case studies of

physiological reactivity to daily life events and stressors have

effectively captured elevations in cortisol during acute periods

of stress (Stalder, Evans, Hucklebridge, & Clow, 2010; Vincen-

nati, Pasqui, Cavazza, Pagotto, & Pasquali, 2009). For example,

Rahe, Rubin, and Arthur (1974) found repeated elevations in

peak cortisol in one participant during times of anguish and

anger over work changes and personal disappointments. They

also found that this participant’s elevated peak cortisol values

were equivalent to levels found among men engaged in militia

demolition training and diving into oceans from hovering heli-

copters, the epitome of a flight-or-fight reaction. Researchers

in the field of behavioral medicine are increasingly using small

case studies and diary research methods to understand the com-

plex interactions among biological, psychological, and beha-

vioral data (Smyth & Stone, 2003; Stalder et al., 2010).

Consistent with the model of allostasis, we utilized social sci-

ence and biological methodologies in the present study. Mea-

sures include self-reports of stressful life events and appraisals

of stress and coping and an indicator of physiological reactivity,

specifically salivary cortisol. We delve more deeply into three

case studies, each of which exemplifies one of the key processes

in the conceptual model: homeostasis, allostasis, and allostatic

load. Each case study integrates self-report and cortisol data over

the first 6 months of each participant’s relocation to a senior

housing community. Our ultimate goals are to demonstrate the

complexity of stress perceptions and reactivity while testing the

utility of the model of allostasis in studying adaptation to salient

stressors experienced by older adults during a time of potential

physical, emotional, and psychological upheaval.

Method

Participation entailed three semistructured interviews over a 6-

month period, the first within 1 month of the move and

subsequent interviews in the 3rd and 6th months post move;

monthly journals of life events in the months between inter-

views; and monthly salivary cortisol sampling. We based the

timing of interview data collection upon Castle’s (2001) results

from a meta-analysis of morbidities and death at 4, 6, and 12

months post relocation across 35 studies. Castle found the inci-

dence of morbidity and mortality increased between 3 and 12

months post relocation. The Medical Institutional Review

Board at the University of Kentucky approved the present study

(protocol #05-0044).

Sample

The managers of congregate senior housing facilities assisted

with identification and recruitment of new and prospective

female residents. Managers provided information on the study,

including contact information for the primary researcher, to

potential participants and asked the women if they would con-

sent to having their contact information shared with the

primary researcher. If the resident/prospective resident agreed,

the manager relayed this information to the project manager.

Once participants were enrolled in the study, we scheduled

an interview within the first 30 days of occupancy in the facil-

ity. The full study sample comprised 26 women between the

ages of 60 and 93 years (mean 76 + 11 years) who had moved

to congregate senior housing facilities (consisting of indepen-

dent- and assisted-living accommodations) in a small city

(population 250,000) on the western fringe of Appalachia in the

United States no more than 1 month before the first interview.

We provided women remuneration for their participation.

Measures and Procedures

Cognitive Screening. The short (6-item) blessed memory test was

administered prior to enrollment in the study. We included only

women who scored less than 10 (i.e., no cognitive impairment)

in the sample (Davis, Morris, & Grant, 1990). This scale has

established reliability and validity (McDowell & Newell,

1996) in detecting memory impairments.

Interview Protocol. We conducted semistructured interviews with

open-ended items on stressors and coping strategies in each

woman’s residence. At each of the three interviews, women

responded to prompts about what had been the most rewarding

and most stressful aspects of relocation (first interview) and the

most rewarding and most stressful aspects of their lives since

the last interview (second and third interviews). After they

identified stressors, we asked participants to indicate how they

coped with each stressor. The Perceived Stress scale (PSS;

Cohen & Williamson, 1988) was embedded in the semistruc-

tured interview, with the interviewer reading individual items

from the scale aloud to the participants and recording their

answers on a Likert-type scale. Participants had a response card

to guide them in the Likert-scale response choices. Eskin and

Parr (1996) reported reliability estimates of .84 for the

14-item and 4-item versions of the PSS.

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We also asked questions regarding sleep quantity and

quality at each interview, including, ‘‘What time did you

awaken this morning? How many hours of sleep did you have

last night? What time of the day do you usually awaken? How

many hours of sleep do you get on a typical night? How many

times do you awaken during the night, on an average night? Do

you regularly take naps? If so, how long are your naps?’’

Journals. During the months when we did not conduct inter-

views, participants kept journals. In accordance with extant lit-

erature on diary research methods (Cain, Depp, & Jeste, 2009;

Clayton & Thorne, 2000; Jacelon & Imperio, 2005), partici-

pants used the journals to record significant events (related to

facility life or external factors such as family), dates of the

events, and their perceptions of the relevance and stressfulness

of each event. The journals also provided information on

procedures for monthly saliva sampling (e.g., dates for, timing

of, and procedures for collection). Participants also used the

journals to rate Likert-scaled items that inquired about sleep

quality, quantity, and degree of rest experienced the night prior

to saliva collection.

Interview and Journal Analytic Strategy. We deidentified open-

ended items for self-report of current stressors and coping

responses and entered them into a spreadsheet. We selected

keywords based upon the frequencies with which the women

mentioned them; the open-ended nature of the items allowed

for multiple responses. We grouped common keywords into

themes, created dichotomous variables representing each

theme, and added them to the database with ‘‘1’’ indicating

presence of the theme as a stressor/coping response and ‘‘0’’

representing the absence of the theme. We then matched

identification numbers with responses and entered the new

variables into the database.

Cortisol Sampling and Analysis. At the conclusion of the first inter-

view, we gave participants six cotton salivettes and instruction

sheets on how to collect the monthly cortisol specimens. Cor-

tisol has a well-documented circadian rhythm of secretion, with

peaks occurring in the morning and levels gradually declining

throughout the day (Edwards, Clow, Evans, & Hucklebridge,

2001). The peak secretion typically occurs 30 min to 1 hr after

waking and the lowest level, the nadir, during the night. The

key times to collect cortisol samples as an indicator of the

degree of stress an individual is experiencing are within 1 hr

of awakening and bedtime (Kumari et al., 2010). An acute

stress response is characterized by an elevated peak and normal

evening values, whereas more chronic stress is indicated by

elevations in both peak and late-evening values.

To assess the diurnal rhythm of cortisol release, we asked

participants to collect saliva samples by saturating a cotton

salivette at the following six time points over a 24-hr period the

day after each interview: (a) just after waking, (b) an hour after

waking, (c) between 1 and 3 p.m., (d) between 4 and 6 p.m.,

(e) between 7 and 9 p.m., and (f) at bedtime. Each salivette was

labeled with the predetermined time for collection and a

checklist to serve as a reminder for when the sample was taken.

Additionally, in the months between the first and third inter-

view, on dates indicated in their journals, participants collected

two samples once a month, within 1 hr of waking and at bed-

time, in order to assess the peak and evening cortisol levels.

There were 30-day intervals between collection dates. The par-

ticipants were asked to place the salivette in the refrigerator as

soon as the saliva collection was completed. We made monthly

reminder calls the day prior to the scheduled collection and

scheduled a specific time and date for pick up. We picked up

the salivettes within a day of the saliva collection and

transported them to the laboratory on ice.

We centrifuged samples at 1,500 g (at 3,000 rpm) for 15 min

and analyzed them in duplicate via enzyme linked immunosor-

bent assay techniques. Intraassay coefficient of variation (CV)

results ranged from 3.5 to 4.7 and interassay CVs ranged from

3.3 to 5.4, indicating acceptable precision in results.

Results

The majority of participating women were widowed (58%) or

divorced (27%) from marriages of significant duration (mean

33 + 19 years) and had been without spouses for an average

of 15 years. Educational attainment of the sample approximates

a normal curve, with 8% completing grade school, 31% obtain-

ing a high school diploma, 35% receiving some college educa-

tion, 19% completing a college degree, and 8% completing a

graduate degree. Participants’ mean self-rated health at

baseline (0¼ poorest health and 10¼ best possible health) was

6.3 (+ 2.2). The average body mass index for the sample was

28.3 kg/m2 (+ 8.42), which is classified as ‘‘overweight.’’

Only two participants were taking hormone-replacement

therapy. On average, participants slept 6.8 hr (+ 1.7) per night,

regularly awakened 3.3 times (+ 3) per night and considered

their sleep quality to be ‘‘somewhat restful’’ (60%). Half of the

sample reported taking daily naps of an average of 45 min

(+ 20) in duration.

We have organized our results below into three sections.

First, we present the distinct diurnal cortisol profiles the 26

women demonstrated. Second, we present the triangulation of

methods we used to identify case exemplars for further analy-

sis. Third, we integrate the interview, journal, and cortisol data

to present case studies of three participants that each illustrate

one of the three primary components of the model of allostasis:

adaptation/homeostasis, allostasis, and allostatic load.

Cortisol Profiles for the Sample

We began our analysis by looking at data from women who had

indicated that relocation was a stressor. It was expected that

these cases would show elevations in peak cortisol values and

that physiological trends over time would follow psychosocial

self-reports of stress. Figure 1 illustrates the four distinct diur-

nal cortisol profiles for the full sample at the time of the first

interview: a ‘‘normal’’ pattern for women over 60 years of age,

an allostatic response, aberrant diurnal cortisol rhythms, and

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allostatic load. Prior research involving careful measurement of

basal cortisol over a period of time found that elevations related

to stress were linked to negative health outcomes and that these

effects were more pronounced in women and exacerbated by

sleep dysregulation (Otte et al., 2005). Given the diurnal

rhythms of and inextricable relations between sleep/wakeful-

ness and cortisol secretion, we evaluated data on sleep beha-

viors to adequately draw conclusions on aberrant cortisol

values (Wrosch, Miller, Lupien, & Pruessner, 2008). Allostatic

load, or exhaustion of the homeostatic mechanism, typically

results in a flattened pattern with roughly equivalent peaks and

nadirs.

Because sleep, use of certain medications, and hormone

replacement therapy affect cortisol levels (Deuschle et al.,

1997), we computed correlations among cortisol levels, self-

reports of quality and quantity of sleep in the night preceding

the collection, and use of hormone replacement therapy and

medications for depression, anxiety, and pain. We found that

peak cortisol values were correlated with perceived stress

(r ¼ .80, p � .01) and evening cortisol values (r ¼ .68,

p � .01). Neither peak nor evening cortisol values were related

to self-reported sleep quality, sleep quantity, or the number of

awakenings during the night. Use of hormone replacement

therapy or medications for depression, anxiety, or pain was not

correlated with perceived stress or the cortisol measures.

However, use of anxiolytics was related to sleep quality

(r ¼ .87, p � .001).

Identifying the Case Examplars

We compared baseline cortisol data for women who mentioned

relocation as a significant stressor in the first interview (n¼ 17)

to the data for those who had not (n¼ 9). All of the women who

had flattened diurnal cortisol rhythms (see Figure 1D) reported

Figure 1. The four distinct diurnal cortisol profiles for the full sample at baseline. A. Depicts the ‘‘normal’’ cortisol pattern for women above theage of 60 (n ¼ 11), with peak cortisol levels around waking time and levels decreasing toward evening. B. Illustrates an allostatic response withcortisol levels elevated throughout the day (n ¼ 6). C. Depicts aberrant diurnal cortisol rhythms (n ¼ 5). Such patterns are often reported toprecede allostatic load and early mortality (Sephton, Sapolsky, Kraemer, & Spiegel, 2000). D. Depicts cases of allostatic load evidenced byexhaustion of the homeostatic mechanism, a flattened diurnal cortisol rhythm, and exacerbation of chronic health conditions (n ¼ 4). Sun andmoon symbols represent the mean peak and evening values, respectively, for adult females over the age of 60 (Aardal & Holm, 1995; Edwardset al., 2001). Dashed lines above and below the mean peak and evening symbols show the 95% CIs for the peak and evening values.

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at the first interview that they considered the move to be a sig-

nificant stressor. We classified women who reported relocation

to be a significant stressor and whose baseline peak cortisol

values were elevated above the 95% confidence interval (CI)

as representative of ‘‘relocation stress.’’ It was from this

category of participants that we selected the case exemplars

for the dynamic processes of homeostasis, allostasis, and

allostatic load.

We triangulated the longitudinal data from diary measures,

interviews, and cortisol data for the women in the ‘‘relocation

stress’’ category, coding self-reports of significant stressors,

effective coping strategies, and satisfaction with the facility

at the 3rd and 6th months in residence using the same method

described above for the baseline data. By examining the

biological, psychological, and behavioral data in this way, we

identified potential case exemplars for each of the three

allostatic processes.

For the process of adaptation/homeostasis, we were looking

for cases in which the cortisol pattern followed peak elevation

in the first month and return to normal range in subsequent

months, while the psychological and behavioral data indicated

that the women encountered perceived stressors but found them

to be manageable. We identified two potential exemplars. We

selected the case of ‘‘Liz’’ due to the relative stability of her

self-reported experiences and cortisol profiles. Her cortisol

levels remained within the 95% CI from Months 2 through 5.

However, a self-reported stressor in Month 6 (mother relocat-

ing) resulted in an elevation in the peak cortisol, illustrating the

dynamic system responsible for establishing stability.

For cases representing allostasis, the process by which the

body attempts to regain homeostasis, we were seeking women

who had peak elevation in the first month and reported ongoing

struggles with stressors and ways to manage those stressors.

Only one exemplar of the dynamic nature of allostasis

emerged: ‘‘Alison’’ was struggling with multiple significant

life stressors and reported emotional fatigue. As her stresses

escalated, she withdrew socially and often ruminated on the

troubles she was facing. Her cortisol profiles indicate a system

escalating cortisol production to mobilize her to face the

stressors and the resultant health impairments, both physical

and mental.

As exemplars of allostatic load, a state in which the body is

no longer able to adjust to the demands placed upon it and that

is typically characterized by onset or exacerbation of chronic

illnesses, we sought cases in which the cortisol peaks and

troughs were proximal to one another, stressors and coping

were ongoing, and health complaints were prominent. We iden-

tified two cases of allostatic load. We selected ‘‘Edna’’ as our

case exemplar based upon her intent to leave the facility within

the month following the last interview because she believed she

had not adapted to her new home, was seeking more contact

with her family, and had experienced the exacerbation of her

health conditions through the 6-month period. Her diurnal

cortisol profiles showed less distinction between peaks and

troughs than would be considered normal, and neither peaks

nor the majority of troughs were within the 95% CIs for a

woman of her age, indicating failure of the homeostatic

mechanism.

We recontacted the three respondents whose profiles we had

identified as exemplars and presented them with a schematic

timeline documenting the information presented in the case

studies below for purposes of member checking.

Case Studies

Homeostasis: The Story of Liz

Liz was a 75-year-old woman who relocated from a nearby

rural community to senior apartments in which her mother

lived. As such, Liz was familiar with the staff and many of the

residents. At the time of the move, Liz was sleeping soundly,

averaging 9 hr per night. She valued sleep and acknowledged

that this longer sleep duration was rare in women of her age.

She had few limitations in activities of daily living but reported

some difficulties with vigorous activities. See Figure 2 for a

graphical depiction of Liz’s cortisol peaks and troughs mapped

to major life events over the 6-month study period.

Pre-Move Major Life Events. In the year preceding the move,

Liz’s spouse died. Liz found her large house in the country too

burdensome and she sought more social contact. Moving to the

facility in which her mother lived appeared to be the ideal

solution as she believed it would also facilitate her ability to

provide assistance as her mother’s dementia progressed. Liz

reported experiencing 14 significant life events in the year

preceding the move, including the death of several family

members as well as close friends; changes in financial status;

and changes in her mother’s health and behavior. Figure 2

shows that her cortisol levels were elevated at the time of the

first interview (baseline).

Pre-Move Perceptions and Cognitive and Behavioral Responses. Liz

reported experiencing a great deal of satisfaction in selling her

home. The most stressful aspect of the year was her spouse’s

death, which precipitated her relocation. Liz used a variety of

coping mechanisms and reported that the most effective strate-

gies were prayer, reading, talking with friends, and volunteer

work.

Post-Move Life Events. At the time of the second interview, Liz

was settling into her new apartment, ‘‘instigating’’ a lot of

activities in the facility and making new friends. She was

becoming more satisfied with her situation as she became

acquainted with other residents. Her sleep patterns had changed

for the worse, with more frequent awakenings leading to her

not feeling as rested in the mornings. In the 3rd month after the

move, Liz fell and broke three ribs. In the 4th month living in

her new residence, Liz took a long weekend to visit family and

was able to leave her mother alone with no problems. Her

daughter remarried a convicted felon who was in a penitentiary,

which angered her to the point of disowning her daughter. At

the time of the third interview (in Month 6), Liz’s mother had

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relocated to the adjacent nursing home, and Liz found herself

completely occupied with emptying her mother’s apartment.

Contact with her children was much less frequent than before.

Post-Move Perceptions and Cognitive and Behavioral Responses. In

the second interview, Liz reported that social activities and

helping others in need provided her with satisfaction. Her

mother’s health was stable and she spent time with her daily.

She mentioned only a few coping strategies, mainly solitary

activities such as reading and quilting, that helped her to wind

down at the end of each day. These activities remained

consistent through the third interview, 6 months after her move,

at which point Liz was content with her life and new home. She

reported that the most positive aspect of living in the facility

was the social connectedness. Her mother experienced more

behavior problems, particularly wandering, between the 4th

and 6th months, but Liz reported finding comfort in knowing

that her mother was receiving good care in the nursing facility.

Post-Move Cortisol. Even though she faced many stressors, a

serious fall, and changes in her daily activities over the course

of the first few months in her new residence, Liz was able to

achieve and maintain homeostasis, as determined by both her

physiologic measures and self-report data. Her self-reported

perceptions of her stress and coping efficacy were supported

by her cortisol levels, which fell within or very close to the

95% CIs for a normal diurnal profile across Months 2–5. In her

6th month, just a week after her mother relocated, her peak cor-

tisol level increased to above the 95% CI. This increase was not

surprising considering the increased level of caregiving respon-

sibilities associated with her mother’s declining mental func-

tion. The rise in the peak is consistent with her appraisal of

stress at that time. However, Liz had handled multiple stressors

successfully to this point and was well-equipped physically,

emotionally, and socially to handle these additional changes.

We would expect that Liz maintained biological homeostasis

in her new home with her social support.

Allostasis: The Story of Alison

Alison was a 79-year-old woman whose husband of 59 years

suffered vascular dementia. When her husband was unable to

0

5

10

15

20

25

30

35

Morning/Peak Evening/Nadir

Month 1 Month 2 Month 3 Month 4 Month 5 Month 6

Mother moved to nursing care. Conflict with adult child. Christmas holiday.

Feeling socially connected with co-residents. Frustration with lack of environmental control.

Vacation with family; Mother stable.Disowned adult daughter.

Fell; broke 3 ribs. Decline in energy.

Relocation following spouse death. Caregiver for mother with dementia.

Making friends and volunteering within facility. Sleep disruptions

Saliv

ary

Cor

tisol

(nm

ol/L

)

Figure 2. Profile of homeostasis: The case study of Liz. Figure illustrates peak and trough cortisol values over the 6-month study period mappedto major life events. Sun and moon symbols represent the mean peak and evening values, respectively, for adult females over the age of 60(Aardal & Holm, 1995; Edwards et al., 2001). Dashed lines above and below the mean peak and evening symbols show the 95% CIs for the peakand evening values.

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live in their rural home any longer, he was placed in a nursing

home in the city. Feeling overwhelmed, Alison made the deci-

sion to sell the house and relocate to the city. See Figure 3 for a

graphical depiction of Alison’s cortisol peaks and troughs

mapped to major life events over the study period.

Pre-Move Major Life Events. Alison reported experiencing nine

significant life events (e.g., fall that resulted in a broken bone,

death of close friends, changes in her husband’s health and per-

sonality, declines in social activities) in the year preceding the

move. Alison’s sleep patterns were ‘‘awful’’ and had not been

good for several years. She reported waking an average of 12

times a night, with a typical night consisting of 4 hr of sleep.

She tried to take daily 1.5-hr naps. When she was alone, she did

not eat properly. Alison reported limitations with many daily

activities and had been unable to do certain tasks due to her

health and functional decline.

Pre-Move Perceptions and Cognitive and Behavioral Responses.Alison could not identify anything that provided her with

satisfaction in the year preceding the move. Alison’s own and

her husband’s health, coupled with financial concerns, were the

most stressful aspects of life in the year before the move. She

found distracting and solitary activities, such as reading and

watching television, somewhat effective in alleviating stress.

She reported that in the past, laughing or finding humor in a

situation had been one of her typical coping strategies, but it

was no longer effective.

Pre-Move Cortisol. Alison’s salivary cortisol peak level was

within normal range in the 1st month. The evening value was

significantly elevated, however, which indicates that the natu-

ral diurnal rhythm had shifted. Elevations in cortisol secretion

in the evening are often related to sleep disturbances in older

populations (Van Cauter, Leproult, & Kupfer, 1996) but are

also known to precede negative changes in health (Plat

et al., 1999).

Post-Move Life Events. At the time of the second interview, in her

3rd month in the assisted living facility, Alison reported better

dietary habits due to communal dining and an increase in phy-

sician visits due to an earache and surgery to remove a severely

0

5

10

15

20

25

30

35

Month 1 Month 4Month 3Month 2 Month 5 Month 6 Month 7

Moved to be nearer spouse in nursing home. Difficulties in sleeping.

Diet improved due to communal dining. New anti-anxiety meds. Teeth grinding is a problem.

Toe amputated.

Severe case of shingles. Sinus infection. Deaths of co-residents and friends. Husband’s condition worsened.

Diet and sleep poor. Depressed.

Saliv

ary

Cor

tisol

(nm

ol/L

)

Morning/Peak Evening/Nadir

Figure 3. Profile of allostatic processes: The case study of Alison. Figure illustrates peak and trough cortisol values over the study periodmapped to major life events. Though the study period was intended to be 6 months, severe health issues in Month 6 for Alison delayed thefinal interview, though she was able to complete cortisol collection for both Months 6 and 7. Sun and moon symbols represent the mean peakand evening values, respectively, for adult females over the age of 60 (Aardal & Holm, 1995; Edwards et al., 2001). Dashed lines above and belowthe mean peak and evening symbols show the 95% CIs for the peak and evening values.

Ewen and Kinney 7

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arthritic toe. Her physician had doubled the dose of her antide-

pressant (Effexor) and prescribed Xanax to help her sleep. Both

medications affect cortisol secretion, typically decreasing

circulating levels (Hinkelmann et al., 2012; Hood et al., 2011).

Alison’s third interview, scheduled for Month 6, had to be

postponed several weeks due to her health. She had a sinus

infection and had developed a severe case of shingles that

affected both eyes and over half of her face. She was, however,

able to complete the saliva collection protocol for both Months

6 and 7, when the interview finally took place. Figure 3 thus

depicts 7 months of cortisol measures. At the time of her third

interview, in Month 7, Alison had finally managed to sleep

through a night. The shingles ‘‘laid her low’’ and her dietary

habits had returned to ‘‘awful.’’ Her husband’s physical and

mental health had declined significantly. He was discharged

to the nursing home with hospice care. She had experienced

numerous losses through death: a friend living in the nursing

home, her cat, three residents of the assisted living facility, and

a few of her childhood friends.

Post-Move Perceptions and Cognitive and Behavioral Responses. At

the second interview, Alison reported that the management and

facility staff were helpful in the week following her surgery,

stopping to check on her and delivering meals to her room. She

said that she mostly kept to herself. By the 7th month, she had

further withdrawn from the social community. Distinctly in the

throes of grief, she stated, ‘‘I lost him [husband] a long time

ago, I realize this now.’’

Post-Move Cortisol. Alison’s salivary cortisol peak levels were

within normal range in the 1st and 3rd months (see Figure 3).

In the 4th through 7th months, the peak cortisol levels vacil-

lated, with some values more than doubling and all of the val-

ues outside of the 95% CIs. Through this same time period the

evening values were within normal limits with the exception of

Month 6 when she was experiencing a shingles infection. It was

during these months that her husband’s health drastically

declined, her friends died, and she developed health complica-

tions. Cortisol dampens the immune system in order to prevent

excessive inflammation of bodily tissues (Yehuda & McEwen,

2004). As Alison’s salivary cortisol profile clearly indicates,

her cortisol levels were exceptionally high during a period that

coincided with the onset of a sinus infection and shingles.

Alison’s case study illustrates her body’s attempt to manage

stress to achieve homeostasis.

Allostatic Load: The Story of Edna

Edna was 80 years old when she relocated from her long-time

country home to senior housing. Edna’s husband had passed

away and her children had moved far from home. Afflicted

with degenerative polyneuropathy in her spine, Edna was

unable to sit, stand, or walk for long. Her granddaughter, who

provided instrumental support, had to relocate for a job, which

forced Edna to move. See Figure 4 for a graphical depiction of

Edna’s cortisol peaks and troughs mapped to major life events

over the 6-month study period.

Pre-Move Major Life Events. Edna reported experiencing 12 sig-

nificant life events in the year prior to the move, most

prominently serious health issues (e.g., blood clots and a pul-

monary embolism that resulted in lung damage). Due to the

serious nature of her health problems, she spent a few weeks

in the hospital and a rehabilitation nursing facility, followed

by 4 weeks residing with her daughters. By the time she moved

to the senior housing facility, she had experienced drastic

changes in living conditions and health behaviors. Edna

expressed a need for more sleep, reporting that she often

awakened at 4 a.m. and averaged 5 hr of sleep per night. She

found that daylight made it difficult for her to sleep, so she did

not take regular naps.

Pre-Move Perceptions and Cognitive and Behavioral Responses. In

the year preceding the move, Edna’s greatest stress was prepar-

ing for the move because she was unable to do so on her own.

‘‘I had hoped to live and die in my own bed in my own home. I

didn’t want to leave. This move nearly killed me.’’ Edna’s peak

and evening cortisol levels were below average and very close

to each other in value, indicating a flattened cortisol rhythm.

Given the nature and duration of the preceding life events and

her perceptions of them as stressful, a state of allostatic load

would be the likely result. In coping with stress, Edna reported

that her most effective strategies were prayer and reading, both

solitary activities.

Post-Move Life Events. At the time of the second interview, Edna

had developed pulmonary hypertension and had resumed

taking painkillers. The pain medications adversely affected her

breathing, which caused her speech to be broken into short sen-

tences. She had only been able to eat with other residents in the

dining room on two occasions. Residents, she reported, did not

socialize in each others’ apartments but only in the common

areas and dining room. Between the 3rd and 6th months, Edna

was hospitalized for pneumonia and was discharged with

oxygen. Within a few weeks, she was also been diagnosed with

congestive heart failure and a urinary tract infection.

Post-Move Perceptions and Cognitive and Behavioral Responses.Edna reported that she felt as though no one at the new facility

knew her. She said the lack of social contact was the greatest

stress for her. In her efforts to ‘‘mix and mingle,’’ she tended

to overdo it. She could not go to the dining room on a regular

basis and was not able to meet or make friends with the other

residents. Edna spent most of her days lying on her side on the

sofa. These perceptions remained consistent from the second to

the third interview. She was pleased with the services available

to her, including delivery of her medications from a nearby

pharmacy. Her sleep had worsened to the point that 5 hr of

sleep per night was a luxury due to constant pain and the

worsening of her respiratory illness. Her feelings of loneliness

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and isolation were distressing and family members were not

visiting as often as they had when she had initially relocated.

Post-Move Cortisol. Edna’s peak salivary cortisol levels were

consistent across time; yet, they were below the mean and

95% CIs for a woman in her age range. The peak and evening

values were very close to each other across the study period,

reflecting a flattened rhythm that was particularly evident in

her cortisol samples for Month 4, during which time she was

hospitalized. This pattern is indicative of a nonresponsive

homeostatic mechanism and reflects the state of allostatic load.

Discussion

The ultimate goals of this study were to demonstrate the

complexity of stress perceptions and reactivity while testing the

utility of the model of allostasis for studying older women’s

adaptation to relocation, a transition that can be accompanied

by physical, emotional, and psychological upheaval. Reloca-

tion stress syndrome is a state in which physiological and/or

psychological disturbances occur as a result of a move from

one environment to another. Castle’s (2001) meta-analysis

identified potential negative outcomes of relocation including

mortality, morbidity, and psychological and social changes.

Castle’s work, however, did not include physiological

measures. Hence our research extends our understanding of the

negative health and social outcomes associated with relocation

to another domain.

Our study design, using longitudinal analysis to examine

physiological, psychological, and behavioral variables simulta-

neously, was ideal for studying the ways in which psychologi-

cal perceptions along with social opportunities and established

community affect outcomes of relocation. The psychosocial

data we derived from the interviews and journals provided

insight into the women’s motivations and challenges regarding

relocation, while the cortisol sampling illuminated their

physiological responses to these challenges.

In one significant finding about the relationship between

relocation and stress, the four women in the present study who

exhibited flattened diurnal salivary cortisol rhythms, an indica-

tor of allostatic load, all considered their recent move to be a

significant stressor. Although the number of cases is small, this

finding could partially explain earlier findings of relocation

stress syndrome and the increased mortality following

0

5

10

15

20

25

30

35

Month 6 Month 2 Month 3 Month 4 Month 5 Month 1

Relocation after long illness. Poor sleep; dependence on pain killers.

Christmas holiday. Feeling isolated. Ate dinner in dining hall for first time.

Hospitalized for pulmonary hypertension.

Preparing for holidays. Adjusting to size of apartment. Seekingcompanionship.

Discharged with congestive heart failurediagnosis. Began receiving oxygen at home.

Urinary tract infection.

Saliv

ary

Cor

tisol

(nm

ol/L

)

Evening/NadirMorning/Peak

Figure 4. Profile of allostatic load: The case study of Edna. Figure illustrates peak and trough cortisol values over the 6-month study periodmapped to major life events. Sun and moon symbols represent the mean peak and evening values, respectively, for adult females over the ageof 60 (Aardal & Holm, 1995; Edwards et al., 2001). Dashed lines above and below the mean peak and evening symbols show the 95% CIs for thepeak and evening values.

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relocation. In fact, these women were exhibiting characteristics

of HPA-axis allostatic load, or exhaustion of the HPA-axis

feedback mechanism, at the time of the move. This finding

demonstrates the utility of using a physiological measure of

stress along with psychological and behavioral measures to

explore the effects of potential stressors, like relocation, in the

lives of older adults.

In applying the model of allostasis to this population and the

stressor of relocation, mortality and comorbidities would serve

as indicators of allostatic load. The three women we selected as

case exemplars of the processes related to the allostatic model,

in fact, all experienced health events over the study period,

including a broken bone, shingles, a series of infections, and

complications of chronic health conditions. None of the women

died within the period. Only Liz, the exemplar of homeostasis,

did not experience the onset or exacerbation of a systemic

illness, as her only experience with a health event was a broken

bone in Month 3. By mapping data from the journals and inter-

views to the cortisol data for these three cases, we were able to

illustrate that increased perceptions of stress were related to

incidents of acute illness. It would have been even more

informative if we could have followed the women for a full

year, as did the studies that Castle analyzed (2001), yet even

in our 6-month study period, the sequelae of comorbid health

conditions were evident in the cases representing allostasis and

allostatic load.

The three cases in our study also provide a clear example of

the relationship between perceived social support and ability to

adjust. Although all three women reported making some friend-

ships within the facility, each approached them differently: Liz,

our exemplar of homeostasis, integrated herself into the extant

structure and received satisfaction from her relationships;

Alison, our exemplar of allostasis, found her friendships to

be a source of both support and stress; and Edna, our exemplar

of allostatic load, was unable to use her potential relationships

to create a support structure of any kind. Regardless of the

differences among the ways in which they approached these

relationships, social interaction and connectedness was an

important and common theme for all three women. It is

interesting to note the divergence between our homeostatic

exemplar on one hand and our allostatic and allostatic load

exemplars on the other in regard to social connectedness: the

two women who were socially isolated and experienced little

or no social support in their new surroundings also suffered

multiple health maladies and demonstrated salivary cortisol

patterns indicative of increased stress. Loss of personal and

social resources may be one explanation as to why older adults

appear to be more vulnerable to the negative effects of stress

(Cairney & Krause, 2008).

Limitations

Consistent with many prior studies on relocation and adapta-

tion, our sample size was small and we lacked a control group

(Castle, 2001). Therefore, we used the primary data collection

as our baseline measure, which left the data right-censored.

While the small sample size could be viewed as a limitation,

it also allowed us to collect detailed, in-depth data across

psychosocial and physiological domains.

A consistent problem noted in the cortisol literature is

assuring that samples are collected at the predetermined times

(Kudielka, Broderick, & Kirschbaum, 2003). Our participants

recorded the times of awakening and sample collections in their

journals. Although we had labeled each vial with a specific col-

lection time, it is possible that participants were not compliant

with the predetermined sampling schedule and/or in using the

appropriate vial. The aberrant profiles in Figure 1C may be

indicative of such a data collection error. Use of a time-

stamped collection protocol is recommended, but it is quite

expensive and was not feasible for this study. Edwards, Clow,

Evans, and Hucklebridge (2001) found that single-sample

measurement of cortisol was reliable when the sampling was

synchronized to awakening, which was our aim. However,

saliva sampling only occurred on 1 day per month, which may

not be optimal for accuracy of the diurnal curve.

Implications for Nursing and Nursing Research

In discussing the difficulty of determining the degree of

relationship between ‘‘stress’’ and ‘‘illness,’’ McEwen (1998)

asserted that the concept of stress is subjective and does not

take into account the enormous individual differences that exist

in coping with the environment. In this study, we explored how

these individual differences might affect older adult women’s

ability to adapt to the stressful life event of relocation. We used

a case study approach to describe exemplars of the primary

states described by the model of allostasis: homeostasis, allos-

tasis, and allostatic load. The longitudinal design and in-depth

data collection methods allowed for mapping of life events,

individual perceptions and coping abilities, and health impacts

directly onto the cortisol graphs, affording a unique perspective

on the role that the interactions among stress, perception, and

coping play in adaptation and health. This approach provided

insight into the transition and acclimation processes that occur

when older women move into a senior housing community,

illustrated the complex interplay among the physiological and

psychosocial components of the model of allostasis, and illumi-

nated aspects of the allostatic processes that prior research on

relocation did not explore. Our results provide support for the

application of the model of allostasis to significant events

requiring changes in behavior, lifestyle, and environment in

later life. Our study also provides preliminary evidence sup-

porting the acceptability and feasibility of collecting salivary

samples for cortisol analysis during significant life events in

this population.

Kirst and Peck (2010) lament the paucity of literature on

contextual interventions based upon population characteristics

and best practices with regard to relocation issues among older

adults. Although relocation to a new residence is, itself, stress-

ful, the adaptation and acclimation period may introduce or

exacerbate stresses associated with relocating. One of the most

exciting potential applications of the present study involves the

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demonstrated ability to observe physiological reactivity to self-

reported stresses and coping abilities. Nurses, mental health

specialists, physicians, and researchers are likely to find this

method of combining self-reported stress and cortisol measures

useful in developing and implementing interventions for

helping older adults adapt to a new residence.

For instance, all three women in our case studies acknowl-

edged the importance of social connections to their well-

being; yet, they grappled to differing degrees with unwritten

social rules for resident conduct among the already-

established social cliques in the facilities to which they had

moved. Previous research has shown that social support offsets

the ill effects of stress (Krause, 2006; Shaw, Krause, Liang, &

Bennett, 2007), and social comparisons offer one interpretive

mechanism for understanding how individuals evaluate

themselves during times of stress (Ryff & Singer, 2008). The

cortisol profiles in our three case studies demonstrate that the

woman who was most successful in establishing social support

in her new residence was also able to maintain physiological

homeostasis. Further exploration of social belonging and sup-

port in a larger sample may lead to the development of inter-

ventions and policies for prospective and new residents of

senior housing communities. Such interventions might include

invitations for prospective residents to attend social events and

meals during which they can observe interpersonal dynamics,

cliques, and staff–resident interactions. New residents could

be paired with established residents for social introductions and

daily check-ins.

Future research on relocation outcomes would benefit from

using the methods we describe here: a longitudinal design

involving the triangulation of self-report, psychosocial, and

physiological measures. Optimally, data collection beginning

with potential participants on the housing waitlist would pro-

vide a better method for ascertaining the baseline physiological

measures as well as for indentifying the social and lifestyle

changes that naturally occur when moving into congregate

housing. This would also afford an opportunity for developing

a control group of peers who are considering a move yet are

currently aging in place within the community.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to

the research, authorship, and/or publication of this article.

Funding

The authors disclosed receipt of the following financial support for the

research, authorship and/or publication of this article: This research

was supported by National Institutes of Health (NIH) grant no. M01

RR02602 through the General Clinical Research Center at the Univer-

sity of Kentucky.

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