Measuring Age-Friendly Housing: A Framework: Sustainability

sustainability
Article
Measuring Age-Friendly Housing: A Framework
Adriana Luciano 1,2, *, Federica Pascale 2 , Francesco Polverino 1 and Alison Pooley 2
1 Department of Civil, Architectural and Environmental Engineering (DICEA), University of Naples
Federico II, 80125 Naples, Italy; polverin@unina.it
2 School of Engineering and the Built Environment, Faculty of Science and Engineering, Anglia Ruskin
University, Chelmsford CM1 1SQ, UK; federica.pascale@anglia.ac.uk (F.P.); alison.pooley@anglia.ac.uk (A.P.)
* Correspondence: adriana.luciano@unina.it; Tel.: +39-3358-187-215

Received: 23 November 2019; Accepted: 20 January 2020; Published: 23 January 2020
Abstract: An ageing population raises the question of providing adequate housing that enables
older people to age in place without losing autonomy and independence. Except for the issue of
accessibility, no framework exists that specifically outlines a standard to achieve and, as a result,
interventions on existing or on new buildings may be inconsistent without leading to a desired rise in
living standards. This research addresses this issue by presenting a framework for the assessment of
the age-appropriateness of housing through a number of metrics that detect and identify physical and
non-physical features of a home environment to enable ageing in place. The study combines data from
a qualitative systematic literature review of 93 papers and qualitative data from structured interviews
with four experts in the field. As a result, 71 metrics were identified, divided into eight main domains,
to describe the framework. This paper provides an improved understanding of the housing features
that enable ageing in place. The tool categorizes and rates qualitative and quantitative aspects that
contribute to the age-friendliness of housing, resulting in an easy to adopt assessment framework.
This is a valuable means for stakeholders engaged in improving the current housing stock or in
constructing new buildings for older people.
Keywords: ageing in place; housing; ageing population; age-friendly housing; assessment framework
1. Introduction
Developments in society dating from the 1960s have led to a demographic change identified as
the ‘second demographic transition’ [1]. One of the main consequences of this unprecedented change
is an ageing population [2] resulting from the increase in life expectancy and falling birth rates [3–5].
In the next decades, the number of people aged 60 years or over is expected to more than double [5]
and an ever-increasing proportion of them will live in an urban context [6]. According to the World
Health Organization (WHO), an ageing population together with urbanization is the major challenge
for the 21st century [3,7]. Assuring health and wellbeing in urban settings during later life is becoming
a priority issue in both developed and developing countries [3,7]. In order to achieve sustainable
development, cities are required to provide services and opportunities tailored to the needs of older
people to enable them to participate in society and to be a human resource [7,8]. In this sense, older
people require a supportive environment to compensate for their physical and social changes [3].
The idea of an ‘age-friendly city’ has therefore been introduced [3]. It considers the evolving needs of
ageing population and provides the structures and the services to promote the residents’ wellbeing and
productivity, supporting sustainability [3,5]. An age-friendly city is central to the aim of Sustainable
Development Goal (SDG) 11 of the 2030 Development Agenda by the United Nations to “make cities
and human settlements inclusive, safe, resilient and sustainable” [9]. An age-friendly city, furthermore,
promotes active ageing defined as the process of “optimizing opportunities for health, participation
Sustainability 2020, 12, 848; doi:10.3390/su12030848 www.mdpi.com/journal/sustainability

Sustainability 2020, 12, 848 2 of 35
and security in order to enhance quality of life as people age” [3] (p. 1). Several non-governmental
organizations and research institutions, alongside the WHO, have developed strategies to improve
lives of older people in their communities. Within such strategies, the built environment is recognized
as an area of concern.
The complex blending between physiological, behavioral, social, and environmental changes that
occur in the process of ageing is well described by the ‘ecological model of aging’ by Lawton [8,10,11]
which describes the dynamic interplay between the competence of an individual and the environmental
press over their life course. According to the model, adaptive behavior comes from the balance between
competence and environmental press: This means that challenges posed by the environment that do not
match personal capacities, negatively impact on behavior and wellbeing. Older people are, therefore,
more exposed to environmental challenges because of their increased vulnerability [12]. Proceeding
from the fact that the major context for ageing is provided by housing, and that independence in
activities of daily living is a health indicator, the fundamental role played by housing in the life of older
people is clear [13,14]. Research reports that over time the significance of home increases [15,16] and
the relationship between people and their homes becomes ever more important [17]. This is reflected in
the fact that older people generally wish to remain in their own home for as long as possible [16,18–20].
Ageing in place [21] has emerged as a strategy to improve the quality of life of older people enabling
them to stay longer in their own home before institutionalization, whilst reducing public and private
health spending [22]. To enable ageing in place, housing must be adequate to accommodate the needs
of older people. This is also mentioned in SDG 11 which sets the objective of ensuring “access for all to
adequate, safe and affordable housing” [9] (p. 21). Several organizations have listed the criteria that
make housing adequate for the needs of older people.
In 2007 the WHO wrote the Global Age-friendly Cities: A Guide [3], containing a checklist of the core
features that help cities become more age-friendly. To develop this guideline, focus groups were conducted
among older people, caregivers, and service providers in 33 cities across all continents, exploring a total
of eight topics. The topics reflected the determinants of active ageing and, for each of them, a checklist
was outlined. Housing is one of the topics related to the built environment together with outdoor spaces
and buildings and transportation. The features that affect its age-friendliness are grouped into nine
domains: Affordability, essential services, design, modifications, maintenance, ageing in place, community
integration, housing options, living environment. For each domain, the most common issues faced by,
and the most common expectations displayed by the older people were reported. As the research gives
a summary of the views expressed by the participants worldwide, it can be considered as a relevant
overview of the topic. However, the contents of this guide are of a theoretical nature and they provide only
an overview of the issues, failing to provide metrics for assessment. In case stakeholders want to use it as
a guideline for their action plans, they must confirm the validity of the checklist and adapt its contents to
the local context in order to obtain an assessment that is most appropriate for the local community [7,23].
In 2015 the American Association of Retired Persons (AARP) launched the Livability Index as a tool to
assess and compare the community livability of cities and towns across the United States [24]. The average
value scored by all communities across the U.S. represents the reference point for the assessment. Livability
is evaluated according to seven major categories including housing and, for each category, a number of
metrics and policies are combined to obtain the score. These metrics give a practical way to assess housing
features but they are evaluated by comparison with the national standards, therefore they are not suitable
to assess the community livability outside the United States. The AARP Home Fit Guide [25], instead,
gives a more detailed description of the features that make a dwelling suitable for an older person. It is
a tool designed to help people assess their home environment and modify it according to their own needs.
The Housing our Ageing Population Panel for Innovation (HAPPI) developed ten principles to guide the
design of housing for older people in order to improve their quality of life [26]. Such guidelines, which in
many cases are based on good design principles, can be considered as a reference in approaching a new
project but not tools to assess the age-friendliness of houses.
Alongside the concept of homes tailored on the needs of older people, that has resulted in
guidelines and design standards, a concept that is gaining increasing interest is that of lifetime homes.
It refers to the ability of a home environment to adapt to the changing needs of individuals during their
lifespan. This encapsulates a broader interpretation of the suitability of housing, extending to the whole
life course of a person. Organizations like Foundation for Lifetime Homes and Neighborhoods and the
AARP have proposed design principles to prepare a house to easily and cost-effectively accommodate
future adaptations [27,28].
The aforementioned guidelines can be considered as design standards, but they cannot be used to
assess current housing and to prioritize interventions. Furthermore, while a large and growing body
of literature has investigated the extent to which environmental features affect perceived and objective
health of older people, less attention has been directed to the assessment of the quality of housing
to enable an understanding of the degree of compliance of a home environment with the needs
of its inhabitants. The need for metrics and assessment tools is mentioned to establish a common
understanding among stakeholders, set goals, and monitor the effects of interventions [7]. In order to
address this gap, the present research aims to identify features that impact on the age-friendliness of
housing and integrate them in a theoretical framework that can serve as a foundation for developing
an evaluation tool. To achieve the aim, the research approach integrates the results of two different
methods. Firstly, a qualitative systematic review was conducted. Data on the features of dwellings that
have been proven to impact the life of older people were collected. Based on these data, the metrics of
the framework were developed and for each metric a score system was defined. The model was then
validated through experts’ opinion.
This study provides three major contributions. Firstly, it updates, contextualizes and operationalizes
the theoretical framework proposed by WHO [3] in relation to the common housing types of Western
European countries. Secondly, as age-friendly cities are a policy goal shared by most of these countries
and housing one of the eight determinants of an age-friendly city, this research offers an in-depth analysis
of housing features relevant for older people. Lastly, it provides a tool to assess the age-friendliness
of housing. This can be a useful decision support system for stakeholders (policymakers, technicians,
homeowners, occupants/residents) to address interventions in existing housing or when designing
new housing.
2. Materials and Methods

To identify the features that impact on age-friendliness of housing and to translate them in terms
of metrics, the following steps were taken. Firstly, through a qualitative systematic review the features
reported by researchers as impacting on the wellbeing of older adults were recorded and organized
into eight domains, which form the structure of the framework. For each domain a list of metrics
was outlined and then associated to a score system corresponding to the different levels of housing
quality. The metrics and the score system were examined by a panel of experts through a questionnaire
in which they expressed their degree of agreement on a Likert scale. Furthermore, through textual
commentary they proposed changes in the metrics and/or in the rating system.
2.1. Qualitative Systematic Review

The purpose of the literature review was to establish the features of houses that enable older
people to live well in their homes and express them in terms of architectural performance requirements.
These constitute the metrics of the age-friendly housing framework.
The following electronic databases were searched: PubMed, Emerald Insight, Scopus, and Web of
Science. They were selected because of their different main subject areas, which could provide a thorough
overview of the topic. In order to include the maximum possible number of relevant studies, the search
strings included general keywords referring to both the home environment and ageing. A common query
was formulated and, according to the syntax of each database, a number of specific queries were used to
narrow down to the field of interest. The searches generated 1844 matches. The titles and the abstracts of
the papers were

Sustainability examined
2020, 12, 848 to determine if they were suitable for the research purpose; exclusion criteria 4 of 32
were listed and duplicates were detected. After the first screening phase, 99 articles were selected to be
screening
fully phase,
read. This 99step
first articles were
allowed to selected to be
identify the fully dimensions
leading read. This first step allowed of
of age-friendliness to housing
identifyandthe
leading dimensions of age-friendliness of housing and to define the domains
to define the domains of the framework. According to the topics covered by the domains, 29 papers were of the framework.
According eligible
considered to the topics
as theycovered by the
presented domains,
contents 29 for
useful papers were considered
identifying the metricseligible
neededas tothey presented
operationalize
contents useful for identifying the metrics needed to operationalize each
each domain. To further investigate the domains, new search questions were formulated. The questions domain. To further
investigate
were the domains,
firstly addressed new search
through questions
a snowball were
sampling formulated.
method The questions
that consisted werefrom
in selecting firstly
theaddressed
reference
through a snowball sampling method that consisted in selecting from the
lists of the 29 eligible papers other relevant papers that dealt with the domains of the framework.reference lists of the 29
Then,
eligible papers other relevant papers that dealt with the domains of the framework.
the search was extended to recommendations, guidelines, conference proceedings, reports, and policy Then, the search
was extended
documents. As a to recommendations,
result, 64 papers were addedguidelines,
leadingconference proceedings,
to a total number reports,
of 93 papers being and policy
included in
documents. As
the review (Figure 1).a result, 64 papers were added leading to a total number of 93 papers being included
in the review (Figure 1).
KEYWORDS: old *; ag *; senior; elderly; hous *; home; built environment; architecture.
EXCLUSION CRITERIA:
 Articles prior to 2007;
 Articles with a medical focus;
 Articles with assisted living facilities as settings (e.g., nursing homes);
 Articles in a language other than English and Italian;
 Articles concerning home care solutions for specific diseases (Alzheimer, etc.).
Records retrieved through database

search:
- Emerald Insight: 82
- PubMed: 793
- Scopus: 545
Web of Science: 424 Articles rejected on
title and abstract
review:
- Not relevant
- Meet exclusion
criteria
- Are duplicates
Candidate studies (n = 99)
Articles rejected on
full text review
Additional articles (n = 64) from:

Articles included (n = 29)
- New search questions
- Main references of included
atricles
- Recommendations, guidelines,
conference proceedings,
Articles included (n = 93)
reports and policy documents
N.B. the asterisk used in the keywords matches any character zero or more times. It has been used to include
in the same search string more words with the same root (e.g., ag * includes aging, ageing, age).
Figure 1. Keywords
Figure 1. Keywords and
and flow
flow chart
chart of
of literature
literature review.
review.
2.2. The Experts’ Opinion Technique

2.2. The Experts’ Opinion Technique
An indicator can be defined as a means to supply simplified information about a complex system
An indicator can be defined as a means to supply simplified information about a complex system
or an unmeasurable criterion [29]. This is the case of age-friendliness of housing for which no tangible
or an unmeasurable criterion [29]. This is the case of age-friendliness of housing for which no tangible
parameters could be directly detected. As the framework presented in this paper is the theoretical
parameters could be directly detected. As the framework presented in this paper is the theoretical
basis to the indicator of age-friendliness of housing, validating its contents was considered of utmost
importance. A conceptual validation was therefore undertaken to be sure that the framework
describes the complexity of the phenomenon and that it is fit for purpose [30,31]. According to Inglis
basis to the indicator of age-friendliness of housing, validating its contents was considered of utmost
importance. A conceptual validation was therefore undertaken to be sure that the framework describes
the complexity of the phenomenon and that it is fit for purpose [30,31]. According to Inglis [32],
referring to the appropriate research literature is a well-founded strategy to validate a framework.
However, appealing also to a panel of experts and asking them to express their opinion about the
comprehensiveness of the framework, leads to a more rigorous validation [32]. For this purpose,
a panel of experts was involved in the research.
The panel was selected to be as heterogeneous as possible: Its members come from different fields
of knowledge reflecting the range of stakeholders who have an interest in the results of the study.
The members of the panel are Italian, and their backgrounds are medicine, architecture, academia,
and social housing management. They were firstly contacted to be informed about the aim of the study
and to invite them to participate. Of the eight experts that were contacted, four accepted to take part in
the research and were included in the panel.
The experts were asked to answer a questionnaire between September and October 2019. They were
mutually anonymous as is common practice to avoid undue influence by certain members of the
panel [33–35]. The questionnaire was sent via email: It contained a brief summary of the research,
the metrics of the indicator, and the related score system. For each metric, the major references,
the description of the parameter, and the way to measure it were reported. Experts were asked to
answer the following questions:
• Do you agree with the score scale? Expand on your answer.

• Do you think that the contents of this metric are comprehensive? If not, write any other content
that you think is useful.
Panelists expressed their agreement on a five-point Likert scale (1 = completely disagree, 5 = completely
agree) that is considered the most adequate scale to provide information about the opinion of a person [36].
Motivations and suggestions were reported in open written responses. Given the small number of panelists,
the mean of the agreement expressed for each metric was calculated and a qualitative assessment of
their opinion was undertaken during a research team workshop. Values under 3 were considered in
disagreement with the proposed metric; values between 3 and 4 were considered in slight agreement, and
values over 4 were considered in full agreement.
3. Results from Literature Review

The literature review led to the outline structure of the framework of age-friendly housing in which
the most recurring determinants of housing quality were reported. The structure of the framework
is based on the checklist proposed by WHO [3] (Table 1). It brings together the major concerns to
consider when assessing the suitability of dwellings to the needs of older people. The framework has
therefore been structured in eight domains as follows (Figure 2): Affordability, community connection,
access to services, safety and security, essential services, design, modification, maintenance. Compared to the
checklist, the framework does not mention ‘housing option’ as it was not considered useful to assess
the age-friendliness of housing, but rather the availability of living options. Furthermore, to be more
consistent with the topics addressed in the checklist, the domains ‘living environment’ and ‘ageing in
place’ were renamed respectively ‘safety and security’ and ‘access to services.’ The other six domains
overlap those reported in the guide by WHO. For each domain, an extensive understanding has been
provided through the analysis of the literature review (Table 2). The following paragraphs reflect the
structure of the framework presented in Figure 2.
Table 1. Age-friendly housing checklist. Source: World Health Organization (WHO). Global age-friendly
cities: A guide; WHO: Geneva, 2007 [3].
Affordability Affordable housing is available for all older people.

Essential Services Essential services are provided that are affordable to all.
Housing is made of appropriate materials and well-structured.
Design There is sufficient space to enable older people to move around freely.
Housing is appropriately equipped to meet environmental conditions.
Housing is adapted for older people, with even surfaces, passages wide enough
for wheelchairs, and appropriately designed bathrooms, toilets and kitchens.
Housing is modified for older people as needed.
Housing modifications are affordable.
Modifications
Equipment for housing modifications is readily available.
Financial assistance is provided for home modifications.
There is a good understanding of how housing can be modified to meet the needs
of older people.
Maintenance services are affordable for older people.
Maintenance There are appropriately qualified and reliable service providers to undertake
maintenance work.
Public housing, rented accommodation and common areas are well-maintained.
Housing is located close to services and facilities.
Ageing in Place
Affordable services are provided to enable older people to remain at home, to
“age in place”.
Older people are well-informed of the services available to help them age in place.
Housing design facilitates continued integration of older people into the
Community Integration
community.
A range of appropriate and affordable housing options is available for older
people, including frail and disabled older people, in the local area.
Housing Options Older people are well-informed of the available housing options.
Sufficient and affordable housing dedicated to older people is provided in the
local area.
There is a range of appropriate services and appropriate amenities and activities
in older people’s housing facilities.
Older people’s housing is integrated in the surrounding community.
Housing is not overcrowded.
Older people are comfortable in their housing environment.
Living Environment
Housing is not located in areas prone to natural disasters.
Older people feel safe in the environment they live in.
Financial assistance is provided for housing security measures.
3.2.2. Overlooking Communal Facilities and Green Area

Older people can benefit from a view of external spaces [3,26,47]. Overlooking communal
facilities and
Sustainability 2020,establishing
a physical and visual relationship with the surroundings makes older
12, 848 7 of 35
people more involved in the community and helps to reduce their sense of isolation [3,44,48,49].
Figure 2. Age-friendly housing framework.

Figure 2. Age-friendly housing framework.
There is a consensus among researchers that the quality of the view plays an important role in
reducing the feeling of loneliness and on the general wellbeing of individuals [23,26,50]. For example,
for older people that spend most of the day at home, overlooking green areas can be the main way
they interact with natural elements [41], which in turn has a positive impact on wellbeing [41,48].
3.2.3. Sharing Spaces

Providing meeting places is important [49]. “Communal areas are not just a way of avoiding
loneliness; they are a positive opportunity to socialize, take part in activities or be entertained” [48]
(p.60). Sharing spaces, providing opportunities to meet, and organizing communal activities reduce
the likelihood of social isolation, loneliness, and depression [46,51]. Participation of the older people
in the design process of such spaces is also recognized as a key point in creating a strong bond within
the community [52].
Table 2. Results of literature review divided by domain.
Domain Metric Reference

1. Affordability Housing costs including: [3,7,24,37–39]
- Renting cost or mortgage payment
- Utilities
- Repair and maintenance costs
2.1. Community connection Presence of outdoor private spaces [3,26,40–46]

2.2. Community connection Overlooking communal facilities and green areas [3,23,26,41,44,47–50]
2.3. Community connection Presence of sharing spaces [46,48,49,51,52]
3. Access to Services Proximity of the house to the following amenities: [3,7,20,24,43,46,50,52–64]
- Health facilities
- Community centers
- Shops
- A stop of a public transport
- Parks
- General services (bank, public services, etc.)
- Places of worship
4.1. Safety and security Safety [52,59,65–78]

4.2. Safety and security Security [3,7,46,53,79–82]
5.1. Essential services Heating system [3,47,48,79,81,83–87]
5.2. Essential services Air conditioning/air cooling system [26,83,85,87]
5.3. Essential services Lighting system [76,77,85,88–90]
Table 2. Cont.

5.4. Essential services Domotics with reference to: [26,47,52,76,83–85,91–94]
- Lighting system
- Doors and windows opening and closing system
- Heating and air conditioning systems
- Water system
- Alarms systems
- Smart meters
6.1. Design Housing size [46,48,59,89,95–97]

6.2. Design Rooms type [3,26,41,46,48,79,85,98,99]
6.3. Design Layout [48,59,69,85,94]
6.4. Design Accessibility with reference to: [19,27,69,89,100–107]
- Pathway to approach house
- Entrance
- External stairs and lift
- Internal doors
- Hallways
- Windows
- Kitchen and living room
- Bathroom
- Bedroom
- Fixed furnishing
- Internal stairs
- Electrical outlets, counters, and systems terminal in general
- Balconies and terraces
Table 2. Cont.

7. Modification Interventions needed to make accessible: [3,38,55,57,67,69,73,85,97,101,104,108–114]
- Pathway to approach house
- Entrance
- External stairs and lift
- Internal doors
- Hallways
- Windows
- Kitchen and living room
- Bathroom
- Bedroom
- Fixed furnishing
- Internal stairs
- Electrical outlets, counters, and systems terminal in general
- Balconies and terraces
- Multi-level house
8.1., 8.2., 8.3., 8.4., 8.5. Maintenance Risk assessment for maintenance with reference to: [3,46,55,115–122]
- Cleaning and control interventions to undertake at least one time
over a seven-day period.
- Cleaning and control interventions to undertake at least one time
over a 30-day period.
- Inspections, checks, revisions, or replacements to undertake at least
every six months
- Inspections, checks, revisions, or replacements to undertake at least
every year.
- Preventative maintenance or replacement of parts at risk to
undertake at least every five years.
3.1. Housing Costs

According to WHO, affordability is “a major factor influencing where older people live and
their quality of life” [3] (p.30). The authors of [37] report that housing costs are the major economic
challenge for most low-income older people. Housing costs can be a barrier to ageing in place and
reduce the ability to afford other vital expenses [38]. There is a common agreement that 30% of the
monthly income is the maximum an older adult can allocate to housing costs (renting cost or mortgage
payment, utilities, repair and maintenance costs) without being considered at risk [7,39]. In the USA
the Livability Index proposes a threshold that corresponds to the average expenditure for housing
costs, measured at a neighborhood scale of 17.9% [24].
3.2. Community Connection

Feeling part of the local community contributes to the age-friendliness of a city [3]. According to
WHO [3] the design of housing can facilitate community interaction on multiple levels.
3.2.1. Presence of Outdoor Private Spaces

Research reports that housing can impact on a feeling of community connection through outdoor
spaces that connect the dweller to the neighborhood: Balconies, patios, gardens, porches, terraces are all
elements that can promote socialization and interaction of older people in the neighborhood [3,26,40–44].
Concerns are expressed about high-rise buildings and modern flats without outdoor spaces because they
impede personal contact with neighbors [3]. To be suitable for the needs of older people, outdoor spaces
should meet a list of minimum requirements, which are: Accessibility, adequate size to accommodate
furnishings (like chairs and tables), protection against atmospheric conditions, and a certain degree of
privacy [26,41,45,46].
3.2.2. Overlooking Communal Facilities and Green Area

Older people can benefit from a view of external spaces [3,26,47]. Overlooking communal facilities
and establishing a physical and visual relationship with the surroundings makes older people more
involved in the community and helps to reduce their sense of isolation [3,44,48,49].
There is a consensus among researchers that the quality of the view plays an important role in
reducing the feeling of loneliness and on the general wellbeing of individuals [23,26,50]. For example,
for older people that spend most of the day at home, overlooking green areas can be the main way
they interact with natural elements [41], which in turn has a positive impact on wellbeing [41,48].
3.2.3. Sharing Spaces

Providing meeting places is important [49]. “Communal areas are not just a way of avoiding
loneliness; they are a positive opportunity to socialize, take part in activities or be entertained” [48]
(p.60). Sharing spaces, providing opportunities to meet, and organizing communal activities reduce
the likelihood of social isolation, loneliness, and depression [46,51]. Participation of the older people in
the design process of such spaces is also recognized as a key point in creating a strong bond within the
community [52].
3.3. Distance from Main Services

The location of housing can have a great impact on its desirability and several benefits are
recognized in living close to a high number of amenities [53]. It is considered of utmost importance for
the independence of older people to be able to access basic services located within short distances from
home, such as shops, health care facilities, public transportation, community centers, leisure facilities,
parks, places of worship, and public services [3,46,54,55]. The extent to which the proximity of such
places is important in older people’s daily lives varies according with the type of amenity [56]. Place
connectivity contributes to establish a social link within the community [43,56–58] and encourages
physical activity with positive implications on health and wellbeing [50,54,57,59–61]. The distance
commonly accepted to be easily walkable by older people is 500 meters which corresponds to a 10-minute
walk [7,53,62,63]. In the tool proposed by AARP, this distance is a half-mile [24], whereas in the guidelines
proposed by the project Welfare housing policies for senior citizens (Wel_hops) [46] it is suggested that
essential services should be less than 400 meters from the home. A cause of concern is the quality
of the pathway whose features can hinder walkability of neighborhoods and prevent older people
from going outside [7,20,52,57,60,62,63]. Literature identifies the following features as fundamental for
neighborhood walkability: Safety (including safety from traffic and vehicles) [3,6,20,46,57,60,62,63], street
lighting [21,46], availability of pathways and sidewalks in good repair [3,7,20,46,52,54,62], availability
of resting places along pedestrian routes [3,52,54], absence of obstacles, and appropriate design [52,57].
However, the extent to which architectural features can promote mobility in older age depends on
the interplay between the person and the environment: Barriers must be considered in relation to the
personal capacities and the psychological resources of individuals [64].
3.4. Safety and Security
3.4.1. Safety
Older people are exposed to a number of hazards in the home environment and, among them,
falls are the most recurring [65–67]. Besides personal determinants of the inhabitants like age or
health status, the features of the home environment greatly impact on the occurrence of falls [65–73].
The most common risk factors for falls are: Slippery surfaces, low chairs, absence of grab bars or
handrails, loose rugs, no arm rest on chairs, missing second banister on stairs, poor lighting, obstructed
pathways, and storage areas out of reach [69,72–77]. Modifying the home environment is considered an
effective way to reduce the likelihood of falling [67,72,78], especially when modifications are combined
with other measures aimed at increasing awareness of risks by older people [65,70]. According to
the findings, simple interventions such as grab bars and handrails, shower seats, raised toilet seats,
anti-slip surfaces, visual cues that outline a pathway at night from bed to bathroom, and fall-detection
systems that call those who are able to help, are highly recommended [52,59,65,77].
3.4.2. Security
A cause of concern for older people is feeling safe in their living environment [3]. Security from crime
is the major aspect of neighborhood satisfaction [79,80] and impacts on health and mental wellbeing of
older people [7]. The overall crime rate of the area where the housing is located is an important determinant
of a sense of security for older people [81]. This aspect, along with neighborhood deterioration, affects
their trust and social ties [82]. Apart from the neighborhood crime rate, the physical security features of
housing need to be considered as a means to prevent burglars and intruders [3]. Poor external lighting,
inadequate locks and chains to windows and doors, lack of burglar alarm systems, and lack of barriers
along the boundaries are the major predictors of an unsecure dwelling [3,53,81]. Surveillance cameras,
absence of hiding places around the house, window locks, chains on entrance doors, gates on the
boundaries, and use of a concierge or security system are the most common dissuasive means against
intrusion [3,46,53,81]. Another aspect to take into account when assessing perceived security is sharing
of the home environment: Older people that live alone are more likely to feel insecure in their home [3].
3.5. Essential Services

The metrics for the framework presented here assume that the minimum requirements for essential
services (i.e., presence of water, electricity) are generally guaranteed in all dwellings.
3.5.1. Heating System

According to the authors of [83] (p.126), “environmental conditions that are within the comfort
zone can positively contribute to the health and well-being of people to age-in-place.” Frailty due to
health conditions makes older people more vulnerable to environmental conditions [48], even more so
if they are affected by dementia [83–85]. Studies report that for people with dementia, the internal
environment is an important parameter to provide comfort and help manage problem behavior [84,85].
Living in houses where indoor temperatures are low is a great concern for older adults; below 16 ◦ C
they are exposed to serious health risks, including risk of respiratory and cardiovascular conditions [81].
According to the WHO there is no demonstrable risk to human health when the temperature is between
18 ◦ C and 24 ◦ C but a higher minimum value may be necessary for vulnerable groups, including older
people [86]. The authors of [83] stated that older people have different comfort needs compared to
the younger population groups. These differences have been proved in a number of studies in terms
of deviation from the comfort zone of the younger population [83]. With reference to a 20–24 ◦ C
comfort zone, for example, the authors reported that this range is not warm enough for older adults as
they generally prefer a warmer environment (+2 ◦ C) [83]. Assuring that older people can control the
indoor temperature is therefore important to support individual thermal preferences and improve
satisfaction [47,79,83].
Heating costs also represent a concern for adults, especially for those with a reduced income [83,84].
Research evidences that in many cases older people on a low income are willing to use little or no
heating with a high risk to their health [84]. Strategies to reduce energy costs, increase comfort, and
save money should therefore be pursued [48,83,84,87].
3.5.2. Air Conditioning System

As with low temperatures, older people are particularly vulnerable to heat causing serious health
problems that can lead to death [87]. Homes need to be well-insulated, well ventilated, and able to
avoid overheating through passive solar design such as thermal mass and solar blinds [26,85]. In more
extreme climates where high temperatures are experienced over longer periods of time, comfort can be
provided by the installation of air-conditioning units [26,85]. In this case, energy-saving systems are
also strictly recommended [83].
3.5.3. Lighting System

Lighting is an important feature of the home environment because of its multiple functions for the
wellbeing of older people: It is essential for vision, regulating biochemical processes, and reducing fall
risks and sleep disorders [77,85]. Furthermore, inadequate lighting is one of the reported barriers that
older people experience in order to participate safely in social and physical activities, which impacts
their independence and social life [77,88,89]. Due to deteriorating vision, older people need a brighter
environment to perform activities compared to younger adults [89]. Within the home environment,
glare should be minimized, for example shielding natural light, and all the ambient and task areas
should be adequately illuminated [76,90]. Location and type of switches are also important: They
should be located near the bed and near the door to be easily operated and should be equipped with
dimmers to control light intensity [76,90].
3.5.4. Domotics
Introducing technology into the design of homes is regarded as a means to support ageing in place,
as well as to facilitate the implementation of health-care services [26,52,83,91]. The great number of
opportunities that technology provides in terms of management and control of the home environment
could be summarized into four categories: 1) Vital signs monitoring; 2) lifestyle monitoring; 3) mobility
and falls monitoring; and 4) domestic environment monitoring [92]. The last category includes smart
home technologies that use electronic information to control and manage internal environmental
conditions, adapting to residents over time [83,84,92]. Electronic systems in smart homes can even
perform certain tasks without requiring input from residents: This is particularly important to enhance
independence in situations with little or limited physical activity [84,91,93]. Fall-detection systems,
alarms (i.e., leaking gas alarm), and emergency call systems meet the need of older people for safety and
security [47,52,76]. Authors agree that technology, to be effective, must be familiar and non-invasive in
a way that permits older people to easily understand and operate [47,76,85,91–93]. This is even more
important for people living with dementia as home automation can lead to confusion and anxiety if
older people do not have control of it [94].
3.6. Design
Housing design impacts the ability of older people to live comfortably at home in several ways [3].
In this study, four areas of investigation have been determined to summarize such features. They are:
Housing size, rooms type, layout, and accessibility.
3.6.1. Housing Size

In terms of dimension of spaces, housing size must be adequate to enable older people to safely
perform activities of daily living [89]. The authors of [95] found that housing size, expressed in square
meters, was differently associated to life satisfaction in relation to the age of inhabitants. The young-old
(65–80 years) experience high life satisfaction when living in larger homes whilst older-old (80 years
and older) are more satisfied if their homes are smaller. According to the authors, this comes from
the different ways to interact with the environment with ageing, reflecting the differences in terms of
a “proactive use of environmental richness in third age versus a docile adaptation to environmental
press in fourth age” [95] (p.247). No specific housing size standards have been established until now.
The authors of [48] report that minimum gross floor areas in an age-friendly apartment should exceed
at least 10% the English national standard for common housing. Houses with reduced space for
maneuvering, doing activities, or just moving are considered unsafe for older people [59]. Conversely,
spacious properties that overwhelm older people can cause a number of problems related to mobility
and to property management in general [46,59]. The impact housing size has on physical activities
must also be considered: Studies have found that large homes require more physical efforts per day
with positive effects on health [96,97].
3.6.2. Types of Rooms

Overcrowding, defined as “the condition where the number of occupants exceeds the capacity of
the dwelling space available, whether measured as rooms, bedrooms or floor area, resulting in adverse
physical and mental health outcomes” [86] (p.22) is a concern for older people [3]. According to the
measure of crowding proposed by Eurostat, a room should be provided for every older adult apart from
couples that could share [98]. This form of measurement has been introduced in the metric. Findings
report that outdoor spaces offering an accessible extension to the home, like balconies, gardens, patios,
and terraces, are positively associated with the wellbeing of older people [26,41,48,85,99]. The positive
effects of exposure to daylight, the contact with nature and the physical activity of gardening are
some of the reasons why older people experience physical and mental benefits. The additional need
of a room for a caregiver is also mentioned by authors [46,85]. Furthermore, Lawton [79] states that
having two bathrooms is the strongest predictor of housing quality satisfaction among older people.
3.6.3. Layout
Given that older people are not a homogenous group, it is useful that housing provides flexibility to
adapt to their specific needs [48]. Semi-open plan layouts that provide a possibility to arrange living,
cooking, and eating spaces, and to easily change this arrangement over time, are suggested [48]. As older
people tend to restrict their activities to a smaller range in order to comfortably reach them, attention must
be paid to the distances that separate the most commonly used rooms [59]. As a general rule, reducing
the number of doors, hallways, and rooms is recommended [69]. The concern of providing the right
layout in the house is increasingly raised if inhabitants are affected by dementia. In this case, the authors
of [85,94] underline the necessity of open floor plans in order to have an overview of all spaces from
all positions in the home. According to the authors, making the toilet visible from the living room is
fundamental to help older people to easily locate it and connecting the bathroom with the bedroom is
also important to reduce the risk of falling.
3.6.4. Accessibility
Accessibility is a crucial feature to consider when designing housing for older people [69] given
the requirement for a barrier-free environment resulting from increasing functional decline [100,101].
Accessibility is a more critical aspect for older people living alone in case they have no household
members to help them perform the activities of daily living [101]. There is a common understanding
among researchers of the main problems attributable to barriers within the home environment: Loss of
independence, social isolation, elevated risk of injury, reduction of life satisfaction, and high health carer
needs [19,89,100,102–104]. In addition, evidence shows a contraction of spending on institutionalization
associated with living in a more accessible home environment [19,101,102]. The absence of barriers,
resulting in a more secure living environment, reduces fall risk and the medical consequences of
injuries, facilitating ageing in place [19,89,101,102]. The authors of [89] also highlight the importance
of accessibility of household appliances to meet the needs of older people. Adaptability of dwellings
to make them accessible when disability appears is also considered an age-friendly feature [101].
In Italy the Ministerial Decree 236/1989 has defined accessibility through several environmental
features that allow a person with reduced mobility to easily make use of the space [105]. As the framework
here presented is tested in Italy, the indications contained in the Italian Ministerial Decree have been
regarded as minimal technical requirements. Such requirements have been enhanced with reference to
those reported in the Swedish Housing Enabler Instrument [106,107] and in the English Lifetime Homes
Revised Criteria [27].
3.7. Modification for Accessibility

Being able to modify home environments in terms of size, space organization and functions
to adapt to the changing needs of people as they age, affects the ability of individuals to age in
place [3,38,55,57,108]. Home modifications can reduce the gap between environment and physical
capacity [109]; especially for people living with dementia that are no longer able to adapt to their
environment [85]. Even if benefits can be achieved by adopting either standard or personalized
modifications [97], the types of interventions and their impact on wellbeing are highly individual [104].
There is a consensus in the literature on the several benefits arising from home modifications:
Improving accessibility, preventing falls, promoting safety, reducing difficulty in performing everyday
life tasks, and reducing the need for health care [38,67,69,97,104,109–111]. However, to be fully
effective, interventions on dwellings must be combined with other strategies such as fall-prevention
programs [85,110].
The authors of [112] show that, after home improvements, a high percentage of older people
can expect to delay institutionalization by 10 years with a great reduction in long term care spending.
Costs and difficulty in engaging tradespeople are frequently reported as the main obstacles of home
modifications [3,67,69,73,108,113]. These problems are widely acknowledged for complex interventions
such as adding a bedroom on the first floor, widening doorways or installing a lift [108]. However, also
simple and cost-effective interventions are associated with improvements in an older person’s daily life.
Grab bars, handrails, shower seats, and raised toilet seats are the most frequently mentioned [38,67,109,114].
To facilitate these interventions, it is of utmost importance that housing is easily adaptable and suitable for
such changes [108,114].
An association has been found between the waiting time for home modifications and the difficulty
in performing activities of daily living [104]. Furthermore, the authors of [101] and Demirkan [114]
noted the lack of a preventive culture of home modification: Interventions are generally undertaken
after a disability has already appeared and not to prevent it.
3.8. Risk Assessment for Maintenance

Regular maintenance is essential to ensure a safe and healthy environment in which a person
can age in place [55,115–118]. Poorly maintained homes increase worry and stress, the risk of illness,
disease, and injury, as well as increased spending on utility bills and repairs due to the lack of
maintenance [115,117–119]. Frequently older people are worried about being able to maintain the upkeep
of their home environment [3,55]. This concern is reported as a key reason to enter residential care
where repairs and maintenance are managed by others [117,119]. The costs involved in maintaining
and making repairs are the first obstacle to predictable maintenance especially for older people on
a low-income [3,117,119,120]. This also determines the deferral of repairs and maintenance [119] with
the aforementioned consequences. Another cause of concern for older people is to be able to get
tradespeople [3,119]. Therefore, relying on assistance with home repairs and maintenance provided by
associations, persons of trust, or family is considered an age-friendly measure [3,119,121]. Studies [46,117]
report that being involved in home maintenance tasks benefits the autonomy and wellbeing of older
people and their participation in such activities should be supported.
To define the metric of the framework, the mapping of maintenance risk proposed by Molinari [122]
and by the American Association of Retired Persons [115] have been used for guidance, meaning that
the framework assesses preventative maintenance as the best strategy.
4. Results from the Experts’ Opinion

Of the 17 metrics assessed by experts, 10 (58.8%) received a full agreement, six (35.3%) received
a slight agreement, and only one (5.9%) received a disagreement. Comments and suggestions written by
experts were then considered. If they were aligned with the findings, the metric remained unchanged.
If they disagreed with the metric, two possible options were evaluated. The first option occurred in
the case of a thoroughly argued dissent that raised questions not addressed in the literature review.
If so, the metric was improved according to the experts’ opinion. The second option took place when
dissent was motivated with arguments in clear contrast to the literature review. If so, they were ignored
assuming that experts’ backgrounds could lead to a narrow understanding of the issue compared to
the multidisciplinary nature of the eight domains investigated.
During the team research workshop, comments were divided into three categories:
• Comments in disagreement with the metric that proposed additional contents underestimated in
the framework;
• Comments in disagreement with the metric and in clear contrast with the literature review;
• Comments in agreement with the metric.
Results are summarized in Table 3.

Table 3. Results of the questionnaires administrated among the experts and qualitative analysis of the related comments.
Metric Mean Score Type of Comments Main Contents of Comments Implications

Experts agreed on considering the threshold of 30% of the monthly income to
address the housing costs as an unsustainable expenditure for older people.
1.1. 2.67 In disagreement Even if they acknowledge that this value is commonly regarded as the Included in the metric
adequate percentage, they pointed out the need to have more affordable
housing options for older people.
In agreement. Experts agreed on the importance of private outdoor spaces to stimulate
2.1. 4 Metric unchanged
No more contents proposed socialization with the neighbors.
Experts agreed on the fact that overlooking communal spaces is important to
In agreement.No more contents
2.2. 4.33 make older people involved in the community life. They also argued that Metric unchanged
proposed
enjoying a pleasant view from home impacts on their wellbeing.
In agreement. Experts recognized the fundamental role played by sharing spaces in order to
2.3. 4.67 Metric unchanged
No more contents proposed encourage socialization and contrast loneliness.
In agreement. Experts shared the idea arising from literature of the positive impact that
No more contents proposed living in a well-served area has on the wellbeing of older people.
One of the experts disagreed with the metric. However, the concerns
Disagreement ignored.
4.1. 4 Partially in slight disagreement connected to the falling risk are well documented in literature and the opinion
Metric unchanged
of the other experts is completely aligned with the proposed contents.
Experts agreed with almost all contents of the metric. However, they
suggested to consider separately the effects that the crime rate of the area, the
4.2. 3.33 In slight disagreement Included in the metric
presence of security services, and the sharing of the home environment with
others have on the sense of security.
One of the experts did not think that an independent heating system is the best
requirement due to high costs involved. However, findings show that
calibrating internal temperature on the individual needs is important as older Disagreement ignored.
5.1. 4.33 Partially in slight disagreement.
people are more vulnerable to environmental conditions. Furthermore, the Metric unchanged
metric refers to the energy-saving systems as the best standard to achieve in
compliance with the reduction in heating costs.
Disagreement ignored.
5.2. 4 Partially in slight disagreement As in the previous metric.
Metric unchanged
Experts agreed with the contents of the metric but suggested to more properly
define uniform lighting.
Table 3. Cont.
Metric Mean Score Type of Comments Main Contents of Comments Implications

Experts were aligned with literature review and considered technology as a
mean to support ageing in place. However, they argued that a cause of
concern is the high costs required by these systems. One of the experts also
stated that a different score should be assigned in relation to the priority of the Disagreement ignored.
5.4. 3.67 In slight disagreement
domotic system. Metric unchanged
The research team did not change the metric because the housing systems costs
are already considered in the first domain. Furthermore, no research was
found to rate the domotic systems.
Experts agreed on the metric even if it is acknowledged that housing size
In agreement. should be tailored on the personal capacities of older people. Furthermore, the
6.1. 4 Included in the metric
No more contents proposed notion of overcrowding adopted is not considered relevant for the Italian
living conditions.
One of the experts suggested attributing a minor score to the outdoor private
spaces as this is a common feature of Italian houses.
One expert suggested evaluating the layout of houses in relation to the number
of inhabitants and the number of rooms. However, in the papers reviewed
6.3. 3.67 In slight disagreement there is a common understanding about the advantages for an older adult to Metric unchanged
live in a house with a semi-open plan layout independently from other
conditions.
In agreement.
6.4. 5 All the experts strongly agree with the metric. Metric unchanged
No more contents proposed
One of the experts suggested modifying the notion of accessibility for the
7.1. 3.67 In slight disagreement multi-storey houses including the possibility to have a room on the ground Included in the metric
floor to use as bedroom.
8.1.
8.2.
In agreement. All the experts acknowledged the importance of conducting predictive
No more contents proposed maintenance to make houses more age-friendly.
8.4.
8.5.
5. Discussion
Home is an important determinant of wellbeing for older people. It can enable them to age in place
improving their life and delaying institutionalization. To achieve this, the home environment must
meet a number of requirements. A wide understanding of the topic has been provided by researchers
who have investigated the relationship between housing features and health outcomes for older people.
Furthermore, numerous criteria have been listed into guidelines and worksheets by national and
international organizations to guide the design of age-friendly housing. The guidance provided by
WHO [3] gives a comprehensive overview of the topic and has been used as the main reference for the
present work. According to the domains identified in the guide, a qualitative systematic literature
review has been conducted. Relevant papers that dealt with affordability, community connection,
access to services, safety and security, essential services, design, modification, and maintenance were
analyzed. During this process it emerged that some of the themes encountered in the WHO study
were not recurrent topics in the literature review: Absence of essential services (electricity, gas, or
water supply), lack of construction materials, and safety from natural disaster, for example, are seldom
mentioned by authors. This can be due to the extensiveness of contexts addressed by the WHO guide,
including developing countries.
In reviewing the literature, recurring subjects and results reported for each of the eight domains
were recorded. Through qualitative analysis of the findings, the metrics of the framework were outlined.
They summarized the evidence arising from the research related to the housing requirements that
have been proved to affect the wellbeing of older people. The metrics were then converted in a score
system ranging from 1 to 5. The score system assigns the lowest score if the requirement is absent or
if the performance is not consistent with the findings, and the highest score if all the requirements
and performances mentioned by authors were fulfilled. The contents included in the metrics and in
the rating system were then validated by a panel of experts. When experts proposed new contents
underestimated in the framework or expressed a motivated disagreement with the metrics and the
related score system, the metrics were changed. This process has led to a framework well supported
by research evidence and experts’ opinion.
Affordability of housing is commonly considered a concern for older people [3,37,38]. The threshold
above which housing costs are regarded as affordable varies according to housing tenure type and the
financial resources of older people [38]; even so, the value of 30% of disposable household income is
commonly accepted [7,38,39] as affordable. The experts suggested reducing this value: Two of them
referred to the data of the Italian Social Insurance Institution (INPS) [123] according to which 70% of
private sector pensions amount to less than €1000 per month. For this reason, experts considered the
threshold of 30% as an excessive burden on older people’s economy that could be the cause of late
payments, particularly if older people live in rented accommodation. Conversely, the experts reported
that in Italy more than 70% of older people own their home, as confirmed by Falasca [20]. In this case,
they considered the percentage of 30% of the disposable income too high to bear the costs of utilities,
repair, and maintenance. The upper limit of 20% of monthly income for affordable housing costs has
been therefore considered, coming closer to the value proposed by AARP [24].
Community connection can be supported by the home environment in different ways. The presence
of outdoor private spaces is recognized as a means to be in contact with the neighborhood and to
socialize [3,26,40–44]. Overlooking communal facilities from the home [3,44,48,49] and sharing spaces
with neighbors [46,48,49,51] are also mentioned when describing the housing features that improve
community connection. Metrics have been specified in relation to the extent to which a dwelling
promotes socialization. Experts agreed with the findings and the metrics proposed.
Access to services, which is described as the proximity of home to the main services like healthcare
facilities, public transportation, and parks, enables independence of older people [3,46,54,55] and
stimulates their physical activity with positive implications on wellbeing [50,54,57,59,61]. Metrics have
been defined assigning a score to the distance from home to services and to the quality of pathways.
Experts were aligned with the literature review and did not provide any additional suggestions.
Safety and Security refer to the risks to which older people are exposed in their home. Given that
most findings reported falling as the main hazard for the safety of older people [65–67], the metric
rates the housing features that reduce the risk of falling. This concept is strictly related to measures to
undertake in the house to make it safer, such as the installation of a grab-bar or a shower seat in the
toilet [52,59,65,67,77]. Experts agreed with the metric. Security in the home environment has been
related to security from intruders. In this case, the context plays an important role: High crime rate and
poor neighborhood conditions are the most common predictors of perceived insecurity among older
people [79–82]. For this reason, physical security features which can detect the degree of security from
burglars [3,53,81] have been introduced in the metric. Sharing a home environment is mentioned when
describing the conditions that improve security of older people [3] and this has been considered in the
framework. Experts suggested assessing security from intruders and sharing of the home environment
separately, as this last aspect is related to a more general perception of the security of an older adult.
Essential services have been included in the framework. The domain has been restricted to the
features and performances of systems that can be adjusted to enhance the indoor comfort of older
people (heating system, air-conditioning system, lighting system, and domotics) assuming that basic
services like water supply and electricity are provided in all dwellings in western European countries.
As a main feature of heating and cooling systems, the possibility to adapt indoor temperature to
individual preference is mentioned [47,79,83]. Furthermore, the use of energy saving solutions is
reported as an age-friendly feature due to the saving in heating or cooling costs [48,83,84,87]; the cost
of energy was cited by experts in the validation process as a cause of concern. Lighting systems include
a number of features that affect the comfort of older people. The most cited were the uniformity of
light in all the rooms and task areas and the location and type of switches [76,90]. These parameters
have been included in the metric conforming also to the opinion of experts. The domain of essential
services also contains domotics. Its metric refers to the ease of use for older people as, according to the
findings, this is the main barrier to the further uptake of smart home technologies [47,76,85,91–93].
Experts raised doubts regarding the costs involved in installing domotics and cited cost as limiting
large-scale uptake of these technologies.
Design impacts several features of the wellbeing of older people. According to the findings,
four main categories can be identified when considering the age-friendliness of a home: Housing
size, room type, layout, and accessibility. No evidence was found in the literature on the minimum
or maximum space that is adequate for an older adult and experts’ opinion did not offer any
further clarity, so the metric was defined in a qualitative way as suggested by the literature [46,59].
The notion of overcrowding of houses was removed from the metric as, according to the experts’
opinion, this is not an issue for Italian older people. Furthermore, the ratio proposed by Eurostat [98]
was not considered consistent with the common size of housing in which Italian older people live.
With regard to room type, the presence of more than one bathroom [79], a caregiver’s room [46,85],
and outdoor spaces [26,41,48,85,99] are cited as age-friendly features and were then included in the
metric. Regarding the layout of the dwellings, authors reported the positive effects of having semi-open
plan [48] and of reducing the number of doors, hallways, and rooms [69], above all for people living
with dementia [85,94]. According to these findings, three schemes of the most common distribution of
rooms have been included in the metric. They represent different configurations with an increasing
amount of space for circulation increasing the ease of use of the home, especially for those with
reduced mobility. The experts did not offer any further comment and one of them declared not to
have an opinion, so the metric remained unchanged. Another key point of design is accessibility of
the home environment [69]. The metric was aligned to the Italian regulation on accessibility [105]
as the framework is tested in Italy. When creating the metric, information contained in the Italian
documents have been improved with the contents provided in two other guidelines: The Lifetime
Homes Criteria [27] and the Housing Enabler Instrument [106,107]. The experts completely agreed
with this metric.
Modification concerns the interventions to make the house more suitable for older people [3,38,55,57,108].
Interventions have been summarized in the metric as those that lead to increased accessibility. They were
rated according to the technical difficulty of making such adaptations. This has been done to consider the
two major concerns that older people face when deciding to modify their home: The costs involved and
the difficulty in engaging tradespeople [3,67,69,73,108,113]. If adaptations are easy to make and do not
require any spatial alteration, it is more likely that the costs involved are affordable and the involvement of
tradespeople less challenging [108]. One of the experts suggested that the requirement of accessibility in
multi-storey housing must take into account the possibility of allocating a bedroom on the ground floor
and not just a bed-space. This suggestion has been included in the metric as it raises the quality standard
of housing.
Maintenance is considered an important task to ensure a safe and a healthy home environment in
which to age [55,115–118]. Predictable maintenance is undermined by the costs involved in maintaining
and making repairs [3,117,119,120] and by the difficulty in relying on someone to undertake the
maintenance [3,119]. The provision of associations, persons of trust, or family that help older people
in maintaining their homes is then considered an age-friendly feature [119,121]. For these reasons the
metric considers two main factors in rating maintenance tasks: First of all, predictive maintenance has
been assumed as the best strategy to adopt and a risk assessment of maintenance has been derived from
the literature [115,122]; furthermore, the presence of a trusted person who can make the interventions is
rated high in the metric. Experts agree with the findings and with the metric, although they were slightly
concerned about the effective feasibility of predictable maintenance.
The final elaboration of the framework, coming from the literature review and the experts’ opinion,
is reported in the Table 4.
Table 4. Metrics of the framework.
ID Domain Assessment Area Measurement Scale Score

1. Affordability
1 - Housing costs are way above the affordability threshold (greater
than 30%)
Housing costs including: 2 - Housing costs are above the affordability threshold (between 20% 1
• Renting cost or mortgage payment; and 30%) 2
1.1. Affordability • Utilities; 3 - Housing costs are about 20% of the monthly income 3
• Repair and maintenance costs 4 - Housing costs are under the affordability threshold (between 20% 4
and 10%) 5
5 - Housing costs are way under the affordability threshold (less than
10%)
2. Community Connection
1 - There are not outdoor spaces
2 - There are outdoor spaces but they are not accessible for people
with reduced mobility
1
3 - There are outdoor spaces accessible for people with reduced
2
Community Presence of outdoor private spaces (balconies, mobility
2.1. 3
Connection terraces, patios, porches, gardens) 4 - Outdoor spaces are accessible for people with reduced mobility
4
and provide adequate size for arranging tables, chairs, etc.
5
5 - Outdoor spaces are accessible for people with reduced mobility
and provide shelter from weather conditions and they also guarantee
privacy
1 - House overlooks facilities that are sources of disturbance
(noise/visual/odor pollution) 1
2 - House overlooks a communal facility 2
Community
2.2. Overlooking communal facilities and green areas 3 - House overlooks a green area 3
Connection
4 - The older adult can enjoy the view without impact on his privacy 4
(e.g., screened glass in the lower part of window) 5
5 - The older adult can enjoy the view even while sitting
Table 4. Cont.

1 - There are not shared spaces
2 - Shared spaces are not accessible for people with reduced mobility
1
3 - There are shared spaces fully accessible for people with reduced
2
Community mobility
2.3. Sharing spaces 3
Connection 4 - There are shared spaces fully accessible for people with reduced
4
mobility. Within them activities take place, but only rarely
5
5 - There are shared spaces fully accessible for people with reduced
mobility. Within them activities take place habitually
3. Access to Services
Proximity of the house to the following amenities:
- 3.1 Health facilities 1 - Reaching the service needs more than 20’ walk
3.1. 2 - Reaching the service needs between 10’ and 20’ walk along an
- 3.2 Community centers
3.2. inaccessible and unsafe road 1
3.3. - 3.3 Shops 3 - Reaching the service needs less than 10’ walk along an inaccessible 2
3.4. Access to services - 3.4 A stop of a public transport and unsafe road 3
3.5. - 3.5 Parks 4 - Reaching the service needs between 10’ and 20’ walk along an 4
3.6. - 3.6 General services (bank, public services, accessible and a safe road 5
3.7. etc.) 5 - Reaching the service needs less than 10’ walk along an accessible
- 3.7 Places of worship and a safe road
4. Safety and Security

1 - House does not prevent fall risk. No measure is undertaken to
Safety measures refer to: guarantee the safety of the older adult
2 - House has a high fall risk. Less than two measures are undertaken
- Adequate lighting;
to guarantee the safety of older adult 1
- Removal of obstacles along the pathways;
3 - House has a medium fall risk. More than two measures are 2
4.1. Safety and Security - Removal or fixing rugs; undertaken to guarantee the safety of the older adult 3
- Grab bars and handrail; 4 - House has a low fall risk. All the measures are undertaken to 4
- Raised seats; guarantee the safety of the older adult 5
- Non-slip surface 5 - House has a low fall risk. All the measures are undertaken to
guarantee the safety of the older adult and a fall-detection system is
provided if fall occurs
Table 4. Cont.

1 - The older adult lives in context perceived as unsecure (high crime
rate, poor lighting around dwelling area, lack of surveillance)
3 - The older adult lives in a context perceived as secure (low crime 1
4.2.1. Safety and Security Security from entry by intruders rate, good lighting around dwelling area, presence of surveillance) 3
5 - The older adult lives in a house located into a secure context (low 5
crime rate, good lighting around dwelling area, presence of
surveillance) and equipped with at least one security system
1 - The older adult lives alone
2 - The older adult lives with another person that has a low level of
1
independence
2
3 - The older adult lives with a caregiver
4.2.2. Safety and Security Sharing of home environment 3
4 - The older adult lives with another person that has a high level of
4
independence
5
5 - The older adult lives with more than one person and at least one
of them has a high level of independence
5. Essential Services
1 - House has no heating system
1
2 - House is heated by individual devices (heater, fireplace, etc.)
2
3 - House has a centralised heating system
5.1. Essential Services Heating system 3
4 - House has an independent heating system
4
5 - House has an independent heating system and energy-saving
5
solutions are adopted
1 - House has no air-cooling system or air conditioning
2 - House is cooled by individual devices (fans, etc.) just in one part
of the house (living room or bedroom) 1
3 - House is cooled by individual devices (fans, etc.) both in living 2
5.2. Essential Services Air conditioning/air cooling system room and bedroom 3
4 - House is cooled thanks to passive solar design solutions that 4
cooperate with individual devices (fans, etc.) 5
5 - House is cooled by individual devices (fans, etc.) and
energy-saving systems are provided
Table 4. Cont.

1 - Lighting is inadequate. There are areas of glare and shadow
2 - Lighting is uniform throughout the house: All the rooms are well
illuminated and there are not areas of glare and shadow
1
3 - Lighting is uniform throughout the house and switches are well
2
located (near the bed, at both the beginning and the end of the stairs,
5.3. Essential Services Lighting system 3
at the entrance of each room)
4
4 - Lighting is uniform throughout the house and task areas are also
5
well illuminated
5 - Lighting is uniform throughout the house and dimmers are
provided to adjust the light intensity according to the user’s needs
Domotics categories refer to:
5.4.1. 5.4.1. Lighting system
1 - There is no domotics
5.4.2. 5.4.2. Doors and windows opening and closing
3 - There is domotics, but the older person is not able to manage it 1
5.4.3. system
Essential Services (this also includes systems with an unfamiliar interface) 3
5.4.4. 5.4.3. Heating and air conditioning systems
5 - There is domotics and the older person is able to manage it (this 5
5.4.5. 5.4.4. Water system
also includes systems with a familiar interface)
5.4.6. 5.4.5. Alarms systems
5.4.6. Smart meters
6. Design
1 - The house is too small: Spaces do not allow to safely perform
activities of daily living
3 - The house is too big: Space size is an obstacle preventing older
1
adult from moving or from adequately heating/cooling the rooms
6.1. Design Housing size 3
5 - Housing size is adequate to the needs of older adult: Privacy is
5
guaranteed, spaces allow to safely perform activities and the physical
effort required to move inside the property is compatible with the
older adult’s competence
Table 4. Cont.

1 - The house has not all the room required to perform activities of
daily living
2 - The house has all the room required to perform activities of daily
living 1
3 - The house has all the room required to perform activities of daily 2
6.2. Design Rooms type living and has more than one bathroom 3
4 - The house has all the room required to perform activities of daily 4
living and has also a caregiver room 5
5 - The house has all the room required to perform activities of daily
living and has also outdoor private spaces apart from balcony (e.g.,
terrace, garden, patio)
1 - The house has a corridor with rooms off
1
3 - The house has an entrance hall with rooms off
6.3. Design Layout 3
5 - The house has an open plan (that comprises kitchen, living room
5
and dining room) with separate bedroom and bathroom
Accessibility categories refer to:
- 6.4.1 Pathway to approach house
6.4.1. - 6.4.2 Entrance
6.4.2. - 6.4.3 External stairs and lift
6.4.3.
- 6.4.4 Internal doors
6.4.4. Each category is:
- 6.4.5 Hallways
6.4.5. 1 - Inaccessible according to the requirements of DM 236/1989
6.4.6. - 6.4.6 Windows 3 - Accessible according to the requirements of DM 236/1989 1
6.4.7. Design - 6.4.7 Kitchen and living room 5 - Best Practice. Accessible according to the requirements of DM 3
6.4.8. - 6.4.8 Bathroom 236/1989 with at least one higher performance. Higher performances 5
6.4.9. - 6.4.9 Bedroom come from those listed in the Housing Enabler Instrument and/or in
6.4.10. - 6.4.10 Fixed furnishing the Lifetime Home Criteria
6.4.11. - 6.4.11 Internal stairs
6.4.12. - 6.4.12 Electrical outlets, counters, and
6.4.13. systems terminal in general
- 6.4.13 Balconies and terraces
Table 4. Cont.

7. Modification
Interventions needed to make accessible:
- 7.1 Pathway to approach house
7.1.1. - 7.2 Entrance
7.1.2. - 7.3 External stairs and lift
7.1.3.
- 7.4 Internal doors
7.1.4. To make it accessible:
- 7.5 Hallways
7.1.5. 1 - It is not possible to make it accessible (technically not possible) 1
7.1.6. - 7.6 Windows 2 - It is necessary to intervene on the frame or on the facilities 2
7.1.7. Modification - 7.7 Kitchen and living room 3 - It is necessary to intervene on masonry or bricked works 3
7.1.8. - 7.8 Bathroom 4 - It is necessary to intervene on flexible systems 4
7.1.9. - 7.9 Bedroom 5 - It is necessary to intervene with little interventions like moving 5
7.1.10. - 7.10 Fixed furnishing furniture, adding a grab bar, fixing anti-slip surfaces on stairs, etc.
7.1.11. - 7.11 Internal stairs
7.1.12. - 7.12 Electrical outlets, counters, and systems
7.1.13. terminal in general
- 7.13 Balconies and terraces
To make it accessible: (in this case “accessible” means that at the

ground-floor the following accessible rooms are provided: A kitchen,
a living room, a bedroom, and a bathroom) 1
1 - It is not possible to make it accessible (technically not possible) 2
7.1.14. - 7.14 Multi-level house 2 - It is necessary to intervene on the frame or on the facilities 3
3 - It is necessary to intervene on masonry or bricked works 4
4 - It is necessary to intervene on flexible systems 5
5 - It is necessary to intervene with little interventions like moving
furniture, adding a grab bar, fixing anti-slip surfaces on stairs, etc.
8. Maintenance
Cleaning and control interventions to undertake at
least one time over a seven-day period. 1 - Cleaning is made less than once a week
1
Category refers to: 3 - Cleaning is made at least once a week
8.1.1. Maintenance 3
5 - Cleaning is made at least once a week. The older adult can rely on
- 8.1.1 Cleaning of housing 5
himself or on a trusted person to make the interventions
Table 4. Cont.

Cleaning and control interventions to undertake at
least one time over a 30-day period.
Categories refer to:
8.2.1. - 8.2.1 Vertical interior finishes
1 - Cleaning and control are made less than once a month
8.2.2. - 8.2.2 Internal doors and windows
3 - Cleaning and control are made at least once a month 1
8.2.3. - 8.2.3 Disposal facility
Maintenance 5 - Cleaning and control are made at least once a month. The older 3
8.2.4. - 8.2.4 Heating and air-conditioning adult can rely on himself or on a trusted person to make the 5
8.2.5. systems devices interventions
8.2.6. - 8.2.5 Electric production systems
- 8.2.6 Electrical outlets, counters, and systems
terminal in general
Inspections, checks, revisions, or replacements to

undertake at least every six months.
8.3.1. 1 - The activities have been undertaken more than six months ago
- 8.3.1 External doors and windows 1
8.3.2. 3 - The activities have been undertaken less than six months ago
Maintenance - 8.3.2 Ceilings, flooring, and walls 3
8.3.3. 5 - The activities have been undertaken less than six months ago. The
- 8.3.3 Stairs 5
8.3.4. older adult can rely on a trusted person to make the interventions
- 8.2.4 Heating and air-conditioning systems
(components and plumbing)
Inspections, checks, revisions, or replacements to

undertake at least every year.
8.4.1. - 8.4.1 Gas system (components and 1 - The activities have been undertaken more than one year ago
8.4.2. system terminals) 3 - The activities have been undertaken less than one year ago 1
8.4.3. Maintenance - 8.4.2 External coating 5 - The activities have been undertaken less than one year ago. The 3
8.4.4. - 8.4.3 Roof older adult can rely on a trusted person to make the interventions, or 5
8.4.5. - 8.4.4 Sewage disposal system (components interventions involve other neighbors
and plumbing)
- 8.4.5 Water-sanitary systems (components)
Table 4. Cont.

Preventative maintenance or replacement of parts
at risk to undertake at least every five years. 1 - The activities have been undertaken more than five years ago
8.5.1. Categories refer to: 3 - The activities have been undertaken less than five years ago 1
8.5.2. Maintenance - 8.5.1 Electrical system (distribution cables) 5 - The activities have been undertaken less than five years ago. The 3
8.5.3. - 8.5.2 Gas system (plumbing) older adult can rely on a trusted person to make the interventions, or 5
- 8.5.3 Water-sanitary systems (plumbing) interventions involve other neighbors
6. Conclusions and Future Research Implications

The systematic qualitative review included in this research identifies the features of housing that
enable older people to age in place. The results of this review were synthesized in a framework for the
assessment of the age-friendliness of housing, founded and built on the guide proposed by WHO [3].
The framework firstly updates, contextualizes, and operationalizes the theoretical framework proposed
by WHO [3] and secondly provides a comprehensive and forward-looking tool supported by a number
of current international studies and guidelines. The metrics of the framework, that summarize the
main results of the research, assign a score to the quality of home environments. This is a valuable
contribution to address the need of age-friendly housing as metrics are an essential reference when
designing interventions on existing or new houses.
The Italian experts involved in the study expressed a general agreement towards the metrics,
further validating the framework. However, the importance that the context (intended as the cultural,
social, and environmental context) has on the living environment and on the perception of its quality
has emerged. According to the experts’ opinion, some metrics have been modified to better assess the
Italian living experience and conditions. This may limit the validity of the metrics in other countries.
However, due to the international references used to build the framework, other countries can adopt it
for the assessment of the age-friendliness of housing by adapting the metrics to the local context (e.g.,
to the local standards on accessibility) by recurring to a panel of local experts.
The present research is part of a larger study aimed at creating a composite indicator that
assesses the age-friendliness of housing. To achieve this goal, apart from the construction of the
framework presented here, a national-scale survey has been conducted among older people in Italy.
The information derived from the literature review and from the experts’ opinion has been further
tested, asking older people the importance that the features of houses included in the metrics have on
their wellbeing. In this way, a weight has been allocated to each metric of the framework. The scope is
to create a tool that gives a measure of the suitability of the home environment according to quality
criteria, derived from research and experts’ opinions and the expectations of the end user of the house,
i.e., older people. The results of the survey will be presented in another contribution.
Author Contributions: Conceptualization, A.L.; methodology, A.L. and F.P. (Federica Pascale); supervision, F.P.
(Federica Pascale), F.P. (Francesco Polverino) and A.P.; validation, A.L. and F.P. (Federica Pascale); writing—original
draft, A.L.; writing—review and editing, A.L., F.P. (Federica Pascale) and A.P. All authors have read and agreed to
the published version of the manuscript.
Funding: This research received no external funding.
Acknowledgments: The authors especially thank the experts who agreed to participate in this study.
Conflicts of Interest: The authors declare no conflict of interest.
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Measuring Age-Friendly Housing: A Framework: Sustainability

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sustainability

Sustainability 2020, 12, 848; doi:10.3390/su12030848 www.mdpi.com/journal/sustainability

2. Materials and Methods

2.1. Qualitative Systematic Review

the papers were

KEYWORDS: old *; ag *; senior; elderly; hous *; home; built environment; architecture.

Records retrieved through database

Additional articles (n = 64) from:

2.2. The Experts’ Opinion Technique

• Do you agree with the score scale? Expand on your answer.

3. Results from Literature Review

Affordability Affordable housing is available for all older people.

3.2.2. Overlooking Communal Facilities and Green Area

Figure 2. Age-friendly housing framework.

3.2.3. Sharing Spaces

Table 2. Results of literature review divided by domain.

Domain Metric Reference

2.1. Community connection Presence of outdoor private spaces [3,26,40–46]

4.1. Safety and security Safety [52,59,65–78]

Domain Metric Reference

6.1. Design Housing size [46,48,59,89,95–97]

Domain Metric Reference

3.1. Housing Costs

3.2. Community Connection

3.2.1. Presence of Outdoor Private Spaces

3.2.2. Overlooking Communal Facilities and Green Area

3.2.3. Sharing Spaces

3.3. Distance from Main Services

3.4. Safety and Security

3.5. Essential Services

3.5.1. Heating System

3.5.2. Air Conditioning System

3.5.3. Lighting System

3.6.1. Housing Size

3.6.2. Types of Rooms

3.7. Modification for Accessibility

3.8. Risk Assessment for Maintenance

4. Results from the Experts’ Opinion

Results are summarized in Table 3.

Metric Mean Score Type of Comments Main Contents of Comments Implications

Metric Mean Score Type of Comments Main Contents of Comments Implications

Table 4. Metrics of the framework.

ID Domain Assessment Area Measurement Scale Score

ID Domain Assessment Area Measurement Scale Score

4. Safety and Security

ID Domain Assessment Area Measurement Scale Score

ID Domain Assessment Area Measurement Scale Score

ID Domain Assessment Area Measurement Scale Score

ID Domain Assessment Area Measurement Scale Score

To make it accessible: (in this case “accessible” means that at the

ID Domain Assessment Area Measurement Scale Score

Inspections, checks, revisions, or replacements to

Inspections, checks, revisions, or replacements to

ID Domain Assessment Area Measurement Scale Score

6. Conclusions and Future Research Implications

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KEYWORDS: old ; ag ; senior; elderly; hous *; home; built environment; architecture.