Background: Population aging and family nuclearization in China have increased the number of a growing number of elderly individuals living alone or with only their spouse ("spousal cohabitation"). Current studies predominantly focus on single health domains, lacking systematic comparisons between these two groups in social support, psychological status, and sleep quality. This gap hampers evidence-based optimization of community health management services. Objective:To compare social support, mental health, sleep quality, and medical care demands between elderly individuals living alone versus with their spouse, analyze the impact of residential patterns on health needs, and provide evidence for improving community health services.  Methods: From December 2024 to April 2025, a multistage random sampling method was employed to select one community from six administrative districts in Tianjin. Elderly individuals aged ≥60 years were enrolled at a 1:3 ratio. Assessments included the modified Social Support Rating Scale, Self-Rating Anxiety Scale (SAS), Self-Rating Depression Scale (SDS), Pittsburgh Sleep Quality Index (PSQI), and structured questionnaires. Continuous variables were expressed as mean ±standard deviation ( Mean ± SD) and compared using independent-sample t-tests; categorical variables were presented as frequencies (percentages) and analyzed via chi-square tests. Multivariate linear regression identified key predictors of standardized psychological-sleep composite scores (Z-score, SAS+SDS+PSQI).  Results: A total of 594 valid questionnaires were collected (response rate: 82.5%), including 156 living-alone individuals and 438 spousal-cohabitation participants. 1. Social Support: The living-alone group scored significantly lower in total social support (34.31±5.57 vs 41.58±11.08, P<0.001), with inferior scores in objective support, subjective support, and support utilization (P<0.01 for all).  2. Mental Health and Sleep: The living-alone group exhibited higher anxiety (40.46±8.51 vs 37.81±9.11, P=0.002), depression (46.14±12.11 vs 43.84±10.93, P=0.038), and sleep disturbance scores (7.29±3.76 vs 5.82±3.87, P<0.001).  3. Chronic Diseases and Medical Barriers: Prevalence of ≥2 chronic diseases was marginally higher in the living-alone group (28.21% vs 26.03%, P<0.05). Significant disparities emerged in treatment challenges: living-alone individuals faced greater difficulty in hospital follow-up (62.30% vs 34.01%, P<0.001), while spousal-cohabitation participants prioritized "high treatment costs" (63.61% vs 41.80%, P<0.001) and "lack of dietary/exercise guidance" (31.29% vs 12.21%, P=0.003).  4. Community Healthcare and Functional Independence: The living-alone group had lower rates of complete self-care (75.64% vs 87.21%, P<0.001) but higher uptake of contracted family physician services (64.10% vs 52.51%, P=0.012). Demand for "enhanced referral collaboration with tertiary hospitals" (35.90% vs 15.07%) and "diversified service offerings" (33.33% vs 11.42%) was significantly higher in this group (P<0.001 for both).  5. Regression Analysis: Multivariate linear regression identified living-alone status （β=1.09, P=0.003） and low social support（β=1.42, P<0.001）as independent risk factors for elevated psychological-sleep scores. Protective factors included full self-care（β=-1.32, P=0.003）, housing area ≥91 m²（β=-0.91，P=0.002）, and monthly income ≥5,000 RMB (β=-0.90, P=0.007).  Conclusion: (1) Compared to spousal-cohabitation elderly, those living alone face compounded challenges including inadequate social support, heightened psychological-sleep risks, and reduced healthcare accessibility, albeit with non-significant differences in multimorbidity prevalence. (2) Living-alone status and low social support independently exacerbate psychological-sleep impairments, while robust self-care capacity, favorable living environments, and community satisfaction demonstrate protective effects. (3) Medical demands of living-alone elderly center on referral coordination and service diversification. We recommend community health institutions establish specialized health records for this population, implement proactive follow-up programs, optimize bidirectional referral channels, and integrate community resources to enhance accessibility and precision of health management services.