Introduction to Aging: A Positive, Interdisciplinary Approach [2 ed.] 0826162932, 9780826162939

Table of contents :
Cover
Title
Copyright
Contents
Preface
Intended Audience
Distinguishing Features
What’s New in the Second Edition
Acknowledgments
Share: Introduction to Aging: A Positive, Interdisciplinary Approach, Second Edition
Part I: We Are All Aging
Chapter 1: The Longevity Dividend
Learning Objectives
The New American Revolution
Our Aging World
A New Paradigm of Aging
Practical Application
Student Activities
Suggested Resources
References
Part II: Physical and Mental Well-Being
Chapter 2: Physical Changes and the Aging Process
Learning Objectives
Normal Physical Changes That Accompany Aging and Adaptations to Them
Biological Theories of Aging
Practical Application
Student Activities
Suggested Resources
References
Chapter 3: Health and Wellness for Older Adults
Learning Objectives
Enhancing and Maintaining Health in the Later Years
Health Promotion
Preventive Measures
Practical Application
Student Activities
Suggested Resources
References
Chapter 4: Mental Health, Cognitive Abilities, and Aging
Learning Objectives
Mental Health and Cognitive Abilities of Older People
Mental Health
Cognitive Abilities
Positive and Negative Influences on Mental Health and Cognitive Abilities
A Positive View of Mental Health and Cognition
Practical Application
Student Activities
Suggested Resources
References
Chapter 5: Sexuality and Aging
Learning Objectives
Let’s Talk About Sex
Sexual Expression
Sexuality and Health
Sexuality in Residential Care Facilities
Education for Everyone
Practical Application
Student Activities
Suggested Resources
References
Chapter 6: Death, Dying, and Bereavement
Learning Objectives
Understanding Death as a Normal Part of Life
Hospice and Palliative Care
Sustaining Life: A Thorny Issue
Euthanasia
Suicide and Aging
Organ Donation: The Gift of Life
Bereavement, Grief, and Mourning
Practical Application
Student Activities
Suggested Resources
References
Part III: Economic and Social Aspects of Aging
Chapter 7: Economics, Work, and Retirement
Learning Objectives
Diversity of Economic Status Among Older People
Sources of Income for Older People
Older People in the Labor Force
Retirement
Practical Application
Student Activities
Suggested Resources
References
Chapter 8: Age-Friendly Communities, Living Arrangements, and Housing Options
Learning Objectives
Living Environments: Communities, Living Arrangements, and Housing Options
Factors Affecting Where and How Older People Live
Age-friendly Communities
Where Do Older People Live?
Living Arrangements
Housing Options for Older People
Homelessness Among Older Adults
Practical Application
Student Activities
Suggested Resources
References
Chapter 9: Family, Friends, and Social Networks of Older Adults
Learning Objectives
Family, Friends, and Social Networks
The Family
Older Parents and Their Adult Children
Grandparents
Friends and Social Networks
Practical Application
Student Activities
Suggested Resources
References
Part IV: Formal Support Systems
Chapter 10: Older Adults Giving and Receiving Support
Learning Objectives
Community Services and Support
The Many Ways Older Adults Contribute to Their Communities
Programs and Support for Older Americans
The Older Americans Act
Need and Unmet Need for Services
Practical Application
Student Activities
Suggested Resources
References
Chapter 11: Medical Conditions, Assisted Living, and Long-Term Care
Learning Objectives
Medical Conditions
Chronic Medical Conditions
Other Medical Conditions
Assisted Living and Long-Term Care
Practical Application
Student Activities
Suggested Resources
References
Chapter 12: Medicare, Medicaid, and Medications
Learning Objectives
Medicare
Medicaid
Medications
Practical Application
Student Activities
Suggested Resources
References
Part V: Older People at Risk
Chapter 13: Older Women and Older Minority Group Members
Learning Objectives
Who Is at Risk?
Risks to Economic Security
Risks to Health
Heterogeneity of Racial/Ethnic and LGBT Groups
Practical Application
Student Activities
Suggested Resources
References
Chapter 14: Elder Abuse and Neglect: Crimes, Scams, and Cons
Learning Objectives
Elder Abuse and Neglect: An International and National Issue
Preventing and Responding to Elder Abuse and Neglect
Practical Application
Student Activities
Suggested Resources
References
Part VI: The Field of Gerontology
Chapter 15: Careers in Aging
Learning Objectives
Exploring Career Opportunities in Aging
What Kinds of Careers Are There in the Field of Aging?
Education in Gerontology
The Role of Professional Organizations in Your Career
Practical Application
Student Activities
Suggested Resources
References
Abbreviations
Index

Citation preview

INTRODUCTION TO

AGING A Positive, Interdisciplinary Approach SECOND EDITION

Judith A. Sugar

Judith A. Sugar, PhD, received her doctoral degree in life-span developmental psychology from York University in Toronto. A nationally recognized teacher and scholar in the field of aging, she has been teaching introductory aging courses for more than two decades. Dr. Sugar chaired the nascent gerontology program at Colorado State University and served as associate director of the Borun Center for Gerontological Research at the University of California, Los Angeles (UCLA) and as director of the Graham and Jean Sanford Center for Aging at the University of Nevada, Reno. As a member of the Nevada Geriatric Education Center from its inception, she developed innovative programs to support faculty across all disciplines who were already teaching courses in gerontology, as well as faculty who were interested in adding gerontology topics to their courses. She continues to develop innovative approaches to teaching gerontology and, most importantly, to recruiting students into the discipline. Her national and regional reputation in the field of aging led to her appointment to the Nevada State Commission on Aging, and she has served in leadership roles in prominent professional gerontological organizations, including the Academy for Gerontology in Higher Education (AGHE), the Gerontological Society of America (GSA), and the American Psychological Association’s Division of Adult Development and Aging. Valued both by students and faculty, she has been honored with numerous awards as a teacher and scholar, including Fellow of the AGHE, Woman of Achievement by the University of Nevada, Reno, and the inaugural award for Distinguished Faculty Scholar by the Sanford Center for Aging.

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IN TRO D U CTI ON T O AGI NG A Pos iti v e, I nterd isciplin ary A pp ro ach Second Edition

Judith A. Sugar, PhD

Contributions by Robert J. Riekse, EdD, Grand Rapids Community College, Emeritus Henry Holstege, PhD, Calvin College, Emeritus Michael A. Faber, MA, AGHEF, Gerontology Instructor, Portland Community College

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Copyright © 2020 Springer Publishing Company, LLC All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without the prior permission of Springer Publishing Company, LLC, or authorization through payment of the appropriate fees to the Copyright Clearance Center, Inc., 222 Rosewood Drive, Danvers, MA 01923, 978-750-8400, fax 978-646-8600, info@ copyright.com or on the Web at www.copyright.com. Springer Publishing Company, LLC 11 West 42nd Street New York, NY 10036 www.springerpub.com http://connect.springerpub.com Acquisitions Editor: Rhonda Dearborn Compositor: S4Carlisle Publishing Services ISBN: 978-0-8261-6293-9 ebook ISBN: 978-0-8261-6294-6 DOI: 10.1891/9780826162946 Instructor’s Materials: Qualified instructors may request supplements by emailing [email protected] Instructor’s Manual: 978-0-8261-6295-3 Instructor’s PowerPoints: 978-0-8261-6296-0 Instructor’s Test Bank: 978-0-8261-6297-7 Student Activities Answer Key is available from: https://www.springerpub.com/sugar Student Activities Answer Key: 978-0-8261-4306-8 The author and the publisher of this Work have made every effort to use sources believed to be reliable to provide information that is accurate and compatible with the standards generally accepted at the time of publication. The author and publisher shall not be liable for any special, consequential, or exemplary damages resulting, in whole or in part, from the readers’ use of, or reliance on, the information contained in this book. The publisher has no responsibility for the persistence or accuracy of URLs for external or third-party Internet websites referred to in this publication and does not guarantee that any content on such websites is, or will remain, accurate or appropriate. CIP data is on file at the Library of Congress

Contact us to receive discount rates on bulk purchases. We can also customize our books to meet your needs. For more information please contact: [email protected]

Judith A. Sugar: https://orcid.org/0000-0002-7788-1892 Publisher’s Note: New and used products purchased from third-party sellers are not guaranteed for quality, authenticity, or access to any included digital components. Printed in the United States of America.

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To the memory of the late Marilyn T. Zivian, PhD

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C O NTE N T S Preface  xiii Share: Introduction to Aging: A Positive, Interdisciplinary Approach, Second Edition

PART I. WE ARE ALL AGING 1. The Longevity Dividend   3 Learning Objectives  3 The New American Revolution   3 Our Aging World   8 A New Paradigm of Aging   14 Practical Application    15 Student Activities  16 Suggested Resources  16 References  17

PART II. PHYSICAL AND MENTAL WELL-BEING 2. Physical Changes and the Aging Process   21 Learning Objectives  21 Normal Physical Changes That Accompany Aging and Adaptations to Them   22 Biological Theories of Aging   33 Practical Application  36 Student Activities  37 Suggested Resources  38 References  38 3. Health and Wellness for Older Adults   41 Learning Objectives  41 Enhancing and Maintaining Health in the Later Years   41 Health Promotion  42 Preventive Measures  52 Practical Application  60 Student Activities  61 Suggested Resources  61 References  62

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Contents

4. Mental Health, Cognitive Abilities, and Aging 65 Learning Objectives 65 Mental Health and Cognitive Abilities of Older People 66 Mental Health 66 Cognitive Abilities 70 Positive and Negative Influences on Mental Health and Cognitive Abilities A Positive View of Mental Health and Cognition 83 Practical Application 83 Student Activities 84 Suggested Resources 84 References 85 5. Sexuality and Aging 89 Learning Objectives 89 Let’s Talk about Sex 90 Sexual Expression 92 Sexuality and Health 96 Sexuality in Residential Care Facilities Education for Everyone 101 Practical Application 103 Student Activities 104 Suggested Resources 105 References 105

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6. Death, Dying, and Bereavement 109 Learning Objectives 109 Understanding Death as a Normal Part of Life Hospice and Palliative Care 112 Sustaining Life: A Thorny Issue 114 Euthanasia 115 Suicide and Aging 117 Organ Donation: The Gift of Life 118 Bereavement, Grief, and Mourning 118 Practical Application 123 Student Activities 123 Suggested Resources 124 References 124

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PART III. ECONOMIC AND SOCIAL ASPECTS OF AGING 7. Economics, Work, and Retirement 129 Learning Objectives 129 Diversity of Economic Status Among Older People Sources of Income for Older People 131 Older People in the Labor Force 139 Retirement 144 Practical Application 151 Student Activities 152 Suggested Resources 152 References 153

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8. Age-Friendly Communities, Living Arrangements, and Housing Options Learning Objectives 157 Living Environments: Communities, Living Arrangements, and Housing Options Factors Affecting Where and How Older People Live 159 Age-Friendly Communities 160 Where Do Older People Live? 162 Living Arrangements 165 Housing Options for Older People 167 Homelessness Among Older Adults 172 Practical Application 173 Student Activities 174 Suggested Resources 175 References 175 9. Family, Friends, and Social Networks of Older Adults Learning Objectives 177 Family, Friends, and Social Networks 178 The Family 178 Older Parents and Their Adult Children 182 Grandparents 186 Friends and Social Networks 187 Practical Application 190 Student Activities 191 Suggested Resources 192 References 192

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PART IV. FORMAL SUPPORT SYSTEMS 10. Older Adults Giving and Receiving Support 199 Learning Objectives 199 Community Services and Support 200 The Many Ways Older Adults Contribute to Their Communities Programs and Support for Older Americans 204 The Older Americans Act 205 Need and Unmet Need for Services 217 Practical Application 219 Student Activities 220 Suggested Resources 221 References 222 11. Medical Conditions, Assisted Living, and Long-Term Care Learning Objectives 223 Medical Conditions 224 Chronic Medical Conditions 225 Other Medical Conditions 232 Assisted Living and Long-Term Care 234 Practical Application 246 Student Activities 247 Suggested Resources 247 References 248 12. Medicare, Medicaid, and Medications Learning Objectives 251 Medicare 252 Medicaid 262 Medications 263 Practical Application 267 Student Activities 268 Suggested Resources 269 References 270

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PART V. OLDER PEOPLE AT RISK 13. Older Women and Older Minority Group Members 275 Learning Objectives 275 Who Is at Risk? 276 Risks to Economic Security 278 Risks to Health 286 Heterogeneity of Racial/Ethnic and LGBT Groups 292 Practical Application 292 Student Activities 293 Suggested Resources 293 References 294 14. Elder Abuse and Neglect: Crimes, Scams, and Cons 297 Learning Objectives 297 Elder Abuse and Neglect: An International and National Issue Preventing and Responding to Elder Abuse and Neglect 309 Practical Application 313 Student Activities 314 Suggested Resources 315 References 315

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PART VI. THE FIELD OF GERONTOLOGY 15. Careers in Aging 321 Learning Objectives 321 Exploring Career Opportunities in Aging 322 What Kinds of Careers Are There in the Field of Aging? Education in Gerontology 326 The Role of Professional Organizations in Your Career Practical Application 330 Student Activities 331 Suggested Resources 331 References 332 Abbreviations Index 337

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PRE FAC E

Do not regret growing older. It is a privilege denied to many. Aging. Everyone is doing it! We are all aging. This calls all of us to learn more about aging and to rid ourselves of our ageist beliefs, attitudes, and behaviors. We can expect to live longer and healthier lives than ever before, giving us an unprecedented opportunity to create a society that takes advantage of the many benefits of that longevity dividend—the accumulated experience, wisdom, and talents of individuals as they age. The impetus for writing this book, as its title reflects, came from my desire to have a textbook with a positive approach to aging for an introductory course I have been teaching for almost 20 years. I feel strongly that, in all our discourse, and especially in an introductory textbook, we need more focus on the good fortunes presented by our increasing longevity, including the ways that our society can foster and support those opportunities. As we age, we should continue to be treated as citizens equal to all others in our potential to grow and contribute to our communities. Redesigning our society to make the most of the gift of longevity will reap huge dividends for individuals, for our communities, and for society at large.

INTENDED AUDIENCE This textbook has been developed for introductory courses in gerontology, as well as other courses with gerontology components. It can be used with undergraduate students and master’s-level students alike. Instructors tell us that the textbook also works well in a variety of other courses where a broad perspective on gerontology is helpful to the course content, for example, public health, psychology, social work, sociology, and business courses. Gerontology is multifaceted and interdisciplinary. By necessity, it encompasses a broad range of subjects, including psychology, sociology, architecture, biology, communications, economics, education, humanities, law, medicine, nursing, political science, public administration and policy, public health, public safety, social work, and vocational skills. Indeed, gerontology encompasses every academic discipline that in some way relates to the lives of older people in contemporary America.

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DISTINGUISHING FEATURES The textbook’s distinguishing features, which were also present in the first edition, are: ■ ■ ■ ■ ■

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■

A positive approach to aging, with an emphasis on the advantages and opportunities presented by the large and growing number of older Americans An interdisciplinary approach, incorporating perspectives from multiple disciplines Presentation of research dispelling the fallacy of negative myths and incorrect stereotypes about aging A broad range of subject areas in the field, from biological aging processes to economics and living arrangements A chapter devoted to women and minority group members who are particularly at risk for poverty and poor health as they age (Chapter 13, Older Women and Older Minority Group Members) The separation of normal physical changes accompanying aging from medical conditions (Chapter 2, Physical Changes and the Aging Process, and Chapter 11, Medical Conditions, Assisted Living, and Long-Term Care, respectively) Suggested Internet resources at the end of each chapter

WHAT’S NEW IN THE SECOND EDITION In addition to more than 400 new references and the latest available data and statistics, brand-new features in this edition include: ■ ■

■

■ ■ ■ ■ ■

A new chapter on careers in aging, which explores expanding opportunities now available in the field (Chapter 15, Careers in Aging) Increased diversity content throughout the book, which is in addition to the separate chapter on older women and older minority group members (Chapter 13, Older Women and Older Minority Group Members) New content on personality (Chapter 4, Mental Health, Cognitive Abilities, and Aging), palliative care (Chapter 6, Death, Dying, and Bereavement), age-friendly communities and homelessness among older adults (Chapter 8, Age-Friendly Communities, Living Arrangements, and Housing Options), social networks (Chapter 9, Family, Friends, and Social Networks of Older Adults), and Medicaid (Chapter 12, Medicare, Medicaid, and Medications) A new approach to elder abuse focusing on solutions to social isolation, a major cause of abuse (Chapter 14, Elder Abuse and Neglect: Crimes, Scams, and Cons) Enhanced content on the many ways in which older people contribute to their communities (Chapter 10, Older Adults Giving and Receiving Support) More scenarios to introduce the content of each chapter Expansion of the number of tables and graphs that display data and statistics Reorganization of some topics: economics, work, and retirement are now in one chapter (Chapter 7, Economics, Work, and Retirement), living arrangements and housing are combined in one chapter (Chapter 8, Age-Friendly Communities,

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Living Arrangements, and Housing Options), and the topics of assisted living and long-term care have been incorporated into the chapter on medical conditions (Chapter 11, Medical Conditions, Assisted Living, and Long-Term Care) Policies covered throughout the book, rather than in a separate chapter, as they apply to their role in an aging society (Chapter 1, The Longevity Dividend), in the workplace and retirement (Chapter 7, Economics, Work, and Retirement), in providing opportunities for older people to give and receive support (Chapter 10, Older Adults Giving and Receiving Support), in healthcare (Chapter 12, Medicare, Medicaid, and Medications), and in addressing elder abuse (Chapter 14, Elder Abuse and Neglect: Crimes, Scams, and Cons) Practical applications of knowledge with activities for students throughout the text The adoption of new language standards for referring to older people to curtail paternalistic views and engender more positive perspectives on aging: for example, use of the terms older adults, older Americans, and older people, rather than the elderly, elderly people, seniors, and so forth Elimination of statements that repeat myths and stereotypes, because such repetitions unfortunately reinforce what too many people believe to be true More data and statistics that unmask the experiences of older women and older minorities that are often hidden in overall averages, for example, overall poverty statistics for older Americans disguise the fact that older women of all minority groups experience significantly higher rates of poverty than do older men, and the fact that older minority group members experience significantly higher rates of poverty than do older majority group members Avoidance of examples of extraordinary older Americans doing extraordinary things, to avoid the common conclusion that they are exceptions to the rule and that becoming a high achiever is a consequence of a person’s individual efforts and personal choices rather than a complex interplay of multiple factors, including social and economic determinants Use of Bloom’s latest taxonomy for learning objectives, incorporating a range of knowledge and cognitive process dimensions

ACKNOWLEDGMENTS I deeply appreciate the help and support I have received from so many people throughout the development of this second edition. First and foremost, I thank Sheri W. Sussman, executive editor at Springer Publishing Company, who encouraged me to write this second edition. Her insights, prodding, and patience are much appreciated. Rhonda Dearborn, senior acquisitions editor, behavioral sciences, and Mindy Chen, assistant editor, behavioral sciences, shepherded the book to completion. I also thank my colleagues at the University of Nevada, Reno, especially my dean and fellow faculty in the School of Community Health Sciences, and the faculty and staff of the Sanford Center for Aging for their support. National and international colleagues and friends in academia and in aging services, too numerous to name, contributed much to the subject matter of this second edition through our many conversations, discussions, and debates about gerontology over the years. I have also benefited greatly from the work of the FrameWorks Institute, which, on behalf

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of eight national organizations dedicated to the field of aging, has undertaken extensive research and analyses to identify effective ways for us to improve our perspectives and communications about aging. The institute’s resulting recommendations on reframing aging have informed content throughout this edition. Undergraduate students in my introductory aging course at the University of Nevada, Reno, regularly provide feedback that I have used to refine the book’s subject matter. My students always inspire my passion to engage them in the aging enterprise. Helpful contributions in preparing several chapters of the book were made by lecturer Susan G. Harris, PhD, and psychology doctoral student Jonathan Singer, both from the University of Nevada, Reno. As coauthors of the first edition of this textbook, special thanks go to Robert J. Riekse, EdD, Henry Holstege, PhD, and Michael A. Faber, MA, AGHEF, for helping to make that edition successful and, thus, helped to make this second edition possible. And, of course, I send my love and appreciation to my family and friends who provided support, encouragement, tolerance of many curtailed engagements, and a myriad of illustrations from everyday living. Judith A. Sugar, PhD

Qualified instructors may obtain access to supplementary material (Instructor’s Manual, Test Bank, and PowerPoints) by emailing [email protected] Student Activities Answer Key can be accessed by visiting the following url: https://www.springerpub.com/sugar

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Share Introduction to Aging: A Positive, Interdisciplinary Approach, Second Edition

PART I WE ARE ALL AGING

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CHAPTER

1

TH E LON GE V I T Y D I V I D E N D

Age has no reality except in the physical world. The essence of a human being is resistant to the passage of time. Our inner lives are eternal, which is to say that our spirits remain as youthful and vigorous as when we were in full bloom. —Gabriel García Márquez, Love in the Time of Cholera (1985 Spanish/1988 English) It is not by muscle, speed, or physical dexterity that great things are achieved, but by reflection, force of character, and judgement; and in these qualities old age is usually not only not poorer, but is even richer. —Cicero, 106–143 BCE

LEARNING OBJECTIVES • Describe what is meant by the longevity dividend. • Summarize the concept of ageism and describe your awareness of its role in our society. • Contrast the demographics of aging in the United States with those of other countries around the world. • Discuss the opportunities and challenges of an aging population. • Explain the importance of mobilizing all sectors of society to realize the opportunities and address the challenges of an aging society.

THE NEW AMERICAN REVOLUTION America is going through a revolution. No, we are not being overthrown by some sinister internal plot or another nation. And no, we are not referring to the technological revolution that swept business, industry, and education beginning in earnest in the 1990s. We are referring to the aging of America. It is a paradigm shift in the overall composition of the U.S. population. As a whole, Americans are living longer, and, as a result there are many more older people among us than ever before in our history. Upon first hearing this news, it may not sound too exciting or even interesting. But, we now have the opportunity to make the most of the potential of an aging America, and what it can mean

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I We Are All Aging

to the lives of each of us, as individuals, family members, friends, neighbors, students, workers, retirees, and citizens. In the new paradigm of aging, it simply means that, as a society, we have to be joyful for our extended years, realistic about the challenges of longer life, and creative in mobilizing and using our vast national resources for the good of all sectors of our growing population. An important aspect of this new paradigm is the concept known as the longevity dividend. The longevity dividend refers to benefits that can result from living longer lives. Older adults who are not only living longer, but actually in better health too, could boost the economy by virtue of their longer periods of productivity, their ability to earn and save more income over time, and their purchases and consumption of more goods. Furthermore, because of their accumulated wisdom, skills, and talents, they have much that they can contribute to our social environment. Thus, discussions pertaining to the aging population should take into account the potential economic and social benefits that older adults are able to offer to their communities, and to society at large.

Longevity and Life Expectancy There have always been a few individuals who lived especially long lives—Jeanne Calment (1875–1997) comes to mind, a French woman who lived to age 122, confirmed to be the longest human life span to date. But what is more important than some individuals living longer is that the average life span across all individuals has been increasing throughout the world. More people are living longer than ever before in human history. Most of the increases in longevity have come about because of improvements in living conditions and socioeconomic conditions, as well as decreases in deaths due to infectious diseases. Given that large differences exist among countries in the extent to which living and socioeconomic conditions have improved, on the one hand, and deaths due to infectious disease have decreased, on the other, as we might expect, there are large differences among countries in the average life expectancy of their citizens. Life expectancy is the average number of additional years of life a person at a specific age can expect to live. Thus, life expectancy can be calculated at any age—given that a person is age X, how many more years can we expect that person to live, on average, beyond age X? For 24 countries around the world, life expectancy at birth now exceeds 80 years (He, Goodkind, & Kowal, 2016). Over the past 100-plus years we have increased the average American’s life span by several decades. Gains in longevity during recent decades have come about primarily due to advancements in tobacco control, motor vehicle safety, workplace safety, family planning, maternal and child health, and prevention of cardiovascular disease and cancer. Although the average life expectancy at birth is now 80 years in the United States, there are differences between men and women and between people of different races and ethnicities. Table 1.1 compares men’s average life expectancy at birth in 1900 with their average life expectancy at birth in 2016, by race and ethnicity. Table 1.2 shows the same data for women. Note that life expectancy has increased dramatically for everyone. Women live longer than do men in all racial and ethnic groups. There are also race and ethnicity differences, such that Hispanic Americans have the longest life expectancy, followed by White Americans, and then Black Americans. In recent decades, reduced mortality rates at older ages have also increased the number of people living to very old ages. Those who are living to 100 years or more are called centenarians. Centenarians make up a small percentage of the older population—0.2%. But researchers want to learn from their experiences. What has helped them to live so long? In 1980, there were 32,000 centenarians in the United States. By 2016, there were almost 82,000 American centenarians (Administration on Aging, U.S. Department of Health and Human Services, 2016).

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1 The Longevity Dividend

5

TABLE 1.1 Life Expectancy for Men at Birth, by Race and Ethnicity: 1900 Versus 2016 YEAR

WHITE

BLACK

HISPANIC

1900

47

33

*

2016

76

72

79

* Data not available for Hispanic men and women in 1900. SOURCE: National Center for Health Statistics. (2018). Health, United States, 2017: With special feature on mortality. Hyattsville, MD: Author. Retrieved from https://www.cdc.gov/nchs/data/hus/hus17.pdf

TABLE 1.2 Life Expectancy for Women at Birth, by Race and Ethnicity: 1900 Versus 2016 YEAR

WHITE

BLACK

HISPANIC

1900

49

34

*

2016

81

78

84

* Data not available for Hispanic men and women in 1900. SOURCE: National Center for Health Statistics. (2018). Health, United States, 2017: With special feature on mortality. Hyattsville, MD: Author. Retrieved from https://www.cdc.gov/nchs/data/hus/hus17.pdf

Living for more years can be a wonderful gift. But let’s face it, no one wants to live to be 80, 90, or 100 if they will be spending all those added years in ill health. The good news is that, around the world, those “extra” years are increasingly becoming healthier years. To differentiate between life span and those years of life during which a person is healthy, the term healthspan has been coined. Healthspan is the portion of a person’s life during which he or she is healthy, and by healthy we mean free of a leading cause of death, for example, heart disease or lung cancer. Figure 1.1 shows the increases in healthspan in world regions over the previous 16 years. The largest increases have been in African countries, with an average gain of over 9 years of additional healthy years of life. The longest healthspans are among people living in the Western Pacific, Europe, and the Americas. Although the gains in countries in the latter regions have not been as dramatic, even people living in the Americas have seen, in less than two decades, an average increase of about two-and-a half additional years of life during which they are free of any of the leading causes of death. Furthermore, promising research is being conducted in the basic biology of aging, with the goal of delaying aging processes. Achieving this goal would take care of age-related diseases such as cancer, heart disease, and diabetes, and lead to dramatic improvements in healthspan for current and future generations of older people. Not only are healthspans getting longer, but current and future generations of older people are becoming more and more educated. In the United States, between 1965 and 2015, the percentage of older people who had completed high school more than tripled, rising from 24% to 85% (Federal Interagency Forum on Aging-Related Statistics, 2016). This is important because there is a strong relationship between level of education and health such that the more education people have, the healthier they are. Furthermore, education increases our ability to be problem solvers and innovators, key functions if we are to address the challenges of our increasingly complex world.

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I  We Are All Aging

75

70

Years of Age

65

60

55

50

Western Pacific Europe Americas Eastern Mediterranean South-East Asia Africa

45

40

2000

2010

2016

FIGURE 1.1  Average human healthspan, in selected years by world region. SOURCE: World Health Organization. (2018). Healthy life expectancy (HALE): Data by WHO region. Retrieved from http://apps.who.int/gho/data/view.main.HALEXREGv?lang=en

Ageism Increased longevity is a human achievement that should be celebrated. Yet, to paraphrase a quote attributed to Dr. Edward Stieglitz (1946) in his book, The Second Forty Years, what is important is not just to add years to our life, but life to our years. The question, then, is what are we going to do with all those extended years of our lives? To take advantage of the opportunities those years afford us, one of the most important things we need to do is to change the negative attitudes and inaccurate stereotypes about aging that are far too pervasive in our society. Ageism is discrimination against people based on their age and it is most commonly directed at older people. The term, of course, can also be used to describe discrimination directed at younger people, for example, paying younger workers lower wages based solely on their age. The late Dr. Robert N. Butler, a leading expert in gerontology and geriatric medicine and a Pulitzer Prize– winning author and founder of the International Longevity Center-USA, coined the term ageism in 1969. He described three aspects to this prejudice: negative attitudes toward older people, old age, and the aging process; discriminatory practices against older people; and, institutional practices and policies that perpetuate negative stereotypes and attitudes about older people. Although ageist attitudes and stereotypes can be positive or negative, when it comes to older people, they are mostly negative. Throughout our lives, we are all exposed to negative stereotypes about people based on their age, stereotypes that are conveyed through news stories, movies and TV programs, and even music. Many of the things we come to believe about older people are wrong. For example, in this textbook we will learn that most older people regard their physical health as good; they are happy; they enjoy and engage in sexual activities; most live in their own homes and have close

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relationships with family members; and, they are very good workers. Older people themselves are not exempt from ageism. Because they are part of our ageist culture, they too have been subjected to messages in our society that denigrate older adults. One way that ageism is exacerbated is when everyone who is age 65 and over is lumped together as “older adults.” This obscures important differences among people as they age. Gerontologists, and the U.S. Census Bureau, use three subcategories when studying aging: ■ ■ ■

The young-old, people 65 through 74 years of age The old-old, people 75 through 84 years of age The oldest-old, people 85 years of age or older

The reason these subcategories are important is because the characteristics, desires, strengths, and needs of people at different stages of life can be very different. There can be great differences between the young-old, the vast majority of whom are living active lives and are in good health, and the oldest-old, many of whom may have multiple chronic conditions and rely on the assistance and support of their families, friends, and communities. This obviously does not mean that all persons who are in the young-old category are vigorous and healthy, but there is a greater likelihood of this being the case. Nor does it mean that most of the oldest-old are frail and living in residential care settings, but there is a greater likelihood of needing more support as a person moves into the oldest years of life. Certainly, all age groups within our population—youth, young adults, middle-aged people, the young-old, the old-old, and the oldest-old—are heterogeneous. We would do well to remember that all age groups are made up of different people with a wide range of resources and needs. Ageism can be implicit or explicit. When it is implicit, it is part of our subconscious thoughts and feelings so we usually fail to recognize it. We are quick to call instances of forgetting in older people a possible outcome of Alzheimer’s, when we would not think twice about a younger person forgetting something. We ignore the fact that lost and found repositories on college and university campuses are testimony to just how often younger people forget. And, not just forget, but forget important and valuable possessions! Ageism is so ingrained in us that we will need to make an effort to overcome these long-held and counterproductive views. And, we can, and we must, do this! America is committed to being a just society for all. Ageist attitudes and stereotypes, however, get in the way of treating older people as equal members of our society. They affect all aspects of older people’s lives and prevent them from fully participating in our society. We can ill afford to squander the experience, talents, and energy of this increasingly large segment of our population that is older adults. Negative Effects of Ageism Ageism has a major detrimental effect on all aspects of older people’s lives. For example, negative attitudes and stereotypes about older workers—attitudes and stereotypes that are just plain incorrect—keep older people from being promoted, result in pressuring them to retire, and make it difficult for them to find employment. Ageism in healthcare settings leads to unnecessary morbidity and premature mortality among older people because they are less likely to be screened for chronic conditions and thus less likely to be diagnosed at early stages of their condition when treatments can be more effective.

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Physical and cognitive functions are also affected by ageism. Negative stereotypes accelerate cellular aging, and predict signs of Alzheimer’s disease (Levy, Pilver, & Pietrzak, 2014; Pietrzak et al., 2016). A lifetime of exposure to ageist messages about memory has been demonstrated to negatively affect actual performance on tests of memory (Levy & Langer, 1994). On the other hand, research has demonstrated that positive views of aging can increase longevity, hasten recovery from disability, and improve driving performance (Lakra, Ng, & Levy, 2012; Levy, Ng, Myers, & Marottoli, 2013; Levy, Slade, Murphy, & Gill, 2012). Several studies have found that ageist attitudes and stereotypes held early in life have detrimental consequences on our cognitive abilities and physical health later in life. These consequences include poorer memory and more cardiovascular events (Levy, Zonderman, Slade, & Ferrucci, 2009, 2012). Imagine, the negative views you hold about older people when you are young can affect your cognitive and physical health in later life! Best, then, to adopt positive views of aging, and if that proves difficult, then act as if you hold positive views, because you will reap the benefits of these views throughout your life.

OUR AGING WORLD In the United States, age 65 is often used as a demarcation for older adults, mainly due to this age being used in the past as the so-called “traditional” age for retirement. The fact is that the age 65 has no physical or psychological significance. But, we will use that age frequently throughout the textbook because this age is used in so many of the surveys and reports of data and statistics about older people. To better understand aging in the United States, it is helpful to look at aging trends around the world. In the year 2000, 420 million people in the world were 65 or older, which was about 7% of the world’s population. By 2050, that number is expected to rise to 1.6 billion, which will then be about 17% of the world’s population (He et al., 2016). With declining fertility (birth) and mortality (death) rates in most countries, populations are aging in virtually all countries—although at different rates. Developed countries tend to have higher proportions of people 65 and older. But the most rapid increases in the proportions of older populations are in the developing countries. Even in countries where the percentage of people age 65 and older remains low, the actual numbers of older people are increasing rapidly. Among the world’s countries with a total population of at least 1 million people, Table 1.3 lists the ones in which at least 10% of their population is age 65 and older, a total of 53 countries. The United States is 34th on that list, with 15% of its population age 65 or older (Federal Interagency Forum on Aging-Related Statistics, 2016). The country with the highest percentage of older people on the list is Japan, with almost 27%. Five other countries have at least 20%—Germany, Italy, Greece, Finland, and Sweden. The country with the highest percentage of older people, however, is a much smaller country than those included in Table 1.3. In Monaco, which has a total population of just under 31,000 people, over 32% are 65 or older (Central Intelligence Agency, 2017). You might be surprised to see that China, the most populous country in the world, is at the very bottom of the list in Table 1.3. It has the greatest number of people age 65 and older in the world—137 million—but they comprise only 10% of China’s population. On the other hand, India, which is not on the list, has just over 6% (80 million) of its population of 1.3 billion people who are 65 years of age or older. The biggest factor in the size of the older population in these two countries is the difference in their fertility rates, China’s is 1.6 per woman and India’s is 2.4 per

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TABLE 1.3 Population of Countries or Areas With At Least 10% of Their Population Age 65 and Over, 2015 POPULATION (NUMBER IN THOUSANDS)

PERCENT

COUNTRY OR AREA

TOTAL

65+

65+

Japan

126,920

33,750

26.6

Germany

80,854

17,346

21.5

Italy

61,855

13,110

21.2

Greece

10,776

2,204

20.5

Finland

5,477

1,107

20.2

Sweden

9,802

1,959

20.0

Lithuania

2,884

552

19.1

Estonia

1,265

242

19.1

Latvia

1,987

377

19.0

Austria

8,666

1,639

18.9

Portugal

10,825

2,045

18.9

France

66,554

12,472

18.7

Bulgaria

7,187

1,345

18.7

Denmark

5,582

1,043

18.7

Slovenia

1,983

365

18.4

Hungary

9,898

1,805

18.2

Belgium

11,324

2,065

18.2

Croatia

4,465

814

18.2

Czech Republic

10,645

1,917

18.0

Netherlands

16,948

3,046

18.0

Switzerland

8,122

1,443

17.8

48,146

8,546

17.7

Spain

(continued )

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TABLE 1.3 Population of Countries or Areas With At Least 10% of Their Population Age 65 and Over, 2015 (continued ) POPULATION (NUMBER IN THOUSANDS) COUNTRY OR AREA

PERCENT

TOTAL

65+

65+

United Kingdom

64,088

11,366

17.7

Canada

35,100

6,223

17.7

Serbia

7,177

1,264

17.6

Puerto Rico

3,598

630

17.5

Norway

5,208

850

16.3

Ukraine

44,429

7,019

15.8

Romania

21,666

3,408

15.7

Poland

38,562

6,044

15.7

Georgia

4,931

766

15.5

Australia

22,751

3,520

15.5

7,141

1,096

15.3

United States

321,369

47,830

14.9

New Zealand

4,438

649

14.6

Belarus

9,590

1,385

14.4

Slovakia

5,445

782

14.4

Uruguay

3,342

469

14.0

Bosnia & Herzegovina

3,867

528

13.7

142,424

19,384

13.6

Korea, South

49,115

6,395

13.0

Cuba

11,031

1,428

12.9

Macedonia

2,096

267

12.7

Ireland

4,892

617

12.6

Hong Kong

Russia

(continued )

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TABLE 1.3 Population of Countries or Areas With At Least 10% of Their Population Age 65 and Over, 2015 (continued ) POPULATION (NUMBER IN THOUSANDS) COUNTRY OR AREA Taiwan

PERCENT

TOTAL

65+

65+

23,415

2,922

12.5

Moldova

3,547

414

11.7

Argentina

43,432

5,018

11.6

Cyprus

1,189

137

11.5

Albania

3,029

342

11.3

Israel

8,049

873

10.8

Armenia

3,056

327

10.7

Chile

17,508

1,789

10.2

China

1,367,485

136,890

10.0

NOTE: Table excludes countries/areas with less than 1 million total population. SOURCE: Federal Interagency Forum on Aging-Related Statistics. (2016). Older Americans. Key indicators of well-being. Washington, DC: U.S. Government Printing Office. Retrieved from https://agingstats.gov/

woman. This factor will continue to play a role in the size and proportion of their older populations for decades to come. Why pay attention to population aging around the world? First, we are a global society so what happens in other countries affects everyone around the world—young people, middle-aged people, older people, consumers, workers, tourists, and business owners, among many others. Secondly, there is much Americans can learn from all of those countries whose older populations are already proportionately much larger than ours, and from many others, such as South Korea, where older people will become a much larger proportion of their population than ours in the not too distant future. The largest group of individuals ever born in one period of American history is the baby boomers, a generation of individuals born between 1946 and 1964, numbering approximately 78 million. The “boom” in births began the year following the end of World War II and resulted in 70% more babies being born than there were in the previous two decades. The first of the baby boomers began turning age 65 in 2011 and beginning in that year, and continuing for many more years, approximately 10,000 of them will turn age 65 every day. The year 2030 marks a demographic turning point for the United States. Beginning that year, all baby boomers will be older than 65, thereby expanding the size of our older population to one in every five Americans. Later that decade, by 2035, older adults are expected to outnumber children under 18 for the first time in U.S. history.

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Opportunities and Challenges Presented by an Aging Population People in all generations have something to contribute to enrich our society and create greater social, economic, and civic well-being for everyone. Each generation has its own set of assets, and older people are no exception. As we age, we build up wisdom, experience, skills, and talents that we should put to good use to move our society forward. We need to remove the barriers to older people participating fully in our communities. There are many things we can do to mobilize the energy of older people to share their talents for the benefit of our communities. Creating intergenerational programs that bring older and younger people together in community centers that welcome people of all ages is but one example. Changing our policies and practices regarding the workplace is another. Older people are among the best workers in America, and yet we limit their ability to stay in the workforce and to rejoin the workforce when they retire too soon. Building housing to accommodate people of all ages and creating innovative transportation options will benefit people of all ages. Such initiatives will also decrease the isolation that people can experience as they get older, and reducing isolation can remove a major cause of the abuse to which older people are all too often subjected. Liberating the Talents of All What does it mean to grow older in the 21st century—as society begins to realize the social revolution it is undergoing, at a time when more and more people are reaching the oldest-old years (85 years of age and older), and the ranks of the youngest-old (65–74 years of age) are beginning to be populated with millions of baby boomers with more vigor, vitality, and better health than any previous generation? Growing older needs to be viewed as simply another phase of life. People need to be encouraged to continue to participate in the labor force if they need to or want to. To secure or retain employment, job training and retraining should be open to all, regardless of age. It means that our society needs to stop closing doors to people simply because of advancing years. The technologies of the new age, including the information superhighway, promise to open even more opportunities for older people to play a vital role in determining their own destinies and to have an impact on their communities and on our society. Recognizing the diversity of the older population, a new perception of aging needs to be developed that avoids the stereotypes that have molded society’s perception of older people, as well as older people’s perception of themselves. In a complex society with all of the challenges that are evident every day, our nation cannot afford to discard or ignore the ongoing contributions all our citizens, of all ages, can make. Challenges of an Aging Population Let us not be naïve or unrealistic. There are huge opportunities for us to benefit from our aging population. But, there are challenges too. It is within our ability to address all of these challenges, some of which have already been mentioned: workplace discrimination; isolation, which can lead to abuse and neglect; poverty, especially among older women and older minority group members; and issues that arise in widowhood, among many others. Both younger and older people are facing economic hardships. Younger people are saddled with student loans and wages are not keeping up with increases in the costs of living, especially housing, making it harder to enjoy the quality of life that many of their parents had. Living longer produces additional strains on older

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people’s economic resources, so we see many older people continuing to be part of the labor force because that is the only way they can make ends meet. Another challenge that is often raised when our aging society is being discussed is how can a proportionately smaller population of younger people support a growing population of older people? This issue is usually brought up in the context of what is termed dependency ratios. Dependency ratios are measures of the population of dependents, that is, people who are not employed because they are considered too young or too old, as a percentage of the population of people who are employed at any given point in time. Importantly, dependency ratios are affected by the need for certain kinds of supports at both ends of the life span. Figure 1.2 displays these ratios for the United States in selected years between 1940 and 2010, and projected through 2060. What we can see in this figure is that the highest ratios took place in the 1960s and 1970s, and that the primary drivers of these ratios were dependents who were young. In fact, they were those baby boomers! Although the dependency ratio in the United States is expected to increase over the next few decades, it is not projected to rise as high as it did during the 1960s and 1970s. So the story that the sky is falling as a consequence of our increasing dependency ratio is not legitimate. We made it through those decades of baby boomers growing into young adults and subsequently taking their place in the workforce, and we were just fine. And, we will also be just fine in terms of our dependency ratio going forward. We will be in even better shape if we alter some of the ways that we limit the contributions of older people in our society—for example, by removing the barriers that keep many older people unemployed when they want to be working. To address the challenges and to take advantage of the opportunities as we age, we will need to develop new policies and practices. One approach is to modify existing legislative acts such as Medicare, Social Security, the Older Americans Act (OAA), the Patient Protection and

90 80

Dependency Ratio

70 60 50 40 30 20

Total Dependency Youth Dependency Older Adult Dependency

10 0

1940 1950 1960 1970 1980 1990 2000 2010 2020 2030 2040 2050 2060

FIGURE 1.2  Youth, older adult, and total dependency ratios: 1940 to 2060. NOTE: Dependency ratios are measures of the population of dependents (people who are not employed because they are considered too young or too old) as a percentage of the population of people in the workforce. SOURCE: Vespa, J., Armstrong, D. M., & Medina, L. (2018). Demographic turning points for the United States: Population projections for 2020 to 2060 (Current Population Reports P25-1144). Washington, DC: U.S. Census ­Bureau. Retrieved from https://www.census.gov/content/dam/Census/library/publications/2018/demo/P25_1144.pdf

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Affordable Care Act (PPACA), and the Americans with Disabilities Act (ADA). Another approach is to encourage new practices and introduce new legislative acts. One example of the first approach is the 2016 amendments to the OAA, which included the establishment of Aging and Disability Resource Centers (ADRCs). ADRCs coordinate with local Area Agencies on Aging (AAA) in order to promote home- and community-based services and enable older adults to live as independently as possible. The amendments also facilitate ways of addressing elder abuse and provide support for family caregivers. In the case of Medicare, we may need to consider new ways to address rising healthcare costs in order to maintain its value in providing essential healthcare benefits for older adults and people living with serious disabilities. Chapter 7, Economics, Work, and Retirement , includes a discussion of the importance of Social Security to all generations of Americans, and thus the significance of possible modest legislative changes that would keep the program financially sound. When it comes to encouraging new practices, one good place to do that would be the workplace. Older workers, as we will see in Chapter 7, Economics, Work, and Retirement, are valuable assets for employers, so offering them the same continuing education and training opportunities as younger workers receive, as well as creating age-friendly work environments, would go a long way in motivating older workers to stay a little longer in the workplace—a major win for everyone—employees of all ages, employers, communities, and societies. One example of somewhat newer legislation to address the growing problem of elder mistreatment (which includes abuse, exploitation, and neglect) is the Elder Justice Act, which was passed in 2003 as part of the PPACA. This act provides for the establishment of forensic centers, the Elder Justice Coordinating Council, funding for state agencies to collect data on elder abuse, and a nurses’ aide registry of those who have completed training on elder abuse. And, an even newer piece of federal legislation, which was signed into law on July 7, 2018, is the federal Supporting Grandparents Raising Grandchildren Act. The number of grandparents raising grandchildren has been rising steadily. In 2017, 7.3 million grandparents reported living with grandchildren under 18 (compared with 6.5 million in 2010). Of those, 36% are solely responsible for their grandchildren. Existing programs, such as the Temporary Assistance for Needy Families (TANF) can be helpful, as can cooperative extension programs and initiatives such as Cornell University’s Parenting the Second Time Around (PASTA) and Relatives as Parents Program (RAPP). This new act will establish a Federal Advisory Council to provide support for grandparents raising children, including providing information about best practices and available resources.

A NEW PARADIGM OF AGING Our nation is facing the reality of a new paradigm of aging in the 21st century—a new view of what it means to be older. In previous generations, older people were often viewed as unique or a separate group from the population as a whole. But all this is changing with our increasing longevity and the opportunities and challenges that our longevity presents to our society. The late Dr. Robert Butler outlined the changes and challenges of an aging society. He believed that society will adapt to the great achievements in longevity—so many people living much longer. To Dr. Butler, the greatest challenges of the new longevity are facing head-on the fallacies and outright myths about old age that permeate so much of our culture, and promoting an “active, engaged, and productive older population” (Butler, 2008, p. 34). Butler goes on to say that this is

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possible by calling for new responsibilities, new goals, and new achievements. Developing new roles and new attitudes toward work and civic engagement for people of all ages will enhance the human condition in ways that society is just beginning to explore. We can make the most of our aging population only if most of our citizens—civic leaders, politicians, policy makers, and citizens in general, including older people themselves—develop a new paradigm of growing older in America. This paradigm consists of looking at aging and all older people as an integral part of our whole society. A new paradigm of aging in America envisions older people playing vital roles in all aspects of life—personal relationships, family life, play, civic engagement, worship, and overall citizenship. We need a new view of aging—a view that takes into account the diversity and potential of people of all ages. Some people are “burned out” at age 50. Others are in their prime at ages 68 or 70. Some are vulnerable in their late middle years due to chronic health conditions. Others find work the most important part of their lives in their late 60s and 70s. Some 40-year-olds would like to take a break from employment and then return to the workforce. Some have experienced discrimination all their lives because of their sex, race, or ethnic background. With the booming growth of the oldest-old, and the young-old entering their later years as a pioneering generation in better health, affluence, and vitality than previous generations experienced, we need a new and broader view of what growing older in America means. All who study aging must realistically understand the aging process; be aware of the major and rapid population changes that are occurring; examine what growing older currently means to society and to older people themselves; be aware of the resources and supports that are available; realize the impacts of an aging society on business, government, and family structures; and participate in the discussions and debates that surround the issues affecting older people. This book is designed to guide the reader in these endeavors.

PRACTICAL APPLICATION INTRODUCTION

Chapter 1 focuses on the longevity dividend and the importance of mobilizing all sectors of the society to realize the opportunities and address the challenges of an aging society. It includes demographic information related to aging in the United States as compared with that of other countries, as well as a discussion about the detrimental effects of ageism on older adults and on society as a whole. It is especially important for gerontology professionals to understand and avoid ageism; therefore, it is the focus of this Practical Application. AGEISM: OVERCOMING SOCIETAL STEREOTYPES AND MYTHS OF AGING

Being aware of harmful labels and misconceptions is important; yet putting a stop to them holds the most relevance to the actual day-to-day practice of gerontology. Whether you are a student considering entry into the field, or a seasoned professional, you should always ask yourself: Am I doing or saying anything that perpetuates a negative stereotype of aging? This could come in the form of off-hand jokes, making disparaging remarks about your own aging process (“I’m getting so old!”), or using elderspeak, belittling terms such as “sweetie” or “dear” when speaking to an older adult. According to Dr. Becca Levy, professor of epidemiology and psychology at Yale University, “little insults [like these] lead to more negative images of

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aging. . . [a]nd those who have more negative images of aging have worse functional health over time, including lower rates of survival” (as cited in Leland, 2008, para. 4). Unfortunately, middle- and younger-aged people are not alone in perpetuating the myths and stereotypes of aging. Often older persons themselves are unintentional culprits. An example of this is an 89-year-old woman with Parkinson’s disease and poor hearing. When asked if she is exercising regularly, or invited to go somewhere away from her nursing home, her usual response is, “I’m too old to do that.” While she does have some very real physical challenges due to her condition, she is able to do much more than she allows herself to do. This response is not completely due to her view of aging. It is also the result of her fear of falling and not being able to communicate effectively with others due to her hearing loss. Yet her quality of life could be much better than it is today if she had a more positive view of aging and greater confidence in her abilities.

STUDENT ACTIVITIES 1. Write a description of a hypothetical older adult who is currently benefiting from a lon-

2. 3.

4. 5.

ger healthspan. Come up with a name, age, and gender for this person, and describe in detail how his or her activities contribute to the longevity dividend. In what ways does he or she positively impact the U.S. economy and society? Describe a situation in which either you or someone around you engaged in a) implicit ageism and b) explicit ageism. Imagine you are designing a demographics study of another country where the population of older adults is proportionately larger than that of the United States. What question would you like to ask in your research? How would answering this question contribute to the current understanding of the demographics of aging in the United States? Describe an ideal workplace that is inclusive of all age groups. Then list four ways employees would benefit from working in such an environment. Outline a proposed initiative designed to promote civic engagement of older people in your community. Focus on a current need in your community and consider ways older adults could help address it.

SUGGESTED RESOURCES Administration for Community Living. Profile of older Americans. Retrieved from https://acl.gov/ aging-and-disability-in-america/data-and-research/profile-older-americans Each year, the U.S. Administration on Aging (AoA) compiles the latest statistics on older Americans, based primarily on data from the U.S. Census Bureau. The profiles include data on demographics, income and poverty, living arrangements, education, health, and caregiving.

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International Longevity Center-USA. Retrieved from http://www.ilc-alliance.org/index.php/members/ details/ilc-usa Founded in 1990 by world-renowned gerontologist, the late Robert N. Butler, the Center was created to educate individuals on how to live longer and better, and advise society on how to maximize the benefits of today’s longer life spans. National Centenarian Awareness Project. Retrieved from https://www.growingbolder.com/national -centenarian-awareness-project/ This nonprofit organization celebrates active centenarians as role models for the future of aging. National Council on Aging (NCOA). Retrieved from https://www.ncoa.org NCOA is a nonprofit service and advocacy organization. Bringing together nonprofit organizations, businesses, and government, it champions issues and creates innovative programs that focus on making life better for older adults, especially those who are vulnerable and disadvantaged. U.S. Census Bureau. Retrieved from https://www.census.gov The Census Bureau’s website provides many resources on population information, including a dynamic U.S. population clock that reports the overall population count, and numbers of new births, deaths, and immigrants, as well as a dynamic world population clock with the overall numbers for the 10 most populous countries in the world.

REFERENCES Administration on Aging, U.S. Department of Health and Human Services. (2016). A profile of older Americans. Retrieved from https://www.acl.gov/sites/default/files/Aging%20and%20Disability%20 in%20America/2016-Profile.pdf Butler, R. N. (2008). The longevity revolution. Philadelphia, PA: Public Affairs, Perseus Books Group. Central Intelligence Agency. (2017). The world factbook. Retrieved from https://www.cia.gov/library/ publications/the-world-factbook/geos/mn.html Federal Interagency Forum on Aging-Related Statistics. (2016). Older Americans. Key indicators of wellbeing. Washington, DC: U.S. Government Printing Office. Retrieved from https://agingstats.gov/ He, W., Goodkind, D., & Kowal, P. (2016). An aging world: 2015 (International Population Reports, P95/16-1). U. S. Census Bureau. Washington, DC: U.S. Government Publishing Office. Retrieved from https://www.census.gov/content/dam/Census/library/publications/2016/demo/p95-16-1.pdf Lakra, D. C., Ng, R., & Levy, B. R. (2012). Increased longevity from viewing retirement positively. Ageing and Society, 32(8), 1418–1427. doi:10.1017/S0144686X11000985 Leland, J. (2008, October 6). In “Sweetie” and “Dear,” a hurt for the elderly. The New York Times. Retrieved from www.nytimes.com/2008/10/07/us/07aging.html Levy, B. R., & Langer, E. (1994). Aging free from stereotypes: Successful memory in China and among the American deaf. Journal of Personality and Social Psychology, 66(6), 989–997. doi:10.1037/0022-3514.66.6.989 Levy, B. R., Ng, R., Myers, L., & Marottoli, R. A. (2013). A psychological predictor of elders’ driving performance: Social comparisons on the road. Journal of Applied Social Psychology, 43(3), 556–561. doi:10.1111/j.1559-1816.2013.01035.x Levy, B. R., Slade, M., Murphy, T. E., & Gill, T. (2012). Association between positive age stereotypes and recovery from disability in older persons. Journal of the American Medical Association, 308(19), 1972–1973. doi:10.1001/jama.2012.14541. Levy, B. R., Pilver, C. E., & Pietrzak, R. H. (2014). Lower prevalence of psychiatric conditions when negative age stereotypes are resisted. Social Science and Medicine, 119, 170–174. doi:10.1016/j .socscimed.2014.06.046 Levy, B. R., Zonderman, A. B., Slade, M. D., & Ferrucci, L. (2009). Age stereotypes held earlier in life predict cardiovascular events in later life. Psychological Science, 20(3), 296–298.

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Levy, B. R., Zonderman, A. B., Slade, M. D., & Ferrucci, L. (2012). Memory shaped by age stereotypes over time. Journals of Gerontology, Series B: Psychological Sciences and Social Sciences, 67(4), 432–436. National Center for Health Statistics. (2018). Health, United States, 2017: With special feature on mortality. Hyattsville, MD: Author. Retrieved from https://www.cdc.gov/nchs/data/hus/hus17.pdf Pietrzak, R. H., Zhu, Y., Slade, M. D., Qi, Q., Krystal, J. H., Southwick, S. M., & Levy, B. R. (2016). Association between negative age stereotypes and accelerated cellular aging: Evidence from two cohorts of older adults. Journal of the American Geriatrics Society, 64(11), e228–e230. Stieglitz, E. J. (1946). The second forty years. Philadelphia, PA: J. B. Lippincott. Vespa, J., Armstrong, D. M., & Medina, L. (2018). Demographic turning points for the United States: Population projections for 2020 to 2060 (Current Population Reports P25-1144). Washington, DC: U.S. Census Bureau. Retrieved from https://www.census.gov/content/dam/Census/library/ publications/2018/demo/P25_1144.pdf World Health Organization. (2018). Healthy life expectancy (HALE): Data by WHO region. Retrieved from http://apps.who.int/gho/data/view.main.HALEXREGv?lang=en

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PART II PHYSICAL AND MENTAL WELL-BEING

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PH Y S I C AL C HAN G E S A N D TH E   AGI N G P R O C E S S

LEARNING OBJECTIVES • Compare normal physical changes that accompany aging and diseases and conditions that become more common with age. • Identify the usual, normal physical changes that accompany aging. • Outline adaptations that older people can make to accommodate normal physical changes. • Explain how attention to normal physical changes can prevent serious consequences for older people. • Summarize the two basic paradigms of biological theories of aging.

PUTTING PHYSICAL AGING CHANGES IN PERSPECTIVE I am now, probably for the first time in my life, the person I have always wanted to be. Oh, not my body! I sometimes despair over my body, the wrinkles, the baggy eyes, the skinny arms. And, often, I am taken aback by that old person who lives in my mirror, but I don’t agonize over those things for long. I would never trade my amazing friends, my wonderful life, for less gray hair. As I’ve aged, I’ve become kinder to myself and less critical of myself. I’ve become my own friend. . . . . I am blessed to have lived long enough to have my hair turn white, and to have my youthful laugh be forever etched into the deep grooves of my face. So many have never laughed, and so many have died before their hair could turn silver. (continued next page )

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As we get older, it is easier to be positive. We care less about what other people think. I don’t question myself anymore. I’ve earned the right to be wrong. I like being old. It has set me free. I am not going to live forever, but while I am still here, I will try not to waste time lamenting too much or too long about what could have been, or worrying too long about what will be. I shall eat dessert and a piece of bread every single day, if I feel like it. May you have a rainbow of smiles on your face and in your heart forever and ever. —Margaret Berry, age 100 (2015)

NORMAL PHYSICAL CHANGES THAT ACCOMPANY AGING AND ADAPTATIONS TO THEM Aging is accompanied by physical changes to the body—no surprise there! But, the physical changes that normally occur as we grow older, such as our feet getting larger, can and should be differentiated from medical conditions that are more likely as we age, such as heart disease. Some physical changes are part of the normal aging process and occur for a majority of people, and sometimes for all people, as they age. For these changes there are mostly simple adaptations—in the case of larger feet, buying shoes in a bigger size. On the other hand, some medical conditions become more common with age, which means that the chances of acquiring them increase with age, but not every older person acquires them. Medical conditions are presented and discussed in Chapter 11, Medical Conditions, Assisted Living, and Long-Term Care. In this chapter, we focus on the physical changes that accompany the normal aging process. There is no specified common timetable for human aging; instead, there are enormous individual differences in the aging process, and all older people do not experience all possible changes. Nevertheless, as people grow older, changes that may be hardly noticeable at first tend to occur throughout the physical systems of the body. Among the physical changes that can be expected to occur as we age, some, such as gray hair and wrinkling skin, are more visible, while others, such as hearing loss and hypothermia, may be less visible.

Hair One of the most noticeable physical changes that occur with aging is hair color turning gray, silver, or white. Although this change is usually a phenomenon of aging, young people’s hair can turn gray too, sometimes as a result of severe physical or emotional stress. No one knows why specific hairs turn gray or white and others do not. Within each hair follicle (tubelike organs in the skin) are cells that add color to the hair shaft. Each specific hair grows for about 3 years, then rests for several months before it starts growing again. As one ages, the color-producing cells cease functioning, and the hair grows out gray or white. At the present time, there is no known process to help those cells continue producing their original color. It is known that there is a genetic component to the action of those cells, and as a result, those whose ancestors’ hair turned gray early

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in life have a higher probability of their hair turning gray early in life (Saxon, Etten, & Perkins, 2010). One way people adapt to this change is by coloring or dyeing their hair. Others wear their new hair color with pride. Another noticeable aging change with respect to hair is thinning or hair loss, which, like most normal aging changes, occurs gradually over time. Hair thinning can lead to baldness, especially in men. Being bald is distressing for some people, so various ways to manage hair loss have been developed, from hair pieces and home remedies to drugs and transplants. Existing drugs have only marginal effects and must be taken continuously to work at all. Hair transplantation is a surgical procedure that moves hair from one part of the head to the balding areas; it can be painful and there are risks of scarring and infection. Low-level laser therapy is another treatment and seems to stimulate hair growth but the most effective way to use it and its long-term effectiveness and safety have yet to be determined (Avci, Gupta, Clark, Wikonkal, & Hamblin, 2014). Lots of research is in the works, so new solutions for those who want to remedy their hair loss may be on the horizon. An entirely different approach is to embrace baldness, and more and more men are doing that.

Skin As people grow older, their skin begins to change. It becomes thinner, loses fat, and wrinkles, losing some of its plumpness and smoothness. For most people these changes begin in their 20s, and are accelerated by smoking and frequent, extended exposure to the sun and very dry air. Thinner skin means that veins and bones can be seen more easily, and scratches, cuts, or bumps can take longer to heal. The wrinkling process varies depending on a person’s genetic heritage. The skin of blonde, pale-skinned people tends to wrinkle sooner than it does for those with darker skin. Adaptations for age-related changes to our skin abound (National Institute on Aging, 2017b). Not smoking, or quitting smoking, is an obvious one. Another is to minimize the effects of the sun by avoiding prolonged direct exposure and using a sunscreen lotion or protective clothing that offer good protection from ultraviolet A and B solar radiation. Tanning parlors are also something to be avoided. Indoors, rooms should be kept moist so that dry skin will not crack. If a humidifier is unaffordable, pans of water placed on a heat register can be used to put moisture into the air. In addition, daily use of moisturizers, such as lotions, creams, and ointments, softens dry skin. Massages and facials are excellent choices for hydrating the skin. Manicures and pedicures can also be helpful because they involve massaging hands and feet with moisturizers.

Thermoregulation Older people do not adjust to temperature changes as well as young people do, and they are more likely to take prescription medications or have a chronic medical condition that further changes their body’s ability to regulate its temperature. For these reasons, older people are more prone to the negative effects of cold temperatures, which can result in hypothermia, and also to hot temperatures, which can result in hyperthermia. The loss of subcutaneous fat and a diminished flow of blood to the skin and extremities, both of which occur with aging, are important contributors to older people’s reduced thermoregulatory abilities. Both hypothermia and hyperthermia can be fatal, so steps should be taken to avoid them. If they occur, they require immediate medical attention.

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Hypothermia Hypothermia is a reduction in core body temperature, with a danger that the body’s temperature will get so low that a person’s life may become endangered. Research seems to indicate that the danger of hypothermia among older persons is much greater than previously believed. Hypothermia can even result in death, although it is often overlooked as a cause of death. Thus, it is important to know the symptoms of hypothermia. One should be alert for the umbles—stumbles, mumbles, fumbles, and grumbles. Check for slowed or slurred speech; sleepiness or confusion; shivering or stiffness in the arms and legs; poor control over body movements; slow reactions; or a weak pulse. Whenever an older person has any of these symptoms and his or her temperature drops to 95°F or lower, immediate medical attention should be sought (National Institute on Aging, 2017a). Prevention of hypothermia among older adults can be quite simple: Indoors, room temperatures should be maintained at no less than 68°F, and additional clothing such as long underwear, socks, slippers, and a hat can be helpful. When it is cold outdoors, wearing layers of loose clothing and a hat, scarf, and gloves or mittens can reduce loss of body heat. Hyperthermia Hyperthermia is an abnormally high body temperature due to hot conditions in the environment in conjunction with imperfect heat-regulating mechanisms in the body, and, like hypothermia, it can be life-threatening. Symptoms of hyperthermia to watch out for include: a strong, rapid pulse or a slow, weak pulse; lack of sweating; dry, flushed skin; change in behavior—agitation, combativeness, or confusion; staggering; and faintness. Whenever an older person has any of these symptoms and his or her temperature reaches above 104°F, immediate medical attention should be sought (National Institute on Aging, 2016a). Some ways to prevent hyperthermia are to stay indoors on hot days in cooled or air-conditioned rooms; drink plenty of fluids, but avoid caffeine and alcoholic beverages; apply cold, wet cloths to the wrists, neck, armpits, and/or groin; and bathe or sponge off with cool water. People without air-conditioning can go to places in the community that can offer a cooler setting, such as senior centers, shopping malls, and libraries. The Low-Income Home Energy Assistance Program (LIHEAP), a federally funded program that operates through state governments, the District of Columbia, tribes and tribal organizations, and U.S. territories, can help families stay warm in the winter and cool in the summer, reducing the risk of health and safety problems that can arise from unsafe heating and cooling practices. This program provides assistance in managing costs associated with: ■ ■ ■

Home energy bills Energy crises, for example, as a result of a natural disaster Weatherization and energy-related minor home repairs

During the hot summer months, New York State used a portion of its LIHEAP funding to help low-income residents with documented medical needs keep their homes at a healthy temperature. Prolonged exposure to very high indoor temperatures is a health risk that disproportionately affects those already suffering from medical ailments. New York State Homes and Community Renewal installed more than 3,200 window air conditioner units, helping to keep some of New York’s most vulnerable people healthy and safe during summer heat waves. (Office of Community Services, n.d.)

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More information about the LIHEAP program is available at www.acf.hhs.gov/ocs/programs/ liheap (U.S. Department of Health and Human Services, Administration for Children and Families).

Vision Only 15% of older adults report any trouble seeing (National Center for Health Statistics [NCHS], 2017). Even so, several changes occur in our eyes as we age, including presbyopia (farsightedness), dry eyes, and cataracts, all of which can be dealt with relatively simply nowadays. These changes usually occur after the age of 40, but younger people can also experience them. There are numerous ways to adapt to aging eyes so that a good quality of life can be maintained throughout the life span. More serious eye conditions, including glaucoma and macular degeneration, are discussed as medical conditions in Chapter 11, Medical Conditions, Assisted Living, and Long-Term Care . Presbyopia/Farsightedness Presbyopia, or farsightedness, is a normal condition, not a disease, and should not disrupt the daily lives of most people. It usually begins to develop when a person is about 40 years of age. As we age, our eyes begin to lose the ability to adjust for different distances, and eventually most people will need bifocals or trifocals to maintain good vision. Presbyopia also means that as a person grows older, it is more difficult to adjust to darkness and to glare, and it takes more time to adapt to changes in light and darkness. These changes in vision make nighttime driving more hazardous for older people. Cataracts Cataracts are very common in older adults, though they can occur in children too. Research has shown that the risk of cataracts is related to frequent sun exposure, which has its greatest effects on younger people (Neale, Purdie, Hirst, & Green, 2003). Protecting our eyes from intense sunlight throughout our life span will decrease susceptibility to cataracts. Eventually, though, most people will develop cataracts if they live long enough. Cataracts result in increasingly blurred or misty vision as the eye’s lens becomes milky. Some cataracts grow larger or denser over time, causing severe vision changes. These cataracts can cause loss of independence for older adults because decreased vision may affect driving, working, reading, and hobbies. Cataract growth can be slowed by protecting our eyes from the sun and from sunlamps, eating healthy foods, limiting alcoholic drinks, and avoiding smoking (Kline & Wenchen, 2005). In the United States, cataract surgery, which replaces the clouded lens with a synthetic one, is the most commonly performed surgery in adults over age 65. Its success rate is very high. Dry Eyes Some people develop dry eyes as they grow older. This dryness can also cause redness in the eye. Mild cases can usually be treated with over-the-counter artificial tear solutions. Optometrists can diagnose and recommend other treatments for more serious cases of dry eye (American Optometric Association, n.d.). In general, a complete eye examination is recommended for those older than age 45, with follow-up examinations every 2 to 4 years thereafter. As noted, some age-related changes in vision

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can be dealt with fairly easily—by wearing bifocals or trifocals for presbyopia, by having surgery for cataracts, and by using artificial tears for dry eyes. Most other changes are best dealt with by changes to our environment. Our built environment has been constructed using parameters that work best for young people. Thus, the amount of light, the existence of stairs and escalators, and the typical size of print, for example, have all been determined for the society we used to be—a society of mostly young people. With our changing demographics, and our desire to make our environment more accessible to people with disabilities, it is time for us to make changes to our existing environment, and rethink parameters for future built environments, to accommodate people of all ages and ability levels. As we age, we require more light to see as well as we did when we were younger (as much as three times more light). Thus, simply increasing the amount of light assists older eyes to see better. Depth perception is also affected, so constructing environments that clearly differentiate changes in levels, for example on stairways, is a good way to increase visibility of those changes, and thus help decrease falls in older people. Varying textures, materials, and colors are helpful ways to signal changes in levels. Also, ramps are preferable, especially to escalators, for moving from one level to another because they are much safer for everyone.

Hearing As we age, limitations in our hearing become much more common than limitations in our vision. In 2015, 30% of people age 65 to 74 years reported trouble hearing, and that percentage rises to 47% for people age 75 and over. Older men are more likely to have hearing problems than are older women—41% of men and 21% of women age 65 to 74, and 55% of men and 41% of women age 75 and over (NCHS, 2017). Most people lose the ability to hear high-pitched sounds first, which leads to poor hearing when there is background noise. They also experience difficulty in hearing higher pitched sounds which are common in women’s and children’s voices, and difficulty in distinguishing between some words because consonants, such as Bs and Ps, and Cs and Ks, tend to be higher pitched than vowels are. Presbycusis, the most common type of sensorineural hearing loss, can occur because of changes in the inner ear, auditory nerve, middle ear, or outer ear. Some of its causes are aging, repeated exposure to loud noise, heredity, head injury, infection, illness, and certain prescription drugs. A recent analysis of national data shows that hearing impairment is declining among adults between ages 20 and 69, a positive sign for the future (Hoffman, Dobie, Losonczy, Themann, & Flamme, 2017). Reasons for this decline may be reduced exposure to loud noise in the workplace, lower rates of smoking, and better management of chronic conditions, such as hypertension, that can impact hearing. Hearing is an essential component of well-being, especially for people who have enjoyed normal hearing for most of their lives. Losing the ability to hear adequately in the routine activities of daily life can be very detrimental. Older adults with moderate to severe hearing loss report more difficulty with tasks such as preparing meals, shopping, and using the telephone than do those with no hearing loss (Gopinath et al., 2012). Once daily activities such as these become compromised, independence and quality of life can be reduced. Thus, an important factor in hearing loss is the increasing isolation of the person with impaired hearing. For most people, hearing loss is gradual. At the beginning of the loss of hearing, it is not unusual for people to be irritable, to seem to be distracted from conversation, and to be unsociable. Often a person may be unaware of the hearing loss and frequently give inappropriate answers to questions that were not heard well enough. As a result, relationships may become strained as others believe the person to be a bit

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confused. As this process continues, the person may begin to feel rejection conveyed in the nonverbal communication of others, and there is a real danger that depression may set in (Gopinath et al., 2009), leading to a cyclical process of increasing isolation and depression. Adaptations to age-related changes in hearing involve those communicating with older people as well as the older people themselves. In communicating with people who have hearing problems, it is helpful to speak more slowly and enunciate clearly. Shouting should be avoided. It is beneficial to speak face to face, so the person can see lip movements. Because much communication is nonverbal, one can attempt to communicate emotions, moods, and acceptance by body language and facial expressions. It is always helpful to eliminate background noise, including noise created by fans, air conditioners, and other appliances. It is important that the acoustics as well as the sound equipment in an auditorium be very good for presentations to older persons. Older persons who believe they are suffering hearing loss can benefit from having a hearing checkup with an audiologist or with an ear, nose, and throat specialist. If there is significant organic reason for hearing loss, many aids are available today that can help. It is important for a person to be diagnosed by a certified specialist, such as an audiologist, and not by a person who only sells hearing aids. Unfortunately, most people who could benefit from some type of hearing aid do not have one. In the first national study that included audiometric testing of a large, representative sample, Chien and Lin (2012) analyzed data from the National Health and Nutritional Examination Surveys (NHANES) on hearing loss and hearing aid use. Of the 27 million Americans 50 years of age or older with a hearing loss, they found that fewer than 4 million (14%) used hearing aids. Hearing aid use does seem to be higher for those age 70 and older, with researchers in one study reporting that of those who could benefit from using a hearing aid, one third were wearing one for at least 5 hours per week (Bainbridge & Ramachandran, 2014), though that still leaves a lot of people without the improvements that hearing aids would afford them. A variety of reasons have been suggested for the relatively low-level use of hearing aids. Some people think their hearing loss is relatively minor, and they would rather not bother with hearing aids, which do not restore the entire range of lost frequencies and still do not fully eliminate distracting background sounds in a noisy environment. Others are concerned about the stigma associated with wearing a hearing aid. There are also those who cannot afford them—good hearing aids are expensive and are not covered by Medicare. At first, a hearing aid may seem unnatural and strange because it amplifies sounds other than speech. It usually takes some time to adjust to a hearing aid, and families and friends, as well as the user of the aid, need patience during the adjustment process. Modern hearing aids are marvels of technological advancement. Many types are available, including ones that fit in the ear canal (completely or partially), in the ear, or behind the ear. Most have been miniaturized so that they are comfortable to wear and are cosmetically acceptable. Hearing aids can be indistinguishable in their appearance from earpieces for electronic devices, so the stigma of wearing a hearing aid may disappear in the near future!

Chemical Senses: Smell and Taste Our senses of smell and taste are intimately connected and interact with one another. For example, what we experience as the flavor of a food is actually a consequence of both the smell and the taste of the food. Just think about how our food does not seem to taste the same when our sense of smell is disrupted by a head cold. Nevertheless, smell and taste are separate senses and each has its own receptors and physiological underpinnings.

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Our sense of smell (olfaction) begins to decrease beginning around age 50, with women having a lower risk of their ability being diminished over time compared to men (Liu, Zong, Doty, & Sun, 2016). Although olfactory cells regenerate throughout the life span, it seems that the ability for them to do so decreases over time. In addition, age-related changes in the brain where information about smell is processed—in the orbitofrontal cortex, hippocampus, and amygdala—may contribute to an age-related decrease in sensitivity to smells (Gunzer, 2017). Estimates of the prevalence of olfactory impairments range from 17% for men in their 60s to 37% for men age 70 and over. Estimates range from 11% for women in their 60s to 25% for women age 70 and over. In addition to gender, prevalence is also affected by race and ethnicity, socioeconomic status, a history of asthma and hypertension, medication use, smoking, and alcohol consumption (Liu et al., 2016). Our sense of taste is important for the pleasures we derive from consuming good food as well as for helping us to avoid consuming harmful substances. In comparison to smell, our ability to taste seems to be less affected by age (Seiberling & Conley, 2004), though much less is known about age-related changes that may take place, or their causes. Taste perception may be affected if saliva production goes down, which happens in some older adults. Illnesses, medications, and smoking can also negatively affect the ability to taste food. Older adults may need a much higher concentration of salt to detect its presence in food (Stevens, Cain, Demarque, & Ruthruff, 1991), which could, for example, negatively affect the likelihood that hypertensive patients will maintain a low-salt diet. Potentially serious problems can arise as a result of changes in our sense of smell and taste. A reduction in these chemosensory abilities can result in decreases in appetite, food consumption, and overall quality of life, and can even endanger an older person’s health and safety. Some older people may lose the pleasure of smelling flowers, perfumes, and well-cooked and seasoned food. At the same time, they may have difficulty smelling gas leaks, smoke, and spoiled food (Seiberling & Conley, 2004). Given these negative effects, it is encouraging that there has been some research into possible ways to ameliorate older adults’ sense of smell. It turns out that exercise seems to be one way. In a study of more than 1,600 older adults over a 10-year period, Schubert et al. (2013) found that those who worked up a sweat exercising at least once per week had a reduced risk of olfactory impairment, and exercising more frequently reduced the risk even more. Thus, these researchers concluded that regular exercise may prevent some decrements in olfaction that otherwise would accompany aging. Another way of reducing aging effects on olfaction seems to be by eating more fish and nuts (Gopinath, Sue, Flood, Burlutsky, & Mitchell, 2015). Adaptations for older adults with a decreased sense of smell include ensuring that smoke detectors are in place and working well, and paying attention to food safety guidelines as well as expiration dates on food products. Friends, neighbors, and family members can be helpful in detecting problematic smells or tastes, too. In addition, when taste seems to be affected, the enjoyment of food can be enhanced by adding spices and incorporating a diversity of food flavors, textures, and temperatures during meal preparation. “Eye appeal” can also positively affect enjoyment, so garnishes, variety in food colors, and placement of food on a plate should not be overlooked.

Touch When it comes to aging, touch is often an overlooked sense, and yet, our skin, through which we experience touch, is the largest of our sense organs. The frequency of touch and responses to it are affected by the context in which it occurs, the relationship between people who are

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engaged in touching, and culture, with some societies, like the American society, actively discouraging touch (Field, 2010). The positive effects of touching are many. It decreases blood pressure, heart rate, and cortisol (stress hormone) levels; increases oxytocin (“love hormone”) levels; improves immune function; increases attentiveness, leading to improved performance on cognitive tasks; decreases depression; reduces pain; and may extend time in deep sleep, the most restful stage of sleep (Field, 2010). What older person could not benefit from these effects? Regrettably, however, little research into touch has been conducted with older people. Two studies give us a glimpse into the value of investing in more research in this arena: a study of older adults giving massages to infants, and another investigating the affective responses to touch of older adults. In the first of these studies, having already learned that massage has positive effects on those receiving it, the researchers wanted to know whether massage also has positive effects on those giving it (Field, Hernandez-Reif, Quintino, Schanberg, & Kuhn, 1998). They recruited older retired volunteers who were taught Swedish massage techniques and then each massaged a 1- to 3-month-old infant for 15 minutes three times a week for 3 weeks. Giving those massages affected the older volunteers immediately, improving their emotional well-being and decreasing anxiety and stress levels. In the second, more recent study, the researchers asked people aged between 13 and 82 years, to rate from unpleasant to pleasant on a 20-point scale, their experience of being gently stroked on their forearm (Sehlstedt et  al., 2016). They found that older people gave significantly higher ratings, indicating that the subjective appreciation of touch increases with age. This finding may not be that surprising given that it has previously been noted that older people may be deprived of touch, especially after a partner or other loved ones die.

Feet Feet get bigger as we age. If you are in your 20s and wear a size 7 shoe now, you may wear a size 8 or even a size 9 by the time you are in your 60s! Over our lifetime, feet tend to flatten out, and may get wider, due to some loss of elasticity in the tendons and ligaments that support them. Other factors that can increase the size of feet are pregnancy and weight gain. Aging also tends to diminish the fat tissue on the bottoms of our feet, leading to soreness when walking for a while on hard surfaces wearing shoes that have thin soles. Sometimes, foot problems are the first sign of more serious medical conditions such as arthritis, diabetes, and nerve or circulatory disorders. In addition, foot pain contributes to falls in older adults (Mickle, Munro, Lord, Menz, & Steele, 2010). If there seems to be a problem, a podiatrist, who specializes in diagnosing and treating foot problems, can be consulted. Foot pain and discomfort, though, need not be a normal part of aging. By the time we reach old age, our feet have had years of wear and tear, so good foot care becomes especially important. Checking regularly for cuts, blisters, and ingrown toenails is a good practice. Some adaptations work well for people of all ages, especially wearing comfortable shoes that fit properly, which can prevent many foot problems. Add insoles, if necessary, to help cushion feet. Podiatrists can prescribe orthotics that are custom-made for a patient based on a complete assessment of his or her feet, ankles, and legs. Research supports the value of these custom orthotics in reducing foot pain and improving function and so some health insurance plans will help pay for them. Raising feet when sitting helps keep blood moving to the feet. Stretching, walking, and gentle foot massages can serve a similar function. Warm footbaths are helpful, too.

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The Urinary Tract Although some age-related changes occur in our kidneys, in the absence of disease, they usually continue to function quite well throughout the later years of life. “Exercise; proper diet, including adequate fluid intake; limited use of medications; and quitting smoking help the urinary system maintain adequate functioning” (Saxon et al., 2010, p. 218). Bladder capacity does decline by 30% to 40%, but this is not a symptom of disease; it is simply a result of the aging process (Saxon et al., 2010). Most elderly persons need to get up in the night to empty their bladder. Older persons should know that having to arise in the night to go to the bathroom is not in itself an indication of any serious disease. If they have to arise more frequently than twice a night, however, they ought to see a healthcare professional. The micturition reflex changes as one ages. Micturition is the signal a person receives when he or she has to urinate. For a young person, the signal is usually sent when the bladder is about half full. As a result, young people have some time left before they must absolutely get to a bathroom. Not so for the elderly. The signal to urinate is given when the bladder is nearly full. Obviously that means when they receive the signal, there is not much time for delay. The reduced capacity of the bladder, coupled with a delayed signal to urinate, can lead to problems of frequent urination and the need to urinate immediately (Saxon et al., 2010). Dribbling urine or urinary incontinence (UI) can be a problem for some older people. This can be viewed as both physiologically and psychologically damaging. Women have a higher probability than men of having incontinence, likely the result of childbirth and the associated weakening of the bladder outlet and pelvic musculofascial attachments. Although UI is more common in older adults, people of any age can experience it. The most common type is stress incontinence, which is brought about by a laugh, a cough, a sneeze, or lifting. In addition to stress incontinence, some older persons suffer from urge incontinence, the sudden urge to go to the bathroom without time to get there. Others suffer from overflow incontinence, a condition in which the bladder becomes too full and urine leaks out (Saxon et al., 2010). There is an increased chance of urinary tract infections as a person grows older. Symptoms of a bladder infection include cloudy or bloody urine, a low-grade fever, pain, or a burning sensation during urination, and a strong need to urinate often, even right after the bladder has been emptied. If the infection spreads to the kidneys, symptoms may include chills and shaking or night sweats; fatigue; fever above 100°F; mental changes or confusion; nausea and vomiting; and side, back, or groin pain. In either case, a healthcare professional should be consulted for diagnosis and treatment. A course of antibiotics usually clears up infections fairly quickly. Older people, especially older men, are at higher risk than younger people of developing kidney stones. Kidney stones are hard masses that form in the kidney out of substances in the urine. They may be as small as a grain of sand or as large as a pearl. Some stones are even as big as golf balls! Most kidney stones pass out of the body with urine. But sometimes a stone will not pass by itself and then medical attention is necessary. The larger the stone, the more likely it is to cause severe pain, in the back or side, that will not go away. Other symptoms include fever and chills, vomiting, urine that smells bad or looks cloudy, a burning sensation during urination, or blood in the urine. The most common treatment is extracorporeal shockwave lithotripsy (ESWL), in which a machine sends shock waves to the stone and breaks it into smaller pieces, which can then be passed out of the body in urine. The best way to prevent kidney stones is to drink lots of water, which helps to flush away the substances that form kidney stones (National Kidney & Urologic

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Diseases Information Clearinghouse, 2011). Producing at least a liter (slightly more than a quart) of urine per day is indicative of drinking adequate fluids. Awareness of age-related changes in the urinary tract, including its reduced capacity, can also be helpful because then older people can plan to regularly visit lavatory facilities, and avoid foods and drinks that may cause them to urinate more often, thereby avoiding the incontinence that might ensue. Another adaptation older people can make to changes in their urinary tracts is to learn to do Kegel exercises to strengthen pelvic muscles, which can even prevent UI. Kegel exercises also strengthen the uterus and large intestine. More information and instructions on how to do the exercises can be found online at medlineplus.gov/ency/patientinstructions/000141.htm

The Musculoskeletal System: Bones and Muscles Bones play many roles in the body. They provide structure, protect internal organs, anchor muscles, and store calcium. Beginning early in life, engaging in regular weight-bearing physical activity and eating foods that are rich in calcium and vitamin D (which helps the body to absorb calcium) build strong bones, optimize bone mass, and may reduce the risk of osteoporosis later in life. Bone thinning, or loss of bone mineral density, begins at about age 35 when the body begins to reabsorb bone cells faster than it makes new bone. Bone thinning, though, does not have to result in osteoporosis, a disease that weakens bones, making them more likely to break. A person with high bone mass as a young adult will be more likely to have a higher bone mass later in life. Thus, it is important for young people, and especially young women who are more susceptible to osteoporosis than are young men, to reach their peak bone mass (genetic potential for bone density) in order to maintain bone health throughout life. Strong bones are important to us for their positive effects on our bodies, which also enable us to participate in all kinds of social and sports activities. Chapter 3, Health and Wellness for Older Adults has more information on maintaining strong bones and preventing osteoporosis. Skeletal muscles help our body to move, keep our body upright and standing tall, and contribute to the health of bones, lung and cardiovascular function, and regulation of our metabolism. Typically, beginning in middle adulthood, we gradually lose muscle mass and muscle function, with both gender and physical activity affecting the extent of the loss. Such losses in muscle mass are associated with a number of negative health outcomes, osteoporosis and hip fractures among them. Strong quadriceps muscles and biceps muscles are especially important because they make it possible to get up out of a chair and to lift things, ultimately affecting a person’s ability to remain independent as he or she ages. Between the ages of 40 and 90 years, quadriceps muscle mass can decrease by as much as 50% in men and 30% in women, and biceps muscle mass can decrease by as much as 30% in men and 20% in women (Arts, Pillen, Overeem, Schelhaas, & Zwarts, 2007). However, losses in muscle mass, and the decreases in function that accompany them, are not inevitable. “Reduce the demand on skeletal muscle and it will adapt to the new lower requirement; increase the demand and the decline due to aging can be minimized, if not eliminated” (Kirkendall & Garrett, 1998, p. 601). Thus, much of the age-related effects on muscles can be prevented by engaging in physical activity throughout the life span. Progressive resistance training, using free weights, resistance machines, or isometrics, has been the exercise method of choice for maintaining and improving muscle mass and strength. Although older adults seem to require more training than do younger adults, with the right exercise program, they are nevertheless able to maintain muscle and even increase it, as well as, or better than, their younger counterparts who do not train (Bickel, Cross, & Bamman, 2011).

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Research is also showing that power training may be even more effective in improving functional independence because it enhances older adults’ ability to carry out daily activities (Hazell, Kenno, & Jakobi, 2007). Of course, older people should consult their healthcare provider prior to beginning a new exercise program. Finally, mounting evidence suggests that a moderate increase in dietary protein to 1.0 to 1.2 g/kg/day for older adults (0.8 g/kg/day is currently recommended for adults aged 19 and older), distributed across the day’s meals or in a high protein meal at midday, has beneficial effects on both bone and muscle health (J. Bauer et al., 2013). Protein needs are even higher for older adults to achieve these beneficial effects if they have acute or chronic disease, severe illness or injury, or significant malnutrition, while daily protein intake should be limited for those with severe kidney disease who are not on dialysis (M. Bauer et al., 2013).

Menopause Menopause, the cessation of menstruation, is a normal part of every woman’s life. It is not a disease or disorder. After menopause, many women feel relieved that they no longer have to worry about menstruation, cramps, or getting pregnant. The average age for menopause is 51, but for some women it happens in their 40s, while for others it happens in their late 50s. Postmenopausal women are more vulnerable to heart disease and osteoporosis, so it is important for them to eat a healthy diet and to make sure they get lots of calcium and weight-bearing exercise to keep their bones strong. The majority of women experience some menopausal symptoms, though not all women find them bothersome. Symptoms can begin several years prior to when the last period occurs. They include changes in menstruation (e.g., increasing variation in length of the cycle, lighter or heavier bleeding), hot flashes (sudden feelings of heat, usually in the upper part of the body, lasting between 30 seconds and 20 minutes), vaginal dryness, trouble sleeping, and mood changes. Some symptoms of menopause can last for months or years after. Changing levels of estrogen and progesterone are related to these symptoms. Hot flashes and night sweats can be alleviated by sleeping in a cool room, drinking cold water or juice when a hot flash is coming on, dressing in layers, and using sheets and clothing that let the skin “breathe.” Exercise and slow, deep breathing may also help reduce hot flashes. Low-dose birth control pills will make menstrual cycles and flow more regular and also help with hot flashes. A water-based lubricant or vaginal moisturizers may relieve vaginal discomfort, but not petroleum jelly which can cause irritation. Sleep problems may be relieved by adopting good sleep hygiene practices, such as adhering to a bedtime routine and creating a comfortable sleeping environment (see more suggestions in Chapter 3, Health and Wellness for Older Adults). Some women require medication. The U.S. Food and Drug Administration has approved the use of paroxetine, a low-dose antidepressant, to treat hot flashes. Women who use an antidepressant to help manage hot flashes generally take a lower dose than those who use the medication to treat depression. Menopausal hormone therapy (MHT; or estrogen replacement therapy, ERT; or hormone replacement therapy, HRT), which steadies the levels of estrogen and progesterone in the body, is very effective at reducing the number and severity of hot flashes and in reducing vaginal dryness and bone loss. MHT was a widely recommended treatment for menopausal symptoms until it was learned that side effects may include an increased risk of breast cancer, stroke, and heart attacks. Newer versions of treatments developed since these findings may reduce the risk of using hormones for women experiencing the menopausal transition, but research is needed to evaluate the long-term safety of these newer treatments. The recommendation for those

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women who can benefit most from hormonal therapy is to consult with their healthcare provider about taking the lowest dose of a combined estrogen–progesterone formula for the shortest time that is consistent with the reason for the therapy (National Institute on Aging, 2016b). As is the case for all prescription medications, hormone therapy should be reevaluated regularly. Synthetic or “bioidentical” hormones are assumed to have the same risks as any hormone therapy, and it is unknown whether herbs or other so-called natural products are helpful or safe because the benefits and risks are still being studied.

Sleep Older adults need about the same amount of sleep as do young adults—7 to 9 hours each night. On the other hand, sleep patterns change with age. We often need more time to fall asleep as we grow older. The amount of time spent in rapid eye movement (REM) sleep and non-REM sleep (the deepest and most restful sleep) shifts as we get older, with a decrease of time in deep sleep. Compared to younger people, older people tend to sleep more lightly and awaken more quickly in response to noises. Once awake, they can find it harder to get back to sleep (Ohayon, Carskadon, Guilleminault, & Vitiello, 2004). It is not clear how many of these changes in sleep result from the normal aging process or from factors such as medications, lack of exercise, napping during the daytime, or disease. Older adults tend to take more medications than do younger people, and medications and their side effects can impair sleep or even stimulate wakefulness. A sedentary lifestyle can lead to sleepiness all the time, or a lack of sleepiness. Sleep may be disturbed more frequently by an older person’s increased probability of needing to urinate during the night, by rhythmic leg movements, or by sleep-disordered breathing such as snoring or sleep apnea. Older persons may suffer from pain due to arthritic or other medical problems that may disrupt sleep. In addition, psychological stress brought about by significant life changes, such as the death of a loved one or moving, can inhibit sleep. A variety of psychological and behavioral treatments have proven to be effective in relieving sleep problems and reducing or eliminating the use of sleep medications, even among individuals whose sleep problems may be related to a chronic condition or pain (Morin et al., 2006). For example, cognitive behavioral therapy has been shown to significantly reduce sleep latency (time to get to sleep), increase total sleep time, and eliminate the use of sleeping pills (Espie, Inglis, Tessier, & Harvey, 2001). In the National Health and Nutrition Survey, 2013 to 2014, 19.2% of 20- to 39-year-olds said that they had told a doctor or other health professional that they had trouble sleeping, 32.8% of 40- to 59-year-olds said they had, and 33.2% of those 60 years of age and up said they had. Thus, while there is a relationship between age and trouble sleeping, poor sleep is not inevitable as we age. Among the ways to adapt to sleep changes is to maintain daytime activities with some exposure to fresh air, if possible. For people of all ages, good sleep hygiene, which is discussed in Chapter 3, Health and Wellness for Older Adults, can go a long way toward regularly obtaining a good night’s sleep.

BIOLOGICAL THEORIES OF AGING Now that you know some important facts about the most common physical changes that accompany aging, you may be asking, “How do these changes come about?” and “Why do these changes come about?” Biologists will tell you that aging is a part of the circle of life. All organisms begin

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TABLE 2.1 Paradigms of Biological Aging and Examples of Their Theories DAMAGE ACCUMULATION PARADIGM

PROGRAMMED PARADIGM

Mutation accumulation theory

Programmed cell death/Telomere theory

Disposable soma theory

Neuroendocrine theory

Mitochondrial theory

Antagonistic pleiotropy theory

aging from the day they are born. Although biologists agree that genetic programming determines the biological course of development from conception to reproductive maturity, there is much debate among them about what happens after that. Ideas about the causes of aging have been around for at least 2,000 years, and as many as 300 have been put forward (Medvedev, 1990). Many of these ideas have been dismissed because they have not stood up to the evidence. Two different paradigms for the causes of aging have emerged over time, each with their related theories (see Table 2.1). According to one paradigm, aging is a result of the accumulation of damage or errors that occur over the lifetime of an organism, gradually diminishing its ability to survive. According to the second paradigm, aging is driven by a genetic program, that is, it is encoded in the genome.

Damage Accumulation Theories of Aging The mutation accumulation theory proposes that genes with negative effects on survival in late life tend to accumulate in an organism’s genome, causing the decline and damage that we associate with aging (Medawar, 1952). Genes whose negative effects on survival appear only later in life would be passed from generation to generation because they do not affect an organism’s offspring production. A good example of this principle can be found in Huntington’s disease, an almost entirely inherited disease, the symptoms for which begin to appear only around age 40. Unless a person has been genetically tested earlier in life, by the time he or she is diagnosed most people who are carriers of Huntington’s may have already had children, and hence passed on the disease to the next generation. Though Huntington’s is a rare disease, its prevalence could be even further reduced if early genetic testing became widely used. According to the disposable soma theory, physiological and/or biochemical resources are limited and must be allocated between maintenance and growth of an organism on the one hand, and reproduction on the other (Kirkwood, 1977, 1990). A higher investment in maintenance could prevent aging, but that would reduce reproduction, ultimately diminishing evolutionary fitness. Thus, natural selection pressure favors reproduction at the expense of maintenance. Failure of maintenance leads to aging because it makes organisms more susceptible to disease and environmental stresses. The mitochondrial theory of aging, originally developed as the free radical theory of aging and subsequently revised (Harman, 2009), proposes that mitochondria produce reactive oxygen species (ROS), which cause oxidative damage to DNA, lipids, and proteins. The damage accumulates over the lifetime of an organism, ultimately leading to a loss of functionality and death. Recent research (Ziegler, Wiley, & Velarde, 2015) has revealed several different mechanisms through which mitochondria could produce these effects.

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Programmed Theories of Aging The programmed cell death, or telomere, theory focuses on the protective structures at the ends of DNA chromosomes (telomeres; Aubert & Lansdorp, 2008). Cells divide a limited number of times over the course of life, and the number depends on an organism’s species. Named after the scientist who discovered the limit, the Hayflick number is between about 40 and 50 for human cells (Hayflick, 1961). With each cell division, telomeres are shortened until the cell stops functioning properly (Harley, Futcher, & Greider, 1990). Cells that are not protected by telomeres deteriorate and die. However, not all cells divide, and for some cells that do, such as stem cells, the telomerase enzyme can rebuild the ends of DNA chromosomes. The neuroendocrine system is composed of a complicated network of hormones that are regulated by the hypothalamus, a structure at the base of the brain, and the pituitary gland. This system regulates virtually every function in the body. According to the neuroendocrine theory of aging (Dilman, 1971, 1986), functional changes are programmed in neurons and hormones, with the hypothalamic-pituitary-adrenal (HPA) axis as the timekeeper for these aging changes. The basic idea of the antagonistic pleiotropy theory is that some genes that confer positive benefits early in life, and are therefore selected, also confer negative effects later in life (Williams, 1957). Pleiotropy means that a single gene influences more than one observable characteristic of an organism. In antagonistic pleiotropy, one of these effects is beneficial and another is detrimental. One example comes from considering the possibility that one allele could have a positive effect on bone growth during an individual’s early stages of development, but a negative effect of depositing excess calcium within arterial walls later in life, leading to high blood pressure and blood clots, and increasing the risk of strokes and heart attacks. Aging is a complex, multifactorial process. Despite a plethora of aging theories, there is not yet a single comprehensive theory that explains why we age. It seems likely that neither the paradigms nor all the theories of aging are mutually exclusive and that aspects of many of them will eventually be brought together to explain the aging process. A giant step in that direction has been taken by a group of researchers who have created the Digital Ageing Atlas (see Suggested Resources), which is compiling data on age-related changes in humans across different biological levels, and making them freely available online (Craig et al., 2015).

Rate of Aging: Caloric and Dietary Restriction, Growth Hormone, and Exercise Regardless of the cause of aging, there is much interest in discovering ways to decrease the rate at which aging takes place. There are very great differences among individuals in the aging process. Among the possible ways of changing the rate of aging, caloric and dietary restriction, the use of growth hormone, and physical activity have all been suggested. Caloric and dietary restriction are both associated with the idea that limiting food intake without malnutrition can slow the aging process. In fact, caloric restriction has been demonstrated to delay the aging process, prevent the onset of aging-related diseases, and increase the life span of a variety of organisms (Xiang & He, 2011). Researchers are beginning to understand the reasons for these effects, although there is much more to be learned (López-Lluch & Navas, 2016). Only one study to date has conducted a randomized trial of the effects of caloric restriction on a large group of humans (age range: 21–50 years), the Comprehensive Assessment of Long-term Effects of Reducing Intake of Energy (CALERIE; Ravussin et al., 2015).

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The participants in the caloric restriction group experienced reduced risk factors for several age-related diseases including those related to cardiovascular disease and diabetes, namely lower blood pressure, lower cholesterol, and decreased insulin resistance. On average, participants in this study achieved only a 12% reduction in calories, though the goal was 25%. Thus, the researchers were careful to point out that, “Our study, which involved a highly motivated population and very intensive behavioral intervention, provides limited evidence regarding the feasibility of [caloric restriction] in broader nonobese populations or with less intensive interventions” (Ravussin et al., 2015, p. 1102). Dietary restriction is an alternative to caloric restriction. There is a variety of different forms of dietary restriction including: time-restricted feeding, an example of which is eating only within a period of 12 hours or fewer per day; intermittent feeding (IF), an example of which is to adopt a reduced calorie diet for only 2 days a week (referred to as a 5:2 diet); and fast-mimicking diets (FMDs), in which on those days when calories are restricted the diet is augmented with micronutrients. Research into dietary restriction regimes in humans, still in its infancy, has begun to show its positive effects on risk factors for age-related diseases (Longo & Panda, 2016). Compared to caloric restriction, some of these forms of dietary restriction are also more likely to be adopted by humans. In the case of growth hormone, there are major concerns about its potentially serious side effects, which do not bode well for it having a role in slowing individuals’ aging processes. Physical activity, however, has much promise in keeping people healthy throughout their life spans. The importance of physical activity is discussed in Chapter 3, Health and Wellness for Older Adults.

PRACTICAL APPLICATION INTRODUCTION

Chapter 2 outlines the normal physical changes that accompany aging and differentiates them from the diseases and conditions that become more common with age. It also provides a discussion of the adaptations that older people can make to accommodate such changes in their health. The chapter concludes with a summary of the two basic paradigms of the biological theories of aging. Your ability to apply evidence-based theory to the scenarios you will encounter in the workplace will play an important role in your professional success. Therefore, the theories presented in Chapter 2 are the focus of this Practical Application. THE BIOLOGICAL THEORIES OF AGING

Chapter 2 offers a summary of the two basic paradigms of the biological theories of aging. Your ability to apply evidence-based theories such as these to the scenarios you will encounter in the workplace will play an important role in your professional success. The damage accumulation and programmed theories of aging provide us with possible frameworks for understanding how and why the physical changes of aging occur. Why is this information important to us? One reason, perhaps driven by a cultural idolization of

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youth, would be to delay or even prevent aging as a way to stay forever young. However, for those of us who work in the field of gerontology, we can employ our understanding of the aging process to better address the needs and issues of the aging community we serve. Take a few moments to reflect on the many physical changes described in Chapter 2 and the challenges associated with them. For example, some older adults experience both physical and emotional distress as a result of urinary incontinence. How could the biological theories of aging be applied to this challenge in order to alleviate the discomfort associated with it? The best answer may not yet be known. Certainly there is more research to be done on the mechanisms of aging. In the meantime, these theories provide valuable insights that may someday result in preventative, diagnostic, and treatment measures aimed at helping older adults. Regardless of your role within the gerontology field, it will be important to stay informed about current theoretical frameworks and the ongoing research behind them in order to make the most informed and ethical decisions on a day-to-day basis.

STUDENT ACTIVITIES 1. Differentiate between the normal physical changes that occur as part of the aging pro-

2.

3.

4.

5.

cess and the medical conditions commonly seen in the aging population. Provide three examples of each. Abe and Maureen are both in their 60s and experiencing many of the physical changes associated with aging. Describe some of the transformations that may be taking place and explain how their experiences might differ given their genders. Think of one or two older adults in your life. List at least three of the normal changes they have experienced as a result of aging, describe the accommodations they made as a result of those changes, and explain how those accommodations helped them maintain their quality of life. On the basis of information provided by the Hearing Loss Association of America (www .hearingloss.org), outline four ways to determine when sound is too loud. Then offer four examples of sounds that, with overexposure, could result in hearing loss. Conduct a search on Google Scholar (scholar.google.com) for journal articles related to the effects of oxidative stress on the aging process. List the titles of five journal articles that look interesting to you and that were published no earlier than 2015.

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SUGGESTED RESOURCES Digital Ageing Atlas. Retrieved from http://ageing-map.org The DAA is a collection of human age-related data from various biological levels—molecular, cellular, physiological, psychological, and pathological. The website includes anatomical models and tools to select and graph the data. Some data are also included from aging studies of mice. The Atlas is available for use at no cost. Hearing Loss Association of America. Retrieved from http://www.yourhearingloss.org HLAA provides assistance and resources for people with hearing loss, and their families, to learn how to adjust to living with hearing loss. HLAA is working to eradicate the stigma associated with hearing loss and to raise public awareness about the need for prevention, treatment, and regular hearing screenings throughout life. National Association for Continence. Retrieved from https://www.nafc.org This nonprofit association’s goal is to destigmatize, promote prevention, and educate the community about incontinence. It provides a national database for individuals seeking support and diagnosis of incontinence and incontinence-related disorders. National Eye Institute. Retrieved from https://www.nei.nih.gov Established by Congress in 1968 to protect and prolong the vision of the American people, NEI’s research leads to sight-saving treatments, reduces visual impairment and blindness, and improves the quality of life for people of all ages. North American Menopause Society. Retrieved from http://www.menopause.org This nonprofit organization is dedicated to promoting the health and quality of life of all women during midlife and beyond through an understanding of menopause and healthy aging. On the website are resources for clinicians, researchers, and the public. Visitors to the site can search for a menopause practitioner in the United States and Canada, find answers to frequently asked questions, get information on menopause topics, and access a variety of other resources.

REFERENCES American Optometric Association. (n.d.). Dry eye. Retrieved from http://www.aoa.org/dry-eye.xml Arts, I. M. P., Pillen, S., Overeem, S., Schelhaas, H. J., & Zwarts, M. J. (2007). Rise and fall of skeletal muscle size over the entire life span. Journal of the American Geriatrics Society, 55(7), 1150–1152. doi: 10.1111/j.1532-5415.2007.01228.x Aubert, G., & Lansdorp, P. M. (2008). Telomeres and aging. Physiological Reviews, 88(2), 557–579. doi:10.1111/j.1532-5415.2007.01228.x Avci, P., Gupta, G. K., Clark, J., Wikonkal, N., & Hamblin, M. R. (2014). Low-level laser (light) therapy (LLLT) for treatment of hair loss. Lasers in Surgery and Medicine, 46(2), 144–151. doi:10.1002/ lsm.22170 Bainbridge, K. E., & Ramachandran, V. (2014). Hearing aid use among older US adults: The National Health and Nutrition Examination survey, 2005-2006 and 2009-2010. Ear and Hearing, 35(3), 289–294. doi:10.1097/01.aud.0000441036.40169.29 Bauer, J., Biolo, G., Cederholm, T., Cesari, M., Cruz-Jentoft, A. J., Morley, J. E., . . . Boirie, Y. (2013). Evidence-based recommendations for optimal dietary protein intake in older people: A position paper from the PROT-AGE study group. Journal of the American Medical Directors Association, 14, 542–559. doi:10.1016/j.jamda.2013.05.021 Bauer, M., McAuliffe, L., Nay, R., & Chenco, C. (2013). Sexuality in older adults: Effect of an education intervention on attitudes and beliefs of residential aged care staff. Educational Gerontology, 39, 82–91. doi:10.1080/03601277.2012.682953 Berry, M. (2015). Old age is a gift. Alcalde. Retrieved from http://alcalde.texasexes.org/2015/07/ old-age-is-a-gift

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Bickel, C. S., Cross, J. M., & Bamman, M. M. (2011). Exercise dosing to retain resistance training adaptations in young and older adults. Medicine and Science in Sports and Exercise, 43(7), 1177–1187. doi:10.1249/MSS.0b013e318207c15d Chien, W., & Lin, F. R. (2012). Prevalence of hearing aid use among older adults in the United States. Archives of Internal Medicine, 172(3), 292–293. doi:10.1001/archinternmed.2011.1408 Craig, T., Smelick, C., Tacutu, R., Wuttke, D., Wood, S. H., Stanley, H., . . . de Magãlhaes, J. P. (2015). The digital ageing atlas: Integrating the diversity of age-related changes into a unified resource. Nucleic Acids Research, 43(D1), D873–D878. doi:10.1093/nar/gku843 Dilman, V. M. (1971). Age-associated elevation of hypothalamic threshold to feedback control, and its role in development, ageing, and disease. Lancet, 297(7711), 1211–1219. doi:10.1016/ S0140-6736(71)91721-1 Dilman, V. M. (1986). Ontogenetic model of ageing and disease formation and the mechanisms of natural selection. Journal of Theoretical Biology, 118(6), 73–81. doi:10.1016/S0022-5193(86)80009-1 Espie, C. A., Inglis, S. J., Tessier, S., & Harvey, L. (2001). The clinical effectiveness of cognitive behaviour therapy for chronic insomnia: Implementation and evaluation of a sleep clinic in general medical practice. Behaviour Research and Therapy, 39(1), 45–60. doi:10.1016/S0005-7967(99)00157-6 Field, T. (2010). Touch for socioemotional and physical well-being: A review. Developmental Review, 30, 367–383. doi:10.1016/j.dr.2011.01.001 Field, T., Hernandez-Reif, M., Quintino, O., Schanberg, S., & Kuhn, C. (1998). Elder retired volunteers benefit from giving massage therapy to infants. Journal of Applied Gerontology, 17, 229–239. doi:10.1177/073346489801700210 Gopinath, B., Schneider, J., McMahon, C. M., Teber, E., Leeder, S. R., & Mitchell, P. (2012). Severity of age-related hearing loss is associated with impaired activities of daily living. Age and Ageing, 41(2), 195–200. doi:10.1093/ageing/afr155 Gopinath, B., Sue, C. M., Flood, V. M., Burlutsky, G., & Mitchell, P. (2015). Dietary intakes of fats, fish and nuts and olfactory impairment in older adults. British Journal of Nutrition, 114(2), 240–247. doi:10.1017/S0007114515001257 Gopinath, B., Wang, J. J., Schneider, J., Burlutsky, G., Snowdon, J., McMahon, C. M., . . . Mitchell, P. (2009). Depressive symptoms among older hearing impaired adults: The Blue Mountains Study. Journal of the American Geriatrics Society, 57(7), 1306–1308. doi:10.1111/j.1532-5415.2009.02317.x Gunzer, W. (2017). Changes of olfactory performance during the process of aging: Psychophysiological testing and its relevance in the fight against malnutrition. Journal of Nutrition, Health and Aging, 21(9), 1010–1015. doi:10.1007/s12603-017-0873-8 Harley, C. B., Futcher, A. B., & Greider, C. W. (1990). Telomeres shorten during ageing of human fibroblasts. Nature, 345, 458–460. doi:10.1038/345458a0 Harman, D. (2009). Origin and evolution of the free radical theory of aging: A brief personal history, 1954–2009. Biogerontology, 10(6), 773–781. doi:10.1007/s10522-009-9234-2 Hayflick, L. (1961). The limited in vitro lifetime of human diploid cell strains. Experimental Cell Research, 37, 614–636. doi:10.1016/0014-4827(65)90211-9 Hazell, T., Kenno, K., & Jakobi, J. M. (2007). Functional benefit of power training for older adults. Journal of Aging and Physical Activity, 15(3), 349–359. doi:10.1123/japa.15.3.349 Hoffman, H. J., Dobie, R. A., Losonczy, K. G., Themann, C. L., & Flamme, G. A. (2017). Declining prevalence of hearing loss in US adults aged 20 to 69 years. JAMA Otolaryngology—Head and Neck Surgery, 143(3), 274–285. doi:10.1001/jamaoto.2016.3527 Kirkendall, D. T., & Garrett, W. E., Jr. (1998). The effects of aging and training on skeletal muscle. The American Journal of Sports Medicine, 26(4), 598–602. doi:10.1177/03635465980260042401 Kirkwood, T. B. (1977). Evolution of ageing. Nature, 270, 301–304. Retrieved from https://www.nature .com/articles/270301a0 Kirkwood, T. B. (1990). The disposable soma theory of aging. In D. E. Harrison (Ed.)., Genetic effects on aging (Vol. 2, pp. 9–19), Caldwell, NJ: Telford Press. Kline, D. W., & Wenchen, L. (2005). Cataracts and the aging driver. Ageing International, 30(2), 105–121. doi:10.1007/s12126-005-1007-x

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Longo, V. D., & Panda, S. (2016). Fasting, circadian rhythms, and time-restricted feeding in healthy lifespan. Cell Metabolism, 23, 1048–1059. doi:10.1016/j.cmet.2016.06.001 López-Lluch, G., & Navas, P. (2016). Calorie restriction as an intervention in ageing. Journal of Physiology, 594(8), 2043–2060. doi:10.1113/JP270543 Medawar, P. B. (1952). An unsolved problem in biology. London, England: H. K. Lewis. Medvedev, Z. A. (1990). An attempt at a rational classification of theories of ageing. Biological Reviews, 65, 375–398. doi:10.1111/j.1469-185X.1990.tb01428.x Mickle, K. J., Munro, B. J., Lord, S. R., Menz, H. B., & Steele, J. R. (2010). Foot pain, plantar pressures, and falls in older people: A prospective study. Journal of the American Geriatrics Society, 58(10), 1936–1940. doi:10.1111/j.1532-5415.2010.03061.x Morin, C. M., Bootzin, R. R., Buysse, D. J., Edinger, J. D., Espie, C. A., & Lichstein, K. L. (2006). Psychological and behavioral treatment of insomnia: Update of the recent evidence (1998-2004). Sleep, 29(11), 1398–1414. doi:10.1093/sleep/29.11.1398 National Center for Health Statistics. (2017). Health, United States, 2016: With chartbook on long-term trends in health (DHHS Publication No. 2017-1232). Hyattsville, MD: Author. Retrieved from https:// www.cdc.gov/nchs/data/hus/hus16.pdf National Institute on Aging. (2016a). Hyperthermia: Hot weather safety for older adults. Retrieved from https://www.nia.nih.gov/health/topics/hyperthermia National Institute on Aging. (2016b, October). Menopause: Treatment for symptoms. Tips from the National Institute on Aging (NIH Publication No. 16–AG-7482). Retrieved from https://order.nia.nih .gov/sites/default/files/2017-07/TS_Menopause_508.pdf National Institute on Aging. (2017a). Cold weather safety for older adults. Retrieved from https://www .nia.nih.gov/health/cold-weather-safety-older-adults National Institute on Aging. (2017b). Skin care and aging. Retrieved from https://www.nia.nih.gov/ health/skin-care-and-aging National Kidney and Urologic Diseases Information Clearinghouse. (2011). Awareness and prevention series. Retrieved from https://www.kidney.niddk.nih.gov/index.aspx Neale, R. E., Purdie, J. L., Hirst, L. W., & Green, A. C. (2003). Sun exposure as a risk factor for nuclear cataract. Epidemiology, 14(6), 707–712. doi:10.1097/01.ede.0000086881.84657.98 Office of Community Services. (n.d.). New York: Keeping it cool! Retrieved from https://www.acf.hhs .gov/ocs/success-story/new-york-keeping-it-cool Ohayon, M. M., Carskadon, M. A., Guilleminault, C., & Vitiello, M. V. (2004). Meta-analysis of quantitative sleep parameters from childhood to old age in healthy individuals: Developing normative sleep values across the human lifespan. Sleep, 27, 1255–1273. doi:10.1093/sleep/27.7.1255 Saxon, S. V., Etten, M. J., & Perkins, E. A. (2010). Physical change and aging: A guide for the helping professions (5th ed.). New York, NY: Springer Publishing Company. Schubert, C. R., Cruickshanks, K. J., Nondahl, D. M., Klein, B. E. K., Klein, R., & Fischer, M. E. (2013). Association of exercise with lower long-term risk of olfactory impairment in older adults. JAMA Otolaryngology—Head and Neck Surgery, 139(10), 1061–1066. doi:10.1001/jamaoto.2013.4759 Sehlstedt, I., Ignell, H., Wasling, H. B., Ackerley, R., Olausson, H., & Croy, I. (2016). Gentle touch perception across the lifespan. Psychology and Aging, 31(2), 176–184. doi:10.1037/pag0000074 Seiberling, K. A., & Conley, D. B. (2004). Aging and olfactory and taste function. Otolaryngologic Clinics of North America, 37(6), 1209–1228. doi:10.1016/j.otc.2004.06.006 Williams, G. C. (1957). Pleiotropy, natural selection, and the evolution of senescence. Evolution, 11, 398–411. doi:10.2307/2406060 Xiang, L., & He, G. (2011). Caloric restriction and antiaging effects. Annals of Nutrition and Metabolism, 58(1), 42–48. doi:10.1159/000323748 Ziegler, D. V., Wiley, C. D., & Velarde, M. C. (2015). Mitochondrial effectors of cellular senescence: Beyond the free radical theory of aging. Aging Cell, 14, 1–7. doi:10.1111/acel.12287

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CHAPTER

3

HEALT H AN D W E L L N E S S FO R OL DE R ADU LT S

LEARNING OBJECTIVES • Recognize the value of good nutrition, physical activity, and good sleep hygiene in older adults’ health. • Summarize the nutrition guidelines for older adults, as contained in MyPlate for Older Adults, and outline how they differ from the guidelines for younger adults. • List the four vaccines that all older adults should have. • Identify the basic screening tests for diseases and conditions that are preventable, or for which there is good prognosis if detected early. • Explain how the risks for chronic diseases can be reduced when negative health behaviors are avoided.

SENIORS AGING HEALTHFULLY When she turned 60, Pearl decided she wanted to stay healthy and active as long as possible. She was careful about what she ate. She became more physically active. Now she takes a long, brisk walk three or four times a week. In bad weather, she joins the mall walkers at the local shopping mall. When it’s nice outside, Pearl works in her garden. When she was younger, Pearl stopped smoking and started using a seatbelt. Now she’s using the Internet to find healthy recipes. Last month, at the age of 84, she danced at her granddaughter’s wedding.

ENHANCING AND MAINTAINING HEALTH IN THE LATER YEARS Life expectancy has risen dramatically in many countries around the world, including in the United States. Simply being alive for more years, though, is not a particularly worthy achievement. When it comes to aging, everyone’s goal is to age in the best possible health. No one wants to live a long life in poor health, or in increasingly poorer health. Of course, to a large extent genetic makeup

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influences risks for different health conditions, and individuals have little or no control over many of these risks. Common health problems, however, are strongly influenced by health behaviors, including those related to nutrition and physical activity, and health literacy. In addition, health behaviors affect the rate at which aging occurs and the quality of life that accompanies aging. The majority (78%) of people 65 years of age and over who are not institutionalized rate their own health as good, very good, or excellent (Federal Interagency Forum on Aging-Related Statistics, 2016). Although poor health is experienced by many older adults, they are in the minority— even among elders who are 85 years of age and over, 68% report good to excellent health. Maintaining, and even enhancing, health and wellness is a lifelong process that requires awareness of one’s state of health and wellness and continually learning and making changes to maximize it. Keep in mind, of course, that in order to engage in this lifelong process, opportunities for healthy choices and healthy living must be readily available. For many Americans, economic, environmental, and social barriers make such engagement difficult at best. In addition, there are motivational factors that influence health and wellness behaviors, which are discussed in the Practical Application at the end of this chapter. Positive health behaviors are things to do to improve or maintain health, and negative health behaviors are things to avoid, or stop doing, to improve or maintain health. Among positive health behaviors are eating nutritious foods, regularly engaging in physical exercise, and following a regular schedule for immunizations and screening tests. Among negative health behaviors are cigarette smoking, misuse of alcohol, and tanning.

HEALTH PROMOTION Health promotion and measures to prevent illnesses and healthcare problems are important at all ages of life. But younger people can get away with paying much less attention to positive health behaviors than older people can. As people age, health problems can pile up, and the toll they take then can become much greater.

Nutrition Good nutrition is important for everyone, but it is particularly important for older people. It directly relates to their health and wellness. Properly nourished older adults enjoy a higher quality of life, live longer, and have decreased disability, fewer infections, faster healing of wounds, fewer secondary medical complications, and shorter hospital stays than older adults who are undernourished (Challa, Sharkey, Chen, & Phillips, 2007). As researchers learn more about nutrition as well as the aging process, more information is becoming available about the unique nutritional needs of people as they age. A Food Guide for Older Adults Dietary needs do change with age. Yet, it was not until 1999 that the first food guide intended specifically for older adults was published. Designed by nutrition researchers at Tufts University, that food guide has subsequently been updated (hnrca.tufts.edu/myplate). Tufts University’s Jean Mayer USDA Human Nutrition Research Center on Aging (2016) adds important elements to the U.S. Department of Agriculture’s (USDA) food guide for other adults (see Figure 3.1). The graphic depicts a plate divided into sections showing the approximate proportion of each food group to include in a diet, with accompanying images of good sources of food for each group. For older adults those proportions are:

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3  Health and Wellness for Older Adults 43

MyPlate for Older Adults

Fruits & Vegetables

Fluids

Whole fruits and vegetables are rich in important nutrients and fiber. Choose fruits and vegetables with deeply colored flesh. Choose canned varieties that are packed in their own juices or low-sodium.

Drink plenty of fluids. Fluids can come from water, tea, coffee, soups, and fruits and vegetables.

Grains

Healthy Oils Liquid vegetable oils and soft margarines provide important fatty acids and some fat-soluble vitamins.

Herbs & Spices Use a variety of herbs and spices to enhance flavor of foods and reduce the need to add salt.

Whole grain and fortified foods are good sources of fiber and B vitamins.

Dairy

Fat-free and low-fat milk, cheeses and yogurts provide protein, calcium and other important nutrients.

Protein

Protein rich foods provide many important nutrients. Choose a variety including nuts, beans, fish, lean meat and poultry.

Remember to Stay Active!

FIGURE 3.1  United States Department of Agriculture’s MyPlate Food Guide. SOURCE: ChooseMyPlate.gov. Retrieved from https://www.choosemyplate.gov/myplate-graphic-resources. “My Plate for Older Adults” Copyright 2016 Tufts University, all rights reserved. “My Plate for Older Adults” graphic and accompanying website were developed with support from the AARP Foundation. “Tufts University” and “AARP Foundation” are registered trademarks and may not be reproduced apart from their inclusion in the “My Plate for Older Adults” graphic without express permission from their respective owners. ■■ ■■ ■■

50% fruits and vegetables 25% grains (with an emphasis on whole grains) 25% protein-rich foods such as nuts, beans, fish, lean meat, poultry, and low-fat or fat-free dairy products

Images of frozen fruits and vegetables emphasize their advantages for older adults—for example, they can be easier to prepare and last longer than do fresh fruits and vegetables but can be equally nutritious. Images of foods high in fiber, such as whole-grain breads, cooked dry beans, and whole fruit, underscore their importance in preventing stomach and intestine problems (e.g., constipation), and in helping to lower cholesterol as well as blood sugar. If more fiber needs to be added to a person’s diet, doing so slowly will avoid unwanted gas. In addition to providing protein, dairy products are also an excellent source of calcium, which is important for healthy bones. The MyPlate for Older Adults graphic also incorporates several other important elements in an older person’s diet: fluid intake and the use of healthy oils and herbs and spices. An image with examples of beverages highlights the need for older adults to ensure adequate fluids in their diet. With age, some of the sense of thirst is lost, so older adults should not delay drinking fluids until they feel thirsty. One way to check whether fluid intake is adequate is to monitor the color of one’s urine, which should be pale yellow. If it is a bright or dark yellow, more liquids need to be consumed. Sometimes older people curtail their fluid intake in order to limit trips to the bathroom, but this is unwise given the negative consequences of dehydration: blood pressure may drop; risk of urinary tract infections, kidney stones, and even increase in kidney failure; and resulting imbalances of potassium and sodium can lead to a loss of consciousness. Drinking plenty of fluids also helps move fiber through the intestines.

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Using healthy oils in food preparation and minimizing saturated fats can confer health benefits, such as lowering cholesterol and lowering risk of heart disease. Olive, canola, peanut, and sunflower oil contain healthier unsaturated fats, while high-fat meats and dairy products, as well as many processed foods, contain saturated fats. Changes in taste that accompany aging can prompt older adults to add extra salt to their food. But, too much salt can lead to high blood pressure, upping the chances of having a heart attack or stroke. Herbs and spices are healthier choices for enhancing the flavor of food. Finally, because it is so important to older adults’ overall health, MyPlate for Older Adults includes the recommendation to stay physically active. It is good to be aware of the potential need for supplements as people age, in particular, calcium and vitamins D and B12. Both calcium and vitamin D are needed to reduce the risk of bone fractures. Postmenopausal women need as much as 1,200 mg of calcium per day, and older men need 1,000 mg/day. No more than 500 mg of calcium should be taken at one time because that is all the body can digest at once. In addition to helping the body absorb calcium, vitamin D plays a role in maintaining healthy nerve, muscle, and immune systems. A vitamin D deficiency has been implicated in risks for chronic diseases, such as heart disease and cancer, and immune function diseases, such as multiple sclerosis and flu and colds (Harvard School of Public Health, n.d.). Vitamin D can be obtained from exposure to sunlight as well as from a few foods. When exposure to sunlight for 10 to 15 minutes several times a week is not possible, a vitamin D supplement may be in order. Because of decreased gastric juices, older adults may not get enough vitamin B12 in their diet. Thus, it is recommended that those over 50 years of age take a vitamin B12 supplement to avoid the anemia and nerve damage that result from deficiencies of this vitamin. As metabolism slows and energy needs decrease with age, the need for calories decreases. Women with relatively low physical activity may need only 1,600 calories per day, but women who are fairly active may need up to 2,200 calories per day. Comparable numbers of calories for men range from 2,000 to 2,800 calories per day. However, even though fewer calories are called for, requirements for nutrients remain the same (except for reduced need for iron in postmenopausal women). Eating more foods that are high in a variety of nutrients and eating fewer refined foods TABLE 3.1 Food Pattern Recommendations for Active 75-Year-Old Women and Men WOMEN

MEN

2,000

2,600

6

9

2.5

3.5

Fruits (cups)

2

2

Milk (cups)

3

3

5.5

6.5

6

8

267

410

Energy (kcal) Grains (oz) Vegetables (cups)

Lean meat and beans (oz) Oils (tsp) Discretionary calories (kcal)

SOURCE: Adapted from Lichtenstein, A. H., Rasmussen, H., Yu, W. W., Epstein, S. R., & Russell, R. M. (2008). Modified MyPyramid for older adults. Journal of Nutrition, 138(1), 5–11. doi:10.1093/jn/138.1.5

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TABLE 3.2 Nutrients: RDA, Sources, and Functions

NUTRIENT

RDA (WOMEN— MEN)

Protein

SOURCES

FUNCTIONS

1.0 g/kg

Nuts, legumes, fish, meat, eggs, dairy products

Builds and repairs body tissues; aids nutrient transport, muscle contractions; energy source

Carbohydrates

130 g

Whole-grain breads and cereals, rice, pasta, beans, fruits, starchy vegetables

Main source of fuel for heat and energy; keep intestinal tract healthy

Fats

15%–30% of calories

Animal and vegetable oils, meat, cheese, butter, nonskim milk

Provide energy; absorb some vitamins; insulate and cushion the body; add flavor to food

Fiber

21–30 g

Soluble: oats, barley, beans, fruit and vegetables Insoluble: corn, wheat bran, leafy green vegetables

Soluble: lowers cholesterol; stabilizes blood glucose levels Insoluble: prevents constipation

A

700–900 mcg

Animal products, orange and yellow fruit and vegetables

Maintains vision, skin, tissue health; aids new cell growth

B1 (thiamine)

1.1–1.2 mg

Whole and enriched grains, legumes, organ meats, leafy green vegetables

Energy metabolism; aids proper function of nervous system; prevents beriberi

B2 (riboflavin)

1.1–1.3 mg

Whole and enriched grains, liver, dairy products

Energy metabolism; building tissue; maintains good vision

B3 (niacin)

14–16 mg

Poultry, fish, meat, eggs dairy products, legumes

Aids in proper digestion; skin and nerve functioning

B6 (pyridoxine)

1.5–1.7 mg

Whole grains, meat, fish, eggs, carrots

Food digestion, metabolism, and absorption; boosts immune system; brain and nerve function

B9 (Folate)

400 mcg (200 mcg folic acid)

Dark green leafy vegetables, legumes, liver, yeast

Promotes normal digestion; essential for red blood cells; may reduce risk of heart disease

VITAMINS

(continued )

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TABLE 3.2 Nutrients: RDA, Sources, and Functions (continued)

NUTRIENT

RDA (WOMEN— MEN)

B12 (cobalamin)

SOURCES

FUNCTIONS

2.4 mcg

Meat, liver, kidney, yogurt, dairy products, fish

Builds proteins, red blood cells; aids nervous tissue function

C (ascorbic acid)

75–90 mg

Fresh vegetables and fruits

Antioxidant; infection resistance; aids collagen formation

D

600–800 IUa

Cheese, whole eggs, salmon, fortified milk; sun

Promotes calcium and phosphate use for healthy bones and teeth

E

15 mg

Vegetable oil, wheat germ, leafy green vegetables

Protects red blood cells; preserves vitamins A and C

K

90–120 mcg

Leafy green vegetables, organ meats, cereals, dairy products

Normal blood clotting; protein synthesis in plasma, bone, kidneys

Calcium

1,200 mg

Dairy products, salmon, sardines, broccoli, cabbage

Healthy bones and teeth; normal blood clotting; nervous system

Magnesium

320–420 mg

Dairy products, meat, fish poultry, legumes

Healthy bones and teeth; nervous system; energy metabolism

Potassium

4.7 g

Bananas, fresh and dried fruit, potatoes, broccoli, spinach

Proper fluid balance; muscle function

Selenium

55 mcg

Kidney, liver, shellfish, brazil nuts

Boosts immune system; maintains thyroid function

Zinc

8–11 mg

Meat, seafood, liver, eggs, milk, whole-grain products

Cell reproduction; tissue growth and repair

MINERALS

a

Vitamin D: The International Osteoporosis Foundation recommends 800 to 1,000 I.U. daily.

g, grams; mcg, micrograms; mg, milligrams; RDA, recommended daily allowance. NOTE: RDA. Where a range is given, the lower number is for women and the higher number is for men. RDAs are based on minimum requirements. Vitamins B5 and B7: B5 (pantothenic acid) is available in many different foods and is also produced by intestinal bacteria, so there are no known major deficiencies of this vitamin. RDA has not been determined; adequate intake is 5 mcg. B7 (biotin) is found in all foods, and thus deficiencies are rare. RDA has not been determined; adequate intake is 30 mcg. Lists of food sources and functions are not exhaustive. SOURCE: Adapted from United States Department of Agriculture’s (USDA) Food and Nutrition Information Center website; includes data from National Policy and Resource Center on Nutrition and Aging, Florida International University.

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and foods that contain less fat and sugar can reduce the number of calories consumed while still supplying the necessary nutrients. Specific quantities of nutrients for active 75-year-old men and women are listed in Table 3.1. Table 3.2 focuses on nutrients, listing recommended daily allowances (RDA), sources, and functions of nutrients. Two additional matters to pay attention to when it comes to older people’s nutrition are protein and antioxidant intake. Due to lower rates of protein synthesis and the higher amounts of protein required to maintain physical function and optimal health, older people need more protein, 1.0 to 1.2 g/kg of weight rather than the 0.8 g/kg that they needed as younger adults (Courtney-Martin, Ball, Pencharz, & Elango, 2016). For example, an older person weighing 154 lb (154/2.2 = 70 kg) should consume between 70 and 84 g of protein per day. Four ounces of chicken, sirloin steak, ground beef, or canned tuna each provide between 31 and 35 g of protein; one cup of cooked lentils, lima beans, or kidney beans provides 16 g of protein; and one cup of 2% cottage cheese provides 32 g of protein. Antioxidants are natural substances found in food that may help protect against some diseases. Antioxidants and common sources of them include beta carotene (dark orange and dark green fruits and vegetables), selenium (seafood, liver, meat, and grains), vitamin C (citrus fruits, peppers, tomatoes, and berries), and vitamin E (wheat germ, nuts, sesame seeds, and canola, olive, and peanut oils). Eating Well on a Tight Budget For many older people with limited budgets, it might take some thought and planning to be able to pay for the foods they should eat. Here are some suggestions. First, they can buy only the foods they need, planning meals and checking the supply of staples such as flour and cereal prior to shopping. In case cooking or going out are not good options, having some frozen or canned food available is an alternative. Powdered, canned, or ultrapasteurized milk in a shelf carton can be stored easily. Large packages of food can be shared with a friend. Frozen vegetables in bags save money because small amounts can be used and the rest can be kept frozen. If a package of meat or fresh produce is too large, a store employee may be able to repackage it in a smaller size. Other ways to keep food costs down include using store brands, which often cost less than name brands; planning meals around food that is on sale; and dividing leftovers into small servings, labeling, dating, and freezing them to use within a few months. In many communities, senior centers serve lunch up to 5 days a week at no cost to those aged 60 and over. This is a chance for seniors to eat a well-balanced meal and to socialize with other people. In some locales, home-delivered meals are also available for those who are homebound. Furthermore, the federal Supplemental Nutrition Assistance Program (SNAP, formerly, the Food Stamp Program) can help people with low incomes buy groceries. Nutrition Services Adequate nutrition services for older people include screening, assessment, counseling, and therapy. All of these are important because even when older people seem to know a lot about nutrition, their ability to use that information in making dietary choices can be limited (Hand, Antrim, & Crabtree, 1990). Nutrition services can be provided to older adults through Medicare, the state Medicaid homeand community-based services waiver program, and the food programs of the federal Administration on Aging. Unfortunately, some local agencies may not offer nutrition services. As a result, the very services that could help older people maintain their health, independence, and quality of life may not be available in some communities.

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Physical Activity and Exercise Regular exercise and physical activity are important for the physical, emotional, and mental health of everyone, including older adults. Regular physical activity over long periods of time can produce long-term health benefits. Based on an extensive review and analysis of many research studies, the national Advisory Committee for the Physical Activity Guidelines (U.S. Department of Health and Human Services, 2008) concluded that there is very good evidence that regular physical activity: ■ ■ ■ ■ ■ ■ ■ ■ ■ ■

Lowers the risk of early death Lowers the risk of heart disease, stroke, type 2 diabetes, high blood pressure, an adverse blood lipid profile, metabolic syndrome, and colon, breast, lung, and endometrial cancers Prevents weight gain, leads to weight loss, particularly when combined with reduced calorie intake, helps to maintain weight after weight loss, and reduces abdominal obesity Improves cardiorespiratory and muscular fitness Prevents falls Reduces depression Leads to better cognitive function among older adults Results in better functional health for older adults Increases bone density and lowers the risk of hip fractures Improves sleep quality

In addition, regular exercise and physical activity can help in managing chronic conditions. For example, studies show that people with arthritis, diabetes, and high blood pressure benefit from regular exercise (Brady et  al., 2013). Although the Physical Activity Guidelines focus on the health benefits of physical activity, these benefits are not the only reasons why people should be active. Physical activity also gives people a chance to have fun, to be with friends and family, to enjoy the outdoors, to improve their personal appearance, and to improve their fitness so that they can participate in more intensive physical activity or sporting events, if they so choose. The good news about physical activity is that over time the proportion of older Americans meeting the national Physical Activity Guidelines has steadily increased (see Figure 3.2), from 6% in 1998 to 12% in 2014 (Federal Interagency Forum on Aging-Related Statistics, 2016). Importantly, even though only 12% of people over 65 met the guidelines for both aerobic and muscle-strengthening activities in 2014, 37% met the guidelines for aerobic activity and 17% met the guidelines for muscle-strengthening activities that year. Figure 3.2 also shows that with age, the proportion of older people who report participating in physical activities goes down. There are gender and race/ethnicity differences too—men are more likely than women to meet the guidelines (15% vs. 9%), and non-Hispanic Whites are more likely than their non-Hispanic Black and Hispanic counterparts to meet the guidelines (13%, compared with 9% and 7%, respectively). So, even though more of the older Americans are engaging in some kind of physical activities, there is no end to the possibilities for developing programs to improve those statistics.

Physical Activity Guidelines for Older Adults Most older people do not have health problems that would prevent them from doing moderate activity or the types of exercises that can be beneficial. In fact, there is a way for almost every older

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100 65–74 75–84 85+

Percent

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60

40

20

0

1998

2000

2002

2004

2006

2008

2010

2012

2014

FIGURE 3.2  Percentage of people age 65+ who reported participating in leisure-time aerobic and muscle-strengthening activities, by age group, 1998 to 2014. NOTE: The measure shown here presents the percentage of people who fully met the Physical Activity Guidelines for Americans for both aerobic activity (at least 150 minutes of moderate-intensity aerobic physical activity or 75 minutes of vigorous-intensity aerobic physical activity, performed in episodes of at least 10 minutes throughout a week) and muscle-strengthening (activities that involve all major muscle groups, 2 or more days a week). Data refer to the civilian noninstitutionalized population. SOURCE: Adapted from Federal Interagency Forum on Aging-Related Statistics. (2016). Older Americans 2016: Key indicators of well-being. Washington, DC: U.S. Government Printing Office. Retrieved from https://agingstats.gov/ docs/LatestReport/Older-Americans-2016-Key-Indicators-of-WellBeing.pdf

adult to exercise safely and gain meaningful health benefits. People without diagnosed chronic conditions (e.g., diabetes, heart disease, or osteoarthritis) and who do not have symptoms (e.g., chest pain, dizziness, joint pain) do not need to consult with a healthcare provider about physical activity (U.S. Department of Health and Human Services, 2008). Anyone who has been leading a mostly sedentary lifestyle, or who is not used to energetic activity, should approach exercise in a gradual way, increasing both the amount and the intensity to an optimal level over time. The national Physical Activity Guidelines for older adults are: ■■

■■

■■

■■

All adults should avoid inactivity. Some physical activity is better than none, and adults who participate in any amount of physical activity gain some health benefits. For substantial health benefits, adults aged 65 and over who are fit and have no limiting chronic conditions or disabilities should do at least 150 minutes a week of moderate-intensity, or 75 minutes a week of vigorous-intensity, aerobic physical activity, or an equivalent combination of moderate- and vigorous-intensity aerobic activity. Aerobic activity should be performed in episodes of at least 10 minutes, preferably spread throughout the week. Additional health benefits are gained by engaging in physical activity beyond this amount. Adults should also do muscle-strengthening activities that involve all major muscle groups on 2 or more days a week because these activities provide additional health benefits. Older adults should also do exercises that maintain or improve balance if they are at risk of falling.

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Older adults should determine their level of effort for physical activity relative to their level of fitness. Older adults with chronic conditions and symptoms or disabilities should consult their healthcare provider about the types and amounts of activity appropriate for them.

Exercises generally fall into five categories: aerobic, muscle-strengthening, bone-strengthening, balance, and flexibility. Some activities fit into more than one of these categories. For example, many aerobic activities also help build muscle strength, and muscle-strengthening exercises can help improve balance. Aerobic activities increase breathing and heart rate. They are especially good for improving the health of the heart, lungs, and cardiovascular system. Aerobic activities include brisk walking, dancing, jogging, swimming, biking, playing tennis, yard work (mowing, raking), and climbing stairs. Muscle-strengthening activities (also called resistance training), as the name conveys, improve muscle strength. Even small increases in muscle strength can make a big difference in older adults’ ability to stay independent and accomplish everyday activities such as carrying groceries and climbing stairs. Muscle-strengthening exercises include lifting weights and using resistance bands. It is important to work all the major muscle groups of the body: the legs, hips, back, abdomen, chest, shoulders, and arms. Bone-strengthening activities, sometimes called weight-bearing activities, produce a force on the bones that promotes bone growth and strength. Examples of these activities include jumping jacks, running, brisk walking, and weight-lifting exercises, many of which can also be aerobic and muscle-strengthening. Balance exercises help prevent falls. Many lower body strength exercises, such as standing on one foot, as well as the popular tai chi, improve balance. Flexibility exercises enable the body to stay limber, which provides more freedom of movement for regular physical activity as well as for everyday activities. Shoulder and upper-arm stretches, calf stretches, and yoga are all ways to improve flexibility. Being physically active can help older adults continue to do the things they enjoy and stay independent as they age. And, there are so many ways to be active. For example, activity can be in short spurts throughout the day, or specific times can be set aside on specific days of the week to exercise. Many physical activities, such as brisk walking, raking leaves, or taking the stairs whenever possible, are free or low cost and do not require special equipment. Older adults can also check out an exercise video or DVD from their public library, find a fitness center, or participate in exercise classes at their local senior center.

Mental Activity The brain is an organ, and like all organs in the body, it needs to be used and exercised regularly. People who remain active by dancing or participating in any other type of physical activity, playing musical instruments, or engaging in focused games (e.g., scrabble) can reduce their risk of mental decline. Likewise, people who become involved in groups such as civic organizations, church groups, social groups, athletic events, and so forth, seem to maintain their cognitive abilities better than those who do not. Social relationships are also important and seem to stimulate brain functioning. The old cliché, “use or lose it,” seems to be true with regard to the brain. Much more information about the role of mental activity is presented in Chapter 4, Mental Health, Cognitive Abilities, and Aging.

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Good Sleep Hygiene It is important to get a good night’s sleep at all ages. Sleep provides the opportunity for the body to repair cell damage, it helps to prevent disease by refreshing the immune system, and it improves concentration and memory function. With age, it is harder to get quality sleep because physiological sleep patterns change, reducing periods of the most restful type of sleep, rapid eye movement (REM) sleep. Nevertheless, daytime sleepiness is not a part of normal aging. Therefore, it is especially important for older adults to practice good sleep hygiene, which includes the following: ■

Engaging in activities to keep energy level up during the day, preparing the body for sleep at night

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Establishing a regular daily schedule of going to bed and rising Creating a comforting environment: a good mattress, pillow, and bedding; a quiet, dark room with a suitable temperature and ventilation Reserving the bed for sleeping, and sex, so it will be associated with only those things Developing a relaxing bedtime routine, such as taking a bath or listening to calming music For periods of wakefulness during the night, trying to stay relaxed by engaging in a repetitive, unstimulating activity, such as counting sheep; and, if a wakefulness period extends to 15 minutes, getting out of bed and doing a quiet activity, keeping the lights dim

■ ■ ■ ■

Other tips for improving sleep include: ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■

Taking a daily walk because exercise releases chemicals in the body that promote restful sleep Taking a 15- to 30-minute nap early in the afternoon, which can improve overall restfulness Getting 2 hours or more of sunlight a day because bright sunlight increases melatonin, which regulates sleep–wake cycles Combining sex and sleep because sex and physical intimacy, such as hugging and massage, can lead to restful sleep Limiting caffeine late in the day Eating no more than a light snack 3 hours before bedtime Limiting beverages within 90 minutes of bedtime Avoiding alcohol before bedtime—it may seem to aid sleep, but it actually causes waking during the night Quitting smoking, or at least avoiding it within 3 hours of bedtime, because nicotine is a stimulant Blocking out snoring or other noises with earplugs or a white-noise machine Limiting use of sleeping aids and sleeping pills because many of them have unpleasant side effects and thus are not a long-term solution to sleep problems

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Reducing mental stress by jotting down worries or concerns, checking off tasks completed on a to-do list, and listing goals for the next day, before retiring Using relaxation techniques, such as progressive relaxation or deep breathing, which can prepare the body for sleep

PREVENTIVE MEASURES Preventive health measures include immunizations, screening tests, and avoiding negative health behaviors. Medicare covers many preventive services at no cost for Medicare enrollees. The topic of Medicare, including eligibility criteria and what it covers, is discussed in Chapter 12, Medicare, Medicaid, and Medications.

Immunizations All adults need immunizations to help prevent getting and spreading serious infectious diseases that can result in poor health, and even death. The real dangers of these diseases greatly outweigh the rare likelihood of side effects from vaccines. As a case in point, together, influenza and pneumonia account for well over 112,000 hospitalizations per year (Goto, Yoshida, Tsugawa, Camargo, & Hasegawa, 2016), and are the fifth leading cause of death in older Americans (Centers for Medicare & Medicaid Services, 2017). Most older adults have heard that they should get a flu shot every year, even if they do not all get one. They may not know that there are three other vaccines they should be sure to get—pneumococcal, shingles, and Tdap/Td (tetanus, diphtheria, and pertussis). Information on vaccinations is updated regularly on the website of the Centers for Disease Control and Prevention (CDC; www.cdc.gov/vaccines/index.html). Influenza (Flu) Vaccine Influenza viruses (flu) cause a contagious respiratory illness. Older adults are among the groups at higher risk (as are children from age 6 to 59 months and anyone with a medical condition) that can benefit significantly from being vaccinated against the illness, which can lead to health complications, hospitalization, and even death. In fact, over half of the hospitalizations and three-quarters of the deaths from influenza occur in people 65 years of age and older (Reed et al., 2015). Even in those cases where the vaccine may not prevent the disease, it nevertheless reduces its severity (Arriola et al., 2017). It is best to get a flu shot during the fall, before the height of the flu season. Along with individuals in the higher risk groups, people who live with or care for them should also receive a flu shot every year. Although the proportion of older people being vaccinated has risen significantly over the previous few decades, differences still exist in vaccination rates among people of different races and ethnicity (see Figure 3.3). Education has an impact too, with 64% of those who have not graduated from high school receiving the vaccine compared with 72% of those with at least a high school diploma (Federal Interagency Forum on Aging-Related Statistics, 2016). Interestingly, the percentage of people receiving flu shots also goes up with age, from 67% for those 65 to 74 years of age to 78% by age 85. The goal of Healthy People 2020, which is for 90% of older adults to be vaccinated annually for the flu, has not yet been reached, although Medicare began paying for annual flu shots in 1993.

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100

Percent

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60

40 Non-Hispanic White Non-Hispanic Black Hispanic

20

0

1989

1993

1995

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2002

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2006

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2012 2014

FIGURE 3.3  Percentage of people age 65+ who reported being vaccinated against influenza, by race and Hispanic origin, 1989 to 2014. NOTE: Percentage consists of people who reported having a flu shot during the past 12 months. Data refer to civilian noninstitutionalized population. SOURCE: Adapted from Federal Interagency Forum on Aging-Related Statistics. (2016). Older Americans 2016: Key indicators of well-being. Washington, DC: U.S. Government Printing Office. Retrieved from https://agingstats.gov/ docs/LatestReport/Older-Americans-2016-Key-Indicators-of-WellBeing.pdf

Pneumococcal Vaccine Pneumonia (pneumococcal disease), which can cause serious infections in the lungs, bloodstream, and the covering of the brain, is one of the primary reasons that older people go to hospital emergency rooms. It is all too frequently also a cause of death for them. To avoid or minimize the effects of pneumonia, beginning in fall 2014, the CDC recommended that older people receive two pneumonia vaccinations: an initial one (13-valent pneumococcal conjugate vaccine, PCV13), and 11 full months after receiving that vaccine, a different, second vaccine (23-valent pneumococcal polysaccharide vaccine, PPSV23; Tomczyk et al., 2014). Despite increases in the rates of pneumonia shots for all older people over time, as is the case for flu shots, differences still exist in vaccination rates among people of different races and ethnicity (see Figure 3.4). Education and gender have an impact too, with 55% of those who have not graduated from high school being vaccinated compared with 63% of those with at least a high school diploma, and 64% of women being vaccinated compared with 58% of men (Federal Interagency Forum on Aging-Related Statistics, 2016). The percentage of people receiving pneumonia shots also goes up with age, from 56% for those 65 to 74 years of age to 69% by age 85. We are far from reaching Healthy People 2020’s goal of 90% of older adults being vaccinated against pneumonia, although Medicare began covering the cost of pneumonia shots in 1981. Shingles Vaccine Shingles is a painful skin rash caused by the varicella zoster virus. The pain and rash usually heal within 2 to 4 weeks, but can last for 3 months or longer. Some people who get shingles

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100 Non-Hispanic White Non-Hispanic Black Hispanic

Percent

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40

20

0

1989

1993

1995

1998

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2012 2014

FIGURE 3.4  Percentage of people age 65+ who reported being vaccinated against pneumonia, by race and Hispanic origin, 1989 to 2014. NOTE: Percentage refers to people who reported ever having a pneumonia vaccination. Data refer to civilian noninstitutionalized population. SOURCE: Adapted from Federal Interagency Forum on Aging-Related Statistics. (2016). Older Americans 2016: Key indicators of well-being. Washington, DC: U.S. Government Printing Office. Retrieved from https://agingstats.gov/ docs/LatestReport/Older-Americans-2016-Key-Indicators-of-WellBeing.pdf

can have complications, the most common of which is chronic nerve pain, which can go on for years. Because this virus is the same one that produces chicken pox, everyone who has had the chicken pox is at risk of getting shingles because the virus remains in the body and then can become active again later in life. A shingles vaccine first became available in 2006, but only 30% of all people 60 and older have received it (Williams et al., 2017). Once again, there are racial and ethnic differences, with 35% of non-Hispanic Whites receiving the vaccine compared with only 14% of non-Hispanic Blacks, and 16% of Hispanics. In October 2017, the CDC recommended that healthy adults aged 50 years and older should receive the new vaccine, Shingrix®, which is now the preferred vaccine to prevent shingles and related complications (CDC, n.d.-a). The CDC conjointly recommended that those who had been previously vaccinated with Zostavax® should also receive this new vaccine. Although shingles is not contagious, everyone should be mindful of the fact that a person with active shingles can transmit the virus to a person who has never had chicken pox. Medicare prescription drug plans may cover the cost of this vaccine. Tdap and Td Vaccines Tdap and Td vaccines protect against tetanus, diphtheria, and pertussis. These vaccines are recommended for older adults because vaccine-induced immunity seems to wane with age, and thinner skin can make them more vulnerable to wounds that would allow the tetanus bacteria into their body. Tetanus (“lockjaw”) is an acute bacterium that affects the central nervous system, causing tightening and spasms of muscles, particularly in the jaw, as well as fever and headaches. It may even result in death by suffocation. Diphtheria is an acute bacterial disease that affects the throat and skin, causing breathing problems, and potentially paralysis and heart failure. Pertussis

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(“whooping cough”) is an acute bacterium that affects the upper respiratory system. Symptoms include intense fits or spells of coughing, and thick, sticky mucus in the throat, with the potential to cause pneumonia, seizures, and brain damage. Diphtheria and pertussis are highly contagious, and both can result in death. These infections are easily passed on to infants who are too young to be vaccinated. The CDC recommends that every adult should get the Tdap vaccine once if they did not receive it as an adolescent to protect against pertussis (whooping cough), and then a Td (tetanus, diphtheria) booster every 10 years (Pilkinton & Talbot, 2015). The cost of Tdap and Td vaccines may be covered in Medicare prescription drug plans. Increasing the rates of immunizations and decreasing the health inequities among the rates of people of different ages, races and ethnicities, genders, and educational levels is an area ripe for innovations, thereby ensuring better health for all.

Screening Tests There are two circumstances under which a screening test makes sense. The first is when a disease or chronic condition has few or no early symptoms but is preventable—a good example is preventing strokes by screening for high blood pressure. The second circumstance is when there are effective treatments for a disease or chronic condition if it is detected early, examples of which include many types of cancer. The U.S. Preventive Services Task Force (USPSTF) makes recommendations about the effectiveness of specific preventive care services for patients without obvious related signs or symptoms, services that include screening tests. It bases its recommendations on the evidence of both the benefits and harms of the tests and an assessment of the balance. The USPSTF recognizes that clinical decisions involve more considerations than evidence alone. The Task Force encourages healthcare providers to consider the evidence but to individualize decision making to the specific patient or situation. Screening tests are regularly reviewed for their effectiveness by the USPSTF, and its recommendations are published on its website (www.uspreventiveservicestaskforce.org/ Page/Name/recommendations). Medicare covers the costs of most preventive services for Medicare enrollees. Blood Pressure, Cholesterol, Blood Glucose, and Bone Density Screenings There are no symptoms for high blood pressure, but if uncontrolled, it can lead to a stroke, a heart attack, heart failure, or kidney failure. Accordingly, routine blood pressure measurement is recommended at least every 2 years for those with normal readings, and every year otherwise. New guidelines, the first in almost 15 years, for the detection, prevention, and management of high blood pressure in adults define normal blood pressure as 120/80 mmHg (Whelton et  al., 2017). The targets for older adults are often slightly different—140/90 mmHg, 150/80 mmHg, or 150/85 mmHg—with the first number (systolic pressure) being more important than the second (diastolic pressure) for adults over age 50 (Health in Aging, 2017). Systolic blood pressure is the pressure caused by the heart contracting and pushing out blood and diastolic blood pressure is the pressure when the heart relaxes and fills with blood in between beats. Slightly higher systolic pressure can help to counteract the risk of it dropping too low and thereby resulting in fainting or falling, which can be a consequence of age-related stiffening of the arteries. For everyone age 20 or older, cholesterol should be checked at least once every 5 years to estimate the risk of developing heart disease. For total cholesterol, which includes both low-density

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lipoprotein (LDL) and high-density lipoprotein (HDL), a level of less than 200 mg/dL is desirable. For LDL (bad) cholesterol, which is the main source of cholesterol buildup and blockage in arteries, a level of less than 100 mg/dL is optimal (100–129 is near optimal). And, for HDL (good) cholesterol, which helps remove cholesterol from arteries, a level of 60 mg/dL or higher is considered protective against heart disease (National Institutes of Health [NIH] MedlinePlus, 2012). Some things that affect cholesterol levels are beyond our control, for example, total cholesterol and LDL levels tend to go up with age, and a tendency for higher cholesterol levels can run in families. The good news is that there is a variety of ways to positively affect cholesterol levels, for example, through diet, by reducing the amount of saturated fat and cholesterol in the foods we eat, and regular physical activity, which can lower LDL and also raise HDL. Diabetes is an all-too-common chronic condition in many older adults. It can lead to serious health consequences, including blindness, kidney failure, limb amputations, heart disease, and stroke. Blood glucose screening can identify people at risk or who are prediabetic so that recommendations can be made to prevent the development of the disease or reduce its adverse consequences. The USPSTF (2015) recommends screening for abnormal blood glucose and type 2 diabetes in adults between the ages of 40 and 70 who are overweight or obese, and who do not show symptoms of diabetes. Bones change throughout the life span, with an ongoing process of new bone being formed and old bone being removed. During growth and development of the body, more bone is being added, and not as much bone is being removed. As discussed in Chapter 2, Physical Changes and the Aging Process, at around age 30, maximum bone density and strength is achieved. Then, more bone is being removed than is being formed, so bone density decreases. If bone density becomes too low, it can result in osteoporosis, which increases the risk of fractures, particularly fractures of the hip, spine, and wrist, which, in turn, can lead to loss of function and independence, reduced quality of life, and premature mortality. A fracture is usually the first sign of osteoporosis, but screening for bone density can alert a person to the need for treatment to avert the negative consequences of the disease. The USPSTF (2011) recommends that all women over age 65 have a bone density test done. Younger women who are at high risk for osteoporosis should also be tested—risks include having a parent who has had a hip fracture, low body weight, smoking cigarettes, drinking large amounts of alcohol, and having been through menopause. Cancer Screenings Research and advances in medical treatments have meant that many cancers that used to go undiagnosed and ran their course quickly can now be detected early, leading to much better prognoses for living longer and higher quality lives despite cancer. An important key to this progress is screening tests. Routine screening for colorectal, breast, and cervical cancer has proven to be especially valuable. Screening for prostate cancer is somewhat controversial. Colorectal cancer is easily treated, with an excellent prognosis if identified early enough. Nevertheless, it is one of the leading causes of cancer deaths, most of which occur in older adults, and one of the main reasons is that not enough people are being screened for it. The USPSTF (2016b) recommends screening for colorectal cancer starting at age 50 and continuing until age 75. Screening at later ages may be beneficial depending on a person’s overall health and prior screening history. Several different tests are available. With the goal of maximizing the number of people who are screened, the USPSTF has concluded that the best approach is for healthcare providers to discuss the testing options with their patients, taking into account the patient’s preferences and the local availability of tests.

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Breast cancer, if detected early enough, can be cured. Contemporary screening technology has led to earlier detection and breast cancer treatments have improved substantially over the previous 30 years. Nevertheless, it is the second leading cause of cancer among women in the United States. The USPSTF (2016a) recommends a mammogram every 2 years between 50 and 74 years of age. Women with a parent, sibling, or child with breast cancer may benefit from beginning mammography screening in their 40s. As is the case for breast cancer, screening for cervical cancer is highly effective. These screenings have become much more common over the years since their introduction in the 1950s, and as a consequence, deaths from cervical cancer have decreased dramatically. Today, cervical cancer deaths are most often attributable to a lack of appropriate screening. Women from age 21 to 65 should be screened for cervical cancer with a Papanicolaou (Pap) smear every 3 years or, for women age 30 to 65, with both a Pap smear and human papillomavirus (HPV) testing every 5 years (USPSTF, 2018). It is recommended that women older than 65 years of age need not be tested if they have had three consecutive Pap smears with no abnormal results. In the case of screening for prostate cancer, there is much controversy because the prostate-specific antigen (PSA) test, which began to be used widely in 1987, is problematic. One of the primary issues is that the test produces a high rate of overdiagnosis and overtreatment, especially among older men. Overdiagnosis occurs when a test detects a disease that will not cause symptoms or death. Though some cases of prostate cancer are aggressive, most cases have a good prognosis, even without treatment. Undergoing unnecessary follow-up procedures and treatments can be harmful, bringing about erectile dysfunction, urinary incontinence, bowel dysfunction, and even a slightly elevated risk of premature death. Furthermore, over the course of 11 to 13 years, there seems to be little to no reduction in deaths due to prostate cancer among those who have been screened. The USPSTF (2017) is currently updating its recommendations, but while awaiting its advice, the best course to follow seems to be to screen men under the age of 70, which would balance the benefits of screening while reducing harm (Gulati et al., 2014). Developing a new and better test for screening prostate cancer would be a good step forward. Other Screenings Hepatitis C is a viral liver infection that can lead to long-term health problems, and even death. The CDC (n.d.-b) estimates that between 2.7 and 3.9 million people in the United States have chronic Hepatitis C and most of them do not know it. Thus, screening is recommended for those at increased risk: a one-time screening for adults born between 1945 and 1965, and periodic screening for those at high risk due to past or current injection drug use, intranasal drug use, receiving a blood transfusion before 1992, incarceration, and getting an unregulated tattoo, as well as other exposures through the skin (USPSTF, 2013). Screenings for obesity, sexual health, vision, and mental health can also be valuable for older adults, although there are no prescribed schedules for them. The best test for obesity is a body mass index (BMI), a measure of body fat based on height and weight. Obesity is associated with a variety of negative health outcomes, heart disease and diabetes being among them. For older adults, being what in younger adults would be termed slightly overweight is a good thing, while being underweight is not. A BMI between 24.0 and 30.9 is associated with lower mortality risk for adults age 65 and above, while a BMI of less than 23.0 is associated with a higher mortality risk (Winter, MacInnis, Wattanapenpaiboon, & Nowson, 2014).

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Older adults should talk with their healthcare provider about being tested for sexually transmitted infections if they are at risk because they have new or multiple sex partners. In addition, those at high risk for HIV should be tested—conditions for high risk include having a blood transfusion between 1978 and 1985, being treated for sexually transmitted diseases, having unprotected sex with multiple partners, and having used injection drugs. Older adults will find that they need to be proactive when it comes to their sexual health because physicians and other healthcare providers often feel uncomfortable about discussing sexual matters with their older patients and thus may avoid doing so. Macular degeneration, glaucoma, and retinopathy are all serious diseases that develop more readily in older people and can all result in serious vision loss and even blindness (see Chapter 11, Medical Conditions, Assisted Living, and Long-Term Care for more information about these diseases). Presbyopia, dry eyes, and cataracts, which were discussed in Chapter 2, Physical Changes and the Aging Process, are more common and more easily treated vision conditions. For the sake of both the serious diseases and the more common eye conditions, a complete eye examination by a qualified professional (e.g., ophthalmologist) is recommended for those older than age 45, and then follow-up examinations every 2 to 4 years thereafter. Depression is not a normal part of aging. It is associated with distress and suffering and can lead to impairments in physical, mental, and social functioning. Older adults should talk with their healthcare provider about being screened for depression if they have felt down, sad, or hopeless over a period of 2 or more weeks, or have felt little interest or pleasure in their usual activities. The good news is that depression is highly treatable. Chapter 4, Mental Health, Cognitive Abilities, and Aging, includes information on some treatment programs that have been proven to work especially well for older adults.

Avoiding Negative Health Behaviors In addition to engaging in behaviors that enhance and maintain health, some behaviors and habits should be curtailed so that health is not compromised. Among the most prevalent negative health behaviors that should be avoided or discontinued are cigarette smoking, misuse of alcohol, and tanning. Cigarette Smoking The good news is that only 8.4% of adults aged 65 years and older are current smokers, although many more used to be and, fortunately, have quit smoking. This rate compares favorably to current smokers who are 18- to 24-years old—13%, and those who are 24- to 64-years-old—17% (Jamal et al., 2016). Cigarette smoking worsens the prognosis and symptoms of all chronic diseases and is the primary cause of lung cancer and chronic obstructive pulmonary disease (COPD). Among older people, the death rate for chronic lower respiratory diseases (primarily COPD) increased by 50% between 1981 and 2014; it is now the third leading cause of death among people age 65 and over (Federal Interagency Forum on Aging-Related Statistics, 2016). Smokers can do nothing better for their health than to quit smoking. There are many approaches to becoming a nonsmoker, and health professionals can help individuals choose one that can be helpful to them. Part of the difference in longevity between various socioeconomic groups in the United States is related to the difference in smoking rates between them. People living below the

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poverty line have a smoking rate of 26% compared with 14% for those living at or above the poverty line, and people with less than a high school education have a smoking rate of 34%, while those with an undergraduate degree have a smoking rate of 7.4% (Jamal et al., 2016). A college education seems to promote healthy living, as there seems to be a clearer understanding of the devastating effects of using tobacco. In addition, there is probably a significant difference in peer pressure, given that smoking is increasingly stigmatized among college students. Misuse of Alcohol Drinking too much alcohol over a long period of time can increase the risk of liver damage, some kinds of cancer, immune system disorders, and brain damage. It also worsens virtually every health condition, including some that are more common in older adults, such as diabetes, high blood pressure, and osteoporosis, and it raises the likelihood of falls and fractures. Furthermore, misuse of alcohol can cause forgetfulness and confusion, symptoms that, in older adults, may be mistaken for signs of Alzheimer’s disease (National Institute on Aging, 2017). Compared with young adults (18 years of age and older), adults 65 years of age and older are much less likely to be binge drinkers, defined as five or more drinks for men and four or more drinks for women on the same occasion. While 26% of young adults are binge drinkers, only 10% of older adults are (Center for Behavioral Health Statistics and Quality, n.d.). Likewise, fewer older people—only 2%—are heavy alcohol users, defined as binge drinking on each of 5 or more days within a 30-day period, compared with 7% of younger adults. Age-related physiological changes increase the risks associated with alcohol. On top of that, the vast majority of older adults use at least one medication, and most of these medications can interact adversely with alcohol. Accordingly, the guidelines of the National Institute on Alcohol Abuse and Alcoholism (n.d.) recommend lower alcohol consumption for older adults than for younger people. Specifically, for healthy older adults who are not taking medications, no more than three drinks of alcohol on any day and no more than seven drinks per week is recommended. Consuming alcohol and using drugs that interact with alcohol should be avoided. No alcohol should be consumed if activities are planned that can be impaired by alcohol, for example, driving or caregiving for others. Health professionals can provide counseling about safe drinking practices or advise on interventions for those at risk for alcohol abuse or dependence. Tanning Ultraviolet radiation exposure at any age, whether from the sun or solar lamps, can cause skin cancer, as well as premature aging, immune system suppression, and eye damage (U.S. Food and Drug Administration, 2017). During midday (10 a.m.–4 p.m.), when the sun is most severe, limiting direct exposure to the sun is a good idea. Except for the 10 to 15 minutes of sun exposure that older people should get a few times a week to enhance their intake of vitamin D, skin should be covered when in sunlight, or sunscreen lotion should be used for protection. The U.S. Food and Drug Administration (2017) now recommends restricting tanning devices to people 18 years of age or older, and requiring that consumers sign an acknowledgement before they use them, and every 6 months thereafter, stating that they have been informed of the health risks that may result from the use of these products.

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PRACTICAL APPLICATION INTRODUCTION

Chapter 3 explains the importance of proper nutrition, physical activity, and good sleep hygiene to the health of older adults and differentiated between the nutritional needs of older and younger adults. It also offers an overview of the recommended vaccines and screening tests older adults should undergo as they age. The chapter concludes with a discussion about reducing the risk of developing chronic diseases by avoiding negative health behaviors and engaging in positive ones. Given the difficulty people have making major changes to behaviors that affect their health, this Practical Application offers some insight into individual motivation for wellness. MOTIVATION FOR WELLNESS

Given the vast amounts of information available in our modern society, most people are generally aware of the things they need to do to maintain good health as they age. Yet it seems that so many choose to ignore what they know. Lifestyle choices, long-established habits (some of which may not have been deemed harmful when the habit began—e.g., smoking), changes to available food sources, and a lack of knowledge about what constitutes proper nutrition have all contributed to a great number of individuals aging in unhealthy ways. What, then, can gerontology professionals do to help older adults develop better habits? They can begin by understanding what motivates people to do so. According to the Encarta Dictionary: English (North American edition), motivation is defined as “the act of giving somebody a reason or incentive to do something.” Using this definition, an informal survey was administered to a group of older individuals at a local senior center. Those identifying themselves as exercising regularly were asked what motivated them to do so—their responses included the following: ■ An urgency brought about by specific chronic diseases/conditions (heart, fibromyalgia, arthritis, stroke, high cholesterol, etc.) ■ Fear based on family history (life-limiting genetic conditions) ■ A desire to maintain balance and mobility ■ Wanting to control their weight Also very revealing were the responses of those who identified themselves as not exercising regularly. When asked why they did not exercise, they said it was due to laziness, discouragement, or conditions such as shortness of breath that made it difficult to exercise. Understanding the motivations of an older person is the starting point for positive intervention through education, encouragement, and appropriate supports. By helping individuals identify and engage their personal motivation to make healthier lifestyle choices, we can help improve, and perhaps even extend, their lives.

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STUDENT ACTIVITIES 1. Imagine you work for a senior center. Your job is not only to create a program to pro-

2.

3.

4.

5.

mote physical activity, but also to convince members to sign up. Design 1 week of daily physical activity recommendations and write your pitch for why members would benefit from participating in your program. Conduct a web search to discover the nutritional services and resources available to older adults in your community or in your state. Indicate whether the options seem plentiful, adequate, or lacking. If they are lacking, describe the services or resources you think would be most beneficial to those in your community. Recall a time when you or someone you know contracted flu or pneumonia. Describe the symptoms and the overall experience. Given what you know about the normal physical changes that occur as individuals age, explain why it is particularly risky for older adults to contract such common infections. Norma is 68 years old and has a family history of breast cancer. Create a screening schedule that shows which tests she can expect to undergo as she continues to age. Visit the “Stories from the Field” page on the Healthy People website (www.healthypeople. gov). Use the interactive map or the list of stories below it to identify four initiatives aimed at helping people avoid negative health behaviors and thus lower their risk for chronic disease.

SUGGESTED RESOURCES National Institutes of Health MedlinePlus. Retrieved from https://www.medlineplus.gov Health information from the National Library of Medicine and the National Institutes of Health. National Institute on Aging. Retrieved from https://www.nia.nih.gov/health An easy-to-use website of the National Institute on Aging, which features basic health and wellness information for older adults. Tufts University’s Jean Mayer USDA Human Nutrition Research Center on Aging. Retrieved from http://hnrca.tufts.edu The focus of this nutrition research center is on the needs of older adults. U.S. Food and Drug Administration. Consumer updates. Retrieved from http://www.fda.gov/ ForConsumers/ConsumerUpdates/default.htm Consumer updates on dietary supplements, drugs, food, medical devices, nutrition, vaccines, pet products, and more. U.S. Preventive Services Task Force. Retrieved from https://www.uspreventiveservicestaskforce.org The U.S. Preventive Services Task Force is an independent, volunteer panel of national experts in prevention and evidence-based medicine. The Task Force works to improve the health of all Americans by making evidence-based recommendations about clinical preventive services such as screenings, counseling services, and preventive medications. All recommendations are published on the Task Force’s website and/or in a peer-reviewed journal.

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REFERENCES Arriola, C., Garg, S., Anderson, E. J., Ryan, P. A., George, A., Zansky, S. M., . . . Chaves, S. S. (2017). Influenza vaccination modifies disease severity among community-dwelling adults hospitalized with influenza. Clinical Infectious Diseases, 65(8), 1289–1297. doi:10.1093/cid/cix468 Brady, T. J., Murphy, L., O’Colmain, B. J., Beauchesne, D., Daniels, B., Greenberg, M., . . . Chervin, D. (2013, January 18). A meta-analysis of health status, health behaviors, and health care utilization outcomes of the Chronic Disease Self-Management Program. Preventing Chronic Disease, 10, 120112. doi:10.5888/pcd10.120112 Center for Behavioral Health Statistics and Quality. (n.d.). Results from the 2016 National Survey on Drug Use and Health: Detailed tables (Table 2.20B—Alcohol use, binge alcohol use, and heavy alcohol use in past month among persons aged 12 or older, by detailed age category: Percentages, 2015 and 2016). Rockville, MD: Substance Abuse and Mental Health Services Administration. Retrieved from https://www.samhsa.gov/data/sites/default/files/NSDUH-DetTabs-2016/NSDUH-DetTabs-2016. htm#tab2-20B Centers for Disease Control and Prevention. (n.d.-a). Vaccination (Shingrix®). Retrieved from https:// www.cdc.gov/shingles/vaccination.html Centers for Disease Control and Prevention. (n.d.-b). Viral hepatitis: Hepatitis C information. Retrieved from https://www.cdc.gov/hepatitis/hcv/index.htm Centers for Medicare & Medicaid Services. (2017). Immunizations. Retrieved from https://www.cms .gov/Medicare/Prevention/Immunizations Challa, S., Sharkey, J. R., Chen, M., & Phillips, C. D. (2007). Association of resident, facility, and geographic characteristics with chronic undernutrition in a nationally represented sample of older residents in U.S. nursing homes. Journal of Nutrition, Health and Aging, 11, 179–184. Courtney-Martin, G., Ball, R. O., Pencharz, P. B., & Elango, R. (2016). Protein requirements during aging. Nutrients, 8(8), 492. doi:10.3390/nu8080492 Federal Interagency Forum on Aging-Related Statistics. (2016). Older Americans 2016: Key indicators of well-being. Washington, DC: U.S. Government Printing Office. Retrieved from https://agingstats.gov/ docs/LatestReport/Older-Americans-2016-Key-Indicators-of-WellBeing.pdf Goto, T., Yoshida, K., Tsugawa, Y., Camargo, C. A., & Hasegawa, K. (2016). Infectious disease-related emergency department visits of elderly adults in the United States, 2011–2012. Journal of the American Geriatrics Society, 64, 31–36. doi:10.1111/jgs.13836 Gulati, R., Tsodikov, A., Etzioni, R., Hunter-Merrill, R. A., Gore, J. L., Mariotto, A. B., & Cooperberg, M. R. (2014). Expected population impacts of discontinued prostate-specific antigen screening. Cancer, 120, 3519–3526. doi:10.1002/cncr.28932 Hand, R., Antrim, L. R., & Crabtree, D. A. (1990). Differences in the technical and applied nutrition knowledge of older adults. Journal of Nutrition for the Elderly, 9(4), 23–34. doi:10.1300/J052v09n04_03 Harvard School of Public Health. (n.d.). Vitamin D and health. Retrieved from https://www.hsph .harvard.edu/nutritionsource/vitamin-d Health in Aging. (2017). High blood pressure (hypertension): Unique to older adults. New York, NY: American Geriatrics Society’s Health in Aging Foundation. Retrieved from http://www.healthinaging .org/aging-and-health-a-to-z/topic:high-blood-pressure/info:unique-to-older-adults Jamal, A., King, B. A., Neff, L. J., Whitmill, J., Babb, S. D., & Graffunder, C. M. (2016, November 11). Current cigarette smoking among adults: United States, 2005-2015. Morbidity and Mortality Weekly Report, 65(44), 1205–1211. Retrieved from https://www.cdc.gov/mmwr/mmwr_wk/wk_pvol.html Lichtenstein, A. H., Rasmussen, H., Yu, W. W., Epstein, S. R., & Russell, R. M. (2008). Modified MyPyramid for older adults. Journal of Nutrition, 138(1), 5–11. doi:10.1093/jn/138.1.5 National Institute on Aging. (2017). Facts about aging and alcohol. Retrieved from https://www.nia.nih .gov/health/facts-about-aging-and-alcohol National Institute on Alcohol Abuse and Alcoholism. (n.d.). Older adults. Retrieved from https://www .niaaa.nih.gov/alcohol-health/special-populations-co-occurring-disorders/older-adults National Institutes of Health MedlinePlus. (2012, Summer). Cholesterol levels: What you need to know. Retrieved from https://medlineplus.gov/magazine/issues/summer12/articles/summer12pg6-7.html

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Pilkinton, M. A., & Talbot, H. K. (2015). Update on vaccination guidelines for older adults. Journal of the American Geriatrics Society, 63, 584–588. doi:10.1111/jgs.13375 Reed, C., Chaves, S. S., Daily, K. P., Emerson, R., Aragon, D., Hancock, E. B., . . . Finelli, L. (2015, March 4). Estimating influenza disease burden from population-based surveillance data in the United States. PLoS One, 10(3), e0118369. doi:10.1371/journal.pone.0118369 Tomczyk, S., Bennett, N. M., Stoecker, C., Gierke, R., Moore, M. R., Whitney, C. G., . . . Pilishvili, T. (2014, September 19). Use of 13-valent pneumococcal conjugate vaccine and 23-valent pneumococcal polysaccharide vaccine among adults aged ≥ 65 years: Recommendations of the Advisory Committee on Immunization Practices (ACIP). Morbidity and Mortality Weekly Report, 63(37), 822–825. Retrieved from https://www.cdc.gov/mmwr/mmwr_wk/wk_pvol.html Tufts University’s Jean Mayer USDA Human Nutrition Research Center on Aging. (2016). MyPlate for older adults. Boston, MA: Author. Retrieved from https://hnrca.tufts.edu/myplate/# U.S. Department of Health and Human Services. (2008). 2008 physical activity. Washington, DC: U.S. Government Printing Office. Retrieved from www.health.gov/paguidelines U.S. Food and Drug Administration. (2017). Tanning. Retrieved from https://www.fda.gov/radiation -emittingproducts/radiationemittingproductsandprocedures/tanning/default.htm USPSTF. (2011). Screening for osteoporosis: U.S. Preventive Services Task Force recommendation statement. Annals of Internal Medicine, 154(5), 356–364. doi:10.7326/0003-4819-154-5-201103010 -00307 USPSTF. (2013). Final recommendation statement. Hepatitis C: Screening. Retrieved from https:// www.uspreventiveservicestaskforce.org/Page/Document/RecommendationStatementFinal/hepatitis -c-screening USPSTF. (2015, October). Abnormal blood glucose and type 2 diabetes mellitus: Screening. Retrieved from https://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFinal/screening -for-abnormal-blood-glucose-and-type-2-diabetes?ds=1&s=blood%20glucos USPSTF. (2016a). Final recommendation statement. Breast cancer: Screening. Retrieved from https:// www.uspreventiveservicestaskforce.org/Page/Document/RecommendationStatementFinal/breast -cancer-screening1 USPSTF. (2016b). Final recommendation statement. Colorectal cancer: Screening. Retrieved from https:// www.uspreventiveservicestaskforce.org/Page/Document/RecommendationStatementFinal/ colorectal-cancer-screening2 USPSTF. (2017). Draft recommendation statement. Prostate cancer: Screening. Retrieved from https:// www.uspreventiveservicestaskforce.org/Page/Document/RecommendationStatementFinal/prostate -cancer-screening USPSTF. (2018). Cervical cancer: Screening. Retrieved from https://www.uspreventiveservicestaskforce .org/Page/Document/UpdateSummaryFinal/cervical-cancer-screening2?ds=1&s=cervical cancer Whelton, P. K., Carey, R. M., Aronow, W. S., Casey, D. E., Jr., Collins, K. J., Himmelfarb, C. D., .  .  . Wright, J. T., Jr. (2017). 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults. Journal of the American College of Cardiology, 71(19), e127–e248. doi:10.1016/j.jacc.2017.11.006 Williams, W. W., Lu, P.-J., O’Halloran, A., Kim, D. K., Grohskopf, L. A., Pilishvilli, T., . . . Fiebelkorn, A. P. (2017, May 5). Surveillance of vaccination coverage among adult populations: United States, 2015. Morbidity and Mortality Weekly Report, Surveillance Summaries, 66(No. SS-11), 1–28. doi:10.15585/ mmwr.ss6611a1 Winter, J. E., MacInnis, R. J., Wattanapenpaiboon, N., & Nowson, C. A. (2014). BMI and all-cause mortality in older adults: A meta-analysis. American Journal of Clinical Nutrition, 99(4), 875–890. doi:10.3945/ajcn.113.068122

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CHAPTER

4

ME N TAL HE ALT H , C O G N I T I V E ABIL I T I E S , AN D A G I N G

LEARNING OBJECTIVES • Identify the major positive characteristics of older adults’ psychological and emotional well-being. • Summarize how personality can change over the life span. • Explain why older people may experience depression. • Illustrate the differences between signs of dementia and normal age-related changes. • Outline the positive contributions that the creative arts can make to older adults’ quality of life. • Discuss the factors that can positively and negatively affect older adults’ mental health and cognitive abilities.

BACK IN SCHOOL Mary, age 81, is taking courses at the local community college. She’s enjoying her classes and has a B average. She is articulate and speaks up in class. She relates well to the younger students and has a keen sense of humor. She complains that she is too old to remember all the material in the books and in the class notes, and then does as well or better than the younger students on her tests. She has learned to use computers and is extremely proud of her computer skills.

CONSEQUENCES OF THE LOSS OF A LOVED ONE Harold is 68 and has been severely depressed since his wife died 2 years ago. He has isolated himself. He looks unkempt. He seems to have little interest in the affairs of the world or in anything else. He has insomnia, does not care to eat, has been losing weight, and cannot concentrate long enough to enjoy a book or even read the local newspaper.

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LIVING WITH ALZHEIMER’S DISEASE I have Alzheimer’s disease. It took me a long time before I could even say the words. When the doctor first told me, I felt like my life was over. For a while, I was depressed. My doctor told me about medicine I could take. She said it would slow down my memory loss for a while. I know it’s not a cure. Still, it feels good to do something. My family has been wonderful. They’re helping me plan for the care I’ll need. I have decided to take each day as it comes. I want to live my life as fully as I can. —National Institute on Aging, 2013

MENTAL HEALTH AND COGNITIVE ABILITIES OF OLDER PEOPLE Older adults are the happiest people in America. How can this be? It defies all the stereotypes about aging. After all, older individuals experience significant losses in their lives, including physical changes, deaths of close friends and family members, and losses that accompany leaving the workforce, among others. For several decades now, we have been slowly uncovering more and more areas of life where older adults thrive and make contributions, not only to their own lives, but also to the lives of others. There are positive and negative aspects of life at every age throughout the life span, and aging is no exception. One goal of this chapter is to present a more balanced view of older adults’ mental health and cognitive abilities, one that moves away from the stereotypes.

MENTAL HEALTH Now that we are beginning to look at more positive aspects of aging, we are discovering some facts about the lives of older adults that are surprising to many people. When it comes to discussing mental health and aging, much of the focus in research and in the media has been on mental health problems that are, in fact, not that common among older adults. In this section, we begin with older adults’ overall sense of well-being and happiness.

Psychological and Emotional Well-Being What is known about adults’ general sense of well-being as they get older? Researchers Stone, Schwartz, Broderick, and Deaton (2010) interviewed 340,847 individuals between the ages of 18 and 85 years about various aspects of psychological well-being. They found that global well-being follows a U-shaped pattern, with the highest points among 18- to 21-year-olds and among 74- to 85-year-olds. The lowest point is among individuals between 45 and 54 years of age. Enjoyment and happiness show a modest increase into old age, again beginning when individuals are in their late 50s. On the other hand, stress and anger decline as individuals age, and worry begins to subside after age 50, reaching its lowest levels after the age of 70 (Stone et al., 2010).

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4.5 Sadness Hopelessness

4.0 3.5 Percent

3.0 2.5 2.0 1.5 1.0 0.5 0.0

18–44

45–64

65–74

75+

Age

FIGURE 4.1  Percentages of adults with feelings of sadness and hopelessness all or most of the time, by age group, United States, 2010. NOTE: In separate questions, respondents were asked how often in the past 30 days they felt so sad, or so hopeless, that nothing could cheer them up. SOURCE: Adapted from Schiller, J. S., Lucas, J. W., Ward, B. W., & Peregovy, J. A. (2012). Summary health statistics for U.S. adults: National Health Interview Survey, 2010 (Table 14, pp. 55–56). Hyattsville, MD: U.S. Department of Health and Human Services. Retrieved from https://www.cdc.gov/nchs/data/series/sr_10/sr10_252.pdf

Older adults may display higher rates of happiness than younger adults because they ignore, overlook, or downplay negative information and situations (Mather, 2012). Their years of experience allow them to put negative events into perspective, resulting in an ability to take things in their stride. In the 2010 National Health Interview Survey, 27,157 adults in the United States responded to a series of questions about their health, including questions about their mental health. Consistent with the findings of Stone et al. (2010), the survey showed that, compared with young and middle-aged adults, people aged 65 and above are the least likely to report feeling sad or hopeless all or most of the time (see Figure 4.1; Schiller, Lucas, Ward, & Peregovy, 2012). As individuals age, they improve their ability to regulate their emotions and become better at recognizing and focusing on those aspects of their lives that they find more meaningful, including close relationships (Charles & Carstensen, 2010). Greater happiness is one outcome of older adults narrowing their focus to the more positive and meaningful connections in their social networks and allowing less meaningful ones to expire. Given that older adults have relatively high rates of psychological well-being and happiness, it should not be entirely surprising to learn that they also have relatively high rates of emotional well-being. In a longitudinal study that took place over 13 years, Dr. Laura Carstensen et al. (2011) asked adults ages 18 to 94 to report on their emotional states several times during a 1-week period in each of 3 years, spaced 5 years apart. Participants indicated their emotional states by rating on a 7-point scale (from 1, not at all, to 7, extremely) each of 19 emotions, 8 positive (e.g., happiness, joy) and 11 negative (e.g., anger, sadness). The main findings were: ■■

Emotional well-being improves over the life span, reaching a peak and then leveling off (but not declining) in the seventh decade of life

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■ ■

Emotions become both more consistent over time, and more mixed (positive and negative emotions are more likely to occur together) as people age People with more reports of positive emotions than negative emotions tend to live longer

Carstensen et al. (2011) concluded that, “Contrary to the popular view that youth is ‘the best time in life,’ the present findings suggest that the peak of emotional life may not occur until well into the 7th decade” (p. 12). The socioemotional selectivity theory explains these findings by asserting that, as people age they are motivated to focus on getting the most out of their remaining years (Carstensen, Fung, & Charles, 2003). Doing so prompts them to devote more time and attention to maximizing their emotional well-being.

Personality Doesn’t she have a sunny personality? He’s such a positive person. These statements, of course, refer to a combination of patterns of thinking, feeling, and behaving that are thought to contribute to differences between individuals—in other words, a person’s personality. The Big Five, as they are called, are broad clusters of personality traits: extroversion, agreeableness, conscientiousness, emotional stability, and openness. According to Walter Mischel, the first person to ever teach a course on personality, [t]he beliefs, assumptions, expectations that you’ve gotten from your friends, family, culture . . . are the filter through which you see the world. Your mind stands between who you are, your personality and whatever situation you are in. It interprets the world around it, and how it feels about what it sees. And so when the stuff inside the mind changes, the person changes. (Spiegel, 2016, para. 55) One perspective on personality is that a person is born with certain personality traits that remain fixed throughout the life span, which can be comforting because it means that life can be quite predictable. A downside to this perspective is that it also means that there is little or no room for psychological development in traits such as emotional stability or conscientiousness. A second perspective on personality is that traits can change throughout the life span and that interventions, such as therapy, can alter traits, such as agreeableness, for the better. This perspective is a hopeful one vis-à-vis a person’s psychological development, although it does entail the possibility that a person may be less predictable. Evidence suggests that personality traits can change in meaningful ways throughout the life span, even if changes may be somewhat curtailed in later life (Roberts et al., 2017). Social vitality (an aspect of extroversion) and openness to experience remain fairly consistent across adulthood, while social dominance (another aspect of extroversion), agreeableness, conscientiousness, and emotional stability seem to change substantially during middle and old age (Roberts, Walton, & Viechtbauer, 2006). Purpose in life is another aspect of personality that has also been studied in older adults. Purpose in life is defined as a person’s sense that his or her own life is meaningful and purposeful. Responding positively to statements such as, I am an active person in carrying out the plans I set for myself, and negatively to statements such as, I don’t have a good sense of what it is I am trying to accomplish in life, will lead to high scores on a measure of purpose in life created by Dr. Carol

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Ryff (1989). Interestingly, numerous studies have found that having a higher purpose in life is a robust factor in decreasing rates of health problems that are more likely in later life. For example, individuals with high scores on purpose in life have lower rates of stroke, heart attacks, and dementia (Boyle, Buchman, Barnes & Bennett, 2010; Kim, Sun, Park, Kubzansky, & Peterson, 2013; Yu et al., 2015), and even show increased longevity (Boyle, Barnes, Buchman, & Bennett, 2009). Thus, purpose in life can play a critical role in a person’s functioning as he or she ages.

Depression Depression is a serious mental health problem that is associated with feelings of despair, a denial of self-worth, and somatic symptoms, including loss of appetite, sleeping difficulties, and fatigue. It is not a normal part of aging. Of course, older adults can become depressed, and when they do it is often a result of significant losses in their lives—loss of a job when they leave the paid workforce; a reduction in income; deaths of their family members, friends, or both; and loss of their home when they move to be near their children or grandchildren or to senior living communities. In addition, they may lose one or more of their children. Individuals who, in the past, were respected for their work in the labor force, their energy, and their wisdom, often find themselves disregarded in their later years. Many older adults who have several of these losses nevertheless retain emotional stability and report high rates of well-being (Clark, Burbank, Greene, Owens & Riebe, 2011). A smaller percentage become overwhelmed by their losses, as did Harold, whose situation is described in one of the opening scenarios, and may need to seek professional help. Despite their losses, older people are much less likely to experience depression than people of any other age group. The rate of depression for adults 55 years and over is 6%, compared with 10% for 18- to 24-year-olds, 8% for 25- to 44-year-olds, and 10% for 45- to 54-year-olds (Reeves et al., 2011). Among those older adults who do suffer from depression, the vast majority of cases—as many as 80%—can be easily treated, so there is considerable hope for those who get professional help. Successful Depression Treatment Programs for Older Adults Three community-based programs have been shown to be effective in treating depression in older adults: IMPACT (Improving Mood Promoting Access to Collaborative Treatment), PEARLS (Program to Encourage Active, Rewarding Lives for Seniors), and Healthy IDEAS (Identifying Depression, Empowering Activities for Seniors; Centers for Disease Control and Prevention [CDC], National Association of Chronic Disease Directors, 2009). All three programs include the use of well-validated measures for depression; ongoing assessment to monitor the effectiveness of treatment and to make appropriate changes when the chosen treatment is found to be ineffective; and a depression care manager, who may be a nurse, social worker, psychologist, or other practitioner. In consultation with the primary care provider and the patient, the care manager delivers or facilitates the treatment plan, educates the client, and keeps track of his or her progress. These programs have also been designed to help overcome one of the barriers for treatment of older adults—their resistance to seeking and participating in mental health treatments. For all treatment approaches, it is helpful when friends and family can provide comfort to their loved ones who are depressed. Mental health stereotypes and stigmas are discussed further in the Practical Application at the end of this chapter.

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COGNITIVE ABILITIES All infants and children begin to crawl, walk, and talk around the same age. In fact, if they do not meet these developmental milestones “on time,” it is usually a sign of a developmental issue that needs to be addressed. In stark contrast to the small differences between individuals in their acquisition of skills and abilities early in life, there is significant variability between individuals in their later years. This is one of the most common themes in the field of aging, and the three scenarios at the beginning of this chapter exemplify this theme. Such large individual differences among older adults have challenged researchers who seek to gain a greater understanding of how mental processes develop into late life. This is because some adults appear to reach their older years with little to no reduction in their mental abilities, and some abilities may even improve, whereas for others, mental abilities seem to decline as they age.

Good News About Cognitive Abilities in the Later Years of Life A growing body of research is demonstrating that, throughout the life span, new neurons develop in the hippocampus, an area of the brain that is critical for cognitive functioning (Boldrini et al., 2018). Researchers argue that this neurogenesis is evolutionarily advantageous because it increases cognitive flexibility for surviving in novel environments (Kempermann, 2012). We also know that some cognitive abilities are maintained, or even improve with age, including general knowledge and vocabulary. Timothy Salthouse is a psychologist who has conducted research on cognitive abilities in older adults for decades. Observing what he termed a dramatic discrepancy between how well older adults function in their everyday lives and their test scores on cognitive tests in the laboratories of research scientists, Dr. Salthouse (2010) has concluded that, Cognition is not the only important factor associated with success in most activities; increased age is often accompanied by greater amounts of experience, which may minimize negative consequences of declining abilities; and people may accommodate to declining abilities in a manner that could minimize any effects on real-world functioning. (p. 150) Indeed, we are learning that people who are happy, who feel better about their abilities, and who have good social support usually do better on challenging cognitive tasks. Nevertheless, researchers have found that some cognitive abilities do decline with age, including how quickly information is perceived and acted upon (speed of processing), and how much information can be actively maintained and manipulated in memory at one time (working memory).

Cross-Sectional and Longitudinal Studies Studies of the relationships between cognitive abilities and aging most often use cross-sectional research designs. On the one hand, in cross-sectional studies, two or more groups of individuals of different ages are tested at a specific point in time. On the other hand, in longitudinal studies, one group of individuals is followed over many years. Table 4.1 presents the interactions between the three variables at work in these two types of studies—year of birth, year of study, and age of participants. Each of the columns for year of study in Table 4.1 (2010, 2020, 2030) represents a possible cross-sectional study. For example, a cross-sectional study could be conducted in 2010, comparing the performance of 20-, 40-, and 60-year-olds on a cognitive task. Note that, in addition to the ages

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TABLE 4.1 Cross-Sectional and Longitudinal Research Variables YEAR OF STUDY YEAR OF BIRTH

2010

2020

2030

1950

60-year-olds

70-year-olds

80-year-olds

1970

40-year-olds

50-year-olds

60-year-olds

1990

20-year-olds

30-year-olds

40-year-olds

of the people being different, their year of birth is different too. The age of individuals is inextricably connected to their birth cohort, and people from different birth cohorts have had different life experiences. Results of cross-sectional studies, then, can be influenced not only by the age of the participants, but also by the cohort, or generation, into which they were born. In Table 4.1, each of the rows for year of birth (1950, 1970, 1990) represents a possible longitudinal study. For example, a longitudinal study could be conducted beginning with participants born in 1970 who could be asked to do cognitive tasks in 2010, at age 40, in 2020, at age 50, and then again in 2030 at age 60. Note that, in this case, while birth cohort is consistent across all years of the study, the age of the participants inextricably changes along with the year in which they are doing the cognitive tasks. Each year of study represents a specific point in historical time, and experiences of the participants can be influenced in and between those points in time. Results of longitudinal studies, then, can be influenced not only by the age of the research participants, but also by the year of the study. Longitudinal studies can reveal changes over time in individuals, but they have their own difficulties, including the fact that people are tested repeatedly, which also may affect the results. Longitudinal studies of cognitive abilities are much less common than cross-sectional studies because they are much more difficult to carry out; abilities of interest, as well as how they are measured, change over time; and they are much more expensive to conduct.

Memory and Aging One of the most studied cognitive abilities is memory. Human memory is fallible, and people are generally bothered when they forget. Concerns about memory loss increase with age, especially because it is the most well-known symptom of Alzheimer’s disease. Myths about memory and aging abound in our society, and belief in these myths has been shown to negatively affect memory performance in older adults (Levy, Zonderman, Slade, & Ferrucci, 2012). The topic of beliefs about cognitive abilities and their effects on performance is discussed at the end of this chapter. A common misconception about memory is that the best memory is one in which nothing is ever forgotten. However, there are significant pitfalls in having a so-called perfect memory. Luria (1968) described one man who had such an exact memory for people that he could not recognize them if they changed their clothing or had a different haircut. There are also some things that no one wants to remember—all their old phone numbers or passwords, for example. Yet, forgetting important things is not good, and a high level of forgetting is usually the symptom of a problem, ranging from stress to dementia. So, memory strategies are valuable because when effectively

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applied, they make it possible to remember important things that might otherwise be forgotten. Adopting strategies to remember events indicates a high level of cognitive functioning, and proficient use of memory strategies is a sign of good cognitive management skills. When a significant proportion of today’s older adults were in school, they learned only one strategy for remembering—rote rehearsal, that is, repeating things over and over. Rote rehearsal by itself is not a good memory technique because it does not help to establish long-term remembering. In fact, it was not until the 1960s that a significant body of experimental evidence began to demonstrate the effectiveness of categorizing and grouping strategies for remembering information. Older cohorts often do not recognize the value of these strategies and even regard them as a form of cheating. These important historical details regarding the effects of older adults’ prior learning experiences must be recognized as critical factors in affecting the strategies that they will tend to use when faced with a memory task (Sugar, 2007). Cross-sectional research studies comparing older adults and younger adults on memory tasks, then, must pay attention to not only the age of the participants, but also to the cohort or generation into which they were born. In addition to their age, another factor that differentiates younger and older people is whether they are in school and have continual opportunities for learning and practicing memory skills. Zivian and Darjes (1983) compared the use of memory strategies and memory performance among four groups of participants—young university students, middle-aged university students, middle-aged out-of-school adults, and older out-of-school adults. Participants studied a list of 30 words composed of five examples of each of six categories (e.g., animals, tools, clothing items), with the words presented in a random order. They then recalled the words in any order they wished. In addition, participants were given a list of 20 memory strategies and asked to rank order them in terms of how useful they thought they would be for learning a list of words similar to the one they had just learned. The results revealed that the best predictor of both strategy usage and memory performance was being in school. On average, those participants who were in school recalled 25 of the 30 words, whereas those who were out of school recalled just 15 of the 30 words. Those in the two in-school groups also reported using significantly more memory strategies than those in the two out-of-school groups. Importantly, the memory strategy that was ranked as the most useful by the older out-of-school adults was a rote rehearsal strategy. In the absence of being in school, engaging in intellectually challenging activities with a high memory demand, such as chess, may provide opportunities during late adulthood to continue to exercise the mental capacities required to learn and practice memory strategies. In addition to effective strategies, a key determinant of memory performance is motivation. Until Hill, Storandt, and Simeone (1990) conducted their research, most of the studies attempting to motivate older adults to improve their performance used monetary awards, which proved to be ineffective. That may have been the case because the amount of money being offered was too little. Hill et al. tried a novel incentive—they presented the opportunity for participants in their study to earn airline tickets, which were expected to be especially attractive to their participants who were all planning airline travel in the upcoming year. All 60 participants, for whom the mean age was 70 years, were given a memory test (the pretest) before being randomly assigned to one of four groups, two of which will be described here: a control group and an incentive group. Participants were asked to learn a list of 30 words and were then tested on their memory for those words (the posttest). After a 35-minute break, they were tested on another comparable 30-word list (delayed recall task). A lottery was set up for the people in the incentive group with two prizes of round-trip airline tickets to anywhere in the continental United States. Immediately before the posttest, the 16 participants in the incentive group were told that they could earn one lottery ticket

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for each word they recalled correctly. It was made clear that the more words they remembered, the more lottery tickets they would earn, and hence, the greater their chances of winning one of the two airline tickets. The equivalent value of one of those tickets was almost $800 in 2018. The participants in the control group were not offered any incentive. The delayed recall task, for which there was no forewarning, gave those in the incentive group an opportunity to earn additional lottery tickets. Figure 4.2 presents the results of Hill et al.’s study. Compared with those in the control group, participants in the incentive group recalled significantly more words at posttest (almost 60% more on average) and maintained their higher performance at delayed recall. The apparent difference between these groups at pretest was not statistically significant. These results are significant for several reasons. First, they demonstrate that offering a personally meaningful, and financially valuable, incentive does motivate older adults to improve their memory performance. Second, the information about the incentive was not presented until right before the participants in the incentive group were asked to recall the words, so their improved performance could not be due to using more effective strategies to learn the words. Instead, their improved performance was the result of a greater effort to recall the words. Most studies of the performance of younger and older adults on memory tasks do not offer any kind of incentive for performance. That works just fine for the young participants, who are almost always college students, and thus, are not only in school where they regularly learn and practice memory skills, but their modus operandi is to perform as well as they can in these types of tasks. Older adults, on the other hand, have no particular motivation to perform well in these settings. Consequently, it seems quite likely that a great number of studies that compare younger and older adults’ performance are underestimating the memory capacity of older adults by as much as 60%. 30

Incentive Group Control Group

Number of Words Recalled

25

20

15

10

5

0

Pretest

Posttest

Delayed

FIGURE 4.2  Mean number of words recalled by older learners at pretest, posttest, and delay, by control and incentive groups. NOTE: Number of words recalled is out of a maximum of 30. SOURCE: Data from Hill, R. D., Storandt, M., & Simeone, C. (1990). The effects of memory skills training on free recall in older learners. Journal of Gerontology, 45(6), P227–P232. doi:10.1093/geronj/45.6.P227

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Too often family members and friends may prematurely react to an older adult’s forgetfulness, the pervasiveness of ageism leading them to assume that their loved one is suffering from cognitive deficits. Such a conclusion could lead to unnecessary institutionalization. Concerns about a steam iron being left on or bills not being paid on time can worry older adults as well as their families and friends. Appropriate instruction in using memory strategies and modern technology, however, can do much to alleviate these fears—for example, using lists and reminder notes to remember to carry out important actions in everyday life and to prevent memory lapses that could jeopardize safety. New products and services furnish other means for reducing concerns about older adults’ personal vulnerability, such as steam irons that shut off after a short period of not being used, and automatic bill paying services. With rapid developments in technology, more applications and tools of that technology could be designed to help everyone, regardless of their age, to remember the important things in their lives.

Cognitive Health: The Healthy Brain Initiative Rather than focusing on abilities that might wane as individuals age, researchers and health professionals have begun to look at opportunities to maintain and even improve cognitive health. Recognized only recently as an important issue for the public health system, cognitive health should be respected for its multidimensional nature and embraced for the positive changes that occur as a natural part of the aging process . . . components of healthy cognitive functioning include: language, thought, memory, executive function (the ability to plan and carry out tasks), judgment, attention, perception, remembered skills such as driving, and the ability to live a purposeful life. (CDC, 2011, p. 7) In 2007, the CDC launched The Healthy Brain Initiative: A National Public Health Road Map to Maintaining Cognitive Health. The initiative has three purposes: to find out what is already known about cognitive health, to investigate gaps in knowledge, and to determine how public health can contribute to cognitive health (CDC, 2011). The initiative seemed to start off well, supporting research on risk and protective factors for cognitive health (e.g., cardiovascular health, exercise), assessing the public’s perceptions about cognitive health, conducting community educational programs on healthy lifestyles, and developing measures of cognitive decline. Sadly, despite its name, most of the initiative’s efforts are now being invested in studying and assessing cognitive impairment, determining needs and services related to it, and developing and supporting state dementia action plans. The Healthy Brain Initiative’s newest endeavor is entitled State and Local Public Health Partnerships to Address Dementia, The 2018–2023 Road Map, which focuses on “making Alzheimer’s our next public health success story” (CDC, n.d., para. 3).

Alzheimer’s Disease and Other Dementias Dementia, which means absence of mind (from Latin, de meaning without, and ment meaning mind), is used to describe more than 70 disorders all of which have one thing in common—a loss of brain function resulting from progressive, degenerative damage to neurons (nerve cells) in the brain. It affects memory, thinking, language, judgment, and emotional behavior, eventually affecting daily functioning and leading to death. The most common type of dementia, accounting for approximately 60% to 80% of cases, is Alzheimer’s disease. It is the sixth leading

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cause of death among Americans. Other common types of dementia are vascular dementia (usually following a stroke) and frontotemporal dementia (also known as “Pick’s disease”). Changes that occur in the brain with most types of dementia are not reversible. Some causes of dementia-like symptoms, however, can be reversed, or at least stopped, if they are diagnosed soon enough. Examples of these causes are: depression; malnutrition (e.g., vitamin B12 deficiency) or dehydration; changes in blood sugar, sodium, or calcium levels; hypothyroidism; a urinary tract infection; a brain tumor; chronic drug abuse; or, the use of certain medications, such as some cholesterol-lowering drugs. Causes of Alzheimer’s Many avenues of research have been explored to determine what causes Alzheimer’s disease. A long-standing hypothesis, the amyloid cascade hypothesis, which is still under investigation, focuses on the fact that amyloid plaques accumulate in the brain and are thought to cause the spread of neurofibrillary tangles. Together, these plaques and tangles are hypothesized to lead to the observed loss of brain function. Another hypothesis has gained much support from basic research on the immune system, and on neuroinflammation in particular (Griffin, 2011a, 2011b). According to this hypothesis, Alzheimer’s begins with neuronal stress, from sources such as infections, traumatic brain injury, and genetic variations in protein alleles. Neuronal stress increases the production of proinflammatory cytokines, including beta-amyloid precursor proteins, which are thought to bring about the increased density of plaques and tangles in the brains of Alzheimer’s patients. Research is confirming that the immune system plays an important, and likely pivotal, role in the development of Alzheimer’s (Heppner, Ransohoff, & Becher, 2015), which could lead to new treatments. While quite a lot of research has been examining the pathogenesis of Alzheimer’s, many questions remain to be answered, including why the pattern of symptoms and progress of the disease differ among individuals, why some individuals decline more rapidly than others, and why some individuals respond better than others to treatment. Diagnosis and Treatment of Alzheimer’s Memory problems are the most well-known indication of Alzheimer’s, but there are other signs, too. The Alzheimer’s Association notes 10 important signs to be aware of, which are listed in Table 4.2. To distinguish these signs from changes that may occur with normal aging, Table 4.2 includes brief descriptions of them, too. A common approach for diagnosing Alzheimer’s has been to obtain a medical and family history from the patient, and administer blood tests and a combination of neuropsychological and neurological tests, the latter often directed at eliminating other conditions, such as strokes, tumors, or other neurological diseases, whose symptoms may be similar to those of Alzheimer’s. The Mini-Mental Status Exam (MMSE; Folstein, Folstein, & McHugh, 1975), which primarily measures memory and orientation to place and time, is the most frequently used neuropsychological test. This approach works reasonably well once cognitive and behavioral signs are obvious. Changes in the brain, though, are believed to begin long before such signs are readily observed. Hallmarks of Alzheimer’s disease are the presence of amyloid plaques and neurofibrillary tangles, which until recently could only be readily observed following an autopsy. These plaques and tangles accumulate in the brain over time and eventually damage and kill neurons. However, new approaches for detecting the disease in its earlier stages are beginning to produce encouraging results (Park & Farrell, 2016). Using newly invented radioactive drugs, amyloid deposits

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TABLE 4.2 Comparing Signs of Alzheimer’s Disease With Typical Age-Related Changes ALZHEIMER’S

TYPICAL AGE-RELATED CHANGE

Memory loss that disrupts daily life

Sometimes forgetting names or appointments, but remembering them later

Challenges in planning or solving problems

Occasionally making errors when balancing a checkbook

Difficulty completing familiar tasks at home, at work, or at leisure

Occasionally needing help to use settings on a microwave or to record a TV show

Confusion about time and place

Getting confused about the day of the week but figuring it out later

Trouble understanding visual images and spatial relationships

Vision changes related to cataracts

New problems with words in speaking or writing

Sometimes having trouble finding the right word

Misplacing things and losing the ability to retrace steps

Misplacing things from time to time and retracing steps to find them

Decreased or poor judgment

Making a bad decision once in a while

Withdrawing from work or social activities

Sometimes feeling weary of work, family, and social obligations

Changes in mood and personality

Developing very specific ways of doing things and becoming irritable when a routine is disrupted

SOURCE: Alzheimer’s Association. (2018). 2018 Alzheimer’s disease facts and figures. Alzheimer’s and Dementia, 14(3), 367–429. doi:10.1016/j.jalz.2018.02.001

can now be seen on PET scans of live patients. Thus far, this approach has been limited to use in clinical populations and research. Once a comprehensive assessment of cognitive function indicates probable Alzheimer’s disease, PET scans can be used to confirm the diagnosis. Research on imaging neurofibrillary tangles in live patients is progressing too. Further advancements in these imaging techniques show promise for diagnosing Alzheimer’s earlier. The U.S. Food and Drug Administration has approved several prescription drugs that can offer modest, temporary relief from symptoms of Alzheimer’s, although they do not change the course of the disease (National Institute on Aging, 2018). For mild to moderate Alzheimer’s, three cholinesterase inhibitors have been shown to lead to a temporary improvement in memory function: donepezil (Aricept®), rivastigmine (Exelon®), and galantamine (Razadyne®). These drugs stop the action of acetylcholinesterase, which is overabundant in Alzheimer’s patients and which degrades acetylcholine, a neurotransmitter associated with learning and memory. For moderate to severe Alzheimer’s, memantine (Namenda) may be helpful. This drug protects

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brain cells from the damage caused by an excess of the chemical glutamate, which is brought on by Alzheimer’s. Donepezil, a rivastigmine patch, and a new combination of memantine and donepezil (Namzaric®) have also been approved to treat moderate to severe Alzheimer’s. However, the National Institute on Aging (2018) discourages the use of many medications that may be used to manage symptoms of Alzheimer’s. For example, sleep aids, antianxiety drugs (to treat agitation), and anticonvulsants (to treat severe aggression) can all cause confusion, dizziness, and falls. Antipsychotic drugs, which may be used to treat agitation and aggression, increase the risk of death in some older people with dementia. Although no cure is yet in sight, actively managing Alzheimer’s can significantly improve the quality of life of patients and their caregivers. Active management includes: ■ ■ ■ ■ ■ ■ ■

Appropriate use of available treatment options Effective management of coexisting conditions Coordination of care among physicians, other healthcare professionals, and lay caregivers Participation in activities that are meaningful and bring purpose to one’s life Having opportunities to connect with others living with dementia; support groups and supportive services are examples of such opportunities Becoming educated about the disease Planning for the future (Alzheimer’s Association, 2018, p. 381)

The Probability of Getting Alzheimer’s Alzheimer’s is not a normal part of aging, although, like many other medical conditions, its prevalence increases with age. The Alzheimer’s Association (2018) has estimated that approximately 5.7 million Americans are living with the disease. More women than men are affected, and one reason is that they live longer than men. The rate is very low for people under age 65, but after age 65, there seems to be a continual increase in the prevalence of Alzheimer’s. In 2016, among Americans aged between 65 and 84 years, Alzheimer’s was listed as the cause of death for 3.2%; for those aged 85 and older, it was 9.1% (Xu, Murphy, Kochanek, Bastian, & Arias, 2018). Although it is likely that Alzheimer’s often goes undiagnosed, and is likely underreported as a cause of death, these data suggest that the prevalence of Alzheimer’s, especially after age 85, is much lower than some have speculated. Furthermore, prevalence rates seem to be trending downward. Langa et al. (2017) found a significant decrease in the rates of Alzheimer’s in the United States between 2000 and 2012. One reason seems to be that educational levels have improved, although that factor does not account for all of the decrease. A small percentage of Alzheimer’s cases ($47,129 per year) that Social Security comprises a relatively small proportion of their income (18%). History of Social Security Social Security was developed to be a floor or base of income for retired older persons, to be supplemented by private pensions and savings—the three income sources often referred to as the three-legged stool of retirement resources. As such, Social Security was never intended to be the sole income source for retirees. Upon signing the Social Security Act into law on August 14, 1935, President Franklin D. Roosevelt stated (Roosevelt, 1935), We can never insure one hundred percent of the population against one hundred percent of the hazards and vicissitudes of life, but we have tried to frame a law which gives some measure of protection to the average citizen and his family against the loss of a job and against poverty-ridden old age. Social Security came out of the Great Depression of the 1930s as one of the most, if not the most, important achievement of President Franklin D. Roosevelt’s New Deal. In the lead-up to the Social Security legislation, a report by the Committee on Economic Security (1935) documented the economic plight of older people as a result of industrialization, the concomitant bias to hire younger workers, and the Great Depression. Workers over age 40 were finding it increasingly difficult to find or keep a job. At the same time, wages had been stagnant for four decades, the value of the dollar had decreased by 40% between 1925 and 1928, and many, many families had lost all their assets in the business and bank failures of the Great Depression. The net result was that economic resources were totally inadequate for most older people to be able to live out their remaining years in anything but abject poverty. The data available to the Committee on Economic Security (1935) on older adults’ economic status revealed that in the early 1930s more than 30% of Connecticut’s older residents had “no income whatsoever,” almost 50% of New York’s older residents “had less than a subsistence income” (defined as $25 per month), and more than 20% of Wisconsin’s older residents “had less than $8 a month.” The research conducted by the Committee on Economic Security included an analysis of social insurance programs in place in other countries around the world. Ultimately, the American Social Security program traces its roots back to Europe in the 1880s, when Chancellor Otto von

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80

Social Security Other pensions/annuities Earnings Asset income Other

70

Percent

60 50 40 30 20 10 0

Lowest fifth

Second fifth

Third fifth

Fourth fifth

Highest fifth

FIGURE 7.1  Percentage distribution of per capita family income for Americans age 65+, by income quintile and source of income, 2014. NOTE: These data refer to the U.S. civilian noninstitutionalized population. The definition of “other” includes, but is not limited to, unemployment compensation, workers’ compensation, veterans’ payments, SSI, and personal contributions. Quintile limits are $12,492, $19,245, $29,027, and $47,129. Estimates may not sum to the totals because of rounding. SOURCE: Federal Interagency Forum on Aging-Related Statistics. (2016). Older Americans. Key indicators of well-being. Washington, DC: U.S. Government Printing Office. Retrieved from https://agingstats.gov/docs/­ LatestReport/Older-Americans-2016-Key-Indicators-of-WellBeing.pdf

­ ismarck of Germany developed a program to require employers and employees to contribute to B a pension fund for retired workers at age 70 (von Herbay, 2014). It should be noted that not many people in Germany lived to age 70 at that time; at birth, life expectancy for males was only 38 years and for females, 41 years. As a result, not much money was paid out in benefits during that era. In 1916, the retirement age in Germany was lowered to age 65. In the early 1900s, both England and France also adopted old age insurance plans. President Roosevelt followed the outlines of the European plans with key components being that the American plan was government sponsored, compulsory, and independently financed. Social Security: The Basics Social Security consists of three primary benefits: a public, defined-benefits pension plan; a life ­insurance program; and a disability insurance program. The pension plan is the benefit that is most well known, and was, in fact, the program enacted in 1935. Benefits for survivors and d ­ ependents were added to the Social Security Act in 1939, and disability insurance was added in 1956. Together, the Old Age and Survivors Insurance (OASI) and the Disability Insurance (DI) programs form the Old Age, Survivors, and Disability Insurance (OASDI) program, generally referred to as Social ­Security, which is intended to replace a portion of a worker’s income upon retirement, disability, or death. Intergenerational Aspects of Social Security All three of Social Security’s primary benefits make the program an intergenerational one, ­affecting people of all ages, so it is incorrect to view Social Security as a program only for older people. Without Social Security, many more families could be forced to live in three-, four-, and

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even five-generational households, and adult children could be financially wiped out by having to pay for the daily needs, healthcare, and, if need be, long-term care of their parents. By providing a base of financial income for retired workers, Social Security relieves younger family members from needing to support their older parents, freeing their incomes to support themselves and their children. Dependents’ benefits for retired or disabled workers’ spouses and minor children are clearly also valuable for families. In addition, younger workers and their families gain financial security by having benefits for their spouses and minor children in the event of their premature deaths. Social Security’s disability insurance replaces a portion of workers’ income should workers suffer from a long-term disability. The importance of this disability insurance cannot be underestimated—data indicate that more than 25% of those who were 20 years of age in 2017 will become disabled before becoming eligible for full retirement benefits (Maleh & Bosley, 2017). Figure 7.2 depicts the percentage of Social Security beneficiaries by type. At the end of 2017, some 62  million Americans were receiving Social Security benefits (Social Security Trustees, 2018). Although the majority of payments goes to retirees, almost onethird of the funds goes to survivors, dependents, and younger workers with serious disabilities. About 88% of A ­ mericans age 65 and over received retirement benefits in 2017 (Social Security Administration, 2018). Survivors of deceased workers include widows/widowers, unmarried children up to age 18, and former spouses, if married for 10 or more years. In 2017, about 95% of the families of younger workers who were paying into Social Security were eligible for survivor benefits (Social Security Administration, 2018). Disability benefits are provided to workers if they have a medical condition that prevents them from being employed, and their condition is expected to last for at least 1 year (or result in death). Almost 90% of younger workers who paid into Social Security are protected by its disability insurance and thus can depend on cash benefits should they become severely disabled (Social Security Administration, 2018). Disabled workers also receive Medicare coverage after 2 years of disability benefits. Without Social Security, an additional 26.6 million Americans would be living in poverty (Renwick & Fox, 2016).

Spouses and children of retired or disabled workers 8%

Survivors of deceased workers 14%

Disabled workers 14%

Retired workers 68%

FIGURE 7.2  Percentage distribution of Social Security beneficiaries by type, 2016. SOURCE: Social Security Administration. (2017, September). Fast facts and figures about Social Security, 2017. Washington, DC: Author. Retrieved from https://www.ssa.gov/policy/docs/chartbooks/fast_facts/2017/index.html

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Social Security Funding and Benefits Social Security is funded primarily by employees who pay 6.2% on their wages (5.015% for OASI, 1.185% for DI), which is matched by employers. Self-employed persons are employees and employers, and thus they pay 12.4% (10.03% for OASI, 2.37% for DI). In 2017, 94% of American workers, 174 million people, had earnings covered by OASDI. In 2017, maximum taxable earnings were $127,200, which means that Social Security taxes are collected only on income up to that amount, with no Social Security taxes collected on wages earned above that amount. Instead of participating in Social Security, some state governments (e.g., Colorado, Maine, Texas) and some local governments (in Georgia, Kentucky, Rhode Island) have their own pension plans. Public employees in these governments do not pay into Social Security and thus are not eligible for Social Security benefits, unless these same employees have worked and paid into Social Security in other jobs. Monthly benefits are based on a person’s work record (years of covered employment), earnings history, and the age at which the first benefit is claimed. Typically, for retirees to be eligible for benefits, they must have worked in a Social Security–participating job for a minimum of 10 years. Retirees can begin claiming benefits as early as age 62, though full retirement age, which is accompanied by higher monthly payments, is 65 to 67 years of age, depending on their date of birth (see more information about retirement ages in the section on Early, Normal [Full], and Late Retirement). In 2016, at full retirement age, Social Security’s maximum benefit was $2,639 per month. As pointed out earlier, female workers typically receive lower benefits, due primarily to lower wages throughout their lives and caregiving responsibilities periodically taking them out of the workforce, which lead to uneven work histories. They are also more likely to work in jobs that do not provide pension benefits. This is why, in 2016, the average Social Security benefit for a retired female worker was $1,202, $317 per month less than the $1,519 per month that her male counterpart earned (Social Security Administration, 2017).

Employee Pensions Employee pension plans may be available through private industry and business, state and local governments, the military, or the Railroad Retirement System. When the Social Security Act was passed, the U.S. Congress expected that employee pensions would be another source of income for older Americans—remember, these pensions were meant to be one leg of the three-legged stool of retirement. Yet, today only 57% of workers have the benefit of retirement savings plans through their employer (Fronstin & Greenwald, 2018). When these pensions are available, they take one of two basic forms: defined-benefit or defined-contribution plans. Defined-Benefit Pension Plans Not introduced in the United States until the end of the 19th century, pensions covered very few workers until wage freezes during World War II prompted private industry to offer pension benefits to attract employees. The typical plan was a defined-benefit pension, the name denoting the fact that it is the employee’s benefit that is defined in this type of plan. For these plans, employers set up and contribute to retirement accounts for their employees, promising pension payments throughout their retirees’ lifetimes. Employees do not put any of their own money into these accounts. Retirement income (either a lump sum or a monthly payment) is typically based on a formula that takes into account how long the person has worked for the employer and an average of the employee’s highest annual earnings over a period of 3 to 5 years. Longer service and higher wages result in larger pensions.

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Defined-Contribution Pension Plans Defined-contribution pension plans are those that allow an employee to set aside and invest part of his or her wages in a tax-deferred retirement account, the name denoting the fact that it is the employee’s contribution that is defined in this type of plan. Funds put into these accounts may be invested in stocks, bonds, a diversified portfolio, or other investment vehicles, with a menu of choices provided by the employer. Employers may partially or fully match their employees’ contributions, but they are not required to do so. The most common type of defined-contribution pension plan is a 401(k), though there are also 403(b) and 457(b) plans, all named after the sections of the Internal Revenue Code that authorize them. The value of a pension under these plans is not predetermined but depends on the amount the employee is able to set aside during his or her working years, plus the amount the employer contributes (if any), and the rate of return on the investment of these funds, minus management and administration fees for the account. The total amount collected is typically available as a lump-sum payment at the time of retirement, and sometimes may be taken as an annuity, with income spread out over many years. Differences Between Defined-Benefit and Defined-Contribution Pension Plans When Congress changed the Internal Revenue Code to include Section 401(k), allowing these taxdeferred retirement accounts, it believed that this was a way for companies to offer employees a way to accumulate savings (the third leg of the 3-legged stool) to supplement their company’s traditional defined-benefit plans and Social Security (the other two legs of the stool). These new plans were not expected to replace private pension income. However, as time went on, more and more employers looked for ways to get out of funding their defined-benefit plans. In 1975, 74% of pensions were defined-benefit plans; by 2013, only 17% of pensions were of this type (Federal Interagency Forum on Aging-Related Statistics, 2016). There are advantages and disadvantages of each of these types of plans. Advantages of defined-benefit plans for employees include the fact that employees are not required to put their own money into their plan. In addition, they know what they will be getting (because their benefit is defined), the funds are managed by professional investors, and employees do not have to manage their retirement account, so they need no investment knowledge. The funds are protected until an employee is age 59½ years or older, when withdrawals can begin. Employees are also automatically enrolled in these plans upon hiring (although sometimes they first have to complete a year on the job). Most financial planners and investment advisors consider people who have one of these plans to be lucky because these plans promise retirees income for life (and survivor benefits if an employee has chosen that option), and few employers offer them now. The onus is on employers to keep their retirement plans solvent and if they fail to do so, there is a safeguard for employees who work for private companies. The Pension Benefit Guarantee Corporation (PBGC), a federal government agency established in 1974, insures the private defined-benefit pensions of nearly 40 million workers, taking over payment of benefits should a plan become insolvent or an employer go bankrupt. Note, however, that pensions of public (government) employees are not backed by the PBGC. The agency’s revenue comes from premiums paid by employers to insure their retirement funds, investment income, and assets acquired from failed pension plans and bankrupt employers. For workers who are in single-employer plans (75% of defined-benefit plans), the maximum pension benefit is determined using a formula prescribed by federal law and takes into account the worker’s age and the year the pension plan ended. For any given employee, the amount that is guaranteed can be found on the PBGC’s

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website (www.pbgc.gov). In 2018, PBGC paid up to $65,045 a year for workers who retired at age 65, and up to $58,541 a year for those whose pension plans included a survivor benefit. Disadvantages of defined-benefit plans for employees include the fact that each plan is tied to a specific employer, and thus is not portable. In addition, the way in which the value of these plans is calculated (years of service and average earnings) creates a disincentive for employees to leave their employer for a job elsewhere. Also, employees must remain with an employer for a minimum number of years—usually 3 to 6 (referred to as the vestment period)—in order to qualify for pension benefits. Employers started offering defined-benefit plans back in the 1940s and 1950s to attract and retain employees. At that time, when wages were not high, employers who were promising lifetime retirement benefits had a competitive advantage. This advantage has waned with changes in the economy and labor force, and the disadvantages of these plans for employers have led to their curtailment. Defined-benefit plans are more costly than defined-contribution plans for employers, in part because they require more administrative work on the part of the employer to guarantee that the funds will be available for employees when they retire. In addition, all the risks associated with investing the funds are borne by employers. Advantages of defined-contribution plans for employees are that the plans offer workers flexibility and portability, and, when they are managed well, they can produce adequate, or even generous, income for retirees. On the other hand, these plans place the financial risk on the employee because if the amount of money set aside in the plan is low or the investment returns are poor, or both, the employee may outlive the income he or she can derive from the plan. Very few people have the background, time, or ability to manage investments, and the potential for mismanaging the pension funds could result in little to no income for retirement. Whatever income is generated is not guaranteed to last for the lifetime of the retiree, and these plans are not insured by PBGC. In addition, there is no automatic enrollment in these plans, and, sadly, many employees do not participate in them, leaving them without a private pension that could augment their Social Security benefits. During the Great Recession, significant problems with these plans emerged. For example, 401(k)s lost a collective $2 trillion in value, which was fully half of the value of all 401(k)s. In addition, another $1 trillion was taken away from workers who lost or changed jobs and rolled their 401(k)s into individual retirement accounts. Furthermore, due to the hardships of the Great Recession, millions of American workers stopped contributing to their retirement accounts or were forced to make early withdrawals (incurring taxes and penalties) to deal with looming foreclosures on their homes and other expenses. Advantages of defined-contribution plans for employers are that they have lower administrative costs; employers do not bear any financial risk; and employers do not have to contribute funds. There are few disadvantages for employers, except perhaps that the portability of these plans means that their employees may be less likely to be loyal to the company. Theoretically, defined-contribution plans could produce higher retirement income than do defined-benefit plans; however, the evidence is that on average they do not. Over the course of time that pension plans have shifted from defined-benefit to defined-contribution, income from employer pension plans has actually decreased (Munnell, Hou, Webb, & Li, 2017). Defined-contribution accounts work best for the wealthy, who not only have the extra cash to invest but also use 401(k)s to shelter their income from taxes while they are working. . . . Millions of people opt not to participate, or contribute too little, or take money out at the wrong time and are charged huge fees. . . . [These accounts have] been a gold mine for Wall Street. Brokerages and insurance companies that manage retirement accounts earned roughly $33 billion in fees [in 2016] according to the Center for Retirement Research at Boston College. (Jordan & Sullivan, 2017, A Wall Street Gold Mine)

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Astoundingly, 58% of participants in 401(k) plans do not know they are paying any fees, d ­ espite the fact that the fees can put a big dent in an employee’s account balance, reducing that balance by 28% or more over the life of a retirement plan (Droblyen, 2017).

Poverty Among Older Americans Tremendous gains in the overall economic status of older persons have been evident since the implementation of Social Security and the cost of living adjustments that were included in the Social Security amendments of 1972. In fact, Social Security has reduced poverty among older adults by 75% (Meyer & Wu, 2018). In 1966, 29% of older people lived below the poverty threshold. By 2014, that proportion had declined to 10%, as measured by the traditional poverty measure (Federal Interagency Forum on Aging-Related Statistics, 2016). Because of concerns about the adequacy of that traditional measure, a Supplemental Poverty Measure (SPM) was developed in 1995 by a National Academy of Sciences’s panel (Citro & Michael, 1995). The SPM does not replace the traditional measure but extends it primarily by taking into account the rising costs of medical care as well as programs d ­ esigned to assist low-income families and individuals. Using the SPM, the poverty rate for older adults is a­ pproximately 5% higher than that which is indicated by the traditional measure (Renwick & Fox, 2016). Whichever one of these measures of poverty is used, there is still a significant number of older people living in poverty today, which means being at risk of having inadequate resources for food, housing, healthcare, and other needs. As Figure 7.3 shows, women and people of color constitute the majority of them. Older women of all ethnicities and races are more likely than older men to live in poverty. Race and ethnicity are also directly related to poverty among older persons. As can be seen in

Women

Hispanic (any race) Asian Black Non-Hispanic White Hispanic (any race) Men

Asian

75+ 65–74

Black Non-Hispanic White 0

5

10

15

20

25

Percent

FIGURE 7.3  Percentage of the U.S. population age 65+ living in poverty, by sex, race, and ethnicity, 2014. NOTE: These data refer to the U.S. civilian noninstitutionalized population. Poverty level: based on money income; excludes noncash benefits (e.g., food stamps). Poverty thresholds: reflect family size and composition; adjusted each year using annual average Consumer Price Index. Non-Hispanic White: people who reported being White and no other race and who are not Hispanic. Black: people who reported being Black or African American and no other race. Asian: people who reported only Asian as their race. SOURCE: Federal Interagency Forum on Aging-Related Statistics. (2016). Older Americans. Key indicators of well-being. Washington, DC: U.S. Government Printing Office. Retrieved from https://agingstats.gov/docs/­ LatestReport/Older-Americans-2016-Key-Indicators-of-WellBeing.pdf

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Figure 7.3, older non-Hispanic White men are far less likely than older men of any other race or ethnicity to be living in poverty. Sex and race/ethnicity also interact: older non-Hispanic White women are less likely than older women of any other race or ethnicity to live in poverty. As discussed earlier in this chapter, factors that account for greater poverty rates of women and people of color are their lifetime experiences of lower-wage jobs, uneven work histories, inadequate healthcare and pension benefits, and discrimination. Supplemental Security Income The Supplemental Security Income (SSI) program is a federal cash assistance program designed to provide a nationally uniform, guaranteed, minimum income for people with low incomes who are 65 years of age or older, or people of any age with low incomes who are blind or disabled. The cash assistance helps those who are eligible to meet their basic needs for food, clothing, and shelter. SSI was authorized as part of the Social Security Act in 1972, and went into effect 2 years later, replacing old state-administered poverty programs. Three congressionally mandated goals were part of SSI: 1. 2. 3.

Construct a coherent, unified income assistance system. Eliminate large differences between the various states in eligibility and benefits. Reduce the stigma of being on welfare by having the program administered by the Social Security Administration rather than state-sponsored welfare offices.

The Supplemental Security Income program, although managed by the Social Security Administration, is funded by general tax revenues, not Social Security taxes. Potential recipients are means-tested to determine their eligibility for the program. Means-testing restricts SSI recipients to those whose financial resources are judged to be sufficiently low, the definition of which is determined by the federal and state governments. There is an online Benefit Eligibility Tool through which a person can determine his or her eligibility for SSI (ssabest.benefits.gov). In 2019, the federal payment standard for SSI benefits was $771 for an eligible individual and $1,157 for an eligible couple. Some states augment federal funding for people who meet their guidelines (e.g., in Nevada, only older or blind people can qualify).

OLDER PEOPLE IN THE LABOR FORCE Among all the paradigm shifts in the aging of America in the 21st century, the trend toward older persons continuing employment beyond age 65 is a major component. In fact, since 1991, the percentage of workers over age 65 has been increasing faster than any other age group (Copeland, 2018). Figure 7.4 displays the labor force participation rates of men and women age 55 and older (the U.S. Bureau of Labor Statistics defines older workers as those age 55 and older). Note that between the ages of 70 and 74, 23% of men and 15% of women are still in the labor force, and even at age 75 and beyond, 12% of men and almost 6% of women are still in the labor force. Single women and Black women have always had a high rate of participation in the paid workforce, but the proportion of non-Hispanic White, Hispanic, and Asian married women in the labor force, especially those with children, has increased markedly over the past several decades. The Bureau of Labor Statistics projects that by 2024, 41 million people age 55 and older will be in the labor force, and 13 million of them will be age 65 or older (Toossi & Torpey, 2017). Compared

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80%

Men Women

70%

Participation Rate

60% 50% 40% 30% 20% 10% 0%

55–59 yrs

60–64 yrs

65–69 yrs

70–74 yrs

75+ yrs

FIGURE 7.4  Labor force participation rates of Americans age 55+, by sex and age group, 2018. NOTE: These data refer to the U.S. civilian noninstitutionalized population. SOURCE: U.S. Bureau of Labor Statistics. (2019). Labor force statistics from the Current Population Survey: ­Employment status of the civilian noninstitutional population by age and sex, 2018. Retrieved from https://www.bls .gov/cps/cpsaat03.htm

with people in younger age groups, older people are more likely to be self-employed—16% compared with 6% of 35- to 44-year-olds, 8% of 45- to 54-year-olds, and 9% of 55- to 64-year-olds. Toossi and Torpey explain, “Knowledge and resources gained through years of experience may put older workers in a good position to work for themselves” (p. 7). Older Americans are also significantly more likely to work part-time—40% compared with 18% of 25- to 54-year-olds (Toossi & Torpey, 2017). Working part-time rather than full-time ­allows older people more scheduling flexibility and enables them to continue to earn some ­income while being able to enjoy other pursuits. It can also be a way to transition, or phase, into retirement. Of course, some older people work part-time because that may be the only kind of job they can find. Unemployment rates for older adults are typically not as high as they are for younger adults, but once out of work, older people remain unemployed for a longer period of time (U.S. Bureau of Labor Statistics, 2018a). In 2017, there were 888,000 people age 55 and over who were looking for full-time work and another 290,000 looking for part-time work (U.S. Bureau of Labor Statistics, 2018b).

Reasons Older People Continue to Work Past Full Retirement Age Why do older people continue working in their later years, even after they may qualify for Social Security retirement and perhaps pension benefits? In general, the health of older people has been improving and they have a longer life expectancy than previous generations, both of which make it possible for many to continue working further into late life. Policy changes, such as the demise of mandatory retirement laws and the elimination of the Social Security earnings penalty at full

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retirement age, have also made it more realistic for older people to work. And, the shift from defined-benefit to defined-contribution pension plans, along with the need to save more for a longer life, have created incentives to continue to work or to go back to full- or part-time work. Substantial benefits can accrue to older people who remain in the workforce for longer periods of time, including better overall well-being; better physical, cognitive, and emotional health; and, of course, greater financial security (U.S. Senate Special Committee on Aging, 2017). Not surprisingly, one of the main reasons older Americans give for continuing or returning to work is economic necessity (Collinson, 2016). Many do not have adequate financial resources to be able to retire, others have concerns about outliving their financial resources, and some worry about the costs of long-term care should they need it. For many older adults, continuing to work past full retirement age has become a fourth leg on the retirement stool. Great numbers of older people are facing the harsh realities of declining pensions, lower than needed retirement savings, and mounting debt due to a number of factors. Retirement investments, including 401(k) plans, will continue to be vulnerable to investment market downturns. Rising drug and healthcare costs will add to these vulnerabilities. Recessions and downturns in the economy are hardest on older workers nearing retirement because they have less time to recover from market losses. According to the results of a Harris Poll survey conducted for the Transamerica Center for Retirement Studies (Collinson, 2016), the Great Recession of 2008 to 2009 is still having negative effects on the financial well-being of Baby Boomers: 45% say they have only somewhat recovered, 13% that they have not begun to recover, and 12% that they may never recover; only 30% say either that they were not impacted or that they have fully recovered. There are other reasons besides economic ones that older people cite for continuing to work—a desire to maintain their daily routines, to remain physically and mentally active, and to sustain social connections initiated through their jobs, as well as the fact that a great number of people simply enjoy working. Being productive workers throughout their lives, especially for older Americans, comes with real satisfaction. As Sara Rix, an AARP strategic policy advisor, stated, “Work is how many of us define ourselves and stay engaged with the world . . . and also how we give back” (Slon, 2007, p. 4). Leaving the labor force can mean disengagement, not just from work, but from life.

The Value of Mature Talent Increasingly, jobs in the modern economy no longer rely on physically demanding manual work, thereby reducing a barrier that has historically been detrimental to older workers. Unfortunately, outdated views of aging still obscure the human capital potential of what Peter Gudmundsson, founder of Hire Maturity in Dallas, Texas, terms mature talent (Moran, 2018). In an extensive analysis of studies testing the validity of negative stereotypes of older workers, Ng and Feldman (2012) found no differences between younger and older workers in terms of their motivation, resistance or willingness to change, the trust they place in coworkers, their psychological and day-to-day physical health, or their vulnerability to work–family imbalance. In terms of interest in career development and training, Ng and Feldman found only a slight difference in favor of younger workers. Furthermore, normal age-related changes in cognition can be easily accommodated in the workplace (see Chapter 4, Mental Health, and Cognitive Abilities, and Aging, for more information about older adults’ cognitive abilities). Among the many positive attributes of older workers are their institutional know-how, wisdom, experience, and reliability. Recognizing the value of that institutional know-how, employers are beginning to introduce practices to implement

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knowledge transfer between their older workers who are preparing to retire and their younger workers. As one CEO put it, “There’s good reason to invest in ‘mentor capitalists’ who invest their time and expertise in companies. . . . You can’t fit 50 years of experience into 20” (Moran, 2018). It is often thought that older workers might be less likely to be up-to-date on technology. But, a review of data on 80,000 programmers available through the online community, StackOverflow where visitors can ask and answer programming questions, revealed that older programmers were at least as knowledgeable as younger ones, and they actually had a wider range of subjects they could address (Morrison & Murphy-Hill, 2013). We are, according to the World Economic Forum’s Future of Jobs Report (2016), on the cusp of a Fourth Industrial Revolution. To meet the resulting changes in the workplace, many of which have already begun to happen, employees of all ages will need to be regularly engaged in acquiring the new skills that these changes will call for. The Forum’s prediction is that, “by 2020, more than a third of the desired core skill sets of most occupations will be comprised of skills that are not yet considered crucial to the job today” (p. 20). Upskilling and reskilling current employees of all ages are going to play critical roles if businesses, and indeed countries, are going to remain competitive in our rapidly evolving economies.

Age Discrimination and Mandatory Retirement Of all the barriers to employment of older workers, age discrimination is one of the most pernicious and pervasive. Age discrimination in employment first came to national attention in 1965. At that time, a report issued by the U.S. Department of Labor documented that more than 50% of all available job openings were not open to persons aged 55 and older because of employers’ explicit policies (Schulz, 1992). The Congress, in recognition of these discriminatory policies, enacted the Age Discrimination in Employment Act (ADEA) in 1967 “to promote employment of older persons based on their ability rather than age; to prohibit arbitrary age discrimination in employment; to help employers and workers find ways of meeting problems arising from the impact of age on employment” (U.S. Equal Employment Opportunity Commission, 1967, p. 1). A major issue in the debate leading to the legislation was the need to balance the rights of older workers to be free of age discrimination in employment with the rights of employers to manage their businesses. The law balanced these competing rights by prohibiting employment decisions based on age alone and instead focusing on employment decisions based on individual assessments of each worker’s ability. In its original form, the ADEA prohibited employment discrimination against persons aged 40 to 65. Amendments to the Act in 1986 made mandatory retirement illegal for most occupations in the United States, with a few exceptions, air traffic controllers, airline pilots, state and local public safety officers, and faculty in colleges and universities among them. Forced retirement of faculty was lifted in 1994. In 1996, an amendment made it possible for state and local governments to set their own retirement ages for police and firefighters. Remaining occupations for which mandatory retirement ages still apply include: ■ ■ ■ ■ ■

Air traffic controllers: age 56 Airline and commercial pilots: age 65 (was age 60 until 2007) Federal law enforcement officers and national park rangers: 57 (or later if fewer than 20 years of service) Foreign service officers (diplomats): age 65 Judges, in some states, for example, Minnesota, New Hampshire, Oregon, and Pennsylvania: age 70

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Some jurisdictions are in the process of increasing their mandatory retirement ages. For example, wanting to keep experienced police officers on the job longer, Pittsburgh is raising their required retirement age from 65 to 70. Several branches of the military are also reconsidering their ages of required retirement; for example, as of January 2018, retirement age for active duty soldiers has been increased from age 55 to 62. The enactment of the Age Discrimination in Employment Act and all subsequent amendments and accompanying legislation would appear to be enough to solve the problem of age discrimination in the American workplace. Such has not been the case. The rate of ADEA charges has actually increased over time (von Schrader & Nazarov, 2016). On the 50th anniversary of the ADEA, an Equal Employment Opportunity Commission report on the state of age discrimination stated that “age discrimination remains a significant and costly problem for workers, their families, and our economy” and argued that we need “to put to rest outdated assumptions about older workers (who should more aptly be described as ‘experienced workers’)” (Lipnic, 2018, pp. 1–2). Although the more obvious and overt forms of age discrimination, such as age limits in job ads and forced retirements at specified ages, have almost disappeared, more subtle and cleverly disguised forms of age discrimination against older workers are still evident. And, new ways of discriminating against older people in employment have been found by some companies. For example, several tech companies are defendants in a lawsuit (Communications Workers of America et al., v T-Mobile US, Inc. et al., December 2017) accusing them of placing recruitment ads on social media and then, through micro-targeting, setting age limits (as low as 38 years of age) on who can see the ads. In June 2009, the U.S. Supreme Court handed down a five-to-four ruling that makes it more difficult for older workers who believe they are victims of age discrimination to prove it. The ruling was in response to a suit filed under the ADEA by a demoted worker. The Court said it is not sufficient to show that age is among the reasons for the bad treatment of an employee; age has to be the primary reason. It should be noted that very few older workers have the resources to bring a case to court. The larger issue here is how society’s stereotypes are imposed on older-aged workers. To address this, laws are very important, but so is a new, more positive approach to aging in America, where workers are viewed according to their abilities, not their age.

Progressive Employers and Age-Friendly Workplaces A major hurdle for older workers is that too many employers are still reluctant to hire older workers, or put in place practices that meet their needs, often due to negative stereotypes unsubstantiated by evidence, as discussed above. In their report on America’s Aging Workforce, the U.S. Senate’s Special Committee on Aging (2017) concludes, “The business case for age-friendly workplaces is strong. Hiring and retaining older workers can help employers retain valuable skills, address workforce shortages, and increase workplace diversity, which can contribute to improved outcomes” (p. 4). Increasingly, forward-thinking employers are developing innovative strategies to keep and attract mature workers, including short-term projects, sabbaticals, telecommuting, job sharing, seasonal work, and labor pools made up of older workers. Columbia University’s Aging Center has instituted the Age Smart Employer awards program, which gives awards to New York City businesses and nonprofits who demonstrate age-friendly practices. The number of submissions has more than doubled over the course of the last few years, and the quality of submissions has been increasing too. Upon receiving an award in 2017 on behalf of Silvercup Studios, a film and TV production facility, Gary

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Kesner said, “I look forward to a day when awards of this kind are no longer necessary, when ageism in the workplace is a thing of the past and hiring mature workers is second nature to all employers” (Eisenberg, 2018). Here are a few other examples of progressive employers: ■

■

■

■

CVS Caremark has a “‘snowbird’ program [that] allows their pharmacists and other high-value workers from northern states to transfer each winter to pharmacies in Florida and other warmer states” (Eubanks, 2017, Baby Bloomers Delaying Retirement). Aerospace Corporation “allows employees to enter retirement as early as age 55. Retirees are allowed to work up to 1,000 hours per year at their old pay rate and can continue contributing to the business while phasing into retirement with less financial strain” (Eubanks, 2017, Baby Bloomers Delaying Retirement). Herman Miller, a furniture company, “has a flexible retirement program that couples the reduction of hours for pending retirees with a coaching service. . . . And it’s a two-way street: Retiring employees put together a knowledge-transfer plan to mentor their replacements. The flex program gives employees six months to two years to phase out of their jobs” (Brenoff, 2018, para. 10). University of Pennsylvania “provides Quality of Work-Life Programs that offer flexible hours, opportunities to work from home, compressed work schedules, part-time work, job sharing, as well as ergonomic modifications that support workers of all ages, including those over 55” (U.S. Senate Special Committee on Aging, 2017, p. 50).

Some evidence suggests that the workplace has become friendlier to older workers, though much progress is still needed to accommodate them. In one inexpensive pilot program, the BMW car company modified the work environment for their older workers, “replacing cement floors with wooden platforms to reduce the impact on knees [and providing] adjustable worktables to reduce physical strain and facilitate personnel rotation during shifts” (Centers for Disease Control and Prevention [CDC], 2012, p. 5). These and other changes that were instituted after discussions with the company’s employees resulted in a rise in productivity and a decrease in absenteeism, demonstrating the value of such programs not only for employees but also for employers. In a study of 2,800 people age 55 years or older, researchers determined that older Americans have a strong interest in and willingness to work into their late 70s if potential jobs offer flexible scheduling or reduced hours of work, or both (Ameriks et al., 2017). And, 20% of those individuals would even accept a reduced hourly wage for such jobs. For many older people, the difference between working or not working for additional years beyond normal retirement age seems to be primarily dictated by a lack of employers offering acceptable job opportunities rather than characteristics of the workers, such as their age.

RETIREMENT The term retirement has had many meanings: [T]he termination of and formal withdrawal from a regular job under the provisions of a statutory pension system, a demographic category, an economic condition, a social status, a developmental phase in the human life span, the transition to old age, and a lifestyle dominated by leisure pursuits or at least by economically nonproductive activity. (Monk, 1994, p. 3)

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Retirement is not something that has always been part of the American scene. In 1900, when the life expectancy for men was 46 years, the average man spent barely more than 1 year in retirement or out of the labor force. With dramatically longer lives, the passage of the Social Security Act of 1935, the advent of Medicare in 1965 (health insurance for persons age 65+), and additional pension coverage in the private and public sectors, retirement became a reality for millions of Americans. Beginning in the middle of the 20th century, and up until about the beginning of the 21st century, it was generally believed that large numbers of Americans would enjoy—and look forward to—years of retirement. Indicative of this time period was the opening, in 1960, of Del Webb’s first retirement community, Sun City, near Phoenix, Arizona, as a destination to live out these retirement years. As the New York Times writer, Steve Lohr (2005) observed, Sun City tapped into what was at that time a new vision of retirement where people could leave work and their old neighborhoods and move to a retirement community designed for endless vacationing for the rest of their lives—or at least until they wanted to move so they could be closer to the support that family members could offer. These years were termed the golden years, which were affordable for many Americans born between 1900 and 1945. These retirement communities sprang up primarily throughout the sunshine states in the southern and southwestern areas of the United States, with major concentrations in Florida, Arizona, and California. There is a question of the extent to which the dreams of these golden years could have been sustained by many over a long timeframe. But the reality is that for a number of reasons, what once seemed to be a realistic future for many American workers appears to be disappearing. Economic realities, social trends, lifestyles, and societal norms tend to change over time, and retirement as an American institution is no exception. In the 21st century, many Americans no longer take for granted that a good portion of their lives will be spent in retirement. As an institution, retirement is in a state of change.

Why Retirement? One way to understand retirement is to examine its historical trends. Another way to grasp the retirement concept is to understand why the goal of retiring has been so widespread. Schulz and Binstock (2006) explored the retirement concept in their book, Aging Nation. Why, they ask, is most of our workers’ increased leisure bunched at the end of the life cycle? When our society became based on an industrialized economy, it was in the self-interest of employers to require long hours when workers were young and get rid of them when they became old. Instead of longer hours for older workers, employers promoted retirement—a way to oust those they assumed were deficient workers. As a result, by 1900, long before public and private pensions were widely established, almost one-third of workers 65 and older were “retired,” that is, no longer in the labor force. But how could these workers afford retirement in the beginning of the 20th century? The reality was that too many of them could not. They had to rely on their own savings (which were typically small), support from relatives, or charity, which was often life in a county poorhouse, and those poorhouses were typically characterized by “insufficient and unfit food, filth, and unhealthful discomfort” (Committee on Economic Security, 1935). As a result, there was a push for some types of retirement incomes, which led to the establishment of the Social Security system in 1935 and the growth of private pensions in the 1940s and beyond, both of which were discussed earlier in this chapter. In addition, Schulz and Binstock point out that industrial growth—spurred by new technologies—resulted in economic output and growth that increased living standards and options for greater leisure, including retirement.

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The Changing Concept of Retirement Baby Boomers are blazing a new path for retirement, rejecting the concept of retirement as an endless vacation. One way in which that is happening is that they are already working, or planning to work, for more years in later life than did previous generations. Most Baby Boomers have expected that they will still be working during their retirement years—some because they enjoy the social contacts at work as well as the work itself, and others because they believe they will need the income or health benefits, or both. Baby Boomers do not want to depend on their children in retirement. Research has consistently shown that most Boomers do not see themselves giving up work after what has been a traditional retirement age. In fact, about 66% of them do not plan to retire at age 65, and even after they retire, 50% of them say that they plan to engage in some kind of paid work, most on a part-time basis (Collinson, 2016). And this trend is not confined to the United States. A global study of the future of retirement, with over 18,000 participants in 16 countries, found that a majority of working-age people around the world (58%) plan to be engaged in some kind of paid work in their retirement (HSBC, 2017). Retirement is also taking on new meanings as the ways of transitioning between work and retirement have become more varied. Some workers still follow what has been the more traditional practice of working full-time until a predetermined date when an abrupt exit from the workplace takes place. Increasingly common today is workers going from full-time work to a gradual exit that is phased-in over a period of time, part-time work with the same or another employer, a second career, or self-employment. Factors Affecting Retirement Decisions Deciding whether to retire and when to retire are not determined solely by reaching a certain birthday in life’s journey. These decisions involve a complex set of conditions and circumstances in each individual’s life, among the most prominent of which are financial well-being and health status. Workers who deem themselves to be financially well off and prepared to maintain that status throughout their later years are more likely to retire early. In fact, some Americans set an age at which they would like to retire and then aim to accumulate the economic resources to make that possible. On the other hand, those who have not been able to save and invest enough, or who have large debts, or both, are much more likely to remain in the labor force for as long as they can. For a long time, it has been recognized that an individual’s health influences his or her retirement decisions in various ways. Healthier older workers tend to continue working for a longer period of time compared with their counterparts who are less healthy, and they are also more likely to come back to work after an initial retirement. Poor health or disabilities can limit a worker’s ability to carry out certain tasks. It may become difficult for a worker in declining health to keep up with the workload of a given work situation. Going through the effort of getting to work and being there all day can simply become too difficult for some. Older workers with higher levels of educational attainment stay in the workforce full-time for more years than do those with lower levels of educational attainment. Retirement decisions are also affected by a partner or spouse retiring. Workers with defined-benefit pension plans tend to retire earlier than those with defined-contribution plans, and workers who can count on employer-sponsored health benefits in retirement also tend to retire earlier than those without such benefits (U.S. Senate Special Committee on Aging, 2017). Research economist Dr. Steven Sass (2016) reviewed research focusing on nonfinancial factors affecting retirement decisions. He found that “a positive work experience is a critical component in decisions of workers ages 65 and over to remain in the labor force” (p. 1). In addition,

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individual workers’ assessments of the extent to which they can meet personal objectives—such as meaningful relationships, a sense of identity, and personal growth—in the workplace versus outside of it are also major determinants in their retirement decisions. While acknowledging the importance of workers estimating the financial implications of their decisions, Sass concluded that “non-financial benefits seem far more important than non-financial costs—both in keeping some workers in the labor force and drawing others into retirement” (p. 1). Early, Normal (Full), and Late Retirement When to begin collecting retirement benefits from Social Security is also a decision that older workers must make. Eligible beneficiaries can choose to begin receiving Social Security retirement benefits as early as age 62 or as late as age 70. The Social Security Act of 1935 set the age to begin receipt of benefits at 65 (subsequently referred to as full retirement age). An amendment in 1956 allowed women to begin collecting benefits as early as age 62, and another amendment in 1961 allowed men to do the same. All those eligible for Social Security benefits can still choose to retire as early as age 62, with a concomitant reduction in monthly benefits to offset the longer time period over which they may receive benefits. In 1983, the U.S. Congress modified full retirement age for future cohorts, introducing a gradual increase from age 65 to a maximum of age 67 on the basis of a beneficiary’s year of birth. For anyone born after 1959, full retirement age is now 67. The purpose of raising the age at full retirement was to extend the solvency of Social Security’s reserve funds, given the fact that people are living longer than they were when Social Security was enacted, while at the same time recognizing that improvements in health are making it more feasible for many people to remain in the labor force for longer periods of time. Eligible individuals also have the option to begin receiving benefits any time after their full retirement age, up to age 70, with a concomitant increase in monthly benefits to compensate for the shorter time period over which they can receive benefits. As an analysis for Urban Institute’s Retirement Project demonstrated, “When people work longer, they produce additional goods and services for the economy . . . earn more income, usually save some of that income, allow their assets to grow, and increase their annual Social Security benefit” (Butrica, Smith, & Steuerle, 2006, p. 2). These economic advantages are even higher for lower- and middle-income Americans than they are for high-income Americans. The Social Security website provides tools for calculating projected benefits under these scenarios (early, full, late retirement; www.ssa.gov). Importantly, regardless of the age at which an individual decides to begin receiving Social Security benefits, the age for signing up for Medicare remains 65; waiting longer may result in penalties. In 2000, the U.S. Congress passed the Senior Citizens’ Freedom to Work Act, removing the previously imposed limit on earnings at full retirement age, so that having reached that milestone, older people would no longer have Social Security benefits withheld if they continued working or decided to rejoin the workforce. For workers who begin receiving benefits before their full retirement age, $1 is withheld for every $2 in earnings earned above an annual limit ($16,920 in 2017). Earnings in or after the month of full retirement age do not affect monthly Social Security benefits. Debates Over Social Security Social Security, as constituted, is considered a right for most workers—rich, middle class, and poor. There is no test to determine if one needs benefits upon retirement. Everyone who works and contributes into the system (which is now mandatory for most U.S. workers) earns benefits. So Social Security benefit payments are not welfare payments. Politicians from time to time think

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they have a ready answer to the national debt and the annual budget deficit by controlling and limiting Social Security benefits, for example, through meanstesting, which would make benefits available only to the poor. But means-testing would destroy one of the most successful programs of our government. Social Security is a contract that American workers have with their government, as well as a contract between generations. With proper management and minor adjustments, it can continue to be a reliable component of the financial future for all Americans. Ever since it was enacted in 1935, Social Security has had its critics and supporters. Contrary to the popular rhetoric of critics, the program has a very large surplus that will continue to grow for the next several years. Remember that Social Security is funded out of its own dedicated revenue system—the Social Security trust funds, and by law, its Board of Trustees is required to “report annually to the Congress on the actuarial status and financial operations of the OASI and DI Trust Funds” (Social Security Board of Trustees, 2018, p. 1). Figure 7.5 shows the financial reserves balance in the Social Security trust funds from 2012 to 2017. Notice that the positive balance in the funds has been increasing over time. This should not be surprising, especially to those knowledgeable about the population demographics of the United States, which includes gerontology students! The very large Baby Boomer generation has been in the workforce and paying into Social Security for a long time. As of 2017, the youngest Boomers could continue working and paying into Social Security for another 14 years before they would be eligible for its full retirement benefits, and the oldest Boomers just reached age 71, only 1 year beyond the maximum age for late retirement. While Figure 7.5 shows the overall assets of the Social Security trust funds over 5 years, Table 7.1 presents details regarding the income, expenditures, and assets of the funds from the Trustees’ report for the 2017 calendar year. Note that at the end of 2017, the trust funds had a positive balance of $2.7 trillion. The Trustees project that those assets will increase to $3.7 trillion by the end of 2021. After 2021, the trust funds’ balance is expected to decline, but will still be able to pay full benefits through 2034. Then, with payroll taxes and other income continuing to flow into the fund, the program could still pay 77% of benefits after that, even if no changes are made to the program. Dr. Alicia Munnell (2017), director of the Center for Retirement Research at B ­ oston

Financial Assets (in billions)

$3,000

$2,900

$2,800

$2,700

$2,600

$2,500

2012

2013

2014

2015

2016

2017

FIGURE 7.5  Financial assets (in billions) of Social Security Trust Funds, 2012 to 2017. SOURCE: Social Security Trustees’ Reports, 2012 to 2017. Retrieved from https://www.ssa.gov/oact/TR

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TABLE 7.1 Summary of Social Security Trust Fund Financial Operations for Calendar Year 2017

OASI Assets at end of 2016 (billions)

DI

TOTAL OASI + DI

$2,801.3

$46.3

$2,847.7

$825.6

$171.0

$996.6

706.5

167.1

873.6

Interest

83.2

1.9

85.1

Taxation of benefits

35.9

2.0

37.9

$806.7

$145.8

$952.5

798.7

142.8

941.5

Railroad retirement benefits

4.3

0.2

4.5

Administrative expenses

3.7

2.8

6.5

$2,820.3

$71.5

$2,891.8

Total Income in 2017 Net payroll tax contributions

Total Expenditures in 2017 Benefit payments

Assets at end of 2017 (billions)

DI, disability insurance; OASI, old age and survivors insurance. NOTE: Railroad Retirement is a federal insurance program, similar to Social Security, designed for workers in the railroad industry; it is administered by the Social Security Administration. Totals do not necessarily equal the sums of rounded components. SOURCE: Adapted from Social Security Trustees. (2018). The 2018 annual report of the Board of Trustees of the federal old-age and survivors insurance [OASI] and federal disability insurance [DI] trust funds. Retrieved from https:// www.ssa.gov/oact/TR/2018/tr2018.pdf

College, has observed, “Social Security faces a manageable financing shortfall over the next 75 years, which should be addressed soon to share the burden more equitably across cohorts, restore confidence in the nation’s major retirement program, and give people time to adjust to needed changes” (p. 1). Social Security has been, and still is, self-funding, so it has added nothing to the national debt. It can remain self-funded and pay full benefits with relatively modest changes, and there are numerous ideas for those. People continuing to work just a little bit longer, changes in revenues, “gentle reductions in the growth of future benefits,” or some combination of these “would place the program on a sound financial footing for 75 years and beyond” (Quinn, 2010, para. 6). Noted professionals in the field of gerontology, such as James H. Schulz and the late Robert H. Binstock (2006), have argued that it is essential to maintain and even strengthen the social insurance programs already in place, such as Social Security, Medicare, and Medicaid, rather than promote radical changes. They have contended that our political leaders and policymakers should be supporting programs that spread the risks people face, instead of making the individual person in our society primarily responsible for taking on the many uncertainties of the economy, work, and retirement. In order to make good decisions about which of the possible changes to Social Security would be best, citizens need to be well informed about the program. In that regard, we have much work to do. One reason that so many false statements about Social Security have gone unchallenged is that

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too many Americans are unfamiliar with the program and its benefits. Amazingly, a great number of Americans do not even know that Social Security is a federal government program. Professor Suzanne Mettler and Julianna Koch (2012) of Cornell University conducted research to find out what Americans know about Social Security. She found that 45% of those people receiving Social Security benefits say that they “have never used a government social program.” This ties in with the famous cry at a town hall meeting about healthcare reform when someone yelled, “Keep your government hands off my Medicare,” apparently not knowing that Medicare is a federal program.

Life in Retirement Financial security, or at least a perception of financial security, is what has made retirement possible. However, as noted earlier in this chapter, retirement is more than a financial consideration. It is a major life event, especially for people whose identities are tied to their life’s work. One of the most important things people of all ages can do to have positive experiences in retirement is to prepare for it by planning ahead. Not until the years following World War II was there any organized effort to help people plan for their retirements. In 1948, Clark Tibbitts and Wilma Donahue of the University of Michigan, along with Ernest Burgess of the University of Chicago, began developing preretirement educational programs (Cooper, 1994). In 1956, Woodrow Hunter of the University of Michigan offered the first preretirement program that was sponsored by a union (Hunter, 1968). Since that time, planning for retirement has become an integral part of a successful transition to another part of the life cycle. Planning has focused mostly on economic aspects of retirement, making sure retirees have sufficient financial assets, but there is more to retirement than that. The big question in retirement becomes, “What should we do for the rest of our lives?” At the first White House Conference on Aging, which was in 1961, President John F. Kennedy spoke about how impressive it was that so many years had been added to people’s lives. But he said it was now important to “add new life to those years” (Lohr, 2005). The number one dream of Boomers, GenXers, and Millennials for their retirement is to travel, cited by 65% of them, followed by spending more time with family and friends (56%), pursuing hobbies (49%), and doing volunteer work (27%; Collinson, 2016). Today, most working-age people and retirees around the world expect that new technologies will help them in retirement, by making it easier to stay connected with family and friends, by facilitating their ability to continue to work if they chose to do so, by supporting their interest in remaining active, and by assisting in their efforts to monitor and maintain their health (HSBC, 2017). Reports by the media, as well as economists, policymakers, and gerontologists, often express concerns that Americans are saving too little for retirement. Some research, however, suggests that consumption of goods and services decreases significantly after retirement, and thus, on average, the financial needs of retirees may be lower than assumed. Keep in mind, though, that needs relative to resources vary and that unexpected events postretirement can take a toll even on those with significant resources. In response to the question, All in all, would you say that your retirement has turned out to be very satisfying, moderately satisfying, or not at all satisfying?, almost half of participants (49%) in a large, longitudinal study of older Americans say that they are very satisfied and another 41% say they are moderately satisfied. Only 10% say they are not at all satisfied (Banerjee, 2016). It is gratifying to see such high numbers of satisfied retirees; however, over the course of 15 years, there has been a decrease in the proportion of those indicating that they are very satisfied, and researchers have not yet determined why that is. The results cut across economic groups, but at the same

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time, older Americans with greater net worth and better health status show higher satisfaction. Not surprisingly, other research shows that people who voluntarily retire have much higher life satisfaction in retirement than those who are forced to retire for health reasons or organizational reasons such as downsizing (Hershey & Henkens, 2014). The Practical Application at the end of this chapter provides additional information on the importance of helping older persons to rediscover their life purpose in retirement.

PRACTICAL APPLICATION INTRODUCTION

Chapter 7 focuses on economics, work, and retirement. It discusses the variability of economic status depending on factors such as sex, race/ethnicity, education, marital status, and living arrangements. It also explores the different retirement options for older Americans, both now and in the past 150 years, and stresses the importance of the Social Security program. Financial security during retirement is vitally important as is the quality of one’s life. Therefore, this Practical Application is devoted to helping older adults rediscover their sense of purpose to ensure a satisfying retirement. HELPING OLDER PEOPLE REDISCOVER THEIR PURPOSE DURING RETIREMENT

According to Jim Emerman, former researcher with the American Society on Aging, in the September/October 2006 edition of Aging Today, “To be successful in the aging process one needs purpose in life; whether one finds that in faith-based organizations, political activity, involvement in the arts and humanities, or in volunteerism. Purpose resonates with health and creativity.” According to Merriam-Webster’s Collegiate Dictionary (2008), “purpose” is “something set up as an object or an end to be attained” (page 104). In other words, in order to have purpose one must take intentional action toward a goal or an end to be attained. This requires knowledge of one’s goal, as well as planning and action toward that goal. On the other hand, life purpose might be defined as: ■ ■ ■ ■

The primary reason for one’s existence What one is here to do while he or she is alive The overall meaning of one’s life that shapes who the person is and all that he or she does One’s own personal mission statement

Having life purpose is important to the health and well-being of older individuals. Those who have a clearly defined life purpose tend to have improved physical and mental health, positive and meaningful relationships with others, the ability to rekindle the passions of their youth, and an optimistic outlook on life. Far too often, for those lacking life purpose, the old adage remains true . . . “if you fail to plan, then you plan to fail.”

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Those who choose gerontology as a profession should recognize as part of their role the need to help older persons rediscover their life purposes. This can be accomplished by utilizing opportunities to encourage older persons to identify their life purposes and then guide them to create short- (6- to 12-month) and long-term (3- to 5-year) goals and to take appropriate action toward these goals, periodically evaluating their progress toward them. As Victor Hugo said, “There is nothing like a dream to create the future” (Les Misérables, 1862).

STUDENT ACTIVITIES 1. Visit the Bureau of Labor Statistics retirement page (www.bls.gov/opub/ted/retirement

2. 3. 4.

5.

.htm). Read an article related to older adults and retirement and write four bullet points that summarize the key takeaways. Write a brief essay in favor of protecting the Social Security program. Explain the risks of relying on a defined-contribution pension plan as a primary source of retirement funds. Ely, 59, has been a general laborer all his life. The paper factory where he works does not offer a pension, and he has never made enough to contribute to the 401(k) plan. He continues to work, but he is unsure how long he will be able to keep it up because of the daily aches and pains he is experiencing. He also worries about getting hurt on the job. Describe the type of income he might be able to expect or apply for when he is no longer able to work. Barring hitting the lottery and quitting your job today, describe your ideal plans for retirement, explaining at what age you would like to retire, on what income you would depend, and how you hope to spend your time. Compare your retirement plan to the actual retirement of an older adult you know.

SUGGESTED RESOURCES Bureau of Labor Statistics. Retrieved from https://www.bls.gov The Bureau of Labor Statistics of the U.S. Department of Labor is the principal federal agency responsible for measuring labor market activity and working conditions. Data available on this website include unemployment, employment, pay and benefits, and workplace injuries. Center for Retirement Research at Boston College. Retrieved from http://crr.bc.edu The Center is a national leader in retirement research, including economics and behavior related to older workers, pensions, and health. The site provides access to research reports; the National Retirement Risk Index, which measures how prepared people are for retirement; and interactive tools to help people of all ages plan for retirement. Social Security Administration. Retrieved from https://www.ssa.gov The official website for Social Security offers information on all programs related to Social Security, including retirement benefits, disability and survivors’ benefits, Supplemental Security Income (SSI), and Medicare.

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U.S. Department of Labor. Retrieved from https://www.dol.gov This federal government website has links and referrals to resources on age discrimination, adult training programs, and job searches. U.S. Department of Labor. (n.d.). What you should know about your retirement plan. Retrieved from https://www.dol.gov/sites/default/files/ebsa/about-ebsa/our-activities/resource-center/publications/ what-you-should-know-about-your-retirement-plan.pdf This publication from the U.S. Department of Labor includes information on types of retirement plans, payment of benefits, what happens to benefits during a plan termination or company merger, and what to do if there are problems. Workforce50.com. Retrieved from https://www.workforce50.com Workforce50.com arms the older workforce with employment resources and career information to achieve their goals. It is committed to helping mature job seekers find meaningful employment opportunities.

REFERENCES Ameriks, J., Briggs, J. S., Caplin, A., Lee, M., Shapiro, D., & Tonetti, C. (2017, November). Older Americans would work longer if jobs were flexible. National Bureau of Economic Research (NBER) Working Paper, No. 24008. Retrieved from https://www.nber.org/papers/w24008 Banerjee, S. (2016, April). Trends in retirement satisfaction in the United States: Fewer having a great time. Employee Benefit Research Institute (EBRI) Notes, 37(4). Retrieved from https://www.ebri.org/ content/trends-in-retirement-satisfaction-in-the-united-states-fewer-having-a-great-time-3342 Brenoff, A. (2018, May 15). Why are boomers still working? Maybe we just don’t know how to retire. Huffington Post. Retrieved from https://www.huffpost.com/entry/why-are-boomers-still-working -retire_n_5af45468e4b09bb419e59b35 Butrica, B. A., Smith, K. E., & Steuerle, C. E. (2006). Working for a good retirement (The Retirement Project Discussion Paper Series). Washington, DC: Urban Institute. Retrieved from http://www .urban.org/UploadedPDF/311333_good_retirement.pdf Centers for Disease Control and Prevention. (2012). Older employees in the workplace. Issue Brief No. 1. Retrieved from https://www.cdc.gov/workplacehealthpromotion/tools-resources/pdfs/Issue_Brief _No_1_Older_Employees_in_the_Workplace_7-12-2012_FINAL508_1.pdf Citro, C. F., & Michael, R. T. (Eds.). (1995). Measuring poverty: A new approach. Washington, DC: National Academies Press. Retrieved from https://www.census.gov/library/publications/1995/demo/citro-01.html Collinson, C. (2016, August). Perspectives on retirement: Baby boomers, generation X, and millenials. Los Angeles, CA: Transamerica Center for Retirement Studies. Retrieved from https://www .transamericacenter.org/docs/default-source/retirement-survey-of-workers/tcrs2016_sr_perspec tives_on_retirement_baby_boomers_genx_millennials.pdf Committee on Economic Security. (1935, January). Old age security: Final staff report. Baltimore, MD: Social Security Administration. Retrieved from https://www.ssa.gov/history/reports/ces/ ces2armstaff.html Communications Workers of America. (2017, December 20). Class action lawsuit hits T-Mobile, Amazon, Cox, and hundreds of large employers for allegedly using Facebook to exclude millions of older Americans from job ads in violation of age discrimination laws. Retrieved from https://cwa-union.org/ news/releases/class-action-lawsuit-hits-tmobile-amazon-cox-for-alleged-age-discrimination Cooper, J. W. (1994). Getting ready to retire: Preretirement planning programs. In A. Monk (Ed.), The Columbia retirement handbook (pp. 59–80). New York, NY: Columbia University Press. Copeland, C. (2018, May 8). Labor force participation rates by age and gender and the age and gender composition of the U.S. civilian labor force and adult population (Issue Brief, no. 449). Washington, DC: Employee Benefit Research Institute. Retrieved from https://www.ebri.org/docs/default-source/ ebri-issue-brief/ebri_ib_449_lfp-8may18.pdf?sfvrsn=2a35342f_2 Droblyen, E. (2017, February 8). Finding hidden 401(k) fees in participant disclosure notices. Mobile, AL: Employee Fiduciary. Retrieved from https://www.employeefiduciary.com/blog/ finding-hidden-401k-fees-in-participant-disclosure-notices

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Eisenberg, R. (2018, February 7). Employers are getting smarter about hiring older workers. Marketwatch. Retrieved from https://www.marketwatch.com/story/employers-are-getting-smarter -about-hiring-older-workers-2018-02-07 Eubanks, B. (2017, June 2). Baby boomers delaying retirement: Generational shifts at work. Forbes. Retrieved from https://www.forbes.com/sites/adp/2017/06/02/baby-boomers-delaying -retirement-generational-shifts-at-work Federal Interagency Forum on Aging-Related Statistics. Older Americans. Key indicators of well-being. (2016). Washington, DC: U.S. Government Printing Office. Retrieved from https://agingstats.gov/ docs/LatestReport/Older-Americans-2016-Key-Indicators-of-WellBeing.pdf Fronstin, P., & Greenwald, L. (2018, April 10). The state of employee benefits: Findings from the Health and Workplace Benefits Survey (Issue Brief, no. 448). Washington, DC: Employee Benefit Research Institute. Retrieved from https://www.ebri.org/health/publications/issue-briefs/content/ the-state-of-employee-benefits-findings-from-the-2017-health-and-workplace-benefits-survey Hershey, D. A., & Henkens, K. (2014). Impact of different types of retirement transitions on perceived satisfaction with life. The Gerontologist, 54(2), 232–244. HSBC. (2017). The future of retirement. Shifting sands. Global report. London, England: Author. Retrieved from https://www.hsbc.com/news-and-insight/insight-archive/2017/the-reality-of-retirement Hunter, W. W. (1968). Preparation for retirement. Ann Arbor: Institute of Gerontology, The University of Michigan-Wayne State University. Jordan, M., & Sullivan, K. (2017, September 30). The new reality of old age in America. Washington Post. Retrieved from https://www.washingtonpost.com/graphics/2017/national/ seniors-financial-insecurity/?utm_term=.06b2aae3923e Lipnic, V. A. (2018). ADEA @ 50. The state of age discrimination and older workers in the U.S. 50 years after the Age Discrimination in Employment Act (ADEA). Washington, DC: U.S. Equal Employment Opportunity Commission. Retrieved from https://www.eeoc.gov/eeoc/history/adea50th/upload/report.pdf Lohr, S. (2005, March 6). The late, great ‘golden years.’ The New York Times (online). Retrieved from https://www.nytimes.com/2005/03/06/weekinreview/the-late-great-golden-years.html Maleh, J., & Bosley, T. (2017, October). Disability and death probability tables for insured workers born in 1997. Baltimore, MD: Social Security Administration. Retrieved from https://www.ssa.gov/oact/ NOTES/ran6/index.html Margerison-Zilko, C., Goldman-Mellor, S., Falconi, A., & Downing, J. (2016). Health impacts of the Great Recession: A critical review. Current Epidemiology Reports, 31(1), 81–91. doi:10.1007/ s40471-016-0068-6 Mettler, S., & Koch, J. (2012, February 12). Who says they have never used a government social program? The role of policy visibility. Retrieved from https://journalistsresource.org/wp-content/uploads/2012/09/ PerceptionGovt-KochMettler-022812.pdf Meyer, B. D., & Wu, D. (2018, May). The poverty reduction of Social Security and means-tested transfers (Working Paper No. 24567). Cambridge, MA: National Bureau of Economic Research. Retrieved from http://www.nber.org/papers/w24567 Moran, G. (2018, March 29). Why you should recruit older workers. Fast Company. Retrieved from https://www.fastcompany.com/40547376/why-you-should-recruit-older-workers Morrison, P., & Murphy-Hill, E. (2013). Is programming knowledge related to age? An exploration of StackOverflow. Raleigh: North Carolina State University. Retrieved from https://people.engr .ncsu.edu/ermurph3/papers/msr13.pdf Munnell, A. H. (2017, July). Social Security’s financial outlook: The 2017 update in perspective. Boston, MA: Center for Retirement Research at Boston College. Retrieved from http://crr.bc.edu/briefs/ social-securitys-financial-outlook-the-2017-update-in-perspective Munnell, A. H., Hou, W., Webb, A., & Li, Y. (2017, March). How has the shift to 401(K) plans affected retirement income. Boston, MA: Center for Retirement Research at Boston College. Retrieved from http://crr.bc.edu/briefs/how-has-the-shift-to-401k-plans-affected-retirement-income Ng, T. W. H., & Feldman, D. C. (2012). Evaluating six common stereotypes about older workers with meta-analytic data. Personnel Psychology, 65, 821–858. Quinn, J. B. (2010, August). Social Security’s 75th: It will outlive its attackers, and thrive. Retrieved from http://janebryantquinn.com/2010/08/1292

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Renwick, T., & Fox, L. (2016, September). The supplemental poverty measure: 2015 (Current Population Reports, P60-258 [RV]). Suitland, MD: U.S. Census Bureau. Retrieved from https://census.gov/ content/dam/Census/library/publications/2016/demo/p60-258.pdf Roosevelt, F. D. (1935, August 14). Presidential statement on signing the Social Security Act. Social Security Administration. Presidential statements. Retrieved from https://www.ssa.gov/history/ fdrstmts.html#signing Sass, S. A. (2016, February). How do non-financial factors affect retirement decisions? (Number 16-3). Boston, MA: Center for Retirement Research at Boston College. Retrieved from http://crr.bc.edu/ briefs/how-do-non-financial-factors-affect-retirement-decisions Schulz, J. H. (1992). The economics of aging (5th ed.). New York, NY: Auburn House. Schulz, J. H., & Binstock, R. H. (2006). Aging nation: The economics and politics of growing older in America. Westport, CT: Praeger. Semuels, A. (2018, February 22). This is what life without retirement savings looks like. The Atlantic. Retrieved from https://www.theatlantic.com/business/archive/2018/02/pensions-safety-net -california/553970 Slon, S. (2007, May & June). A new way to retire? AARP Magazine, p. 4. Smeeding, T. (2012, October). Income, wealth, and debt and the Great Recession. The Russell Sage Foundation and the Stanford Center on Poverty and Inequality. Retrieved from https://inequality .stanford.edu/sites/default/files/IncomeWealthDebt_fact_sheet.pdf Social Security Administration. (2017, September). Fast facts and figures about social security, 2017. Washington, DC: Author. Retrieved from https://www.ssa.gov/policy/docs/chartbooks/fast_facts/ 2017/index.html Social Security Administration. (2018, March). Fact sheet on the Old-Age, Survivors, and Disability Insurance Program. Washington, DC: Author. Retrieved from https://www.ssa.gov/OACT/FACTS/ Social Security Trustees. (2018). The 2018 annual report of the Board of Trustees of the federal old-age and survivors insurance and federal disability insurance trust funds. Washington, DC: Author. Retrieved from https://www.ssa.gov/OACT/TR/2018 Toossi, M., & Torpey, E. (2017, May). Older workers: Labor force trends and career options. Career Outlook. Washington, DC: U.S. Bureau of Labor Statistics. Retrieved from https://www.bls.gov/ careeroutlook/2017/article/older-workers.htm U.S. Bureau of Labor Statistics. (2018a). Labor statistics from the Current Population Survey: Table 31. Unemployed persons by age, sex, race, Hispanic or Latino ethnicity, marital status, and duration of unemployment. Annual average, 2017. Washington, DC: Author. Retrieved from https://www.bls.gov/ cps/cpsaat31.pdf U.S. Bureau of Labor Statistics. (2018b). Labor statistics from the Current Population Survey: Table 8. Employed and unemployed full- and part-time workers by age, sex, race, Hispanic or Latino ethnicity. Annual average, 2017. Washington, DC: Author. Retrieved from https://www.bls.gov/cps/cpsaat08 .pdf U.S. Bureau of Labor Statistics. (2019). Labor force statistics from current population survey: Employment status of the civilian noninstitutional population by age, sex, and race 2019. Retrieved from https:// www.bls.gov/cps/cpsaat03.htm U.S. Equal Employment Opportunity Commission. (1967). Age discrimination in employment act of 1967 (Pub. L. 90–202). Retrieved from https://www.eeoc.gov/laws/statutes/adea.cfm U.S. Senate Special Committee on Aging. (2017, December). America’s aging workforce: Opportunities and challenges. Washington, DC: Author. Retrieved from https://www.aging.senate.gov/imo/media/ doc/Aging%20Workforce%20Report%20FINAL.pdf von Herbay, A. (2014). Otto von Bismarck is not the origin of old age at 65. The Gerontologist, 54(1), 5. doi:10.1093/geront/gnt111 von Schrader, S., & Nazarov, Z. E. (2016). Trends and patterns in age discrimination in employment act (ADEA) charges. Research on Aging, 38(5), 580–601. doi:10.1177/0164027515593989 World Economic Forum. (2016, January). The future of jobs. Employment, skills and workforce strategy for the Fourth Industrial Revolution. Geneva, Switzerland: Author. Retrieved from https://www.weforum .org/reports/the-future-of-jobs

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CHAPTER

8

AGE -FR I E N DLY C O M M U N I T I E S , LI VI N G AR R AN G E M E N T S , AND HOUS I N G O P T I O N S

LEARNING OBJECTIVES • Explain the importance of living environments to older people. • Summarize the main features of an age-friendly community. • Outline what influences older people’s decisions about where to live. • Identify the advantages and disadvantages of living alone for older people. • Compare and contrast the features of different types of housing options for older people. • Discuss the issue of homelessness among older adults, and its solutions.

BOB: STAYING PUT Bob Egbert, 85, . . . lives in a Bountiful [Utah] neighborhood where he sees his daughter and his . . . brother daily. He also sees old friends. His living room is immaculate and artfully arranged; he explains . . . it’s exactly as his wife, Beneta, kept it. She died 16 years ago. He likes familiar things. He says he loves his kids and they love him, but he wouldn’t want to live with them. Egbert gardens and sometimes, when he wants more company, he visits the local senior center. It serves lunch and there are classes and activities, but it’s also full of familiar neighbors and friends. —Collins, 2017

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PAM: MOVING INTO A NEW KIND OF RETIREMENT COMMUNITY Recently retired, Pam Watkins wanted a new lifestyle. The former school principal saw her . . . neighborhood . . . increasingly populated with young families busy with kids or work. She wanted more people her own age to “play with,” but didn’t want to live in a “grave-yardish” retirement community. So, last year, Watkins and her husband moved into . . . a new, large, master-planned community with neighborhoods for seniors as well as those of all ages. There are community spaces for everyone, but also a seniors-only clubhouse with lounge, fitness center and a resort-style saltwater pool and spa. —Khouri, 2017

BONNIE: SHARING HER HOME In 2008, Bonnie Moore was going through a divorce. And as she was adjusting to a one-income lifestyle, the recession hit and her five-bedroom, three-bathroom home lost half its value. “All of the money that I had put into remodeling just disappeared,” Moore said. “I had, what I considered, just a wonderful house that I could no longer afford and I had to decide what to do. Do I just walk away from the house and go get an apartment some place or do I try to keep the house?” Moore, now 69, decided to keep the house—a resolution made possible by roommates. But she wasn’t open to finding just anyone. “I decided that I wanted to live with women approximately my same age; I wanted to have that sense of camaraderie,” she said. Moore is among a growing number of single seniors seeking companionship and an affordable living situation. . . . Moore shares her home with four other women, all between the ages of 52 and 69. And while they all get along as roommates, they don’t feel the need to spend every minute together. —Nania, 2015

LIVING ENVIRONMENTS: COMMUNITIES, LIVING ARRANGEMENTS, AND HOUSING OPTIONS This chapter focuses on older people’s living environments—where and how they live. Their living environments include the communities in which they live, with whom they share their accommodations, and the type of housing in which they live. As with most aspects of older adult life, great diversity is common in all of these areas. The opening scenarios indicate just that, with some older people aging in place, others moving to retirement communities with enticing amenities, and yet others sharing their accommodations with others. Living environments are vitally important to life satisfaction, and they have a significant impact on a person’s quality of life. This is particularly true for older people because they spend so much of their time in and around their communities and homes. Most no longer go off to a job anymore, at least not on a regular basis. Living environments also relate to an older person’s ability

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to interact and relate to other people. Housing itself is widely recognized as a leading determinant of physical and mental well-being (Bipartisan Policy Center, 2016). Most older people (88%) would prefer to continue to live in their existing residences as long as possible, and just as many would also like to remain in their current communities (Barrett, 2014). Contrary to popular belief, a very small number and percentage of older people live in institutional settings. Those figures increase with age, but even for those aged 85 and older, less than 10% live in institutional settings, and most of those individuals live in nursing homes (Administration on Aging, U.S. Department of Health and Human Services, 2016).

FACTORS AFFECTING WHERE AND HOW OLDER PEOPLE LIVE How do you decide where and how to live? Factors that affect such a decision include resources, opportunities, needs, and preferences (Wolf & Soldo, 1988). Resources consist of external factors such as income and other financial sources, while opportunities encompass the availability of family and friends, perhaps to sharing accommodations with them. Needs are internal factors, unique to individuals, such as their health and physical abilities. Preferences, of course, are an individual’s choices, but they also more than likely reflect social and cultural norms about where and how to live. Older people’s preferences are to be near family and friends and to places they want to go. Walkability and accessibility of church and social events are important too, as is a community of different age groups (Barrett, 2014).

Resources/Financial Status One of the major factors that affects where and how older people live is their finances, including income and other resources. The financial status of older people is discussed extensively in Chapter 7, Economics, Work, and Retirement. Here what an older person’s financial status means to his or her living environment is examined. As with other segments of the population, an older person’s financial status has a direct relationship with his or her ability to live in a housing unit that adequately meets the needs of daily living. For some, this may mean upgrading and remodeling existing single-family homes to adapt them to the changing needs of older people, including such things as bathroom and washing facilities on the ground floor, new insulation for warmth in the winter or cooling in the summer, and adequate lighting to accommodate vision changes. For others, it may mean the ability to move to a new neighborhood when essential services leave the old neighborhood or when the neighborhood becomes less safe. For still others, financial resources may mean the ability to leave their old home location to move to a retirement area in another section of their state or the nation. Included in these are the “snowbirds” who migrate to warmer climates upon retirement. For others, as they continue to age, it may mean moving to some form of congregate living arrangement where they can receive additional support services when they need them. For many older people, finances are a matter of survival in housing. Keeping a roof over their heads becomes a major struggle. Some do not win that struggle; they join the ranks of the homeless. This has become a much bigger issue since the collapse of the housing market, which began in 2006 and became a crisis in the Great Recession of 2008 to 2009, and the fallout of that collapse continues to have consequences for many older people.

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AGE-FRIENDLY COMMUNITIES In America, and around the world, there is a new movement afoot to make communities agefriendly. Leading this movement, the World Health Organization (WHO, 2007) has defined age-friendly communities as those that “encourage active aging by optimizing opportunities for health, participation and security in order to enhance quality of life as people age” (p. 1). It has established a global network to encourage actions by cities and communities to make their locations age-friendly. Currently, 541 cities and communities across 37 countries are members of the network. As noted by Fitzgerald and Caro (2014), most progress in these aging-friendly initiatives has been made in more developed countries because economics and politics hamper such efforts in developing countries. WHO’s website, Age-friendly World (extranet.who.int/agefriendly world/about-us), furnishes a link to their global network, and access to a global database of agefriendly practices, as well as a host of other resources, which include age-friendly assessments, guides and toolkits, publications, and videos. Key components of age-friendly communities are: accessible and affordable housing, public transportation and walkable neighborhoods, accessible outdoor spaces and buildings, and facilitation and encouragement of older people’s participation in the life of the community. While some communities around the world, and particularly in North America and Europe, have embraced this initiative, it is a big initiative and thus is still in its infancy. Currently, most communities are far from age-friendly, few even focusing on the opportunities and challenges of their larger and larger older populations.

Adapting and Building Homes for Older People One major aspect of aging in a place that has gained a lot of attention from the building industry is adapting existing homes to the particular desires and needs of people as they age. When it comes to home modifications, one place to find information and get training is through a website of the University of Southern California’s Leonard Davis School of Gerontology, www.homemods.org. The site has lots of resources, among them funding sources, assessment tools, a list of products that may be helpful, and a National Directory of Home Modification and Repair Resources that can be searched by state. The University of Southern California’s School of Gerontology even has a series of five courses that can be completed to earn an Executive Certificate in Home Modification. The National Association of Home Builders sponsors a Certified Aging-in-Place Specialist designation to teach “the technical, business management, and customer service skills essential to competing in the fastest growing segment of the residential remodeling industry: home modification for [people] aging-in-place” (n.d., para. 1) Some of the recommendations of one builder for modifying a home to make it age-friendly (Butler, 2016) are: 1. 2. 3. 4. 5.

Raise the outlets, lower the switches. Use aging-friendly, that is, paddle-style, light switches. Use bright light for illumination and install dimmers for control. Use wide doorframes. Select door knobs, cabinet hardware, and plumbing fixture that can be used without excessive pinching, twisting, or force.

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6. 7. 8. 9. 10.

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Make staircases 42 inches wide or wider, make the treads deeper and the risers a bit shorter, and put handrails on each side. Securely mount grab bars in the tub, shower, and toilet areas. Install kitchen countertops at various heights to allow for use by people of different heights, and also for sitting and standing. Install a zero-step entry into the home. Evaluate appliances for their usability by people of different abilities, and locate them to minimize lifting and bending.

Of course, designing and building homes from the outset that conform to universal design principles can cater to the desire for independence in people of all ages and ability levels. Such homes feel comfortable, not institutional, while unobtrusively incorporating features that are “enabling rather than disabling” (Stevenson, 2013).

Availability of Transportation and Services The living environments of older persons include not only the housing units in which they live, but also other aspects of living, such as the availability of shopping facilities, medical services, transportation, and access to relatives and friends. Good transportation and access to relatives and friends can be more important than the quality of the living unit itself. For an older person who does not drive, a home may become a virtual prison if transportation is not readily available. Transportation is a major issue facing older people in all types of settings—rural, urban, and suburban. This is particularly true of the older suburbs where so many aged people live. Most activities in which older people participate, and most services they need to access, require some form of transportation, typically a private car, or public transportation, which is limited in many areas of the nation. The impairments that older persons may experience as they continue to age can hinder their use of either public or private transportation without special assistance. And without adequate and appropriate transportation, many older persons are at risk of losing their independence. They become trapped in their homes when they are not able to access programs and services or to attend and engage in activities that are vital to their lives—religious services, shopping, movies, doctors’ appointments, and so on. Attempts to meet the transportation needs of older adults and also of people who are disabled go back to the amendments to the Urban Mass Transit Act of 1964. Currently, there exists a wide array of transportation programs at the local, state, and federal levels including the purchasing of vehicles and the installation of assistive devices and wheelchair lifts. The Federal Transit Administration in the U.S. Department of Transportation, in partnership with Easterseals, the National Association of Area Agencies on Aging, and the U.S. Administration on Community Living, has established the National Aging and Disability Transportation Center (NADTC) to promote the availability and accessibility of transportation options for older adults, people with disabilities, and their caregivers. The NADTC (www.nadtc.org) provides grants, training, and webinars, as well as other resources to help communities create such accessible transportation options. As is the case with all such programs, adequate funding is essential. In some communities, private companies, such as Uber and Lyft, have added affordable

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transportation options for older adults. More information about funding for transportation services and the unmet needs for transportation is presented in Chapter 10, Older Adults Giving and Receiving Support.

WHERE DO OLDER PEOPLE LIVE? The proportion of older people in the population varies considerably by state. More than half of the people aged 65 and over live in just 10 states, with Florida, Maine, and West Virginia having the highest percentages. Utah and Alaska have the smallest proportion of older citizens (Federal Interagency Forum on Aging-Related Statistics, 2016). Contrary to popular beliefs, older adults are less likely to move from one residence to another than are people under 65 years of age—only 3% compared to 13% from 2015 to 2016 (Administration on Aging, U.S. Department of Health and Human Services, 2016). Of those who do move, only 16% move out-of-state or abroad.

Metropolitan Areas, Older Suburban Areas, and Small-Town Living In reviewing the living environments and situations of older people in today’s world, it is important to note that 80% of people over the age of 65 live in metropolitan areas (Administration on Aging, U.S. Department of Health and Human Services, 2016). And, the oldest-old population (aged 85 and older) is three times as likely to be living inside metropolitan areas as outside these areas. Of those in metropolitan areas, 60% live in the suburbs. In older suburban areas, the difficulties of aging in place continue to emerge. The American suburb was built around the automobile—its widespread ownership and use. The automobile revolutionized how Americans lived, worked, and played. Workplaces, shopping centers, recreational facilities, and many houses of worship were all built around the use of the automobile. As people grow older, physical changes occur that may affect their desire or ability to drive. These changes are very gradual for most people and hardly noticed at first. However, they are real and in time will affect people who depend on their own automobiles for transportation. What makes this situation worse is that public mass transportation is minimal in most American suburbs. Much of what is available is geared toward moving suburbanites to central city business and financial districts. Advocates for older people are calling for ways to provide transportation to stores, doctors’ offices, houses of worship, and other services when driving becomes difficult, particularly during the hours of darkness and on congested freeways. Relatively few older persons live in communities of fewer than 2,500 residents, reflecting the long-term trend toward suburbanization and urbanization in America. Older persons in small towns tend to have fewer services, lower income, and poorer health than do older persons who live in metropolitan areas. However, older persons in small towns tend to interact more with friends and neighbors, with younger people and with persons their age, than do their counterparts in metropolitan areas. For many older persons, small towns are just much easier places in which to live. Generally, things move slower, including traffic. Points of interest as well as services, such as stores, houses of worship, banks, post offices, are closer. Change is usually less pronounced, and relatives, friends, and neighbors are not likely to move away. Knowing more people around town gives older people a sense of security. If they become ill, a friend, neighbor, or even a store owner or manager will deliver food. Knowing where everything is in a small town and being familiar with how to get around in it are great comforts. However, services to deal with

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crises or prolonged-illness situations usually are limited. With the closing or threatened closing of many rural hospitals, this is particularly true of emergency medical care, a real crisis for many people in rural and small-town America.

Moving and Migration of Older People It is not at all common for older people to move as they get older, though you might think otherwise due to media attention on retirement communities and such. From 2015 to 2016, only 3% of older people moved compared to 13% of the under-65 population (Administration on Aging, U.S. Department of Health and Human Services, 2016). Among the small percentage of older people who did move, 62% moved within the same county and another 22% remained in the same state. Advantages and Disadvantages of Moving Relatively few older people make an “amenity move,” that is, move for a better climate; fiscal characteristics that might include favorable property, sales, or income taxes; or specialized healthcare access. Those who do move tend to do so soon after retirement, when economic, social, and health resources are adequate to support such moves. One in five older persons moves for family reasons other than a change in marital status. The older population’s domestic migration is typically due to older parents’ wishes to live closer to their children or grandchildren, or to move back to their former communities if, when younger, they were among the few who left their communities. In addition, some older people move after they retire to enjoy recreational areas or beneficial climates. A move may be required because of the inadequacy of an older person’s present living environment, the closing of a retirement home or some type of supportive facility, or changes in the older person’s physical or emotional well-being. The question can be asked, Why are some older persons opposed to moving when a move could greatly improve their living accommodations? One reason is money, or the lack of it, as was discussed previously. To move from deteriorating housing into a better housing unit costs money, both in the form of higher housing costs and moving expenses. Insufficient funds, real or perceived, is often the cause of an older person not wanting to move. Second, some people, young or old, simply resist change, especially a change that affects so much of their lives. Fear of the unknown is a limiting factor for people of all ages, but particularly for the old who may have fewer physical or emotional resources to cope with unknown changing life conditions. Third, relocation is a traumatic event, especially when a person’s life centers on his or her place of residence. Relocation means leaving behind the old neighborhood, familiar surroundings, old friends and acquaintances, and neighborhood ties built over the years. Familiar surroundings in old neighborhoods give older persons a sense of stability and security. Before the mass movement of people to suburban areas, living in older residential areas offered conveniences for many older persons because these areas were close to facilities such as stores, physicians, and dentists. As services of all types continue to move toward the suburbs, many older people are left without them unless they have access to reliable, inexpensive transportation. In evaluating their existing housing situations, most of the older people refer to distances from medical and shopping facilities as a key factor. Newer Trends in Moving Although not widespread, there are a couple of newer trends when it comes to people moving as they get older. One is the development of various types of retirement housing options on or near college

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and university campuses. This is particularly attractive to those college graduates who, in retirement, want to return to their respective college or university campuses to become connected once again to college activities including taking or auditing classes, attending lectures, and enjoying sporting events. For those universities that have medical schools, such living arrangements can also provide older people with direct access to excellent medical care, where they may benefit from cutting-edge medical research. An added bonus is the opportunity for intergenerational living, which can be very stimulating for both young and old. Currently, more than 100 colleges and universities have university-based retirement communities (UBRCs) on or near their campuses. One highlighted by Stevenson (2014), Mary’s Woods at Marylhurst, Lake Oswego, Oregon, “offers residents WiFi, free computer classes, a complimentary iPad on move-in and steep discounts on tuition for classes.” Another mini-trend is the movement of affluent older people to town centers. The downtowns of numerous cities across the nation have been seeing an increase in the building of new, upscale condominiums, and older buildings (including old factories) being refurbished into apartments and condominiums. These areas typically include specialty shops, cafes, theaters, museums, and other attractions, with similarities to the town squares of earlier times.

Retirement Communities For many years, retirement communities have been described as places where people move when they retire. This does not mean that all residents in a retirement community are no longer employed in the workforce, but rather that the residents typically have retired from their primary job and have relocated to a community populated by other older people most of whom are also retired from full-time jobs. Retirement communities typically have included high-rise senior housing complexes, leisure villages, mobile home parks, or other forms of housing units. Among the largest and most elaborate retirement communities are Sun City, Arizona, and Leisure World, California, which have been in existence for many years. An elaborate range of amenities and services to meet the wishes and needs of retired persons continue to be found in these villages. Housing options, recreational facilities, medical assistance, houses of worship, and a range of educational opportunities seem to have had no limit in this type of retirement environment. With so many older people choosing to remain in their own homes and communities, the result can become something known as Naturally Occurring Retirement Communities (NORCs). These are communities wherein groups or clusters of persons are aging in place—staying in the same residence where they have lived for a long time while working, and perhaps while raising their families. Recently, there has been increasing interest in providing the services these older people may need to remain independent in their own homes. As the nation’s Baby Boomers continue to move into their older ages, a growing concern is where and under what circumstances will they live out their 60s, 70s, 80s, and beyond? Will most of them want to move to a warmer climate if they do not already live in one? Will most of them want to move to some fancy retirement village or home? Will many want to move in with their relatives—adult children, grandchildren, or some other kinfolk? As noted previously, the answer to all these questions is a resounding “no.” Most want to remain in their communities, so the real question is how are they going to be able to do this? One important consideration is the availability of services they may require to stay in their own homes. And this is where NORCs can come into play. NORCs are a way to organize communities in which clusters of people can naturally grow old together. They feature the following:

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Provide ways for older people to retain or develop positive roles as opposed to viewing them as only a bunch of people with needs Empower older people to be civically engaged Promote social connections—keeping current ones and developing new ones Develop an assortment of supports for older people that are flexible and available

LIVING ARRANGEMENTS The living arrangements of the older population reflect health status, socioeconomic situations, family caregiving, cultural ties, and more. Independent living arrangements—living alone or with a spouse or partner—are considered most desirable for older adults in the United States because they offer more autonomy, which is highly valued in American society. However, these living arrangements, in particular living alone, can increase social isolation and reliance upon formal social supports. Whether living in separate homes, apartments, condominiums, mobile homes, or any other type of housing unit, most people value some degree of independence with the ability to rely on family members living nearby. In our predominantly non-Hispanic White culture, for the most part, there has never been an emphasis on older people moving in with grown children and their families unless it was really necessary. Arranging for an independent living situation for older parents is not seen as abandoning them. In most instances, it is best for both parties—the older people and their adult children. In 2016, 13.6  million people aged 65 and older lived alone (Administration on Aging, U.S. Department of Health and Human Services, 2016), with the proportion increasing with age. This trend has been of some concern to aging specialists looking at the aging of the Baby Boom generation because as they grow older, larger numbers of older people are projected to live alone. But some experts have pointed out that this may not be as big a problem as some have anticipated as Baby Boomers are more practiced than their parents or grandparents at living alone. This is due to increase in the numbers of those who never married, higher divorce rates, and later marriages, which has translated into many Baby Boomers having had more experiences in living alone than earlier generations. As such, it is speculated that it will likely be less difficult for many Baby Boomers to cope with living alone than it has been for older generations.

Gender and Ethnicity/Race Differences in Living Arrangements The living arrangements of the older population vary by gender and ethnicity/race. As depicted in Figure 8.1, older women across all races and ethnicities are much more likely to live alone than are older men. Over one-third of older non-Hispanic White women and Black women live alone, while the proportions of older Hispanic and Asian women are closer to one-quarter. Men aged 65 and older are more likely than women the same age to live with their spouses (Administration on Aging, U.S. Department of Health and Human Services, 2016). As men and women move into the later years—aged 85 and older—more than half of older men still live with their spouses or partners while less than one-eighth of older women do so. Far more women in this oldest age category live alone than live with their spouses, partners, or others (children, friends, etc.). Only 12.2% of older non-Hispanic White women live with relatives, while 26% of older Asian women and more than 30% of older Black American and older Hispanic women do so (Federal Interagency Forum on Aging-Related Statistics, 2016). And this pattern is similar for men—only 4.4% of older

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50

Men Women

45 40

Percent

35 30 25 20 15 10 5 0

Non-Hispanic White

Black

Hispanic

Asian

FIGURE 8.1  Percentage of older adults living alone, by gender and race/ethnicity. SOURCE: Federal Interagency Forum on Aging-Related Statistics. (2016). Older Americans. Key indicators of well-being. Washington, DC: U.S. Government Printing Office. Retrieved from https://agingstats.gov/docs/ LatestReport/Older-Americans-2016-Key-Indicators-of-WellBeing.pdfx

non-Hispanic White men live with relatives, while 9.5% of older Asian men, 12.8% of older Hispanic men, and 13.7% of older Black American men do so. The proportion of older men living with their spouses is lowest among Black Americans (50%) and highest among Asians (78.2%; Federal Interagency Forum on Aging-Related Statistics, 2016). Cultural differences may play a role in determining the living arrangements of older people, but so too do financial status and other factors. Older people who live alone are more likely than are older people who live with family to be poor—15.4% versus 5.7%, respectively, living in poverty (Administration on Aging, U.S. ­Department of Health and Human Services, 2016). Thus, the fact that older women are more likely to live alone puts them in jeopardy of going into poverty or near poverty. Many women who are single, whether by choice, divorce, or death of a partner, realize that they are not as prepared for their retirement years as are women of their same ages who have spouses or partners. One reason is that, compared to men, a majority of women have not been able to earn as much money from employment, which also affects their pension, if they have one. In one solution to this situation, Bonnie, about whom we learned in one of the opening scenarios of this chapter, decided to share her large home with other single women of a similar age. In addition to the financial reasons for doing so, an obvious concurrent benefit is having companionship available. Connie Skillingstad has founded a helpful service, Golden Girls (goldengirlsnetwork.com), aimed at older women who are interested in shared housing. This nonprofit service helps women look at nontraditional options for housing that meet their financial, social, and emotional needs.

Staying Connected at Home A key factor for older people who live alone is staying connected with the outside world—­ particularly with close relatives or friends who can be available in times of need. Fortunately, continued developments in technology are making this easier and easier. It all started with Alexander

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Graham Bell who invented the telephone. The telephone is still important for keeping people connected, but wireless communications and computing power are also keys in this objective. There is a new generation of devices that can summon aid, alert people to take their medications, help caregivers keep tabs on an older person’s movements, and let doctors monitor vital signs from a distance. There are emergency pendants that contain a button that can be pressed to reach a 24-hour dispatcher who will notify a relative, friend, caregiver, or emergency services in the event of a fall, for example. Each year, one-third of all older adults experience a fall. About a quarter of those who fall will lose some independence due to injury from the fall. Pillboxes, pagers, vibrating watches, and dispensers that talk to users to alert or remind them about taking their medication can increase medication adherence, which is especially important for older adults with chronic conditions. Monitoring devices, such as motion detectors, can reassure family members and others who live at a distance that an older person is carrying out his or her daily routine as usual. Experts predict that in the near future, additional technologies will converge to the point where older people, their families and friends, and healthcare providers will be as connected as they want to be.

Living With Adult Children Many people believe that families today are quite different from the families of earlier times. Obviously, many things have changed, such as high technology applications, higher divorce rates, and fast-paced lifestyles; but contrary to common belief, what has not changed in American family life are intergenerational living arrangements. Many people feel that they have an obligation to automatically move their aging parents into their own homes when one parent becomes widowed or has difficulty with maintaining his or her own home. Many people feel this is the way it was done in earlier periods of our history. One of the pioneers in gerontology, Clark Tibbitts (1968), noted that the three-generation family, where older parents moved into the home of a nuclear family, has been relatively rare. Even in American colonial times, the three-generation family was an exception. The historical evidence for this comes from examining family wills in Plymouth Colony (Demos, 1965). Another study of family life in the 17th century noted the difference between Massachusetts families of residence, which were mostly nuclear, and families of interaction or obligation (Greven, 1966). This was a kinship group of two or more generations living in a single community, not a single house.

HOUSING OPTIONS FOR OLDER PEOPLE In some important aspects, what are referred to as housing options for older people are often not really options at all because (a) as noted previously, the vast majority of older persons and Baby Boomers want to or plan to continue staying in the housing unit in which they are living and never move; (b) many older people are not willing to consider other types of housing, even if another type of unit may be more suitable to their needs; and (c) many older people simply cannot afford to move to different or perhaps more appropriate housing.

Home Ownership The community-dwelling older population in the United States is primarily home owning. In 2015, 78% of older homeowners owned their homes free and clear (Administration on Aging, U.S. Department of Health and Human Services, 2016). The rate of home ownership varies by region

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of the nation, and also by family status and living arrangements. For example, the majority of older married couples own their own homes. In 2015, the median value of homes owned by older people was $150,000 (with a median purchase price of $53,000). In comparison, the median home value for all homeowners was $180,000 (with a median price of $127,000). Although it has been a persistent problem for many older householders for decades, a housing problem that has gained national attention puts many older people at real financial and physical risk—the cost of energy. Since the first part of the 21st century, the price of energy has soared, making it difficult for more and more older people to adequately heat and cool their homes. Increasing energy costs greatly impact older people because so many live on fixed and/or inadequate incomes. Homeowners may try to take some steps to cope with these soaring energy costs. For example, to conserve energy they may turn down thermostats to lower room temperatures. But room temperatures too low for the comfort of older people can result in hypothermia—a physical condition that if extended too long can result in physical harm or even death. Similarly, turning cooling systems down or off can result in room temperatures that are too high, leading to hyperthermia, which can also be life-threatening. More about hypothermia and hyperthermia is discussed in Chapter 3, Health and Wellness for Older Adults. Fortunately, the U.S. Department of Health and Human Services, through its Low-Income Home Energy Assistance Program, gives grants to states to assist those with low incomes in heating and cooling their homes by helping to pay their energy bills. Most states and some energy companies offer additional assistance with home energy costs for older people and other vulnerable populations. The U.S. Department of Energy, through its Weatherization Assistance Program, provides funding to states to facilitate renovations that make the home more energy efficient, thereby permanently reducing energy costs. Tax Relief Programs for Homeowners Most states have some form of property tax relief program for older persons. They may be called circuit-breaker programs or homestead exemptions. Circuit-breaker programs provide tax cuts or refunds to older homeowners when property taxes go above a certain percentage of their household income. Homestead exemptions are usually fixed-percentage reductions in the assessed valuation of an older person’s primary residence. For example, if homestead exemptions are in place when property taxes are raised, many older homeowners pay just a little extra in taxes. Reverse Mortgages Reverse mortgages are loans to older householders that are secured by the value of their homes and do not need to be paid until the borrower dies, sells the home, or moves out permanently. Homeowners, however, do continue to pay their property taxes and homeowner’s insurance. In order to obtain one of these mortgages, a borrower must be at least 62 years old and own the home. The house must be a primary residence. There are no income requirements for this type of loan. The two types of reverse mortgage loans in the United States are: (a) the Home Equity Conversion Mortgage (HECM), which is backed by the federal government and was signed into law in 1988, and (b) private reverse mortgages, which are not covered by federal mortgage insurance. Older homeowners turn to reverse mortgages for a variety of reasons: to pay off existing mortgages, to pay for prescription drugs, to improve the quality of their lives (e.g., by buying a new car or going on a vacation), and to pay for home healthcare. But a reverse mortgage is not for everyone. Some even call it “the loan of last resort.” Some experts think these loans may be best

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for persons in their 70s and 80s, but they may not be as good for persons in their 60s because they could outlive their resources in their later years and that would leave them with little or nothing upon which to rely.

Housing Conditions and Safety Most older Americans live in adequate, affordable housing. Some, however, live in costly and physically inadequate housing, which can pose serious problems for an older person’s physical or psychological well-being, or both. While housing costs have remained the most prevalent housing problem for all older Americans over the years, some older American households and intergenerational households continue to face physically inadequate housing problems, such as housing that lacks complete plumbing or has multiple and major upkeep problems (Federal Interagency Forum on Aging-Related Statistics, 2016). The median year in which the houses of older people were constructed was 1969, meaning that by 2015 half of their houses are over 50 years old. In comparison, the median construction year of houses for all homeowners was 1978 (Administration on Aging, U.S. Department of Health and Human Services, 2016). These older homes are subject to greater costs for repairs and upkeep. A key aspect of the housing conditions of older people is physical safety. This is particularly important in preventing falls. In northern climates, falling is typically thought of as being related to snow or ice-covered walkways and steps. And, indeed, thousands of people—including many older persons—fall every winter, resulting in severe consequences. But it is actually inside the home where older people are more likely to fall. According to home safety experts, there are key remedial steps that older householders can take to dramatically enhance their safety at home. One of the most dangerous rooms in an older person’s home is the bathroom. Falls, slips, and scalding water are all major risks. Consistent with the previous examples of modifications to make homes age-friendly, recommendations to make bathrooms safer include adequate lighting, with some light on throughout the night; strategically positioned grab bars, especially around the bathtub, shower, and toilet; nonslip surfaces on the bottoms of bathtubs, showers, and bathroom floors; a phone in bathrooms so those needing assistance can call for help; single-lever faucets; benches in shower stalls or showers with seats built into them; and no clutter on countertops or floors.

Types of Housing Options and Communities Single-family homes are one option for older adults, but living in a condominium, apartment, or mobile home can have its advantages. Additional types of housing options and communities for older adults are listed and briefly described in Table 8.1. Continuing Care Retirement Communities, assisted living facilities, and nursing homes are discussed in Chapter 11, Medical Conditions, Assisted Living, and Long-Term Care. Condominiums and Apartments Condominiums, or “condos,” are a form of real estate ownership. They can take almost any form of housing unit from detached single units on the ground level to “cubes” or apartments in highrise buildings. They are housing units that are individually owned but part of a multifamily housing sitting on common grounds that typically have support facilities and recreational facilities. Condominium owners are real estate owners. They own (or are buying) the housing unit they

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TABLE 8.1 Types of Housing Options and Communities HOUSING AND COMMUNITY OPTION

DESCRIPTION

Active adult community

independent living community restricted to active older people (usually 55+); includes recreational and social activities, and other amenities

Naturally occurring retirement community

housing development or neighborhood that has evolved over time to include a large proportion of older adults; some have developed supportive service programs tailored to needs of residents to assist them in maintaining their independence and remaining in their homes

Housing cooperative

alternative form of home ownership in which property is collectively owned and governed by a group of individuals who have created a corporation (usually nonprofit) to build or buy a block of homes, and who decide on the design, organization, and management of the cooperative

Accessory apartment

private apartment in a single-family home; includes sitting and sleeping area, kitchen, bathroom, and sometimes a separate entrance; sometimes called “mother-in-law” units

Elder cottage/tiny house

also called Elder Cottage Housing Opportunity (ECHO) or granny pod; small home located on same property as single-family home, often an adult child’s home; predated current interest of people of all ages in tiny homes because they are manageable in size and cost, and provide some flexibility because they can be moved to a desired location

Single-room occupancy unit (SRO)

a single room for independent living in a multi-unit building with hotel-style housing; usually has shared bathrooms and may have shared cooking facilities; once common in big cities, SROs were almost regulated out of existence; now making a comeback as one approach to reducing homelessness

live in, plus a fractional share of the common grounds and facilities. Owning a condominium is just like owning one’s own house except the condo owner generally does not do the maintenance and repairs and is partial owner of the common areas. The condo owner pays a fee that covers the cost of ongoing maintenance and repairs. As property owners, condominium dwellers can obtain a mortgage on their property, deduct the interest they pay on the mortgage from their tax returns, pay real estate taxes, and sell the property. For many older persons, condominium living combines many of the benefits of living in single-family home while eliminating responsibilities for grass cutting, snow removal, and other chores. Another option for older people who decide to move from their single-family home is to move to an apartment. Many styles of apartments are available in a variety of price ranges. For the older person, apartment living can be attractive because it transfers the responsibilities of property

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ownership to someone else. A person’s commitment is usually for a fixed period of time, typically a year at a time. This can be an advantage or a disadvantage. During the rental year, housing costs are fixed so the person can budget housing costs with no surprises, such as the need for a new roof or furnace or escalating taxes or utility costs. However, at the end of the year’s lease, the price of the apartment may go up. If apartments have been overbuilt in an area, rents tend to be much more stable, so it is important to be familiar with the apartment market. It may be possible for an older person to get a longer-term commitment for a fixed amount of rent, or, if not a locked-in price, at least a cap on the yearly increase. Because so many older people live on some form of fixed incomes, price stability for their housing can be a key factor in their ability to survive financially. On the other hand, if for some reason they become dissatisfied with their apartment, yearly leases give them the flexibility to move to a living unit that they like better. Some older people are not keen on the loss of privacy in an apartment setting. Others feel a loss of ownership or control. Still others believe paying rent is money “down the drain.” However, for many older persons, apartment living can be an economical way to obtain tax-free equity from the sale of the old homestead, as well as to get out from under the escalating cost of taxes, insurance, utilities, and maintenance associated with keeping their own homes. Mobile Homes Mobile homes can be very appealing to some older people. They are an affordable housing option that gives them the feeling of a secure living environment if they are in a mobile home park that they enjoy, while at the same time allowing them the independence and privacy of a single-family home. One consideration in choosing a mobile home park is the restrictions they impose on residents. Some are so restrictive that residents are not permitted to wash their cars or have visitors overnight. Mobile home parks take two forms: those where residents own the lots on which their mobile homes sit and those where lots are rented. Mobile home parks where residents own their lots are generally cooperatively managed and have cooperatively owned recreational buildings and services. Some even have their own fire departments and emergency paramedical units, such as Trailer Estates in Manatee County, Florida. There older residents participate directly in the decision-making processes of operating the park. There is no “rent” to pay each month beyond the service charges. This type of park cannot be sold unless there is a cooperative decision to do so by the park’s resident owners. As a result, resident owners of a cooperatively owned mobile home park generally are in a good position to control their own living environments. On the other hand, mobile home parks where the lots are rented leads to the same kind of issue faced by apartment dwellers, a lack of control over rental costs. Spiraling costs of monthly rent are particularly problematic for prime recreational areas of the South and Southwest. As rental prices increase, many older persons are forced to sell because they can no longer afford the monthly fees for their mobile home lots. Most parks will not accept older mobile homes. Even if they were to find a park that would accept older mobile homes, many older persons on modest, fixed incomes simply cannot afford the expenses involved in moving a mobile home.

Public Housing The concept of public housing came about in President Franklin D. Roosevelt’s “New Deal” with the passage of the Housing Act of 1937, 2 years after the passage of the Social Security Act. Almost 20 years later, in 1956, the Housing Act was amended to provide public housing specifically for

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older people. Through its various sections, public housing for older people has been cooperatively provided through federal government loan programs to municipalities, religious organizations, private investors, and various social agencies. Public housing has been developed primarily through two provisions. One is Section 202 of the Housing Act. Through this section of the law, long-term loans are made to nonprofit organizations to develop multifamily housing complexes to provide affordable housing for older people. Rents are limited to 20% of a person’s income. Section 202 housing was designed to make sure that older residents have access to services that enable them to live independently, such as the availability of meals, transportation, personal assistance, and housekeeping. Residents need to be aged 62 or older with income below 50% of the area’s median income. A major problem is a lack of supply of these types of units. Section 8, created by the Housing and Community Development Act back in 1974, is a program designed to provide subsidized rent to low-income households who can show financial need, including older people. In this program, money is provided through the Department of Housing and Urban Development (HUD) to landlords to make up the difference between 30% of a person’s income and what is considered fair-market rent. In this program, the tenants can choose their own rental units (within price ranges) in a wide variety of rental housing styles, including apartment buildings, duplexes, single-family homes, and others.

HOMELESSNESS AMONG OLDER ADULTS When it comes to homelessness, older people are often a forgotten population. The National Alliance to End Homelessness, for example, divides people who are homeless into seven categories, but older adults are not among them. They are also not mentioned in the Alliance’s annual reports on The State of Homelessness in America. The definition of “older” for people who are homeless is age 50 or older, in large part because their health resembles that of people who are aged 65 or older. And, poor health is exacerbated by homelessness because it makes it difficult to get good nutrition and good sleep, and to manage chronic health conditions. In the 1980s, it was estimated that older adults made up only 10% of the homeless population, but the current rate is estimated at nearly 50%, and almost half of these older individuals have become homeless later in their lives, that is, after age 50 (Brown et al., 2016). What is responsible for this dramatic increase in homelessness among older adults? Research suggests that there is a strong cohort effect—the younger wave of Baby Boomers, born between 1954 and 1964, are experiencing a relatively high rate of homelessness, which is attributed to a number of factors that coalesced around them beginning in their young adult lives (Culhane, Metraux, Bryne, Stino, & Bainbridge, 2013). Just as most of the people in this cohort were entering the labor market, employment opportunities dropped. Even those with a college education ended up in lower-level occupations relative to their education, and the negative impact on their wages followed them for at least two decades after they began their careers (Kahn, 2010). Furthermore, beginning in the early 1980s, wages stagnated and have continued to do so. At the same time, housing costs started to rise and significant cuts were made to long-standing programs composing America’s safety net. During the Great Recession in 2008 to 2009, many of these younger Boomers lost their jobs and those who had homes lost equity in them, or lost them entirely. Healthcare costs have been rising sharply for decades now, and employers have been cutting health benefits. Not yet eligible for Medicare, younger Boomers may have little or no health insurance, in which case they are just one illness away from a financial crisis. Pensions from private employers have become rarer, with less than

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half now offering any kind of pension. These consequences too are beginning to take their toll on the younger Boomer cohort as they enter what would be their retirement years with significantly fewer resources than previous generations have had. Preventing homelessness among older adults and ameliorating conditions for those who are already homeless depend on reducing poverty and creating more affordable housing solutions. Maintaining and enhancing safety net programs, including Social Security, Supplemental Security Income, Medicaid, and Medicare, would go a long way toward achieving the goal of reducing poverty. For those who are homeless or at risk of homelessness, increasing the housing stock of single-room occupancy units (Sullivan & Burke, 2013), and the stock of permanent supportive housing, which combines affordable units with appropriate coordinated services, can be major contributors to solving the homelessness crisis among older adults (Dohler, Bailey, Rice, & Katch, 2016).

PRACTICAL APPLICATION INTRODUCTION

Chapter 8 discusses living arrangements, housing options, and age-friendly communities for older adults. It stresses the importance of living environment to older people and outlines the factors that influence their decisions about where to live. The chapter also outlines the advantages and disadvantages of living alone and investigates the issue of homelessness among older adults. Given the importance of aging in place to older adults, it is the focus of this Practical Application. AGING IN PLACE

In the immortal words of Dorothy from the Wizard of Oz, “There is no place like home.” This, at least, is the opinion of the majority of older people who wish to age in place. To this end, the role of the gerontologist should be to provide the support necessary to help those they serve to remain safely within their homes (however, they may define them) in the community. The concept of home is different for different people. It may be a house, apartment, condominium, trailer, or even a joint living arrangement with a friend, family member, or significant other. No matter where someone chooses to live, home is usually the one place where an individual feels most comfortable and in control of his or her own life. Therefore, it is no surprise that most individuals wish to age in place within their homes and would resist any change that would take them away from that. Is it possible for everyone to age in place? Absolutely not. Each person’s situation is unique and needs to be examined on an individual basis. Too often, family caregivers are made to promise that they will never place their loved ones in a nursing home. Yet in some cases, a long-term care facility might be most beneficial to the individual given his or her care needs, need for social stimulation, finances, and/or availability of qualified and capable family caregivers. It is important to keep in mind that not everyone has the right personality, patience, and/or ability to provide care for an older loved one. Determining safety in the home is a complex issue with no easy answer. The professional or family member contemplating safety needs to take a number of factors into consideration, including but not limited to, the following:

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Is there evidence of memory loss or other mental factors resulting in an individual’s vulnerability to scams/financial exploitation, potential for wandering from the home, falls, and/or other safety/fire hazards? Is the physical structure of the home and/or immediate neighborhood/environment unsafe? Is the individual’s condition impaired to the point of not being able to tend to basic needs, even with available assistance?

Mental competency can also be difficult to determine. If it is in question, caregivers can pursue an in-home assessment from a competent professional. If mental competency is still uncertain, they can make a referral to state adult protective services. Each individual’s situation needs to be carefully assessed, and even then, if the person in question remains mentally competent and appears to be safe, it is his or her right to choose where to live.

STUDENT ACTIVITIES 1. Ask three older adults to identify what is most valuable to them about their homes. (In

2.

3.

4.

5.

6.

other words, what would be most difficult for them to give up?) Compare their answers, making sure to note similarities and differences. Visit the Age-Friendly World website (extranet.who.int/agefriendlyworld/) and search for an age-friendly community in the United States. Make a list of at least eight services or benefits available to older adults within the community. Explain where you live now and why you choose to live there. Compare that with where you see yourself living in your retirement and why you would make that choice at that time. Imagine you work at a senior center and your task this week is to help older adults who live alone to stave off feelings of isolation and loneliness. Create a flyer for them that outlines your ideas and includes a list of activities available at your center, as well as other organizations and resources in your area that might be beneficial to them. (Your list can be based on real or fictitious information.) Glenda has been living alone in her suburban two-bedroom condo since her husband died 3 years ago. She is on a fixed income and is considering getting a roommate. Help her make a decision by creating a table in which you present the various advantages and disadvantages of each living situation. Use Google Scholar (scholar.google.com) to conduct a search about homelessness and older adults. Select an article published since 2015 and write a summary of the article’s main points. Conclude with a statement of your reaction to the article.

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SUGGESTED RESOURCES Age-Friendly Communities. (n.d.). Retrieved from http://healthy.uwaterloo.ca/~afc This website, sponsored by the University of Waterloo, provides tools and resources to help guide communities toward developing solutions to become more age friendly, while recognizing the uniqueness of each community. National Aging in Place Council. (n.d.). Retrieved from http://www.ageinplace.org The NAIPC is a senior support network dedicated to providing information and resources to assist older adults in remaining independent in their own homes as long as possible. The website includes practical advice (e.g., on making homes senior friendly, transportation resources), financial options (e.g., home equity loans), and a search feature to find service providers ranging from elder law to travel. National Association of Housing Cooperatives. (n.d.). Retrieved from http://www.coophousing.org Incorporated in 1960, the NAHC is a nonprofit national federation of housing cooperatives, mutual housing associations, and other resident-owned or controlled housing, professionals, organizations, and individuals interested in promoting the interests of cooperative housing communities. National Association of Senior Move Managers. (n.d.). Retrieved from http://www.nasmm.org The members of this association focus on assisting older people and their loved ones in the United States, Canada, and abroad, with the emotional and physical aspects of relocation or aging in place. Naturally Occurring Retirement Communities. (n.d.). Retrieved from http://www.norcblueprint.org This initiative provides assistance to communities for designing and managing high-quality NORC programs to serve older adults and their communities. National Shared Housing Resource Center. (n.d.). Retrieved from http://nationalsharedhousing.org The NSHRC is a clearinghouse of information for people looking to find a shared housing organization in their community or to help get a program started. The site has a directory of programs by state, and a list of regional representatives with contact information. Federal Trade Consumer. (n.d.). Reverse mortgages. Retrieved from https://www.consumer.ftc.gov/ articles/0192-reverse-mortgages The FTC is the nation’s consumer protection agency. This website provides information on how reverse mortgages work, the types of reverse mortgages available, and how to get the best deal.

REFERENCES Administration on Aging, U.S. Department of Health and Human Services. (2016). A profile of older Americans. Retrieved from https://www.acl.gov/sites/default/files/Aging%20and%20Disability%20 in%20America/2016-Profile.pdf Barrett, L. (2014). Home and community preferences of the 45+ population 2014. Washington, DC: AARP. Retrieved from http://www.aarp.org/research/topics/community/info-2015/Home-and -Community-Preferences-45Plus.html Bipartisan Policy Center. (2016, May). Healthy aging begins at home. Washington, DC: Author. Retrieved from https://bipartisanpolicy.org/wp-content/uploads/2016/05/BPC-Healthy-Aging.pdf Brown, R. T., Goodman, L., Guzman, D., Tieu, L., Ponath, C., & Kushel, M. B. (2016). Pathways to homelessness among older homeless adults: Results from the HOPE HOME Study. PLoS One, 11(5), e0155065. doi:10.1371/journal.pone.o155065 Butler, V. (2016, February). ‘Aging friendly’ improvements for most every home remodeling project. Retrieved from http://www.aarp.org/livable-communities/housing/info-2016/aging-friendly-renovation -improvements.html Collins, L. M. (2017, May 8). Most elderly want to stay in their homes, but is that what’s best? Deseret News InDepth. Retrieved from http://www.deseretnews.com/article/865675803/Most-elderly-want -to-stay-in-their-homes-but-is-that-whats-best.html Culhane, D. P., Metraux, S., Byrne, T., Stino, M., & Bainbridge, J. (2013). The age structure of contemporary homelessness: Evidence and implications for public policy. Analysis of Social Issues and Public Policy, 13(1), 228–244. doi:10.1111/asap.12004

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Demos, J. (1965). Notes on life in Plymouth Colony. William and Mary Quarterly, 22(3), 264–286. doi:10.2307/1920699 Dohler, E., Bailey, P., Rice, D., & Katch, H. (2016, May 31). Supportive housing helps vulnerable people live and thrive in the community. Washington, DC: Center on Budget and Policy Priorities. Retrieved from https://www.cbpp.org/research/housing/supportive-housing-helps-vulnerable-people-live-and-thrive -in-the-community Federal Interagency Forum on Aging-Related Statistics. (2016). Older Americans. Key indicators of wellbeing. Washington, DC: U.S. Government Printing Office. Retrieved from https://agingstats.gov/ docs/LatestReport/Older-Americans-2016-Key-Indicators-of-WellBeing.pdf Fitzgerald, K. G., & Caro, F. G. (2014). An overview of age-friendly cities and communities around the world. Journal of Aging and Social Policy, 26(1/2), 1–18. doi:10.1080/08959420.2014.860786 Greven, P. (1966). Family structure in seventeenth century Andover, Mass. William and Mary Quarterly, 23(3), 234–356. doi:10.2307/1922509 Kahn, L. B. (2010). The long-term labor market consequences of graduating from college in a bad economy. Labour Economics, 17(2), 303–316. doi:10.1016/j.labeco.2009.09.002 Khouri, A. (2017, June 22). A new generation of senior housing is making ‘elderly islands’ obsolete. Los Angeles Times. Retrieved from http://www.latimes.com/business/la-fi-senior-housing-20170622 -story.html Nania, R. (2015, April 8). Shared housing trend grows among older adults. Retrieved from https://iasp .brandeis.edu/about/2015/SR.pdf National Association of Home Builders. (n.d.). Certified aging-in-place specialist (CAPS). Retrieved from www.nahb.org/en/learn/designations/certified-aging-in-place-specialist.aspx Stevenson,S.(2013,May15).Aginginplace:Seniorlivinganduniversaldesign.APlaceforMom:SeniorLivingBlog. Retrieved from https://www.aplaceformom.com/blog/2013-5-15-senior-living-and-universal-design Stevenson, S. (2014, September 3). University based retirement communities. A Place for Mom: Senior Living Blog. Retrieved from https://www.aplaceformom.com/blog/9-3-14-seniors-head-back-to-school Sullivan, B. J., & Burke, J. (2013). Single-room occupancy housing in New York City: The origins and dimensions of a crisis. The City University of New York Law Review, 17(1), 901–931. doi:10.31641/ clr170104 Tibbitts, C. (1968). Some social aspects of gerontology. The Gerontologist, 8(2), 131–133. doi:10.1093/ geront/8.2.131 Wolf, D. A., & Soldo, B. J. (1988). Household composition choices of older unmarried women. Demography, 25, 387–403. doi:10.2307/2061539 World Health Organization. (2007). Global age-friendly cities: A guide. Retrieved from http://www.who .int/ageing/publications/Global_age_friendly_cities_Guide_English.pdf

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CHAPTER

9

FAMI LY, FR I E N D S , A N D S O C I A L NET W OR K S OF O L D E R A D U LT S

LEARNING OBJECTIVES • Identify key characteristics of older adults’ intimate relationships. • Describe the relationships between older people and their adult children. • Discuss the various roles that grandparents play in the lives of their grandchildren. • Assess the responsibilities of family caregivers and their effects on caregivers. • Outline the roles and importance of friends in the older people’s lives. • Explain the value of social networks.

A PARENT’S CONCERN Glen, who is 74, has been a widower for 2 years. He has a very close relationship with a 66-year-old widow. He is thinking about marriage but is concerned about what his two children will think. His significant other has four children who believe that Mr. Diamond is too old for their mother. Both sets of children are concerned about who will get the estates if the parents marry.

CHANGING TIMES Five years ago, Dave’s mother moved from their old house in Philadelphia to an apartment that was closer to his sister in Baltimore. Before the move, the 30-minute drive to visit his mom wasn’t a big deal, and Dave had lunch with her weekly. Sometimes they’d go to a ball game together. After the move, neither Dave nor his mom expected much to change—what was another hour or so of drive time? But as time passed, the trip seemed to get longer, time together was harder to arrange, and as a result, they saw less of each other. Then his mom’s (continued next page )

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health began to slide. When Dave’s sister called to say their mom had fallen and broken her hip, Dave needed and wanted to help. Should he offer to hire a nurse? Should he take a week off work and help out himself? After all the years his mom had devoted to caring for the family, what could Dave do from far away to help her—and his sister? —National Institute on Aging, 2016, pp. 1–2

HATTIE’S FRIENDS Hattie has lived most of her adult life in the same house. Her husband built it when they were first married. She raised her three children there. Her church and doctor’s office were in a shopping center four blocks away. Hattie is now 89 years old. One of her three children died over 10 years ago, and the other two live on opposite sides of the nation. She had a lot of friends over the years, but many of them have died, are confined to nursing homes, or are living with or near their children. With the loss of her husband 2 years ago, and with her children living great distances away, Hattie has increasingly relied on her friends for mutual support in facing the changes and losses in her life. In the past 6 months, Hattie’s church has announced it is relocating to the suburbs, where most of its members live. Her doctor’s office, along with other offices and stores in the neighborhood shopping center, is being demolished for a new urban freeway. Last week her only remaining friend, who was still driving in the daylight hours, suffered a stroke. Hattie’s children, who have been providing some home-help services for their mother, are encouraging her to move to a residential living facility for older people that has a continuing-care option, meaning she can be provided any level of assistance she needs as she grows older. Feeling all alone in her old house and neighborhood, Hattie is willing to consider moving, but she is afraid because she doesn’t know anybody in the facility her children have suggested. How can she survive without her old friends? Will she still be able to see those friends if she moves to the new facility? Will she be able to make new friends at age 89? Hattie’s old friends are important to her. She has passed the time with them when they have been able to get together, and she has been able to confide in them in times of happiness and times of stress and loss.

FAMILY, FRIENDS, AND SOCIAL NETWORKS Family, friends, and social networks are important to people throughout the life span. This chapter outlines the roles that family, friends, and social networks play in older adults’ lives. They are all vital to the physical, psychological, and social well-being of older adults.

THE FAMILY Family relationships may include a spouse or partner, parents, adult children, grandchildren, brothers and sisters, as well as other relatives. These relationships can have considerable consequences, both positive and negative, on older adults’ well-being. For example, family members

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can provide social support and resources, increasing an older person’s emotional outlook and self-esteem (Thoits, 2010). On the other hand, family relationships can have negative effects, causing long-term stress and undermining an older person’s health.

Intimate Relationships Intimate relationships are among the most important for an individual’s overall well-being. One index of intimate relationships is marital status, and data are more widely available on that characteristic than on other possible indices. The marital status of older men and older women by age group are shown separately, in Figure 9.1A and B. The reason for separate depictions for men and women is clear—there are dramatic differences in marital status between the sexes as they age. In particular, note that men are much more likely to be married and much less likely to be widowed at every age as compared to women. People who are married have better mental and physical health and longer life expectancy than individuals who are widowed, have been divorced, or never married (Liu & Waite, 2014). Whether an older adult lives in a family setting or lives alone also has much to do with his or her being in or out of poverty. And, having a partner impacts the availability of support for a person— including emotional, financial, and physical support, particularly in times of illness or infirmity. Clearly, as the data in Figure 9.1A and B indicate, older women are at greater risk for some of the negative effects that can accompany being widowed, divorced, or never married. Chapter 13, Older Women and Older Minority Group Members, goes into more detail about differences between men and women that impact their well-being and quality of life as they age. Emotional Well-Being and Happiness in Intimate Relationships Most older couples report that their marriages improve over time (Alford-Cooper, 2016) and their well-being increases as well (Carr, Freedman, Cornman, & Schwartz, 2014). Furthermore, older couples who are happy in their marriages report better health outcomes and well-being (Margelisch, Schneewind, Violette, & Perrig-Chiello, 2017) as well as better sleep (Chen, Waite, & Lauderdale, 2015) than do older couples who are unhappy in their marriages. Two models, the marital resource model (Waite & Gallagher, 2000) and the stress model (Williams & Umberson, 2004), have been used to explain the effects that marriage can have on men and women. According to the marital resource model, marriage often lead to gains in tangible resources, such as more income, and intangible resources, such as increased social networks, which are likely to result in enhanced well-being. On the other hand, according to the stress model, marriage can lead to significant conflicts, and such conflicts can then result in stress that harms well-being and can even bring about a divorce. Older men tend to be more satisfied with their marriages and the degree to which their emotional needs are fulfilled than are older women (Carr et  al., 2014). Even in low-quality marriages, Carr et al. (2014) showed that older men demonstrate higher life satisfaction relative to their wives. Also, it seems that older husbands’ happiness in relationships is based on what their wives do for them, whereas older wives’ happiness is based on what they feel they do for their husbands (Boerner, Jopp, Carr, Sosinsky, & Kim, 2014). Thus, the happiness of both men and women is based on what the husband receives. It is hypothesized, however, that these sex differences may shift, as younger generations are moving toward a less patriarchal family structure (Carstensen, 2011).

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A

Men

80

74

74

70

59

Percent

60 50 34

40 30

16

13

20

7

10 0

8

6

65–74

4

3 75–84

3

85+

Age Group Married Divorced

B

Widowed Never married

Women 73

80 70

Percent

60

58 42 43

50 40 30 20

20

17 5

10 0

65–74

17

11

6

4 75–84

4

85+

Age Group Married Divorced

Widowed Never married

FIGURE 9.1  (A) Marital status of men age 65 and over, by age group, 2015. (B) Marital status of women age 65 and over, by age group, 2015. NOTE: Married includes married, spouse present; married, spouse absent; and separated. Reference population: These data refer to the civilian noninstitutionalized population. SOURCE: Federal Interagency Forum on Aging-Related Statistics. (2016). Older Americans. Key indicators of well-being. Washington, DC: U.S. Government Printing Office. Retrieved from https://agingstats.gov/docs/­ LatestReport/Older-Americans-2016-Key-Indicators-of-WellBeing.pdf

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Divorce and Remarriage Among Older People As ongoing research indicates, divorce continues to be relatively infrequent among older people. However, the divorce rate doubled between 1990 and 2015, rising to 10 in 1,000 married persons aged 50 and older (Stepler, 2017). For adults age 65 and older, the divorce rate, which had been very low previously, has risen to an even greater degree, tripling since 1990 to 6 individuals per 1,000 married persons in 2015. This increase may continue as younger adults who experienced relatively high divorce rates grow older. The success of a second marriage depends, to a considerable extent, on the reaction of the older couple’s adult children. Parents are bonded to their children whether they have a positive relationship with their children or not. Adult children who reject the remarriage of their parents put a lot of stress on that marriage. Many individuals spend holidays with their families, and if the children reject their parents’ remarriage and the blended family, it creates a strain on the event and the entire family system. One of the opening scenarios describes the situation with Glen, a widower, who is deciding whether to remarry. Being worried about what his children will think is a normal response. It can be difficult for widowers and widows to even go out with someone because they may feel guilty about betraying their children or their deceased spouse, or both. Step-parenting is often difficult under the best of circumstances, as two different family histories come together with possible changes in family structure, which may lead to misunderstandings. Some adult children are concerned about their parents’ estates and how step-parents may spend, or eventually acquire, assets that they believe to be rightfully theirs. However, most second marriages of older couples are successful, especially if the individuals have a similar cultural history and the approval of their children, and can coordinate, without friction, their financial resources (Brown & Kawamura, 2010). Not too many unmarried couples want to marry their dating partners. Some are not willing to give up their independence. Others say they do not have the same reasons for marriage that younger people do, such as starting a new life and beginning a new family. Many older couples do not marry because of financial considerations, including possible loss of pensions or Social Security incomes, complex estate provisions, and inheritances for children. Older Adults’ Dating Older adults are living longer, and divorce rates later in life have been increasing, leading to greater numbers of older people being interested in dating (Buchanan & Rotkirch, 2018). Opportunities for older adults to meet people whom they may want to date can be more limited than they are for younger people because older adults are less likely to be in settings, such as the workplace, where numerous social interactions occur, and can lead to romantic relationships. Thus, an online dating site could be helpful in bringing single older adults together. We often hear that older adults do not make much use of the Internet. However, recent research has shown that older adults are using dating sites at an increasing rate (McWilliams & Barrett, 2014). Furthermore, 24% of adults who are aged 65 and older know someone who uses online dating, and 20% know someone who has begun a long-term relationship via online dating (Pew Research Center, 2013). Google searches for online dating sites for older adults come up with millions of results in less than a minute. Some of the major dating sites that are designed specifically for older adults to meet others in their same age range are Silver Singles, Senior Match, OurTime, Zoosk Seniors, and Elite Singles. For example, Silver Singles is aimed at helping adults aged 50 and older find long-term relationships. OurTime, which has merged with Senior People

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Meet, is more relaxed about relationship expectations, but makes a point of emphasizing differing needs between older adults and those in their 20s or 30s. Senior Match mentions on its landing page that users under the age of 45 are not allowed. It is important to note that con artists often prey upon older adults on these sites. To perpetrate these sweetheart scams, con artists will go to a lot of trouble to develop romantic relationships so they can then bilk their targets out of thousands, and even tens of thousands of dollars. Users of online dating sites should be cautious when using them. See Chapter 14, Elder Abuse and Neglect: Crimes, Scams, and Cons, for more about crimes, scams, and cons directed at older adults.

OLDER PARENTS AND THEIR ADULT CHILDREN With people living longer, it is now the case that many older adults still have parents who are alive. Thus, a 68-year-old may have 80- or 90-year-old parents who are still alive. Older adults with still-living parents are sometimes referred to as boomerang seniors, because they are moving back to be closer to their much older parents (Jayson, 2017). Nearly two-thirds of the very old have children who have also reached old age (Fram, 2013). When older children are the primary caregivers for their very old parents, the resulting relationship can be complex. About one-half of older-adult children report feeling happy that their parent is still alive, and three-fourths of advanced-age parents report feeling very grateful for their children’s support (Boerner, Jopp, van Riesenbeck, & Rott, 2015). However, there are both physical and emotional challenges in this parent–child relationship; accordingly, 75% of older adults report feeling overburdened in their caregiver role.

Family Caregiving There is little doubt that the family is the basic support system for most of the older Americans, in spite of changes that have occurred in the American family, such as family members not living as close to each other and some family members more focused on their careers than on their families (Carstensen, 2011). However, for emotional support, social interaction (visiting, spending holidays together, etc.), and various types of assistance in times of need (e.g., health problems), the American family remains ready to help its older relatives. The type of family support older adults receive depends to a great extent on their family situation—whether they are married, partnered, widowed, separated, divorced, or never married; whether they have living children or grandchildren, or both; whether they live with a significant other, alone, with adult children, or with friends or other relatives. To some extent, the type of family support available for older adults also depends on whether they are living in the community or in a residential setting, such as a retirement community or nursing facility (Zarit & Zarit, 2015). Older adults who age in place live longer and report that they have a better quality of life compared to older adults who move to a residential care setting (e.g., D’astous, Abrams, Vandrevala, Samsi, & Manthorpe, 2017; Dawson, Bowes, Kelly, Velzke, & Ward, 2015). Not surprisingly, then, older adults and their family members are looking for options to avoid a move to a care facility. These options may include family or home-based caregiving, community-based paid care, self-care using assistive devices, or some combination of all of these. Home-based care and community-based care are the most common arrangements for older Americans. Over the years, numerous studies have shown that most of the help older adults receive comes from family members (Adelman, Tmanova, Delgado, Dion, & Lachs, 2014). Families

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provide 80% to 90% of personal care and help with various tasks both in and outside the house, including transportation and shopping (National Alliance for Caregiving, 2015). The primary caregivers for older adults are daughters, daughters-in-law, and granddaughters, and they provide even more care than do older persons’ spouses (Freedman & Spillman, 2014). This does not mean that male children do not provide caregiving or take on a caregiving role. Kasper, Freedman, Spillman, and Wolff (2015) found that 17% of caregiving adult children were sons. Interestingly, when adult children live with their parents, including sons, they may do a substantial amount of caregiving (Kasper et al., 2015). Figure 9.2 displays how much caregiving is carried out by caregivers with different relationships to the care recipient. It also displays the proportion of time those caregivers devote to caregiving responsibilities. Daughters make up the greatest number of caregivers, followed by other relatives (often daughters-in-law) and spouses. Daughters and spouses also devote more hours in assisting their loved ones with selfcare, household, or medical activities than do other informal caregivers. Impact of Caregiving on Family Members In the United States, long-term caregiving has usually been conducted by family members. In 2015, 35% of care was conducted by family members (Oldenkamp et al., 2016). Caregiving for a family member can have both positive and negative effects on the caregiver. While the emphasis in the research has been on the negative effects of caregiving, studies have shown that caring for a family member can also have positive effects, adding purpose to the caregiver’s quality of life (Polenick, Sherman, Birditt, Zarit, & Kales, 2018).

35

Percent of caregivers Percent of caregiving hours

31

31 29

30

Percent

25

22

21 18

20

18 16

15 9

10 4

5 0

Spouse

Daughter

Son

Other relative

Non-relative

FIGURE 9.2  Percentage distribution of informal caregivers and number of caregiving hours provided, by relationship to care recipient, 2011. NOTE: Reference population is people of all ages who, in the last month, helped with one or more self-care, household, or medical activities for a Medicare enrollee aged 65 or over who had a chronic disability. SOURCE: Federal Interagency Forum on Aging-Related Statistics. (2016). Older Americans. Key indicators of well-being. Washington, DC: U.S. Government Printing Office. Retrieved from https://agingstats.gov/docs/­ LatestReport/Older-Americans-2016-Key-Indicators-of-WellBeing.pdf

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100 90

86

Percent of Caregivers

80 69

70 60

46

50 40 30

19

20

14 7

10 0

15

Satisfied recipient is well cared for

Brought More closer to confident care in recipient caregiving abilities

More things than I can handle

6

Don’t have Emotional Financial Physical time for difficulties difficulties difficulties myself

FIGURE 9.3  Percentage of informal caregivers reporting positive and negative aspects of caregiving with substantial impact on them, 2011. NOTE: Reference population: People of all ages who, in the last month, helped with one or more self-care, household, or medical activities for a Medicare enrollee age 65 or over who had a chronic disability. Estimates may not sum to the totals because of rounding. SOURCE: Federal Interagency Forum on Aging-Related Statistics. (2016). Older Americans. Key indicators of well-being. Washington, DC: U.S. Government Printing Office. Retrieved from https://agingstats.gov/docs/­ LatestReport/Older-Americans-2016-Key-Indicators-of-WellBeing.pdf

Figure 9.3 shows caregivers’ reports of substantial positive and negative effects of caregiving responsibilities on their lives. Positive effects include feeling satisfied that the care recipient is well cared for, being brought closer to the care recipient, and feeling more confident in their caregiving abilities. The percentage of caregivers reporting these positive effects is high—from almost 50% to close to 90%. There are more negative effects reported, but the percentages tend to be lower, from 6% to 19%. The biggest negative effect seems to be that informal caregivers say that they have more things to do than they can handle. Not having enough time for themselves and emotional difficulties are reported by more caregivers than are physical or financial difficulties. For years now, studies have shown that long-term family caregivers are at a high risk for sleep deprivation, immune deficiency, depression, anxiety, and even premature death (e.g., Zarit & Savla, 2016; Zarit & Zarit, 2015). Many of these negative effects of caregiving on family members are due to them being untrained and finding themselves having to perform highly skilled tasks (e.g., changing catheter bags; providing wound care; medication management), without adequate support from health professionals (Adelman et al., 2014). Research has even put caregivers at the same risk for burnout as nurses, teachers, and air traffic controllers (Bevans & Sternberg, 2012).

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Supporting Family Caregivers A primary goal of supporting family caregivers is to help them keep their loved ones in their own homes while providing an appropriate level of care. This goal builds upon what most older adults want as they go through the aging process—to stay at home as long as possible. As we have just learned, however, the responsibilities of caregiving can take a toll on family members. Fortunately, a growing number of resources exist to mitigate the negative effects on informal caregivers, and even to enhance the caregiving experience. These resources include assistive devices and technology, support groups, and community-based services. Assistive devices, used either alone or in combination with other care arrangements, are becoming more common. Examples range from smart devices that can remind people about taking their medications to remote sensing devices that can monitor a person’s daily activities. The use of assistive devices can improve functioning, enhance independence, and help an older person remain in his or her own home for a longer period of time (Freedman & Spillman, 2014). They can also decrease caregiver responsibilities and reduce the number of hours that are needed for personal care. Recent studies have found that acceptance of mobile technology applications is quite high for older adults, as long as they feel the technology is useful and easy to use (e.g., Singer & Levine, 2016; Singer et al., 2018). For example, in one study, older adults were comfortable with using wrist-worn devices to monitor symptoms as part of home healthcare (Charness, Best, & Evans, 2016). In reviewing 44 mobile applications for caregivers, Grossman, Zak, and Zelinski (2018) found that they provide a myriad of features, including information/resources, ways to facilitate communication between family caregivers, support/chat groups, burden assessments, and tips and information on managing problem behaviors. Ten of the 44 mobile applications provided specific components to address self-care for the family caregiver, providing emotional and social support, forms of stress relief, and respite. Support groups can reduce family caregivers’ burdens and caregivers can gain support from others in similar situations. Today, there are numerous support groups for family caregivers and most are specialized for the caregiving situation. For example, the American Heart Association has support groups for medical conditions resulting from a stroke or heart disease (Billinger et al., 2014). These interventions have been found to be effective in reducing burden and burnout (Adelman et al., 2014). Until the Alzheimer’s Association was founded in 1979, there was little organized support for the caregivers of people living with Alzheimer’s. Local chapters of the Alzheimer’s Association usually have support group meetings once a month and allow caregivers to discuss difficulties they may be having, their experiences with caregiving, and happy memories of their loved ones. Many local chapters of the Alzheimer’s Associations also have respite grants that allow informal caregivers to come to groups and receive free care for their family members while they are attending the support group meeting. An array of community-based services is available to assist older adults as well as caregivers in carrying out their tasks. No government program provides for 24-hour, in-home care and paying for in-home services can be tricky. Some are available at little or no cost depending on the service, how it is accessed, and whether the recipient qualifies through programs of the Older Americans Act (OAA), Medicare, Medicaid, or state social service departments. Usually local area agencies on aging or state units on aging can assist in finding services that meet the needs of specific older adults. These services include care management, home health services, homemaker/home care services, friendly visitor programs, and telephone reassurance programs. Additional community-based services may also be available for older adults and their caregivers. These include adult day care,

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respite care, congregate meals, transportation, home delivered meals, and home repair. Some of these services may be funded by the OAA, and available through agencies accessible through state government departments that serve older people. More information on OAA-funded services is presented in Chapter 10, Older Adults Giving and Receiving Support. Detailed information on understanding caregiver behavior, caring for the caregiver, role reversal, and dealing with resistance from the care recipient is explored in the Practical Application at the end of this chapter. Reasons to Choose In-Home Care Older adults and their families usually prefer long-term care in a home-based setting. Reasons include comfort level, a sense of guilt, and the high costs of alternatives. Remaining in the familiar surroundings of one’s own home engenders feelings of independence, security, and comfort. Simply put, people generally enjoy and prefer the setting where they have lived, often for a very long time. The warmth of caregiving from loved ones can be far superior to what can be expected from strangers. Sometimes, though, the desire to stay in people’s own homes may be prioritized over a better choice of care. A sense—sometimes an overwhelming sense—of guilt can drive family members to assume primary responsibility for the care of an older family member. Children may believe they have an obligation to care for their parents; after all, their parents raised them. There may also be religious reasons for a person feeling that it is his or her duty to care for the family member. Costs are another concern when it comes to caregiving. Many—too many—simply cannot afford an alternative. There is no federal or state funding for long-term care other than Medicaid, which is a joint program of federal and state governments designed for the poor or those persons who are forced to become poor before they can qualify for benefits under this program. In order to receive assistance through Medicaid to pay for long-term care, many middle-class older adults become impoverished for the first time in their lives—a humiliating condition for proud persons who worked hard all their lives while supporting schools, cities, towns, states, and governments through their taxes, as well as serving in all sorts of capacities in the community, and, for many, serving in the military (Warren & Tyagi, 2016).

GRANDPARENTS Grandparenting is not a new role. For decades, there have been endless stories and anecdotes about grandparents who take pleasure in “spoiling” their grandchildren. Grandparenting has been portrayed as an opportunity to indulge grandchildren in ways a person never could or would for his or her own children. With older adults living longer, and many of them healthier and wealthier than previous generations of older people, grandparents today often have more resources to play active roles in their grandchildren’s lives (Zhou, Mao, Lee, & Chi, 2017). The Changing Roles of Grandparents One of the roles that grandparents seem to be taking on in greater numbers is the role of raising their grandchildren (Buchanan & Rotkirch, 2018). The shift from the spoiling role to the caretaking/parenting role is a consequence of several factors. First, it is simply that grandparents are living longer and multigenerational families (including four-generation and even five-generation families) are becoming more prevalent, which has created a higher probability that they are available to take care of their grandchildren (Buchanan & Rotkirch, 2018). Changing family structures

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have had an impact on grandparenting roles too. Rising numbers of single-parent families have brought about an increase in requests for grandparents to provide care for their grandchildren (Buchanan & Rotkirch, 2018). The lack of adequate, and affordable, child care has left many American families depending on grandparents to take care of their children while they are at work, mitigating financial burdens on the family. Unlike many other developed countries, the United States does not have a coordinated, state-supported system of child day care. Essentially, each family is responsible for its own child care. Costs can be so high that the benefits for the family of a parent’s participation in the paid labor force may come into question. Parents who are affected by the nation’s opioid crisis, as well as other substance use issues, incarceration, and mental illness have given rise to scores of grandparents taking on parenting roles that their adult children can no longer fulfill. In 2016, grandparents were providing primary care for 2.9 million children under the age of 18, and almost 1 million of these grandparents were over the age of 60 (Annie E. Casey Foundation, 2017; Generations United, 2017). Grandparents play a critical role in these children’s lives. The positive loving relationships they have with their grandchildren as well as the stable home environment that they provide mitigate the effects of adverse childhood experiences (ACEs), which lead to a multitude of negative outcomes, including higher risks for chronic diseases and mental health issues in adulthood (Generations United, 2017). As one child who was raised by his grandmother put it, One thing I’ve noticed is that most people go to grandma’s house and get spoiled, but for me it was the only safe place I had. Getting to live with grandma was like ‘going to grandma’s house’ all the time. I had more love there than anywhere else in my life. (Generations United, 2017, p. 7) In 2003, a Supreme Court decision made it possible for grandparents raising their grandchildren to receive foster care benefits. The Court ruled that benefits could not be denied to relatives if they would otherwise be eligible to be foster parents. This decision has helped many economically challenged grandparents to care for their grandchildren. Nevertheless, many grandparents are not licensed foster parents and thus do not receive these benefits. Yet, by keeping their grandchildren out of foster care, they help save taxpayers an estimated $4 billion per year (Generations United, 2017).

FRIENDS AND SOCIAL NETWORKS Friends and social networks are important in everyone’s life, regardless of how old he or she is. As people age, their friends and social networks may decrease in size, but the importance of each reaches its peak in older adulthood. Friends and social networks can help in challenging times (e.g., bereavement; traumatic event) and increase the likelihood of being able to remain independent.

Friends As significant as families can be in the support systems of older adults, throughout their lives most adults have another valuable source of mutual assistance that adds to their quality of life—friends. Few things are more important than good friends. Friends play critical roles in the lives of people throughout their lives, from toddlers making their first attempts at personal interaction in the sandbox to 99-year-olds sharing stories and good times. One issue that older adults face that people of other ages encounter much less frequently, however, is the loss of friends who have played a vital

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role in their lives. Furthermore, friendships have been shown to be even more important to older adults than they are to other age groups, because an older adult’s family members may be busy with their own lives, thus leaving older people to rely more heavily on friends for support. Hattie, whose situation is described in one of the opening scenarios, expresses valid concerns about moving to a residential living facility. She risks losing friends that she has spent many years cultivating. The depth of Hattie’s friendships is the key to her emotional well-being, and long-term friendships cannot be replaced, even if some new friendships can be developed in a brand new setting. Friends and Feelings of Well-Being Research has shown that having close ties with friends is important to an older person’s well-being, including his or her physical and psychological functioning (e.g., Finlay, Franke, McKay, & Sims-Gould, 2015; Gardiner, Geldenhuys, & Gott, 2018). For instance, more intimate social ties have a greater effect on pulmonary function compared to peripheral social roles (Crittenden et al., 2014). In rural environments, smaller family and friend networks correlate with greater resilience when mental status is low (McKibbin et al., 2016). There is evidence that friendships bring about feelings of joy and contentment, enabling people to function well psychologically (Finlay et al., 2015). Having friends also decreases the probability of older adults developing chronic health problems, being injured in accidents, and experiencing psychological problems (e.g., Finlay et  al., 2015). Indeed, friendships even seem to lead to increased longevity. In a study by Chopik (2017), while family and friend relationships correlated with health and happiness overall, only friendships were a strong predictor of health and happiness among older adults. Friendships among older adults also lead to less stressful interactions, fewer conflicts, and fewer resulting negative appraisals of said conflicts (Rook & Charles, 2017). Friends can offer support to help with challenges that older adults may face (Rawlins, 2017). Life changes can be quite challenging for older adults and they experience them at a higher rate than most other adults. These changes may be in their living situation, a loss of identity related to their jobs or careers following retirement, or the loss of friends and family members as a result of death. Moving into a retirement living community where a person already has a friend can be a great advantage (Rawlins, 2017). Developing new friendships in these kinds of residential settings can also make a real contribution to a person’s well-being. Friends can also play a crucial role in adjusting to a congregate living situation, such as an assisted living facility or a nursing home. As stated earlier in this chapter, older adults experience the highest rates of loss and a support network of friends has been found to increase resilience and reduce negative outcomes that can result from these losses (MacLeod, Musich, Hawkins, Alsgaard, & Wicker, 2016). Individuals who lack friendships have higher rates of isolation and loneliness, both of which have been found to have the greatest prevalence in individuals 80 years of age and over (Cohen-Mansfield & Perach, 2015). Isolation and loneliness negatively affect individuals in numerous ways, increasing the risks for depressed mood, psychological distress, psychiatric morbidity, and depression (Cohen-Mansfield & Perach, 2015). Other outcomes of loneliness include a higher rate of Alzheimer’s disease, coronary issues, chronic illnesses, and functional disability; impaired hearing; lack of mobility/motor decline; poorer overall health; and poor self-reported functioning (Cohen-Mansfield & Perach, 2015; Shankar, McMunn, Demakakos, Hamer, & Steptoe, 2017). Due to both its physical and psychological effects, loneliness has also been found to reduce life expectancy (Bodner & Bergman, 2016). Furthermore, loneliness is a predictor of suicide in people age 65 and older, and having friends seems to reduce the risk of suicide (Stickley & Koyanagi, 2016).

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The number of friends a person has is not directly correlated with feelings of isolation or loneliness, but the type of friends is. How close a person is to his or her friends, both emotionally and geographically, is related to experiences of isolation and loneliness. For example, a person may have six friends, but they may interact with them only occasionally, and those friends may not be there for the person when the spouse dies. On the other hand, a person with a close friend will always have someone with whom to interact on a regular basis and with whom to talk when he or she needs emotional support. Clearly, friends play an enormously important role in the lives of older adults, enhancing their well-being and quality of life, and reducing their risks for negative effects of physical and psychological conditions that can become more common with age.

Social Networks Social networks refer to the interpersonal relationships that can provide an individual with various types of social support, for example, instrumental assistance, information, emotional reinforcement, and supporting others in times of need (Mick, Kawchi, & Lin, 2014). Instrumental assistance refers to tangible support, such as securing basic housing, financial support, and assistance in activities of daily living (ADL). Informational support includes the provision of helpful advice and suggestions. Emotional reinforcement refers to the provision of positive feelings such as love, caring, sympathy, and so on. The Value of Social Networks Social networks play more of a positive role than a negative role in older adults’ lives (Rook, 2015). They can provide help in times of need as well as in day-to-day companionship. Social networks can also be critically important in helping to reduce the effects of major life changes, such as moving or losing a loved one. Furthermore, a Dutch longitudinal study has demonstrated that older adults with larger and more diverse social networks have the lowest mortality risk over a 20-year span (Ellwardt et al., 2017). On the other hand, a person who lacks a social network may become isolated, which has been shown to be a major problem for older adults, leading to significant negative effects, for example, physical problems, psychological problems, and feelings of loneliness. For instance, isolation can lead to less engagement in physical activity (Smith et al., 2015) as well as self-reported chronic diseases, high cholesterol levels, depression, diabetes, and lower self-health perception (Richard et al., 2017). English and Carstensen (2014) found that older adults tend to reduce their social networks as they age (sometimes even in half), in order to maximize emotional satisfaction and meaning in social interactions. This network pruning is a method of emotion regulation; individuals maintain emotional well-being in their social environment by maximizing positive interactions and minimizing negative ones. The Socioemotional Selectivity Theory (SST) posits that older adults are both better able and more motivated to regulate their emotions (Carstensen, 2006). Older adults are more likely to perceive time as an increasingly limited resource, and thus place greater priority on goals related to satisfaction and emotional meaning in their relationships, as opposed to reciprocity and transactional value (English & Carstensen, 2014). Although there has been a tendency for the size of people’s social networks to decrease with age, recent research has found that increased longevity is leading to a new trend for older adults to maintain their social networks well into their later lives (Smith et al., 2015). And, recent research has shown that the characteristics of older adults’ social networks can be an even greater

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predictor of positive outcomes than the simple fact of having a social network (Rafnsson, Shankar, & Steptoe, 2015). Using the English Longitudinal Study of Aging to examine the effect of social networks on the well-being of older adults over a 6-year span, Rafnsson et al. (2015) found that the size of a social network and the frequency of contact with others in a network resulted in higher rates of satisfaction in their lives and a perceived increased quality of life. Social networks of more than eight contacts, as well as a contact frequency greater than nine, exerted the largest positive influence on quality of life. These findings not only add to the literature that social networks have a positive relationship on a person’s life, but also suggest that, compared to people of other ages, older adults may need a larger social network. Due to losses of friends and other members of their social networks, it has been argued that older adults should be regularly adding new and younger people to their network. A Stanford study has demonstrated that relationships between older adults and younger people are mutually beneficial. For instance, older adults can provide complementary support to family relationships, or can buttress weak familial interactions. In turn, helping young people provides a sense of purpose and fulfillment for older adults (Carstensen, Freedman, & Larson, 2016). Religious and Spiritual Communities Not all support systems are available to all older people, but one support system that can be a major part of a person’s social network is a religious or spiritual community. Some individuals, because of previous experiences, cultural backgrounds, or personal encounters, tend to rely heavily on religion or spirituality to help them take advantage of the opportunities that aging affords, as well as to adjust to the changes and challenges of aging (Ferraro & Kim, 2014). Older people have been found to be the most prevalent age group attending religious functions (Ferraro & Kim, 2014). This is important, because religious communities can offer support, as well as reduce social isolation. For many older adults, religion and spirituality can give them a sense of purpose in life (Galek, Flannelly, Ellison, Silton, & Jankowski, 2015). Religious communities may give older people opportunities through which they can continue to see themselves as contributing persons, participating in a circle of relationships that enables them to focus beyond themselves. Individuals who are religiously involved tend to have more psychologically close contacts than do others. Many older adults are members of religious or spiritual groups for these reasons, which, as discussed above, can help maintain or improve both their physical and psychological functioning.

PRACTICAL APPLICATION INTRODUCTION

Chapter 9 explores family, friends, and social networks of older adults, with a particular focus on intimate relationships, relationships between older people and their adult children, and the various roles grandparents play in the lives of their grandchildren. It also outlines the responsibilities of family caregivers. Given the toll caregiving can take, this Practical Application highlights the importance of tending to the needs of the caregiver.

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CARING FOR THE CAREGIVER

It is very important for a caregiver of an older person to not only take good care of her or his older loved one, but also take good care of herself or himself. Family caregivers often sacrifice their own work, relationships, recreation, and sleep in an effort to meet the needs of their care recipients. Family caregivers also tend to feel the need to do it all by themselves, often not taking advantage of the formal and informal supports available to them. It is these types of behaviors that put family caregivers at high risk for burnout. In these cases, the old adage, “you can’t give what you don’t have,” truly applies. The good news is that professionals working with family caregivers can help them to avoid burnout by encouraging them to do the following: ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■

Educate themselves about their loved one’s condition Take time off to restore themselves by taking breaks from caregiving Ask others for help and join a caregiver support group Understand and accept their feelings as normal and deal with any feelings of guilt they might be experiencing Maintain meaningful relationships with family and friends Take care of themselves physically, emotionally, and spiritually Adjust their priorities and be realistic in their expectations and commitments Explore available community resources and seek appropriate advice from professionals such as attorneys, financial planners, medical and mental health specialists, clergy, etc. Plan ahead for and utilize possible needed services, such as adult day care, respite, and other long-term care options Celebrate even small successes, and find ways to reward themselves Recognize that no one is perfect, remain flexible, and use humor wherever possible

STUDENT ACTIVITIES 1. Outline the challenges and benefits for older adults of being in an intimate relationship

versus being alone. 2. List three ways adult children can impact, positively or negatively, the health and well-being of their older adult parents. 3. Describe in your own words the evolving relationship between grandparents and their grandchildren. Explain how the opioid crisis, in particular, has affected this relationship. 4. Visit the Alzheimer’s Association website and read the article entitled “Changes to Your Relationship” (www.alz.org/help-support/caregiving/caregiver-health/relationship-changes). Then, outline the ways in which a caregiver’s relationships might change when that person’s spouse or partner has Alzheimer’s disease or dementia and explain how the caregiver can manage or cope with those changes.

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5. Mary, age 77, lives alone in the house where she and her now-deceased husband raised

their only son, Michael. She remains close to a core group of friends, all of whom live within just a few miles of her home. She volunteers at the local library and is actively involved at her church. Michael lives 4 hours away by car and keeps urging her to move into a condo down the road from his house so that he can keep an eye on her and help her if she needs it. He is consulting you, a gerontology professional, about convincing his mother to move. Write an email to him in which you offer your professional opinion. 6. Describe your social network, including what types of friendships you have, what activities you do together, and what supports (if any) you provide to each other. Identify what aspects of your social network you value most and what parts of it you could live without.

SUGGESTED RESOURCES AARP’s Family Caregiving website. (n.d.). Retrieved from https://www.aarp.org/caregiving This website incorporates a plethora of resources for family caregivers—from the basics on starting a family conversation about caregiving to handling financial and legal issues. Connect2Affect. (n.d.). Retrieved from https://connect2affect.org AARP spearheaded Connect2affect to seek solutions to social isolation among older adults. The goal is to create a network of resources that meets the needs of anyone who is isolated or lonely, and that helps build the social connections older adults need to thrive. Family Caregiver Alliance. (n.d.). Retrieved from https://www.caregiver.org The Alliance is a national community-based nonprofit organization. Its mission is to improve the quality of life for caregivers and those for whom they care through information, services, and advocacy. The website is full of information and publications for caregivers, including a care navigator and technical assistance center. Grandfamilies.org. (n.d.). Retrieved from http://www.grandfamilies.org Grandfamilies.org serves as a national legal resource in support of grandfamilies within and outside the child welfare system. Its goals are to educate individuals about state laws, legislation, and policy in support of grandfamilies; to assist interested policymakers, advocates, caregivers, and attorneys in exploring policy options to support relatives and the children in their care; and to provide technical assistance and training. Topics include care and custody, foster care licensing, healthcare, housing, and kinship navigator programs. GRAND. Living the Ageless Life. Retrieved from https://www.grandmagazine.com/grandparents GRAND is a lifestyle magazine for today’s grandparents. In conjunction with its website, it provides grandparents of all ages and in all stages of life, information and inspiration. Standard features include: positive aging, connection generations, and all things GRANDparent: grandchildren gifts, long-distance grandparenting, kinship care and grandparents’ rights, and more.

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Federal Interagency Forum on Aging-Related Statistics. (2016). Older Americans. Key indicators of wellbeing. Washington, DC: U.S. Government Printing Office. Retrieved from https://agingstats.gov/ docs/LatestReport/Older-Americans-2016-Key-Indicators-of-WellBeing.pdf Ferraro, K. F., & Kim, S. (2014). Health benefits of religion among Black and White older adults? Race, religiosity, and C-reactive protein. Social Science and Medicine, 120, 92–99. doi:10.1016/j .socscimed.2014.08.030 Finlay, J., Franke, T., McKay, H., & Sims-Gould, J. (2015). Therapeutic landscapes and well-being in later life: Impacts of blue and green spaces for older adults. Health and Place, 34, 97–106. doi:10.1016/j .healthplace.2015.05.001 Fram, A. (2013, January 14). Old and older: When children of aging parents are elders themselves. The New Jewish Home. Retrieved from https://jewishhome.org/old-and-older-when-children -of-aging-parents-are-elders-themselves Freedman, V. A., & Spillman, B. C. (2014). Disability and care needs among older Americans. The Milbank Quarterly, 92(3), 509–541. doi:10.1111/1468-0009.12076 Galek, K., Flannelly, K. J., Ellison, C. G., Silton, N. R., & Jankowski, K. R. (2015). Religion, meaning and purpose, and mental health. Psychology of Religion and Spirituality, 7(1), 1–12. doi:10.1037/a0037887 Gardiner, C., Geldenhuys, G., & Gott, M. (2018). Interventions to reduce social isolation and loneliness among older people: An integrative review. Health and Social Care in the Community, 26(2), 147–157. doi:10.1111/hsc.12367 Generations United. (2017). State of grandfamilies. In loving arms. Retrieved from https://dl2 .pushbulletusercontent.com/uhDY7UgdGYnOod6G7VFkdKnuzE3yALmr/17-InLovingArms -Grandfamilies.pdf Grossman, M. R., Zak, D. K., & Zelinski, E. M. (2018). Mobile apps for caregivers of older adults: Quantitative content analysis. JMIR mHealth and uHealth, 6(7), e162. doi:10.2196/mhealth.9345 Jayson, S. (2017, March 30). Boomerang seniors: Aging adults move to be near Mom or Dad. USA Today. Retrieved from https://www.usatoday.com/story/news/2017/03/30/kaiser-boomerang-seniors-aging -adults-move-near-mom-dad/99788434 Kasper, J. D., Freedman, V. A., Spillman, B. C., & Wolff, J. L. (2015). The disproportionate impact of dementia on family and unpaid caregiving to older adults. Health Affairs, 34(10), 1642–1649. doi:10.1377/hlthaff.2015.0536 Liu, H., & Waite, L. (2014). Bad marriage, broken heart? Age and gender differences in the link between marital quality and cardiovascular risks among older adults. Journal of Health and Social Behavior, 55, 403–423. doi:10.1177/0022146514556893 MacLeod, S., Musich, S., Hawkins, K., Alsgaard, K., & Wicker, E. R. (2016). The impact of resilience among older adults. Geriatric Nursing, 37(4), 266–272. doi:10.1016/j.gerinurse.2016.02.014 Margelisch, K., Schneewind, K. A., Violette, J., & Perrig-Chiello, P. (2017). Marriage stability, satisfaction and well-being in old age: Variability and continuity in long-term continuously married older persons. Aging and Mental Health, 21(4), 389–398. McKibbin, C., Lee, A., Steinman, B. A., Carrico, C., Bourassa, K., & Slosser, A. (2016, July 10). Health status and social networks as predictors of resilience in older adults residing in rural and remote environments. Journal of Aging Research, 4305894. doi: 10.1155/2016/43055894 McWilliams, S., & Barrett, A. E. (2014). Online dating in middle and later life: Gendered expectations and experiences. Journal of Family Issues, 35(3), 411–436. doi:10.1177/0192513X12468437 Mick, P., Kawachi, I., & Lin, F. R. (2014). The association between hearing loss and social isolation in older adults. Otolaryngology–Head and Neck Surgery, 150(3), 378–384. doi:10.1177/ 0194599813518021 National Alliance for Caregiving. (2015). Caregiving in the U.S. Bethesda, MD: Author. Retrieved from https://www.caregiving.org/caregiving2015 National Institute on Aging. (2016, June). Long-distance caregiving. Twenty questions and answers (NIH Publication No. 16-5496). Retrieved from https://order.nia.nih.gov/sites/default/files/2017-07/L-D -Caregiving_508.pdf Oldenkamp, M., Hagedoorn, M., Slaets, J., Stolk, R., Wittek, R., & Smidt, N. (2016). Subjective burden among spousal and adult-child informal caregivers of older adults: Results from a longitudinal cohort study. BMC Geriatrics, 16(1), 208. doi:10.1186/s12877-016-0387-y

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Pew Research Center. (2013). Dating apps and online dating sites. Retrieved from https://www .pewinternet.org/2013/10/21/part-2-dating-apps-and-online-dating-sites/ Polenick, C. A., Sherman, C. W., Birditt, K. S., Zarit, S. H., & Kales, H. C. (2018). Purpose in life among family care partners managing dementia: Links to caregiving gains. The Gerontologist. Advance online publication. doi:10.1093/geront/gny063 Rafnsson, S. B., Shankar, A., & Steptoe, A. (2015). Longitudinal influences of social network characteristics on subjective well-being of older adults: Findings from the ELSA study. Journal of Aging and Health, 27(5), 919–934. doi:10.1177/0898264315572111 Rawlins, W. (2017). Friendship matters. New York, NY: Routledge. Richard, A., Rohrmann, S., Vandeleur, C. L., Schmid, M., Barth, J., & Eichholzer, M. (2017). Loneliness is adversely associated with physical and mental health and lifestyle factors: Results from a Swiss national survey. PLosONE, 12(7), e0181442. doi:10.1371/journal.pone.0181442 Rook, K. S. (2015). Social networks in later life: Weighing positive and negative effects on health and well-being. Current Directions in Psychological Science, 24(1), 45–51. doi:10.1177/0963721414551364 Rook, K. S., & Charles, S. T. (2017). Close social ties and health in later life: Strengths and vulnerabilities. American Psychologist, 72(6), 567–577. Shankar, A., McMunn, A., Demakakos, P., Hamer, M., & Steptoe, A. (2017). Social isolation and loneliness: Prospective associations with functional status in older adults. Health Psychology, 36(2), 179–187. doi:10.1037/hea0000437 Singer, J., & Levine, S. R. (2016). Stroke and technology: Prescribing mHealth apps for healthcare providers, patients and caregivers: A brief, selected reviews. Future Neurology, 11(2), 109–112. doi:10.2217/fnl-2016-0005 Singer, J., Weingast, S., Stefanov, D., Gilles, N., Faysel, M., Girouard, S., .  .  . Levine, S. R. (2018). Developing a mobile application for stroke caregivers: A pilot national survey. International Journal of Medical Informatics, 7(1), 1–19. doi:10.7309/jmtm.7.2.5 Smith, E. J., Marcum, C. S., Boessen, A., Almquist, Z. W., Hipp, J. R., Nagle, N. N., & Butts, C. T. (2015). The relationship of age to personal network size, relational multiplexity, and proximity to alters in the western United States. Journals of Gerontology Series B: Psychological Sciences and Social Sciences, 70(1), 91–99. doi:10.1093/geronb/gbu142 Stepler, R. (2017). Led by Baby Boomers, divorce rates climb for America’s 50+ population. Washington, DC: Pew Research Center Fact Tank. Retrieved from http://www.pewresearch.org/fact-tank/2017/03/09/ led-by-baby-boomers-divorce-rates-climb-for-americas-50-population Stickley, A., & Koyanagi, A. (2016). Loneliness, common mental disorders and suicidal behavior: Findings from a general population survey. Journal of Affective Disorders, 197, 81–87. doi:10.1016/ j.jad.2016.02.054 Thoits, P. A. (2010). Stress and health: Major findings and policy implications. Journal of Health and Social Behavior, 51, S41–S53. doi:10.1177/0022146510383499 Waite, L. J., & Gallagher, M. (2000). The case for marriage: Why married people are happier, healthier, and better off financially. New York, NY: Doubleday. Warren, E., & Tyagi, A. W. (2016). The two-income trap: Why middle-class parents are (still) going broke. New York, NY: Basic Books. Williams, K., & Umberson, D. (2004). Marital status, marital transitions, and health: A gendered life course perspective. Journal of Health and Social Behavior, 45, 81–98. doi:10.1177/002214650404500106 Zarit, S. H., & Savla, J. (2016). Caregivers and stress. In G. Fink (Ed.), Stress: Concepts, cognition, emotion, and behavior (pp. 339–344). Cambridge, MA: Academic Press. Zarit, S. H., & Zarit, J. M. (2015). Family caregiving. In B. A. Bensadon & C. E. Schmidt (Eds.), Psychology and geriatrics: Integrated care for an aging population (pp. 21–43). Cambridge, MA: Academic Press. Zhou, J., Mao, W., Lee, Y., & Chi, I. (2017). The impact of caring for grandchildren on grandparents’ physical health outcomes: The role of intergenerational support. Research on Aging, 39(5), 612–634. doi:10.1177/0164027515623332

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PART IV FORMAL SUPPORT SYSTEMS

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CHAPTER

10

O LD E R ADULT S G I V I N G A N D REC E I V I N G S UP P O R T

LEARNING OBJECTIVES • Outline the many ways that older adults contribute to their communities. • Discuss the opportunities currently available for older adults to volunteer in their communities. • List the components of the National Aging Services Network. • Summarize the types of services and programs, offered primarily through the Aging Services Network, that focus specifically on older Americans. • Explain why on the one hand, services may be underused, and on the other, ways in which programs stretch resources to reach more older adults than could otherwise be served.

VALUING COMMUNITY-BASED SUPPORT Margaret Reilly, 89, is a walking testimonial for the Gulfport Multipurpose Senior Center. “It’s the spice of my life,” she says. “Whatever you want to do is there.” Margaret should know since she has volunteered at the Center for more than 25 years . . .. Now, she volunteers 2 hours a day, . . . plays canasta, visits the Fitness Center twice a week and participates in the Wii Fit group Thursday afternoons. “There’s no reason for anybody to feel lonely,” Margaret says. “Everyone is so nice and so knowledgeable. I’ve learned a great deal being involved at the Senior Center.” —Oatley, 2011 (continued next page )

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Tana has been taking care of herself since she left home at 16. She’s worked as a telephone operator, a riveter, a civics teacher, and a museum docent. She has built a strong, intergenerational community and she has no intention of leaving her apartment for a nursing home just because she’s “98 years young.” With a little daily assistance from Mystic Valley Elder Services, such as help with dressing and personal care to get ready for the day, assistance with grocery shopping, and transportation to medical appointments, Tana stays independent and happy in her Stoneham home. She even hosts her grandniece for sleepovers once a month, a special treat for them both that wouldn’t be possible if Tana lived in a nursing home. —Mystic Valley Elder Services, 2017 Tim is an RSVP volunteer in Minnesota. Whether Tim is tutoring in the classroom, sending kids home on a positive note via bus duty, or simply correcting student’s papers, he instills a positive learning experience for all students. This fall will mark the start of Tim’s fourth year as a volunteer at Kennedy Elementary School in St. Joseph where he has served over 3,100 hours in multiple fourth-grade classrooms. During the school year, Tim spends all day, every day offering a helping hand to students. Tim said he enjoys working with the kids individually and as a group, and he says, “I love the satisfaction of seeing the kids when the lights go on in their eyes and they just get the idea.” When asking Tim his favorite part about volunteering, he said he enjoys joking with the students as much as he enjoys working with them on scholarly topics. Tim stated he continues to volunteer because he enjoys creating the connections with the students. “I have made many bonds with children in the classroom that I will never, ever forget” Tim said. —Minnesota Senior Corps, www.mnseniorcorps.org/volunteering/ why/stories/view-story.aspx?StoryId=1531

COMMUNITY SERVICES AND SUPPORT Everyone at every stage of their lives benefits from community services and support. Different life stages call for different contributions. For example, young people and their families are the primary beneficiaries of support for education. Those in the workforce and their families benefit from the building and maintenance of roads and highways and public transit. They also benefit from unemployment benefits, which keep many families afloat, especially during recessions or downturns in the economy. And, with the growing number of floods, fires, and winter storms throughout the country, where would families be if there was no disaster relief? Homeowners benefit from being able to claim a tax deduction for the interest they pay on their mortgages. All citizens benefit from fire protection and police services. Nonprofit organizations often contribute to these efforts, but they do not, and could not, come close to funding all the needs that a society has in these domains. It is from this perspective that this chapter examines the range of community services and support offered by and for older Americans.

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THE MANY WAYS OLDER ADULTS CONTRIBUTE TO THEIR COMMUNITIES Whenever older adults and services and support are mentioned in the same breath, thoughts immediately turn to what is available for them. Many older adults certainly benefit from the services that their communities can provide for them. Yet, with their life-time experience and knowledge, older adults have much to give, too. Everyone benefits when they have reliable and safe ways to access opportunities to contribute to their communities. Some of these opportunities already exist, and examples of them are presented in the following, but there is much that can be done to create more. Wiles and Jayasinha (2013) have identified four forms that older adults’ contributions to their communities take: volunteering, activism, advocacy, and nurturing.

Older Adults’ Contributions as Volunteers in Their Communities More than 11 million older Americans volunteered in 2015, according to the most recent available data on volunteering in the United States (U.S. Bureau of Labor Statistics, 2016). And, when they volunteer, they devote almost twice as many hours to it as do younger adults, an average of 94 hours per year. The net result is that older adults contribute a total of over 1.3 billion hours per year. Presented in what follows are a few examples of a wide range of different contributions older adults make to their communities through their volunteer work. These contributions are tracked because they are overseen by organizations or agencies (primarily nonprofits and government) and most have some reporting requirements. Senior Corps Programs Every community has lots of possible volunteer opportunities. For older adults, Senior Corps provides one means of easily accessing and exploring options that are vetted by caring professionals. The options include some perks too, such as training and sometimes reimbursement for expenses such as transportation to volunteer sites. Senior Corps is a program of the Corporation for National and Community Service, an independent federal agency created in 1993 to connect Americans of all ages and backgrounds with opportunities to give back to their communities and their nation. Senior Corps incorporates three long-standing programs that link Americans aged 55 and over with the people and organizations in their communities that need them most. The three programs are RSVP, the Foster Grandparent Program, and the Senior Companion Program. RSVP Established in 1971 and now one of the largest senior volunteer organizations in the nation, RSVP is open to all people ages 55 and over. It offers a variety of opportunities for volunteers to share their knowledge, experiences, abilities, and skills for the betterment of their communities and themselves. These volunteers serve in many areas including youth counseling, literacy enhancement, refugee assistance, consumer education, crime prevention, housing rehabilitation, after-school programs, and respite care for older adults. Commitments range from a few hours to 40 hours per week. Volunteers choose how, where, and how often they want to serve. There are no monetary incentives, but sponsoring organizations may reimburse them for costs incurred during their service, including meals and transportation.

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The Foster Grandparent Program The Foster Grandparent Program, which began in 1965, provides loving and experienced tutors and mentors to children and youth with special needs that limit their academic, social, or emotional development. Volunteers must be 55 years of age or older. Working one-on-one and serving between 15 and 40 hours a week, Foster Grandparents provide support in schools, hospitals, drug treatment centers, correctional institutions, and child care centers. Among other activities, they review schoolwork, reinforce values, and care for premature infants and children with disabilities. Those who meet low-income guidelines can receive a small stipend. All volunteers in this program receive monthly training, reimbursement for transportation costs, and accident and liability insurance and meals while on duty. The Senior Companion Program The Senior Companion Program, which began in 1974, helps older people who are frail and other adults maintain independence, primarily in the clients’ own homes, and enables their clients to return to home care settings after hospitalization or rehabilitation. Volunteers must be 55 years of age or over. Senior companions serve between 15 and 40 hours a week and typically assist between two and four clients. Among other activities, they help with daily living tasks, such as grocery shopping; provide friendship and companionship; alert healthcare professionals and family members to potential problems; and provide respite to family caregivers. Those who meet low-income guidelines may receive a small stipend. All Senior Companions receive monthly training, reimbursement for transportation costs, and accident and liability insurance and meals while on duty. Through these three formal volunteer programs, in 2016, 270,000 older adult volunteers contributed 79  million hours providing service to more than 1.1  million clients. The Independent Sector, a coalition of charities, foundations, corporations, and individuals (independentsector.org/ volunteer_time) estimated the value of volunteer time in 2016 at $24.14 per hour, making older adults’ volunteer service worth $1.9 billion to the U.S. economy. Table 10.1 gives details on the number of volunteers in each program, the number of hours served, and the number of clients served. AARP Foundation’s Experience Corps Begun in 1995, the AARP Foundation’s Experience Corps is a tutoring and mentoring program for elementary school children, kindergarten through third grade. Its focus is on reading skills and relationship building. More than 2,000 volunteers age 50 and over have been trained to work TABLE 10.1 Senior Corps Programs: Number of Volunteers, Hours Served, and Clients Served RETIRED AND SENIOR VOLUNTEER PROGRAM

FOSTER GRANDPARENTS PROGRAM

SENIOR COMPANIONS PROGRAM

Number of volunteers

232,400

25,200

12,200

Hours served

46 million

23 million

10 million

Clients served

875,000

189,100

49,650

SOURCE: Corporation for National & Community Service. (2017). Senior Corps fact sheet. Retrieved from https:// www.nationalservice.gov/sites/default/files/documents/CNCS-Fact-Sheet-2017-SeniorCorps_2.pdf.

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with 30,000 students in more than 20 cities in the United States. Volunteers devote between 6 and 15 hours per week at schools participating in the program. In an analysis of the effectiveness of the program, researchers demonstrated that students who began the school year as very poor readers made significant improvements in their reading skills over the course of the year as a consequence of one session a week with a trained Experience Corps volunteer (Morrow-Howell, Jonson-Reid, McCrary, Lee, & Spitznagel, 2009). SCORE: Counselors to America’s Small Businesses SCORE, once named the Service Corps of Retired Executives, is a nonprofit network of more than 10,000 business professionals who volunteer to mentor individuals who want to develop new businesses or increase the success of their current businesses (www.score.org). Although it has expanded its cadre of volunteers, as its original name implies, many of the organization’s mentors are older professionals who have retired. SCORE has helped more than 10 million entrepreneurs since its establishment in 1964. In 2016, it donated 1 million hours to help entrepreneurs start 5,400 new businesses, resulting in the creation of over 78,000 new jobs.

Older Adults’ Contributions as Activists, Advocates, and Nurturers in Their Communities Although many of the civic contributions that older adults make through their activism, advocacy, and nurturing are unique to their communities, arising in response to specific needs and interests of the citizens within them, others have a broader reach. Activism fits that bill because it may be directed at global, national, regional, or local issues; it may even be centered in a neighborhood. Perhaps one of the most renowned older activists was Maggie Kuhn, who founded the Gray Panthers in 1970 to fight for human rights, for economic and social justice, and against age discrimination, after she was forced to retire at what was then the mandatory retirement age of 65. The motto of the Gray Panthers was “Age and Youth in Action,” reflecting the group’s interest in intergenerational activism. A more localized example is Ann Stewart, an 89-year-old Bostonian, who along with others she recruited, took to the streets in 2013 to protest a doubling of fares for paratransit riders. The net result of her activism—the fares were lowered instead! And there are so many more examples. What are some examples in your community? Networking and raising awareness of issues are key components of advocacy groups. Let us take Gray is Green, which you most likely have never heard of. It is an online group of environmentally conscious older adults who focus on ecological sustainability, economic justice, and social justice. They call themselves Gray-Greens! Their website features ideas, resources, a blog, and a speaker’s bureau, with the goals of engaging older adults in advocating for good public policies, serving as role models and mentors for young people, and making personal decisions that minimize their ecological footprint. As another example, most states have a Silver-Haired Legislature, which prioritizes issues that are important to older people and then enlists support throughout their communities to advocate for bills and influence decisions in their state legislatures. Nurturing relationships, which involves providing mutually beneficial social or other support within communities, is another way that older adults contribute their talents and skills. These relationships are in addition to the personal ones they have with family and friends. For example, in Ojai, California, older adults signed up for a group whose goal was to eliminate graffiti in their community. Available 24/7, callers reporting graffiti would see a team of older adults go out and remove or paint over it immediately. Neighborhood Service Exchange programs are popping up around the country, and older adults who can donate their time and skills are getting on board. While the

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exchanges, or swaps, may be direct between two neighbors, they are often organized in such a way that people donating services earn hours of services which they can then use at a later date. The Athens Community Council on Aging in Georgia has two community gardens where older adults do the gardening and produce more than 400 pounds of food. In addition to providing nutritious food, the social interaction that the gardening engenders between neighbors is also important. One other major way that older Americans contribute to their communities is through philanthropy. The majority of philanthropic donations come from older Americans. Of course, donors must have sufficient financial resources to be able to give to others. It also takes time and planning to donate to nonprofit organizations and causes about which donors care, and gifts are often given over a period of years. Although most Americans are not wealthy, others have had the kind of economic, educational, and social environments that have provided them with a good living and the ability to accumulate substantial assets over their lifetimes. For those who have been able to accumulate wealth, then, it is not surprising that charitable giving increases with age. According to the most recently available data, the giving rate of households headed by an individual age 65 or older is 73%, compared with 57% for those age 41 to 64, and only 38% for those age 40 and under (Philanthropy Panel Study, 2017). And, the average amount given by older people ($1,200) is also higher—30% higher than for those age 41 to 64 ($900), and more than twice as much as the average amount given by those age 40 and under ($500). The bottom line is that older Americans provide much in the way of support and contributions to their communities in many different ways. While not all have the wherewithal to be able to contribute, whether due to their economic situation, their access to opportunities, or other barriers, their giving should not be overlooked, and our society should work to make it possible for all those who would like to contribute to do so.

PROGRAMS AND SUPPORT FOR OLDER AMERICANS Having looked at the support the older Americans provide, we now turn to the support that is available for them. Two basic types of programs and services benefit older people in America: ones that are designed for people of any age and ones that are designed specifically for older people. An example of the first type is the Supplemental Nutrition Assistance Program (SNAP, previously called the “Food Stamp” Program), originally established to alleviate malnutrition and hunger among low-income persons by increasing their food-purchasing power. Any person can qualify if he or she meets income and asset guidelines. Relatively early in its history, the nation collectively decided that it was not a good thing to have starving people. Emergency aid to the poor usually included some type of starvation prevention, often in the form of distribution of excess commodities such as flour, peanut butter, eggs, and powdered milk. Following an eight-county experimental antihunger program in 1961, the Food Stamp Act was passed in 1964, making it available to all states as an option to giving out food commodities. In 2016, 44.3 million Americans were receiving SNAP benefits, of whom nearly half (45%) were children and 4.1 million (9%) were aged 60 or older (Gray & Cunnyngham, 2016). Most of the older people (76%) who do receive SNAP benefits live alone and receive an average of only $114 per month in SNAP benefits. Programs of the second type are designed specifically for older Americans. These programs arose out of collective decisions that it was in the best interests of the nation, as well as older people and their families, to design and develop programs and services specifically to meet some of the basic needs of older people and to offer them opportunities to serve their communities. From the beginning of the United States under its Constitution in 1789, it took a long time to come to a collective decision to organize a part of government to specifically assist older persons, particularly on the national level.

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Remember, it was not until 1935 that Social Security was enacted into law. Before that time, in cases of abject poverty the welfare of older people was the responsibility of families, and to some extent local governments. Of course, there were not nearly as many older people then as there are today. Not until 1965, when the Older Americans Act (OAA) was passed, did we see a systematic, organized approach to providing services and programs on a nationwide basis to enhance the lives of older people.

THE OLDER AMERICANS ACT The Older Americans Act (OAA) was enacted in 1965 to address the social service needs of older people. The Act grew out of the deliberations of the first White House Conference on Aging, which was held in 1961, and it continues to be the primary source of support for critical services to keep older Americans healthy and independent—services such as meals, job training, health promotion, caregiver support, transportation, and more. OAA’s mission is broad: to help older people maintain maximum independence in their homes and communities, to promote a continuum of care for older people who are vulnerable, and to avoid unnecessary and costly institutionalization. Since its initial passage, the Act has been amended by Congress many times with targeted programs being added to respond to specific needs of the older population. All people aged 60 and over—more than 68 million people in 2016—are eligible to receive services provided through OAA funding, regardless of income or need. To date, Congress has resisted any attempts to make the OAA programs and services means-tested, in other words, to require proof that income is low enough or that one has a demonstrated need. And yet, despite the broad sweep of services included in its mission, the OAA’s reach is constrained by modest resources.

Objectives of the Older Americans Act The language of the OAA concerning the objectives for older Americans provides insight into the societal decision that resulted in the legislation. It states: The Congress hereby finds and declares that, in keeping with the traditional American concept of the inherent dignity of the individual in our democratic society, the older people of our Nation are entitled to, and it is the joint and several duty and responsibility of the governments of the United States, of the several states and their political subdivisions, and of Indian tribes to assist our older people to secure equal opportunity to the full and free enjoyment of the following objectives: 1. 2. 3.

4.

An adequate income in retirement in accordance with the American standard of living The best possible physical and mental health which science can make available and without regard to economic status Obtaining and maintaining suitable housing, independently selected, designed and located with reference to special needs and available at costs which older citizens can afford Full restorative services for those who require institutional care, and a comprehensive array of community-based, long-term care services adequate to appropriately sustain older people in their communities and in their homes, including support to family members and other persons providing voluntary care to older individuals needing long-term care services

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5. 6. 7. 8.

9. 10.

Opportunity for employment with no discriminatory personnel practices due to age Retirement in health, honor, dignity—after years of contribution to the economy Participating in and contributing to meaningful activity within the widest range of civic, cultural, educational and training, and recreational opportunities Efficient community services, including access to low-cost transportation, which provide a choice in supported living arrangements and social assistance in a coordinated manner and which are readily available when needed, with emphasis on maintaining a continuum of care for vulnerable older individuals Immediate benefit from proven research knowledge, which can sustain and improve health and happiness Freedom, independence, and the free exercise of individual initiative in planning and managing their own lives, full participation in the planning and operation of community-based services and programs provided for their benefit, and protection against abuse, neglect, and exploitation. (Title I, Sec. 101, Older Americans Act of 1965, as amended in 2016, Public Law 114–144)

Structure to Implement the Older Americans Act To achieve the objectives of the OAA and to provide the services that result from them, the Congress established the Administration on Aging (AoA). The AoA is now housed under the Administration on Community Living, which is a part of the Department of Health and Human Services. The AoA administers most of the programs that come under the OAA and is the primary federal agency to advocate for older persons. When it comes to policy and program decisions, an important idea in developing OAA’s framework was that decentralization of authority and the use of local control would make a more effective and responsive service system for those receiving services at the local level. Thus, The AoA oversees an Aging Services Network (see Figure 10.1) consisting of 56 State Units on Aging, 622 Area Agencies on Aging (established under OAA in 1973), and 256 Tribal Organizations (established under OAA in 1978). Approximately 20,000 local organizations provide services through all the sectors of the Aging Network. The 56 State Units on Aging (state agencies), which are found in each of the states, the District of Columbia, Puerto Rico, American Samoa, Guam, the Northern Mariana Islands, and the Virgin Islands, are awarded federal funds to implement their state’s plans on aging. The state agencies can be independent units of state government—for example, a state may have a Department of Aging Services—or part of an existing state agency—for example, one of a state’s human service departments. However constructed, each state office is responsible for developing a statewide plan to serve older people, and these plans are approved by the AoA. The AoA then distributes funding for programs and services through grants to the state agencies. Through these grants, states receive a set amount of funding and are given the flexibility to design and operate OAA programs within federal guidelines. Grant amounts are generally based on funding formulas that reflect the size of the population of people aged 60 and over in the state. Area Agencies on Aging (AAA, referred to as triple A’s) are offices established by the state units. At the discretion of the state, an area agency can be a unit of county, city, or town government. It can even be a private, nonprofit agency. Each AAA develops its own 2-, 3-, or 4-year plan to facilitate and support the development of programs to address the needs of older adults

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U.S. Department of Health and Human Services

Administration for Community Living

Administration on Aging

State Units on Aging (N = 56)

Tribal Organizations (N = 256)

Area Agencies on Aging (N = 622)

Local Service Provider Organizations

Consumers

FIGURE 10.1 U.S. National Aging Services Network. SOURCE: National Association of Area Agencies on Aging. (2017). National survey of area agencies on aging. Serving America’s older adults. Retrieved from https://www.n4a.org/Files/2017%20AAA%20Survey%20Report/ AAANationalSurvey_web.pdf

within its defined geographical region. State units approve each AAA’s plans and then allocate funding to their area agencies. State and local agencies are responsible for planning, developing, and coordinating an array of programs and services within each state. States also provide services to older adults through other funding, such as Medicaid, and through separate programs and departments. Local AAAs do not usually provide services directly to their clients unless it is absolutely necessary to ensure an adequate supply of such services. Instead, they contract with local providers for services in their areas. A few states (Nevada is one) have no AAAs, and so their state units allocate funds directly to local providers. The AoA also awards grants to tribal organizations to provide supportive and nutrition services that maintain the unique cultural and other needs of older Native Americans. Two Native American Resource Centers, one in North Dakota and one in Colorado, address issues related to community-based long-term care among Indian communities on reservations.

Older Americans Act: Seven Titles To implement its objectives, the OAA authorizes seven “titles” that include a series of formula-based and discretionary grants. Each title is simply a subsection of the Act. All programs are administered at the federal level by the Administration on Aging, except for Title V, the Community

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Service Senior Employment Program, which is administered by the U.S. Department of Labor. The seven titles of the Older Americans Act are: ■ ■ ■ ■ ■ ■ ■

Title I: Declaration of Objectives; Definitions Title II: Administration on Aging (AoA) Title III: Grants for States and Community Programs on Aging Title IV: Activities for Health, Independence, and Longevity Title V: Community Service Senior Employment Program Title VI: Grants for Services for Native Americans Title VII: Vulnerable Elder Rights Protection Activities

Older Americans Act Title I: Declaration of Objectives; Definitions Title I outlines the underlying philosophy of the OAA legislation and its objectives. It also provides for definitions that apply to the act. In 1973, the age of the target population to be served was changed from the original age of 65 to 60. Total funding for the Older Americans Act in fiscal year 2016 was $1.915 billion, well under 1% of the total federal budget for that year (Colello & Napili, 2016). Table 10.2 shows the distribution of this funding for FY2016 among the titles of the Act.

Older Americans Act Title II: Administration on Aging Title II established the AoA as the chief federal agency to advocate for older persons and sets out the responsibilities of the AoA and the Assistant Secretary for Aging. The Assistant Secretary is

TABLE 10.2 Older Americans Act Funding for Fiscal Year 2016, by Title

TITLE

SERVICES

PERCENTAGE OF OAA BUDGET

AMOUNT (MILLIONS)

II

Administration on Aging

2.1%

$40.1

III

State and Community Programs

71.0%

$1,353.0

IV

Health, Independence, and Longevity

0.9%

$16.7

V

Community Service Employment

22.7%

$434.4

VI

Native American Services

2.0%

$38.7

VII

Vulnerable Elder Rights Protection

1.1%

$20.7

SOURCE: Colello, K. J., & Napili, A. (2016, March). Older Americans act: Background and overview (Congressional Research Service, R43414). Retrieved from https://fas.org/sgp/crs/misc/R43414.pdf

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appointed by the President, with the advice and consent of the Senate. Funding authorized under Title II, which comprised 2.1% of the OAA’s budget in fiscal year 2016, goes toward program administration and Aging Network support activities, which include the following: ■

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Eldercare Locator, a national public service that helps identify community resources for older people and their families (more information about this service is found later in this chapter) Pension Counseling and Information Program funds six regional counseling projects that help older Americans learn about and receive the retirement benefits to which they are entitled Senior Medicare Patrol Program funds projects that educate older Americans and their families to recognize and report Medicare and Medicaid fraud National Long-Term Care Ombudsman Resource Center provides training and technical assistance to state and local ombudsmen who handle complaints and represent the interests of residents of long-term care facilities National Center on Elder Abuse provides information to the public and professionals, and provides training and technical assistance to state elder abuse agencies and to community-based organizations National Center for Benefits Outreach and Enrollment helps to enroll seniors and persons with disabilities into federal and state benefits programs for which they are eligible but not yet enrolled Health and Long-Term Care Programs Initiative helps older Americans plan for long-term care services and supports so that they can maintain their independence in the community

Having programs and services does little good if the intended recipients do not know about them or do not know how to access them. As such, information and assistance become community-based social services in their own right. In 1991, the National Association of Area Agencies on Aging (n4a), with funding from the AoA, established Eldercare Locator, a nationwide call center and website that connects older Americans and their families, friends, and caregivers with trustworthy information on services in their area for older adults. The goal of Eldercare Locator is to provide users with information and resources that will help older people live independently and safely in their homes and communities for as long as possible. With that in mind, information is provided about such resources as meals, caregiver training and education, adult day care centers, legal assistance, home health services, and transportation services. The call center, toll-free 1-800-677-1116, is available between 9:00 a.m. and 8:00 p.m., Eastern Standard Time, Monday through Friday. Language interpretation service for 150 languages is also available during these business hours. Messages left with the Eldercare Locator are returned the next business day. Eldercare Locator can also be emailed at [email protected]. The website (www.eldercare.gov) allows users to search for services by zip code, by city and state, or by topic, or engage in an online chat with an information specialist during regular business hours. The Eldercare Locator taps into an extensive network of organizations that are familiar with state and local community resources. In 2016, Eldercare Locator received more than 300,000 requests via phone, email, and online chats for assistance from consumers across all states, the District of Columbia, and most U.S. territories, an average of almost 1,300 inquiries per day (U.S. Administration on Aging, 2017). Most

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of these contacts—97%—are via phone. In addition, the website receives an average of 40,000 visits per month. It is important to note that this service is invaluable to the vast majority of those consumers who contact Eldercare Locator because they do not know where else to turn for assistance. Ninety-eight percent of callers report that their questions are fully answered by Eldercare Locator staff. The top five requests in 2016 were for the following: ■ ■ ■ ■ ■

Transportation: 21%, most for medical appointments Home and community-based services: 20%, most for personal care such as bathing and dressing, or chores, such as house cleaning and cooking Housing options: 9%, most for independent housing or home repairs Medical services and supplies: 9%, most for general financial assistance, dental care, or prescription assistance Health insurance information: 6%, most for claims or bills

Almost half of the funding for Title II goes toward health and long-term care programs, which include Aging and Disability Resource Centers (ADRCs). ADRCs are a joint initiative of the Administration on Aging and the Centers for Medicare and Medicaid Services. They were designed to be single points of entry (also referred to as No Wrong Door programs) to provide consumers with objective and trusted sources of information and streamlined access to home- and community-based services and supports. The goal of ADRCs is to help older people and those of any age with disabilities, as well as their caregivers, to continue to live in their own homes. There are 525 ADRC sites, in 53 states and territories.

Older Americans Act Title III: Grants for State and Community Programs Most of OAA’s funding (71% in fiscal year 2016) goes toward Title III, which provides funds for supportive services (Part B), nutrition services (Part C), health promotion (Part D), and family caregiver support (Part E), all with the goal of helping older people remain independent in their own homes and communities. (Part A addresses the purpose and administration for Title III.) Title III-B: Supportive Services Services funded by Title III Part B include transportation, senior center activities, home care for those who have difficulty performing daily activities such as bathing, case management, and adult day care. Assuring the availability of transportation options for seniors is critical in maintaining quality of life for older Americans. Concerns about older drivers’ safety, coupled with the need to maintain mobility in the community, are responsible for much of the growing interest in transportation options. Among the ideas that communities are implementing are subsidized taxicab fares, community shuttle buses, and volunteer driver programs. A nonprofit organization dedicated to fostering “new ideas and options to enhance mobility and transportation for today’s and tomorrow’s older population,” the Beverly Foundation developed five criteria for evaluating the extent to which transportation options are senior friendly. Known as the Five A’s of Senior Friendly Transportation, they are availability, accessibility, acceptability, affordability, and adaptability. Table 10.3 provides a brief description of each of these criteria.

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TABLE 10.3 The 5 A’s of Senior-Friendly Transportation CRITERION

DESCRIPTION

Availability

Transportation exists and is available when needed.

Accessibility

Transportation can be reached and used (bus stairs can be negotiated, bus seats are high enough, bus stop is readable, vehicle comes to the door).

Acceptability

Standards relate to conditions such as cleanliness of vehicle, safety (stops located in safe areas), and user-friendliness (courteous, helpful drivers).

Affordability

Costs (fees) are affordable, comparable to or less than driving a car, and vouchers or coupons help defray out-of-pocket expenses.

Adaptability

Transportation can be modified or adjusted to meet special needs (wheelchair can be accommodated, trip chaining is possible).

SOURCE: Kerschner, H., & Harris, J. (2007, March/April). Better options for older adults. Public Roads, 70(5). Retrieved from https://www.fhwa.dot.gov/publications/publicroads/07mar/03.cfm

Multipurpose Senior Centers Contrary to popular misconceptions, senior centers are not places where older people can live, such as assisted living facilities or nursing homes. Instead, multipurpose senior centers are usually community focal points for older people to access resources and services funded through the OAA. Although the history of a center for older people goes back to a program developed in New York City in 1943, senior centers were not funded through the OAA until 1975. Now, nearly 11,000 senior centers serve 1 million older adults every day (National Council on Aging, 2015). Senior center programming is usually of two types: services, and recreation and education. Typical services, in addition to meals, are counseling and referral; assistance with housing and employment; health programs, including screening clinics and health education; legal and income counseling; friendly visitor outreach programs; homemaker assistance; telephone reassurance; home repair programs; and transportation assistance. In Malden, Massachusetts, for example, the Mystic Valley senior center offers programs that benefit over 50,000 older adults and adults with disabilities throughout nine communities in the surrounding area. In 2016 to 2017, the center connected almost 8,000 people with home care assistance and delivered over half a million meals to approximately 4,000 people, helping them all remain in their own homes (Mystic Valley Elder Services, 2017). Senior centers also provide a place where seniors can gather for social interaction and recreational and educational activities, which may include physical activities; arts and crafts; nature, science, and outdoor life; drama, music, and dance; table games; excursions; and, speakers, lectures, and forums. Activities are usually designed to appeal to both men and women. Often led by the active involvement of older adults in their communities, senior centers are evolving and incorporating programs to appeal to Baby Boomers, while continuing to serve present users. One new trend is to avoid the word “senior” in their names. For example, Mather’s— More Than A Café, with three locations in Chicago, delivers free tips by email and has Facebook and Twitter accounts, in addition to offering meals, educational programs, and leisure activities.

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The Summit, in Grand Prairie, Texas focuses on exercise and wellness. It reaches out to the over 50 crowd with a cappuccino and wine bar, and outdoor concerts and dances. Home-Based Services Perhaps the most important services that enable older people to remain in their own homes and communities are in-home services. Too often admission to nursing homes, chronic-care hospitals, and other long-term facilities is used to meet the needs of impaired older individuals when appropriate assistance at home, or in the home of an adult child or friend, would be a better solution. Not only is staying at home usually much more cost effective, but most older people also want to remain in the familiar surroundings of their own home. In-home services may be provided by medical professionals, home health aides, or personal care aides. Nurses, physicians, and physical therapists, for example, can provide medical care. Home health aides are trained to provide routine healthcare such as changing bandages and dressing wounds, applying topical medications, and monitoring or reporting changes in health status to a supervising medical professional. They may also provide personal care such as bathing and dressing and, in some states, they may be able to administer medication. Personal care aides may assist with housekeeping (e.g., making beds, laundry), preparing meals, shopping, and running errands. Being able to afford in-home services is a major problem for many older persons. Title III provides some support for in-home services through local Area Agencies on Aging, or state units, with the primary purpose of keeping older people in their own homes and out of long-term care institutions for as long as possible. In-home services may also be covered by Medicare, Medicaid, and client fees. Medicare covers short-term health-related services and clients who meet Medicare eligibility requirements (Chapter 12, Medicare, Medicaid, and Medications, provides information about Medicare coverage for in-home services). Medicaid can also be used to pay for in-home services when the client and the service meet Medicaid eligibility requirements, which include strict income guidelines that are dictated by state governments. Finally, there are proprietary (for-profit) in-home service agencies that offer services for fees paid by the clients. AARP has excellent information on caregiving, which includes guidelines for hiring a home care worker; they are available online through AARP’s website (www.aarp.org/caregiving/care-guides/at-home/#). Case Management Services Case management services include assessing an individual’s needs, developing a plan of care, locating appropriate services, coordinating services, authorizing and arranging for services, monitoring services, and monitoring and reassessing needs. These services are usually carried out by a qualified person, often a nurse or social worker, or team of healthcare professionals. In the case management process, the case managers can help determine eligibility for various services as well as assist with applications for government-sponsored programs. Case management services are becoming increasingly critical as service delivery systems become more complex and the number of older people who need in-home services continues to grow. Many family caregivers are hesitant to call someone into their home to help with this kind of assessment. Most think they know what needs to be done, and most want to do what they deem needs to be done by themselves. Many think it is their duty and their responsibility, but deep down they also know that they cannot do everything. They cannot continue to give around-the-clock care and continually worry about older parents who are frail, without paying the consequences in terms of personal health, family unity, and emotional well-being. After a case manager’s initial assessment, there is usually no obligation—suggestions may be followed, rejected, or modified.

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Using any of the services and following some of the suggestions for help do not mean that caregivers are abandoning their responsibilities to their loved ones. It means that they are wise enough to know that they cannot do everything by themselves all the time. By using a case management approach, family caregivers can plug in some assistance so that they can continue to be effective caregivers. It means that they can use their own resources in more effective ways. Case management services can provide adult children who live far away from their parents the opportunity to assist in the care of their older parents when needed. Aging Life Care professionals (formerly known as “geriatric care managers”) are educated and experienced in health and human services so they can assist and advocate for older adults and their loved ones in a comprehensive set of areas. They can offer their experience in health and disability (e.g., navigating the healthcare system), finances (e.g., assisting with bill paying), housing (e.g., finding appropriate residential options), family issues (e.g., problem-solving with families who live far from their loved ones), local resources (e.g., locating and accessing services), legal issues (e.g., referring to specially trained attorneys), and crisis intervention (e.g., helping when emergencies occur). The Aging Life Care Association has a website that features many online resources, as well as a way to locate such professionals throughout the United States and Canada (www.aginglifecare.org). Some agencies, such as the Jewish Family and Children’s Agencies, have also developed an Elder Support Network through which family members are able to arrange for case management and supportive services throughout the nation with fees based on a sliding scale determined by the family member’s income. Adult Day Care First organized in England in the 1940s, adult day care is a response to the need for family members to take a break from caregiving responsibilities on a regular basis. Unlike senior centers, adult day care programs are usually not “drop-in” situations. They are generally offered Monday through Friday during the day, with clients attending a regular number of days each week for up to 8 hours per day. Adult day care offers family members opportunities to continue to work outside the home or participate in any activity, free from caregiving for some hours each day. Adult day care programs vary in the services they provide. Services can include screening for physical conditions; medical care (generally arranged with an outside physician); nursing care; occupational, physical, and recreational therapy; social work; transportation; meals; personal care; educational programs; and counseling. Funding for these programs can come from OAA’s Title III, Social Services Block Grants, Medicaid, and fees paid by users and their families, or some combination of these sources. Day care programs may be located in an independent facility, a senior center, a neighborhood center, a hospital, or a religious institution. Day care has become an important component of community services available to older people and their families. It plays a key role in alleviating isolation, preventing or delaying institutionalization, and providing a break for families from caretaking responsibilities. Title III-C: Nutrition Services Nutrition services are the most well known of the services supported by the OAA. They are designed to provide balanced and nutritious meals in congregate settings, such as senior centers, community centers, and churches, or in the homes of those older adults who have difficulties that limit their ability to obtain or prepare food. The OAA identifies three purposes for the nutrition programs: (a) to reduce hunger and food insecurity, (b) to promote socialization of older individuals, and (c) to promote the health and well-being of older individuals by assisting them in gaining access to nutrition and other

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disease prevention and health promotion services. While improving the nutritional intake of older people, the congregate meals programs have addressed many other problems older people may face including social isolation, loneliness, and limited access to social and health services. Even homebound older people get a brief conversation along with their home-delivered meals. Meals on Wheels America can provide 250 meals per year for about the same amount as it costs for an older person to spend a single day in the hospital. There are 5,000 senior nutrition programs throughout the United States, serving over 1 million meals per day (congregate and home-delivered). Professionals who work at the nutrition program sites are aided by 2 million volunteers nationwide (Meals on Wheels America, 2016). Title III-D: Disease Prevention and Health Promotion OAA grants “seed money” for programs whose purpose is to prevent or delay chronic conditions and promote health among older people. State and area agencies are meant to use these federal funds to leverage other sources of funding. The types of activities that can be supported vary widely and include both group services, such as physical fitness and chronic disease management classes, and individualized services, such as medical and dental screening, nutrition counseling, pharmacology consultation, and immunizations. Title III-E: Family Caregiver Support The National Family Caregiver Support Program recognizes the extensive demands placed on family members and friends who provide care for their loved ones. It funds some assistance and support for these caregivers. Training for caregivers, home rehabilitation and adaptations (e.g., safety bars in bathrooms), and respite care to give temporary relief from caregiving responsibilities are among the services funded. Closely related to day care, respite care generally offers more intensive care on a limited-time basis for older persons who require ongoing care. This care may be in the caregiver’s home, or the older person may be brought to a respite-care facility, which may be a nursing home or other long-term care facility. The duration of the assistance may range from a few hours to a few days. Respite care is relatively new and generally underfunded by social-support funding systems. Some are being developed on a fee-for-service basis. Respite care in communities is seen as an effective means for older people to be able to remain in their own homes for longer periods of time. This service helps family and friends provide care that older people may need.

Older Americans Act Title IV: Activities for Health, Independence, and Longevity Title IV provides authority for training, research, and demonstration projects in the field of aging, which received less than 1% of OAA’s funding in fiscal year 2016. Its four major purposes are as follows: 1. 2. 3. 4.

To expand the nation’s knowledge and understanding of the older population and the aging process To design, test, and promote the use of innovative ideas and best practices in programs and services for older individuals To help meet the needs of trained personnel in the field of aging To increase awareness of citizens of all ages of the need to assume personal responsibility for their own longevity

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Title IV has supported a wide range of projects related to income, health, housing, and long-term care. Funds are awarded to a spectrum of grantees, including public and private organizations, state and area agencies on aging, and colleges and universities. In recent years, funds have been awarded to support a national Alzheimer’s disease call center, multigenerational civic engagement projects, and a number of national organizations serving older minorities.

Older Americans Act Title V: Community Service Senior Opportunities Act Title V, sometimes referred to as the “Senior Community Service Employment Program” (SCSEP), helps to support part-time community service jobs for unemployed people aged 55 and older who have low incomes and poor employment prospects. In fiscal year 2016, this Title received 22.7% of OAA’s funding. The Department of Labor contracts with all 50 states, the District of Columbia, Puerto Rico, American Samoa, Guam, the Northern Marianas Islands, the U.S. Virgin Islands, and national organizations that recruit and enroll workers in community service jobs, in settings such as hospitals, schools, and senior nutrition sites. The national organizations include the AARP Foundation, the Association National Pro Personas Mayores, Easter Seals, Goodwill Industries, the National Able Network, the National Asian Pacific Center on Aging, the National Caucus and Center on the Black Aged, the National Council on Aging, the National Indian Council on Aging, the National Urban League, and Senior Service America.

Older Americans Act Title VI: Grants for Services for Native Americans This title, added to the OAA in 1978, provides grants for American Indian tribal organizations, Alaskan Native organizations, and nonprofit groups representing Native Hawaiians to develop nutrition and supportive services for older Native Americans. These services are especially important to Native Americans who live foreshortened lives and have higher rates of a number of chronic conditions compared with most other Americans (see Chapter 13, Older Women and Older Minority Group Members, for details on racial/ethnic differences in chronic conditions). In fiscal year 2016, Title VI received just 2% of OAA’s funding. Supportive services include information and referral, transportation, and caregiver services. In a survey of Title VI programs in 2017, the top achievements cited by the programs’ directors were the following: ■ ■ ■ ■ ■

Providing healthy meals to elders in a social setting that helps to address isolation while supporting healthy living Serving traditional foods and offering activities and services for elders that are grounded in cultural traditions Retaining staff committed to service elders despite challenges such as low or stagnant wages Being recognized as trusted resources in their communities Partnering with tribal schools, community health centers, and diabetes education initiatives (National Title VI Program Survey, 2017, p. 2)

Older Americans Act Title VII: Vulnerable Elder Rights Protection Activities Title VII was added to OAA in 1992. In fiscal year 2016, this title received just 1.1% of OAA’s funding. It authorizes the long-term care (LTC) ombudsman program, as well as a program to prevent

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abuse, neglect, and exploitation of older adults. Ombudsmen are advocates for residents of nursing homes, board and care homes, assisted living facilities, and other adult care facilities. They work to resolve problems of individual residents and to bring about changes at the local, state, and national levels to improve care. While many residents receive good care in long-term care facilities, others are neglected, and incidents of psychological, physical, and other kinds of abuse do occur. Thus, trained staff and volunteer ombudsmen regularly visit long-term care facilities, monitor conditions and care, and provide a voice for residents. Ombudsmen’s responsibilities include: ■

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Identifying, investigating, and resolving complaints made by or on behalf of residents—complaints may relate to action, inaction, or decisions of care providers that adversely affect the health, safety, or rights of residents Providing information to residents about long-term care services Representing the interests of residents before governmental agencies Seeking administrative, legal, and other remedies to protect residents Analyzing, commenting on, and recommending changes in laws and regulations pertaining to the health, safety, welfare, and rights of residents Educating and informing consumers and the general public regarding issues and concerns related to long-term care, and facilitating public comment on laws, regulations, policies, and actions Promoting the development of citizen organizations to participate in the program Providing technical support for the development of resident and family councils to protect the well-being and rights of residents Advocating for changes to improve residents’ quality of life and care

In fiscal year 2015, 1,300 paid staff and 7,734 volunteers provided ombudsman services for 75,000 residential care facilities, with a combined total of 3 million beds (LTC Ombudsman, 2015). Under the elder abuse prevention program, states are required to carry out activities to make the public aware of ways to identify and prevent abuse, neglect, and exploitation and to coordinate activities of Area Agencies on Aging with adult protective services in each state. Although funds are allocated to states on the basis of the state’s share of the older population, ombudsmen are to serve all populations in facilities, regardless of age.

Legal Assistance Legal assistance and elder rights programs work in conjunction with other Administration on Aging programs and services to maximize the independence, autonomy, and well-being of older persons. Legal programs under Title VII, as well as Title III-B and Title IV, provide and enhance important protections for older people. Title VII requires each state to appoint a legal assistance developer. Similar to a state longterm care ombudsman, the legal assistance developer is responsible for developing and coordinating the state’s legal services and elder rights programs. Legal assistance provided under Title III-B protects older persons against direct challenges to their independence, choice, and financial security. Areas of legal service may include assistance in accessing public benefits (e.g., Medicare, veterans’ benefits), drafting advance directives, dealing with issues related to guardianship, accessing available housing options, handling foreclosure or eviction proceedings that jeopardize independence, and advising on abuse issues, including fraud and financial exploitation.

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Title IV authorizes the National Center on Law and Elder Rights and Model Approaches to Statewide Legal Assistance Systems. The National Center serves to enhance the quality, cost effectiveness, and accessibility of legal assistance and elder rights protections to older people with social or economic needs. Core resource support includes case consultation for professionals in the field of law and aging to assist them in resolving complex legal problems affecting older people; legal training for professionals and advocates from aging and legal service networks on a wide range of legal and elder issues; and technical assistance in developing efficient and effective legal and aging service delivery systems that address priority issues affecting older people. Among the legal issues on which the Center offers support are the following: ■ ■ ■ ■ ■

Saving an older person’s home from foreclosure Protecting against consumer scams and creditor harassment Addressing elder abuse in the community and in long-term care facilities Accessing public benefits essential to financial security, independence, and health Creating advance directives that help avoid guardianship and facilitate supported decision-making arrangements

Model Approaches is a discretionary grant program designed to help states develop and implement cost-effective, replicable approaches to broaden and integrate state legal service networks. One effective approach is the use of legal hotlines or helplines, which provide information and advice, and, if needed, can refer callers to local legal services. Senior legal hotlines are available in 22 states, Puerto Rico, and the District of Columbia. The National Association of Senior Legal Hotlines has a website—naslh.org/our-members—for accessing these hotlines. Older adults can call the tollfree hotlines to speak with trained attorneys about any legal matter with which they need help.

NEED AND UNMET NEED FOR SERVICES Measuring need and unmet need for services is difficult. Despite the Administration on Aging’s support and technical assistance, requiring agencies to complete surveys can be complicated and costly, and once gathered, the resulting information may become outdated quickly. Furthermore, states differ in how they are structured and how they administer diverse funding for home- and community-based services. In some states, funding is administered across multiple agencies, and the state unit on aging may not have access to information on older adults receiving services from sister agencies. Nevertheless, in preparation for the reauthorization of OAA, the U.S. Senate’s Committee on Health, Education, Labor, and Pensions asked the Government Accountability Office (GAO) to update its previous findings on the need for home- and community-based services and the potential unmet need for these services. In response, the GAO (2015) analyzed data from a variety of national surveys (e.g., Current Population Survey, Health Retirement Study). For its previous report, the GAO (2011) also conducted its own survey of 125 area agencies on aging, made site visits to four states, and interviewed additional state and national officials to gather information on requests for and use of services, use of funds, and the impact of the economic climate on requests and availability of Title III services.

Nutrition Food insecurity is a strong predictor of chronic diseases, including diabetes, heart disease, and lung disease, and poor nutrition can contribute to depression. In 2016, 10 million older adults

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were food insecure, meaning, for example, that they skip meals because they do not have enough money for food. The percentage of low-income older adults who are food-insecure increased from 19% to 24% between 2008 and 2013 (GAO, 2015). The GAO’s 2011 survey found that about 22% of agencies were unable to serve all clients who request home-delivered meals. Agencies also noted that many older adults who would benefit from meal services do not know they exist or that they are eligible to receive them.

Assistance With Activities of Daily Living Activities of daily living (ADLs) are key life tasks that people need to perform in order live independently, which include dressing and grooming, bathing, transferring (e.g., from a bed to a chair or wheelchair), toileting, and feeding oneself. The GAO has determined that approximately 66% of the 16 million older adults who have difficulties with daily activities receive limited or no home-based care. For example, among older adults with three or more difficulties with ADLs, only 30% receive any professional help with these basic tasks. Of course, family members are the source of most help for older adults needing it. Unfortunately, we do not know the extent to which the help received is sufficient to meet a senior’s needs.

Transportation Approximately 9 million older Americans are likely to need transportation services owing to circumstances such as being unable to drive or not having access to a vehicle (GAO, 2015). People aged 80 or older, women, and those living below the poverty threshold are especially likely to need these services. Good transportation services play an important role in enabling older adults who no longer drive to maintain access to healthcare services, grocery shopping, social support networks, and recreational opportunities. In the GAO’s 2011 survey, 62% of state and local agency officials reported that transportation is among the most requested services and that the unmet need is substantial. In some communities, lack of funding limits transportation to only essential medical treatments such as dialysis. The reality is that the resources of most programs and services are not adequate to meet the demands for them by the rapidly growing numbers of older adults. In a survey of Americans’ perspectives on public transportation, the TransitCenter Foundation concluded that by providing frequent, fast, walkable transit; convenient paratransit; and a range of flexible services for riders with limited mobility, cities can convert older residents into “all-purpose” transit riders who [use transit often and] can rely on transit for many different purposes. This will help people age in place, while providing the side benefit of making transit and paratransit more useful for residents of all ages. (Beatty, 2017, p. 2)

Stretching Resources The actual appropriations for all the titles of the Older Americans Act (OAA) have always been well under 1% of the federal budget, a proverbial “drop in the bucket.” Indeed, Torres-Gil (1992), in his book on public policy on aging, written before his becoming Assistant Secretary for Aging, questioned how so relatively few dollars in the hands of one small agency (the Administration on Aging) within the mammoth Department of Health and Human Services could meet its goals.

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In fiscal year 2016, on average, OAA funds comprised only 39% of the budgets of local Area Agencies on Aging or state units’ aging (National Association of Area Agencies on Aging, 2017). Other sources of funding for programs and services come from other federal sources, state and local budgets, private donors, and in-kind and voluntary contributions, sometimes even from the clients themselves. As a member of Nevada’s Commission on Aging, this textbook’s author has marveled at the ingenuity and frugality of local agencies in meeting as many of the needs of seniors in their communities as possible. For example, many community agencies in Nevada garnered food donations, volunteer drivers, and gifts of vehicles to augment the small amount of funding they received through the OAA for meal and transportation services. The Thompson Senior Center (2016) serves four communities in Vermont. In fiscal year 2016, only 16% of its annual budget of $485,000 came from Older Americans Act funding. The bulk of the center’s income came from fundraising events, donations, funding from local towns in the four communities, and grants. The center provided meals (over 18,000), just under half home-delivered; transportation for medical appointments, shopping, and so forth (3,600 rides); education and wellness events (e.g., medical talks, wellness clinics); fitness activities (e.g., yoga, tai chi, walking group); and socialization activities (e.g., card games, music, book club). The Center also benefitted from 165 volunteers who donated more than 7,500 hours to the center, as drivers, waitstaff, receptionists, and more. Current law prohibits mandatory fees, but providers are allowed to ask for voluntary contributions from those receiving nutrition and supportive services. It is important to note, though, that seniors cannot be denied any service because they cannot make a contribution for a service. Recognizing its enormous responsibilities and limited funding to carry them out, the Administration on Aging follows OAA guidelines that require programs to target or make it a priority to serve older adults with the greatest economic and social need. This has come to mean primarily those with low-income, from rural areas, of minority ethnic or racial groups, or who are frail. The OAA is designed to provide services to all older persons regardless of income and need. Torres-Gil (1992) has noted that targeting services without alienating healthier, active, affluent older persons is a real challenge. The OAA has provided somewhat of a safety net for older adults, especially for those who may need the services that many state and area agencies try to provide. Nevertheless, the provisions of the OAA continue to be overextended and underfunded. Every time the OAA is reauthorized, more responsibilities are added to the portfolio of the Administration on Aging without the increases in funding that would reasonably permit those responsibilities to be fully carried out. And, the number of older adults eligible for services is growing by leaps and bounds—every day 10,000 more Americans become eligible as they turn 60 years of age.

PRACTICAL APPLICATION INTRODUCTION

The focus of Chapter 10 is on how older adults contribute to their communities and how they receive support. It outlines the many volunteer programs available to older adults and describes the services and programs available primarily through the federal government’s Aging Services Network, established by the Older Adults Act. The chapter also explores the issue of need and unmet need for services. This Practical Application highlights the tremendous contributions older adults make through their extensive volunteer work.

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BE INSPIRED . . . BE INSPIRING

There is much one can learn from the wisdom of elders. This is one of the fortunate aspects of a career in gerontology—the fact that one has the opportunity to learn many important life lessons from the wit, wisdom, and life experiences of older individuals. Those who choose to work with older adults should be open to the inspiration around them, and, in turn, use the knowledge and insight gained to inspire and teach others. One way in which older adults are particularly inspirational is through their volunteerism. Many people who are retired are just as passionate and motivated as they were during their working years and seek to share their time, knowledge, and experience with their communities. As a testament to the societal value of their work and the meaning it gives to their lives, consider the following quotes from some rather famous older adult volunteers. ■

■ ■ ■ ■ ■ ■

I believe that, in making what seems to be a sacrifice, you will find fulfillment in the memorable experience of helping others less fortunate than yourself. (President Jimmy Carter) The intelligent way to be selfish is to work for the welfare of others. (The Dalai Lama) The best way to find yourself is to lose yourself in the service of others. (Mahatma Gandhi) You will get satisfaction out of doing something to give back to the community that you never get in any other way. (Ruth Bader Ginsburg) If every American donated five hours a week, it would equal the labor of twenty million full-time volunteers. (Whoopi Goldberg) As you grow older, you will discover that you have two hands. One for helping yourself, the other for helping others. (Audrey Hepburn) I slept and I dreamed that life is all joy, and I woke and I saw that life is all service. I served and I saw that service was joy. (Mother Teresa)

STUDENT ACTIVITIES 1. Identify an older adult who is or has been particularly involved in volunteerism. Describe

the contributions he or she has made to the community. This can be someone you know personally or a notable public figure, present or past. 2. Of all of the possible volunteer opportunities available in the Senior Corps programs, identify three ways you would volunteer your time and explain briefly why they would be meaningful to you. 3. Choose one of the seven titles outlined in the Older Americans Act and write a brief summary identifying its key takeaways.

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4. Conduct a web search to find your state’s agency devoted to older adult services as

part of the federal government’s Aging Services Network (e.g., Kentucky Department for Aging and Independent Living; Massachusetts Office of Elder Affairs). Outline at least five initiatives, services, or resources outlined on the website. (If your state does not have an agency, find one for a neighboring state.) 5. Make a list of some of the ingenious ways local older adult support agencies may be

able to supplement funding received from the Older American Act in order to meet the needs of older adults in their communities.

SUGGESTED RESOURCES AARP. (n.d.). Experience corps. Retrieved from https://www.aarp.org/experience-corps Experience Corps is a tutoring and mentoring program in which adult volunteers aged 50 years and older are trained to teach reading skills and build relationships to foster the success of young elementary school students who are very poor readers. In addition to information on the program, the website connects visitors to cities participating in the program. Aging Life Care Association. (n.d.). Retrieved from http://www.aginglifecare.org ALCA is an association with more than 2,000 members who provide a range of services for older adults, which may include assessment, support, and referrals for individuals and families. In addition to a wealth of information about care management, the website has an easy-to-use feature to search for Aging Life Care professionals by geographical region. Eldercare Locator. (n.d.). Retrieved from https://eldercare.acl.gov/Public/index.aspx A public service of the Administration on Aging, this website connects older Americans and their caregivers with information on a wide variety of senior services, ranging from Alzheimer’s to volunteerism. The ability to search by zip code or city/state makes it easy to find local help. National Association of Area Agencies on Aging. (n.d.). Retrieved from https://www.n4a.org This Association supports the national network of Area Agencies on Aging and Title VI Native American aging programs, offering advocacy, training, and technical assistance. The website includes a directory through which all AAAs and Title VI agencies can be located. National Association of States United for Aging and Disabilities. (n.d.). Retrieved from http://www .nasuad.org This Association, representing all 56 state and territorial agencies, seeks to design, improve, and sustain the delivery of home- and community-based services for older adults and individuals with disabilities. It provides many resources and information for these state agencies, most of which are freely available to the public on their website. National Center on Law and Elder Rights. (n.d.). Retrieved from https://www.acl.gov/node/834 Authorized by Title IV of the Older Americans Act, the National Center on Law and Elder Rights (NCLER) empowers aging and legal professionals with tools and resources they need to provide older clients and consumers with high-quality legal assistance in areas of critical importance to their independence, health, and financial security. Senior Corps. (n.d.). Retrieved from https://www.nationalservice.gov/programs/senior-corps Senior Corps connects today’s adults aged 55 and older with the people and organizations that need them most. Volunteers can receive guidance and training in three programs: RSVP, Foster Grandparent Program, and Senior Companion Program.

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REFERENCES Beatty, A. (2017). All-ages access. Making transit work for everyone in America’s rapidly aging cities. New York, NY: TransitCenter. Retrieved from http://transitcenter.org/wp-content/uploads/2017/08/ ALL-AGES.pdf Colello, K. J., & Napili, A. (2016, March). Older Americans act: Overview and funding (Congressional Research Service, R43414). Retrieved from https://fas.org/sgp/crs/misc/R43414.pdf Corporation for National & Community Service. (2017). Senior Corps fact sheet. Retrieved from https:// www.nationalservice.gov/sites/default/files/documents/CNCS-Fact-Sheet-2017-SeniorCorps_2.pdf Government Accountability Office. (2011, February). Older Americans act. More should be done to measure the extent of unmet need for services (Report to the Chairman, Special Committee on Aging, U.S. Senate. GAO-11-237). Washington, DC: Author. Retrieved from http://www.gao.gov/products/GAO-11-237 Government Accountability Office. (2015, June 10). Older Americans act: Updated information on unmet need for services (Report to the Chairman, Special Committee on Aging, U.S. Senate. GAO-15-601R). Washington, DC: Author. Retrieved from http://www.gao.gov/products/GAO-15-601R Gray, K. F., & Cunnyngham, K. (2016, June). Trends in Supplemental Nutrition Assistance Program participation rates: Fiscal year 2010 to fiscal year 2014. Alexandria, VA: U.S. Department of Agriculture, Food and Nutrition Service, Office of Research and Analysis. Retrieved from https:// fns-prod.azureedge.net/sites/default/files/ops/Trends2010-2014.pdf Kerschner, H., & Harris, J. (2007 March/April). Better options for older adults. Public Roads, 70(5). Retrieved from https://www.fhwa.dot.gov/publications/publicroads/07mar/03.cfm LTC Ombudsman. (2015). LTC Ombudsman national and state data. Washington, DC: Administration for Community Living. Retrieved from https://acl.gov/programs/long-term-care-ombudsman/ ltc-ombudsman-national-and-state-data Meals on Wheels America. (2016). Annual report. Together we rise. Arlington, VA. Retrieved from https://www.mealsonwheelsamerica.org/docs/default-source/financials/mowa-2016-annual-report —final.pdf Morrow-Howell, N., Jonson-Reid, M., McCrary, S., Lee, Y., & Spitznagel, E. (2009). Evaluation of experience corps. Student reading outcomes. St. Louis, MO: Washington University. Retrieved from https://openscholarship.wustl.edu/cgi/viewcontent.cgi?article=1848&context=csd_research Mystic Valley Elder Services. (2017). Our annual report: Building community connections. Malden, MA: Author. Retrieved from https://www.mves.org/annualreport National Association of Area Agencies on Aging. (2017). National survey of area agencies on aging. Serving America’s older adults. Retrieved from https://www.n4a.org/Files/2017%20AAA%20 Survey%20Report/AAANationalSurvey_web.pdf National Council on Aging. (2015). Senior centers. Fact sheet. Retrieved from http://www.ncoa.org/ press-room/fact-sheets National Title VI Program Survey. (2017). Serving tribal elders across the United States. Washington, DC: National Association of Area Agencies on Aging. Retrieved from https://www.n4a.org/Files/Title%20 VI%20Survey/Title%20VI%20Program%20Survey_508.pdf Oatley, A. (2011, April). Volunteering is her “spice of life.” Community That Cares, p. 1. Retrieved from http://gulfportseniorfoundation.org/newsletters/CommunityThatCaresApril2011.pdf Philanthropy Panel Study. (2017). Overview of overall giving. Indiana University Lilly Family School of Philanthropy. Retrieved from http://generosityforlife.org/wp-content/uploads/2017/10/Overall -Giving-10.5.17-jb-CJC.pdf Thompson Senior Center. (2016). Annual report. Woodstock, VT. Retrieved from http://www .thompsonseniorcenter.org/about/annual-reports Torres-Gil, F. M. (1992). The new aging: Politics and change in America. Westport, CT: Auburn House. U.S. Administration on Aging. (2017). Making connections. Consumer needs in an aging America. Washington, DC: Eldercare Locator. Retrieved from https://eldercare.acl.gov/Public/About/docs/ n4a-data-report.pdf U.S. Bureau of Labor Statistics. (2016, February). Volunteering in the United States—2015. Retrieved from https://www.bls.gov/news.release/volun.nr0.htm Wiles, J. L., & Jayasinha, R. (2013). Care for place: The contributions older people make to their communities. Journal of Aging Studies, 27, 93–101.

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CHAPTER

11

ME DI C AL C ON D I T I O N S , A S S I S T E D LI VI N G, AN D L O N G - T E R M C A R E

LEARNING OBJECTIVES • Identify the most common chronic conditions that older adults may experience. • Recognize other medical conditions that can accompany aging. • Outline the major similarities and differences between continuing care retirement communities, assisted living communities, and nursing homes. • Evaluate the new trends in assisted living and nursing homes. • Discuss the challenges of financing long-term care in the political climate of contemporary America.

MORTON, AGE 82: A CANCER SURVIVOR “Diagnosed with lung cancer at age 76, Morton was able to have the cancerous tissue completely [surgically] removed. Now 82, he’s enjoying life, cancer free” (Neighmond, 2016). Unfortunately, too often, decisions about medical treatments are made on the basis of age rather than the patient’s prognosis, which can result in older adults receiving neither information about preventive strategies or treatments nor treatments like the one described here that can lead to longer, enjoyable lives. According to the National Cancer Institute, in 2016, nearly 62% of cancer survivors were aged 65 or older, and that percentage is expected to rise to 73% by 2040.

ESTHER: MOVING TO ASSISTED LIVING Esther was the best cook in her family. Nieces and nephews always talked about Aunt Esther’s chocolate cakes and excellent dinners. After she turned 80, she began to develop macular degeneration (the loss of central vision). Gradually she lost more and more of her vision. It became hard to read even the largest print. Her general health was quite good, with her high blood pressure controlled through (continued next page )

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medication. Her husband, so typical of their generation, neither ever learned to cook nor wanted to try. His health was quite good, but he could no longer drive for a variety of physical reasons. Esther and her husband had always been very independent. They did not rely on anyone. They helped lots of people in various ways. With Esther’s limited vision, what were they to do? When they had some friends move into an assisted living facility that did not require an entry fee and rented on a monthto-month basis for a reasonable rent that included two meals a day, they saw that as an option for them, too. It was a new facility and really quite nice. Each apartment had a living room, bedroom, bath, walk-in closet, and small kitchen to prepare meals if they wanted to. They thought they would try it. The biggest adjustment was eating with other people on a regular basis. At first, this was difficult for Esther because she was so used to being in charge of the food preparation and the eating arrangements, but she adjusted quite well after a time. Both Esther and her husband made many friends and actually looked forward to meals as a time to get together with their new friends.

ADULT SON FORCED TO PAY PARENT’S LONG-TERM-CARE COSTS Unbeknownst to most Americans, 29 states and Puerto Rico have filial responsibility or filial support laws requiring adult children to care for their parents (see Medical Alert Advice, 2019, for information about each state’s law). Although these laws have seldom been enforced in the past, recently, there have been several cases where adult children have been held legally responsible for the costs of their parent’s nursing home care. For example, in May 2012, “the Pennsylvania Superior Court upheld a lower court decision1 . . . that allowed a nursing home to seek payment from a family member . . . for costs his mother incurred” for eight months of care totaling more than $90,000 (Kaplan, 2012). The ruling was upheld because her son’s income at the time was over $80,000, and therefore, he was deemed to be of “sufficient means” to be able to cover the bill. The existence of these laws and their potential effects on families remind us of the need to address the challenges that can arise in caring for older people. 1

Health Care & Retirement Corporation of America v. Pittas

MEDICAL CONDITIONS When it comes to aging, medical conditions quickly become one of the most important issues facing people. As people grow older, they are more likely to have medical conditions that require attention and that can hinder their ability to perform the daily tasks of living. And yet, the number of healthcare providers prepared to deal with a growing population of older Americans is woefully inadequate, as pointed out in Retooling for An Aging America: Building the Health Care Workforce, a key report by the Institute of Medicine (IOM, 2008). In addition to recruiting and retaining more healthcare specialists in aging and more caregivers, the report concluded that, “all licensure, certification, and maintenance of certification for healthcare professionals should include demonstration of competence in the care of older adults as a criterion” (p. 161). Unfortunately, there has been little to no improvement in the geriatric workforce since that IOM report. Unless medical students are going into pediatrics, a substantial proportion of their

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patients will be over the age of 65 once they begin practicing. Nevertheless, according to the American Geriatrics Society (2017), nationwide the total number of geriatricians in 2016 was 7,293, which was an increase of fewer than 200 over what was reported in the 2008 IOM report. An estimated shortfall of 13,176 geriatricians by 2030 has been calculated on the basis of the projected growth of the over-65 population, the projection that 30% of older adults need care by a geriatrician, and a caseload of 700 patients per physician. Making up that shortfall would require training more than 1,600 geriatricians every year for the next 14 years. A true primary care specialty, geriatrics includes hospital care, office care, house-call medicine, day care, and nursing home care. Trained to look at the whole person, geriatricians are adept at differentiating between diseases and normal physiological aging processes, managing symptoms that stem from multiple diseases, and developing an appropriate care plan for each patient, a plan that can minimize emergency care and potentially avoid placement in an institution. It is not just in medicine where more training in gerontology is needed. It is needed in all healthcare disciplines. To mention just one more, in the prestigious McMillan Lecture at the 2016 American Physical Therapy Association Conference, renowned physical therapist Dr. Carole B. Lewis (2016) focused her entire lecture on the urgent need for physical therapists to be trained to work with older adults. Improved medical care and prevention efforts have contributed to dramatic increases in life expectancy in the United States during the past century. They have also produced a major shift in the leading causes of death for all age groups, from acute illnesses and infectious diseases to chronic conditions and degenerative illnesses. Acute conditions are those that are expected to be of limited duration and can range from simple bruises to heart attacks, pneumonia, or broken bones. They often require a hospital stay. Chronic conditions, such as hypertension and arthritis, are those that are expected to be long term and most often permanent and may or may not require hospital stays.

CHRONIC MEDICAL CONDITIONS Chronic conditions are the leading causes of death for Americans age 65 and older. Heart disease (25.5%), cancer (21.1%), chronic lower respiratory disease (6.6%), and cerebrovascular diseases (stroke, 6.0%) together account for 59% of all deaths in this age group (Heron, 2017). Currently, 80% of older Americans are living with at least one chronic condition, and 50% have at least two such conditions. The top five chronic conditions of older adults are hypertension, arthritis, heart disease, cancer, and diabetes. The percentage of older people who report having each of these conditions, by sex and by race and ethnic group, are depicted in Figure 11.1A and B.

Hypertension and Stroke People can have hypertension (high blood pressure) and still feel just fine. That’s because signs of hypertension cannot be seen or felt. Nevertheless, hypertension, sometimes called the silent killer, is a major health problem. If it is not controlled with lifestyle changes or medicine, or both, it can lead to stroke, heart disease, kidney failure, or eye problems. Blood pressure is the force of blood pushing against the walls of arteries. When blood pressure is measured, the results are given in two numbers. The first number, called systolic pressure, measures the pressure of the heartbeat. The second number, called diastolic pressure, measures the pressure while the heart relaxes between beats. New guidelines, the first in almost 15 years,

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A 80

Men Women

70 60

54.9

56.7

Percent

50

54.2

42.6 35.0

40

24.9

30

26.2 21.2

22.7 19.2

20 10 0

Hypertension

Arthritis

Heart Disease

Cancer

Diabetes

B 80

Non-Hispanic White Non-Hispanic Black Hispanic

70.6

70 60

54.2

57.1 50.1

51.3 43.7

Percent

50 40

32.1 32.3

30.7 26.4

30

26.0 22.9 18.3

16.7

20

12.5

10 0

Hypertension

Arthritis

Heart Disease

Cancer

Diabetes

FIGURE 11.1  (A) Percentage of people age 65+ who reported having selected chronic medical conditions, by sex, 2013 to 2014. (B) Percentage of people age 65+ who reported having selected chronic medical conditions, by race and ethnic group, 2013–2014. SOURCE: Federal Interagency Forum on Aging-Related Statistics. (2016). Older Americans. Key indicators of well-being. Washington, DC: U.S. Government Printing Office. Retrieved from https://agingstats.gov/docs/­ LatestReport/Older-Americans-2016-Key-Indicators-of-WellBeing.pdf

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for the detection, prevention, and management of high blood pressure in adults define normal blood pressure as 120/80 mmHg (Whelton et  al., 2017). Target blood pressure rates for older adults are often slightly different—140/90 mmHg, 150/80 mmHg, or 150/85 mmHg (Health in Aging, 2017)—with the first number (systolic pressure) being more important than the second (diastolic pressure) for adults over age 50 (Basile, 2002). Anyone can have hypertension, but the risks increase with age. As can be seen in Figure 11A, women have a slightly higher rate of hypertension than men do. Among racial and ethnic groups, non-Hispanic Blacks have a substantially higher rate than do Hispanics and non-Hispanic Whites, 70.6%, 57.1%, and 54.2%, respectively. Hypertension is one of the main risk factors for stroke. In 2015, 120,156 older people died from a stroke (Heron, 2017). A stroke occurs when a clot blocks the blood supply to part of the brain or when a blood vessel in or around the brain bursts. In either case, parts of the brain become damaged or die. Symptoms of a stroke include: ■ ■ ■ ■ ■

Sudden numbness or weakness, especially on one side of the body Sudden confusion or trouble speaking or understanding speech Sudden trouble seeing in one or both eyes Sudden trouble with walking, dizziness, or loss of balance or coordination Sudden severe headache with no known cause

The chances of survival and recovery are higher the sooner emergency treatment is given. Acute stroke therapies try to stop a stroke while it is happening by quickly dissolving or removing the blood clot or stopping bleeding into or around the brain. Poststroke rehabilitation helps overcome physical and other disabilities that result from stroke damage. Recovery can take months or years, and many people who have a stroke never fully recover. The good news is that blood pressure can be controlled in most people. To start with, there are many lifestyle changes that can lower the risk, among them: keeping a healthy body weight; exercising for at least 30 minutes a day most days of the week; eating a diet rich in fruits, vegetables, whole grains, and low-fat dairy products; cutting down on salt; keeping alcohol intake low; not smoking; and managing stress. If these lifestyle changes do not work well enough, there are medications that can control blood pressure. These medications do not cure hypertension, so if necessary, they will need to be taken for the rest of the person’s life. Lifestyle changes may help lower the dose of medication needed.

Arthritis Arthritis is a disease that can attack joints in almost any part of the body, causing them to be painful and stiff. Some types of arthritis cause changes that can be seen and felt—swelling, warmth, and redness in joints—and may last only a short time, but be very uncomfortable, or there may be less pain, though joints are still being slowly damaged. Women have a substantially higher rate of arthritis than men do, 54.2% versus 42.6% (see Figure 11.1). Non-Hispanic Whites and non-Hispanic Blacks have similar rates of arthritis, whereas the rate among Hispanics is somewhat lower (see Figure 11.1B). Older people most often have one of three types of arthritis: osteoarthritis, rheumatoid arthritis, and gout. Osteoarthritis starts when cartilage that pads bones in a joint begins to wear away. Once the cartilage has worn away, bones rub against each other. Osteoarthritis occurs mostly in

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the hands, neck, lower back, or the large weight-bearing joints of the body, such as knees and hips. Symptoms range from stiffness and mild pain that comes and goes to pain that does not stop, even when the person is resting or sleeping. Sometimes osteoarthritis causes joints to feel stiff after the person has not moved them for a while, for example, after riding in a car. The stiffness goes away when the joints are moved. Growing older is what most often puts people at risk for osteoarthritis, possibly because joints and the cartilage around them become less able to recover from stress and damage. Also, osteoarthritis in the hands may run in families. In the knees it is linked with being overweight, and in the knees, hips, or hands, it may be due to injuries or overuse. Rheumatoid arthritis is an autoimmune disease, a type of illness in which the body attacks itself. It causes pain, swelling, and stiffness that last for hours, and it can happen in many different joints at the same time. Although rheumatoid arthritis can damage almost any joint, it often occurs in the same joint on both sides of the body. It can also cause problems with the heart, muscles, blood vessels, nervous system, and eyes. Gout is one of the most painful kinds of arthritis. It usually happens in the big toes, but other joints can also be affected. Swelling may cause the skin to pull tightly around a joint and make the area red or purple and very tender. Learning what brings on the attacks can help prevent future attacks. Eating foods rich in purines, such as liver and dried beans, can lead to a gout attack. Using alcohol and being overweight may make gout worse. Some blood pressure medications can also increase the chance of a gout attack. The primary goals of treatment for arthritis are to prevent joint damage, manage pain, and maintain physical functioning to preserve a good quality of life. Getting enough rest; doing the right exercises; eating a healthy, well-balanced diet; and learning the right way to use and protect joints are keys to living with any kind of arthritis. Three types of exercises are best for arthritis: range-of-motion exercises, such as dancing, which relieves stiffness, maintains flexibility, and keeps joints moving; strengthening exercises, such as weight training, which enhances muscle strength to support and protect joints; and, aerobic or endurance exercises, such as bicycle riding, which make the heart and arteries healthier, help prevent weight gain, and may also lessen swelling in some joints. The National Institute on Aging has a free booklet, entitled Workout to Go, on how to start and stick with a safe exercise program. The booklet can be downloaded at go4life.nia. nih.gov/workout-to-go Along with exercise and weight control, there are other ways to ease the pain around joints. Examples include using a heating pad or cold pack, soaking in a warm bath, or swimming in a heated pool. The right shoes and a cane can help with pain in the feet, knees, and hips when walking. There are also gadgets to help with opening jars or turning doorknobs, for example. Some medicines can help with pain and swelling. When damage to joints becomes disabling or when other treatments do not help with pain, healthcare providers may suggest surgery to repair or replace affected joints with artificial ones. Pain and arthritis do not have to be part of growing older. Pain and stiffness can be lessened and more serious damage to joints prevented by working with healthcare professionals.

Heart Disease The term heart disease actually refers to several types of heart conditions. The most common type in the United States is coronary artery disease (CAD), which can cause heart attacks, chest pain or discomfort (also called angina), heart failure, and arrhythmias. CAD happens when the arteries that supply blood to the heart muscle become hardened and narrowed due to atherosclerosis, the

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buildup of cholesterol and plaque on the inner walls of arteries. As can be seen in Figure 11.1A and B, compared with older women, the rate of heart disease is higher in men, and the rate is higher in non-Hispanic Whites than non-Hispanic Blacks and lowest in Hispanics. In 2015 heart disease led to the deaths of more than half a million older adults. Heart disease is the leading cause of death among older people, for both men and women, of all racial and ethnic origins, with one exception—male Asian and Pacific Islanders, for whom it is a close second to cancer (Heron, 2017). Risk factors for heart disease include high cholesterol, hypertension, diabetes, cigarette smoking, being overweight or obese, poor diet, physical inactivity, and alcohol use. Risk can be determined by checking cholesterol, blood pressure, and blood glucose and by examining family history of heart disease. The five major symptoms of a heart attack are pain or discomfort in the jaw, neck, or back; feeling weak, lightheaded, or faint; chest pain or discomfort; pain or discomfort in the arms or shoulder; and shortness of breath (Centers for Disease Control and Prevention [CDC], 2015). Other symptoms, which women are more likely to have, are unusual or unexplained tiredness and nausea or vomiting. Of course, on noticing symptoms of a heart attack, 9-1-1 should be called immediately. The sooner a person having a heart attack gets to an emergency room, the sooner he or she can receive treatment to prevent or reduce total blockage and heart muscle damage. There are steps to take to prevent or reduce the risks of heart disease and, for those who already have CAD, to lower the risk of worsening heart disease or of having a heart attack. Among recommended lifestyle changes are eating a healthy diet, including plenty of fresh fruit and vegetables and foods low in saturated fat and cholesterol and high in fiber; engaging in moderate-intensity exercise for at least 30 minutes on most days of the week; not smoking; and limiting alcohol use. If lifestyle changes are not enough to lower risks, then prescription medications can treat high cholesterol, hypertension, an irregular heartbeat, and low blood flow. In some cases, more advanced treatments and surgical procedures can help restore blood flow to the heart.

Cancer Cancer is not just one disease, but many diseases in which the genetic material in cells becomes damaged or changed for a number of different reasons, some of which are known (e.g., environmental toxins, radiation, chemicals in tobacco), and others of which are not. Damaged cells divide without control and are able to invade other tissues. There are more than 100 types of cancer, usually named for the organs where the cancers form, for example, colorectal cancer and lung cancer (National Cancer Institute, 2015). Because of advances in early detection and treatment, people are living many years after a diagnosis of cancer. As a consequence, what was once thought to be a death sentence is increasingly viewed as a chronic condition. Survival rates do differ enormously, however, by type of cancer, stage at which the cancer is diagnosed, and accessibility and use of treatment, all of which are affected by age, sex, race, and ethnicity. For example, the 5-year survival rate for all cancers combined is 68% for non-Hispanic Whites, but only 61% for nonHispanic Blacks (American Cancer Society, 2017). In the United States, most cancers (87%) are diagnosed in people age 50 years or older (American Cancer Society, 2017). As can be seen in Figure 11.1A and B, older men have higher rates of cancer than older women do, which is the case for all racial and ethnic groups (Jemal et al., 2017), and non-Hispanic Whites have higher rates of cancer than non-Hispanic Blacks do, who have higher rates than Hispanics do. Cancers are the second leading cause of death among older people, for both men and women, of all racial and ethnic origins, with one exception—male

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Asian and Pacific Islanders, for whom it is the leading cause (Heron, 2017). In 2015, over 400,000 older Americans died of cancer. For all racial and ethnic groups, the most common type of cancer in men is prostate cancer and the most common type in women is breast cancer. Although lung cancer is the second most common cancer in both men and women, it is the leading cause of cancer deaths for both. The third most common cancer in both men and women is colon cancer (Jemal et al., 2017). The CDC supports comprehensive cancer control programs throughout the country. These programs provide an integrated and coordinated approach to reducing the incidence of cancer, morbidity, and mortality through prevention, early detection, treatment, and rehabilitation. These efforts encourage healthy lifestyles, promote recommended cancer screening guidelines and tests, increase access to quality cancer care, and improve quality of life for cancer survivors. The number of new cancer cases could be reduced, and many cancer deaths could be prevented, with early screening, especially for individuals at increased risk. Screening for cervical and colorectal cancers helps prevent these diseases by finding precancerous lesions so the lesions can be treated before they become cancerous. Screening for breast cancer also helps identify the disease at an earlier, often highly treatable, stage. A person’s cancer risk can also be reduced by receiving regular medical attention, avoiding tobacco, limiting alcohol use, avoiding excessive exposure to ultraviolet rays from the sun and tanning beds, eating a diet rich in fruits and vegetables, maintaining a healthy weight, and being physically active. In some cases, vaccines can help reduce cancer risk; for example, the human papillomavirus (HPV) vaccine helps prevent most cervical cancers and some vaginal and vulvar cancers, if administered in young adulthood. Making cancer screening, information, and referral services available and readily accessible to all Americans can reduce cancer incidence and deaths.

Type 2 Diabetes Type 2 diabetes, which is also referred to as adult-onset diabetes or diabetes mellitus, is the most prevalent type of diabetes, accounting for 90% to 95% of all diagnosed cases in adults (Centers for Disease Control and Prevention, 2017). It results from difficulties in insulin production or action, or both. Insulin is a hormone that the body needs to absorb and use glucose (sugar) as a fuel for cells. Diabetes can lead to serious complications, such as blindness, kidney damage, heart disease, and lower-limb amputations. Although rates of diabetes are somewhat similar for older men (22.7%) and women (19.2%; see Figure 11.1), there are substantial differences among racial and ethnic groups (see Figure 11.1B). The rate of diabetes is significantly higher in older non-Hispanic Blacks (32.1%) and Hispanics (32.3%) than it is in non-Hispanic Whites (18.3%). Older Asian Americans and Native Hawaiians/Pacific Islanders also have high rates of diabetes, 27.2% and 34.3%, respectively (Kirtland, Cho, & Geiss, 2015), and Native Americans (American Indians/Native Alaskans) have twice the rate of non-Hispanic Whites, making them more likely than any other older American to have diabetes (Bullock et al., 2017). Many people with type 2 diabetes can control their blood glucose by following a healthy meal plan and exercise program, losing excess weight, and taking oral medication. Others may also need insulin to control their blood glucose or medications to control their cholesterol and blood pressure. Although helpful, treatment does not always prevent diabetes’s complications. Better than treating diabetes after it has developed is preventing it from developing, or at least delaying its onset. The National Institute of Diabetes and Digestive and Kidney Diseases funded the first major U.S. study to determine whether an intensive lifestyle intervention or treatment with the diabetes drug

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“metformin” could prevent or delay the onset of diabetes in a diverse group of more than 3,200 prediabetic adults—the Diabetes Prevention Program (Diabetes Prevention Program Research Group, 1999). Prediabetes, as the name implies, is a condition in which blood glucose levels are higher than normal but not high enough for a person to be classified as diabetic. Nevertheless, prediabetics are at high risk for diabetes unless they take action to bring their blood glucose under control. Results of the Diabetes Prevention Program showed that over a 3-year period, both the lifestyle intervention and the drug treatment were highly effective in reducing the incidence of diabetes (Diabetes Prevention Program Research Group, 2002). The lifestyle intervention, which included a healthy low-calorie, low-fat diet and 150 minutes or more of moderate-intensity physical activity, was more effective than the drug treatment, decreasing the incidence by 58% compared with 31% for the drug treatment. Importantly, the effects were similar across all ages, both sexes, and all racial and ethnic groups. Subsequent follow-up research has shown that both interventions continue to have positive effects for at least 10 years (Diabetes Prevention Program Research Group, 2009). On the basis of the success and long-lasting effects of these programs, and the fact that the savings in healthcare costs exceed their costs, the CDC is formally recognizing programs that meet certain standards, which include using an approved curriculum, to ensure high quality. Some private insurance companies and Medicare and Medicaid plans now offer CDC-recognized programs to their beneficiaries. In-person programs, many of which are offered at YMCAs, are available in hundreds of locations around the country, and online programs are also available (see nccd.cdc. gov/DDT_DPRP/Programs.aspx).

Chronic Disease Self-Management Chronic conditions can become disabling, threatening the person’s well-being and independence. For people with chronic conditions, Chronic Disease Self-Management Programs, developed by Dr. Kate Lorig and her team at Stanford University, can be of enormous value (Self-Management Resource Center, 2018). Self-management programs have been developed for a variety of chronic diseases, including arthritis, cancer, diabetes, and heart disease, and are offered in communities throughout the country, with some now available online too. The programs focus on building problem-solving and coping skills and support to help people manage their own chronic conditions. The face-to-face interactive workshops are conducted in small groups for 2 hours each week for 6 weeks, guided by two trained instructors, at least one of whom must have the chronic disease that is the focus of the workshop. Topics covered include appropriate exercise, nutrition, managing difficult symptoms (e.g., pain and fatigue), reducing stress, techniques for dealing with difficult emotions, effective communication with healthcare providers, and problem solving. Chronic Disease Self-Management Programs (CDSMP) have been found to result in positive health outcomes and lower healthcare costs (Ory et al., 2013). Participants report better overall health and lower levels of pain and fatigue and are less likely to be depressed; patient–physician communication and medication compliance are improved; and there are fewer emergency room visits and hospitalizations as a result of the program. Bob, who attended a CDSMP program for arthritis, said, “I have learned about the importance of exercise and stress management to improve my symptoms. I have so much to live for, arthritis is not going to get in the way” (www .cdc.gov/learnmorefeelbetter/sme/testimonials.htm). More than 300,000 people have participated in CDSMP programs. The savings in healthcare costs, if just 10% of Americans with a chronic condition participated, could be as much as $6.6 billion per year (National Council on Aging, 2016).

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OTHER MEDICAL CONDITIONS HIV/AIDS Anyone at any age can be infected with human immunodeficiency virus (HIV). HIV is a virus that damages and weakens the body’s immune system, seriously limiting the ability to fight infection and disease. Having HIV puts a person in danger of experiencing other life-threatening infections and certain cancers. HIV has essentially become a chronic disease because with successful treatment people with HIV can nevertheless live a long and relatively healthy life. People usually acquire HIV from unprotected sex with someone living with HIV or by sharing needles with a person living with HIV. Other risk factors include having had a blood transfusion in the U.S. between 1978 and 1985, having had a blood transfusion or operation in a developing country at any time, and being diagnosed with, or treated for, hepatitis or tuberculosis at any time. Signs of early HIV infection include flu-like symptoms such as a headache, muscle aches, swollen glands, fevers, and chills. When the body cannot fight off infections and other diseases anymore, HIV can lead to AIDS—acquired immunodeficiency syndrome. Early diagnosis and treatment of HIV can prevent the development of AIDS. Symptoms at later HIV or AIDS stages include lack of energy, loss of appetite, weight loss, chronic or recurrent diarrhea, and short-term memory loss. Older people are less likely than younger people to use protection when having sex or to take precautions if they are using needles, making them more vulnerable to HIV infection. They are also less likely to get tested. They might not even think about being tested because they may not consider themselves to be at risk for the virus or they may feel ashamed or afraid of being tested. Furthermore, healthcare professionals often avoid talking to older patients about their sexual behaviors (and drug use), so they also do not always think to test them for HIV. Some signs and symptoms can be mistaken for the aches and pains of normal aging and other medical conditions can mask the signs of HIV/AIDS. By the time an older person is diagnosed, the virus may be in the late stages and more likely to progress to AIDS. Older people living with HIV are at increased risk for developing cardiovascular disease and dementia. Nearly half of the people living with HIV in the United States are age 50 or older, a total of 464,000 individuals (CDC, 2017). Many were diagnosed in their younger years, but thousands of older people get HIV every year. As of 2015, more than 72,000 people age 65 or older were living with diagnosed HIV infection, of whom 48,000 have been classified as having AIDS. Although there is no cure for HIV, a combination of drugs, called highly active antiretroviral therapy (HAART), is an effective treatment, greatly reducing the risk of death from HIV/AIDS-related complications.

Osteoporosis Another chronic condition that is of great concern, especially for older women, is osteoporosis. Osteoporosis, or porous bone, is a disease of the skeletal system characterized by low bone mass and deterioration of bone tissue. Bone thinning, or loss of bone mineral density, begins at about age 35 when the body begins to reabsorb bone cells faster than it makes new bone. It can lead to osteoporosis, which increases the risk of bone fractures, typically in the wrist, hip, and spine. An estimated 10.2 million Americans age 50 years and older have osteoporosis, and another 43.4 million have low bone mass, putting them at increased risk for osteoporosis (Wright et al., 2016). Prevalence of osteoporosis increases with age and is affected by sex, race, and ethnicity. Rates for women increase from 12% for those age 60 to 69 to 35% for those age 80 and older; comparable rates for

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men are 3% and 11%, respectively. Rates are higher for Mexican American women (20%) and non-Hispanic White women (16%) than they are for non-Hispanic Black women (8%). One of the major worries of people with osteoporosis is falling, which can lead to devastating consequences. Fall-related injuries cause significant disability, loss of independence, early admission to nursing homes, and death. Each year as many as 12 million older adults experience a fall, and 2.6 million of those falls lead to some kind of medical attention, most frequently for fractures. Among the major medical expenditures associated with falls are hospitalization, surgery, and rehabilitation. In 2013, the estimated average cost of each fall was between approximately $9,000 and $13,000 (United Health Foundation, 2016). Importantly, falls are the seventh leading cause of death among older adults. In 2016, 30,000 older Americans died as a result of a fall (Burns & Kakara, 2018). To improve or maintain bone health, the CDC recommends eating a healthy diet that includes adequate amounts of calcium and vitamin D, performing weight-bearing exercises regularly, refraining from smoking, and limiting alcohol use. A recent review of 24 studies found that consuming 50 to 100 g of dried plums/prunes per day may increase bone formation and reduce bone resorption, leading to healthier bones in postmenopausal women, with no negative side effects (Wallace, 2017). Chapter 3, Health and Wellness for Older Adults, has more information on maintaining strong bones and preventing osteoporosis.

Eye Diseases A few serious conditions affecting vision can develop more readily in older people—macular degeneration, glaucoma, and retinopathy. Early detection can make a difference in the progression and prognosis for these conditions. A leading cause of severe vision loss in adults over age 60 in the United States, age-related macular degeneration (AMD) occurs when the small central portion of the retina, known as the “macula,” deteriorates. The macula is the most important region of the eye because it is packed with light receptors that make focused, precise vision possible, such as that needed for reading, driving, sewing, and similar tasks. AMD can be detected during a comprehensive eye exam that includes a visual acuity test, which measures vision at various distances; a dilated eye exam, during which the pupils are dilated and the retina and optic nerve are examined; and tonometry, which measures pressure inside the eye. The causes of AMD are unknown, though some risk factors, such as smoking, obesity, hypertension, and family history, have been identified. There is no cure, but treatment may prevent severe vision loss or slow the progression of the disease. Treatments include laser therapy, drugs, and low vision aids. Researchers are currently investigating new surgical treatments and the use of stem cells too. Glaucoma is a group of diseases that can damage the eye’s optic nerve, resulting in vision loss and blindness. The risk is much greater for people over age 60, though it can occur in younger people. It also occurs more frequently in Black Americans and Mexican Americans, and in those with a family history of the condition. For reasons that are still unknown, excess pressure builds up in the eye because fluid (aqueous humor) drains too slowly out of one or both eyes. Without treatment, people with glaucoma slowly lose their peripheral vision. Over time, straight-ahead vision may decrease, too, until no vision remains. Although glaucoma cannot be prevented, regular eye check-ups are important because there are usually no early symptoms or pain, and the sooner glaucoma is diagnosed and treated, the better the outcome. In addition to the vision tests for macular degeneration, glaucoma is diagnosed with two additional tests: a visual field test, which measures peripheral vision, and pachymetry, which measures the cornea’s thickness. Prescription eye drops or pills and laser surgery are the most common treatments.

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Retinopathy is a disease of the retina, the light-sensitive membrane at the back of the eye, that can also lead to poor vision and even blindness. Weakening blood vessels lead to blood leaking into the front of the retina, formation of scar tissue, and retinal detachment, as well as swelling of the macula. Causes include arteriosclerosis, diabetes, and hypertension, and therefore controlling cholesterol, blood sugar, and blood pressure can help prevent retinopathy. A dilated eye exam can detect retinopathy. With early detection, new laser treatments can minimize loss of vision; otherwise, surgery can stabilize vision.

Sleep Disorders Four sleep disorders are more common among older people: insomnia, circadian rhythm disorders, sleep apnea, and leg movements, although, according to renowned sleep researcher Sonia Ancoli-Israel (2004), none are inextricably connected to healthy aging. Insomnia affects up to half of the older population. It occurs when a person has trouble falling asleep or staying asleep. There are many possible causes of insomnia, including changes in personal circumstances (losing a loved one, relocating), which may result in a temporary bout of insomnia, or pain associated with conditions such as arthritis or heartburn, which often leads to chronic insomnia. In addition, many medications produce insomnia. Alcohol can contribute to insomnia, too. A common belief is that drinking alcohol helps a person to fall asleep, which is true, but the problem is that a few hours later, it wakes the person up. Treatment for insomnia, of course, will depend on its cause, so it can range from counseling to pharmacotherapy. Circadian rhythm disorders are another source of poor sleep. Older adults may not get a full night’s sleep if they fight age-related changes in circadian rhythms that make them sleepy earlier in the evening and cause them to wake about 8 hours after that sleepiness sets in. Naps in the early evening can also disrupt sleep–wake cycles. Exposure to bright light, from the sun or bright light boxes, late in the day or early evening is effective in resetting circadian rhythms. Sleep apnea, or sleep-disordered breathing, is usually a chronic condition that disrupts sleep because it causes periodic pauses in breathing or shallow breaths. Symptoms include loud snoring and excessive daytime sleepiness. Untreated sleep apnea can increase the risk of hypertension, heart attack, and stroke, as well as accidents. Continuous positive airway pressure (CPAP), in which a device uses mild air pressure to keep the airways open during sleep, is the treatment of choice. Some people with sleep apnea can benefit from weight loss (if they are overweight or obese), avoiding alcohol, or even sleeping on their sides rather than on their backs. Movement disorders, typically periodic involuntary leg movements during sleep, can involve as many as three movements per minute and, like sleep apnea, they disrupt sleep and result in daytime sleepiness. Up to 45% of older people suffer from some type of periodic leg movement problems. Although there are no cures for these disorders, regular exercise can help, and if that does not work, medications are available to treat symptoms.

ASSISTED LIVING AND LONG-TERM CARE Most older Americans live independently in traditional communities. All of the housing options discussed in Chapter 8, Age-Friendly Communities, Living Arrangements, and Housing Options, even those that involve sharing a private home with others, are essentially independent living environments. Many older adults remain in their own homes with help from home- and community-based services, which were discussed in Chapter 9, Family, Friends, and Social Networks of Older Adults. Here we focus on assisted living communities and nursing homes.

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Assisted living communities offer accommodations with a limited range of services and support, whereas nursing homes offer more comprehensive care, with access to aides and skilled nursing 24/7. Figure 11.2 depicts the proportion of older adults who live in each of three primary residential settings: traditional communities, community housing with services (mostly assisted living), and long-term care facilities (nursing homes). The probability of living in a nursing home increases as people get older, but note that it is barely more than 1% for 65- to 74-year-olds and less than 4% for 75- to 84-year-olds. Even for people age 85 and over, only 15% live in a nursing home (Federal Interagency Forum on Aging-Related Statistics, 2016). For those who want the assurance of an environment that will meet their needs as they continue to move through their later years, regardless of the status of their mobility and health, there are continuing care retirement communities (CCRCs), where independent living, and at least one level of care, such as assisted living, are all available on the same campus.

Continuing Care Retirement Communities CCRCs are sometimes called life-care or continuum-of-care communities, and are now being referred to as life-plan communities in order to emphasize the living aspect over the care aspect. They are designed for healthy people wanting peace of mind about where they are going to live Traditional community Community housing with services Long-term care facilities

100 90 80

Percent

70 60 50 40 30 20 10 0

65–74

75–84

85+

FIGURE 11.2  Percentage distribution of Medicare beneficiaries age 65+ residing in selected residential settings, by age group, 2013. NOTE: Community housing with services defined as retirement communities/apartments, continuing care ­retirement facilities, assisted living facilities, and similar situations with access to one or more of these services (whether used or not) through the residence: meal preparation, cleaning/housekeeping services, laundry services, or help with medications. Long-term care facility defined as residence/unit certified by Medicare or Medicaid; or with three or more beds, licensed as nursing home or other long-term care facility, and provides at least one ­personal care service; or provides 24/7 supervision by a non-family, paid caregiver. SOURCE: Federal Interagency Forum on Aging-Related Statistics. (2016). Older Americans. Key indicators of well-being. Washington, DC: U.S. Government Printing Office. Retrieved from https://agingstats.gov/docs/­ LatestReport/Older-Americans-2016-Key-Indicators-of-WellBeing.pdf

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as they grow older and how they will manage with a potential future medical condition or frailty that can accompany advanced old age. CCRCs usually provide housing and a range of social and recreational services and amenities. For those who want or need other services, congregate meals, personal care, supportive care, and nursing care, besides sometimes memory care, can be provided. Key features of CCRCs are: ■ ■ ■

They offer multiple levels of care, which include housing, services, and healthcare for an extended period of time, usually the lifetime of the resident. Would-be residents must be capable of living independently when they move in. Incoming residents typically enter into contractual agreements to pay a lump-sum entrance fee and then monthly fees that will provide for care for the rest of their lives.

A study of people who have moved into CCRCs found that the main reasons for such moves are planning ahead for possible changing physical and mental needs, freedom from having to maintain their own homes, and a wish not to be a burden on their loved ones (Krout, Moen, Holmes, Oggins, & Bowen, 2002). CCRCs can be especially beneficial for couples because one partner may have different needs from the other, and they can nevertheless both live on the same campus. Although there are no federal regulations for CCRCs, 38 states do regulate them, with wide variations in requirements and oversight (Government Accountability Office, 2010). The nonprofit Commission on Accreditation of Rehabilitation Facilities (CARF International) accredits CCRCs, but there is no requirement that facilities participate in its accreditation process. As a result, it is important that older persons who contemplate moving into a CCRC understand what services are available to meet current and future needs, the costs and the types of contracts offered, and the possible pitfalls in signing a contract for this type of community. In 2017, there were 1,955 CCRCs in the United States, most affiliated with nonprofit organizations (McKnight’s Senior Living, 2018). In general, these facilities are geared for the middle- and upper-income people—with some exceptions. Nationally, the entrance fee averaged $282,230 and monthly fees averaged $2,874 in 2015, though costs can vary tremendously, with some entrance fees exceeding $1.5 million (Legg Mason, 2016). Factors that affect fees are geographical location, type of buildings, size of individual residences, and levels of services provided. An exception to the typical middle- and upper-income tone to CCRCs would be those operated by some religious and/or charitable organizations, such as the Holland Home of Grand Rapids, Michigan. Although accommodating upper-income older persons with rather opulent suites and apartments, in 2016 Holland Home provided $5.5 million of financial assistance to 35% of its residents (Holland Home, 2017). Many of those persons simply outlived their resources. It also offers a Relocation Bonus, which helps with moving-related costs, and a Home Buy-Out Program, which helps would-be residents sell their homes, promising to buy them after 180 days, so they can afford to pay the entrance fees. CCRCs can be ideal for older people who can afford the fees and who can adapt to living in an environment that is somewhat institutional and controlled. They can be a solution to guarantee longterm care. However, because of the relatively large fees involved, and because CCRCs accept only people without serious health conditions, this approach does not address the public policy issue of the need for long-term care services and supports to be widely available to those who need them.

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Assisted Living Communities The goal of assisted living is to enable individuals to live in a homelike environment where services are provided for individuals who need some form of assistance with daily living but do not require continuing medical or nursing care or full-time personal assistance. The common factors in all of these facilities are housing units that have a common dining room in which meals are served on a regular basis, access to a range of social and recreational services, some assistance with personal care, some level of healthcare (e.g., medication management), and some method of 24-hour supervision. They also usually offer transportation and housekeeping and laundry services, and some facilities have individual units with a small efficiency kitchen. A full-range of personal care services, as well as specialized services for people living with Alzheimer’s disease or another dementia, may be available at an additional cost. Unlike nursing homes, which are regulated by the federal government, assisted living facilities are licensed, or certified, and regulated by state governments. Thus, standards for care vary widely from state to state, and to a somewhat lesser degree, from facility to facility. States also differ in the terms they use for assisted living facilities, for example, some refer to them as residential care or shared housing. A report by the National Center for Assisted Living (2017) entitled Assisted Living State Regulatory Review summarizes key state requirements vis-à-vis residents’ admissions and discharges, staffing, and required training, as well as information on the agency within the state government that licenses assisted living facilities. A summary of each state’s regulations can be found through the center’s website at www.ahcancal.org/ncal/advocacy/regs/Pages/AssistedLivingRegulations.aspx Assisted Living Communities and Their Residents The 30,200 assisted living communities in the United States provide a total of 1 million licensed beds (Harris-Kojetin et al., 2016). They range in capacity from 4 to 499 beds, with an average of 33 licensed beds per community. As can be seen in Figure 11.3, almost half of the nation’s assisted living facilities are quite small, with between 4 and 10 beds each. There is an interesting regional pattern also, with a higher proportion of assisted living facilities in the West (42%), lower proportions in the South (28%) and Midwest (22%), and only a small proportion in the Northeast (8%). A substantial majority (82%) of assisted living communities are run as for-profit businesses, and a little more than half (56%) are owned by private businesses that manage two or more communities. Although approximately half of assisted living communities are Medicaid certified, meaning that the facility can accept Medicaid patients, the costs of assisted living are usually paid for privately by residents with only a small proportion of residents receiving funding through Medicaid. The median annual cost of an assisted living unit is $45,000, with medians for individual states ranging from $32,400 in Missouri to $72,180 in Delaware (Genworth Financial, 2017). Current Trends in Assisted Living Communities A growing trend is for assisted living communities to cater to niche markets. For example, Newington, Connecticut’s Veterans Landing is the first assisted living community being built for older veterans and their spouses (Burm, 2017b). Legends Landing is a senior living community that will combine “independent living and memory care for retired [professional football] Hall of Famers as well as members of the [National Football League’s] Legends Community and coaches, officials and administrators” (Bowers, 2017). Set to open in 2020, the community is being built

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Extra Large: 101+ beds

Large: 26–100 beds

Small: 4–10 beds

Medium: 11–25 beds

FIGURE 11.3  Assisted living: percentage by size of facility. SOURCE: Harris-Kojetin, L., Sengupta, M., Park-Lee, E., Valverde, R., Caffrey, C., Rome, V., & Lendon, J. (2016). Long-term care providers and services users in the United States: Data from the National Study of Long-Term Care Providers, 2013–2014 (Vital and Health Statistics, Series 3, Analytical and epidemiological studies, number 38). ­Hyattsville, MD: U.S. Department of Health and Human Services. Retrieved from https://www.cdc.gov/nchs/data/ series/sr_03/sr03_038.pdf

on the campus of the Pro Football Hall of Fame in Canton, Ohio. Main Street communities are designed as self-contained villages, with neighborhoods and downtowns that include cafes, and restaurants to plant stores, salons and spas, and more, often operated by independent retailers (Burm, 2017a). Residents walk out their front doors to a sidewalk instead of a hallway. One such community, Rose Villa, in Portland, Oregon, has an aquatics center, fitness center, dog park, woodshop, art studio, and performing arts center. Assisted living communities designed like resorts are another rapidly growing choice. “Designed for people ‘aged 55 and better,’ these age-restricted communities offer high-end living and recreation facilities, cutting-edge amenities, beautiful grounds, and place a huge emphasis on entertainment and fun!” (Fowler, 2018). Each of these resort-style communities is unique, with its own selected amenities and services, types of housing, and associated costs. From Belmont Village in Westwood, California, where residents can attend lectures from retired UCLA professors, to Atria Kew Gardens, in Kew Gardens, New York, which hosts 200 events a month, the options for assisted living will only continue to expand to meet the needs, interests, and demands of current and future generations of older adults.

Long-Term Care Most long-term services and supports are provided by family members, in the older person’s home or in a family member’s home. The overall goal of in-home care is the diversion of people from nursing homes when they can be served at home and in the community. This goal builds upon what most older people want as they go through the aging process—to stay at home as long as possible. This type of caregiving is discussed in Chapter 9, Family, Friends, and Social Networks of Older Adults. If there comes a time when the services and supports that are needed are beyond what can reasonably be provided in a home, then nursing homes, which are also sometimes referred to as skilled nursing facilities, can be an alternative. In fact, nursing homes care for some of the oldest and frailest members of society.

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Key characteristics of nursing homes are the provision of supportive housing in a secure setting where medical or nursing care and personal assistance are available 24/7; meals, transportation, housekeeping and laundry services, and activities are included; and physical and occupational therapy may be offered, too. Some nursing homes are prepared to admit and care for people living with Alzheimer’s disease or another dementia. Almost all nursing homes are certified by Medicare and Medicaid and can accept individuals with payment from either of these sources. Consequently, they are regulated by the federal government and must meet defined standards, which include developing a comprehensive care plan for each resident, maintaining the dignity and respect of each resident, and ensuring that residents have the right to choose activities, schedules, and healthcare. The Older Americans Act, which is discussed in Chapter 10, Older Adults Giving and Receiving Support, requires every state to have an ombudsman program for long-term care (LTC). Ombudsmen advocate for residents of assisted living facilities and nursing homes and are trained to resolve problems of individual residents. Staff and volunteers provide information on LTC to individuals and facilities, visit facilities at least quarterly, provide assistance and training to managers of LTC facilities and their staff, and attend family council and resident council meetings in the facilities. The National Long-Term Care Ombudsman Resource Center has an excellent website through which ombudsmen can be located and many long-term care resources can be accessed at ltcombudsman.org/about/about-ombudsman. Moving to a nursing home (or an assisted living facility, for that matter) can be traumatic for an older person. If an older person is not involved in decision making about relocating, the outcomes are often quite negative, ranging from poor adjustment to the new residence to increased risk of mortality (Bekhet, Zauszniewski, & Wykle, 2008). On the other hand, when conversations about the possibility of moving occur well before any move and include the older person, and when the older person is involved in the decision-making process and preparations for moving, relocation can be a positive experience (Oswald & Rowles, 2006; Rutman & Freedman, 1988). Even after a loved one is residing in a nursing home, it is recommended that relatives and friends continue to be actively involved in the care of their loved one. In addition to visiting, other important roles and functions to which they can contribute are monitoring care, participating in decision making, acquainting the staff with the older person, knowing the rights of nursing home patients, encouraging the older person to participate in resident councils, and participating in family councils (Riekse & Holstege, 1996). Nursing Homes and Their Residents The 15,600 nursing homes in the United States provide a total of 1,663,200 certified beds (Harris -Kojetin et al., 2016). They range in capacity from 2 to 1,389 beds, with an average of 106 certified beds. There is an interesting regional pattern, with greater proportions of nursing homes in the South (35%) and Midwest (33%) and smaller proportions in the Northeast (17%) and West (16%). The occupancy rate for nursing homes is about 82%, the majority (56%) is owned by private businesses that manage two or more homes, and 70% of them are for-profit. Almost all are Medicare and Medicaid certified, meaning that they can accept Medicare patients (for rehabilitation) and Medicaid patients (for long-term care). The median annual cost of nursing home care in a semiprivate room is $86,000, with medians for individual states ranging from $54,000 in Oklahoma to $292,000 in Alaska (Genworth Financial, 2017). The median annual cost for a private room is $97,500, with medians for individual states ranging from $63,500 in Oklahoma to $292,000 in Alaska.

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Most of the residents in nursing homes—1,163,000 of them—are older adults, although another 207,000 are people under 65 years of age who are convalescing or have severe long-term disabilities (Federal Interagency Forum on Aging-Related Statistics, 2016). It is important to note that both the number and proportion of older people living in nursing homes have declined since 1995, when approximately 1.5 million older adults were nursing home residents, which was 4.4% of all older adults at that time (National Center for Health Statistics, 2017). Currently, the overall proportion is approximately 3%, though the proportion increases across the older adult age range, as noted previously. This decline is likely due to a combination of the improved health of older people and the use of other kinds of long-term services and supports, such as in-home healthcare and assisted living. Current Trends in Nursing Homes: The Culture Change Movement Initiated in 1997 by a small group of professionals who were working in long-term care, the nonprofit Pioneer Network (n.d.) developed a culture change model to completely remake nursing homes. Using the culture change model, the goal of the Pioneer Network is to transform the environment and practices in nursing homes for the benefit of residents, staff, and the administration of the homes. Among the changes that the model proposes to achieve those goals are: ■ ■ ■

Increased privacy and choices for residents More autonomy for direct care staff (nursing aides) in making decisions about their work in caring for residents Conversions of the physical and organizational structure of the residences so that they look and function more like homes, with the same staff members caring for a small group of residents rather than the strange, traditional practice of continually rotating staff

On the basis of the results of a 2007 national survey of 1,435 nursing homes, Doty, Koren, and Sturla (2008) reported that 31% of nursing homes were culture change adopters, incorporating most or all of the recommended changes as outlined by the model; another 25% were culture change strivers, very committed to the model but with only a few changes or none at all having been adopted; and the remaining 43% were deemed traditional nursing homes, with little commitment and few if any changes adopted. Nursing homes that adopted more aspects of the culture change model reaped greater rewards in terms of higher occupancy rates, which were related to being in a more favorable marketing position; improved staff retention; and reduced costs. The researchers were encouraged that such positive outcomes would cause more nursing homes throughout the nation to start making the changes to their facilities that would bring them in step with the culture change model. And, they were correct! Just a few years after the Doty et al. study, in a survey of an even larger sample of nursing homes—3,695—Miller et al. (2014) found that most nursing homes had implemented at least some aspects emanating from the culture change model, leaving only 15% as traditional nursing homes. Paying for Long-Term Care Paying for long-term care is one of the greatest financial threats to older Americans and their families. With the high costs revealed above, it is clear that most Americans cannot afford this type of care. An all-too-common scenario is that a family’s financial resources are drained, extensive demands are placed on family caregivers, most of whom then suffer additional personal financial

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losses, and eventually the people needing care qualify for Medicaid funding because they meet their state’s poverty threshold. Almost half of the total amount spent on long-term care in the United States is paid for by Medicaid—a federal-state program that offers relatively wide coverage for people who are poor. For older adults and people with severe disabilities, Medicare will pay for short-term rehabilitative services, which amounts to another 20% of the total amount spent on long-term care in the United States. Almost all of the rest of long-term care is paid out of pocket (meaning self-paid) or through private insurance (Colello & Talaga, 2015). Although private long-term care insurance has been around since the late 1970s, it has been of limited use in dealing with the funding challenges associated with long-term care. Just a decade or two ago, there were as many as 100 companies offering this insurance and now there are only about a dozen. In part due to the lack of gerontological knowledge in these companies, a number of problems led to their demise: they failed to account for increases in the longevity of the population, they assumed demand for the insurance would be greater, and predictions of their returns on invested premiums failed to materialize when interest rates bottomed out. Consequently, many companies went out of business or stopped offering policies because they were losing so much money. For example, Genworth Financial lost $2 billion on its policies and is still losing as much as $150 million per year (Ostrov, 2016). In trying to curb their losses, companies started jacking up premiums, which had two negative effects: existing customers who could not keep up with their payments lost their insurance, and others were dissuaded from becoming new customers. The U.S. Congress has tried a number of ways to encourage consumers to purchase private longterm care insurance: (1) tax credits or deductions for taxpayers, (2) the ability for those who buy such insurance to become eligible for Medicaid while retaining substantially more of their financial assets than they would otherwise be able to, and (3) a major marketing campaign, entitled Own Your Own Future, through media and mailings. These efforts have not been successful (Gleckman, 2010). Although the main objectives of the Patient Protection and Affordable Care Act (2010) were the financial protection of all Americans and the extension of health insurance coverage to the uninsured, a key component, often never mentioned, was the inclusion of the Community Living Assistance Services and Supports (CLASS) Act. The purpose of that Act was to establish a national, voluntary insurance program for purchasing services and supports for long-term care. According to Lisa Shugarman in an article in Public Policy and Aging Report (2010), the CLASS Act “fundamentally [reframed] the concept of long-term care from one of poverty, sickness, and loneliness to one of choice, community and personal responsibility in the face of functional impairment” (p. 3). Unfortunately, partly because of its projected costs, the CLASS Act was repealed in 2013. The nonprofit Urban Institute and the nonprofit Bipartisan Policy Center have each made new recommendations for helping to solve the challenge of financing long-term services and supports. With the goal of helping older adults remain in their homes as long as possible, thereby delaying entry into long-term care facilities, the Urban Institute’s Long-Term Care Financing Collaborative (2015) has proposed doing a better job of integrating services and supports with medical care, offering more support for family caregivers, and making better use of community-based resources. A new report from the Bipartisan Policy Center (2017) recommends private longterm care insurance improvements, a Medicare respite care benefit, and a beneficiary-financed Medicare supplemental benefit, perhaps offered through Medicare Advantage or Medigap plans. Members of the Center’s Long-Term Care Initiative were not able to come to consensus on “a politically viable means of financing a public catastrophic benefit” (p. 26), although they agreed that such a benefit is needed. Their report warned that “the omission of [a federally funded

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catastrophic health insurance program] means that millions of Americans will continue to face catastrophic expenses until they spend down to Medicaid eligibility (and the burden it will continue to impose on and be shared by states)” (p. 27). Unfortunately, it seems unlikely that any of these recommendations will be put into practice any time soon. In the meantime, Consumer Reports has provided pros and cons for each of the three major options for long-term care insurance policies (Stark, 2017): ■

Traditional Long-Term-Care Insurance: These policies will cover a specified amount for each day of nursing home care for a limited time, typically 3 years. One risk is that there are currently few protections against premiums for such policies, which average just under $2,800 per year, escalating year after year. Some states, such as Maryland, have limited annual increases, but a raise of even 15% per year (Maryland’s limit) still leaves the majority of consumers with premiums they can no longer afford in just a few short years. And, of course, as with all insurance, lapses in paying premiums result in cancellation of the policy.

■

Short-Term-Care Insurance: These policies pay for up to 360 days of care, and some may allow the care to be delivered in a person’s home or in a long-term care facility. An advantage of these policies is that the annual premium may be as much as one-third of the cost of traditional policies. A major risk is that the person will need significantly more than 1 year of care. Hybrid Life and Long-Term-Care Policies: As the name implies, these policies combine these two types of policies. They allow policyholders to use the death benefit from their life insurance to pay for their care, and heirs can still receive the full benefits of the life insurance if no payments are made for care. The downside is that the total cost of these policies, which average about $90,000, is usually paid up front. Over time, potential lost earnings that could have accrued from investing those dollars “could end up making hybrids the most expensive long-term-care policy of all” (p. 41).

■

Comparing Assisted Living Communities and Nursing Homes Need for supportive housing is generally determined by two measures of functional ability or functional status: activities of daily living (ADLs) and instrumental activities of daily living (IADLs). ADLs are basic personal care tasks needed to maintain independent living, including bathing, dressing, toileting, transferring between bed and chair, continence (controlling bladder and bowels), and eating. IADLs include tasks related to independent living—using a phone, shopping, preparing meals, housekeeping, doing laundry, taking medicines, transporting themselves (by car, bus, cab, etc.), and managing finances. As can be seen in Figure 11.4, there is a strong relationship between type of residential setting and limitations in ADLs and IADLs. Most older people who live in traditional communities have no limitations, whereas those who live in longterm care facilities usually have limitations in at least three ADLs. A comparison of data on selected characteristics of residents of assisted living communities and nursing homes is provided in Table 11.1. Overall, for both types of supportive housing, approximately half of the older residents are age 85 or over. Note, however, that a higher proportion of people under age 65 reside in nursing homes and that is because younger people with long-term disabilities are more likely to live there. Residents in both types of housing are much

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70

No functional limitations IADL limitation(s) only 1–2 ADL limitations 3 or more ADL limitations

60

Percent

50 40 30 20 10 0

Traditional Community

Community Housing Long-Term Care with Services Facilities

FIGURE 11.4  Percentage distribution of Medicare beneficiaries age 65+ with limitations in performing ADLs and IADLs, by residential setting, 2013. ADL, activities of daily living; IADL, instrumental activities of daily living. NOTE: Community housing with services: retirement communities/apartments, continuing care retirement f­acilities, assisted living facilities, and similar situations with access to one or more of these services (whether used or not) through the residence: meal preparation, cleaning/housekeeping services, laundry services, or help with ­medications. Long-term care (LTC) facility: residence/unit certified by Medicare or Medicaid; or with three or more beds, licensed as nursing home or other LTC facility, and provides at least one personal care service; or provides 24/7 ­supervision by a non-family, paid caregiver. LTC residents with no limitations may include individuals with ­limitations in performing certain ADLs, for example, doing housework or meal preparation. SOURCE: Federal Interagency Forum on Aging-Related Statistics. (2016). Older Americans. Key indicators of well-being. Washington, DC: U.S. Government Printing Office. Retrieved from https://agingstats.gov/docs/­ LatestReport/Older-Americans-2016-Key-Indicators-of-WellBeing.pdf

TABLE 11.1 Comparison of Assisted Living Facilities and Nursing Homes: Selected Residents’ Characteristics by Percentage ASSISTED LIVING %

NURSING HOME %

7.2

15.1

65–74

10.4

16.1

75–84

29.9

27.2

85+

52.6

41.6

Age Under 65

(continued )

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TABLE 11.1 Comparison of Assisted Living Facilities and Nursing Homes: Selected Residents’ Characteristics by Percentage (continued ) ASSISTED LIVING %

NURSING HOME %

Men

29.8

33.2

Women

70.2

66.8

2.5

5.2

Non-Hispanic White

84.3

76.1

Non-Hispanic Black

3.8

14.0

Other

9.3

4.7

Eating

19.8

58.0

Bathing

62.4

96.4

Dressing

47.4

91.8

Toileting

39.3

87.9

Walking/locomotion

29.1

90.7

Transferring in and out of chair/bed

29.7

85.2

15.1

62.9

Sex

Race and ethnicity Hispanic

ADL assistance

Medicaid as payer source

NOTES: Other race/ethnicity includes non-Hispanic American Indian/Alaskan Native, non-Hispanic Asian, non-Hispanic Native Hawaiian or other Pacific Islander, non-Hispanic of two or more races, and unknown race and ethnicity. ADL, activities of daily living. SOURCE: Harris-Kojetin, L., Sengupta, M., Park-Lee, E., Valverde, R., Caffrey, C., Rome, V., & Lendon, J. (2016). Long-term care providers and services users in the United States: Data from the National Study of Long-Term Care Providers, 2013-2014 (Table 4, p. 105). Vital and Health Statistics, Series 3, Analytical and epidemiological studies, number 38. Hyattsville, MD: U.S. Department of Health and Human Services. Retrieved from https://www.cdc.gov/ nchs/data/series/sr_03/sr03_038.pdf

more likely to be women than men and much more likely to be non-Hispanic White than another race/ethnicity. Non-Hispanic Blacks are a larger percentage of nursing home residents than assisted living residents. One of the biggest differences between residents can be found in their need for assistance for ADLs. To the extent that assisted living residents need assistance, it tends to be with bathing and dressing, whereas the vast majority of nursing home residents need assistance with almost all ADLs, except for eating, for which just over half of those residents receive help.

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The other big difference between residents is that Medicaid is a source of payment for only a very small percentage of assisted living residents, whereas it is a source of payment for a majority of nursing home residents. AssistedLiving.com has a self-assessment checklist to determine how to choose between an assisted living facility and a nursing home: www.assistedliving.com/assisted-living-versus-nursing-homes-02-08-2013. Additional information on the importance of careful planning when shopping for long-term care options is included in the Practical Application at the end of this chapter.

Finding and Evaluating Supportive Care Communities In considering a move to any supportive care community, be it a CCRC, assisted living, or a nursing home, it is essential to visit each potential choice to evaluate and compare them. To get started, there are many online sources to find possible options and then to evaluate them. With limited regulation of CCRCs, and no required licensing or accreditation, it is all the more important that anyone contemplating moving into such a community ensure that he or she learn the services, costs, and nature of the contracts being offered by each of the communities being considered. CCRCs that have opted to be accredited by the CARF can be located through that organization’s website: www.carf.org/advancedProviderSearch.aspx. Pull-down menus on the site can be used to choose geographical location, program, and age group/special population. A nonprofit organization of residents and would-be residents of CCRCs, the National Continuing Care Residents Association (NaCCRA) works to promote, protect, and improve the CCRC lifestyle. Its website—https://www.naccra.com—has excellent resources, including a consumer’s guide, written by residents of CCRCs, for those considering moving to a CCRC. Legg Mason, a for-profit asset management company, has a downloadable worksheet for assessing CCRCs, which can be accessed through www.leggmason.com/en-us/perspectives/in-focus/retirement/ aging.html For assisted living communities, the National Center for Assisted Living (NCAL) furnishes resources for consumers to find and collect information on communities that are organized by state. Links to each state’s financial assistance programs, long-term ombudsman program, and licensing agency can also be found on NCAL’s website (www.ahcancal.org/ncal/about/assistedliving/Pages/ local.aspx). In addition, A Place for Mom ranks the amount and usability of information on the website of the agency in each state that licenses or certifies assisted living residences and also provides details about those residences in most states (to the extent that details are available), including contact information and documentation of state inspections and violations of regulations: www.aplaceformom.com/blog/checking-assisted-living-violations-07-26-2013. For example, Florida’s website is ranked number one because it has a form that is easy to use, the state agency updates its information regularly, and all records pertaining to the state’s facilities are fully accessible online. Louisiana’s website is ranked number 50 because it provides only very basic information about its facilities and the state’s records are not available online. Legg Mason also has a downloadable worksheet for assessing assisted living communities, which can be accessed through www.leggmason.com/en-us/ perspectives/in-focus/retirement/aging.html. AARP offers helpful information on finding assisted living residences and tips for planning visits and reviewing contracts at www.aarp.org/caregiving/ basics/info-2017/assisted-living-options.html as well as a downloadable checklist to fill out during a visit—assets.aarp.org/external_sites/caregiving/checklists/checklist_assistedLiving.html The best resource for finding and evaluating nursing homes is Nursing Home Compare (www .medicare.gov/NursingHomeCompare), a Medicare website that contains details about more than

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15,000 nursing homes around the country that are certified by Medicare and Medicaid. These details include general information about nursing homes, star ratings, quality of resident care, staffing, health and fire safety inspections, and penalties that have been levied for serious health or fire safety violations. Nursing homes can be compared by entering a zip code, city and state, or state alone. There is also an option to enter the name of a nursing home. Legg Mason has a downloadable worksheet for assessing nursing homes, which can be accessed through www .leggmason.com/en-us/perspectives/in-focus/retirement/aging.html. In addition, AARP offers several resources from how to inspect a nursing home to how to research a nursing home at www .aarp.org/caregiving/local/info-2017/nursing-homes-checklist.html as well as a downloadable checklist to fill out during a visit—assets.aarp.org/external_sites/caregiving/checklists/checklist_ nursingHomes.html If visiting communities in person is not a viable option, help is available. The local Area Agency on Aging (AAA) or state unit on aging, which can be found at www.eldercare.gov, can connect consumers with a long-term care ombudsman who will be familiar with facilities under his or her jurisdiction. Another possibility is to hire an Aging Life Care Professional who can help older adults and family members select some initial options and then winnow them down to the choice that best suits the older adult’s preferences and needs. A local Aging Life Care Professional, who can be found through the website of the national Aging Life Care Association—www.aginglifecare.org—can also take older clients to tour each of the communities they are considering.

PRACTICAL APPLICATION INTRODUCTION

Chapter 11 describes medical conditions experienced by older adults and outlines the major features of continuing care retirement communities, assisted living communities, and nursing homes. It also highlights the difficulty many people face in paying for the long-term care they need. Given the significant financial burden of long-term care, it is the focus of this Practical Application. PLANNING FOR LONG-TERM CARE

For many, paying for long-term care will be the single greatest financial investment of their lives. This being the case, why is it that so many individuals do not carefully plan and shop for needed long-term care? This could be compared to someone going to shop for a new luxury vehicle and buying the first one they see, without ever taking a test drive, kicking the tires, or doing extensive comparisons of the costs and features of different models and brands. This just would not happen, so why does it happen with the purchase of the much more expensive long-term care placement and services? The answer to this question often relates to the fact that family caregivers and many older adults themselves fail to plan ahead and be proactive. Instead, they are reactive when in crisis. This may be because it is difficult for individuals to think that they themselves or someone they love might grow old, frail, and dependent on others for care. Therefore, the role of the professional working in this field is to support older persons and their family members in times of crisis, as well as work proactively to educate and encourage advanced planning for the successful aging of all.

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STUDENT ACTIVITIES 1. Norma, age 62, is starting to experience joint pain associated with arthritis. Outline 2.

3.

4. 5.

steps she can take to treat her arthritis and prevent it from getting worse. Identify who, among older adults, is most at risk for the following medical conditions. ○ HIV/AIDS ○ Osteoporosis ○ Eye diseases ○ Sleep disorders Visit the websites of three nursing homes in your town or state. Identify three similarities and three differences in the services or environments they offer. Try to determine whether they are “culture change adopters,” “culture change strivers,” or “traditional nursing homes,” according to the culture change model developed by the Pioneer Network. Write a description of your ideal assisted living community that caters to your own unique interests. Highlight activities or amenities that would be unique to your community. Write a paragraph outlining and explaining your position on where funding should come from for long-term care in the United States.

SUGGESTED RESOURCES Medicare. (n.d.). Retrieved from https://www.medicare.gov/forms-help-and-resources/index.html Through this part of the Medicare website, consumers can find and compare healthcare providers, home health agencies, hospitals, medical item suppliers, nursing homes, health and drug plans, and dialysis facilities. Data are updated regularly. National Center for Assisted Living. (n.d.). Retrieved from https://www.ahcancal.org/ncal/about/ assistedliving/Pages/local.aspx This nonprofit center is dedicated to serving the needs of the assisted living profession and the individuals the profession serves through national advocacy, quality initiatives, and professional development. It is the assisted living voice of the American Health Care Association, the nation’s largest organization representing long-term care. Its URL links to the center’s webpage that provides information and resources for consumers. National Diabetes Prevention Program. (n.d.). Retrieved from https://www.cdc.gov/diabetes/prevention/ index.html The Centers for Disease Control and Prevention’s (CDC) website for this prevention program has information for the public—about prediabetes and type 2 diabetes, the CDC-recognized researchbased prevention program and how to locate one—and information for professionals on implementing a program, screening and referring patients, and adding a program as a health benefit. National Institute on Aging, Health Information. (n.d.). Retrieved from https://www.nia.nih.gov/health On this website is information on more than 80 topics related to health and aging, including chronic diseases, assisted living and nursing homes, and information for healthcare professionals (e.g., Talking with your older patient). Pioneer Network. (n.d.). Retrieved from https://www.pioneernetwork.net The Pioneer Network is a national, nonprofit organization that works to promote culture change and person-centered care for older adults. Its resource library, which can be accessed through its website, provides tools for providers to get started in developing components of the nursing home that will reflect the culture change model of person-directed care.

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National Center for Health Statistics. (2017). Health, United States, 2016: With chartbook on long-term trends in health (DHHS Publication No. 2017-1232). Hyattsville, MD: Author. Retrieved from https:// www.cdc.gov/nchs/data/hus/hus16.pdf National Council on Aging. (2016). Chronic disease self-management: Fact sheet. Retrieved from https:// www.ncoa.org/resources/fact-sheet-cdsmp Ory, M. G., Ahn, S., Jiang, L., Smith, M. L., Ritter, P. L., Whitelaw, N., & Lorig, K. (2013). Successes of a national study of the Chronic Disease Management Program: Meeting the triple aim of health care reform. Medical Care, 51(11), 992–998. doi:10.1097/MLR.0b013e3182a95dd1 Ostrov, B. F. (2016, March 17). Long-term care insurance: Less bang, more buck. Kaiser Health News. Retrieved from https://khn.org/news/long-term-care-insurance-less-bang-more-buck Oswald, F., & Rowles, G. D. (2006). Beyond the relocation trauma in old age: New trends in today’s elders’ residential decisions. In H.-W. Wahl, C. Tesch-Romer, & A. Hoff (Eds.), New dynamics in old age: Environmental and societal perspectives (pp. 127–152). Amityville, NY: Baywood Publishing. Patient Protection and Affordable Care Act. (2010). H.R. 3590. Retrieved from https://www.gpo.gov/ fdsys/pkg/BILLS-111hr3590enr/pdf/BILLS-111hr3590enr.pdf Pioneer Network. (n.d.). Pioneers in culture change and person-centered care. Retrieved from https:// www.pioneernetwork.net/about-us/overview Riekse, R., & Holstege, H. (1996). Growing older in America. New York, NY: McGraw-Hill. Rutman, D. L., & Freedman, J. L. (1988). Anticipating relocation: Coping strategies and the meaning of home for older people. Canadian Journal on Aging, 7(1), 17–31. doi:10.1017/S071498080000708X Self-Management Resource Center. (2018). History of Stanford self-management programs. Retrieved from https://www.selfmanagementresource.com/about/history/ Shugarman, L. R. (2010). Health care reform and long-term care: The whole is greater than the sum of its parts. Public Policy and Aging Report, 20(2), 3–7. doi:10.1093/ppar/20.2.3 Stark, E. (2017, October). Long-term-care insurance gets a makeover. Consumer Reports, pp. 40–41. United Health Foundation. (2016, May). America’s health rankings: Senior report. Retrieved from http:// www.americashealthrankings.org Urban Institute. (2015, July). Vision of a better future for people needing long-term services and supports. Long-Term Care Financing Collaborative. Retrieved from https://www.urban.org/research/ publication/vision-better-future-people-needing-long-term-services-and-supports Wallace, T. C. (2017). Dried plums, prunes and bone health: A comprehensive review. Nutrients, 9, 401. doi:10.3390/nu9040401 Whelton, P. K., Carey, R. M., Aronow, W. S., Casey, D. E., Jr., Collins, K. J., Himmelfarb, C. D., .  .  . Wright, J. T., Jr. (2018). 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/ PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults. Journal of the American College of Cardiology. Advance online publication. doi:10.1016/ j.jacc.2017.11.006 Wright, N. C., Looker, A. C., Saag, K. G., Curtis, J. R., Delzell, E. S. Randall, S., & Dawson-Hughes, B. (2016). The recent prevalence of osteoporosis and low bone mass in the United States based on bone mineral density at the femoral neck or lumbar spine. Journal of Bone Mineral Research, 29(11), 2520–2526. doi:10.1002/jbmr.2269

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12

ME DI C AR E , ME D I C A I D , AND ME DI C AT I O N S

LEARNING OBJECTIVES • Identify who is eligible for Medicare and outline each of its parts. • Explain how Medicare is funded and the current status of its trust funds. • Describe what a Medigap policy is. • Compare and contrast Medicare and Medicaid. • Select the primary causes of medication-related problems among older adults. • Discuss ways to reduce medication-related problems among older adults.

STORY Mary Land, of Racine, Wisconsin, knows the value of Medicare all too well after watching her mother, [age] 88, cope with a diagnosis of Parkinson’s disease and make remarkable progress. “My mother was just able to use her Medicare benefits to enter into a rehab facility earlier in 2015,” says Mary. “Without the rehab she could not even move at all. At all! She is now home and dressing herself and enjoying her life. She can transport herself upstairs and get in and out of bed. Without Medicare—none of this would have been possible. She would have just wasted away.” —December 2, 2016, retiredamericans.org/medicare-stories-mary-land (continued next page )

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A 71-year-old female accidentally received thiothixene (Navane), an antipsychotic, instead of her anti-hypertensive medication amlodipine (Norvasc) for 3 months. [The written prescription was deemed legible.] She sustained physical and psychological harm including ambulatory dysfunction, tremors, mood swings, and personality changes. Despite the many opportunities for intervention, multiple healthcare providers overlooked her symptoms. . . . [Following] a diagnosis of thiothixene-related drug-induced Parkinsonism . . . thiothixene was discontinued and her clinical status improved. —da Silva & Krishnamurthy, 2016

MEDICARE Medicare is the nation’s health insurance program for individuals aged 65 and over and certain younger people who are severely disabled. Recognition of the vulnerability of older people to soaring medical costs was one factor that led to the passage of Medicare in 1965. A report of results from the Social Security Administration’s 1963 Survey of the Aged noted that, For many persons who are living longer because of medical sciences, the added years are years of economic insecurity. Insecurity is heightened by the ever-present, gnawing anxiety that one serious illness may wipe out a life’s savings and leave the older person dependent on children, a public assistance agency, or both, for financial help. (Langford, 1964, p.3) A part of President Lyndon Johnson’s Great Society, Medicare goes a long way toward protecting the finances of Medicare recipients and their families. Medicare is an intergenerational program because it can benefit people of all ages, as well as family members of those who are eligible for the program. The most recognized beneficiaries are Americans aged 65 and older—47.8 million in 2016—but the program also provides health benefits to American workers who have become severely disabled or people who suffer from end-stage renal disease (kidney failure requiring dialysis or a kidney transplant) or ALS (amyotrophic lateral sclerosis, Lou Gehrig’s disease)—an additional 9 million people in 2016 (Medicare Board of Trustees, 2017). Without Medicare, the cost of health insurance for older people would be prohibitive, so many family members would find that they would need to assume responsibility for their parents’ and grandparents’ (and even great grandparents’) healthcare costs. In 2016, half of all Medicare beneficiaries were living on less than $26,200 and one-quarter were living on less than $15,250 (Jacobson, Griffin, Neuman, & Smith, 2017). With 93% of the nation’s noninstitutionalized persons aged 65 and older enrolled in Medicare in 2015 (Administration on Aging, U.S. Department of Health and Human Services, 2016), the program’s importance to older Americans and their families is clear. Furthermore, 97% of older people report that they have a usual place to go for medical care, and only 2% say that they could not obtain needed medical care during the previous 12 months due to financial barriers (Administration on Aging, U.S. Department of Health and Human Services, 2016). Medicare covers many types of services and other benefits through four distinct parts: ■ ■

Part A (Hospital Insurance) Part B (Medical Insurance)

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Part C (Medicare Advantage) Part D (Prescription Drug Benefit)

Those who are eligible for Medicare have options for how they receive their coverage. Beneficiaries can receive Medicare through Part A and Part B, which together are referred to as Original Medicare. Original Medicare is a traditional fee-for-service (or pay-per-visit) coverage under which Medicare funds are used to pay healthcare providers directly for parts A and B benefits. In 2016, 68% of beneficiaries opted for Original Medicare (Medicare Board of Trustees, 2017). Enrollees in Original Medicare can add to their health insurance coverage with a Part D plan and, if they so choose, a Medigap policy. Part C is another way to receive Medicare benefits. It combines Part A and Part B, and usually Part D. Both Part C and Part D are managed by private insurance companies approved by Medicare. Online portals that are accessed through the Medicare website make it possible to compare hospitals, nursing homes, physicians, home health agencies, dialysis facilities, hospice providers, inpatient rehabilitation facilities, and long-term care hospitals (data.medicare.gov). For example, quality of care can be compared across over 4,000 Medicare-certified hospitals in the United States on a whole host of measures, including ambulatory surgery, cancer treatment, complications and deaths, hospital readmissions, joint replacement care, outpatient procedures, patient surveys, timely and effective care, and more.

Medicare Part A: Hospital Insurance Medicare Part A is hospital insurance (HI) that helps cover medically necessary inpatient care in hospitals, inpatient care in skilled nursing facilities, home healthcare, and hospice. Details about the benefits associated with each of these four areas of coverage are in Table 12.1. The opening scenario of this TABLE 12.1 Medicare Part A Benefits 2017 Hospital care

Inpatient hospital services and supplies (semi-private rooms, general nursing, meals, drugs); inpatient mental healthcare. Premium: $0 for most people Deductible: $1,316 Days 1–60: $0 Days 61–90: $329 per day Days 91–150: $658 per daya Days 151 and beyond: all costs 20% of cost of inpatient mental health services from physicians and other providers

Skilled nursing facility care

Inpatient skilled nursing and rehabilitative services (semi-private room, meals, drugs); medical supplies and equipment. After 3 days or more of inpatient hospital stay. Days 1–20: $0 Days 21–100: $164.50 per day Days 101 and beyond: all costs (continued )

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TABLE 12.1 Medicare Part A Benefits 2017 (continued ) Home health services

Intermittent skilled nursing care; physical and occupational therapy, speech-language pathology services, medical social services, medical supplies, durable medical equipment. Must be homebound. Covered services: $0 Durable medical equipment: 20% coinsurance

Hospice care

Physician, nursing, and social work services; physical, occupational, speech-language therapy; dietary counseling; drugs for symptom control and pain relief; medical equipment and supplies; spiritual and grief counseling for patient and his or her family; inpatient respite care. Focus on comfort and pain relief for those with a life expectancy of 6 months or fewer. Hospice care: $0 Prescriptions: $5 copayment each Respite care: 5% coinsurance

a

Days 91 to 150 are lifetime reserve days, a total of 60 additional days that can be used during a lifetime.

NOTE: All Medicare Part A services must be medically necessary. Part B pays for most physician services for inpatients.

chapter describes an older person who was able to use rehabilitation services covered by Part A, which subsequently enabled her to return home following her diagnosis of Parkinson’s. Most people do not pay a monthly premium to receive Part A benefits because they or their spouses paid Medicare taxes (1.45% of earned income) while in the workforce. People who do not meet this criterion may be able to get Part A coverage by paying a monthly premium ($413 in 2017). Those who opt for Original Medicare can go to any hospital, physician, or other healthcare provider that accepts Medicare, which is almost all of them. There is a website to locate providers and facilities that accept Medicare: www.medicare .gov/forms-help-and-resources/find-doctors-hospitals-and-facilities/quality-care-finder.html

Medicare Part B: Medical Insurance Medicare Part B is a voluntary program for Part A recipients. Most of the older people choose to enroll in it. Table 12.2 presents details about Part B benefits: medically necessary services, diagnostic tests and laboratory services, home health services, mental healthcare, and preventive and screening services. The Affordable Care Act added free annual wellness check-ups and eliminated deductibles and/or copayments for most of the preventive services. Additional details about these services, as well as updates on coverage, are available through Medicare’s website (www.medicare. gov). In 2017, enrollees paid a $183 annual deductible and a monthly premium of $134 (the standard for individuals who earn $85,000 or less, and joint tax filers who earn $170,000 or less); the premium is higher for the 5% of beneficiaries with a higher income. The Part B premium is usually deducted from monthly Social Security benefits.

Medicare Part C: Medicare Advantage Plans Part C plans, now referred to as Medicare Advantage plans, are offered by private companies that contract with Medicare to deliver Part A and Part B benefits to their patients, usually through

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TABLE 12.2 Medicare Part B Benefits 2017 Premium: $134 per month (for most people) Deductible: $183 per year Medically necessary services

Physician, ambulance, emergency department services; some physical, occupational, and speech-language therapy; cardiac and pulmonary rehabilitation; outpatient chemotherapy; durable medical equipment and supplies (e.g., canes, oxygen equipment; diabetic testing supplies) 20% coinsurance

Diagnostic tests and laboratory services

Diagnostic tests: CT scans, MRIs, EKGs, x-rays, PET scans; Clinical lab services: blood tests, urinalysis, some screening tests. Diagnostic tests: 20% coinsurance Clinical lab services: $0

Home health services

Part-time skilled nursing care; physical, occupational, and speechlanguage therapy; medical supplies; durable medical equipment. Must be homebound. Covered services: $0 Durable medical equipment: 20% coinsurance

Mental healthcare (outpatient)

Visits with a mental healthcare professional in office setting, clinic, or outpatient department for counseling or psychotherapy. Most services: 20% coinsurance

PREVENTIVE AND SCREENING SERVICES: $0 (FOR MOST SERVICES)

Wellness visits

“Welcome to Medicare” preventive visit within 12 months of Part B enrollment; annual wellness visits thereafter

Vaccinations

Flu (annual), hepatitis B, pneumonia

Screenings

Abdominal aortic aneurysm, bone density, cancer (breast, cervical, colorectal, lung, prostate, vaginal), cardiovascular disease, diabetes, glaucoma, Hepatitis C, HIV, depression

Other services

Screening and counseling for alcohol misuse, obesity, and sexually transmitted infections; behavioral therapy for cardiovascular disease; diabetes self-management training; medication management; nutrition therapy; tobacco use cessation counseling

NOTE: All Medicare Part B services must be medically necessary.

either an HMO (health maintenance organization) or a local PPO (preferred provider organization). Generally, these plans also incorporate prescription drug coverage (Part D). Although enrollees are typically restricted to using healthcare providers, hospitals, and other facilities within the plan’s network, they get all the benefits of Original Medicare and usually have extra benefits beyond what Original Medicare would pay for, such as vision care and health club memberships. Companies that offer these plans determine the monthly premiums, deductibles, copayments or

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coinsurance, and set their own rules for providing services, for example, whether enrollees must have a referral to see a specialist. In 2016, approximately 32% of Medicare beneficiaries chose to enroll in a Medicare Advantage plan (Medicare Board of Trustees, 2017), most of which are HMOs. In the first major study of provider networks in more than 400 Medicare Advantage plans, some heretofore unrecognized issues were uncovered, specifically the difficulty of finding information about network providers and hospitals, and the lack of accuracy of that information (Jacobson, Trilling, Neuman, Damico, & Gold, 2016). The researchers found that directories of providers were sometimes not available, others were hundreds to thousands of pages long with no index, and yet others contained multiple blatant errors, such as hospitals being listed though they had been closed for years. Being able to determine which providers and healthcare facilities are in a plan’s network is important for those who are considering enrolling in a Medicare Advantage plan. It is also important for those already enrolled who are seeking care, one of the reasons being that using an out-of-networker provider can be very expensive.

Medicare Part D: Prescription Drug Coverage The Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA, P.L. 108–173) established a new, voluntary prescription drug benefit under a new Medicare Part D, effective January 1, 2006. Prior to enactment of Medicare Part D, 25% of all older adults and 33% of older adults with low incomes had no prescription drug benefits. Medications were becoming more and more expensive, consuming an ever-increasing proportion of older adults’ fixed-incomes. Not surprisingly, then, research had shown that among older adults without drug coverage, even those with congestive heart failure, diabetes, or multiple chronic conditions were forgoing their medications or skipping doses due to costs, while others were cutting back on food and other basic needs so that they could pay for their prescriptions (Safran et al., 2005). The Medicare Part D program helps cover the cost of prescription drugs. All Part D plans must also cover all commercially available vaccines, such as the shingles vaccine, that are reasonable and necessary to prevent illness (except hepatitis B, influenza, and pneumococcal pneumonia, which are covered by Medicare Part B). All Medicare Part D plans must meet certain minimum requirements, but they are offered through private companies that have some flexibility in determining which drugs are covered and the costs (deductible, monthly premiums, and copayments/coinsurance), so there are significant differences among them. About 5% of Part D enrollees—people with individual incomes above $85,000 or joint incomes above $170,000—pay an income-related monthly adjustment amount in addition to their plan’s premium. Each calendar year, prescription drug insurance encompasses initial coverage, a coverage gap (informally known as the donut hole), and then catastrophic coverage. Figure 12.1 shows how much enrollees and Part D plans pay in each of these segments for 2017. Since 2010, the Affordable Care Act has gradually been reducing the amount enrollees pay for drugs while in the gap, and by 2019, enrollees will pay no more than 25% of drug costs in that gap. In general, to obtain their drug benefits, older adults must enroll in a plan when they first become eligible for Medicare, or pay a delayed enrollment surcharge that is effective for the entire time they are enrolled in Part D, usually for the rest of their lives. Why is there a surcharge for late enrollment? Think about how costly fire insurance for a home would be if everyone waited until their home was on fire before trying to purchase insurance. Although we purchase fire insurance hoping that we never have to collect on it, it is an important way for people who are

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Initial Coverage

Donut Hole

Catastrophic Coverage

 $3,700

$3,701 – $4,950

 $4,951

Sum of: • Part D payments • Deductible • Copays

Enrollee pays: • 40% of name-brand Rx costs • 51% of generic Rx costs

Enrollee pays: 5% of all Rx costs

FIGURE 12.1  Medicare prescription drug coverage (Part D), 2017.

not independently wealthy to be protected from shouldering the entire price of repairing or ­rebuilding their homes. And so it is for prescription drug coverage. If there was no surcharge for late ­enrollment in Part D, then people would almost certainly wait until they needed medications before they enrolled, and at that point the cost would be prohibitive for everyone. Medicare prescription drug plans can change from year to year, and individuals’ needs may also change. To ensure that their plans continue to meet their needs, older adults should review them annually and make adjustments to them or switch plans during the open enrollment p ­ eriod from October 15th to December 7th. Many states and the U.S. Virgin Islands offer help in paying for drugs. For example, the Maine Low Cost Drugs for the Elderly or Disabled Program will pay 80% minus $2 of the cost of most drugs for those who are eligible for their state’s program. I­ nformation about these State Pharmaceutical Assistance Programs can be found at www.­medicare.gov/ pharmaceutical-assistance-program/state-programs.aspx

Enrolling in Medicare The Social Security Administration enrolls most people in Medicare, and the Centers for ­Medicare and Medicaid Services (CMS) administers it. Older adults who are receiving Social Security are automatically enrolled in Medicare Part A and Part B, and receive an Initial Enrollment Period Package, which includes their Medicare card, about 3 months prior to their 65th birthday. New Medicare cards have been designed to prevent identity theft and, as of April 2018, they are being

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provided to all current and future beneficiaries. For those who are getting Social Security due to a severe disability, their package will arrive about 3 months prior to their eligibility for Medicare benefits. Those who are not receiving retirement benefits from Social Security (e.g., because they are still working) need to sign up, which they can do online, via the phone, or by making an appointment at their local Social Security office, at least 3 months prior to turning age 65. The annual open enrollment period, between October 15th and December 7th, is a good time to review Medicare plans (Original Medicare, Medicare Advantage, Prescription Drug Plans, and Medigap policies) and make changes if so desired. A wealth of information about Medicare is available over the phone (1-800-MEDICARE) and online (www.medicare.gov). Also, every state has a State Health Insurance Assistance Program (SHIP) that provides free one-on-one health benefits counseling, which includes: help in making decisions on which plans to consider (Original Medicare vs. Medicare Advantage, Part D plans, and Medigap policies); information on programs for people with limited income and resources; and help with claims, billing, and appeals. SHIP programs can be located online through this website: www.shiptacenter.org

What Does Medicare Not Cover? Medicare covers most healthcare expenditure, but its emphasis is on acute care and does not cover everything. During inpatient hospital care, Medicare does not pay for private-duty nursing, a private room (unless medically necessary), or personal care items (e.g., razors, toothbrushes). In addition, services and other items not covered are: ■ ■ ■

■

Routine eye exams, hearing exams, dental care, and foot care (the latter may be covered for certain conditions, e.g., diabetes) Eyeglasses and contact lenses (except after cataract surgery), hearing aids and fittings, and most dental procedures (e.g., cleanings, fillings, tooth extractions, or dentures) Nursing home care or long-term care, private-duty nurses, and custodial care (nonskilled personal care to help with activities of daily living), except for limited skilled nursing facility care under certain conditions Healthcare outside the United States (with very limited exceptions)

Medigap Policies: Medicare Supplement Insurance for Original Medicare Beneficiaries A Medigap policy is private health insurance that supplements Original Medicare (Parts A and B). It helps pay for some of the out-of-pocket costs that Original Medicare does not cover—for example, deductibles, coinsurance, and copayments—and may include certain additional benefits, such as emergency foreign travel. Medigap policies are sold by private insurance companies and overseen by state governments, which must follow federal regulations on these policies. In most cases, insurance companies can sell only standardized Medigap policies (identified by letters A through N) so that consumers can compare them easily, though companies are not required to sell all possible policies. Cost is usually the only difference between policies with the same letter sold by different companies. Because states determine the types of policies that can be sold to their residents, there are variations among the states in the plans that are available. The best time to buy a Medigap policy is within 6 months of enrolling in Medicare Part B. The reason

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is that during this open enrollment period, insurance companies are prohibited from doing any of these things because of a person’s health problems: refusing to sell a person any Medigap policy it offers, charging more for a policy than it charges someone with no health problems, or adding a waiting period for coverage to begin. All standardized Medigap policies are guaranteed renewable even for those with health problems, as long as the enrollee pays his or her premium on time. As of December 2015, 32% of Original Medicare beneficiaries were enrolled in a Medigap policy, a total of 11.8 million people (America’s Health Insurance Plans, 2017a). A recent survey of older adults with Medigap policies found that 89% of them were satisfied with their policy and appreciated the cost-savings and quality of care their policy offered (America’s Health Insurance Plans, 2017b). More information on Medigap policies, including how to find policies, is available on the Medicare website (www.medicare.gov/supplements-other-insurance/whats-medicare -supplement-insurance-medigap). SHIP programs, which were described in the section titled Enrolling in Medicare, can also help.

Help With Medical Costs Older adults with limited income and resources may find that they need help to cover Medicare’s out-of-pocket costs. Medicare Savings Programs administered by states may help pay Medicare premiums, and in some cases, the Part A and Part B deductibles, coinsurance, and copayments. Through the Qualified Medicare Beneficiary program, states pay Part A and/or Part B premiums, deductibles, coinsurance, and copayments for older people whose poverty-level incomes and resources make them eligible. For older people with slightly more income and resources, the Specified Low-Income Medicare Beneficiary and Qualifying Individual programs will pay Part B premiums for those who are eligible, and for Qualified Disabled and Working Individuals, states will pay Part A premiums. Information about these Medicare Savings Programs can be found at local Social Security offices, and on Medicare’s website (www.medicare.gov/your-medicare-costs/ help-paying-costs/get-help-paying-costs.html).

Funding Medicare The Social Security Act established the Medicare Board of Trustees to oversee the financial operations of Medicare’s two trust funds, which are held by the U.S. Treasury—the Hospital Insurance (HI) Trust Fund and the Supplementary Medical Insurance (SMI) Trust Fund. The Act requires that the Board, among other duties, report annually to the Congress on the financial and actuarial status of the funds (Medicare Board of Trustees, 2017). Table 12.3 presents Medicare data for calendar year 2016, in total and for each part of the program. Sources of income for Medicare, as shown in Table 12.3, include: payroll taxes, interest earned on trust funds, taxation of benefits, premiums, general tax revenue, and “other” (which includes individual states’ funding on Parts B and D). The HI Trust Fund pays for Medicare’s Part A benefits and its administration. Inpatient hospital care is by far the greatest share of Part A benefits; the cost of a hospital stay varies from state to state and even from hospital to hospital, but the national average is approximately $10,000 per day. HI is funded primarily through payroll taxes on employees—1.45% of earned income, which is matched by employers. Employees earning in excess of $200,000 per calendar year ($250,000 for married couples filing jointly) pay an additional 0.9% on the “excess” income (which is not matched by employers). In 2013, Medicare taxes began to be

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TABLE 12.3 Medicare Data for Calendar Year 2016 SUPPLEMENTARY MEDICAL INSURANCE HEALTH INSURANCE PART A

MEDICAL INSURANCE PART B

PRESCRIPTION DRUGS PART D

PART A + B+D TOTAL

Assets at end of 2015 (billions)

$193.8

$68.2

$1.3

$263.2

Total Income

$290.8

$313.2

$106.2

$710.2

253.5

—

—

253.5

7.7

2.1

0.0

9.8

23.0

—

—

23.0

Premiums

3.3

72.1

13.8

89.1

General revenue

1.2

235.6

82.4

319.2

Other

2.1

3.4

10.0

15.5

$285.4

$293.4

$100.0

$678.7

280.5

289.5

99.5

669.5

141.3

49.6

—

191.0

29.1

—

—

29.1

7.1

11.5

—

18.5

—

69.9

—

69.9

85.2

103.4

—

188.6

—

—

99.5

99.5

17.8

55.0

—

72.8

4.9

3.9

0.5

9.2

$199.1

$88.0

$7.6

$294.7

Payroll taxes Interest Taxation of benefits

Total Expenditures Benefits Hospital Skilled nursing facility Home healthcare Physicians’ fee schedule services Private health plans (Part C) Prescription drugs Other Administrative expenses Assets at end of 2016 (billions)

NOTE: Totals do not necessarily equal the sums of rounded components. SOURCE: Medicare Board of Trustees. (2017). Trustees Reports (current and prior). Washington, DC: The Boards of Trustees of the Federal Hospital Insurance and Federal Supplementary Medical Insurance Trust Funds. Retrieved from https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/ReportsTrust Funds/TrusteesReports.html

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levied on investment income—3.8% on income from dividends, interest, annuities, royalties, and capital gains (referred to as Unearned Income Medicare Contribution Surtax, or the Net Investment Income Tax). Other sources of funds for the HI Trust Fund include interest earned on Medicare trust fund investments, income taxes paid on benefits, and premiums from people who pay a Part A premium. The SMI Trust Fund pays for Part B and Part D benefits and their administration. As can be seen in Table 12.3, it is funded through a combination of premiums paid by enrollees in Part B and Part D, interest on SMI trust funds, and transfers from the U.S. Treasury’s general fund. Beneficiaries can choose to receive all their Medicare services through managed care plans under the Part C program, in which case payment is made on their behalf in appropriate parts from the HI and SMI trust funds, and includes any premiums Part C enrollees may pay. Compared to private insurance plans, Medicare’s coverage is more cost-effective, and part of the reason is that its administrative costs are so much lower, just 3% of total expenditures. As shown in Table 12.3, total income for Medicare was $710.2 billion and total expenditures were $678.7 billion in 2016. Total assets of the Medicare funds actually increased in 2016 by $31.5 billion. In recent years, there has been considerable debate about the increasing costs of Medicare; the depletion of Medicare Trust Funds in the absence of changes in funding; how costs can be curtailed; and, recently, whether we should even have this national health insurance program for older adults and other eligible beneficiaries. In 1970, just 5 years after Medicare was introduced, the Medicare Trustees’s report projected insolvency for the HI Trust Fund by 1972, and in 1997 the Trustees were projecting insolvency by 2001 (Zorn, 2011). Of course, changes to Medicare since its inception have kept it from running low on funds, and changes will continue to be necessary to keep it so. Keeping rapidly growing costs in check is a problem for all healthcare entities. Medicare Part B and Part D accounts in the SMI [supplemental medical insurance] trust fund are expected to be adequately financed because premium income and general revenue income are reset each year to cover expected costs” (Medicare Board of Trustees, 2017, p. 9). Medicare Part A’s expenditures, however, have been increasing at a faster rate than its income. Among the changes that could improve Medicare benefits as well as its financial health are:” ■

■

■

Equalize the payments for beneficiaries’ services so that they are the same for those enrolled in Original Medicare and those enrolled in private Medicare Advantage plans. (Medicare currently pays extra for Medicare Advantage enrollees.) Waive the requirement for a 3-day hospital stay prior to covering care in a rehabilitation facility. (Inpatient hospital services are the largest source of expenditures for Medicare Part A.) Amend the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 to enable Medicare to negotiate the best possible drug prices, as the Veterans Administration and Department of Defense are able to do.

Until recently, little effort had been focused on how to keep older people and other Medicare-eligible recipients healthier and thereby avoid costly hospitalizations and treatments. Now beneficiaries can take advantage of preventive services, such as cancer screenings and tobacco cessation programs, at little or no cost. But much more needs to be done to maximize health and quality of life in the later years, and most such actions can lead to significant cost

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savings, too. For example, most cases of chronic kidney disease are caused by diabetes and high blood pressure, two preventable health conditions. And yet, Medicare’s expenditures for endstage renal disease alone, which results from a lack of prevention and early interventions for kidney disease, were $44.9 billion, more than $75,000 for each of the 597,212 patients on dialysis in 2015 (United States Renal Data System, 2017). We are only beginning to scratch the surface in terms of our prevention efforts and making better use of our healthcare dollars for prevention and treatments that are demonstrated to be effective.

MEDICAID Medicare and Medicaid are often confused with each other, likely due, at least in part, to their similar names. Older adults can benefit from both Medicare and Medicaid, if they meet the respective eligibility requirements of each program, in which case they are deemed dual-eligible beneficiaries. Although both programs relate to healthcare services, they are distinct programs. Differences between the two programs encompass eligibility criteria, administration, services, funding, and costs. Eligibility for Medicare requires being aged 65 or older, or having ALS or endstage renal disease, or being a worker who is permanently disabled. On the other hand, eligibility for Medicaid is based on need; that is, a person must have limited income and financial resources. Medicare is administered by the federal government. Thus, Medicare coverage, rules, and regulations are similar throughout the United States. On the other hand, Medicaid is a cooperative program between the federal government and state governments. Following national guidelines established by federal laws, regulations, and policies, each state: establishes its own eligibility standards; determines the type, amount, duration, and scope of services; sets the rate of payment for services; and administers its own program. Thus, there is wide variability among states in their definitions and determination of eligibility, in the services that are offered, and in the costs of those services. Healthcare services covered by Medicare were described in the preceding paragraph. Medicaid covers services that are medically necessary, as determined by the state, and typically also covers additional services beyond those provided under Medicare, including long-term care in the community and in nursing homes, vision care, and hearing aids. Medicare funding comes from payroll taxes that beneficiaries paid while they were employed, and then through premiums, deductibles, and copayments that beneficiaries pay when they are using their benefits. On the other hand, Medicaid’s funding comes from federal, state, and local tax funds, and sometimes from small copayments.

Dual-Eligible Beneficiaries It is possible to be enrolled in both Medicare and Medicaid, and dual-eligible beneficiaries is the term applied to those who are. In 2016, approximately 20% of Medicare recipients qualified as dually eligible for Medicaid (CMS Medicare-Medicaid Coordination Office, 2017). Dual-eligible beneficiaries in 2016 numbered 11.7  million people, comprising 7  million older people and 4.7 million people with disabilities, the majority of whom were female (60%) and white (63%). Most people who are dually eligible receive full Medicaid benefits, with help on their Medicare out-of-pocket expenses, such as premiums, deductibles, and copayments, as well as additional services beyond those provided under Medicare, including long-term care in the community and nursing homes, vision care, and hearing aids. Services covered by both programs are first paid by

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Medicare, with Medicaid filling in the difference up to the state’s payment limit. Those dual-eligible beneficiaries who do not qualify for full Medicaid benefits may receive partial benefits, which cover only Medicare out-of-pocket expenses.

MEDICATIONS Medications play an essential role in the health of older adults. “Geriatric health care professionals and their patients rely heavily on pharmacotherapy to cure or manage diseases, palliate symptoms, improve functional status and quality of life, and potentially prolong survival” (Naples, Handler, Maher, Schmader, & Hanlon, 2017, p. 849). As we age, the likelihood of acquiring one or more medical conditions increases, as was discussed in Chapter 11, Medical Conditions, Assisted Living, and LongTerm Care. Thus, we should not be surprised that, on average, older adults take more medications than younger people do. In addition, advances in pharmaceutical research and development have meant that many more options are now available to treat and ameliorate symptoms of many medical conditions, which is generally a very good thing. Although side effects of medications are usually well known, older adults can experience other potentially serious problems from taking medications. The way that medications are absorbed and used by the body can change with age. For example, changes in the digestive system can affect how fast medications enter the bloodstream. Changes in body weight can influence the amount of medication needed and how long it stays in the body. The circulatory system may slow down, which can affect how fast medications get to the liver and kidneys. The liver and kidneys also may work more slowly, affecting the way a medication breaks down and is removed from the body. These age-related changes make older adults more susceptible to medication-related problems.

Prescriptions, Over-the-Counter Medications, and Dietary Supplements In a nationally representative sample of community-dwelling older Americans (aged 62–85 years of age), researchers have found that 36% are concurrently using at least five prescription medications (Qato, Wilder, Schuum, Gillet, & Alexander, 2016). Taking multiple medications concurrently is referred to as polypharmacy. Antihypertensives (to reduce blood pressure), statins (to lower cholesterol), antiplatelets (to decrease risk of blood clots), and analgesics (to reduce pain) are prescription medications used most frequently by older people. Over-the-counter medications, which do not require a prescription, are regularly used by 38% of older Americans, the most common ones being aspirin (for pain relief and to lower the risk of heart attacks) and omeprazole (used to counter excess acid in the stomach; Qato et al., 2016). And, although research has not supported the use of dietary supplements to improve health, they are regularly used by 64% of older Americans, and 47% use two or more concurrently (Qato et al., 2016). The supplements used most often are multivitamins and calcium. Most consumers do not realize that the U.S. Food and Drug Administration (FDA) does not have the authority to review supplements for their safety and effectiveness prior to them going on the market, as it does for prescription and over-the-counter (OTC) medications. The FDA can take actions against companies if their products are found to be unsafe, falsely labeled, or making claims with respect to prevention, diagnosis, or treatment of a disease. Such actions may be too late for some consumers. Navarro et al. (2014) found that supplements, especially those marketed for bodybuilding and to lose weight, and surprisingly also pills containing concentrated amounts of green tea extracts, can cause serious liver damage and may even result in death.

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Medication-Related Problems Although medication-related problems can affect people of all ages, they are especially prevalent among older adults because so many more of these problems occur in this population and the negative effects can be so much more hazardous to their health. Age-related physiological changes and polypharmacy are two reasons for the greater prevalence of these problems in older adults. Another reason is that research on new drugs seldom includes older participants, so physiological changes can more easily lead to doses of medication that are too low, in which case they may not have their intended benefits, or too high, in which case they can cause dangerous side effects. Polypharmacy is also associated with a higher risk of side effects and adverse drug reactions, which are problematic in their own right, and worse yet, they can both lead to yet more drugs being prescribed. Other reasons for medication-related problems are undertreatment, medication error, lack of adherence, potentially inappropriate drug use, and adverse drug reactions. Undertreatment is the result of medication not being prescribed when in fact it would be beneficial. Common examples of undertreatment in older adults occur in pain management, secondary heart attack prevention, and depression. A medication error is any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the health care professional, patient, or consumer. Such events may be related to professional practice, health care products, procedures, and systems, including prescribing, order communication, product labeling, packaging, and nomenclature, compounding, dispensing, distribution, administration, education, monitoring, and use. (National Coordinating Council for Medication Error Reporting and Prevention, 2017) The second scenario at the beginning of this chapter exemplifies this type of medicationrelated problem, beginning with the incorrect prescription being given to the patient, presumably because the name of the incorrect drug resembled the name of the drug that was meant to be given to the patient. Another error was the lack of monitoring of the patient’s medications. Additionally, if the patient had been fully informed about possible side effects of the drug she was to have received, she could have alerted her healthcare provider when she began experiencing different ones. Lack of adherence to medication regimens is another source of medication-related problems. Nonadherence can be unintentional, for example, due to poor instructions or misunderstanding of instructions for taking medication, and complicated regimens, especially when multiple medications are being taken. In a review of medication regimens for 200 adults aged 70 and older, a pharmacist and a physician agreed that more than 50% of the regimens were overly complicated and could easily be simplified to improve adherence (Lindquist, Lindquist, Zickuhr, Friesema, & Wolf, 2014). Nonadherence can also be intentional, for example, reducing dosages or not filling prescriptions due to cost, wanting to avoid unpleasant side effects, or feeling that the medication is no longer needed because symptoms seem to have gone away. The latter reason often occurs in the case of drugs for high blood pressure and antibiotics. Lack of adherence to medication regimens leads to emergency room visits, hospitalizations, outpatient visits, and yet more prescription drugs, all of which negatively affect patients and their loved ones, and all of which are avoidable. Costs to the U.S. healthcare system were estimated to be over $100 billion in 2012 (IMS Institute for Healthcare Informatics, 2013).

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Potentially Inappropriate Drug Use In the late 1980s and early 1990s, the late geriatrician Mark Beers discovered that particular kinds of drugs were leading to serious side effects in nursing home residents. For this reason, he developed criteria for potentially inappropriate medications that should not be prescribed, or that should be carefully considered before being prescribed, for older adults because the harm from these medications outweighs their benefits (Beers, Ouslander, Rollingher, Reuben, & Beck, 1991). The American Geriatrics Society (AGS) has since assumed responsibility for keeping the criteria up to date. There are now several sets of the AGS Beers Criteria (AGS, 2015), namely, ■ ■ ■ ■ ■

Potentially inappropriate medication use in older adults Potentially inappropriate medication use in older adults due to drug–disease or drug–syndrome interactions Potentially inappropriate medications to be used with caution in older adults Potentially clinically important drug–drug interactions to be avoided in older adults Medications that should be avoided or have their dosage reduced for older people with poor kidney function

For each set of criteria, the medications, rationale, recommendations, quality of evidence, and strength of recommendations are noted (see AGS, 2015 for a complete list). The Beers criteria have had a positive impact on reducing the use of harmful medications in older adults (Steinman et al., 2015), though more can be done to increase awareness of them and, in fact, all aspects of the specific healthcare needs of older patients. A helpful guide for patients, clinicians, health systems, and payors on how to use the AGS Beers Criteria has been published (Steinman et  al., 2015), and there is also now a list of alternatives for the potentially inappropriate medications (Hanlon, Semla, & Schmader, 2015). Adverse Drug Reactions An adverse drug reaction (ADR) is any unwanted or harmful effect a drug may have. ADRs are one of the leading causes of morbidity and mortality in U.S. healthcare. It is estimated that 35% of emergency department visits for ADRs are made by older adults, leading to 44% of those individuals being hospitalized, a rate seven times higher than it is for younger people (Shehab et al., 2016). The human toll in terms of morbidity—including increased falls, fractures, and depression—and mortality, as well as the economic impact of ADRs demand that more attention be paid to them. The causes of ADRs are many. They can result when drugs negatively interact with each other, with medical conditions, or with food or alcohol. When drugs interact with each other, one drug may cause the other not to work as well or even make it stronger than it should be. This is a frequent cause of ADRs in older adults because they are more likely to be taking multiple medications. A medical condition, such as hypertension or asthma, can make certain drugs potentially harmful. Food in the digestive system can affect how a drug is absorbed, and some drugs may also affect the way nutrients are absorbed or used in the body. Mixing alcohol with drugs may cause sleepiness, slow reactions, or even death. Older bodies may react differently to alcohol, as well as to the mix of alcohol and medicines. Mixing prescription and other medications, including OTC drugs, vitamins and minerals, and herbal supplements, can also cause adverse reactions. For example, drugs for heart disease are less effective when taken with the herbal supplement

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St. John’s Wort. Warfarin (a prescription blood thinner), ginkgo biloba (a herbal supplement), aspirin (an OTC medication), and vitamin E (a dietary supplement) can each thin the blood. The risk of internal bleeding or a stroke increases when any combination of these medications is taken.

What Can Be Done to Reduce Medication-Related Problems? Researchers, healthcare systems, healthcare providers, patients, and policy makers can all play a role in reducing medication-related problems. Older adults should be included as participants in research on medications, especially for medications aimed at medical conditions that are most common in this population. Information from providers, pharmacies, and other parts of the healthcare system should be coordinated in databases easily searchable by all authorized users. Embedding information on medications and the AGS Beers Criteria, for example, into tools that healthcare providers use in their everyday practices would increase the ease and frequency of using such information. Healthcare providers can engage in shared decision making with their patients, and together with pharmacists can suggest simpler medication regimes, help reduce costs by suggesting less expensive/generic medications, and recommend medication reminders and pill boxes. Patients can keep an up-to-date list of the names of all their medications (prescriptions, OTC medications, and dietary and herbal supplements), including how often they are taken and their dosages. The U.S. Food and Drug Administration has developed a form called My Medicine Record, which can be downloaded (www.fda.gov/Drugs/ResourcesForYou/ucm079489.htm), filled out, and shared with healthcare providers and pharmacists at all visits. My Medicine Record contains a chart to record medication information; a page to record personal and emergency contacts, as well as healthcare provider and pharmacy contact information, and more. Also helpful

BOX 12.1 GOOD QUESTIONS TO ASK HEALTHCARE PROVIDERS AND PHARMACISTS ABOUT MEDICATIONS ■ ■ ■ ■ ■ ■ ■ ■ ■ ■

What is the name of this medication, and what is it supposed to do? When and how should I take the medication, and for how long? When will the medication begin to work and how can I tell if it is working? What if I forget to take my medication or take a dose incorrectly? What are the side effects and what should I do if they occur? Does this medication contain anything that can cause an allergic reaction? Will I have any testing to monitor the medication’s effects? How should I store my medications, and how long can I keep them? Are there foods, drinks, other medications, nonprescription medications, or herbal supplements I should avoid? What is the generic form of this medication, and can I take it?

SOURCE: Adapted from University of Pittsburgh Medical Center. (n.d.). New medicines: Questions to ask the doctor. Retrieved from http://www.upmc.com/patients-visitors/education/older-adults/Pages/questions-all-patients-should -ask-pharmacist.aspx

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is having a set of questions to ask healthcare providers and pharmacists before taking medications—Box 12.1 has a list of some good questions. One way policy makers have already made a difference is through including programs, such as Medication Therapy Management (discussed in the section Medication Management Programs), in legislation and funding of healthcare. Something policy makers can do now is to work on new legislation and policies to decrease the cost of medications, which is known to be a major factor in medication-related problems, ultimately leading to negative healthcare outcomes and higher costs. Medication Management Programs Medication management programs, sometimes called “Medication Therapy Management” (MTM) or “medication reviews,” first became available in 2006 at no cost for individuals with a Medicare Part D plan who take medications for more than one chronic health condition. These programs include a comprehensive review of all medications by a pharmacist or other healthcare professional who will talk with patients about the following: ■ ■ ■ ■ ■

How well their medications are working Whether their medications have side effects Whether there are interactions between the medications they are taking Whether the costs of their medications can be reduced Other problems they may be having with their medications

All OTC medications, as well as dietary supplements, vitamins, minerals, and herbals, should be reviewed at the same time. Information about medication management programs can be obtained online through local or state units on aging (via www.medicare.gov/drug-coverage-part-d/ what-drug-plans-cover/medication-therapy-management-programs-for-complex-health-needs).

PRACTICAL APPLICATION INTRODUCTION

Chapter 12 outlines the various components of the Medicare and Medicaid programs. It also describes some of the medication-related problems older adults experience and offers insights into how to avoid them. Managing multiple medications is particularly challenging for older adults; it is, therefore, the focus of this Practical Application. STRATEGIES FOR MANAGING MULTIPLE MEDICATIONS

An important way for older adults to prevent medication-related problems is to enroll in an MTM program, the benefits of which are outlined in Chapter 12. However, not everyone participates in Medicare Part D, and there is still the issue of how to effectively manage administering medications at home. Anyone taking multiple medications runs the risk from time to time of missing a dose or losing track of what was taken when. Professionals in the field of gerontology can help older adults and their caretakers reduce the chances of having medication-related problems by offering them some helpful tips.

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FOR THE INDIVIDUALS THEMSELVES: ■ Use a pill organizer, one for morning and one for evening (if applicable). ■ Tie taking medications to a daily activity by keeping them near something that is used daily, like the coffee machine or tube of toothpaste. ■ Develop a reward system: Put a small treat, like a piece of chocolate, in the pill box to provide incentive. (This does not apply to those with sugar or chocolate restrictions!) ■ Set daily reminders using: ○ an alarm with a distinctive yet pleasing sound; or ○ a medication reminder app. ■ Post sticky notes in strategic places as a backup to the reminders. ■ Keep an extra dose in the car or in a purse in case you find yourself somewhere without them. FOR CARETAKERS: ■ Provide a detailed checklist outlining exactly what medications need to be taken when. Keep a few copies and give at least one copy to the person taking the medications. ■ Count pills frequently to make sure there are not too few or too many remaining at the end of a day, week, or month. ■ Consider a professional caregiver if pill management is proving too difficult.

STUDENT ACTIVITIES 1. Read the following scenarios and identify what type of coverage would best suit each

individual based on his or her eligibility and needs. Responses may include a combination of the following types of coverage: ○ ○ ○ ○ ○ ■

■

Original Medicare (Parts A and B) Medicare Advantage (Part C) Medicare Part D Medicaid Medigap Magda, 68, is financially secure but would like insurance to help cover her regular doctor visits and her deductibles on follow-up services. She frequently visits her daughter who lives in Canada and would like to know whether she will be covered if she were to have a medical emergency while traveling abroad. Jack, 61, is permanently disabled due to an on-the-job accident and lives on a fixed income of $18,350 per year. He is in relatively poor health, makes frequent visits to the doctor, and takes a number of medications.

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■

■

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Erica, 48, works full time and supports her 15-year-old daughter on $26,000 per year. She struggles to pay for even the most basic medical care for her daughter and especially herself. Jose, 72, lives comfortably on his company pension. He is in good health but would like to know that his preventive and screening services are covered, including dental and vision care, as well as his prescriptions and any unforeseen hospital visits he might need to have. Mona, 74, is in excellent health. She walks 3 miles every day, takes no prescription medications, and requires only routine visits to the doctor. It’s important to her to be insured, but feels she can cover her own dental visits and occasional prescriptions.

2. Given the uncertainty of future funding for Medicare, write one paragraph describing an

initiative that could help reduce our society’s reliance on it. 3. Describe a situation in which you or someone you know experienced a

medication-related problem. Explain how the issue was addressed. (If you have no experience with this, create a fictional person, describe his or her medication-related problem, and explain how it could be addressed.) 4. Go to the Health Tools page of the AARP website (healthtools.aarp.org/drug-director) and

click on the “Drugs” tab. Select two medications, list drugs that may interact with them, and identify what patients should watch out for while taking them.

SUGGESTED RESOURCES DailyMed. Retrieved from https://dailymed.nlm.nih.gov/dailymed/about.cfm This website, a public service of the U.S. National Library of Medicine, provides health information to healthcare providers and the public with a standard, comprehensive, up-to-date, look-up and download resource for medication content and labeling as found in medication package inserts for prescription and OTC medications. AARP also has a website that provides a similar service, with simplified descriptions of key aspects of drugs (see http://healthtools.aarp.org/drug-directory). Medicaid. Retrieved from https://www.medicaid.gov This federal government website provides information and resources for the Medicaid program, the Children’s Health Insurance Program (CHIP), and for the Basic Health Program. Medicare. Retrieved from https://www.medicare.gov This federal government website provides tools for signing up and managing Medicare coverage, creating and maintaining personal health records, and information on all things related to Medicare, including how to find healthcare professionals, facilities, and services. National Center for Complementary and Integrative Health. Retrieved from https://nccih.nih.gov Established in 1998, the National Center for Complementary and Integrative Health is the federal government’s lead agency for scientific research on the diverse medical and healthcare systems, practices, and products that are not generally considered part of conventional medicine. The Center’s website has pages devoted to health topics, research, grants and funding, training, and news and events. State Health Insurance Program National Technical Assistance Center. Retrieved from https://www .shiptacenter.org Through this website, funded by the U.S. Administration for Community Living, visitors can find local help with Medicare by selecting their state on a pull-down menu.

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U.S. Food and Drug Administration. (n.d.). Information for consumers on using dietary supplements. Retrieved from https://www.fda.gov/Food/DietarySupplements/UsingDietarySupplements/default.htm This website provides information for consumers on dietary supplements, including tips for older dietary supplement users, updates on products and safety warnings, how to report a problem, and a video on Thinking About Taking a Dietary Supplement.

REFERENCES Administration on Aging, U.S. Department of Health and Human Services. (2016). A Profile of Older Americans. Retrieved from https://www.acl.gov/sites/default/files/Aging%20and%20Disability%20 in%20America/2016-Profile.pdf America’s Health Insurance Plans. (2017a). Trends in Medigap enrollment and coverage options, 2015. Retrieved from https://www.ahip.org/wp-content/uploads/2017/05/Medigap_Report_5.1.17.pdf America’s Health Insurance Plans. (2017b). Exploring Medicare supplemental: Beneficiary satisfaction and the road ahead. Retrieved from https://www.ahip.org/wp-content/uploads/2017/09/Medicare -Supplemental-Insurance-Findings.pdf American Geriatrics Society. (2015). Medications and older adults. The 2015 American Geriatrics Society updated Beers® criteria: Medications that older adults should avoid or use with caution. Retrieved from http://www.healthinaging.org/medications-older-adults Beers, M. H., Ouslander, J. G., Rollingher, J., Reuben, D. B., & Beck, J. C. (1991). Explicit criteria for determining potentially inappropriate medication use in nursing home residents. Archives of Internal Medicine, 151(9), 1825–1832. doi:10.1001/archinte.1991.00400090107019 CMS Medicare-Medicaid Coordination Office. (2017, November). Data analysis brief: Medicare-Medicaid dual enrollment 2006 through 2016. Retrieved from https://www.cms.gov/Medicare-Medicaid -Coordination/Medicare-and-Medicaid-Coordination/Medicare-Medicaid-Coordination-Office/ DataStatisticalResources/Downloads/Eleven-YearEver-EnrolledTrendsReport_2006-2016.pdf da Silva, B. A., & Krishnamurthy, M. (2016). The alarming reality of medication error: A patient case and review of Pennsylvania and national data. Journal of Community Hospital Internal Medicine Perspectives, 6(4), 31758. doi:10.3402/jchimp.v6.31758 Hanlon, J. T., Semla, T. P., & Schmader, K. E. (2015). Alternative medications for medications in the use of high-risk medications in the elderly and potentially harmful drug-disease interactions in the elderly quality measures. Journal of the American Geriatrics Society, 63(12), e8–e18. doi:10.1111/jgs.13807 IMS Institute for Healthcare Informatics. (2013, June). Avoidable costs in U.S. healthcare. Retrieved from http://offers.premierinc.com/rs/381-NBB-525/images/Avoidable_Costs_in%20_US_Healthcare -IHII_AvoidableCosts_2013%5B1%5D.pdf Jacobson, G., Griffin, S., Neuman, T., & Smith, K. (2017, April). Income and assets of Medicare beneficiaries, 2016-2035. Oakland, CA: Kaiser Family Foundation. Retrieved from https://www.kff .org/medicare/issue-brief/income-and-assets-of-medicare-beneficiaries-2016-2035 Jacobson, G., Trilling, A., Neuman, T., Damico, A., & Gold, M. (2016, June). Medicare advantage hospital networks: How much do they vary? Oakland, CA: Kaiser Family Foundation. Retrieved from https:// www.kff.org/medicare/report/medicare-advantage-hospital-networks-how-much-do-they-vary Langford, E. A. (1964, July). Medical care costs for the aged: First findings of the 1963 survey of the aged. Social Security Bulletin, pp. 3–8. Retrieved from https://www.ssa.gov/policy/docs/ssb/v27n7/v27n7p3.pdf Lindquist, L. A., Lindquist, L. M., Zickuhr, L., Friesema, E., & Wolf, M. S. (2014). Unnecessary complexity of home medication regimens among seniors. Patient Education and Counseling, 96(1), 93–97. doi:10.1016/j.pec.2014.03.022 Medicare Board of Trustees. (2017). Trustees Reports (current and prior). Washington, DC: The Boards of Trustees of the Federal Hospital Insurance and Federal Supplementary Medical Insurance Trust Funds. Retrieved from https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics -Trends-and-Reports/ReportsTrustFunds/TrusteesReports.html Naples, J. G., Handler, S. M., Maher, R. L., Schmader, K. E., & Hanlon, J. T. (2017). Geriatric pharmacotherapy and polypharmacy. In H. M. Fillit, K. Rockwood, & J. Young (Eds.), Brocklehurst’s textbook of geriatric medicine and gerontology (8th ed., pp. 849–954). Philadelphia, PA: Elsevier.

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National Coordinating Council for Medication Error Reporting and Prevention. (2017). About medication errors. Retrieved from http://www.nccmerp.org/about-medication-errors Qato, D. M., Wilder, J., Schuum, P., Gillet, V., & Alexander, G. C. (2016). Changes in prescription and over-the-counter medication and dietary supplement use among older adults in the United States, 2005-2011. Journal of the American Medical Association Internal Medicine, 176(4), 473–482. doi:10.1001/jamainternmed.2015.8581 Safran, D. G., Neuman, P., Schoen, C., Kitchman, M. S., Wilson, I. B., Cooper, B., . . . Rogers, W. H. (2005). Prescription drug coverage and seniors: Findings from a 2003 national survey. Health Affairs, 24(Suppl., Web Exclusives), 152–166. doi:10.1377/hlthaff.w5.152 Shehab, N., Lovegrove, M. C., Geller, A. I. Rose, K. O., Weidle, N. J., & Budnitz, D. S. (2016). US emergency department visits for outpatient adverse drug events, 2013-2014. Journal of the American Medical Association, 316(20), 2115–2125. doi:10.1001/jama.2016.16201 Steinman, M. A., Beizer, J. L., DuBeau, C. E., Laird, R. D., Lundebjerg, N. E., & Mulhausen, P. (2015). How to use the American Geriatrics Society 2015 Beers Criteria: A guide for patients, clinicians, health systems, and payors. Journal of the American Geriatrics Society, 63(12), e1–e7. doi:10.1111/ jgs.13701 United States Renal Data System. (2017). Annual data report. Retrieved from https://www.usrds .org/2017/view/Default.aspx University of Pittsburgh Medical Center. (n.d.). New medicines: Questions to ask the doctor. Retrieved from http://www.upmc.com/patients-visitors/education/older-adults/Pages/questions-all-patients -should-ask-pharmacist.aspx Zorn, E. (2011, May 5). Change of subject: Medicare is going bankrupt! Again. Chicago Tribune. Retrieved from http://blogs.chicagotribune.com/news_columnists_ezorn/2011/05/medicare-is-going-bankrupt -again.html

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PART V OLDER PEOPLE AT RISK

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CHAPTER

13

O LD E R W OME N A N D O L D E R M I N OR I T Y GR OU P M E M B E R S

LEARNING OBJECTIVES • Describe the characteristics of older Americans who are at risk. • Summarize the reasons why women are especially at risk for poverty during their later years. • Explain the roles of caregiving responsibilities, partner status, and living arrangements on the economic security of older people at risk. • Discuss the impact of health inequities on health outcomes of older people at risk. • Evaluate the importance of preventive health services among older people at risk.

ESTHER: THE UNPAID WORKER Esther’s fondest dream as a youngster was to be a schoolteacher. But she was expected to contribute to the family income as soon as she was able, which in her case was after completing 10th grade at age 16. This was how it was for working-class families in America in the 1920s. Only a privileged few actually went on to college. Esther got a job in an office and by age of 21 was manager of the accounting section. She married at age 23 and continued to work until the birth of her first child. Then, she helped her husband start a small contracting firm. Esther kept all the records, paid the bills, and managed the payroll when the firm added employees. She continued to do this even after she had two more children. The Great Depression of the 1930s sent their business reeling for a few years, with very little work or income. World War II also interrupted the contracting business when Esther’s husband took a job in a manufacturing plant for 3 years to support the war efforts. After World War II, things picked up and the business flourished. Once again, Esther played a key role in the business. In addition, she managed a store that she and her husband started to furnish household products to returning servicemen and their families. Because their businesses were small and often struggling, Esther was never a paid employee. No Social Security taxes were ever (continued next page )

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withheld for her. Because they lived and worked at a time when wages and prices were very low by today’s standards, Esther and her husband were not able to save much money for their later years— especially extended later years, as she and her husband lived into their 90s. During all her busy years, Esther was a homemaker, raised her three children, worked in the family businesses, volunteered in the community and in her church, and cared for her parents when they became frail. For all of these activities, lasting over 45 years, she received no public or private pension. Her only reward was to get 50% of her husband’s Social Security benefits based on his earnings and work record. Needless to say, by the time she and her husband reached their 90s, they were running out of money as they continued to spend increasingly more on medical expenses in spite of Medicare, and spend more on personal assistance as they did less and less for themselves. Esther was one of the more fortunate older Americans. If she had been amember of a minority group, widowed earlier, never married, or divorced, her financial situation would have been more desperate. Such is the situation of millions of older Americans.

WISHING FOR A BETTER WORLD I have done well. I am educated. I am self-sufficient. I have a relationship with my children. I am alone—I never had a partner because I lived in a closet. I still have two sets of friends— they may suspect but are too polite to ask and I would not share anyway. My hope is that today is a more gentle time. Young people come out, are accepted, and build lives and long-term friendships, being who they are—72-year-old gay man. —Fredriksen-Goldsen et al., 2011, p. 10

WHO IS AT RISK? This chapter focuses on Americans at risk for poor economic and health outcomes as they age— women, people of color, and lesbian, gay, bisexual, and transgender (LGBT) individuals. At various points in the history of gerontology, intersections of age and sex have been seen as resulting in double jeopardy, and intersections of age, sex, race, and ethnicity have been seen as resulting in triple jeopardy for the well-being of older Americans. Now well into the second millennium, sexual orientation should be added as a fourth dimension of intersectionality, resulting in quadruple jeopardy—old, female, racial/ethnic minority, and sexual minority.

Demographics: Sex, Race, Ethnicity, and Sexual Orientation What are the demographics of older Americans at risk? Women outnumber men at every age, but the difference increases with age. Thus, an aging society is an increasingly female society. Figure 13.1 displays U.S. Census Bureau (2018a) data on the number of older women and men by selected age groups in 2016.

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9.0

Men Women

8.0

Number (in millions)

7.0 6.0 5.0 4.0 3.0 2.0 1.0 0.0

65–69

70–74

75–79 Age Group

80–84

85+

FIGURE 13.1  Number (in millions) of people age 65 and over, by sex and age group: 2016. SOURCE: U.S. Census Bureau. (2018a). Current population survey. Annual social and economic supplement, 2016. (Table 1. Population by Age and Sex). Retrieved from https://www.census.gov/data/tables/2016/demo/age-and -sex/2016-age-sex-composition.html

In 2016, there were more than 26 million American women aged 65 or older, and 3.6 million of them were aged 85 or older. In that same year, there were more than 21 million American men aged 65 or older, and 2 million of them were aged 85 or older. The U.S. Census Bureau (2018b) projects that by 2060 the number of women aged 65 or older will almost double to 51 million, and 11 million of them will be between the ages of 85 and 99, and 422,000 will be aged 100 or older. In that same year, the Census Bureau is projecting that the number of men aged 65 or older will more than double to 43.6 million, with 7.5 million of them between the ages of 85 and 99, and 168,000 of whom will be aged 100 years or older. Consistent with the increasing size of the older population over the next decades, the diversity of older Americans will also increase significantly. Figure 13.2 shows the proportion of our older population in each of the four major racial and ethnic groups—White, Black, Hispanic, and Asian—in 2016, and also the projected proportions in 2060 (U.S. Census Bureau, 2018c). In 2016, within the population of people aged 65 and older, White Americans were a large majority at 38.1 million, Black Americans comprised 4.4 million, Hispanic Americans comprised 3.9 million, and Asian Americans comprised 2.2 million. By 2060, the U.S. Census Bureau projects there will be 52  million older White Americans, 13 million older Black Americans, 20 million older Hispanic Americans, and 8 million older Asian Americans. Two factors contribute to increases in the number of older people of color: improvements in their health and increases in immigration, especially among Asian and Hispanic people. Data on the demographics of the LGBT population are scarce. Government agencies, such as the U.S. Census Bureau, have only just begun to include questions about sexual orientation and gender identity on their surveys, and it is uncommon to collect such data on older people. Although the letter Q, for queer or questioning, is sometimes added to the LGBT acronym, in

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Hispanic 8%

Asian 4%

2016

Black 9%

Asian 9%

2060

Hispanic 21% White 55%

White 77% Black 14%

FIGURE 13.2  Percentage of people age 65 and over, by race and ethnic origin: 2016 and 2060 (projected). SOURCE: U.S. Census Bureau. Population Division. (2018c). Race and Hispanic origin by selected age groups: Main projections series for the United States: 2017–2060 (Table 6). Retrieved from https://www.census.gov/data/tables/2017/demo/popproj/2017-summary-tables.html

keeping with the majority of research on this population, this chapter will stick with the LGBT acronym. Of the five surveys described in the Institute of Medicine’s (IOM) report on LGBT health, none included people over age 59 in their samples (IOM, 2011). One estimate is that there are 1.5 million individuals 65 and older who self-identify as lesbian, gay, bisexual, and transgender, and that number is expected to double by 2030 (Zelle & Arms, 2015).

RISKS TO ECONOMIC SECURITY Risks to the economic security of older women and minorities abound, and poverty is an all-too-common outcome. Among all older Americans, women and minority group members are the most likely to live at or near poverty levels. In 2016, the federal government’s poverty threshold for a single American aged 65 years or older was an annual income of $11,511 or less, and for two people with a householder 65 years or older, it was $14,522 or less. Individuals who are identified as living in poverty are very likely to have inadequate resources for food, housing, healthcare, and other needs. Based on the federal government’s official definition of poverty, 4.6 million older Americans were living in poverty in 2016, 10.6% of older women and 7.6% of older men (Semega, Fontenot, & Kollar, 2017). Rates of poverty for Black, Hispanic, and Asian Americans in 2016 were 22% (N = 9.2 million), 19.4% (N = 11.1 million), and 10.1% (N = 1.9 million), respectively, compared to 8.8% for White Americans (N = 17.3 million). In general, people who identify as lesbian, gay, or bisexual are more likely to live in poverty than their heterosexual counterparts are (Badgett, Durso, & Schneebaum, 2013). Furthermore, as is the case for heterosexual adults, women in the LGBT population are more vulnerable to poverty than men are. Researchers have been unable to determine poverty rates for transgender people due to the fact that few federal or state surveys collect data on this subpopulation.

Income Inequities The opening scenario about Esther, the unpaid worker, is all too typical for many women, ­especially so for earlier cohorts of women. They contribute their labor to their families through

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homemaking and raising their children, and sometimes to a family business too, as Esther did. Yet, they receive no paycheck and thus are not eligible for any pension either. They depend entirely on their husband’s or partner’s income and pension. Following a divorce or widowhood, women like Esther are likely to live in poverty. The ability of both women and men who are in the paid labor force to accumulate assets and savings for their later years depends on how much they earn and whether they have a job through which they can earn a pension. One important reason for the greater probability of women and minorities being impoverished in old age is that their earnings throughout their years in the labor force are relatively low. Women face cumulative discrimination in the workplace that begins when they first enter the labor force, continues in their wages and promotions throughout their employment, and then affects their financial resources and benefits in retirement. Men who are members of racial, ethnic, and sexual minorities also experience discrimination in the workplace that affects their lifetime earnings and retirement benefits. Figure 13.3 shows median annual earnings in 2016 for full-time workers, by sex, race, and ethnicity. Several patterns are apparent in Figure 13.3: ■ ■

■

Women’s earnings are lower than men’s earnings for every racial and ethnic group. On average, when earnings of both sexes are considered, Asian Americans have the highest earnings, followed by White Americans (3% less), Black Americans (39% less), and Hispanic Americans (40% less). The difference between the highest and lowest earning racial/ethnic groups amounts to an average of $200 per week in 2016. Compared to Asian and White Americans, earnings of Black and Hispanic Americans are substantially lower for both women and men. There is an interaction between sex and race/ethnicity, a reminder that characteristics that contribute to older people being at risk are not simply additive. Even though White and Asian American women earn more than their Black and Hispanic sisters, the differences between their annual earnings and those of their male counterparts are $16,900 and $19,800, respectively. Black and Hispanic women’s annual earnings meanwhile are $6,800 and $10,600 less, respectively, than their male counterparts’ earnings. The smaller differences between female and male Black and Hispanic workers can be attributed, at least in part, to the fact that these male workers’ wages are low enough that the wages of their female peers cannot be that much lower.

One of the saddest commentaries on our society is that so many women live in poverty during their later years. One “explanation” for this is that because women live to older ages than men do, women are more likely to outlive their financial resources. Although it is certainly true that, on average, women live longer than men do, it seems more than disingenuous to blame older women’s poverty on their longevity. In fact, discriminatory policies and practices in a wide variety of businesses, industries, and government agencies result in a substantial proportion of American women beginning their golden years with few, if any, accumulated financial resources. A longstanding wage gap between women and men has been very gradually closing since passage of the Equal Pay Act in 1963. The women’s movement in the 1970s and its concomitant effects on the increased participation of women in the paid workforce have helped to decrease sex differences in wages and salaries. In 1975, the median income for women was $21,300 and for men it was $36,200. By 2015, the median income for women was $40,740 and for men it was $51,200.

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$50,000

Men Women

$45,000 $40,000 $35,000 $30,000 $25,000 $20,000 $15,000 $10,000 $5,000 $-

White

Asian

Black

Hispanic

Note: Full-time workers, age 15 and over.

FIGURE 13.3  Median annual earnings for full-time workers, by sex and race and ethnic origin: 2016. NOTE: Full-time workers, age 15 and over. SOURCE: U.S. Census Bureau. (2018b). Current population survey, annual social and economic supplements (Table P-8). Retrieved from https://www.census.gov/data/tables/time-series/demo/income-poverty/historical-income-people.html.

As Figure 13.4 indicates, although much progress in closing the gap was made during the 1970s and 1980s, progress has subsequently stalled. Since 1975, the wage gap for White women has been closing by approximately half a percent per year. At that rate, they can expect to achieve parity with White male workers by the year 2056. Due to the much lower wages of Black and H ­ ispanic women, it will take until 2124 for Black female workers, and until 2248 for Hispanic female workers to reach parity with White male workers (Institute for Women’s Policy Research, 2016). Equal pay days symbolize how many additional months and days past 12 months that women have to work to make what men made during the previous 12-month period. The actual days can change (ideally, for the better) from year to year and from country to country. For example, in 2016, Germany’s Equal Pay Day for all women was March 19, and the U.S.’s Equal Pay Day for all women was April 12. In 2018, in the U.S. Equal Pay Days were: ■■ ■■ ■■ ■■ ■■ ■■

February 22: Asian American Women’s Equal Pay Day April 10: All Women’s Equal Pay Day April 17: White Women’s Equal Pay Day August 7: Black Women’s Equal Pay Day September 27: Native Women’s Equal Pay Day November 1: Latinas’ Equal Pay Day

To get a sense of just how much lower a woman’s earnings could be over a lifetime of work, this textbook’s author, Dr. Judith Sugar (2007), constructed a hypothetical case of a woman (call her “Sonia”) who began full-time employment in 1975 and planned to retire in 2015. Using data

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45

Gender Pay Gap (in cents/hour)

40 35 30 25 20 15 10 5 0 1975

1985

1995

2005

2015

Year

FIGURE 13.4  Gender wage gap, by selected years: 1975 to 2015. SOURCE: National Committee on Pay Equity. (2018). The wage gap over time: In real dollars, women see a continuing gap. Retrieved from https://www.pay-equity.org/info-time.html.

from the U.S. Bureau of Labor Statistics on average sex differences in salary, Sonia’s annual salary shortfalls were calculated for each of a hypothesized 40 years of full-time paid work between 1975 and 2015. The resulting total is a whopping shortfall of $480,000 in earnings compared to those earned by a male employee over the same time period! This amount does not include the interest and potential other income that Sonia could accrue through investing the additional $480,000 she would have earned if she were a male employee. Economist Dr. Evelyn Murphy, founder and president of the Women Are Getting Even (WAGE) Project, has estimated that the wage gap is even costlier for women (National Committee on Pay Equity, 2018). Comparing earnings of women with different educational backgrounds over 47 years of full-time work, Dr. Murphy has concluded that the wage gap costs female workers with a high school diploma $700,000, female workers with a college degree $1.2 million, and female workers with a professional school degree $2 million. Having those “extra” dollars would go a long way toward ending poverty among older women. Although differences in salaries within occupational types do exist, what is clear is that ­female workers earn less than male workers do in all occupational categories (Schein & Haruvi, 2015). So, occupational choices alone do not protect women from lower wages, nor does a college ­education. In a study of male and female college graduates’ pay, Judy Dey and Catherine Hill, researchers with the Educational Foundation of the American Association of University Women (AAUW), found that: Controlling for hours, occupation, parenthood, and other factors [experience, training, etc.] normally associated with pay, college-educated women still earn less than their male peers earn. . . . As early as one year after graduation, a pay gap is found between women and men who had the same college major. . . . In biological sciences, a mixed-gender major, women earn only 75 percent as much as men earn. Female students cannot simply choose a major that will allow them to avoid the pay gap. (Dey & Hill, 2007, p. 9)

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TABLE 13.1 Median Annual Earnings for Full-Time Workers Age 65 and Over, By Sex, Race, and Ethnicity: 2016 MEN

WOMEN

DIFFERENCE

White

$34,503

$19,754

$14,749

Asian

$26,196

$14,696

$11,500

Black

$22,177

$15,696

$6,481

Hispanic

$19,508

$12,489

$7,019

SOURCE: U.S. Census Bureau. (2018b). Current population survey. Annual social and economic supplements (Table P-8). Retrieved from https://www.census.gov/data/tables/time-series/demo/income-poverty/historical -income-people.html.

Thus, while some progress has been made in improving women’s salaries relative to men’s, women are still at a significant disadvantage in their paychecks. This disadvantage results in lower wages throughout their employment years, and a substantial risk of economic insecurity or poverty after they are no longer in the labor force. And, if women stay in the labor force, or reenter it, after age 65, they can continue to expect lower wages than men receive. Table 13.1 shows the median annual earnings and differences in those earnings for men and women aged 65 and older, by race and ethnicity. Once again we see that women’s earnings are lower than men’s for all racial and ethnic groups, and that the biggest differences are between men and women who are White or Asian. Note that the earnings listed in the table are for full-time workers. Most women make less than 60% of what their male counterparts make, and the income for older Hispanic women is barely above the poverty threshold.

The Influence of Caregiving on Women’s Economic Security Taking on the role of a caregiver presents another notable reason for being at risk for economic insecurity and poverty in late life. As was pointed out in Chapter 9, Family, Friends, and Social Networks of Older Adults, the majority of caregivers in America are women. Caregiving responsibilities of any kind often lead women to cut back on their work hours, go from full- to part-time work, pass up promotions, change jobs for greater flexibility in their work schedules, take leaves of absence, quit their jobs, or take early retirement. Caring for a child usually brings about these interruptions in work history when women are younger, and caring for a parent, parent-in-law, or other relative has a similar impact on middle-aged and older women. Ultimately, these gaps in women’s employment negatively affect not only their wages but also their retirement benefits, leading to long-term consequences for their economic security. The MetLife Mature Market Institute (2011) estimated that the financial costs to female caregivers of exiting the labor force early totaled $324,000 in 2008—$143,000 from lost wages, $131,351 from lost Social Security benefits, and $50,000 from lost private pension benefits. In addition to income losses due to changes in the circumstances related to their employment, caregivers also have out-of-pocket expenses. In 2016, more than 75% of family caregivers were incurring such costs, which averaged $7,000 per year, and, for long-distance caregivers the costs averaged $12,000 per year (Rainville, Skufca, & Mehegan, 2016). Hispanic Americans spend more than White Americans, an average of $9,000 per year, and, although Black Americans spend about the same amount as White Americans, their lower incomes mean that they spend a higher percentage of their income on these out-of-pocket costs.

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Work History The role of work history in economic insecurity is also especially pertinent for women. It is impossible to understand the vulnerability of older women in American society without acknowledging the social roles that women have conventionally held. Traditionally, women’s roles have focused on being wives, homemakers, mothers, community volunteers, and caregivers of ill and frail family members. For these roles, so important to any society, women have received no pay and no credits toward any retirement system. Their familial roles and less-than-full-time and intermittent participation in the labor force interact, frequently leading to economic and social dependency, costly for both them and society. One of the main reasons women work part time rather than full time is to enable them to fulfill caregiving responsibilities for family members. Although more American women aged 16 years and over are employed full time rather than part time (49 vs. 19 million), they are more than twice as likely to be part-time workers as men are (U.S. Bureau of Labor Statistics, 2018). In fact, during the critical years between 25 and 54 years of age, when employees are in the growth years of their careers for earnings, promotions, and accumulating retirement savings, only 77% of employed women are working full time compared to 89% of men. Working part time, as opposed to full time, leads to several problems for women as they age: ■ ■ ■ ■

Their incomes will typically be too low to allow them to set aside savings for retirement. They are less apt to be offered promotions that would increase their incomes. Their contributions toward Social Security and other retirement vehicles, if any, will be lower. They are less likely to receive benefits, especially healthcare insurance and employers’ contributions to a pension fund.

Working part time is one strategy women use to manage caregiving and other familial responsibilities. Another is to take a leave of absence from work. Due to concerns about young women taking leaves of absence and then potentially not returning to work, Sylvia Hewlett and Carolyn Luce (2005) conducted a survey to learn about ways to keep talented women on the road to career success. Among other questions, the nationally representative group of more than 2,400 college-educated women were asked about their experiences on returning to their jobs after taking leaves for various periods of time. The effect on their salaries was striking: compared to women who had not taken time out, those who took 1 year or less lost an average of 11% in their salaries, and those who took 3 years or more lost an average of 37% in their salaries. They were also significantly less likely to receive promotions after their return to work. The negative effect of the leaves women take, both in the short-term and the long-term, are examples of the costs women bear when they have an intermittent work history.

Partner Status Another major influence on the likelihood of older persons becoming impoverished in their later years is their partner status, including whether they are legally married. Compared to being single, having a partner means having two potential earners in a household as well as shared living arrangements, which significantly reduces the chances of living in poverty. Unmarried folks

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(single, divorced, or widowed) who live alone have poverty rates at 18% compared to 5% for older adults who are married (Federal Interagency Forum on Aging-Related Statistics, 2016). For older women who live alone, poverty rates range from 17% for White women to a shocking 37% for Asian and Hispanic women, with Black women not far behind at 30%. Furthermore, being legally married bestows advantages on partners when it comes to healthcare and retirement benefits. Couples in the LGBT community are at a distinct disadvantage in this regard because even though the U.S. Supreme Court legalized same-sex marriages in 2015 (Obergefell vs. Hodges), some states still have laws that allow marriage only between heterosexual couples. The availability of benefits for same-sex couples, whether married or not, also varies widely by employer. The Social Security Administration, however, does recognize same-sex couples as well as some nonmarital legal relationships, such as some civil unions and domestic partnerships. Thus, individuals in these relationships are eligible for the same Social Security benefits as married heterosexual couples. In addition to adverse economic consequences, living alone means that as people continue to grow older and are more prone to need assistance, help may not be readily available. For older LGBT people, like the gay man in one of this chapter’s opening scenarios, living alone may be less of a choice than it may appear to be. He has decided not to let his friends know that he is gay fearing their reactions, reactions which could harm the relationships he has with them. How much better off would he be if he were to be legally married, or even in a civil union or domestic partnership? The model partner status for older heterosexual men is married, whereas the model status for older heterosexual women is widowed. In 2015, almost three-quarters of men (74%) aged 65 to 74 were married, compared to a little over half of women (58%) in the same age group (Federal Interagency Forum on Aging-Related Statistics, 2016). The proportion of women who are married declines at older ages: 42% for those aged 75 to 84, and only 17% for those aged 85 and over. For men, the proportion that is married is also lower at older ages but not as low as for older women. Even among the oldest-old, the majority of men (59%) are still married. As they age, women of every racial and ethnic group are more apt to live alone than men are, mostly due to their longer lives and the tendency for women to marry men some years older, which together bring about the greater prevalence of widowhood among women. In fact, older women are almost twice as likely as older men to live alone. Figure 13.5 shows the living arrangements of older Americans by sex, race, and ethnicity. Older White women and older Black women have the highest rates of living alone, while older Black men have a much higher rate of living alone than do other men. Widowhood Many older women live alone because, compared to older men, they are much more likely to be widowed, and the prospect of widowhood rises with age. Women aged 65 and over are almost three times as likely as men of the same age to be widowed, 34% compared to 12% (Federal Interagency Forum on Aging-Related Statistics, 2016). Nearly three-quarters of women (73%) aged 85 and over are widowed, compared to only 34% of men in the same age group. Widowhood presents especially serious economic problems for older women for several reasons. First, many older women rely on their husbands’ retirement benefits. When the husband dies, Social Security benefits are reduced to the level of a single person. Private pension benefits are similarly reduced, or may provide nothing at all for the surviving spouse. A woman’s accumulated savings throughout her lifetime is frequently inadequate to meet expenses without funds from her husband’s retirement benefits. Secondly, a considerable portion of any household

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50

Men Women

45 40

Percent

35 30 25 20 15 10 5 0

White

Asian

Black

Hispanic

Note: These data refer to the civilian noninstitutionalized population.

FIGURE 13.5  Percentage of older Americans living alone by sex, race, and ethnicity: 2015. NOTE: These data refer to the civilian noninstitutionalized population. SOURCE: Federal Interagency Forum on Aging-Related Statistics. (2016). Older Americans. Key indicators of well-being. Washington, DC: U.S. Government Printing Office. Retrieved from https://agingstats.gov/docs/­ LatestReport/Older-Americans-2016-Key-Indicators-of-WellBeing.pdf

savings may have been spent on medical bills prior to the husband’s death. And, thirdly, if a woman subsequently lives alone, she loses the benefit of reduced costs from economies of scale for basic needs such as housing.

Retirement Pensions and Policies Resources to support older women and minorities in their later years are often inadequate. This is an especially challenging issue for women of all races, ethnicities, sexual orientations, and gender identities because their greater longevity means they need more financial resources in old age than men do. The lifetime pattern of work that is often used as a standard or norm for setting retirement policies is a linear one in which a period of education is followed by a period of work, and then by a period of retirement. This has been the predominant pattern for American men, especially White men. Consistent with this lifetime pattern, all plans for pension income, including Social Security, are based on a model of full-time, and long-term, employment in the labor force, which is also the most common scenario for White American men. Pension plans are based on earnings, and, as has been noted, on average, the earnings of women and minority group members are comparatively low. Remember the hypothetical case of Sonia presented a little earlier in this chapter? Both her Social Security benefits and private pension would be adversely affected by her lower income because both are based on employment earnings. And, because employers must match employees’ Social Security contributions, and ­often match contributions to private pension plans too, Sonia’s employer would also contribute considerably fewer dollars to her pension savings than would be the case if her paychecks were larger.

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Policies regarding vesting periods for pensions also work against the fact that women are often in and out of the labor force. Vesting means that the employee has earned the right to keep pension contributions an employer makes on the employee’s behalf. Regulations regarding vesting periods used to be highly advantageous to employers. For example, workers who left a company prior to an established 20-year vesting period would relinquish all contributions their employers had made to their pensions. (No matter how long a person works for a company, when they leave, they always have the right to keep their own contributions.) Continuous employment for 20 years with a single company is not the norm for young women who may want to temporarily leave the labor force to bear and raise children, for example. Thus, long vesting periods discriminate against women, and, in so doing, contribute to the likelihood that they will be impoverished in their later years. This situation has improved as vesting periods have been reduced, and now the federal government requires employers to choose from two vesting options, though employers can also provide more generous plans (e.g., shorter vesting periods). One option is for workers to be 100% vested after 3 years with an employer. The other option is a 6-year graduated schedule through which workers become 20% vested after 2 years and 20% for each year until they reach 100% after 6 years with an employer. With the uptick in employers’ use of 401(k) plans for pensions, married women face the possibility of new inequities. One example comes from the Pension Rights Center (n.d.): A wife will lose her right to a share of the money in her husband’s 401(k) plan if her husband leaves the job that sponsors the plan and cashes out the account or rolls it over into an IRA. The wife’s consent is not required. With 401(k) money increasingly becoming the largest asset of many marriages, this can result in a significant reduction of retirement income for women who work inside the home. . . . Spousal consent is required to cash out benefits from defined benefit plans as well as defined contribution . . . plans. (paras. 1, 3)

RISKS TO HEALTH Life expectancy is a basic measure of the overall health of a population. In Chapter 1, The Longevity Dividend, the average life expectancy of Americans was presented. How do older people at risk fare on this measure of health? Table 13.2 presents data on life expectancy at birth by sex, race, and ethnicity. It is a well-known fact of biology that the females of every species outlive the males, and humans are no exception. The differences between men and women at birth, which range TABLE 13.2 Life Expectancy at Birth, by Sex, Race, and Ethnicity: 2014 MEN

WOMEN

White

76.7

81.4

Black

72.5

78.4

Hispanic

79.2

84.0

Asian

84.1

88.9

SOURCE: Federal Interagency Forum on Aging-Related Statistics. (2016). Older Americans. Key indicators of well-being (Table 15b). Washington, DC: U.S. Government Printing Office. Retrieved from https://agingstats.gov/ docs/LatestReport/Older-Americans-2016-Key-Indicators-of-WellBeing.pdf

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from 4.7 to 6.3 years, narrow for all racial and ethnic groups to about 3 years by age 65. Thus, a significant proportion of the sex differences in life expectancy is a result of conditions and events that lead to earlier deaths for men, for example, risky behaviors of young men that lead to deaths from traffic accidents. Reaching age 65 depends upon a person surviving all those health conditions and events that are more prevalent at younger ages. Of course, other health conditions, for example, heart disease, start to become more prevalent as a person ages. As Table 13.2 shows, Hispanic Americans have a greater life expectancy than White or Black Americans at birth. The better health outcomes of Hispanics compared to Whites has been deemed the Hispanic paradox, because the relatively low socioeconomic circumstances of many Hispanics should predispose them to poorer health outcomes (Lariscy, Hummer, & Hayward, 2015). This paradox, and the greater life expectancy of Asian American women, suggest that there is much to be learned from studying life expectancy, health status, and the influences on them, in our increasingly diverse older population. What do older people think about their own health? Figure 13.6 shows the proportion of older Americans who rate their own health as good or excellent, by age group, race, and ethnicity. First, note that a majority of all older people, even those who are aged 85 or older, assess their

White Black Hispanic

90 80 70

Percent

60 50 40 30 20 10 0

65–74

75–84 Age

85+

Note: Data are based on a 3-year average for both sexes from 2012-2014.

FIGURE 13.6  Percentage of people age 65 and over with self-assessed good to excellent health status, by age group, race, and ethnicity: 2012 to 2014. NOTE: Data are based on a 3-year average for both sexes from 2012 to 2014. SOURCE: Federal Interagency Forum on Aging-Related Statistics. (2016). Older Americans. Key indicators of well-being (Table 19). Washington, DC: U.S. Government Printing Office. Retrieved from https://agingstats.gov/docs/ LatestReport/Older-Americans-2016-Key-Indicators-of-WellBeing.pdf

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own health as “good” to “excellent.” Secondly, note that at every age, older White people give higher ratings of their own health than do older people of other racial and ethnic groups, clearly indicating that we have inequities in health among our diverse population of older people. A study by the IOM (2011) on the health of LGBT individuals found that, compared to heterosexual adults, fewer gay, lesbian, and bisexual adults rated their health as very good or excellent. Within the older LGBT community, reports of poor health are more common among bisexual men and transgender people (Fredriksen-Goldsen et al., 2011).

Health Disparities and Health Inequities The terms health disparities and health inequities are frequently used interchangeably, though they focus on different aspects of the fact that there are large gaps between population groups in the United States with regard to healthcare, and the diagnosis, treatment, and outcomes of health conditions. The term health disparities focuses on differences between groups, and especially on groups with the poorest health. On the other hand, the term health inequities focuses on the causes of such differences, especially the unfair distribution of health resources among population groups. Health inequities lead to poorer health outcomes and unnecessary deaths, and they are a growing concern given the rapidly increasing population of older adults and the increasing diversity of that population. In addition, escalating costs of healthcare should cause us to devote more attention to eliminating these inequities. LaVeist, Gaskin, and Richard (2011) determined that the costs of medical care, lost productivity, and premature deaths as a result of racial and ethnic health inequities amounted to an alarming $309 billion per year (and that was in 2008!). To assuage concerns that they were focusing too much on the financial losses incurred through these inequities, LaVeist et al. stated, We should address health disparities because such inequities are inconsistent with the values of our society. . . . What our analysis shows is that social justice can be cost effective. The large number of premature deaths represents a substantial loss of human potential, a loss of talent and productivity that might otherwise have contributed to the betterment of society. . . . Usually we think . . . that doing something will cost more than continuing to do what we are accustomed to doing. But in the case of health inequalities, doing nothing has a cost we should not continue to bear. (p. 235)

Chronic Health Conditions Across the life span, there are differences between the most prevalent health conditions in men and women, some of which, of course, are due to anatomical differences—for example, the prevalence of some types of cancers, such as uterine, cervical, and prostate. In addition, although breast cancer and osteoporosis occur in both men and women, they are much more prevalent in women. But other differences exist between older men and women, too. As age increases, so does the likelihood of developing a chronic condition, so it is not necessarily surprising that because women live longer than men do, they are also more likely to be affected by a chronic condition. Arthritis is more prevalent in older women (54%) than in older men (43%). However, more of the older men (35%) than women (25%) have heart disease. On the whole, the prevalence of some chronic health conditions among individuals aged 65 and above has increased over time.

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For example, the percentage of individuals who reported hypertension, cancer, and diabetes was higher in 2014 as compared to the percentage in 1998 (Federal Interagency Forum on AgingRelated Statistics, 2016). Table 13.3 gives the percentage of older Americans with the top five chronic conditions by race and ethnicity. The differences among the groups are striking. Black Americans are more likely to have hypertension and diabetes; White Americans are more likely to have heart disease and cancer; and Hispanic Americans, like Black Americans, are more at risk for diabetes than are White Americans. Consistent with the Hispanic paradox, the percentages of Hispanic Americans with arthritis, heart disease, and cancer are lower than the percentages of White Americans and Black Americans with those conditions. It is one thing to be diagnosed with a chronic disease and another to die prematurely from one. A fine-grained analysis of data on coronary heart disease (CHD) reveals that Black women and men aged 45 to 74 years have much higher rates of death due to CHD than do White, Asian/ Pacific Islander, or American Indian/Alaskan Native women and men. Premature death rates for Black women are higher (38%) than for White women (19%), and higher for Black men (62%) than for White men (42%; Truman et al., 2011). Although data on the health of American Indians, Native Alaskans, Native Hawaiians, and other Pacific Islanders are gradually becoming more readily available, much of the research on these populations omits older adults. Thus, there is limited knowledge about the health status and health disparities in these populations. There are two studies though that offer some information on the prevalence of chronic conditions among older American Indian and Alaska Natives (AI/AN). In their sample of over 500 American Indians who were aged 55 or older, Goins and Pilkerton (2010) reported that 58% had been diagnosed with hypertension, 44% with arthritis, and 42% with diabetes. In the second study, with a sample of 198 AI/AN people who were aged 60 or older, Kim, Bryant, Goins, Worley, and Chiriboga (2012) reported a comparable rate of hypertension (60%), but a somewhat lower rate of diabetes (31%). Kim et al. did not report a prevalence rate for arthritis, but they did report a rate of 25% for heart disease. Taken together, these two studies indicate that the chronic condition that garners the highest rate among older AI/AN people is diabetes, and that rate is comparable to, or higher than, the rate of diabetes among older Black and Hispanic Americans.

TABLE 13.3 Percentage of Older Americans With Selected Chronic Conditions, by Race and Ethnicity: 2013 to 2014

HYPERTENSION

ARTHRITIS

HEART DISEASE

CANCER (ANY)

DIABETES

White

54.2

50.1

30.7

26.0

18.3

Black

70.6

51.3

26.4

16.7

32.1

Hispanic

57.1

43.7

22.9

12.5

32.3

NOTE: Data are based on a 2-year average from 2013 to 2014. These data refer to the civilian noninstitutionalized population. SOURCE: Federal Interagency Forum on Aging-Related Statistics. (2016). Older Americans. Key indicators of well-being (Table 17a). Washington, DC: U.S. Government Printing Office. Retrieved from https://agingstats.gov/ docs/LatestReport/Older-Americans-2016-Key-Indicators-of-WellBeing.pdf

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A study of heart disease and its risk factors among Asians, Pacific Islanders, and Whites in Hawaii found that rates of heart disease, diabetes, and hypertension for Native Hawaiians were elevated relative to Whites (Juarez, Davis, Brady, & Chung, 2012). The researchers concluded that Our study highlights the importance of examining prevalence rates of disease and risk factors separately for API [Asians and Pacific Islanders] sub-groups and reveals the extent to which health disparities emerge at an early age. . . . By age 40, Native Hawaiians were at higher risk for diabetes and by age 50, they were at higher risk for heart disease than other groups. (pp. 1007–1008) Far too little is known about the health of older LGBT individuals. The LGBT literature seldom includes information on older people, and the gerontology literature seldom includes information on the LGBT population. Due to experiences of stigmatization and their historically marginalized status in society, LGBT people often avoid or delay seeking healthcare, and even when they do seek it, they may not divulge their sexual orientation or gender identity to healthcare providers, all of which can jeopardize their health. When they are available, information on chronic conditions in the LGBT community cannot always be directly compared to information from other groups because research with older LGBT people often includes individuals beginning at age 50. For most reports on chronic conditions in other populations, the age range begins at 65. Dr. Fredriksen-Goldsen et al. (2011) reported that within the LGBT community the rate for hypertension was 45%, for arthritis 34%, for heart disease 13%, for cancer 19%, and for diabetes 15%. The fact that some of these rates are lower than the rates for other minority groups may be, at least in part, attributable to the lower age range for most LGBT research participants. On average, when it comes to chronic conditions, lesbians and bisexual women are similar to each other, as are gay and bisexual men. Comparisons between sexual minorities and heterosexual people have revealed that older lesbian and bisexual women have higher rates of heart disease, older gay and bisexual men have higher rates of hypertension and diabetes, and older bisexual men have a higher rate of diabetes than older gay men do (Fredriksen-Golden, 2014). The health effects of transgender individuals’ long-term use of hormone therapy have not been studied, although it is thought that the risks for cancers and cardiovascular disease may be elevated (IOM, 2011). HIV/AIDS is a concern in the LGBT community, especially for men who have sex with men and transgender women. The limited research on HIV/AIDS in older sexual minorities indicates that 9% of older LGBT people are living with HIV, and that percentage rises to 14% among gay and bisexual men (Fredriksen-Goldsen et al., 2011). Although older adults, regardless of their sexual orientation, are largely ignored when HIV/AIDS is discussed, Chapter 5, Sexuality and Aging, presents information about the rates of HIV/AIDS among older adults and why they may be at a higher risk for HIV transmission than most people recognize, including older adults themselves. It should be noted that HIV prevention programs rarely address older adults.

Preventive Services: Vaccinations and Screening Tests Preventive services are one of the keys to preserving and extending the health of older Americans. With appropriate follow-up when necessary, services such as immunizations and screening tests are effective in preventing many medical conditions and diseases, and in detecting them in their early stages when treatment can be more effective. Older adults’ use of preventive services depends on a wide variety of factors including their access to healthcare professionals and preventive

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services, what they know about the services, as well as the actual costs of the services. Barriers for older people at risk, including poverty, discrimination, and health literacy, affect the use of preventive services. Discrimination against racial, ethnic, and sexual minorities within healthcare settings has also been shown to affect whether, or how late, preventive services, such as cancer screenings, are provided (Rogers, Thrasher, Miao, Boscardin, & Smith, 2015; Zelle & Arms, 2015). Vaccinations Chapter 3, Health and Wellness for Older Adults, includes a discussion of the vaccinations that are most beneficial for older adults: influenza (flu), pneumococcal (pneumonia), and herpes zoster (shingles). Nevertheless, many older people do not get vaccinated, including a disproportionately large share of older minority group members. Of all vaccinations, the highest vaccination rates for older people are for influenza—71% for White Americans, 66% for Asian Americans, 60% for Black Americans, and 57% for Hispanic Americans (Norris, Vahratian, & Cohen, 2017). These numbers have substantially increased from very low rates prior to 1993, when Medicare Part B began covering the cost of annual flu vaccinations. Nevertheless, there is room for improvement, especially for older people of color. Pneumonia is one of the leading reasons that older people end up in hospital emergency rooms. It is also all too frequently a cause of death for them. Even though Medicare Part B has covered the cost of pneumonia vaccinations since 1981, many older adults do not get vaccinated for the disease, and there are differences between racial and ethnic groups here, too. White Americans have a higher rate, 68%, followed by Black Americans, 50%, Asian Americans, 49%, and Hispanic Americans, 42% (Norris et al., 2017). A vaccine for shingles was first approved by the U.S. Food and Drug Administration in 2006, and subsequently all Medicare Part D plans started covering it. Unlike flu and pneumonia vaccinations, for which Medicare Part B covers all the costs, Part D plans may require costsharing, with the patient partially paying through his or her deductible or a copay. The relative newness of the vaccine as well as the potential cost undoubtedly contribute to the low vaccination rates for shingles; however, the rates have increased in recent years. As is the case for other vaccinations, older White Americans have a higher rate, 38%, followed by Asian Americans, 31%, Hispanic Americans, 19%, and Black Americans, 14% (Norris et al., 2017). Screenings As we learned in Chapter 3, Health and Wellness for Older Adults, screening tests are best used to detect medical conditions that are preventable but have few or no early symptoms, and for conditions that can benefit from early detection. When it comes to mammogram screenings, rates could be higher for women of all race and ethnic groups. Data from the National Center for Health Statistics (2017) show that across all races and ethnicities, only about two-thirds of older women are being screened for breast cancer. Rates of breast cancer increase with age, and are highest for women over age 70. A lot of attention has been focused on screening for colorectal cancer because, of those cancers that affect both men and women, it is the second leading cause of cancer-related deaths in the United States. Furthermore, when screening is done early enough, the prognosis is very good. The Centers for Disease Control and Prevention estimates that if everyone aged 50 years or older was regularly screened for colorectal cancer, at least 60% of deaths from this cancer could be avoided. Medicare Part B provides coverage for screening for many cancers, including colorectal cancer.

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Nevertheless, the percentage of older adults being screened for colorectal cancer hovers around only 63%, and is a much lower 49% for older Hispanic Americans. Differences in screening rates suggest the need for further research to determine the reasons for these differences and then to find ways to address them, keeping in mind that reasons may vary by sex, race, and ethnicity. Research on health disparities is still in its infancy. Basic data collection on populations and subpopulations of older people at risk is critical for identifying and prioritizing the issues, for designing ways to ameliorate the disparities, and for evaluating the effectiveness of proposed solutions. There is also a “need for community-based approaches that include policy, systems, environmental, and individual-level changes . . . and [a] need to tailor prevention strategies to the needs of specific communities to eliminate health disparities” (Liao et al., 2011, pp. 16–17).

HETEROGENEITY OF RACIAL/ETHNIC AND LGBT GROUPS Racial, ethnic, and LGBT groups have been presented in this chapter as if they were homogeneous. Of course, within each of these groups there is much diversity. In the case of racial and ethnic groups, for example, Cuban Americans, Mexican Americans, and Puerto Ricans are all grouped with the ethnic label of Hispanic despite vast differences in their economic and sociopolitical backgrounds, which, in turn, can impact their economic security and risks for different health conditions. The LGBT community is similarly diverse with respect to sexual orientation, gender identity, sex, race, and ethnicity. Although some of the issues facing older adults in these groups have much in common, such as their historically marginalized social status, it is important to note that there are significant differences among subgroups within these populations. Such differences signal a need for more refined strategies and policies to improve the overall health of all older adults.

PRACTICAL APPLICATION INTRODUCTION

Chapter 13 identifies older women, people of color, and members of the LGBT community as being at risk for poverty during their later years. It explains the impact of caregiving responsibilities, partner status, and living arrangements on economic security of older adults at risk and highlights the detrimental effect of health inequities on their health outcomes. Finally, the chapter stresses the importance of preventive health services for older adults at risk. Understanding the needs and risks of women, people of color, and LGBT individuals is an important part of working in the field of gerontology. This Practical Application focuses on how to develop that understanding. UNDERSTANDING THE ISSUES AND NEEDS OF OLDER WOMEN, PEOPLE OF COLOR, AND LGBT INDIVIDUALS

As outlined in Chapter 13, older women, people of color, and LGBT individuals are economically and socially disadvantaged in many ways in American society. As a result, they represent the populations with the highest needs. An effective gerontology professional strives to understand the issues these groups face and also recognizes that each individual will deal with challenges

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in different ways. This requires an open mind and a willingness to learn about different cultures, belief systems, and lifestyles. Volunteering for organizations that represent and provide services for older women, people of color, and LGBT individuals is an excellent way to gain first-hand experience with the complexities of their lives. Volunteer activities afford aspiring professionals opportunities to meet new people, experience different cultures and belief systems, and try new things to discover their potential niche within the field of gerontology.

STUDENT ACTIVITIES 1. Explain the concepts of triple and quadruple jeopardy and describe the characteristics of

individuals who might fall into those categories. 2. Imagine that a good friend has come to you seeking advice. Her mother-in-law lives nearby and currently has a professional caregiver who comes to her house every day to help with basic tasks and to make sure she is taking her medications. Your friend and her husband are looking for ways to save money on her mother-in-law’s care. Your friend is considering going from full-time to part-time work, so she can take the place of the caregiver. Outline your advice to your friend. 3. Explain how investing in social justice reduces healthcare costs in American society. 4. Outline some of the barriers to preventive health services for women, people of color, and LGBT individuals.

SUGGESTED RESOURCES National Asian Pacific Center on Aging. Retrieved from http://www.napca.org The NAPCA’s mission is to preserve and promote the dignity, well-being, and quality of life of Asian Americans and Pacific Islanders as they age. Founded in 1979, the Center envisions a society in which all Asian Americans and Pacific Islanders age with dignity and well-being. It focuses on healthy aging, mature workers, and the prevention of elder abuse, and its website provides information on valuable resources, which include direct services, outreach, research, and advocacy. National Caucus and Center on Black Aging, Inc. Retrieved from https://www.ncba-aged.org The NCBA believes older adults—regardless of race, ethnicity, or status—are the fabric of our country and have earned the right to enjoy their golden years without fear or lack of resources. Founded in 1970, the NCBA helps to protect and improve the quality of life of older populations, making certain that legislators, policymakers, philanthropists, advocacy groups, service organizations, thought leaders, and the public at-large include minority seniors in their programs, policy- and law-making, and giving. Three areas of focus are employment, health and wellness, and affordable housing. National Hispanic Council on Aging. Retrieved from https://www.nhcoa.org The NHCOA is the leading national organization working to improve the lives of Hispanic older adults, their families, and their caregivers. The Council’s priorities are health, economic security, housing and leadership empowerment and development. It works to educate, empower, and support aging Hispanic communities, through research, education, referrals to healthcare, and financial resources.

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National Indian Council on Aging. Retrieved from https://nicoa.org The mission of NICOA is to advocate for improved comprehensive health, social services, and economic well-being for older American Indians and Alaska Natives. The Council’s website provides resources on healthcare, conferences, advocacy, and employment. There is information available on diabetes education, long-term care, and job training, among other topics. National Resource Center on LGBT Aging. Retrieved from https://www.lgbtagingcenter.org This Center offers technical, educational, and training assistance to LGBT organizations, aging providers, and older LGBT adults. On the website are links to articles, publications, videos, webinars, slideshows, and audio programs, which can be searched by topic (more than 25, ranging from financial security to transgender issues). Website visitors can also search for resources in their communities. National Women’s Law Center. Retrieved from https://nwlc.org Founded in 1972, the NWLC works to protect and promote equality and opportunity for women and families. It champions policies and laws that help women and girls achieve their potential at every stage of their lives—at school, at work, at home, and in retirement. Issues that the Center focuses on include: poverty and economic security, racial and ethnic justice, LGBTQ equality, healthcare and reproductive rights, education and Title IX, workplace issues, and child care and early learning. SAGE: Advocacy and Services for LGBT Elders. Retrieved from https://www.sageusa.org Since 1978, SAGE has worked tirelessly on behalf of LGBT older people. Building on the momentum of the Stonewall uprising and the emerging LGBT civil rights movement, a group of activists came together to ensure that LGBT older people could age with respect and dignity. The site provides many resources on advocacy, as well as information on how to find services and programs, housing, and education and training. Women’s Institute for a Secure Retirement. Retrieved from http://www.wiserwomen.org Founded in 1996, WISER is a nonprofit organization that focuses on improving the long-term financial quality of life for women. The Institute supports research, conducts workshops, and creates consumer publications on issues relating to women’s retirement income, including Social Security, divorce, pay equity, pensions, savings and investments, home ownership, and long-term care and disability insurance.

REFERENCES Badgett, M. V. L., Durso, L. E., & Schneebaum, A. (2013). New patterns of poverty in the lesbian, gay, and bisexual community. Los Angeles, CA: The Williams Institute. Retrieved from https://williamsinstitute .law.ucla.edu/research/census-lgbt-demographics-studies/lgbt-poverty-update-june-2013 Dey, J. G., & Hill, C. (2007). Behind the pay gap. Washington, DC: American Association of University Women Educational Foundation. Retrieved from https://www.aauw.org/research/ behind-the-pay-gap Federal Interagency Forum on Aging-Related Statistics. (2016). Older Americans: Key indicators of wellbeing. Washington, DC: U.S. Government Printing Office. Retrieved from https://agingstats.gov/ docs/LatestReport/Older-Americans-2016-Key-Indicators-of-WellBeing.pdf Fredriksen-Golden, K. I. (2014). Promoting health equity among LGBT mid-life and older adults. Generations, 38(4), 86–92. Fredriksen-Goldsen, K. I., Kim, H.-J., Emlet, C. A., Muraco, A., Erosheva, E. A., Hoy-Ellis, C. P., . . . Petry, H. (2011). The aging and health report. Disparities and resilience among lesbian, gay, bisexual, and transgender older adults. Seattle: University of Washington, Institute for Multigenerational Health. Retrieved from http://www.age-pride.org/wordpress/wp-content/uploads/2012/10/Full -report10-25-12.pdf Goins, R. T., & Pilkerton, C. S. (2010). Comorbidity among older American Indians: The native elder care study. Journal of Cross Cultural Gerontology, 25, 343–354. doi:10.1007/s10823-010-9119-5 Hewlett, S. A., & Luce, C. B. (2005, March). Off-ramps and on-ramps. Keeping talented women on the road to success. Harvard Business Review, pp. 43–54. Institute for Women’s Policy Research. (2016, November). If current trends continue, Hispanic women will wait 232 years for equal pay; Black women will wait 108 years. Retrieved from https://iwpr.org/

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publications/if-current-trends-continue-hispanic-women-will-wait-232-years-for-equal-pay-black -women-will-wait-108-years Institute of Medicine. (2011). The health of lesbian, gay, bisexual, and transgender people: Building a foundation for better understanding. Washington, DC: National Academies Press. Retrieved from https:// www.nap.edu/catalog/13128/the-health-of-lesbian-gay-bisexual-and-transgender-people-building Juarez, D. T., Davis, J. W., Brady, S. K., & Chung, R. S. (2012). Prevalence of heart disease and its risk factors related to age in Asians, Pacific Islanders, and Whites in Hawaii. Journal of Health Care for the Poor and Underserved, 23(3), 1000–1010. doi:10.1353/hpu.2012.0103 Kim, G., Bryant, A. N., Goins, R. T., Worley, C. B., & Chiriboga, D. A. (2012). Disparities in health status and health care access and use among older American Indians and Alaska Native and non-Hispanic Whites in California. Journal of Aging and Health, 24(5), 799–811. doi:10.1177/0898264312444309 Lariscy, J. T., Hummer, R. A., & Hayward, M. D. (2015). Hispanic older adult mortality in the United States: New estimates and an assessment of factors shaping the Hispanic paradox. Demography, 52(1), 1–14. doi:10.1007/s13524-014-0357-y LaVeist, T. A., Gaskin, D., & Richard, P. (2011). Estimating the economic burden of racial health inequalities in the United States. International Journal of Health Services, 41(2), 231–238. doi:10.2190/ HS.41.2.c Liao, Y., Bang, D., Cosgrove, S., Dulin, R., Harris, Z., Stewart, A., . . . Giles, W. (2011, May 20). Surveillance of health status in minority communities—Racial and Ethnic Approaches to Community Health across the U.S. (REACH U.S.) Risk Factor Survey, United States, 2009. Morbidity and Mortality Weekly Report, Surveillance Summaries, 60(SS06), 1–41. Retrieved from https://www.cdc.gov/mmwr/pdf/ss/ss6006.pdf MetLife Mature Market Institute. (2011, June). MetLife study of caregiving costs to working caregivers. Westport, CT: Author. Retrieved from http://www.metlife.com/mmi/index.html National Center for Health Statistics. (2017). Health, United States, 2016. Figure 19. Mammography use and colorectal cancer testing use, by race and Hispanic origin: United States, selected years 1987–2015. MD: Hyattsville. Retrieved from http://www.cdc.gov/nchs/hus/contents2016.htm#fig19 National Committee on Pay Equity. (2018). The wage gap over time: In real dollars, women see a continuing gap. Retrieved from https://www.pay-equity.org/info-time.html Norris, T., Vahratian, A., & Cohen, R. A. (2017, June). Vaccination coverage among adults aged 65 and over: United States, 2015 (NCHS Data Brief No. 281). Washington, DC: U.S. Department of Health and Human Services. Retrieved from https://www.cdc.gov/nchs/data/databriefs/db281.pdf Pension Rights Center. (n.d.). Pension inequities targeting women. Fact sheet. Retrieved from http://www .pensionrights.org/publications/fact-sheet/pension-inequities-targeting-women Rainville, C., Skufca, L., & Mehegan, L. (2016, November). Family caregiving and out-of-pocket costs: 2016 report. Washington, DC: AARP. Retrieved from https://www.aarp.org/content/dam/aarp/ research/surveys_statistics/ltc/2016/family-caregiving-costs.doi.10.26419%252Fres.00138.001.pdf Rogers, S. E., Thrasher, A. D., Miao, Y., Boscardin, W. J., & Smith, A. K. (2015). Discrimination in healthcare settings is associated with disability in older adults: Health and Retirement Study, 2008–2012. Journal of General Internal Medicine, 30(10), 1413–1420. doi:10.1007/s11606-015-3233-6 Schein, A. J., & Haruvi, N. (2015). Older women, economic power, and consumerism. In V. Muhlbauer, J. Chrisler, & F. Denmark (Eds.), Women and aging (pp. 31–49). Berlin, Germany: Springer. Semega, J. L., Fontenot, K. R., & Kollar, M. A. (2017, September). Income and poverty in the United States: 2016 (U.S. Census Bureau, Current Population Reports, P60-259). Washington, DC: U.S. Government Printing Office. Retrieved from https://www.census.gov/library/publications/2017/ demo/p60-259.html Sugar, J. A. (2007). Work and retirement: Challenges and opportunities for women over 50. In J. C. Chrisler & V. Muhlbauer (Eds.), Women over 50: Psychological perspectives (pp. 164–181). New York, NY: Springer. Truman, B. I., Smith, C. K., Roy, K., Chen, Z, Moonesinghe, R., Zhu, J., . . . Zaza, S. (2011, January 14). CDC health disparities and inequalities report—United States, 2011. Morbidity and Mortality Weekly Report, 60(Supplement). Retrieved from https://www.cdc.gov/mmwr/preview/ind2011_su.html U.S. Bureau of Labor Statistics. (2018, August). Persons at work in nonagricultural industries by age, sex, race, Hispanic or Latino ethnicity, marital status, and usual full- or part-time status. Retrieved from https://www.bls.gov/web/empsit/cpseea27.pdf

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U.S. Census Bureau. (2018a). Current population survey. Annual social and economic supplement, 2016 (Table 1. Population by Age and Sex). Retrieved from https://www.census.gov/data/tables/2016/ demo/age-and-sex/2016-age-sex-composition.html U.S. Census Bureau. (2018b). Current population survey. Annual social and economic supplement, 2016 (Table P-8). Retrieved from https://www.census.gov/data/tables/time-series/demo/income-poverty/ historical-income-people.html U.S. Census Bureau, Population Division. (2018c, September). Projected age groups and sex composition of the population: Main projections series for the United States, 2017—2060 (Table 2). Retrieved from https://www.census.gov/data/tables/2017/demo/popproj/2017-summary-tables.html Zelle, A., & Arms, T. (2015). Psychosocial effects of health disparities of lesbian, gay, bisexual, and transgender older adults. Journal of Psychosocial Nursing and Mental Health Services, 53(7), 25–30. doi:10.3928/02793695-20150623-04

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CHAPTER

14

ELD E R AB US E A N D N E G L E C T: CRI ME S , S C AMS , A N D C O N S

LEARNING OBJECTIVES • Define elder abuse. • List the five major types of abuse. • Summarize the consequences of elder abuse. • Discuss the social-ecological model as it applies to elder abuse. • Explain why financial abuse, fraud, and scams are more likely to be perpetrated on older people. • Outline some ways that our society can overcome elder abuse and neglect.

ELDER ABUSE IN CONTEXT In our country, we believe in justice for all. Yet we fail to live up to this promise, especially for older people. We can, however, work together to build a just society. We can approach it as we might plan to construct a building. The first step is to put in place load-bearing beams to support the building’s structure and safeguard its inhabitants. To create a just society, we need beams like services and programs that integrate older people into our communities. If these beams are in place and continually maintained, older people will have more opportunities to stay connected. But if we don’t have these kinds of beams, or if they are weak, older people will likely experience social isolation, which increases the likelihood of abuse and neglect. Maria, age 77, reminds us why we need strong support beams for older people. Maria has lived alone in her apartment ever since her husband died 3 years ago. Her local community center closed last year, so she rarely has opportunities to interact with other people. Sometimes, she goes days on end without speaking to anyone. Her son, who lives an hour away, used to stop by twice a week to help with household chores and bring groceries. As his work responsibilities have increased, however, he has not been able to visit regularly. On the rare occasions when he does visit, he is overwhelmed (continued next page )

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by his responsibility as his mother’s sole social support, and he becomes frustrated with her. Maria lacks regular and positive social interactions with a variety of people; as a result, her living conditions and health have deteriorated, and she is becoming malnourished. She is not alone. Millions of older people in our country are socially isolated, putting them at greater risk of neglect and abuse. The good news is that we can better support people like Maria and reduce stress on family caregivers. Senior centers, community institutions, and friendly visitor programs, for example, connect older people with others and help them participate in community life. If we build a strong social structure around older people, we can reduce social isolation and overcome elder abuse and neglect. We can create a more just society for Maria and for all older people across our country. We can live up to our national promise of justice for all. —FrameWorks Institute, 2017

ELDER ABUSE AND NEGLECT: AN INTERNATIONAL AND NATIONAL ISSUE Two reports in British medical journals in 1975 were the first to formally identify elder abuse (Baker, 1975; Burston, 1975). Writing in the British Medical Journal, Burston stated, “Hardly a week goes by without some reference in the national press or medical journals to baby-battering, and I think it is about time that all of us realized that elderly people too are at times deliberately battered” (p. 592). Indeed, elder abuse has been one of the most under-recognized social problems around the world. In the United States, elder abuse as a national issue first surfaced in 1978 when Congressman Claude Pepper, a tireless advocate for the needs and rights of older individuals, held hearings in the House of Representatives to expose the “hidden problem.” Around the same time, an episode of Quincy, a late-1970s TV drama series, depicted a case of elder abuse, [which, it has been argued] . . . built support for the elder abuse agenda and contributed to public demands for changes in state and federal statutes. Also, The Battered Elder Syndrome was published by Block and Sinnott (1979) around this time. (Payne, 2009, p. 581) A joint hearing by the U.S. Senate and U.S. House of Representatives in 1980 led to a report recommending that the federal government help the states deal with elder abuse by establishing a Prevention, Identification, and Treatment of Elder Abuse Act (Wolf, 1988). There was essentially no federal action until Congressman Pepper tried a new strategy, adding amendments to the 1987 reauthorization of the Older Americans Act (OAA) that defined elder abuse and authorized $5 million for program grants for elder abuse services and education (learn more about the OAA in Chapter 10, Older Adults Giving and Receiving Support). Nevertheless, Congress waited until 1990 to appropriate $3 million for fiscal year 1991 for these services. In the 1992 amendments to the OAA, $15 million was authorized to fund elder abuse programs; however, only $4.4 million was actually appropriated for fiscal year 1993 (Tatara, 1994). OAA appropriations for elder abuse prevention in fiscal year 2011 were $5 million, which is actually a reduction in funding of approximately $1.9 million relative to the value of the dollar in 1993. While the focus of this chapter is on elder abuse and neglect, we should acknowledge that these are not the only crimes committed against older people. Violent crimes, such as rape and

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sexual assault, robbery, and aggravated assault, are much more common among younger people. According to the 2016 annual report of the Bureau of Justice Statistics, rates for violent crime (which do not include homicide) were 4.4 per 1,000 for those 65 and older, and 30.9 for 18- to 24-year-olds (Morgan & Kena, 2017). Data on homicides in 2016, which are collected by the Federal Bureau of Investigation (FBI), showed 736 homicides committed against those 65 and older, and more than five times that number—3,790—against 17- to 24-year-olds (FBI, 2017a, 2017b). This does not mean that there are not many older people living in high-crime areas where it is dangerous for them to leave their homes. And, despite the fact that older people are less likely to be victims of these violent crimes, they are more fearful of crime than younger people are. The fear and reality of crimes result in many older adults, particularly those who live in urban settings, being afraid to venture out of their own homes.

Defining Elder Abuse Numerous definitions of elder abuse exist. In fact, one group of researchers has documented more than 40 definitions of the term, many of which restrict themselves by type of abuse, who the perpetrator is (e.g., family member, caregiver, stranger), or the setting in which abuse occurs (e.g., the person’s home, a nursing home; Castle, Ferguson-Rome, & Teresi, 2015). Perhaps the best definition is the one by the American Medical Association because it encompasses all types of elder abuse and neglect regardless of the perpetrator or setting: “an act of commission or omission that results in harm or threatened harm to the health or welfare of an older adult” (Stiles, Koren, & Walsh, 2002, p. 34). In the United States, each state has its own laws that define elder abuse, so the definitions vary from one state to another. In 1992, a new section (Title VII) was added to the OAA to authorize programs to protect older adults from abuse (see Chapter 10, Older Adults Giving and Receiving Support, for more information about Title VII). One of the important gatherers of national data on elder abuse is the National Center on Elder Abuse (NCEA), which can be easily accessed via the Internet (for additional information on the NCEA, see Suggested Resources at the end of this chapter). The NCEA has organized the sources of elder abuse into three basic categories: domestic elder abuse, institutional elder abuse, and self-neglect. Domestic elder abuse refers to mistreatment of an older person by someone who has a special relationship with him or her, for example, a spouse, a child, a sibling, a friend, or a caregiver, in the older person’s home or in the home of the person caring for the older person. Institutional abuse generally refers to the abuse that occurs in residential living facilities designated for older people, such as assisted living facilities and nursing homes. Persons perpetrating institutional elder abuse usually are those who have a legal or contractual obligation to provide care and protection to the victims. They may include paid caregivers, staff, and professionals. A relatively new area of investigation for institutional abuse has been the abuse of one resident by another. Self-neglect refers to an unwillingness or inability to do the needed self-care resulting in a threat to the person’s own safety or health. Such behavior generally results from the physical or mental impairment of the older person (Burnes et al., 2015). Forms of mistreatment that can occur in domestic abuse or institutional abuse include: ■ ■ ■

Physical abuse: Deliberate use of physical force that results in bodily injury, pain, or impairment Sexual abuse: Nonconsensual sexual contact of any kind Psychological or emotional abuse: Willful infliction of mental or emotional anguish by threat, humiliation, intimidation, or other verbal or nonverbal abusive conduct

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■ ■

Neglect: Willful or non-willful failure to provide for a person’s safety, physical, or emotional needs Financial abuse or exploitation: Unauthorized use of funds, property, or any other material resources of a person

Most instances of physical, sexual, and financial abuses are classified as crimes in all states. Certain psychological or emotional abuse and neglect cases are considered criminal offenses depending on the perpetrator’s conduct and the consequences for the victims (Connolly, 2008). On the other hand, self-neglect is not considered a crime in all states. Elder abuse laws in some states do not even address self-neglect (Abumaria, 2017).

Possible Signs of Abuse and Neglect There are a variety of indicators that may point to elder abuse. Overt indicators for different types of elder abuse are the following: Physical Abuse ■ ■ ■ ■ ■

Unexplained bruises and welts Unexplained burns Unexplained fractures, lacerations, or abrasions Unexplained pain Restraint or grip markings

Sexual Abuse ■ ■ ■ ■ ■

Torn, stained, or bloody underclothing Pain or itching in genital area Bruises or bleeding in external genitalia, vaginal, or anal areas Unexplained sexually transmitted diseases Unexpected and unreported reluctance to cooperate with toileting, bathing, and physical examination of genitalia

Psychological or Emotional Abuse ■ ■ ■ ■ ■

Unusual changes in behavior or sleep patterns Subtle signs of fear or intimidation, such as deferring to a potential abuser Evidence of isolation of person from trusted family members and friends Depression, anxiety, or both Direct observation of verbal abuse

Neglect ■ ■

Consistent hunger, dehydration, unexplained weight loss, poor hygiene, and inappropriate attire, including soiled clothing Consistent lack of supervision, especially in dangerous activities or for long periods

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Unattended physical problems or medical needs, including urine burns or pressure sores Absence of, or nonfunctioning, needed assistive devices (e.g., eyeglasses, hearing aids, dentures, walking aids, wheelchairs) Over or under medication

Financial Abuse or Exploitation ■ ■ ■ ■

Unusual changes in money management or bank accounts Unusual or sudden changes in a will or other financial documents Fraudulent signatures on financial documents Unpaid bills

How Widespread Is Elder Abuse and Neglect? Accurate estimates of elder abuse and neglect are hard to establish for many reasons, among them: the fact that abuse and neglect may go undetected; a variety of agencies conduct investigations and collect data (e.g., police, Adult Protective Services, legal services), data they do not often share with each other; and, even when older people themselves recognize that abuse is occurring, they are often reluctant to report it, fearing the consequences. According to the National Council on Aging (2018), it is estimated that only 1 in 14 elder abuse incidents come to the attention of authorities. In one national study of domestic abuse—the National Elder Mistreatment Study—Ron Acierno et al. (2010) at the Medical University of South Carolina interviewed over 5,000 community-residing people aged 60 and over who were cognitively intact. They found that in the past year 11% of their interviewees reported having experienced at least one type of abuse (physical, sexual, emotional, or neglect) within the past year. In addition, 5% reported financial exploitation by family members. Consistent with previous studies, the interviewees for the National Elder Mistreatment Study said that they seldom reported their experiences of abuse to police. It should be noted that the survey did not include cases of self-neglect or financial abuse by people other than family members. Furthermore, residents of nursing homes and other facilities were not interviewed, so the prevalence rates found in this research do not reflect the full extent of the problem of elder abuse and neglect. Rates of abuse in residential living facilities are hard to come by too because, among other things, reporting is not mandated by all states, and research has often focused on only a small number of facilities or residents, or a single type of abuse. One study in 2005 found that almost half of the 260 nursing homes on which data were collected had at least one report of abuse (Allen, Kellett, & Gruman, 2003). In a more recent qualitative study, several thousand nurse aides in the state of Pennsylvania were asked about their observations, reports, or suspicions of abuse by nursing home staff (Castle, 2012). Over a third of the nurse aides reported observing or seeing evidence of verbal abuse (arguing with residents), and over one-quarter reported observing or seeing evidence of psychological abuse (intimidation). Lower percentages reported medication abuse (inappropriately delaying medication, 19%), caregiving abuse (threatening to stop taking care of residents, 10%), and material exploitation (taking belongings, 10%), and much lower percentages reported physical or sexual abuse (6% and 2%, respectively). Taken together these findings make it clear that abuse is all too common in nursing homes. Among confirmed cases of elder abuse, between one-third and one-half are instances of selfneglect (Gray-Vickrey, 2004; Rovi, Chen, Vega, Johnson, & Mouton, 2009). Most states offer some protective services for older people who neglect themselves, but they are careful to consider

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a person’s right to refuse these services. Adult Protective Services cannot remove persons from their homes against their will or force them to accept help unless the person has been found to be incompetent by a court of law. At that point, a court order is usually granted to appoint a legal guardian to make decisions on behalf of the person. Sometimes, self-neglect results in placing the person in a residential living facility, again through court action. These procedures usually are used only as last resorts for individuals in situations that are threatening to their health or safety, or both.

Consequences of Elder Abuse and Neglect Elder abuse and neglect can lead to a myriad of negative outcomes, including death. Each type of elder abuse has its own immediate consequences, for example, the broken bones, bruises, pain that can result from physical abuse, and the loss of assets associated with financial abuse. But the outcomes of abuse and neglect go far beyond these obvious signs. Abuse robs victims of their dignity, their overall quality of life, and their health. It also affects those around them and society as a whole. Perpetrators who are family members or other trusted individuals, such as friends and neighbors, often try to isolate the victim. Scammers and fraudsters often prey upon older people whom they believe to be isolated, for example, those who live alone. It is also the case that people who are being abused may withdraw and become socially isolated because they are concerned about the consequences of others finding out about the abuse. Other psychosocial effects, such as higher rates of depression, anxiety, and other forms of psychological distress are also common (Dong, Chen, Chang, & Simon, 2013). Among the many adverse health consequences of elder abuse and neglect are more visits to hospital emergency rooms, more hospitalizations, increased disability, and more nursing home placements, and ultimately, premature death (Lachs & Pillemer, 2015). Loved ones, too, can be affected by all of these outcomes, and society as a whole bears the burden and responsibility for these costs as well.

What Are the Vulnerabilities and Risk Factors? The American Psychological Association (2012) states, “Elder abuse affects older men and women across all socioeconomic groups, cultures, races, and ethnicities” (p. 3). That being said, there is evidence that some older people are more likely to be victims, including people with lower incomes and those with physical or mental health challenges (Lachs & Pillemer, 2015). Furthermore, as this chapter’s opening scenario indicated, isolation is a major risk factor for abuse and neglect. In individuals 60 years of age and over, between 7% and 24% face social isolation (Chen & Schulz, 2016). While some research has found gender differences among victims, other research has not. Differences between studies in the participants or sources of data may account for this inconsistency. Some studies may have taken into account the fact that because women live longer, there are more older women than older men, and they are more likely to live alone, which increases their risk for both isolation and abuse. Furthermore, abuse and neglect of older men frequently goes unreported, at least in part due to gender-role socialization that leads older men to be reluctant to admit that they have been abused (Kosberg, 2014).

Who Are the Perpetrators? Who is responsible for abusing older adults? Surprisingly little is known about the perpetrators of abuse and neglect other than basic demographic attributes, no doubt, at least in part, due to the

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difficulty of including them in research. The National Council on Aging (2018) contains reports that most abuse is committed by family members, most commonly spouses and adult children. Characteristics of perpetrators who are family members and trusted others are financial problems, substance abuse or gambling, and physical or mental health problems (Johannesen & LoGuidice, 2013). One of the most robust factors leading to abuse is a person being dependent on the victim, whether for financial resources, housing, food, or all three (Anetzberger, 2012). The vast majority of family caregivers do not abuse the people for whom they care, so it is no surprise that the old idea that caregiver stress leads to elder abuse and neglect has not held up to scrutiny. In residential care facilities, especially nursing homes, direct care workers often lack training in the skills and knowledge to serve their charges well. That, along with heavy workloads and a less-than-supportive work environment, can be a recipe for abuse. Financial fraud and scams can be committed by family members and trusted others, or by strangers. The most prominent characteristics of strangers who commit fraud or run scams on older people are greed and their total disregard for those they target.

Causes of Elder Abuse and Neglect There is no single cause of elder abuse and neglect. Elder abuse and neglect are complex, and numerous factors are involved in their occurrence. Previous theoretical and conceptual models have honed in on the perpetrator, and occasionally, the dyad of the abused person and his or her abuser. In trying to establish the prevalence of the mistreatment of older adults, many studies have focused heavily on characteristics of the victims, especially demographic characteristics, many of which, of course, cannot be changed (e.g., age, gender, race/ethnicity). These efforts have been helpful in working toward a more complete picture of the subject, but scholars in the field are now turning to social-ecological models to examine abuse at multiple levels. Good theoretical and conceptual models of elder abuse and neglect can lead to more effective education, training, and prevention strategies. The social-ecological model used by the Centers for Disease Control and Prevention (CDC) as a framework for violence prevention seems to be well suited to the subject of elder abuse and neglect (see Figure 14.1). At the individual level is the identification of victims’ and perpetrators’ demographic and personal history factors. Prevention at this level would focus on changing attitudes, beliefs, and behaviors. At the relationship level are a person’s family members and other loved ones. Prevention at this level would focus on strategies to reduce conflict, increase problem-solving skills, and promote healthy relationships. At the community level are the social and physical environments with which a person interacts. Prevention strategies at this level would focus on reducing isolation and improving availability and access to programs and services that would create opportunities for social engagement. Finally, at the societal level are the social and cultural norms that support or discourage elder abuse and neglect. Prevention at this level would focus on policy initiatives that would work toward creating a climate in which elder abuse and neglect are no longer tolerated. Financial Abuse, Fraud, and Scams Financial abuse is the illegal or improper use of financial and/or material resources to the disadvantage of the older person, or the profit or advantage of someone else, or both. Research on this type of abuse is relatively new. Most of the work on elder abuse has focused on physical, psychological, and sexual abuse, and neglect.

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Society

Community

Relationship

Individual

FIGURE 14.1  Social-ecological model.

Prevalence of Financial Abuse In a systematic review of 12 studies with more than 40,000 older Americans, David Burnes et al. (2017) estimated that each year approximately 1 in every 18 community-dwelling older adults is subjected to financial fraud by strangers. This rate is slightly higher than the proportion of community-dwelling older adults subjected to financial abuse by family members and trusted others. It is important to remember, however, that these statistics are only our best estimates because it is well known that abuse and neglect of all kinds are underreported. For example, research conducted for a study of domestic elder abuse in New York State (Lifespan of Greater Rochester, Weill Cornell Medical Center of Cornell University, and New York City Department for the ­Aging, 2011) found that for every 44 cases of financial abuse that survey participants said they had experienced, only one case was actually reported to authorities. Reasons for underreporting are many, among them: not fully recognizing that their experience is one of abuse, not being aware that it can be reported, fear of the abuser, thinking that nothing can be done about it, not knowing to whom to report it, shame, embarrassment. If people are dependent on the abuser for their basic needs, they worry about what will happen to them if they report the abuse. When family members are the perpetrators, older adults may be especially concerned about challenges to their autonomy once others learn about the abuse, and they may have concerns about law enforcement and social services becoming involved in ways that could be unhelpful to the family. When the available data and the extent of underreporting are taken into account, it becomes clear that millions of older Americans experience at least one incident of financial abuse every year. Estimates suggest that just over half of the perpetrators of elder financial abuse are strangers, and one-third are family members, friends, neighbors, or caregivers. Businesses, such as insurance companies, banks, legal firms, attorneys, contractors, and nursing home administrators, compose just over 10% of the cases, and Medicare and Medicaid fraud account for the remaining 4% (MetLife Mature Market Institute, 2011).

Consequences of Financial Abuse Financial abuse by family members and trusted others is almost always directed at older people, but anyone can become the target of fraud, scams, and cons by strangers. In fact, young people more often succumb to these schemes than older people do. On the other hand, older people who are defrauded have much higher losses on average than any other age group (Federal Trade Commission [FTC], 2018). In 2010, it was estimated that older Americans were losing at least $2.9 billion per

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year to financial abuse (MetLife Mature Market Institute, 2011). Having been deprived of their own assets, older victims may need to resort to depending on Supplemental Security Income and Medicaid for support. Beyond the money that older people lose, this type of abuse also engenders the same kinds of negative physical and psychological consequences that follow other types of abuse (described in the section on Consequences of Elder Abuse and Neglect). Psychological consequences can be particularly devastating, robbing older people of their dignity and self-confidence. A unique study of nontraditional costs of financial fraud collected data through a survey of 600 adults, aged 25 and older, who played an active role in their own self-reported incidents of financial fraud (Financial Industry Regulatory Authority [FINRA] Investor Education Foundation, 2015). Most respondents said that they had only communicated a few times with the perpetrator, and somewhat surprisingly, almost one-third reported that they had been introduced to the perpetrator by a family member, friend, or professional contact. For younger people, contacts with perpetrators were more likely to have been made through social networks. One-quarter of victims said that they had not reported the incident because they did not know where, or to whom, to report it. One type of nontraditional cost was indirect financial costs, such as late fees, legal, or medical fees. Younger people were more likely than older people to incur these costs (65% of 25-to-34-year-olds vs. 33% of those 55 years of age or older), and 12% of younger people ended up declaring bankruptcy, compared to only 4% of older adults. A second type of nontraditional costs were nonfinancial. Of these costs, stress, anxiety, difficulty sleeping, loss of personal confidence, and depression were the most prevalent, with at least one-third of the victims suffering from these outcomes to a serious degree. On average, younger people suffered from twice as many of these outcomes as older people did. Feeling victimized and betrayed, as well as anger and regret, were the most common negative emotional reactions, experienced by seven of every ten victims. Thus, financial abuse and fraud result in a multitude of negative effects many of which last long after the abuse or fraud has been committed, and affect every aspect of an older person’s life. With greater financial assets and resources than previous generations, and a higher likelihood of being socially isolated, today’s older adults are especially desirable targets for fraudsters and scammers. And, older people are now disproportionately targeted with schemes that are specifically aimed at them. Analyzing sales materials used by a company (Alliance for Mature Americans) to defraud 10,000 older Americans out of more than $200 million, DeLiema, Yon, and Wilber (2016) chronicled the tactics that were being specifically directed at older consumers to get them to invest in living trusts and annuities. Among the multitude of persuasion tricks, company representatives were using age-related concerns in their sales pitches, for example, “the desire for financial autonomy, anxiety about cognitive and physical decline, and fear of disappointing family members for poor financial planning” (p. 340).

Methods and Types of Consumer Fraud A variety of methods are used to commit fraud, including the postal service, face-to-face interactions, the telephone, and the Internet. Countless types of fraud exist, and perpetrators are always coming up with new ones. Methods: Postal Service, Face-to-Face, Telephone, and Internet Fraud Though not as prevalent as they once were, the postal service and face-to-face schemes are still used to defraud people today. In fact, the U.S. Postal Service even has a Guide to Preventing Mail

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Fraud (available online), which provides details on more than 20 types of fraud that are committed through the postal service, as well as information on whom to contact in the event of suspected mail fraud. Face-to-face, or door-to-door, scams have also not gone away. The investment scams of the Alliance for Mature Americans, just described, relied heavily on its sales representatives interacting with older people in person. Telemarketing scammers contact individuals on their landline or cell phone. In one version of these scams, older persons are asked to call an 800 or 900 number. They will then be offered prizes, cheap or free trips, or vacation housing at reduced prices, for example. Typically, the caller will request a credit card number, and use that credit card information to make purchases, which are then charged to the older person. The swindlers will usually be willing to settle for a checking account number. These callers often work from boiler rooms, in which groups of persons will be calling constantly, trying to make connections with older adults. They usually pressure the persons by telling them that the offer must be accepted immediately because it is only good for a very short period of time (e.g., 24 hours or less). Crimes once committed in person or by mail are increasingly being committed over the Internet. The FBI’s Internet Crime Complaint Center (ICS, www.ic3.gov) receives reports from the public concerning Internet-facilitated criminal activity, and analyzes and disseminates that information to the public and law enforcement. Figure 14.2 displays the financial losses in 2017, by age group. Compared to other age groups, slightly more people aged 60 and over were victims—a total of just under 50,000—with losses in excess of $342 million. The FBI’s IC3 website lists and describes current and ongoing types of Internet crimes, provides prevention tips, and includes instructions for reporting such crimes. Older Americans who are using the Internet, and future generations of older adults who will have had more lifetime experience with the Internet, will increasingly become targets for fraud committed through this method. $350,000,000

Financial Losses (2017)

$300,000,000 $250,000,000 $200,000,000 $150,000,000 $100,000,000 $50,000,000 $0

20–29

30–39

40–49

50–59

60+

Age Group

FIGURE 14.2  Total financial losses from Internet fraud, by age group, 2017. SOURCE: Federal Bureau of Investigation. (2017a, May). 2016 Internet crime report. Internet Crime Complaint ­Center. Retrieved from https://www.ic3.gov/media/default.aspx

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Types of Consumer Fraud The FTC tracks 30 different types of fraud, scams, and confidence schemes, which are all classified as “consumer fraud.” Examples of frauds and scams often used in preying upon older adults are: ■

■

■

■

■

Prizes, lottery, and sweepstake scams, in which scammers pose as representatives of entities through which the victim is said to have won valuable prizes or large sums of money. The scammers then ask for shipping or insurance fees or taxes in order to release the victim’s winnings. Grandparent scams, in which callers pretend to be a grandchild who is in trouble and needs money to resolve the situation; in one type of call, the imposter says he or she has been robbed while on a trip, and needs money to get back home. Scammers use Facebook and other social media to collect information to create realistic stories. Social Security, Medicare, and Medicaid scams, in which imposters claiming to be official government representatives attempt to extract personal information, such as bank account information, with stories about new benefit cards or saying that they can improve the victim’s benefits. Internal Revenue Service (IRS) scams, which are being committed by phone and email, have many variations. They are all intended to obtain personal information and often money too. In a common ruse, scammers tell their victims that they owe money to the IRS and must pay it immediately or face arrest. Sweetheart/affinity scams that use online dating websites and social networking sites on which con artists create fake profiles to build relationships and then, in the name of love, get the victim to send them money.

In addition to these types of fraud, older adults are especially vulnerable to investment fraud because they generally have more assets than younger individuals, and may suffer from isolation or feelings of loneliness, or both. Sophisticated, computer-generated lists, as well as information that can be garnered from social media sites, provide con artists with ways to identify newly retired employees, those receiving lump-sum pension payments, newly widowed older people, and older people who have sold their homes (Goergen & Beaulieu, 2017). In 2016, a major national survey conducted for the Investor Protection Trust found that, “17 percent of Americans aged 65 or older—more than 6.8 million senior citizens—already have been taken advantage of financially in terms of an inappropriate investment, unreasonably high fees for financial services, or outright fraud” (Investor Protection Trust, 2016, p. 2). However, this percentage is likely to be an underestimate because, among other reasons, at any given point in time, many older adults may still not know they were part of an investment fraud. Of course, legitimate financial advisors are in the business of selling investments, but there are standards and rules set by the FINRA (2018), a private self-regulating organization, which oversees every broker and brokerage firm doing business in the United States. FINRA can and does adjudicate cases brought by investors. In addition to expelling or suspending over 1,200 individual brokers and 49 brokerage firms in 2017, FINRA collected $65 million in fines and recovered $67 million in funds wrongfully taken from investors.

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Misuse of Guardianships Another major area of fraud against older people is the misuse of guardianships. Guardianships are granted by court orders to manage the affairs of individuals who are judged incompetent to manage their own financial and personal affairs, including matters related to their health. A guardian can be a family member, a nonprofit social service agency, a public guardian, or a professional guardian. State or county offices may appoint a public guardian, and these offices also determine the conditions under which someone can be designated as a professional guardian. “The appointment of a guardian typically means that the incapacitated person loses basic rights, such as the ability to sign contracts, vote, marry or divorce, buy or sell real estate, or make decisions about medical procedures” (U.S. Government Accountability Office [GAO], 2010, p. 3). Once a guardianship is granted by the court, it is not easy to reverse the appointment. Many people seek guardianship status to serve the best interests of their older clients. Unfortunately, many others take advantage of their authority, usually for financial gain, and the resulting financial abuse can also be accompanied by physical and psychological abuse. In response to a request from the U.S. Senate’s Special Committee on Aging, in 2010 the U.S. GAO was tasked with investigating the scope of allegations of abuse by guardians, looking into examples of abuse cases, and testing the processes by which states certify guardians. The federal government itself does not regulate guardianships. The GAO’s research could not draw conclusions about the extent of abuses by guardians because there is no entity—federal, state, or local government agency, or any other organization—that compiles data on allegations of such abuse. As a consequence, the number of abuses perpetrated by guardians is unknown. A few representative cases encountered by the GAO (2010, p. 7) follow: ■

■

■

In Arizona, court-appointed guardians allegedly siphoned off millions of dollars from their wards, including $1 million from a 77-year-old woman whose properties and personal belongings, such as her wedding album, were auctioned at a fraction of their cost. A Texas couple, ages 67 and 70, were declared mentally incompetent and placed in a nursing home after the husband broke his hip. Under the care of court-appointed guardians, their house went into foreclosure, their car was repossessed, their electricity was shut off, and their credit was allowed to deteriorate. The couple was allegedly given a $60 monthly allowance and permitted no personal belongings except a television. A 93-year-old Florida woman died after her grandson became her temporary guardian by claiming she had terminal colon cancer. He then moved her to hospice care, where she died 12 days later from the effects of morphine. The woman’s condition was later determined to be ulcerative colitis, and the guardian’s claims that she had 6 months to live were false. In addition, the guardian is accused of stealing $250,000 from the woman’s estate.

Guardianship certification is intended to provide assurance that a guardian is qualified to fulfill the role of managers of their ward’s financial or personal affairs, or both. How well does that certification work? To test the guardianship approval process, representatives for the GAO applied to four states for guardianship certification using fake identities of someone with bad credit or the Social Security number of a deceased person. Guardianship certification was granted in all four of those states—Illinois, Nevada, New York, and North Carolina. Even after appointing a guardian, most states do not demand much accountability from them. Most state courts are too

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busy to become very involved in examining in any great detail the activities of the guardians. The GAO found three consistent problems: ■

■ ■

State courts fail to adequately screen potential guardians, appointing individuals with criminal convictions or significant financial problems, or both, to manage estates worth hundreds of thousands or even millions of dollars. State courts fail to adequately oversee guardians after their appointment, allowing the abuse of vulnerable older adults and their assets to continue. State courts fail to communicate with federal agencies about abusive guardians once the court becomes aware of the abuse, which in some cases enables the guardians to continue to receive and manage federal benefits. (GAO, 2010, pp. 7–8)

Proving financial exploitation is difficult because it usually requires examining financial records and following the flow of the victim’s and the victimizer’s funds. In addition to these difficulties is the high probability that if a guardianship has been granted, the victim very likely will not be able to provide testimony because of physical or psychological conditions that led to the guardianship. In other situations, the victimized person may pass away, and the guardian’s exploitation of the person’s estate may never become known.

PREVENTING AND RESPONDING TO ELDER ABUSE AND NEGLECT We can prevent elder abuse and neglect. Key strategies to aid us in meeting that goal are: create public awareness; increase access to programs and services to reduce isolation of older people; educate healthcare providers, service providers, and caregivers; and, educate older people in the prevention and reporting of abuse. Although elder abuse and neglect were first recognized as a significant societal problem in the 1980s, they have received short shrift from federal government agencies. In 1992, a new section was added to the OAA, Title VII, to authorize programs to protect older adults from abuse, which included the long-term care ombudsman program described in Chapter 10, Older Adults Giving and Receiving Support. The CDC has been even slower to address elder abuse. Its publication on the History of Violence Prevention does not even mention elder abuse, and it was not until 2016 that the CDC officially recognized elder abuse as a public health problem (Hall, Karsh, & Crosby, 2016). The field of public health has been successful in creating effective public health campaigns to reduce smoking. Raising public awareness and knowledge about elder abuse and its prevalence require similar attention. Isolation is now recognized as a major contributor to elder abuse and neglect. The scenario at the beginning of this chapter gives an example of just how isolation, especially when accompanied by other issues, can lead to an older person being victimized. It also suggests some ways to prevent or reduce isolation. Table 14.1 presents major causes of isolation and additional ways to achieve that goal. Some communities have formed something called Triad/SALT organizations in order to combat crimes against older people. Triads are organized when the local police and sheriff ’s departments agree to work cooperatively with older adults and community groups to prevent crimes against them. The Triad concept began in 1987, when members of the AARP, the International Association of Chiefs of Police (IACP), and the National Sheriffs’ Association (NSA) met to

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TABLE 14.1 Causes of Isolation and Ways to Prevent or Reduce It MOST PREVALENT CAUSES OF ISOLATION

RESPONSES THAT MAY PREVENT OR REDUCE ISOLATION

Transportation challenges

Lack of accessible and affordable transportation options; no longer driving

Volunteer-based ride programs; livable/age-friendly community initiatives

Life transitions, role loss or change

Leaving the workforce; loss of a partner or friends; becoming a caregiver

Support groups; lifelong learning; senior centers; creative/artful aging

Societal barriers

Ageism; lack of opportunities to engage and contribute

Intergenerational programs; lifelong learning; policies to support an older workforce

Lack of access and inequality

Poverty; rural living; marginalized groups (racial/ ethnic minorities, LGBT, etc.)

Resiliency and empowerment models; home-sharing models; technology training

Poor health and well-being

Untreated hearing loss; mobility impairments; frailty; poor mental health

Chronic disease self-management programs; falls prevention programs

LGBT, lesbian, gay, bisexual, and transgender. SOURCE: Adapted from AARP Foundation. (2018). About isolation. Retrieved from https://connect2affect.org/ about-isolation/

consider methods of reducing crime against older people. Seniors and Lawmen Together (SALT) is the organization that Triads usually create when law enforcement personnel ask older people, as well as those who work with them, to serve on an advisory council. The SALT organization typically conducts a survey to determine the needs and concerns of older people in their region regarding criminal activity. In describing the operation of the program, Cantrell (1994) wrote, Volunteers may staff reception desks in law enforcement agencies, present programs to senior organizations, conduct informal house security surveys, and become leaders in new or rejuvenated neighborhood watch groups. They may also provide information and support to crime victims, call citizens concerning civil warrants, or assist law enforcement agencies in maintaining records or property rooms at substations or in other areas. (p. 21) In some areas, a Triad will create telephone programs in which older people are called daily. In other areas, Triads have created shopping programs, where grocery stores provide vans to transport older people in regularly scheduled shopping trips. Triads also teach safe ways to carry money and other valuables, as well as carjacking prevention. Far too infrequently do healthcare and service providers receive education and training in how to prevent elder abuse, how to recognize/detect it, how to report it, and how and where to refer clients for help. In some communities, continuing education programs may offer this kind of training. Workshops and other training programs that include prevention approaches may also be offered for family caregivers and staff of residential living facilities. Most care in nursing homes is provided by

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certified nursing assistants (CNAs), or direct care workers, so they are an especially good audience for education on elder abuse. Detecting and reporting abuse are common elements included in training programs, but prevention is also important. Training in prevention might include “interpersonal skills, managing difficult situations, problem solving, cultural issues that affect staff-resident relationships, conflict resolution, stress reduction, [and] information about dementia” (DeHart, Webb, & Cornman, 2009, p. 362). Redesigning work environments and responsibilities of staff could help to reduce situations that may lead to, or provide opportunities for, abuse of residents and caregivers. Aging units within each state, as well as local senior centers, may offer presentations for older adults and their loved ones on how to avoid elder abuse. Help in preventing and responding to cases of suspected elder abuse and neglect is also available through a wide variety of government offices, community nonprofit organizations, businesses, and service providers. Table 14.2 provides a list of such resources. The Eldercare Locator service, which was discussed in Chapter 10, Older Adults Giving and Receiving Support, can assist in finding local contact information for many of these resources (1-800-677-1116, [email protected], or www.eldercare.gov). TABLE 14.2 Resources for Preventing and Responding to Cases of Suspected Elder Abuse RESOURCES

ROLE

Adult protective services

Receive mandatory reports of suspected abuse

Community nonprofit organizations

Can mitigate all forms of abuse through programs and services they offer (e.g., senior centers)

Home healthcare agencies and personnel

Important in detection and mitigation of abuse

Housing authority

Handles issues involving eviction, squatting, or misuse of housing

Healthcare providers

Play critical roles in identifying abuse and making appropriate referrals

Hospital personnel

Should be prepared to identify cases of abuse

Residential living facilities

Should have policies and practices in place to prevent and detect abuse (by staff and by residents); can provide shelter to persons who have been abused

Police

Often first responders in cases of abuse

District attorney’s office

Prosecutes cases of abuse

Legal services agencies

Handle legal issues raised in cases of abuse, including decision-making capacity, living wills, and guardianship

Banks and financial services industry

Should have policies and practices in place to detect exploitation

SOURCE: Adapted from Lachs, M. S., & Pillemer, K. A. (2015). Elder abuse. New England Journal of Medicine, 373 (20), 1947–1956. doi:10.1056/NEJMra1404688

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Preventing and Responding to Financial Abuse There seems to be no shortage of organizations and programs available to educate older adults and their loved ones about warning signs and best practices for avoiding financial abuse, fraud, and scams. The success of these programs, of course, depends on people knowing about them, and when appropriate, participating in them. Mears, Reisig, Scaggs, and Holtfreter (2016) have learned that gender, race, ethnicity, education, and use of the Internet affect the types of media that older people use in finding out about fraud. As a result, to reach the broadest audience, they recommend using multiple and diverse media, from radio and television, to print sources, to electronic media. The FTC explains that scammers want to get money from their victims as quickly as possible, in a way that makes it hard to trace them, and hard for the victims to get their money back. Consequently, the FTC warns that anyone asking a person to wire money, or pay them with a gift card or cash reload card, is conducting a scam, because these payment methods meet all those scammers’ goals. The National Council on Aging (2017) has created a list of the 8 Tips for How Seniors Can Protect Themselves from Money Scams: 1. 2. 3. 4. 5. 6. 7. 8.

Be aware that you are at risk from strangers—and from those closest to you. Don’t isolate yourself—stay involved! Always tell solicitors: “I never buy from (or give to) anyone who calls or visits me unannounced. Send me something in writing.” Shred all receipts with your credit card number. Sign up for the “Do Not Call” list and take yourself off multiple mailing lists. Use direct deposit for benefit checks to prevent checks from being stolen from your mailbox. Never give your credit card, banking, Social Security, Medicare, or other personal information over the phone unless you initiated the call. Be skeptical of all unsolicited offers and thoroughly do your research.

Reporting Abuse and Fraud The types and methods of committing fraud and scams are constantly evolving, so keeping up with them can be difficult. Fortunately, in addition to those entities listed in Table 14.2, AARP and several national government offices offer alerts as well as ways to report abuse and fraud. ■

■ ■

AARP has a Fraud Watch Network (www.aarp.org/fraudwatchnetwork) with up-todate scam alerts that can be delivered directly to consumers via e-mail; a scam-tracking map with warnings from local law enforcement and community members who are sharing their experiences; a Con Artists Playbook, featuring con artists revealing how they commit their crimes; and, a phone number to call to talk with volunteers who are trained to help older people in spotting and reporting fraud and scams. The NCEA website (ncea.acl.gov) lists hotline, helplines, and referral sources for every state. The FTC (www.consumer.ftc.gov/features/scam-alerts) keeps a list of recent scams that can be searched by date or topic, and consumers can sign up to receive alerts via e-mail.

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■

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The U.S. Senate Special Committee on Aging has set up a hotline for reporting fraud and assisting victims: www.aging.senate.gov/fraud-hotline The IRS has a website with information on how to know if it is really the IRS calling or knocking on the door, as well as tax scams and consumer alerts: www.irs.gov/ newsroom/tax-scamsconsumer-alerts U.S. Department of Justice, as part of its Elder Justice Initiative, has established Senior Scam Alert: www.justice.gov/elderjustice/senior-scam-alert

The types and variations of scams and cons committed against older persons are endless. They continue to evolve, and marketing techniques continue to develop based on new technologies and strategies. What does not change is the fact that older adults are exploited by greedy, ruthless con artists—exploitation that can result in loss of health, financial ruin, and even death. In preparation for the 2015 White House Conference on Aging, 750 stakeholders from around the country established priorities for preventing and intervening in elder abuse and neglect (Pillemer, Connolly, Breckman, Spreng, & Lachs, 2015). These priorities are: ■ ■ ■

Develop a knowledge base for addressing elder mistreatment, including scientific evaluation of prevention and intervention services Create a comprehensive network of elder mistreatment services and training opportunities for professionals to improve outcomes Forge a coordinated policy approach to reduce elder mistreatment, including a leadership unit in the federal government to coordinate elder justice at the federal, state, and local levels (pp. 322–325)

Elder abuse and neglect are preventable. If justice for older adults requires that we take steps to address elder abuse, do so. Additional information on abuse and neglect can be found in the Practical Application at the end of this chapter.

PRACTICAL APPLICATION INTRODUCTION

Chapter 14 describes elder abuse and highlights its consequences. It demonstrates how the social-ecological model is applied to elder abuse and outlines some of the financial frauds and scams perpetrated against older adults. The chapter concludes with an explanation of how our society can overcome elder abuse and neglect. The health and safety of older adults under the care of others is of utmost importance; therefore, the reporting of elder abuse is the focus of this Practical Application. REPORTING ELDER ABUSE, NEGLECT, AND EXPLOITATION

Families often get a bum rap with the common stereotype that they abandon their older loved ones. As noted throughout this text, families actually provide the majority of care for their elderly loved ones. American families often provide heroic levels of loving care including physical, financial, emotional, social, and spiritual support for their older loved ones.

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Although not commonplace, elder abuse and financial exploitation do exist in America, and sadly, they often go unreported. It is important to note that professionals working with older persons are required to report any suspicion of elder abuse, neglect, and exploitation. Many professions are legally required to report such abuse, including anyone licensed, registered, or certified to provide healthcare, education, social welfare, mental health services, and law enforcement. The role of the professional in helping to prevent elder abuse, neglect, and exploitation should not be underestimated. Through education, close observation, diligence, and when necessary, early reporting, the gerontology professional can help save the lives and well-being of those older adults at risk.

STUDENT ACTIVITIES 1. Conduct a web search to determine how your state defines elder abuse, then summarize

the resources and recommendations related to elder abuse found on your state’s website. 2. Imagine you are an educational consultant who provides professional training to residential care facility employees about elder abuse. Create an outline of your presentation, the topic of which is “Elder Abuse: What Is It and How Does It Hurt Older Adults?” 3. Read the following scenarios and determine which level of the social-ecological model they represent. ■

■

■ ■

Jasmine is a law student who aims to defend older adults in cases of discrimination and elder abuse. She volunteers much of her time at the state house bringing the issue of elder abuse to the attention of lawmakers. Isaac is a care worker at a nursing home. He just attended a lecture about elder abuse and wants to share what he has learned with residents, so they are aware of the issue and able to report questionable behavior they experience or witness. Valeria is a driver for Meals on Wheels America and spends her days delivering meals to older adults and ensuring their safety within their homes. Maury is a counselor and author who has recently written a book aimed at helping older adults express to family members their needs and wishes in the years to come.

4. Write a paragraph explaining the pitfalls of guardianship. 5. Emma just turned 80 and lives alone in her suburban home outside Philadelphia. Her

two sons and five grandchildren live within a 15-minute drive from her house. In fact, two of her grandchildren go to school just a few blocks away. She is generally healthy and able to care for her basic needs, but she struggles to keep up with paying her bills and maintaining her home. Describe an ideal scenario in which Emma receives the help she needs, stays connected to her community, and feels cared for by her family. Explain who helps her and how, and outline the support she utilizes within her community in order to care for herself.

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SUGGESTED RESOURCES Center of Excellence on Elder Abuse and Neglect. (n.d.). Retrieved from http://www.centeronelderabuse .org/index.asp This Center, located at the University of California, Irvine’s School of Medicine, supports and disseminates research on innovative approaches to preventing elder abuse. It also conducts training activities and provides training materials via their website for home health aides and certified nursing assistants, nursing students, pharmacists, and pharmacy students, among others. Elder Investment Fraud and Financial Exploitation (EIFFE) Prevention Program. (n.d.). Retrieved from http://www.nasaa.org/1733/eiffe A variety of organizations have joined forces to create the EIFFE program to educate caregivers, including medical professionals, about financial abuse of older people. The website includes links to resources for older people, service providers, and educators. International Network for the Prevention of Elder Abuse (INPEA). (n.d.). Retrieved from http://www .inpea.net Established in 1997, the INPEA’s mission is to eliminate mistreatment of older adults globally. Members include individuals and organizations. Reports and resources from around the world are available via this website. National Adult Protective Services Association. (n.d.). Retrieved from http://www.napsa-now.org A national nonprofit organization, this association aims to improve the quality of services for older and vulnerable adults who have been mistreated, as well as to prevent mistreatment whenever possible. Among other resources, the site provides links to Adult Protective Services offices in all 50 states, Puerto Rico, and Guam. National Center on Elder Abuse. (n.d.). Retrieved from https://ncea.acl.gov The Center’s website provides descriptions and definitions of elder abuse, and laws concerning elder abuse. Resources, for families, caregivers, and individuals, include who to notify about elder abuse, how to contact authorities, and how to find state resources.

REFERENCES AARP Foundation. (2018). About isolation. Retrieved from https://connect2affect.org/about-isolation/ Abumaria, I. M. (2017). Self-neglect. US state law. Retrieved from https://selfneglect.org/self-neglect-facts/ ethics-and-the-law/us-state-law Acierno, R., Hernandez, M. A., Amstadter, A. B., Resnick, H. S., Steve, K., Muzzy, W., & Kilpatrick, D. G. (2010). Prevalence and correlates of emotional, physical, sexual, and financial abuse and potential neglect in the United States: The National Elder Mistreatment Study. American Journal of Public Health, 100(2), 292–297. doi:10.2105/AJPH.2009.163089 Allen, P., Kellett, K., & Gruman, C. (2003). Elder abuse in Connecticut’s nursing homes. Journal of Elder Abuse & Neglect, 15(1), 19–42. American Psychological Association. (2012). Elder abuse and neglect: In search of solutions. Washington, DC: Author. Retrieved from https://www.apa.org/pi/aging/elder-abuse.pdf Anetzberger, G. J. (2012). An update on the nature and scope of elder abuse. Generations, 36(3), 12–20. Baker, A. A. (1975). Granny battering. Modern Geriatrics, 5, 20–24. Burnes, D., Henderson, C. R., Jr., Sheppard, C., Zhao, R., Pillemer, K., & Lachs, M. S. (2017). Prevalence of financial fraud and scams among older adults in the United States. American Journal of Public Health, 107(8), e13–e21. doi:10.2105/AJPH.2017.303821a Burnes, D., Pillemer, K., Caccamise, P. L., Mason, A., Henderson Jr, C. R., Berman, J., . . . Salamone, A. (2015). Prevalence of and risk factors for elder abuse and neglect in the community: A populationbased study. Journal of the American Geriatrics Society, 63(9), 1906–1912. Burston, G. R. (1975). Letter: Granny-battering. British Medical Journal, 3, 592. doi:10.1136/ bmj.3.5983.592-a Cantrell, B. (1994). Triad: Reducing criminal victimization of the elderly. FBI Law Enforcement Bulletin, 63(2), 19–23.

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Castle, N. G. (2012). Nurse aides’ reports of resident abuse in nursing homes. Journal of Applied Gerontology, 31(3), 402–422. doi:10.1177/0733464810389174 Castle, N., Ferguson-Rome, J. C., & Teresi, J. A. (2015). Elder abuse in residential long-term care: An update to the 2003 National Research Council Report. Journal of Applied Gerontology, 34(4), 407–443. doi:10.1177/0733464813492583 Chen, Y. R. R., & Schulz, P. J. (2016). The effect of information communication technology interventions on reducing social isolation in the elderly: A systematic review. Journal of Medical Internet Research, 18(1), 1–11. doi:10.2196/jmir.4596 Connolly, M.-T. (2008). Elder self-neglect and the justice system: An essay from an interdisciplinary perspective. Journal of the American Geriatrics Society, 56(S2), S244–S252. doi:10.1111/j.1532-5415.2008.01976.x DeHart, D., Webb, J., & Cornman, C. (2009). Prevention of elder mistreatment in nursing homes: Competencies for direct-care staff. Journal of Elder Abuse and Neglect, 21(4), 360–378. doi:10.1080/08946560903005174 DeLiema, M., Yon, Y., & Wilber, K. H. (2016). Tricks of the trade: Motivating sales agents to con older adults. The Gerontologist, 56(2), 335–344. doi:10.1093/geront/gnu039 Dong, X., Chen, R., Chang, E. S., & Simon, M. (2013). Elder abuse and psychological well-being: A systematic review and implications for research and policy: A mini review. Gerontology, 59, 132–142. doi:10.1159/000341652 Federal Bureau of Investigation. (2017a, May). 2016 Internet crime report. Internet Crime Complaint Center. Retrieved from https://www.ic3.gov/media/default.aspx Federal Bureau of Investigation. (2017b). Crime in the United States, 2016. Retrieved from https://ucr.fbi .gov/crime-in-the-u.s/2016/crime-in-the-u.s.-2016 Federal Trade Commission. (2018, March). Consumer sentinel network: Data book 2017. Retrieved from https://www.ftc.gov/system/files/documents/reports/consumer-sentinel-network-data-book-2017/ consumer_sentinel_data_book_2017.pdf Financial Industry Regulatory Authority. (2018). Key statistics for 2017. Retrieved from http://www .finra.org/newsroom/statistics#key FINRA Investor Education Foundation. (2015, March). Non-traditional costs of financial fraud: Report of survey findings. Retrieved from https://www.finrafoundation.org/files/ non-traditional-costs-financial-fraud FrameWorks Institute. (2017). Talking elder abuse: Key framing guides. Retrieved from https://www .frameworksinstitute.org/toolkits/elderabuse/elements/items/elder_abuse_tk_storytelling_strategies .pdf Goergen, T., & Beaulieu, M. (2017). Crime prevention over the life course: Elder abuse. In B. Teasdale & M. Bradley (Eds.), Preventing crime and violence (pp. 123–138). New York, NY: Springer. Government Accountability Office. (2010, September). Guardianships: Cases of financial exploitation, neglect, and abuse of seniors. Washington, DC: Author. Retrieved from https://www.gao.gov/new .items/d101046.pdf Gray-Vickrey, P. (2004). Combating elder abuse: Here’s what to look for, what to ask, and how to respond if you suspect that an older patient is a victim. Nursing, 34(10), 47–51. doi:10.1097/00152193-200410000-00040 Hall, J., Karsh, D. L., & Crosby, A. (2016). Elder abuse surveillance: Uniform definitions and recommended core data elements. Atlanta, GA: Centers for Disease Control and Prevention. Retrieved from https://www.cdc.gov/violenceprevention/pdf/EA_Book_Revised_2016.pdf Investor Protection Trust. (2016, March 22). Elder investment fraud and financial exploitation. Retrieved from http://www.investorprotection.org/downloads/IPT_EIFFE_Medical_Survey_Report_03-22-16. pdf Johannesen, M., & LoGuidice, D. (2013). Elder abuse: A systematic review of risk factors in communitydwelling elders. Age and Ageing, 42, 292–298. doi:10.1093/ageing/afs195 Kosberg, J. L. (2014). Rosalie Wolf Memorial Lecture: Reconsidering assumptions regarding men as elder abuse perpetrators and as elder abuse victims. Journal of Elder Abuse and Neglect, 26(3), 207–222. doi:10.1080/08946566.2014.898442

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Lachs, M. S., & Pillemer, K. A. (2015). Elder abuse. New England Journal of Medicine, 373(20), 1947–1956. doi:10.1056/NEJMra1404688 Lifespan of Greater Rochester, Weill Cornell Medical Center of Cornell University, and New York City Department for the Aging. (2011). Under the radar: New York State Elder Abuse Prevalence Study. Retrieved from https://ocfs.ny.gov/main/psa Mears, D. P., Reisig, M. D., Scaggs, S., & Holtfreter, K. (2016). Efforts to reduce consumer fraud victimization among the elderly: The effect of information access on program awareness and contact. Crime and Delinquency, 62(9), 1235–1259. doi:10.1177/0011128714555759 MetLife Mature Market Institute. (2011). The MetLife study of elder financial abuse: Crimes of occasion, desperation and predation against America’s elders. Westport, CT: Author. Retrieved from http:// ltcombudsman.org/uploads/files/issues/mmi-elder-financial-abuse.pdf Morgan, R. E., & Kena, G. (2017, December). Criminal victimization, 2016. Washington, DC: U.S. Bureau of Justice Studies. Retrieved from https://www.bjs.gov/content/pub/pdf/cv16.pdf National Council on Aging. (2017). 8 Tips for how seniors can protect themselves from money scams. Retrieved from https://www.ncoa.org/economic-security/money-management/scams-security/ protection-from-scams National Council on Aging. (2018). Elder abuse facts. Retrieved from https://www.ncoa.org/public -policy-action/elder-justice/elder-abuse-facts/ Payne, B. K. (2009). Elder abuse. In J. Miller (Ed.), 21st Century criminology: A reference handbook (pp. 581–590). Thousand Oaks, CA: Sage. Pillemer, K., Connolly, M. T., Breckman, R., Spreng, N., & Lachs, M. S. (2015). Elder mistreatment: Priorities for consideration by the White House Conference on Aging. The Gerontologist, 55(2), 320–327. doi:10.1093/geront/gnu180 Rovi, S., Chen, P. H., Vega, M., Johnson, M. S., & Mouton, C. P. (2009). Mapping the elder mistreatment iceberg: US hospitalizations with elder abuse and neglect diagnoses. Journal of Elder Abuse and Neglect, 21(4), 346–359. doi:10.1080/08946560903005109 Stiles, M. M., Koren, C., & Walsh, K. (2002). Identifying elder abuse in the primary care setting. Clinical Geriatrics, 10(7), 33–41. Tatara, T. (1994). Elder abuse: Questions and answers. Washington, DC: National Center on Elder Abuse. Wolf, R. S. (1988). The evolution of policy: A 10-year retrospective. Public Welfare, 46(2), 7–13.

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PART VI THE FIELD OF GERONTOLOGY

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CHAPTER

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CAR E E R S I N AG I N G

LEARNING OBJECTIVES • Explain why everyone, no matter what his or her career interests and ultimate career choice are, needs at least some education in the field of aging. • Give examples of the vast array of career opportunities in aging. • Compare different ways of finding jobs in aging, and explain why entrepreneurship is a growing area for jobs in aging. • Describe educational pathways for undergraduates, and professional and graduate students in the field of aging. • Discuss how joining professional organizations can advance your career prospects. • Appraise the value of obtaining a credential in the field of aging.

THREE VERY DIFFERENT CAREERS IN THE FIELD OF AGING “Do you like variety? Creating your own role within an organization? If you answered ‘yes,’ then working as a gerontologist in the private sector may be the career for you. I’ve created my own role within many organizations and industries over the past 15 years—and had great fun along the way,” says Stephanie Chappell. Stephanie is a corporate financial gerontologist. She has worked in the health insurance industry, senior living, hospital systems and home healthcare, and the financial services industry. In the health insurance industry, she worked with an HMO [Health Maintenance Organization], helping them to provide programs and services for their Medicare clients. In the Senior Living industry, Stephanie dealt with licensing and compliance with regulations for over 80 assisted-living communities throughout the country, as well as establishing training programs for staff who worked in these communities. In the hospital and home healthcare industries, she assisted in designing marketing plans for a hospital and managed a home healthcare agency. Now, employed by a financial services company, Stephanie devotes herself to developing programs for their clients who are preparing for retirement. To read more about her career in all these organizations, go to businessandaging.blogs.com —Chappell, 2005

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Gretchen Jordan is a volunteer coordinator for her state’s Office of Long-Term Care Ombudsman. She recruits volunteers and works with other staff in the state agency on training and supervision of these volunteers who help protect the rights and dignity of residents in long-term care. About her career she says, “I really enjoy being able to connect folks who are searching for a meaningful volunteer role with the right volunteer opportunity. .  .  .. I also appreciate the ability to work a flexible schedule, when needed, and having the tools I need to complete my tasks. It is rewarding to let the public know about our agency and the good work we do on behalf of the residents.” —Grabinski, 2014, p. 246

Ryan Duffy saw a need for fitness classes and personal training tailored to older adults, so he developed his own business to do his part in fulfilling these needs. He teaches classes and offers personal training in Tai Chi, Chi Kung, and meditation. About his career he says, “Many older clients come to my class with an intention of improving their physical health and quality of life. What is most rewarding about working with them is that they value what I am teaching and put to work what they learn; they put energy and focus into what they are doing because they have a purpose behind it. They have achieved a certain level of appreciation and understanding that the subtleties and often neglected parts of our lives need work if we want to continue to be healthy and thrive.” —Grabinski, 2014, pp. 95–96

EXPLORING CAREER OPPORTUNITIES IN AGING Stephanie Chappell’s, Gretchen Jordan’s, and Ryan Duffy’s careers represent three very different kinds of an endless number of options that are available in the field of aging. In Stephanie’s case, she has applied her education and interests in the financial arena in different private sector industries. Gretchen enjoys a rewarding career with a state agency. And, Ryan has carved out his career as an entrepreneur using his experiences and new-found interests as an undergraduate, and then building on them with his education. If this textbook is one you are using in an aging (or gerontology) course, then you are already on the road to an amazing array of rewarding career opportunities in virtually any aspect of the labor force in which you are interested. By the time you have completed this course, you will have more background in gerontology than most of your peers, and, in fact, more than the vast majority of people in the world. And, a background in gerontology is valuable for all careers, now and in the future. You might think that a pediatrician would be an exception, but then you need only to recognize that many pediatricians’ patients are brought to their appointments by their grandparents, many of whom are also their grandchildren’s primary caregivers. So, it would be most helpful for pediatricians to have learned about the roles and challenges of today’s grandparents. Every area of work benefits from an educational background in gerontology, as well as some practical experience that can be gained

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through an internship or a service-learning project. Of course, if you now have more interest in gerontology after taking your first course in the field, or if you want to have an advantage in applying for jobs or graduate or professional degree programs, you should definitely take additional gerontology courses. As an undergraduate, complete a major, minor, or certificate if you can. With an undergraduate degree in hand from a wide range of majors, you can apply to a gerontology master’s program, and then, ultimately if you so choose, to a doctoral program. More information about gerontological education at the undergraduate and graduate levels is presented later in this chapter.

WHAT KINDS OF CAREERS ARE THERE IN  THE FIELD OF AGING? People with a background in gerontology plan, manage, administer, and evaluate programs; educate and offer training for older adults, family members, and practitioners; conduct research; engage in policy development and advocacy; design and develop products and services; and provide direct services to older adults and their families. Improving the lives of older adults is the primary goal of those who work in the field of gerontology, and doing so invariably also improves the quality of life of those who spend time with them, whether they are family members, friends, neighbors, or those who work with and for older adults. In engineering, we need people who can design products to meet the desires and needs of the world’s rapidly aging population. In journalism, we need reporters and broadcasters who will share accurate information and stories about older people, helping to dispel myths and stereotypes. Those with a background in writing will find a demand for people, known as “memorists,” who will work with older people to chronicle their lives. While older people themselves often want to hire such people, sometimes family members are interested in doing so too. After spending time in a physical therapy clinic, perhaps shadowing a licensed physical therapist or gaining experience as an assistant, students who aspire to a career as a physical therapist quickly learn that a sizeable proportion of their patients will be older adults. Astute students then realize that it would be good for them to learn something about older folks, some of whom will be their future patients. In psychology, we need people who will provide counseling to older adults and their loved ones, perhaps working with them to resolve conflicts and reconcile estranged family members. There is much to learn about the aging process, such as determining cognitive strengths and supporting the development of ways to compensate for cognitive losses, and psychologists can play a role here too as researchers. With a background in aging, people with a psychology or business degree might also work in industry or organizations helping them to make appropriate adjustments to the work environment to take advantage of the assets that older employees bring to the work place. Businesses can definitely use people to advise them on how to market and advertise their products and services to older people. The apparel industry is badly in need of people who will design stylish clothing, shoes, and accessories to appeal to an increasingly large older demographic. The travel industry is beginning to realize the potential of the longevity dividend—one of the hottest new trends is multigenerational travel. These examples have barely scratched the surface of the career options for those with some education and experience in gerontology.

Workplace Settings and Examples of Careers Workplace settings for those who would like to find a position with an existing employer include: private industry and business, where Stephanie Chappelle, about whom we learned in one of the opening scenarios, found her positions; government agencies (local, state, federal, and international),

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where Gretchen Jordan, who was featured in another scenario, is employed; and in academic and educational institutions, and nonprofit organizations. Graduates can work in education; health, clinical, or social services; recreation or leisure services; advocacy or protective services; or administration and management. Table 15.1 lists examples of careers, broken down into different categories. All these careers have a shortage of people with knowledge and experience in gerontology.

TABLE 15.1 Examples of Careers in Aging, by Category CATEGORY

EXAMPLES OF CAREERS

Arts and entertainment

Film producer, TV producer, director, creative writer, drama coach, music director, theater company manager, teacher (art, dance, music, theater)

Business

Advertiser, consultant, manager, marketer

Education and research

College or university instructor, community educator, health educator, researcher

Financial industry

Banker, development director, estate planner, financial advisor, fundraiser, grant writer, insurance advisor

Healthcare and allied health

Audiologist, community health worker, dietitian, dentist, drug & alcohol counselor, emergency medical technician, geriatrician, geriatric nurse practitioner, geriatric pharmacist, geropsychiatrist, geropsychologist, home healthcare worker, hospice care provider, hospital discharge coordinator, long-term care administrator, occupational therapist, physical therapist, podiatrist, prosthetic specialist, speech therapist

Health promotion and education

Community educator, dietitian, fitness trainer, health educator, nutritionist

Law, public policy, and advocacy

Elder law attorney, lobbyist, mediator, politician

Leisure, hospitality, recreation industry

Activities director, leisure services administrator, recreational specialist, tour company director, tour planner, travel agent

Nonprofit and government agencies

Director of services, fundraiser, grant writer, volunteer coordinator, Area Agency on Aging director, state division on aging administrator

Social services

Aging life care managers (aka geriatric care managers), certified aging-in-place specialist, Senior Center director, social worker

Therapy

Animal-assisted therapist, art therapist, dance/movement therapist, drama therapist, grief counselor, marriage and family counselor, massage therapist, music therapist 

Emerging career opportunities

Architect (universal design specialist), assistive technology specialist, interior designer, moving and downsizing specialist, patient navigator

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One of the best resources for learning about these and other kinds of jobs in the field of gerontology is the latest edition of 101+ Careers in Gerontology (Grabinski, 2014). This book presents a wealth of information for each of its many featured careers, including educational and experience requirements, needed skills, and salary ranges. The book’s author also includes interviews with 25 people working in the field, describing how they first learned about gerontology, their career paths, the primary tasks and responsibilities of their current professional positions, the most rewarding and challenging aspects of their careers, advice for those considering careers in aging, and more. Another way to learn about careers in aging is to attend the programs offered during Careers in Aging Week. Every year in early April, through events held during that week, colleges and universities around the world promote awareness of careers in aging and aging research, with the support of the Academy for Gerontology in Higher Education (AGHE) and the Gerontological Society of America (GSA). Often people from the local community who work in the field of aging or whose jobs entail a significant focus on the older population will present details about their careers and how they got into them. Former graduates of a campus’s gerontology program may also be available to discuss their career trajectories. Definitely worth exploring too is the website, Exploring careers in aging (businessandaging.blogs.com), where you will find not only information on specific types of careers, but a potpourri of career-related resources, among them links to aging-related organizations, articles and audiovisual materials, and news about careers in aging. Finally, WorldWideLearn (www.worldwidelearn.com/online-education-guide/health-medical/ gerontology-major.htm) is a good website where there is a section devoted to learning more about careers in aging, as well as degree options and jobs.

How Do I Find a Job in the Field of Aging? There are lots of ways to find jobs in aging. Several job and career websites now list positions in gerontology throughout the country, and even around the world. Two professional organizations in the field that offer career resources are the GSA, and the American Society on Aging (ASA). GSA’s website, AgeWork (www.agework.com/agework), posts job openings and lets job seekers post their resumes and receive alerts on new job ads. You can also submit your resume on the website for a free review prior to uploading it. On ASA’s website, Career Advantage (careers.asaging .org), employers can post positions that can be searched by job seekers using a keyword or job title and a geographical location (U.S. states, Canadian provinces, and other non-U.S. countries). Also available on this website are a great number of career resources, advice on how to advance your career and interviewing among them. Of course, there are also commercial websites for finding jobs. Indeed (www.indeed.com) is one of the best because, unlike some others, entering the word, gerontology, will bring up thousands of positions, and you can narrow your search by geographical location across 60 countries.

Start Your Own Business! Entrepreneurial students can start their own businesses to create and provide services and products that do not yet exist, or are in short supply. One of the scenarios at the beginning of this chapter described just such a student—Ryan Duffy. He saw an unmet need for fitness training designed specifically for older adults and so he started his own fitness business aimed at these consumers. According to Stephanie Chappell, the financial gerontologist about whom we learned in another one of the opening scenarios,

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with more industries valuing the mature market, there are so many options today to create your own career path [using] the skills and knowledge learned in school along with those you pick up on-the-job[,e.g.,] problem solving, analytical, writing, project management, and consensus building skills. Also useful are personal qualities such as: curiosity to learn, creativity and adaptability. (Chappell, 2005, Conclusion) Upon graduating from the University of Nevada, Reno’s undergraduate program in gerontology, Tammy Sisson started two businesses: Lend-A-Hand Senior Services, and iCareSafely. Opened in 1992, Lend-A-Hand Senior Services is an in-home healthcare agency that screens, hires, trains, and supervises caregivers to serve older adults and their families in Reno, Nevada, and surrounding areas. Lend-A-Hand furnishes transportation assistance, grocery shopping, light housekeeping, laundry services, healthy meal preparation, bathing and personal care, and companionship. It was the first nonmedical home care agency in the region to offer dementia care and stroke care. The success of her business has been acknowledged with top ratings from users, and an acknowledgement of her business acumen came in 2007 when Ms. Sisson was awarded Entrepreneur of the Year in Northern Nevada. Recognizing the importance of well-trained caregivers and seeing a need for that training, Ms. Sisson then started a second business, iCareSafely (www.icaresafely.com), an online training and certification program for personal care attendants. The goal of the program is to prepare caregivers with knowledge and understanding that can be applied to their responsibilities in a confident and professional manner. Individual sets of five to six courses can be completed online and currently satisfy requirements for the states of Arkansas, California, and Nevada, including elder abuse training. At the International Association for Gerontology and Geriatrics conference in summer 2017, a competition was held for entrepreneurs to present their ideas for products or services to a panel of judges to win funding to start a new business with a focus on older adults. Events such as these, which are being held at conferences and on college and university campuses around the world, are modeled on successful television programs such as Dragons’ Den and Shark Tank, where contestants “pitch” their business ideas to potential investors (“dragons,” “sharks”), who can then decide whether they want to make a deal to finance the entrepreneur. Consistent with this increasingly popular focus on entrepreneurship, Aging2.0 (www.aging2.com), an international, interdisciplinary, and intergenerational organization, was started in 2012 to support “innovators taking on the biggest challenges and opportunities in aging.” To achieve its mission, Aging2.0, in concert with its corporate partners and more than 50 chapters, sponsors start-up competitions, conferences, and other events around the world. The opportunities for entrepreneurs to develop new businesses to meet the interests and demands created by the longevity dividend are enormous. Furthermore, investors are now recognizing the opportunities for them to be successful through encouraging and supporting entrepreneurs in gerontology. What new product or service can you design?

EDUCATION IN GERONTOLOGY Now that you have discovered the wide range of career opportunities in gerontology, you will want to know what educational background will help you earn the one of your choosing. Education in gerontology can take a number of different forms. Colleges and universities offer undergraduate and graduate programs and certificates. Professional organizations, hospitals, and businesses, as well as colleges and universities, also offer seminars and training programs focused on specific topics within gerontology.

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Undergraduate Programs For undergraduates, a gerontology academic program on their campus may consist of a major, a minor, a certificate program, or as many as all three of these. A minor or certificate in gerontology can complement another major, for example, biology or psychology. Core classes in gerontology include: Introduction to Aging, Biology of Aging or Health and Aging, Psychology of Aging, and Sociology of Aging. Examples of other gerontology classes are: Aging and Culture, Aging and Social Policy, Applied Gerontology, Creativity and Aging, Counseling Older Adults, Death and Dying, and Health Promotion and Older Adults. Some of the academic departments that may have a selection of courses with some or all of their content related to gerontology are: Health Sciences, Human Development and Family Studies, Psychology, and Sociology. Most programs will also include a field or internship experience, which is an ideal way to explore a particular career area. Field experience, or a practicum or internship, in an aging-related organization is especially helpful because it provides hands-on experience and the chance to see to what extent you are interested in the types of work in which the organization is involved. Possible settings for field experience are community senior centers, state or local offices on aging, area agencies on aging, and senior housing. Field experiences may also lead to a full-time position with the organization once you have graduated. Taking part in a field experience or practicum also demonstrates a strong interest in the field of aging, and, of course, field study supervisors are excellent sources for letters of reference for jobs, or for applications to professional or graduate school. In addition to taking gerontology courses and completing a field experience, practicum, or internship, you can also engage in other activities that are good experiences to document in applications for jobs or professional or graduate schools. GeroCentral (www.gerocentral.org/training-career) recommends volunteering in a place that serves older adults—a community senior center, the gerontology program office of a college campus, a geriatric clinic, for example, and participating in aging research in gerontology, psychology, human development, or social work, for example. Attending gerontology conferences and participating in a campus’s gerontology student club as well as professional organizations dedicated to gerontology are also valuable experiences, and provide excellent networking opportunities. More about the value of professional organizations to your career is presented in the section “The Role of Professional Organizations in your Career.” Of course, the textbook you are reading now, Introduction to Aging: A Positive, Interdisciplinary Approach, provides a good overview of the field. For insight into hot topics, a good choice is Aging: Concepts and Controversies (Moody & Sasser, 2018). Encyclopedias and handbooks cover major topics and are written by leaders in the field. Examples are: The Encyclopedia of Adulthood and Aging (Whitbourne, 2016), the Handbook of Aging and the Social Sciences (George & Ferraro, 2016), the Handbook of the Biology of Aging (Kaeberlein & Martin, 2015), the Handbook of Families and Aging (Blieszner & Bedford, 2012), the Handbook of Minority Aging (Baker & Whitfield, 2014), and, the Handbook of the Psychology of Aging (Schaie & Willis, 2015).

Graduate and Professional Programs Students who graduate with a master’s degree or a doctoral degree in gerontology will usually have more job opportunities, as well as higher salaries. Graduate programs in gerontology include master’s degrees, doctoral degrees, and graduate certificates. Admission to most professional and graduate schools in the United States requires a grade point average (GPA) of 3.0 or above (out

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of 4). Many graduate and professional schools also require a standardized entrance examination, for example the Graduate Record Examination (GRE), or a profession-specific test such as the Graduate Management Admission Test (GMAT), the Dental Admission Test (DAT), or the Medical College Admission Test (MCAT). For schools in the United States, students whose first language is not English may also need to take a language proficiency test. Students should check specific admission requirements for the programs they are considering well in advance of their proposed application date. The most common graduate degree in gerontology is a master’s, which prepares students to work in applied areas within the public and private sectors, or to pursue a doctoral degree. Master’s degrees in gerontology are offered by nearly 100 universities. Some master’s degree programs have specialized tracks—for example, management of aging services, geriatric care management, and educational gerontology. In many universities, you may be able to obtain a master’s degree in another field, for example, social work, with a specialization in aging. With this specialization, social workers will find a wide range of choices for their careers: gerontological social workers can provide their professional services to older adults, and their families too, to address cultural barriers; to find job opportunities; to locate resources and community services; to identify abuse and neglect; and to offer support groups, to name just a few of the choices (Ingrao, 2015). Gerontological social workers are even being hired to help businesses better address older consumers through product development, marketing, and sales. The University of Southern California offered the first PhD in gerontology, and now more than 10 American universities offer such a degree. Doctoral graduates are prepared for academic and research careers, and for professional and leadership positions in private and public institutions and agencies that focus on the older population. PhD programs may have tracks or emphases, for example, social gerontology, population health and epidemiology, or public policy. In addition, 17 American universities offer doctoral degrees in other fields with specializations in gerontology. For example, some clinical and counseling psychology programs offer a geropsychology specialization.

Choosing an Educational Program in Gerontology The Directory of Educational Programs in Gerontology and Geriatrics is the premier choice for researching educational programs in gerontology. It is published by the AGHE and is now available for free online (www.aghe.org/resources/online-directory). It contains information on undergraduate and graduate degree programs, certificates, and postdoctoral opportunities at almost 300 American universities and colleges. Each entry has details on specific areas of study, whether distance learning is an option, contact information, and more. The Directory is searchable by type of program (undergraduate, graduate, certificate, postdoctoral opportunities) and geographic location. In addition to the directory specifically focused on gerontology and geriatrics programs, many disciplines also publish directories of their graduate programs, so if you are interested in adding a gerontology emphasis or specialization to another major, those directories would be good places to find programs. For example, a Graduate Studies Directory is maintained online by the American Psychological Association’s (APA) Division 20, Adult Development and Aging (see www.apadivisions.org/division-20/publications/graduate-studies/index.aspx). For each graduate program there is a list of courses; the number of faculty; availability of assistantships, practicum and internship placements; and contact information. In addition, the Society of Clinical Gerontology, APA’s Division 12-Section II, provides information on graduate programs and pre- and postdoctoral training sites in geropsychology (see www.geropsychology.org).

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THE ROLE OF PROFESSIONAL ORGANIZATIONS IN YOUR CAREER Involvement and membership in professional organizations is valuable for career building and networking, for finding a mentor, for gaining leadership experience, and for participating in service activities, all of which can advance your educational and professional development opportunities. Professional organizations also provide many career resources, most of which are available online through their websites. Sigma Phi Omega (SPO, www.sigmaphiomega.org) is the International Academic Honor and Professional Society in Gerontology. The society recognizes academic excellence in gerontology, and promotes interactions between faculty, students, and local professionals, and opportunities for service activities in the community, primarily through local chapters. To become a member, a student must be enrolled in a gerontology education program (undergraduate major or minor, certificate, master’s, or doctorate), and with a GPA of 3.3 or higher for undergraduates, or 3.5 or higher for graduate students. Application information and materials are available on SPO’s website, where a list of current chapters and advisors can also be found. If a local SPO chapter does not already exist, starting one requires just two students and a faculty member who agrees to serve as the chapter’s advisor. Information about how to start a chapter can be found on the SPO website. Annual meetings of the Sigma Phi Omega are held in conjunction with the meetings of the AGHE, and include presentations of papers or posters, or both, as well as a business meeting and a reception. These meetings provide opportunities for students to gain professional experience in presenting posters or papers as well as a venue for meeting and networking with faculty from around the country and beyond. The GSA has sponsored Emerging Scholars and Professionals Organization (ESPO, www .geron.org/membership/emerging-scholar-and-professional-organization), since 1960. Members of this GSA section have access to awards, a mentorship program, discounted registration fees and travel stipends to attend conferences, discounted subscriptions to journals, materials on how to publish in the field, as well as other perks. ESPO has also put together a webinar on how networking can assist you in your career development. You can watch it at: www.youtube.com/ watch?v=EeoGILWpUFY The ASA has a formal network for their Students and Emerging Professionals Group (STEP, www.asaging.org/students-and-emerging-professionals-step-group). Anyone who is a student, recent graduate, or new to the field can go to their website and sign up to learn about ASA’s annual Aging in America Conference and receive news from their AgeBlog. Once signed up, you can participate in their mentoring program and other activities and get involved in ASA by serving on a committee. As you have likely learned by now, being able to document your educational background and knowledge are keys to earning a good job and getting into graduate and professional school. Fortunately, in addition to networking opportunities and continuing education, the nonprofit National Association for Professional Gerontologists (NAPG, www.napgerontologists.org) fills the desire for credentialing at all levels of education in gerontology. Table 15.2 lists the credential available for each educational level. Credentials can be earned by presenting evidence of your education in gerontology from an accredited school of higher education or by taking and passing an examination, details about which are available on NAPG’s website. Student memberships are available for those enrolled in a college or university’s gerontology academic program or a related field with a gerontology emphasis or specialization.

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TABLE 15.2 The National Association for Professional Gerontologists’ Credentials by Educational Level EDUCATIONAL LEVEL

CREDENTIAL

Associate/Certificate

Gerontological Coordinator

Baccalaureate

Gerontological Specialist

Graduate

Gerontologist

Professional/Scholar

Affiliate

Your Future Career in Aging As we learned at the beginning of this textbook, every single day until the year 2029, 10,000 Americans will be turning 65. By 2030, 72 million Americans will be age 65 or over, comprising almost 20% of our population. This phenomenal demographic “age wave,” driven by the Baby Boom generation, is leading to a vast array of career choices in the field of aging. There could not be a better time to be in the field. If you want to make a difference in our society for the fastest growing segment of our population, then a career in aging is for you!

PRACTICAL APPLICATION INTRODUCTION

Chapter 15 explores the many career opportunities within the field of gerontology and explains how the study of aging can be applied to any position in any field. It outlines educational pathways, professional organizations, credentialing opportunities, and job-seeking resources for those interested in a career in gerontology. The chapter also highlights the importance of entrepreneurship and innovation to help address the unmet needs of older adults. This Practical Application offers concluding remarks about the unlimited opportunity in the field of gerontology. GERONTOLOGY: WHERE OPPORTUNITY ABOUNDS

As the aging population continues to grow in the United States and around the world, careers in gerontology will continue to evolve. Many future jobs in the field may look very different from today’s established careers. Many may not even be defined as gerontology jobs. Rather, gerontological knowledge and skills in working with older people will be a key component of countless service occupations. A new paradigm of aging offers exciting opportunities to students with gerontological knowledge in all kinds of work situations. In this pioneering field, students are encouraged to continually and creatively think about how they might impact the future of gerontology and, especially, the lives of the older adults who rely on them.

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STUDENT ACTIVITIES 1. Identify the jobs of three people you know and explain how having a background in

gerontology could help them in their roles. 2. Of the professional opportunities described in Chapter 15, identify the career that appeals most to you and explain why. 3. Visit the Aging2.0 website (www.aging2.com), and select one of the topics under the “Grand Challenges” tab. Identify an “Organization to Watch” or an “Event to Attend,” and describe its relevance to the mission of promoting entrepreneurship in the field of gerontology. 4. Alma is an undergraduate student in Florida who aspires to help older adults living in residential care facilities by improving the system from within. She wants to become a gerontologist at a nursing home, so she can be involved in decisions that directly benefit the residents in her care. Outline the steps she might consider taking in order to reach her goal. As part of your recommendations to Alma, use the following website to identify three programs of study she may wish to consider and explain how they apply to her interests. www.apadivisions.org/division-20/publications/graduate-studies/index

SUGGESTED RESOURCES Aging2.0. (n.d.). Retrieved from https://www.aging2.com An international, interdisciplinary, and intergenerational organization that supports entrepreneurs and offers start-up competitions, conferences, and other events around the world. AgeWork. (n.d.). Retrieved from http://www.agework.com/agework Sponsored by the Gerontological Society of America, this website posts job openings and lets job seekers post their resumes and receive alerts on new job ads. Career Advantage. (n.d.). Retrieved from https://careers.asaging.org Sponsored by the American Society on Aging, this website posts job openings in gerontology that job seekers can search by keyword, job title, and geographical location. The website also provides access to many other career resources, including advice on interviewing and how to advance your career. Emerging Scholars and Professionals Organization. (n.d.). Retrieved from https://www.geron.org/ membership/emerging-scholar-and-professional-organization A membership section of the Gerontological Society on Aging, which provides extensive resources for students and new professionals in aging or aging-related careers. Exploring Careers in Aging. (n.d.). Retrieved from http://businessandaging.blogs.com A website devoted to a host of resources, including links to aging-related organizations, articles and audiovisual materials, and news about careers in aging. GeroCentral. (n.d.). Retrieved from http://www.gerocentral.org/training-career Focused on clinical gerontology, this website provides information on training and careers in the field. Indeed. (n.d.). Retrieved from https://www.indeed.com A general job-finding website that is especially good for positions in gerontology because entering the word, “gerontology,” will bring up thousands of positions, and you can narrow your search by geographical location.

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National Association for Professional Gerontologists. (n.d.). Retrieved from http://www .napgerontologists.org NAPG is a nonprofit organization that promotes and credentials education of professionals in the field of aging. Online Directory of Educational Programs in Gerontology and Geriatrics. (n.d.). Retrieved from https:// www.aghe.org/resources/online-directory An excellent, free resource for researching educational programs in gerontology, published by the Academy for Gerontology in Higher Education (AGHE). Sigma Phi Omega. (n.d.). Retrieved from https://www.sigmaphiomega.org The International Academic Honor and Professional Society in Gerontology. WorldWideLearn. (n.d.). Gerontology majors guide. Retrieved from https://www.worldwidelearn.com/ online-education-guide/health-medical/gerontology-major.htm This website provides a guide to learn about your degree and career options in the field of aging.

REFERENCES Baker, T. A., & Whitfield, K. E. (Eds.). (2014). Handbook of minority aging. New York, NY: Springer Publishing Company. Blieszner, R., & Bedford, V. H. (Eds.). (2012). Handbook of families and aging (2nd ed.). Santa Barbara, CA: ABC-CLIO. Chappell, S. (2005). Exploring careers in gerontology. Retrieved from https://businessandaging.blogs .com/ecg/2006/12/working_as_a_ge.html George, L. K., & Ferraro, K. F. (Eds.). (2016). Handbook of aging and the social sciences (8th ed.). San Diego, CA: Elsevier. Grabinski, C. J. (2014). 101+ careers in gerontology (2nd ed.). New York, NY: Springer Publishing Company. Ingrao, C. (2015, February 10). Gerontological social work: Meeting the needs of an aging population. Retrieved from https://socialwork.simmons.edu/gerontological-social-work-meeting-needs-aging-population Kaeberlein, M. R., & Martin, G. M. (Eds.). (2015). Handbook of the biology of aging (8th ed.). San Diego, CA: Elsevier. Moody, H. R., & Sasser, J. R. (2018). Aging: Concepts and controversies (9th ed.). Thousand Oaks, CA: Sage. Schaie, K. W., & Willis, S. L. (Eds.). (2015). Handbook of the psychology of aging (8th ed.). San Diego, CA: Elsevier. Whitbourne, S. K. (Ed.). (2016). The encyclopedia of adulthood and aging. Malden, MA: Wiley-Blackwell.

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A BB R E V I AT I ON S

AAA AAUW ACE ADA ADEA ADL ADR ADRC AGHE AGS AI/AN ALS AMA AMD AoA APA APP ASA ASKAS BMI CAD CALERIE CANA CARF CCRCs CDC CDSMP CHD CIA CLASS CMS CNA COPD CPAP DAT

Area Agencies on Aging American Association of University Women adverse childhood experience Americans with Disabilities Act Age Discrimination in Employment Act activities of daily living adverse drug reaction Aging and Disability Resource Center Academy for Gerontology in Higher Education American Geriatrics Society American Indian and Alaska Natives amyotrophic lateral sclerosis American Medical Association age-related macular degeneration Administration on Aging American Psychological Association amyloid precursor protein gene American Society on Aging Aging Sexuality Knowledge and Attitudes Scale body mass index coronary artery disease Comprehensive Assessment of Long term Effects of Reducing Intake of Energy Cremation Association of North America Commission on Accreditation of Rehabilitation Facilities continuing care retirement communities Centers for Disease Control and Prevention Chronic Disease Self-Management Program coronary heart disease Central Intelligence Agency Community Living Assistance Services and Supports Act Centers for Medicare and Medicaid Services certified nursing assistant chronic obstructive pulmonary disease continuous positive airway pressure Dental Admission Test

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334

Abbreviations

DI DWDA ECHO ED ELSA ERT ESPO ESWL FBI FDA FMDs GAO GMAT GPA GRE GSA HAART HALE HCPOA HDL HECM HI HIV HMO HPA HPV HUD IACP IADL IDEAS IF IMPACT INPEA IOM IRS LDL LGBT MCAT MHT MMA MTM NaCCRA NADTC NAPA NAPG NCAL

Disability Insurance Death with Dignity Act Elder Cottage Housing Opportunity erectile dysfunction English Longitudinal Study of Ageing estrogen replacement therapy Emerging Scholars and Professionals Organization extracorporeal shockwave lithotripsy Federal Bureau of Investigation Food and Drug Administration fast-mimicking diets Government Accountability Office Graduate Management Admission Test grade point average Graduate Record Examination Gerontological Society of America highly active antiretroviral therapy healthy adjusted life expectancy healthcare power of attorney high-density lipoprotein Home Equity Conversion Mortgage hospital insurance human immunodeficiency virus health maintenance organization hypothalamic-pituitary-adrenal human papillomavirus Housing and Urban Development International Association of Chiefs of Police instrumental activities of daily living Identifying Depression, Empowering Activities for Seniors intermittent feeding Improving Mood Promoting Access to Collaborative Treatment International Network for the Prevention of Elder Abuse Institute of Medicine Internal Revenue Service low-density lipoprotein lesbian, gay, bisexual, and transgender Medical College Admission Test menopausal hormone therapy Medicare Prescription Drug, Improvement, and Modernization Act Medication Therapy Management National Continuing Care Residents Association National Aging and Disability Transportation Center National Alzheimer’s Project Act National Association for Professional Gerontologists National Center for Assisted Living

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Abbreviations

NCEA NCHS NCLER NHANES NIH NORCs NSA OAA OASI OTC PASTA PBGC PEARLS PMZ POLST PPACA PPO PSA PSEN2 RAPP RDA REM ROS SAID SALT SCSEP SHIP SMI SNAP SPM SPO SRO SSI SST STEP STIs TANF UBRCs UI USDA USPSTF WAGE WHO

335

National Center on Elder Abuse National Center for Health Statistics National Center on Law and Elder Rights National Health and Nutritional Examination Surveys National Institutes of Health naturally occurring retirement communities National Sheriffs’ Association Older Americans Act Old Age and Survivors Insurance over-the-counter Parenting the Second Time Around Pension Benefit Guarantee Corporation Program to Encourage Active, Rewarding Lives for Seniors postmenopausal zest Physician Orders for Life-Sustaining Treatment Patient Protection and Affordable Care Act preferred provider organization prostate-specific antigen presenilin 2 gene Relatives as Parents Program recommended daily allowances rapid eye movement reactive oxygen species Staff Attitudes About Intimacy and Dementia Seniors and Lawmen Together Senior Community Service Employment Program State Health Insurance Assistance Program Supplementary Medical Insurance Supplemental Nutrition Assistance Program Supplemental Poverty Measure Sigma Phi Omega single-room occupancy unit Supplemental Security Income Socioemotional Selectivity Theory Students and Emerging Professionals Group sexually transmitted infections Temporary Assistance for Needy Families university-based retirement communities urinary incontinence U.S. Department of Agriculture U.S. Preventive Services Task Force Women Are Getting Even World Health Organization

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I NDE X

activities of daily living (ADLs), 189, 218, 242–244, 258 assistance with, 218 assisted living facilities and, 242–244 definition, 218 Medicare and, 258 need for supportive housing and, 242–243 nursing homes and, 242–244 adult protective services, 301–302, 311, 315 National Adult Protective Services Association, 315 advance directives, 112, 114–115 concept of a good death and, 112 end-of-life care planning and, 114–115 Patient Self-Determination Act, and, 114 Physician Orders for Life-Sustaining Treatment (POLST), 115 adverse childhood experiences (ACEs), 187 adverse drug reactions (ADRs), 264–265 Affordable Care Act. See Patient Protection and Affordable Care Act age categories, 7 young–old (65–74), 7 old-old (75–84), 7 oldest-old (85+), 7 age-friendly communities, 160–162, 169, 175 adapting and building homes for older people, 160–161 availability of transportation and services, 161-162 certified aging-in-place specialist, 160 global network, 160 housing conditions and safety, 169 key components of, 160 age-friendly workplaces, 143–144 ageism, 6–8, 15–16, 90, 310 ageist attitudes held early in life, effects of, 8 cardiovascular events, 8 memory performance, 8 as cause of isolation, 310 definition, 6 negative effects of, 7–8 on cognitive and physical functions, 8 in healthcare settings, 8

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on older workers, 8 older people and, 7, 16 sexuality and, 90 stereotypes, 6–8, 15–16 younger people and, 6 alcohol, 28, 51–52, 56, 59 alcohol consumption guidelines, 59 avoidance before bedtime, 51 misuse of, 59 negative health behavior, rates of binge drinking, 59 risk of osteoporosis and, 56 sleep and, 52 smell and, 28 Alzheimer’s disease, 74–78, 81, 84 active management of, 77 National Institute on Aging, Alzheimer’s Disease Education and Referral Center, 84 causes, 75 amyloid cascade hypothesis, 75 neuronal stress, 75 diagnosis, 75–76 early-onset, 77 impact on families, 78 medications and, 76–77 national plan to address, 78 National Alzheimer’s Project Act (NAPA), 78 negative age stereotypes and, 81 prevalence of, 77 reversible dementia-like symptoms, 75 signs of, 76–77 support groups, 78 treatment, 76–77 American Indian and Alaska Natives (AI/AN), 206–207, 215, 230, 289, 294 chronic medical conditions and, 230, 289 lack of health data on, 289 national aging services network and, 206–207 National Indian Council on Aging, 215, 294 Older Americans Act and, 207, 215 Title VI: Grants for Services to Native Americans, 215

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338

Index

Area Agencies on Aging (AAAs), 161, 206–219, 221, 246 National Association of Area Agencies on Aging, 209, 221 need and unmet need for services, 217–219 Older Americans Act and, 206–217 arthritis, 225–228, 231, 234, 247, 288–290 gender and ethnicity/race differences in, 227, 288–289 gout, 228 LGBT individuals and, 290 osteoarthritis, 227–228 prevalence of, 225–226 rheumatoid arthritis, 228 treatment, 228 Asian Americans and Pacific Islanders, 139–140, 229–230, 277–282, 287, 289–293 chronic medical conditions, 229–230, 290 demographics, 277–278 economics, 278–282 income inequities, 279–280, 282 poverty rate, 278 labor force participation, 139–140 lack of health data on, 289–290 life expectancy, 287 National Asian Pacific Center on Aging, 293 preventive health services and, 290–292 immunizations, 291 screenings, 291–292 suicide and, 117–118 assisted living and long-term care, 234–247 assisted living communities and residents, 237–238 Community Living Assistance Services and Supports (CLASS) Act, 241 comparison of assisted living and nursing homes, 242–245 continuing care retirement communities (CCRCs), 235–236 current trends in, 237–238, 240 finding and evaluating supportive care communities, 245–246 long-term care, 238–242 ombudsmen, 239, 309 paying for, 240–242 National Center for Assisted Living, 237, 245, 247 nursing homes, 239–240 culture change movement, 240 elder abuse and, 299–304, 308 number of, 240 residents, 239–240 percentage of older adults living in, 235

baby boomers, 11, 91–92, 146, 150, 164–165, 172, 211 definition, 11 homelessness and, 172

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number of, 11 living alone, 165 retirement and, 146, 150 retirement communities and, 164 senior centers appealing to, 211 sexuality and, 91–92 biological theories of aging, 34–36 causes of aging, 34 damage accumulation theories, 34 disposable soma theory, 34 mitochondrial theory, 34 mutation accumulation theory, 34 paradigms and examples, 34 programmed theories, 34–35 antagonistic pleiotropy theory, 35 neuroendocrine theory, 35 programmed cell death, telomere theory, 35 rate of aging, 35–36 Black Americans, 4–5, 48, 139–140, 225–227, 233, 244, 277–282, 285–293 assisted living and nursing home residents and, 244 chronic medical conditions and, 225–227, 233, 288–290 demographics, 277–278 economics, 278–282 income inequities, 279–282 poverty rate, 278 heterogeneity of ethnic and racial groups, 292 labor force participation, 139–140 life expectancy, 4–5, 287 National Caucus and Center on Black Aging, Inc., 293 physical activity and, 48 preventive health services and, 290–292 immunizations, 291 screenings, 291–292 retirement pensions and policies and, 285–286 self-ratings of health, 287–288 suicide and, 117–118 bones, 31–32, 48, 50, 56, 232–233 adaptations for age-related changes in, 32, 48, 50 age-related changes in, 31 bone density screening, 56 building strong bones, 31 osteoporosis, 31, 56, 232–233 physical activity and, 48, 50

cancer, 56–57, 225–226, 229–231, 288–292 breast cancer, 57, 230, 288 cancer control programs, 230 cervical cancer, 57 colon/colorectal cancer, 56, 230

11-Jun-19 7:32:33 PM

Index

chronic disease self-management programs (CDSMP), 231 factors affecting survival rates, 229 gender and ethnicity/race differences in, 229–230, 288–289, 291 human papillomavirus (HPV) vaccine, 230 LGBT individuals and, 290 lung cancer, 230 prevalence of, 225–226 prostate cancer, 57, 230 reducing risk of, 230 screening for, 56–57, 230, 291–292 careers in aging, 321–332 101+ Careers in Gerontology, 325 Aging2.0, 326 Careers in Aging Week, 325 examples of careers, 323–324 future trends in, 330 resources for finding a career in aging, 325 roles of professional organizations, 329 start a business, 325–326 workplace settings, 323–325 caregiving, 182–186, 221 hours of, 183 Eldercare Locator, 221 impact on family members, 183–184 positive and negative aspects, 184 reasons to choose in-home care, 186 support for, 185–186, 192 centenarians, 4, 17 definition, 4 in U.S., 4 National Centenarian Awareness Project, 17 chemical senses. See smell, taste chronic medical conditions, 31, 56, 58, 97–100, 225–233, 255, 289–290, 310 arthritis, 225–228 cancer, 229–230 chronic disease self-management programs (CDSMP), 231 chronic obstructive pulmonary disease (COPD), 58 diabetes (type 2), 230–231 elder abuse and, 310 gender and ethnicity/race differences in, 225–226 heart disease, 228–229, 289 HIV/AIDS, 58, 97–100, 232, 255, 290 hypertension and stroke, 48, 55, 225–227 LGBT individuals and, 290 osteoporosis, 31, 56, 232–233 rates of, 225–226 cigarette smoking, 23, 25, 28, 51, 56, 58–59 cataracts and, 25 chronic obstructive pulmonary disease (COPD), 58 education level and, 59

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339

risk of osteoporosis and, 56 rates of, 58 skin and, 23 sleep and, 51 smell and, 28 cognitive abilities, 50, 70–74, 80–83. See also Alzheimer’s disease brain-training programs, 81 Healthy Brain Initiative, 74 medical conditions and, 81–82 medications and, 82 memory, 70–74 mental activity, 50 negative stereotypes, 80–81 nutrition and, 82 physical exercise and, 50, 81 positive view of, 83 positive and negative influences on, 80–82 continuing care retirement communities (CCRCs), 235–236, 245–246 costs of, 236 finding and evaluating CCRCs, 245–246 key features of, 235–236 National Continuing Care Residents Association (NaCCRA), 245 regulation of, 236 creativity, 78–80, 84 conceptual innovators, 79 experimental innovators, 79 National Center for Creative Aging, 84 positive effects of participating in the arts, 79–80 cremation, 121–122 rates of, 121 Cremation Association of North America (CANA), 121 crimes against older people, 298–300, 306–310 cross-sectional and longitudinal studies, 70–71 birth cohorts and, 71 difficulties of, 70–71

death, 110–124, 302, 313 advance directives, 112, 114–115 anxiety about, 110 concept of a good death, 111–112 cremation, 121–122 Death with Dignity Act (DWDA), 115–116, 124 elder abuse and, 302, 313 funerals, memorial services, celebrations of life, 120–122 grief and mourning, 118–120 definitions, 118 Kübler-Ross’ 5 stages of grief, 119 Worden’s 4 stages of mourning, 119–120

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340

Index

death (cont.) healthcare providers and, 110, 114–115 hospice and palliative care, 112–113 living will and durable power of attorney for healthcare, 114–115 organ donation, 118 Patient Self-Determination Act, 114 Physician Orders for Life-Sustaining Treatment (POLST), 115 physician-assisted suicide, 114–116 spirituality and, 111 suicide, 117–118 dementia, 74–75, See also Alzheimer’s disease demographics of aging, 4, 8–11, 13 baby boomers, 11 centenarians, 4 dependency ratios, 13 global trends, 8–11 U.S., 8 dependency ratios, 13 definition, 13 youth and older adult, 13 depression, 58, 69 evidence-based treatments, 69 Identifying Depression, Empowering Activities for Seniors (IDEAS), 69 Improving Mood Promoting Access to Collaborative Treatment (IMPACT), 69 Program to Encourage Active, Rewarding Lives for Seniors (PEARLS), 69 factors contributing to, 69 rates of, 69 screening for, 58 diabetes (type 2), 48, 56, 225–226, 230–231 gender and ethnicity/race differences in, 230 LGBT individuals and, 290 prevalence of, 225–226 prevention of, 230–231 screening for, 56 treatment, 230

economic status, 130–140, 147–150, 278–286, 305–306 diversity among older adults in, 130–131 economic declines and, 131–132 employee pensions, 135–138 financial assets and elder abuse, 305–306 gender and ethnicity/race differences in, 131–132, 278–286 labor force participation, 139–141 gender and ethnicity/race differences in, 139–140 Social Security and, 131–135, 138–140, 147-150 sources of income, 131–140 elder abuse, 298–313

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adult protective services, 302 causes of, 303 Center of Excellence on Elder Abuse and Neglect, 315 consequences of, 302 consumer fraud, 305–307 definition, 299–300 domestic abuse, 299, 303 financial abuse, 304–307 consequences of, 304–305 investment fraud, 307 methods and types of consumer fraud, 305–307 perpetrators, 304 prevalence of, 304 prevention of, 309–313 forms of, 299–300 guardianships, 308–309 institutional abuse, 299, 301, 303 International Network for the Prevention of Elder Abuse (INPEA), 315 isolation and, 302, 309–312 National Adult Protective Services Association, 315 National Center on Elder Abuse, 299 perpetrators, 302–303 prevalence, 301–302 prevention, 303, 309–311 reporting, 301, 312–313 residential living facilities and, 299, 301 self-neglect, 299–302 signs of, 300–301 social-ecological model of, 303–304 Triad/SALT (Seniors and Lawmen Together) organizations, 312 vulnerabilities and risk factors, 302 elder rights, 208, 216–218, 222 funding for, 208 legal assistance, 216–217 long-term care ombudsman program, 216 model approaches to statewide legal assistance systems, 217 National Center on Law and Elder Rights (NCLER), 217, 222 need and unmet need for services, 217–218 Older Americans Act and, 208, 216 erectile dysfunction (ED), 57, 97, 100 ethnicity and race, 4–5, 131, 139–140, 165–166, 225–227, 230, 233, 244, 276–292, 303, 312. See also Asian Americans and Pacific Islanders, American Indian and Alaska Natives, Black Americans, Hispanic Americans, non-Hispanic White Americans assisted living and nursing home residents and, 244 caregiving, 282

11-Jun-19 7:32:33 PM

Index

341

chronic medical conditions and, 225–227, 230, 233, 280–290 demographics, 276–278 economics, 131, 278–282 elder abuse and, 303, 312 heterogeneity of minority groups, 292 labor force participation, 139–140 lack of health data on, 289 life expectancy, 4–5, 287 living arrangements and, 165–166, 284–285 partner status and, 283–284 preventive health services, 290–292 retirement pensions and policies, 285–286 self-ratings of health, 287–288 suicide and, 117–118 exercise. See physical activity

Supporting Grandparents Raising Grandchildren Act, 14 feet, 22, 29 age-related changes in, 29 adaptations to age-related changes in, 29 foot problems and signs of medical conditions, 29 friends, 187–189, 300–302, 310 closeness of, 189 critical roles of, 187–188 elder abuse and, 300–302, 310 positive effects on well-being, 188 funerals, memorial services, and celebrations of life, 120–122 cultural differences, 121 funeral industry, 121–122 social roles of, 121

family, 178–186, 299, 301–305, 308 adult children, 182 caregiving, 182–186 gender differences in, 183 impact on family members, 183–184 positive and negative aspects, 184 support for, 185–186, 192 divorce and remarriage, 181 elder abuse and, 299, 301–305 guardianships and, 308 intimate relationships, 179–182 marital status, 180 federal legislation Age Discrimination in Employment Act (ADEA), 142–143 Americans with Disabilities Act (ADA), 14 CLASS Act. See Community Living Assistance Services and Supports Elder Justice Act, 14 Equal Pay Act, 279 Food Stamp Act, 204 Housing and Community Development Act, 172 Housing Act, 171–172 Medicare, 252–262 Medicare Prescription Drug, Improvement, and Modernization Act (MMA), 256, 261 Medicaid, 262–263 National Alzheimer’s Project Act (NAPA), 78 Patient Protection and Affordable Care Act, 13–14, 241 Patient Self-Determination Act, 114 Senior Citizen’s Freedom to Work Act, 147 Social Security Act, 132–135, 139, 147–150 Supplemental Nutrition Assistance Program (SNAP), 47, 204

gender, 4–5, 26, 48, 131, 279–281, 283–284, 302–303, 312. See also women assisted living and nursing home residents and, 244 caregiving, 182–184, 282 chronic medical conditions and, 225-227, 230, 233, 280-290 demographics, 276–278 economics, 131, 278–286 elder abuse and, 302–303, 312 labor force participation, 139–140 life expectancy and, 4–5, 287 living arrangements and, 165–166, 284–285 partner status, 283–284 physical activity and, 48 poverty and, 138–139 preventive health services, 290–292 suicide rates and, 117 gerontology education, 326–330 certificates, 328–330 choosing an educational program, 328 courses, 327 field experience/practicum/internship, 327 graduate and professional programs, 327–328 doctoral degrees, 328 master’s degrees, 328 kinds of careers in aging, 323 overview, major and hot topics, 327 seminars and training programs, 327 undergraduate programs, 323, 327 value of professional organizations, 327, 329 volunteer experiences, 327 grandparents, 14, 186–187, 192, 202, 307, 322 changing roles, 186–187 foster care benefits and, 187 Foster Grandparent Program, 202 grandparent scams, 307

Sugar62939_PTR_INDEX_337-348_06-11-19.indd 341

11-Jun-19 7:32:33 PM

342

Index

grandparents (cont.) numbers providing primary care for grandchildren, 187 positive effects in grandchildren’s lives, 187 single-parent families, and, 187 Supporting Grandparents Raising Grandchildren Act, 14 grief, 118–120 definition, 118 Kübler-Ross’s five stages of, 119 mourning stages and, 120 normal grief behaviors, 120 guardianships, 308–309 certification and regulation of, 308–309 definition, 308 loss of rights and, 308 misuse of, 308–309

hair, 22–23 adaptations to age-related changes in, 23 age-related changes in, 22–23 hearing, sense of, 26–27, 38 adaptations to age-related changes in, 27 age-related changes in, 26–27 gender differences in, 26 hearing aids, 27 reasons for not using, 27 hearing loss, 26–27 causes of, 26 declining rates of, 26 detrimental effects of, 26–27 presbycusis, 26 Hearing Loss Association of America, 38 hearing tests, 27 healthspan, 5–6 Africa, 5–6 Americas, 5–6 Europe, 5–6 healthy life expectancy (HALE), 6 Western Pacific, 5–6 healthcare power of attorney (HCPOA), 114 healthcare workforce and aging, 224–225 healthy brain initiative, 74 heart disease, 43–45, 48–50, 55–56, 225–226, 228–229, 288–290 gender and ethnicity/race differences in, 229, 288–289 LGBT individuals and, 290 nutrition and, 43–45 physical activity and, 48–50 prevalence of, 225–226, 229 prevention of, 229 screening for, 55–56

Sugar62939_PTR_INDEX_337-348_06-11-19.indd 342

symptoms of, 229 types of heart conditions, 228 high school completion rates, U.S., 5 Hispanic Americans, 4–5, 48, 131, 139–140, 225–227, 230, 233, 244, 277–292, 294 assisted living and nursing home residents and, 244 chronic medical conditions and, 225–227, 230, 233, 280–290 demographics, 276–278 economics, 131, 278–282 income inequities, 131, 278–282 income sources, 131 poverty, 278 heterogeneity of Hispanic Americans, 292 labor force participation, 139–140 life expectancy, 4–5, 287 National Hispanic Council on Aging, 294 physical activity and, 48 preventive health services, 290–292 immunizations, 291 screenings, 291–292 retirement pensions and policies, 285–286 self-ratings of health, 287–288 HIV/AIDS, 58, 97–100, 232, 255, 290 LGBT community and, 290 prevalence of HIV, 98–99, 232 risk factors, 232 safe sex practices and, 97–100 signs and symptoms of, 232 testing, 58, 232, 255 treatment, 232 home ownership, 167–168 Low-Income Home Energy Assistance Program (LIHEAP), 168 reverse mortgages, 168–169 home equity conversion mortgage (HECM), 168 tax relief programs for homeowners, 168 homelessness among older adults, 172–173 hospice and palliative care, 112–113, 123 comparison of, 112–113 National Hospice and Palliative Care Organization, 124 origins of, 112–113 housing options, 160–172 adapting and building homes for older people 160–161 elder cottage housing opportunity (ECHO), 170 home ownership, 167–169 Housing Act, 171–172 Housing and Community Development Act, 172 housing conditions and safety, 169 mobile homes, 171 naturally-occurring retirement communities (NORCs), 164–165

11-Jun-19 7:32:33 PM

Index

public housing, 171–172 retirement communities, 145, 160–165, 169–170, 175, 235–236, 245–246 single-room occupancy unit (SRO), 170 university-based retirement communities (UBRCs), 163–164 hypertension and stroke, 48, 55, 225–227 blood pressure screening, 55 controlling blood pressure, 227 gender and ethnicity/race differences in, 227 physical activity/exercise and, 48 symptoms of stroke, 227 target blood pressure rates for older adults, 227

immunizations, 52–55 influenza (flu), 52–53 pneumonia, 53 rates of, 52–54 shingles, 53–54 Tdap and Td, 54–55 income, 131–132, 280, 282 inequities, 280, 282 sources of, 131–132 Supplemental Security Income (SSI), 130–131, 139, 173, 305 instrumental activities of daily living (IADLs), 242–244 definition, 242 limitations by residential setting, 243–244 intimate relationships, 179–182 dating, 181–182 divorce, 181 emotional well-being and happiness, 179–180 marital satisfaction, 179 marital status, 179–180 gender and, 179–180 second marriages, 181 sweetheart scams, 182, 307

labor force participation, 139–142 lesbian, gay, bisexual, and transgender (LGBT) individuals, 95–96, 98, 101, 276–278, 284, 287–288, 290–294 chronic medical conditions, 290 demographics, 277 heterogeneity of LGBT groups, 292 lack of health data on, 290 living arrangements, 284 National Resource Center on LGBT Aging, 294 partner status, 284 poverty and, 278

Sugar62939_PTR_INDEX_337-348_06-11-19.indd 343

343

preventive health services, 290–292 immunizations, 291 screenings, 291–292 SAGE: Advocacy and Services for LGBT Elders, 294 sexuality and, 95–96, 98, 101 self-ratings of health, 288 life expectancy, 4–6, 287 at birth, U.S., 4 definition, 4 gender and ethnicity/race differences in, 4–5, 287 global, 4 healthy life expectancy (HALE), 6 human healthspan by world regions, 6 living arrangements, 165–167, 173 gender and ethnicity/race differences, 165–166 living alone, 165 living with adult children, 167 National Shared Housing Resource Center, 175 staying connected, 166–167 living environments, 159–172 age-friendly communities, 160–161 factors affecting, 159 housing options, 160–161, 163–165, 170–172 importance to life satisfaction, 158–159 location preferences, 162–163 moving and migration, 163–164 retirement communities, 145, 160–165, 169–170, 175, 235–236, 245–246 transportation availability of, 161–162 longevity dividend, 4–6, 9–12, 14–15 definition, 4 global aging populations, 9–11 liberating the talents of all, 12 new paradigm of aging, 14–15 reasons for reduced mortality rates, 4 longitudinal studies. See cross-sectional and longitudinal studies long-term care. See assisted living and long-term care

Medicaid, 207, 209, 210, 212, 213, 257, 262–263, 267–268, 304–305, 307 administration, 262 Centers for Medicare and Medicaid Services (CMS), 210, 257 dual-eligible beneficiaries, 262–263 eligibility, 262 fraud and, 304–305, 307 funding and costs, 262 services, 262 medical conditions, 31, 48, 55–56, 58, 97–100, 225–234, 255, 290 acute vs chronic, 225 arthritis, 227–228

11-Jun-19 7:32:33 PM

344

Index

medical conditions (cont.) cancer, 229–230 chronic disease self-management programs (CDSMP), 231 diabetes (type 2), 230–231 ethnicity and race differences, 225–226 eye diseases, 58, 233–234 age-related macular degeneration, 233 glaucoma, 233 retinopathy, 234 gender and ethnicity/race differences in, 225–226 heart disease, 228–229 HIV/AIDS, 58, 97–100, 232, 255, 290 hypertension and stroke, 48, 55, 225–227 osteoporosis, 31, 56, 232–233 sleep disorders, 234 Medicare, 13–14, 47, 52–55, 210, 252–263, 304, 307 beneficiaries, 252, 262 amyotrophic lateral sclerosis (ALS) and, 252, 262 end-stage renal disease and, 252, 262 dual eligible beneficiaries, 262 Centers for Medicare and Medicaid Services (CMS), 210, 257 enrollment, 252, 257–258 fraud, 304, 307 funding, 259–262 Medicare Trustees’ report, 259–260 help with medical costs, 259 immunizations and, 52–55 Medicare Part A: Hospital Insurance, 252–254, 259, 260–261 Medicare Part B: Medical Insurance, 254–255 Medicare Part C: Medicare Advantage Plans, 254–256 Medicare Part D: Prescription Drug Coverage, 256–257, 260 Medigap policies, 258–259 nutrition services and, 47 original Medicare, 253 Prescription Drug, Improvement and Modernization Act (MMA), 256, 261 satisfaction with, 252 State Health Insurance Assistance Program (SHIP), 258–259 Supplementary Medical Insurance (SMI), 259–260 what’s not covered, 258 medications, 28, 82, 256–257, 260–267 adverse drug reactions, 265–266 dietary supplements, 263 Medicare Part D: Prescription Drug Coverage, 256–257, 260 medication therapy management (MTM), 267 medication-related problems, 264–266 reducing medication-related problems, 266

Sugar62939_PTR_INDEX_337-348_06-11-19.indd 344

over-the-counter (OTC) medications, 82, 263, 265–266 polypharmacy, 263 potentially inappropriate drug use, 265 Prescription Drug, Improvement and Modernization Act (MMA), 256, 261 questions to ask healthcare providers about medications, 266–267 rates of prescription use, 263 smell and, 28 Medigap policies, 258–259 memory, 71–74, 80–82 being in-school and, 72 forgetting, 71–72 memory strategies, 71–72 negative age stereotypes and, 80–81 motivation and, 72–73 technology and, 74 menopause, 32–33, 38, 56, 97 age at, 32 medication and, 32 hormone therapy, 32 North American Menopause Society, 38 postmenopausal zest (PMZ), 97 risk of heart disease and osteoporosis and, 32, 56 symptoms, 32 alleviating symptoms, 32 use of synthetic hormones for, 33 mental health, 66–69, 80–83 depression, 69 happiness, 66–67 negative stereotypes, 80–81 personality, 68–69 positive view, 83 positive and negative influences on, 80–82 psychological and emotional well-being, 66–68 moving and migration, 163–164, 175 advantages and disadvantages of moving, 163 National Association of Senior Move Managers, 175 newer trends in moving, 163–164 muscles, 31–32 age-related changes in, 31 physical activity and, 32 resistance training, 31 musculoskeletal system, 31–32; See also bones, muscles effects of dietary protein on, 32

National Association for Professional Gerontologists (NAPG), 329–330 Native Americans. See American Indian and Alaska Natives negative health behaviors, avoidance of, 58–59 new paradigm of aging, 3–4, 14–15

11-Jun-19 7:32:33 PM

Index

non-Hispanic White Americans, 4–5, 48, 117–118, 138–140, 165–166, 225–227, 244, 277–278, 284–292 assisted living and nursing home residents and, 244 chronic medical conditions and, 225–227, 288–290 demographics, 277–278 labor force participation, 139–140 life expectancy, 4–5, 287 living arrangements and, 165–166, 284–285 partner status, 283–284 poverty and, 138–139, 278 physical activity, 48 preventive health services, 290-292 immunizations, 291 screenings, 291-292 retirement pensions and policies, 285–286 self-ratings of health, 287–288 suicide and, 117–118 nursing homes. See assisted living and long-term care nutrition, 27, 35–36, 42–47, 82, 204, 213–214, 218 caloric and dietary restriction, 35–36 eating well on a tight budget, 47 fluid intake, 43 food guide, 42–47 food guide for older adults: MyPlate for Older Adults, 43 food insecurity, 218 Food Stamp Act, 204 nutrients, recommended daily allowances (RDA), sources, and functions, 44–46 nutrition services, 27 Older Americans Act, Title III-C: Nutrition Services, 213–214 protein, 47 Supplemental Nutrition Assistance Program (SNAP), 47, 204

obesity, 57 body mass index (BMI) and, 57 mortality risk and, 57 negative health outcomes, 57 screening for, 57 Old Age and Survivors Insurance (OASI). See Social Security Older Americans Act (OAA), 13–14, 185, 205–221, 239, 298 Area Agencies on Aging (AAAs), 206–207 National Association of Area Agencies on Aging, 221 funding sources, 219 legal assistance, 216–217 model approaches to statewide legal assistance systems, 217

Sugar62939_PTR_INDEX_337-348_06-11-19.indd 345

345

National Association of Senior Legal Hotlines, 217 National Center on Law and Elder Rights, 217 long-term care ombudsmen, 239 Native Americans and, 207 need and unmet need for services, 217–219 nutrition, 218 assistance with activities of daily living (ADLs), 218 transportation, 218 objectives of, 205–206 statewide plans to serve older people, 206–207 stretching resources, and, 219 structure to implement, 206–207 Administration on Aging, 206 Area Agencies on Aging (AAAs), 206–207 U.S. National Aging Services Network, 207 Title I: Declaration of Objectives; Definitions, 208 Title II: Administration on aging, 209-210 Title III: Grants for State and Community Programs, 210-214 Title IV: Activities for Health, Independence, and Longevity, 214–215 Title V: Community Service Senior Opportunities Act, 215 Title VI: Grants for Services for Native Americans, 215 Title VII: Vulnerable Elder Rights Protection Activities, 216 older adults’ contributions to their communities, 201–204, 222 activism, 203 advocacy, 203 nurturing, 203–204 philanthropy, 204 volunteering, 201–203 AARP Foundation’s Experience Corps, 202–203 SCORE: Counselors to America’s Small Businesses, 203 Senior Corps programs, 201–202, 222 older workers, 7, 14, 139–144, 153, 215, 282–283. See also Social Security, Medicare age discrimination and, 142–143 Age Discrimination in Employment Act (ADEA), 142 Communication Workers of America et al., v T-Mobile US, Inc. et al., 143 age-friendly workplaces and progressive employers, 143–144 differences between younger and older workers, 141–142 gender and ethnicity race and, 139–140 labor force participation, 139–142 mandatory retirement and, 142–143 negative effects of ageism, 7 part-time employment, 140

11-Jun-19 7:32:33 PM

346

Index

older workers (cont.) reasons for working past full retirement age, 140–141 Senior Citizen’s Freedom to Work Act, 147 Senior Community Service Employment Program (SCSEP), 215 value of older workers, 14, 141–142 work history, 282–283

palliative care. See hospice and palliative care Patient Protection and Affordable Care Act (PPACA), 13–14, 241 pensions, 135–138 defined-benefit pension plans, 135, 136–138 defined-contribution pension plans, 136–138 Pension Benefit Guarantee Corporation (PBGC), 136–137 personality, 68–69 physical activity, 28, 47–50 aerobic activities, 48– 50 balance exercises, 50 bone-strengthening activities, 50 flexibility exercises, 50 gender and ethnicity/race differences in, 48 long-term health benefits of, 48 mental activity and, 50 muscle-strengthening activities, 48– 50 national physical activity guidelines, 48–50 need for, 47–48 participation rates of older adults in, 48 physical changes with age, 22–33 adaptations to, 22–33 differentiating from medical conditions, 22 feet, 22, 29 hair, 22–23 hearing, 26–27 menopause, 32–33 musculoskeletal system, 31–32 skin, 23 sleep, 33 smell and taste, 27–28 thermoregulation, 23–25 touch, 28–29 urinary tract, 30–31 vision, 25–26 physician-assisted suicide, 115–116, 123 Physician Orders for Life-Sustaining Treatment (POLST), 115 poverty, 47, 130–131, 138–139, 166, 173, 204, 259–260, 278–282, 305 LGBT individuals and, 278 living arrangements and, 166 rates of, 138–139 gender and ethnicity/race and, 138–139, 278–282

Sugar62939_PTR_INDEX_337-348_06-11-19.indd 346

Social Security and, 138 Supplemental Nutrition Assistance Program (SNAP), 47, 204 Supplemental Poverty Measure (SPM), 138 Supplemental Security Income (SSI), 130–131, 139, 173, 305 Supplementary Medical Insurance (SMI), 259–260 Prescription Drug, Improvement and Modernization Act (MMA), 256, 261. See also Medicare preventive health measures, 52–59 avoiding negative health behaviors, 58–59 immunizations, 52–55 screening tests, 55–58 U.S. Preventive Services Task Force (USPSTF), 55 professional organizations in aging, 99–100, 151, 265–266, 325–326, 329–332 American Geriatrics Society (AGS), 99–100, 265–266 American Society on Aging (ASA), 151, 325, 329 Association/Academy for Gerontology in Higher Education, 325, 328–329 Gerontological Society of America (GSA), 325, 329 International Association for Gerontology and Geriatrics, 326 National Association for Professional Gerontologists (NAPG), 329–330, 332 student organizations Emerging Scholars and Professionals Organization (ESPO), 329, 331 Sigma Phi Omega (SPO), 329, 332 Students and Emerging Professionals Group (STEP), 329 psychological and emotional well-being, 66–68,

rate of aging, 35–36 caloric and dietary restriction and, 35–36 growth hormone and, 36 physical activity and, 36 retirement, 130, 135–138, 142–152. See also retirement communities age discrimination and, 142–143 Center for Retirement Research at Boston College, 152 early, normal (full), and late, 147 employee pensions, 135–138. See also pensions factors affecting retirement decisions, 146 meanings of, 144 satisfaction with, 150–151 Social Security and, 145 retirement communities, 145, 160–165, 169–170, 175, 235–236, 245–246 age-friendly communities, 160–162, 169, 175 continuing care retirement communities (CCRCs), 235–236, 245–246

11-Jun-19 7:32:34 PM

Index

moving and migration of older people, 163–164, 175 naturally occurring retirement communities (NORCs), 164, 170 university-based retirement communities (UBRCs), 164 reverse mortgages, 168–169

screening tests, 42, 52, 55–56 blood pressure, 55 blood glucose, 56 body mass index (BMI), 57 bone density, 56 cancer, 56–57 cholesterol, 55–56 depression, 58 diabetes (type 2), 56 hepatitis C, 57 obesity, 57 prostate- specific antigen (PSA), 57 sexually transmitted infections, 58 U.S. Preventive Services Task Force (USPSTF), 55 vision, 58 self-neglect, 299–302 definition, 299 crime of, 300 prevalence of, 301 protective services and, 302 senior centers, 47, 210–212, 214 meals, congregate and home-delivered, 47, 214 multipurpose senior centers, 211–212 Older Americans Act and, 210–211 Senior Corps programs, 201–202 Foster Grandparent Program, 202 RSVP, 200–201 Senior Companion Program, 202 sexuality, 91–103 attitudes towards older adults’ sexuality, 91–92 condom use, 98 cross-sectional research designs and, 91 education, 101–102 female and male menopause, 96–97 gender and, 94 health and, 96–100 healthcare providers and, 96, 100, 103 HIV/AIDS and, 98–100 importance of, 93–94 media spokespeople and, 102–103 measures of knowledge and attitudes, 102 PLISSIT model, 100 residential care facilities and, 100–101 safe sex practices, 97–100 self-reporting of sexual attitudes and behaviors, 91 sexual expression and behaviors, 92–94 sexual partners and relationships and, 95–96

Sugar62939_PTR_INDEX_337-348_06-11-19.indd 347

347

sexually transmitted diseases. See sexually transmitted infections sexually transmitted infections (STIs), 58, 90, 97–100, 255 ageism and, 90 HIV/AIDS, 58, 97–100, 232, 255, 290 safe sex practices, 97–100 screening for, 58 skin, 23, 28–29, 59 adaptations to age-related changes in, 23 age-related changes in, 23 cigarette smoking and, 23 tanning and, 59 touch and, 28–29 sleep, 33–34, 51–52, 234 adaptations to age-related changes in, 33 age-related changes in, 33 factors affecting, 33 good sleep hygiene, 51–52 medications and, 33 rapid eye movement (REM) sleep, 33, 51 quality of, 34, 51–52 sleep disorders, 234 circadian rhythm disorders, 234 insomnia, 234 movement disorders (periodic involuntary leg movements), 234 sleep apnea, 234 treatments for, 33, 234 smell, sense of, 27–28 adaptations to age-related changes in, 28 age-related changes in, 28 gender differences in, 28 factors affecting, 28 physical activity and, 28 smoking, See cigarette smoking social networks, 189–190 definition, 189 religious and spiritual communities, 190 size of, 189–190 socioemotional selectivity theory (SST) and, 189 types of support, 189 instrumental assistance, 189 informational support, 189 emotional reinforcement, 189 value of, 189–190 Social Security, 13–14, 132–135, 139, 145–152, 171–173, 259, 305–308 basics, 133–135 funding and benefits, 135 beneficiaries, 133–134 debates over, 148–150 disability insurance (DI), 133–135, 148–149 financial abuse and, 307–308 history of, 132–133

11-Jun-19 7:32:34 PM

348

Index

Social Security (cont.) intergenerational aspects of, 133–134 life insurance benefit, 133–134 Senior Citizen’s Freedom to Work Act, 147 Social Security Act, 132–135, 139, 145, 148, 171, 259 Social Security Administration, 152 Supplemental Security Income (SSI), 130–131, 139, 173, 305 Trust Fund, 148–149 socioemotional selectivity theory (SST), 68, 189 stroke. See hypertension and stroke suicide, 115–118 caregivers and, 117 gender and ethnicity/race and, 117 physician-assisted, 115–116 rates of, 117–118

taste, sense of, 27–28 adaptations to age-related changes in, 28 age-related changes in, 28 thermoregulation, 23–25 adaptations to age-related changes in, 24–25 age-related changes in, 23–24 hyperthermia, 24 hypothermia, 24 touch, sense of, 28–29 age-related changes in, 29 factors affecting responses to, 28 massage and, 29 positive effects of, 29 transportation, 8, 24, 160–162, 210–211, 218–219 5 A’s of senior-friendly transportation, 210–211 age-friendly communities and, 160 availability of, 161–162 driving, 8, 25, 162, 210 transportation services, 218–219 National Aging and Disability Transportation Center (NADTC), 161 Urban Mass Transit Act, 161 urinary tract, 30–31, 37–38, 57 adaptations to age-related changes in, 30–31 age-related changes in, 30–31 infections, 30 Kegel (pelvic floor) exercises, 31 kidney stones, 30 micturition reflex, 30 National Association for Continence, 38 urinary incontinence (UI), 30–31, 37, 57

vaccines, See immunizations vision, 25–26, 45, 57–58, 233–234 adaptations to age-related changes in, 25–26 age-related changes in, 25–26

Sugar62939_PTR_INDEX_337-348_06-11-19.indd 348

presbyopia (farsightedness), 25 cataracts, 25 dry eyes, 26–27 eye diseases, 58, 233–234 age-related macular degeneration (AMD), 233 glaucoma, 233 retinopathy, 234 eye examinations, 26 National Eye Institute, 38 volunteerism, 200–204 AARP Foundation’s Experience Corps, 202–203 contributions as activists, 203–204 contributions as volunteers, 201 Counselors to America’s Small Businesses, 203 Senior Corps programs, 200–202 Foster Grandparent Program, 202 RSVP, 200–201 Senior Companion Program, 202 value of volunteers, 202–204 White Americans. See non-Hispanic White Americans women, 4–5, 32, 131, 138–140, 165–166, 179–180, 182–184, 225–227, 233, 276–292, 294, 302, 312. See also gender caregiving, 182–184, 282 chronic medical conditions and, 225–227, 230, 233, 280–290 demographics, 276–278 economics, 131, 278–284 income inequities, 131, 280, 282 poverty, 138–139, 278 elder abuse and, 302, 312 Equal Pay Act, 279 labor force participation, 139–140 life expectancy, 4–5, 287 living arrangements and, 165–166, 284–285 menopause, 32–33, 38, 56, 97 National Women’s Law Center, 294 partner status, 179–180, 283–284 preventive health services, 290–292 immunizations, 291 screenings, 291–292 retirement pensions and policies and, 285–286 Women’s Institute for a Secure Retirement, 294 widowhood, 284–285 work. See older workers

young people, 11, 22–23, 26, 30–31, 299, 304–305 ageism and, 6 ageist attitudes held early in life, effects of, 8 building bone mass, 31 economic hardships, 13 financial abuse and, 304–306 GenXers’ and Millennials’ dreams for retirement, 150 violent crimes against, 299

11-Jun-19 7:32:34 PM