How many of who? Overall Population Trends of Elders in the U.S. Return to the Beginning
We have all heard about the "graying of America." You may have already seen a steady increase in the number of your elder patients over the past ten years. Overall numbers of elders will continue to grow over the coming decades. However, short term trends can also predict much about the numbers, family structure, and diversity of particular groups of older adults you care for.
A. The "Graying" of America, the "Birth Dearth" and the Coming "Baby Boomers"
Currently 35 million Americans are 65 years of age or older. They make up about 12% of the total population (Administration on Aging, 2001a). By 2030, 70 million people, or 20% of the population, will be 65 or older (Administration on Aging, 2001a). So, here's the first thing to know:
Fact #1. In general, nurses who care for elders are likely to see even greater numbers of them in the future.
What does this mean?
You'll need to keep learning about gerontology and geriatrics, as well as the world of seniors in general, even if this isn't your specialty. Pat yourself on the back for taking this course!
Do what you can to make your office more "senior friendly." How about making forms and signs in your office in bigger print? Is your office fully accessible? Is the furniture too low for elders to get out of or too high for them to get on without a footstool? Might elders fall over scatter rugs and other potential hazards? Is there an emergency call button in your bathroom? Are the magazines in your waiting room of interest to elders?
You and your staff need to feel comfortable around elders and question assumptions you may have about them. Many significant medical problems that elders have - such as incontinence or AIDS and other sexually transmitted diseases -- too often go undiagnosed because practitioners are either embarrassed to discuss them with people much older than themselves or they don't know that elders are at risk. Do you need to do some staff training or even look at your own attitudes about aging?
Have you considered how to make it easier for your older patients who can no longer drive to get to you? Is your office on a public transportation line? Can you make appointments for elders that coordinate with public transportation schedules? Do you offer any evening or weekend hours? For seniors who depend on working family members to get to you, appointments outside of regular business hours can be a lifesaver.
Fact #2. The elder population is, for the first time in many years, increasing at a lower rate than the general population. However, over the next five to ten years, the number of people in their 60s will increase substantially as "Baby Boomers" become "Senior Boomers" (Administration on Aging, 2001a)
The seniors responsible for the elder surge in the 1990s were born in the 1910s and 1920s. During the Depression and World War II, the birth rate dropped, creating a "Birth Dearth." Then, directly after World War II, the "Baby Boomers" came along, creating a second wave of growth in the elder population that will take place between 2010 to 2030 (Redfoot & Pandya, 2002).
What does this mean to you?
Over the next few years you may look into your waiting room and say "Where are the elders? Maybe we can go back to the way we used to do things…" However, don't be complacent. You are going to have another surge come along.
The "Baby Boomer" patients in their 60s will have their own special health needs. First, many seniors depended on their workplace for their social network, their sense of purpose in life, and a sense of control over their lives. Patients who used to self-confidently exude health and well being may become adrift and depressed when they suddenly have no place to go in the morning, no one to direct, nothing to do, and no one to talk to. Fortunately, for many, part-time work or volunteering may help fill the gap. Second, those who retire before age 65 may not have adequate health coverage and therefore forego care if they are no longer eligible for employer-sponsored plans and are not old enough for Medicare. Finally, patients in their 60s may have the tremendous stress of care giving for parents in their 80s and 90s.
Fact #3. The elder population is becoming more diverse in terms of gender and race.
After years when older women greatly outnumbered older men, the gender ratio is becoming more equal as more men live to older ages, probably due to medical advances (Redfoot & Pandya, 2002). In addition, minority elders, currently, 16.4% of the elder population, will be about 25% by 2030 (Administration on Aging, 2001a).
What does this mean?
You may need to become more familiar with diseases that are particularly prevalent among men and minorities, such as, for example, prostate disease and cancer, since you'll see more of them.
In addition, you will need to understand how elders' cultural backgrounds affect health care needs. For example, cultures differ greatly in what they perceive to be elder abuse and what is considered acceptable treatment of seniors (Brandl & Cook-Daniels, 2002). Some cultures view dementia as shameful while others see it as a purely medical disorder with no stigma (Wessling, 2003). Elders who have suffered discrimination may lack confidence in the health care system, so you may have to work harder to establish trust.
Be aware of disparities between what care is available to white and minority elders. "Minority elderly Medicare beneficiaries are less likely to receive specialized services, such as angioplasty, coronary artery bypass graft surgery, or hip fracture repair. Only 43% of black elders received flu shots in 1998 compared with 65% of white elders" (Davis, 1999, p. 11). Examine your practices and policies, written and unwritten, that may result in less care for minority elders and hone your advocacy skills to ensure that older minority patients receive the procedures and preventive services they need to be healthy.
Fact #4. Family structures in elder households are changing.
On one hand, elders may tend to remain married longer because of the longer lifespan of men. However, at the same time, the divorce rate among elders is growing. Between 1990 and 2000, the rate grew from 3% to 4%. In addition, about 5 million seniors live together as couples but are not married. Some groups of seniors also have more children than others. While the "birth dearth" elders had larger numbers of children, more "Baby Boomers" are childless or have few children (Redfoot & Pandya, 2002).
What does this mean?
Older women are less likely to be widowed. Because more husbands will be alive to provide care giving to their wives, fewer older women may need professional in-home care or to be institutionalized (Redfoot & Pandya, 2002). Also, fewer of your older female patients may be poor if they are living with someone else instead of alone (Administration on Aging, 2001b). Both these factors are likely to improve the health and well being of your older female patients.
Couples that at one time may have remained unhappily married may now be divorced. These divorced elder patients may end up needing more nursing or in-home care since their ex-spouses are not available as caregivers. Divorced wives will also likely have lower incomes than they would had they remained married. One positive effect, however, may be a reduction in spousal elder abuse.
More adult children will be available in the next few years to help their "Birth Dearth" elder parents meet their health needs. However, the "Baby Boomers" will have fewer children to care for them, which may result in more need for nursing home or in-home care.
B. Income, Education, and Housing
Fact #5. At least some of your elder patients are likely living in poverty and so may not be able to afford health care, prescriptions, or the in-home services they need to be healthy.
The 2000 median income for older men was $19,168 while for women it was $10,899 (Administration on Aging, 2001c). While these may seem adequate, they are not if an elder has several thousand dollars per year in out-of-pocket health costs. About one in ten elders were below the poverty level in 2000. This rate is higher for women, minorities, those living alone, and the oldest-old (Administration on Aging, 2001b). While overall poverty rates for elders are less than for younger people, elders are more likely to be in poverty longer and are less likely to ever get out of poverty than younger people (Wu, 2003).
Elder poverty can sometimes be hard to spot. For example, those who live in areas where real estate prices risen dramatically may have valuable homes, but little cash to meet their daily needs. Also, for frail seniors who are homebound, no one may be coming into the house to notice that it has no heat or food.
Unfortunately, income problems may be worse for the "Boomer" seniors. Those retiring now may run out of money before they die because their retirement income comes more from savings and investments than pensions which will continue as long as the patient lives (Korcyzk, 2002).
What does this mean?
One important way to improve your patient's health may be to find ways to bring down their out-of-pocket health care costs. Do you encourage generic prescriptions? Do you recommend over-the-counter or home remedies instead of prescription medication when you can? Does your documentation ensure that your patient's bills will be properly covered by insurance? Does the practice or facility in which you work accept Medicaid? Do you tell your patients about free care or low-cost care your facility provides?
Consider whether income might be at fault when a patient presents with malnutrition or other symptoms that you would not expect. Also, a patient who does not take prescribed medication may not be able to afford it. While your patient will probably not bring up income problems, they might accept information about government-sponsored benefits if you offer it in your waiting room or in private discussions. Elder services like meals-on-wheels and free clinics in senior centers can also help patients make ends meet. Offering a patient a resource list of benefits and services and how to get them may be as important to health as a new prescription.
Fact # 6. Today's elders are more likely to have a college education than seniors in the past.
Currently, 20% of older men and 11% of older men have college degrees. This rate is higher than in the past and will climb even higher in the future (Federal Interagency Forum on Aging Related Statistics, 2000).
What does this mean?
Older patients may come into your office with more knowledge about their conditions and treatments. They will probably have more access to information, both good and bad, through the internet. So, expect more questions, be prepared to correct misinformation, and have a variety of printed materials on-hand for patients who request it.
You may find that your older patients have fewer ailments related to blue-collar work since higher levels of education have come at the same time as an increase in white collar work histories (Cutler, 2001, cited in Korczyk, 2002). At the same time, elder patients may have more "white collar" conditions, such as those related to computer work.
Fact #7. Elders live in homes that are older than those of younger people.
The median year of construction for elders' houses was 1962, seven years older than homes belonging to the general population (Administration on Aging, 2001d). In many cases, these homes are not adapted for the special mobility needs of their occupants. In fact, 8% of those over age 45 surveyed said that their home has mobility barriers for someone living in it (Bayer & Harper, 2000).
Your frail elder patients who cannot afford to update or maintain their home may be at risk for injuries. As a result, you may be saving your elderly patients potentially life-threatening accidents by giving them one of the widely available "home safety checklists" and discussing common hazards. If you can have information on hand about programs that subsidize home adaptations, so much the better.
C. What Is "Elderly" to Your Elderly Patients? What Is a "Good Old Age"?
Fact # 8. Most of your elderly patients do not think of themselves as old.
Have you ever heard the old joke that old age is "ten years older than whatever age you are"? It has more than a little truth in it. A recent survey found that 42% of those 65+ thought of themselves as middle-aged or young, "Only 15% of those 75+ consider themselves to be 'very old.'" (National Council on Aging, 2002, p. 6).
What does this mean
Avoid language or actions that imply that you think your patients are "elderly" just because they have reached a certain age. No one likes to be told "What do you expect at your age?" when what they expect is to be diagnosed and treated appropriately however many candles were on their latest birthday cake. If your patients think that your view is out-of-sync with their own self-image, they may lose confidence in you.
On the other hand, remember that someone in their 60s or 70s who appears to be a vigorous, middle-aged person still needs the screenings and other care appropriate for their age.
Fact #9. Elders care most about their friends and family but worry most about their health.
Elders responding to a survey about what is important to them for a good older age said that they valued, in order: family and friends, health, spiritual life, community, and new learning. They worried most about: memory loss, pain, long term care costs, not being productive, and outliving their pensions (National Council on Aging, 2002)
What does this mean?
The health behaviors of your patients will reflect the importance of their relationships. A number of very successful health promotion models, including walking groups, rely on socializing as a motivator. You may wish to remind an elderly patient to consider the effect of their death or disability on their family when deciding to undergo a procedure or treatment. However, elders may also sacrifice their health and well being for their families. This is especially true of caregivers who are at increased risk for self-neglect (Gallant & Connell, 1997) and low income elders who may give so much money to family members that they do not have enough to care for themselves.
Notice that "losing years of life" is not on the list of concerns. Clearly quality of life is more important than quantity of life for your elder patients. It may be helpful to remember this when trying to understand the decisions that older patients make. A treatment or procedure that will possibly add years of life may not be a good choice in the eyes of your older patient who is concerned about the pain or disability that may result. A patient who continues to live independently at home after you believe it is time for a nursing facility may not be mentally incompetent, just choosing what is most important.
The more you know about what is quality life for a particular patient, the better you can discuss risks and benefits of a treatment or procedure. Effects on independence, pain, cognitive functioning, and the ability to carry on the tasks of daily living are all likely to be essential information from the patient's point of view. Cost may also be important for lower income patients.
