Victoria M. Rizzo, PhD - Columbia University, School of Social Work
Jessica Seidman, MSW - Columbia University, School of Social Work.
As the tsunami wave of older adults approaches between now and the year 2020, health promotion has become a topic of great importance in the United States and internationally. Despite the myths about aging and ageism in our society, many older adults are healthy and able. Nearly all adults aged 65 and over are likely to have several chronic health problems, but most of them are not disabled. In fact, many adults aged 65 and over lead productive lives while managing chronic illness. They work, volunteer, travel, exercise, etc. For this reason, it is important that our work with the aging population include a focus on health promotion and health maintenance, as well as on chronic disease, palliative care, substance abuse, and mental health.
In this module, we present an overview of the demographics and trends that influence the aging process of adults aged 65 years and older in the United States. Although these factors cannot be definitively identified as determinants of health outcomes, they represent some characteristics within American society that help to predict how well people age (World Health Organization [WHO], 2002). We also provide an overview of health promotion models in aging and discuss the role that social workers can play in health promotion for the aging population. Even though this module focuses on the healthy aging of the older population, it is important to note that these factors influence an individual’s health and quality of life throughout the life course.
Although the growth illustrated by these demographic trends is significant, it has been relatively slow compared with the increases projected to occur in the next 30 to 50 years (Centers for Disease Control [CDC] & The Merck Company Foundation [Merck], 2007). In 2000, the population aged 65 and older was approximately 35 million (12% of the total). By 2030, this older cohort’s size is expected to double and will represent roughly 20% of the total population—or one in every five people (Marshall & Altpeter, 2005). The CDC has forecasted that the increase in older citizens will begin to soar as the baby boomers enter this age bracket (CDC & Merck, 2007). By 2050, the number of baby boomers aged 85 years and older is expected to rise to roughly 21 million (Federal Interagency Forum, 2008). These projected increases in life expectancy can be attributed to improved medical care and an emphasis on disease prevention measures over the last century (CDC & Merck, 2007).
Marital status has a large impact on an older person’s emotional and economic circumstances as well as accessibility to informal caregivers. Similarly, the composition of one’s household can be expected to influence one’s socioeconomic position. Although, in general, both women and men are less likely to have a living spouse as they increase in age, the women are three times more likely than the men to be widowed. Divorce and singlehood are comparatively low among women and men aged 85 years and older.
These factors must be considered when examining an older person’s overall well-being and the probability that the person will practice preventive health care and participate in behaviors that promote health.
The higher their level of education, the greater the likelihood that people will have the resources to exercise ample control over their lifestyle and health care choices and therefore have abundant opportunities to practice behaviors that foster better health outcomes. In the last 50 years, the number of older people with a high school diploma has increased 52%. In 2007, 25% of men and 15% of women had an undergraduate degree, and the gender gap related to achieving a college education is predicted to shrink in the coming years (Federal Interagency Forum, 2008).
Hispanic people make up the largest-growing segment of the older population, followed by Asians. In 2005, there were a recorded 2 million Hispanic older people in the country. By 2050, their number is expected to increase to 15 million. In contrast, from 2006 to 2050 the population of White non-Hispanic older is expected to drop by 20%—from 81% to 61% (Federal Interagency Forum, 2008).
Older adults may experience the effects of disparities in health status more than any other population group, especially those who are members of racial and ethnic minority groups (CDC & Merck, 2007). The general health status among members of these groups who are 65 years old and older falls behind that of members of nonminority groups. Some factors contributing to the gap in health care outcomes are a result of the prevalence of lower socioeconomic status among minority groups and the need of older people for ongoing care because of the greater probability that they will develop a chronic illness (CDC & Merck, 2007).
Cultural diversity is another factor involved in shaping the aging process. Cultural values and practices influence how society views older people and the aging process (WHO, 2002). An individual’s perceptions about the process will affect how receptive he or she is with regard to the importance of prevention, detection, and treatment (WHO, 2002). One example of the disparities in health care is that older members of racial and ethnic minority groups are immunized at lower rates than their White counterparts are. According to a recently released report (CDC & Merck, 2007), multiple factors have been tied to the disproportionate use of health care services among different population groups: for example, the level of health care awareness and access to health care providers.
Good health in the later years facilitates a quality of life that includes the optimum degree of independence and social engagement (Robinson, 2007). One primary and certainly achievable goal of healthy aging initiatives proposed by health care organizations is to increase the numbers of older people who live longer, high-quality, productive, and independent lives (CDC & Merck, 2007). The above-mentioned indicators affect an older person’s ability to practice healthy behaviors. Since the beginning of the 20th century, the levels of medical care and preventive practices have been major factors resulting in increased life expectancy. However, roughly 80% of older adults are living with at least one chronic condition (CDC & Merck, 2007).
More than one third of the deaths that occur in the general population of the United States are preventable (CDC & Merck, 2007). The following three behaviors alone contributed to nearly 35% of all deaths in 2000: smoking, poor diet, and physical inactivity. Furthermore, the cost of medical care for older people is three to five times higher than it is for younger people. By 2030, the cost of providing health care for people aged 65 years and older is expected to increase by 25% (CDC & Merck, 2007). However, adoption of healthy behaviors and access to regular health screenings could prevent many chronic conditions, help reduce disparities among different population groups, and, ultimately, reduce health care costs.
The large increase in the older population has resulted in the supreme challenge of meeting the consequential economic and social demands. In response to this increase plus the inevitability of some age-determined physiological decline, the adoption of strategies that promote health can aid in maintaining quality of life in later years (Nakasato & Carnes, 2006). Successful aging (also called “healthy aging” and “active aging”) is characterized by three main characteristics or actions: (1) low risk of disease and disease-related disability, (2) high mental and physical functioning, and (3) active engagement with life (Nakasato & Carnes, 2006).
The World Health Organization (2002) reported that the upsurge in societal costs related to the increase in populations of older people and their medical needs can be met by immediately adopting and implementing policies and programs based on “active ageing—the process of optimizing opportunities for health, participation, and security in order to enhance quality of life as people age” (p. 12). Between 2002 and 2025, the growth of older populations is likely to exceed that of the populations of children and young adults.
The ability of older people to contribute actively to society depends on their well-being and quality of life. The majority of them lead active, fulfilling lives because of their good health status. To ensure that policy makers and the society continue to promote active aging, it is important to eliminate common myths about aging that can create barriers to the promotion of health (WHO, 1999). A few examples of these misguided myths appear below:
The reality is that more than 60% of older people live in developing countries. Of an estimated 580 million older adults in the world, roughly 355 million live in developing countries (WHO, 1999). The World Health Organization (WHO) estimated that by 2020, the global older population would reach 1,000 million, and roughly 700 million of them would be living in developing countries. The WHO (1999) reports that as life expectancy has increased, worldwide fertility rates have declined. Note that the life expectancy in such countries as Nigeria, China, and India has increased dramatically over the last 58 years and is expected to continue rising. As citizens of an aging world it is necessary for the world’s societies to acknowledge older persons as a valuable resource and to combat ageism by collectively facilitating opportunities to involve older adults actively in this process. To achieve this goal, health care services not only must be available but also must include health promotion and encourage intergenerational solidarity.
As a population, people aged 65 and older are not a homogeneous group. Their diversity is based on such factors as gender, ethnic or cultural background, composition of family and community, country of origin, type of living arrangements and environment, levels of education and income, degree of involvement and activity, level of skills, and types of social roles. All these factors affect an individual’s life experience and have a strong influence on his or her aging process (WHO, 1999).
Because health and level of activity in the later years are primarily determined by one’s life course of experiences, exposures, and actions, one’s choices for active living should begin early in life. Participating in family and community life, eating well-balanced meals, being physically active, and avoiding unhealthy behaviors can promote more successful aging.
Participation of older adults in daily activities can range from volunteer or paid work to physical fitness activities to meaningful hobbies. Roughly 2 million children in the United States are cared for by their grandparents, and an estimated 1.2 million of these children live with their grandparents (WHO, 1999). This means that the grand parents provide the care that parents would provide because they aren’t available. Some grandparents regularly perform parenting responsibilities for their grandchildren. All individuals age within the context of their surroundings which include family, friends, and community. The ability of older people to partake of and enjoy life depends on the risks and opportunities available to them throughout their lives and on the support network that surrounds them (WHO, 2002).
As a result of differences in gender roles and responsibilities, life expectancy, and biological characteristics, the aging process is different for men and women. An examination of mortality and morbidity in the later years reveals that older women live longer than their male counterparts, experience different chronic conditions, and are at higher risk for functional limitations (WHO, 1999). In addition, they tend to report a greater need for help with personal care and the activities of daily living than older men do.
Because women make up the majority of the aging population (Robinson, 2007), one particular area of concern to society is the ability to meet women’s increasing requirements for health care and long-term care as they age. As a result of their longer life expectancy, they are more likely than their male counterparts to be widowed and to lack a significant other who can be their primary caregiver (WHO, 1999). Therefore, more women are dependent on formal care services provided either in the home or in long-term health care facilities.
Men are generally at higher risk than women are for heart disease and stroke, although the higher prevalence of these diseases among men should not negate the fact that women also are at risk (WHO, 2002) for these and other illnesses, such as cancer, chronic lower respiratory diseases, and Alzheimer’s disease. Another common illness among older women is osteoporosis, the signs and symptoms of which are not visible, thus making the disease a silent threat for increased disability and decreased quality of life (Robinson, 2007).
Throughout the 20th century, the patterns of illness in the aging population have changed dramatically. Historically, acute infectious diseases were the most prevalent causes of death. Today, however, chronic illnesses that can be managed over time are seen more frequently in the older population (Rowe & Kahn, 1998). This shift in the nature of older individuals’ health needs has led to changes in the degree of disability caused by chronic illnesses. Manton, Gu, and Lamb (2006) reported a significant decrease in the occurrence of chronic disability among older adults between 1982 and 2005. In 1982, 73.5% of people aged 65 years and older identified themselves as nondisabled, whereas 81% did so in 2005. According to Manton and coauthors, major long-term improvements in the ratio of activity level to total life expectancy are projected for people aged 85 and older. If current trends persist, the number of severely disabled individuals should decline 50% by the year 2050 (WHO, 1999).
The trend in care services for older adults has been shifting from residential and housing services that focus on maintenance to community-based services that emphasize treatment and rehabilitation (Robinson, 2007). Today, the focus on illness is how it affects a person’s ability to function within the community. As Robinson pointed out, many older adults can function at a high level. For example, they can be providers as well as recipients of care (WHO, 1999).
According to the WHO (2002), in 2001 roughly 20% of older adults worldwide received formal care services. Approximately two thirds of those services were home based and included, but were not limited to, visiting nurses and home-delivered meals. To maintain older adults’ independence and promote their well-being, rehabilitative services, physical environments adapted to their needs, and education regarding healthy lifestyles must be available to them. It is virtually never too late to adopt healthy behaviors, such as smoking cessation, proper diet, and physical activity that can improve a person’s quality of life (Rowe & Kahn, 1998).
In 1991 the Department of Health and Human Services released Healthy People 2000. In 2000 it published Healthy People 2010 in response to evidence that adopting healthy behaviors at any stage of life is beneficial for well-being (CDC & Merck, 2007). To improve the health of Americans nationwide, the two reports established specific health goals for communities. The activities put forth in Healthy People 2010 are generally age-specific. When reviewed as a group, the list contains 500 health objectives for Americans to accomplish by 2010. When viewed as a whole, the suggested programs support a lifelong approach to healthy living.
Using a nationally administered survey, all 50 states will be evaluated regarding the following areas targeted in the 2010 report: health status, health behaviors, preventive care, health screening, and injuries (CDC & Merck, 2007). For example, the preventive care measures being targeted include flu and pneumonia vaccines, mammograms, colorectal cancer screening, and cholesterol checks.
Valuing older people for their ongoing roles and participation in their families, communities, and economies is important. Like everyone else, the less older people are challenged, the less they can achieve. The elimination of age discrimination will require an emphasis on programming that is flexible and offers lifelong opportunities for learning. Therefore, educational facilities and institutions should adjust their curriculum to accommodate differences between older and younger people regarding the pace at which they learn and their ability to retain information (Rowe & Kahn, 1998).
Longitudinal studies focusing on promotion of health have highlighted how healthy behaviors have a direct impact on the length and quality of a person’s life. In the context of the myth that older adults do not contribute to society, deriving a constant sense of purpose or involvement by participating in society is a crucial and central aim of successful aging. The Administration on Aging (2008) points out that older adults are actively engaged in their communities both formally and informally by providing millions of hours of volunteer, community, and civic service. They not only contribute their spare time, but impart knowledge of culture, values, and life experiences to younger generations as well. As older adults live longer, healthier lives, they will be able to continue contributing their valuable knowledge to society. Regular activity, along with a stable support system and confidence in their ability to handle what life has to offer, helps them to maintain good health (Rowe & Kahn, 1998).
Older members of communities are not only invested in their own network of family and friends; they also are interested in and care about the greater community. For example, Senior Corps (Research Triangle Institute [RTI] International, 2003)—a program developed by the Corporation for National and Community Service—has connected roughly 500,000 senior volunteers 55 years and older with opportunities for meaningful unpaid work. The organization’s offerings include the Retired Senior Volunteer Program (or RSVP), the Foster Grandparent Program, and the Senior Companion program (RTI International, 2003). Participants in these programs have devoted more than 1 billion hours to communities nationwide.
Another volunteer program, Seniors for Schools, shares their leadership and organizational skills with the greater community. The program’s mission is to provide literacy services to children in primary schools across the United States (Project STAR, 2001). In 2000, 486 volunteers served 5,462 students. Programs such as these demonstrate the willingness and ability of older individuals to engage with people of all ages in their communities. As their quality of life and life expectancy increase, the number of programs available to the rapidly increasing population of older people will increase rapidly as well.
Administration on Aging. (2008). Promoting healthy lifestyles. Retrieved March 2, 2008, from http://www.aoa.gov/eldfam/Volunteer_Opps/Volunteer_Opps.aspx
Centers for Disease Control (CDC) & The Merck Company Foundation. (2007). The state of aging and health in America. Whitehouse Station, NJ: The Merck Company Foundation. Retrieved February 8, 2008, from http://www.cdc.gov/aging
Federal Interagency Forum on Aging Related Statistics. (2008). Older Americans update 2008:Key Indicators of Well-being. Retrieved March 18, 2008, fromhttp://www.agingstats.gov/agingstatsdotnet/main_site/default.aspx
Manton, K. G., Gu, X., & Lamb, V. L. (2006). Change in chronic disability from 1982 to 2004/2005 as measured by long-term changes in function and health in the U.S. elderly population. Proceedings of the National Academy of Sciences, 103, 18374-18379.
Marshall, V. W., & Altpeter, M. (2005). Cultivating social work leadership in health promotion and aging: Strategies for active aging interventions. Health & Social Work, 30(2), 135-144.
Nakasato, Y. R., & Carnes, B. A. (2006). Health promotion in older adults: Promoting successful aging in primary care settings. Geriatrics, 61(4), 27-32.
Research Triangle Institute International. (2003). Final report of the senior companion quality of care evaluation. Report prepared for the Corporation for National and Community Service. Research Triangle Park, NC: Author. Retrieved May 6, 2008, from http://www.seniorcorps.gov/pdf/final_scp_report.pdf
Robinson, K. (2007). Trends in health status and health care use among older women. Aging trends. Hyattsville, MD: National Center for Health Statistics. Retrieved March 18, 2008, fromhttp://www.cdc.gov/nchs/data/ahcd/agingtrends/07olderwomen.pdf
Rowe, J. W., & Kahn, R. L. (1998). Successful aging. New York: Pantheon Books.
Project STAR. (2001). Seniors for Schools evaluation results 1999-2000 school year. San Mateo, CA: Author. Retrieved May 6, 2008, from http://www.seniorcorps.org/pdf/seniors_4schools.pdf
World Health Organisation (WHO). (1999). Ageing: Exploding the myths. Geneva, Switzerland: Author. Retrieved February 5, 2008, from http://libdoc.who.int/hq/1999/WHO_HSC_AHE_99.1.pdf
WHO. (2002). Active ageing: A policy framework. Geneva, Switzerland: Author. Retrieved February 5, 2008, from http://whqlibdoc.who.int/hq/2002/WHO_NMH_NPH_02.8.pdf
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