Three Legs in the Evening: Health Care of the Aged

By Thomas W Elwood

Entering the older age brackets of life is associated in a great many cases with the onset of disability. Much of the material contained in this book is a recognition that this unassailable fact cannot be ignored, while simultaneously acknowledging that significant positive features also relate to the process of growing old. The ranks of individ

• Language: English
• Publisher: Science & Medicine, Inc
• Release date: Apr 1, 2019
• ISBN: 9781792304521

Book preview

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CHAPTER 1:

PROFILE OF THE AGED

This chapter offers a description of some key aspects of the older age brackets of life, how the process of aging is measured, the experience of being disabled, the impact of bodily dissatisfaction on wellbeing, changes in the portion of the population entering older age, international comparisons of the aged portion of the population, life expectancies, and the effects of health behavior on growing older.

As noted in the Introduction to this book, a classic riddle from ancient times involved questions posed by the Sphinx to travelers, along the following lines: " What walks on four legs in the morning, two legs in the afternoon, and three legs in the evening? " Failure to respond correctly resulted in being eaten by the Sphinx. Oedipus Rex was the first to supply the correct answer, which is human beings .

The cover of this book shows an older woman with a cane, a common assistance device to aid in walking. Entering the older age brackets of life is associated in a great many cases with the onset of disability. Much of what follows in this chapter and in subsequent portions of this book is a recognition that this unassailable fact cannot be ignored. Simultaneously, it should be emphasized that a great many positive attributes can be associated with the process of aging. Enormous improvements in health care have been made in recent decades. Government agencies at all levels are involved in the provision and financing of valuable health and health-related social services that enhance life. Just as importantly, academic programs continue to produce graduates across the health professions who have the necessary knowledge and skills to provide high-quality health care for members of older age cohorts.

A study published in Frontiers in Psychology focuses on questions such as: Is 50 old? When do we stop being young? If individuals could choose to be any age, what age would they be? The investigation examines age differences in aging perceptions (e.g., how old do you feel?) and estimates of the timing of developmental transitions (e.g., when does someone become an older adult?). Aging perceptions are operationalized as evaluations that individuals tie to different ages by reporting (a) the age they would like to be ideally, (b) the age they feel like, (c) the age they hope to live until, and (d) how old other people think they are. [¹]

Chronological age is a firm measure of longevity, but it obviously is found to be lacking in providing guidance regarding when transitions occur in life. For example, at an early stage, chronological age serves as a metric for indicating when childhood ends and aids in determining when an individual can obtain a license to drive a car, purchase alcohol beverages, and join the military. Yet, the measure fails to take into account significant differences that may exist in overall cognitive, emotional, and developmental maturity of individuals who happen to be the same age.

Defining age at the other end of the spectrum is equally problematic. Reaching the age of 65 used to mean that participation in a particular job would end and retirement would begin. Yet, that figure does little to distinguish individuals on the basis of important factors that pertain to their physical and mental health status. A 75-year-old may take part in vigorous physical exercise and temporarily experience what it is like to be age 18 all over again, but just 2 days later only be able to walk around in the shape of a frail 90-year old individual after various muscular aches and pains exert their effect.

This book is about health care of the aged. In it, many studies will be referred to that consider individuals who are assigned to different brackets, such as 60-70 or 75-85. For the aforementioned reasons, just because an individual chronologically is assigned to a particular bracket, it does not mean he or she belongs there as measured by other metrics. One person with a chronological age of 75 may be in superb physical condition, enjoy robust health, continue to be employed, and be able to display more energy than many individuals who are 60 years old. Conversely, some individuals at age 60 may possess the same decrements in physical and mental health that might characterize someone in poor health who is age 75.

Reasonable questions to ponder are whether there is an upper limit to the human lifespan, and if so, can technology expand it even further? Some researchers believe that it is possible to reach the age of 110, assuming the journey between ages 90 to 105 can be survived after which death rates become more level. Results of one investigation show that individuals between the ages of 105 and 109, known as semi-supercentenarians, had a 50/50 chance of dying within the year and an expected further life span of 1.5 years. That life expectancy rate was projected to be the same for 110-year-olds, or supercentenarians.[²]

Many studies of population aging focus on only one characteristic: chronological age. A more comprehensive approach entails considering other measures of population aging, such as remaining life expectancy, health, normal public pension age, and hand-grip strength. It is clear that different segments of the population have quite different characteristics at a given chronological age. For example, why is someone aged 60 considered to be middle-aged today, while 150 to 200 years ago, a person of the same age would be considered elderly? The reason is that young and old are relative notions and their common reference point is life expectancy. In 1800, only about one third of women would have survived until age 60, while today in developed countries, more than 90% of women will celebrate their 60th birthday. Prospective age measures how old people are, not only from the date of their birth but also in relation to their lengthening life expectancies. [³]

According to experts at Oxford Dictionaries, youthquake was the Word of the Year chosen for 2017. The term is defined as significant cultural, political, or social change arising from the actions or influence of young people. While acknowledging the importance of focusing on actions of young individuals, perhaps a similar argument can be made in favor of examining tectonic plates that stem from the steady occurrence of dramatic quakes associated with the aging of the population in the U.S. and throughout the world.

As an illustration of the growing interest on how to address various challenges resulting from significant growth in the number and proportion of the elderly, an emerging field in aging research called geroscience signifies that studies of this nature are not simply an academic pursuit. They also actually hold significant promise for enhancing human existence. Four out of five Americans age 65 and older suffer from at least one chronic disease, and more than half suffer from multiple comorbidities. Aging being the major risk factor for all those diseases, it follows that research into aging could be pivotal in efforts to reduce the suffering associated with the ravages of old age. A central issue is to determine whether individuals acquire disease from aging or if certain aspects of aging are caused by disease? [⁴]

Measures Of Aging

One measure used to quantify the burden of disease associated with chronic conditions among older adults is to estimate quality-adjusted life years (QALYs). The purpose of one study was to measure the impact of both individual health conditions and combinations of conditions using samples from the annual nationwide Medicare Health Outcomes Survey (HOS). The focus was on the burden of disease for U.S. older adults associated with 15 common chronic conditions among the elderly, along with the burden associated with combinations of these 15 chronic conditions. The results show that over 90% of respondents reported at least one condition and 72% reported multiple conditions. Respondents with depression and congestive heart failure had the lowest age-adjusted QALY (1.1–1.5 years for men and 1.5–2.2 years for women), whereas those with hypertension, arthritis, and sciatica had higher QALY (4.2–5.4 and 6.4–7.2 years, respectively). Having either depression or congestive heart failure and any 1 or 2 of the other 13 conditions was associated with the lowest QALY among the possible dyads and triads of chronic conditions. Dyads and triads with hypertension or arthritis were more prevalent but had higher QALY. [ ⁵]

Healthy grandparenthood represents the period of overlap during which grandparents and grandchildren can build relationships. The health of grandparents has important implications for upward and downward intergenerational transfers within kinship networks in aging societies. Although the length of grandparenthood is determined by fertility and mortality patterns, the amount of time spent as a healthy grandparent is also affected by morbidity.

A study involving the length of healthy grandparenthood used U.S. and Canadian data to examine changes in healthy grandparenthood during years when it was postponed (i.e., older age of parents when first bearing children), health improved, and mortality declined. The findings show that the period of healthy grandparenthood is becoming longer because of improvements in health and mortality, which more than offset delays in grandparenthood. Important variation exists within the United States by race/ethnicity and education, which has implications for family relationships and transfers.

An example of a potential transfer that healthy grandparents can provide is childcare to grandchildren, which can serve as a critical aid to adult children during their prime career-building phase of life. In contrast, unhealthy grandparenthood represents a period when the middle generation may be more likely to provide care upward, and relationships between grandparents and grandchildren may not be as active. The health of grandparents also affects intergenerational family dynamics because it determines whether they are providers or recipients of transfers. The length of healthy grandparenthood is perhaps more important than the overall length of grandparenthood for understanding the experience of grandparents and their families.

Differential fertility patterns lead to large racial/ethnic and educational differences in the timing of grandparenthood. On average, U.S. black and Hispanic women become parents earlier than non-Hispanic white women. Also, the more-educated also have higher median ages at first birth, which affects spacing between generations. Such differences have a compound effect across generations, leading to shorter generational length among blacks and Hispanics and less-educated families than among non-Hispanic whites and highly educated families. [⁶]

Under ideal circumstances, all members of this three-generational arrangement benefit. Grandparents have the satisfaction of experiencing added purpose in life by being able to assist their children and grandchildren. Parents are freed in many cases from having to arrange and pay for daycare services, while also deriving comfort from the knowledge that their offspring are in the care of loving adults. The children themselves not only experience the love of grandparents, but are in a position to benefit from a transfer of knowledge to them by a different generation of adults. A potential downside is that some parents may be tempted to overdo a good thing by taking excess advantage of a willingness by their parents to furnish assistance to the family.

Disablement

Shown below is a figure of the disablement process. Arthritis is used as an illustration of a disease that may lead to impairment that involves joint stiffness and pain. Related impairments may include functional limitation of a cognitive, sensory, or physical nature, such as difficulty bending, which ultimately may result in a disability involving a limitation in an activity of daily living (ADL), such as bathing. A framework is presented in the figure of an inherently dynamic developmental course, while acknowledging that risk factors involving sociodemographic attributes as well as interventions may affect onset and progression of each phase, including recovery.

A goal of one study was to assess how characteristics measured early in the disablement process are associated with subsequent trajectories of ADL disability. The investigators used seven waves of longitudinal data from the Health and Retirement Study (HRS) for 1998 to 2010 to examine how sociodemographic risk factors, self-reported diseases, a global pain index, and sensory, cognitive, and physical functional limitations at baseline are associated with multi-period trajectories of limitations in ADLs. The probability of ADL limitation by age for older Americans from 1998 to 2010 can best be described by three common trajectories. Members of the group with lowest overall probabilities of ADL limitation at all ages (39.5% of the baseline sample) experienced little chance of ADL difficulty until their mid-80s. In contrast, members of the group with highest probabilities (17.7% of baseline sample) already had an almost 50–50 chance of limitation by age 65, and the probability increased to almost 1.0 by age 90.

Being Black is persistently associated with worse ADL trajectories across models, whereas being married is associated with better trajectories. The former may reflect the cumulative disadvantage that Blacks experience throughout their lives, differential severity and management of disease, differential accommodation of limitations, and differential self-reporting of activity limitation. The latter may reflect the benefits of social support through marriage, differential management of disease, and differential accommodation of limitations. [⁷]

Conception of the disablement process. Source: Adapted from Martin, L.G. et al.,[⁷] The Journals of Gerontology: Series B, Vol. 72, No. 1, Jan. 2017, pp.129–139.

Meanwhile, increased attention is being devoted to the health care needs of lesbian, gay, and bisexual individuals who are referred to as sexual minority (SM). It is believed that certain SM subgroups continue to be disadvantaged due to lack of data and a lack of knowledge about them. One analysis indicates that heavy alcohol consumption continues to stand out as a negative health behavior, which is higher in SM older adults compared with heterosexual older adults. Similarly, heightened alcohol consumption has been found in sexual minorities across the life course. The long-term and complex side effects from heavy or binge alcohol use throughout the life course can lead to increased health issues in older populations, including decreased life expectancy. [⁸]

Can dissatisfaction with one’s body be detrimental to wellbeing? Growing old has an impact on bodily changes that are highly visible, such as facial wrinkles, hair loss, and alterations in skin elasticity. A hoop star who at one time could dunk a basketball may need to stand on a stool just to be able to reach and touch the bottom of the net at a later stage in life. Less visible but perhaps more significant for many males is a deteriorating ability to perform sexually. A plethora of advertisements on radio and television pertaining to products that can treat erectile dysfunction successfully illustrate the advisability of treating this problem.

A study conducted in the United Kingdom among a group of White British and South Asian adults aged 65-92 highlighted the following themes: appearance indicates capability and identity; physical ability trumps appearance; felt pressures to age ‘gracefully’ while resisting appearance changes; and gender and cultural differences. The results suggest that older adults’ body image can have important implications for their wellbeing. Some participants perceived physical ability to be more important than appearance, particularly in the face of declining health and abilities associated with older age. Decline in physical ability was perceived to be accompanied frequently by a loss of independence, wellbeing, and identity. [⁹]

Bodily changes that reflect normal aging processes may not be highly valued if instead the culture values the importance of presenting a youthful appearance. On U.S. college campuses during the 1960s, a common mantra was, Don’t trust anyone over 30. As an aside, since the individuals who were pursuing academic degrees then since have joined the ranks of the aged, it is worth pondering how many of them currently adhere to that perspective.

Plastic surgery and Botox treatments represent one way of enabling a face to appear younger, but normal skin changes in other parts of the body are not as easy to disguise. Apart from any unwanted harmful side effects that may accompany various treatments, a more serious consequence for some individuals is the psychological damage that might be inflicted. Mental health problems will be covered in greater depth in Chapter 7 of this book. Suffice it to say that given all the kinds of problems that can develop in later life, it is unfortunate that some of them might stem from a perceived mismatch between what a particular culture appears to value and an individual’s ability to project a physical image that conforms to cultural expectations.

Demographic Characteristics

The average life expectancy in the world in the 1960s was less than 55 years old. Now, being 60 years old is not considered so ancient because of improvements in life expectancy (nearing 70 years old globally), health, and life-style. Population aging is defined as when the median age rises in a country because of increasing life expectancy and lower fertility rates, but one’s actual age is not necessarily the best measure of human aging itself. Rather, aging should be based on the number of years individuals are likely to live. What’s important in aging is how we function, not how many birthdays we’ve had. Nevertheless, this living reality shift struggles to be reflected by policy makers in their aging calculations and corresponding classifications that nonetheless strongly characterize age-related social stigma. [ ¹⁰] Some of that stigma can be viewed as a result of negative opinions about aging’s effect on bodily appearance and physical abilities.

Shown below are some life stages in the form of an ascending and descending set of stairs, labeled with specific ages from 1 to 90. Rising from the left, a peak is reached at age 30 and then a gradual descent begins. Some ornamentation shows the sun rising at life’s beginning and having set in the evening of life, with a clock about to strike noon at the apex. An hourglass is full and then runs out. All five images in this particular article reveal a sense of decline, diminishment, or narrowing—that aging is a matter of becoming less.

As a counterweight, one can consider a sixth image—that of a branching tree. Trees begin with a single straight trunk, but then reach branching points and further branching points. Some limbs continue growing and some cease; some branches deflect other branches. The essential point is the increasing complexity of the structure over time. In an analogous way, the life course is a process of increasing differentiation and individuation.[¹¹]

Health care personnel will be affected by the steady growth in the proportion of the elderly population. America’s 65-and-over population is projected to nearly double over the next three decades; however, the U.S. Census Bureau projects this country’s population will age at a slower rate compared with other nations. Worldwide, the 65-and-over population will more than double. The world population continues to grow older rapidly as fertility rates in most world regions have fallen to low levels and individuals tend to live longer. When the global population reached 7 billion in 2012, 562 million (or 8.0%) were aged 65 and over. In 2015, three years later, the older population rose by 55 million and the proportion of the older population reached 8.5% of the total population.[¹²]

The life and age of woman: stages of woman’s life from the infancy to the brink of the grave, A. Alden, 1835. Library of Congress: http://www.loc.gov/pictures/item/2006686268/. Source: Ekerdt, D.J.,[¹¹] The Gerontologist, Vol. 56, No. 2, Apr. 2016, pp. 184-192

The United States can be compared to other large and wealthy nations across the following domains: health spending, quality of care, access and affordability, and health and wellbeing. A sampling of findings across 10 key indicators among 50 indicators shows that:

Comparable countries have an average life expectancy of 82 years, which is 3 years longer than what the U.S. enjoys and the gap is growing rather than staying even or diminishing.

Disease burden accounts for both longevity and quality of life. Significant gains have been made in the U.S. over the past quarter century, dropping 16% from 1990 to 2015, with particular improvement seen for circulatory diseases. Nevertheless, disease burden rates are 25% higher in the U.S. than comparable countries on average and the gap has widened slightly.

Thirty-day mortality following hospital admission improved in recent years for heart attack and stroke (decreasing 8% and 4%, respectively), but worsened for heart failure (increasing 6%) from 2009 to 2015. While not all deaths are preventable, lower rates of death shortly following a hospital stay may suggest care has improved. Relative to comparable countries, 30-day mortality is lower in the U.S. following hospital admissions for heart attack and stroke.

The rate of potentially preventable hospital admissions has improved, decreasing 23% from 2005 to 2013. Relative to comparable countries, admission rates are higher in the U.S. than in comparable countries for several diseases that possibly could be prevented—e.g., congestive heart failure (68%), asthma (194%), and diabetes (38%)—although admission rates for hypertension are lower (by 24%) in the U.S. relative to the average of comparable countries.

Due to recent gains in health coverage in the U.S. as a result of the Patient Protection and Affordable Care Act that became law in 2010, the uninsured rate among the non-elderly dropped from 18% in 2010 to 10% in 2016. Even with 91% of the total U.S. population now insured, coverage lags behind comparable countries, all of which provide essentially universal coverage.

Health spending per person has grown steadily from $355 per capita in 1970 to $9,990 in 2015. More recently, from 2010 to 2015, per capita spending grew an average of 3.6% per year. Over the past 5 years, health spending in the U.S. has grown even more slowly than in comparable countries. On average, other wealthy countries spend about half as much per person on health than the U.S.

Health spending continues to grow faster than the economy , but the difference has moderated in recent years. U.S. health care spending accounted for 17.8% of GDP in 2015, which is much more than comparable countries, where health spending averages 10.8% of GDP. [ ¹² ]

U.S. health care spending increased 3.9% to reach $3.5 trillion, or $10,739 per person in 2017. Health care spending growth in 2017 was similar to average growth from 2008 to 2013, which preceded the faster growth experienced during the 2014-15 period that was marked by insurance coverage expansion and high rates of growth in retail prescription drug spending. The overall share of gross domestic product (GDP) related to health care spending was 17.9% in 2017, similar to that in 2016 (18.0%).[¹³]

Although there is general improvement across many indicators, there are often disparities across racial or ethnic groups, genders, and income levels. Some cross-national differences in health outcomes and costs may be due to a variety of social, economic, and environmental factors that influence health and are not solely or directly influenced by the health system.[¹⁴]

Within the United States, an endeavor funded by The Robert Wood Johnson Foundation enabled a detailed analysis to be developed of state rankings on 39 health outcomes, and correlations between those health outcomes and 123 determinants of health spanning five domains: health care, health behaviors, social and economic factors, the physical and social environment, and public policies and spending. The results show that health indices vary dramatically across all 50 states. For example, as of 2010, the average life expectancy of newborns varied by 6.3 years, from 75.0 years in Mississippi to 81.3 years in Hawaii. The prevalence of diabetes ranged 2.5-fold, from 5.4% in Alaska to 13.5% percent in Alabama.

Other patterns reveal that southern states along the Gulf Coast and the Appalachian Ridge often have more adverse health conditions, epitomized by the stroke belt, the band of states where the prevalence of cerebrovascular disease is especially high. Closer analysis, however, shows certain exceptions. States with generally favorable health rankings sometimes scored poorly on specific conditions, and vice versa. Certain health issues are worst in Mountain states or are especially favorable (or unfavorable) in the Northern Plains. The Pacific states stand out for some health conditions, as do states bordering Mexico, with large Hispanic/Latino populations.[¹⁵]

Among various changes occurring in the U.S. population, one of them is moving the nation toward a milestone, which is an historic increase in the number of deaths every year. Projections indicate that mortality may reach more than 3.6 million in 2037, an amount 1 million greater than in 2015.

The chief reason is that as the nation’s baby boom cohort ages (born between 1946 and 1964, the youngest are 54 in 2018), the number and percentage of individuals who die will increase dramatically every year, peaking in 2055 before leveling off gradually. The nation as a whole is aging, but not every area of the country or every racial and ethnic group is graying at the same rate. Yet, in some areas, mortality is having a surprisingly substantial impact on the remaining population.

As part of a mid-decade research plan, trends in the U.S. Census Bureau’s 2015 series of population estimates were examined. While the U.S. population as a whole is not expected to experience natural decrease (fewer births than deaths), two states (West Virginia and Maine) and almost a third of counties experienced this demographic threshold in 2015. In these areas, unless a sufficient number of individuals move in, the population will decline every year. As the older population dies, the racial and ethnic makeup of the younger population will play a larger role in shaping the demographic profile of the population. In most areas, the impact is minor year to year, but over time these patterns will bring about substantial changes. With the highest median age of all racial and ethnic groups (43.3), the non-Hispanic White population is the only group projected to experience natural decrease in the near future.[¹⁶]

According to data made available in mid-2017 by the U.S. Census Bureau, the nation’s population has a distinctly older age profile than it did 18 years ago. The median age, the age where half of the population is younger and the other half older, rose from 35.3 years on April 1, 2000, to 37.9 years on July 1, 2016. The number of residents age 65 and over grew from 35.0 million in 2000 to 49.2 million in 2016, accounting for 12.4% and 15.2% of the total population, respectively.

Each state experienced either an increase or had the same median age as a year earlier. At 44.6 years, the median age in Maine is the highest in the nation. New Hampshire’s median age of 43.0 years is the next highest, followed by Vermont at 42.7 years. Utah had the lowest median age (30.8 years), followed by Alaska (33.9 years) and the District of Columbia (33.9 years). Two-thirds (66.7%) of the nation’s counties experienced an increase in median age in 2016. Two counties had median ages over 60: Sumter, FL (67.1 years) and Catron, NM. (60.5 years). This trend mainly can be accounted for by the baby-boom generation. Members of that group began reaching age 65 in 2011 and will continue to do so at a rate of approximately 10,000 per day over a 19-year span.[¹⁷]

Median age by county, 2015. Source: Devine, J.,[¹⁶] U.S. Census Bureau, Oct. 2017.

The graphic shown opposite was released by the Census Bureau in April 2017.[¹⁸]

Regional differences across the United States involving median age, life expectancy, and mortality occur for different reasons. Low fertility rates mean that fewer babies are being born in some jurisdictions. Stagnating industries may account for job plant closings and a decline in economic opportunities, which acts as a stimulus for younger members of the population to leave for other sections of the U.S. to seek gainful employment. Urban and rural areas often differ quite dramatically in the availability of health care resources, such as health professionals and hospitals. Income differentials affect the ability to pay for health care, especially when certain services require out-of-pocket expenditures.

Other nations face similar problems insofar as geographical areas may differ by having higher percentages of residents age 65 and older. The U.S. is not alone among nations in seeking solutions to challenges that arise in meeting the needs of a burgeoning older population. Often, aging is accompanied by the presence of one or more chronic conditions experienced by elderly patients.

China offers a good example of a country where the demographics are changing rapidly and in ways that can strain long-standing values about aging, family, and caregiving. By 2025, it is likely that the Chinese will represent one-quarter of the world’s population over age 60 years, but the government appears to lack the structure and capacity to care for its aged inhabitants. Robust economic development creates new jobs that must be filled. Younger individuals who migrate to other locations to fill them may no longer be in a favorable position to care for their aging parents.

In July 2013, the National People’s Congress passed an unprecedented and controversial law: the Protection of the Rights and Interests of Elderly People. The law mandates that adult children provide culturally expected support to their parents 60 years or older. Duties include frequent visits and sending greetings to attend to the spiritual needs of the elderly. The reporting mechanism relies on parents filing lawsuits against their children for neglect. In Shanghai, violators will find their names publically and shamefully called out and their credit standing negatively affected by the government.[¹⁹]

An aging nation. Source: U.S. Census Bureau, An aging nation,[¹⁸] Apr 10, 2017. https://www.census.gov/library/visualizations/2017/comm/cb17-ff08_older_americans.html.

Efforts to instill a sense of shame may work in some cultures, but not in others. Governments have the power to have a negative effect on credit standings, but it is difficult to imagine that kind of effort taking hold in the United States. Nations also differ in the extent to which marriages occur within a culture and the proportion of those unions that produce children. Individuals who never married, along with couples who never procreated, would be in no danger of feeling the impact of policies that involve shaming or affecting credit worthiness. Other remedies must be employed to provide the kinds of necessary support for older members of the population.

Health Behavior

Given that a long life enables certain behaviors to become deeply engrained, what is the possibility of achieving positive changes among older individuals? For example, it may be worthwhile to identify factors that encourage or hinder engagement in different classes of health behaviors in high-functioning older adults, and to use this information to promote healthy lifestyle choices in this group more successfully. Identifying psychological factors associated with engagement in healthy behaviors in later life may be viewed as an important key to effective behavior interventions.

In one study, 204 adults with an average age of 80 were asked to assess objective and perceived health, positive affect and negative affect, aging attitudes, and three classes of health behaviors: eating/nutrition, exercise, and general health behavior. Regression models found better eating behavior was best explained by older age, more exercise was best explained by more positive affect, and better general lifestyle behavior was best explained by worse perceived health. Based on these results, the investigators believe that programs that promote health behaviors in older adults can utilize the findings to tailor interventions to the health behavior of interest.[²⁰]

As mentioned in the Introduction to this book, its author lives in a community that almost exclusively is inhabited by some 1,400 older residents, many of whom are either in their nineties or have already passed the century mark. Previously called Leisure World of Virginia (LWVA), the name recently was changed to Lansdowne Woods of Virginia, again LWVA. On any given day, the place resonates with a wide range of formal activities in the form of clubs and groups (e.g., fitness, drama, hiking, music, library chat, travel) and informal activities (e.g., dances, films, morning coffee sessions, potluck dinners, bible study, happy hours). Enormous opportunities exist to engage with other residents in meaningful and enjoyable ways. Discussions often include encouragement to stay the course of eating healthy foods, maintaining weight loss, keeping physically fit, and learning how to avoid falling down.

The fitness center is a hub for undertaking vigorous physical exercise that is combined with significant amounts of social interaction that often involve offerings of mutual encouragement by participants. A visitor might be surprised to learn that the woman moving so energetically on an elliptical machine arrived with the aid of a walker. Individuals in wheel chairs use weightlifting apparatus, showing that maintaining a healthy level of physical fitness is a proven means of enhancing balance, strength, and stamina in ways that reduce the likelihood of sustaining falls, a leading cause of disablement and emergency department visits by older individuals.

A growing body of evidence indicates that continued participation in leisure activities is associated with positive health outcomes in later life. Such activities cover a broad spectrum, including visits with friends and family. One investigation used the National Health and Aging Trends Study (NHATS), a large nationally representative sample, to examine the value of leisure activities for three cognitive status groups (no dementia, possible dementia, probable dementia), comparing valued activities to actual participation, and exploring two common potential barriers to activity participation, transportation and health.

Four leisure activities available in the NHATS data set were considered: visiting with friends and family; attending religious services; participating in clubs, classes, or other organized activities; and going out for enjoyment. Descriptive analyses revealed that, regardless of the level of cognition, most individuals continue to value opportunities for meaningful engagement in each of the four activities. With the exception of attending religious services, significant differences in the attributed value of each activity were found across levels of cognitive status.

Specifically, a higher percentage of cognitively healthy individuals attributed greater importance to activities than individuals with possible or probable dementia. Likewise, those with possible dementia attributed greater importance to activities than those with probable dementia (i.e., more severe impairment). A greater percentage of individuals with possible or probable dementia were less likely to perform personally valued activities over the past month compared with the cognitively intact group. As to barriers to participation, compared to cognitively healthy individuals, individuals with probable cognitive impairments were more likely to endorse transportation as a reason for limiting participation in going out for enjoyment.

The investigators concluded that given the importance of activity engagement to health and well-being, activity professionals and practitioners should assess individual preferences for activity, even among those with cognitive impairment, and facilitate participation in preferred activities by addressing both internal (e.g., health) and extrinsic barriers (e.g., transportation) to participation. Transportation barriers might be overcome by seeking other alternatives, such as using a bus or a taxi or having family members meet with their older relative within his or her residence.[²¹]

Closing Thoughts

The often-used term elderly conveys little useful information about this group beyond signifying that its members range in age from 65 to perhaps as old as 110. The current chapter describes some of the heterogeneity that characterizes such individuals. Further elaboration will occur in the next chapter where some emphasis will be placed on aspects, such as education level, morbidity data, and triggers of decline.

Meanwhile, the health care industry must adjust itself continuously to respond effectively to a population that is undergoing a major demographic transition in the form of aging. Apart from demography, other factors, such as attitudes, behaviors, and preferences influence consumers in the decisions they make regarding health insurance products, health care services, and their own wellbeing. A segmentation analysis by the Deloitte Center for Health Solutions provides a convenient way of distinguishing key subgroup populations in the U.S.

The analysis categorizes individuals into four distinct groups that reflect their differences in preferences for managing their health and interacting with various health care professionals. Given the changing nature of the landscape, the U.S. health care system is viewed by the analysts as drawing parallels with the Wild West of the 19th century. The segments and some of their characteristics are:

• Bystanders (14%) represent the oldest group, which also is characterized by being lowest in income, more male than female, and most likely to be in excellent health. Some key differentiators are that they are least likely to use technology for health care, look up quality ratings of providers, and change physicians or health plans even if dissatisfied.

• Trailblazers (16%) represent the youngest group, which also is characterized by being highest in income, more female than male, and most likely to be in poor health. Some key differentiators are: they are more likely than other segments to use technology for health care, most likely to look up quality ratings of providers, and most likely to change doctors if dissatisfied with communication.

• Prospectors (30%) represent the second youngest group, which also is characterized by being second highest in income and having the same female/male ratio. Some key differentiators are: they are the second most likely group to use technology for health care, second most likely to look up quality ratings of providers, and less likely to change doctors if dissatisfied with communication style.

• Homesteaders (40%) represent the second oldest group, which also is characterized by being second lowest in income, and more female than male. Some key differentiators are: they are the second less likely group to use technology for health care, less likely to look up quality ratings of providers, and less likely to change doctors if dissatisfied with communication style. [ ²²]

Obviously, not every consumer of health care will fit accurately into these four segments. The classification also fails to take into account that individuals are capable of change. The quality of their interactions with health professionals may be pivotal in enabling changes to occur in some key differentiators. The passage of time also can be expected to alter the percentages that are shown for 2018.

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CHAPTER 2:

OTHER SALIENT CHARACTERISTICS OF THE AGED

This chapter serves as a continuation of Chapter 1 by further developing a profile of older age individuals. Life expectancy and mortality rates are considered in the context of race and ethnicity. The presence of multiple morbidities is a driving force in growing amounts of health care expenditures for this group of individuals. Certain triggers associated with a decline in personal health status accompanied by the lack of availability of kin to assist in the provision of health and health-related social services are factors that contribute to rising health care costs and the need to move patients into institutional forms of care.

Life Expectancy

Despite a small decrease in a recent 2-year period, during the past century, life expectancy in most countries has increased rapidly with advances in public health and living standards, improved diet, and rising levels of education. In 1900, life expectancy in the United States was 47