ATrain Education


Continuing Education for Health Professionals

Elders and Their Care

Module 1

Demographics of Aging

Human populations continue to age at an impressive rate. In 1900 only 1% of the earth’s population15 million personswas older than 65 years of age. By the year 2050 these figures will have risen to 20% and 2.5 billion, respectively.

Strausbaugh, 2001

The growth in the number and proportion of older adults is unprecedented in the history of the United States. Two factorslonger life spans and aging baby boomerswill combine to double the population of Americans aged 65 and older during the next two decades. Improved medical care and prevention efforts have contributed to these dramatic increases in life expectancy over the past century. Every day in America about 10,000 people turn 65, and by 2030 older adults will comprise about one-fifth of the U.S. population (CDC, 2007).

The growth of the population age 65 and over affects many aspects of our society, challenging policymakers, families, businesses, and healthcare providers to meet the needs of aging individuals. Improving the health status and addressing the needs of this age group should be a top priority of American healthcare (Federal Interagency Forum on Aging-Related Statistics, 2010).

Number of Persons 65+, 19002030 (numbers in millions)

image: aging statistics graph

Source: AOA, 2011a.

The demographics of aging continue to change dramatically. The older population is growing rapidly and the aging of the baby boomers (born between 1946 and 1964) is accelerating this growth. The older population in 2030 is expected to be twice as large as in 2000, growing from 35 to 71 million and representing nearly 20% of the total U.S. population (Interagency Forum, 2010).

In 2009 older adults accounted for more than 1 in every 8 Americans. There were roughly 23 million older women and 17 million older mena ratio of 135 women for every 100 men. The female to male ratio increases with age, to a high of 216 women for every 100 men in the 85 and over age group (AOA, 2011b).

Since 1900 the percentage of Americans aged 65 and above has more than tripled, and the older population itself is increasingly older. In 2008 the group of older adults:

  • Aged 6574 was 9.5 times larger than in 1900
  • Aged 7584 was 17 times larger than in 1900
  • Aged 85+ was 46 times larger than in 1900 (AOA, 2011b)

Living to 100 is becoming more commonplace. In 1950 there were approximately three thousand centenarians in the United States. By 2009 there were more than 64,000 persons aged 100 or more and by 2050 there could be nearly 1 million American centenarians (AOA, 2011b).

This larger population of older Americans will be better educated than previous generations. In 1965 less than one-quarter of the older population had graduated from high school, and only 5% had at least a bachelor’s degree. By 2008, 77% had at least a high school diploma, and 21% had a bachelor’s degree or more (Interagency Forum, 2010).

Older Americans are becoming a more diverse population. Racial and ethnic minorities are the fastest growing segment of the older population and their numbers are projected to increase to about 40% by 2050. The population of older Asians is projected to double and the population of older Hispanics is projected to triple by 2050 (Fritz, 2005).

Attitudes About Aging

American attitudes about aging have been influenced by many years of television and movies celebrating youth and beauty. Aging is increasingly viewed as a social issue rather than a natural process. In the media, generally, older adults seem to be left out of the picture or are not seen as useful members of the family. They are often characterized as asexual, slow-thinking, chronically ill, and burdens on society (Life in the USA, 2010). These stereotypes of older Americans have resulted in the perception by society and by older adults themselves that they have less value than younger people.

Rather than assuming roles as leaders in their communities, as in some countries, the older adults in American society become invisible. Talents and experience gained after many years of work in their chosen fields are no longer valued. Instead, “they waste their prodigious talents traveling, entertaining, socializing, watching TV, or playing golf. And, unlike other cultures, older Americans often abandon themselves to control by other people, often their children and their healthcare providers” (Day, 2012). Capable and experienced older adults may be forced into retirement or feel pressured to retire at the height of their careers, causing economic hardship for them and their families.

Ageismprejudicial behavior that treats people unfairly because of their ageleads to stigmatization and marginalization. It can inflict psychological and emotional abuse on older adults. Reaction to age discrimination may be acceptance, denial, or avoidance. Those who accept the stereotypes may become apathetic or depressed and withdraw from society. Those who deny the stereotypes may try to fight age with hair color, youthful clothing, and plastic surgery.

Although recent trends in the United States show improvements in functional health, increased levels of disability remain a major public health problem, especially in later life. Those adults with health risk factors such as being overweight, smoking, and having alcohol problems, as well as those with chronic health conditions, are more likely to have poor functional health (Lachman and Agrigoroaei, 2010).

There is increasing evidence that specific psychological, social, and physical protective factors are associated with better health in later life. Among these factors, control beliefs, social support, and physical exercise are consistently identified as predictors of functional health. Moreover, a variety of studies have shown that control beliefs, social support, and physical exercise are modifiable and thus can be subject to interventions to reduce disability and improve functional health (Lachman and Agrigoroaei, 2010).

Control beliefs involve the perception that we can influence what happens in our life and to what extent our actions can bring about desired outcomes such as good health. It includes beliefs or expectations about one’s abilities and perceptions about external constraints. Stronger beliefs about control over outcomes are associated with better reported health, fewer and less severe symptoms, faster recovery from illness, and higher functional status. Control beliefs show a pattern of decline in adulthood, making older adults more vulnerable in terms of expectancies about their ability to affect their health. The sense of control is related to functional health, in part, because those who have a higher sense of control are more likely to engage in health-promoting behaviors, such as exercising and eating a healthier diet (Lachman and Agrigoroaei, 2010).

Social interactions involve a combination of supportive and stressful experiences. High quality social relationships are those in which support is relatively high and strain relatively low. Social support is associated with health, in that those who are socially embedded and experience positive relationships are better off than those who are isolated or involved in strained or stressful relationships. There is also longitudinal evidence for the relationship between positive social exchanges and patterns of physical disability, and socially vulnerable elders are more likely to show disability, frailty, and higher mortality risk. The mechanisms that have been considered include physiologic factors such as stress hormones, immune functioning, and inflammatory processes that may be exacerbated for those with low social support or social isolation. Moreover, those who have supportive relationships are more likely to reap the benefits of a more active, engaged, and healthy lifestyle (Lachman and Agrigoroaei, 2010).

The benefits of physical exercise for health are widely documented. Those who engage in regular exercise are likely to reduce or avoid disability due to the positive effects on, for example, cardiovascular and pulmonary functioning, bone density, and muscle mass. Nevertheless, exercise maintenance is challenging and the long-term benefits of exercise interventions have not been conclusively demonstrated (Lachman and Agrigoroaei, 2010).

Health Disparities

Health disparities are preventable differences in the burden of disease, injury, and violence, or in opportunities to achieve optimal health, experienced by socially disadvantaged racial, ethnic, and other population groups and communities. Health disparities exist in all age groups, including older adults. Although life expectancy and overall health have improved in recent years for most Americans, not all older adults are benefiting equally due to factors such as economic status, race, gender, and sexual orientation (CDC, 2011a).

Health disparity is defined as “a particular type of health difference that is closely linked with social, economic, or environmental disadvantage.” Health disparities adversely affect groups of people who have systematically experienced greater obstacles to healthbased on their racial or ethnic group, religion, socioeconomic status, gender, age, mental health, cognitive, sensory, or physical disability, sexual orientation or gender identity, geographic location, or other characteristics historically linked to discrimination or exclusion (, 2011).

Although America’s older adult population is becoming more racially and ethnically diverse, the health status of racial and ethnic minorities lags far behind that of non-minority populations. The burden of many chronic diseases and conditionsespecially high blood pressure, diabetes, and cancervaries widely by race and ethnicity.

Aging encompasses an intricate web of interdependent genetic, biochemical, physiologic, economic, social, and psychological factors, some of which are better understood than others. A society’s ability to reduce the burden of illness among older adults depends on an increased understanding of the dynamics of aging and how health is affected by environmental and lifestyle factors (NIA, 2010a).

Socioeconomic circumstances and the places people live and work strongly influence their health. In the United States, as elsewhere, the risk for mortality, morbidity, unhealthy behaviors, reduced access to healthcare, and poor quality of care increases with decreasing socioeconomic circumstances (MMWR, 2011).

Because vulnerable populations are more likely than others to be affected adversely by economic recession, the recent downturn in the global economy has worsened health disparities throughout the United States. If the coverage and effectiveness of safety-net and targeted programs do not keep pace with needs, these disparities will only worsen.

A recent CDC report (MMWR, 2011) on health disparities in the United State noted these key points about health disparities:

  • Lower income residents report fewer average healthy days. Residents of states with larger inequalities in reported number of healthy days also report fewer healthy days on average.
  • Air pollutionrelated disparities associated with fine particulates and ozone can impact the health of people who live or work near these sources. Both the poor and the wealthy experience the negative health effects of air pollution, but racial and ethnic minority groups, who are more likely to live in urban counties, continue to experience a larger impact.
  • Men are much more likely to die from coronary disease, and African American men and women are much more likely to die of heart disease and stroke than their white counterparts. Coronary disease and stroke are not only leading causes of death in the United States but they also account for the largest proportion of inequality in life expectancy between whites and African American s, despite the existence of low-cost, highly effective preventive treatment.
  • Rates of preventable hospitalizations increase as incomes decrease. Data from the Agency for Healthcare Research and Quality (AHRQ) indicate that eliminating these disparities would prevent approximately 1 million hospitalizations and save $6.7 billion in healthcare costs each year. There are also large racial and ethnic disparities in preventable hospitalizations, with African Americans experiencing a rate more than double that of whites.
  • Racial and ethnic minorities, with the exception of Asians/Pacific Islanders, experience disproportionately higher rates of new human immunodeficiency virus (HIV) diagnoses than whites, as do men who have sex with men (MSM). Disparities continue to widen as rates increase among African American and American Indian/Alaska Native males, as well as MSM, even as rates hold steady or are decreasing in other groups.
  • Hypertension is by far most prevalent among non-Hispanic blacks (42% vs. 28.8% among whites), while levels of control are lowest for Mexican Americans. Although men and women have roughly equivalent hypertension prevalence, women are significantly more likely to have the condition controlled. Uninsured persons are twice as likely to have uncontrolled hypertension than those with health insurance.
  • More than half of alcohol consumption by adults in the United States is in the form of binge drinking (consuming four or more alcoholic drinks on one or more occasions for women and five or more for men). Younger people and men are more likely to binge drink and consume more alcohol than older men and women. The prevalence of binge drinking is higher in groups with higher incomes and higher educational levels, although people who binge drink and have lower incomes and less educational attainment levels binge drink more frequently and, when they do binge drink, drink more heavily. American Indian/Native Americans report more binge drinking episodes per month and higher alcohol consumption per episode than other groups.
  • Tobacco use is the leading cause of preventable illness and death in the United States. Despite overall declines in cigarette smoking, disparities in smoking rates persist among certain racial and ethnic minority groups, particularly among American Indians/Alaska Natives. Smoking rates decline significantly with increasing income and educational attainment.

Hispanic and African Americans

During the two decades from 1980 to 2000, the U.S. population became steadily older and more ethnically diverse. There are approximately 14 million elder Hispanics, 8.6 million elder African/African-Americans, and 5.8 million elder adults from other racial and ethnic groups (NIA, 2010a). From 1992 to 2005, household income inequality has increased significantly.

Although the combined effects of these changes on health disparities are difficult to assess, the nation is likely to continue experiencing substantial racial, ethnic, and socioeconomic health disparities, even though overall health outcomes are improving for the nation (MMWR, 2011).

Differences in healthbased on race, ethnicity, sexual orientation, or economicscan be reduced, but will require public awareness and understanding of which groups are most vulnerable, which disparities are most correctable through available interventions, and whether disparities are being resolved over time. These problems must be addressed with intervention strategies related not only to health and social programs but also, more broadly, to access to economic, educational, employment, and housing opportunities. The combined effects of programs universally available to everyone and programs targeted to communities with special needs are essential to reduce disparities (MMWR, 2011).

By 2019 the Hispanic population aged 65 and older is projected to be the largest racial/ethnic minority in this age group. In 2007 about 7.5% of Hispanic elders reported that they had no usual source of medical care. In 2000, 6.5% reported delays in obtaining healthcare due to cost, and in 2001, 20.7% reported that they were not satisfied with the quality of the healthcare they received. The comparable figures for the total population aged 65 or older show that 5.1% reported that they had no usual source of medical care, 4.8 percent reported delays in obtaining healthcare due to cost, and in 2001, 15.6% reported that they were not satisfied with the quality of the healthcare they received (AOA, 2010a).

Source: AOA, 2011a.

Older Hispanic American Access to Medical Care


No usual source of medical care

Delays in obtaining healthcare due to cost

Not satisfied with the quality of healthcare received

Older Hispanic adults




Total population of older adults




Older adults who are members of racial and ethnic minorities living in the community are less likely to be diagnosed with depression than their white counterparts, or, when diagnosed, less likely to get treated (NIMH, 2012). In a recent study, about 6.4% of whites, 4.2% of African Americans, and 7.2% of Hispanics were diagnosed with depression. Among those diagnosed, 73% of whites received treatment (with antidepressants, psychotherapy, or both) while 60% of African Americans received treatment and 63.4% of Hispanics received treatment (NIMH, 2012). These kinds of diagnosis and treatment differences are consistent with previous studies. Researchers noted pronounced differences in socioeconomic status and quality of insurance coverage across ethnicities. Fewer whites reported having low incomes than ethnic minorities. However, these differences did not appear to account for the disparities in diagnosis or treatment rates.

Source: AOA, 2011a.

Diagnosis and Treatment of Depression


Diagnosed with depression

Received treatment

Older Hispanic American adults



Older African American adults



Older white adults



In another study, Texas researchers examined the post-hospital care of 34,203 patients hospitalized for hip fracture between 2001 and 2005. All were aged 65 or older (mostly women) and on Medicare. The racial breakdown was 95.3% whites, 3.5% African Americans, and 1.3% Hispanics. The majority of patients (60.1%) were discharged to a skilled nursing facility or inpatient rehabilitation facility (23.5%). Fewer patients were discharged home to a home healthcare organization or outpatient therapy (5.8%), home to self-care (6.2%), or other environment (4.4%). Hispanics were nearly three times as likely to be discharged home to self-care as whites (16.4% vs. 5.9%). African Americans had nearly 50% higher odds of being discharged home to self-care than whites (8.7% vs. 5.9%) (AHRQ, 2009).

Source: AHRQ, 2009.

Post Hospital Care Following Hip Fracture


Racial breakdown

Discharged to home




African American






The researchers offer some possible explanations as to why these higher rates of discharge home occur among minorities. First, minorities tend to have larger families with younger members who can care for older relatives. Also, minorities tend to have less favorable perceptions of rehabilitation facilities than do the family members of white patients (AHRQ, 2009).

Households containing families headed by African Americans aged 65 and older reported a median income in 2008 of about $35,000 compared to about $44,000 for all older households. The poverty rate in 2008 for African American elders was 20%, which was more than twice the rate for all older adults. Nonetheless, the 20% figure represents a significant decline from a 48% poverty rate for older African Americans in 1968 (AOA, 2010b).

In the years 2006 to 2008, 96% of African American elders reported that they had a usual source of care. Only 16% reported (in 2003) that they or a family member was unable to obtain or was delayed in receiving needed medical care. In 2008, 34% of African American elders had both Medicare and supplementary private health insurance, while 54% of all older adults had both Medicare and supplementary private health insurance (AOA, 2010b).

According to the American Heart Association, African Americans are less likely than whites and Hispanics to receive evidence-based stroke care (AHA, 2010). According to the AHA, African Americans were:

  • Sixteen percent less likely than whites to receive the clot-busting drug tissue plasminogen activator (tPA) and to receive anticoagulants for atrial fibrillation
  • Twelve percent less likely than whites to receive deep vein thrombosis prevention and to be discharged with anti-clotting medications
  • Three percent less likely than whites to receive early anti-clotting medications
  • Nine percent less likely than whites to receive cholesterol-lowering therapy
  • Fifteen percent less likely than whites, and Hispanics were 18% less likely than whites, to receive smoking cessation counseling.
  • Ten percent less likely than whites to receive “defect-free care,” defined as the proportion of patients who receive all of the interventions for which they are eligible (AHA, 2010)

Lesbian, Gay, Bisexual, and Transgender Americans

[This section is taken from, 2011.]

Lesbian, gay, bisexual, and transgender (LGBT) individuals encompass all races and ethnicities, religions, social classes, and ages. Sexual orientation and gender identity questions are not asked on most national or state surveys, making it difficult to estimate the number of LGBT individuals and their health needs.

Research suggests that LGBT individuals face health disparities linked to societal stigma, discrimination, and denial of their civil and human rights. Discrimination against LGBT people has been associated with high rates of psychiatric disorders, substance abuse, and suicide.

Experiences of violence and victimization are frequent for LGBT individuals and have long-lasting effects on the individual and the community. Personal, family, and social acceptance of sexual orientation and gender identity positively affects their mental health and personal safety.

Eliminating health disparities and enhancing efforts to improve health are necessary to ensure that LGBT individuals can lead long, healthy lives. The many benefits of addressing health concerns and reducing disparities include:

  • Reductions in disease transmission and progression
  • Increased mental and physical well-being
  • Reduced healthcare costs
  • Increased longevity

Efforts to improve LGBT health include:

  • Curbing human immunodeficiency virus (HIV) and sexually transmitted diseases (STDs).
  • Implementing anti-bullying policies in schools.
  • Providing supportive social services to reduce suicide and homelessness among youth.
  • Inquiring about and being supportive of a patient’s sexual orientation to enhance the patient-provider interaction and regular use of care.
  • Providing medical students access to LGBT patients to increase provision of culturally competent care.

Efforts to address health disparities among LGBT persons include:

  • Expansion of domestic partner health insurance coverage
  • Establishment of LGBT health centers
  • Dissemination of effective HIV/STD interventions

Aging with HIV and AIDS

The number of people aged 50 years and older living with HIV/AIDS has been increasing in recent years. This increase is partly due to antiretroviral therapy (HAART, which has made it possible for many HIV-infected persons to live longer) and partly to newly diagnosed infections in persons over the age of 50. As the population continues to age, it is important to be aware of specific challenges faced by older Americans and to ensure that they get information and services to help protect them from infection (CDC, 2008a).

In 2005 people aged 50 and older accounted for:

  • 15% of new HIV/AIDS diagnoses
  • 24% of persons living with HIV/AIDS (increased from 17% in 2001)
  • 19% of all AIDS diagnoses
  • 29% of persons living with AIDS
  • 35% of all deaths of persons with AIDS
  • The rates of HIV/AIDS among persons 50 and older were 12 times as high among African Americans and 5 times as high among Hispanics compared with whites (CDC, 2008a)

People over the age of 50 have many of the same risk factors for HIV infection as younger people. Many older people are sexually activebut may not be practicing safe sex to reduce their risk for HIV infection. Older women may be especially at risk because age-related vaginal thinning and dryness can cause tears in the vaginal area. HIV transmission through injection drug use accounts for more than 16% of AIDS cases among people aged 50 and older (CDC, 2008a).

Some older adults are less knowledgeable than younger people about HIV/AIDS and therefore less likely to protect themselves. Many do not perceive themselves as at risk for HIV, do not use condoms, and do not get tested for HIV. Older adults of minority races and ethnicities may face discrimination and stigma that can lead to delayed testing, diagnosis, and reluctance to seek services.

Healthcare professionals may underestimate their older patients’ risk for HIV/AIDS and may miss opportunities to deliver prevention messages, offer HIV testing, or make an early diagnosis that could help their patients get early care. In addition, physicians may miss a diagnosis of AIDS because some symptoms such as fatigue, weight loss, and mental confusion can mimic those of normal aging. Early diagnosis, which typically leads to the prescription of HAART and to other medical and social services, can improve a person’s chances of living a longer and healthier life (CDC, 2008a).

The stigma of HIV/AIDS may be more severe among older people, leading them to hide their diagnosis from family and friends. Failure to disclose HIV infection may limit or preclude potential emotional and practical support.

Stigma is founded on fear and misinformation. Theodore de Bruyn observed that stigma is associated with HIV/AIDS because “It is a life-threatening disease; people are afraid of contracting HIV; it is associated with behaviors that are considered deviant; [they have] a belief that HIV/AIDS has been contracted through unacceptable lifestyle choices; and, some believe it is the result of a moral fault that deserves punishment” (Bidwell, 2011).

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