Vulnerable Population: The Elderly

by

Laurie Brummett and Susan Goo

California State University, Fullerton

Department of Nursing

N508: Advanced Practice Nursing

Vulnerable Populations

Objectives #1. Apply the Integrated Model of Health Disparities

Framework (Institute of Medicine) to identify factors that contribute to health disparities in the elderly.

#2. Identify stereotypical beliefs, prejudices, and

obstacles that can lead to health disparities in the elderly.

#3. Explore the role of culturally competent care in

reducing health disparities and promoting optimal health in the elderly.

DemographicsDemographics

Trends and statistics concerning the elderly population in the

United States

Statistics on 65+ in the U.S. In 2003, 35.9 million were over 65 or 12% of

the population. Between 2010 and 2030 Baby Boomers will

turn 65. By 2030 the older population will be twice as

large as 2000 (72 million!).

People are living longer

Life expectancy has increased – In 2000, life expectancy at birth was 76.9– In 1900, it was 47.3– Due to Improvements in medicine, science,

public health and technology

Disparities in life expectation

Gender gap– Female life expectancy higher than males at

most ages– Both White and Black women live longer

than males– Attributed to attitudes, behaviors, social

roles, and

biological risks.

In 2000, females life expectancy: 79.5; vs. males: 74.1

FACTORS THAT INFLUENCE BEFORE CARE, ACCESS TO CARE, AND HEALTHCARE DELIVERY IN THE ELDERLY

Health – Before Care Disparities Income levels, poverty, other social

conditions Safety and adequacy of housing Employment status and type of

employment Education levels Lifestyle choices – diet, exercise, tobacco

and alcohol use Environmental conditions

Living arrangements About 30.2% (10.9 million) of all

noninstitutionalized older persons in 2007 lived alone (7.9 million women, 2.9 million men).

Percentage of institutionalized elderly increases significantly with age:– 1% of persons 65-74 years– 4% of persons 75-84 years – 15% for persons 85+

Approximately 2%-5% lived in senior housing with at least one supportive service available

Living with a spouse

Over half (55.3%) the older noninstitutionalized persons lived with their spouse in 2007.

The proportion living with their spouse decreased with age, especially for women.

Only 30.1% of women 75+ years old lived with a spouse.

(Based on data from the Bureau of the Census including the 2007 Current Population Survey, Annual Social and Economic Supplement and the 2007 American Community Survey. See: March 2008 Current Population Survey Internet releases, Detailed Tables and unpublished data from the Centers for Medicare and Medicaid Services.)

Racial Gaps2000 Statistics

Blacks: life expectancy 71.7 compared to 77.4 for whites

National Center for Health Statistics (NCHS) does not produce official life tables for races other than Whites and Blacks

Problems with data quality does not allow comparisons for the Hispanic population.

U.S. Department of Health and Human Services, National Institutes of Health, National Institute on Aging; U.S. Department of Commerce, Economics and Statistics Administration, U.S. Census Bureau.

Projected Distribution of 65+ by Race and Hispanic Origin

Projected Distribution of 65+ Population, by Race and Hispanic Origin2000 and 2050

8.1%12.2%

5.6%

83.5%

2.4%

40.0%

6.5%

16.4%

64.2%60.0%

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

80.0%

90.0%

Non-Hispanic White Non-Hispanic Black Non-HispanicAmerican, Indian

and Alaska Native

Non-HispanicAsian and Pacif ic

Islander

Hispanic

2000

2050

The Older Hispanic Population

The Hispanic older population was 2.5 million in 2007 and is projected to grow to over 17 million by 2050.

By 2019, the Hispanic population aged 65 and older is projected to be the largest racial/ethnic minority in this age group.

Percentage of 65+ Population Living in Poverty,by Selected Characteristics, 1998

10.5

16.0

21.026.4

8.2

0.0 5.0 10.0 15.0 20.0 25.0 30.0

Total

Non-Hispanic White

Non-Hispanic Asian and Pacific Islander

Hispanic

Non-Hispanic Black

Poverty About 3.6 million elderly persons (9.7%)

were below the poverty level in 2007. Another 2.4 million or 6.4% of the elderly

were classified as "near-poor" (income between the poverty level and 125% of

this level). Current Population Survey, Annual Social and Economic Supplement, “Income,

Poverty and Health Insurance Coverage in the United States, 2007” by the U.S. Bureau of the Census, census bureau website.

Homelessness among the elderly

Many elderly have limited fixed incomes

In no state does Supplemental Security Income (SSI) pay enough to afford housing at the Free Market Rate

For every unit of affordable elderly housing there are 9 people waiting

(National Coalition for the Homeless, 2008)

Decreased Life Expectancy for Homeless Elderly

Poor aged 50 – 65 fall through the cracks, as not eligible for Medicare

Homeless aged 50 – 65 are more like 70 yr olds

Life expectancy of homeless is 42 – 52 yrs

Homeless elderly more likely to have depression and dementia

(National Coalition for the Homeless, 2008)

Homeless Elderly at High Risk for Victimization

Homeless elderly more likely to sleep on the streets because of:– Distrust of crowds– Inability to wait in long

lines for a bed– Inability to climb stairs of

shelter Police more likely to

ignore victimization of elderly homeless

(National Coalition for the Homeless, 2008)

Employment

In 2007, 5.8 million (16.0 %) Americans age 65 and over were in the labor force

Includes 3.2 million men (20.5%) and 2.6 million women (12.6%).

Employment rate for the 65-69 year olds has been continuing to rise slightly over the past several years.

Current Population Survey, U.S. Bureau of the Census, http://www.bls.gov/cps/home.htm

Education

The percentage of 65+ who had completed high school varied by race and ethnic origin in 2007: – 81.1% of Whites, – 71.7% of Asians and Pacific Islanders, – 57.4% of African-Americans, and – 42.2% of Hispanics

Health -Access to Care

Financial resources Availability and proximity of providers Access to transportation Insurance coverage Regular source of care Language barriers Legal barriers Prior experience with the health care system Cultural preferences Health literacy levels Diversity of the healthcare workforceKosoko-Lasaki, Cook & O’Brien, 2009

Elderly Health Insurance(Source:, "Income, Poverty, and Health Insurance Coverage in the United States: 2007," P60 235, issued August, 2008, by the U.S. Bureau of the Census. Medicare beneficiary data is from the Medicare Current Beneficiary Survey)

Figure 8:

That’s not the whole story…

In 2006 older consumers averaged out-of-pocket health care expenditures of $4,631, an increase of 62% since 1996.

The elderly spent 12.7% of their total expenditures on health, more than twice the proportion spent by all consumers (5.7%).

Sources: Data releases from the web sites of the National Center

for Health Statistics (including the Health Data Interactive data warehouse, accessed 12/30/2008); from the Agency for Healthcare Research and Quality and from the Bureau of Labor Statistics web site)

What about the undocumented elderly?

Who can apply for Social Security?-If you're a non-citizen applying to enter the U.S., you must:

-Request a Social Security number card as part of your immigrant visa application;

-Be age 18 or older when you arrive in the U.S.; and

- Be a lawfully admitted permanent resident. (www.socialsecurity.gov)

Health Literacy

Health Literacy

Common health problems of the elderly

In 2004-2005 – hypertension (48%), – diagnosed arthritis (47%), – all types of heart disease (32%), – any cancer (20%), – diabetes (16%), and – sinusitis (14%). Sources: Data releases from the web sites of the National Center for Health Statistics

(including the Health Data Interactive data warehouse, accessed 12/30/2008); from the Agency for Healthcare Research and Quality and from the Bureau of Labor Statistics web site

Prevalence of Hypertension

208.1

337.9 338.7

439.2

376.9

543.8

0

100

200

300

400

500

600pe

r 100

0

45-64 65-74 75+

Age

WhiteBlack

(NHIS, 1994)

Varying Risks for Heart Disease

Death Rate for Heart Disease by Sex, Race, and Age, US, 1996

1.00

2.50

1.63

2.42

0.00

1.00

2.00

3.00

Race

Ag

e A

dju

ste

d D

ea

ths

pe

r 1

00

,00

0

p

op

ula

tion

usi

ng

Wh

ites

as

Ind

ex

White Black Hispanic Native Americans

Health care access

In 2007, over 96% of older persons reported that they did have a usual place to go for medical care.

only 2.5% said that they failed to obtain needed medical care during the previous 12 months due to financial barriers.

Older persons averaged more office visits with doctors in 2005 than other ages

Sources: Data releases from the web sites of the National Center for Health Statistics (including the Health Data Interactive data warehouse, accessed 12/30/2008); from the Agency for Healthcare Research and Quality and from the Bureau of Labor Statistics web site

NutritionNutrition Screening Initiative (NSI) estimates malnutrition among

•40 – 60% of elderly in hospitals

•40 – 85% of nursing home residents

•20 – 60% of elderly home care patients

(DiMaria-Ghalili & Amella, 2005)

Causes of Malnutrition in the Elderly

• Inadequate intake

• Malabsorbtion

• Loss of nutrients r/t physiological disorders like:

• diarrhea• hemorrhage• renal failure

• Drug or alcohol addiction

• Infection

(DiMaria-Ghalili & Amella, 2005)

Emic Perspective

Perception of Health

Overall, in 2007, 39% of noninstitutionalized elderly saw their health as excellent or very good– Of African Americans: 23.7%– American Indians: 24.3%– Older Hispanics: 28.9%

Most elderly have at least one chronic condition Many have multiple conditionsSources: Data releases from the web sites of the National Center for Health Statistics

(including the Health Data Interactive data warehouse, accessed 12/30/2008); from the Agency for Healthcare Research and Quality and from the Bureau of Labor Statistics web site)

Satisfaction with Health CareSources: Data releases from the web sites of the National Center for Health Statistics (including

the Health Data Interactive data warehouse, accessed 12/30/2008); from the Agency for Healthcare Research and Quality and from the Bureau of Labor Statistics web site)

Total Non-Hispanic Non-Hispanic HispanicWhite Black

Percent Reporting Difficulty 2.3 2.1 3.8 2.9Obtaining CarePercent Reporting They 5.5 5.0 9.6 7.3Delayed Getting CareDue to CostPercent Reporting They 3.0 2.9 2.5 3.7Were Unsatisfied or VeryUnsatisfied with Health Care