Adults over age 65 (older adults) are among the fastest growing age group in the United States, in part due to the “Baby Boomer” generation (adults born between 1946 and 1964) who started turning 65 in 2011. Between 2000 and 2010, the population aged 65 and over increased at a faster rate (15.1%) than the total US population (9.7%), resulting in 40.3 million adults over age 65, more than in any prior census.¹ By 2030, an estimated 70 million people, or 20% of the US population, will be over age 65, with the largest percentage increase among the old-old, those over age 85 years.²

The increasing size of the population of older adults is not unique to the United States. As infectious diseases become better treated, life expectancy, along with chronic disease burden in developing countries, is increasing. By 2050, there will be nearly 1.5 billion adults over age 65 worldwide.³ Regional differences in the pace of aging exist; in sub-Saharan Africa, with 44% of the population under age 15, this pace is slower compared to Japan, China, and Europe where the median age in 2050 is expected to be nearly 50 years (versus 44 years in North America).^4,5

Despite these variations, all countries will face the challenge of caring for an aging population. Around the year 2020, it is projected that the number of adults older than 65 years will outnumber children younger than 5 years worldwide.³ The imbalance between the number of young people available to care for the increasing number of older adults is exemplified in China. As a result of the “one child per family” policy instituted in 1980, a single child will be challenged to care for aging parents and grandparents, thus increasing the need for development of other solutions, resources, and even facilities to care for older adults.⁶

The growing population of older adults presents unique challenges to providers, health-care systems, and caregivers in every country because of the vulnerabilities that often accompany aging. This chapter describes the vulnerabilities of older adults in the United States, although the concepts apply to any country, and discusses strategies to effectively care for this population (Box 23-1).

MULTIPLE CHRONIC ILLNESSES

Age is highly associated with increased burden of disease. Although 20% of all adults are affected by chronic illness, 80% of adults over age 65 report having at least one chronic condition and 52% have two or more conditions. In the United States, six of the seven leading causes of death in older adults are chronic illnesses: heart disease, cancer, chronic lower respiratory diseases, cerebrovascular diseases, Alzheimer’s disease, and diabetes mellitus.⁷ Chronic diseases decrease quality of life and function and can lead to institutionalization.

CULTURAL AND EDUCATIONAL DIVERSITY

In the 2010 US census, 80% of adults aged 65 years and older were non-Hispanic white. By 2050, it is estimated that this proportion will drop to 58%. The percent of minorities will increase: Hispanic older adults will increase from 7% to nearly 20%, Asian Americans from 3.3% to 8.5%, and African Americans from 8.3% in 2010 to 11.2% in 2050.⁸ The increasing diversity of the older adult population is partly due to the aging immigrant population. In the 2010 census, more than one in eight US adults over age 65 were foreign born; this proportion will continue to grow.⁹ Immigrants who migrate after age 60 are especially vulnerable as they are more likely to have low income, limited English language skills, lower educational levels, and little or no US work experience, which makes them ineligible for Medicare (see Chapter 29).⁹

Between 2000 and 2010, the percent of adults over age 75 with at least a high school education and bachelor’s degree increased from 61% to 75% and from 13% to 19%, respectively. Despite the gains in educational attainment of this age group, the percentages remain lower compared to all adults over age 25, of whom 87% had attained at least a high school degree and 30% at least a Bachelor’s degree. In addition, significant heterogeneity in educational levels in older adults exists among different racial groups. In 2010, 80% of non-Hispanic whites had at least a high school education, compared to 57% of African Americans and 39% of Hispanics.¹⁰

Formal education is no guarantee that the older adult will be able to adequately negotiate the health-care system. Many older adults have inadequate health literacy which may lead to difficulty reading prescription bottles or appointment slips, less understanding of more complex medical documents, higher health-care costs, and more likelihood of hospitalization (see Chapter 15). Difficulty seeing and hearing may compound these difficulties.

Because of Social Security and Medicare, older adults are perceived as economically secure. However, in 2010, 9% of older adults had annual incomes at or below the federal poverty level (FPL) of $10,458. Although this represents a substantial improvement from the 35% poverty rate observed in the 1950s, a further 28% of seniors are considered “low income,” defined as having incomes less than 200% of the FPL.¹¹ In addition, poverty in older adults is not equally distributed across the population: the oldest old, women, those who live alone, the foreign born, and members of ethnic and racial minority groups are at higher risk for living in poverty.¹¹ Therefore, the typical poor older adult is a woman from a minority group who lives alone.

Poverty harms health. Because most adults over age 65 have health coverage through Medicare, it might be expected that they would be relatively protected from the negative health effects of poverty. However, this expectation is not supported by the literature.¹²

The poor have higher rates of mortality that are not fully understood. An inverse, linear relationship between income and mortality has been documented among Medicare beneficiaries.¹³ In a study of socioeconomic status (SES) and mortality among older adults in four US communities, of the SES indicators studied, low income was the most consistently associated with increased mortality.¹⁴ Another study of seniors who reported difficulty paying for food and medical bills at the time of discharge from an acute hospitalization found that those with the highest level of financial disability had a 25% higher 1-year mortality rate.²

Furthermore, older adults in the lowest income tertile (<$13,000) have been reported to have 60% higher rates of depression and twice the rate of functional limitation, and are less than half as likely to report good or very good health status.¹⁵ The reasons for the health inequities observed in lower-income Medicare beneficiaries are complex (see Chapters 3 and 4).

Medicare is the primary insurer for older adults in the US. Over 95% of seniors are eligible and are covered, at least by Part A, which covers inpatient hospital and rehabilitation care. However, Medicare does not provide comprehensive coverage, as it excludes services such as eyeglasses, dentures, and long-term care. The Congressional Budget Office (CBO) estimates that Medicare covers only 45% of the health-care costs for the average beneficiary. In 2007, the median out-of-pocket annual spending for a Medicare beneficiary was $3138; 10% of Medicare beneficiaries spent more than $7800.¹⁶ One in four beneficiaries spend 30% or more of their income on health care.¹⁷

To help cover the cost sharing under Medicare, most beneficiaries have supplemental coverage through private insurance, Medicaid, Medicare Advantage (MA or “Part C”) or Medigap plans.¹⁶ In 2014, 30% of Medicare beneficiaries were enrolled in an MA plan.¹⁸ MA plans are offered by private companies that receive a fixed amount for each beneficiary covered under the MA plan. Beneficiaries enrolled in MA plans do not have traditional Medicare, as all services are provided by the MA plan, similar to a health maintenance organization. Some MA plans cover services not covered by traditional Medicare, such as dental care, hearing aids, and eyeglasses. Medigap coverage is sold by private companies with varying levels of coverage of costs such as copayments and deductibles. Medigap plans do not cover long-term care, dental care, eyeglasses, or hearing aids. Patients enrolled in Medigap have to be enrolled in traditional Medicare. In 2010, 23% of Medicare beneficiaries had a Medigap policy. About 40% of Medicare beneficiaries are also enrolled in Medicaid (“dual-eligibles”). Medicaid has traditionally provided coverage for poor older adults and has been the primary insurer for long-term care services, accounting for 30% of Medicaid expenditures in FY2011.

Despite Medicare coverage, lower-income older adults may still experience difficulties with access to care. In a survey of participants in the Cardiovascular Health Study, low-income respondents (defined as <$12,000 per year) were 2.6 times more likely to report a barrier to seeing a physician as those with incomes greater than $50,000.¹⁹ Forty-seven percent of Medicare beneficiaries with incomes at or below 100% of the FPL reported difficulty with getting care or services, or difficulty paying medical bills.²⁰

Older adults who do not have coverage for or access to affordable medications often reduce their adherence to recommended medications because of cost concerns. Despite Medicare coverage, a low-income beneficiary may still pay 30% or more of his/her income in out-of-pocket health-care costs, with the bulk going toward prescription drugs. Medications that are not available in generic formulations, those that treat chronic illnesses that may not present with noticeable symptoms such as hypertension, and high-cost medications such as some antilipidemics are more likely to be reduced or stopped with predictable consequences for health. Mrs. Jones’s question is not uncommon; seniors living on low-fixed incomes who lack drug coverage may self-ration or even forgo taking their medications.^21,22

As part of the Medicare Prescription Drug Improvement and Modernization Act of 2003, a voluntary prescription drug benefit, Part D, was added and began in 2006. By the end of the first year of the plan, most enrolled beneficiaries without prior prescription coverage spent less on out-of-pocket prescription cost.²³ However, for some patients, the out-of-pocket costs remained high, as the Part D benefit has a built-in coverage gap. In 2014, the beneficiary first paid a $310 deductible and 25% of the next $2540 in drug costs. There was no further coverage until the out-of-pocket costs reached $4550 (i.e., the total spending on drugs reaches $6440). Catastrophic coverage began at this level and 95% of future drug costs were covered for the rest of the calendar year.²⁴ This gap in coverage has been referred to as the “doughnut hole.” In 2007, 18.5% of Part D beneficiaries over age 65 reached the doughnut hole; only 11.6% of those reached the catastrophic coverage threshold.²⁵ The Affordable Care Act (ACA) provides a $250 rebate to Part D beneficiaries with any spending in the coverage gap and phases in coverage of the gap, reducing the copayment rate from 100% to 25% by 2020.²⁶

Subsidies for lower-income adults are included in the Part D drug plan. Under Medicare Part D, beneficiaries at 135% of FPL or less have no premium or deductibles, pay a copayment of $2.55 for generic and $6.35 for brand name medications (in 2014), and have no doughnut hole.²⁷ The Kaiser Family Foundation estimates that beneficiaries who qualify for the low-income subsidy spend 83% less on out-of-pocket costs on prescription drugs (approximately $584) than they would have in the absence of a low-income subsidy Part D drug benefit.²⁸ The low-income benefit phases out between 135% and 150% FPL. At 150% of FPL, the standard benefit applies. In October 2013, 11 million (about 30%) Part D beneficiaries were receiving low-income subsidies; an additional 2 million beneficiaries were eligible but not participating.

What does the prescription drug benefit mean to patients like Mrs. Jones? Assuming that she is taking the recommended medications, she is likely to be receiving at least six prescriptions (Table 23-1), If she is not eligible for any subsidy program, she will have an annual out-of-pocket cost of approximately $514, in addition to a monthly premium of $32.²⁷ If she is eligible for a low-income subsidy, then she would pay no monthly premium and her monthly medication cost would be approximately $15. Even without a low-income subsidy, she would save approximately 20% in out-of-pocket expense with the Part D plan, even when accounting for premium costs.

Food security is defined as “access at all times to a nutritionally adequate, culturally compatible diet that is not obtained through emergency food programs.” In 2011, about 8.4% of households with older adults experienced food insecurity.²⁹ Prevalence of food insecurity is higher in low-income older adults and minority groups.³⁰ Despite the existence of federal nutrition programs for poor older adults, only 40% of eligible households participate. Food insecurity in older adults is caused not only by financial constraints but also physical limitations, lack of social support, and poor medical and dental health. In 2010, 25% of men and women over age 65 reported having no natural teeth.⁷ Dentures are expensive and not often covered by insurance. In turn, food insecurity contributes to poor physical and mental health, medication nonadherence, and poor chronic disease management. Mrs. Jones’s weight loss may be related to medical or dental problems, but she may also be limiting her intake due to financial strain.

DEPRESSION

Data from the Health and Retirement Study in 2008 showed 11% of men and 16% of women reported clinically significant depressive symptoms.⁷ Rates of depression are higher for older adults with medical comorbidities, with prevalence rates of depressive symptoms in hospitalized patients above 20% and nearly 45% in long-term care patients.^31,32

Despite its high prevalence, depression in older adults is often unrecognized and untreated because the symptoms of depression can mimic medical illness or be attributed to medication effects or life events. In addition, seniors themselves may be reluctant to seek mental health treatment or report symptoms.

The costs (direct and indirect) associated with depression in the elderly are high. White men over age 85 have over four times the national rate for completed suicide: 45/100,000.³³ Depressed patients have impaired functioning, worsening of chronic medical conditions, and increased health-care costs.