1. Vulnerable Population: The Elderly by Laurie Brummett and Susan Goo California State University, Fullerton Department of Nursing N508: Advanced Practice Nursing Vulnerable Populations

2. 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.

3. Demographics Trends and statistics concerning the elderly population in the United States

4. 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!).

5. 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

6. 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.

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

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

9. 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

11. 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

12. 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.)

13. Racial Gaps 2000 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.

14. Projected Distribution of 65+ by Race and Hispanic Origin

15. 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.

17. 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.

18. 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)

19. 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)

20. 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)

21. 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

22. 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

23. 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 workforce Kosoko-Lasaki, Cook & O’Brien, 2009

24. Elderly Health Insurance (Source:, "Income, Poverty, and Health Insurance Coverage in the United States: 2007," P60­235, issued August, 2008, by the U.S. Bureau of the Census. Medicare beneficiary data is from the Medicare Current Beneficiary Survey) Figure 8:

25. 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)

26. 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)

27. Health Literacy

28. 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

29. Prevalence of Hypertension (NHIS, 1994)

30. Varying Risks for Heart Disease

31. 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

32. Nutrition Nutrition 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)

33. 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)

34. Emic Perspective

35. 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 conditions 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)

36. Satisfaction with Health Care 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)