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Introduction

“No man is an island, entire of itself.”

John Donne, Meditation XVII

Care of the older adult must occur within the context of her community and social environment, of which health care is only a small part. Geriatric care is most effectively provided within the framework of an integrated care team that includes members well versed in care coordination who have expertise and knowledge regarding community resources available to assist older adults and their caregivers. This is particularly important for older adults facing functional decline and frailty. The Disablement Process delineated by Verbrugge and Jette demonstrates how intraindividual and extraindividual factors cumulatively interact with pathophysiologic changes to result in disability. Using this conceptual model, “society,” broadly defined as the person’s entire social and physical environment, and the individual, both present opportunities to intervene to delay or prevent functional loss. For example, a person with age-related eye changes may be able to mitigate functional loss through interventions involving her community, such as adequate refraction and correction or increased font size on written materials. The typical older adult may also face multiple concurrent pathophysiologic changes, such as decreased renal function, cardiovascular disease, and joint changes from arthritis. Thus, appropriate interventions for one condition may interact negatively with other interventions to increase the risk for functional loss and disablement. Because of the physiologic changes and complexities faced by many older adults, the Environmental Press model (Nahemow, Lawton, and Center) also applies. This model describes the interaction between a person’s ability to function and her exposure to environmental demands. Many older adults may have a lower physiologic baseline than younger adults and may not have the “physiologic reserve” to manage new environmental or psychosocial demands (eg, the death of a caregiver) or medical insults from new or exacerbations of existing disease. When the demand exceeds the person’s reserve, she may become unable to function in her community. In addition, older adults may be dependent on extraindividual supports, such as modifications to their housing and built environment, financial entitlements, and paid or casual (unpaid) caregiving. This chapter discusses the significance of the social environment and context as it affects the health and care of older adults, focusing on the following areas:

  • Financial issues

  • Food insecurity

  • Housing and long-term care

  • Caregiving

Financial Issues in the Third Age

The Social Security Act was signed into law in 1935. The first monthly benefits began to be paid in 1940. Despite this benefit, more than a third of older Americans lived below the poverty line well into the 1960s. It was not until the 1970s, some 10 years after the enactment of Medicare, that this began to significantly improve, suggesting that medical issues and the lack of medical coverage were important factors in the impoverishment of older adults throughout most of the 20th century. Although adults older than age 65 years are currently the least likely age group ...

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