4: The Social Context of Older Adults

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

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 to be officially defined as “poor,” those who depend primarily on Social Security may find it difficult to pay for basic needs, such as housing, medical costs, and transportation. The UCLA Center for Health Policy Research has defined an “Elder Economic Security Index” for estimated baseline living costs that in some metropolitan areas in California is over twice the average Social Security benefit. For example, in San Francisco, the Elder Index in 2010 was $27,622 roughly $13,000 more than the average Social Security payment that year, increasing the likelihood that an older adult whose sole income in retirement was Social Security would have difficulty paying for basic needs.

Even though most older adults do not live in poverty, they may still have difficulty meeting their basic needs. The U.S. Department of Agriculture (USDA) defines food security as the ability for all persons in a household to have ready access to nutritionally adequate, safe foods through socially acceptable means (ie, not through means such as stealing or scavenging). By this definition, fewer than 10% of older adults experience food insecurity. However, organizations, such as the Meals on Wheels Association of America, report that up to 15% of older adults experienced some form of food insecurity in 2010. The risk of being food-insecure was higher in southern U.S. states, for Hispanic or African American older adults, those who live alone or in rural areas, and those in households with children. Population studies demonstrate that older adults who are food insecure are at higher risk for chronic disease and cognitive impairment.

The Supplemental Nutrition Assessment Program (SNAP), formerly the food stamp program, provides cash allowances for food purchases. Specific eligibility criteria vary from state to state, but are primarily linked to income and assets. “Elderly” (defined as older than age 60 years by the USDA) adults may qualify even if they exceed the income limits on the basis of disability, receive Supplemental Security Income (SSI), or they reside in federally subsidized housing for the elderly. Yet, even with expanded eligibility, older adults are less likely to participate in SNAP than the general population. According to the USDA, only 9% of SNAP participants were older than age 60 years, and only 35% of eligible older adults participate, compared with two-thirds of all eligible younger individuals. It is not clear why older adults have a lower participation in SNAP. Potential reasons include reluctance to accept the benefit or logistical challenges related to the application process (such as requiring in-person applications or applications being written at a high level of literacy).

Another option to address food insecurity in older adults may be congregate meal programs such as senior center lunches or home-delivered meals, for example, “Meals on Wheels,” which is available in many communities. Although these programs are generally low cost or operate on a sliding scale, most do require some payment. Given the linkages between adequate nutrition and positive outcomes for chronic conditions such as diabetes and cardiovascular disease, health care professionals who care for older adults should routinely assess for issues related to food access or food preparation (see Chapter 6, “Geriatric Assessment”).

Signed into law in 1965, Medicare is a primary reason why most U.S. seniors no longer live in poverty. Traditional Medicare is a single-payer, federally managed form of health insurance coverage for older adults that covers hospital care and, with additional optional premiums, outpatient services and pharmaceuticals. Despite funding issues, Medicare remains a popular U.S. government entitlement. Although there have been several important additions (eg, hospice services in 1989; prescription drugs in 2006), Medicare continues to have notable coverage gaps. Beneficiaries are required to pay significant amounts in the form of deductibles and copayments. For lower-income beneficiaries, these out-of-pocket costs may represent a significant proportion of their monthly incomes (Figure 4–1). Some older adults, the “dual eligibles” may also qualify for Medicaid, a state and federally funded health insurance program that is limited to those with very low incomes. The coverage provisions and eligibility criteria for Medicaid vary from state to state.

In 2012, even those older adults whose incomes qualify them for Medicaid face copayments for their medications. It is important for prescribers to inquire about enrollment in low income subsidy plans for drug coverage. In addition, some patients may practice “economic nonadherence” and self-ration, dose adjust, or fail to obtain medications because of unaffordable copayments for medications or other financial considerations such as deductibles or insurance premiums. Although it is hoped that economic nonadherence has declined as a result of the availability of Medicare D in 2006, even a full subsidy, low-income beneficiary may be required to pay several dollars’ copayment per prescription. Considering that recommended, guideline-driven care for type 2 diabetes alone may result in the prescription of 5 or more medications, those with multiple chronic conditions may find the cumulative associated costs for medications overly burdensome. Financial issues as a reason for nonadherence should be considered when patients do not respond in expected ways to appropriately prescribed medications.

Most U.S. older adults live in their own homes, with a relatively small percentage (4% according to the Administration on Aging in 2011) residing in long-term care facilities. An increasing proportion of older adults are redefining the concept of home. According to the National Center for Assisted Living, nearly 1 million adults in the United States today reside in assisted-living facilities. “Assisted living” is not a regulated term and its definition may vary regionally. Assisted-living services may be provided in a variety of venues—from a private home with several extra bedrooms to large facilities that may appear similar in concept to nursing homes. However, all assisted-living facilities differ from nursing homes or skilled nursing facilities in that they are not licensed to provide skilled nursing care (eg, wound care, rehabilitation, and medication titration) and may have regulatory restrictions limiting or prohibiting the admission of medically acute or functionally impaired residents. In some communities, older adults have creative arrangements, such as naturally occurring retirement communities (NORCs). Residents in NORCs live in their own homes but contribute services or funds to obtain services such as housekeeping or transportation that enable them to remain safely in the community. The goal of these models is to avoid institutional long-term custodial care for as long as possible.

Although Medicare covers a limited number of days of skilled nursing facility care in association with a qualifying hospitalization, the majority of nursing home days are deemed “custodial” and are not covered by Medicare. Custodial care is defined as unskilled personal care provided for patients who need assistance with activities of daily living, such as bathing or eating. Many older adults are concerned about future needs for long-term care (LTC) and are looking for options to be able to remain independent at “home” as long as possible. If long-term, custodial care is needed, the costs are usually initially paid by individuals and families, and later by Medicaid as financial assets are “spent down” to meet eligibility levels. LTC insurance is available for purchase, although many older adults may find the premiums cost-prohibitive relative to the potential benefit. Most reputable plans pay a per-diem rate for LTC services provided either in the home or a facility. The per-diem rate may not cover the entire cost of the service, but may enable some individuals to remain at home or choose a higher-quality nursing facility. There have also been highly publicized cases of insurers refusing or being slow to pay LTC insurance benefits. Patients or their families seeking to purchase LTC insurance should research the financial health and benefit payment record of insurance providers under consideration.

Alternatives to institutional LTC include adult day health centers or social adult day centers. The availability and funding for such programs varies across states. Depending on the program and its focus, these services may include physical therapy, meals, socialization, nursing/medical care, transportation, and supervision. Many of these programs are designed to allow families to safely manage older adults with cognitive impairments in a safe environment with social stimulation during the day when caregivers need to work outside the home. The Program for All-Inclusive Care for the Elderly (PACE) is an integrated social and health maintenance organization model that began with On-Lok in San Francisco in 1971. PACE became an established Medicare benefit in 1997, although state Medicaid programs may opt not to participate. As of 2012, there are 89 PACE organizations in 30 states, serving fewer than 12,000 beneficiaries. The program was designed primarily for dual-eligible participants (ie, those covered by both Medicare and Medicaid) who meet eligibility criteria for nursing home care. The goal of PACE is to prevent or delay nursing home placement with additional social, medical, and caregiving supports that enable participants to remain in their communities as long as possible. PACE organizations are paid a higher capitated rate compared with other Medicare Advantage/Health Maintenance Organization (HMO) plans in exchange for assuming full risk for all needed care, including nursing home stays, whether intermittent or permanent. The cost, complexity, and regulatory requirements of the PACE model have limited its dissemination and impact.

Many older adults and their families are surprised to learn that Medicare, with very limited exceptions such as hospice, does not cover unskilled personal care such as bathing or feeding. Older adults may elect to pay out of pocket to receive care at home, but as care needs increase, these costs may increase to become comparable with nursing home care costs. Although Medicaid may provide limited coverage for personal care aides in some states, and the Veterans Health Affairs provides some coverage for eligible veterans, the burden of caregiving typically falls on family or other unpaid caregivers. AARP estimates that 43.5 million adults in the United States are caregivers for older adults. Most caregivers are female, with an average age of 50 years. Most of these unpaid caregivers who are providing care for a family member also work outside the home. Four in 10 caregivers felt that they did not have a choice regarding caregiving. Although most reported good health status, 32% reported a high caregiving burden. Increased age and poorer health status in caregivers were associated with a perception of high burden. Of those who also work outside the home, 64% needed scheduling accommodations to meet their caregiving responsibilities, often in the form of arriving late, leaving early, or taking time off.

Medical providers may not view the caregiver of their patients as the providers’ principal health concern. However, most caregivers provide care because of the recipients’ age, chronic medical conditions, or Alzheimer disease or other dementing illness, with the goal of allowing independent living at home. Many frail and dependent older adults are “one caregiver away” from a crisis that leads to placement in institutional care. In addition, caregiver stress and burden are risk factors for elder abuse and most health care professionals are mandated reporters (see Chapter 72, “Detecting, Assessing, & Responding to Elder Mistreatment”). Validated instruments, such as the Caregiver Strain Index (CSI) can be used to more objectively assess for stress and burden. The CSI is easy to administer and a score of >7 should prompt intervention to assist the caregiver. Caregivers report that they need information regarding respite care, self-care, and stress management, and options for extended or LTC, but do not always know where to find it. Some may turn to the Internet, but 30% will ask a doctor, nurse, or other health care professional. Organizations such as the Family Caregiver Alliance (www.caregiver.org) and the Alzheimer’s Association (www.alz.org) have free educational resources and information regarding support groups and respite care that may be useful to caregivers. While many primary care providers may view caregiver education and support as the responsibility of social services clinicians, only 2% of caregivers reported that they would seek advice from a social worker. This may either reflect a lack of knowledge of or access to social services in the health care systems known to these caregivers.

The social context and environment of their patients may be unknown to many health care professionals. Problems, such as financial stress or lack of adequate caregiving, may have a negative impact on health and functional status as much as or more than chronic diseases. Older adults who do not live in a health care facility spend <1% of their lives in contact with health care professionals and >99% of their time self-managing their chronic conditions and functional issues in their social environment. Physicians and other primary care providers are important sources of health-related information for older adults and may be asked to advise patients and families about their options or to refer to other services available in their own communities. Clinicians who wish to expand their effectiveness in caring for older adults should:

• Become familiar with the health impact of limitations in Medicare coverage

• Remain vigilant for evidence of elder abuse or mistreatment in caregiving situations

• Learn about available community resources, for example via the Area Agency on Aging (AAA), direct service providers or clearinghouses for information and referrals. The national roster of AAAs can be accessed at http://www.n4a.org/about-n4a/?fa=aaa-title-VI