to date from the UN, in the US, as of 2020, females outnumber males at a ratio of 1.1:1 at age 65, 1.2:1 at 75, 1.5:1 at 85, and 2.5:1 at 95. These ratios are projected to decline by 2050, such that the male to female ratio in adults age 65 will equalize, however females will continue to outnumber males at older ages but to a lesser degree (Figure 4.2). In the US, there is also a fair amount of regional variability. The ratio of females to males is much less in rural counties, particularly in the Western part of the country (excluding California), possibly due to male migration for occupational reasons.7
In much of the developed world, gender ratios of older adults are similar to those in the US. In developing countries, due to less access to education and healthcare, higher rates of physical abuse, and risk of poverty in widowhood, women have lower life expectancies, resulting in female to male ratios closer to 1.1 India and China, which have historically practised female infanticide, have significantly more males than females, and these effects extend into older adulthood.
Approximately 0.5% of adults over 65 identify as transgender in the United States.8 Transgender older adults face a unique set of challenges, including cumulative effects of a lifetime of discrimination, and generally report higher rates of anxiety, depression and loneliness and less robust support networks than age‐matched peers. There is also a dearth of cultural competency training for providers of older adults around issues of gender and sexual identity. Additional information on LGBT+ older adults can be found in Chapter 5.
Geographic considerations: migration and immigration
In the United States, approximately 13.5% of the population over 65 is foreign‐born.9 Of those, three of four are naturalized citizens. Foreign‐born older adults are significantly less likely to speak English at home; approximately half of foreign‐born older adults reported to the US Census that they speak English ‘less than very well.’ This is an important consideration for providers working with older adults, as it could have major impacts on their ability to navigate the complex American healthcare system.
One in ten foreign‐born older adults in the US migrated as an older adult, most commonly following sponsorship by their adult children. Adults who migrate at older ages are considered a vulnerable migrant population and face a unique set of challenges as compared to native‐born adults. Older adult migrants are much more likely to have low incomes and be financially dependent on others.10 They are also more likely to suffer from social isolation and loneliness. Engagement with family and neighbours (particularly in the absence of language barriers) and engagement with religious organizations have been shown to ameliorate loneliness and improve quality of life.11
Globally, adults over 65 make up approximately 11.7% of the total migrant population. As in the US, the majority of immigrants tend to migrate at a younger age and remain in their destination country at an older age (www.migrationdataportal.org). This trend is more prominent in developed countries and the Northern hemisphere. In the Southern hemisphere, older adults are more likely to return to their country of origin. However, complete immigration data for a number of developing countries is lacking. As in the US, international immigrants are particularly vulnerable to social isolation and financial insecurity. Many older adult immigrant households are composed of immigrant grandparents and their naturalized grandchildren, suggesting that immigrants play an important role in childcare and help to maintain the household of their adult children.
Figure 4.2 United States population separated by age and gender in 2020 and 2050 (projected).
Source: Data from United States population separate by age and gender in 2020 and 2050, United Nations Data Retrieval System (www.un.org).
Adult immigrants may have different rates of certain diseases in older age than the population to which they immigrated. For example, immigrants from Yugoslavia and Hungary had a higher stroke incidence than Swedes living in Malmo, Sweden,12 and Japanese immigrants to Brazil have different cancer mortality rates than do Japanese in Japan.13 The ‘healthy immigrant effect’ is a phenomenon in which immigrants are, on average, healthier than native‐born residents.14 It has been described in the US, Canada, Australia, and several European countries. There are many explanations for this effect, including self‐selection (i.e. a tendency for healthier and/or wealthier individuals to migrate), health screening requirements in receiving countries, and retention of healthier, native habits. The health of immigrants and native‐born individuals does tend to converge after multiple decades, likely due to immigrants adopting the health and lifestyle habits of their receiving country. However, immigrants may or may not adapt to the diet and health practices of their host country.
Quality of life may also change. Older American‐born adults of Polish descent had a significantly better subjective quality of life than first‐generation Polish immigrants living in the US, who in turn had a better subjective quality of life than those who lived their entire lives in Poland.15 Studies of Chinese immigrants to Canada and New Zealand have suggested a high rate of depression compared with the general population, and a similarly high rate of depression is seen in Hispanic immigrants to those countries.16
Relationships, viewpoints, and ageing
It is useful to view older people as a product of life‐course events. Thus, infancy, childhood, and adolescence occur in the first two decades of life and involve preparation for a job while living at home as a dependent. Adulthood and middle age bring with them increasing involvement in work, marriage, and creating a family in an independent setting. People in old age may have experienced the departure of grown children, retirement, the death of loved ones, and increasing dependency. This may help account for the notion that the very old are, or at least perceive themselves to be, isolated and a ‘burden to society’ and have feelings of unworthiness. To maximize the quality of life in older adults, providers must understand the importance of social relationships and family structures and how they interact with individuals' health status. Providers must work with public policy advocates to combat insidious ageism that leads older adults to think of themselves as ‘others’ or a ‘burden.’ These concepts are discussed in more detail below.
Shifting attitudes
Traditionally, older adults have been viewed as less assertive than younger people. Because many were brought up in a culture in which the individual had fewer rights than they have today, they may be less inclined than younger people to appeal against official decisions, seek the help of elected representatives, or try to overcome bureaucratic inertia. However, as the Baby Boomer generation (those born between 1946 and 1964) ages, this is rapidly changing. As a generation, Baby Boomers tend to be more individualist and assertive. They are more apt to engage with technology, allowing them to access medical and healthcare information to actively participate in their care. Although it is difficult to broadly characterize an entire generation, providers should focus on shared decision‐making models that engage older adults' preferences and values and avoid paternalistic care. Providers should also recognize that older adults often focus on quality of life versus quantity of years remaining. Older adults are increasingly focusing on what matters most to them as a driver for medical decision‐making.
Marriage, cohabitation, and divorce
The structure of relationships in older adulthood is changing. Figure 4.3 shows relationship trends in adults over 50 in the US from 1990 to 2015. While the majority