and societal structures
Housing
Longino and Bradley described the migration patterns of older people in terms of three moves.25 The first generally occurs at retirement and involves moving for improved amenities (such as weather, lower cost of living, or proximity to friends and family). The second move is precipitated by moderate functional disabilities, complicated by the loss of a spouse, and is often toward the community in which an adult child resides. The third move is due primarily to severe disabilities and is local and toward an institution such as a congregate living or custodial facility.
Older adults generally prefer to age in place. However, they may face a number of challenges with regard to housing. Structural problems with the dwelling may be difficult to remedy for adults on a fixed income and/or with physical or cognitive limitations. In developed countries, provisional government grants may be available to help older adults offset the costs of needed structural repairs. Community volunteer organizations may be available to help with minor repairs or decorating. For adults having trouble affording property taxes or utility services, local governments and utility companies may have loan services, payment plans, or reduced payment options for residents with limited income. Providers should familiarize themselves with locally available services for at‐risk seniors.
For seniors with functional limitations, efforts should be made to optimize the home setting rather than pursuing institutionalization. Physical and occupational therapists can perform in‐home assessments to reduce falls risk and recommend appropriate adaptive equipment. Smart‐home technology is an evolving area of interest. Devices such as voice‐activated electronics, fall sensors, and surveillance cameras may enable older adults to remain safely in their homes.
Environment
The environment in which a person lives can have a significant impact on their overall health status. There are numerous examples of major differences in lifespan in people living in different neighbourhoods that are geographically near one another. One of the most marked examples is in Scotland, where the life expectancy in Calton, a poor suburb of Glasgow, is 54 years, whereas in Lenzie, just 12 km away, life expectancy is 82 years.26 In Raleigh, North Carolina, life expectancy can vary by as much as 12 years, depending on ZIP Code.27 In Canada, people living in poor areas have more arthritis, diabetes, high blood pressure, congestive heart failure, chronic obstructive pulmonary disease, and depression than those living in more affluent areas.28
There are several mechanisms by which the living environment influences health status. Perception of crime limits older people's desire to walk outside their houses, leading to reduced physical exertion and risk of social isolation. Low‐income areas may be ‘food deserts’: areas with limited access to fresh, healthy food options due to a dearth of grocery stores or farmers' markets. Lower life expectancy may also be associated with higher amounts of environmental pollutants, which in turn can lead to respiratory disorders, cardiovascular disease, and adverse epigenetic effects. Globally, an estimated 844 million people lack access to clean, fresh water. Disparities in living environments will require enhanced public policy and environmental regulation. Some older adults who are financially able will ultimately choose to move to another area they perceive as safer, although in doing so, they risk loss of social networks and isolation.
Making a move
A doctor's opinion about housing decisions is often as highly respected as their opinion about health decisions, particularly on that difficult decision – ‘Should I move?’ Although each case is unique, it is possible to list guidelines for decision‐making. Figure 4.4 provides optimal and suboptimal reasons for moving. In general, every attempt should be made to solve housing problems if doing so will eliminate the need for a move. Mobilization of community resources, adaptations based on physical and occupational therapy recommendations, and integration of technology can also allow older adults to age in place. However, due to cognitive changes, health decline, or the need for additional emotional support, the time may come when older adults can no longer safely live alone. The decision of whether an older adult should move into a relative's home or to an institutional environment represents one of the hardest decisions associated with ageing for both the older person and the potential caregiver.
Figure 4.4 A summary of suboptimal and ideal reasons for older adults to consider moving. Older adults and their care team should attempt to address suboptimal reasons with the listed strategies before initiating a move.
Sheltered or congregate housing in the UK and senior apartment buildings or assisted living facilities in the US are the types of housing that most people think of when new housing for elderly people is mentioned, although many innovative and non‐traditional housing options are being developed and explored. For instance, senior‐friendly communities with shared communal resources that emphasize ‘neighbour helping neighbour’, cooperative housing developments, and even co‐housing programmes providing inexpensive housing for college students in exchange for housekeeping services for seniors are all being trialled. Older adults should work with their families and providers to understand what needs are not being met and their anticipated healthcare trajectory to make the best decision about future housing.
Incarcerated older adults
There has been a rapid increase in the number of incarcerated older adults, particularly in the US. Between 1995 and 2008, the number of incarcerated adults over 55 increased 278%, compared to a 53% increase in the overall jailed population. By 2030, it is estimated that one‐third of the incarcerated population in the US will be over the age of 55. Older adults in prison report poorer health status and increased rates of geriatric syndromes such as disability, falls, incontinence, and multimorbidity than those in the community, suggesting the prison environment leads to accelerated ageing.29 Incarcerated older adults also experience higher rates of HIV, hepatitis, and homelessness and report higher rates of isolation and abuse.
Finding ways to implement cost‐effective, humane geriatric care for this population is an ongoing area of active research. Two‐thirds of currently incarcerated older adults are not serving life sentences and thus will experience release and re‐entry into their communities. High rates of isolation, unemployment, multimorbidity, and mental health comorbidities can add difficulty to this challenging transition. Multidisciplinary teams, including geriatric‐trained parole officers and geriatric providers familiar with incarceration‐associated health issues, may be effective in improving outcomes during these transitions.
Employment and retirement
Data from both the US Bureau of Labour and Statistics and Eurofound demonstrate increasing employment rates among adults age 55 or older, and these rates are projected to increase through 2024.3,30 As of 2015, adults over 55 made up approximately 22% of the US workforce. As the Baby Boomer generation continues to age, a small minority are expected to continue working well into their 70s. Although they are only a small proportion of the workforce, workers age 70–75 are expected to experience the largest relative growth over the next decade.
Reasons for working into older age are myriad. Some work for financial necessity or financial incentives, such as contributing additional income toward retirement plans or pensions. Additionally, longer life expectancy, improved health status, and higher educational attainment in developed countries such as the US and EU increase the amount of time adults remain in the workforce.
International efforts to combat ageism and workplace discrimination have led to improved working conditions for older adults. Many industries in the developed world are moving toward eliminating mandatory retirement ages. However, discrimination does persist.