Aging, Dying, and Death


This Module contains 7 Lessons:
  • Lesson 1: Profile of America's aging population
  • Lesson 2: Diseases common in elderly population
  • Lesson 3: Aging and Mental Health
  • Lesson 4: Healthy Aging
  • Lesson 5: Safety
  • Lesson 6: Ageism
  • Lesson 7: End of Life Issues
  • Optional: Advance Care Planning for Health Professional

Lesson 1: Profile of Older Americans
Population Growth
Source: Healthy People,
Older adults are among the fastest growing age groups, and the first “baby boomers” (adults born between 1946 and 1964) turned 65 in 2011.
Source: A Profile of Older Americans: 2010,

The older population (65+) numbered 40.4 million in 2010, an increase of 5.4 million or 15.3% since 2000. The number of Americans aged 45-64 – who will reach 65 over the next two decades – increased by 31% during this decade.
  • Over one in every eight, or 13.1%, of the population is an older American.
  • Persons reaching age 65 have an average life expectancy of an additional 18.8 years (20.0 years for females and 17.3 years for males).
  • Older women outnumber older men at 23.0 million older women to 17.5 million older men.
The population 65 and over has increased from 35 million in 2000 to 40 million in 2010 (a 15% increase) and is projected to increase to 55 million in 2020 (a 36% increase for that decade). The 85+ population is projected to increase from 5.5 million in 2010 and then to 6.6 million in 2020 (19%) for that decade.

Think-for-Yourself: How will the upcoming increases in the percentage of older adults impact health and health services? Why does it matter?

The median income of older persons in 2010 was $25,704 for males and $15,072 for females. Median money income (after adjusting for inflation) of all households headed by older people fell 1.5% (not statistically significant) from 2009 to 2010. Households containing families headed by persons 65+ reported a median income in 2010 of $45,763. The major sources of income as reported by older persons in 2009 were Social Security (reported by 87% of older persons), income from assets (reported by 53%), private pensions (reported by 28%), government employee pensions (reported by 14%), and earnings (reported by 26%). Social Security constituted 90% or more of the income received by 35% of beneficiaries in 2009 (22% of married couples and 43% of non-married beneficiaries).
Almost 3.5 million elderly persons (9.0%) were below the poverty level in 2010. This poverty rate is not statistically different from the poverty rate in 2009 (8.9%). During 2011, the U.S. Census Bureau also released a new Supplemental Poverty Measure (SPM) which takes into account regional variations in the livings costs, non-cash benefits received, and non-discretionary expenditures but does not replace the official poverty measure. The SPM shows a poverty level for older persons of 15.9%, an increase of over 75% over the official rate of 9.0% mainly due to medical out-of-pocket expenses. About 11% (3.7 million) of older Medicare enrollees received personal care from a paid or unpaid source in 1999.
Minority Groups Over Age 65
In 2010, 20.0% of persons 65+ were minorities--8.4% were African-Americans. Persons of Hispanic origin (who may be of any race) represented 6.9% of the older population. About 3.5% were Asian or Pacific Islander, and less than 1% were American Indian or Native Alaskan. In addition, 0.8% of persons 65+ identified themselves as being of two or more races. Minority populations have increased from 5.7 million in 2000 (16.3% of the elderly population) to 8.1 million in 2010 (20% of the elderly) and are projected to increase to 13.1 million in 2020 (24% of the elderly).
  • Older men were much more likely to be married than older women--72% of men vs. 42% of women (Figure 2). 40% older women in 2010 were widows.
  • About 29% (11.3 million) of noninstitutionalized older persons live alone (8.1 million women, 3.2 million men).
  • Almost half of older women (47%) age 75+ live alone.
  • About 485,000 grandparents aged 65 or more had the primary responsibility for their grandchildren who lived with them.

Learning Activity 1.1: Use the BenefitsCheckUp tool to determine what benefit programs you might be eligible for if you were over age 65 right now.
  • Complete the form as though you were born before 1945. Make estimates to answer the questions.
  • Ask someone you know who is over the age of 65 to complete the form.
  • Which of these benefits do you think will still be available for older adults in 2020 or 2030?
BenefitsCheckUp quickly finds federal, state, and private benefit programs available to help you save money on health care, food assistance, prescriptions, utilities, and more.

Lesson 2: Diseases Common in Elderly Population

Diseases common in elderly population

Source: Healthy People,

More than 37 million "baby boomer" adults born between 1946 and 1964 (60 percent) will manage more than 1 chronic condition by 2030.
Older adults are at high risk for developing chronic illnesses and related disabilities. These chronic conditions include:
  • Diabetes mellitus
  • Arthritis
  • Congestive heart failure
  • Dementia
Many experience hospitalizations, nursing home admissions, and low-quality care. They also may lose the ability to live independently at home. Chronic conditions are the leading cause of death among older adults.

Learning Activity 2.1: Interview an older adult who has a chronic illness and related disability.
Ask about -
  • what it is like to deal with the health care system in order to manage the illness
  • quality of life and the impact the illness has on daily activities
  • caregivers

Why Is the Health of Older Adults Important?
Health Services
  • Preventive health services are valuable for maintaining the quality of life and wellness of older adults. In fact, the Patient Protection and Affordable Care Act of 2010 includes provisions related to relevant Medicare services. However, preventive services are underused, especially among certain racial and ethnic groups.
  • Ensuring quality health care for older adults is difficult, but the Centers for Medicare & Medicaid Services (CMS) has programs designed to improve physician, hospital, and nursing home care, among others.
  • Older adults use many health care services, have complex conditions, and require professional expertise that meets their needs. Most providers receive some type of training on aging, but the percentage of those who actually specialize in this area is small. More certified specialists are needed to meet the needs of this group.
Quality of Life
  • Through programs that address chronic illnesses, Federal Government agencies are improving the quality of life for older adults. To combat existing health disparities, many of these programs target minorities and underserved populations.
  • The ability to complete basic daily activities may decrease if illness, chronic disease, or injury limit physical or mental abilities of older adults. These limitations make it hard for older adults to remain at home. Early prevention and physical activity can help prevent such declines. Unfortunately, less than 20 percent of older adults engage in enough physical activity, and fewer do strength training. Minority populations often have lower rates of physical activity.
  • Most older adults want to remain in their communities as long as possible. Unfortunately, when they acquire disabilities, there is often not enough support available to help them. States that invest in such services show lower rates of growth in long-term care expenditures.
Injury Prevention
  • Each year, 1 out of 3 older adults falls. Falls often cause severe disability among survivors. Injuries from falls lead to:
    • Fear of falling
    • Sedentary behavior
    • Impaired function
    • Lower quality of life
Falls are the leading cause of death due to unintentional injury among older adults; deaths and injuries can be prevented by addressing risk factors.
  • Caregivers for older adults living at home are typically unpaid family members. Caregiver stress often results in unnecessary nursing home placement.
  • One to 2 million older adults in the United States are injured or mistreated by a loved one or a caregiver. A measure of elder abuse has been added to encourage data collection on this issue.

Understanding the Health of Older Adults

The Healthy People 2020 objectives on older adults are designed to promote healthy outcomes for this population. Many factors affect the health, function, and quality of life of older adults.

Individual Behavioral Determinants of Health in Older Adults

Behaviors such as participation in physical activity, self-management of chronic diseases, or use of preventive health services can improve health outcomes.

Social Environment Determinants of Health in Older Adults
Housing and transportation services affect the ability of older adults to access care. People from minority populations tend to be in poorer health and use health care less often than people from nonminority populations.

Health Services-Related Determinants of Health in Older Adults

The quality of the health and social services available to older adults and their caregivers affects their ability to manage chronic conditions and long-term care needs effectively.

Emerging Issues in the Health of Older Adults

Emerging issues for improving the health of older adults include efforts to:
  • Coordinate care.
  • Help older adults manage their own care.
  • Establish quality measures.
  • Identify minimum levels of training for people who care for older adults.
  • Research and analyze appropriate training to equip providers with the tools they need to meet the needs of older adults.
There is growing recognition that data sources are limited for certain subpopulations of older adults, including the aging lesbian, gay, bisexual, and transgender populations. Research for these groups will inform future health and policy initiatives.

Chronic Diseases among Older Adults

Chronic diseases are long-term illnesses that are rarely cured. Chronic diseases such as heart disease, stroke, cancer, and diabetes are among the most common and costly health conditions. Chronic health conditions negatively affect quality of life, contributing to declines in functioning and the inability to remain in the community. Many chronic conditions can be prevented or modified with behavioral interventions. Six of the seven leading causes of death among older Americans are chronic diseases.
As shown in the bar chart above, the prevalence of certain chronic conditions differs by sex. Women report higher levels of arthritis and hypertension than men. Men report higher levels of heart disease and cancer.
There are differences by race and ethnicity in the prevalence of certain chronic conditions. In 2007–2008, among people age 65 and over, non-Hispanic blacks report higher levels of hypertension and diabetes than non-Hispanic whites (71 percent compared with 54 percent for hypertension and 30 percent compared with 16 percent for diabetes). Hispanics also report higher levels of diabetes than non-Hispanic whites (27 percent compared with 16 percent), but lower levels of arthritis (42 percent compared with 51 percent).
Arthritis, Osteoporosis, and Chronic Back Conditions

Arthritis, osteoporosis, and chronic back conditions all have major effects on quality of life, the ability to work, and basic activities of daily living.
There are more than 100 types of arthritis. Arthritis commonly occurs with other chronic conditions, such as diabetes, heart disease, and obesity. Interventions to treat the pain and reduce the functional limitations from arthritis are important, and may also enable people with these other chronic conditions to be more physically active.
Osteoporosis is a disease marked by reduced bone strength leading to an increased risk of fractures (broken bones). Chronic back pain (CBP) is common, costly, and potentially disabling.

Why Are Arthritis, Osteoporosis, and Chronic Back Conditions Important?

Arthritis affects 1 in 5 adults and continues to be the most common cause of disability. It costs more than $128 billion per year. All of the human and economic costs are projected to increase over time as the population ages.
There are interventions that can reduce arthritis pain and functional limitations, but they remain underused. These include:
  • Increased physical activity
  • Self-management education
  • Weight loss among overweight/obese adults


In the United States, an estimated 5.3 million people aged 50 years and older have osteoporosis. Most of these people are women, but about 0.8 million are men. Just over 34 million more people, including 12 million men, have low bone mass, which puts them at increased risk for developing osteoporosis. Half of all women and as many as 1 in 4 men aged 50 years and older will have an osteoporosis-related fracture in their lifetime.

Chronic Back Conditions

About 80 percent of Americans experience low back pain (LBP) in their lifetime. It is estimated that each year:
  • 15-20 percent of the population develop protracted back pain.
  • 2-8 percent have chronic back pain (pain that lasts more than 3 months).
  • 3-4 percent of the population is temporarily disabled due to back pain.
  • 1 percent of the working-age population is disabled completely and permanently as a result of LBP.
Americans spend at least $50 billion each year on LBP. LBP is the:
  • Second leading cause of lost work time (after the common cold)
  • Third most common reason to undergo a surgical procedure
  • Fifth most frequent cause of hospitalization

Understanding Arthritis, Osteoporosis, and Chronic Back Conditions


Many factors determine the pain, function, and quality of life of those with arthritis. Greater physical activity can reduce pain and improve function. However, physical activity remains an underused intervention, even though there are a variety of programs to help people with arthritis increase physical activity safely and with little pain. Self-management education can achieve similar positive outcomes by teaching people skills and techniques to deal with the day-to-day issues that result from arthritis. Weight loss among those who are overweight or obese also helps reduce symptoms of arthritis.


There are many factors that contribute to osteoporosis and fractures. Nutrition and physical activity are important modifiable (controllable) risk factors. Family history and personal history of fractures are also risk factors for osteoporosis.

Chronic Back Conditions

CBP is often progressive and its cause(s) can be difficult to determine. Most important, previous studies have shown that patients with CBP make up at least 90 percent of total spending on the treatment of lower back pain.

Emerging Issues in Arthritis, Osteoporosis, and Chronic Back Conditions

Several emerging issues may warrant future Healthy People objectives for arthritis, osteoporosis, and chronic back conditions.
  • Fatigue is a clinically important symptom of many types of arthritis and other rheumatic conditions. It is often just as problematic as pain.
  • Early diagnosis of inflammatory types of arthritis is of growing importance, because the early use of disease-modifying anti-rheumatic drugs has resulted in much more successful treatment of these conditions. There is a continuing effort to develop early biomarkers (both biochemical and imaging markers) of arthritis, osteoporosis, and chronic back conditions to allow adequate and early assessment and treatment of these conditions.
  • Worksite accommodation will become a greater issue as the number of working-age people with arthritis and chronic back conditions increases.
  • Social participation, an important part of the World Health Organization (WHO) International Classification of Functioning, Disability, and Health (ICF), should be measured for people with arthritis and other chronic conditions.
  • Anxiety and depression re frequently observed outcomes associated with chronic conditions such as arthritis, osteoporosis, and chronic back conditions.
  • Better measures of arthritis and chronic back pain self-management education will help focus intervention efforts.
  • A greater availability of health-related quality-of-life measures will be important in order to monitor nonfatal, but chronic, disabling conditions such as arthritis, osteoporosis, and chronic back conditions.

Dementias, Including Alzheimer's Disease

Source: Healthy People,

Dementia is the loss of cognitive functioning—thinking, remembering, and reasoning—to such an extent that it interferes with a person’s daily life. Dementia is not a disease itself, but rather a set of symptoms. Memory loss is a common symptom of dementia, although memory loss by itself does not mean a person has dementia. Alzheimer’s disease is the most common cause of dementia, accounting for the majority of all diagnosed cases.
Diagnosis of dementia is key to effective treatment and care. It is important to distinguish dementia from temporary, reversible conditions that may cause loss of cognitive functioning. Temporary, reversible conditions include:
  • Series of strokes
  • Side effects from medication
  • Chronic alcoholism
  • Some tumors and infections in the brain
  • Vitamin B12 deficiency
  • Dehydration
These conditions are not dementia, but they can be serious and should be treated by a doctor as soon as possible.
Why Are Dementias, Including Alzheimer’s Disease, Important?
Alzheimer’s disease is the 6th leading cause of death among adults aged 18 years and older. Estimates vary, but experts suggest that up to 5.1 million Americans aged 65 years and older have Alzheimer’s disease. These numbers are predicted to more than double by 2050 unless more effective ways to treat and prevent Alzheimer’s disease are found.
Dementia affects an individual’s health, quality of life, and ability to live independently. It can diminish a person’s ability to effectively:
  • Manage medications and medical conditions.
  • Maintain a bank account.
  • Drive a car or use appliances safely.
  • Avoid physical injury.
  • Maintain social relationships.
  • Carry out activities of daily living, such as bathing or dressing.
People living with dementia are at greater risk for general disability and experience frequent injury from falls. Older adults with dementia are 3 times more likely to have preventable hospitalizations. As their dementia worsens, people need more health services and, oftentimes, long-term care. Many individuals requiring long-term care experience major personal and financial challenges that affect their families, their caregivers, and society.
There are important steps to take to improve the identification of and care for people with dementia. These include:
  • Increasing the availability of existing effective diagnostic tools.
  • Decreasing the number of people with undiagnosed dementia.
  • Reducing the severity of symptoms through better medical management.
  • Supporting family caregivers with social, behavioral, and legal resources.
  • Encouraging healthy behaviors to reduce the risk of co-occurring conditions.
Understanding Dementias, Including Alzheimer’s Disease
Several factors determine the risk of developing dementia, including age and family history. Other factors affect the management of dementia by families, communities, and the health care system.
Aging is a well-known risk factor for Alzheimer’s disease and other types of dementias. Among adults aged 65 years and older, the prevalence of Alzheimer’s disease doubles every 5 years.
Family History
People with a family history of Alzheimer’s disease are generally considered to be at greater risk of developing the disease. Researchers have identified 3 genes that are linked to early-onset Alzheimer’s disease. Until recently, only 1 gene had been identified that increases the risk of late-onset Alzheimer’s disease. However, during 2009 and 2010, international teams studying the genetics of Alzheimer’s disease have identified and confirmed 3 new genes that are associated with increased risk of late-onset Alzheimer’s disease.
Health Services
Many individuals with Alzheimer’s disease or other dementias are undiagnosed. Primary care providers do not routinely test for Alzheimer’s disease. Alzheimer’s disease and other dementias are more often undiagnosed in rural and minority populations than in urban or white populations.
Some chronic conditions are common in people with Alzheimer’s disease and other dementias. Dementias can greatly complicate the medical management of these conditions; this increases the need for coordination of care among different specialists.
Lack of diagnosis seriously reduces a person’s access to available treatments and valuable information. Active medical management, information and support, and coordination of medical and community services have been shown to improve quality and outcomes of care for people with dementia.
Emerging Issues in Dementias, Including Alzheimer’s Disease
Over the past decade, there has been significant scientific progress in understanding and managing dementia, with most of the research focused on Alzheimer’s disease. During the next decade, it will be important that progress be made in:
  • Improving the early diagnosis of Alzheimer’s disease and other dementias.
  • Developing interventions to delay or prevent Alzheimer’s disease and other dementias.
  • Finding better ways to manage dementia when other chronic conditions are present.
  • Understanding the influence of lifestyle factors on a person’s risk of cognitive decline and dementia.

Think-for-Yourself: If you had the opportunity to decide how to spend some limited funding to improve the health of older adults, how would spend it? Why?
  • Spend it all on a specific condition?
  • Which condition?
  • Spend it on prevention, treatment, or cure?
  • Spend it on national, state, or local efforts?

Lesson 3: Aging and Mental Health

Mental Health Problems in Older Adults

Source: CDC,
It is estimated that 20% of people age 55 years or older experience some type of mental health concern. The most common conditions include anxiety, severe cognitive impairment, and mood disorders (such as depression or bipolar disorder). Mental health issues are often implicated as a factor in cases of suicide. Older men have the highest suicide rate of any age group. Men aged 85 years or older have a suicide rate of 45.23 per 100,000, compared to an overall rate of 11.01 per 100,000 for all ages.
Social Support
Social support serves major support functions, including emotional support (e.g., sharing problems or venting emotions), informational support (e.g., advice and guidance), and instrumental support (e.g., providing rides or assisting with housekeeping).
  • Adequate social and emotional support is associated with reduced risk of mental illness, physical illness, and mortality
  • The majority (nearly 90%) of adults age 50 or older indicated that they are receiving adequate amounts of support.
  • Adults age 65 or older were more likely than adults age 50–64 to report that they “rarely” or “never” received the social and emotional support they needed (12.2% compared to 8.1%, respectively).
  • Approximately one-fifth of Hispanic and other, non-Hispanic adults age 65 years or older reported that they were not receiving the support they need, compared to about one-tenth of older white adults.
  • Among adults age 50 or older, men were more likely than women to report they “rarely” or “never” received the support they needed (11.39% compared to 8.49%).

Depression is Not a Normal Part of Growing Older

Depression is a true and treatable medical condition, not a normal part of aging. However older adults are at an increased risk for experiencing depression. If you are concerned about a loved one, offer to go with him or her to see a health care provider to be diagnosed and treated.
Depression is not just having "the blues" or the emotions we feel when grieving the loss of a loved one. It is a true medical condition that is treatable, like diabetes or hypertension.

How Do I Know If It's Depression?

Someone who is depressed has feelings of sadness or anxiety that last for weeks at a time. He or she may also experience–
  • Feelings of hopelessness and/or pessimism
  • Feelings of guilt, worthlessness and/or helplessness
  • Irritability, restlessness
  • Loss of interest in activities or hobbies once pleasurable
  • Fatigue and decreased energy
  • Difficulty concentrating, remembering details and making decisions
  • Insomnia, early–morning wakefulness, or excessive sleeping
  • Overeating or appetite loss
  • Thoughts of suicide, suicide attempts
  • Persistent aches or pains, headaches, cramps, or digestive problems that do not get better, even with treatment

How is Depression Different for Older Adults?

  • Older adults are at increased risk. We know that about 80% of older adults have at least one chronic health condition, and 50% have two or more. Depression is more common in people who also have other illnesses (such as heart disease or cancer) or whose function becomes limited.
  • Older adults are often misdiagnosed and undertreated. Healthcare providers may mistake an older adult's symptoms of depression as just a natural reaction to illness or the life changes that may occur as we age, and therefore not see the depression as something to be treated. Older adults themselves often share this belief and do not seek help because they don't understand that they could feel better with appropriate treatment.

How Many Older Adults Are Depressed?

The good news is that the majority of older adults are not depressed. Some estimates of major depression in older people living in the community range from less than 1% to about 5% but rise to 13.5% in those who require home healthcare and to 11.5% in older hospital patients.

Optional Learning Activity: Use the interactive maps at this website to determine The State of Mental Health and Aging in America for each of the following indicators -

Lesson 4: Healthy Aging

Healthy Aging

Source: Helping People To Live Long and Productive Lives and Enjoy a Good Quality Of Life: At a Glance 2011,

Implications of an Aging Society

By 2030, the number of U.S. adults aged 65 or older will more than double to about 71 million. The rapidly increasing number of older Americans has far-reaching implications for our nation's public health system and will place unprecedented demands on the provision of health care and aging-related services. Public health efforts to promote health and functional independence are critical strategies in helping older adults stay healthy. Research has shown that poor health does not have to be an inevitable consequence of aging. Older adults who practice healthy behaviors, take advantage of clinical preventive services, and continue to engage with family and friends are more likely to remain healthy, live independently, and incur fewer health-related costs.
An essential component to keeping older adults healthy is preventing chronic diseases and reducing associated complications. About 80% of older adults have one chronic condition, and 50% have at least two. Infectious diseases (such as influenza and pneumococcal disease) and injuries also take a disproportionate toll on older adults. Efforts to identify strategies to prevent or reduce the risk of disease and injury and to widely apply effective interventions must be pursued.
Tips on how to stay healthy, get good health care, and manage lifestyle changes as you age are available at Healthy Aging at NIH Senior Health.

Learning Activity 4.1:

Lesson 5: Safety
Falls Among Older Adults: An Overview

Each year, one in every three adults age 65 and older falls. Falls can cause moderate to severe injuries, such as hip fractures and head traumas, and can increase the risk of early death. Fortunately, falls are a public health problem that is largely preventable.

How big is the problem?

  • One out of three adults age 65 and older falls each year1,2 but less than half talk to their healthcare providers about it.
  • Among older adults (those 65 or older), falls are the leading cause of injury death. They are also the most common cause of nonfatal injuries and hospital admissions for trauma.
  • In 2008, over 19,700 older adults died from unintentional fall injuries.
  • In 2009, 2.2 million nonfatal fall injuries among older adults were treated in emergency departments and more than 581,000 of these patients were hospitalized.
  • In 2000, direct medical costs of falls totaled a little over $19 billion—$179 million for fatal falls and $19 billion for nonfatal fall injuries. This equals $28.2 billion in 2010 dollars.

What outcomes are linked to falls?

  • Twenty to thirty percent of people who fall suffer moderate to severe injuries such as lacerations, hip fractures, or head traumas. These injuries can make it hard to get around or live independently, and increase the risk of early death.
  • Falls are the most common cause of traumatic brain injuries (TBI). In 2000, TBI accounted for 46% of fatal falls among older adults.
  • Most fractures among older adults are caused by falls. The most common are fractures of the spine, hip, forearm, leg, ankle, pelvis, upper arm, and hand.
  • Many people who fall, even if they are not injured, develop a fear of falling. This fear may cause them to limit their activities leading to reduced mobility and loss of physical fitness, which in turn increases their actual risk of falling.

Who is at risk?

Fall-related Deaths
  • In 2008, 82% of fall deaths were among people 65 and older.
  • Men are more likely to die from a fall. After taking age into account, the fall death rate in 2007 was 46% higher for men than for women.
  • Older whites are 2.5 times more likely to die from falls as their black counterparts.
  • Rates also differ by ethnicity. Older non-Hispanics have higher fatal fall rates than Hispanics.
Fall Injuries
  • The chances of falling and of being seriously injured in a fall increase with age. In 2009, the rate of fall injuries for adults 85 and older was almost four times that for adults 65 to 74.
  • People age 75 and older who fall are four to five times more likely than those age 65 to 74 to be admitted to a long-term care facility for a year or longer.
  • Women are more likely than men to be injured in a fall. In 2009, women were 58% more likely than men to suffer a nonfatal fall injury.
  • Rates of fall-related fractures among older women are more than twice those for men.
  • Over 90% of hip fractures are caused by falls. In 2007, there were 264,000 hip fractures and the rate for women was almost three times the rate for men.
  • White women have significantly higher hip fracture rates than black women.

How can older adults prevent falls?

Older adults can remain independent and reduce their chances of falling. They can:
  • Exercise regularly. It is important that the exercises focus on increasing leg strength and improving balance, and that they get more challenging over time. Tai Chi programs are especially good.
  • Ask their doctor or pharmacist to review their medicines—both prescription and over-the counter—to identify medicines that may cause side effects or interactions such as dizziness or drowsiness.
  • Have their eyes checked by an eye doctor at least once a year and update their eyeglasses to maximize their vision. Consider getting a pair with single vision distance lenses for some activities such as walking outside.
  • Make their homes safer by reducing tripping hazards, adding grab bars inside and outside the tub or shower and next to the toilet, adding stair railings and improving the lighting in their homes.
To lower their hip fracture risk, older adults can:
  • Get adequate calcium and vitamin D—from food and/or from supplements.
  • Do weight bearing exercise.
  • Get screened and treated for osteoporosis.

Falls in the Bathroom


Activities that take place in the bathroom, such as showering and bathing, are a simple part of most peoples’ daily routine. Yet, slips in the tub and falls in the shower or from the toilet may cause serious injuries.

According to a new CDC study published in the Morbidity and Mortality Weekly Report (MMWR), an estimated 234,000 people ages 15 and older were treated in U.S. emergency departments (ED) in 2008 for injuries that occurred in bathrooms. Four out of 5 of these injuries were caused by falls—which can have especially serious consequences for older adults.
Almost one-third (30 percent) of adults aged 65 and above who were injured in bathrooms were diagnosed with fractures. Among adults aged 85 and older, 38 percent were hospitalized as a result of their injuries.
Read the new CDC study on bathroom injuries and the related press release.

Steps for Safety in the Bathroom

Certain home safety measures may reduce the risk for all household members of being injured in the bathroom. Some prevention strategies include:
  • Adding non-slip surfaces and grab bars inside and outside the tub or shower to reduce slips and falls.
  • Installing grab bars next to the toilet for added support, if needed.

Preventing Falls among Older Adults

Four out of five injuries that took place in bathrooms in 2008 were the result of falls. Falls can be especially dangerous for adults ages 65 and older.
Older adults can take steps to make falls less likely. If you are 65 or older, take the following steps to reduce your risk of falling:
  • Get some exercise: Lack of exercise can lead to weak legs, which increases the chance of falling. Exercise programs like Tai Chi can increase strength as well as improve balance, making falls less likely for aging adults.
  • Be mindful of medications: Some medicines—or combinations of medicines— can have side effects like dizziness or drowsiness. This can make falls more likely. Having a doctor or pharmacist review all your medications can help reduce the chance of risky side effects and drug interactions.
  • Keep your vision sharp: Poor vision can make it harder to get around safely. To help make sure you're seeing clearly, have your eyes checked every year and wear glasses or contact lenses with the right prescription strength.
  • Eliminate hazards at home. About half of all falls happen at home. A home safety check can help identify fall hazards, like clutter and poor lighting that should be removed or changed.

Learning Activity 5.1: Make your own home safe for older adults.
  • What would you need to do to make your home safer for older adults?
  • How much would it cost and how much time would it take for you to make these changes?

Violence Elder Abuse

Source: Centers for Disease Control,

Elder maltreatment includes several types of violence that occur among those ages 60 and older. The violence usually occurs at the hands of a caregiver or a person the elder trusts. There are six types of elder maltreatment:
  • Physical—This occurs when an elder is injured as a result of hitting, kicking, pushing, slapping, burning, or other show of force.
  • Sexual—This involves forcing an elder to take part in a sexual act when the elder does not or cannot consent.
  • Emotional—This refers to behaviors that harm an elder’s self-worth or emotional well being. Examples include name calling, scaring, embarrassing, destroying property, or not letting the elder see friends and family.
  • This is the failure to meet an elder’s basic needs. These needs include food, housing, clothing, and medical care.
  • This happens when a caregiver leaves an elder alone and no longer provides care for him or her.
  • Financial—This is illegally misusing an elder’s money, property, or assets.
Elder maltreatment can have several physical and emotional effects on an elder.
Many victims suffer physical injuries. Some are minor like cuts, scratches, bruises, and welts. Others are more serious and can cause lasting disabilities. These include head injuries, broken bones, constant physical pain, and soreness. Physical injuries can also lead to premature death and make existing health problems worse.
Elder maltreatment can have emotional effects as well. Victims are often fearful and anxious. They may have problems with trust and be wary around others.
Many cases are not reported because elders are afraid to tell police, friends, or family about the violence. Victims have to decide: tell someone they are being hurt or continue being abused by someone they depend upon or care for deeply.

Who is at risk for elder abuse

Several factors can increase the risk that someone will hurt an elder. However, having these risk factors does not always mean violence will occur.

Some of the risk factors for hurting an elder include:
  • Using drugs or alcohol, especially drinking heavily
  • High levels of stress
  • Lack of social support
  • High emotional or financial dependence on the elder
  • Lack of training in taking care of elders
  • Depression

Risk Factors

A combination of individual, relational, community, and societal factors contribute to the risk of becoming a perpetrator of elder maltreatment. They are contributing factors and may or may not be direct causes.
Understanding these factors can help identify various opportunities for prevention.
Risk Factors for Perpetration
Individual Level
  • Current diagnosis of mental illness
  • Current abuse of alcohol
  • High levels of hostility
  • Poor or inadequate preparation or training for care giving responsibilities
  • Assumption of caregiving responsibilities at an early age
  • Inadequate coping skills
  • Exposure to maltreatment as a child
Relationship Level
  • High financial and emotional dependence upon a vulnerable elder
  • Past experience of disruptive behavior
  • Lack of social support
Community Level
  • Formal services, such as respite care for those providing care to elders, are limited, inaccessible, or unavailable
Societal Level

A culture where:
  • there is high tolerance and acceptance of aggressive behavior
  • health care personnel, guardians, and other agents are given greater freedom in routine care provision and decision making;
  • family members are expected to care for elders without seeking help from others;
  • persons are encouraged to endure suffering or remain silent regarding their pains; or
  • there are negative beliefs about aging and elders.
In addition to the above factors, there are also specific characteristics of institutional settings that may increase the risk for perpetration of vulnerable elders in these settings, including: unsympathetic or negative attitudes toward residents, chronic staffing problems, lack of administrative oversight, staff burnout, and stressful working conditions.

Protective Factors for Elder Maltreatment

Protective factors reduce risk for perpetrating abuse and neglect. Protective factors have not been studied as extensively or rigorously as risk factors. However, identifying and understanding protective factors are equally as important as researching risk factors.
Several potential protective factors are identified below. Research is needed to determine whether these factors do indeed buffer elders from maltreatment.
The goal is to stop elder maltreatment before it starts. While not much research has been done, there are several things we can do to prevent it:
  • Listen to elders and their caregivers
  • Report abuse or suspected abuse to Adult Protective Services
  • Educate oneself and others about how to recognize and report elder abuse
  • Learn how the signs of elder abuse differ from the normal aging process
  • If you take care of an elder here are some things you can do to prevent violence:
  • Get help from friends, family, or local relief care groups
  • Take a break— if only for a couple of hours
  • Involve more people than just family in financial matters
  • Find an adult day care program
  • Seek counseling or other support if you are feeling depressed
  • If you are having problems with drug or alcohol abuse, get help

Lesson 6: Ageism

Ageism and Health Consequences
Source: Ageism, NCEA, AOA,

In the 1960s, Robert Butler coined the phrase ageism, which he defined as:
"A process of systematic stereotyping of and discrimination against people because they are old, just as racism and sexism accomplish this with skin color and gender. Old people are categorized as senile, rigid in thought and manner, old-fashioned in morality and skills . . . . Ageism allows the younger generations to see older people as different from themselves; thus they subtly cease to identify with their elders as human beings . . . ."

(See R. Butler, Why Survive? Being Old in America, 1975 - item no. 71 of this bibliography.)
While some advocates for elders suggest that ageism is a cause of elder abuse, neglect, and exploitation, we do not have enough valid research into the attitudes of known perpetrators of elder mistreatment to be able to definitively make that statement. However, as the following references indicate, ageism contributes to conditions that disadvantage and marginalize older individuals in society.
Inequitable treatment occurring in the workplace, in the health care sector, and in the legal arena appears to be based, at least in part, on age discrimination. Even efforts to offer protection may be based upon compassionate ageism that may lead to disempowerment. Ageist beliefs and policies categorize seniors as a homogenous group, ignoring diversity issues and individual needs. Furthermore, it appears that aging individuals are not only subjected to ageist beliefs by others; they internalize these beliefs as well. Age discrimination can impact elders in tangible ways by contributing to reduced financial security and poorer health outcomes, but also appears to a have subtler, though perhaps more pervasive impact, by contributing to social isolation (a risk factor for mistreatment), lower self-esteem and poorer quality of life. When combined with other prejudices, such as sexism, racism and biases against the disabled (known as "ableism"), the health and well-being of elders is further jeopardized.

Learning Activity 6.1:
  • Take the Implicit Association Test (IAT) on aging and reflect on your results
  • Ask someone else to take the IAT and Interview that person about the results
  • How might the results may impact your attitudes?

Consequences of Attributing Illness to Old Age
Source: Stewart TL, Chipperfield JG, Perry RP, Weiner B. (2011). Attributing illness to 'old age:' Consequences of a self-directed stereotype for health and mortality. Psychol Health.

"Stereotypic beliefs about older adults and the aging process have led to endorsement of the myth that 'to be old is to be ill.' A study on older adults' beliefs about the causes of their chronic illness (i.e., heart disease, cancer, diabetes, etc.), found that attributing an illness to 'old age' is associated with negative health outcomes. 'Old age' attributions were associated with more frequent perceived health symptoms, poorer health maintenance behaviors and a greater likelihood of mortality. The probability of death was more than double among those who strongly attributed illness symptoms to 'old age' as compared to those who did not.

Lesson 7: End of Life Issues
Life Expectancy

Life expectancy is a summary measure of the overall health of a population. It represents the average number of years of life remaining to a person at a given age if death rates were to remain constant. In the United States, improvements in health have resulted in increased life expectancy and contributed to the growth of the older population over the past century.
Americans are living longer than ever before. Life expectancies at both age 65 and age 85 have increased. Under current mortality conditions, people who survive to age 65 can expect to live an average of 18.5 more years, about 4 years longer than people age 65 in 1960. The life expectancy of people who survive to age 85 today is 6.8 years for women and 5.7 years for men.
Life expectancy varies by race, but the difference decreases with age. In 2006, life expectancy at birth was 5 years higher for white people than for black people. At age 65, white people can expect to live an average of 1.5 years longer than black people. Among those who survive to age 85, however, the life expectancy among black people is slightly higher (6.7 years) than white people (6.3 years).
Life expectancy at age 65 in the United States is lower than that of many other industrialized nations. In 2005, women age 65 in Japan could expect to live on average 3.7 years longer than women in the United States. Among men, the difference was 1.3 years.
Heart disease and cancer are the top two leading causes of death among all people age 65 and over, irrespective of sex, race, or Hispanic origin. Other causes of death vary among older people by sex and race and Hispanic origin. For example, men have higher suicide rates than do women at all ages, with the largest difference occurring at age 85 and over (43 deaths per 100,000 population for men compared with 3 per 100,000 for women). Non-Hispanic white men age 85 and over have the highest rate of suicide overall at 48 deaths per 100,000.

End of Life Issues

Source: NLM, NIH,

Sometimes, in spite of treatment, a condition or illness will cause death. In those cases, patients can decide what they do and do not want done. They can decide whether they want aggressive treatment that might prolong life or whether they prefer to stop treatment, which could mean dying sooner but more comfortably. They may want to plan their own funeral. Advance directives can help make the patient's wishes clear to families and health care providers.
Care at the end of life focuses on making patients comfortable. They still receive medicines and treatments to control pain and other symptoms. Some patients choose to die at home. Others enter a hospital or a hospice. Either way, services are available to help patients and their families deal with issues surrounding death.
For more about dying and death, read End of Life: Helping With Comfort and Care, a 68-page guide that discusses finding hospice care, what happens at the time of death, managing grief, and preparing advance directives along with resources for more information.

Costs of End of Life Care

Source:Advance Directives Might Curb Cost of End-of-Life Care by Serena Gordon, Health News,//

End-of-life care is often a controversial subject, and when policymakers are looking for ways to control Medicare costs, such care typically comes up in the discussion. That's not surprising, because end-of-life care accounted for more than one-quarter of Medicare spending last year, according to background information in the study. One concern is that this spending may be largely earmarked for aggressive care that's not necessarily what the patient might have wanted.
And, that's where advance directives can be useful. They allow patients to document their wishes, whether they want all life-sustaining measures to be taken or if they'd prefer to avoid such procedures.

Advance Directives
Source: NIH, Medline, //

What kind of medical care would you want if you were too ill or hurt to express your wishes? Advance directives are legal documents that allow you to convey your decisions about end-of-life care ahead of time. They provide a way for you to communicate your wishes to family, friends and health care professionals, and to avoid confusion later on.
A living will tells how you feel about care intended to sustain life. You can accept or refuse medical care. There are many issues to address, including
  • The use of dialysis and breathing machines
  • If you want to be resuscitated if breathing or heartbeat stops
  • Tube feeding
  • Organ or tissue donation
A durable power of attorney for health care is a document that names your health care proxy. Your proxy is someone you trust to make health decisions if you are unable to do so.

Optional Learning Activity: Watch this vieo about advance care planning (3:38 minutes).
  • Have YOU made your health care wishes known to someone?

Hospice Care
Source: NIH, Medline, //

Hospice care is end-of-life care provided by health professionals and volunteers. They give medical, psychological and spiritual support. The goal of the care is to help people who are dying have peace, comfort and dignity. The caregivers try to control pain and other symptoms so a person can remain as alert and comfortable as possible. Hospice programs also provide services to support a patient's family.
Usually, a hospice patient is expected to live 6 months or less. Hospice care can take place
  • At home
  • At a hospice center
  • In a hospital
  • In a skilled nursing facility

Optional: Advance Care Planning for Health Professionals

Contemporary Health Issues

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