Americans are living longer than ever before, and it is expected that the older population will continue to grow. Presently, people who survive to age 65 years can expect to live an average of nearly 18 more years. The life expectancy of people who survive to age 85 years today is about 7 more years for women and 6 more years for men. Life expectancy varies by race, but the difference decreases with age. In 1900, people aged 65 years and older made up 4% of the population. In 2006, nearly 37 million people aged 65 years and over lived in the United States, accounting for just over 12% of the total population. The oldest-old population (those 85 years and older) grew from just over 100,000 in 1900 to 5.3 million in 2006 (Federal Interagency Forum on Aging-Related Statistics, 2008). There are about 40,000 centenarians in the United States (Ebersole et al., 2008).

The baby boomers (individuals born between 1946 and 1964) will start turning 65 years old in 2011, and the number of older adults will increase dramatically. By 2030, the number of Americans aged 65 years and older is expected to be twice as large as their counterparts in 2000, growing from 35 million to 71.5 million, and will represent nearly 20% of the total U.S. population. The greatest growth will occur in the population aged 85 years and older, whose numbers are projected to grow from 5.3 million in 2006 to nearly 21 million by 2050 (Federal Interagency Forum on Aging-Related Statistics, 2008).

In addition to growing larger, the older population is becoming more diverse, as is the rest of the population. In 2006, non-Hispanic whites accounted for nearly 81% of the U.S. older population. Blacks made up 9%, Asians made up 3%, and Hispanics (of any race) accounted for 6% of the older population. The older population will grow among all racial and ethnic groups; however, the older Hispanic population is projected to grow the fastest (Federal Interagency Forum on Aging-Related Statistics, 2008).

The proportion of the population aged 65 years and over varies by state. In 2006, Florida had the highest proportion of people aged 65 years and over (17%). Pennsylvania and West Virginia also had high proportions, each slightly over 15% (Federal Interagency Forum on Aging-Related Statistics, 2008). The nine states with the largest number of elderly individuals (1 million or more) are California, Florida, New York, Texas, Pennsylvania, Ohio, Illinois, Michigan, and New Jersey (Administration on Aging, 2001).

Older women outnumber older men in the United States. In 2006, women accounted for 58% of the population aged 65 years and over and 68% of the population aged 85 years and over (Federal Interagency Forum on Aging-Related Statistics, 2008).

Older men are more likely than older women to be married. In 2007, more than three quarters (78%) of men aged 65 to 74 years were married, compared with more than half (57%) of women in the same age-group. The proportion married is lower at older ages: 38% of women aged 75 to 84 and 15% of women aged 85 years and over were married. Widowhood is more common among older women than older men. Women aged 65 years and over were three times as likely as men of the same age to be widowed: 42% compared with 13%. In 2007, 76% of women aged 85 years and over were widowed, compared with 34% of men. Relatively small proportions of older men (8%) and women (10%) were divorced in 2007, and a small proportion of the older population has never married (Federal Interagency Forum on Aging-Related Statistics, 2008).

Educational attainment has increased among older adults. In 2007, 76% of older adults were high school graduates (compared with 24% in 1965). Older blacks and Hispanics aged 65 years and older completed high school at lower rates than their white and Asian counterparts (58% and 42%, compared with 81% and 72%). In 2007, 19% of older adults had a bachelor’s degree or higher (compared with 5% in 1965). Older Asians had the highest proportion with a bachelor’s degree or higher (32%), compared with 21% for non-Hispanic whites, 10% for blacks, and 9% for Hispanics. Older men attained a bachelor’s degree more often than older women (25% compared with 15%); however, the gender gap in completion of a college education is narrowing (Federal Interagency Forum on Aging-Related Statistics, 2008).

As age increases and widowhood rates rise, the percentage of the population living alone increases accordingly. In 2007, 73% of older men lived with their spouse, whereas fewer than one half (42%) of older women did. In contrast, older women were more than twice as likely as older men to live alone (39% and 19%, respectively). Older Hispanic (33%), black (32%), and Asian (30%) women were more likely than white women (14%) to live with relatives other than a spouse. Older white and black women were more likely than women of other races to live alone (approximately 40% each, compared with about 20% for Asian and 26% for Hispanic women). Older black men (29%) lived alone more than three times as often as older Asian men (8%). Older Hispanic men were more likely (17%) than men of other races and ethnicities to live with relatives other than a spouse (Federal Interagency Forum on Aging-Related Statistics, 2008).

In 2006, the median household income of older adults was $27,798. Aggregate income for the population aged 65 years and over came largely from four sources: Social Security provided 37%, earnings accounted for 28%, pensions provided 18%, and asset income accounted for 15%. Among older Americans in the lowest fifth of the income distribution, Social Security accounts for 83% of aggregate income, and public assistance accounts for another 8%. For those whose income is in the highest income category, Social Security, pensions, and asset income each account for about one fifth of aggregate income, and earnings account for the remaining two fifths (Federal Interagency Forum on Aging-Related Statistics, 2008).

With aging, a good percentage of income is spent on health care. Most older adults have Medicare, which provides health insurance for those who are 65 years of age or older, disabled, or have end-stage renal disease. Medicare is funded, in part, by Social Security contributions from employers, employees, and the self-employed. Medicare Part A is a hospital insurance plan that covers acute care, short-term rehabilitative care, and some costs associated with hospice and home health care. For 2009, the Part A deductible for acute care was $1068 for the first 60 days of a hospital stay per benefit period. This amount increases for longer hospital stays. Rehabilitative care generally provided in skilled nursing facilities is only covered if it occurs after a 3-day hospital stay and requires “skilled care” provided by a licensed nurse or by a physical or occupational therapist. Medicare Part A will pay 100% of the first 20 days of a nursing home stay, with a daily co-pay for days 21 to 100 and no coverage after that (U.S. Department of Health and Human Services [USDHHS]/Centers for Medicare and Medicaid Services [CMS], 2006).

Medicare Part B covers the costs for physician and nurse practitioner services; outpatient services, such as diagnostic procedures (e.g., laboratory and x-ray); qualified physical, speech, and occupational therapy; ambulance services; durable medical equipment; and some home health care services. Charges are paid by Medicare at a rate of 80% of what Medicare considers an “allowable charge.” The client is responsible for the remaining 20% of the charge. In addition, the client is responsible for an annual Part B deductible ($135.00 in 2009) and a monthly premium of $96.40. This amount is generally deducted directly from the monthly Social Security check. Most individuals purchase Medigap policies, which cover the deductibles and co-pays. Another option is to join a Medicare Advantage Plan, which often provides more choices and benefits such as extra days in the hospital. To join a Medicare Advantage Plan, an older adult must have Medicare Part A and Part B. In addition to the Part B premium, there may be an additional monthly premium for the extra benefits provided (USDHHS/CMS, 2006).

The newest component of Medicare is the prescription drug coverage that became available in January 2006. The prescription drug plan is designed to help lower prescription drug costs. The individual chooses the drug plan and pays a monthly premium (about $37/month) and an annual deductible ($250 in 2006—this may increase in subsequent years). After the plan participant meets the deductible, he or she is responsible for 25% co-pay up to $2250. The individual is responsible for 100% of the next $2850, or a total out-of-pocket cost of $3600. At that point, the plan will pay 95% of prescription drug costs (USDHHS/CMS, 2006).

For older adults with low incomes, Medicaid may be available to offset the Medicare deductibles and co-pays and to provide additional health benefits. Each state establishes its own eligibility criteria within the broad guidelines established by the federal government. Medicaid generally covers more services than Medicare, including custodial care in nursing homes, without deductibles or co-pays.

To determine who is considered poor, the U.S. Census Bureau compares family income (or an unrelated individual’s income) with a set of poverty thresholds that vary by family size and composition and are updated annually for inflation. By 2006, the proportion of the older population living in poverty had decreased dramatically to 9%. Older women (12%) were more likely than older men (7%) to live in poverty. Older people who live alone have higher rates of poverty than those who are married. Race and ethnicity are also related to poverty among the older population. In 2006, older whites were far less likely than older blacks and Hispanics to be living in poverty (about 7% compared with 23% and 19%, respectively) (Federal Interagency Forum on Aging-Related Statistics, 2008).

Community nurses will be increasingly called upon to care for older adults of diverse backgrounds who reside in various living arrangements. Although educational attainment has increased among the elderly population, many older adults have less than a high school education; therefore nurses must be sensitive and creative when providing instruction and teaching. Nurses cannot assume that an older adult has had a formal education. In addition, instructions may need to be given at a slower pace. It may also be imperative to include family or significant others when providing instruction. Also, written information may be sent home for further reference.

On the other hand, increased educational levels of current and future elders also provide a challenge for the community health nurse. These elders are, and will be, more informed and will make greater demands for current and scientifically based information, thus requiring the community health nurse to be knowledgeable about the latest developments in health care. Last, nurses must be aware of community programs and services that address the needs of a diverse older population. Many of these resources are discussed in this chapter.

Many organizations such as the American Cancer Society, the American Heart Association, and the USDHHS Preventive Services Task Force have established recommendations for health promotion screenings and examinations. Box 19-2 depicts some of the more widely agreed-on screenings and examinations for older adults. These established recommendations might be very useful to community nurses when educating older adults about the benefits of screening and early detection of disease. Frequently, earlier detection of disease allows better treatment, lower health care costs, and the possibility of cure.

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