During this century, there has been an unprecedented increase in the number of people who live to the age of 65 and older. While only one of 25 Americans reached age 65 at the turn of the century, one of every 8 Americans was at least 65 years old in 1990. By the year 2030, the number of older Americans will nearly double and make up 20% of the entire population. While new health technologies and social environments improve the life circumstances for older people, what constitutes a "good" quality of life remains unclear.
Quality of life is an elusive phenomenon that has been conceptualized in various ways. The term quality of life is used interchangeably with terms such as life satisfaction (Laborde & Powers, 1980), happiness (Shinn & Johnson, 1978), and well being (Carstensen & Cone, 1983). However, quality of life is multidimensional, encompassing biological, psychological, interpersonal, social, economic, and cultural dimensions (Flanagan, 1978). An understanding of the factors that impact on the quality of life of older people is important for identifying those elderly people who are at risk for less than optimal quality of life. The purpose of this paper is to examine the issues surrounding quality of life of older adults. Specifically, the historical development and the salient political, social, and economic issues will be discussed. Implications for policy and practice will be addressed.
Historically, the elderly were esteemed and revered by their families and society. Older adults enjoyed positions of power, ownership of property, and economic security. Elderly people were respected for their knowledge and were consulted on important matters. Living in one household was common for multigenerational families.
However, in the late 1800s, the industrial revolution occurred in this country and with it a change in the social, economic, and moral status of older adults. Modernization theory proposes that industrialization caused the decreased social standing of older individuals (Cowgill, 1974). Advances in health technology resulted in a decrease in birth rates and death rates, leading to an increase in the number of older people. Advances in economic technology resulted in the creation of new occupations and a lower demand for workers. The job skills of older workers became obsolete, and competition between older and younger workers occurred, effecting the retirement of older workers. Mass education of children resulted in older people with relatively obsolete knowledge. Older people were often left behind in rural areas because of urbanization. The combined effects of these factors resulted in negative attitudes toward older adults. Common myths surrounding aging and older adults perpetuated these attitudes in our society today. Some of these misconceptions included the beliefs that:
* Most older people are senile.
* Older people are alike.
* Older people are unproductive.
* Older adults are rigid and unable to change.
* Older people cannot learn new skills.
* Most older adults are dependent (Ebersole & Hess, 1985).
Organizations for older adults have attempted to reverse the inequities experienced by those age 65 and older. At least one third of the elderly population have become members of organizations such as the American Association of Retired Persons (AARP) and the National Council of Senior Citizens (Atchley, 1991). These organizations strive to portray a positive image of aging and the elderly, to identify and publicize the needs of older adults, and to lobby for legislation addressing the problems confronting older adults in the United States.
POLITICAL, SOCIAL, AND ECONOMIC FACTORS AFFECTING QUALITY OF LIFE
The federal government has periodically taken a role in ensuring a basic quality of life for older Americans. Legislation addressing the economic security of older adults began in the 1930s. Many elderly people were living in poverty because of the Great Depression of 1930. Congress reacted by passing the Social Security Act of 1935. One provision of this legislation was to provide economic assistance and income security for the poor elderly and the retired elderly. The Social Security Act was amended in 1939 to extend benefits to spouses and other dependents. Financed by employer and employee contributions, social security is sensitive to economic activity, inflation, and the number of workers (Gelfand, 1993). A significant reduction in the workforce will occur as the baby boomer generation reaches retirement age. A smaller workforce will support a larger number of older individuals, resulting in intergenerational conflict.
Health profoundly affects the quality of life of the individual. Symptoms and treatment options may result in physical and social functioning limitations, emotional problems, and a decrease in quality of life. In 1965 with the passage of Medicare and Medicaid, the federal government began to address the health care needs of older adults. Current issues surrounding the adequacy and effectiveness of the Medicare and Medicaid programs include cost containment, the financing of long-term care, the coordination of services, and the scope of services provided. Medicare coverage consists of two parts. Part A covers inpatient hospital care, skilled nursing care facilities, and home health and hospice care. Part B covers medically necessary doctor services and some other services. However, while Medicare helps defray many of the medical expenses of older adults, beneficiaries are responsible for Parts A and B charges not covered by the Medicare program and for various cost-sharing requirements for covered services. Under Part A, the beneficiary must pay an inpatient hospital deductible at the beginning of each benefit period ($736 in 1996). If more than 60 days of inpatient care are required, co-insurance payments must be paid by the beneficiary. In addition, Medicare Part A does not provide coverage for extensive long-term care at a nursing care facility or at home. Under Part B, the beneficiary must pay monthly premiums ($42.50 in 1996), an annual deductible of $100, and co-insurance payments equaling 20% of allowable charges (Melillo, 1996). There is also a disparity in coverage for services. For example, mental health services are not reimbursed comparable to physical health services. Until recently, there was a cap on benefits for mental health services. Although the cap has been eliminated, the patient still has to pay 50% of the total costs, while physical health care requires only a 20% co-payment (Health Care Financing Administration, 1996).
Medicaid is a jointly funded cooperative venture between the federal and state governments to provide medical care to eligible needy people. Although Medicaid is available for poor older adults, eligibility requirements by individual states vary greatly, resulting in 64% of poor older adults receiving no Medicaid benefits (Peres, 1987). Additionally, Medicaid eligibility may change from month to month, complicating access to and continuity of health care. Access to health care is based on the ability to pay, and some older adults simply cannot pay for needed services. Furthermore, health care providers who choose not to treat Medicaid patients are rationing access to health care. Lack of treatment and management of illness ultimately influences quality of life.
Federal legislation has also provided for social services for older adults. In 1965, the Older Americans Act was passed by Congress, creating a national network of services and programs for older adults at the federal, state, and local levels (GeIf and, 1993). An amendment to this legislation in 1972 provided for a national nutrition program for older adults. The creation of Area Agencies on Aging and the Nursing Home Ombudsman program and the provision of home-delivered meals to older adults resulted with an amendment in 1973. The act was amended again in 1987 to provide for nonmedical home care services for frail elderly people, including home health aides, homemaker services, and adult day care. This amendment also addressed elder abuse prevention, health promotion activities for older adults, and outreach to elderly people potentially eligible for supplemental security income (SSI), food stamps, and Medicaid.
The federal government has also passed legislation related to employment and retirement issues of older adults. The Age Discrimination Employment Act of 1967 prohibited employers from using age as a standard for hiring and firing and from discriminating against older adults on the job. While an amendment in 1978 increased the mandatory retirement age from 65 years to 70 years, mandatory retirement from most jobs was banned in a 1986 amendment (Gelfand, 1993). The Employees Retirement Income Security Act created the National Pension Benefit Guarantee Corporation in 1974 to ensure the security of private pensions of older Americans.
Research on aging and health became a focus in the 1970s and 1980s. The National Institute on Aging (NIA) was added to the National Institutes of Health in 1974. The NIA was responsible for setting research priorities and for funding basic research on aging. The Healthy People 2000 Consortium was developed in 1987 under the auspices of the Public Health Service. Composed of nearly 300 national organizations and all state health departments, the consortium held eight regional hearings to formulate national health objectives for health promotion and disease prevention.
Federal legislation on behalf of older people has attempted to improve the lives of and to promote the general well-being of older adults. However, recent attempts to contain health care costs and reduce the federal deficit pose new and continuing threats to older adults.
Many social factors affect the quality of life of older adults. Seventy-seven percent of older adults own their homes (Naif eh, 1993). However, minority, rural, and central-city elderly people often live in poorquality housing (Mikelsons & Turner, 1992). In 1989, half of all poor elderly homeowners spent at least 46% of their income on housing (Apgar, DiPasquale, McArdle, & Olson, 1989). Limited cash resources and functional limitations may prevent elderly people from maintaining, repairing, and modifying their homes. Many older adults could continue to live independently in their own homes with home modifications, such as additional lighting, hand rails, grab bars, wider doorways, roll out trays in lower cupboards, lever faucets and door handles, hand-held showers, and replacing stairs with ramps. However, home modification can be costly (GeIf and, 1993). While funding for home repair and modification is available through federal programs, few elderly people receive help. In 1990, less than 300 older adults received loans for home modification through the Section 312 Rehabilitation Loan Program (Gelfand, 1993).
Other factors affect the quality of life of older adults. Some older adults have inadequate nutrition. Physical and cognitive limitations may prevent some older adults from preparing nutritious meals, and inadequate financial resources may prevent others from purchasing nutritious foods. While the Older Americans Act (Title III) provides for nutrition services, the quality of the programs varies, and the services are not easily implemented in rural areas (Recommendations, 1987).
Transportation also influences quality of life. Elderly people may no longer be able to drive a car due to limitations in vision, hearing, cognition, and physical agility. They, therefore, must depend on others. Older adults may feel as though they are inconveniencing their family and friends and may not alert them to their transportation needs. Heightened attention to transportation accessibility has resulted in the passage of important legislation: the Social Security Act (Title XIX); the Older Americans Act (Title III); the Social Services Block Grant; the Federal Transit Act (Sections 9, 16B2, 1 8); the Americans With Disabilities Act;, and the establishment of the National Elder-Care Institute on Transportation. However, many elderly people still experience transportation difficulties. Public transportation is often unavailable, inaccessible, and expensive. Consequently, some older adults may be missing opportunities to socialize, shop for necessary items, and seek vital health care because of decreased access to transportation.
Personal relationships influence the perceived quality of life of older adults. The social network of older adults decreases as they age because their spouses, siblings, parents, and lifelong friends have died. Older women live alone more often than older men. Older women are three times as likely to be widowed as older men. Older men are twice as likely to be married as older women. Approximately one third of the caregivers of the elderly are elderly themselves (Stone, 1988). Wives are the majority of caregivers age 65 and older. Living alone and providing care for an elderly spouse may result in isolation and lead to loneliness, low self-esteem, and depression in some elders.
Elder abuse is another social atrocity affecting the quality of life of some older adults in the United States. Approximately 5%, or L5 million, of older adults experience some type of abuse, including physical abuse, emotional abuse, financial abuse, and neglect (House Select Committee on Aging, Subcommittee on Health and Long-term Care, 1990). Older adults report occurrences of abuse less than any other age group; only one in eight cases of elder abuse is reported. As the number of frail older adults increases, elder abuse must become a priority of the government and society to ensure the safety and quality of life of older adults.
Economic factors also influence the quality of life of the older adult. Money income dramatically decreases, as much as 55%, when older adults retire (Uhlenberg, 1987). In 1993, 9.6% of the poor were people age 65 and older, and the poverty rate was 12.2% for older adults (United States Bureau of the Census, 1994). Social security is the primary source of money income for older adults and is the sole source of income for 13% of older adults (Manheimer, 1994). Previous employment history and amount of contributions made determine eligibility for social security. Therefore, an individual can reach age 65 and not receive social security benefits.
The heterogeneity of the elderly population makes it difficult to generalize their economic status. Gender, race, marital status, and age differences exist within older adults regarding economic status. Older men have higher incomes than older women. Nearly three fourths of poor older adults are women (Littman, 1991). White elderly people are financially better off than Black and Hispanic elders. The poverty rate for Black elderly people is almost three and a half times more than the poverty rate for White older adults, while the poverty rate for Hispanic American elderly people is more than twice the poverty rate for White older adults (Littman, 1991). Married elderly couples have higher incomes than single elderly individuals. The young-old (65 to 74 years) are more financially secure than the old-old (older than age 85). Therefore, an 87-year-old widowed Black woman is at substantial risk for being poor and experiencing financial difficulties.
IMPLICATIONS FOR POLICY AND PRACTICE
Although life expectancy has greatly increased during this century, society has not adequately planned for the social, economic, and health care needs of older adults. Nursing can play an integral role in effecting change in the political and practice arenas.
One strategy for meeting the health care needs of older adults is for the federal government to mandate for health care providers trained to provide holistic care to older adults. Physicians and nurses need to be prepared to address the complex needs of older adults by adopting a biopsychosocial approach to this population. Unfortunately, holistic courses devoted to aging and older adults are nonexistent in some medical and nursing education curricula, resulting in limited numbers of health care providers best trained to care for older adults. As we move into the 21st century, faculties of schools of medicine and nursing must critically evaluate and modify their curricula to prepare practitioners sensitive to the health care needs of an aging society. Ideally, geriatricians and geriatric nurse practitioners would provide the primary health care for older individuals. Geriatric nurse practitioners can provide quality cost-effective health care to elderly people with acute and chronic conditions (Garrard, Kane, Ratner, & Buchanan, 1991; Naylor et al., 1994). However, current policy precludes third-party reimbursement of most nurses. The nursing profession must continue to lobby for legislation at the state and federal levels for third-party reimbursement of advanced practice nurses who care for older adults.
Older individuals are in need of education regarding their right to health care, information regarding their health, the possible alternatives for treatment and their consequences, health promotion and disease prevention, and the various health care professionals capable of providing health care. Nurses should continue to fulfill this educational need. Physicians, nurses, and other health care professionals must include older individuals in their health care. Unfortunately, many health care providers continue to assume older people are demented or unable to make any decisions regarding their health care simply because they are old. Nurses should continue to fulfill the role of advocate for older adults. Health promotion and disease prevention activities should be more actively initiated with older adults. Many elderly people believe physicians are the only health care providers who can meet their needs. The public, overall, is unaware of the existence of nurse practitioners and clinical nurse specialists and their respective roles. The nursing profession must continue to educate the public about nursing.
The federal government needs to continue to allocate more funding for established programs, such as Social Security, social services through the Older Americans Act, and the National Institutes of Health. Furthermore, the federal government needs to play a supportive role in the development and funding of new programs for older adults, such as a comprehensive long-term care system. In 1993, approximately 1.5 million individuals received home health care on an average day (National Center for Health Statistics, 1996). Approximately, 75% of these recipients were age 65 and older, while nearly 25% were age 85 and older. However, the range of long-term care services is narrow, medically oriented, and fragmented. Approximately 80 federal programs are available to assist individuals with long-term care problems (O'Shaughnessy & Price, 1987). The sheer number of programs available reflects the hitand-miss approach that has been taken in meeting the needs of older adults. Consequently, duplication of efforts and omission of badly needed services are the norm. Furthermore, the dominance of the medical model in the health care system emphasizes the acuteness of health and illness, perpetuates a cure orientation to health care, and directly influences the types of services delivered (Bould, Sanborn, & Reif, 1989; Callahan, 1994). Many older adults who suffer from chronic illnesses require health care but may not require medical care or nursing home care. Although some individuals could be safely maintained in their homes with home care services, they may not have the resources to purchase the services and may not be eligible to receive Medicaid benefits. Alternatives to institutionalization must be investigated and developed, especially for frail older adults. Formal support services aimed at promoting functional independence need to be available to those with functional limitations so that they can perform activities of daily living as independently as possible and remain in their own homes. Additionally, more congregate living and assisted living arrangements would enhance the continuity of care for elders. Lastly, a mechanism for ensuring continuity of care must be created. The nursing profession must continue to advocate for public policy addressing the housing and longterm health care issues of older adults at the local, state, and federal levels.
Seven states do not have mandatory reporting of elder abuse (House Select Committee on Aging, Subcommittee on Health and LongTerm Care, 1990). On average, the states spent $3.80 per older adult for protective services in 1989. Nurses must urge the state and federal governments to enact legislation ensuring mandatory reporting and adequate funding of elder abuse programs in all states.
Nurses must continue to conduct and collaborate with other professionals in research investigating the biopsychosocial issues of aging. Such research would strengthen nursing's knowledge base about older adults. New stages of the life course may be identified as life expectancy increases. Nursing interventions specific for older adults may be developed, implemented, and evaluated. Additionally, health care outcomes in older adults can be evaluated, and recommendations for future health policy proposed. For example, relocation to a nursing home is a potentially stressful event for many older adults and may result in negative outcomes, such as a decline in physical health (Mirotznik & Ruskin, 1984, 1985), the development of depression (Foster, Cataldo, & Boksay, 1991; Katz, Lesher, KIeban, Jethanandani, & Parmelee, 1989; Parmelee, Katz, & Lawton, 1992), and increased mortality (Rantz & Egan, 1 987). Such findings served as an impetus for the creation of the Nursing Home Ombudsman program in 1987. However, the persistence of such findings suggests the need for additional research to evaluate the effectiveness of health policy as it relates to older adults relocating to the nursing home. Therefore, the nursing profession must continue to be politically active at the state and federal levels to safeguard and increase funding for nursing and interdisciplinary research on issues related to quality of life of older adults.
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