Abstract and Keywords
The rapidly growing older population is more heterogeneous than any other age group. Although many face vulnerabilities and inequities as they age, most are resilient. This entry explores the “greying of America,” examines the definition and measurement of aging, reviews the diversity among older adults in the United States, discusses productive, successful, and active aging, and suggests leadership roles for social workers in enhancing the well-being of elders and their families.
The dramatic growth of the population age 65 and older is a demographic imperative influencing social institutions: families, workplaces, educational settings, health and mental health care delivery systems, and the leisure industry. It also has far-reaching implications for social work. Social workers in all practice arenas find themselves working with older adults and their families. This entry reviews the demographics of aging; vulnerabilities and challenges faced by older adults; emerging opportunities for active, productive, and resilient aging; and concludes with a discussion of the implications for social work. Although the ageing of the population is a global trend the focus here is on the United States.
Aging: The Demographic Imperative
The U.S. population is growing older in a trend some refer to as “the greying of America.” Today, roughly one in seven Americans is 65 or older, a ratio that is expected to rise to one in five by 2040. In 2014, those aged 65 and older comprised 14.5% of the population, compared to 4% in 1900. This figure is expected to rise to 21% by 2040. Demographers predict that older adults, who numbered 44.7 million in 2013, may number 88.5 million by 2050, effectively doubling the aged population in a span of 30 years. The population aged 85 and older, sometimes called the “oldest-old,” is the most rapidly growing age group in the United States. Their numbers are projected to increase fourfold by 2050. The population of centenarians, people age 100 or older, will also grow substantially, since baby boomers are expected to survive to age 100 at rates never before achieved. One in 26 Americans can expect to live to be 100 years by 2025, compared with only 1 in 500 in 2000 (Administration on Aging [AOA], 2016; U.S. Census Bureau, 2011B).
These demographic shifts largely reflect 20th century increases in life expectancy (average length of time that one can expect to live based on birth year). In 1900, U.S. life expectancy was about 47.3 years, while by 2013 it had risen to 78.8 years. Longevity varies by gender and race. Women typically live longer than men, and those 2013 are expected to live 81.2 years compared to 76.4 years for men. This 5-year gender difference is projected to continue well into the future (Federal Interagency Forum on Aging-Related Statistics, 2012; U.S. Census Bureau, 2011A). Pervasive racial disparities in the United States are reflected in life expectancy. So, a white child born in 2013 could expect to live 79.1 years, while an African-American child born the same year had a life expectancy of 75.5 years (National Center for Health Statistics, 2015). Gains in life expectancy have been attributed to better hygiene and clean drinking water, improved medical care, prevention of infectious diseases (vaccinations), improved working conditions, better nutrition, lifestyle changes, higher incomes, and rising education (Costa, 2005; Oeppen & Vaupel, 2002).
Population aging is a global phenomenon, occurring in most countries in the world. In 2015, the number of people 60 years and older was estimated at 901 million, or about 12% of the world’s population. By 2050, that number is projected to increase to 2.1 billion. Population ageing is occurring much more rapidly in developing countries than in developed nations, with the population over 60 expected to increase from 475 million in 2009 to 1.6 billion in 2050, when about the vast majority (about 80%) of the world’s older adults will be living in developing countries. At present, Japan has both the longest life expectancy (84 years at birth in 2012) and the highest proportion of elders in the world (32% in 2013). (United Nations, 2015)
In about twenty-six nations, most in sub-Saharan Africa, population aging has been stymied by massive deprivation. These range from Uganda and Zimbabwe, with life expectancies at birth of 59 years in 2012 to Sierra Leone, which reported the world’s shortest live expectancy (46 years at birth in 2012). Most of these countries report very small populations aged 60 and over (4% in both Uganda and Sierra Leon in 2013). Both the proportion and the absolute number of older adults in this region is expected to increase dramatically in coming decades. (World Health Organization, 2015; U.S. Department of Health and Human Services, 2007).
Age: Definitions and Measurement
Aging cannot be defined merely in chronological terms, which tend to obscure the biological, psychological, and social-cultural diversity of older adults. Arguably more relevant than chronological age, the term “functional age” refers to a combination of chronological, physiological, mental, and emotional attributes and abilities (Melzer & Lang, 2011). The concept of functional age has wide interdisciplinary applications, and has been used as the basis of holistic assessment of older adults in a range of settings. (Greene & Jones, 2007; Bradley, et al, 2000). It also has been applied more narrowly to the measurement of personal biological age. The resulting indices of fitness and frailty can more accurately predict mortality than chronological age (Graham, et al, 1999; Mitnitski, et al, 2002). Likewise, the epigenetic clock presents the tantalizing prospect of developing an index that accurately measures physical aging (Marioni et al, 2016).
Because aging is unique to each individual, older people are more diverse than other age groups. They vary more, on many dimensions. Some are employed; most are retired. Most are healthy; some are frail, Most can get around; some are homebound. Most have workable memories; some have dementia. Most live independently; a few are in nursing homes. Most rely on Social Security income; some enjoy the benefits of pensions and investments. Most men 65 and older are married; most women this age are not. Late life can be a time of accumulated advantage or, the intersection of disadvantage can leave older adults in positions of extreme vulnerability. Such is the case for one of the most economically vulnerable groups in America: older women of color. (AOA, 2014).
As adults live longer, they usually manage their chronic conditions without developing frailty or physical disability. Disability rates have declined since 2002 in all age groups 65 years and older, especially the oldest-old (Crimmins & Beltrán-Sánchez, 2010; Fuller-Thomson, Yu, Nuru-Jeter, Guralnik, & Minler, 2009; Manton, Gu, & Lowrimore, 2008). Most older adults have at least one chronic condition, with arthritis the most commonly diagnosed (46%). About a third (36%) report some type of disability. The most common is ambulatory difficulty, experienced by about 23%. Nonetheless, the vast majority of Americans over 65 able to carry out activities of daily living (ADLs include tasks like dressing, feeding and grooming) without assistance (AOA, 2014). The need for assistance with these tasks, which generally increases with age, typically determines whether older adults can remain in their homes. Although the baby boomers are healthier than prior cohorts, their sheer numbers will impose demands on the health care system. Recent estimates suggest that by 2030, about 30% of older adults may have activity limitations that require some assistance and 20% may have severe limitations. In sum, while people are living longer, many experience chronic illness and disability (Manton, Gu, & Lamb, 2006; National Institutes of Health [NIH],2011).
Elements of Diversity: Ethnicity/Race, Gender, and GLBT Identification
Ethnic minorities comprise just over 20% of the total older population (8.6% African American, 7.5% Latino, 3.9% Asian or Pacific Islander, and less than 1% American Indian or Native Alaskan) (AOA, 2014). As with the rest of the nation, ethnic minorities make up a rapidly growing portion of older adults in the United States. By 2050, older people of color are projected to increase in numbers at a rate almost 42% faster than the rate of growth in the Caucasian population. This reflects higher fertility rates among people of color, coupled with immigration patterns. Although at present people of color experience shorter life expectancy, this effect can be expected to diminish in future generations. (AOA, 2014).
Women form the fastest growing segment of the older population, especially among the oldest-old, making the aging society a largely female society: they represent 58% of the population age 65 and older and 70% of those ages 85 and older. Women at age 85 and older outnumber their male counterparts by five to two. Among centenarians the female-to-male ratio is three to one (U.S. Census Bureau, 2011B). As a result, older women are more likely than their male counterparts to live alone. Over one in three (37%) older women lives alone, compared with 19% of men. They are also more likely to rely exclusively on Social Security for their income and to live in poverty (AARP, 2016; Hess, et al, 2015).
Estimates of the number of older people identified as gay, lesbian, bisexual, and transgender (GLBT) range from as low as 3% to as high as 18–20%. This translates into at least 2 million older lesbians and gay men, a number that will likely increase to over 6 million by the year 2030 (Fredriksen-Goldsen & Muraco, 2010). The general invisibility of older adults is heightened for those who are GLBT, the most “invisible of an already invisible minority” (Blando, 2001; Gates, 2011). Some studies find that the aging experience is more difficult for GLBT adults who may experience greater social isolation and distress while others suggest that lifelong marginalization and skills in managing a stigmatized status may help GLBT elders adapt the challenges of aging (Fredriksen-Goldsen, Kim, Emlet, et al., 2011; Gabbay & Wahler, 2002; McFarland & Sanders, 2003; Thompson, 2006). The situation can be especially dire for queer individuals who enter long-term care facilities, an experience that some have described as “re-entering the closet” (O’Neill, Swan, & Mulé, 2015).
Geography and Living Arrangements
The concentration of older adults varies considerably by state, with Florida boasting the highest proportion of elders (18.7%) and Utah and Alaska the lowest, with 9.8% and 9.0% respectively. Notably, Alaska has the highest rate of growth in its senior population as residents 65 and older increased by 62% between 2003 and 2013. Like other age groups, most (81%) older adults (81%) live in metropolitan areas. Residential relocation is relatively rare; in a typical year, less than 6% of people age 65 and older move, usually within the same county, compared with nearly 17% of people under age 65. The oldest-old are most likely to relocate, often into or near their children’s homes, which is typically precipitated by widowhood, health problems, or disability (AOA, 2014; Frey, 2010).
Most older adults prefer to remain in their own home, regardless of its condition, reflecting the widespread desire to “age in place.” As a result, 96.6% of those ages 65 and older live in independent housing, which they typically own. About 28% of these people live alone. Only about 1.5 million (3.4%) of the population over 65 lived in residential facilities such as nursing homes or assisted living in 2014. Of course, the risk of admission to a nursing home increases with age, and over the course of a lifetime 35% eventually enter a nursing home (Johnson, Toohey, & Wiener, 2007). Most nursing home residents are women, and most are white. (AOA, 2014).
Education, Employment, and Economic Status
Today’s older adults are better educated than their parents. In 2014, about 84% of those 65 and older had a high school degree, compared with 28% in 1970. Another 26% of the current cohort hold bachelor’s degrees or higher. Not surprisingly, the baby boomers who began to turn 65 in 2010 and the adults currently aged 65–69 years are better educated than the oldest-old. Amidst these cohort effects, racial differences are striking. In 2014, 88% of Whites, 84% had at least a high school diploma. Because of historical patterns of discrimination in educational opportunities, 74% of older African Americans and 54% of older Latinos had completed high school (AOA, 2014). Because education so fundamentally influences economic well-being these racial differences have a major impact on poverty rates among persons of color in old age.
The 21st century has seen a reversal of a long-term trend towards reduced labor force participation by older Americans. Today more Americans are working in their later years. Many are probably working longer than they had anticipated, in part due to the effects of the Great Recession. Over one in five (22%) men 65 and over remains in labor force, and the 14% participation rate for older women is the highest the United States has ever seen. These trends, coupled with the increase in the population over 65, have resulted in a general “greying” of the U.S. labor force. (Hayutin, Beals, & Borges, 2013; Hicks & Kingson, 2009).
Older adults’ economic status generally improved following the 1935 establishment of Old Age and Survivor’s Insurance (generally known as “Social Security”). Subsequent decades saw a steady decline in absolute poverty, particularly for those who were married. The decline in relative poverty among older adults seems to have stopped in the 1980s, when Reagan’s National Commission on Social Security Reform initiated a series of cost-cutting measures. Notably, this was the same time that income inequality in the United States began its precipitous incline (Engelhardt & Gruber, 2004).
The 20th Century decline in poverty among older adults is largely attributed to Social Security benefits. Today, the program provides income to the vast majority (86%) of elders, with over a third (35%) counting on it for over 90% of their income. About 15% of older people subsist on incomes classified as “poor” or “near-poor.” Poverty rates are higher among women and elders of color (Social Security Administration, 2015; AOA, 2014).
Families and Caregiving
The family is the primary source of social support for older adults: over 90% of elders have living family members and about 60% reside in a family setting, typically with a spouse or partner. Over half (57%) of those aged 65 and older are living in the community with a spouse, while only 4% have never married. Although 80% of adults ages 65 and older have children, only about 6% of older men and 17% of women live with children, siblings, or other relatives. Significant differences exist, however, in living arrangements by gender and age. Because of women’s longer life expectancy, higher rates of widowhood, and fewer options for remarriage, only 46% of women over age 65 are married and living with a spouse as compared with nearly 72% of men. Older African Americans and Latinos are less likely than Whites to be living with a spouse (AOA, 2014; Uhlenberg, 2004).
Marital status affects living arrangements and the nature of caregiving readily available in case of illness. Marriage appears to be a protective factor, associated with physical and mental health, life satisfaction, and happiness, especially for men (Lyyra & Heikkinen, 2006). GLBT elders who have partners tend to be less lonely and enjoy better physical and mental health than those living alone (Metlife Mature Market Institute, 2006). The aging family of the future will be profoundly affected by the rising number of younger adults who are single and never-married, divorced, and single parents along with reduced fertility and smaller family size.
With increased life expectancy, multigenerational families—composed of four or even five generations—are more common now, a pattern that crosses racial and ethnic groups and social classes. The percent of Americans living in multigenerational households had declined from 1940 to 1980 to about 12% of the population. But from 1980 to 2000, such households increased by 39%. As a result, 16% of U.S. households—about 6.6 million—now encompasses three or more generations. The percent of children under 18 who lived in a household that included a grandparent increased from 8% in 2001 to 10% in 2010. The growth of multigenerational families means that some parents and children now share five decades of life, siblings perhaps eight decades, and the grandparent–grandchild bond may last three or more decades (Pew Research Center, 2010B).
Among parents ages 65 and older, 80% are grandparents, with some women being grandmothers for more than 40 years. This is because the transition to grandparenthood typically occurs in middle age, not old age, so about 50% of grandparents are younger than 60 years. As a result, there is wide diversity among grandparents, who vary in age from their late 30s to over 100 years old, with grandchildren ranging from newborns to retirees. Most grandparents derive great satisfaction from interaction with grandchildren (Pew Research Center, 2010B; Reitzes & Mutran, 2004).
Grandparents have traditionally provided care for grandchildren, especially within families of color and immigrant families (Cox, 2002). Since the mid-1990s there has been a dramatic increase in the number of grandparents who assume primary responsibility for their grandchildren. With almost 2.9 million custodial grandparents providing such care, skipped-generation households—the absence of the parent generation—are currently the fastest growing type. This means that about 7.8 million children live in households headed by grandparents or other relatives. Custodial grandparenting crosscuts social class, race, and ethnicity. The majority of sole grandparent caregivers are White (53%), but Latinos (18%) and African Americans (24%) are disproportionately represented, given their percentage of the total population. In most instances, the parents—an invisible middle generation—are absent because of substance use or incarceration. Most custodial grandparents are women, even among older couples, and are younger than 65; the 30% who are age 65 and older typically deal with age-related changes along with the emotional stress of feeling alone and isolated from age peers.
Grandparent caregivers have been called the “silent saviors” of the family; in addition to a greater likelihood of living in poverty, they face numerous legal, health-care, and financial barriers. These challenges are even greater for grandparents who are raising a chronically ill or “special needs” child. (Generations United, 2012; Hayslip & Kaminski, 2005; Kropf & Yoon, 2006; Musil, Warner, Zauszniewski, Jeanblanc, & Kercher, 2006; Pew Research Center, 2010A).
Generally, families maintain a pattern of reciprocal support between older and younger members, with older adults providing support to children and grandchildren as long as they are able (Silverstein, Conroy, Wang, Giarrusso, & Bengston, 2002). As another example of this pattern, increasing numbers of elders are providing care for their adult children with developmental disabilities or mental illness who are now living longer (McCallion, 2006).
The reciprocal nature of caregiving shifts as more adults—especially the oldest-old—live longer with chronic illness and seek to remain in the community. Families, who provide most of this care, are a significant factor influencing whether an older adult will live in a long-term care facility or at home. Over 80% of older adults with limitations in three or more ADLs are able to live in the community, primarily because of family assistance; moreover, 66% of older people who receive long-term services and supports at home get all their care exclusively from family members. Informal caregiving has been shown to help delay or prevent the use of skilled nursing home care. The economic value contributed by family caregivers to society is estimated to be $450 billion, far more than the total expenditures for formal services. Family caregivers, then, constitute a large and often overlooked component of the American economy and systems of health care and long-term services and supports (Feinberg, Reinhard, Houser, & Choula, 2011; Gonyea, 2008; Hargrave, 2008; Raphael & Cornwell, 2008; Van Houtven & Norton, 2008).
Among caregivers, about 36% care for a parent and about 23% for a partner. Women form about 66% of the caregivers who have primary responsibility, providing more hours of assistance than their male counterparts. Women are more likely to provide emotional support and personal care, while men assist with instrumental tasks such as transportation, home maintenance, and finances. The average caregiver is 47 years old, female, married, earning an income outside the home of $35,000, and has performed their role for 4.6 years, devoting 25 hours per week of care (Family Caregiver Alliance, 2009). Caregiving for elders occurs across the life course, however; a growing number of young caregivers, age 8–18, are helping a parent or grandparent and caregivers who are in their 60s or even 70s are caring for centenarians (NAC & AARP, 2009).
Although there are gains from caregiving, the physical and mental health, financial and emotional costs of care—conceptualized as objective and subjective burden—generally exceed the benefits, and approximately 30% of caregivers experiencing stress or burden. Caregiving is associated with a range of illnesses, including higher rates of depression, anxiety, heart disease, and even mortality (Feinberg et al., 2011; Pinquart & Sorenson, 2006). Financial costs include the direct costs of medical care, adaptive equipment, or hired help and as indirect opportunity costs of lost income, missed promotions, or unemployment. Averaging 12 years out of the paid workforce to provide care to family members, women suffer long-term economic costs of caregiving, including higher rates of poverty in old age. The caregiver’s appraisal of the situation or subjective burden, such as feeling alone and overwhelmed, is more salient than objective burden or the actual tasks performed. On the other hand, living with the care recipient, being a woman, coping with an elder’s behavioral problems, especially those associated with dementia, and long hours of intensive levels of care are associated with increased caregiver stress (Family Caregiver Alliance, 2009; Family Caregiver Alliance & National Center on Caregiving, 2011).
Children and partners typically turn to skilled nursing care as a “last resort” when faced with their own illness or severe family strain. Although most caregivers do not use formal services, psycho-educational programs, support groups, and respite care are relatively effective interventions in reducing caregiver stress, all of which have implications for social work roles (Belle et al., 2006; Gonyea, Connor, & Boyle, 2006; Kuhn & Fulton, 2004; Mittelman, Roth, Coon, & Haley, 2004; Parker, Mills, & Abbey, 2008; Zarit & Femia, 2008).
Vulnerabilities and Challenges of Aging
Inequities Across the Life Course
The concept of life course is central to understanding the vulnerabilities faced by some groups of elders. A life course approach captures how earlier life experiences and decisions affect options in later life and for future generations within and across cultures and time. It recognizes that gender- and race-based inequities, which limit opportunities earlier in life, are intensified in old age, resulting in increased economic and health disparities and cumulative disadvantage for older women and persons of color. Gender, ethnic minority status, sexual orientation, low educational and socioeconomic levels, and increased age are all associated with reduced social capital and increased health difficulties (Ferraro, Shippee, & Schafer, 2009; George, 2007; O’Rand, 2006; Williams, 2005). Nevertheless, many older adults who have experienced cumulative disadvantages demonstrate resilience and optimism.
The overall economic status of older people masks higher rates of poverty among women, elders of color, the oldest-old, and those living alone. Older women (11.6%) are more likely to be poor than men (6.8%). Older African Americans (17.6%) and Latinos (19.8%) are far more likely to be poor than Whites (7.4%) (AOA, 2014). Women and persons of color are least likely to have held jobs with private pensions and most likely to depend on Social Security as their primary source of income. Because of economic, family caregiving, and health disparities experienced across the life course, older women, elders of color, and the oldest-old are also most likely to experience disabling illness and inadequate housing (Ferraro et al., 2009; Johnson & Wilson, 2010; Walker, 2009). Chronic disability magnifies the risk of poverty throughout the life course. When the intersections among structural variables are examined, it is not surprising that poor women of color age 85 and older have the highest prevalence of multiple chronic illnesses and functional limitations (Centers for Disease Control and Health Promotion [CDC], 2010; Whitfield, Angel, Burton, & Hayward, 2006; Williams, 2005).
Physical and Mental Challenges
Typical aging involves coping with a range of physical, mental, and emotional challenges. Many, particularly those with sedentary lifestyles, experience declines in muscle mass that are often referred to as “sarcopenia” (von Haehling, Morley, & Anker, 2010). Sexual functioning also changes in later life, with common difficulties that can make intercourse unpleasant. These may include: diminished interest, erectile dysfunction, and thinning and drying of the vaginal tissues (Laumann, Das & Waite, 2008). While our understanding of brain plasticity underscores the ability of older adults to learn and develop new skills, later life does bring delayed reflexes and slower information processing (Erickson, Gildengers, & Butters, 2013).
More than 80% of persons age 65 and older have at least one chronic disease, and 66% have multiple illnesses. The most common chronic conditions, which limit the functional abilities of older adults, are arthritis, heart disease, and hypertension. Heart disease, cancer, and strokes account for more than two-thirds of all deaths among people age 65 and older (CDC, 2010; Federal Interagency Forum on Aging-Related Statistics, 2012).
Heart disease is the number-one risk factor among adults age 65 and older, killing 40% more people than all forms of cancer combined, and accounting for 20% of adult disabilities, with the highest rates among the oldest-old and among African Americans (American Heart Association, 2012). Disabling chronic diseases tend to occur earlier among African Americans, Latinos, and American Indians than among Whites. Comorbidity—coping with two or more chronic conditions—is a concept central to understanding health status and its secondary consequences, such as depression and anxiety, and is more common in older women and elders of color than in Caucasian men.
Normal aging does not result in significant declines in intelligence, learning, and memory, though age-related changes can affect the speed of information processing. The prevalence of mental illness among older adults ranges from 15 to 25%, and is generally higher among those living in institutional settings. In some instances, these mental illnesses have been present throughout a person’s life course, while others have their onset in old age. Most older adults with chronic mental illness live in the community but fewer than 25% of those who need mental health services ever receive treatment, a pattern across all service areas (Gellis, 2006; Kaskie & Estes, 2001).
Anxiety and depression are the most common mental illnesses in late life, with minor depression estimated to be as high as 10 to 30% among community-dwelling elders (Gellis, 2006; SAMSA, 2011). Rates of depression are highest among women, those lacking social supports, and low-income elders (Blazer, 2003; Mitchell & Subramaniam, 2005). Depression often coexists with medical conditions such as heart disease, stroke, arthritis, cancer, diabetes, chronic lung disease, and Alzheimer’s disease, compounding dysfunction and delaying the recovery process.
Depression often goes undiagnosed (and therefore untreated) among older people. Its symptoms can differ from those experienced by younger adults, often presenting as somatic, rather than affective concerns. Further, given the stigma associated with mental illness, many elders prefer to mask or deny their symptoms. When properly diagnosed and treated, most (60% to 80%) older adults with late onset depression experience a reduction in their symptoms. Several evidence-based practices have been identified for late-life depression, including psychotherapeutic interventions and antidepressant medications (SAMSA, 2011).
The prevalence of irreversible dementia increases with advancing age. Among those 71 to 79 years of age, approximately 5% experience dementia. This risk increases to 18% among those aged 80 to 89, and 37% among those 90 and older (Plassman, et al, 2007). There is some evidence to suggest that rates of dementia are declining in the United States. Absent significant medical breakthroughs; however, the number of dementia cases is expected to rise with of the older population (Hurd, Martorell, & Langa (2015). Alzheimer’s disease (AD), the most common dementia in late life, accounts for 60 to 80% of all dementias.
Although the majority of elderly people live with others, about 19% of men and 35% of women age 65 and older live alone; after age 75, these rates increase. Those living alone are most likely to be women, elders of color, the oldest-old, low-income, and in rural areas (AOA, 2014). Among those living alone, the most vulnerable are the homeless. Homeless elders (defined as age 55 and older because they are often 10 to 20 years older physiologically than their chronological age) comprise 8 to 10% of the homeless population (Sermons & Henry, 2010). Those living alone and the oldest-old are most vulnerable to being placed in nursing homes, assisted living, adult family homes, and hospitals. Among older age 95 and older, 25% are skilled nursing facilities, for example, (U.S. Census Bureau, 2011C).
“Productive,” “Successful,” or “Active” Aging
With the aging of the baby boomers, who may live a third of their lives in a healthier and more financially secure retirement than previous cohorts, increasing attention is given to concepts of productive aging and civic engagement. These concepts recognize that elders are our society’s most underutilized asset, with wisdom, skills, and life experience to contribute to addressing social problems. This has translated into growing numbers of civic engagement initiatives, such as voluntarism, intergenerational programs, and cross-generational political advocacy, which are typically associated with higher life satisfaction (Freedman, 2011; Metlife, 2008).
Another widely used concept is successful aging, defined as a combination of physical and functional health, high cognitive functioning, and active involvement with society. However, this concept tends to convey a middle-age, middle-class norm of busyness that is often associated with age-denial.
The concepts of productivity, civic engagement, and successful aging implicitly assume that all elders have resources to age successfully and be productive, such as volunteering. They tend to overlook structural constraints, such as unhealthy communities, limited employment options, and daily preoccupation with economic survival, that prevent choosing healthy lifestyles.
An emphasis on activity characteristic of mainstream Western culture may also overlook elders—often from other cultures—who are spiritual and contemplative, and experience a high degree of subjective well-being. A narrow definition of successful aging can be stigmatizing to older adults with chronic illness who develop strategies to compensate for their functional disabilities and experience quality of life. Instead, models of successful aging need to recognize that older adults may experience subjective well-being, engage in personally meaningful activities, and “age well,” even though they may not be classified as successful in terms of external factors (George, 2006).
Because of class, race, and gender biases implicit within successful aging, the concepts of active aging and resilience may be more useful for conceptualizing elders’ strengths (for example, internal, family, social, community, and cultural capacities) when faced with adversity. In fact, many older adults find meaning in their lives because of adversity, not despite it. Even when impaired, they may contribute to society in diverse ways (Fredriksen-Goldsen, 2006; Zarit, 2009).
The concept of “active aging” is relevant to culturally and economically diverse populations since it focuses on improving quality of life for all people, including those who are frail, disabled, or require assistance. It is consistent with the growing emphasis on autonomy and choice with aging, regardless of physical and mental decline, that benefits both the individual and society. The determinants of active aging include individual behaviors, personal characteristics, the physical and social environment, structural variables such as gender and race, economic security, and access to and use of health and social services across the life course (WHO, 2002).
Both policies and social environments need to be modified so that all adults have opportunities to be productive in the broadest sense of the term (Hendricks & Hatch, 2006; Kahn, 2003; Martinson & Minkler, 2006; Wray, 2003). The World Health Organization’s initiative, “Global Age-friendly Cities,” aims to help communities throughout the globe eliminate barriers to engagement of older adults (WHO, 2007).
Social Work’s Contribution
With global aging, the need for social workers with gerontology expertise is rising. The U.S. Department of Labor Statistics reports a growing demand for social workers to serve the aging population in the United States, particularly in healthcare settings (Bureau of Labor Statistics, 2015). In this context, social workers often serve on hospital ethics committees, where they assist in sorting out the complex ethical considerations that can arise in relation to patient care, particularly at the end of life (Allen, 2011). This has been an important and expanding social work role since 1992, when the Joint Commission on the Accreditation of Health Care Organizations required establishment of these committees (Csikai, 1998).
Most American social workers have at least some older clients. In a national study of licensed social workers in the United States, 78% reported having any older adult clients, while a quarter reported that older adults made up more than half of their client population. Only 9% indicated aging as their primary practice area. Notably, younger social workers in the study were less likely to report that they served older adults. Social workers who work primarily with older adults often deal with medical conditions (both chronic and acute), as well as psychosocial stressors, physical disabilities, and cooccurring conditions. They are less likely than those serving other age groups to report dealing primarily with psychological problems (National Association of Social Workers, 2006).
The opportunity and challenge for social work, with its social justice mission, is to address both positive aging and the life course inequities faced by women, persons of color, and GLBT individuals (Rowan & Giunta, 2014). With its person-in-environment perspective and strengths-based values, social work is well placed to advocate for structural and policy changes to reduce inequities and defend the social safety net for vulnerable elders.
As the primary providers of mental health services, social workers are also central to addressing depression, substance abuse, and elder mistreatment. They are often the lead professionals supporting multigenerational families by providing psychosocial interventions to reduce the stress of cross-generational caregiving across the life course. Social work assessments are strengths-based and take account of the needs of the total caregiving system, not just the elder person. Similarly, social workers can provide leadership in developing and testing innovative models of integrated care or service delivery and interventions with caregiving dyads.
As more adults live longer with disability, social workers are central to community-based models for chronic disease management and to fostering the social supports essential to support health-promoting behaviors. Similarly, social workers, with their value of self-determination and dignity, play vital roles in changing the culture of care of institutional settings to be resident-centered and to empower the direct care staff. Social workers also can facilitate the use of assistive technology, including computer-based options, along with informal social networks to enable elders to remain in their homes. In times of shrinking public resources and increasing societal and moral issues affecting all ages, social workers can foster intergenerational alliances that crosscut traditional age-based approaches to services. And most important, social workers, by building on the strengths of all elders, even those with limited functional disability, continually reaffirm the dignity and worth of older adults.
Administration on Aging: http://www.aoa.gov
Alzheimer’s Association: http://www.alz.org
American Society on Aging: http://www.as.aging.org
Association for Gerontology Education in Social Work: http://www.agesocialwork.org
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