HCA415 Community & Public Health-WK2-A1

Chapter 6 Young Adults, Older Adults, and the Elderly

6.1 Introduction

The National Research Council (NRC) and the Institute of Medicine (IOM) stated in 2013 that

[t]he United States is among the wealthiest nations in the world, but it is far from the healthiest. Although life expectancy and survival rates in the United States have improved dramatically over the past century, Americans live shorter lives and experience more injuries and illnesses than people in other high income countries. (Woolf & Aron, 2013, p. 1)

Examples of high-income countries (peer countries) used for comparison in the IOM report were 16 nations that included countries such as Australia, Canada, France, Germany, and Japan. In comparison with citizens of almost all these peer countries, Americans had a shorter life expectancy; during the recent 30-year period, this discrepancy in life expectancy increased. Other health areas in which the United States compared unfavorably were infant mortality, death rates for injuries, and occurrence of sexually transmitted infections among adolescents. Mortality rates for heart disease and chronic lung disease tended to be higher in the United States as well. Finally, Americans have the highest levels of obesity in comparison with peer countries.

As noted in the joint report from the NRC and the IOM, the United States lags behind other developed countries with respect to life expectancy. In a similar vein, Healthy People 2020 affirmed that

[l]ife expectancies are one of the most commonly used measures for international health comparison. In 2007, the United States ranked 27th and 26th out of 33 countries within its peer group of Organization for Economic Co-operation and Development (OECD) countries for life expectancy at birth for females and males, respectively. (HealthyPeople.gov, 2011, para. 2)

In 2009, the overall U.S. life expectancy was 78.5 years, which was a record high value, but still below the level achieved by other developed countries. For example, in Canada, life expectancy was about 81.5 years, or 3 years higher than in the United States (Central Intelligence Agency, 2012). Among the causes for the reduced life expectancy of the U.S. population is the persistence of modifiable risk factors for preventable chronic diseases and unintentional injuries. Another contribution is the poor health status of demographic subgroups such as non-White communities that must confront health-related disparities.

This chapter examines demographic and health-related characteristics of adults and the elderly in the United States. In this analysis, the text will subdivide the adult population into younger adults and older adults, who have somewhat differing patterns of morbidity and mortality. For the purposes of this chapter, the young adult group comprises persons between the approximate ages of about 20 through 40. By definition, young adults at the beginning of this age range have transitioned recently from the formative teenage years to adult responsibilities connected with obtaining higher education or occupational proficiency, becoming established in a career, finding independent living arrangements, and establishing families.

Young adults are generally healthy in comparison with older age groups, but they experience adverse health outcomes from harmful behavioral and lifestyle influences. Health issues for this group include communicable diseases, sexually transmitted infections, suicide and homicide, unintentional injuries, and substance-related behaviors—for example, cigarette smoking, binge drinking, and nonprescription drug use.

This chapter defines older adults as those between the ages of about 40 to 45 years to around 64 years. Although about one half of older adults perceive their health status as excellent or very good, many older adults are afflicted by circulatory diseases, cancer, arthritis, diabetes, and other chronic diseases. Cancer is the leading cause of mortality among persons aged 45 to 64 years.

The "baby boomer" generation encompasses persons born between 1946 and 1964 and makes up about a quarter of the U.S. population. According to a study that appeared in JAMA Internal Medicine, baby boomers' health in some respects is poorer than that of the generation that came before them (King et al., 2013). "Despite their longer life expectancy over previous generations, US baby boomers have higher rates of chronic disease, more disability, and lower self-rated health than members of the previous generation at the same age" (King et al., 2013, p. 386). Members of the baby boomer generation are more likely to be afflicted with high blood pressure, high cholesterol, diabetes, and obesity.

Demographic trends point to the increased life expectancy and aging of the U.S. population. The elderly are the fastest-growing demographic in this country. The proportion of elderly persons (i.e., those 65 years of age and over), has continued to expand since the end of the 20th century. The growing number of elderly individuals impacts the health of a community.

In comparison with previous generations, elderly persons are becoming increasingly active. The "golden years" hold the promise of being one of the most fulfilling stages of life; yet this time of life is confronted with age-associated mortality and morbidity. Unique health challenges arise from debilitating conditions such as dementia, injuries from falling, loss of functional status, and the need for caregiving. Forward-thinking and progressive communities can make supportive interventions and living arrangements available to improve the quality of life of elderly persons. In Section 6.5: Aging and Community Health, we will present the Healthy People 2020 objectives for the elderly. As of this writing, objectives specifically for young adults and older adults were not available.

6.2 Overview of Demographic Trends

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The U.S. population is an aging one. By 2030, about 20% of the population is expected to be 65 or older.

The study of demographic trends—changes in the age and sex composition of the population—helps one to learn about trends in the future makeup of the population. The Census Bureau indicates that "[u]nderstanding a population's age and sex composition yields insights into changing phenomenon and highlights the future social and economic challenges" (Howden & Meyer, 2011, p. 1). Future alterations in the age and sex compositions of the population of the United States will produce numerous challenges to community health from the effects of an aging population, the ratio of males to females, and the influences of racial and ethnic makeup.

Since Census 2000, the population of the United States has continued to age, reaching a median age of 37.2 years in 2010. Figure 6.1 shows the age distribution and median age of the U.S. population from 1960 to 2010. The Census Bureau reports that the population growth rate among older ages was faster than among younger ages. In 2010, a total of 13% of the population was 65 years of age and older. By the year 2030, approximately 20% of the population will be in this age range. The median age of the population varies by U.S. state as shown in Figure 6.2; in many states, the median age in 2010 was over 40 years of age.

Figure 6.1: U.S. population: Age distribution and median age, 1960 to 2010

Source: Adapted from United States Census Bureau. (2011, May). 2010 Census Briefs. Retrieved from http://www.census.gov/prod/cen2010/briefs/c2010br-03.pdf

The aging population is increasing at a much faster rate than the youth population, which will shift the focus of community and public health in the next few decades.

Figure 6.2: U.S. population: Median age by state, 2010

Source: Adapted from Howden, L. M., & Meyer, J. A. (2011). Age and sex composition: 2010. 2010 Census Briefs, p. 8. Retrieved from http://www.census.gov/prod/cen2010/briefs/c2010br-03.pdf

Sex and Age Composition of the Population

Table 6.1 presents data on the total numbers in the U.S. population by sex and age group. Between 2000 and 2010, the population increased from 281 million persons to 308 million persons. In 2010, the sex distribution of the population was 50.8% female versus 49.2% male. A total of 112.8 million persons (36.5%) were between the ages of 18 and 44 years, and 81.5 million persons (26.4%) were from 45 to 64 years old. Those aged 65 and over represented 40.3 per million persons, or 13.0% of the population. The population increased in all age groups except among persons aged 25 to 44 years; this population decreased by 3.4%.

Not shown in the table is information about the sex distribution of the U.S. population by age. Data from the 2010 census indicate that among younger persons there were more males than females; in contrast, among older age groups, the reverse was true. For example, among those age 75 years and over, there were 11,288,000 females in comparison with 7,266,000 males.

Racial and Ethnic Composition of the Population

The racial and ethnic composition of the U.S. population is diverse and is continuing to increase in diversity (United States Census Bureau, 2012). In the 2010 Census, race was measured by a question that asked respondents (both native-born and immigrants) to self-identify their racial and/or ethnic group membership. The fastest-growing population group over the decade immediately before 2010 was Asians, who increased by 43% between 2000 and 2010. There were 14.7 million persons classified as Asian (Asian race alone). "'Asian' refers to a person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent, including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam" (Humes, Jones, & Ramirez, 2011, p. 3). The totals for the Asian population included immigrants as well as native-born individuals.

The Hispanic population also grew rapidly and totaled 16% of the population in 2010. "'Hispanic or Latino' refers to a person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture regardless of race" (Humes et al., 2011, p. 2). The Black population increased by 12.3%, reaching 12.6% of the total population in 2010. The subgroup with the slowest rate of percentage growth between 2000 and 2010 was the White population (White race alone), with an increase of 5.7%. The proportion of the total population contributed by Whites declined from 75.1% in 2000 to 72.4% in 2010.

6.3 Young Adults

The health of young adults is an understudied topic in comparison with the health of other age groups (Park et al., 2006). Healthy People 2020 stresses the need to address important public health and social problems such as homicide, suicide, and motor vehicle crashes among young adults in the United States (HealthyPeople.gov, 2012).

The youngest members of the young adult group (those in their early 20s) often are included inappropriately with adolescents for discussions of health characteristics. Young adults should be considered as a separate group from adolescents because of the unique changes they are experiencing in their environment as they transition to the roles and responsibilities of adulthood. For example, young adulthood is a time of graduating from college or completing an occupational education program. At this stage of life, young people may choose to live independently from their parents. This is also the time when many young adults marry, start families, and embark on careers.

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Young adults comprise individuals in the 20–40 age range. Many of the behaviors developed in adolescence carry over into young adulthood at the same time as an array of new life experiences begin to affect patterns of morbidity and mortality.

Nevertheless, some of the health-related issues similar to those that arose during adolescence continue to impact young adults. And adverse health trends that began during adolescence often tend to peak during early young adulthood. These issues include unintentional injuries, pregnancy and reproductive health, use of substances, adverse mental health outcomes, experience of violence and homicide, becoming overweight, and utilization of health care. Also relevant is the continuing impact of infectious diseases (especially vaccine preventable diseases) and sexually transmitted infections.

Morbidity and Mortality Patterns

The death rates for young adults are intermediate between those of teenagers and older adults. For young adults in 2009, the death rate among persons who were 20 to 24 years old was about half that of persons in the older ranges of the young adult continuum (35 to 44 years old). Among young adults aged 20 to 24 years, 25 to 34 years, and 35 to 44 years, the death rates were 87.7 per 100,000, 102.3 per 100,000, and 179.8 per 100,000, respectively (Heron, 2012). The overall age-adjusted death rate in the United States was 741.1 deaths per 100,000. In Chapter 2, the crude (unadjusted) death rate was defined as the number of deaths during a given year divided by the size of a reference population (for example, the population of the United States) during the midpoint of the year. An alternative measure is the age-adjusted death rate, which is a measure of mortality in a population in which statistical procedures have been applied to permit fair comparisons across populations by removing the effects of age differences (Friis & Sellers, 2009). Crude death rates do not allow for such fair comparisons.

Figure 6.3 portrays the leading causes of death among young adults in three age groups. Continuing the trend observed among teenagers, unintentional injuries were the leading cause of death among young adults in 2010. Intentional injuries (suicide and homicide) were ranked in second and third place among young adults who were 20 to 24 and 25 to 34, and in fourth and fifth place for adults aged 35 to 44 years. Among this older age group, malignant neoplasms and heart disease were the second and third leading causes of death; these causes were in fourth and fifth place for adults who were 20 to 24 years and 25 to 34 years. Causes of mortality related to complications of pregnancy were among the 10 leading causes of death among adults aged 20 to 24 years, but not among persons aged 25 to 34 years and 35 to 44 years. HIV infections (for example, AIDS-related complications) were ranked among the 10 leading causes of death for all three young adult age groups.

Figure 6.3: The 10 leading causes of death among adults in the United States, 2010

Source: Adapted from CDC, Leading causes of death reports, national and regional, 1999–2010. Retrieved from http://www.cdc.gov/injury/wisqars/index.html

What sorts of public health programs can address the leading causes of death? How can they be tailored to the specific age group affected?

The following sections provide more detailed information on three leading mortality causes that affect young adults:

• Unintentional injuries including motor vehicle crashes

• Intentional injuries (e.g., homicide and suicide)

• HIV infection (for example, AIDS-related complications).

Unintentional Injuries

Injuries are the leading cause of death in the United States for people under the age of 45; adolescents and young adults have the highest injury rates of all age groups. Refer to Figure 6.4 for a description of the 10 leading causes of all injury deaths among young adults aged 20 to 39 years in 2010. Of a total of 51,435 injury deaths, the three leading causes of injury deaths were unintentional poisoning, unintentional motor vehicle traffic deaths, and homicide deaths from firearms.

Figure 6.4: The 10 leading causes of all injury deaths among young adults aged 20 to 39 years, 2010

Source: Adapted from CDC, Leading causes of death reports, national and regional, 1999–2010. Retrieved from http://www.cdc.gov/injury/wisqars/index.html

Almost 50% of injury-related youth deaths are caused by unintentional accidents involving poisoning or motor vehicles.

Injuries are categorized as unintentional and intentional. Unintentional injuries are those that occur when there is no deliberate intention for self-harm or harming other people. Examples of unintentional injuries are motor vehicle traffic injuries, drowning, falls, sports-related injuries, burns, animal bites, poisonings, and unintentional injuries from use of firearms.

Figure 6.5 shows the distribution of unintentional injury deaths among young adults. Persons aged 20 to 39 years sustained 29,322 unintentional injury deaths in 2010. Among young adults, the leading cause of unintentional injuries was unintentional poisoning (12,700 deaths), followed by motor vehicle traffic injuries (11,930) and drowning (in third place with 1,018 deaths). Among persons of all ages in the United States, there were about 32,000 unintentional poisoning deaths (CDC, 2012f). More than 90% were from drug overdoses, most frequently pain medications.

Figure 6.5: The 10 leading causes of unintentional injury deaths among young adults aged 20 to 39 years, 2010

Source: Adapted from CDC, Leading causes of death reports, national and regional, 1999–2010. Retrieved from http://www.cdc.gov/injury/wisqars/index.html

More than 80% of unintentional injury deaths among 20- to 30-year-olds in 2010 were the result of poisoning or traffic accidents.

Motor vehicle crashes cause fatalities among drivers and their passengers as well as among pedestrians and bicyclists who are struck by cars. For all ages, the dominant cause of unintentional injuries in the United States was motor vehicle traffic injuries: a total of 33,687 deaths in 2010.

Table 6.2 gives information on crude death rates for unintentional motor vehicle traffic deaths by age group. The 2007 data for unintentional motor vehicle traffic deaths revealed that among all young adults, there were 15,523 deaths with a crude rate of 19 per 100,000. Persons aged 20 to 24 years had the highest crude rate (26.9 per 100,000) of unintentional motor vehicle traffic deaths; the rate decreased with increasing age group.

Intentional Injuries

An intentional injury is an injury caused willfully (on purpose). Intentional injuries are associated with community violence, youth violence (for example, bullying and gang violence), school violence (such as the 2012 shooting at Sandy Hook Elementary School in Newtown, Connecticut), homicide, sexual violence, and suicide (Emory University, 2013). The causes of intentional injuries include assault, suffocation, ingestion of poisons, discharge of firearms, and cutting/piercing. Figure 6.6 shows the distribution of violence-related injury deaths among young adults. Violence-related injuries caused 20,414 deaths in 2010. Homicides by firearm accounted for 6,603 deaths. There were a total of 5,336 suicides by firearm; 3,897 suicides by suffocation; and 1,610 suicides by poisoning.

Figure 6.6: The 10 leading causes of violence-related injury deaths, United States, 2010

Source: Adapted from CDC, Leading causes of death reports, national and regional, 1999–2010. Retrieved from http://www.cdc.gov/injury/wisqars/index.html

Firearm-related deaths comprise over 50% of injury-related deaths. What public health initiatives might address the high-level of firearm-related deaths? In what ways might these initiatives translate into public policy?

HIV Infection

Infection with the human immunodeficiency virus (HIV) was among the 10 leading causes of death for young adults in 2010. HIV infection was the eighth leading cause of death for young adults aged 20 to 24 and 35 to 44, and ranked sixth among 25- to 34-year-olds. In 2009, HIV was responsible for 3,433 deaths among adults who were 20 to 44 years of age (CDC, 2011g). During 2009, a total of 39% of new HIV infections developed among children and young adults, aged 13 to 29 years. The highest incidence of HIV infection among all age groups in the United States occurred among young adults aged 20 to 24 years. The incidence rate for this age group was 36.9 cases per 100,000. Table 6.3 presents diagnoses of HIV infections by 5-year age groups for young adults.

Infectious Diseases

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Vaccinations—including the HPV vaccine—continue to be important methods of health protection for young adults.

Although some young adults might think that they are invulnerable to infectious diseases, these conditions are important determinants of morbidity (and occasionally mortality) for persons in this age group. Young adults continue to need to be protected against vaccine preventable diseases such as meningitis, influenza, and several other conditions. A serious bout with a vaccine preventable infectious disease can possibly be life threatening, produce disabilities, or, at the very least, limit the activities of young adults. Sexually transmitted infections are another group of epidemiologically important infectious diseases for young adults.

Bacterial Meningitis and Other Vaccine Preventable Diseases

The CDC states that bacterial meningitis, or meningococcal disease, "is a bacterial infection caused by the agent Neisseria menigitidis" (Cohn et al., 2013, p. 4). The symptoms of this condition include a fever that begins suddenly and is accompanied by nausea, severe headache, and frequently vomiting and a stiff neck, and sometimes a rash (Heymann, 2008). Untreated meningitis is fatal in about one half of cases. Treatments with antibiotics and supportive medical care have reduced the percentage of fatal cases. Nevertheless, approximately 8% to 15% of persons who receive treatment die, and as many as 20% of the survivors may develop complications such as cognitive deficits. On average, 800 to 1,200 cases of meningococcal disease occurred each year in the United States between 2005 and 2011.

High rates of meningococcal disease occur among adolescents and young adults aged 16 to 21 years in comparison with other age groups. For this reason, all persons aged 11 through 18 years and college freshmen aged 19 to 21 years should receive routine administration of a vaccine for meningococcal disease. The recommended vaccine is the meningococcal conjugate vaccine (MCD4), known as a quadrivalent vaccine and licensed in 2005 (Immunization Action Coalition, 2012). Neisseria menigitidis has several subtypes; currently available vaccines—quadrivalent vaccines—protect against four of these subtypes (called A, C, Y, and W-135), but not against subtype B, which causes about 33% of meningitis cases in the United States.

Persons at risk for meningococcal disease are those who have chronic illnesses; are exposed to secondhand cigarette smoke; share drinking glasses and utensils; come from low socioeconomic backgrounds; or live in crowded conditions. A study of college students found that freshmen who reside in college dormitories have an increased risk for meningitis in comparison with other college students (Cohn et al., 2013). Consequently, all first-year college students who reside in dormitories should receive an immunization. Moreover, college students who live in dormitories should recognize the common indicators of meningitis as described in the previous paragraph and seek treatment if they experience these symptoms. Consult the website "Voices of Meningitis" to learn about the real-life experiences of persons who were affected by meningitis at http://www.voicesofmeningitis.org/index.html.

In addition to meningitis, other important vaccine preventable diseases for young adults are tetanus, diphtheria, whooping cough, seasonal influenza, and infections with the human papilloma virus (HPV) (CDC, 2012g). See Spotlight: Vaccines Recommended for Young Adults Ages 19–24 for a list of recommended vaccines for young adults.

Spotlight: Vaccines Recommended for Young Adults Ages 19–24

Meningococcal conjugate vaccine Helps prevent meningococcal disease (bacterial meningitis)—sometimes may be required for college freshmen

Tdap vaccine Protects against tetanus, diphtheria, and pertussis (also known as whooping cough)

HPV vaccine Protects against the human papillomavirus (HPV), the virus that causes most cervical cancers, anal cancer, and genital warts

Seasonal flu vaccine Protects against seasonal influenza

Source: Adapted from Vaccines.gov. (n.d.). College & young adults. Retrieved from http://www.vaccines.gov/who_and_when/college/

Sexually-Transmitted Infections (STIs)

Adolescents (aged 15 to 19 years) and young adults (aged 20 to 24 years) have a greater risk of developing STIs than adults in older age groups (CDC, 2011a). Possible explanations for this increased risk are biologic, sociocultural, and behavioral factors. An example of one of the possible behavioral factors is unprotected sexual activity with multiple partners. In addition to HIV, three STIs that have a higher incidence among young adults in comparison with older adults are chlamydia, gonorrhea, and syphilis. In 2010, incidence rates of these STIs were highest among persons aged 20 to 24 years in comparison with other adolescent and young adult age groups. (Refer to Figure 6.7.)

Figure 6.7: Chlamydia, gonorrhea, and syphilis rates per 100,000 among adolescents and young adults, 2010

Source: Data taken from Centers for Disease Control and Prevention. (2011a). 2010 sexually transmitted diseases surveillance, STDs in adolescents and young adults. Retrieved from http://www.cdc.gov/std/stats10/adol.htm

Behavioral Risk Factors for Morbidity and Mortality

A significant proportion of the causes of morbidity and mortality among young adults have strong associations with behavioral risk factors linked with adverse lifestyle choices. Research has confirmed the important role of individual health behaviors in early mortality and morbidity (CDC, 2013a). The Behavioral Risk Factor Surveillance System (BRFSS) collects nationally representative, state-based data on behavioral health risk factors. In 2011, more than half a million interviews were obtained from U.S. adults.

Two examples of behavioral risk factors are binge drinking and cigarette smoking, both of which are important for young adults in terms of these factors' direct and indirect contributions to morbidity and mortality. In addition, a third behavioral risk factor involves risks for sexually transmitted infections (STIs). These risks increase as interpersonal relationships become less familiar and exclusive. For example, risky sexual behavioral lifestyle choices include the following: having a few or multiple anonymous sexual partners or having multiple familiar sexual partners. These examples contrast with a lifestyle that involves a monogamous sexual relationship during one's lifetime, or a lifestyle characterized by sexual abstinence or celibacy. (Note that behavioral risk factors for chronic diseases are discussed in more detail in Chapter 8.)

Young adulthood is a developmental stage with increased opportunities for adoption of deleterious lifestyles. Most persons in the early years of adulthood are entering a phase during which they achieve increased autonomy. For example, many young adults who enroll in college live independently for the first time. Greater autonomy increases the opportunity for exposure to new risk factors, particularly engaging in unprotected sexual activity, consumption of alcohol, use of illegal drugs, and abuse of prescription medicines (CDC, 2012c). Examples of drugs that college students might use are marijuana, cocaine, hallucinogens, and inhalants such as nitrous oxide (laughing gas).

Binge Drinking

Consumption of excessive amounts of alcohol causes an estimated 80,000 deaths and $223.5 billion in economic costs each year in the United States (CDC, 2012h). The CDC concludes that about half of alcohol-related deaths can be attributed to binge drinking, or heavy alcohol consumption over a short period of time. The economic impacts stem from lost productivity at work, medical expenses for the health effects of excessive drinking, and law enforcement for alcohol-related issues, and the effects of vehicle crashes caused by alcohol-impaired drivers (CDC, 2011d). Other issues related to binge drinking are "violence, suicide, hypertension, acute myocardial infarction, sexually transmitted diseases, unintended pregnancy, fetal alcohol syndrome, and sudden infant death syndrome" (CDC, 2012h, para 6).

Data from the Behavioral Risk Factor Surveillance System indicated that the prevalence of binge drinking in 2010 was highest among respondents aged 18 to 24 years (CDC, 2012h). More than one-quarter of persons in this age group and persons aged 25 to 34 years were binge drinkers, 28.2% and 27.9%, respectively (CDC, 2012h). A total of 19.2% of persons aged 35 to 44 years were binge drinkers. On average, binge drinkers had slightly more than four episodes of binge drinking per month and during these episodes consumed about 8 or 9 drinks.

Cigarette Smoking

Increased Incidence of Smoking Among Adolescents and Teens

As the population of aging smokers declines, the numbers of youth smokers has increased.

Critical Thinking Question:

1. Can you think of any public health initiatives that are directly aimed at youth smoking? Have they been successful?

In the United States, the most significant preventable cause of morbidity and mortality is tobacco use. Each year, smoking-related illnesses are responsible for more than 400,000 deaths among adults in the United States. In most instances, uptake of daily smoking among adults is established by 18 years of age. By 26 years of age, 99% of adults who are daily smokers have used their first cigarette (USDHHS, 2012a). Thus, given their tendency to become daily smokers, young adults form an important high-risk group that should be targeted for smoking cessation programs.

One of the most important sources of information about the prevalence of cigarette smoking is the National Health Interview Survey (NHIS). The NHIS is a national survey of the health-related characteristics of the U.S. population. In operation since 1957, the NHIS gathers information on health issues such as cigarette smoking by administering personal interviews to U.S. residents (CDC, 2013b). Conducted annually, the NHIS is representative of the U.S. civilian noninstitutionalized population. Each year, survey interviewers contact from 35,000 to 40,000 households and 75,000 to 100,000 respondents.

Data from the 2011 NHIS demonstrate that progress has been made with respect to a decline in smoking prevalence among adults aged 18 to 24 years. From 2005 to 2011, the prevalence of smoking declined from 24.4% to 18.9%, the lowest prevalence of any age group among adults. The prevalence of smoking among persons aged 25 to 44 years was 22.1% in 2011 (CDC, 2012b). During that year, the overall prevalence of smoking in the country was 19.0%, a level that represented only a slight decline since 2005. The Healthy People 2020 target for smoking is 12.0%. Among the population-based methods for reducing smoking prevalence are media campaigns against tobacco use; increases in the prices of tobacco products; and laws and regulations that prohibit smoking in bars, workplaces, and public areas. These efforts will need to be reinforced in order to further reduce smoking levels.

Obesity Among Young Adults

Obesity is the final condition discussed in this review of behavioral risk factors for adverse health outcomes. The commonly used measure of obesity is the body mass index (BMI), which is defined as a person's weight in kilograms divided by height in meters squared. Persons who have a BMI of 30 or higher are considered to be obese.

Rates of obesity have reached epidemic levels in America. In addition, obesity is a risk factor for diabetes and other chronic diseases. Lowering rates of obesity among young adults can prevent the later development of such diseases.

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The Affordable Health Care Act, signed by President Obama on March 23, 2010, provides extended coverage to American youth, as well as to those who were previously ineligible.

In 2009 through 2010, 35.7 % of U.S. adults were obese (Ogden et al., 2012). The percentages of men and women who were obese were similar (35.5% and 33.4% for men and women, respectively). Between 1999 to 2000 and 2009 to 2010, the prevalence of obesity among men increased from 27.5% to 35.5%. In comparison, the prevalence of obesity among women did not change significantly.

The prevalence of obesity among persons aged 20 to 39 years was 32.6% (33.2% and 31.9% for men and women, respectively). The rates of obesity among this age group were lower than those among older age groups. Data for these older age groups are provided later in the chapter.

Health Insurance Coverage

The issue of health insurance coverage for young adults has been a significant challenge for public health. Formerly, most young persons who were covered under their parents' health insurance plans lost coverage when they reached late adolescence, generally at age 19. Should these uninsured young adults experience a serious injury or illness, they might have had to forgo needed medical care or face possible financial ruin from the costs of their care. Furthermore, persons younger than 19 years of age were excluded from coverage if their parents did not have family coverage provided by employment or an individually purchased health insurance policy. Many families of low-income service workers did not have health insurance that covered themselves or family members. However, changes enacted under the Affordable Care Act have extended coverage for previously ineligible young adults under age 26 (Healthcare.gov, n.d.). The Affordable Care Act extends coverage of young adults on their parents' employment-based health insurance plan up to the age of 26. The Act has introduced several other important provisions, which are discussed in Spotlight: Coverage of Young Adults Expanded under the Affordable Care Act.

Spotlight: Coverage of Young Adults Expanded Under the Affordable Care Act

Top Things to Know for Young Adults

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The Patient Protection and Affordable Care Act represents 2,409 pages of information.

• Under the Affordable Care Act, young adults under age 26 can be insured as a dependent on their parent's health insurance. The only exception is if a parent has an existing job-based plan and the young adult can get his or her own job-based coverage.

• New health plans must now cover certain preventive services without cost sharing.

• Starting in 2014, those who are unemployed or have a limited income up to about $15,000 per year for a single person (higher income for couples/families with children) may be eligible for health coverage through Medicaid.

• Starting in 2014, if an employer doesn't offer insurance, employees will be able to buy insurance directly in an Affordable Insurance Exchange. An Exchange is a new transparent and competitive insurance marketplace where individuals and small businesses can buy affordable and qualified health benefit plans. Exchanges will offer you a choice of health plans that meet certain benefits and cost standards. Starting in 2014, members of Congress will be getting their health care insurance through Exchanges, and many others will be able to buy their insurance through Exchanges, too.

• Starting in 2014 those whose income is less than the equivalent of about $43,000 for a single individual and whose jobs do not offer affordable coverage may get tax credits to help pay for insurance.

Source: Health care.gov. (n.d.). Young adults and the Affordable Care Act. Retrieved from http://www.healthcare.gov/news/factsheets/2011/08/yng-adults-aff-care-act.pdf

6.4 Older Adults

For the purposes of this chapter, older adults are classified as persons roughly between the ages of the early 40s to 64 years. Patterns of morbidity and mortality are somewhat different for older adults than for younger adults. In the United States, chronic diseases are more prevalent among older adults than among younger adults. Reflecting the increasing impact of chronic diseases, overall mortality is higher for older adults. Cancer is the leading cause of death for persons between the ages of 45 and 64 years. In contrast, the category of unintentional injuries is the leading cause of mortality among young adults.

Morbidity and Mortality Patterns

The death rates among older adults (45 to 54 and 55 to 64 years of age) were 420.6 per 100,000 and 871.9 per 100,000, respectively, in the United States in 2009 (Kochanek et al., 2011). Refer back to Figure 6.3, which shows the 10 leading causes of death among adults in the United States. Malignant neoplasms and diseases of the heart were the first and second leading causes of death and, together, caused almost one half of deaths among 45- to 54-year-olds and slightly less than two-thirds of deaths among 55- to 64-year-olds. Unintentional injuries were the third leading cause of death among adults aged 45 to 54 years and the fourth leading cause among those aged 55 to 64 years. The third leading cause of death among older adults in this latter age group was chronic lower respiratory diseases. Other chronic conditions such as diabetes, cerebrovascular diseases (stroke), and chronic liver disease/cirrhosis were among the leading causes of death for older adults.

About one half of older adults perceive their health as being excellent or very good. Nevertheless, among adults 45 to 64 years of age, the prevalence of chronic diseases is higher than among persons who are younger than 44. For example, about one-third of older adults have hypertension and arthritis in comparison with about one-tenth of young adults. The following sections provide additional information on self-perceived health status and chronic diseases and conditions among older adults.

Self-Reported Health Status

The National Health Interview Survey (NHIS) collects information on U.S. adults' self-reported health status, which the respondent can designate as excellent, very good, good, fair, or poor. For the overall population of the United States, almost two-thirds of all respondents (61%), both men and women, from all age groups reported their health as excellent to very good (Schiller et al., 2012). Figure 6.8 provides data from the 2010 NHIS regarding self-reported health status by age group and ethnicity. The percentages of persons who reported excellent or very good health decreased as age group increased and ranged from 70.2% (18 to 44 years old) to 39.0% (75 years old and older). Among racial and ethnic groups, Asians reported the highest percentages of excellent or very good health.

Figure 6.8: Self-reported health statuses of adults by age and ethnicity, United States, 2012

Source: Data from Schiller, J. S., Lucas, J. W., Ward, B. W., & Peregoy, J. A. (2012). Summary health statistics for U.S. adults: National Health Interview Survey, 2010. National Center for Health Statistics. Vital and Health Statistics, 10(252), 76.

In what ways can public and community health professionals use this data to target populations for health initiatives? Which demographic might need the most attention, and why?

According to data from the NHIS, poverty was associated with lower levels of self-reported health status. Findings from the survey support a relationship between demographic variables and positive and negative health outcomes in the United States. Minority and socially disadvantaged Americans tend to have lower self-reported health statuses than White, affluent, and educated citizens.

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Even though about half of older adults believe themselves to be in good health, chronic diseases such as cancer and heart disease are the prominent causes of mortality in this age range.

Possible concerns regarding information from the NHIS are the reliability and validity of the data that are gathered. Although NHIS data are robust and generally sound, single-item measures of self-reported health status such as the one used by the NHIS have both strengths and limitations. One of the advantages of the single-item measure is ease of administration in a survey. A disadvantage of the measure is that it can be interpreted in different ways by different persons. These differences in interpretation can affect the validity of responses. Some respondents tend to think that the question is asking about general physical functioning, whereas others (particularly older people) believe that the question is querying specific health problems (Krause & Jay, 1994). Also, the sample design used in the NHIS is representative of the entire United States but may not provide precise information at the state level for a particular year of data collection. Racial groups (for example, Blacks, Asians, and Hispanics) are oversampled in order to assure that adequate data are obtained from these groups.

Prevalence of Chronic Diseases and Conditions

A chronic disease is a long-standing condition for which a cure usually is not available and that does not resolve on its own. The CDC states that "[c]hronic diseases—such as heart disease, stroke, cancer, diabetes, and arthritis—are among the most common, costly, and preventable of all health problems in the U.S." (CDC, 2012a, para 1). Approximately one half of all adults in the United States have at least one chronic disease. The most prevalent chronic diseases in this country are circulatory diseases, cancer, diabetes, arthritis, and obesity. Circulatory conditions include hypertension, coronary heart disease, other forms of heart disease, and stroke.

In 2010, 34.4% and 13.2% of older adults aged 45 to 64 had hypertension and heart disease, respectively. (See Figure 6.9.) Arthritis, the most common cause of disability among adults, affected 30.3% of older adults. Asthma and diabetes each afflicted about 12% of older adults. Sensory deficits and dental health issues are also prevalent among older adults. In 2010, nearly one-fifth had trouble hearing, one-eighth had difficulties with vision, and more than 7% were edentulous (missing all natural teeth).

Figure 6.9: Percentages of chronic disease and conditions among adults aged 45 to 64

Source: Data from Schiller, J. S., Lucas, J. W., Ward, B. W., & Peregoy, J. A. (2012). Summary health statistics for U.S. adults: National Health Interview Survey, 2010. National Center for Health Statistics. Vital Health Stat 10(252, 1–217).

Some, though not all, of the most prevalent chronic diseases can be prevented through healthy lifestyle choices. There are a number of public and community health initiatives work to address these before they become chronic conditions.

Obesity Among Older Adults

Chapter 1 stated that obesity among adults is currently an issue of great concern for the community. During 2009 through 2010, about one-third of all U.S. adults were obese. With respect to adults aged 40 to 59 years, 37% were obese in 2009 through 2010; the percentages for men and women were 37% and 36%, respectively (Ogden et al., 2012).

In comparison with other ethnic and racial groups, the highest overall rates of obesity for Americans in 2009 occurred among non-Hispanic Black women and Hispanics, 41.9% and 30.7%, respectively (CDC, 2010a). States vary in the percentages of their residents who are obese. In 2009, the highest percentage (34.4%) was in Mississippi. (Refer to Figure 6.10.)

Figure 6.10: Prevalence of obesity among adults, United States, 2009

Source: Adapted from Centers for Disease Control and Prevention. (2010). Adult obesity: Obesity rises among adults. CDC Vitalsigns (p. 3). Atlanta, GA: CDC.

What public health initiatives in Colorado might explain the low percentage of obese adults? In June 2013, the American Medical Association declared obesity a disease—how might this impact policies and initiatives around the country?

In the United States, the prevalence of obesity has increased among all education and income levels. Although socioeconomic status is related to obesity, this relationship differs according to gender and racial and ethnic group membership. Among non-Hispanic White women, obesity prevalence increases with decreasing income levels. Among non-Hispanic Black and Mexican American men, lower income levels are associated with lower levels of obesity. Spotlight: Socioeconomic Factors and Obesity, United States, 2005–2008 gives additional information on the socioeconomic (income and education) and gender-related correlates of obesity among American adults.

Spotlight: Socioeconomic Factors and Obesity, United States, 2005–2008

Income

• Between 1988–1994 and 2007–2008, the prevalence of obesity among adults increased at all income levels.

Education

• Between 1988–1994 and 2007–2008, the prevalence of obesity among adults at all levels of education increased.

Income and Gender

• Among men, obesity prevalence is generally similar at all income levels, with a tendency to be slightly higher at higher income levels. Overall, almost 33% of men who live in households with income at or above 350% of the poverty level are obese, while 29.2% of men who live below 130% of the poverty level are obese.

• Among women, obesity prevalence increases as income decreases. Overall, 29.0% of women who live in households with incomes at or above 350% of the poverty level are obese, and 42.0% of those with income below 130% of the poverty level are obese.

Education Level and Gender

• Among men, there is no significant trend [association] between education level and obesity prevalence. Among women, obesity prevalence increases as education decreases.

Source: Adapted from Ogden, C. L., Lamb, M. M., Carroll, M. D., & Flegal, K. M. (2010). Obesity and socioeconomic status and adults: United States, 2005–2008. NCHS Data Brief (50).

Health Promotion Strategies for Older Adults

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Because risk factors for chronic diseases can be lessened through diet and exercise, older adults have the ability to alter their future health paths.

Many of the forms of chronic-disease morbidity and mortality that affect older adults are highly preventable. Interventions aimed at primary prevention of chronic diseases help prevent the occurrence of chronic diseases in the first place and also limit their complications among adults who are already affected. The main preventable causes of chronic diseases are lack of exercise, inadequate or unhealthful diet (for example, a high-fat diet lacking vegetables), cigarette smoking and other tobacco use, and excessive alcohol consumption. Health promotion strategies for adults need to encourage the following steps:

• increase activity levels and decrease sedentary lifestyles, especially among older adults

• lose weight, if overweight or obese

• reduce consumption of saturated fats

• increase the intake of fruits and vegetables

• stop smoking cigarettes, a cause of lung cancer and other chronic diseases

• drink alcohol in moderation and avoid binge drinking.

From the perspective of public health, a number of communitywide promotion strategies for preventing chronic diseases have been implemented in the United States and worldwide. Among these public health interventions are programs that support smoking cessation, reduce exposure to secondhand cigarette smoke, make a wider selection of fruits and vegetables available in grocery stores, and label menus for nutrition content.

Because the causes of many chronic diseases stem from modifiable risk factors, adults have great potential to benefit from chronic disease prevention programs. An example of a type of program to help adults reduce their risk behaviors and adopt health promotion activities is one that uses the transtheoretical model (TTM) of behavior change (Prochaska, 2008). Empirical evidence has demonstrated the success of the TTM when applied to smoking cessation interventions.

In response to the pressing need to reduce the contributions of chronic diseases to morbidity and mortality in this country, the federal government supports community-based programs for chronic disease prevention. Through funding from The American Recovery and Reinvestment Act of 2009 (CDC, 2010e), the Department of Health and Human Services developed the Communities Putting Prevention to Work (CPPW) initiative, which fosters community efforts to intervene in obesity and smoking (CDC, 2011c), the two leading preventable causes of death in America.

In 2010, the CPPW initiative funded programs for obesity and tobacco use prevention in a diverse selection of 44 communities across the United States. The CDC granted a total of $372.8 million in funding for the CPPW initiative in that year. Of the total, $230 million was for obesity awards and $142.8 for tobacco awards (CDC, 2010b). An example of a tobacco award is one provided to Austin/Travis County in Texas (CDC, n.d). This award creates tobacco-free places such as schools, businesses, and waiting areas for public transportation. So far, the Austin/Travis County award has been effective in protecting more than 60,000 transportation riders from tobacco smoke. Another example of CPPW funding is support provided to Los Angeles County in California (CDC, 2013c). The award has been used to implement bans on exposure to cigarette smoke in parks, piers, and other public areas in Hermosa Beach; to create smoke-free housing in multiunit housing in South Pasadena; and to provide smoking cessation services to residents of homeless shelters. These and other funded efforts have protected thousands of county residents from secondhand cigarette smoke exposure.

Internationally, the World Health Organization has recognized the importance of health promotion at the global level. A series of international health promotion conferences, beginning with the first international conference held in Ottawa, Canada, in 1986, have tackled the complex issues surrounding health promotion. The recommendations of these conferences are compiled in a report from WHO (2009). The first conference created the Ottawa Charter for Health Promotion, which developed an action plan "to achieve Health for All by the year 2000 and beyond" (WHO, 2009, p. 1). Among the conclusions presented in the Ottawa Charter were the prerequisites for health; these prerequisites included "peace, shelter, education, food, income, a stable ecosystem, sustainable resources, [and] social justice and equity" (WHO, 2009, p. 1).

6.5 The Elderly

The population of the United States is becoming increasingly older. "The older population is an important and growing segment of the United States population" (Werner, 2011). However, despite this demographic trend, many older persons are engaged in a full range of active pursuits, including employment beyond the "normal" retirement age of 65 years. In fact, some members of the older population barely resemble the senior citizens of past generations.

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As the population in the United States continues to age, senior citizens are tending to work for a longer portion of their lives than previous generations.

Nowadays, age 72 is the "new 30." In support of this observation, researchers compared the life expectancy of persons who live in present-day Japan, one of the countries whose residents have long life expectancies, with the life expectancies of hunter-gatherers. These were people who subsisted on foods gathered from the wild. About 12 millennia ago, all humans were hunter-gatherers; this form of subsistence phased out with the adoption of farming. The researchers concluded that "hunter-gatherers at age 30 have the same probability of death as present-day Japanese at the age of 72: hence the age of a person in Japan that is equivalent to a 30-y[ear]-old hunter-gatherer is 72. In other words, compared with the evolutionary pattern, 72 is the new 30" (Burger, Baudisch, & Vaupel, 2012).

In addition to continuing paid employment, a substantial number of older individuals contribute their expertise to the community by volunteering and making valued social contributions. When older individuals become grandparents, some of them assume primary responsibility for taking care of their grandchildren. According to USA Today, increasing numbers of grandparents (more than 2.5 million in 2012) provided the primary care for their grandchildren nationwide (Facciolo, 2012). One of the methods to maintaining high levels of involvement and forestalling the health problems associated with aging is through participation in physical activity, especially aerobic activity, among older persons who are in satisfactory health.

Healthy People 2020 Objectives for the Elderly

Healthy People 2020 refers to persons 65 years of age and older as "older adults" (Healthy People.gov, 2013a). Note that Healthy People's age range is different from the one used in this book to categorize "older adults." Healthy People 2020 has developed 12 objectives plus several sub-objectives for each major objective for persons 65 years of age and older. Refer to Health Care in Action: Healthy People 2020 Objectives for Older Adults (Persons Aged 65 Years and Older) for 8 of the 12 objectives. These objectives are linked to the issues of assessment, policy making, and assurance (which will be discussed in Section 6.6). Based on assessments of national morbidity and mortality data, Healthy People has established quantitative targets to be met regarding each of the 12 objectives. For example, with respect to Objective OA-5, the goal is to "[r]educe the proportion of older adults who have moderate to severe functional limitations." The quantitative goal is a 10% reduction in functional limitations such as inability to perform self-care tasks from 29.3% of the elderly population in 2007 to 26.4% by year 2020.

Health Care in Action: Healthy People 2020 Objectives for Older Adults (Persons Aged 65 Years and Older)

Prevention

OA-1 Increase the proportion of older adults who use the Welcome to Medicare benefit

OA-2 Increase the proportion of older adults who are up to date on a core set of clinical preventive services

OA-2.1 Increase the proportion of males aged 65 years and older who are up to date on a core set of clinical preventive services

OA-2.2 Increase the proportion of females aged 65 years and older who are up to date on a core set of clinical preventive services

OA-3 (Developmental) Increase the proportion of older adults with one or more chronic health conditions who report confidence in managing their conditions

OA-4 Increase the proportion of older adults who receive Diabetes Self-Management Benefits

OA-5 Reduce the proportion of older adults who have moderate to severe functional limitations

OA-6 Increase the proportion of older adults with reduced physical or cognitive function who engage in light, moderate, or vigorous leisure-time physical activities

OA-7 Increase the proportion of the health care workforce with geriatric certification

OA-7.1 Increase the proportion of physicians with geriatric certification

OA-7.2 Increase the proportion of psychiatrists with geriatric certification

OA-7.3 Increase the proportion of registered nurses with geriatric certification

OA-7.4 Increase the proportion of dentists with geriatric certification

OA-7.5 Increase the proportion of physical therapists with geriatric certification

OA-7.6 Increase the proportion of registered dieticians with geriatric certification

Long-Term Services and Supports

OA-8 (Developmental) Reduce the proportion of noninstitutionalized older adults with disabilities who have an unmet need for long-term services and supports

Source: HealthyPeople.gov. (2013a). Older adults—Healthy People. Retrieved from http://www.healthypeople.gov/2020/topicsobjectives2020/objectiveslist.aspx?topicId=31

Demographic Characteristics of the Elderly Population

This section presents information on the demographic characteristics of older Americans (see Spotlight: A Profile of Older Americans: 2011), including age, sex, marital status, and geographic distribution. The next section summarizes data on several of these demographic variables.

Spotlight: A Profile of Older Americans: 2011

• 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% between 2000 and 2010.

• More than one in every eight, or 13.1%, of the population, is an older American.

• Persons reaching the age of 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.

Source: Adapted and reprinted from United States Department of Health and Human Services (2012c). Administration on Aging. A profile of older Americans: 2011. Highlights. Retrieved from http://www.aoa.gov/AoARoot/Aging_Statistics/Profile/2011/2.aspx

Growth of the Elderly Population

Figure 6.11 shows changes in the numbers of persons in the population who were 65 years of age and older between 1900 and 2010. The graph demonstrates an upward trend over time in the absolute numbers and percentages of individuals in this age range.

Figure 6.11: Population 65 years and older by size and percent of total population, 1900 to 2010

Adapted from Werner, C. A. (2011). The older population: 2010. 2010 Census Briefs (p. 3). Washington, DC: United States Census Bureau.

The "graying" of the total population will result in new foci of community and public health.

Marital Status

In 2010, a larger percentage of older men than women were married (approximately 72% of men in comparison with 42% of women). About three times as many women (40%) as men (13%) were widowed. Among both men and women, divorced or separated persons formed slightly more than one-tenth of the population; single (never married) individuals represented one-twentieth of the population (USDHHS, 2012e).

Race

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The senior population in the United States is looking much different than in decades past.

Data from Census 2010 indicate that one-fifth of persons 65 and older in the United States were members of minority groups (USDHHS, 2012f). The breakdown of this percentage by race is as follows:

• African American, 8.4%

• Hispanic origin (may be of any race), 6.9%

• Asian or Pacific Islander, 3.5%

• American Indian or Native Alaskan, less than 1%

• Two or more races, less than 1%.

Geographic Locations of the Elderly

From state to state, the numbers of persons aged 65 and older vary considerably (USDHHS, 2012b). More than half of this population lived in 11 states during 2010, with the largest numbers in California (4.3 million), Florida (3.3 million), New York (2.6 million), and Texas (2.6 million). In 17 states, this age group contributed 14% or more of the population. For example, 17.4% of the population in Florida was aged 65 and older in 2010.

The Oldest-Old Population

The term oldest-old refers to persons who are 85 years of age and older. Figure 6.12 shows the number of persons who are classified as among the oldest-old. The largest percentage in this age group is made up of persons who are 85 to 89 years old (65.9% of the oldest-old during 2010) (Werner, 2011). The age group composed of 90- to 94-year-old individuals had the largest percentage increase among the oldest-old age groups shown in Figure 6.12. This age group increased from 25.0% in 1990 to 26.2% in 2000 and 26.4% in 2010. People 100 years and older made up 1% of the population in 2010.

Figure 6.12: Percent distribution of the oldest-old population by age and sex, 1990, 2000, and 2010

Source: Adapted from Werner, C. A. (2011). The older population: 2010. 2010 Census Briefs (p. 7). Washington, D.C.: U.S. Census Bureau.

In 1990, 66.9% of the aging population was between the ages of 85 and 89 years of age. This number is now 65.9%, showing a decrease in this population and an increase in the population of those aged 95 to 99 years. How is living longer going to affect public and community health? What other trends can you see, in terms of gender? In those aged 100 years and older?

The gender distribution differed in the four age groups (85 to 89 years, 90 to 94 years, 95 to 99 years, and 100 years and older) shown in the figure. In 2010, a larger percentage of men than women (71.2% versus 63.4%) were in the 85- to 89-year-old age group. However, women in comparison with men made up a larger percentage of the population aged 90 to 94 years (27.6% versus 23.7%), 95 to 99 years (7.8% versus 4.6%), and 100 years and older (1.2% versus 0.5%). Demographic trends indicate that more and more men are surviving to older ages. As a result, gender differences in the oldest-old population have narrowed in recent decades (Werner, 2011).

Morbidity and Mortality Patterns

With respect to morbidity and mortality among persons 65 and older, information on morbidity includes the prevalence of the major chronic illnesses such as heart disease, cancer, and diabetes. The leading cause or mortality in this age group is heart disease. As with younger age groups, specific risk factors associated with morbidity and mortality can be modified in order to improve the overall health and functional status of elderly persons.

Leading Causes of Mortality

In 2009 there were approximately 1.76 million deaths among persons aged 65 and over in the United States (CDC, 2011f). Death rates increased dramatically from the 65- to 74-year-old-group to the oldest age groups (i.e., 85 and over). The death rates (per 100,000 persons in the population) among different age subgroups of the elderly were as follows:

• 65–74:            1,928.8 per 100,000

• 75–84:            4,774.4 per 100,000

• 85 and over:   13,021.2 per 100,000.

The leading causes of death among the elderly are more similar to the causes among adults aged 45 to 64 years than they are to the causes among adults aged 44 years of age and younger. In 2010, the leading causes of death among those 65 and older were heart disease, cancer, chronic lower respiratory disease, cerebrovascular diseases, and Alzheimer's disease. Unintentional injuries were the ninth leading cause of death in this age group. In contrast, as we've noted previously, unintentional injuries were the leading causes of death among young adults. Refer back to Figure 6.3 for more detailed information.

Leading Causes of Morbidity

Table 6.4 lists examples of significant health issues for the elderly population. Additional information on elderly persons' health characteristics and health risk factors will be provided in Spotlight: Elderly Persons' Health and Health-Related Characteristics in the United States and in the following sections of this text. Most of the information regarding morbidity pertains to noninstitutionalized persons (individuals not living in an institutional setting such as a nursing home).

According to self-reports of health status, approximately one-quarter of elderly persons indicated that they were in fair or poor health in 2010 (CDC, 2011f). Almost 10% of the elderly population required help with tasks related to personal care. Approximately 40% of men and women aged 65 to 74 years were obese. The prevalence of diabetes was slightly more than 25%. Roughly two-thirds of men and women had hypertension; 81.3% of women age 75 and over had hypertension.

Spotlight: Elderly Persons' Health and Health-Related Characteristics in the United States

Life Expectancy (2009)

Men at 65 years: 17.6 years; Women at 65 years: 20.3 years

Health Status

• Percent of noninstitutionalized persons age 65 and over in fair or poor health: 24.4% (2010)

• Percent of noninstitutionalized persons age 65 and over who need help with personal care from other persons: 7.3% (2011)

Health Risk Factors

• Smoking—Percent of noninstitutionalized persons age 65 and over who currently smoke cigarettes: 7.9%

• Obesity—Percent of noninstitutionalized persons who are obese (2005–2008)

  • Men age 65–74: 41.5%

  • Men age 75 and over: 26.6%

  • Women age 65–74: 40.3%

  • Women age 75 and over: 28.7%

• Diabetes—Percent of noninstitutionalized persons age 65 and over with diabetes (physician-diagnosed and undiagnosed): 25.7% (2003–2006)

• Hypertension—Percent of noninstitutionalized persons with hypertension (2007–2010)

  • Men age 65–74 years: 64.1%

  • Men age 75 and over: 71.7%

  • Women age 65–74: 69.3%

  • Women age 75 and over: 81.3%

Nursing Home Care

• Number of nursing home residents age 65 and over: 1.3 million

• Nursing home residents per 10,000 persons age 65 and over: 363

Source: Centers for Disease Control and Prevention. (2011f). Older persons' health. Retrieved from http://www.cdc.gov/nchs/fastats/older_americans.htm

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Memory loss associated with Alzheimer's disease is greatly exaggerated in comparison with the degree of loss that generally accompanies the aging process.

Impaired Activities of Daily Living

Activities of daily living (ADLs) are self-care tasks that individuals need to be able to perform in order to function independently. Examples of ADLs are eating, dressing, and bathing. Instrumental activities of daily living (IADLs) are those involved with responsibilities such as maintaining one's household and purchasing needed items such as groceries. Loss of ability to perform ADLs and IADLs is associated with aging and increases greatly after age 75. Among persons between the ages of 65 and 74 years, slightly more than 3% experienced limitations in ADLs, and about 6% had limitations in IADLs in 2006. After age 75, approximately three times as many elderly persons had limitations in ADLs and IADLs (CDC, 2008).

Alzheimer's Disease/Dementia

Alzheimer's disease is a form of dementia that occurs more frequently among older persons than among younger individuals. In fact, it is the most frequently occurring type of dementia found among older adults (CDC, 2010c). Although this condition most often develops after age 60, it can afflict younger individuals as well. Alzheimer's disease is a disorder associated with loss of the brain's ability to control thinking, memory, and decision making. The condition produces more profound memory loss than that associated with the normal aging process. Contributing factors for Alzheimer's disease include increasing age; family history; and, possibly, high blood pressure, high cholesterol, and diabetes.

As noted, the prevalence of Alzheimer's disease increases with age; it is among the leading causes of death in the United States, particularly among the elderly. Mortality from Alzheimer's disease can be the result of brain injuries from unrecognized strokes and falling, loss of motor skills that leads to fatal injuries, difficulty in chewing that causes choking, and increased susceptibility to infections caused by incontinence. Spotlight: Alzheimer's Disease: The Facts details the disease further.

Spotlight: Alzheimer's Disease: The Facts

• About 5% of both men and women aged 65 to 74 have the condition.

• Nearly half of those aged 85 and older may have the disease.

• It is now the sixth leading cause of death among American adults aged 18 and older, and the fifth leading cause of death for those aged 65 and older.

• Current estimates for the prevalence of Alzheimer's disease range from 2.6 million to 5.2 million Americans.

• If present trends continue, by 2050, as many as 16 million people may be living in the United States with Alzheimer's disease.

Source: Adapted from Centers for Disease Control and Prevention. (2010c). CDC Features, Alzheimer's disease. Retrieved from http://www.CDC.gov/Features/Alzheimers/

Falls

Falls can result in fatal or serious injuries that include hip fractures and concussions and other head trauma. In addition, falls are associated with increased risk of early mortality. Among older adults, falls are the leading cause of injury death, traumatic brain injuries, nonfatal injuries, and hospital admissions for trauma (CDC, 2012d). Falls exact enormous costs in the United States for medical care—$30 billion in 2010.

The NHIS found that the national rate among the total U.S. population for nonfatal fall injuries for which a health care professional was consulted was 43 per 1,000 people in the population. Refer to Figure 6.13, which shows that the highest rate of falls (115 per 1,000 population) occurred among persons aged 75 and older. In this age group, people who fall are up to five times more likely to be admitted to a nursing home than individuals aged 65 to 74 years. Older women experience more than twice as many fall-related fractures as men. More than 95% of hip fractures are linked to falls. Older adults can reduce their risks of falling by engaging in exercise regimens, stopping medicines that cause dizziness, correcting impaired vision, and reducing household hazards that could cause falls.

Figure 6.13: Rate of nonfatal, medically consulted fall injury episodes, by age group— National Health Interview Survey, United States, 2010

Source: Adapted from Centers for Disease Control and Prevention. (2012, February). Quick stats. MMWR, (61)4, 81.

With so many fall injury episodes reported among some of the youngest and oldest segments of the populations, what types of public health programs, initiatives, and resources might target these populations?

Elder Maltreatment

The term elder maltreatment is used to describe "any abuse or neglect of persons age 60 and older by a caregiver or other person in a relationship involving an expectation of trust" (CDC, 2010f, para 2). Often, when elderly people lose the ability to provide for their own needs, their only recourse is to turn to family members or paid caregivers for assistance. Sometimes these caregivers abuse the elderly persons who are in their care.

With the growth of the elderly population, the issue of elder maltreatment is likely to become an increasingly salient issue for community health. According to the CDC,

Elder abuse is a significant public health problem. Each year, hundreds of thousands of adults over the age of 60 are abused, neglected, or financially exploited. In the United States alone, over 500,000 older adults are believed to be abused or neglected each year. These statistics are likely an underestimate because many victims are unable or afraid to tell the police, family, or friends about the violence. (CDC, 2011h, para 1)

Elderly persons can also be maltreated and neglected in long-term care facilities. One example is elderly persons' development of pressure sores when personnel in the facility do not move patients frequently enough, so that they remain in the same position in bed or in a wheelchair.

Several health promotion strategies are available for prevention of maltreatment of elderly persons (Nerenberg, 2002). Some of these strategies involve support groups, educational programs, and respite care. Support groups for caregivers provide instruction regarding how to be an effective caregiver and also offer mutual social support for caregivers. Education regarding the aging process, disease symptoms, behavior management, and the effects of medications helps caregivers understand and cope with some of the behaviors of the elderly persons who are receiving care. Finally, respite programs (for example, a volunteer who substitutes for the primary caregiver) can provide needed relief from the stresses of caregiving. Thus, these measures aid the health and well-being of the caregivers as well as their patients.

Health Promotion Strategies for the Elderly

The goal of health promotion strategies for the elderly should be the achievement of optimal physical and mental functioning and an active lifestyle no matter how old the individual is. Strategies should address key dimensions that are linked to morbidity and mortality. Consequently, these strategies should promote the adoption of healthy behaviors, the use of clinical preventive services, management of loss of cognitive ability, improvement of mental health, and provision of services for serious and terminal illnesses (CDC, 2011b).

AMELIE-BENOIST/BSIP/BSIP/SuperStock

Ultimately, health promotion strategies aim to optimize the physical and mental functioning of the individual, regardless of age.

Strategies for primary prevention of illnesses include maintenance of recommended immunizations such as those for tetanus. Immunizations specifically for older persons are the Pneumovax vaccine (beginning at age 65) for pneumococcal disease and Zostavax vaccine (beginning at age 50) for shingles (herpes zoster), which is more common among older persons than younger individuals. Among the many other kinds of primary prevention are regular exercise to prevent overweight and osteoporosis, consumption of a low-fat diet to prevent obesity and heart disease, and maintaining social contacts and interactions with family members and friends.

Health promotion strategies within the realm of secondary prevention are periodic screening for chronic diseases: cancer; osteoporosis; diabetes; and heart disease risk factors (hypertension and elevated blood cholesterol). Other types of screening may be directed toward hearing and vision deficits, dermatologic problems, and mental health conditions such as mental disorders and dementia.

In addition to these strategies for primary and secondary prevention, other components of health promotion strategies for the elderly relate to caregiving and appropriate living arrangements. These components will be discussed in the remainder of this section.

Caregiving

The definition of a caregiver is one who "provide[s] assistance to someone who is, in some degree, incapacitated and needs help" (CDC, 2010d, para 1). Many individuals, especially those over the age of 75, have disabilities or chronic illnesses. For these elderly persons, caregiving is essential for the performance of ADLs and IADLs.

Caregiving can be a demanding role that can engender enormous stresses. The term caregiver stress refers to the stresses experienced by those who provide care to family members or friends and who can experience depression and anxiety, impaired physical health, and even increased mortality (CDC, 2010d).

Caregiving is a public health issue of great significance for society. As the elderly population grows in the United States, the need for caregiving will increase by a corresponding amount. Often family members provide care. However, the number of family members available in the future to provide care is likely to be insufficient because their numbers will grow at a slower rate than the elderly population. With the growth of the elderly population as a proportion of the total population, fewer younger people will be available to attend to the needs of the elderly. To address this issue, more external services, such as assisted living facilities, nursing homes, and in-home services, as well as both public and community initiatives, will be required to care for the aging public.

Living Arrangements for the Elderly

Among elderly persons who do not reside in institutions, slightly more than half live with their spouses (USDHHS, 2012d). Other statistics regarding living arrangements of older Americans (based on 2010 data) include:

• A larger percentage of older men (69.9%) than older women (41.3%) lived with a spouse.

• The percentage of women (aged 75 years and older) living with the spouse was much lower than men of the same age; for both genders, the proportion who lived alone increased with age.

• Many households comprised grandparents living with their grandchildren.

• Only 4.1% of the 65 and older population lived in institutional settings.

Other living arrangements for older persons include age-restricted retirement communities and planned developments that are geared toward active older adults and elderly persons who can live independently. These communities are located throughout the United States and may consist of single-family homes, cluster housing, and apartments, as well as other types of structures. Age-restricted communities are for persons who are 55 years of age and older. As the baby boomer population continues to age, these types of communities are likely to grow in popularity.

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Age-restricted communities provide shopping, health care, and activities suited to the aging population. Seniors are more easily able to socialize and remain engaged in this type of community, which may contribute to a longer life expectancy.

Facilities designed for senior citizens who require assistance for medical needs and other types of physical assistance are called continuing care or assisted living communities. They are appropriate for persons who can function at a high level but who may require some forms of help. For persons who develop more severe medical conditions, institutional settings such as skilled nursing units and memory care facilities (for persons with Alzheimer's disease) are residential options. However, as noted, only about 4% of persons who are 65 years of age and older reside in these types of institutional settings.

Maintenance of Healthy Life Expectancy

One of the most important things older adults can do to maintain optimal health is to stay physically and socially active (CDC, 2012e). According to Healthy People,

Healthy life expectancy is the average number of healthy years a person can expect to live if age-specific death rates and age-specific morbidity rates remain the same throughout his or her lifetime. Thus, healthy life expectancy is a snapshot of current death and illness patterns and can illustrate the long-range implications of the prevailing age-specific death and illness rates. The measure allows for easy comparisons across populations and over long periods of time. Healthy People 2020 tracks healthy life expectancy using 3 measures: (1) Expected years of life in good or better health; (2) Expected years of life free of limitation of activity; and (3) Expected years of life free of selected chronic diseases. (HealthyPeople.gov, 2011)

In view of public health's commitment to social justice, progressive communities should strive to enhance healthy life expectancy and promote a high quality of life among the elderly. Social justice issues are very applicable to the elderly population of this country. "Research has revealed that inequity in the provision of medical needs is more common among older African Americans, older women, as well as those with incomes below the poverty line" (Dilworth-Anderson, Pierre, & Hilliard, 2012).

The elderly have made numerous contributions to society in the past and continue to be a valued part of the community. Many people in their 80s and beyond continue to live extremely active lives. Some persons in their 80s engage in risk-taking activities such as zip-lining, skydiving, river rafting, and mountain climbing. In 2013, an 80-year-old Japanese man—Yuichiro Miura—became the oldest person to reach the summit of Mount Everest. Also in 2013, the oldest person in the United States (and third oldest person in the world) was 114-year-old Jeralean Talley (born May 23, 1899). Ms. Talley was reported to have a keen memory and was able to mow her lawn when she was 105, but had to give up bowling at age 104.

6.6 Assessment, Policy, and Assurance

This section covers the topics of assessment, policy implications, and assurances for population protections for young adults, older adults, and the elderly. We will consider the following questions: How does a community assess the health issues regarding these groups? What has public health already done to provide protections for them? What policy implications are there in process or already in action? What assurances are there that they are having an impact?

Assessment

With respect to the population subgroups—young adults, older adults, and the elderly—assessment pertains to the collection of information about the health characteristics and behavioral risk factors for these groups. One information source is vital statistics data, which are useful for identifying the leading causes of mortality and gathering information about the life expectancy of the three subgroups of the population. Data from the United States Bureau of the Census describe changing demographic and socioeconomic trends in these subpopulations. Some examples provided earlier were the percentages of the population composition by race and ethnicity (for example, Whites, Blacks, and Hispanics) and projections for the aging of the population.

With respect to behavioral risk factors for adverse health outcomes, the Behavioral Risk Factor Surveillance System (BRFSS) provides much helpful data for needs assessment regarding high-risk groups. These groups would benefit from programs for primary and secondary prevention of chronic diseases that are significant causes of morbidity and mortality in this country. Another source of information comes from the NHIS, which is used to provide nationally representative data on the health-related characteristics of the U.S. population.

Spotlight: Healthy People 2020 Objective OA-6 (Physical Activity for Elderly): Assessment provides an overview of the assessment procedure used in Healthy People 2020 for Objective OA-6 (elderly persons). This assessment uses data from the NHIS and has a target of 35.9% for 2020.

Spotlight: Healthy People 2020 Objective OA-6 (Physical Activity for Elderly): Assessment Data Source and Target for Objective

OA-6 Increase the proportion of older adults with reduced physical or cognitive function who engage in light, moderate, or vigorous leisure-time physical activities.

Source: HealthyPeople.gov. (2013). OA-6. Retrieved from http://www.healthypeople.gov/2020/topicsobjectives2020/TechSpecs.aspx?hp2020id=OA-6

Policies for Protecting the Population

The process of developing policies for protecting the population follows the assessment phase. Policies should be responsive to the most important issues identified during assessment. In illustration, these policies might address high-risk groups for behaviors associated with adverse health outcomes. Also, the goal of policy making might be to increase community well-being and decrease the costs of utilization of health services.

Examples of policies to protect young adults, older adults, and the elderly are the adoption of requirements for immunizations against meningococcal disease among college students; public service announcements against cigarette smoking and binge drinking; the decision to require menu labeling for calorie content of food sold in restaurants; and promotion of fall prevention and exercise programs for elderly persons. In order to be acceptable to the community, policy development needs to be a collaborative effort among health departments and community stakeholders. As an example, stakeholders for programs for the elderly might be local government agencies for the elderly, the American Association of Retired People, and members of community senior citizens' centers.

The Assurance Function

The assurance function means that there is documentation that programs are working as intended. One example of assurance is showing that an implemented program has produced a demonstrable change, such as a reduction in morbidity or mortality. These outcomes, called performance indicators, should be geared to the particular program and should be measurable by questionnaires, behavioral ratings, clients' attitudes, and other outcome indices. Ideally, programs should have built-in evaluation components that are conducted on a continuing basis. Programs that have demonstrated effectiveness are called evidence-based strategies.

Related to the assurance function is the sustainability of programs. Valuable and needed programs should have demonstrated ability to be maintained in the future. Programs that are adopted on a short-term basis are unlikely to produce lasting results. Program sustainability can be achieved through continuous funding by long-term grants and tax levies. As an example, tobacco taxes are a method for increasing the sustainability of government-funded smoking cessation programs.

One illustration of assurance is the decline in cigarette smoking among young adults in the United States. As discussed earlier in the chapter, the prevalence of smoking among persons aged 18 to 24 years declined from 24.4% to 18.9% between 2005 and 2011; the prevalence in 2011 represented the lowest level reported for any adult age group (CDC, 2012b). During 2011, the overall prevalence of smoking in the country was 19.0%, a level that represented only a slight decline since 2005 and was above the Healthy People 2020 target of 12%.

Other examples of assurance are declines in mortality from heart disease and decreases in the incidence of vaccine preventable diseases. However, at the same time, rates of obesity (and associated diabetes) have reached epidemic levels in the United States. Policy initiatives directed toward increasing public awareness of obesity are becoming more common. However, much additional work needs to be done in community and public health to combat this new epidemic.

Summary

This chapter covered three major age groups: young adults (ages 20 through 40 years), older adults (ages 40 through 64), and the elderly (ages 65 years and older). Regarding the health of its adult citizens, the United States lags behind many other countries with respect to health indicators such as life expectancy. Health promotion programs should target each of the three stages of life development.

The study of demographic trends helps one project the future makeup of the population. Demographic trends suggest that the U.S. population is growing older. The age composition of the community—whether made up primarily of younger persons, older adults, senior citizens, or a mix of individuals from all ages—affects the profile of community health and the social environment.

Young adults tend to be an understudied group with respect to health. The health issues that confront them are similar to those that occur among teenagers and often peak during young adulthood. An example is meningococcal disease among college students. Many of the adverse health outcomes—sexually transmitted infections, homicide, suicide, and unintentional injuries—that occur among young adults are behaviorally associated and highly preventable. Unintentional injuries are the leading cause of young adult mortality.

Among older adults, chronic diseases increase in prevalence. Although most adults in this country report that their health is excellent or very good, a large proportion of the adult population has at least one major chronic illness. Adverse conditions such as hypertension, heart disease, arthritis, and asthma affect a large percentage of adults aged 45 to 64 years. Obesity affects more than one-third of older adults. The leading cause of mortality among this age group is cancer.

By the year 2030, approximately 20% of the population will be 65 years of age or older. The growing numbers of older persons present many benefits and challenges to the health of the community. As a result of increases in healthy life expectancy, many contemporary elders now contribute their expertise actively to the community either through gainful employment or volunteering.

The health problems that disproportionately affect the elderly population include Alzheimer's disease, unintentional injuries caused by falls, and the need for assistance with activities of daily living (ADLs). Some elderly community members require specialized housing arrangements and protection from elder maltreatment during a time of frailty. Health promotion strategies such as exercise programs for the elderly have been introduced as helpful interventions for maintaining optimal functional status.

This chapter concludes with the topic of assessment, policy, and assurance for community health and public health programs for young adults, older adults, and the elderly.

Study Questions and Exercises

What are two reasons for the lower life expectancy reported for the United States in comparison with other developed countries?

Describe trends in the demographic composition of the U.S. population with respect to the three groups covered in this chapter (i.e., young adults, older adults, and the elderly). Discuss the impact of these demographic trends on the provision of health services and preventive services in the community.

List five health issues that are of particular relevance to young adults. Discuss causes of these health issues.

Compare and contrast the three leading causes of mortality among young adults, older adults, and the elderly. Provide a rationale for these differences.

What is the relative importance of unintentional injuries as a cause of morbidity and mortality among all three age groups?

Develop two goals for a health promotion program for older adults. What specific actions should older adults take in order to prevent chronic diseases?

What is the significance of falls among the elderly? Describe causes and methods of prevention of falls.

What are trends in the incidence of Alzheimer's disease? How might one account for these trends?

What is meant by the term caregiver stress? Which age groups are most likely to be affected by caregiver stress?

In your opinion, what should be three goals of a health promotion program for elderly adults?

Key Terms

Click on each key term to see the definition.

activities of daily living (ADLs)

age-adjusted death rate

age-restricted communities

Alzheimer's disease

Asian

baby boomer generation

binge drinking

body mass index (BMI)

caregiver

caregiver stress

chronic disease

elder maltreatment

elderly persons

healthy life expectancy

Hispanic or Latino

instrumental activities of daily living (IADLs)

intentional injury

meningococcal disease

obesity

older adults

oldest-old

unintentional injuries

young adult