Elders

Adults age 65 or older. A brief profile of adults age 65 or older who live in rural America is provided and the state of knowledge about important aspects of growing old in a rural environment is summarized in this article. The specific focus of the article is on the social and economic characteristics of rural elders, their health status, family relations and patterns of formal service utilization. The entry concludes with a brief comment on the primary conceptual frameworks used in rural gerontology.

One of the most dramatic demographic shifts occurring in the U.S. is the “graying of America.” In 2006, about one in five elders in the U.S. lived in a sparsely populated or geographically remote rural area (nonmetropolitan residence); 20.5 percent of the overall elderly population, or 7.6 million elders, lived in rural communities.

Distribution of Rural Elders

Rural elders live in a wide variety of topographical, environmental, social and economic settings, and comprise both long-term local residents and recent migrants. Although the term rural was once thought to be interchangeable with farm, today the vast majority of older rural Americans do not live on farms or in farmlike settings (Krout, 1986).

In general, the nonmetropolitan population in the U.S. tends to be older than its metropolitan counterpart. Compared to metropolitan counties, a higher proportion of the nonmetropolitan population is age 65 or over (15.2 percent for nonmetropolitan compared to 11.9 percent for metropolitan). One in four nonmetropolitan communities has an elderly population (65+) over 18 percent (Jones et al., 2007) In addition, “the elderly make up 17 percent of the total population of all nonmetro population-loss counties” (Jones et al., 2007)

The age structure and race/ethnic composition of the nonmetropolitan population vary considerably by geographic region. For example, 16.6 percent of the nonmetropolitan population in the West North Central region1 of the U.S. is age 65 or older, whereas in the Western Mountain states,2 only 13.6 percent of the nonmetropolitan population is elderly. This regional variation is magnified when comparisons are made between states. For example, over one-fifth of the nonmetropolitan population of Florida (19.6 percent) is composed of persons aged 65 or older. In contrast, fewer than one in 15 (7 percent) nonmetropolitan residents of Alaska are aged 65 or older.

Because minority elders tend to be disproportionately located in urban areas, the population of rural elders at the national level tends to be less racially and ethnically diverse. Approximately 90 percent of the nonmetropolitan elderly population is White. Nonwhite rural elders, however, tend to be clustered in specific regions of the country. Consequently, the concentration of older rural African Americans in Southeastern states, older rural Hispanics in Southwestern states, and older rural Native Americans in Western states make issues of rural diversity more salient in these particular areas.

Personal Characteristics of Rural Elders

The social and economic characteristics of older adults living in rural America tend to set them apart from their counterparts who reside in more urban and suburban settings, with rural elders generally being distinguished by greater vulnerability (Coward and Dwyer, 1991). While 9.4 percent of the elderly were in poverty nationwide in 2006, 11 percent of nonmetropolitan elderly were in poverty. Educational attainment also differs by place of residence. Sixty-eight percent of nonmetropolitan elders obtained at least a high school education, compared with 73 percent of metropolitan elders. In comparison, 16 percent of nonmetropolitan elders did not make it to high school (<ninth grade), compared to only 13 percent of metropolitan elders. Nonmetropolitan elders are also less likely to have completed college. Only 16 percent of nonmetropolitan elders have completed some type of post-high school education (associate’s degree or higher), compared to 24 percent of metropolitan elders.

Although there is a marked difference between metro and personal characteristics, immigration and aging-in-place are changing the demographics of regional areas. Retirement-destination nonmetropolitan communities (Florida, Ozark Mountains, Texas Hill country, Great Smoky Mountains, and the destinations in the Southwest) attract the more educated, wealthier married elderly, whereas age-in-place nonmetropolitan communities are more likely made up of individuals with less income, lower educational attainment, and higher dependence on social security located in the Great Plains (Jones et al., 2007).

The relative economic disadvantage of elders in small communities is reflected in other aspects of their lives. Although the rate of home ownership is higher among elders in rural areas and small towns, the housing they occupy is disproportionately substandard and dilapidated (Bull and Bane, 1992). Rural elders are less likely than their urban counterparts to have worked in a job that provides a pension plan. Consequently, the careers of men working in rural areas are less likely to end with retirement.

Health of Rural Elders

Metropolitan elders report better health than their nonmetropolitan peers (Rogers, 2002). There is substantial evidence in the gerontological literature that elders living in rural America are in poorer health than their more urban and suburban counterparts (Coward and Dwyer, 1991; Coward and Lee, 1985). More so, rural elderly are at a disadvantage when it comes to access to medical personnel, hospitals and long-term care services in comparison to their urban peers (Frenzen, 1991; Hicks, 1990). Rural elderly are also at greater risk for poorer nutritional health compared to their urban peers (Quandt and Chao, 2000).

Such differences are not universal across all dimensions of health or among all subgroups of older rural adults. For example, nonfarm rural elders report the largest number of medical conditions and the most difficulty performing activities of daily living (e.g., bathing, dressing, getting to or using the toilet, shopping for groceries, preparing meals and doing housework) compared to elders from other residential categories (worse even than inner-city elders). While older farmers are among the most healthy segments of older persons in our society, this within-group variation should not detract from an appreciation of the overall poorer health of rural elders as a group. The better health of older farmers simply cannot counterbalance the prevailing poorer health of the much larger group of nonfarm elders.

Only a small number of studies attempted to determine whether these residential differences in health persist when the effects of other factors known to influence health are taken into account (e.g., income, race, gender and age). The results have been mixed; in some comparisons the introduction of other variables account for the residential differences that are observed, whereas in other cases they have not. Thus, for some differences in health, it is not residence in a particular setting per se that causes poor health. Rather, compositional differences in the populations that live in different settings account for the observed differences in health.

This does not mean that place of residence is irrelevant to health care planners and advocates. Residence remains an important dimension of public policy planning for the aged because, ultimately, the location of health and human services must be thought of in geographic terms; services must be located in a particular place. At this most fundamental level, the distribution of need by geographic location is a critical consideration in health services planning despite the compositional differences that may be responsible for residence variation in health.

Family Relations of Rural Elders

The family relations of elders who reside in small towns and rural communities are substantively different from their counterparts who live in more urban and suburban environments (Bull, 1993). Rural elders (65+) are more apt to have a marital partner (rural 53 percent; urban 50 percent) and, on average, to have more children, but they are also more likely to live alone (Glasgow, 2000). Although rural elders are more likely to accept social support than their urban peers through informal community exchange networks (Enwefa et al., 2004), there are critical advantages to these familial differences since spouses and adult children are the primary family members with whom elders live and the principal source of aid and assistance for elders. On closer examination, the rural marital advantage favors elder men. Thirty percent of rural men 65 and older, compared to 59 percent of rural women 65 and older, are widowed/divorced/separated/or never married. Elder men are more likely to have a spouse present in times of care need than elder females.

Although rural elders seem to be advantaged by having a larger number of adult children, this does not appear to translate into a greater propensity to co-reside with a child (Coward et al., 1993). In terms of the proximity of children to elderly parents, there is evidence of significant variability within the rural population. Elderly farm residents are likely to have at least one very proximate child, most often a son, who participates in the farming operation and may eventually inherit it. Rural nonfarm elders, in contrast, are the least likely of any residential group to have proximate children, perhaps because younger people must often move to more urban areas in pursuit of educational and occupational opportunities. Given this pattern of geographic proximity, it is not surprising that farm and large-city elders report comparatively high rates of interaction with their children, while lower rates are observed among rural nonfarm and small-town elders.

Formal Service Utilization Patterns of Rural Elders

There is substantial evidence that older residents of small towns and rural communities, while having a usual source of care (Larson and Fleishman, 2003), have access to a fewer number and narrower range of formal health and human services (Krout, 1994; Rowles et al., 1996). These deficiencies are exacerbated when the elder rural individual is disabled, due to lack of or poor quality of transportation and distance from urban centers where many services are located (Iezzoni et al., 2006) As a consequence, rural elders are less apt to receive formal services at any one point in time and are less apt to add a formal service provider to their caregiving network over time. Generalizations are not universal.

Nonmetropolitan elderly residents living in towns of under 10,000 people are more likely to access any formal care and Medicare home health care than their metropolitan peers (McAuley et al., 2006). Research has also demonstrated, for example, that rural elders are more likely to attend a senior center than are their urban and suburban counterparts. Similarly, recent research reported the greater availability and use of nursing home beds per capita among nonmetropolitan elders, especially those in small, thinly populated nonmetropolitan counties, compared to older adults living in small, medium-sized, or large standard metropolitan statistical areas. The greatest deficiencies in rural social service systems for the elderly appear to be in the area of medical and community-based services for the frail and disabled, such as rehabilitative home health services, hospice, adult day services and respite care.

Two Conceptual Perspectives on Rural Gerontology Many rural gerontologists envision residence in a sparsely populated, geographically remote area as a factor that can exacerbate other difficulties with which older people cope. Some scholars describe the double jeopardy of growing old and living in a rural setting. Others describe the triple jeopardy of growing old, living in a rural setting, and coping with a third condition or circumstance that places older people at risk of poor health or a lower quality of life (e.g., poverty, the cumulative effects of a lifetime of discrimination, or a debilitating chronic illness). From this perspective, there is much that is not known about specific subgroups of rural elders (e.g., older rural Blacks, Latinos, and Native Americans; persons over the age of 85 who live in rural settings; older rural women; or rural elders living in poverty). Further research is needed on these important subgroups of rural elders.

Rural gerontology makes use of the concept of the person-environment fit. According to this conceptual framework, the degree to which older people become disabled is a product of the interaction of their physical and mental functional capacities and the demands of the environment in which they live. Gerontologists traditionally emphasized strategies to alter or adapt the immediate environment of older adults (e.g., adding assistive devices such as hand rails, ramps, and specially designed door knobs to homes). Rural gerontologists examine the degree to which the macro environment enhances or impedes the quality of life and effective functioning of older adults. Additional research is needed to identify the specific dimensions of life in rural America that most influence the lives of older adults.

— Raymond T. Coward, Chuck W. Peek, and Chris F. Biga

See also

• Education, Adult; Mental Health of Older Adults; Nursing Homes; Policy, Health Care; Public Services; Quality of Life; Rural Health Care; Rural Demography; Senior Centers

References

• Bull, C. N. Aging in Rural America. Newbury, CA: SAGE Publications, Inc., 1993.
• Bull, C. N. and S. D. Bane. The Future of Aging in Rural America. Kansas City, MO: University of Missouri, 1992.
• Coward, R. T. and J. W. Dwyer. Health Programs and Services for Elders in Rural America: A Review of the Life Circumstances and Formal Services that Affect the Health and Well-Being of Elders. Kansas City, MO: National Resource Center for Rural Elderly, University of Missouri, Kansas City, 1991.
• Coward, R. T. and G. R. Lee. The Elderly in Rural Society: Every Fourth Elder. New York, NY: Springer Publishing Company, Inc., 1985.
• Coward, R. T., G. R. Lee, J. W. Dwyer, and K. Seccombe. Old and Alone in Rural America. Washington, DC: American Association of Retired Persons, 1993.
• Enwefa, S.C., R.L. Enwefa, and R. Jennings. “Factors that Affect Aging Within the Elderly Population in Rural Communities.” Pp. 749-760 in NAAAS and Affiliates, vol. 2004 Monograph Series (Part I). Houston, TX, 2004.
• Frenzen, P.D. “The Increasing Supply of Physicians in U. S. Urban and Rural Access, 1975-1988.” American Journal of Public Health 81 (1991): 1141-1147.
• Glasgow, N. “Rural/Urban Patterns of Aging and Caregiving in the United States.” Journal of Family Issues 21 (2000): 611-631.
• Hicks, L.L. “Availability and Accessibility of Rural Health Care.” Journal of Rural Health 6 (1990): 485-505.
• Iezzoni, L.I., M.B. Lilleen, and B.L. O’Day. “Rural Residents with Disabilities Confront Substantial Barriers to Obtain Primary Care.” Health Services Research 41 (2006): 1258-1275.
• Jones, Carol A., William Kandel, and Timothy Parker. “Population Dynamics Are Changing the Profile of Rural Areas.” Amber Waves 5 (2007): 30-35.
• Krout, J.A. The Aged in Rural America. New York, NY: Greenwood Press, 1986. .
• Providing Community-Based Services in the Rural Elderly. Newbury Park, CA: SAGE Publications, Inc., 1994.
• Larson, S.L. and J.A. Fleishman. “Rural-Urban Differences in Usual Source of Care and Ambulatory Service Use.” Medical Care 41 (2003): III-65–III-74.
• McAuley, W.J., W.D. Spector, J. Van Nostrand, and T. Shaffer. “The Influence of Rural Location on Utilization of Formal Home Care: The Role of Medicaid.” The Gerontologist 44 (2006): 655-664.
• Quandt, S. and D. Chao. “Gender Differences in Nutritional Risk Among Older Rural Adults.” Journal of Applied Gerontology 19 (2000): 138-150.
• Rogers, C.C. “The Older Population in 21st Century Rural America.” Rural America 17 (2002): 2-10.
• Rowles, G. D., J. E. Beaulieu, and W. W. Myers. Long-Term Care for the Rural Elderly. New York, NY: Springer Publishing Co, Inc., 1996.