the US and much of the developed world, laws and public policies protect those with a disability, including promoting accessibility in the workplace and community. Ancillary providers such as physical, occupational, and speech therapists can provide rehabilitation and adaptive equipment to help preserve functioning. However, in much of the developing world, such services and protections are lacking. The WHO reports that in four South African countries, for instance, only 26–55% of people received needed medical rehabilitation, 17–37% received assistive devices, and less than 25% were able to receive vocational training. Even in developed countries, older adults may have difficulty obtaining all the recommended resources, particularly adults in rural communities or with financial insecurity. Resources meant to help those with disabilities, such as meal delivery services, may have long waitlists due to inadequate funding. Adults with disabilities also face stigmatization in the workplace and communities. Communities worldwide must commit resources to promote a safe and inclusive environment for those of all abilities to thrive.
Table 4.2 Communication strategies for speaking to patients with hearing loss.
| Don’t yell – shouting causes sound distortion. |
| Maintain a quiet environment with minimal background noise. |
| Maintain good lighting. |
| Face the person, and maintain eye contact. |
| Annunciate. |
| Speak at a reasonable speed. |
| Use transition statements, and avoid sudden shifts in conversation topics. |
| Augment communication with writing, diagrams, etc. |
| Use ‘teach‐back’ or similar methods to ensure understanding. |
Poverty
The word poverty is so commonly used that it may seem unnecessary to define it, but the word has two aspects that need to be distinguished: poverty threshold and relative poverty. The poverty threshold is defined by comparing a household’s income with the level of prices of the basic commodities necessary for life – the subsistence level, sometimes called the poverty line. Those whose incomes are below the minimum level necessary for subsistence are deemed to be living in poverty. Relative poverty is defined by comparing a household’s income with the average income level in their society. Although individuals' incomes may be sufficient to provide themselves and their dependents with the necessities of life, they may struggle to maintain an acceptable quality of life. J.K. Galbraith, an American economist, has described the condition of relative poverty thusly: ‘People are poverty stricken when their income, even if it is adequate for survival, falls markedly below that of the community. Then they cannot have what the larger community regards as the minimum necessary for decency, and they cannot wholly escape, therefore, the judgement of the larger community that they are indecent. They are degraded, for in the literal sense, they live outside the grades or categories which the community regards as acceptable.’ A modern‐day example in the US of relative poverty includes adults who cannot afford reliable internet access. Once deemed a luxury, internet access is so ubiquitous that much of society now takes it for granted. Not only are adults stigmatized if they cannot afford online access, but they may not be able to keep up employment or manage practicalities such as bill payment without it.
According to US Census data from 2018, since the mid‐1960s, poverty rates for people 65 and older living in the US have declined from nearly 30%, to under 10% as of 2017. Older people now have poverty rates similar to those of working people.
Eighty‐four percent of US older adults receive Social Security. When examining older adults by income level, Social Security made up the majority of a person's income in the lowest income quintile of older adults. Approximately 30% of older adults received income from a pension or retirement plan, and approximately 21% continued to earn income through employment. Almost half of older adults earned income from assets (such as interest, dividends, rental income, etc.); however, the median value is very low (< $500 per annum). A small minority of older adults make a substantial income from their assets and tend to be in the highest income quintile. Less than 10% of older adults receive income from supplemental security income (SSI) or other public welfare sources. Ethnic and racial minorities were less likely to receive Social Security and more likely to receive SSI.42 Older women, particularly those who did not marry, are at the highest risk of poverty, as they are least likely to be eligible for national security or occupational pensions. Longer life expectancy also means women are at increased risk of spending down their savings. As women engage with the workforce at higher rates, this disparity will likely decline.
Globally, there is limited data on poverty in older age. The UN estimates that older age is a significant risk factor for poverty, particularly in countries with inadequate social support and financial infrastructure. Rates of poverty vary widely. In the Netherlands and the Czech Republic, rates of poverty in adults over 65 are as low as 3%, while in the Republic of Korea, rates approach 50%. In Zambia, rates of poverty in older adulthood are as high as 80%. As in developed countries, older women are at significantly higher risk of poverty.
Social isolation and loneliness
Older adults are prone to social isolation for a number of reasons. As part of growing older, older adults are more likely to experience widowhood, the loss of friends and family, and physical separation from family due to geographic moves. Hearing and vision loss, cognitive impairment, and physical disability all lead to mobility impairments and a reduced ability to drive, navigate public transportation, or leave the home. Older adults living in rural areas or who face financial insecurity may have limited means to engage with their communities. Risk factors for social isolation and related adverse health effects and possible mitigation factors are summarized in Figure 4.5.
Social isolation is defined as objective physical separation from other people, while loneliness is defined as subjective distress due to feeling separated or alone.43 Although correlated, the two terms are not synonymous. Older adults who are physically isolated may report robust relationships, particularly with online connectivity and/or engagement in meaningful leisure activities. Conversely, adults who live with or near others, even family members, may report loneliness if the quality of these relationships is poor. Both social isolation and loneliness are associated with a number of adverse health effects. Loneliness increases the risk of depression, anxiety, and suicidality. Social isolation increases the risk of cognitive impairment and delayed time to diagnosis. Chronic social isolation and loneliness trigger an increased inflammatory state, leading to increased risk of cardiovascular disease, exacerbations of chronic illnesses, and a suppressed immune system.
Figure 4.5 Risk factors, possible adverse events, and possible treatment options for loneliness in older adults.
Approximately one‐quarter of community‐dwelling older adults in the US were characterized as socially isolated. Lower income, lower educational attainment, unmarried relationship status, and Caucasian race were all correlated with a higher risk of social isolation.44 Loneliness is difficult to capture objectively, but various surveys have indicated that 20–45% of adults report feeling lonely some or all of the time. Living alone and dissatisfaction with one's social circle, family, or community increased the risk of loneliness.
Treatment
