The population of older adults is projected to increase dramatically as Baby Boomers continue to reach age 65 into 2029. This article discusses key shifts in this demographic, including changes in overall health status and living arrangements, that can aid in defining older adults and their medical needs. It also highlights the changes in dental use patterns and the increase in demand for comprehensive dental services for older adults in recent years. The article focuses on the fact that oral health contributes to overall health and the dental workforce must be prepared to treat older adults in their practices.
In 2034, 1 in 4 Americans will be over the age of 65 and for the first time in US history there will be more older adults than people below the age of 18.
A variety of social, cultural, economic, functional, and general vulnerability factors can aid in assessing the overall health status of older adult patients and determining the appropriate delivery of care for this demographic.
Older adults are retaining their natural dentition for longer than previous generations and the need and use of comprehensive dental services is increasing.
Disparities between dental use based on older adults’ socioeconomic backgrounds are evident; policymakers should work on Medicaid and Medicare reforms to improve access to oral health care for all older adults.
The integration of oral health and overall health would greatly benefit the older adult population.
Definition of older adults
According to the United Nations’ 2019 report on World Population Aging, older persons are those 65 years of age or older. Researchers continue to face challenges on how to integrate an appropriate multidimensional definition that incorporates chronologic, social, cultural and functional markers to help define the process of aging. Although it is difficult to find a single comprehensive definition for old age, for several years, sociologists have divided older adults into 3 life-stage subgroups: the young-old (approximately 65–74 years), the middle-old (ages 75–84), and the old-old (over age 85).
Over the past years, there has been an increased research interest on older adults. As a result of this, several previously used terms have been retired. Box 1 illustrates an updated glossary of commonly used terms in geriatrics. Terms such as elderly (unless used to describe an entire population) are no longer used owing to their negative perpetuation of stereotypes (see Box 1 ). Another commonly used term that has recently been under much controversy and debate is “successful aging,” the new definition emphasizes “being able to anticipate and cope with age related changes,” , rather than “freedom from disease and active engagement with life,” as originally proposed by Rowe and Kahn in 1998.
Older adults: Persons aged ≥65 years. a
Successful aging: A multidimensional concept, an ability of older adults to anticipate and cope with impending or existing age related changes.
Frailty: A state of increased vulnerability to stressors owing to age related decline in physiologic reserve across neuromuscular, metabolic and immune systems.
ADLs: A term used to collectively describe fundamental skills that are required to independently care for oneself such as eating, bathing, and mobility.
Basic ADLs: Skills required to manage one’s basic physical needs including personal hygiene or grooming, dressing, toileting, transferring or ambulating, and eating
Instrumental ADLs: Include more complex activities that are related to the ability to live independently in the community. This would include activities such as managing finances and medications, food preparation, housekeeping, laundry.
Based on their functional ability, older adults can be broadly classified as robust, frail, or dependent. Frailty is defined as a “state of increased vulnerability to stressors owing to age related decline in physiologic reserve across neuromuscular, metabolic and immune systems.” Frail older adults have difficulties with instrumental activities of daily living (ADLs). Dependent older adults are those with difficulties with basic ADLs (see Box 1 ). Older adults can be further classified based on their dependency. , Table 1 has been reproduced from Federation Dentaire International’s 2019 Roadmap for Healthy Aging. It is a valuable model for application in a variety of scenarios, including policy development and treatment planning. ,
|Level of Dependency||Definition|
|No dependency CSHA levels 1 and 2||Robust people who exercise regularly and are the most fit group for their age.|
|Pre-dependency CSHA level 3||People with chronic systemic conditions that could impact oral health but, at the point of presentation, are not currently impacting oral health. A comorbidity whose symptoms are well controlled (4 in Pretty and colleagues ).|
|Low dependency CSHA level 4||People with identified chronic conditions that are affecting oral health but who currently receive or do not require help to access dental services or maintain oral health. These patients are not entirely dependent, but their disease symptoms are affecting them (4 in Pretty and colleagues ).|
|Medium dependency CSHA level 5||People with an identified chronic systemic condition that currently impacts their oral health and who receive or do not require help to access dental services or maintain oral health. This category includes patients who demand to be seen at home or who do not have transport to a dental clinic.|
|High dependency CSHA levels 6 and 7||People who have complex medical problems preventing them from moving to receive dental care at a dental clinic. They differ from patients categorized in medium dependency because they cannot be moved and must be seen at home.|
Having considered recent developments in the definition of aging, the 2015 World Health Organization World report on Aging and Health made significant changes to their definition. They stated that, owing to the growing diversity in older populations, there is “no typical older person” and no standard age for retirement; globally, populations are becoming older with an improved survival beyond the age of 65 years. According to the Gerontological Society of America’s report in 2018, in the United States, the population of older adults is projected to exceed the population group younger than 18 years by 2035 ( Fig. 1 ). It is predicted that a large numbers of Americans will continue to live in good health far past traditional retirement age. The report emphasized that generalizations made about age-specific functional limitations have been proven incorrect and studies have shown that more than 50% of people who reach age 85 had no health-based limitations affecting their work or their housework (see Fig. 1 ). ,
Hence, as the American and the global population continues to age, defying all previously set notions about old age, the definition of older adults remains fluid. Researchers must continue to acknowledge the diversity in aging and take into account a variety of factors, including social, cultural, economic, functional, and general vulnerability to assess the overall health status and the appropriate delivery of care for this demographic group.
Changes in living arrangements and conditions
Several alterations associated with later life events can prompt a change in the living arrangements for older adults. These may include changes in the family structure, such as the loss of a spouse or partner, the onset of functional limitations, or changes in work and income such as retirement. Understanding the changes in living arrangements are paramount because these factors are important determinants of overall health and mortality of older adults.
In 2012, the United States Aging Survey Findings revealed that, despite physical and economic difficulties, older Americans were determined to age in place. Today, a majority of older Americans live in single-family homes, 76% are between 65 and 79 years of age, 68% are aged 80 years and over, and 26% live alone. In 2006, 1 or more adult children lived approximately 280 miles from their older adult parent, but current research shows that multigenerational living arrangements are becoming more common. , Over the past decade, the percentage of older women living alone has decreased from 38% percent to 32%, although the percentage of older men living alone has increased slightly from 15% to 18%.
In 2017, 59% of older adults lived with their spouse or partner and 11% of older adults lived with their adult children (with children moving into the parents’ home or vice versa). The number of 3-generation households with at least 1 older adult family member increased to 3.2 million in 2016 from 1.7 million in 2006. Most of these 3-generation families were Hispanic and Asian households compared with other ethnic backgrounds. The 2018 report on Housing America’s Older Adults showed that one-half of a million older adult households that include grandparents also had grandchildren but no middle generation present.
With a larger older population aging in place, the demand for home health care services providing medical and other essential services is sure to increase. In 2006, 3 million Medicare beneficiaries received home health services, including skilled nursing, physical therapy, speech–language therapy, home aides, and medical social work. In 2007, it was estimated that 5% of older Americans received these services; models have predicted that by 2020 home health visits would increase by 36%. The provision of these services enables older adults to maintain their autonomy and independence while receiving assistance with ADLs and instrumental ADLs in the comfort of their homes.
Assisted living facilities (ALFs) are becoming a more popular community living option available to those older adults who require assistance with ADLs. Many older Americans view ALFs as a home-like alternative to a wide range of long-term care facilities. Based on a social care model, they provide housing, meals, and assistance with ADLs, but are not intended to provide 24/7 skilled nursing care. According to the National Center for Health Statistics: 2015-2016 report, more than 800,000 older Americans resided in ALFs as of 2014. The majority of these residents were categorized as 85 years and older, female, and non-Hispanic white. Unlike long-term care facilities, ALFs do not come under federal regulations for staffing and training; smaller ALFs are private, for profit, and operate mainly through private funding, whereas larger ALFs may be part of larger chains and may accept Medicaid.
In 2016, regulated long-term care service providers served more than 8.3 million Americans. These services included 4600 adult day services centers, 12,200 home health agencies, 4300 hospices, 15,600 nursing homes, and 28,900 assisted living and similar residential care communities ( Fig. 2 ).
Around 1.5 million older Americans (3.1%) aged 65 and over lived in institutional settings in 2016. Among them, 1.1 million lived in nursing homes. With increases in age, statisticians noted an increase in percentages among nursing home residents, ranging from 1% for those between 65 and 74 years of age to 3% for persons between the ages of 75 and 84 years of age, and 9% for those aged 85 years and older. In 2018, the statistics changed, according to the Centers for Disease Control and Prevention (available at: www.cdc.gov/nchs/fastats/nursing-home-care.htm ; www.cdc.gov/nchs/fastats/nursing-home-care.htm ) 1.7 million people now reside in one of the 15,000 long-term care facilities around the United States in a given year. For those seeking long-term care, 2 types of facilities are available. Skilled nursing facilities provide rehabilitative or postacute care immediately after an emergency hospital stay, whereas nursing homes and long-term care hospitals or long-term chronic care hospitals provide permanent custodial support, 24/7 medical care, along with assistance with ADLs. Unlike ALFs, nursing homes are mandated by federal regulations and usually accept Medicare and Medicaid.
Another model of care is the hospice and/or palliative care model that provides specialized medical care for older adults with chronic illnesses toward the end of life. This type of care can be delivered in the hospital, patient’s home, nursing home, or as an outpatient at a doctor’s office. In US hospitals with more than 50 beds, 25% reported a palliative care program in 2000, in 2016 that number increased to 75%. Hospice care has a holistic and patient-centric approach, and these programs not only help older adults cope with their terminal illness, but they also provide support to their families. In 2017, there was a 4.7% increase in hospice care use by Medicare beneficiaries compared with the previous year and beneficiaries who identified as Asian and Hispanic have increased by 32% and 21%, respectively, since 2014. Sixty percent of hospice care recipients in 2017 were women and 66% were over the age of 80 years. The demand for aging in place and hospice care have increased in recent years. In 2019, an article in the New England Journal of Medicine reported that, for the first time since the early twentieth century, the home has surpassed the hospital as the most common place of death for older adults in the United States.
The United States’ demographic transformation is caused by a rapidly aging population. The United States follows in the path of Japan and countries in Europe where a majority of the people are over the age of 65; as a result, the population in these countries is projected to shrink within the next 3 decades. Decreasing fertility rates and the aging Baby Boomer generation are the major reasons for this dramatic change in the United States. Currently, older Americans make up 15% of the population, but in 2030 as all the Boomers turn 65 or older, older adults will comprise 21% of the population. It is projected that by 2060, the United States will have 3 times the number of older adults over the age of 85. One in 4 Americans will be over the age of 65 and one-half of a million centenarians will be added to the population. This development is bound to increase health care demands, along with the need for more home health and assisted living services ( Fig. 3 ).