Are We Prepared to Help Older Adults Age in Place?

May 15, 2023Research Brief

Most older adults want to remain within their homes and communities as they age. This research brief examines data trends in Central Indiana and Indiana that relate to potential challenges and opportunities for older adults who want to age in place and continue to contribute to their communities.

Key findings include:

Over the last decade in Central Indiana, the number of older adults with conditions that will require some form of care from others has grown
While the count of older adults with a disability has dropped for the White population, it has increased for the Black and Hispanic older adult population
In general, prevalence of depression and obesity has increased across all older adult age groups in Central Indiana, while diabetes prevalence has remained the same
The number of younger adults in Central Indiana with disabilities also is growing
Both the physician and nurse workforces in Indiana have been relatively stagnant or declining in fields related to geriatrics
The share of older adults who reported feeling burdened by caregiving in Central Indiana dropped from 2017 to 2021

In this report, we refer to three subsets of older adults. Younger-old: age 55-64 Middle-old: age 65-84 Oldest-old: age 85+

Questions about this research brief? Email us at stateoa@iu.edu.

Introduction

Older adults are among the fastest growing demographic group both nationally and in Central Indiana. This trend means that in the coming years there will be more older adults in the population than ever before. This raises the question: “What are the anticipated needs of our growing older adult population, and will our communities have adequate health care and support services available to allow older adults to successfully age in place?”

This report focuses on the first part of that question. Specifically, it dives into the characteristics of the older adult population that are related to the ability to age in place and then assesses current resources available to help adults age in place. As the available data permits, this report quantifies the Central Indiana older adult population¹ by several important breakdowns, such as race, gender, and age groups.

Understanding how to support aging in place is important. According to national surveys, most individuals want to stay within their communities as they grow older, stay connected to local relationships built up over the years, and maintain freedom and autonomy in daily living. However, depending both on individual health and the resources available within a community, aging in place may not be feasible for all within Central Indiana. We exam this important topic within Central Indiana, with an initial focus on characteristics and potential needs of older adults who want to age in place.

What are the characteristics of the older adult population who will need help if to age in place?

Many older adults (defined hereafter as age 55+) are still quite active and healthy, both physically and mentally. However, with age comes increased risk factors for several types of physical and mental ailments that may make aging in place challenging, and often requiring some form of help or assistance.

Variables most likely to be associated with greater need of healthcare services at an older age

For older adults on Medicare and/or Medicaid, common beneficiaries include those with diabetes, depression, or obesity. All three conditions are associated with a greater likelihood of needing assistance to age in place—from at-home care to healthcare facility access. While varying slightly by county, diabetes prevalence for all age groups has remained steady over the last decade, with a recent uptick in the oldest-old (age 85+) population. However, both depression and obesity have increased on average for older adults throughout Central Indiana, with obesity rates steadily increasing not only in the oldest-old (age 85+) and middle-old (age 65-84), populations, but those age 64 and younger as well. For example, in Marion County, the obesity rate for Medicare and Medicaid beneficiaries has tripled for adults age 65+ in the last decade. With an increasing number of older adults experiencing obesity each year comes an increasing number of older adults with increased risk factors for other ailments that can lead to increased mortality and morbidity, such as cardiovascular disease and severe illness from COVID-19.

When further breaking down obesity, diabetes, and depression by race, there are several disparities worth pointing out which may have implications for at-home care needs of older adults. For instance, for several counties with available data (especially Marion and Hamilton counties), diabetes prevalence among older adults is greater for Hispanic and Black individuals relative to the White population. While this varies between counties and among age groups within the older adult population, it is clear that several subpopulations of older adults are more likely to experience diabetes and the associated health effects.

The nuance of older adult health outcomes between counties is also important to point out as this may reflect geographic disparities. For example, Hamilton County has noticeably lower diabetes prevalence for older adults than other counties such as Marion and Shelby Counties. This may be related to a variety of factors, such as greater availability of medical resources and services in some areas over others, or upstream societal factors influencing diabetes health outcomes in some areas more than others (as Type I and Type II diabetes are grouped together here).

Important health trends in older adults related to aging in place

Changes in the health of the older adult population in Central Indiana and beyond have important implications for the type of care and facilities needed to help older adults age in place. One important trend worth elaborating on is the increasing rates of obesity among older adults. As noted earlier, while this leads to greater risk factors for other diseases and health complications within older adults, it also adds additional needs and requirements for caregivers. For example, caregivers may require special equipment to move obese older adults as needed for hygiene, nutrition, and health care. Also, larger beds can be required. This trend of a greater proportion of older adults who are obese is also likely to continue based on even higher rates of Medicaid and/or Medicare beneficiaries who are age 64 and under that are obese. This trend is not limited to Central Indiana. A national study found an increase in prevalence of obesity among long-stay nursing home residents from 2005-2015.

In addition to obesity, the rates/prevalence of depression, disability, and deaths from Alzheimer’s have been on the rise in the older adult population over the last decade in Central Indiana. All these health outcomes have potential implications for the types of resources needed for older adults to safely and comfortably age in place. The rise in depression rates among Medicaid and/or Medicare beneficiaries has been gradual in most counties in Central Indiana over the last decade and is highest among those age 64 and under and those age 85 and over. The rise in depression may be linked to greater feelings of isolation—as research has shown that it is not necessarily objective isolation that leads to greater depression and psychological distress in older adults but perceived subjective social isolation from family and/or friends. Addressing feelings of isolation and loneliness are important barriers to aging in place for many older adults, and prevalence may increase in the future with higher depression rates already for those under age 65.

The rise in depression in older adults has occurred concurrently with rises in suicide rates in older adult males in the last couple decades—much higher than that of females in Central Indiana. While depression rates in general are low compared to death rates from accidents or Alzheimer’s, collective data on depression and suicide suggests that there will likely be a growing need for mental health services for the older adult population. Data on depression is particularly striking for those with disabilities in Indiana, with the National Core Indicators for Aging and Disabilities (NCI-AD) 2019-2020 Adult Consumer Survey report revealing that two-thirds of people they surveyed (primarily older adults with disabilities) felt sad or depressed and have talked to someone about it within the last twelve months. Access to at-home mental health services or nearby facilities would be an integral component of allowing older adults with depression and other mental health challenges to age in place—but other societal factors such as transportation access may also be essential as part of the bigger picture in lowering feelings of isolation and improving access to health services while aging in place.

In Central Indiana, age-adjusted death rates for Alzheimer’s have been steadily increasing over the last decade. With the growing older adult population, there will be additional older adults in Central Indiana likely needing some form of care for Alzheimer’s or other forms of dementia. This is especially pertinent from an equity lens, for older adults in Hispanic and Black populations tend to have higher rates of Alzheimer’s disease, which may be tied to other health conditions such as heart disease and diabetes.

How many older adults in Central Indiana are likely to need help?

With a growing older adult population in Central Indiana, it is expected that there will be more older adults who will need some form of assistance to age in place. Variance in need among different subpopulations of older adults is also expected. For example, while the overall number of older adults with a disability has been steady for the last 4-5 years, the number of White older adults with a disability has dropped and the numbers of Hispanic and of Black older adults with a disability have both increased. This may be due to a diversifying older adult population. Similar trends can be seen in older adults with a self-care disability, although the associated uncertainty in values for Hispanics is greater.

When evaluating current and future needs of the older adult population, it is also important to consider trends in younger age groups. In all younger adult age brackets, and particularly the 18-34 age group, the number of those with a disability in Central Indiana has increased from 2012 to 2021. This indicates that in the future, there will likely be more older adults with disabilities who may need some form of assistance to age in place. The general rise in the number of individuals with disabilities within younger age groups also means more people in general competing for similar resources. Also of note are the gender differences in the counts of individuals with disabilities—there are many more females age 75 and over that have a disability relative to males in Central Indiana, which may be due to longer average life expectancy for females.

Adding total counts of older adults with self-care disabilities² results in an estimate of about 31,000 older adults (age 55+) in Central Indiana in 2021. Focusing more on this portion of the older adult population can give greater insights into the current unmet needs for aging in place. For example, the Indiana National Core Indicators for Aging and Disabilities (NCI-AD) Adult Consumer Survey report, which surveyed adults with disabilities,³ found that nearly half of those surveyed had concerns about falling or being unstable. Additionally, 14 percent of respondents felt that they need a ramp or stairlift either installed or replaced at their home. Most adults (91 percent) with disabilities in Indiana also live in their own home or a family house or apartment. This translates to thousands of older adults in Central Indiana with disabilities who need at-home modifications to safely age in place and is particularly relevant as the rate of deaths from accidents in older adults has been on the rise in the last couple decades in Central Indiana.

The number of older adults needing help aging in place will likely increase given the growing older adult population in Central Indiana, which surpassed an estimated 500,000 in 2021, and given the increasing rates of depression, obesity, and Alzheimer’s deaths. For example, a rise in depression prevalence of just three percent (which is below average over the last decade for most age groups of adults in Central Indiana based on Centers for Medicare & Medicaid Services (CMS) data) would mean an additional 15,000 older adults likely needing some form of mental health service. The question then arises, who is currently in place to help older adults who want to remain in their communities and age in place?

Who is available to help older adults who want to remain in the community (age in place)?

As detailed in the SoAR chapter on caregiving, many individuals who help older adults age in place are informal caregivers—friends and family who provide essential services without pay to assist others. Importantly, most older adults are caregivers themselves, with four out of five older adults in Central Indiana reporting that they assist a friend, family, or neighbor. It is estimated that in Indiana, there are approximately 790,000 family caregivers worth an economic value of $10.8 million dollars for their unpaid services. However, available data on the actual number of caregivers in Central Indiana and the trend over time is difficult to come by, for most caregiving services are informal and not accurately documented through any databases.

Nurse helps senior citizen out of bed in a wheelchair

Deep Dive: Caregiving

Caregiving impact on older adults

Caregiving, while rewarding, can be a trying and difficult experience for many depending on the circumstance, length of time, and level of involvement needed. For example, during the height of the COVID-19 pandemic, caregivers reported a much higher rate of adverse mental health conditions relative to non-caregivers. A stark statistic is that nearly 40 percent of caregivers had passive suicidal ideation within the last month, and 32 percent had serious suicidal ideation within the past month. The rate of serious suicidal ideation was eight times more than non-caregivers during this time.

However, the COVID-19 pandemic may have had other effects on caregivers as well due to measures such as social distancing and limited visitations. From 2017 to 2021, the Community Assessment Survey for Older Adults (CASOA) found that in general, the share of older adult caregivers felt less burdened by caregiving. This could be related to a variety of factors, such as social distancing limiting the ability and time of some to provide care in certain settings, or more flexible work options (remote work) that took stress and burden off caregiving and allowed caregivers to spend more time with the person they were caring for. Regardless of the reasoning behind these trends, there are still many older adult caregivers and caregivers in general who experience feelings of being burdened, stress, or anxiety. Thus, it is also imperative that there is appropriate support to help caregivers when needed, which will be discussed further in the second edition of this research brief that will focus on service gaps for the older adult population.

Two professions essential to helping older adults age in place, nurses and physicians, are well documented in regard to workforce numbers and specialty in Indiana. When looking at geriatric physicians, one can see that although the number has increased slightly from 2017 to 2021, the percentage as a portion of all physicians has actually decreased from 0.7 percent to 0.5 percent. While other physician specialties are obviously critical to older adults as well (i.e., emergency medicine and internal medicine), it is important to note the low proportion of physicians specializing in geriatrics. When examining registered nurse (RN) primary specialties in Indiana, there are some interesting workforce trends as well. From 2017 to 2021, the percentage of the RN workforce in geriatrics/gerontology dropped from five percent to 4.4 percent, with the number of RNs in that field only increasing by 107. Again, while other nursing specialties are still very pertinent to the older adult population, the proportion of those specializing in care of older adults is quite low compared to other specialties and relative to the older adult population.

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What is the likelihood of unmet need?

An important component of a rising older adult population and more adults wanting to age in place is whether there are enough people to help older adults age in place. While difficult to assess with absolute certainty the likelihood of unmet need, there are several workforce trends pointing towards unmet need in the future for Central Indiana older adults.

One example of a workforce trend indicating potential unmet need is the registered nurse population in Indiana. While this workforce previously had been increasing, it stagnated from 2019 to 2021, possibly due to the COVID-19 pandemic. However, the older adult population in both Indiana and Central Indiana has continued to sharply increase during this time. Another way to look at this is through the ratio of registered nurses in Indiana relative to the older adult populations in Indiana and Central Indiana. This ratio has decreased from 2013 to 2021 for both Indiana and Central Indiana. While there isn’t information in the literature about an “ideal ratio” for older adults specifically, the national median population/RN ratio is around 96:1⁴ and in general, the greater number of nurses per capita was associated with better population level health outcomes.

There are geographic disparities in the RN nurse to population ratio within Central Indiana with more rural counties having greater population to RN ratios, oftentimes well above the national median of 96 individuals per nurse.

In addition to the Indiana nursing workforce, data is available for the physician workforce that can be useful to evaluate the potential of unmet need for older adults. While the total number of physicians has increased from 2015 to 2021, the percentage of physicians in Indiana with a geriatric medicine specialty has decreased and remains low compared to other specialties. Additionally, the raw number of geriatric medicine physicians has decreased from 2019 to 2021, dropping from 101 to 91 physicians. As mentioned earlier, many other healthcare and social service specialties are relevant to older adults who want to age in place. The growth of the healthcare sector as well as the social service sector needs to keep pace with the growth of the older adult population for older adults to have the appropriate care needed for aging in place.

Conclusions

Most older adults want to stay within their communities and age in place. There are several trends within the aging adult population in Central Indiana that point to increased need for healthcare and social services to best support aging in place. The second part in our series on aging in place in Central Indiana will elucidate more on the availability of specific services, potential service gaps for the older adult population, possible social disparities in access to these services, and what can be done moving forward to address these needs.

When referring to Central Indiana within this report, we generally mean the 8-county region of: Boone, Hamilton, Hendricks, Marion, Hancock, Morgan, Johnson, and Shelby counties. However, when using Public Use Microdata Sample (PUMS) from the Census Bureau for data and charts, Central Indiana entails adding Putnam and Brown counties due to data aggregation limitations.
Self-care difficulty was derived from whether respondents of the American Community Survey (ACS) stated that they had “difficulty dressing or bathing.” Difficulty with these activities are two of six specific Activities of Daily Living (ADLs) often used by health care providers to assess patients’ self-care needs.
Primarily older adults, from three programs–Medicaid Waivers, the Community and Home Options to Institutional Care for the Elderly and Disabled (CHOICE) Program, and Title III, Older Americans Act (OAA).
Based on county-level data on 1,929,414 RNs in 33 states in 2012.

STATE OF AGING IN CENTRAL INDIANA