Teaching Aging Through Intersectionality for MSTEM and Other Disciplines

Aging Demographics, Theories, and Processes

To understand the lives of older adults and their families, all students taking aging courses should be exposed to “the basics,” including demographics, theories, and processes related to aging. It is essential for students to understand the demographics of the population and the rapid growth of those 65+, which has grown almost 35% in the past decade and represents over 15% of the population of the United States. The 85 + population is seeing even more growth and is projected to double by the year 2040 (Administration on Aging [AOA], 2018). These demographics are important for students to acknowledge in terms of the impact it will have on society, but it can also offer them a call to action in terms of thinking about opportunities that will exist in working with and on behalf of older adults and their families.

The study of aging demographics gives students an understanding of the present and future landscape of the population. Theories are designed to explain and predict behavior and phenomena and are important tools for understanding situations and problems that occur in the lives of this growing population. As one of the oldest theories related to older adulthood, lifespan developmental theory provides a solid foundation for understanding older adulthood, including the theories of Erikson and Levinson showing older adulthood as a time of life reflection and evaluation. During this life stage, older adults spend time reflecting on and evaluating their lives as well as the loss of some roles and the addition of others, declines in health, and the preparation for the end of life (Rogers, 2019). There are also specific theories directed at understanding the adaptation to aging. Gerotranscendence theory suggests that older persons move more toward their inner selves (including spiritual matters and interpersonal relationships) and away from the societal pressure to be productive. As two very similar perspectives, continuity theory explains that each individual has the capacity to maintain their own level of engagement in society that assists them to live a personally satisfying life; and activity theory purports that older adults are the most satisfied with life when they remain active in and engaged in social relationships and pursuits (Hooyman & Kiyak, 2011).

Common Issues and Roles in Aging

There are many issues that affect the lives and well-being of the growing population of older adults and these issues should be included in any educational content provided to students in MSTEM and other disciplines. This includes issues related to health and well-being such as social support, chronic illness and disability, end of life, sexuality, substance abuse, mental health conditions, and suicide as well as common roles acquired in this stage of the life course such as retirement, grandparenthood, and widowhood.

Although over 40% of elders living in the community report their health as being “excellent” or very “good,” the majority of persons over 65 have at least one chronic (or long-term) health condition. Arthritis, heart disease, diabetes, high blood pressure, and cancer are the most common chronic conditions facing this population (Centers for Disease Control and Prevention, 2013a). Aside from chronic illness there are also physiological changes that normally occur with aging. These changes occur in every bodily system and include decreases in lung capacity, cardiac output, skin tone and elasticity, muscle mass, bone density, kidney function, and sensory function. Changes in the nervous system include a loss of neurons and neurotransmitters, which can cause slower reaction time for older adults. Although the likelihood of developing these conditions increase with age, Alzheimer’s disease and other dementias are not a normal part of aging (Hooyman et al., 2015). Some older adults experience disability due to chronic health conditions. Chronic conditions and disabilities can impair an older individual’s ability to function and perform what are called activities of daily living (ADLs). ADLs involve self-care activities such as bathing, toileting, grooming, and feeding oneself. Physical and mental impairments can also affect what are called instrumental activities of daily living (IADLs) which include more complex tasks such as shopping, paying bills, providing transportation, and taking needed medications (Hooyman, Kawamoto, & Kiyak).

Like physical health, mental health is an important component of well-being for persons of all ages. Many mental health conditions are life-long, beginning in younger years and continuing through older adulthood. Some, however, begin in later years as a result of loss, chronic illness, or other changes. Depression is the most common mental health condition affecting older adults, affecting 3%–5% of those 65 + living in the community. Those at increased risk for depression in later life have chronic illnesses or dementia, reside in skilled nursing facilities, and are socially isolated. Although they respond to treatment just as well as younger persons, depression in older adulthood tends to go undiagnosed with symptoms being attributed to normal aging or chronic illness (Fiske et al., 2009). Although depression is less common in older adults, the rates of suicide are highest for this age group (Conwell et al., 2011). Anxiety disorder is almost as common as depression among older adults. Like depression, it is often misdiagnosed but when accurately diagnosed, older adults respond very well to treatment. As in other stages of the life course, anxiety can also co-occur with depression in older adulthood. Depression and anxiety can be responses to loss. Old age is often a time of many losses, such as the loss of loved ones, the loss of functioning due to illness, and the loss of roles such as in the case of retirement. It is also a time when individuals contemplate and experience the end of their own lives (Hooyman, Kawamoto, & Kiyak; Wolitzky-Taylor et al., 2010).

Dementia is considered a mental health condition and affects 5%–8% of persons over the age of 65. The term dementia is used to describe a host of conditions, reversible and irreversible, that cause significant declines in cognitive functioning such as memory, communication, and judgment. Alzheimer’s disease is the most common type of dementia, representing 50%–70% of the cases. As previously mentioned, dementia is not a normal part of aging but its prevalence does increase with age, with 36% of those 85 + showing symptoms of Alzheimer’s disease. Many dementias increase in symptoms over time and individual’s often experience difficulty with ADLs and IALs and requiring some level of care in the home or in an institution (Alzheimer’s Association, 2019; Hooyman et al., 2015).

Drug and alcohol abuse is a problem that affects the young and old. This problem can have even more adverse effects on older adults as they are physically more sensitive to substances due to changes in the aging body and the abuse of substances can exacerbate existing chronic illnesses. Although reported as affecting 3.5% of those aged 50 and older, alcohol is the most abused substance by older adults and it is often considered a hidden problem as its symptoms are often confused with those of chronic illnesses and aging and they often drink at home and are less likely to be arrested for driving under the influence (DUI) (Benshoff & Koch, 2003; Center for Behavioral Health Statistics and Quality, 2015). In terms of drug abuse, the use of illicit drugs has been found to decrease with age. Currently affecting only 4% of the population over 50, it is expected that the baby boom generation may have higher rates of usage than other cohorts of older adults (Han et al., 2009; Center for Behavioral Health Statistics and Quality, 2015, ). Prescription drug abuse can also be a problem among older adults as they are prescribed more medications than any other age group. This type of abuse is often considered to be unintentional as misuse of medications could be due to cognitive deficits or simply that an individual has multiple medications to manage. Slower metabolism, the use of over the counter and herbal treatments, and possible interactions of medications can prove hazardous to older adults. Due to limited income, some elders may also share medications with family or friends or take medications that were previously prescribed (National Institute on Drug Abuse, 2011).

Sexuality in older adulthood is not a topic that society and many individuals are comfortable discussing. In addition, several myths surround this topic such as “most older do not have sex,” “most older adults are not interested in sex,” and “most older adults are not healthy enough to have sex.” In reality, many individuals continue to have and enjoy sex well into older adulthood (Schick et al., 2010). Poorer health status does, however, negatively affects sexual activity and satisfaction among older adults. Chronic illnesses and medications to treat such illnesses can be the cause of reduced sexual activity and enjoyment among this population. Dementia, in particular, can produce barriers to sexual satisfaction for sufferers and their partners. Normal physiological changes that accompany the aging process can also cause problems in this area of life. Older women may experience thinning of the vagina walls and reduced lubrication as well as a slower response to sexual stimulation and a decrease in intensity and frequency of orgasms. Older men may experience difficulty achieving and maintaining an erection and slower response to sexual stimulation (Hillman, 2012; Lindau et al., 2007; Waite et al., 2009). Unfortunately, many older adults do not discuss sexual activity or problems with their partners or health care professionals. This, in part, may be responsible for the growing rate of HIV among the older adult population (Centers for Disease Control and Prevention, 2015).

Contrary to popular belief, the majority of older adults are not isolated from family, friends, and their community. This support can take many forms, such as assistance with ADLs and IADLs or emotional comfort. This social support or the availability of assistance and care from family, friends, and others has been found to be a mediator to health and mental health problems for older adults. Older adults with strong social support networks have been found to experience many benefits, including improved health status, cognitive functioning, and quality of life and decreased depression and anxiety. Social support also buffers the effects of illness, loss, and other negative events and conditions on older adults (Hooyman et al., 2015).

There are a variety of roles that older adults assume; some are more traditional such as volunteer or grandparent, while others challenge the traditional roles and pursue more adventurous activities in their later years such as skydiving or breaking world records. Often role change is associated with a precipitating event, such as the first grandchild being born. Grand-parenting can be an opportunity for older adults to provide care and nurturing for their grandchildren while also supporting their children. Increased life expectancy for older adults also increases the number of years that they can be involved with and influence the lives of their grandchildren. There are many families that live long distances from grandparents in our mobile society, and although distance can provide challenges in developing cross-generational relationships, distance alone does not diminish a quality relationship between grandparents and their grandchildren. Blended families are becoming more common in the United States for a variety of reasons. For many in the sandwich generation, adults caring for their young children and their parents, combining households can be beneficial for all. Combined incomes allows for a higher quality of living, grandparents are able to help care for the grandchildren, and there is only one household to maintain. In the United States, over 6 million children live with their grandparents, one in twelve will live in households where the grandparent is the head of household (Pinholt et al., 2014).

Older adults face many aspects of caregiving as they age and not just for their grandchildren, but for their spouse and/or other family members or friends. This role can be very rewarding and one in which relationships are developed and enriched. Caregiving can also make a person feel needed and give them a sense of purpose. According to the Alzheimer’s Association, in 2019 informal caregivers of those with Alzheimer’s and other dementias provided 18.5 billion hours of unpaid care, which translates into $233.9 billion dollars. One of the negative aspects of caregiving is caregiver stress. Caregiver stress is the emotional and physical strain of providing care for someone else. The caregiver can experience a variety of symptoms to include, depression, anxiety, sleeplessness, irritability, and a weaker immune system. The longer the caregiver is in their role, the more symptoms they are likely to develop. Symptoms of caregiver stress can lead to illness and missed workdays for the caregiver. The time-consuming nature of providing care can lead caregivers to feel a of loss-of-self during these years. The caregiving role becomes consuming for the individual so that even in the time when they are not providing direct care it becomes difficult to engage in other life activities. A sense of guilt for enjoying activities can keep the caregiver from pursuing recreation for themselves or the respite time they are afforded is limited and therefore spent taking care of other necessities. Caregivers must work daily to balance their own needs with those of the one they providing care.

The loss and grief that is faced in later adulthood can in many ways be defining for adults. Every adult faces losses and they must also face their own mortality more so than any other time in their life. Loss of physical abilities is a threat to how adults live their lives day to day. Diminished activities of daily living and instrumental activities of daily living affect the level of independence of an individual. Adults generally start compensating for losses in their physical abilities by using assistive devices to help them perform activities or they alter their behaviors to avoid certain tasks. Loss of mental capacity affects a person’s ability to perform their ADLs/IADLs and although they may have the physical ability they require prompting and supervision to carry out simple tasks. Decreased ability to perform ADLs and IADLs is expected through the aging process; however, this does not negate the feelings of grief that follow these losses. Widowhood is a role and life-altering experience that goes beyond an emotional loss, but also affects household income, status in society and social networks, and sometimes the ability to live independently if the caregiver is the one that passes away. Over half of adults over the age of 65 live with their spouse (57%) but with increased age this number declines (AOA, 2018).

Working gives many people a sense of purpose and belonging, therefore retirement and the loss of the “worker” role can bring a mixture of feelings. Americans often define themselves by the jobs they perform at work and by the income they bring into the household; retirement forces them to adjust their lifestyles and activities. Satisfaction in retirement is greatly influenced by what motivated the retirement and how prepared one is to be retired. Poor health, diminished physical or mental abilities, or caregiving responsibilities can force workers to leave their jobs before they had planned. If a worker is relying on Social Security as a retirement income, this can be significantly less than their working income and can ultimately affect living arrangements, the ability to own a car, pay for food, and medications. When a worker is forced to retire prior to being eligible for Social Security, they may have to rely on family for support. For those that have planned well for retirement and are able to choose when to retire, their experience can be quite positive. They may still feel the sense of loss of the familiar routine of going to work, but are able to adjust to their new life with little difficulty.

Policies and Programs for Older Adults and Their Families

Health care and social policies can greatly affect the lives of elders and their families and are important for students of all disciplines to understand. Financial security for older adults is closely related to these policies. Financial well-being throughout adulthood provides for adequate housing, proper nutrition, and access to health care. One of the biggest challenges older adults face is maintaining financial security 20–30 years after retirement. When Social Security was first enacted, life expectancy was 62 years and retirement eligibility did not begin until age 65. Now that adults are living longer they have to find new ways to plan for their many years in retirement. Ideally pensions and savings would supplement Social Security benefits; however, Social Security alone continues to be the main source of income for most older Americans, especially minorities and women (White House Conference on Aging [WHCOA], 2015).

For those who do not have a retirement, life savings, or long-term health insurance, there are some programs that can offer assistance for older adults. One of the largest resources for older adults is the Medicaid waiver program, which is available to those who meet financial and medical criteria to receive long term care services in their homes and community settings. Care can include a combination of medical and nonmedical services such as case management, homemaker services, assisted living, and respite care (Centers for Medicare and Medicaid Services, 2015). Medicare is also a critical program for older adults as it pays toward doctor and hospital bills, medical equipment, and medications. Programs provided locally under the federal Older Americans Act (OAA) have also positively impacted the lives of older adults and their families. These include home delivered meals, homemaker services, respite care, transportation, and information and referral (Hooyman et al., 2015).

Adult Protective Services is often contacted for assistance when family is unable or unwilling to provide care. Adult Protective Services (APS) generally investigates situations of adult abuse, neglect, financial exploitation, and self-neglect. Older adults can experience victimization earlier in life, throughout life, or at the end of life. Abuse occurs at the hands of both informal (family and friends) and formal (paid staff) caregivers. Sadly, it is thought that only one-in-twenty-four cases of elder abuse are actually reported. Risk factors for abuse that have identified by the literature in this area have included poor health, physical disabilities, cognitive impairment, low income, and low social support and social isolation (Anetzberger, 2012; U.S. Department of Justice, 2014).

Technology has made it much easier for the general public to get involved in policy change, using social media, webinars, and live streaming events in which the public can provide comment. Shaping policy is no longer something that happens from a distance and those working on the front lines have a way to make their voices heard. Of course, advocating for policy change does not just happen on a national level, it is also very important on a local level. This can mean changes in agency procedures that more effectively address client need, it can mean instituting transportation opportunities for elders in remote communities, or starting an adult day care in a senior center. Students in all fields should learn how to become empowered and active in aging policy.

Integrating Intersectionality Into the Model

As explored in the previous sections, there are many common issues, experiences, and roles that are helpful in understanding the lives of older adults. But to fully understand the population and to effectively work with and on behalf of them, students and professionals must also identify the diversity within this group. The theory of intersectionality can help guide the identification of these differences. Persons who have lived 60 or more years have had that many years to accumulate a variety of experiences. In theory, this would make older adults more different from each other than younger adults. Adding characteristics such as ethnicity, gender, sexual orientation, class, education, religion, ability/disability, and geographic location to age increases this diversity significantly. Looking at older adults through a lens of intersecting identities has the power to transform our perspective on aging and older adults.

In terms of theories on aging, there are several more contemporary frameworks that provide a more diverse picture of older adulthood and they have described older age as being defined by social processes as well as a movement by older adults to redefine the life stage. These theories also account better for the diversity among older adults and their life trajectories. Using these lenses, older adults may be seen as a subculture having its own norms and expectations or as part of a political economy and struggle, resulting in inequalities for the older population. Similar to the subculture view, feminist theory points to the disadvantages of aging as a female (such as the risk of poverty and the stigma associated with physical aging) and society’s lack of concern for their special experiences and issues. Social phenomenology and constructivist theories advise how older persons have reconstructed society’s definition of the aging process and have provided a healthier, more active picture of the life stage. Similarly, postmodern theory stresses the significance of personal narratives or stories of older adults over scientific “truths” and professions that attempt to define their processes and experiences (Hooyman & Kiyak, 2011).

As a group, older adults are often marginalized in society, as all older adults are subject to “ageism” or prejudice, discrimination, and oppression related to age. In the United States, youth is glorified and considered attractive and physically aging is something to prevent and hide. Older adults are thought of as frail and dependent and hold a lower status in society. Although it is illegal to discriminate based on age in the workplace, instances of individuals being fired or not being hired because of their older age is still widespread. Other examples of ageism include jokes and greeting cards about being “old” and adhering to the many myths and stereotypes about aging such as “most older people have dementia” and “older people are not interested in having sex.” As a result, an older adult can internalize these negative messages from society and can feel devalued and suffer from poor self-concept. These attitudes can also become institutionalized in public policies and programming, isolating older adults and furthering the stereotypes of dependency (Bugental & Hehman, 2007).

Although the majority in terms of number in the older population, women experience many difficulties in later life. For instance, women are more likely to be widowed and live alone. Widows account for 32% of older women (8.9 million) compared to 2.6 million widowers or 11% of older men (AOA, 2018). They also have lower income, with older men having a median income of $29,327 and older women earning $16, 301 and a poverty rate of 12% compared to 7% for men (AOA, 2018). Older women are also have greater functional limitations than their male counterparts and are at higher risk for clinical depression (Federal Interagency Forum on Aging-Related Statistics, 2012). Women also use more long-term care services than men and make up 68% of nursing home residents (Centers for Disease Control and Prevention, 2013b). Women of all ages have greater responsibility for providing care to spouses and parents, with women making up 68% of family caregivers for persons age 50 and older (National Alliance for Caregiving and AARP, 2009). Older women are also more often subjected to negative attitudes related to signs of physical aging.

It is well documented that ethnic minorities experience many challenges and health disparities compared to their Caucasian counterparts. In general, about double the number of ethnic minorities are poor as compared to older Whites. A health disparity is “a particular type of health difference that is closely linked with social, economic, and/or environmental disadvantage,” (USDHHS, 2010) and minority elders have been shown to exhibit several as compared to their Caucasian counterparts. African American and Hispanic persons in particular tend to report poorer health and greater activity limitations, have lower incomes and levels of education, and less access to needed health and social services (AOA, 2018). Many older ethnic minorities have also experienced prejudice, discrimination, and oppression related to race during their lifetimes. As a related population, older immigrants face additional challenges as they must adapt to another culture and possibly learn a second language.

Although the United States and other countries have instituted same-sex marriage and attitudes toward LGBT persons are changing for the better, oppression, and discrimination against LGBTs still occurs. Older cohorts of LGBTs have also lived through decades that have included predominantly negative attitudes about and treatment toward them (Morrow, 2001). Transgender is still considered a mental illness in the most recent Diagnostic Statistical Manual and homosexuality was only removed from it in 1,972. At the time of this book publication, the United States has not issued employment and housing protections for LGBTs at the federal level. LGBTs have unique challenges in aging, including fear of and real experiences with discrimination and oppression and the loss of support from friends and family when they came out as LGBT (Hash, 2006). Fortunately, many LGBT persons have created what are called “family of choice” or a support network that includes family members as well as partners and friends (Masini & Barrett, 2008). Older LGBTs suffer disproportionately from physical and mental health conditions. Transgender persons face the most challenges as they often do not receive appropriate and sensitive care that they can afford (Fredriksen-Goldsen et al., 2011).

When health and or mental health care are needed, rural elders often face a shortage of services. Rural areas have been shown to have a shortage of health care professionals and medical specialists within that field. Rural people of all ages must often travel significant distances to access care (Hartman & Weierbach, 2013; Williams et al., 2006). To compound this problem, rural areas have more limited access to public transportation (Park et al., 2010). Elders in rural communities are also disadvantaged in terms of having lower incomes and lower quality and more limited access to accessible housing (USDHHS, 2008). Rural residents experience many challenges as they age such as increased rates of chronic diseases and disability (Bennett et al., 2008).