Rural Elderly

Description of the life circumstances of older people living in remote or rural areas is complicated by different definitions of rural residence and by the lack of variability within residential categories. The U.S. Bureau of the Census, for example, classifies residence based solely on the size of the population living in a predetermined geographical area. An ‘‘urbanized are&squo;’ refers to one or more places plus the surrounding territory or fringe that include at least fifty thousand people. Urban residents are people living in either an urbanized area or outside an urbanized area in a place (e.g., township) with at least twenty-five hundred total residents. All other residents are considered rural. Rural residents are subdivided further into ‘‘far&squo;’ and ‘‘nonfar&squo;’ designations. According to the Census Bureau, about 24 percent of people aged sixty-five and over lived in rural areas in 1990, approximately the same proportion as the general population living in rural areas. About 16 percent of people aged sixty-five and over were rural farm residents in 1990, compared to only 1.5 percent of the total population (McLaughlin and Jensen).

Because the definition of rural residence used by the U.S. Office of Management and Budget (OMB) includes other criteria, such as commuting patterns and business activity, the Census and OMB sometimes classify residence differently. Different definitions and simplistic dichotomous categories frustrate efforts to learn more about the lives of rural elderly persons because researchers often rely upon data gathered by government agencies. Indeed, the terms ‘‘rura&squo;’ and ‘‘nonmetropolita&squo;’ will be used here inter-changeably, depending upon the data source cited. Rural elderly residents include those living in a remote county on a Wyoming ranch forty-five miles from the nearest small town, as well as those living on the outskirts of a large city. Similarly, the nonmetropolitan category includes remote counties as well as those with populations over 100,000 people. These definitions also matter because they influence national and state funding allocations. Further, the tax base contained within the geographic boundaries of these areas affects local millage rates and the potential to provide needed health and human services. Whether counties are nonmetropolitan or communities have fewer than 2,500 people would also make little difference if these counties or communities were alike. It is known, however, that counties differ according to indicators such as premature mortality (Mansfield, Wilson, Kobrinski, and Mitchell) and small communities differ according to poverty (Weinberg) and health services delivery and availability. Such differences affect the lives of elders with regard to availability and access to needed health and other services, opportunities for paid employment, or involvement in volunteer or leisure activities.

The changing rural older adult population

With the exception of the Northeast, nonmetropolitan residents are older than their metropolitan counterparts. Although there are signs that this distinction is beginning to reverse (e.g., Beale), the Census Bureau estimates that the nonmetropolitan population over age sixty-five grew by over 7 percent and the population aged eighty-five and older increased by about 21 percent from 1990 to 1996 (Ricketts et al.) Change in the percentage of older persons who live in rural areas is influenced by both immigration and a phenomenon called aging in place, accompanied by the outmigration of younger people. Comparing census data from 1970 to 1990 (McLaughlin and Jensen), states associated with retirement immigration, including Florida and Arizona, and states with elderly populations that are small to begin with, such as Alaska, have the fastest growing elderly populations. In primarily southern and western states impacted by retirement migration out of northern states, however, growth in the number of elders is not uniform across rural areas. Elderly people who are generally more affluent tend to move to areas within states or from one state to another with features such as bodies of water and a strong tourism base (Johnson). The short- to medium-term impact of this movement on receiving rural communities is generally economically positive (Glasgow and Reeder, 1990; Serow, 1990). Elderly migrants purchase property, increasing the tax base, and they create service sector employment (Reeder and Glasgow). Over the long run, however, Longino and Smith speculate that the demand for social and medical supportive services will gradually increase as elderly migrants age in place and experience associated illness and disability.

States with large numbers of older adults who are aging in place (e.g., Kansas and Iowa) are also experiencing outmigration of younger people from rural areas in search of employment. When this happens, the proportion of the population that is older becomes relatively large and stable. The situation of rural older adults who are aging in place is better understood by considering their lifelong work and economic histories. Census data from 1990 show that rural workers hold lower paying and lower occupational status jobs. This explains why younger people are moving to areas with better jobs, leaving older family members behind to age in place. Compared to urban elders, rural elders have likely held jobs throughout their working lives in seasonal farming, forestry, fishing, or in lower paying occupations. This explains why older persons in rural regions characterized by aging in place are economically vulnerable. They have lower incomes and are more likely to be poor, and they are less educated then their urban counterparts (Coward, McLaughlin, Duncan, and Bull). Thus, increases in the proportion of rural older persons can have negative or positive economic precursors. In either case, however, the long-term effect will likely be increasing demand for services and assistance.

Characteristics of rural older adults

As stated previously, nonmetropolitan older adults are more likely than their metropolitan counterparts to have low incomes (below 200 percent of poverty) and lower lifetime earnings that negatively impact social security benefits (Krout, 1994). At the same time, they derive a higher proportion of their incomes from social security (Coburn and Bolda). The rural elderly are more likely than older urban residents to rely on Medicaid, because of lower lifetime earnings, or Medicare as their sole health insurance provider. Although rural older persons are more likely than urban older adults to own their homes outright, their homes tend to be of lower value and in need of repair compared to the homes of urban elderly people (Coburn and Bolda). Coburn and Bolda also describe rural or nonmetropolitan elderly people as significantly more likely than their urban or metropolitan counterparts to rate their health as fair or poor and to have problems doing activities of daily living, increasing their risk of premature mortality and diminished life satisfaction.

In contrast to popular notions about rural life, there is little evidence that older adults living in rural areas have more extensive kin networks from which to draw informal support than their urban counterparts (Coward and Cutler). Although rural elders are more likely than urban residents to be married, providing a source of assistance when needed, Stoller points out that the rural-urban difference in marital rates disappears by age eighty-five, when older people are more likely to need assistance. Stoller also points out that about one-third of rural elders are widowed. By age eighty-five, over 80 percent of rural women are widows, compared to 40 percent of men. Given more traditional views of marital roles among older rural couples, particularly among husbands who often assume responsibility for transportation and finances, older rural widows are at high risk for financial vulnerability due to a lifetime of unpaid work and isolation. Remote locations and small community sizes that limit sources of assistance, combined with the outmigration of younger family members, places rural older adults in a vulnerable position concerning access to formal services and the availability of informal assistance from outside the home when needed.

On the positive side, older people living in rural areas are more likely than their urban counterparts to be married and less likely to be divorced until age eighty-five, when this rural advantage disappears (Stoller). Rural farm, but not necessarily nonfarm, elders are more likely than urban residents to live with or near at least one of their children. According to Lee et al., this child is often also engaged in the farm enterprise. Aside from the results of statistical comparisons, an obvious conclusion is that the majority of older persons living in rural areas are there because they prefer this environment: they have chosen to live in locations that are quieter and less populated, so their lives are less impacted than those of urban residents by the press of humanity. Fewer amenities and complex supportive services are not a problem as long as functional independence can be maintained.

Health and home- and community-based service use among rural older adults

National Health Interview Survey data point to a tendency for nonmetropolitan elders aged sixty-five to sixty-nine, adjacent to a metropolitan area, to visit physicians less frequently than same-aged people living in other locations. Rural elderly residents aged seventy-five and over, however, were as likely or more likely to visit a physician as their urban counterparts (Coburn and Bolda). It seems that rural elders who are financially able manage to get to physicians when there is a need, regardless of distance. In their study of health and community-based service use among rural southeastern community-dwelling older adults, Mitchell, Mathews, and Griffin (1997) found that rural and small town (under twenty-five hundred) residence had no effect on visits to primary care or specialty physicians when poverty status, transportation needs, and the availability of informal care were considered. This suggests that the poverty status, transportation problems, and lack of informal assistance coinciding with rural residence may be more important predictors of visits to primary care and specialty physicians than residence.

Services that help older persons stay in their homes as long as possible include those available through the Older Americans Act (OAA), the Social Services Block Grant (SSBG) program, Medicaid waivers, and largely for-profit in-home care. Initially assisting all older persons, OAA services now target socially impaired and economically disadvantaged people age sixty-five and over. OAA services include senior centers, transportation, in-home services, legal assistance, congregate meals, home delivered meals, and in-home services for the frail. Allocated to states through Title XX of the Social Security Act based upon the size of the needy population, SSBG assistance includes homemaker, chore service, home health care, protective services, and nutrition for older people. Medicaid funds home- and community-based long-term, skilled nursing care for eligible older adults as an alternative to institutional care. With Medicare restrictions in hospital care reimbursement in the 1980s, the private sector began to offer home health care following hospital discharge. Many agencies have expanded their services to include other types of in-home assistance, including chore service. This array of services is so complex that some have tried to categorize them in a more meaningful way. For example, Cox (1993) groups them as preventive for those less impaired, supportive for the moderately impaired, and protective for the severely impaired.

Assessment of the extent to which rural residence compromises access to home- and community-based services among older adults has been frustrated by inconsistent definitions of rural residence and because of different service designations across studies. Federal service delivery requirement (e.g., only volunteers can deliver meals), transportation costs, and the lack of larger numbers of service personnel found in urban areas, certainly limits innovation and the penetration of specialized services into rural communities (e.g., Salmon, Nelson, and Rouse). Consequently, Rowles concludes that relocation away from the rural community becomes the only option when rural elderly people lose capacity to accommodate declining physical capability, and when the support from kin, neighbors, or aging peers is no longer viable. Since the supply of nursing homes and nursing home beds is nearly 43 percent greater in nonmetropolitan than metropolitan areas (Coburn and Bolda) and complex in-home services that replace or delay institutionalization are generally less available in rural compared to urban areas (Nelson), this rural relocation is more likely to be to a skilled nursing facility than would be an urban relocation.

Regional studies with samples sufficiently large to uncover variability among older rural residents are needed to unmask findings of ‘‘little if any residential variabilit&squo;’ resulting from simplistic dichotomous residential definitions. For example, virtually all of the contributors to Coward and Krou&squo;s (1998) edited volume called for research to better understand the implications of the variety of rural locations across America. The culture of rural Kansas is certainly different than the culture of rural Vermont, and such cultural difference impacts all aspects of rural aging, from the propensity towards self-care to the availability of residential alternatives.