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Forgotten: elderly persons with disability - a consequence of policy.

Forgotten: Elderly Persons With Disability--A Consequence of Policy

The prolongation in life expectancy has greatly increased the proportion of older individuals within the population. In 1900 there were only 3 million persons aged 65 and over in the United States. By 1981 24 million persons in the United States were 65 or over. The increase in numbers for this age group is projected to be 31 million by the year 2000 and 55 million by the year 2030. (U.S. Department of Health Services, 1979).

Although many elderly persons remain active and are not affected by the disabling effects of chronic disease, the incidence of chronic disease and associated disability increase with age by about 3 1/2 times. (Black, 1984). Aging should not be thought of as synonymous with disease or disability; however, the frequency and rate of total disability, occupational disabilities and secondary work limitations is greater after age 55 than for any other age group (Social Security Administration, 1981).

Even though the incidence of disability increases with age, contact with and services offered to olderly persons by rehabilitation agencies appears to decrease (Blake, 1981). After the age of 24, the number of persons receiving rehabilitation services is inversely proportional to the age of the individuals served (Blake, 1981). Rehabilitation goals for younger individuals with chronic health problems generally place a priority on increasing functional capabilities whether the outcome is work related or not (Hunt, 1984). However, rehabilitation goals for older persons with the same chronic health problems may be minimal or non-existent (Becker & Kaufman, 1988; Richardson, 1981).

Lack of rehabilitation services for the older age group evokes several consequences. First, rather than receiving services which would assist them to remain in the workforce longer, older individuals may instead be encouraged or forced to retire from employment. Second, rather than receiving services which would assist them to remain independent within their own home older individuals may, instead, be institutionalized because of functional limitations related to activities of daily living.

The social consequences of disinterest in the rehabilitation needs of elderly persons is far reaching both in terms of lost human potential and in financial ramifications. Providing the same rehabilitation services to elderly persons with disability as those which would be offered to younger persons with the same disability is a step to counteract loos of human as well as financial resources.

Distribution of Rehabilitation Services

Major chronic, disabling conditions such as diabetes, heart disease, visual impairments, hearing impairments, and mental conditions are often progressive, requiring long term treatment (Brody, 1983; Hunt, 1984). The occurrence of these conditions in elderly persons contribute to the incidence of severe disability with increasing age (Becker & Kaufman, 1988; Blake, 1984). Younger individuals with these conditions are eligible for rehabilitation services which enable them to increase functional capacities, maintain independence, and reduce development of complications. The same rehabilitation services for the same conditions, however are often not available to persons over 60 years of age. (Becker & Kaufman 1988).

Examples of inequitable distribution of rehabilitation services based on age are numerous. Although 85% of all amputations in the United States during peacetime occur in elderly persons as the result of complications of arteriosclerosis or diabetes (Brody, 1983) until recently many elderly persons were rejected for prosthetic fitting and training (Lippmann & Englewood, 1974). Rationale for rejecting such services for older persons was the perception that older individuals would be unable to learn how to use the prosthesis properly, even though there was no evidence to substantiate this claim (Brody, 1983).

Hemiplegia due to stroke comprises a majority of disabilities in older persons. Although at least 80% of elderly persons with hemiplegia have rehabilitation potential shortly after their stroke, functional potential is diminished when bed rest is prolonge and an effective rehabilitation program is not begun (Hirschberg, 1976). Although physical rehabilitation may be available to older persons during and shortly after hospitalization, more extensive rehabilitation services which would incorporate the individual into the community are often not available (Beck & Kaufman, 1988).

The incidence of blindness as a complication of diabetes increases with aging. However, most services to blind people are given to younger individuals, despite the fact that the majority of the visually impaired are in the older age group (Barry, 1981; Blake, 1984).

A large number of older individuals are disabled because of cardiac disease. Emphasis, however, is frequently placed on the medical management of the cardiac condition rather than on rehabilitation of the older persons after hospital discharge (Rush, 1971). Consequently, the functional decline which often accompanies (Rush, 1971). As with the younger adult, hospital discharge should include referral to a rehabilitation agency which could evaluate the patient's situation and provide necessary services to assist the older individual to return to a productive, independent lifestyle (Carlson, 1988).

One quarter of mental health problems are found in the older population (Birren & Sloan, 1980). The incidence of disabling depression among elderly persons range from five to forty-four percent (Blazer & Williams, 1980). Estimates of alcoholism among elderly persons who are not institutionalized range from 2-12 percent (Gomberg, 1982). Despite the incidence of mental health problems which could be effectively treated, only two percent of outpatient psychiatric and psychological services are received by elderly individuals (Birren & Sloan, 1981).

Ageism and Policy

The discrepancy that exists between the incidence of disabilities and services provided to the elderly may have several explanations. However, the part that policy plays in the discrepancy cannot be ignored. The human condition or need for which services are to be provided are often determined and operationally defined by policy itself (Hahn, 1985). Just as disability itself has been defined by policy, implying a problem or disadvantage requiring compensatory or ameliorative action (Hahn, 1985), so has the term elderly been defined by policy. The passage of the Social Security Act of 1935 created a public definition of old age chronologically, as well as suggesting the vocational potential, or lack thereof for persons 65 years and older. Additional amendments to the Social Security Act continue to imply that old age, unemployability and disability are synonymous (Sink & Craft, 1981).

Traditionally, the State-Federal Vocational Rehabilitation program restricted service to those of working age, which was defined as 16-64 years of age (Bahcall & Berven, 1986). Although the restriction was removed in 1973, so that older adults were no longer excluded, no significant expansion of services to older adults has occurred. A review of data from the Rehabilitation Service Administration (Myers, 1985) indicates that only 2.4% of individuals receiving rehabilitation services through State-Federal programs in 1979 were 65 years or older. Delivery of rehabilitation services appears to continue to be oriented toward the vocational goal of remunerative work and cost-benefit (Barry, 1980; Bozarth, 1981). Preference for remunerative work as an outcome goal however, overlooks the value and cost-benefit of improving functional abilities which may be unrelated to employment but mibht be related to independent living. As a result many potential rehabilitation clients may not receive services because they are considered too old to be employed (Barry, 1980). Under these circumstances it is easy to understand why older individuals have received a minor portion of services. Although the independent living movement of the 1970s, which resulted from the Rehabilitation Amendments of 1973, expanded opportunities for many disabled persons, disabled elderly individuals are frequently overlooked with regard to services which would enable them to maintain their independence as well. Instead, an increasing and custodial care of older are currently spent for maintenance and custodial care of older persons with disability (Williams & Jones, 1985). The same funds could, however, be utilized to improve independent living capabilities for elderly persons with disabilities as an alternative to institutionalization.

Allocation and subsequent use of funds is often determined by policy. Policy, however, is frequently shaped or influenced by attitudes of policy makers and subsequently by society as a whole (Sink & Craft, 1981). To the extent that these attitudes reflect an emphasis on health and youth, both age and disability could be devalued. If disability is viewed negatively by some, to be both elderly and disabled may be viewed as double jeopardy (Benedict & Ganikos, 1981).

"Ageism" has been described by Butler (1975) as a generalized negative attitude toward elderly persons which is based chiefly upon societies' fear of aging, and upon societies' perception of elderly persons as a whole. In the United States, elderly persons have been perceived as less important and less desirable than the young and fit (Becker & Kaufman, 1988; Benefict & Ganikos, 1981). The increased incidence of chronic health problems in older people tends to intensify this view.

Negative attitudes at all levels of care impact upon older persons' rehabilitation potential. While disabling conditions appearing in young adults may be aggressively diagnosed and treated, the same conditions occurring in elderly persons may be attributed to the aging process alone, and not adequately diagnosed or treated (Becker & Kaufman, 1988; Carlson, 1988). For example, older people with memory problems may be thought of as "senile" rather than as possibly suffering from a neurological disorder which may be correctable or rehabilitated (Hunt, 1984). Incontinence may be viewed as a symptom of general deterioration rather than as a treatable condition (Jernigan, 1981).

Often older persons as well as young persons responsible for their care have accepted these problems and labels as an expected, inevitable, unavoidable part of aging (Brody, 1983). Such age biases can influence feelings and behaviors of other professionals toward older persons, influence the older persons' feelings and behaviors toward the helper, and influence the older persons' own perception about themselves (Benedict & Ganikos, 1981). In such instances, the most handicapping factor may be attitudes and perceptions rather than the condition itself.

Implications for Rehabilitation


Although lack of rehabilitation services to the elderly, in part, can be attributed to societal attitudes and social policy, lack of services may also be influenced by attitudes of rehabilitation professionals themselves (Myers, 1983).

Rehabilitation professionals serve as advocates for persons with a wide range of disabilities. The advocacy role, however, may not be viewed as extending to elderly persons.

Part of this age bias may be a result of rehabilitation professionals' own fear of aging, stereotypes of older persons, or the belief that rehabilitation services should focus only on employability. Another factor may be lack of educational preparation to deal effectively with the elderly population (Brummel-Smith, 1984). Just as rehabilitation training programs have components which focus on medical and psychosocial aspects of disability and on increasing the rehabilitation professional's awareness of social-environmental barriers which interfere with the rehabilitation process, educational programs should also have a component which focuses on physiological, psychosocial, and socio-environmental circumstances of elderly persons. Such a component can help to increase skill and confidence of the rehabilitation professional in working with older persons, increase awareness of need, and help the rehabilitation professional examine their own attitude toward aging.

A proactive stance by State-Federal Rehabilitation departments in proposing, developing, and seeking funds for new programming to address previously unmet needs of the elderly persons who are disabled is another way in which services to this group might be improved (Bahcall & Berven, 1986). At the same time, however, methods of evaluation which measure benefits in terms of increased functional ability, improve social and psychological well being, and independent living should be developed whether or not employment outcome is feasible for the older individual.

Advocacy to influence legislation which is more responsive to the rehabilitation needs of older persons with disability is also a step to improving rehabilitation services to this group (Richardson, 1981). Legislation should be directed toward expansion of rehabilitation for older persons with disability and to improving linkages between Rehabilitation Services Administration and all federal agencies concerned with aging. Amendments to existing legislation for inclusion of rehabilitation incentives and use of technology to permit continued independence of older persons with disability within their chosen environment should be a priority.


Just as the number of older people in the United States is growing, so is the number of older persons with disability. With the general attainable life span ranging from 77-93, longer life expectancy will result in substantial increases in debilitating conditions which require rehabilitation services. However, provision of rehabilitation services to this group has not kept pace. Whether this is due to service policy, legislation, professionals' lack of knowledge and actions, or societal bias, the problem will soon reach major proportions.

Integration of current knowledge into all levels of rehabilitation programs regarding physiological, psychological and social needs of older persons can help rehabilitation professionals prepare to meet these needs in the future. Services provided should be responsive to both subjective (self-assessed) and objective (professional evaluated) needs of elderly persons. Funding directed toward expansion of basic and applied geriatric rehabilitation research can benefit educational programs and professionals in the field as well as benefiting older persons with disability.

Finally, a major step toward providing adequate rehabilitation services to older persons with disability will be the development of a viable long-term care policy which would focus on functional impairment of older persons. Such policy should be directed toward assisting older persons with disability to maintain autonomy and independent living rather than focusing on their age or employability.

As the number of older people increase, existing resources could become limited. Poliocy which commits federal funds for custodial care without also making available funds to enhance older persons' ability to live independently negates human potential and strains existing resources. Needs of older individuals with disability may be met more efficiently and at less cost by rehabilitation services within the community. Implementation of policy for rehabilitation services directed toward maintenance of independent living of older individuals with disability can have far reaching effects. These effects are important not only for older persons themselves, but for society as a whole. Rehabilitation is concerned with assisting individuals to achieve optimal functioning with their limitations (Becker & Kaufman, 1988). Consequently, such assistance should not be age specific.


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Author:Falvo, Donna R.
Publication:The Journal of Rehabilitation
Date:Apr 1, 1990
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