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GERONTOLOGY for the Health Care Professional

FOURTH EDITION

Edited by

Regula H. Robnett, PhD, OTR/L, FAOTA

Professor, Department of Occupational Therapy University of New England

Nancy Brossoie, PhD Senior Research Scientist, Center for

Gerontology Virginia Tech

Walter C. Chop, MS, RRT Professor Emeritus, Respiratory Therapy

Department Southern Maine Community College

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Library of Congress Cataloging-in-Publication Data Names: Robnett, Regula H., editor. | Chop, Walter

C., editor. | Brossoie, Nancy, editor. Title: Gerontology for the health care professional /

[edited by] Regula H. Robnett, Walter Chop, and Nancy Brossoie.

Description: Fourth edition. | Burlington, MA : Jones & Barlett Learning, [2020] | Includes bibliographical references and index.

Identifiers: LCCN 2018013913 | ISBN 9781284140569 (pbk. : alk. paper)

Subjects: | MESH: Geriatrics | Aged | Aging– physiology | Geriatric Assessment

Classification: LCC RA564.8 | NLM WT 100 | DDC 618.97–dc23

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Dedication

This edition is dedicated to:

The older adults who have shown us how to live productive, healthy, and

happy lives and for reminding us that age is more than just a number.

Our authors for their tireless writing efforts and commitment in educating healthcare workers, from students to

seasoned professionals.

Our families who sacrificed their needs and wants when our work on this

edition had to come first.

We thank all of you.

–Regi, Nancy, and Walter

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Brief Contents

Introduction How to Use This Text About the Authors Acknowledgments Contributors Reviewers

Chapter 1 Age Matters: Profiles of an Aging Society

Chapter 2 Social Gerontology Chapter 3 Aging in Place and the Continuum

of Care Chapter 4 Loss, Grief, Death, and Dying Chapter 5 Health Literacy and Clear

Communication: Keys to Engaging Older Adults and Their Families

Chapter 6 Policy Issues for Older Adults

Chapter 7 The Physiology and Pathology of Aging

Chapter 8 Cognitive and Psychological Changes Related to Aging

Chapter 9 Functional Performance in Later Life: Basic Sensory, Perceptual, and Physical Changes Associated with Aging

Chapter 10 Drugs and the Older Adult Chapter 11 Nutrition and Aging Chapter 12 Perspectives on Oral Care in

Healthy Aging and Prevention for the Older Adult

Chapter 13 Sexuality and Aging Chapter 14 Reframing Aging Issues to Ensure

a Better Future

Epilogue Answers to Review Questions Glossary Index

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Contents

Introduction How to Use This Text About the Authors Acknowledgments Contributors Reviewers

Chapter 1 Age Matters: Profiles of an Aging Society

Nancy Brossoie, PhD Regula H. Robnett, PhD, OTR/L, FAOTA Walter C. Chop, MS, RRT

Introduction Global Aging

Age, Sex, and Distribution Fertility Rates Longevity Migration

Aging in the United States

Age and Age Groups Geographic Distribution Sex Race Marital Status Living Arrangements

Economic Status Poverty Income Sources of Income

Work and Retirement Status Health Status

Chronic Health Conditions Functional Limitations Vaccinations Self-Rated Health

Caregivers Long-Term Care Services

Death Causes

Aging Successfully Successful Aging Quality of Life in Old Age

Summary Case Studies Test Your Knowledge References

Chapter 2 Social Gerontology

Nancy Brossoie, PhD Walter C. Chop, MS, RRT

Gerontology Historical Perspectives on Aging Theories About Aging Ageism

Ageist Stereotypes Myths About Aging Ageist Language Ageist Attitudes of Healthcare

Professionals Media Stereotyping of Older Adults

Social Roles in the Second Half of Life Retiree Grandparent Surrogate Parent Caregiver Social Roles in Context

Social Relationships Personal Relationships Computers and Social Media The Aging Couple Aging Parent and Adult Child Never Married or Childless in Late Life Friendships

Elder Abuse Victims of Abuse Self-Neglect Among Older Adults Perpetrators of Abuse Signs of Abuse Mandated Reporting

Employment and Civic Engagement Workplace Discrimination Retirement

Summary Case Studies Test Your Knowledge References

Chapter 3 Aging in Place and the Continuum of Care

Ann O'Sullivan, OTR/L, LSW, FAOTA Nancy Brossoie, PhD Regula H. Robnett, PhD, OTR/L, FAOTA

Introduction Aging in Place

Independence Productive Aging Competency Person-Centered Care Technology-Based Services Universal Design Continuum of Care Independent Living Active Adult Communities Congregate Living Arrangements

Community-Based Services and Supports Home and Community-Based Services Home Health Services Program of All-Inclusive Care for the

Elderly Aging Network Services

Service-Enriched Communities Continuing Care Retirement Community Assisted Living Facility Nursing Facilities Rehabilitation

Person-Centered Approaches to Institutional Care

Hogeweyk Eden Alternative

Special Topics and Issues Telehealth Paying for LTCSS Homelessness Home Modifications Reverse Mortgages

Summary Case Studies Test Your Knowledge References

Chapter 4 Loss, Grief, Death, and Dying Regula H. Robnett, PhD, OTR/L, FAOTA Nancy Brossoie, PhD

Introduction Loss and Grief

Loss Grief

Theories on Managing Grief Attachment Theory Stage Process Model

Phase Process Model Coping with Loss and Grief

Complicated Grief Supporting a Person Who Has Sustained a

Loss Rituals Burnout Compassion Fatigue

Death and Dying Death Perspectives on Death

Seeking a Good Death Advanced Directives

End-of-Life Care Options Hospice Working with Dying Patients

Summary Case Studies Test Your Knowledge References

Chapter 5 Health Literacy and Clear Communication: Keys to Engaging Older Adults and Their Families

Audrey Riffenburgh, PhD Sue Stableford, MPH, MSB

A Patient's Experience of Health Communication

Understanding and Using Health Care: Why Older Adults Often Struggle

Health Literacy Challenges Organizational Barriers Individual Factors

Literacy, Numeracy, and Health Literacy Challenges

Literacy Numeracy

Impacts of Literacy and Health Literacy Skills: Two Major Keys to Good Health

The Impact of National Policies on Health Literacy Practice

Accrediting, Standard Setting, and Policy Organizations

Federal Government Agencies The Business and Legal Case for Health

Literacy Clear Health Communication: An Often

Overlooked Necessity What Is Plain Language? How Will I Know It

If I Hear It? What Is Plain Language? How Will I Know it

if I See it? A Call to Action Case Studies Test Your Knowledge References

Chapter 6 Policy Issues for Older Adults Laney Bruner Canhoto, PhD, MSW, MPH

Introduction

Policy Overview The Ever-Evolving Nature of Policy Historical Perspectives on Elder Policy

Policy Issues Income Policies Healthcare Policies Older Adults and Disabilities Policies Long-Term Services and Supports

Summary Case Studies Test Your Knowledge Resources References

Chapter 7 The Physiology and Pathology of Aging

Kimberly Wilson, DNP, RN Introduction Theories of Aging

Programmed Theories of Aging Environmental Theories of Aging

Physiological Changes of Aging Cardiovascular System Respiratory System Gastrointestinal System Genitourinary System Musculoskeletal System Nervous System Endocrine System Immune System

Integumentary System Sensory Organs

Summary Case Studies Test Your Knowledge References

Chapter 8 Cognitive and Psychological Changes Related to Aging

Regula H. Robnett, PhD, OTR/L, FAOTA Introduction Typical Cognitive Changes of Aging

Typical Cognition Overview Crystallized and Fluid Intelligence Processing Speed Learning in Late Life Specific Factors Impacting Cognition Specific Aspects of Cognition Assessing Cognition Interventions to Maintain or Enhance

Cognition in Older Adults The PACES Program to Promote Brain

Health Atypical Changes of Cognitive Aging

Risk Factors for Cognitive Decline Minor Neurocognitive Disorders (Mild

Cognitive Impairment [MCI]) Overview of DSM-V Major

Neurocognitive Disorders Working with Persons Who Have Major

NCD

Comparing Dementia with Depression and Delirium

Related Potentially Reversible Disorders

Personality Development Five-Factor Model of Personality Personality Summary Behavior Change

Summary Case Studies Test Your Knowledge References

Chapter 9 Functional Performance in Later Life: Basic Sensory, Perceptual, and Physical Changes Associated with Aging

Jessica J. Bolduc, DrOT, MS, OTR/L Introduction Vision

Visual Perception Hearing Smell Taste Physical Changes

Range of Motion Strength Endurance Physical Exercise Praxis

Physical Performance Reaction Time Motor Coordination

Work Performance Sleep

Normal Sleep Impact of Sleep on Older Adults Sleep Disorders Treatment of Sleep Disorders

Summary Case Studies Test Your Knowledge References

Chapter 10 Drugs and the Older Adult David J. Mokler, PhD

Introduction Pharmacokinetics

Drug Absorption Drug Distribution Drug Metabolism Drug Excretion

Pharmacodynamics Pharmacogenomics Anticholinergic Syndrome

Other Syndromes Drug Dependence, Misuse, and Addiction Beers List and Stopp/Start Herbal Medicines and Supplements

Polypharmacy Summary Case Studies Test Your Knowledge References

Chapter 11 Nutrition and Aging Kathryn H. Thompson, PhD, RD

Introduction Screening

The Nutrition Screening Initiative Undernutrition: Weight and Malnutrition

Treatment of Weight Loss and Other Nutritional Problems Related to Aging

Weight Loss Treatment of Gastrointestinal Problems Overnutrition Cardiovascular Disease Diabetes

General Nutrition Recommendations Drug and Nutrient Interactions

Alcohol Summary Case Studies Test Your Knowledge References

Chapter 12 Perspectives on Oral Care in Healthy Aging and Prevention for the Older

Adult Marji Harmer-Beem, RDH, MS

Introduction Oral Health in America: A Report of the

Surgeon General Oral Structures and Chronic Oral Diseases

Separating Oral Aging from Disease Recognizing Barriers to Care The Interprofessional Role in Oral Care and

Prevention Prevention Simple Oral Screening

New Models of Care Summary Case Studies Test Your Knowledge References

Chapter 13 Sexuality and Aging Nancy MacRae, MS, OTR/L, FAOTA

Introduction Sex and Sexuality Aging and Sexuality Intimacy Physiologic Changes in Sexual Functioning

Women Men

Gender Differences

Raising the Subject of Sexual Functioning Assessing and Addressing Sexual

Functioning Sexual Functioning and Health

Problems Medication Effects Inappropriate Sexual Behaviors Toward

Practitioners Special Populations

Older Lesbians and Gay Males Transgender Adults Adults with Physical Disabilities

Adults Living in Institutions Adults Infected with HIV Summary Case Studies Test Your Knowledge References

Chapter 14 Reframing Aging Issues to Ensure a Better Future

Raven H. Weaver, PhD Aging: A Global Perspective Aging as a Social Enterprise

Structural Inequalities Socioeconomic Security Health Inequalities

Aging as a Family Affair Family Caregiving

Formal Caregiving Aging as an Individual Experience

Self-Perceptions and Attitudes Health Behaviors

Aging and the Healthcare Workforce Responsibilities of Healthcare

Professionals Summary Case Studies Test Your Knowledge References

Epilogue Answers to Review Questions Glossary Index

T

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Introduction

hank you for choosing to open this textbook and read this page. Gerontology for the Health Care Professional, Fourth Edition is designed

with you in mind. Our goal is to provide a textbook that is reader-friendly and includes information that easily translates to healthcare practices.

As you read each chapter, we encourage you to consider the interprofessional roles of each of the healthcare professions listed below. While this is not an exclusive list and, most of the time, only a small portion of all the possible professions will actually be involved in working with any given client, we encourage you to think about how each profession could be involved and when a consultation or referral would be in order. You may need to investigate some of the following professions to familiarize yourself with their roles and further research is certainly encouraged.

The most prominent healthcare professionals involved in gerontological care are:

Alternative Medicine Practitioners Art Therapists

Athletic Trainers Audiologists Cardiovascular Technologists Case Managers Counselors Dental Practitioners Dieticians/Nutritionists Emergency Medical Practitioners Gerontologists Horticulture Therapists Imaging Technologists Massage Therapists Medical Laboratory Practitioners Medical Records Health Information Specialists Music Therapists Neuropsychologists Nursing Practitioners Occupational Therapy Practitioners Orientation and Mobility Specialists (low vision) Orthotists Physical Therapy Practitioners Physician Assistants Physicians Polysomnographers Prosthetists Psychiatrists Psychologists Radiological Technologists Recreation Therapists Rehabilitation Teachers (low vision) Respiratory Therapists Social Workers Speech and Language Pathologists Visual Care Specialists

We are fortunate to be living in an information- rich age in which Internet resources are readily available as never before. Certainly not everything available online can be relied upon, and therefore we need to read what is out there in cyberspace with critical and questioning eyes. However, for individuals who want to learn, the floodgates have opened and the world of information is there for the learning.

▶ How This Text Is Organized The Fourth Edition begins with chapters on the social, psychological, and biological aspects of aging, including:

Demographics (Chapter 1) Social Relationships and Roles (Chapter 2) Community Living (Chapter 3) End of Life (Chapter 4) Communication (Chapter 5) Policy (Chapter 6) Physiology (Chapter 7) Cognition and Psychology (Chapter 8) Later chapters explore issues that, although not

exclusive to older people, are of primary importance to the older population. These issues include:

Functional Performance (Chapter 9) Drugs (Chapter 10) Nutrition (Chapter 11) Oral Health (Chapter 12) Sexuality (Chapter 13) Future of Aging (Chapter 14)

▶ What Is New to the Fourth Edition

NEW! Now in FULL color with a new and expanded art program! REVISED! Chapter 1 on demographics of aging offers more information about aging worldwide and the factors that contribute to a growing worldwide population. REVISED! Chapter 2 on social gerontology includes an expanded section on elder abuse. REVISED! Chapter 3 on community living has been expanded to include more information on aging in place and the continuum of care. NEW! New Chapter 4 on Loss, Grief, Death, and Dying. REVISED! Chapter 13 on sex and gender issues has been revised to reflect the lives of the LGBTQ community and other hidden populations. REVISED! Chapter 14 on the future of aging examines aging issues using community, family, and individual perspectives. NEW AND REVISED! Case Studies have been revised and additional ones added so there are two per chapter. UPDATED DATA! All information is updated to reflect current census data and statistics.

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How to Use This Text

Gerontology for the Health Care Professional, Fourth Edition incorporates a number of engaging pedagogical features to aid in the student's understanding and retention of the material.

▶ Instructor Resources Qualified instructors will receive a full suite of instructor resources, including:

More than 250 slides in PowerPoint format A test bank with chapter-by-chapter questions along with midterm and final tests Case studies along with potential answers An Instructor's Manual containing a summary, key terms and definitions, teaching tips, and a

list of material and online resources

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About the Authors

Regula H. Robnett, PhD, OTR/L, FAOTA Professor Department of Occupational Therapy University of New England Portland, Maine

Regi Robnett has 27 years of experience as an occupational therapist and over 30 years of experience working with older people in various capacities. She has worked at the University of New England for 22 years. Regi holds a PhD in Gerontology from the University of Massachusetts, Boston. She teaches courses in the biopsychosocial dimensions of older adults, communication, culture, and group process as well as research (often incorporating older adults and their concerns) and mental health. Regi enjoys doing community work to benefit older adults, often with her students.

Nancy Brossoie, PhD Senior Research Scientist Center for Gerontology

Virginia Tech Blacksburg, Virginia

Nancy Brossoie is a senior research faculty member in behavioral and social science. Her primary research interests include aging in place, age- friendly communities, substance misuse in late life, and building community capacity to meet the needs of vulnerable populations. Nancy's expertise is informed by 17 years supervising home and community-based service delivery, evaluating programs and services at the state and community levels, and developing strategic plan initiatives for hospital systems, long-term care organizations, and mental health agencies.

Walter C. Chop, MS, RRT Professor Emeritus Respiratory Therapy Department Southern Maine Community College Portland, Maine

Walter Chop served as chair and professor in the Respiratory Therapy Department, Southern Maine Community College, for over 29 years. During his tenure at the college, he has also served as chair of Allied Health Sciences for 22 years. He has written numerous articles on both gerontology and respiratory care. For the past 10 years, he has been a member of the American Association for Respiratory Care Gerontology Committee.

I

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Acknowledgments

t takes many individuals to create the final product that becomes a textbook. We thank everyone who has contributed to the process that has made the Fourth Edition of Gerontology for

the Health Care Professional possible. Specifically, All the contributing authors whose hard work and dedication created the substance of this text: Jessica Bolduc, Ann O'Sullivan, Sue Stableford, Marji Harmer-Beem, Kathryn Thompson, Nancy MacRae, Laney Bruner Canhoto, Audrey Riffenburgh, Kimberly Wilson, David Mokler, and Raven Weaver. All the good people at Jones & Bartlett Learning, especially Cathy Esperti, Rachael Souza, Juna Abrams, Robert Boder, Troy Liston, and Sameer Jena. Our loving families, whose ongoing support and encouragement kept us going.

If we inadvertently left anyone out, we ask for your forgiveness.

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Contributors

Jessica J. Bolduc, DrOT, MS, OTR/L Staff Occupational Therapist, Mercy Hospital Adjunct Faculty, University of New England Portland, Maine

Laney Bruner Canhoto, PhD, MSW, MPH Assistant Professor Family Medicine and Community Health University of Massachusetts Medical School Worcester, Massachusetts

Marji Harmer-Beem, RDH, MS Associate Professor Dental Hygiene Program University of New England Portland, Maine

Nancy MacRae, MS, OTR/L, FAOTA Associate Professor Occupational Therapy Department University of New England Portland, Maine

David J. Mokler, PhD Professor of Pharmacology and Chair Department of Biomedical Sciences College of Osteopathic Medicine University of New England Biddeford, Maine

Ann O'Sullivan, OTR/L, LSW, FAOTA Trainer and Consultant Scarborough, Maine

Audrey Riffenburgh, PhD President, Plain Language Works, LLC Founding Member, Clear Language Group Albuquerque, New Mexico

Sue Stableford, MPH, MSB Consultant and Trainer Health Literacy, Plain Language, & Clear Health Communication

Kathryn H. Thompson, PhD, RD Professor University of New England College of Osteopathic Medicine Biddeford, Maine

Kimberly Wilson, DNP, RN Program Director of Accelerated Bachelor of Science in Nursing (ABSN) Assistant Professor Jefferson College of Health Sciences Roanoke, Virginia

Raven H. Weaver, PhD Assistant Professor

Washington State University Pullman, Washington

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Reviewers

Keciana Enaohwo, MS, MA, CHW-I Houston Community College Houston, Texas

Laura M. Horn, MEd, RD, LD Professor Cincinnati State Technical and Community College Cincinnati, Ohio

Karen L. Madsen, FNP-BC Assistant Professor Missouri Southern State University Joplin, Missouri

Susan C. Maloney, PhD, CRNP, FNP-BC Assistant Professor Edinboro University Edinboro, Pennsylvania

Audrey McCrary-Quarles, PhD Associate Professor South Carolina State University Orangeburg, South Carolina

Cindy Meyer, MEd, MSCPM, OTR/L, OTA/Retired OTA Program Director South Arkansas Community College El Dorado, Arkansas

Margaret H. Teaford, PhD Associate Professor Emeritia Ohio State University Columbus, Ohio

Linda J. Tsoumas, PT, MS, EdD Professor of Physical Therapy MCPHS University Worcester, Massachusetts

Ann Marie Zvorsky, MSN, RN, CNE Medical-Surgical Nursing Instructor The Joseph F. McCloskey School of Nursing at Schuylkill Health Pottsville, Pennsylvania

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CHAPTER 1 Age Matters: Profiles of an Aging Society Nancy Brossoie, PhD Regula H. Robnett, PhD, OTR/L, FAOTA Walter C. Chop, MS, RRT

CHAPTER OUTLINE

INTRODUCTION

GLOBAL AGING

Age, Sex, and Distribution

Fertility Rates

Longevity

Population Health

Migration

AGING IN THE UNITED STATES

Age and Age Groups

Geographic Distribution

Sex

Race

Marital Status

Living Arrangements

ECONOMIC STATUS

Poverty

Income

Sources of Income

WORK AND RETIREMENT STATUS

HEALTH STATUS

Chronic Health Conditions

Functional Limitations

Vaccinations

Self-Rated Health

CAREGIVERS

Long-Term Care Services

DEATH

Causes

AGING SUCCESSFULLY

Successful Aging

Quality of Life in Old Age

Life Satisfaction

Well-being

SUMMARY

BEHAVIORAL OBJECTIVES

Upon completion of this chapter, the reader will be able to:

1. Explain terms used to describe and classify age.

2. Describe how populations are aging around the world.

3. Explain the difference between the terms lifespan and longevity.

4. Describe three key factors that influence population

aging.

5. Describe the general characteristics of the U.S. population of adults age 65 years and older.

6. Describe the most common chronic health conditions among older adults.

7. Explain the types of services provided by formal and informal caregivers.

8. Identify the most common causes of death among older adults.

9. Discuss the impacts the U.S. baby boom generation is having on U.S. society.

10. Explain how marital status, income level, sex, and race can affect quality of life.

KEY TERMS

Activities of daily living Baby boom generation Biopsychosocial Centenarian Chronological age Formal caregivers Functional age Gerontology Incidence Informal caregivers Instrumental activities of daily living Life expectancy Lifespan Longevity Old Old-old Prevalence Quality of life Snowbirds Successful aging

Super-centenarian Total fertility rate Young-old

▶ Introduction We all start to age from the moment we are born. Aging is a lifespan process that influences every aspect of our lives. Yet, many people do not think about growing older or the issues that accompany growing older until they see their parents' health decline or experience health challenges of their own. The field of gerontology is the study of aging and age-related issues and the biological, sociological, and psychological (biopsychosocial) factors that influence aging and old age. As a heath care professional, you will need to have a basic grasp of aging and age-related issues, which this text attempts to provide.

The first step to learning about issues that influence and affect old age is to consider what the term “old age” implies. Old age is a subjective concept that can change over time and depends on cultural and social considerations. What we thought of as old in the 19th century is considered middle age now. What we considered old when we were 15, will vary greatly from when we are 40 or even 75!

Researchers define age in ways that help them study age in their fields of interest. Public health and health policy leaders rely on defining old age by chronological age (i.e., the length of time a person is alive) to inform policy and programs. Countries, including the United States use ages 60, 62, or 65 as benchmark ages or age eligibility thresholds for policies that affect older adults. Health scientists find functional age (i.e., the level at which a person can

perform) is more useful than chronological age in determining an individual's health status. Social scientists often group older adults into age groups (e.g., ages 50–64, 65–74, 75–84, and 85+) that reflect similar life experiences and obligations, historical memories, and health problems within each group. Similarly, some researchers may apply terms to age groupings such as young-old (i.e., 50–64), old (i.e., 65–84), and old-old or oldest of old (ages 85 and older) to describe the stage of members in very late life. Within the old-old age group are two well-studied sub-groups —centenarians (i.e., persons at least 100 years old) and super-centenarians (i.e., persons at least 110 years old). How and why centenarians have been able to reach old age continues to be of great interest to scientists.

Whatever classification for age you choose to use in your work is a matter of preference, as long as you realize the limitations and variations implied by the term. A salient point to note and what is stressed throughout this text, is that there is a great amount of variability among older adults. Older adults are a heterogeneous group. Some individuals retain a sound mind and body into late life, while other persons do not. Some people remain financially secure, while other individuals fall into poverty. While the aging process is not a one-size fits all experience, the fundamental processes are shared by all.

▶ Global Aging Age, Sex, and Distribution The world population is growing larger and getting older every year. The United Nations Department of Economic and Social Affairs (2017) reported that by mid-2017, the world population exceeded 7.5 billion people, an increase of 1 billion people since 2002. There are slightly more males than females (i.e., 102 males per 100 females) worldwide and they are distributed relatively equally across age groups as illustrated in FIGURE 1-1. As a group, females tend to live longer than males, explaining less decline in group size later in life. The median age (i.e., the age in which half of the population is above and below) of the entire world population is 30 years, which is also illustrated by the width of the age group bars in Figure 1-1.

FIGURE 1-1 Worldwide population by sex and age group.

Reproduced from The World Factbook 2017. Washington, DC: Central Intelligence Agency, 2017. www.cia.gov/library/publications/the-world-factbook/index.htm.

Worldwide population growth is expected to remain steady as the population increases by approximately 83 million people each year. TABLE 1-1 includes estimates for total population growth in 2030, 2050, and 2100 as well as population data by world region.

TABLE 1-1 Population of World and Population by Region, 2017

Data from United Nations, Department of Economic and Social Affairs. (2017). World Population Prospects: The 2017 Revision, Key Findings and Advance Tables. Working Paper No. ESA/P/WP/248.

Conversations about world population can be more effective if the world is discussed by geographic regions, such as Africa, Asia, Europe, Latin America and the Caribbean, Northern America, and Oceania. Even though the governments and policies of countries within a single region may differ, their geographic location

unites them by shared and common resources, climate, lifestyles, and cultures.

As shown in TABLE 1-2, 60% of the world population lives in Asia (4.5 billion). China and India are the most populated countries in the entire world and account for 90% of Asia's population. Within Asia, adults age 25–59 represent nearly half (48%) of the region's population (see Table 1-2). The second largest populated world region is Africa and it contains 17% of the world population (1.25 billion). Africa's population is relatively young with 40% of the population age 0–14 years. Only 5% of Africa's population is age 60+ years. Conversely, Europe (the third largest populated region) is the “oldest” region with 25% of its population representing adults age 60+ years and 16% of its population age 0–14 years. The population in Latin America and the Caribbean (646 million) is slightly less than Europe (742 million people), but one quarter of its population (25%) are 0–14 years old and it is home to half as many older adults (12%). Northern America, which includes the United States, ranks 5th in population size among regions and includes 361 million people. Only 22% of the North America population is 60+ years old. The least populated region is Oceania, which is home to 41 million people; 17% of whom are age 60+ years.

TABLE 1-2 World Population and Population by Age Groups and Region, 2017

Data from United Nations, Department of Economic and Social Affairs. (2017). World Population Prospects: The 2017 Revision, Key Findings and Advance Tables. Working Paper No. ESA/P/WP/248.

The population differences by region illustrate the fact that population size alone does not predict the age composition of a population. Instead, demographers look to three key and interrelated factors: fertility rate, longevity, and migration.

Fertility Rates The number of older adults in the world today is directly connected to the total fertility rate (TFR; i.e., the average number of live births a child- bearing women would have in her lifetime) at the time they were born. In the 1950s, the TFR in the regions of Africa, Asia, Latin American and the Caribbean was approximately five live births per woman, a veritable population explosion when compared to Europe's TFR, which was less than three lives births per woman during the same years. Consequently, countries that experienced a high TFR in the mid-20th century are now faced with a growing economically inactive (i.e., retired or not

working) older population that needs to be supported. Countries that experienced a low TFR at the same time, now tout a smaller aging population and are likely to be in a better position to provide members with economic and physical support.

War can dramatically impact TFR. During wartime, live births decrease because men and women are sent away from home to fight. However, post-war economies often generate socioeconomic growth that supports marriages, births, and an increased TFR. After World War II, the TFR skyrocketed in the United States and the large number of babies born between 1946 and 1964 have been subsequently referred to as members of the baby boom generation. Like the United States, South Korea also had a baby boom that is now entering old age. However, the years of birth for Korea's baby boomers (1955–1963) began with the end of the Korean War and not World War II (Howe, Jackson, & Nakashima, 2007).

By tracking fertility rates in a region, policy makers and service providers can better predict the needs of a population and prepare for change. When countries experience sudden changes in fertility rates, it dramatically affects the population balance. For example, South Korea is the fastest growing aging society. It doubled its aging population from 7% (1999) to 14% (2017) in just 18 years and it continues to rise at a rapid rate (Klassen, 2010). Perhaps more troublesome is that the TFR in South Korea is the lowest in the world at 1.25; meaning that the population is barely able to replace people who die (referred to as the fertility replacement rate). Declining birth rates are expected to dramatically impact the size and

productivity of the South Korean labor force and the national economy. Simply put, when older adults stop working, there will be few workers to replace them. One fear is if South Korean industry leaders are faced with a decreasing labor pool, they may seek laborers and manufacturing deals in neighboring countries, further reducing the nation's productivity. Moreover, the South Korean government faces challenges in meeting increased healthcare costs and the need to develop a system of services and supports to address the needs of the growing older population.