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impaired communication that goes unnoticed by providers or even loved ones. They may find treatments, such as hearing aids and cochlear implants, to be prohibitively expensive. Hearing loss is associated with social isolation and increased risk of depression and correlates with risk of cognitive impairment, although the causative relationship between hearing loss and cognition is not yet understood. All providers who care for older adults should understand communication strategies for communicating with adults who are hard of hearing, summarized in Table 4.2. Personalized sound amplifiers can be inexpensive alternatives to hearing aids for adults with mild to moderate hearing loss.

      Disability

      Like sensory impairment, older adults have high rates of disability, defined as a deficiency in self‐care such as the ability to perform an activity of daily living or instrumental activity of daily living. As of 2011, the World Health Organization estimated that 15% of the global population lives with some form of disability, up from 10% of the global population in the 1970s.⁴¹ In older adults, disability is most likely the result of multiple chronic diseases. Disabilities are associated with poorer health status, reduced economic productivity, higher rates of poverty, and increased dependency and risk of institutionalized.

      In the US and much of the developed world, laws and public policies protect those with a disability, including promoting accessibility in the workplace and community. Ancillary providers such as physical, occupational, and speech therapists can provide rehabilitation and adaptive equipment to help preserve functioning. However, in much of the developing world, such services and protections are lacking. The WHO reports that in four South African countries, for instance, only 26–55% of people received needed medical rehabilitation, 17–37% received assistive devices, and less than 25% were able to receive vocational training. Even in developed countries, older adults may have difficulty obtaining all the recommended resources, particularly adults in rural communities or with financial insecurity. Resources meant to help those with disabilities, such as meal delivery services, may have long waitlists due to inadequate funding. Adults with disabilities also face stigmatization in the workplace and communities. Communities worldwide must commit resources to promote a safe and inclusive environment for those of all abilities to thrive.

Table 4.2 Communication strategies for speaking to patients with hearing loss.

Don’t yell – shouting causes sound distortion.

Maintain a quiet environment with minimal background noise.

Maintain good lighting.

Face the person, and maintain eye contact.

Annunciate.

Speak at a reasonable speed.

Use transition statements, and avoid sudden shifts in conversation topics.

Augment communication with writing, diagrams, etc.

Use ‘teach‐back’ or similar methods to ensure understanding.

      Poverty

      The word poverty is so commonly used that it may seem unnecessary to define it, but the word has two aspects that need to be distinguished: poverty threshold and relative poverty. The poverty threshold is defined by comparing a household’s income with the level of prices of the basic commodities necessary for life – the subsistence level, sometimes called the poverty line. Those whose incomes are below the minimum level necessary for subsistence are deemed to be living in poverty. Relative poverty is defined by comparing a household’s income with the average income level in their society. Although individuals' incomes may be sufficient to provide themselves and their dependents with the necessities of life, they may struggle to maintain an acceptable quality of life. J.K. Galbraith, an American economist, has described the condition of relative poverty thusly: ‘People are poverty stricken when their income, even if it is adequate for survival, falls markedly below that of the community. Then they cannot have what the larger community regards as the minimum necessary for decency, and they cannot wholly escape, therefore, the judgement of the larger community that they are indecent. They are degraded, for in the literal sense, they live outside the grades or categories which the community regards as acceptable.’ A modern‐day example in the US of relative poverty includes adults who cannot afford reliable internet access. Once deemed a luxury, internet access is so ubiquitous that much of society now takes it for granted. Not only are adults stigmatized if they cannot afford online access, but they may not be able to keep up employment or manage practicalities such as bill payment without it.

      According to US Census data from 2018, since the mid‐1960s, poverty rates for people 65 and older living in the US have declined from nearly 30%, to under 10% as of 2017. Older people now have poverty rates similar to those of working people.

Eighty‐four percent of US older adults receive Social Security. When examining older adults by income level, Social Security made up the majority of a person's income in the lowest income quintile of older adults. Approximately 30% of older adults received income from a pension or retirement plan, and approximately 21% continued to earn income through employment. Almost half of older adults earned income from assets (such as interest, dividends, rental income, etc.); however, the median value is very low (< $500 per annum). A small minority of older adults make a substantial income from their assets and tend to be in the highest income quintile. Less than 10% of older adults receive income from supplemental security income (SSI) or other public welfare sources. Ethnic and racial minorities were less likely to receive Social Security and more likely to receive SSI.⁴² Older women, particularly those who did not marry, are at the highest risk of poverty, as they are least likely to be eligible for national security or occupational pensions. Longer life expectancy also means women are at increased risk of spending down their savings. As women engage with the workforce at higher rates, this disparity will likely decline.

      Globally, there is limited data on poverty in older age. The UN estimates that older age is a significant risk factor for poverty, particularly in countries with inadequate social support and financial infrastructure. Rates of poverty vary widely. In the Netherlands and the Czech Republic, rates of poverty in adults over 65 are as low as 3%, while in the Republic of Korea, rates approach 50%. In Zambia, rates of poverty in older adulthood are as high as 80%. As in developed countries, older women are at significantly higher risk of poverty.

      Social isolation and loneliness

Older adults are prone to social isolation for a number of reasons. As part of growing older, older adults are more likely to experience widowhood, the loss of friends and family, and physical separation from family due to geographic moves. Hearing and vision loss, cognitive impairment, and physical disability all lead to mobility impairments and a reduced ability to drive, navigate public transportation, or leave the home. Older adults living in rural areas or who face financial insecurity may have limited means to engage with their communities. Risk factors for social isolation and related adverse health effects and possible mitigation factors are summarized in Figure 4.5.

Social isolation is defined as objective physical separation from other people, while loneliness is defined as subjective distress due to feeling separated or alone.⁴³ Although correlated, the two terms are not synonymous. Older adults who are physically isolated may report robust relationships, particularly with online connectivity and/or engagement in meaningful leisure activities. Conversely, adults who live with or near others, even family members, may report loneliness if the quality of these relationships is poor. Both social isolation and loneliness are associated with a number of adverse health effects. Loneliness increases the risk of depression, anxiety, and suicidality.

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