Executive Summary

Mirroring a worldwide phenomenon in industrialized nations, the United States is experiencing a demographic change known as population aging, brought about by a combination of lengthening life expectancy, declining fertility, and the progression through life of an unusually large “baby boom” generation. As part of the overall population aging, the nation’s workforce is aging, and the population of older workers—defined as those age 45 and over—is projected to include an increasing number of women and ethnic minorities.

Currently, there are in the United States 93 million people age 45 and over, representing 44 percent of the civilian, noninstitutionalized population over the age of 15. By the year 2050, it is projected there will be 170 million people 45 or older, representing 53 percent of the population. Since the life expectancy of women exceeds that of men and the number of women exceeds the number of men at all age groups, the percentage of the population who are women age 45 and older is expected to grow faster than that of men. Furthermore, the number of ethnic minorities is increasing at a faster rate than the white population at all ages. By 2050, ethnic minorities are projected to represent approximately 40 percent of those over 45.

Even though the elderly population today is on average healthier, better educated, and wealthier than the elderly population of previous generations, there are two major reasons for focusing on the health and safety needs of older workers. First, to maximize benefits to the economy and investment capital, it is important to know which older workers can be



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Executive Summary Mirroring a worldwide phenomenon in industrialized nations, the United States is experiencing a demographic change known as population aging, brought about by a combination of lengthening life expectancy, declining fertility, and the progression through life of an unusually large “baby boom” generation. As part of the overall population aging, the nation’s workforce is aging, and the population of older workers—defined as those age 45 and over—is projected to include an increasing number of women and ethnic minorities. Currently, there are in the United States 93 million people age 45 and over, representing 44 percent of the civilian, noninstitutionalized popula- tion over the age of 15. By the year 2050, it is projected there will be 170 million people 45 or older, representing 53 percent of the population. Since the life expectancy of women exceeds that of men and the number of women exceeds the number of men at all age groups, the percentage of the population who are women age 45 and older is expected to grow faster than that of men. Furthermore, the number of ethnic minorities is increas- ing at a faster rate than the white population at all ages. By 2050, ethnic minorities are projected to represent approximately 40 percent of those over 45. Even though the elderly population today is on average healthier, better educated, and wealthier than the elderly population of previous genera- tions, there are two major reasons for focusing on the health and safety needs of older workers. First, to maximize benefits to the economy and investment capital, it is important to know which older workers can be 1

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2 HEALTH AND SAFETY NEEDS OF OLDER WORKERS expected to work productively, what kinds of tasks they are best suited for, and if their productivity can be increased through cost-effective accommo- dations and support programs in the workplace and community. Second, policy makers want to know how to maximize older workers’ opportunities for making employment-related choices that promote health, safety, and life satisfaction in their later years. To date, concern among policy makers about the aging of the population has tended to focus on the adequacy of Medicare and Social Security trust funds, mechanisms for retirement sav- ings, and the need for long-term care. Far less attention has been paid to the health and safety needs of older American workers. CHARACTERISTICS OF OLDER WORKERS Older workers differ from their younger counterparts in a variety of physical/biological, psychological/mental, and social dimensions. In some cases these reflect normative changes of aging (for example, presbyopia), while in others they represent age-dependent increases in the likelihood of developing various abnormal conditions, such as coronary artery disease. These age-related differences, whether normative or pathologic, may cause disadvantages to older workers because their work performance is dimin- ished relative to younger workers or because their susceptibility to environ- mental hazards is increased. In other cases, however, changes associated with age (e.g., increased experience) may actually enhance capabilities and performance at work. Age-related changes that are most likely important to job exposures and job experience among older workers occur in the following organ systems: skeletal muscle, bone, vision, hearing, pulmonary function, skin, metabolism, and immunity. More generally, the slope of age-related changes in organs or systems declines at a greater rate with increasing age. How- ever, cognitive and adaptive skills that come with experience and extensive training are relevant to meeting job challenges and changes. Furthermore, most occupations (except, for example, some public safety occupations) usually do not require performance at full individual capacity. Workplace or other exposures may cause decrements in function from full capacity without affecting work performance or function at usual levels. The health, function, and survivorship of each older worker cohort will depend in part on exposures and events that occurred earlier in life in addition to environmental (including work) exposures concurrent with ag- ing. Most general physiological and biological functions in older persons tend to have greater variation than in younger persons (there are exceptions in the realm of cognitive variables), and so performance relying on those functions often does not correlate very well with chronological age. Age- related changes may be accompanied by the presence of comorbidity. There

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3 EXECUTIVE SUMMARY has not, however, been much research on the effects of workplace expo- sures on health in the presence of controlled clinical conditions or their treatments. The limited efforts to study the relation between age and job perfor- mance have been inconclusive, possibly due to the varying balance between cognitive declines and the benefits of age- or job-related experience. These efforts could be enhanced by accelerated development of the O*NET (Oc- cupational Information Network) database, a replacement for the Dictio- nary of Occupational Titles that describes in detail the knowledge, skills, and abilities required to perform jobs; this would facilitate matching of the capabilities and limitations of older workers to the knowledge, skills, and abilities required by jobs. The O*NET is described on the U.S. Department of Labor website at www.doleta.gov/programs/onet. In addition to the emphasis on physical, chemical, and biomechanical workplace hazards, there has been increasing recognition of the work- related mental health and psychosocial and organizational issues among older workers. This recognition may be due in part to a shift in the United States and most industrialized countries from a manufacturing to a service economy, where interpersonal issues are more apparent. In many respects older workers appear to have higher levels of emotional stability than young adults. It is likely that among older persons, workers are less likely than nonworkers to have serious or severe mental illness or disorder be- cause of the debilitating nature of these conditions. Yet, certain workplace situations may have disparate effects on older workers’ mental health, such as ageism, increasing physical and cognitive demands, and pressure to retire. Mental health problems with job implications include the consequences of work-related stress, clinical depression, and a variety of other psycho- logical problems such as burnout, alcohol, and other substance abuse, un- explained physical symptoms, and chronic fatigue as well as the secondary consequences of these conditions, such as longer absences associated with injuries. Older workers may bring to the workplace mental health problems that have long histories and origins outside of the job setting. Common or severe mental conditions such as depression may cause stress, conflict, poor productivity and, potentially, threats to individual safety and health related to the conditions or their treatments. There is evidence that work-related stress impairs worker satisfaction and productivity and may contribute to long-term physical diseases and conditions, as well as increase the costs of absenteeism and low productivity. Work-related stressful experiences, in- cluding injuries, can contribute to depression, and enduring structural fac- tors in some institutions lead to various psychological problems. The prevalence of problem drinking and alcoholism among older work- ers is not known, but the consequences of alcohol abuse are known to be

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4 HEALTH AND SAFETY NEEDS OF OLDER WORKERS more serious among the elderly. The problem with alcohol and drug abuse at work may increase as the baby boomer cohort grows older, because this cohort had higher rates of substance use, including alcohol, than previous generations. Another underevaluated area is problems associated with medi- cation abuse among older workers. THE SOCIAL AND ECONOMIC CONTEXT OF WORK FOR OLDER PERSONS The health and safety needs of older workers reflect not only their individual life course histories, but also factors related to socioeconomic status, gender, race, ethnicity, and recent changes in the labor market and in the nature of work. In exploring how social factors might produce health disparities in the context of an aging workforce, older workers should not be regarded as a uniform population; within the population of older work- ers, there are disparities related to social class, race/ethnicity, and gender, and this has implications for how best to conduct research and develop policy for protecting older workers’ health. The nature of work may play a part in generating social inequalities in health, since one’s job is the principal determinant of general standard of living, important in shaping self-identity and personal growth, and an im- portant criterion of social stratification. Many minority older workers have been exposed to deficits in education and health care, to poverty, and to discrimination; many of these challenges persist into old age and shape the opportunities and outcomes for minority elders. Gender is also an important social determinant of the work experiences of and related health outcomes for older workers. Gender influences social roles, the types of jobs people hold, the resulting work-related exposures, the patterns of work over the life course, consequent income differentials, and projected retirement experiences. During the second half of the 20th century, there was a decline in the labor force participation rate of older men and a rise in the labor force participation rate of women. The down- ward trend in labor force participation rates of men aged 62 and over ended in the mid-1980s when participation rates leveled off. The reasons for this substantial change in the labor force participation rate trends of men and women since the mid-1980s are not fully understood but may include structural changes in the social security system, the banning of mandatory retirement rules, and the shift from defined-benefit to defined-contribution retirement plans. Within the overall pattern of labor force participation there are signifi- cant differences in employment survival rates across people with different socioeconomic characteristics and who work in different industries and occupations. There are significant differences in job demands, injury risks,

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5 EXECUTIVE SUMMARY and toxic exposures. Job characteristics that may differentially affect the health of older workers can also affect their retirement decisions. There have been significant changes in the labor market and in the nature of work to which older workers must respond. During the past century, the median income of Americans increased substantially, many aspects of their working conditions improved, and their life span increased. However, income growth has been uneven across the income distribution, and while the health and safety conditions of workers in some occupations and industries have improved, others have not. There is limited evidence on how these trends are affecting the health and safety of older workers. There is also concern over how well the illness or disorder and injury data that we currently collect measure these trends. In the mid-20th century, about a third of the American workforce was employed in manufacturing. Today, not much more than a tenth are so employed; about 80 percent are now working in the service sector. The high-growth occupations are concentrated in either low-wage service sector jobs or occupations that require advanced training and pay high wages. The skill distribution of the future workforce is likely to increase somewhat faster at the high and low ends than in the middle. For most of the past century average weekly hours worked decreased gradually, but during the last 25 years weekly hours have increased slightly for men and more steeply for women, reflecting women’s increased partici- pation in the workforce. There also has been a recent increase in the num- ber of those 55 and older who work more than 48 hours per week. A better understanding of the age-specific effects of working hours over weekly and annual intervals will require better information on trends in patterns of working hours according to age, gender, race, and socioeconomic status. The health effects of new organizational approaches such as lean produc- tion, total quality management, new team concepts, cellular or modular manufacturing, reengineering, high-performance work organizations, and patient-focused care are largely unknown for workers of any age, but some studies suggest increased health and safety risks. The extent to which and mechanisms whereby socioeconomic and demographic variables relate to the employment and retirement patterns of older workers and to their health is an area in need of targeted research. EFFECTS OF WORK ON OLDER WORKERS The total cost of occupational illness or disorder and injury in the United States for 1992 has been estimated at $132.8 billion, approximately 2.5 percent of the gross domestic product; the estimates have not been stratified by age. The number of workplace injuries, illnesses or disorders, and fatalities has been declining over the years but remains unacceptably

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6 HEALTH AND SAFETY NEEDS OF OLDER WORKERS high. The Bureau of Labor Statistics (BLS) reported that a total of 5.2 mil- lion workplace injuries and illnesses or disorders were reported in private industry during 2001—the lowest rate since BLS began reporting in 1973. Recent years have seen approximately 6,000 fatalities from workplace injuries annually, a number that has been declining steadily for more than 40 years. However, in contrast to younger workers, the number of lost workday cases among older workers has been slowly rising since 1992; workers aged 45 and older accounted for 30 percent of lost workday cases reported by BLS for 2000. Evidence also indicates that, compared with younger workers, older workers experience relatively low overall frequency of work-related injury and illness or disorder but relatively high rates of workplace fatality and high injury severity. The increased prevalence of impairments among older workers, as opposed to younger workers, and the growth of our older workforce will increase the number of workers who bring impairments to the job with them and who will, therefore, be at increased risk for occupational injuries. High-risk jobs for older workers are jobs that present exposure to relatively common work risks. According to data from 1988 (the most recent available on exposures at work), the most prevalent exposures are biomechanical risk factors. Workers between the ages of 45 and 64 experi- enced lower exposure prevalence than younger workers, although about one-quarter of those in the older age group reported a substantial amount of bending or twisting of hands or wrists, and one-fifth of older male workers reported repeated bending and twisting or reaching. There is a substantial need for research on the physiological, pathological, and func- tional effects of common and potentially harmful worksite exposures— physiochemical, biological, biomechanical, and psychosocial—on older workers. Industries that appear to represent higher risk for biomechanical and other hazardous exposures are manufacturing, transportation, medical ser- vices, mining, utilities, agriculture, and forestry/fishing/trapping—most of which are projected to experience at least moderate growth in employment. Almost half of the 333,800 reports of occupational illnesses or disorders and 65 percent of the repeated trauma cases occurred in manufacturing industries. Among those occupations identified as older worker intensive, the following appear to represent higher risk for biomechanical exposures and, in some cases, additional hazardous exposures: administrative sup- port; production/craft/repair; transportation and material moving; farming/ forestry/fishing; private household services; protective services; and services– other, most of which are also projected to experience moderate to high growth in employment. Some changes in work organization also may have adverse health ef- fects (e.g., musculoskeletal disorders and cardiovascular disease) on the

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7 EXECUTIVE SUMMARY workforce. These changes include certain types of organizational restruc- turing, downsizing, outsourcing, job insecurity, nonstandard work arrange- ments, and stressful job characteristics. Job flexibility and job control ap- pear also as important factors associated with health outcomes, the best studied of which is cardiovascular disease. In recent years workers over age 50 have reported in health surveys that their jobs contain many physical and emotional challenges and stresses, but most reported that they enjoyed going to work. Older workers were healthier and functioning at a higher level than their nonworking counter- parts, but a majority reported at least one chronic illness or disorder, sug- gesting that some of these conditions do not substantially interfere with job functions, though they may point to a higher risk of future illness or disor- der and disability. About one-sixth of workers reported that their health status was fair or poor, possibly leading to risk of job loss and progression of illness or disorder. Assessing the causes and extent of work-related injuries and illnesses or disorders and comparing health and safety risks across industries and oc- cupations, for older versus younger workers of varying demographic char- acteristics and job histories, is hampered by limitations in existing data collection systems. Available data on occupational injuries and illnesses or disorders from BLS and workers’ compensation systems reflect substantial underreporting, particularly with respect to occupational illness or disor- der. Explanations for the poor assessment of occupational illness or disor- der burden include: inadequate recognition of work-related long-term la- tent illnesses or disorders; inadequate training and awareness of medical providers; and a variety of disincentives to reporting workplace problems. Data from 1988 are the most recently available that permit some estimate of the distribution of work exposures. Additionally, little is known about the age distribution of work-related musculoskeletal disorders despite the fact that these are the most commonly reported work-related disorders. PUBLIC POLICIES AND PRACTICES RELATED TO THE OLDER WORKFORCE AND SAFE WORK Public policy interventions affect the ability of older workers to con- tinue to work safely and to exit from the workforce. Laws that govern these abilities include occupational safety and health protections, antidiscrimina- tion laws, and mandated interventions that regulate or encourage leaves of absence and accommodations at work. There are also nonwage benefits that affect workers’ decisions regarding when and how to exit the labor market. Certain elements of relevant public policy are simple to articulate. For example: age-based discrimination against workers over 40 is illegal; all

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8 HEALTH AND SAFETY NEEDS OF OLDER WORKERS workers who participate in the Social Security system have some guaran- teed health insurance and disability and retirement income protections, at least after specified periods of participation in covered employment. Be- yond this, there are few special legal protections for aging workers. In general, employment policies must be age neutral, so employers are re- quired to treat older workers in the same manner as they treat otherwise equivalent younger workers. The key question is whether the laws that mandate intervention in employment provide adequate protection to workers as they age so that they can continue to work safely or have the necessary economic security to exit the workforce at the appropriate time. The answer to these questions is not the same for all workers in all industries. There has been little study of the effectiveness of these mandated interventions in relation to older work- ers’ health and safety needs. Employment regulation is a patchwork. Independent contractors and self-employed workers are excluded from almost all protective employment laws and collective bargaining agreements. Also excluded are people who do not report their wages. Most protective statutes exclude small employ- ers. Private benefits may be available only to full-time permanent employ- ees. Tension between federal and state regulation further complicates the terrain. In key areas of interest to aging workers (e.g., compensation pro- grams for occupational injuries and illnesses or disorders) the legal rules may vary depending upon the state in which the worker lives and works. Unlike most other industrialized countries, the United States does not provide universal health insurance to its citizens. In 1995, 72 percent of American workers between 18 and 64 had health insurance coverage under an employer-based plan, either through their own employer or through the employer of another family member; 18 percent of American workers were left totally uninsured. Close to one-third of workers over 55 do not have health insurance provided by their employers. As chronic health conditions increase with age, the lack of health insurance and the accompanying barri- ers to access to health care may significantly impact the ability of these workers to remain in the workforce. INTERVENTIONS FOR OLDER WORKERS The premise of many interventions is that it is preferable to change the working environment to accommodate the needs of workers than to attempt only to adapt the workers themselves through administrative or training interventions. In principle, hazards should be addressed as close to the source as possible. Therefore, job design, including redesign and reengineer- ing to improve the accommodations for older workers, deserves the highest level of attention. There are existing design approaches to accommodate a

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9 EXECUTIVE SUMMARY variety of age-related changes, such as declines in vision, hearing, and physical strength and capacity, as well as approaches that address work- related musculoskeletal disorders that are anticipated to be an important problem for aging workers. There also is evidence for the effectiveness of a limited number of interventions to address cardiovascular disease by im- proving work organization and job design, and by reducing job stressors. Many effective interventions also involve changing the social climate in the workplace (e.g., empowering workers), training for better work practices (e.g., ergonomic interventions to improve body posture for bending and lifting), improving physical fitness with exercise, and substituting machine work for human exertion. Training is another potent intervention and seems particularly relevant for older workers, as they are likely to be the most distant from their initial professional and job training. Access to training, however, is often too limited. Health promotion efforts now have received the greatest attention in workplaces within large organizations; smaller organizations have typically paid far less attention to health promotion efforts. Although many of these efforts focus on preventing common diseases that are not uniquely caused by work, mitigating hazardous aspects of the work environment is an im- portant example of health promotion. Attention to general health promo- tion programs is as relevant for older as for younger workers and may result in greater decrements in preventable disease rates per unit of resource expenditure for older workers, in part because chronic disease rates are higher at older ages. General health promotion programs directed at work- ers appear to be more effective when tied to environmental controls in the workplace. Accommodations for workers with impairments and return-to-work programs are important interventions for older workers, who are more likely to bring impairments into the workplace and to be out of work longer than their younger colleagues after an injury at work. Modified work pro- grams have been clearly shown to facilitate the return to work of workers with temporary or permanent impairments. Factors known to result in shortening the duration of disability consis- tently include medical and vocational rehabilitation interventions, organi- zational-level employer factors, and employer- and insurer-based disability prevention and disability management interventions. However, several chal- lenges must be overcome before researchers can establish which interven- tions are most effective. Multidisciplinary teams are needed to address the social/behavioral, biomedical, and analytic issues in the research. Research- ers need to agree on the best outcome variables to use in return-to-work studies, and the methodological quality of research needs to be improved. For example, survival models can be used to improve efficiency, and hierar-

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10 HEALTH AND SAFETY NEEDS OF OLDER WORKERS chical models can be used to assess risk factors from several levels, ranging from the individual to the societal. Although most employee assistance programs (EAPs) have not empha- sized employee needs related to aging, they have strong potential as a support for older workers in relation to occupational health and safety concerns. EAPs can assist workers challenged by the need to provide elder- care support, plan for retirement or outplacement, and address substance abuse and emotional distress. Many of the existing intervention programs have at least some demon- strated efficacy, but nearly all have been incompletely evaluated. There are enormous research opportunities to develop new programs and modify existing ones. With changing work organizations and processes, a dynamic economic climate, and a demographically diverse workforce, intervention research should be a high priority. This research should include cost-benefit analysis and identification of the components that make interventions effec- tive (their “active ingredients”). CONCLUSIONS AND RECOMMENDATIONS Chapter 9 of this report summarizes conclusions and presents detailed recommendations pertaining to three major themes that emerge from ex- amination of the health and safety needs of older workers: (1) Conducting informative research requires improved databases and data systems necessary to track the health and safety needs of older workers and the programs that address them. • New longitudinal datasets should be developed that contain detailed information on workers’ employment histories and the specific demands of their jobs, as well as objective information on the health and safety risks to workers in the job. • Ongoing longitudinal surveys (for example, the Health and Retire- ment Study and the Panel Study of Income Dynamics) should either in- crease the information they gather on health and safety risk factors of the workplace or develop periodic modules to do so. • The National Institute for Occupational Safety and Health (NIOSH) should collaborate with the Bureau of Labor Statistics in conduct- ing a comprehensive review and evaluation of occupational injury and illness or disorder reporting systems, examining the extent of, and trends in, underreporting and underascertainment. • NIOSH should develop a database that characterizes types and levels of exposures associated with work; exposures considered should in- clude chemical, physical, biomechanical, and psychosocial factors.

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11 EXECUTIVE SUMMARY • The BLS should initiate reporting of workplace injury and illness or disorder rates according to demographic characteristics (for age, gender, and ethnicity at a minimum). • The National Center for Health Statistics (NCHS) and NIOSH should develop a survey supplement on work risk factors and occupational disorders for periodic inclusion in the National Health Interview Surveys. • The NCHS and NIOSH should collaborate in an effort to identify, using the National Health and Nutrition Examination Survey, subpopula- tions of older workers where chemical exposure is likely to be an important work risk factor and to develop a list of chemicals to be included in surveys of such populations in the future. • NIOSH and the Department of Labor (DOL) should collaborate and be funded to develop a survey instrument and periodically conduct surveys to describe the prevalence of and trends in job characteristics and other workplace risk factors in a manner similar to the Quality of Employ- ment Surveys. • Enhanced efforts should be devoted to achieving a comprehensive, interactive O*NET database as quickly as possible. (2) Research is needed to provide better understanding of the factors that relate to the health and safety needs of older workers. • Substantial research should be conducted on the physiological, pathological, and functional effects of common and potentially harmful worksite exposures—physiochemical, biological, biomechanical, and psy- chosocial—on older workers. • A research program should be conducted to provide systematic and substantial understanding of the effects of potentially harmful workplace exposures on individual and population outcomes among older workers with existing chronic conditions. • Targeted research should be undertaken to identify the extent to which, and mechanisms whereby, socioeconomic and demographic vari- ables are related to health and safety risks of older workers; the degree to which these variables predict employment in hazardous occupations and industries; and how they may be associated with retirement decisions and barriers. (3) Research is needed to identify and clarify the aspects of policies, pro- grams, and intervention techniques and strategies that are effective and that are not effective in addressing the health and safety needs of older workers. • Evaluation research should be conducted to determine the degree to which public policies intended to enable workers to remain at work

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12 HEALTH AND SAFETY NEEDS OF OLDER WORKERS safely and productively have met these objectives specifically with regard to older workers. • For promising job design, training, and workplace accommodation interventions, research should be conducted to determine the prevalence, effectiveness, and associated costs of intervention. • Research should be conducted to assess the effectiveness, benefits, and costs of worksite health promotion programs and techniques tailored to older workers. • Research should be undertaken to assess the full (direct and indi- rect) costs of older workers’ occupational injuries and illnesses or disorders to individuals, family, and society. Requisite funding for these efforts should be provided.