adults. In fact, those over age 85 are four times as likely to live in a nursing home as those aged 75 to 84 (Jones, 2002). On average, older adults living in nursing homes and residential care facilities tend to have more severe disabilities than older adults living in their own private homes, although more disabled older adults live in the community than in long-term care settings. Residents of long-term care facilities often have the additional need for symptom management and palliative care, that is, for noncurative care that is focused on alleviating physical symptoms and addressing psychological, social, and spiritual needs (Moon and Coccuti, 2002).

Approximately 80 percent of deaths in the United States occur among older adults (Kung et al., 2008). The leading causes of death among older adults are diseases of the heart, malignant neoplasms, cerebrovascular diseases, chronic lower respiratory diseases, and Alzheimer’s Disease (NCHS, 2007). Studies indicate that older adults follow different trajectories of dying (IOM, 1997). Some have normal functioning but then die suddenly. Others die after a distinct terminal phase of illness, such as occurs with many types of cancer. Still others have a slower decline with periodic crises before dying from complications, as is the case with stroke or dementia. On average, about one-fourth of Medicare outlays occur in the beneficiary’s last year of life, with 38 percent of beneficiaries spending at least some time in a nursing home and 19 percent using hospice services (Hogan et al., 2001). About half of Medicare patients who die from cancer use hospice services in the last year of life. Deciding whether to use palliative care or curative treatment for illness during these times is a very personal choice and depends on the individuals being affected (Moon and Coccuti, 2002).

Mental Health Conditions

Vulnerability to mental health conditions tends to increase as older adults age and become more likely to encounter stressful events, including declines in health and the loss of loved ones. Approximately 20 percent of adults ages 55 and older have a mental health condition, the most common being anxiety disorders (e.g., generalized anxiety and panic disorders), severe cognitive impairment (e.g., Alzheimer’s disease), and mood disorders (e.g., depression and bipolar disorder) (AOA, 2001). Cognitive impairment with no dementia (CIND) has been described as the intermediate state between normal cognitive function and dementia, a chronic illness characterized by a decline in memory and other cognitive functions. The prevalence of dementia increases with age, escalating from about 5 percent among individuals aged 71 to 79 to about 37 percent among those aged 90 and older (Plassman et al., 2007). In 2007, 42 percent of adults 85 years or older had Alzheimer’s disease (Alzheimer’s Association, 2007), although estimates have varied somewhat. Additionally, suicide rates for men 65



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