Photo: From the new report, “Aging in Rural and Frontier Oregon” by the Oregon Office of Rural Health.
Looking out the window of her home in the small, coastal city of Manzanita, Ore. – where only about 600 people permanently reside, and many more vacationers visit--Leila Salmon described the scene before her: “I’m looking right now at Neahkahnie Mountain, which goes right down to the ocean and the rainbow that just came out over the ocean and the mountain.”
Salmon, age 87, has resided in rural Tillamook County since she moved back to the state, after her second husband died, to be closer to her children in Portland, about 90 minutes away. One of her daughters has since retired and built a house nearby.
“I’ve never lived any place where people felt so attached to the land and the preservation of the land, and the beauty that surrounds you [is] a bonus to living here,” she said. “It never fails to amaze, amuse and satisfy me.”
Still, for many like Salmon, there are health challenges associated with aging in place in a rural community, including limited access to a range of health care services.
90 Miles From Care
Yet, as America grays, many older adults are choosing to age in place where they grew up – or in places they have since come to call home – outside of major cities, in the broad patchwork of rural, wide open spaces that stitch the country together from sea to shining sea. But to tackle challenges and ensure older adults receive the care they need while living in more remote places, additional foresight and coordination is required, experts say.
“Just a year ago, I started having uncomfortable bladder symptoms,” Salmon says. “Because our local health provider, which is a federally qualified health center, doesn’t have specialists, they [referred] me to Oregon Health and Science University (OHSU), which is 90 miles from here.”
Although Salmon can still drive herself, her daughter drove her to OHSU in Portland for initial visits and subsequent treatment after she was diagnosed with bladder cancer. “It necessitated regular trips to Portland -- the 90 miles over the Oregon Coast Range,” she said. Although a challenge, she noted, it worked out well. “At the moment, I’m cancer-free.”
Having a strong support network is critical to aging in place -- particularly in a rural area, said Cassandra Ford, an associate professor of nursing at the University of Alabama, Tuscaloosa. She has lived in rural areas and worked with rural populations as a nurse and researcher for much of her career.
“Sometimes that can be family, sometimes that can be friends, sometimes that’s neighbors,” Ford said.
Often it is informal caregivers -- frequently family -- who provide older adults help with basic care needs, such as taking medications, or activities of daily living, such as bathing, dressing and making meals.
In other cases, where an older adult is more independent, a support network may be comprised of family or friends, who call regularly and drop by to check in and make sure that person is doing OK.
Access to Care
With access to care being a central issue, research finds that older adults who live in rural regions tend to have more health problems and take more medications than their peers in urban areas.
One Oregon-based study published in June in the Journal of Rural Health found that individuals ages 85 and older living in rural areas dealt with more disease – from diabetes to depression. They took between five and six prescription medications, [http://tinyurl.com/zhzdelm] on average, compared with fewer than four (or 3.7) medications, on average, for their urban counterparts.
“They’re more likely to suffer from additional chronic conditions, and the chronic conditions are going to get worse at a faster rate than people in urban areas,” said Leah Goeres, a former postdoctoral fellow at Oregon State University, who led the research.
Goeres is now a pharmacist and outpatient care clinical coordinator at CareOregon, which provides health-plan services for Medicaid and Medicare members in Oregon. The reasons rural residents often have more health issues than their urban counterparts aren’t clear. But experts suggest a number of factors may play a role: lagging access to care; education differences; less awareness about prevention and treatment options; and income differences – poverty is frequently a concern in rural areas.
Efforts are being made across the country, however, to accommodate people who want to age in place. That includes supporting veterans. “When we ask our veterans what they want, they really want to be able to age in place,” said Under Secretary for Health for the U.S. Department of Veterans Affairs, David J. Shulkin, MD. Veterans disproportionately hail from and choose to live out their golden years in rural areas.
To help meet the health care needs of rural veterans who choose to age in place, the VA is employing a variety of approaches like telehealth.
"We’ve done over 2 million [telehealth] visits, and 45 percent of all of our veterans enrolled in our telehealth program are in rural areas,” Shulkin said. “This gives a rural veteran access to specialty care in ways that it would be very hard to get in their local community.”
In addition, the VA provides training for caregivers. “If you want to keep rural veterans at home, according to their preference, they often do need help,” he said. For some veterans, particularly those with complex care needs, the VA is also dispatching nurses and doctors to provide primary care in their homes.
Resources for Combatting Isolation
Whether you have a military background or not, experts say it’s important to reach out to your care providers and community organizations, like local Area Agencies on Aging, to determine what resources are available. No one should have to age in place alone.
Isolation is a top concern among older adults, said Lyn Holley, a professor of gerontology at University of Nebraska–Omaha. Research suggests that becoming socially disconnected can have far-reaching implications, from increasing the risk of depression to heart disease. Although many people aging in place in urban areas face the same danger of becoming isolated, experts say, the geography of open spaces – the space between neighbors, family or friends – can exacerbate the issue.
Connecting to local resources and community is all the more necessary, not just for social and emotional health, but also given the rigors involved in aging at home in areas with more limited services. The demands of rural living are significant, Holley said. “You’re not going to have a drop-in housekeeper.”
The challenges of rural aging vary by the individual and the community in which they live. For caregivers and others providing support, that makes it all the more important to listen to the needs of an individual, experts say. To meet them where they are – wherever that is.
Michael O. Schroeder, a health editor at U.S. News & World Report, wrote this article, the first in a series, with the support of a journalism fellowship from New America Media (NAM), the Gerontological Society of America(GSA) and the John A. Hartford Foundation.
Read more about the challenges of rural aging in the NAM-GSA fellowship series by Spokane’s Spokesman-Review reporter Erica Curless and photographer Tyler Tjomsland.