by Per Ostmo, MPA, and Jessica Rosencrans, BBA

Funded by the Federal Office of Rural Health Policy (FORHP), under the Health Resources and Services Administration (HRSA), the Rural Health Research Gateway disseminates work of the FORHP-funded Rural Health Research Centers (RHRCs) to diverse audiences. This resource provides a summary of recent research, conducted by the RHRCs, on aging.

Older Adults in the U.S.

From 2013 to 2017, compared to urban counties, rural counties had higher shares of population age 65 and older (18.1% vs 14.3%), hereafter referred to as "older adults."¹ See Figure 1. Rural counties also had higher shares of older adults who: were non-Hispanic White (88.9% vs 75.4%), lived in the state in which they were born (65.3% vs 43.3%), owned their home (80.2% vs 72.2%), and had a disability (39.0% vs 34.7%).¹ Conversely, rural older adults had less total household wealth ($264,573 vs $471,290) and were less likely to have moved in the past year (5.7% vs 6.7%) than urban older adults.¹

Compared to urban counties, rural counties also had a higher share of the "oldest old," adults age 85 and older (2.2% vs 1.9%).¹ See Figure 1. There were 56 counties with 5.0% or more of their population age 85 and older – all but two were rural noncore.² The 54 noncore counties with the highest percentage of the oldest old differed in significant ways from other counties: their average population size was smaller, had better health on average, and had lower rates of smoking, obesity, housing problems, food insecurity, and air pollution than all other counties.² They also had nearly double the rate of social associations per capita.²

Living Alone

Rural adults are more likely than urban adults to live alone, with the exception of married adults, American Indian/Alaska Native adults, and adults age 25-44.³

Overall, 14.9% of adults live alone in rural areas, whereas 13.6% of adults live alone in urban areas.³ Furthermore, 28.2% of older adults live alone in rural areas versus 26.8% in urban areas.¹ See Figure 2.

Compared to urban adults living alone, rural adults living alone were more likely to have a disability (32.8% vs 24.6%) and be age 75 or older (23.4% vs 19.1%).³ The most common disability was ambulatory difficulty, defined as having serious difficulty walking or climbing stairs (20.8% of rural adults living alone and 15.5% of urban adults living alone).³

Social Engagement

In 2019, compared to urban residents aging in place, rural residents aging in place were more likely to say people in their community know each other well (89% vs 83%) and were more likely to have volunteered in the past month (33% vs 26%).⁴ Both rural and urban residents were very likely to have visited a family member or a friend, who doesn't live with them, in the last month (89% vs 87%).⁴

Among rural residents aging in place, Black residents were most likely to have attended a religious service in the past month (73%), followed by White residents (61%), and residents indicating “other” race/ethnicity (47%).⁴ White residents were most likely to have performed their self- reported favorite activity in the last year (85%), followed by Black residents (79%), and residents indicating “other” race/ethnicity (58%).⁴ Finally, White residents were least likely to report transportation as a barrier to social engagement (3%), followed by Black residents (6%), and residents indicating “other” race/ethnicity (7%).⁴

Meals on Wheels programs serve a vital role in meeting the nutritional needs of older adults while also providing opportunities to address social, safety, and other health needs.⁵ Meals on Wheels clients are often members of particularly vulnerable populations, such as those who identify as Black, Indigenous, or people of color, live at or below the poverty line, are widowed, are veterans, or live in exclusively rural areas.⁵ A study using 2019 survey data with rural Meals on Wheels program managers found that 88% of respondents reported loneliness and social isolation as serious issues among the clients they serve.⁵ Respondents also listed issues relating to safety concerns, such as inadequate home maintenance and trip hazards; and health concerns, including improper storage of perishable food, mobility limitations, and lack of personal emergency alert systems to notify others in case of emergency.⁵

Long-Term Care Preferences

When examining preferences for long-term care arrangements, in 2018, the majority of rural (62.5%) and urban (60.4%) residents indicated they would prefer to remain in their own home, either with the help of friends/family (33.0% rural vs 29.9% urban) or paid help (29.5% rural vs 30.5% urban).⁶ Very few older adults indicated that living with an adult child would be a top choice for care (4.3% rural vs 5.4% urban).⁶ Living in an assisted living setting or in a nursing home was a top preference for 31.6% of rural residents and 32.1% of urban residents.⁶

Racial and ethnic differences presented themselves within the rural context. Compared to non-Hispanic White rural residents, Black rural residents were less likely to report a first choice of receiving care in their own home with paid help (22.9% vs 29.8%) and more likely to report a preference for living with an adult child (10.8% vs 3.6%).⁶ Hispanic/other race rural residents were the most likely to report a preference for receiving care in their own home with the help of a paid worker (30.9%) and least likely to report a preference for receiving care in assisted living or a nursing home (27.9%).⁶

Differences in preferences between genders and across levels of educational attainment also presented themselves within the rural context.⁶ A plurality of women chose receiving care in one's own home with help from a paid worker as their first choice (33.9%), while a plurality of men chose receiving care in one's own home with help from family members and/or friends as their first choice (36.1%).⁶ Rural residents with a college degree or higher were more likely to report receiving care in one's own home with paid help as their first choice, compared with rural residents with a high school degree or less than a high school degree (37.0% vs 26.5% and 26.8%).⁶

Nursing Home Availability

A 2019 examination of nursing home availability in rural America defined nursing homes as Medicare and/or Medicaid certified facilities providing post-acute care (skilling nursing facilities) and/or long-term care (nursing facilities) services.⁷ A lower percentage of noncore counties have nursing homes than micropolitan or metropolitan counties.⁷ See Figure 3.

Compared to metropolitan counties, a higher percentage of noncore counties had access to hospitals with skilled nursing facility-type swing beds (61% vs 22%) and nursing facility-type swing beds (52% vs 17%).⁷ However, even after accounting for the presence of swing beds, a higher percentage of noncore counties have no access to post-acute and/or long-term care services (10% vs 4%).⁷

Between 2008 and 2018, 472 nursing homes in nonmetropolitan counties and 783 nursing homes in metropolitan counties closed.⁸ There were 44 newly created nursing home desert counties during this time.⁸ Forty of these new nursing home deserts were in nonmetropolitan counties.⁸

Conclusion

On average, rural populations are older than urban populations, and the proportion of older adults is increasing more quickly in rural communities.¹ The majority of older adults would prefer to remain in their own home as they age, but older adults living alone in rural areas are at risk of social isolation, loneliness, and unsafe living conditions.^5,6 Home-based services, such as Meals on Wheels can provide valuable insight into the needs of these at-risk populations.⁵

While some older adults would prefer to live in an assisted living or nursing home setting, noncore counties are less likely to have these services available.^6,7,8 Policy efforts to support rural older adults might include addressing the need for affordable housing that is accessible for individuals with mobility limitations, public transit options for individuals who are unable to drive, and broadband internet infrastructure to increase opportunities for social engagement.^3,4

Resources

1. University of Minnesota Rural Health Research Center (2020). Rural-Urban Differences Among Older Adults.
2. University of Minnesota Rural Health Research Center (2020). Characteristics of Counties with the Highest Proportion of the Oldest Old.
3. University of Minnesota Rural Health Research Center (2021). Demographics and Disability Status of Adults Living Alone in Rural Areas.
4. University of Minnesota Rural Health Research Center (2022). Social Cohesion and Social Engagement Among Older Adults Aging in Place: Rural/Urban Differences.
5. University of Minnesota Rural Health Research Center (2022). Social Isolation and Safety Issues Among Rural Older Adults Living Alone: Perspectives of Meals on Wheels Programs.
6. University of Minnesota Rural Health Research Center (2021). Preferences for Long-Term Care Arrangements Among Rural and Urban Older Adults.
7. RUPRI Rural Health Research Center (2022). Nursing Homes in Rural America: A Chartbook.
8. RUPRI Rural Health Research Center (2021). Trends in Nursing Home Closures in Metropolitan and Nonmetropolitan Counties in the United States, 2008-2018