Looking out the window of her home in the small, coastal city of Manzanita, Oregon -- where only about 600 people permanently reside, and many more vacationers visit -- Leila Salmon describes 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."
The twice widowed 87-year-old 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 says. "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. And 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, which is 90 miles from here." Though 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 says. Though a challenge, she notes 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, says Cassandra Ford, an associate professor of nursing at the University of Alabama in Tuscaloosa, who 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 says. In instances where older adults need more help with basic care needs, like taking medications, or activities of daily living, such as bathing, dressing and making meals, it's often informal caregivers -- frequently family -- who provide this. 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.
With access to care being a central issue, research finds that older adults who live in rural areas 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 85 years and older who lived in rural areas dealt with more disease -- from diabetes to depression -- and took between five and six prescription medications, on average, as compared with fewer than four (or 3.7) medications, on average, for their urban counterparts.
"They're more likely to suffer from more chronic conditions, and the chronic conditions are going to get worse at a faster rate than people in urban areas," says 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," says Under Secretary for Health for the U.S. Department of Veterans Affairs, Dr. David J. Shulkin. And 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 says. "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 offers a caregiver support program that also provides training for caregivers. "If you want to keep rural veterans at home, according to their preference, they often do need help," he says. For some veterans, particularly those with complex care needs, the VA is also dispatching nurses and doctors to provide primary care in their homes.
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, says 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. And though 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 given the rigors involved in aging at home in areas with more limited services. The demands of rural living are significant, Holley says. "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.
This article was written with the support of a journalism fellowship from New America Media, the Gerontological Society of America and the John A. Hartford Foundation.
Michael Schroeder is a health editor at U.S. News. He covers a wide array of topics ranging from cancer to depression and prevention to overtreatment. He's been reporting on health since 2005. You can follow him on Twitter or email him at email@example.com.