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Elder Orphans Hiding in Plain Sight: A Growing Vulnerable Population


Abstract and Figures

Adults are increasingly aging alone with multiple chronic diseases and are geographically distant from family or friends. It is challenging for clinicians to identify these individuals, often struggling with managing the growing difficulties and the complexities involved in delivering care to this population. Clinicians often may not recognize or know how to address the needs that these patients have in managing their own health. While many such patients function well at baseline, the slightest insult can initiate a cascade of avoidable negative events. We have resurrected the term elder orphan to describe individuals living alone with little to no support system. Using public data sets, including the US Census and University of Michigan’s Health and Retirement Study, we estimated the prevalence of adults 65 years and older to be around 22%. Thus, in this paper, we strive to describe and quantify this growing vulnerable population and offer practical approaches to identify and develop care plans that are consistent with each person’s goals of care. The complex medical and psychosocial issues for elder orphans significantly impact the individual person, communities, and health-care expenditures. We hope to encourage professionals across disciplines to work cooperatively to screen elders and implement policies to prevent elder orphans from hiding in plain sight.
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Research Article
Elder Orphans Hiding in Plain Sight:
A Growing Vulnerable Population
Maria T. Carney,1Janice Fujiwara,1Brian E. Emmert Jr.,1
Tara A. Liberman,1and Barbara Paris2
1Long Island Jewish Medical Center, Northwell Health, Hofstra Northwell School of Medicine, New Hyde Park, NY 11040, USA
2Maimonides Medical Center, Icahn School of Medicine at Mount Sinai, Brooklyn, NY 11219, USA
Correspondence should be addressed to Maria T. Carney;
Received  February ; Revised  June ; Accepted  July 
Academic Editor: Iracema Leroi
Copyright ©  Maria T. Carney et al. is is an open access article distributed under the Creative Commons Attribution License,
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Adults are increasingly aging alone with multiple chronic diseases and are geographically distant from family or friends. It is
challenging for clinicians to identify these individuals, oen struggling with managing the growing diculties and the complexities
involved in delivering care to this population. Clinicians oen may not recognize or know how to address the needs that these
patients have in managing their own health. While many such patients function well at baseline, the slightest insult can initiate a
cascade of avoidable negative events. We have resurrected the term elder orphan to describe individuals living alone with little to
no support system. Using public data sets, including the US Census and University of Michigans Health and Retirement Study,
we estimated the prevalence of adults  years and older to be around %. us, in this paper, we strive to describe and quantify
this growing vulnerable population and oer practical approaches to identify and develop care plans that are consistent with each
persons goals of care. e complex medical and psychosocial issues for elder orphans signicantly impact the individual person,
communities, and health-care expenditures. We hope to encourage professionals across disciplines to work cooperatively to screen
elders and implement policies to prevent elder orphans from hiding in plain sight.
1. Introduction
It is common for physicians who provide care to older
adults to encounter an elder orphan in their oce, hospital,
or an emergency room, but they do not recognize them
assuchoridentifytherisksrelatedtothis.We de ne
elder orphans as aged, community-dwelling individuals who
are socially and/or physically isolated, without an available
is demographic, those aging alone with limited support,
is expected to increase as the United States population
chronic illnesses. Recent national media reports have also
brought attention to this growing problem [–]. us, we
strive to raise awareness of the concept of aging alone without
an available caregiver and introduce the term elder orphan to
more clearly dene this vulnerable population and identify
these individuals as high risk in an eort to call to action
health-care providers, government agencies, and general
public to address their needs and minimize preventable
illness. We also provide guidance on how to screen and care
Below, two case scenarios are described which underscore
theconceptsandrisksinvolvedwithelder orphans.ese
cases highlight the crucial need to identify members of this
population in order to prevent medical crises.
Case 1 (Ms. H. M.). Ms. H. M. is a -year-old widow living
is dependent upon her. She has managed to live at home with
little help for many years. Over the past few months, however,
she noticed that her function is declining; she is becoming
unable to drive or even do many household chores. Moreover,
because of a growing lethargy, she is nding it more dicult
to even cook and clean. A ercely independent woman, she
Hindawi Publishing Corporation
Current Gerontology and Geriatrics Research
Volume 2016, Article ID 4723250, 11 pages
Current Gerontology and Geriatrics Research
has attempted to hire aides, but she promptly lets them go
because of diculty supervising them.
Aer meeting with a social worker while still able to make
decisions and through an introduction to legal guidance in
the community, a plan of action was determined for both
her and her son, as well as the beginnings of preparations
happen to her. A distant but willing family member was
reconnected and helped support the plan created. rough
identication of her and her son’s risk to be “orphaned” and
the creation of a care-giving plan and identication of a
of medical catastrophe for this elder orphan and her son (who
will eventually inherit elder orphan status) has decreased
Case 2 (Mr. H. B.). Mr. H. B. is a -year-old man living alone
in his apartment in Long Island, New York. He was admitted
wound care aer a failed suicide attempt, having slit his wrists
with a razor. Upon admission, it was found that Mr. H. B. was
never married and was childless and his closest relative was
residing in California, thus uninvolved in his care. Mr. H. B.’s
relative had little knowledge of his condition. Once wound
care was complete, nding placement for Mr. H. B. was
dicult, as he was not healthy enough to travel to California
to be near his only relative, nor was he psychologically or
medically well enough to be discharged home alone. With
no known caregiver identied, aer a several-week stay in
the hospital, he was eventually relocated to a skilled nursing
facility for further wound care with a long-term plan to be
relocated near his only relative in California.
e term elder orphan was utilized on rounds with Case
 to highlight the vulnerability of individuals with limited
to no support in the community whose abilities are being
challenged and risk of losing independence is signicant. is
particular case led to much discussion and academic interest
because of an additional perceived increase in individuals
being seen at the hospital who lack care-giving and decision-
making support by spouse, partner, family, or community.
For patients like Ms. H. M. and Mr. H. B., we utilize
the term elder orphan. It is imperative that the medical and
social community become more familiar with this term as
it highlights a population aging alone without a caregiver
and with signicant barriers to care. Furthermore, the term
elder orphan when utilized properly creates an important
notication to health-care providers that care-giving needs
are lacking and are an important aspect to treatment. More-
over, we expect the prevalence of those aging alone and
thosewhoareatriskofbeingelder orphans to continue
to increase as individuals are living longer, with multiple
chronic diseases, alone, and geographically distanced from
other family members. us, in this paper, our goals are
threefold: to evaluate the terms synonymous with aging alone
or “elder orphan” use in literature, identify the prevalence
of being at risk to be elder orphans and the risks facing this
population, and provide guidance when faced with caring for
an elder orphan.
2. Methods
2.1. Literature Search. A literature search was undertaken to
examine the use of the term elderorphanoranytermsynony-
mous with age, isolated, and/or alone. To better characterize
this vulnerable population and identify clinical correlates for
risk factors, four databases were searched: PubMed, Google
Scholar, Health Reference, and CINAHL. Reviews of police
and emergency management department programs, U.S.
Census data, and the North Shore-LIJ Health System social
work database were also conducted to assist in terminology
use for vulnerable adults. e search terms utilized included
elder orphan,unbefriended elder, patients without surrogates,
vulnerable elderly, social isolation, loneliness, childless unmar-
ried, frail elderly, lone elders,andaging alone as shown in
the following list (synonyms encountered in reviewing the
medical literature on social isolation in older adults).
Similar terms encountered while searching “elder orphan”
are the following:
Aging alone.
Elder orphan.
Frail elderly.
Patients without surrogates.
Social isolation.
Unbefriended elder.
Vulnerable elderly.
A total of  publications were identied and reviewed from
international medical, legal, and lay press sources dating back
approximately  years (Table ).
2.2. Prevalence. Estimates of the prevalence of elder orphans
living in the United States were determined by using previ-
ously published, valid, and publicly accessible national sur-
veys. Initially, we conducted an analysis of U.S. Census data.
We then turned our attention to the Health and Retirement
Study (HRS) []. e HRS is sponsored by the National
Institute on Aging (Grant number NIA UAG) and
is conducted by the University of Michigan. It surveyed a rep-
aged  years and older about aspects of their personal life and
family. We recoded and parsed the data so as to examine mar-
ital status, number of children, number of children in contact,
number of children in close proximity, number of siblings,
this analysis, we devised a spectrum of categories which, by
denition, can lead to aged, isolated, alone status. We then
extrapolated the prevalence (in percent of the population) for
each tier in the spectrum, using the numbers derived from
the HRS, and then further estimated the prevalence of at-risk
elder orphans in the general population.
3. Results
3.1. Literature Search
3.1.1. Use of Term. rough the literature search eorts the
term elder orphan was found to be rst designated by Kunerth
Current Gerontology and Geriatrics Research
T : e table shows the results of a literature search regarding previous work completed on elder orphans. Search terms of “elder orphan,” “unbefriended elderly,” “patients without
surrogates,” and “vulnerable elderly” were used in Google Scholar, PubMed, CINAHL, and Health Reference databases.
Author Year Title Comments
Elder orphan
Soniat B. & Pollack M.  “Elderly Orphans with Alzheimer’s Disease:
Non-Traditional Support Systems”
Describes dierences between a functional family
system and an informal support network providing
assistance to an “elderly orphan”
Sherer R. A.  “Who Will Care for Elder Orphans?” Geriatric Times article describing a growing population
and a bill to expand medical training programs
Unbefriended elderly
Gillick M. R.  “Medical Decision-Making for the Un-Befriended
Nursing Home Resident”
Reviews pathways of addressing decision-making in
nursing home residents without decision-making
capacity or surrogates, such as use of ethics committees
Freeman I. C. 
“One More Faulty Solution Is Novelty without Progress:
A Reply to “Medical Decision-Making for the
Un-Befriended Nursing Home Resident””
Refutes the idea that a simple, less cumbersome process
is needed for nursing home residents without
decision-making capacity or surrogates
Teaster P. B . “e Wards of Public Guardians: Voices of the
rough qualitative data collection and analysis, this
study explores the interaction between adult public
guardianship wards and their public guardians,
including ward satisfaction and perceptions, guardian
responsiveness, and investigation of the guardian-ward
Karp N. & Wood E.  “Incapacitated and Alone: Healthcare Decision-Making
for Unbefriended Older People”
Synopsis of a  American Bar Association
Commission on Law and Aging report. is report
found limited existing studies on the unbefriended
elderly; however, available estimated data was
compelling enough for the Commission to issue
recommendations to ensure the ethical treatment of the
unbefriended elderly
Po p e T. M . & S e l l e r s T. “Legal Brieng: e Unbefriended: Making Healthcare
Decisions for Patients without Surrogates”
Overview of legal developments in medical
decision-making for the unbefriended elderly,
including an outline of the problems involved in this
type of medical decision-making and a selection of
potential solutions
Current Gerontology and Geriatrics Research
T  : C ontinu e d .
Author Year Title Comments
Johnstone M.-J.  “Caring about the Unbefriended Elderly”
A presentation of the shortcomings of interventions for
the elderly when the individual is an unbefriended
elder and a call for nurses to identify and advocate for
this vulnerable group of patients
Patients without surrogates
Meier D. E.  “Voiceless and Vulnerable: Dementia Patients without
Surrogates in an Era of Capitation”
Describes how the growth of a dementia population
will add to the dilemma of diculties of complex
health-care decision-making and the increase in scal
pressures by health-care environments while advocating
for caution of undertreatment of the most vulnerable
Miller T. E., Coleman C. H., & Cugliari A. M.  “Treatment Decisions for Patients without Surrogates:
Rethinking Policies for a Vulnerable Population”
Provides an outline of the laws and policies surrounding
decision-making for incapacitated individuals without
surrogates, discusses the substitutes used by state
governments that exist, and provides a model for
healthcare to assist these special needs populations
Chichin E. R.  “Ethics and the Elderly” Addresses health-care decision-making with elderly
and uses case examples to explore situations
Crampton A.  “e Importance of Adult Guardianship for Social
Work Practice”
is article reviews the guardianship decision-making
process and how social workers can have a role in
promoting social justice through this process
Frank C.  “Surrogate Decision-Making for “Friendless” Patients”
is article reviews surrogate decision-making and
explores how and why alternative means of substituted
decision-making must be found
Quinn M. J.  Guardianships of Adults
Describes the history and institution of guardianship,
provides alternatives to guardianship, explains the
criteria for guardianship, and describes the court
process and court monitoring of guardianships for
community health and social service practitioners
Siegel M. D. 
“Alone at Life’s End: Trying to Protect the Autonomy of
Patients without Surrogates or Decision-Making
Comments on White D. B. article in Critical Care
Medicine  exploring decision-making on critically
ill individuals without surrogates and highlights the
need for more attention on this vulnerable group
Castillo L. S., Williams B. A., Hooper S. M., & others  “Lost in Translation: e Unintended Consequences of
Advance Directive Law on Clinical Care”
Describes potential negative clinical impact of advance
directive laws on all patients and particularly on
vulnerable populations
Current Gerontology and Geriatrics Research
T  : C ontinu e d .
Author Year Title Comments
Pope T. M.  “Making Medical Decisions for Patients without
Describes this marginalized, vulnerable population and
addresses the need to focus attention on prevention of
being without a surrogate
Vulnerable elderly
Morris J. N. & Sherwood S. 
“Informal Support Resources for Vulnerable Elderly
Persons: Can ey Be Counted on, Why Do ey
Work ?
e issue of informal support system resiliency is
analyzed for approximately  vulnerable elderly
persons in a variety of communities
Auerbach M., Taylor M., & Marosy J.  HomeCareChallenge:CareoftheVulnerableElderlyEarly describer of provision of care to an at-risk
population in the home
Davidson B.  “Vulnerable Elderly in Acute Care Settings: A
Developing Model”
Early describer of creation of a new model of care
focusing on an at-risk population
omas B. L.  “Research Considerations: Guardianship and the
Vulnerable Elderly”
Challenges inherent assumptions in guardianship
protocol and calls for more research into risks and
benets of guardianship assignment and decisions
Shapiro E.  “Market Forces and Vulnerable Elderly People: Who
An editorial calling for the need of regulations and
quality control to protect vulnerable elders from cost
containment initiatives
Billipp S. H. 
“e Psychosocial Impact of Interactive Computer Use
within a Vulnerable Elderly Population: A Report on a
Randomized Prospective Trial in a Home Health Care
Compared weekly nurse visits with nurse and
interactive computer use and found that interactive
computer use could be an added and more benecial
resource for isolated, vulnerable older adults in the
community to minimize
Grundy E.  “Ageing and Vulnerable Elderly People: European
Describes the processes and circumstances that create
vulnerability among older people, specically to a very
poor quality of life or an untimely or degrading death.
Policy initiatives describe that aim to reduce
vulnerability by focusing on each part of the dynamic
process that creates vulnerability, namely, ensuring that
people reach later life with “reserve,” reducing the
challenges they face in later life, and providing adequate
compensatory supports
Current Gerontology and Geriatrics Research
T  : C ontinu e d .
Author Year Title Comments
Rollins J. N.  “Oce-Based Intervention Improves Vulnerable
Elderly Care”
Describes quality improvement initiative focusing on
vulnerable older adults
Cumbler E., Carter J., & Kutner J.  “Failure at the Transition of Care: Challenges in the
Discharge of the Vulnerable Elderly Patient”
Describes the challenges facing individuals with limited
social support for smooth transitions of care
Franzini L. & Dyer C. B. 
“Healthcare Costs and Utilization of Vulnerable Elderly
People Reported to Adult Protective Services for
Describes a study that demonstrates the same or
potentially less cost to a health-care system by referral
of self-neglectors to APS and a geriatric health-care
team, demonstrates that costs are not higher, and
theorizes that costs may be even less because preventive
eorts are initiated to provide support before a medical
crisis occurs
Morley J. E.  Caring for the Vulnerable Elderly: Are Available
Quality Indicators Appropriate?”
Explores and questions appropriateness of ACOVE-
Rosenberg J. A. 
“Poverty, Guardianship, and the Vulnerable Elderly:
Human Narrative and Statistical Patterns in a Snapshot
of Adult Guardianship Cases in New York City”
Explores guardianship, explains demographics such as
gender, race, socioeconomic, and housing characteristic
association with risk for need of guardianship (e.g.,
women living alone are more likely to be in need), and
uses cases to describe
Day M. R., Bantry-White E., & Glavin P.  “Protection of Vulnerable Adults: An Interdisciplinary
Work s h o p
Provided an interdisciplinary shared learning
experience for the students to prepare them for their
critical role in safeguarding vulnerable adults. e aim
of the workshop was to increase knowledge, awareness,
and understanding of roles and responsibilities and
critical practice problems in the prevention and
management of elder abuse and self-neglect
Harrington P., Preston J., Savattone D., & Volk-Cra B.  “Establishing Healthcare-Related Legal Options for the
Vulnerable Patient”
Explores legal options for individuals with no surrogate
and having no decision-making capacity
Shaer S. L. & Day H. D. 
“Systematic Outpatient Screening for the Elderly: Care
of the Vulnerable Elderly Practice Improvement
Module to Assess Resident Care of Older Adults”
Describes a practice improvement project to screen for
vulnerable elderly geriatric needs including surrogate
decision-maker; a potential model to identify those
aging alone
vanHoutH.P.,JansenA.P.,vanMarwijkH.W.,&others 
“Prevention of Adverse Health Trajectories in a
Vulnerable Elderly Population through Nurse Home
Studied the eect of a preventative home care nursing
visit program but failed to decrease hospital admissions
Glasper A.  “Improving Health Care for the Vulnerable Elderly in
Explores how a department of health can improve
healthcare for the vulnerable elderly
Current Gerontology and Geriatrics Research
[] in  and Sherer [] in  in the lay press, and then it
resurfaced in a state nursing journal in  in a didactic arti-
population that requires special consideration. Since then,
the term has been dormant, and as a consequence pertinent
concepts related to the elder orphan,suchastheestimated
prevalence of and risks associated with being an elder orphan,
are not well documented in the medical literature.
in order to highlight a need to intervene for social support
with a goal of minimizing adverse medical events and frailty.
Elder orphans are a unique subset of the aging population, as
their inclusion in this category is oen due to circumstance
rather than choice. As independent individuals, they have
functioned suciently well on their own and thus do not
actively plan for their medical future. As they age and decline,
they realize, oen too late, that they can no longer complete
many of the tasks that they were previously able to do.
Stemming from this inability, elder orphans may no longer
medical events occur that can easily lead to hospitalization.
ese events oen incur signicant costs to the health system
and undue suering to the patient. By raising awareness
for this group of aging adults by referencing them with a
benevolent and informative title such as elder orphan,we
hope this group will get more attention by the medical and
social community. Advanced planning and consciousness
will be raised for these individuals, and with coordination
between medical and community organizations they can
be directed to appropriate services before their function
declines, facilitating maintenance of quality of life in their
own communities for as long as possible.
e term elder orphan raises clear awareness to medical
providers of the vulnerability of the individual and the
importance of managing the patient’s care comprehensively
and multidisciplinarily.
3.2. Risks
3.2.1. Social Support. In addition to the likelihood of not
receiving adequate care, being at risk for elder orphan status
(aged, community-dwelling individuals who are socially
and/or physically isolated, without an available known family
member or designated surrogate or caregiver) can have a
series of adverse biopsychosocial consequences on an indi-
vidual. Low social support has been linked to both poor
physical and psychological health and an increased risk
of mortality for the elderly population [, ]. Moreover,
decreased social interaction that can stem from this lack of
support is correlated with low aect and arousal [], poor
cognitive and social skills [], and altered neurophysiological
functioning [].
3.2.2. Isolation and Loneliness. Isolation and loneliness are
distinct in that isolation is the objective state of having min-
imal contact with others, whereas loneliness is the subjective
feeling of being socially alone and isolated. Both of these
states have been identied as risk factors for physical and
cognitive decline.
Perissinotto et al. [] completed a longitudinal cohort
study of  subjects and found that among those who are
 years of age and older loneliness was a predictor of both
functional decline (in areas including mobility, climbing,
upper extremity tasks, and activities of daily living) and
death. Additionally, Sorkin et al. [] found that greater
levels of loneliness and lower levels of emotional support
and companionship were correlated with an increased risk of
coronary disease.
Social isolation has been shown to be a risk factor for
medical complications and mortality. Wenger et al. [] stud-
ied working class individuals and found that social isolation
is correlated with advancing age; being male and single;
living alone; and having no children. ese researchers also
found an association between social isolation and retirement
migration (moving to a new area upon retirement), poor
health, restricted mobility, admission to institutional care,
low morale, poor rehabilitation, and mental illness.
In a study of  community-dwelling elderly women,
ompson and Heller [] found that both subjectively and
being than the population mean. Moreover, those who were
objectively isolated comorbidly exhibited poorer functional
health. Finally, Udell et al. [] found that in an international
outpatient population with atherothrombosis living alone
was associated with both increased cardiovascular death and
four-year mortality, a trend which was found to grow stronger
as the population aged.
3.2.3. Marriage and Children. Being married provides advan-
tages for medical care and support for patients. In an analysis
of childless elderly patients discharged from a hospital,
marital status was found to be a major determinant of
the level of support the patient received aer discharge.
Although childless, married individuals tended to rely solely
on each other and thus were more socially isolated, they
were resourceful in using long-term accumulation of social
resources to meet their needs [].
Childlessness is an important risk factor for social iso-
lation. Many studies have shown that childless adults oen
do have support networks, usually consisting of relatives,
friends, and neighbors. However, these networks are less
likely to provide the long-term commitment and comparable
high level of support that children oer [, ]. Interestingly,
evidence is inconclusive regarding the long-term dierence
between childless older adults and elders with children.
Although the childless elderly appear to score lower on mea-
sures of objective social support, another evidence suggests
that their psychological wellbeing does not signicantly dier
from older adults with children []. It is important to note
that gender was a mediating factor; Zhang and Hayward
found that childless men had higher rates of loneliness and
depression than childless women.
An interesting concept regarding childlessness in the
elderly arises when considering parents who outlive their
children. e loss of a child can cause severe psychosocial
stress on an individual, especially when the child dies as a
result of disease. Parents may attribute the death as resulting
from their actions or perceived inactions and, as part of their
Current Gerontology and Geriatrics Research
bereavement process, socially isolate themselves []. If the
parent is older or single, this isolation can have devastating
consequences on his or her health and welfare.
Another trend that may further impact adults outliving
their children is described in the American Medical Associa-
tion  study that found that the current generation may be
the rst to encounter parents outliving their children. is is
attributed to childhood obesity which in turn increases rates
on hypertension, diabetes, stroke, and osteoarthritis upon
reaching middle age. e University of Michigan’s Joyce Lee
found that people born between  and  became obese
at much faster rates than previous generations [].
3.3. Prevalence. According to  U.S. Census data, nearly
 percent of women aged  to  years have no children,
as compared to about  percent in  []. Furthermore,
in , almost one third of Americans aged – years are
single, a  percent increase from % in  []. ere
are no signs of this trend reversing. While being a parent
or spouse does not guarantee care in old age, the bulk of
America’s elderly are cared for primarily by their spouses and
children [].
Limited data exists to measure the prevalence of this
limited support using marital status, having children, having
siblings, or having children or siblings not in contact or not
within  miles (existing HRS criteria and surrogate condi-
tions deemed by authors as possible local care-giving involve-
ment ability) (Table ). Based on data from the HRS, we esti-
mate that the prevalence of being at high risk for elder orphan
status is to be as high as .%. Fortunately, we found that
individuals who are most likely already elder orphans, by def-
inition, are just a small percentage of the population (Table ).
4. Discussion
We dene elder orphans as aged, community-dwelling indi-
viduals who are socially and/or physically isolated and have
no known family member or designated surrogate available
to them. Both the safety and the independence of this
demographic are threatened. With the high prevalence of
individuals aging alone and the clear risks associated, it is
crucial that the medical and social community become aware
of this pressing issue. Moreover, the medical community must
actively screen and take steps to care for individuals who fall
into this demographic; consider the following lists: Questions
to Screen for Risk for Elder Orphan Status and Ten-Step
GuidetoCaringforanElder Orphan.
Questions to Screen for Risk for Elder Orphan Status
(i) Do you have a spouse or signicant other?
(ii) Do you have children? Are they nearby?
(iii) Do you have family members or friends that help you
cope with life challenges?
(iv) Do you have someone to help you make medical
(vi) Do you have a health-care proxy or any advance
(vii) Who is the person you would call upon in an emer-
gency or crisis situation?
(viii) Do you have a home health aide to help with personal
care such as bathing, dressing, and other activities of
daily living?
Ten-Step Guide to Caring for an Elder Orphan
(1) Identify All Medical Issues. is may involve speaking with
the patient’s known providers and other personal contacts,
telephoning pharmacies, and accessing old charts, laboratory
work, and imaging studies. Consider asking the following:
(i) Have you fallen in the past  months?
(ii) Do you have  or more chronic illnesses?
(iii) Do you take  or more medications?
(iv) Have you been hospitalized in the past  months?
(2) Identify Cognitive and Functional Abilities.Useofcogni-
tive, depression, and functional assessment tools (e.g., Mini-
Cog Assessment, Geriatric Depression Scale, Activities of
Daily Living, and Instrumental Activities of Daily Living
assessments) may be particularly helpful with the patient’s
care assessment and plans for discharge [–]. Consider
asking the following:
(i) Do you need help with bathing, dressing, shopping,
and paying bills?
(ii) Do you feel sad?
(iii) Are you lonely?
(3) Obtain Detailed Social Support Information.Itisimportant
to call any possible contacts that may be benecial in identify-
ing care for elder orphans.ismayincludeout-of-townfam-
ily, friends, neighbors, physicians, and signicant others. Fur-
thermore, all resources and benets available for the patient
need to be identied. A social worker can assist with gather-
ing some of the information. Consider asking the following:
(i) Who could help you in a crisis?
(ii) Do you have a long-term care policy?
(iii) Are you a veteran in the military?
(4) Create a Manageable and Realistic Treatment Plan.Indi-
viduals without support need to have treatment plans that can
be achieved.
(5) Utilize Service Delivery to Home. For example, utilize
home care, pharmacy, and food delivery services.
(6) Make Safety and Injury Prevention a Priority; Address
Safety and Injury Issues. Consider asking the following:
(i) Have you fallen?
Current Gerontology and Geriatrics Research
T : e table shows the prevalence of those at risk of becoming an elder orphan based on  data. Prevalence was calculated by
dividing the sum of the total individuals in the “unmarried, with children, but not in contact” tier and the “unmarried, without children” tier
(the two biggest risk factors for becoming an elder orphan) by the total of respondents to the health and retirement study [].
Risk description Number Percent (out of ,
Unmarried, with children, but not in contact , .%
Unmarried, with children, but they are not in contact, and there are no siblings within  miles , .%
Unmarried, with children, but children live further than  miles away , .%
Unmarried, with children, but not within  miles, and there are no siblings within  miles  .%
Unmarried, without children , .%
Unmarried without children or siblings  .%
Totally unmarried, without children, or unmarried with children, not in contact , .%
Total prevalence of at-risk individuals = (unmarried, with children, not in contact) + (unmarried without children) = (, + ,)/, = .%.
(iii) Are you driving? Did you experience any accidents?
Do you wear your seatbelt regularly? Have you gotten
lost while driving?
(7) Address Goals of Care and Advance Directives.Byfocusing
on health-care proxy and living will, future resuscitation,
mechanical ventilation, treatment, hospitalization, and even
funeral and burial arrangement wishes may elicit support
systems that exist. Consider asking the following:
(i) Do you have a health-care proxy or durable power of
attorney for healthcare?
(ii) Do you have a living will?
(iii) Do you have a will for your belongings, property?
Who has helped you with these?
(iv) Have you discussed future treatment, hospitalization,
burial wishes, or arrangements with anyone or made
future plans?
(8) Understand Privacy Issues (HIPAA). Health-care workers
must be cognizant of privacy laws while understanding that
medical care and health advocacy. Health professionals must
respected but do not form a barrier to coordination of care.
(9) Assess Decision-Making Capacity and Involve the Indi-
vidual as Much as Possible. Assess whether the person has
the ability to make specic decisions, as capacity is valid
solely on a case-by-case basis and based on a specic issue
being decided on. Although a person may be failing in some
cognitive abilities, it does not necessarily mean that they lack
the ability to make certain health-care decisions [].
(10) Determine If Guardianship Is Needed, and If So, Seek It.A
guardianship is a legal relationship created when a person or
institution is named in a will or assigned by the court to take
care of incompetent adults. Consider contacting hospital legal
or social work departments.
In Questions to Screen for Risk for Elder Orphan Status
we outline key screening questions that can help health-
care providers identify individuals at risk of being elder
orphans. ese suggested questions can be self-administered
or easily incorporated into other assessments completed by
oce assistants to help identify individuals at risk. Further
studies on the eectiveness of these questions as a screening
tool are needed. As shown in the Ten-Step Guide to Caring
for an Elder Orphan, we have developed these -steps to
assist providers in sorting through the complex physical and
psychosocial issues that elder orphans face. We oer prac-
tical approaches to developing a multidisciplinary, holistic
approach and care plan for these individuals to address a
growing public health need.
Identifying these individuals prior to loss of function
or admission into acute care facilities will help to expe-
dite appropriate medical care, avert negative outcomes, and
reduce the burden on the health system. Early identication
of these at-risk individuals allows for care plans that can
better meet the needs of the elder orphan.
We suggest t h e t e r m elder orphan as a benevolent iden-
tier for a group of individuals who nd themselves in this
in the medical and social community to assist these older
adults in society who are unable to complete instrumental
activities of daily life and have no available caregivers, as well
Although other terms have been used to describe individuals
who fall within the category of vulnerable older adults (e.g.,
the unbefriended elderly who are alone and lack decision-
stigmatize these individuals and oen fall within legal realm.
us, we resurrect the use of elder orphan as a benevolent and
medical alternative to a more broad population of individuals
who are alone and unsupported.
e purpose of the term, elder orphan,isforuseinhealth-
care environment to highlight vulnerability and attract atten-
tion to the need for a care-giving and medical decision-
use of the term will lead to allocation of more resources for
the individual. Further studies should investigate the impact
 Current Gerontology and Geriatrics Research
for unintended negative consequences such as stigmatization.
A limitation to our estimation of prevalence is that with
the available data the physical and cognitive health of the
subjects’ relatives and friends is unknown, such as in Case ,
Ms. H. M. Future studies should analyze these variables in
order to oer a more accurate prevalence. Moreover, as the
ment of individuals with signicant or domestic partners that
are involved caregivers. More detailed analyses are needed to
more accurately measure an at-risk elder orphan population.
e expected future increase in the number of individuals
without support from children and/or spouses/partners,
combined with a population that is living longer, poses an
enormous challenge to both the health-care system and the
community. us, further studies are needed to elucidate the
exact prevalence of this population, the needs of this group,
and the resources currently available to them. Moreover, a
critical view of the risks of being an elder orphan must be
delineated in order to more adequately prepare for and mini-
mize them. In these future studies, care must be taken to
examine the number, health status, and relationship of the
subjects’ existing family members, as well as their marital
status and health-care advocates.
In addition, the services needed for this population
should be scrutinized. is at-risk group requires access to
a host of services in order to help them thrive independently
inthecommunity.oseidentiedaselder orphans should
be educated about advanced directives and creating a plan of
care far in advance of needing acute care. More importantly,
they should receive assistance as needed and as available to
implement and achieve a plan of care. A few simple measures
can help stem catastrophe, and some possible resources
needed for this population are the following:
(i) Community based aging resource centers and adult
day care centers (community access to social services
and senior organizations with a goal of preventing
avoidable hospital admissions).
(ii) Community multidisciplinary teams to care for
patients with medical, functional, social, and safety
(iii) Public-private partnerships to help vulnerable pop-
ulations, linking health-care teams with community
and government agencies (e.g., social services, adult
protective services, and senior agencies).
Based on our clinical experience and a literature review,
we propose ten steps physicians and other providers should
take into account to identify and help address the medical
and psychosocial needs of elder orphans in the community,
as outlined in Ten-Step Guide to Caring for an Elder Orphan.
5. Conclusion
e elder orphan population is an increasingly prevalent and
at-risk demographic living precariously in the community.
ey oen go unrecognized by health-care providers and the
community alike, silently living in danger of medical crises.
e medical, public health, and general community need to
become more aware of these individuals in order to protect
inQuestionstoScreenforRiskforElder Orphan Status and
ten-step guide in Ten-Step Guide to Caring for an Elder
Orphan can help when faced with caring for an older adult
with no one. Further action is vital but steps, as outlined,
could begin to address this growing population, identify the
needs, raise awareness in order to mobilize public health and
community resources, and prioritize development of care-
giving and decision-making plans, so that these individuals
are no longer hiding in plain sight.
A poster presentation of this paper was presented at the 
Annual Scientic Meeting of the American Geriatric Society.
Competing Interests
None of the authors listed have nancial interests or conict
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... Social isolation among older adults is increasingly common (Carney et al., 2016;Margolis & Verdery, 2017) in a world of changing societal norms (Carr & Utz, 2020), relative increased ease and frequency of relocations, often far from family (AARP, 2012), and estrangement from family members (Scharp & Curran, 2018). Approximately 43% of adults over age 60 in the United States describe feeling lonely, and these older adults have an increased risk of both functional decline and death (Kotwal & Meier, 2022;Perissinotto et al., 2012). ...
... Capacity was implied to be present when not explicitly noted as missing in defining a term of interest. When the process of capacity determination (Appelbaum, 2007) was discussed in detail, which only occurred in 6% of the articles in which capacity was mentioned, this process was described as being in the context of a specific decision at a specific point in time (Carney et al., 2016;Connor et al., 2016;Patel & Ackermann 2018;Pope, 2019). ...
... Prior articles defined individual terms such as "unbefriended" (Farrell et al., 2017), "unrepresented" (Pope, 2019), "adult orphans" (Montayre et al., 2019), and "elder orphans" (Carney et al., 2016) in the context of discussing important clinical issues surrounding these groups without always addressing competing or equivalent terminology. When competing terminology has been explicitly discussed (Pope, 2017), recommendations to inform consensus terminology have not been present. ...
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Socially isolated adults, including those with and without the ability to make medical decisions, are encountered in clinical practice and are at risk for adverse health outcomes. Consensus is lacking on appropriate terminology to describe subpopulations of these patients. In addition, little is known about the settings in which they present. These gaps prevent clinicians and policymakers from identifying and understanding these populations and deploying appropriate resources to meet their complex needs. We conducted a narrative review of literature on socially isolated adults aged 50 and older to assess and integrate the available evidence regarding the terminology used to describe unrepresented patients and adults without advocates to inform consensus on terminology. We also identified the settings in which unrepresented patients and adults without advocates are described in the literature, including both within and outside health care settings. Our results indicate that there is heterogeneity and inconsistency in the terminology used to describe socially isolated adults, as well as heterogeneity in the settings in which they are identified in the literature. Our findings suggest that future work should include achieving consensus on terminology and integrating proactive interdisciplinary interventions across health systems and communities to prevent adults without advocates from becoming unrepresented.
... Along with this "demographic imperative" of aging, social and cultural factors have led to greater numbers of older adults living alone, many without close family support. "Elder orphans" is a term that has been applied to those who live alone and lack family or other close relationships to offer care or support (Carney et al., 2016). In their review of the phenomenon, Carney and colleagues define "elder orphans" as older adults who are socially or physically isolated, are unmarried or unpartnered (whether widowed, divorced, or never married), and have no children or close family members available to serve as caregivers (Carney et al., 2016;Ianzito, 2017). ...
... "Elder orphans" is a term that has been applied to those who live alone and lack family or other close relationships to offer care or support (Carney et al., 2016). In their review of the phenomenon, Carney and colleagues define "elder orphans" as older adults who are socially or physically isolated, are unmarried or unpartnered (whether widowed, divorced, or never married), and have no children or close family members available to serve as caregivers (Carney et al., 2016;Ianzito, 2017). Using 2010 data from the Health and Retirement Study (HRS), these authors determined the prevalence of those at high risk for becoming elder orphans-unmarried and childless, or unmarried, with children who are not in contact-to be 22.6% of the study population. ...
... The size of the Baby Boomer population, compared to prior generations, is a factor in the increase of the solo ager population (Ortman et al., 2014). Over one-third of Baby Boomers have no children, and this population is particularly vulnerable to aging alone with little to no social support (Carney et al., 2016;Lin & Brown, 2012). Meanwhile, the number of divorced and separated older adults in the United States has risen from 5. 3% in 1980to 15% in 2017(Administration for Community Living, 2018. ...
Solo agers may be vulnerable to social isolation and mental health sequelae, particularly if they lack close family or friendship ties. This study examined associations among indicators of solo aging, frequency of loneliness, and Major Depressive Disorder among adults aged 60+. Depressed participants were diagnosed by a geriatric psychiatrist and control participants were not depressed. We hypothesized that older adults with more indicators of solo aging (i.e., living alone, being unmarried, not having family or friends nearby) would be more often lonely and more likely to be depressed. In multivariate analyses controlling for health comorbidities and financial difficulty, each additional solo aging indicator significantly increased the likelihood of frequent loneliness, 95% CI OR [1.50, 2.80], and having a depression diagnosis 95% CI OR [1.04, 2.07]. Solo agers may be vulnerable to loneliness and depression, reinforcing the need for assessment and intervention for social isolation among older adults.
... Although the concept of an "elderly orphan" was first noted in 1994 and the term "elder orphan" was first used in 2005, targeted studies of this population using this term have only recently begun to emerge in the literature after the recurrence of the term in 2016 (Carney et al., 2016;Soniat & Pollack, 1994;Varner, 2005). In recent years, the term "elder" has been replaced by "older adult" to refer to those over age 65 and additional terms, including "unbefriended older adult" and "kinless older adult", have developed roughly concurrently to describe older adults without available caregivers or surrogates (Farrell et al., 2017;Lundebjerg et al., 2017;Margolis & Verdery, 2017). ...
... "Unbefriended older adult" has the added distinction that an older adult has lost their decision-making capacity and does not have an advanced directive or surrogate to make decisions in their place (Farrell et al., 2017). "Elder Orphan" refers to older adults who do not have caregivers or surrogates and who are also socially and/or physically isolated (Carney et al., 2016). As the search strategy for this study relied on the term "elder orphan" and the definition provided by Carney et al., we continue to use "elder orphan" where necessary for clarity but have also used alternative terms where possible. ...
... Also excluded were studies examining the health outcomes of caregivers and those who receive care from informal caregivers. Although existing literature on elder orphans are based on samples age 65 years an older, a minimum age of study participants was not defined as part of the inclusion criteria, as many adults can experience the effects of aging younger than the traditional definition of 65 years (Roofeh et al., 2020;Carney et al., 2016;Montayre et al., 2019;. The main methodology, search strategy, and eligibility criteria were agreed upon by all authors prior to search, data extraction, and quality assessment. ...
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... Even in geriatrics research, people living with dementia are often excluded (Taylor et al., 2012), especially those without care partners (de Medeiros et al., 2022). Survey Downloaded from by guest on 23 February 2023 A c c e p t e d M a n u s c r i p t research on kinless older adults, sometimes called "elder orphans" (Montayre et al., 2020), has offered important insights into the dimensions, correlates, and consequences of this growing phenomenon (Carney et al., 2016;Montayre et al., 2019;Plick et al., 2021;Roofeh et al., 2020;Soniat & Pollack, 1994;Verdery et al., 2019). However, survey data provide limited insight into the daily lives of kinless older adults or their interactions with health system. ...
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Objectives To examine the circumstances and needs of older adults who were “kinless,” defined as having no living spouse or children, when they developed dementia. Methods We conducted a secondary analysis of information from the Adult Changes in Thought (ACT) Study. Among 848 participants diagnosed with dementia between 1992 and 2016, we identified 64 who had no living spouse or child at dementia onset. We then conducted a qualitative analysis of administrative documents pertaining to these participants: handwritten comments recorded after each study visit, and medical history documents containing clinical chart notes from participants’ medical records. Results In this community dwelling cohort of older adults diagnosed with dementia, 8.4% were kinless at dementia onset. Participants in this sample had an average age of 87 years old, half lived alone, and one-third lived with unrelated persons. Through inductive content analysis we identified four themes that describe their circumstances and needs: 1) life trajectories, 2) caregiving resources, 3) care needs and gaps, and 4) turning points in caregiving arrangements. Discussion Our qualitative analysis reveals that the life trajectories that led members of the analytic cohort to be kinless at dementia onset were quite varied. This research highlights the importance of non-family caregivers, and participants’ own roles as caregivers. Our findings suggest that providers and health systems may need to work with other parties to directly provide dementia caregiving support rather than rely on family, and address factors such as neighborhood affordability that particularly affect older adults who have limited family support.
... In the absence of advance directives and appointed healthcare proxies, care teams often identify family or friends who can provide information about patients' wishes and values [10]. However, sometimes patients become decisionally incapacitated without any advance directives or personal contacts known to the healthcare team [11]. We refer to such patients as being Incapacitated with No Evident Advance Directives or Surrogates (INEADS). ...
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The prevalence of patients who are Incapacitated with No Evident Advance Directives or Surrogates (INEADS) remains unknown because such data are not routinely captured in structured electronic health records. This study sought to develop and validate a natural language processing (NLP) algorithm to identify information related to being INEADS from clinical notes. We used a publicly available dataset of critical care patients from 2001 through 2012 at a United States academic medical center, which contained 418,393 relevant clinical notes for 23,904 adult admissions. We developed 17 subcategories indicating reduced or elevated potential for being INEADS, and created a vocabulary of terms and expressions within each. We used an NLP application to create a language model and expand these vocabularies. The NLP algorithm was validated against gold-standard manual review of 300 notes and showed good performance overall (F-score = 0.83). More than 80% of admissions had notes containing information in at least one subcategory. Thirty percent (n = 7,134) contained at least one of five social subcategories indicating elevated potential for being INEADS, and <1% (n = 81) contained at least four, which we classified as high likelihood of being INEADS. Among these, n = 8 admissions had no subcategory indicating reduced likelihood of being INEADS, and appeared to meet the definition of INEADS following manual review. Among the remaining n = 73 who had at least one subcategory indicating reduced likelihood of being INEADS, manual review of a 10% sample showed that most did not appear to be INEADS. Compared with the full cohort, the high likelihood group was significantly more likely to die during hospitalization and within four years, to have Medicaid, to have an emergency admission, and to be male. This investigation demonstrates potential for NLP to identify INEADS patients, and may inform interventions to enhance advance care planning for patients who lack social support.
This study evaluates help sources for personal and health tasks of adults living in the community without a spouse or nearby children. Using data from the National Health and Aging Trends Study (NHATS), a nationally representative sample of Medicare beneficiaries ages 65 and over, we conducted a population-based study of 2998 community-dwelling adults who received assistance with personal, household, or medical tasks in the past month. Using ANOVA, we compared adults aging solo to those with spouses at home and/or children in the same state. Adults aging solo were significantly more likely to identify non-child/spouse family, friends, neighbors and paid aides as part of their social networks. Their sources of unpaid help included siblings (33%), friends (32%), and non-family (e.g., neighbors (23%)). Adults aging solo were more likely to use paid caregivers, despite having lower incomes than married peers. Interventions to support adults aging solo should incorporate diverse social/help networks.
This editorial comments on the article by Zietlow et al.
Measuring childlessness is complicated by the increasing complexity of family structure. Using data from the 2014 Health and Retirement Study, in this research note we compared three definitions of childlessness: (1) respondent never fathered/gave birth to a child, (2) respondent had no children who were living and in contact, and (3) respondent and spouse/partner had no children or stepchildren who were living and in contact. Results showed that the prevalence of childlessness among Americans aged 55 or older ranged from 9.2% to 13.6% depending on which definition was used. The association between select individual characteristics (gender and marital status) and the likelihood of childlessness, as well as the association between childlessness and loneliness and living arrangements, also varied depending on how childlessness was defined. Therefore, how we define childlessness can affect our understanding of its prevalence, correlates, and relationships with well-being. Future research on childlessness should carefully consider the choice of definition and its implications for research and policy discussions.
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This paper reviews the empirical literature on social isolation and loneliness and identifies a wide range of published correlates. Using data from a study conducted in North Wales, which included many of the same correlated variables, a statistical modelling technique is used to refine models of isolation and loneliness by controlling for co-variance. The resulting models indicate that the critical factors for isolation are: marital status, network type and social class; and, for loneliness: network type, household composition and health.
Living alone, a proxy for social support, has been inconsistently linked with cardiovascular risk. We investigated whether living alone was associated with increased mortality and cardiovascular risk in the global REduction of Atherothrombosis for Continued Health (REACH) Registry. Stable outpatients at risk of or with atherothrombosis were recruited from December 1, 2003, through December 31, 2004, and followed up to 4 years for cardiovascular events. Events were examined by living arrangement with risk adjustment for age, sex, clinical risk factors, therapy, preexisting vascular disease, and sociodemographic factors. Effect modification was tested by age, sex, employment, ethnicity, education, and geography. Among the 44 573 REACH participants, 8594 (19%) were living alone. Living alone was associated with higher 4-year mortality (14.1% vs 11.1%) and cardiovascular death (8.6% vs 6.8%; log-rank P < .01 for both comparisons); however, there was significant effect modification by age (P value for interaction = .03). Specifically, among younger participants, living alone compared with those living with others was associated with higher mortality (age 45-65 years: 7.7% vs 5.7%; adjusted hazard ratio [HR], 1.24 [95% CI, 1.01-1.51]; age 66-80 years: 13.2% vs 12.3%; adjusted HR, 1.12 [95% CI, 1.01-1.26]), but this was not observed among older participants (age > 80 years: 24.6% vs 28.4%; adjusted HR, 0.92 [95% CI, 0.79-1.06]). A similar trend was observed for the risk of cardiovascular death. In an international outpatient population with atherothrombosis aged 45 years or older, living alone was associated with increased mortality among all but the most elderly patients, although this observation warrants confirmation.
Loneliness is a common source of distress, suffering, and impaired quality of life in older persons. We examined the relationship between loneliness, functional decline, and death in adults older than 60 years in the United States. This is a longitudinal cohort study of 1604 participants in the psychosocial module of the Health and Retirement Study, a nationally representative study of older persons. Baseline assessment was in 2002 and follow-up assessments occurred every 2 years until 2008. Subjects were asked if they (1) feel left out, (2) feel isolated, or (3) lack companionship. Subjects were categorized as not lonely if they responded hardly ever to all 3 questions and lonely if they responded some of the time or often to any of the 3 questions. The primary outcomes were time to death over 6 years and functional decline over 6 years on the following 4 measures: difficulty on an increased number of activities of daily living (ADL), difficulty in an increased number of upper extremity tasks, decline in mobility, or increased difficulty in stair climbing. Multivariate analyses adjusted for demographic variables, socioeconomic status, living situation, depression, and various medical conditions. The mean age of subjects was 71 years. Fifty-nine percent were women; 81% were white, 11%, black, and 6%, Hispanic; and 18% lived alone. Among the elderly participants, 43% reported feeling lonely. Loneliness was associated with all outcome measures. Lonely subjects were more likely to experience decline in ADL (24.8% vs 12.5%; adjusted risk ratio [RR], 1.59; 95% CI, 1.23-2.07); develop difficulties with upper extremity tasks (41.5% vs 28.3%; adjusted RR, 1.28; 95% CI, 1.08-1.52); experience decline in mobility (38.1% vs 29.4%; adjusted RR, 1.18; 95% CI, 0.99-1.41); or experience difficulty in climbing (40.8% vs 27.9%; adjusted RR, 1.31; 95% CI, 1.10-1.57). Loneliness was associated with an increased risk of death (22.8% vs 14.2%; adjusted HR, 1.45; 95% CI, 1.11-1.88). Among participants who were older than 60 years, loneliness was a predictor of functional decline and death.
Our study provides a national portrait of the Baby Boom generation, paying particular attention to the heterogeneity among unmarried Boomers and whether it operates similarly among women versus men. We used the 1980, 1990, and 2000 Census 5% samples and the 2009 American Community Survey (ACS) to document the trends in the share and marital status composition of the unmarried population during midlife. Using the 2009 ACS, we developed a sociodemographic portrait of Baby Boomers according to marital status. One in three Baby Boomers was unmarried. The vast majority of these unmarried Boomers were either divorced or never-married; just 10% were widowed. Unmarried Boomers faced greater economic, health, and social vulnerabilities compared to married Boomers. Divorced Boomers had more economic resources and better health than widowed and never-married Boomers. Widows appeared to be the most disadvantaged among Boomer women, whereas never-marrieds were the least advantaged among Boomer men. The rise in unmarrieds at midlife leaves Baby Boomers vulnerable to the vagaries of aging. Health care and social service providers as well as policy makers must recognize the various risk profiles of different unmarried Boomers to ensure that all Boomers age well and that society is able to provide adequate services to all Boomers, regardless of marital status.