When we think about older adults in the US, we usually focus on those living in cities or suburbs. By doing so, we forget about the rural elderly, who represent an outsized share of people living in these communities and who have very special challenges.

According to a new report by the US Census bureau, about 10.6 million older adults live in rural communities—roughly one quarter of all seniors. But they represent a much larger fraction of their local  populations than urban seniors.  About 17.5 percent of rural residents are over 65, while only about 14 percent of urban residents are older adults. Three-quarters of rural older adults live in the South and Midwest, but in states such as Maine and Vermont almost two-thirds of seniors live in rural communities.

And the more rural the area, the older it likely is. Census found that about 20 percent of the residents of what it calls “completely rural” communities are 65 or older.

Poorer and sicker

Overall, rural seniors are more likely to be white and less educated than those living in cities, and, interestingly, more likely to be men and less likely to be living alone or in nursing homes. Their earnings are substantially lower than those in cities:  About $46,000 compared to $56,000 in mean earnings. Those living in the most rural communities make even less and are more likely to be living in poverty.

Rural seniors are less likely to be 85 or older than those living in cities or suburbs. Yet, other studies find the physical health of older adults in rural communities is worse and they are more likely to suffer from chronic disease—a typical pattern for people with less education, less income, and less access to medical care.

Two trends are driving the aging of rural communities—younger, working age people are leaving and older people are, well, growing older. One result: in rural communities, there are fewer people of caregiving age relative to those of dependent age (both children and seniors) than in cities.  And the broader pattern holds: The more rural the community, the harder it is to find people of caregiving age, whether family caregivers or paid aides.

While the Census study did not look at the specific challenges of older adults living in rural areas, it isn’t hard to figure them out.

Transportation, difficult for older adults no matter where they live, is especially hard in rural communities. There rarely is any public transportation. Corporate ride-sharing such as Uber or Lyft is rare or non-existent, and travel distances to shopping, health care facilities, or entertainment are greater.  For those in the northern US or in mountainous communities in the south or southwest, winter travel is a special problem.

Health care is another challenge. Many of these communities have no full-time physicians and, increasingly, no hospitals or even clinics. There are few, if any, nursing homes in rural counties. And their quality often is lower than in other communities.  In many rural areas, there are no Medicare- or Medicaid-certified home care agencies or hospice programs. Thus, providers must travel many miles to deliver care, if it is available at all.

Mobility. Rural seniors also are more likely are more likely to be living in older, multi-story homes. They must navigate longer distances to neighbors or even to their mailbox than their urban counterparts. Maintaining their older, single-family homes may be more difficult.

Social isolation. For these and other reasons, it is very hard for rural older adults to maintain social relationships.  In many families, working age children have long since left for jobs in larger communities.  Neighbors have died or moved away. Living alone in a rural farmhouse can be very isolating, and loneliness itself can be debilitating.

There are solutions. For example, faith communities are especially important in rural areas, where they may be among the last remaining social institutions. They can work together to support congregants (or others) who need help. Local governments, fraternal organizations, and other non-profits–even with limited resources– can build programs that assist seniors aging at home. Some organizations, such as FeonixMobilityRising help community groups build transportation networks by, for example, matching volunteers with those who need rides).

For some older adults, co-housing with younger people or seniors-only group homes may be a solution. So may technology in the form of remote health monitoring or other telehealth solutions that Medicare is beginning to pay for. Down the road, pardon the expression, researchers at MIT are looking at autonomous vehicles that may turn out to be a better solution in relatively traffic-free rural communities than in heavily congested cities.

Older adults are too often ignored in the best of circumstances. But it is especially easy to forget those who live in rural communities. The Census study reminds us that those seniors matter too.