Public Health and Aging America: Uncharted Adventures

1
Public Health and Aging America Uncharted
Adventures

• J. James Cotter, PhD
• Assistant Professor and Vice Chairman, Division
  of Quality Health Care, Department of Internal
  Medicine
• Assistant Professor, Department of Gerontology
• Virginia Commonwealth University

2
Defining the Aged

• 40 - Age discrimination
• 50 - AARP discounts
• 60 - Older Americans Act
• 65-67 - Medicare and Social Security
• 75 - frailty marker
• 85 - the old-old

3
Best Years of My Life

• 84 of all Americans say they would be happy to
  live to be 90
• What defines old age
• decline in physical ability - 41
• decline in mental functioning - 32
• reaching a specific age - 14
• National Council on Aging survey, 2001

4
Growth of the Aging Population
5
Life Expectancy
National Vital Statistics Report, Vol. 47, No.
28, December 13, 1999 National Research Council,
1988
6
Number of Centenarians

• Jeanne Calment, died in 1997 at the age of 122.
• A 65 year old must live 57 more years to catch
  her record.

7
Changing structure of society

• Traditional aging pyramid

• New aging pyramid

8
Changing Dependency
9
Growing diversity
10
Dychtwalds 5 Social Train Wrecks

• Using 65 as a marker
• Epidemic of chronic disease
• Caregiving crunch
• Poverty in old age
• Elder wasteland

Dychtwald, Age Power, 1999
11
Gerontographics Life-stage Model
Moschis, American Demographics, 1996
12
Facts About the 50-Plus Markethttp//www.agewave.
com/

• More than 2 trillion in income
• 70 of the financial assets in America
• 50 of all discretionary income - 13,286 per
  household
• The 50-plus consume 74 of all prescription
  drugs, a 100 billion market.
• Today's 50-plus adults represent 80 of all
  luxury travel
• Number of 55-plus health club members jumped 119
  (1987-1995) the number of 65-plus members jumped
  669 .

13
Changing Family Structure

• Source US Census, 2000

14
Older People of the 21st Century

• General
• smaller families, reconfigured families
• suburbs
• women in the work force
• social movements

• Health
• prevention is key
• disability ? dependence
• influence of lifestyle
• influence of lifetime access to health care

Silverstone, Gerontologist, 1996
15
Social Security Reform

• Raising the normal or earliest eligibility age
  for retirement could have substantial net
  positive effects on the financial integrity of
  the Old-Age and Survivors Insurance Trust Fund
  and the Disability Insurance Trust Fund.
• GAO Social Security Reform Implications of
  Raising the Retirement Aged, August 27, 1999

16
Aging Network
Based on Torres-Gil, The New Aging, p.56
17
Social Policies (1)

• Income Policy
• OASI,
• private and public pensions,
• SSI,
• tax benefits (property, capital gains exclusion,
  SS exempt)

JJC
18
Social Policies (2)

• Health Policy
• Medicare (HI),
• Medicaid,
• LTC
• fragmentation
• institutional bias

JJC
19
Social Policies (3)

• Housing Policy
• Section 202,
• Section 8,
• CCRCs,
• mobile home parks,
• ACRs, boarding houses, Assisted Living

JJC
20
Social Policies (4)

• Social Services SSBG(XX), OAA
• Civil Rights ADEA, EEOC
• Volunteer Policy
• Senior Companion,
• Foster Grandparent,
• RSVP,
• SCORE

JJC
21
Older Americans Act

• AoA, SUAs and AAAs
• Nutrition Services
• Supportive Services
• Research and Demonstration Projects
• Ombudsman and Elder Rights

JJC
22
State Level

• Health and Human Resources
• Aging
• Social Services
• Health
• Medicaid agency
• Housing
• Transportation

JJC
23
Politics of the aging - definition

• participation by and for the elderly in the
  political process.

24
Key Events in Aging Politics

• 1. Social Insurance - Social Security
• 2. Senior Lobby - Townsend/AARP / Gray Panthers
• 3. Aging Network-AoA, SUA, AAA
• 4. Medicare / Medicaid
• 5. Older Americans Act
• 6. SSI and COLA
• 7. Medicare Catastrophic Coverage Act
• 8. Voting Behavior
• 9. White House Conferences on Aging
• 10. 1994 Republican Congress

JJC
25
Political Participation

• Higher voting rates
• Identity as senior citizens
• Age-based organizations

26
Voting
27
Current Political Issues

• Medicare (Rx)
• Social Security (Privatization)
• Generational tensions (Private)
• Longevity (Financing)
• Health care reorganization (HMOs)
• Long-term care (Tax Credit)
• Housing (Assisted Living)

JJC
28
Hopes for New Aging Politics

• Away from the interest-group nature of the
  politics
• Away from age-segregated policies and programs
• Aging support for non-aging issues
• Educate younger persons about longevity
• Private troubles - public issues

Torres-Gil, New Aging, 1992
29
AARP

• The most powerful interest group in Washington -
  Fortune magazine, Dec 8, 1997
• Revenue 469 million (1994) - selling services
• 1,700 employees
• Its political strategies cannot alienate its
  members
• MCCA and support for health care reform
  antagonized some members
• How much attention to low-income aged
• Able to coalesce aging into a viable political
  force?
• Under attack on its lobbying and non-profit status

Torres-Gil, New Aging, 1992
30
Policy Dilemmas

• How do we involve older persons?
• How can we break the needy/greedy image cycle?
• How do we balance public and private
  responsibility?
• Where does federal control end and state control
  begin?
• How can we prepare young for aging?

JJC
31
Healthier Older Population ?

• Fries (1984), Compression of morbidity
• Palmore (1986), relative health of elderly has
  improved
• Rogers (1990), living longer and healthier
• Manton (1995), significant decreases in
  prevalence of 16 medical conditions
• Cassel (2000), declining or postponing disease?
• Natl Acad Sciences (2001), 65 disabled down 6.5
  since 1982 (26.2 v 19.7)

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Prevention Mortality, Disability and Morbidity
surviving
Age
33
In Search of the Secrets of Aging

• Caloric restriction
• Syndrome X
• Heat Shock Proteins
• Hormones
• Immune system

• Longevity genes
• Cell senescence
• Oxygen radicals
• Glycation
• DNA Repair

34
Institute for the FutureHealth Care Paradigm
Shift

• Biomedical model
• Acute episodes
• Individual
• Cure
• Disease

• Multi-factor approach
• Chronic illness
• Communities
• Adaptation
• Person /disease

35
Financing Medical Care

• HMOs
• Personal responsibility

36
Health Care Premium and Cost Annual Increase,
1991-2000
Source Center for Studying Health System Change,
11/00
37
Health Care Financing

• "Soaring" prescription drug costs will likely
  soon lead to "large increases" in workers' health
  insurance premiums and to "changes or cutbacks"
  in prescription drug benefits.
• Hartford Courant, 4/24/01

38
Percent Change per capita in Health Care
Expenditures, 1998-2000
Source Center for Studying Health System Change,
11/00
39
Workers Pay More for Care (USA Today, 4/5/01)

• of Rx price rather than flat co-payment
• Varying percents based on type of condition -
  chronic, acute, lifestyle
• Two-tier health plans - limited benefits
• Varying co-payments - will AMC reputation cost
  more?
• Increase share of premiums gt 33

40
Paths to Reform Blumenthal, NEJM, 2001

• Defined contribution plans
• Medical savings accounts
• Increased co-payments
• Increased deductibles
• Government price controls

41
Economic Value of Long-term Care
Source Arno, Levine, Memmot (1999) Health Affairs
42
Delivering Medical Care to Older Persons

• Geriatricians/ Anti-aging physicians
• Geriatric Training for Health Care Professionals
• GEMs
• Telemedicine

43
Need for Primary Care Physicians certified in
Geriatrics
Source Alliance for Aging Research, 1996
44
Ronald Klatz, M.D.founding physician of the
anti-aging medicine movement

• Today's boomers will live, on average, to see age
  100. Some boomers will celebrate their 130th
  birthdays healthy, happy, with full mental and
  physical faculties intact.
• New method to collect organs from non-beating
  heart donors, expanding the bank of organs for
  transplants
• A genetically engineered "gene therapy" cure for
  male pattern baldness.
• At home 2-way telemedicine consultations between
  many elderly persons too frail, too weak, or just
  too busy to drive to their doctor appointment.
• Inhaled drug delivery systems e.g. Insulin

45
Geriatric Medicine Update
Loss of function from habitual inactivity, poor
nutrition, disease

• Exercise - improved walking, balance, ROM
  decreased risk of morbidity, mortality,
  institutionalization
• Exercise, dietary restriction, sodium limit - 60
  of older hypertensive patients weaned from
  medication
• Biophosphanates - decrease bone resorption
• NSAIDs, estrogen possibly effective against
  cognitive decline

Applegate and Pahor, JAMA, 1997
46
Improving chronic conditions

• Counseling/ Tx on smoking cessation
• Counseling/ Tx on diet
• Counseling/ Tx on exercise

47
Self-reported arthritis prevalence
per CDC MMWR May 04, 2001 / 50(17)334-6
48
Model of Telehealth
Telehealth
Telemedicine
Tele-education
Telecommunications / Internet
Providers
Students
Patients
49
Telemedicine and geriatric care

• A telemedicine system as a care modality for
  dementia patients in Korea.
• Lee et al. Alzheimer. Dis. Assoc. Disord. 2000
• "Electronic House Call" with a primary care
  physician - 61 reported they were comfortable
  using the computer system without assistance. No
  negative effect on physician relationship seen.
  (Bratton and Cody, Mayo Clinic Proc, 2000)

50
Electronic minders

• Infrared sensors can follow Shizue Ozasa's every
  move as she maneuvers around her room.
• Chips in her shoes can trigger locks should she
  try to leave.
• A database can record everything she does.
• Big Brother at his most benevolent--and most
  lucrative.
• NAIS Care Owada, a nursing home in Osaka

Oldies Look Golden to Japan Inc. (WSJ)
51
Technology in the home care

• Miniaturization and portability
• Alarms, monitors, safety systems
• Self-care extenders e.g. computer
• Treatment IV, chemo, dialysis
• Mechanical aids
• Advantages and Disadvantages

• Kaye Davitt, Health and Social Work, 1995

52
Special Areas for Concern

• Sex and AIDS
• Depression and Suicide
• Alcohol and Substance Abuse
• End-of-life Care
• Alzheimers Disease

53
Sex and aging

• 80 of people over the age of 60 are sexually
  active (at least 1x mo) (National Council on
  Aging Roper Starch poll, 1998)
• 10.2 of AIDS cases diagnosed in 1995 over the
  age of 50 3.5 over the age of 65
• Sexual history not part of the MD profile usually
  done on older persons
• (Gaeta et al, J Emer Med., 1995 Feldman, Arch
  Int Med.,1994)

54
Depression

• In a study of 3,410 older persons in an HMO,
  primary care physicians miss 1/2 of depression
  (measured by the GDS) in older persons.
• Garrard, Rolnick, Nitz et al, J Gerontology,
  April, 1998
• Suicide rate for older white men is double other
  groups (59/100,000).

55
Substance Abuse and Aging

• 1/3 of alcoholics are over the age of 60
• Underdiagnosis - mimics other symptoms, ageism
• Questioning on the quantity and frequency of
  drinking the CAGE increases the number of
  problem drinkers detected. (Adams, Barry,
  Fleming, JAMA,1996)
• Alcohol-related hospitalizations among elderly
  people are common rates for myocardial
  infarction (1). (Adams, Yuan, Barboriak, Rimm,
  JAMA, 1993)
• Primary care physician and Brief intervention -
  the most cost-effective intervention for alcohol
  problems (Hodler et al, J Studies Alc., 1991)

56
End-of-life care

• Oregon Health Sciences University study (P.
  Bascom, MD)
• 67 of medical students had some EOL exposure but
  only in early stages of terminal illness
• 60 had never participated in notifying families
  of patient death
• pilot hospice option added to community medicine
  rotation
• Advanced directives not being followed

57
Alzheimers Disease

• 4 million people affected 14 million in 2030
• Caregivers 36 hour day
• Pharmacologic tx - cholinesterase inhibitors for
  early stages, anti-psychotics in later stages for
  behavior
• Non-pharmcologic tx for behavior - SCUs

58
Incidence of Alzheimers Disease in East Boston
Hebert et al., JAMA, 1995
59
Assessment of Alzheimers Disease - Guidelines
Development

• 1984 Institute for Neurological Disorders and
  Stroke (Neurology, July, 1984)
• 1997 American Consensus (AAGP, Alz.Assoc.,AGS)
  (JAMA, 1997)
• 1998 NIA and Alz. Assoc.

• Medical history
• Clinical exam
• Lab tests

• Neuro-imaging
• Other

60
Number of Special Care Units in nursing homes
61
Public Health Agents of Change (after Torres-Gil)

• Understand the social and demographic trends
  affecting an aging society
• Reexamine the underlying principles of the
  present system
• Consider the influence of generational claims,
  longevity and diversity on current system
• Reformulate a social contract between
  individuals, society and government
• Assisting agencies, organizations and older
  persons to adapt to multiple challenges

62
Conclusion
Almost 1/2 of all humans over the age of 65 are
alive today. Klein Bloom, Successful Aging,
1997