Health and The Elderly

1
Health and The Elderly

• Mark Abdelmalak
• Hany Fahim
• Ricken Patel
• Dheeraj Muddasani
• Darshan Vaidya

2
What Is the Problem?

• The elderly African American population has a
  disproportionately higher risk for negative
  health outcomes in comparison to Americans of
  European descent

3
The Question

• What factors contribute to the disparity between
  the health status of African Americans versus the
  elderly of other races?
• Need to explore this from a life-course framework

4
Population Distribution

• In 2000, persons of age 65 numbered 35 million,
  or 12.4 of the U.S. Population
• 16.4 of the 35 million elderly were minorities,
  with a distribution as shown

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Leading Causes of Death Among African Americans
Age 65

• 1)      Heart Disease
• 2)      Cancer
• 3)      Stroke
• 4)      Diabetes
• 5) Pneumonia /Influenza

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Truth may be hard to accept

• African Americans are two times more likely than
  whites to have diabetes
• Higher lung and prostate cancer incidence and
  mortality than whites in all age groups
• 30 more likely to die of heart disease (1 in 3 ?
  hypertension)
• Highest overall risk of kidney disease
• Stroke death rate 33 higher than white women
• Rate of CV disease 80 higher than rate for white
  women

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When America Gets a Cold, African Americans Get
Pneumonia!!

• 47 of elderly African-Americans received the flu
  vaccine in 1998 vs. 66 of elderly whites
• 26 of elderly African-Americans received the
  pneumonia vaccine in 1998 compared with 50 of
  elderly whites

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• Discriminatory Hospital Care for Seriously Ill
  Elderly Blacks
• Dr. John Z. Ayanian asserts, black Medicare
  patients hospitalized for heart failure or
  pneumonia in three large States received poorer
  overall quality of care than other Medicare
  patients treated for the same illnesses.

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Dr. John Ayanians Findings

• 32 of black pneumonia patients given antibiotics
  w/in 6 hrs. of admission, compared with 53 of
  other Medicare patients
• Blacks less likely to have had blood cultures
  collected on 1st or 2nd day of hospitalization
• Disparities 1 additional death per 200 patients
  treated

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Cardiovascular Disease
v      Cardiovascular disease is one of the
leading causes of mortality today. v     
 Coronary heart disease accounts for 70 to 80
of deaths in men and women in adults over 60
years of age. v      Congestive Heart Failure
(CHF), is the most common cause of
hospitalization in the elderly. v     
Cardiovascular disease is an important public
health problem in African Americans. In 1998,
cardiovascular disease accounted for 34 of
deaths in black men and 41 of deaths in black
women African Americans have a
disproportionately high rate of hypertension.
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Diabetes Mellitus

• When tested, Diabetes mellitus occurred in 127 of
  1150 whites (11), in 93 of 444 African-Americans
  (21), and in 4 of 28 Asians (14).
• The prevalence of diabetes mellitus in 2003 older
  persons seen in an academic hospital-based
  geriatrics practice was 17 and was greater in
  African-Americans than in whites

15
Who Lives Longer?
Life Expectancy by Age Group and Race, in Years,
1997
Source Administration on Aging, 2000
16
Life Expectancy

• Life expectancy at birth has historically been
  shorter for African Americans than older
  Americans, but the differences disappear or
  reverse themselves at older ages, creating the
  Crossover Phenomenon.
• As of 1997, Black women in the U.S. has a life
  expectancy at birth of 74.7 years, and Black men
  67.2 years.
• At age 85, life expectancy for Black women is 6.7
  years and 5.7 years for Black men.

17
Population growth and distribution

• There has been continuous growth in the overall
  population of blacks in the United states since
  1790.
• In 1970 there were 22 millions blacks in the
  United states, of whom approximately 1.5 million
  or 7 were 65 years of age or older. Since 1970
  there has been considerable growth in the
  population of blacks 65 and over.

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Health History

• There is a general agreement that blacks elders
  have traditionally been treated with great
  respect in their families.
• This tradition extends from known cutoms of
  proslavery civilization on the African continent
  through modern customs African Americans families
  and kinship groups in the United States.

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Health History Contd

• African American elders tend to precieve their
  health as more problematic than do white elders.
• 17 of African American rate their health as
  poor, as compared with 7 of white elders.

20
Life Course framework

• Blacks who grew old in the United States had to
  withstand a variety of psychologically,
  physically and socially degrading experiences
  resulting from the political economy of race
  relations in the United States. (i.e. slavery,
  CRM, social maltreatment, Tuskegee experiment.)
• Among the determinates of the treatment of
  elderly Blacks in the social history of the U.S.,
  economic factors had a significant bearing.

21
Crossover Phenomenon

• Despite lower life expectancies for African
  Americans from birth, a mortality crossover
  phenomenon occurs at the age of 73 for black
  males and age 85 for black females.
• Since many African American elders have had to
  cope with stress and few economic resources
  throughout their lifetimes therefore, negative
  outcomes in older age may appear less serious.

22
Crossover Phenomenon Contd

• Also, it might be because the elders may simply
  have developed a more reliable set of coping
  strategies to deal with the stresses of old age.

23
Education

• The Administration of aging (2000) reported that
  in 1998, 44 of non-Hispanic black Americans age
  65 and over had graduated from High school and 7
  had bachelors Degree or Higher.

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Patters of Health Risk

• Many Morbidity and mortality rates are higher
  among African American elders than in the general
  population. Because of decreased educational
  levels and decreases in personal resources, the
  awareness of health problems, knowledge of causes
  and risk factors, and capacity to access medical
  care maybe greatly decreased.

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Mortality

• Death rates from all Causes for Elders 65-74 and
  75-84 are higher among Black elders than any of
  the other racial ad ethnic groups.
• Those who are 85 and over, the rates are higher
  among whites and second highest among Blacks.
• Older African Americans are less likely than
  white elders to have health insurance or to have
  seen a doctor in the pervious year.

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Family Roles

• African American families have developed and
  retain distinctive models of family interaction
  that combine traditional patterns of roles and
  responsibilities with adaptations called forth by
  American experience.
• The Black kinship system tends to more extensive
  and cohesive that the family system of whites.

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Living Arrangements

• Among Community dwelling elders, African
  Americans men were more likely to live alone
  (approximately 24) and less likely to live with
  spouse (approximately 52) than men from any of
  the four other older racial/ethnic populations.
• Historically, African Americans have resided in
  nursing homes at about half of rate of white
  elders.

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Cultural Biases and Misdiagnoses

• Cultural bias about health and illness, and
  beliefs about which individuals and/or groups are
  most susceptible to one or another disorder are
  key among these factors.
• It is also believed among some psychiatrists that
  African Americans, as a group, tended to have low
  rates of depression because of their historical
  social and educational oppression.

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Cultural Biases and Misdiagnoses Contd

• Epidemiological and etiological research have
  subsequently shown that depression and other
  illnesses are much more complex disorders than
  that suggested by the foregoing statements and
  must be carefully studied, including
  cross-cultural variations in symptoms of
  disorders before drawing conclusions and
  formulating treatment plans

32
Showing Respect!!!!

• Particularly because of the experience of many
  african American elders who grew up with
  segregated health care and social service systems
  in which they faced continual discrimination, it
  is extremly important to show respect to them in
  clinical settings in order to put them at ease
  and establish rapport.

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Adapting Assessments Techniques to Skin Color

• Since African American elders have a wide range
  of skin color, it is very important for nurses
  and physicians to use appropriate assessments
  that reflect skin tone changes for conditions
  such as cyanosis.

34
Specialized Procedures in Cardiac Care

• Numerous studies in the late 1980s and 1990s
  found that African Americans are less likely to
  undergo cardiac catheterization and
  coronary-artery bypass graft surgery than their
  white counterparts.
• Our findings suggest that a patients race and
  sex may influence a physicians recommendation
  with respect to a cardiac catheterization
  regardless that patients clinical
  characterization.

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End of Life Care

• Some African American families may request that
  certain diagnoses or disease prognoses be
  withheld from the patient to shelter them from
  disturbing information
• Other patients and families favor forthright
  discussion of all medical issues and treatment
  plans.

36
Care giving

• Comparisons of informal care giving by black and
  White older adults showed that blacks are more
  likely to be caregivers and more likely to assist
  friends.
• Blacks have frequent contact with family,
  relatives, friends and neighbors, although they
  utilize the members of their network differently
  for emergency and non-emergency situations.

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Minority Population

• Minority Americans today comprise 14 of the
  nation's elderly and 16 of the total Medicare
  population.
• The minority population is projected to more than
  double by 2025 and will represent one in three
  seniors..

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Minority Population Cont
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Poverty Rates

• In 1990, the poverty rate for older African
  Americans was 30.7 and only 9.6 for older white
  Americans.
• One of every 11 elderly Caucasian persons lived
  in poverty in 1998, compared with 26.4 of
  elderly African Americans and 21 of elderly
  Hispanics.

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Poverty Rates Cont

• About 1/3 of African American beneficiaries have
  incomes below the poverty level, which is more
  than three times the share of whites.
• Moreover, nearly two-thirds of African American
  beneficiaries have income below twice the poverty
  level compared with 41 percent of whites.

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Poverty Rates Cont
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Characteristics of Minority Medicare Beneficiaries
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Disparities in Health Insurance Coverage

• A quarter of African American beneficiaries have
  no supplemental coverage, compared with 10
  percent of all whites.
• 2/3 of all white beneficiaries have Medigap or
  employer sponsored retiree benefits, compared
  with only a third of African Americans.

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Disparities in Health Insurance coverage cont
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Causes of Disparities in Health Insurance Coverage

• Unemployment
• The national unemployment rate for African
  Americans rose to 10.1 percent, up .3 percent
  from October, and up a 1.3 percentage from
  September. The unemployment rate for the white
  population was at 5.1 percent in November  
  almost half of the African-American unemployment
  rate.

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Causes of Disparities in Health Insurance Coverage

• The high rate of unemployment for Blacks has
  several causes.
• First, inferior quality inner-city schools yield
  both more drop-outs and students without the
  skills needed in today's high tech labor market.
• Second, shifts away from manufacturing and
  central city employment have deprived Blacks of
  traditional sources of employment.

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Causes of Disparities in Health Insurance Coverage

• Last but not least, discrimination is still a
  reality adversely affecting the employment
  prospects of Blacks - especially in smaller firms
  where many of today's jobs are being created.

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Health Insurance Coverage

• How unemployment and underemployment affects
  Health Insurance Coverage
• Social Security
• Out of Pocket spending

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Health Care Is Driven by Economics

• Most health policy for the elderly fails to take
  into account the distinctive health and SES
  statuses of racial and ethnic minority elderly.
  In fact, changes in the U.S. economy leads to a
  scapegoating of minorities which jeopardizes the
  fulfillment of their healthcare needs

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Hudson County Elderly

• 2000 Statistics
• Greater than 11 percent of the Countys
  population was 65 years or older. Of this
  percentage, 8 percent were African American.
• Source Department of Labor, Population and
  Labor Force Projections for New Jersey 1995 to
  2030, January, 1994 1980 Census, 1990 Census

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Poverty among Elderly in Hudson County

• Much of the elderly population in Hudson County
  is poor
• Over 22.5 percent of the Countys frail elderly
  (aged 75 and over) have been living in poverty
  since 1990
• In comparison, 12.7 percent of the frail elderly
  is living in poverty Statewide

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Expected Increase in Elderly

• The elderly population is expected to increase as
  the Baby Boom Generation (persons born from 1946
  to 1964) grows older.
• This will in turn increase the demand for
  services to the elderly in Hudson County.

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Elderly Services in Hudson County

• Programs Used
• Social Service Block Grants
• Medicaid Programs
• Home Health Services
• Community Care for the Elderly and Disabled
  (CCPED) program
• Services Provided
• Providing Meals
• Homemaker Services
• Housekeeping
• Transportation
• Adult Day Care

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Meals-On-Wheels

• Meals-On-Wheels is a service that brings
  nutritional food straight to the homes of elderly
• One of the best services for Hudson Countys
  elderly residents and can also be seen in many
  cities throughout the United States
• Three agencies help to administer this program in
  Hudson County

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Life Expectancy in Australia

• Australians are living longer than in the past.
• The proportion of people over 65 is 12 today and
  is expected to reach 20 by 2030.

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Hudson County vs. Australia

• Hudson County (and the rest of the US) provide
  nearly universal health insurance coverage for
  its 65 population
• 1998 survey found much higher rates of access
  difficulties and costs concerns in the US,
  compared to the universal coverage in Australia

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Health Care Access

• 12 percent of elderly in Hudson County said it
  was extremely, very, or somewhat difficult
  to get needed medical care, compared with 6
  percent in Australia.
• 10 percent of the elderly in Hudson County did
  not visit a doctor in the past year, compared
  with 2 percent in Australia

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Mature-age Employment Programs

• The goals of Mature-age Employment Programs are
  to improve job opportunities and also
  employability of older people seeking employment.
• New South Wales Mature Workers Program
• Has been operating in Australia since 1990.
• This program has two services
• employment (operated through community-based
  organizations)
• training
• Evaluation after five years showed that 50 of
  past clients were still employed at the time of
  the survey, and most attributed this to the
  program.

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Home and Community Care (HACC)

• HACC is an Australian program that funds a wide
  variety of service agencies to provide a variety
  of support services for the elderly including
• Home help cooking, cleaning, washing, ironing,
  or banking
• Transport for medical, social, or other reasons
• Food services meals-on-wheels, congregate meals,
  or help with grocery shopping
• Personal care bathing and dressing
• Health services home nursing, physiotherapy, or
  podiatry
• Home maintenance help around the house with
  small tasks and gardening

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Health Promotion

• Programs to encourage healthier lifestyles and
  improved population health
• Active Australia
• The Food and Nutrition Policy
• Strategic Framework for the Prevention of Chronic
  Disease
• In recognition that falling accounts for 30 of
  all hospital admissions among the elderly,
  Australians have also developed a coordinated
  strategy to reduce falls among elderly

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Stay on Your Feet (SOYF)

• In recognition that falling accounts for 30 of
  all hospital admissions among the elderly,
  Australians have also developed a coordinated
  strategy to reduce falls among elderly.
• The program addressed the following risk factors
• Physical inactivity, poor balance and gait,
  chronic illness, poor vision, unsafe footwear,
  medication misuse, and unsafe home and public
  environments
• The initiative resulted in a 20 reduction in
  hospitalization due to falls among the elderly

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What Solutions Can Be Implemented ???
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HHS ABC Radio Team Up

• Closing the Health Gap campaign
• designed to inform, educate, challenge and
  empower African Americans to change behaviors
  through providing lifestyle tips and info on
  local sources of health care and public health
  programs
• All 240 of ABC radios urban advantage network
  affiliates will air messages from 10 sec. 1min
  intervals
• HHS sec. Tommy Thompson and U.S. Surgeon general
  David Satcher will narrate other spots

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Center for Family and Community Health (Berkeley,
CA)

• People disadvantaged economically, educationally,
  and politically are at high risk
• Objectives
• 1) Developed a plan for a volunteer-run medical
  clinic to provide free, urgent care
• 2)Secured space for the clinic from a local
  hospital
• 3)Promote more free clinics nationwide

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Univ. Of Alabama Center for Helath Promotion

• Trained community advisors
• Created a cookbook of favorite recipes modified
  for heart health and encouraged low-fat meals at
  church dinners
• Food Stamp programs to buy fresh produce
• Walking groups nutrition/exercise activity
• Broadcasted educational and health promotion
  messages on radio and cable
• Exercise room built in Community Life Center

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Modified MD Protocol?

• Must examine your own beliefs, stereotypes, and
  values about African Americans
• Are my attitudes toward African Americans open,
  welcoming, and unbiased?
• Am I well-versed in the historical background and
  contributions of African Americans to society?
• Am I aware of the heterogeneity and diversity
  within this group?

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Protocol Continued.

• Can I disagree with an African American without
  feeling intimidated or guilty?
• Am I treating African Americans with respect and
  building a level of trust with them?
• Am I aware of their traditions, religious
  beliefs, and alternative medicinal remedies?
• DONT MAKE AFRICAN AMERICAN PATIENTS LOSE FAITH
  IN EQUALITY IN HEALTHCARE..BE SENSITIVE TO EACH
  INDIVIDUAL AND HIS/HER NEEDS
• They should not have to be a disappointment
  generation

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Meharry Consortium Geriatric Education Center
(MCGEC)

• Main Goals
• 1. Provide healthcare and for minority elderly
• 2. Recruit and retain students of all health
  professions in geriatrics
• 3. Educate minority elderly of their needs and
  opportunities available to them

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MCGEC Goals Continued

• 4. Teach classes to health care professionals
  about the health care needs of elderly people
• 5. Emphasize the importance of elderly in our
  diverse population
• 6. Need-based research and gathering of data
• 7. Distribute courses for health care
  professionals that focus on minorities and
  underserved populations of older adults

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Church Involvement Is a Must

• -Have programs that provide food and clothing
• -Organized visits of the sick as well as elderly
  shutins
• -Church plays a significant role in promoting
  self worth and self esteem through validation of
  shared beliefs and attitudes held by the
  congregation

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More Church Influence

• African Americans believe in traditional medicine
  or folk medicine
• Illness is broken down into one of three
  categories natural, occult, and spiritual
• The only cure for the latter two categories is
  God. Faith or spiritual leaders are regarded as
  divine, possessing the powerful gift of healing
  from God.

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General Solution Agenda

• Ideally Includes
• Training advisors
• Community-run activities, exercise sessions,
  interactive activities
• Increase awareness about nutrition, health risks,
  and available opportunities
• Meals on Wheels
• DRTS (Demand Responsive Transportation System in
  Finland)
• EACH (Extended Aged Care at Home in Australia)
• Church Influence