Sunday, December 10, 2006

How Public Health Has Failed to Define Aging as an Appropriate Health Issue - Carol Rossi

The last time you had to cross the street, attempting to beat the pedestrian light did you ever think what it must be like to be an elderly person, possibly with arthritis, hard of hearing and/or with vision issues? Have you ever had to balance the choice of what was more important, paying your rent or buying medications? Can you imagine losing your entire nest egg, liquidating your assets, only to share a sterile room in a long term care facility simply because of decreased mobility and lack of caregiver support? How do you think it would feel to lose your best friend and spouse after multiple decades?

These issues are real and the elderly face them every day. Elders endure. It’s not that older Americans do not want to speak up; it is more that with the grace of age they are tolerant and more concerned with benevolent efforts. So why does such a valuable resource to our culture continue to face the prejudice and bias of the current health care system? How has the United States (US) remained ignorant and lax about implementing change that focuses on the specific care needs and services relevant for older Americans? Geriatric medicine has been and continues to be merely symptom driven; it is predominately responsive to catastrophic events. Public health programs for the elderly are limited and management of elder health issues has fallen predominantly in the realm of the primary care physician. It has become the primary care physicians’ role to manage multi-system illness and co-morbities. This is a difficult task for physicians with limited time constraints. They have less than fifteen minutes to assess the specialized health care needs of this population due to Health Maintenance Organizations (HMOs) constraints and limited governmental insurance reimbursement. While there have been some improvement attempts by promoting disease management based care, gerontology is not primarily disease preventative or a health promoting type driven delivery of health care. HMOs do offer the services of case managers specialized in different disease states, but this type of service is not with the individual patient as the focus, rather it is an attempt to control spiraling costs and to profit. Despite the advances in medicine, all health care including the public health realm have been slow to recognize that geriatrics involves a unique and specialized population. It has failed to define ageing as an appropriate health issue worthy of fiscal resources, specific programs and access for existing benefits.
A review in the development of health care coverage for the elderly demonstrates this gap. The first conference on aging was held by the White House in 1961. The first world conference on aging was held in 1998. This is a gap of thirty-seven years! Suddenly the world has recognized that the world is aging. Advances in medicine and living conditions have resulted in an increase in the average lifespan. I find it interesting that a positive result is only now becoming a world issue. In 1965 the programs for Medicare and Medicaid was established along with the Older Americans Act. This program has been in existence for forty-one years and it is only now that nursing and medical school programs are recognizing the importance of adding gerontology as a separate and specific need within the education curriculums (26). Even now many nurse practitioner programs do not include gerontology as a track for specialization. Ironic isn’t it that health care in America is facing a critical shortage of personnel and that many of the clinicians still in practice are not trained in the care for the elderly. This very population that has been ignored is saturated with chronic disease co-morbidities which utilize a high percentage of health care dollars. Comparatively with only approximately 46 million Americans uninsured, the US spends more on health care than industrialized countries who provide insurance to all their citizens (51). Additionally, burdensome insurance processes have caused many physician practices to drop services in elder care due to the difficulties in managing their members. The epidemiological shift from acute illness and infectious disease to chronic disease and degenerative illness demands that health care reorganize its’ focus. The basic facts are that the population is aging and less fertile. The ‘Baby Boomers’ in the United States have already started to age and will continue to grow as a population. Estimates predict that the 12.4% of elders in the year 2000 will swell to 19.6% in 2030. This increase in an elder population will continue to burden and impact public health, health care financing and delivery systems, informal care giving, pension systems, medical and social systems (6). It is encouraging that 1999 was declared the International Year of Older Persons and with the main focus of advancing health and well-being into old age the second world conference on aging was held in 2002 (62, 25). With all the discussion that has occurred, why is the US still unprepared for an ageing population? Why haven’t more programs been developed for the elderly?

In a brief review of the federal and state offices (10, 14, 35, 38, 39, 40), multiple strategies are outlined by a myriad of offices about the need for improvement in elder health care. If fact the number of agencies that exist for aging specific issues boggles the mind. Those agencies include, but are not limited to, the following: Health and Human Services, the Centers for Medicare and Medicaid, the Administration on Aging, the
Massachusetts Councils on Aging, the Office of Healthy Aging and the Attorney General’s office. What is not so easy to find is actual existing programs. In fairness there are multiple resource documents and telephone hotlines, unfortunately this assumes that elders have computer access and push button telephones, but little exists in actual preventative public health programs (38, 39, and 40). Under the Massachusetts Office of Healthy Aging there are ten programs listed, but only four have actual links for more in-depth information. Only two of these links is actual programs; one of the programs, ‘Keep Moving’ is not up-to-date or available in many towns and the other is ‘End of Life’ resources. Finally, most communities are not prepared or ready to deal with an aging population, especially in times of disaster. Only 46 percent of communities in the US are examining strategies to deal with the swelling aged population. Key findings show that many elders in the community do not have access to services, housing is not modified to support elders with physical limitations, no central point exists to provide information, no programs exist to offer training programs, few communities have fitness programs and while eighty percent have home delivered meals only twenty-five percent have nutrition education (46).

The need for heath and well-being for older persons has already been recognized. Despite this recognition, all energy has remained focused on outlining strategies rather than mplementing change. In order to trigger a catharsis for change promoting elder issues; it is important to explore the subtle causes for ignorance, bias and prejudice.

Argument 1: Value of Elder Persons in Society

“The Agenda-Setting Theory says the media aren’t always successful at telling us what to think, but they are quite successful at telling us what to think about.” (41) If we examine how the media depicts older persons in our society we find that while racism and sexism is not acceptable, ageism is tolerated. If in fact the media has the ability to set agenda and tell us what issues are important, we have failed miserably to display the elders in our society as a valuable resource. Let’s review some frequent commercials that utilize well-known actors that tell us what to think about: Shirley Jones a singer and beloved mom on the famous television show ‘The Partridge Family’ advertises denture adhesive; June Allyson infamous mom of ‘Leave it to Beaver’ advertises adult diapers; Ed McMahon of Johnny Carson ‘Late Night’ fame advertises motorized scooters; Bob Dole, former presidential candidate found ‘too old’ to run for office advertises virility medication; and how about former commercials depicting the cute old ladies of ‘Where’s the Beef” or ‘I’ve fallen and can’t get up’ fame. It certainly doesn’t help our societal point of reference for our older citizens to be associated with no teeth, incontinence, immobility, impotence, or so called cuteness. There is one new commercial that does depict older people as persons with lots of life to live as contributors to society; it is from leading money management financial company. The message is that retirement is the time to start living. Interestingly and most assuredly intentional, the actor is Dennis Hopper, the original motorcycling free spirit from the 1970s movie ‘Easy Rider’. Leave it to a financial institution to get the focus correct just in time for the maturation of the Woodstock remembered ‘Baby Boomers’! Then of course there are the reference terms related to age: statesman, elder, senior citizen, golden ager and older person sit right along side with geezer, gomer, biddy, old fart, coot, old fogie, and pensioner. While these terms have similar denotations their connotations and social contexts are very different. If one were to conduct a survey of how to define or what to call an older person the myriad of responses would represent the differences in social mores and cultures that compose our society. Dr. F. Michael Gloth writes that many successful societies have invested in the concept of elders being a valuable resource and that although few things are guaranteed in the aging process, one thing that is most certain is as individuals age they acquire greater experience, which usually correlates with knowledge and greater wisdom. He goes on to say that the mantra ‘the children are our future’ is a mindless political sound bite (28). With this type of media influence, no wonder health care dollars have not been appropriated to a population which such a negative stigma. Even health care coverage that was set up for older persons has a negative connotation. For example, Medicare is perceived to be for retired people and the elderly over age 65 and Medicaid is for poor elderly or people on welfare. After reading current elder blogs, ‘elderly’ is not a beloved term of reference for this age group; the preferred reference is older person. Older Americans have not found current health care programs supportive of their specific needs (42). The US government could make a leap from discussing strategies of promoting elder health and wellness by utilizing the media to implement campaigns that educate and change society’s reference point towards valuing our elderly. But this brings us to another issue, how do we define the elder population?

Argument 2: Defining the Elder Population

How do we define a population that has a myriad of adjectives but no clear term of reference? As stated our elderly prefer the term older persons. However even the use of this descriptive is misleading. What is the reference point? The ‘Framing Model’ suggests that how something is framed influences choices people make…” (56) If we cannot even frame who the target population is or decide upon a common language how can there be a structure to frame the target audience. In essence we have not defined the social structure (60). A review of statistical data and analysis further supports that that while there has been some attempt to stratify age groups this structure requires further examination to redefine age sets that reflect our current and aging society. Lack of data supports the unenviable fact that the elder population has not been identified as an important health care issue. For example, in a statistical analysis of health issues among adults in Massachusetts for calendar year 2005, (www.mass.gov) many measures were not even considered for analysis of persons older than age 64. Traditionally the scope of public health has been for maternal child health issues and infectious diseases. While these programs are important; public health programs must be expanded to include health prevention among older adults. A review of the following statistics helps support this point (11):
· 47% of Americans over age 64 have fair or poor health even though 90% have a primary health care provider
· 33% over age 64 are disabled with 12% requiring regular physical assistance
· 13.1% over age 64 are smokers
· 25% of households provide care to people age 50 and older
· 64.4% aged 65 to 74 are overweight and 21.7% are severely obese
· No statistics existed for persons over age 64 as being tested for HIV
· The highest percentages of persons with diabetes, hypercholesteremia, heart disease, stroke and arthritis were over age 64
· Older persons have the lowest percentages for regular exercise or any physical activity

With national health care costs continuing to rise into the trillions, there is a dire need to develop creative and fiscally responsible alternatives to nursing homes, to address decreasing state budgets, to restructure the Medicare, Medicaid and Managed Care, to change employee retirement benefits and to challenge society’s views on ageing. Unless a social context is determined and defined to reflect current population trends define the structure of age, no model will exist in order to provide a framework. Geriatric health care will not change from catastrophic care toward a model that supports preventive care which supports other alternatives than disease management unless this issue is addressed.

Argument 3: Examples & Economics of Undervaluing Aging Issues

Basic economics as a social science recognizes the production, distribution and consumption of resources. The elderly population consumes more health care dollars than any other age group. Americans who are living longer have increased demands for health care services. The bias in health care in producing preventative programs can be linked to the ethical principles of equity and rationing. Unless the elderly population in our society is valued economic equity will occur nor meet the need for interventions. New measures need to be developed to deliver and measure effective health care. For example, Depression in the elderly is often undiagnosed and untreated, which considering the statistics is alarming. Murder-suicide is growing, and this is worldwide. Although older adults make up 12% of the US population, they account for 18% of all Suicides (5). It is quite possible that this statistic is under reported. Late life mood disorders are common and may be interpreted as cognitive impairment. Researchers estimate that 20% of community dwelling elders experience symptoms of depression (64). Social Isolation, health factors, family and environment are all related factors. It is not a standard part of the yearly physical exam conducted by the primary care physician to use standardized tests to assess and measure cognitive impairment and depression. Although treatment in this area still holds fear and stigma for the current elder population, this should change with the change in elder demographics. Simple warning signs may be evident with just a bit of exploration into an older person’s mood, outlook, or evaluation of apathy and feelings of hopelessness. Safe and effective treatments do exist and simply interviewing another family member, close friend or utilizing a standardized tool may indicate when intervention and treatment is needed. A change in the allotment of increased time for a yearly geriatric assessment could allow the use of existing tools and interviewing key persons in an elder’s life as preventative measures to identify the need for treatment. Intervention with medication and counseling could greatly improve often misdiagnosed mild cognitive impairment and the overall quality of an elder’s life. Another example of a devalued appropriate health issue is home health care services. In order to qualify for home care services one must require skilled care, be homebound, and require the services of a nurse, physical therapist or speech therapist. Services specific to manage a plan of care for an individual, which require the assistance of a home health aide, use to qualify for a nurse to manage these services with reduced visit frequency. This type of health care service has become increasingly focused on acute care rehabilitation and no longer supports the care of people with chronic conditions. A study by the Carol Levine of the United Hospital Fund of New York found that “…unpaid family caregivers-almost three-quarters of whom were women, with a mean age of 57-provide substantial amounts of care but receive inadequate support from healthcare providers.” (4) Many caregivers are not adequately informed or prepared for homecare services to end. While resources from the National Institute of Health have been increasingly awarded towards efforts in research, the battle of care giving on the home front is fast becoming a growing public health concern. There is a direct relationship of public economic burden for increased long-term care costs when there is no relief for caregivers who provide care to people with chronic and disabling conditions. Many people can’t afford to take paid leave and provide care with little or no training (23). Redefining family based care and expanding the role of interventions available to support keeping elders at home can have an important economic impact.

In Conclusion

Health is a human right and rationalizing health care is a significant financial and ethical issue. Aging is a natural process, a normal part of the human life cycle. If only the consolidated view of ageing was that it is a privilege and societal achievement. By definition (61), public health is concerned with threats to the overall health of a community based on population health analysis. Considering the impending impact of a growing population shift and lack of existing public health programs, consultations with gerontologists or persons who understand the target population is needed. The challenge of identifying and focusing on ageing health issues is a challenge which requires joint approaches and strategies with implementations from all the social and behavioral sciences. In particular, Gerontologists derive from a multitude of fields which includes the study of physical, mental and social and societal changes in older persons as they age. Ageing is a multidisciplinary field and integrates information from several separate areas of study including core areas such as biology, sociology and psychology along with other areas of study like public policy, humanities and economics. Application of this knowledge has broad implications for economics, policies and programs. Prevention costs less than the personal burdens of preventable disease and injury. Perhaps as outlined by Malcolm Gladwell in his book, The Tipping Point, we just need to find modest ideas for creative solutions that become contagious, by tipping into a new point of focus (65). What we need is to find people passionate about redefining aging as an appropriate health issue. However, what remains elusive is what defines a middle aged or elder person. Perhaps old age cannot be defined exactly because it does not have the same meaning in all societies. We must rethink the distinctions that define age and its’ boundaries. We cannot have word of mouth stickiness without speaking the same language. It is important for all of us to be accountable and renew the focus on the health care of older persons. This is one global concern that has the potential for positive economic impact. By its’ very definition public health is concerned with threats of overall health of a community based on population health analysis. The focus of public health intervention is to prevent rather than treat a disease through surveillance of cases and the promotion of healthy behaviors. The World Health Organization defines health as a state of complete physical, mental and social well-being not merely the absence of disease or infirmity (2). While geriatrics is only about fifty years old by definition, it is not a new area of medicine, just overlooked. Focusing on ageing related issues is an appropriate public health issue now. With the growth of the ‘baby boomers’ society can no longer turn a blind eye on the need for changes in health care delivery and fiscal allotment for preventative programs designed with older Americans as the primary focus rather than an added afterthought. Disease and disability are not inevitable consequences of aging. We are all constituents of an ageing society. The stability of our health care system requires seminal thinking to get around structures, agencies and program that do not support our current societal needs. Although change can be cathartic and exciting, it can also be chaotic and stressful. Changing negative views and supporting elder Americans as important and viable citizens for the success of all society will go far to influencing appropriates changes long overdue.

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