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OCR for page 40
5. Older Adults
The need for special national objectives for older
people was recognized in Healthy People: The Surgeon
General's Report on Health Promotion and Disease
Prevention, which was published in 1979.t Although
the Surgeon General proposed mortality reduction
goals for other age groups, the main goal for older
adults was to improve health and quality of life,
particularly to reduce the number of restricted activity
days resulting from acute or chronic conditions. This
priority grew out of a realization that health promo-
tion and disease prevention activities can have pro-
found effects on the quality of life of older
Americans. The point was reemphasized in 1988 at
the Surgeon General's Workshop on Health Promo-
tion and Aging, at which almost 200 experts recom-
mended a series of health promotion and disease
prevention activities for older people in nine areas:
alcohol, oral health, physical fitness and exercise,
injury prevention, medication, mental health, nutri-
tion, preventive health services, and smoking cessa-
tion. These recommendations were submitted as
testimony for the Year 2000 Health Objectives.2
(~799)
As a group, the elderly are more likely than
younger people to suffer from multiple, chronic, and
often disabling conditions, and they are more likely to
be physically and socially dependent. However, the
aging process is complex and varies substantially from
one person to another. The conditions that many
older people face are not inevitable: some causes of
physical and mental decline can be prevented, and
older people can learn to live with other conditions
and still maintain high levels of physical, psychologi-
cal, and social function. According to Healthy People,
With adequate social and health services, a greater
proportion of the elderly could maintain a relatively
independent lifestyle and vastly improve the quality of
their lives.n3
Some of those who testified about the special
health promotion and disease prevention needs of
older adults focused their comments on common and
crosscutting issues, especially the quality of life.
Others focused on specific health problems faced by
older people and interventions for these problems.
Some witnesses spoke primarily about health promo-
tion activities for older people, including health
education; modifying risk factors such as smoking and
40 Healthy People 2000: Citizens Chart the Course
alcohol; reducing the misuse of medication; improving
mental health; and increasing physical and recreational
activity. Other testifiers addressed the prevention of
specific diseases and health problems faced by older
adults, including cancer, heart disease, osteoporosis,
infectious diseases, dental problems, and hearing or
communication problems. Additional testimony dealt
with health protection issues such as the prevention
of elder abuse and injuries. Although these topics
mirror those of the general national objectives, the
specific issues of concern for older adults differ
substantially from those of the general population. A
number of testifiers also addressed special issues that
arise in the context of long-term care. Others dis-
cussed implementation issues, especially problems of
access to health care and the need for better data on
the health status of older people.
Although many of the issues discussed in this
chapter were incorporated in the 1990 Objectives,
witnesses called for even more emphasis on addressing
the health concerns of those age 65 and over in the
Year 2000 Health Objectives.
CROSSCUTTING ISSUES AND QUALITY OF LIFE
Many who testified about the special needs and
opportunities for health promotion and disease
prevention in the elderly focused their attention on
measuring and improving the quality of life for older
adults. Others stressed the heterogeneity among the
elderly, the differences between them and the rest of
the population, and the implications of these differ-
ences for setting objectives.
As Anne Somers of the University of Medicine and
Dentistry of New Jersey and Victoria Weisfeld of the
Robert Wood Johnson Foundation, point out:
The very concept of "old ages and all our
protective policies and programs for the "aged"
relate to the presumption of a sharp decline in
physical and/or mental capacity, as well as life
expectancy, after 65. This is now patently
inaccurate but as a nation we haven't decided
how to adjust to the changed situation. (#428)
Rather than "rationing" care, Somers and Weisfeld
call for "a positive national commitment to 'healthy
OCR for page 41
and productive aging'."
It is no longer enough to say that older people
have an equal right to good health care, includ
ing prevention and long-term care. The corol
lary is the obligation to take care of our own
health insofar as possible, to learn to cope with
various chronic conditions, and to continue
working and contributing to society for as long
as possible. (~428)
In light of this, Somers and Weisfeld propose two
broad goals:
1. to improve the "health span" or Active life
expectancy of older persons, including those with
some chronic impairment. In other words, increase
the number of years of independent functioning and
capacity for productive activity; and
2. to set the stage for upward redefinition of the
concept of "old age," moving gradually from the
obsolete figure of 65 toward a more realistic 75, with
a target of at least 70 years of age by the year 2000.
(#428J
Other testifiers underlined the idea that not all
those referred to as "elderly are alike. Susan Marine
of Boulder, Colorado, suggests that objectives for
older people should be divided into two subgroups.
The subgroup for those age 65-84 should be made
up of "goals for decreasing mortality from cardiovas-
cular diseases and cancer, as well as goals for main-
taining functional independence." For those 85 and
older, the objectives should be "goals for maximizing
functional independence and the quality of life.
(#370) Similarly, Robert Katzman of the University
of California, San Diego suggests two sets of goals for
some topics: one for the Young old (age 60-80)
and another for the sold old" (over age 80~. (~794J
Many witnesses addressed the issue of quality of
life. Paul Hunter of the American Medical Student
Association, quoting President John F. Kennedy,
expresses it most vividly: "It is not enough for a
great nation to have added new years to life. Our
objective must be to add new life to those years."
(#612)
Somers and Weisfeld suggest that the proportion of
noninstitutionalized older people with self-reported
health status of "excellent" to "good" should increase
to 75 percent; that the labor force participation rate
of those age 65 and over should be at least 20 per-
cent (employed full-time, employed part-time, or
looking for work); and that an additional 30 percent
should be engaged in some form of unpaid but
productive activity, including care of disabled family
members. (#428)
Donald Patrick of the University of Washington
suggests that objectives for older adults be evaluated
in terms of the health-related quality of life by using
the concept of quality-adjusted life years. Quality-
adjusted life years measure the functional and social
dependence caused by a particular disease or medical
treatment, he says, thus allowing a determination of
the efficacy and cost-effectiveness of a particular
intervention. To improve the quality of life for older
people, Patrick suggests four health promotion and
disease prevention strategies for the elderly: early
identification of risk factors for which there are
efficacious interventions to modify the onset or course
of disease, disability, and dependency; modification of
physical and social environments; maintenance and
improvement of desirable health habits; and enhance-
ment of personal autonomy. f#341J
lathe Alliance for Aging Research suggests that the
overall goal of health promotion/disease prevention
strategies aimed at the elderly should be to decrease
frailty, Ha general but useful term encompassing a
variety of impairments that limit functional abilities
and increase vulnerability to trauma and other stresses
among older persons. (#776J Several others recom-
mend that overall functioning be measured in terms
of the activities of daily living (ADL) scales, which
assess one's ability to perform six basic functions:
bathing, dressing, eating, toileting, moving from bed
to chair, and independent ambulation. (~766) Some
experts, however, find the ADL "a barely adequate
measure because it relies on self-report rather than
observation" (#4593, or they criticize it because the
scales are So limited" and "skewed toward particular
types of functional disability. (~794)
John Cornman of the Gerontological Society of
America suggests four facts regarding the health of
older people to guide formulation of the objectives:
1. Widespread and substantial heterogeneity of
health conditions exists among older adults, even
within the same age group.
2. There are physiological differences between older
and younger people that should influence health care;
for example, disease symptoms may vary with ages and
older persons may react differently to drugs than do
younger persons.
3. Because lifestyle factors at earlier ages affect
health status at later ages, disease prevention and
health promotion goals established for younger
persons also are important to older persons.
4. Preventive measures should be applied to older
Older Adults 41
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persons because modification of behavior and habits
is also beneficial in older age. (#766)
To benefit fully from various measures aimed at
improving the quality of life among older adults, they
must be active participants in their own care and
health promotion, rasher ' then allowing things to be
done "tot them, according to James Haviland of
Seattle, Washington. (~795)
HEALTH PROMOTION AND HEALTH
PROTECTION FOR OLDER ADULTS
Although a large number of behavior-related factors
were mentioned by the witnesses, most of the tes-
timony centered around smoking, alcohol and drug
problems, mental health, physical and recreational
activity, and health education. Others addressed is-
sues that come under the heading of health protec-
tion, mainly the prevention of accidental injury and
violence or abuse.
Smoking Cessation
According to Claude Earl Fox, the Alabama State
Health Officer, evidence shows that people can
decrease their chances of dying of a smoking-related
cause even if they stop smoking at an older age.
(~066) Rebecca Richards of the North Woods
Health Careers Consortium agrees and calls for
increased public and professional awareness of this
fact. In particular, she recommends that smoking
cessation programs aimed at the elderly be undertaken
in communities and at senior centers. (#183)
Similarly, participants at the Surgeon General's
Workshop on Health Promotion and Aging also
recognized the benefits of smoking cessation and
proposed a number of educational approaches aimed
at opinion leaders, the media, and health professionals
to convey the message that cessation can be beneficial
for older people. They also proposed a range of
activities to make nonsmoking the norm in environ-
ments that older people frequent and to encourage
smoking cessation programs. (#799J
Alcohol
Richards reports estimates that one in twelve elderly
men will develop a drinking problem.4 She recom-
mends that reimbursement be expanded for treatment
of drug and alcohol problems in the elderly, citing
recent research showing that older people are more
likely to complete such treatment successfully and to
42 Healthy People 2000: Citizens Chart the Course
remain free of the abused substance for longer
periods of time than are young people.5 (#183)
Fox says that excessive use of alcohol among the
elderly can disguise certain medical problems. For
example, alcohol can mask pain, leading to delay in
seeking medical attention for a heart attack. Alcohol
also affects blood sugar metabolism, leads to liver
disease, causes digestive problems, encourages poor
nutrition habits, and alters the function of the brain.
Another serious problem is the dangerous interaction
of alcohol and drugs. (~066)
In light of such problems, participants at the
Surgeon General's Workshop on Health Promotion
and Aging recommended professional and public
education programs to inform people about the
problems of alcoholism and their prevention, and
service programs in the community to help older
adults overcome alcohol problems. (#799)
Misuse of Medication
Rather than concern about the abuse of addictive
substances so often expressed for adolescents and
young adults, the most pressing "drug" issue for many
older adults is the misuse of medication.
The American Society of Hospital Pharmacists sees
a need for an objective dealing with misuse of medi-
cation by the elderly population. Some of the ways
suggested to reduce misuse are heightened awareness
about medication information on the part of
physicians, increased cooperation among various
health care professionals, and more patient education
on the use of prescription and nonprescription drugs.
(#574)
Edward Wagner of the Group Health Cooperative
of Puget Sound calls for more attention to the
adverse effects of prescribed medications, the use of
psychoactive drugs and their relationship to injury,
and the excessive or inappropriate use of commonly
prescribed cardiovascular and psychoactive drugs,
which may be a risk factor for falls, fractures, and
hospitalization. Wagner would like to see a federal
initiative to reduce the inappropriate or excessive use
of antihypertensive drugs or toxic psychoactive and
psychotropic drugs. (~738)
Mental Health
Dementia becomes a major problem over age 75,
according to Katzman, and in the very elderly (over
age 85) the demented constitute about one-third of
the population. He recommends training Ha cohort
OCR for page 43
of nursing aides or other paraprofessionals" to help
provide the needed optimum care and to help prevent
excess disability. (#794)
Richards notes that although recent initiatives have
focused attention and some resources on dementias,
other mental health disorders common to older adults
also require attention. A community study in North
Carolina showed a prevalence rate for depression in
older adults of 8.2 per 100.6 Another study, suggest-
ing that health care providers may not be educated to
recognize mental health problems of the elderly,
indicated that 90 percent of elderly men who com-
mitted suicide had visited their physicians within their
last three months.7 (#183)
John Miner of the Massachusetts Mental Health
Center emphasizes that the mental health needs of
the elderly, especially for emotional support and a
feeling of personal caring, should be particularly
stressed in the education of nurses and physicians.
(#468)
James Sykes, representing the National Council on
the Aging, states that "mental health is a vital goal
for all Americans but especially for the large and
growing population of retired persons. The insults of
the psychological effects of years of purposelessness
are as severe as cancer." Rather than strategies to
prevent mental illness, health promotion strategies are
needed that provide status, purpose, and useful roles
to people whose retirement has changed their usual
bases for purposeful lives. There is also a need for
well-trained and appropriately compensated providers
of care, as well as family members who come into
daily contact with impaired older persons. (~768)
James Sugarman of the Retired Senior Volunteer
Program Directors recommends volunteer work as one
answer to finding productive, fulfilling roles in older
age. He further comments that the exercise, regular
diet, and physical and psychic benefits derived from
volunteerism are important and should be emphasized
in local, state, and national programs. (#769)
Physical Activity and Recreation
Scientific evidence has demonstrated that carefully
planned programs of physical activity can prevent or
diminish the degree of functional loss associated with
some chronic diseases affecting the older population,
says Fob (~066) According to a 1987 survey, only
7.7 percent of women and 8.5 percent of men over 65
currently exercise at 60 percent of functional capacity
for 20 minutes or more, three or four times a week.8
Fox recommends as an objective that 40 percent of
adults over 65 be engaging in regular, appropriate
physical exercise, such as walking, swimming, or other
aerobic activities, by the year 2000. (#066J
Richards points out the obstacles to exercise
programs. Walking, a common form of exercise for
older adults, may be difficult for those with arthritis
or painful foot conditions. Walking in adverse weath-
er can be dangerous for those with cardiovascular or
balance problems. Swimming pools, particularly ther-
apeutic pools, are not available in many communities.
Richards feels that access to exercise programs for all
older adults should be a priority for the new objec-
tives and that transportation to, and reimbursement
for, the cost of exercise programs at appropriate
facilities must be addressed as part of this objective.
(~183J Others stress the importance of building
exercise into regular daily activities rather than
depending on traveling to distant facilities. (#459)
The National Recreation and Park Association
(NRPA) also stresses recreational activity as crucial to
the improved health and wellness of older individuals.
The NRPA suggests that services be provided in
settings as close to home and as consistent with usual
lifestyle as possible. Each state and regional office on
the aging, the NRPA says, should be required to
include park and recreation programs for the aged in
its referral systems to ensure greater access to recrea-
tion by the elderly. (~777J
Injury Control
Richards says that morbidity rates, not just death
rates, from accidents and falls of the elderly should be
examined. The cost of the morbidity (both direct
medical costs and indirect costs such as subsequent
institutionalization or missed work by care givers)
should be compared to the cost of providing preven-
tive services directed at known risk factors for falls.
She says, for example, that vision problems are known
to be a significant risk factor for falls, yet eyeglasses
and examinations to prescribe, fit, or change them are
not covered by Medicare.9 (~183)
Michael Oliva of Aurora, Colorado, calls for more
money to be provided from appropriate agencies for
injury control programs for the elderly. All health
care providers who serve the elderly, Oliva says,
including Community Health Centers and those who
provide health promotion and wellness programs for
the elderly, should include injury control in their
plans of care. (#378)
The Surgeon General's Workshop on Health Pro-
motion and Aging calls for architects, engineers, city
Older Adults 43
OCR for page 44
planners, and similar professionals to be educated
about the capabilities and limitations of older persons,
and recommended that they incorporate these factors
into their designs. (#799)
Elder Abuse
Increasingly, elderly people are caring for others who
are even more elderly or sick, says Richards. The
added stress on older care givers, as with younger care
givers, can lead to abuse. She suggests an objective
to reduce elder abuse by requiring that facilities
discharging Medicare patients demonstrate that
comprehensive, systematic discharge planning has
occurred. Elder abuse could be decreased by carrying
out a systematic assessment of the older person and
the potential care giver, as well as the entire family
constellation.~° (~183)
Melanie Hwalek, a psychologist and gerontologist
in Michigan, agrees that there is a need for objectives
to prevent and treat elder abuse and neglect. There
also is a need for valid and reliable measurement
instruments to assess both the risk of elder abuse in
community populations and the substantiation of elder
abuse among suspected cases from state reporting
systems and human services agencies. She cites and
supports the solutions advocated by the Surgeon
General's Workshop on Violence and Public Health,
including the development of educational programs
for professionals on detection, assessment, and treat-
ment of abuse; educational programs for the public;
community outreach; research, especially national
studies on incidence and prevention; and a national
clearinghouse for coordinating research, training, and
program development, along with services to help
elder abuse victims and to help families care for older
people. (~403)
A number of people point out that many providers
of long-term and chronic care are family members,
usually women, and that they experience stress and
often suffer from ill health and financial worries.
(#110; #451) Olivia Maynard, Director of the
Michigan Office of Services to the Aging, suggests
increased awareness of the problems of family care
givers through public service announcements, iden-
tification of community resources to assist in coping
with family stress, and physicians providing informa-
tion to family members about resources at the time of
diagnosis of a serious or disabling chronic condition.
More family care givers should be enrolled in support
or self-help groups. In addition, more emphasis
should be placed on stress identification and control
44 Healthy People 2000: Citizens Chart the Course
by private, voluntary, and public health organizations,
as well as on the provision of education on com-
munity resources by employers. (#145J
PREVENTIVE SERVICES FOR OLDER ADULTS
Somers and Weisfeld report that although some of
the problems older people face are beyond prevention,
"a much greater proportion is amenable to preventive
interventions at the primary, secondary, or tertiary
levels." Many older people, however, "are still denied
access to effective preventive services as a result of
nonavailability, financial constraints, ignorance, or
indifference-their own as well as that of many health
professionals. The result is a great deal of suffering
as well as unnecessary use of expensive acute care."
(#428)
Wilda Ferguson of the Virginia Department for the
Aging, representing the National Association of State
Units on Aging, agrees that preventive services are
not sufficiently used by older people. More creative
and effective ways are required to provide older
persons and their care givers with the basic informa-
tion they need about the process of aging and its
impact on physical and psychological health. "Myths,
fatalism, or the ready acceptance of an idea that
ailments among the elderly are to be borne rather
than dealt with" must be overcome, says Ferguson.
(#772)
The Preventive Health Services Working Group of
the Surgeon General's Workshop on Health Promo-
tion and Aging suggests two broad goals for preven-
tive services: "1) to prevent physical, psychological,
and iatrogenic disorders; and 2) to prolong the period
of independent living with particular attention to
quality of life." It recommends that preventive
services be individualized according to active life
expectant; physical activity; cognitive capacity; and
the presence, nature, or stage of disease, and that this
individualization respect the principles of minimal
disruption of lifestyle, preservation of autonomy, and
minimal iatrogenic insults and recognize that
avoidance of death may not be the ultimate goal.
Based on this, the working group makes a number of
recommendations about the training of health profes-
sionals and others who work with the elderly, and the
implementation of preventive services in programs and
settings that are accessible to older people. They
suggest that these programs take into account the
heterogeneity in the elderly population and that they
address factors that prevent disability as well as
disease. More particularly, the working group is
OCR for page 45
skeptical of mass screening programs for disease or
risk factors outside primary care settings. (~799)
Other witnesses addressed a wide range of issues
relevant to the prevention of specific diseases, espe-
cially those involving the provision of preventive
services. The topics include cancer, heart disease,
infectious diseases, oral health, hearing and com-
munication disorders, and osteoporosis. For many of
these conditions, witnesses pointed out that primary
prevention in early or midlife is the most important
strategy for reducing such disabilities in older people.
However, primary, and especially secondary or tertiary,
interventions can make ~ difference. Problems
associated with vision loss, although still important to
many older adults, have decreased in recent years due
to the improved treatment of cataracts. Senile macu-
lar degeneration, however, still causes serious impair-
ment for many. (#794)
Cardiovascular Disease
Somers and Weisfeld indicate that heart disease and
related circulatory conditions are still the major cause
of severe disability among the noninstitutionalized
elderly and major risk factors are not only known but,
in most cases, controllable. (#428) Rosalie Young
of Wayne State University agrees and says that, jUSt
as for other chronic diseases, the most effective
strategy for controlling heart disease, postponing
disability, and preventing progression of chronic
conditions is risk factor reduction. (#478j
"The major cardiovascular risk factors (hyperten-
sion, dyslipidemia, impaired glucose tolerance, ciga-
rette smoking, obesity, and physical deconditioning),"
says Young, "are highly prevalent among elders yet all
are modifiable." To do so, Young proposes health
promotion objectives for older adults to increase
exercise, reduce smoking, reduce serum cholesterol
through diet and medication, reduce salt and total
caloric intake of overweight persons and thus reduce
obesity, and increase the number of physician visits to
enable more preventive care. (#478)
Young adds that beyond primary prevention,
treatment of heart disease by using the cardiologist's
vast armamentarium of surgical and medical strategies
offers benefits to some older patients, especially in
terms of improving their quality of life. (~478J
Cancer
According to Ann Norman of the University of
Washington, about one in ten women in the United
States will develop breast cancer In any given years
75 percent of this cancer will be detected among
women 50 years and older.~4 The death rate in this
group is particularly high, and one reason is the low
level of screening. According to Norman, the Year
2000 Health Objectives should be consistent with
those of the National Cancer Institute, which recom-
mend increasing the percentage of 50- to 70-year-old
women who undergo breast examinations and mam-
mograms, and of 40- to 70-year-old women who
undergo Pap smears.~5 f#336) Although not as
serious a problem as breast cancer is for women,
prostate cancer is an important problem of aging
males. (#794)
C)steoporosis
Osteoporosis is more common in White women over
45 than heart attacks, strokes, diabetes, and other
major chronic disorders, according to Thomas Heston
of the University of Washington. (~338) Wayne
Tsuji of the Washington State Arthritis Foundation
says that osteoporosis leads to vertebral compression
fractures and hip fractures, which cause great pain and
disability. However, measures such as calcium and
estrogen supplementation, weight bearing exercise, and
cutting back on alcohol or tobacco can help prevent
osteoporosis and the disability it causes. Further-
more, Tsuji notes that older women at higher risk can
be screened for osteoporosis so that they can be
treated before the point of fracture or other damage.
(#339J (See Chapter 27 for further discussion on
this topic.) Primary prevention, however, must be
started at a younger age, particularly by increasing the
calcium consumption of young and middle-aged
women.
Infectious Diseases
Because the elderly are at greater risk than other
adults for infectious diseases, immunization is of
primary importance, according to Steven Mostow of
the Rose Medical Center in Denver. For example,
Older Adults 45
OCR for page 46
he reports that most deaths from influenza could be
prevented with a national immunization program
targeted at the elderly and those with heart or lung
disease; control of influenza in these groups is not
only achievable but very cost-effective. "A massive
annual media campaign to promote influenza vaccina-
tion among the elderly, sponsored by the Influenza
Alert Committee of the American Lung Association
of Colorado, has increased influenza immunization
rates from 8 percent to 32 percent in the past four
years (1984-1988~.~ (#380)
The impact of food-borne diarrhea! illness is
greater on those already physically compromised,
including many elderly. The Association of Food and
Drug Officials suggests that this is preventable
through proper manufacturing and food handling
practices. (#384)
Katherine Hunter, representing the American
Society of Microbiology, recommends that the
incidence of pneumonia in the elderly be addressed.
All nursing homes should have an active, result-
oriented infection control committee analogous to
those in hospitals. Furthermore, all nursing homes
should screen employees and patients for tuberculosis.
(~259)
Dental Health
The American Dental Hygienists' Association
(ADHA) claims that "of the entire population, older
peoples, total body health is the most dependent upon
their oral health. Debilitating oral conditions limit
the older person's ability to eat a balanced diet, and
inadequate nutritional intake results in compromise`]
health." The ADHA recommends educational pro-
grams developed specifically to inform older people
about the impact of oral health on their overall
health status, and suggests that federal and private
insurance programs include payment for preventive
oral health services. (#575)
Because more people are maintaining their natural
teeth as they age, caries are an increasing problem for
the elderly. Ronald Ettinger of the American Society
for Geriatric Dentistry suggests that caries can be
reduced in the aging population by the development
of techniques to identify those at risk. He also re-
ports that dental care of the elderly in institutions is
neglected and that the institutionalized have a far
greater need for dental care than the noninstitutional-
ized elderly. (#069)
46 Healthy People 2000: citizens Chart the Course
Hearing and Communication
According to James Lovell of the National Hearing
Aid Society, it is important to recognize the high
prevalence of untreated hearing impairment in older
people and to include greater awareness of age-
related hearing loss and its remedies in the objectives.
He believes that the majority of such people can be
brought back to higher functioning by the use of
available technology, with a consequent improvement
in the quality of life. (#409) Shirley Sparks of
Western Michigan University also discusses com-
munication disorders among the elderly. She suggests
goals assuring that the current prevalence of sig-
nificant hearing loss and speech or language problems
in the elderly should not increase and that the dis-
ability of the resulting social isolation should
decrease. (#396)
LONG-TERM HEALTH CARE NEEDS OF THE
AGING
One of the issues most often addressed in testimony
on older people is caring for those with permanent
or chronic impairments of health and functioning. A
number of witnesses sllggcsted that the objectives
should emphasize maintaining the personal indepen-
dence of those with long-term dysfunctions, thus
preventing their unnecessary institutionalization in
nursing homes and hospitals. fi¢079) Most of the
chronically ill elderly could remain at home if they
were provided with the personal care services re-
quired. Physical security and appropriate living ar-
rangements are important. Institutionalization pro-
motes dependency and, therefore, increases disability.
Deinstitutionalization (or preventing institutiona-
lization in the first place) must, however, be accom-
panied by the assurance of individualize<] services and
treatments; these are the keys to secondary pre-
vent~on. (#01 Jo
Violet Barkauskas of the University of Michigan
reports that vulnerable elderly often are discharged
from the hospital with reduced functional ability; she
suggests that objectives be set to screen all over-6S
hospital patients at discharge tO (lelermine the need
for continuing care. (~714)
Patrick Griffith of Morehouse Medical School
projects that the incidence of intellectual loss will
escalate after the year 2000 with the growth of the
elderly segment of the population. Therefore, Griffith
OCR for page 47
believes it is necessary to increase the number of
long-term care facilities that take Alzheimer's patients,
increase the number of persons trained to treat those
affected? increase the number of centers for such
training, and undertake a comprehensive multidiscipli-
na~y diagnostic assessment of ways to manage this
population. (#670) Several testifiers pointed to a
need for coordinated and holistic home health care
services for the elderly. Such care would include not
only medical services, but social support; nutritionists'
services; home care pharmacists; and instruction about
housework, meals, and transportation. (#074)
Sharon Grigsby, President of the Visiting Nurse
Foundation in Los Angeles, writes that Come care
should have a bright future in the next century. It is
a logical alternative to the dilemma of increasing
health care demands in an era of fiscal restraints."
Visiting nurses were suggested as one means of
providing health care for the elderly in their own
homes; prevention of further disability and dysfunction
is an important part of their purview. (#074)
Kay Hollers, representing the National Association
for Home Care (i'686), suggests that the public be
educated about the availability of home care through
media, public health education, and marketing ap-
proaches. Financial disincentives to families for home
care should be removed, and Medicare should provide
home care benefits, says Hollers. David Lurie, Com-
missioner of the Minneapolis Department of Health,
notes that programs to assure the quality of home
health services also are necessary. (#5353
Sheldon Goldberg, President of the American
Association of Homes for the Aging, has another
suggestion for maintaining independence. He de-
scribes continuing care retirement communities, in
which older people can live independently for as long
as possible while having access to health care at
whatever level is necessary. He recommends research
to determine the demand for such communities; their
effect on health and life expectancy; the cost and
utilization of health care in such settings; and
Medicare utilization rates in these communities.
(#770)
Another possible answer for long-term health care
needs is to provide more adult day care, reimbursable
through Medicare or Medicaid. A large portion of
the population served here would be those with
Alzheimer's disease. (~637)
IMPLEMENTATION
Many witnesses had suggestions about implementation
of the objectives for older people. Somers and
Weisfeld suggest a broad range of actions at all levels.
Others focus on improving access to health care and
preventive service in particular, especially through
Medicare and Medicaid. Still others comment about
data and various information needs relevant to older
people.
Somers and Weisfeld suggest a number of steps to
implement the broad and specific strategies required
to improve the quality of life of older Americans. At
the federal level, they propose that the Public Health
Service and the Health Care Financing Administration
work together to determine which preventive services
for the elderly are effective and to incorporate those
services into Medicare or other health programs.
They propose that states consider mandating clinical
prevention packages in the health services they
provide or regulate and that governments at all levels
develop information and educational materials dircct-
ed at the media and the general public. Somers and
Weisfeld suggest that all health professionals devote
more time and attention to prevention, and that their
schools and certifying bodies move toward facilitating
and ensuring this. They propose that insurance
companies and employers move to adopt a full range
of preventive services in the health packages they
provide, and that employers implement worksite
wellness programs and flexible retirement policies.
Finally, they suggest that the media have an important
role to play in educating the public, and they propose
ways to maintain and improve the quality of its
messages. (~4283
Access to Health Care
To carry out the national objectives, greater access to
preventive care is necessary, according to many
testifiers. (#142J Private insurance and Medicare
policies about reimbursement for preventive services
constitute a large part of the problem, but Marine
points out that available services often are poorly
coordinated. (#370)
Richards discusses barriers to cancer screening in
older adults. They include transportation difficulties,
lack of insurance coverage for screening and prevcn
Older Adults 47
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lion, and difficulty in cancer self-detection due to
physical losses (visual, musculoskeletal) and concur-
rent debilitating diseases. One way to overcome these
problems, she says, is to conduct screening procedures
at geriatric day-care centers, retirement centers, and
senior centers. (~183)
Another way to address the access problem, accord-
ing to Richards, is through Medicare versions of
prepaid health plans, known as Medicare health
maintenance organizations (HMOs). In addition,
social health maintenance organizations (SHMOs)
integrate health care with psychosocial, environmental,
and informal supports to reduce dependency. The
SHMO is geared to coordination of services and to
maximizing the functional capacity of older adults.
Richards suggests objectives to increase the availability
of Medicare HMOs and SHMOs and to increase
public awareness of this option. (#183)
Several witnesses spoke about educational efforts
that should be undertaken to sensitize those who
work with the aging to problems that may arise in
later years and ways to deal with them. Miner feels
that formal course work in geriatrics should be
mandatory for those entering health care fields. In
addition, primary care providers should be better
educated about conditions in the elderly that suggest
referral to mental health services and about their
needs for emotional support and personalized caring.
(~468) Paul Hunter and his colleagues believe that
students in the health professions should have ex-
perience in facilities for the elderly. (~612)
Current efforts in health promotion and aging are
hampered by the limited involvement of medical care
providers, according to Robert Newcomer and Rena
Pasick of the University of California, San Francisco.
This can be improved through changes in Medicare
reimbursement rules, minimum standards for profes-
sional training, and better definitions of the roles of
all health providers. f#482)
Several testifiers stated that Medicare should
reimburse a greater variebr of services, especially
preventive services, than it does now. (#062; #074;
#336; #612) Richards states, "Unfortunately, a very
tidy summary of the preventive services most needed
REFERENCES
in this age group can be found in a publication, The
Medicare Handbook, under a category entitled 'What
Medicare Does Not Cover'.nt6 Richards suggests that
the following items should be reimbursable: dental
services; nutritionist's services, especially for those
with multiple health problems; home care pharmacists
to monitor multiple medications; mental health
services; long-term care costs; periodic health and
screening examinations; the costs of eyeglasses and
examinations to prescribe them; breast examinations;
mammography; and Pap smears. (~183)
Data and Information Needs
The American Association of Retired Persons
(AARP) notes that the 1990 Objectives include
relatively few objectives pertaining specifically to older
adults. The AARP believes that this omission is due
to gaps in data collection systems and measurement
techniques. It recommends that the Public Health
Service focus resources on expanding data collection
for assessing health status and health risk in older
adults. Data are needed on the use of preventive
services and reimbursement for such services; acci-
dents and injuries (especially in-home fires); misuse of
alcohol or drugs (including prescription drugs);
suicide; and use of mental health services by the
elderly. (#767)
Walter Bortz of the Palo Alto Medical Foundation
suggests that data are needed to show how preventive
strategies work in older people and how health
behavior is affected by the negative stereotype of
aging. (#508)
Richards also believes that While there is growing
evidence that health promotion pays off in improved
quality of life, we must convince policymakers that
prevention also saves scarce health dollars." She
recommends the researching of long-term questions:
for example, do older adults with arthritis who begin
a regular exercise program require institutionalization
less often or at a later age than those who do not
exercise? She suggests an increase in the number of
projects doing follow-up to measure the long-term
effects of health promotion. (~183J
1. U.S. Department of Health, Education and Welfare: Healthy People: The Surgeon General's Report on
Health Promotion and Disease Prevention (DHEW Publication No. [PHS] 79-55071), 1979
48 Healthy People 2000: Citizens Chart the Course
OCR for page 49
2. U.S. Department of Health and Human Services: Surgeon General's Workshop on Health Promotion and
Aging, March 20-23, 1988; Proceedings. Edited by FG Abdellah, SR Moore
3. U.S. Department of Health, Education and Welfare: op. cit., reference 1
4. Atkinson R. Kofoed LL: Alcohol and drug abuse. Geriatric Medicine, Vol. II. Edited by CK Cassel, JR
Walsh. New York: Springer-llerlag, 1984
5. Ibid.
6. U'Ren RC: Affective disorders. Geriatric Medicine, Vol. I. Edited by CK Cassel, JR Walsh. New York:
Springer-Verlag, 1984
7. Ibid.
8. Alabama Department of Public Health: 1986 Behavioral Risk Factor Surveillance System, Alabama Statewide
Survey, 1987 Weighted. February 1988
9. Health Care Financing Administration: The Medicare Handbook, 1990. Washington, D.C.: U.S. Government
Printing Office, 1990
10. Kosberg J.: Preventing elder abuse: Identification of high risk factors prior to placement decisions. Gerontol
28(1):43-5O9 1988
11. U.S. Department of Health and Human Services: The Surgeon General's Workshop on Violence and Public
Health: Report. (Publication No. [HAS-D-MC] 86-1), May 1986
12. LaPlante MP: Disability risks of chronic illnesses and impairments. Disability Statistics Report. No. 2.
Institute for Health and Aging, University of California; San Francisco, November 1989
13. American Cancer Society: Cancer Facts and Figures, 1989. Atlanta, Gal: American Cancer Society, Inc.,
1989
14. National Cancer Institute: Cancer Statistics Review: 1973-1986. (NIH Publication No. 89-2789), May 1989
15. Greenwald P. Sondik E (Eds.): Cancer Control Objectives for the Nation, 1985-2000. National Cancer
Institute Monographs, No. 2. (NIH Publication No. 86-2880), 1986
16. Health Care Financing Administration: op. cit., reference 9
TESTIFIERS CITED IN CHAPTER 5
012 Baker, Milton; Syracuse Developmental Services Office
062 Ettinger, Ronald; American Society for Geriatric Dentistry
066 Fox, Claude Earl; Alabama Department of Public Health
074 Grigsby, Sharon; The Visiting Nurse Foundation
079 Halamandaris, Vat; National Association for Home Care
110 Angelo, Dolores; University of Colorado Health Sciences Center
142 Markstrom, Mae; Lake Superior State University, and Baker, Mary and Stanley Light, Dixie; Wellness
C.AR.E. Center (Sault Sainte Marie, Michigan)
145 Maynard, Olivia; Michigan Office of Services to the Aging
183 Richards, Rebecca; North Woods Health Careers Consortium (Wausau, Wisconsin)
259 Hunter, Katherine; Baptist Medical Center, Montclair (Alabama)
Older Adults 49
OCR for page 50
336 Norman, Ann Duepy; University of Washington
338 Heston, Thomas; University of Washington
339 Tsuji, Wayne; Washington State Arthritis Foundation
341 Patrick, Donald; University of Washington
370 Marine, Susan; Boulder, Colorado
378 Oliva, Michael; Aurora, Colorado
380 Mostow, Steven; Rose Medical Center (Denver)
384 Messenger, Tom; Association of Food and Drug Officials
396 Sparks, Shirley; Western Michigan University
403 Hwalek, Melanie; SPEC Associates (Detroit)
409 Lovell, James; National Hearing Aid Society
428 Somers, Anne; University of Medicine and Dentistry of New Jersey, and Weisfeld, Victoria; Robert Wood
Johnson Foundation
451 Bennett, Ruth; Columbia University
459 Ostfeld, Adrian; Yale University
468 Miner, John; Massachusetts Mental Health Center
478 Young, Rosalie; Wayne State University
482 Newcomer, Robert and Pasick, Rena; University of California, San Francisco
508 Bortz, II, Walter; Palo Alto Medical Foundation
535 Lurie, David; Minneapolis Health Department
574 Smith, Marie; American Society of Hospital Pharmacists
575 Reveal, Marge; American Dental Hygienists' Association
612 Hunter, Paul; American Medical Student Association/Foundation
637 Adams, Gordon, Moses, Dennis and Baubman, James; Chapman College (San Diego)
670 Griffith, Patrick; Morehouse School of Medicine
686 Hollers, Kay; National Association for Home Care
714 Barkauskas, Violet; University of Michigan
738 Wagner, Edward; Group Health Cooperative of Puget Sound
766 Cornman, John; The Gerontological Society of America
767 Hurst, Victor; American Association of Retired Persons
768 Sykes, James; The National Council on the Aging
769 Sugarman, James; National Association of Retired Senior Volunteer Program Directors
770 Goldberg, Sheldon; American Association of Homes for the Aging
772 Ferguson, Wilda; Virginia Department for the Aging
776 Fainsinger, Ann; Alliance for Aging Research
777 Karlin, Steve; National Recreation and Park Association
793 Scitovsly, Anne; Palo Alto Medical Foundation
794 Katzman, Robert; University of California, San Diego
795 Haviland, James; Seattle, Washington
799 Surgeon General's Workshop on Health Promotion and Aging
50 Healthy People 2000: Citizens Chart the Course
Representative terms from entire chapter:
preventive services
