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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

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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

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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

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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

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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

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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. fi079) 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

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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

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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

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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