The health of older Americans will become a critical national policy issue during this century. As the population of older adults increases dramatically, there are few signs that adequate resources are available to meet the challenge of providing health care and good quality of life for older adults and their families. A fundamental change in the values emphasized in the American culture, and in other cultures, will be required to change the present health care system from one which focuses on diagnosis and treatment of disease to a system that attends to the major issues that affect quality of life of older adults and their families. This article discusses four critical areas influencing the quality of life of older Americans: providing resources to individuals to help manage chronic medical conditions, assuring a sufficient number of primary health care providers educated in geriatrics and gerontology, removing financial barriers to accessing health care and medications, and changing the American cultural value system that emphasizes disease treatment over providing emotional, educational, and support resources. To make these profound changes in the formal health care system, health care providers, health care organizations, and policy makers must commit to embracing the importance of quality of life as an integral component of health care for older citizens.
Key Words: aged, 80 and over; health services for the aged; chronic disease; family caregivers, quality of life
Issues Affecting the Health of Older Citizens: Meeting the Challenge
The health of older citizens will become a critical national policy issue during this century. As a country, we Americans may have to rethink fundamental cultural values about the meaning of providing health care to older adults with chronic conditions. Simply treating disease is no longer sufficient. The growing number of older adults, and the families who care for them, will need emotional, educational, and financial resources that are not currently available. Planning to meet this challenge is important because an elderly population explosion is coming, beginning in 2010.
The "oldest old" Americans—those aged 85 years or more—are the fastest growing group in the US.
By 2030, 70 million U.S. citizens will be over age 65, and 8.5 million Americans will be over age 85 (National Center for Health Statistics, 1999). The "oldest old" Americans—those aged 85 years or more—are the fastest growing group in the US. This trend is important to those planning health care needs for the future because the oldest old individuals are most likely to be disabled, use multiple medications, or need consistent caregiving. Many older adults will be from ethnically diverse cultures. For example, Hispanic elders, now 5.6% of the elderly population, will increase to 16.4% of the elderly population during the next 50 years. In some states such as California, where 25% of the population is foreign born, the proportion of older Americans from diverse cultures will be even higher (National Center for Health Statistics, 2002).
This growing elderly population will have an increasing need for health care and related services, an effect that will ripple through society as we grapple with the implications of caring for our elders. The increased proportion of older adults in the population need not present major problems if we can provide appropriate resources for adequate quality of life for older adults, such as specialized health care that includes attention to the management of chronic illness, support for family caregivers, and the financial constraints of older adults. Even today, when the number of older adults is smaller, critical health and quality of life issues remain unresolved, issues that may grow worse as the population of older adults increases.
The purpose of this article is to provide an overview of major issues that affect whether the growing number of older adults can expect to enjoy a healthy old age. Four critical areas will be discussed: providing resources to individuals to help manage chronic medical conditions, assuring a sufficient number of primary health care providers educated in geriatrics and gerontology, removing financial barriers to accessing health care and medications, and changing the cultural value system that emphasizes disease treatment over providing emotional, educational, and support resources. Reassessing current public policies that influence our ability to provide for the health and well-being of older citizens will influence our success in meeting these health challenges. The policy implications of these four major health issues will be briefly discussed in this article and addressed in more detail in the other articles in this topic of the journal, each of which focuses on a particular challenge related to health care and aging.
Issue 1: Older Adults Need Help Managing Multiple Chronic Conditions
Many people who have chronic conditions lead active, productive lives.
Between 1900 and 2000, life expectancy in the United States increased from 51 to 80 years for women and from 48 to 74 years from men (Population Reference Bureau, 2002). As Americans have increased their years of life, the prevalence of chronic conditions associated with age has also increased. It is estimated that by 2040, almost 160 million people in the US, most of them elderly, will be living with chronic conditions (National Academy on an Aging Society, 1999). Chronic conditions can cause limitations in daily activities, hospitalization, transition to a nursing home, and poor quality of life. However, many people who have chronic conditions lead active, productive lives.
There are several reasons why some older adults with chronic conditions remain independent and active, while others decline into frailty and dependence. First, some chronic conditions, such as chronic obstructive pulmonary disease, may be more disabling or more severe than other conditions. Second, some chronic conditions, such as hypertension, may be controllable with medications. Third, some older adults have the resources to self-manage their chronic conditions so that symptoms are controlled. Thus, in cases where the chronic condition is not itself disabling (if managed) and medications are available (and affordable), the provision of support in self-management of symptoms may allow many older adults to remain in their homes and lead lives that include normal activities.
Older adults need a variety of resources to help them manage chronic conditions, especially when several chronic conditions are present, a common occurrence. Medical help for treatment of chronic disease conditions is available to most older adults through Medicare and Medicaid. In contrast, the care resources needed to manage chronic conditions in day-to-day life are not as readily available. In order to balance behavioral changes, medications, and symptom relief strategies, older adults need knowledge about what to do, the belief that they can achieve success, and family to help. When elders do not have family members close by, additional financial resources may be needed to acquire assistance. Providing emotional support and education to elders and families will require a fundamental change in the American value system, which currently promotes the logical medical treatment of chronic conditions, and ignores the emotional needs of patients and family caregivers who cope with multiple chronic conditions.
Issue 2: Too Few Primary Health Care Providers are Educated to Provide Geriatric-Focused Care
The current shortage of nurses is expected to accelerate in coming years, and the impending lack of nurses to care for the nation’s older adults will be a critical health care issue. To prevent, or at least mitigate, the expected shortage of gerontological nurses in the US, increased recruitment of nurses to gerontological specialties must be initiated now.
Between 2010 and 2030, the number of registered nurses in the US is expected to steadily decline, as older nurses retire and fewer students enter baccalaureate nursing programs (American Association of Colleges of Nursing, 2002; University of Illinois at Chicago: College of Nursing-Nursing Institute, 2001). By 2020, the registered nurse (RN) workforce is expected to be 20% below projected requirements (Buerhaus, Staiger, & Auerbach, 2000; Reinhard, Barber, Mezey, Mitty, & Peed, 2002). The decline in the supply of nurses during the next 20 years will occur just as 78 million baby boomers retire and enroll in Medicare. From 2010 to 2030, the number of people aged 85 and older—the age group most likely to need nursing care—will increase by more than 4 million (U.S. Census Bureau, 2002).
Unfortunately, most RNs have little or no preparation in gerontological nursing as part of their education.
Unfortunately, most RNs have little or no preparation in gerontological nursing as part of their education. A recent survey disclosed that fewer than 25% of baccalaureate nursing programs include a course in gerontological nursing (Rosenfeld, Bottrell, Fulmer, & Mezey, 1999). The shortage of nurses who specialize in care of older adults is even more acute in advanced practice nursing. Though 63 nursing programs in the US currently prepare advanced practice gerontological nurses, most graduate only a few students each year, not nearly enough to meet even today’s need for nurses in long-term care settings, where many advanced practice gerontological nurses practice (Mezey & Fulmer, 2002).
Currently, only 12.3% of RNs are from ethnically diverse groups, a figure that does not mirror the 33% of the general population that is ethnically diverse (American Association of Colleges of Nursing, 2001). Elderly Americans, already a heterogeneous group, will include more culturally diverse individuals as the population ages. In 2000, 16% of older adults in the US were members of ethnic groups, but by 2050, the proportion is expected to increase to 36% (Himes, 2002). The current number of advanced practice gerontological nurses from diverse ethnic groups is not known, but there is little doubt that the number should be increased so the nursing workforce is more representative of the populations being served.
Other disciplines have a similar shortage of geriatrics-educated professionals. Only 14 of the nation’s 145 medical schools require a course in geriatrics for medical students, and less than 0.5% of medical school faculty are geriatric specialists. In pharmacy today, only 720 of 200,000 pharmacists have geriatric certification. Though at least 5,000 geriatric psychiatrists are needed to meet today’s mental health care needs of older adults, about 2,400 geriatric psychiatrists are practicing in the US (Merck Institute, 2002).
These critical shortages in the number of health care providers who are educated in the unique health needs of older adults will continue to worsen as the demand increases in future years. Changes in policy, if implemented soon, may help meet this challenge. New policies that could improve the geriatric knowledge of the health care workforce include mandating a specified number of credits in geriatrics as a condition for license renewal, initiating new continuing education programs in academic institutions to attract professionals without geriatric training, and working with state licensing boards to implement requirements for geriatric course content in nursing, medical, and pharmacy education curricula (Merck Institute, 2002).
Issue 3: Financial Issues Drive Health Care Choices for Many Older Adults
Older adults and their families face many financial issues in acquiring treatments and resources to support health. Financial resources can be quickly drained by paying for multiple prescriptions for chronic conditions (Center on an Aging Society, 2002; Merck Institute, 2002), inadequate reimbursement for mental health services (Merck Institute), and the lost work time and productivity of unpaid family caregivers (Kassner & Bectel, 1998; U.S. Bureau of the Census, 1996).
The expense of paying for multiple prescriptions, which are not reimbursed by Medicare, is a well-known political health issue that is regularly addressed, with great publicity, by Congress, and, with less publicity, dropped from the legislative agenda. For elderly individuals, the cost of medications is a critical financial problem that never goes away. Many older adults have several chronic conditions that require costly prescription drugs to manage symptoms. For example, the average annual drug expenditure for diabetes is $1379, for heart disease, $1187, and for hypertension, $1021. The average annual out-of-pocket prescription drug expenditure for Medicare beneficiaries is $581, because many individuals buy supplementary insurance to help pay for drugs. Low income older adults who qualify for Medicaid may be more fortunate because Medicaid programs cover 60% of drug costs, though many states are planning to reduce or restrict their Medicaid drug benefits in 2003. Not surprisingly, nearly 20% of adults over age 65 report that they have taken less medication than prescribed in the past two years. Others have reported that they sometimes do not fill prescriptions, skip doses to make medication last longer, or spend less on food and heat so they can afford medicine (Center on an Aging Society, 2002).
Older adults visit physicians more often than younger adults do, averaging 15 physician visits per year for adults aged 85 and older compared to 7.2 visits for adults aged 45 to 64 (Merck Institute, 2002). Most office visits for health care require only a small co-payment for Medicare beneficiaries. In contrast, older adults are not frequent users of mental health services, accounting for only 7% to 9% of mental health utilization in hospital, community, and private practice settings. This underuse of mental health services may be due to lack of education among primary care health care providers in geriatric mental health assessment. However, another likely cause is the lower reimbursement by Medicare for mental health conditions, compared to reimbursement for physical conditions. Thus, the high rates of untreated mental health problems among older adults (only 50% of older adults with acknowledged mental problems receive treatment from any provider and only 3% of those see a specialty mental health provider) may be due to the inability to pay Medicare’s 50% co-payment for mental health outpatient services (compared to 20% for general medical services) (Merck Institute).
As adults age, some need help only with daily activities, such as cleaning, cooking, or personal care, in order to remain in their own homes. Unfortunately, Medicare does not reimburse for this type of care, so older individuals who need this "custodial" help must pay for it out-of-pocket or rely on unpaid caregivers, often family members or other support persons. Though some older adults may qualify for subsidized community programs, 70% of people over age 65 who need help with daily activities are cared for by unpaid caregivers, primarily spouses (24%) or daughters (20%) (Kassner & Bectel, 1998). This does not include the many families that are actively engaged in remote family caregiving through phone, visit and email supports. The number of family caregivers available to care for older adults is steadily decreasing in the US. In 1950, the "parent-support ratio" (the number of persons 85 years or older per 100 persons aged 50 to 64) was three. By 1993 this ratio had tripled to 10. By 2050 it is projected to triple again to 29 (U.S. Bureau of the Census, 1996).
The health care system must demonstrate far more focused interest in the family and "like family" (non-kin caregivers) as health care clients, because these caregivers provide the primary social, financial, and physical support for older Americans. As such, the family and "like family" caregivers are a major resource for American society, saving the health care system many dollars, perhaps as much as $196 billion per year (Rosalynn Carter Institute, 2002). On the other hand, this reliance on unpaid caregivers incurs costs to American society in lost productivity when caregivers cannot work. One study estimated that the lost productivity due to caregiving costs U.S. businesses $11 to $29 billion annually (Metlife Institute, 1999). If home and community-based long-term care of older adults continues to be primarily delivered by informal caregivers, they deserve to be the focus of attention for researchers so support systems can be designed that meet their needs, and their lost productivity can be recognized and, perhaps, mitigated.
Issue 4: Cultural Values Do Not Give Priority to Providing Services and Support for Older Adults
Despite improvements in health care that have increased the life expectancy of persons throughout the world, aging is still viewed by many Americans with fear and trepidation.
Two of the most beautiful words in the English language--"nursing" and "home"--when put together in the term "nursing home" have become a symbol of fear, isolation, and suffering in the minds of many middle-aged and older persons.
Two of the most beautiful words in the English language--"nursing" and "home"--when put together in the term "nursing home" have become a symbol of fear, isolation, and suffering in the minds of many middle-aged and older persons. Life course planning in America is common in the financial planning arena, but has not been applied in the same way to lifelong improvement of self-care competency, and planning for learning the skills of relationships, care receiving, and caregiving. This lack of planning may be due to the dominant American cultural fear of aging. Unfortunately, this lack of motivation to make personal health-conscious decisions in early and mid-life may result in inadequate planning for lifelong meaningful activity, social support and living arrangements for later life. Thus, many older adults are not prepared for the natural occurrences of physical decline, loss, and grief.
The presence of strong elder bias in the American culture prevents the application of new scientific knowledge and ways of thinking to clinical practice in the care of older persons. Older adults may have a variety of risk profiles for poor health, from the robust to the frail elderly. Yet, most of the stereotypes of aging picture the frail and disabled. Thus, many health care providers do not think interventions to teach techniques for self-management of symptoms are worthwhile in older adults because they will not live long enough to justify the effort.
Wagner, Austin, and Von Korff (1996) have identified the conditions of the health care system necessary for the care of older adults with chronic disease and their families. These conditions in large part focus on "delivery by design" and include such features as having formal interest in the client’s feelings of self-efficacy, the presence of well-oiled outreach and monitoring activities, the capacity to provide personal, individual, and group coaching in behavior change, and overt attention to customization of standards of care to fit expressed preferences and family abilities. Unfortunately, these performance attributes have rarely been designed into health delivery systems. The primary model driving both formal care design and financing is care in urgent and emergent conditions, rather than preventive services or support for management of chronic conditions (Institute of Medicine, 2001).
Almost all financing schemes, including Medicare, are derived from methodologies directed at paying for acute care and procedure-oriented visits or hospitalizations. During the last fifteen years, significant reductions in hospital length of stay have produced a complex cascade of unintended consequences and burden for families caring for acutely and chronically ill elders.
This focus on "setting-specific" strategies rather than family-centered care in planning that is coordinated through time, place, and person, has produced chaos, redundant costs, and unmet needs.
Often, multiple transitions mandated by payment systems funding various levels of care (skilled care, intermediate, assisted living, and foster care) have produced extreme complexity, lack of coordination, and lack of assessment of the true needs of families for safe care in the home. Unfortunately this focus on "setting-specific" strategies rather than family-centered care planning that is coordinated through time, place, and person, has produced chaos, redundant costs, and unmet needs. Assisting families to uncover values and personal goals as they learn to interpret complex care regimens, self-care directions, and treatment orders is often not a part of routine care in formal health care organizations. Funding for basic group educational classes to coach families in growing self-care skills and competencies is not provided for in current billing provisions. The best practices for improving self-care skill that have been learned in patient education centers and large funded studies in managed care organizations have seldom been translated into Medicare, Medicaid or commercial business payment systems.
In the American culture and value system, emotional and cognitive understanding of illness and health often are not congruent.
While elders and families are intimately involved in the emotional aspects of illness and disability, health care providers are likely to disregard emotional experiences and concentrate on logical solutions to treat or manage chronic disease conditions.
While elders and families are intimately involved in the emotional aspects of illness and disability, health care providers are likely to disregard emotional experiences and concentrate on logical solutions to treat or manage chronic disease conditions. Though medical anthropologists have described health and illness in terms of culture, health providers in clinical practice pay little attention to the "experience" of illness (Kleinman & Seeman, 2000). In the care of older persons, this lack of attention to the lived experience of chronic illness results in insufficient adjustment of care plans to fit with practical and financial realities of patients and families.
Summary and Conclusion
Older adults seek better quality of life in the later years. Quality of life has come to mean much more than just physical health or the absence of disease. It includes a general sense of happiness and satisfaction, meaningful activity, and the ability to express culture, values, beliefs, and relationships (U.S. Department of Health and Human Services, 2000).
The health care system's current emphasis on physical health as the main component of quality of life has in part created an artificial and dysfunctional way of examining what needs attention.
Thus, the health care system’s current emphasis on physical health as the main component of quality of life has in part created an artificial and dysfunctional way of examining what needs attention. A better approach to improving quality of life would be to focus increased interest on understanding meaningful life issues in the home affecting physical, social, emotional, and financial health.
Though quality of life is a complex and personal concept for each older adult, four crucial issues were discussed in this paper that affect the quality of life of many older Americans: insufficient resources to help individuals and families manage multiple chronic conditions, the lack of health care providers educated in broad-based geriatric care, the high cost of health care, and the lack of attention paid to the needs of older adults in American society. There are no easy answers to solving the problems associated with these issues, as the solutions would require establishing new priorities in the value system of American society. The challenge is not to increase the number of health care providers who are focused on diagnosing medical problems in older adults. Instead, the challenge is to place value on the full spectrum of helping older adults enjoy quality of life in old age. This change of values will only occur with a commitment to embrace the importance of aging issues by universities that educate primary health care providers, by health care organizations that decide what health care will be received by elders and their families and how much that care will cost, and by legislators who determine the budgets for national health priorities.
Jill Bennett, PhD, RN, CNS
Jill Bennett, PhD, RN, CNS is an Assistant Professor and Scientist at the School of Nursing, Oregon Health & Science University (OHSU). She is a gerontological clinical nurse specialist and holds a PhD from University of California San Francisco in gerontological nursing. She has been a fellow at the Hartford Institute for Geriatric Nursing and the Summer Institute on the Design and Conduct of Randomized Clinical Trials at the National Institutes of Health. In 2003, she received the Regional Geriatric Nursing Research Award as a new investigator from the Western Institute of Nursing. Her research is focused on motivating older adults with chronic conditions to engage in physical activities.
Marna K. Flaherty-Robb, RN, MSN
Marna K. Flaherty-Robb, RN, MSN is Associate Dean for Practice Development and Integration at Oregon Health & Sciences University. She also is Co-Director of the Best Practice Initiative of the OHSU John A. Hartford Center of Geriatric Nursing Excellence, and is a co-principal investigator on the OHSU Center for Healthy Aging. She served as Regional Services Manager within the Kaiser Permanente Program for many years, participated on the executive committee for the Social HMO Demonstration, and consulted with the Elder Services Planning team of the Care Management Institute at Kaiser Permanente. Her expertise is in translating research and best evidence into services and programs to serve families.
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