Aging and Health

At the present time, there are 44.7 million American citizens over the age of 65; this is approximately 14.1% of the population of the United States. The number of seniors will continue to increase dramatically in the coming generations. This phenomenon is referred to as the silver tsunami. By 2050, the number of citizens over the age of 65 is expected to surpass 82 million. This is the result of several factors: 1) increased life expectancy, 2) increased immigration, and 3) decreases in the fertility rate. A child born in the year 2014 has an average life expectancy of 78-79 years; for a person aged 65 in 2014, their life expectancy is between 84-85 years. Centenarians are the fastest growing segment of the population. Age classifications are defined as youngest-old (ages 65-74), middle-old (ages 75-84), and oldest-old (ages 85+).

Ageism is a process of systematic stereotyping of and discrimination against people because they are old. Because of preconceived notions of aging patients, health care delivery is frequently affected. Older adults are often perceived as “senile”, “old-fashioned”, and “rigid”. As with patients of any age, it is critically important that a patient’s beliefs and desires be factored into their health care and not simply dismissed because of their age.

Statistics provided in the following discussion come from the Department of Health and Human Services and the Centers for Disease Control and Prevention. Demographically, at present, women live longer than men: there are approximately 128 women to every 100 men at age 65, and 196 women to every 100 men at age 85. Older men (72%) are more likely to be married than older women (46%). There are three times as many widows (8.7 million) than widowers (2.3 million). More men live with their spouses compared to women (72% to 46%). Approximately 28% of older adults residing in the community live alone, and about half of older women over the age of 75 live alone. Furthermore, the number of elderly men and women residing in long-term care facilities are similar until the oldest age groups are considered.

The median income of men is approximately $29,300, of women is approximately $16,300, and for a family is approximately $51,600. For one-third of seniors, social security benefits account for almost 90% of their total income. In 2015, the average amount of social security benefits for a retiree was $1,300 and $680 for their spouse. For reference, the cost of a Medicare premium is roughly $100 per month. Overall, 4.2 million seniors (ca. 10%) live in poverty with another 2.5 million (ca. 5%) nearing poverty. Women have a higher poverty rate than men (12% to 7%). The highest poverty rates are seen among older Hispanic women who live alone (ca. 45%).

Implications of Increased Life Expectancy on Health

Chronic diseases are the leading cause of pain, disability, and loss of function in older adults. Almost 80% of older adults have one chronic disease, nearly 50% have two chronic diseases, and 20% have three. Among these, hypertension (71%) is the most common, followed by osteoarthritis (49%), coronary artery disease (35%), cancer (25%), and diabetes mellitus type 2 (21%). Other common chronic diseases include major depressive disorder, dementia (including Alzheimer’s disease, vascular dementia, and other types), hyperlipidemia, osteoporosis, reactive airway disease, chronic obstructive pulmonary disease (COPD), atrial fibrillation, congestive heart failure (CHF, may be split into systolic and diastolic), chronic kidney disease, and cerebrovascular disease including cerebrovascular accidents and transient ischemic attacks.

The most significant and lasting effect of chronic diseases is decreased functional status. Functional status is, furthermore, the best predictor of mortality. Functional status is defined by an older adults’ ability to independently perform Activities of Daily Living (ADLs) and Instrumental Activities of Daily Living (IADLs). (Table 1.1) Subsequent chapters will detail how to determine independence of ADLs and IADLs to assess functional status. Community-residing older adults are more likely to have a deficit with walking compared to other ADLs and accessing transportation compared to other IADLs.

The impact of aging on the health care system is reflected by the amount of spending in the in-patient hospital setting (ca. 35%). Outpatient or office-based care comprises about 30%. Pharmacy and medication costs are roughly 20%, and 10% is used for home health services. The remaining amount is used for dental care and emergency room visits that do not result in hospital admission.

Compression of morbidity refers to the observation that disability has been compressed into the period just before death, as shown by disability-free life expectancy rising and also the impact of prevention and delay in disability in addition to improved recovery from disability. Disability-free life expectancy is defined as the average number of years an individual is expected to live free of disability if current patterns of mortality and disability continue.

As the number of citizens in society age, many are opting to “age in place”, that is, they remain in their own homes. Some will live with family members, friends, or other caregivers if their health begins to deteriorate. Caregiver burden occurs when caregivers experience negative psychological, behavioral, and physiological manifestations. For persons who have recently begun to cohabitate, an adjustment period is often necessary. Caregiver burden can lead to caregiver burnout resulting in decreased quality of care from caregiver to patient and of the caregiver to themselves. Particularly with regard to women, as they have begun to enter the workforce in recent decades, they have often had to balance being a caregiver for elderly persons in addition to balancing a job or career. Elder abuse is discussed later in this chapter.

Geriatrics

Geriatrics is the branch of medicine that focuses on the health care of elderly people which aims to promote health by preventing and treating diseases and disabilities in older adults, typically over the age 65. Often, an interdisciplinary team (IDT) is involved with the care of geriatric patients. Members of the interdisciplinary team include nurses (LPNs and RNs), social workers, case managers (who are typically RNs), physical therapists, occupational therapists, speech therapists, nutritionists, psychologists, and, of course, primary care and specialist physicians.

Some members of the interdisciplinary care team and their contributions include:

• A nurse provides direct care to patients and serves as an integral member of the interdisciplinary team to develop a specialized care plan for each patient.
• A physical therapist provides therapy for the preservation, enhancement, and restoration of movement and physical function impaired or threatened by disease, injury or disability.
• An occupational therapist provides therapy for injured, ill, or disabled patients through the therapeutic use of everyday activities by assisting the patient in developing, recovering, improving, and maintaining the skills needed for daily living and working.
• A speech therapist performs assessments, diagnosis, and treatment for speech, language and social communication. They also assess for swallowing disorders (dysphagia).
• A social worker conducts comprehensive assessments of individual and caregiver to develop care plan as well as facilitate community resources to address ongoing supportive services, educate and counsel the patient and caregiver throughout the disease process, and conducts advocacy efforts on behalf of the patient.
• A case manager assesses, plans, implements, monitors, and evaluates actions required to meet the patient’s health care needs.

Health Care Payment Models

Medicare is health insurance for people who are 65 years of age or older, certain people under 65 with disabilities, and people of any age with end-stage renal disease (ESRD) requiring hemodialysis (HD) or a kidney transplant. Medicare is regulated at a federal level.

There are four different parts to Medicare, as described by the Centers for Medicare and Medicaid (CMS):

Medicare Part A: hospital insurance

1. In-patient care in a hospital
2. Skilled nursing facility (acute/sub-acute rehab)
3. Hospice care
4. Home health care

Medicare Part B: medical insurance

1. Services from doctors and other providers
2. Outpatient care and preventive services
3. Home health care
4. Durable medical equipment (DME)

Medicare Part C: Medicare Advantage

1. Includes all benefits under Parts A and B
2. Usually includes prescription coverage (Part D)
3. Run by Medicare-approved private insurance companies that follow rules set by Medicare
4. Plans have a limit on out-of-pocket costs for medical services
5. May include extra benefits and services not covered by original Medicare

Medicare Part D: prescription drug coverage

1. Helps cover the cost of prescription drugs
2. Run by Medicare-approved drug plans
3. May help lower drug costs and protect against future higher costs

Medicaid is a joint federal and state program that helps pay medical costs if a patient has limited income or resources and meets other requirements. Persons with Medicaid may get coverage for services that Medicare may not or may partially cover, such as nursing home care, personal care, and home-based and community-based services. Each state has different rules about eligibility and applying for Medicaid. If a person qualifies for Medicaid in their state, they automatically qualify for Extra Help, a program that helps with paying for Medicare prescription drug coverage (Part D).

Though primarily for patients who have limited income or resources, others eligible for Medicaid include those over the age of 65, a child under 19 years of age, a pregnant woman, a person living with a disability that prevents them from working, a parent or adult caring for a child, an adult without dependent children in certain states, and an eligible immigrant. Benefits of Medicaid include doctor visits, hospital stays, long-term services and supports, preventive care (immunizations and screening exams such as mammograms and colonoscopies, among others), prenatal and maternity care, mental health care, necessary medications, and, unlike adults, vision and dental care for children. Some persons are able to qualify for both Medicare and Medicaid are called dual eligible persons. If a person has both Medicare and Medicaid, most of their health insurance costs are likely covered.

Geriatric Care Settings

Though discussed in the previous section regarding Medicare and Medicaid, consideration of locations of health care delivery is also important. In-patient care is done in the hospital. Medicare Part A is the primary payor source. In some cases, following extended hospital stays, geriatric patients often become physically deconditioned due to prolonged time spent in bed, even if they are followed by physical and occupational therapy services. These interdisciplinary services will often recommend discharge to a sub-acute rehabilitation facility as opposed to being discharged home due to a high likelihood that the patient would return to the hospital after being discharged.

Sub-acute rehabilitation allows the patient’s maximum functional capacity to be identified and achieved prior to potentially being discharged home, moving to a long-term care facility, or being picked up by hospice services. Sub-acute rehabilitation facilities are also able to provide intravenous antibiotics, treat wounds such as pressure ulcers, and to acclimate patients to their current level of function and determine hope for improvement. Medicare Part A is primary payor source for sub-acute rehabilitation as well.

Independent living facilities are facilities where older adults live independently. Assisted living facilities assist in meal preparation and managing medications. In both cases, a physician is often available several days per week. The cost of living in such domiciles is often covered entirely by the patient or family (also called “private pay”). Physician visits are covered under Medicare Part B.

Long-term nursing care facilities (i.e. “nursing homes”) are often in the same location as sub-acute rehabilitation facilities and are able to provide all functional needs including ADLs, medications, meals, and socialization. Medicaid is the primary payor source, however, residents can also pay privately but will require liquidation of assets. Other insurances may or may not contribute to payment of long-term care services. There are facilities known as continuing care retirement communities where a continuum of aging care needs from independent living, assisted living, sub-acute rehabilitation, and long-term nursing care can all be met within the community.

Elder abuse is an act of commission or omission that results in harm or threatened harm to the health or welfare of an older adult. It may be intentional or unintentional. Females are the most often at risk for elder abuse and 90% of cases are perpetrated by a family member. Elder abuse is a common concern across geriatric care settings. Types of elder abuse include physical abuse, sexual abuse, psychological or emotional abuse, financial or material abuse, and neglect. Physical abuse may result in injury or impairment, occur using drugs or restraints, force feeding, or physical/corporal punishment. Signs of physical abuse include bruising, laceration, burns, and evidence of drugging. Signs of sexual abuse can include new difficulty walking or standing and new sexually transmitted or urinary tract infections. Psychological abuse occurs when an elder is treated as a child or isolated from family, friends, or social situations. Financial or material abuse results from the misuse of an elder’s resources for personal or monetary benefit, acquiring property or resources without the person’s knowledge or consent, misusing a joint checking account, or obtaining money using the elder’s credit. Neglect is the most common form of elder abuse; it can either occur as caregiver neglect, abandonment, or self-neglect. Physicians are mandatory reporters of elder abuse and suspicion is grounds for reporting. Facilities are required to have an ombudsman’s name and contact information posted. Ombudsman were established by Older Americans Act of 1976. Every resident must have access to the ombudsman. Suspicion of abuse is reported to the ombudsman.

The Omnibus Budget Reconciliation Act (OBRA) of 1987 included Nursing Home Reform Amendments including:

• An emphasis on a resident’s quality of life as well as the quality of care
• New expectations that each resident’s ability to walk, bathe, and perform other activities of daily living (ADLs) will be maintained or improved absent medical reasons
• A resident assessment process leading to the development of of an individualized care plan
• 75 hours of training and testing of paraprofessional staff (i.e. Certified Nursing Assistants (CNAs)
• Right to remain in the nursing home absent non-payment, dangerous resident behaviors, or a significant change in the resident’s medical condition
• New opportunities for potential and current residents with mental illnesses for services inside and outside the nursing home
• A right to safely maintain or bank personal funds with the nursing home
• Rights to return to the nursing home after a hospital stay or overnight visit with family and friends
• The right to choose a personal physician and have access to medical records
• The right to organize and participate in a resident council or family council
• The right to be free of unnecessary and inappropriate physical and chemical restraints
• Uniform certification standards for Medicare and Medicaid homes
• Prohibitions on turning to family members to pay for Medicare and Medicaid services
• New remedies to be applies to certified nursing homes that fail to meet minimum federal standards

Cultural Considerations in Geriatrics

Ethnic groups vary widely in their approach to medical decision making, disclosure of terminal medical diagnoses, and end-of-life care. Shared decision making depends on high-quality interactions between physicians and the person responsible for making decisions, whether it is the patient or a designated individual. Some cultures involve a particular person, such as the oldest child, to make decisions; others involve the whole family or no one else at all. The same is true with regard to sharing medical diagnoses, particularly terminal diagnoses such as cancer.

When caring for older adults, it is good practice to document what the patient prefers to identify their culture as in the medical records. Patients who are not born in the United States may not have the same conception of illness from a perspective of someone who is well versed in American culture. Other patients may defer to others in learning diagnoses. Gender roles are defined differently across different cultures as well.

Lesbian, gay, bisexual, and transgender (LGBT) health considerations are also important. Many older adults that reside in the United States may have been born, raised, or lived in a time or place where such behavior was criminalized and considered pathologic or as a psychiatric disorder. Because of this, many older adults do not or did not disclose their gender identity or sexual orientation. Health considerations of racial, ethnic, and sexual minorities are important and should be explored.

Review Questions

1. Which of the following statements regarding aging is correct?

A. At the present time, there were more men per 100 women in the oldest-old age group compared to the youngest-old group.
B. The number of women aged 65 and older living alone is approximately equal to the number of men living alone.
C. As more women have entered the workforce, they have had a reduced role as caregivers for elderly persons.
D. The numbers of elderly men and women residing in a long-term care setting are similar until the oldest-old age group is considered.

2. Community-residing older adults are more likely to have a deficit with _____ compared to other ADLs and _____ compared to other IADLs.

A. Walking; Transportation
B. Continence; Managing finances
C. Transferring; Managing medications
D. Bathing; Preparing meals

3. 3. An 83-year-old male is due to be discharged from sub-acute rehabilitation. He continues to have deficits with preparing his meals and taking his medications correctly. He has approximately $100000 in savings. He does not want to be discharged to a “nursing home”, but he cannot return to his home where he was living alone. He agrees to be discharged to an assisted living facility which will cost him $5000/month to stay. Which of the following is correct regarding services provided by an assisted living facility?

A. Assisted living facilities assist in medication management but do not assist with meal preparation.
B. Assisted living facilities assist in meal preparation but do not assist in medication management.
C. Assisted living facilities do not assist in either meal preparation or medication management.
D. Assisted living facilities assist in both medication management and meal preparation.

4. An 85-year-old female is discharged from the hospital after multiple recent hospital admissions to a nursing home for sub-acute rehabilitation. After several weeks, she is cut from therapy services by Medicare. She is not able to care for herself at home due to progressively worsening dementia. At the time of admission to the hospital, her monthly income was derived by a monthly Social Security payment of $750/month ($9000/year). She has no life savings. She will transition to long-term care at the facility where she was transferred for sub-acute rehabilitation. If she lives for another 5 years, who will be the primary payor source?

A. Social Security income
B. Medicare Part A
C. Medicare Part B
D. Medicare Part D
E. Medicaid

5. Which of the following is true regarding sub-acute rehabilitation placement?

A. Sub-acute rehabilitation will allow for further aggressive management of patients in a controlled healthcare setting and may lead to clinical improvement.
B. Sub-acute rehabilitation will allow a patient’s maximum functional capacity to be identified and achieved prior to potentially being picked up by hospice services.
C. Sub-acute rehabilitation will allow the patient to be evaluated and followed aggressively by all members of the interdisciplinary team to ensure that he returns to his prior level of function.
D. Sub-acute rehabilitation will offer an appropriate bridge to eventual long-term care placement and hospice benefits without a break in the continuity of health care delivery.
E. Sub-acute rehabilitation will provide no benefits to patients and he should be placed on hospice services immediately.

6. What is the primary goal of a sub-acute rehabilitation stay for an independently-ambulating patient with osteomyelitis?

A. To deliver antibiotics via peripherally inserted central catheter (PICC) line.
B. Return to pre-hospitalization level of function.
C. To treat extensive pressure ulcer wounds.
D. To acclimate the patient to their new level of function as a result of their illness.
E. To transition to long-term care and begin end-of-life planning.

7. Which of the following statements best describes the role of a physical therapist?

A. Physical therapists provide therapy for the preservation, enhancement, and restoration of movement and physical function impaired or threatened by disease, injury or disability.
B. Physical therapists provide therapy for injured, ill, or disabled patients through the therapeutic use of everyday activities by assisting the patient in developing, recovering, improving, and maintaining the skills needed for daily living and working.
C. Physical therapists perform assessments, diagnosis, and treatment for speech, language and social communication.
D. Physical therapists conduct comprehensive assessments of individual and caregiver to develop care plan as well as facilitate community resources to address ongoing supportive services, educate and counsel the patient and caregiver throughout the disease process, and conducts advocacy efforts on behalf of the patient.
E. Physical therapists provide direct care to patients and serve as an integral member of the interdisciplinary team to develop a specialized care plan for each patient.

Answers to Review Questions

1. D
2. A
3. D
4. E
5. B
6. A
7. A