The Complex Terrain of Aging
The earthquake that struck Kashiwazaki, Japan in July, 2007 did more than smash up houses and kill 11 people: it exposed a fault line that had nothing to do with the island nation’s unstable perch on the Pacific Ocean’s “Ring of Fire.” All of the dead were over 65
The great heat wave that battered Chicago 12 years ago made life about as unpleasant as it can get in that Midwest city, but for older people—most of whom were poor and minority—it was a killer.
No one knows for sure how many people the heat wave that rolled across Europe killed in August 2003, but in France the death toll was at least 15,000, the majority of them elderly.
Natural disasters have always had a way of shaking the glitter off systems and revealing the underlying fissures, be it inadequately maintained levees in New Orleans, or in the cases above, a systemic failure by social, political and medical institutions to deal with a demographic tsunami.
By the year 2050, the number of humans 65 years or older will increase from a little over 600 million to two billion, two-thirds of whom will be in the Third World. “Aging is affecting virtually every country,” United Nations General Secretary Ban Ki-Moon told a Tokyo conference on aging this past April. “The world has never seen such rapid, large and ubiquitous growth in the number and proportion of elderly people.”
In the U.S., the number of people over 65—currently 35 million— will double by 2030, jumping from 13 percent of the population to 20 percent.
At the same time the elderly population is climbing—adults over 85 are currently the fastest growing demographic group in the U.S.—the number of doctors and nurses who treat them is declining, and the population of traditional caregivers is either stagnant or falling.
What makes this particularity challenging is that geriatrics, the branch of medicine that deals with the diseases, debilities, and care of older people, is an enormously complex kaleidoscope of medical procedures, government policy, and demographics. If things go wrong in any of these areas it can lead to a train wreck.
For example, in the aftermath of the 1995 Midwest heat wave, researchers found that it was not so much the temperature that killed people, but poverty, isolation and fear. Many elders were too poor to afford air conditioning; they lived alone, and were too afraid to go out in the mean streets of Chicago. Isolated behind locked doors, they baked to death.
But tying together all the strands that make up the complex field of geriatrics is not a simple task.
On one level, the infirmities of age like diabetes, arthritis, incontinence, and high blood pressure are medical conditions that can be treated with drugs. But as Dr. Claudia Landau, Geriatric Curriculum Coordinator and an Associate Clinical Professor of Medicine at the University of California, Berkeley argues, when it comes to treating older people, “The medical model is not going to work.”
Geriatrics, she says, needs doctors and nurses to be as much sociologists and anthropologists as medical workers. “They have to know whether their patients are poor or rich, they need to know the total terrain. If you don’t attend to all of the elements you are not going to care for old people very effectively.”
The medical model is relentlessly pushed by an avalanche of television ads on treatments for incontinence, diabetes, and high blood pressure, what researchers Dr. Carol L. Estes and Steven P. Wallace, PhD, call the “commodification” of aging by a “medical-industrial complex” whose bottom line is money.
“Adult diapers and drugs produce significant profits for their manufacturers, creating incentives to promote these products,” write Estes and Wallace in Social Injustice and Public Health. “As a consequence, behavioral therapy, which is time consuming and not very profitable, is rarely used even though it is more effective.”
While bladder control seems like one of aging’s minor aliments, it is a major reason older people are institutionalized.
Studies show that conditions like incontinence, diabetes and high blood pressure respond just as well to exercise and dietary regimes as they do to target drugs. Indeed, many times the drugs create the problems.
Dr. Wendel Brunner, now Director of Public Health in Contra Costa County, California, recalls that when he was working in a clinic, “Old people would come in with bags of medicine. I would throw away most of it, and they would get better.”
Treating older people takes certain skills that most general practitioners and specialists don’t have. One of those skills is listening. “As we get older our homeostasis changes and doctors need to be tuned into that. You have to listen and take the time. You have to value communication,” says Landau. She calls this “cognitive medicine.”
Is an older patient disorientated because he or she is losing their mental facilities, or because of depression? Do they have an infection? (which can be difficult to spot because older people tend not to run fevers). Or is their medication wrong?
A doctor or nurse certified in geriatrics is trained to triage these very questions.
But out of 145 medical schools in the U.S., only nine have geriatric departments. There is only one geriatric doctor for every 5000 people in the U.S. Fewer than 9,000 of the 650,000 doctors in the U.S. are certified in geriatrics and fewer than 3 percent of medical students take courses in the subject. As a result, the number of U.S. geriatricians has fallen by one-third.
“It’s a problem,” warns William Satariano, a professor of Epidemiology and Community Health at UC Berkeley’s Public Health School and an expert on aging.
Doctors, for example, need to be particularly careful when prescribing drugs to elders. Diuretics are commonly proscribed for controlling high blood pressure, a chronic disease many older people suffer from. But if patients are not properly hydrated, diuretics can cause dizziness and falling. Some 350,000 Americans fall and break their hips each year, of which 40 percent will end up in nursing homes. A fifth will never walk again.
Side effects can be exaggerated when different doctors prescribe drugs without any centralized monitoring. “Multiple doctors prescribing multiple medicines cause multiple problems,” says Brunner.
Wallace and Estes found that many doctors tend to under treat older patients, with some claiming “those over 80 should receive no curative treatments…because they have lived out their ‘natural lives.’”
But a Harvard study found that when 90 year olds were put on Nautilus trainers they got better. Landau recalls advocating physical therapy for older patients when she worked in a public health clinic, only to be accused of “torturing” them by some staff members. “I told them to humor me and lo, and behold, people got better.”
One reason why there are fewer geriatric doctors is that they are among the lowest paid in the profession. While radiologists and orthopedic surgeons average $400,000 a year, geriatricians average $150,000 a year. Brunner, however, is not overly sympathetic to this argument: “It is hard to feel bad about any doctor’s income. The problem is not that we don’t pay doctors enough.”
The shortage is not restricted to doctors. Only 720 of the 200,000 pharmacists in the U.S. have geriatric certification, and the situation is only slightly better for social workers.
Bonnie Martin, RN, a geriatric nurse in San Francisco, and a member of the California Nurses Association’s Board of Directors, says the situation in nursing is “very similar.” According to Martin, “very few RNs choose to work with the elderly and very few NP (nurse practitioners) attend geriatric programs.” Much of the care for the elderly “is left to LVNs (licensed vocational nurses) and certified nursing care, in spite of the fact that the elderly need more complex nursing care than most other patient populations.”
Joan Stanley, RN, Senior Director of Education Policy of the American Association of Colleges of Nursing, and Mathy Mezey, RN, a professor at New York University, write, “The care of older adults is now the number one business of the U.S. health care system, cutting across hospitals, home care and nursing homes.”
Stanley and Mezey argue that “Evidence shows that older-person care delivered by nurses with specialized geriatric knowledge and skills improves outcome,” by improving patient assessment, reducing falls, and lowering costs.
Yet less than 1 percent of the 2.7 million nurses in the U.S. and Canada are certified in geriatrics and only 27 percent of nurses in baccalaureate programs have required classes in geriatric medicine.
Martin says the reason is that “nurses in LTC (long term care) tend to be paid significantly less, have fewer benefits and are not considered among the nursing ‘elite,’ an outgrowth of how little we value our elderly.”
Elder care is falling increasingly on aides, whose pay averages $9.34 an hour. The low pay and lack of benefits results in large yearly turnovers. What is more, the traditional pool for such aides—women age 25 to 54 with little education—is not growing to match the rise in the elder population.
Another dimension of the problem is part of Landau’s “total terrain”: class, race and gender.
There has long been a significant gap between the care that whites, as compared to minorities, receive, and who delivers that care. In 2004, a commission headed by Lewis W. Sullivan, former Secretary of U.S. Department of Health and Human Services, found that “From cancer, heart disease, and HIV/AIDS to diabetes and mental health, African Americans, Hispanic Americans, and American Indians tend to receive less and lower quality care than whites, resulting in higher mortality rates.”
Inferior care, Wallace told Registered Nurse, has a “weathering effect” on people, by which he means the “accumulated impact of being poor, living in poor conditions and the high stress of living in a racist environment,” all contributing to deteriorating health.
For instance, Wallace says that “food insecurity” among minorities is twice that among non-Latino whites, and that food insecurity is associated with a host of chronic diseases like diabetes, hypertension, and coronary heart disease.
This disparity of access to health care has an impact on what U.C. Berkeley’s Satariano refers to as “the middle years, where the accumulation of insults the poor suffer play out. It is during these middle years that we begin to lose some of our resistance to disease.”
New research finds that poverty level income—$10, 210 for a single person, $13,690 for a couple—falls short of meeting basic needs. According to the National Academy of Social Insurance, people need to earn between 150 percent to 300 percent above the poverty line “to meet basic living expenses without assistance.”
Gender creates yet another dimension to the problem. Women, age 45-55, with a family income of less than $35,000 a year, make up the overwhelming bulk of people who volunteer their labor to care for aged parents or grandparents. Some 80 percent of them hold full-time jobs. It is this “informal” labor force that keeps the crisis of elder care from going into free fall.
More than 20 million U.S. employees have ailing parents, and only one percent of the companies they work for pay for subsidized elder care. Medicare will not pay for long term care (LTC), and Medicaid will only do so once the elders’ assets are exhausted. The result of the government’s unwillingness to take any responsibility in this area means that 64 percent of LTC is “informal,” and another 28 percent is a combination of informal care and elder resources. The average informal caregiver puts in 18 hours a week.
“The problem of long term care is the elephant in the room when policymakers and planners gather to talk about health care systems,” Mary Jane Koran, a member of the National Commission for Quality Long Term Care told the House Sub-committee on Labor, Health and Human Services in February of this year.
The Bush Administration’s solution to the LTC crisis is to push market driven schemes, like reverse mortgages and private long term insurance. More than eight million Americans have purchased LTC insurance, only to find that companies throw up one road block after another when it comes time to cash in. A study in California found one in four claims were denied. In the meantime the industry has pulled in more than $50 billion in premiums.
As for reverse mortgages, they essentially wipe out one of the few assets working class people can pass on to their children.
According to the American Association of Retired People, this informal labor network is valued at anywhere from $275 to $350 billion a year, more than twice what Medicare costs.
But demographics are working against “informal” care giving as a solution to the LTC crisis because people are having fewer children. In 1955 the average family size was 3.7. In 2000 that figure was 2.1. According to a study by the Robert M. LaFollette School of Public Affairs, “The average working couple has more living parents than children.”
Because people are living longer they are more vulnerable to Alzheimer’s disease. According to the Alzheimer’s Association, by age 85, nearly 50 percent of the population will be stricken with the disease. Relatives will care for over 85 percent of those.
As for the caregivers: no good deed goes unpunished. “Women of all races tend to have jobs that either do not provide health care, are lower paying so they can’t afford private insurance, or they work part time in order to care for their family and have no benefits,” says Miller. “Therefore, by the time they become eligible for Medicare, their health may be significantly worse.”
Because women are paid less, and may end up missing work to act as caregivers, they also end up drawing less Social Security. The Academy of Social Insurance estimates that family caregivers give up about $659,000 in lifetime wages and pension benefits.
Another part of the “total terrain” has to do with where people age.
Studies show that elders do better if they stay in their homes rather than going to a care facility. Staying in place also saves money. But most homes are not designed for elders.
Satariano, the author of “The Epidemiology of Aging: An Ecological Approach,” argues that “The problems of older people require addressing things that some people think of as falling outside the realm of health care,” like the design of cars and houses. This, he says, means pulling city planners and building contractors into the mix. “How do we design more walkable communities? Can we build communities that have short distances to walk to stores, supermarkets where they [elders] can purchase fresh fruits and vegetables?”
Since up to 70 percent of diseases that afflict seniors are behavioral, not genetic, this is not just a matter of providing people better cuisine. Eating properly and exercising by walking in safe, well lighted parks, is part of the formula for what Satariano calls “adding life to years, not just years to life.”
Satariano’s “ecological,” approach argues for creating environments that are senior friendly. “Houses should be designed with a minimal number of steps, bathroom walls should be reinforced for attaching supports, and doors made wider for wheelchairs.”
Wallace told Registered Nurse the same approach to improving elder health should be applied to planning communities. Reflecting roofs, cooling trees, and parks—so-called “heat islands”—would reduce hot weather deaths. City planners and zoning boards should encourage the building of “granny units” so family can be nearby. He says these initiatives should be no more controversial than putting fluoride in the water to reduce tooth decay: “You just do it!”
“The core problem is that we don’t need more medicine, we need to set up communities so that people can become more active,” says Wallace.
“Instead of thinking what we need to do to keep people in their homes—where 90 percent of older people want to be—long term care gets caught up in cross currents and ideological debates,” says Wallace, “where free market advocates see privatization as a solution to everything.”
Martin adds a human element to LTC: “There is a huge emotional and physical toll to being institutionalized. There is a complete loss of privacy, dignity and control over your life. You are told when and what you eat. On shower days you are stripped naked, wrapped in a towel, placed in a shower chair and dragged down the hall to the shower room.”
Brunner agrees that avoiding institutionalization is important. “How do we set up a social support system and infrastructure to help old people get services at home and keep them out of nursing homes.”
Finding solutions will not easy and tend to run up against a cohort of powerful lobbyists that run the gamut from pharmaceutical companies to the insurance behemoths. On the other hand, the political power of seniors has grown over the past decade, and local and state governments, not to mention the medical establishment, are coming under increasing pressure to respond to demands to improve elder care.
At least the outlines of a solution are out there.
One is to end health disparity. “Everything links back to growing income inequality,” says Brunner, and Satariano agrees: “The issue of disparity is critical.”
Kay McVey, RN, and President Emeritus of the California Nurses Association, says income is directly related to the quality of elder care. If patients don’t have the money, they can “end up tied to a gurney or strapped in a wheelchair and stuck in the back of a facility.”
Two is to create a nation-wide health care system that coordinates care. “Single payer health care would end the idea that you can make big profits off of old people. It establishes one standard of care for everyone, whether you are in an acute care facility or a long term care facility,” says McVay. The only criteria should be: “What does the patient need?”
Three is to improve training. “ Medical schools must train students to treat older Americans,” says Brunner. “We have a right to make demands on our institutions, says Satariano. “You have to teach geriatrics,” says Landau bluntly.
Four is designing communities and programs that take into account the “ecology” of aging. “When you are elderly you need not just medical attention and medications,” says McVay, “you need good nutrition and exercise and things that challenge your mind. Otherwise it is just warehousing. It shouldn’t be that way and needn’t be that way.”
Mobilizing the medical profession, lobbying federal, state and local governments to stop turning a blind eye to the problem, and neutralizing the lobbying power of the “medical-industrial complex” will be a formidable task, and yet given the size of the constituencies involved, one that may not be as difficult as it initially looks.
In the end, it will also take a sea change in our attitude about elders, “Who are not exactly revered,” as Landau points out.
“I know it sounds sort of corny, but you have to have love and empathy. Aging is about loss—loss of independence, loss of mobility, eyesight, hearing, cognition—you need an approach that allows people to deal with loss in a collective, supporting way,” she says.