Absent effective preventive measures and improved health management, senior healthcare costs will financially cripple our healthcare system. Currently, Americans over 65 represent 13% of all hospital care, and 50% of all physician work hours.(3) But there are positive signs on the horizon. First, seniors’ disability rates are declining in the U.S. Since 1980 there has been a nearly 15% decrease in the prevalence of chronic disability and institutionalization among people 65 and older.(4) A drop in disability translates directly into cost savings since it is seven times more expensive to care for a disabled senior versus a healthy one.(5)

A second reason for optimism is that boomers are healthier than their parents. Earlier diagnosis and treatment of chronic diseases, behavioral changes in diet and exercise, and the health consumer empowerment movement have each played a role.(5) And the third sign of positive change is that both science and technology are progressing and contributing to better understanding of diseases and the execution of methods to both diagnose and treat them.

If that is the good news, what are the concerns? One major concern is that our country is poorly prepared from a health-professional manpower standpoint to properly manage the complexity of aging. The average 75-year-old today has three chronic diseases and is on 4.5 medicines. Yet fewer than 1% of all doctors, nurses, pharmacists and physical therapists have had advanced geriatric training.(3) How does this disconnect play out? Let’s take just one case in point, the under diagnosis of depression in the elderly – an easy miss if you’ve not been alerted by your training to look for it, and if you’ve been raised in the age of, “Mom’s slowing down is just part of her getting old.”

Depression is often misdiagnosed as cognitive impairment, in spite of the fact that there are many good reasons to be depressed: retirement, widowhood, bereavement and isolation.(3) But the cause of depression can be much more subtle. For example, having a hearing impairment is frequently associated with depression. More aggressive approaches to hearing loss would be very beneficial. Present in 1/3 of those over 65, 2/3 of those over 70, and 3/4 of those over 80, hearing affects quality of life and interpersonal relationships, and is a significant safety issue.(6) And if other diseases cause depression in the elderly, the reverse is true as well. Depression increases the risk of disability from all other causes in the elderly by 67%.(6) Training in geriatrics sensitizes clinicians to these various interactions.

A second concern is treatment strategies. Where should we begin? A logical starting point is with cognitive impairment. There are some four million American seniors currently suffering from Alzheimer’s disease and dementia, with numbers expected to reach 14 million by 2040. The numbers increase with age. While 2% may have the disease at age 65, 16% are affected by 85.(7) The costs are staggering, estimated currently at $100 billion per year, making it the third most expensive disease in the U.S.(8) Nearly 50% of all nursing home patients are cognitively impaired.(3) The scientific focus on neurodegenerative diseases in both public and private sectors is enormous, and reflects both the seriousness of the problem and the potential positive impact that would accompany a solution.

Where else is there significant pay dirt? Incontinence affects 13 million Americans, including half of all nursing patients, at a cost of nearly $12 billion per year.(9) Experts suggest that we also target other conditions that lead to institutionalization. Major activity limitations are a common cause of nursing home admissions. The most common cause is arthritis, affecting 50% of people over 65, and an estimated 60 million people by 2020.(10) Hip fractures are a second source of immobility, projected to occur 420,000 times in the year 2020, nearly all fall related, and resulting in a loss of independence in nearly 30% of those affected. Fully 80% occur in women, who are at special risk because of osteoporosis.(3)

In addition to the obvious benefits of medical treatment and the creation of safe environments, the expansion of exercise and muscle strengthening could make a real difference in the incidence of falls and fractures. At present, even minimal exercise is totally absent in one-third of those over 65, and weight training is nearly non-existent.(11)

Finally, a focus on medications, their interactions, assistance in their accurate and regular administration and regular evaluation would lead to further improvement.Dollars spent on both geriatric training, and the prevention of those conditions most likely to cause disability and institutionalization, are an extraordinarily wise investment. Adding a single month of independence and health to America’s senior population would save $5 billion. A 10% decrease in hospitalization and institutionalization would accrue $50 billion in savings per year.5
But is good health simply delaying the inevitable, a long and expensive deterioration occurring later in life? Surprisingly, no. Studies of centenarians have shown that their decades of relative good health are followed by a highly compressed period of compromised health at the end of life.(12)

References:

1.Hobbs FB, Damon BL, eds. 65+ in the United States. Washington, DC: US Bureau of the Census; 1996. Available at:Accessed October 27, 1998. http://www.census.gov/prod/1/pop/p23-190/p23190-f.pdf

2.Hodes RJ, Cahan V, Pruzan M. The National Institute on Aging at its twentieth anniversary: achievements and promise of research on aging. J Am Ger Soc. 1996;44:204-206.

3.Manton KG, Corder LS, Stallard E. Monitoring changes in the health of the U.S. elderly populations: correlates with biomedical research and clinical innovations. FASEB J. 1997;11:923-930.

4.Pardes H, Manton KG, Lander ES, Tolley HD, Ullian AD, Palmer H. Effects on medical research on health care and the economy. Science. 1999;283:36-37.

5.Alliance for Aging Research. Ten Reasons Why America is Not Ready for the coming Age Boom, 2002.

6.Penninx BW, Leveille S, Ferrucci L, et al. Exploring the effect of depression on physical disability: longitudinal evidence from the established populations for epidemiologic studies of the elderly. Am J Public Health. 1999; 89:1346-1352.

7.Kane RA, Kane RL, Ladd RC. The Heart of Long-Term Care. New York, NY: Oxford University Press. 1998.

8.Meek PD. McKeithan K, Schumock GT. Economic considerations in Alzheimer’s disease. Pharmacotherapy. 1998;18:79-82.

9.Freiman M, Brown E. Special care units in nursing homes-selected characteristics, 1996. Rockville, Md: Agency for Health Care Policy and Research; 1999. MEPS Research Findings #6. ACHPR Publication No. 99-0017; January 1999.

10.American Association of Retired Persons (AARP). Fitness: do you make physical activity and integral part of your daily routine? AARP Webplace. Available at:http://www.aarp.org/confacts/health/fitness.html. Accessed September 13, 1999.

11.Fantl JA, Newman DK, Colling J, et al. Urinary incontinence in adults: acute and chronic management. Clinical Practice Guideline Number 2 (1996 Update). Rockville, Md: agency for Health Care Policy and Research; 1996. AHCPR Publication No. 97-0682.

12.Perls TT. Centarians prove the compression of morbidity hypothesis, but what about the rest of us who are genetically less fortunate. Med Hypotheses. 1997;49:405-407.