Samira Hussney          MPH 439

 

Aging and Public Health in the U.S

 

1.                 Who are the Elderly?

 

a.      Profile on age, income, health, healthcare, and disability

 

b.     Top leading causes of death for the elderly

 

1.     Heart disease

2.     Cancer

3.     Stroke

4.     Chronic obstructive pulmonary disease

5.     Influenza and pneumonia

 

2.                 Public Health Programs for the Elderly

 

a.      Primary Prevention:

·        Physical activities

·        Diet

·        Influenza Immunization

·        Reducing Falls

 

b.     Secondary Prevention

·        Screening

 

c.     Tertiary Prevention

·        Rehabilitation

 

3.                 References

·        Footnotes

·        Websites

·        Geriatric textbooks

 

 

 

 

 

Who are the elderly in the U.S?

 

Profile on age, income, health, healthcare, and disability:

The older population, persons 65 years or older, numbered 35.0 million in 2000 according to the U.S Census Bureau.  They represented 12.4% of the U.S. population, about one in every eight Americans.  The number of older Americans increased by 3.7 million or 12.0% since 1990, compared to an increase of 13.3% for the under-65 population.  However, the number of Americans aged 45-64 years old the “babyboomers” who will reach 65 over the next two decades increased by 34% during this period.  There are 20.6 million older women and 14.4 million older men, or a sex ratio of 143 women for every 100 men.  The female to male sex ratio increases with age, ranging from 117 for the 65-69 age group to a high of 245 for persons 85 and over.1

 

Since 1900, the percentage of Americans 65 and older has more than tripled (4.1% in 1900 to 12.4% in 2000), and the number has increased eleven times (from 3.1 million to 35.0 million).  The older population itself is getting older.  The 65-74 age group (18.4 million) was eight times larger than in 1900, but the 75-84 age group (12.4 million) was 16 times larger and the 85+ group (4.2 million) was 34 times larger.

 

Persons reaching age 65 has an average life expectancy of an additional 17.9 years (19.2 years for females and 16.3 years for males).  A child born in 2000 could expect to live 76.9 years, about 29 years longer than a child born in 1900.  Much of this increase occurred because of reduced death rates for children and young adult.  However, the past two decades have also seen reduced death rates for the population aged 65-84. Older women outnumber older men at 20.6 million older women to 14.4 million older men.  About 30 persons of older people live alone (7.4 million women, 2.4 million men).  In 2001, older men were more likely to be married as older women, 73% of men and 41% of women.  Almost half of older women in 2001 were widows. Divorced and separated older persons represented only 10% of all older persons.

The older population will continue to grow significantly in the future.  This growth slowed somewhat during the 1990’s because of the relatively small number of babies born during the Great Depression of the 1930’s.  But the older population will burgeon between the years 2010 and 2030 when the “baby boom” generation reaches age 65. By 2030, there will be about 70 million older persons, more than twice their number in 2000.  People 65 and over represented 12.4% of the population in the year 2000 but are expected to grow to be 20% of the population by 2030. 1

 

Minority populations are projected to represent 25.4% of the elderly population in 2030, up from 16.4% in 2000.  In the year 2000, 16.4% of persons 65+ were minorities – 8% were African-American, 2.4% were Asian or Pacific Islander, and less than 1% were American Indian or Native Alaskan.  Persons of Hispanic origin, who may be of any race, represented 5.6% of the older population.  In addition, 0.8% of persons 65+ identified themselves as being of two or more races.  Only 6.6% of minority race and Hispanic populations were 65+ in 2000. 

 

The median income of older persons in 2001 was $19,688 for males and $11,313 for females.  Real median income, after adjusting for inflation, fell by 2.6% for older people since 2000.  The Social Security Administration reported that the major sources of income for older people was:

 

·        Social Security (reported by 90 percent of older persons),

·        Income from assets (reported by 59 percent,

·        Public and private pensions (reported by 41 percent), and

·        Earnings (reported by 22 percent).

 

About 3.4 million older persons lived below the poverty level in 2001.  The poverty rate for persons 65+ continued at a historically low rate of 10.1 percent.  Another 2.2 million older adults were classified as “near poor” that is income between poverty level and 125 percent of this level. Households containing families headed by persons 65+ reported a median income in 2001 of $33,938 ($34,661 for Whites, $26,610 for African-Americans, and $24,287 for Hispanics). 

 

In 2000, 27% of older persons assessed their health as fair or poor, compared to 9% for all persons.  There was little difference between the sexes on this measure, but older African-Americans (41.6%) and older Hispanics (35.1%) were much more likely to rate their health as fair or poor than were older Whites (26%).  Limitations on activities because of chronic conditions increase with age.  Among those 65-74 years old, 26.1 percent reported a limitation caused by a chronic condition.  In contrast, almost half (45.1%) of those 75 years and over reported they were limited by chronic conditions. 

 

In 1997, more than half of the older population (54.5%) reported having at least one disability of some type (physical or nonphysical).  Over a third reported at least one severe disability.  Over 4.5 million had difficulty in carrying out activities of daily living and 6.9 million reported difficulties with instrumental activities of daily living which include preparing meals, shopping, managing money, using the telephone, doing housework, and taking medication.

 

The percentages of disabilities increase sharply with age.  Disability takes a much heavier toll on the very old.  Almost three-fourths (73.6%) of those aged 80+ report at least one disability.  Over half of those aged 80+ had one or more severe disabilities and 34.9% of the 80+ population reported needing assistance as a result of disability.  There is a strong relationship between disability status and reported health status.  Among those 65+ with a severe disability, 68% reported their health as fair or poor.  Among the 65+ persons who reported no disability, only 10.5% reported their health as fair or poor.  Presence of a severe disability is also associated with lower income levels and educational attainment. 

 

Most older persons have at least one chronic condition and many have multiple conditions.  The most frequently occurring conditions were: arthritis, hypertension,

hearing impairments, heart disease, cataracts, orthopedic impairments, sinusitis, and diabetes.  Older people had about four times the number of days of hospitalization as did the under 65 aged population.  The average length of a hospital stay was 6.4 days for older people, compared to only 4.6 days for all people. The average length of stay for older people has decreased 6 days since 1964.  Older persons averaged more contacts with doctors than did persons of all ages (7.0 contacts vs 3.7 contacts).  In 2000, older consumers averaged $3,493 in out-of-pocket health care expenditures, an increase of more than half since 1990.*  In contrast, the total population spent considerably less, averaging $2,182 in out-of-pocket costs.  Older Americans spend 12.6% of their total expenditures on health, more than twice the proportion spent by all consumers (5.5%).  Health costs incurred on average by older consumers in 2000 consisted of $1,775 (51%) for insurance, $884 (25%) for drugs, $693 (20%) for medical services, and $142 (4%) for medical supplies. (for more information on the profile of the elderly in the U.S go to this website: www.censu.gov)

Top leading causes of death for the elderly:

Three-quarters of all deaths in the United States occur among persons 65 years of age and over.  Heart disease and cancer have been the two leading causes of death among the elderly for the past two decades.  Over one third (35 percent) of all deaths are due to heart disease, including heart attacks and chronic ischemic heart disease.  Cancer accounted for about one-fifth (22 percent) of all deaths.  Since 1990 there has been a downward trend among white men 65-74 years old (3 percent decline) and 75-84 years of age (6 percent) although the trend varies greatly by type of cancer. This decrease does not hold among women or the oldest old.  Breast cancer increased until 1990 and then stabilized among white women 65-84 years old; it continued to increase among the oldest group of white women and among black women over 75 years of age.12

 

Other important chronic diseases among persons 65 years of age and older include stroke (cerebrovascular disease), chronic obstructive pulmonary diseases, diabetes, and pneumonia and influenza.  The leading causes of death are the same for the different age-

 

*Principal sources of data for the Profile of Older Americans are the U.S. Bureau of Census, the National Center on Health Statistics, and the Bureau of Labor Statistics. The Profile incorporates the latest data available but not all items are updated on an annual basis.

 

 

race-sex groups, but the order of their ranking varies.  Heart disease remains the leading cause of death for most of the groups.  Cancer is as common as heart disease within the youngest age group, 65-74 years of age, but decreases in importance with age, ranking among women 85 years of age and older.

 

The third leading cause of death and disability is most often stroke.  Stroke incidence is strongly dependent on both the age and gender of individual, with advancing age and male sex considered as major stroke risk factor.  The U.S. census studies have shown that men are more frequently discharged from acute care hospitals with the primary diagnosis of cerebrovascular disease for all age groups over 55 years and older.  Men have increased mortality rates until age 75, when stroke fatality rates appear to increase in women.  Incidence of cardiovascular disease is increased in men compared to women and one possible explanation is their hormonal differences. Numerous studies have established that the hormonal therapy with estrogen for women is associated with at least 50% reduction in cardiovascular disease.  

 

Because of improved primary medical prevention, stroke risk factors such as hypertension have been reduced.  Improved early diagnosis and treatment of acute stoke is responsible for the decrease in stroke mortality and the increase in survival.  This is particularly applicable to the geriatric age groups which are more likely to have preexisting medical problems and functional impairments prior to developing a stroke.  Even relatively minor physical and cognitive impairments following a stroke can seriously influence the ability to resume an independent life in the geriatric group.  According to a study done by the World Health Organization in eleven countries for a period of ten years, the study confirmed that stroke incidence rates increase sharply with age for all populations  indicating that the relationship between aging and stroke incidence is a cross-cultural phenomenon. 

 

However, among white men and women in the U.S 65-74 years old, the fourth leading cause is chronic obstructive pulmonary diseases (COPD) which include chronic bronchitis, emphysema, asthma, and other chronic respiratory diseases.  Deaths from COPD are believed to be caused primarily by cigarette smoking.  COPD ranks as the fourth or fifth cause of death for almost all other age-race-sex groups.  The remaining leading causes vary in rank among different age, race, and sex groups.

 

Elderly decedents frequently suffer from more than one life threatening condition at the time of death.  It is sometimes difficult for the attending physician or other official charged with filling out the death certificate to identify the initiating cause among other conditions.  While a single cause, known as the underlying cause of death, is used in all statistical reporting, the death certificate also allows for a listing of other causes in addition to a single underlying cause, up to 20 diseases and conditions.

 

Although infectious diseases are no longer the most common causes of death, pneumonia and influenza remain among the top 10 causes of death.  According to the statistics in 1997, pneumonia and influenza were responsible to 5.5 percent of deaths of people 65 years of age and older.  However, the role infectious diseases play in declining health and mortality is not fully apparent.  This is because several other medical conditions caused by infectious diseases, such as rheumatic heart disease and others, are classified as diseases of the heart despite their infectious origin. Pneumonia is one of the most serious infections in elderly persons, especially among women and the oldest old.  In  a study of a nursing home acquired pneumonia, death resulted in 40 percent of patients who required hospitalization. 

 

The following table explains the rates for the different diseases in the different races:

Table 1 Top five leading causes of deaths for persons 65 years and over by race.14  For more information on ethnic groups and diseases go to this website:

www.aoa.gov 

 

 

 

 

 

 

 

 

 

Rank

Five leading causes of death per 100,000 people over the age of 65 per year by group

 

White

Black

American Indian

Asian or Pacific Islander

Hispanic

1

Heart Disease (1,721.8)

 

Heart Disease (1,838.5)

 

Heart Disease (962.2)

 

Heart Disease (856.1)

 

Heart Disease (1,005.1)

 

2

Malignant neoplasms

(1,128.9)

Malignant neoplasms

(1,281.9)

Malignant neoplasms

(671.9)

Malignant neoplasms

(656.6)

Malignant neoplasms

(639.2)

 

3

Cerebrovascular

Disease

(424.7)

Cerebrovascular

Disease

(479.3)

Cerebrovascular

Disease

(249.0)

Cerebrovascular

Disease

(311.1)

Cerebrovascular

Disease

(235.5)

 

4

Chronic lower respiratory diseases

(323.1)

Diabetes

Mellitus

(274.7)

Diabetes Mellitus

(223.2)

Influenza and Pneumonia

 (118.4)

Chronic lower respiratory diseases

(189.8)

 

5

Influenza and Pneumonia

(171.4)

 Chronic lower respiratory diseases

 (183.8)

Chronic lower respiratory diseases

(192.6)

Chronic lower respiratory diseases

 (117.0)

 

Influenza and Pneumonia

(113.7)

 

 

Primary prevention programs

Primary prevention is to prevent the development of the disease.  This chapter will explain more about primary prevention, than secondary and tertiary, because it is a major concern in public health.  Because the elderly population is growing in size and in proportion of the total population in the U.S. the costs to the community of the elderly being in poor health are also growing.  There is evidence supporting the important role of preventive behavior and public health measures which are playing in explaining the differences in reduced levels and trends in mortality and disability.  Preventive  measures such as physical activities, diet, reducing falls and immunizations are essential. 

Exercise has been shown to build muscle and bones, reduce high blood pressure and the incidence of heart disease, diabetes, and colon cancer, and alleviate the pain of arthritis and depression.  Yet, surveys reveal that 56 percent of men and 61 percent of women either never engaged in physical activity or did so on irregular basis.  Older people are afraid to exercise believing it would harm them.9  On the contrary regular physical activity in their daily routines is recommended and clinician counseling is necessary to promote and encourage older people to stay active.  Studies have shown that physically inactive persons have a greater risk of developing hypertension than those who exercise.  A similar effect on blood pressure appears in both men and women.  The effects of exercise on the mobility and independence of the elderly is of primary concern.  As people get older, they interact more with their general practitioner.  Therefore, physicians are in excellent position to encourage positive behaviors such as exercise and diet.  Unfortunately, many doctors do not seem to be informed about the benefits of geriatric exercise.  Even among physicians who do prescribe exercise, few of them spend more than 3 to 5 minutes to counsel.9

 

Adherence to exercise has been a problem.  Perceived frailty and poor health may provide the greatest barrier to exercise adherence for an elderly person.  Exercise is difficult because of tiredness as well as the lack of commitment and time.  Thus, interventions should focus on increasing the confidence of older people so that they can overcome barriers to exercise.  To become more physically active need only thirty minutes a day.  That means a person can walk for ten minutes and later walk for twenty minutes, or vacuum the carpet vigorously for twenty minutes.  But the person has to be consistent and do this on daily basis.  Some elderly need to consult with their doctor to start an exercise program that is safe, and will help them achieve their goals.  Remember, almost all individuals will benefit from increasing their activity level.  Start slowly and gradually build up to the full program prescribed.  Tai Chi has been used in the Far East for centuries and has also been practiced in the United States mostly by older individuals of Asian descent to improve balance and fitness.  Tai Chi is gaining popularity and can currently be learned at many health clubs and senior centers.

 

Adequate nutrition and a well balanced diet is also of vital importance in old age in order to prevent and control the hazards of aging.  With older age, the energy needs are reduced as a result the quantity of food intake is lowered while the nutrients should remain unchanged.  For example, milk, fresh fruits, vegetables particularly green leafy vegetables, and dietary fiber should be included to meet the body’s needs.  Intake of calcium to compensate for it’s loss due to aging is very essential.  Iron deficiency leads to anaemia, so the diet for the elderly should contain sufficient amount of iron  Foods rich in saturated fats should be avoided because they increase the risk of coronary heart disease.  The association between foods, high in dietary fat, and certain forms of cancer is being studied. It is clear that a direct relationship exists between nutritional risk factors and certain key diseases.  According to a study published in the Journal of the American Medical Association, eating dark breads or cereal high in fiber lowered the risk of cardiovascular disease in a group of adults aged 65 or older by 21 percent compared to those with the lowest cereal fiber consumption.  A change in diet late in life can lessen a person’s risk.  Older people who get regular exercise, avoid tobacco use, and eat healthy have half the risk for disability of those who do not have a healthy lifestyle.2

 

Many elderly people become incontinent and they think that if they drink less juice or water they will have less problems, this is not healthy.  Elderly with dentures avoid eating crunchy food that is high in fiber, they instead go for soft food that is high in fat.  Cooked or baked vegetables and soft breakfast cereals are denture friendly.  

 

For the elderly who live alone and can not cook everyday, there are community programs to provide healthy meals for them at a reasonable cost.  Meals on Wheals is one of the good programs.  Other programs are provided such as the Elderly Nutrition Program which provide nutritionally balanced meals to those who are 60 years of age and older. As people get older they get relaxed and get wider, fatter and less healthy.  They want to eat more and do less exercise.  Older people need to stay active and eat healthy to reduce the risk of disease.

 

The National Center for Chronic Disease Prevention and Health Promotion is developing new partnerships with Public Health Agencies and state health departments to put promising prevention strategies into effect in communities across America.  For example, the Northwest Effectiveness Center at the University of Washington is working with senior centers to help people older than 65 exercise more, eat well and preserve their independence.  One of their programs was the Arthritis self-help program and the outcome of this program was that for every $1 spent on the program, $3.42 was saved in the cost of hospitalization and visits to physicians.

 

Immunization:  Influenza is an important cause of morbidity and mortality in the elderly.  Many observers have stated that influenza is a disease which can be controlled with effective prevention treatment.  Influenza vaccine has been shown to successfully reduce influenza and pneumonia associated hospitalizations and deaths.  Influenza vaccine should be given to all people 65 years of age and over on annual basis.  Elderly persons are at increased risk for complications from influenza infections.  More than 90% of the deaths attributed to pneumonia and influenza in these epidemics occurred among persons aged 65 and older.  In a large study done in a community dwelling elderly persons, influenza vaccination reduced hospitalization rates by 48-57% for pneumonia and influenza.11  Persons who were 65 years of age and older reported that during epidemic periods influenza vaccination prevented 31-45% of hospitalizations and 43-49% of deaths due to all respiratory conditions.  Evidence is showing that during the influenza outbreaks, influenza vaccine is reducing illness, hospitalization and deaths in the elderly living in institutions and senior centers. Vaccination of nursing homes residents may prevent institutional outbreaks. The cost benefit and cost effectiveness support the recommendations for vaccination of all persons aged 65 and over. Immunization was cost effective and resulted in cost savings compared with no vaccination strategy.  It is clear that strategies aimed at the patient or healthcare provider are needed to increase implementation of vaccination policy to ensure that any recommended vaccine program is clinically and economically effective.  Vaccine is most cost effective when included as part of routine health care encounter.  The Medicare Influenza Vaccination Demonstration, performed 1988-1992, found influenza immunization to be effective and offer cost savings to the Medicare program.  Therefore, as of May 1, 1993, influenza immunization joined pneumonia immunization as a fully reimbursed Medicare service.

“When should the vaccine be given?” -  Mid October to mid November is the recommended period for vaccination.   Evidence suggests that aggressive promotions of vaccination directly to patients by physicians and health care institutions increase vaccination rates.  The American Geriatrics Society strongly recommends that comprehensive programs to provide wide spread influenza vaccination will contribute significantly to maintaining the health of older Americans.8

 

Reducing Falls:  The annual incidence of falls among the elderly is approximately 30 percent in persons over the age of 65 years.13  Children fall all the time but they bounce, however, falls are more serious for the elderly.  The risk of falls is greater in older persons, with the annual incidence up to 50 percent in those over age 75.  Approximately 30 to 50 percent of falls result in minor soft tissue injuries that do not require medical attention.  An estimated 1 percent of falls result in hip fractures; 3 to 5 percent result in other types of fractures, and an additional 5 percent produce serious soft tissue injuries.  Because of the significant incidence of falls in the elderly, physicians should have an organized approach to fall assessment and prevention.  Detecting the history of falls is essential.  Falls could happen from environmental factors such as slippery floors, loose rugs, uneven thresholds, or from age related factors such as; vision, medications, weak lower extremeties, and problems with walking and balance.  Studies have shown that frequency of falling is higher in hospitals and nursing homes compared with those living in the community.  It is estimated that one in five in older hospitalized patients will fall during a hospital stay.  In nursing homes, up to 50 percent of residents fall each year.

 

Of all the fall related fractures, hip fractures cause the greatest number of deaths and lead to the most severe health problems and reduced quality of life (Hall 2000).  Most patients with hip fractures are hospitalized for about one week.  Medicare costs for hip fractures were estimated to be over $3 billion in 2000.  Through self-help, seniors can reduce the environmental risk factors by:

  1. Increasing lower body strength and improving balance through regular physical activities,
  2. Asking their doctor or pharmacist to review their medications, 
  3. Removing tripping objects at home such as slippery rugs and clutter in walkways,
  4. Using non-slip mats in bathtubs and on shower floors,
  5. Having grab bars put in next to toilet, in the tub or shower,
  6. Having hand rails put in on both sides of stairways, and
  7. Improving lightening throughout the home.

Health professionals could prescribe interventions such as:  Bone strengthening medications, foot wear interventions in the shoes which could help balance and stability, and assistive devices such as walkers and canes.  In addition, educational training programs for staff in hospitals and nursing homes help to reduce incidences in those institutions.  In the long term, interventions to reduce falls will cut the cost of specialists and hospitalization in the elderly.  There are many programs for reducing falls in the elderly which make a difference in health outcome.  For example, the Toledo program “Guard Rails”, another example is “Tai-chi” it was reported that older people who participate in programs like this are less likely to fall.  

 

Secondary prevention - Screening

Secondary prevention is to identify and treat symptoms existing in persons with risk factors or pre-clinical disease such as screening.  Screening could be done for blood pressure, colon cancer, mammograms, pap test, prostate exam, vision screening, hearing impairment, and hypertension.  Many screening tests are considered effective preventive intervention.  For example: screening for colorectal cancer is recommended for all persons aged 50 and older.  The frequency of screening varies with the test chosen.  Pap smears for instance could be discontinued for women after the age of 65 if the patient has received regular screening prior to that time and all tests came normal.  For Prostate Cancer, PSA measurement for men is recommended by the American Cancer Society to begin at age 50 (age 40 for African American men).  Screening for Hypertension is recommended for all adults at least every two years. Women aged 65 and older should be screened routinely for osteoporosis.  Screening should begin at age 60 for women at increased risk for osteoporotic fractures.  Vision screening is recommended for all elderly people.  Although evidence is insufficient to recommend routine screening in elderly persons, clinicians should consider cholesterol screening on a case by case basis for persons age 65-75 years old with additional risk factors.

 

Will the patient survive long enough to benefit from screening?  Many recommendations for screening in the elderly state that screening should be continued if the patient is in “good health” or has a reasonable life expectancy.11  The answer often is derived from time-to-benefit from screening and the patient’s estimated remaining years of life.  Also, age associated body changes may cause screening tests to perform differently in older patients.  Mammography, for instance, performs better in older women, whereas the Pap smear test is more reliable in younger people.  Mammography screening helps older women in detecting tumors and the fact that tumors grow slower in older women this means that through screening breast masses could be detected and removed.

 

Screening for hearing impairment:  Hearing loss can be identified in 33% of persons aged 65 and older and in up to half of persons 85 years and older.  Older persons are particularly prone to suffering the associated social and emotional disabilities that come from loss of hearing.  Since screening is a preventive measure it should be suggested that all older persons aged 65 and older should have a hearing impairment screening.

 

Several disease and patient specific factors need to be considered when assessing the candidacy of an older person for screening.  The physician must assess the impact of aging on the screening test performance.  The patient’s remaining years of life and candidacy for further testing should be assessed.  Systematic assessments should lead to maximizing the benefit of screening elderly people while minimizing the harm and the unnecessary cost involved.  Public health recommendations need to weigh the benefit of screening elderly people against the cost and potential harm from screening.  For elderly patients who have a short life expectancy, clinical care focus should be on a treatment that is likely to be of more immediate benefit than on screening.  Older people with multiple medical problems or dementia may find screening burdensome.  The decision for screening for older people should be based on the individual’s medical condition, life expectancy, and personal preference and willingness.  Thus, patients should be allowed to be excluded from screening test if it is unlikely to be of benefit to them and on the other hand should have access to it if they wish.  Guidelines and insurers should not employ strict age-based criteria for deciding who should be screened or whose screening tests should be paid for.

 

 

Tertiary Prevention - Rehabilitation

In tertiary prevention, an existing, usually chronic condition is appropriately managed to prevent frailty and further functional loss.  Geriatric rehabilitation services are designed to enhance and restore functional ability and enable many older people to live with less restrictions, thereby resulting in net savings in health care costs.  Geriatric rehabilitation is done after any kind of major surgery i.e. heart, lung, hip, knee, stroke etc. Rehabilitation should not be restricted to short term hospital rehab units or free standing rehabilitation hospitals.  Services should be available in all settings in which older persons receive health care such as medical units in general hospitals, nursing homes, and home care programs.  An interdisciplinary approach is very effective in the delivery of geriatric rehabilitative services.  It may involve physical, speech, occupational and recreational therapists, doctors, nurses, social workers, and other health professionals.7

 

Primary care providers should be trained to assess the need for these services.  They need to know when to seek the consultation of rehabilitation professionals and monitor the progress towards achieving the goals of these services.  Although these services are often beneficial, focus has to be geared towards the merits and costs of some approaches.  Intensive therapy after a stroke or brain injury may result in more rapid progress in the patient and earlier discharge from the hospital.  Rehabilitation after a knee surgery may accelerate the functional recovery.  Rehabilitation can also be tailored toward specific problems such as heart disease, hip fracture, and leg amputation.  Speech disorders may also require rehabilitation.  Because patients respond differently, rehabilitation programs must be individualized.

 

Rehabilitation is central to the practice of medicine in the elderly.  The evidence of its efficacy led commissioners and health providers to invest in rehabilitation.  Its scope is wide and includes acute and chronic perspectives.  It is an intervention between impairment and disability or between disability and handicap - with the ultimate aim of reducing handicap.  It can also be more focused, for example, at specific therapy to reduce the impairment associated with a painful shoulder.  Poly pharmacy is now as important as rehabilitation in geriatric practice and that is reviewing the medications of the elderly people.4

 

Evaluation of the rehabilitation process is necessary to provide evidence for its effectiveness.  Intervention should include treatment, care and advice on coping strategies for patients and carers.  The most favorable outcomes of the intervention would be the reduced use of hospitals and nursing homes and reduced annual medical care costs.  A good example of this was the demonstration that falls could be prevented in the elderly people by targeting rehabilitation on those identified as being at high risk of falling.

 

Funding for rehabilitation services of various durations and intensities should be provided to the elderly because it is an important component of geriatric care.  However, data and evaluations are needed to determine which older individuals with functional disability will derive the greatest benefit from these services.  For example, it has been established that women continue to live longer than men and although they appear to have more biological protection  from stroke until the oldest age group, those who develop strokes may be more severely impaired and are less likely to be referred for rehabilitation. A point to consider also is the willingness of the older disabled patients to go for rehabilitation services.  Medical professionals can not force patients to participate in these activities because the patients’ wishes must be respected.  Healthcare workers should be sensitive to the willingness of the older patients as well as the compliance with the prescribed therapy.  Healthcare workers should be advocates for patients and include them in the decision making process.  In some people factors which contribute to willingness to undergo therapy could be; independence, stamina, lack of pain, no presence of regressive behavior, and the belief that older people should participate in some physical activity.  The deterrent factors could be; lower sense of independence, presence of pain, depression, dementia, and the expectation of help from others.  In a comparative study done between Japan and the U.S.A, the differences were found to be in the family background and culture.  Japan had a higher bed-ridden elderly than the U.S because the Japanese people depend on others and expect help from them all the time much more than the American people.  They expect to live with their children or grandchildren and be taken care of.  Healthcare workers in Japan have to educate the elderly patients and repeatedly encourage them to utilize their functional capacity as much as possible in their daily activities.  However, it is worthwhile mentioning that excessive willingness for rehabilitation for older people could be dangerous and should be examined as well.

 

 

References:

1.  Department of Health and Human Services, USA (2002). A profile of older Americans: 2002. Retrieved April 10, 2003 from: http://www.aoa.gov/aoa/stats/profile/default.htm

2. Media Relations & Marketing (2002).  Elderly need to emphasize good diet and exercise.  Retrived 4/1/03  from www.mediarelations.ksu.edu  

3.  Tom Hickey, Marjorie A. Speers, Thomas R. Prohaska,  Public health and aging.  Johns Hopkins University Press, 1997.

4.  Stanley F. Wainapel, Avital Fast,  Alternative medicine and rehabilitation.  New York: Demos, c2003

5.  Mary Law, Evidence-based rehabilitation: a guide to practice.  Thorofare, NJ:  Slack, c2002

6.  Marie S. Seabrook, Elderly Americans: issues and programs.  Nova Science Publisher, 2002.

7.  The Merck Manual of Geriatrics.  Chapter 5. Prevention of disease and Disability. Retrieved 4/4/03 from www.merck.com/pubs/mm_geriatrics

8.   Disease Management & Health Outcomes (2002).  Economic Evaluations of Influenza Vaccination in the Elderly: Impact on Public Health Policy.  Retrieved 4/10/03

from:  http://journals.ohiolink.edu/cgi-bin/sciserv.pl?

9.The National Institute of Health.  Exercise: A Guide from the National Institute on Aging, (99-4258), 3-5, 16-19.

10.The American Geriatrics Society (1996).  AGS Position Statement Prevention and Treatment of Influenza in the Elderly.  Retreived 4/9/03 from: www.americangeriatrics.org/products/positionspapers

11. Adult Health Screening.  Preventive Health Care.  Retrieved 4/10/03 from www.sh.Isuhsc.edu/fammed/OutpatientManual/PreventHealthCare.htm

12. National Center for Chronic Disease Prevention and Health Promotion.  Healthy Aging.  Retrieved 4/4/03 from www.cdc.gov/nccdphp/bb-aging/

13. National Center for Injury Prevention and Control.  Falls and Hip Fractures Among Older Adults.  Retrieved 4/4/03 from www.cdc.gov/ncipc/factsheets/falls

14. Center for Disease Control and Prevention.  Deaths: Leading causes for 2000. National Vital Statistics Reports 2002; 50(16).