Smoking Cessation

According to Claude Earl Fox, the Alabama State Health Officer, evidence shows that people can decrease their chances of dying of a smoking-related cause even if they stop smoking at an older age. (#066) Rebecca Richards of the North Woods Health Careers Consortium agrees and calls for increased public and professional awareness of this fact. In particular, she recommends that smoking cessation programs aimed at the elderly be undertaken in communities and at senior centers. (#183)

Similarly, participants at the Surgeon General's Workshop on Health Promotion and Aging also recognized the benefits of smoking cessation and proposed a number of educational approaches aimed at opinion leaders, the media, and health professionals to convey the message that cessation can be beneficial for older people. They also proposed a range of activities to make nonsmoking the norm in environments that older people frequent and to encourage smoking cessation programs. (#799)

Alcohol

Richards reports estimates that one in twelve elderly men will develop a drinking problem.⁴ She recommends that reimbursement be expanded for treatment of drug and alcohol problems in the elderly, citing recent research showing that older people are more likely to complete such treatment successfully and to remain free of the abused substance for longer periods of time than are young people.⁵ (#183)

Fox says that excessive use of alcohol among the elderly can disguise certain medical problems. For example, alcohol can mask pain, leading to delay in seeking medical attention for a heart attack. Alcohol also affects blood sugar metabolism, leads to liver disease, causes digestive problems, encourages poor nutrition habits, and alters the function of the brain. Another serious problem is the dangerous interaction of alcohol and drugs. (#066)

In light of such problems, participants at the Surgeon General's Workshop on Health Promotion and Aging recommended professional and public education programs to inform people about the problems of alcoholism and their prevention, and service programs in the community to help older adults overcome alcohol problems. (#799)

Misuse of Medication

Rather than concern about the abuse of addictive substances so often expressed for adolescents and young adults, the most pressing "drug" issue for many older adults is the misuse of medication.

The American Society of Hospital Pharmacists sees a need for an objective dealing with misuse of medication by the elderly population. Some of the ways suggested to reduce misuse are heightened awareness about medication information on the part of physicians, increased cooperation among various health care professionals, and more patient education on the use of prescription and nonprescription drugs. (#574)

Edward Wagner of the Group Health Cooperative of Puget Sound calls for more attention to the adverse effects of prescribed medications, the use of psychoactive drugs and their relationship to injury, and the excessive or inappropriate use of commonly prescribed cardiovascular and psychoactive drugs, which may be a risk factor for falls, fractures, and hospitalization. Wagner would like to see a federal initiative to reduce the inappropriate or excessive use of antihypertensive drugs or toxic psychoactive and psychotropic drugs. (#738)

Mental Health

Dementia becomes a major problem over age 75, according to Katzman, and in the very elderly (over age 85) the demented constitute about one-third of the population. He recommends training "a cohort of nursing aides or other paraprofessionals" to help provide the needed optimum care and to help prevent excess disability. (#794)

Richards notes that although recent initiatives have focused attention and some resources on dementias, other mental health disorders common to older adults also require attention. A community study in North Carolina showed a prevalence rate for depression in older adults of 8.2 per 100.⁶ Another study, suggesting that health care providers may not be educated to recognize mental health problems of the elderly, indicated that 90 percent of elderly men who committed suicide had visited their physicians within their last three months.⁷ (#183)

John Miner of the Massachusetts Mental Health Center emphasizes that the mental health needs of the elderly, especially for emotional support and a feeling of personal caring, should be particularly stressed in the education of nurses and physicians. (#468)

James Sykes, representing the National Council on the Aging, states that "mental health is a vital goal for all Americans but especially for the large and growing population of retired persons. The insults of the psychological effects of years of purposelessness are as severe as cancer." Rather than strategies to prevent mental illness, health promotion strategies are needed that provide status, purpose, and useful roles to people whose retirement has changed their usual bases for purposeful lives. There is also a need for well-trained and appropriately compensated providers of care, as well as family members who come into daily contact with impaired older persons. (#768)

James Sugarman of the Retired Senior Volunteer Program Directors recommends volunteer work as one answer to finding productive, fulfilling roles in older age. He further comments that the exercise, regular diet, and physical and psychic benefits derived from volunteerism are important and should be emphasized in local, state, and national programs. (#769)

Physical Activity and Recreation

Scientific evidence has demonstrated that carefully planned programs of physical activity can prevent or diminish the degree of functional loss associated with some chronic diseases affecting the older population, says Fox. (#066) According to a 1987 survey, only 7.7 percent of women and 8.5 percent of men over 65 currently exercise at 60 percent of functional capacity for 20 minutes or more, three or four times a week.⁸ Fox recommends as an objective that 40 percent of adults over 65 be engaging in regular, appropriate physical exercise, such as walking, swimming, or other aerobic activities, by the year 2000. (#066)

Richards points out the obstacles to exercise programs. Walking, a common form of exercise for older adults, may be difficult for those with arthritis or painful foot conditions. Walking in adverse weather can be dangerous for those with cardiovascular or balance problems. Swimming pools, particularly therapeutic pools, are not available in many communities. Richards feels that access to exercise programs for all older adults should be a priority for the new objectives and that transportation to, and reimbursement for, the cost of exercise programs at appropriate facilities must be addressed as part of this objective. (#183) Others stress the importance of building exercise into regular daily activities rather than depending on traveling to distant facilities. (#459)

The National Recreation and Park Association (NRPA) also stresses recreational activity as crucial to the improved health and wellness of older individuals. The NRPA suggests that services be provided in settings as close to home and as consistent with usual lifestyle as possible. Each state and regional office on the aging, the NRPA says, should be required to include park and recreation programs for the aged in its referral systems to ensure greater access to recreation by the elderly. (#777)

Injury Control

Richards says that morbidity rates, not just death rates, from accidents and falls of the elderly should be examined. The cost of the morbidity (both direct medical costs and indirect costs such as subsequent institutionalization or missed work by care givers) should be compared to the cost of providing preventive services directed at known risk factors for falls. She says, for example, that vision problems are known to be a significant risk factor for falls, yet eyeglasses and examinations to prescribe, fit, or change them are not covered by Medicare.⁹ (#183)

Michael Oliva of Aurora, Colorado, calls for more money to be provided from appropriate agencies for injury control programs for the elderly. All health care providers who serve the elderly, Oliva says, including Community Health Centers and those who provide health promotion and wellness programs for the elderly, should include injury control in their plans of care. (#378)

The Surgeon General's Workshop on Health Promotion and Aging calls for architects, engineers, city planners, and similar professionals to be educated about the capabilities and limitations of older persons, and recommended that they incorporate these factors into their designs. (#799)

Elder Abuse

Increasingly, elderly people are caring for others who are even more elderly or sick, says Richards. The added stress on older care givers, as with younger care givers, can lead to abuse. She suggests an objective to reduce elder abuse by requiring that facilities discharging Medicare patients demonstrate that comprehensive, systematic discharge planning has occurred. Elder abuse could be decreased by carrying out a systematic assessment of the older person and the potential care giver, as well as the entire family constellation.¹⁰ (#183)

Melanie Hwalek, a psychologist and gerontologist in Michigan, agrees that there is a need for objectives to prevent and treat elder abuse and neglect. There also is a need for valid and reliable measurement instruments to assess both the risk of elder abuse in community populations and the substantiation of elder abuse among suspected cases from state reporting systems and human services agencies. She cites and supports the solutions advocated by the Surgeon General's Workshop on Violence and Public Health, including the development of educational programs for professionals on detection, assessment, and treatment of abuse; educational programs for the public; community outreach; research, especially national studies on incidence and prevention; and a national clearinghouse for coordinating research, training, and program development, along with services to help elder abuse victims and to help families care for older people.¹¹ (#403)

A number of people point out that many providers of long-term and chronic care are family members, usually women, and that they experience stress and often suffer from ill health and financial worries. (#110; #451) Olivia Maynard, Director of the Michigan Office of Services to the Aging, suggests increased awareness of the problems of family care givers through public service announcements, identification of community resources to assist in coping with family stress, and physicians providing information to family members about resources at the time of diagnosis of a serious or disabling chronic condition. More family care givers should be enrolled in support or self-help groups. In addition, more emphasis should be placed on stress identification and control by private, voluntary, and public health organizations, as well as on the provision of education on community resources by employers. (#145)

Cardiovascular Disease

Somers and Weisfeld indicate that heart disease and related circulatory conditions are still the major cause of severe disability among the noninstitutionalized elderly and major risk factors are not only known but, in most cases, controllable.¹² (#428) Rosalie Young of Wayne State University agrees and says that, just as for other chronic diseases, the most effective strategy for controlling heart disease, postponing disability, and preventing progression of chronic conditions is risk factor reduction. (#478)

"The major cardiovascular risk factors (hypertension, dyslipidemia, impaired glucose tolerance, cigarette smoking, obesity, and physical deconditioning)," says Young, "are highly prevalent among elders yet all are modifiable." To do so, Young proposes health promotion objectives for older adults to increase exercise, reduce smoking, reduce serum cholesterol through diet and medication, reduce salt and total caloric intake of overweight persons and thus reduce obesity, and increase the number of physician visits to enable more preventive care. (#478)

Young adds that beyond primary prevention, treatment of heart disease by using the cardiologist's vast armamentarium of surgical and medical strategies offers benefits to some older patients, especially in terms of improving their quality of life. (#478)

Cancer

According to Ann Norman of the University of Washington, about one in ten women in the United States will develop breast cancer in any given year;¹³ 75 percent of this cancer will be detected among women 50 years and older.¹⁴ The death rate in this group is particularly high, and one reason is the low level of screening. According to Norman, the Year 2000 Health Objectives should be consistent with those of the National Cancer Institute, which recommend increasing the percentage of 50- to 70-year-old women who undergo breast examinations and mammograms, and of 40- to 70-year-old women who undergo Pap smears. ¹⁵ (#336) Although not as serious a problem as breast cancer is for women, prostate cancer is an important problem of aging males. (#794)

Osteoporosis

Osteoporosis is more common in White women over 45 than heart attacks, strokes, diabetes, and other major chronic disorders, according to Thomas Heston of the University of Washington. (#338) Wayne Tsuji of the Washington State Arthritis Foundation says that osteoporosis leads to vertebral compression fractures and hip fractures, which cause great pain and disability. However, measures such as calcium and estrogen supplementation, weight bearing exercise, and cutting back on alcohol or tobacco can help prevent osteoporosis and the disability it causes. Furthermore, Tsuji notes that older women at higher risk can be screened for osteoporosis so that they can be treated before the point of fracture or other damage. (#339) (See Chapter 27 for further discussion on this topic.) Primary prevention, however, must be started at a younger age, particularly by increasing the calcium consumption of young and middle-aged women.

Infectious Diseases

Because the elderly are at greater risk than other adults for infectious diseases, immunization is of primary importance, according to Steven Mostow of the Rose Medical Center in Denver. For example, he reports that most deaths from influenza could be prevented with a national immunization program targeted at the elderly and those with heart or lung disease; control of influenza in these groups is not only achievable but very cost-effective. "A massive annual media campaign to promote influenza vaccination among the elderly, sponsored by the Influenza Alert Committee of the American Lung Association of Colorado, has increased influenza immunization rates from 8 percent to 32 percent in the past four years (1984-1988)." (#380)

The impact of food-borne diarrheal illness is greater on those already physically compromised, including many elderly. The Association of Food and Drug Officials suggests that this is preventable through proper manufacturing and food handling practices. (#384)

Katherine Hunter, representing the American Society of Microbiology, recommends that the incidence of pneumonia in the elderly be addressed. All nursing homes should have an active, result-oriented infection control committee analogous to those in hospitals. Furthermore, all nursing homes should screen employees and patients for tuberculosis. (#259)

Dental Health

The American Dental Hygienists' Association (ADHA) claims that "of the entire population, older peoples' total body health is the most dependent upon their oral health. Debilitating oral conditions limit the older person's ability to eat a balanced diet, and inadequate nutritional intake results in compromised health." The ADHA recommends educational programs developed specifically to inform older people about the impact of oral health on their overall health status, and suggests that federal and private insurance programs include payment for preventive oral health services. (#575)

Because more people are maintaining their natural teeth as they age, caries are an increasing problem for the elderly. Ronald Ettinger of the American Society for Geriatric Dentistry suggests that caries can be reduced in the aging population by the development of techniques to identify those at risk. He also reports that dental care of the elderly in institutions is neglected and that the institutionalized have a far greater need for dental care than the noninstitutionalized elderly. (#062)

Hearing and Communication

According to James Lovell of the National Hearing Aid Society, it is important to recognize the high prevalence of untreated hearing impairment in older people and to include greater awareness of age-related hearing loss and its remedies in the objectives. He believes that the majority of such people can be brought back to higher functioning by the use of available technology, with a consequent improvement in the quality of life. (#409) Shirley Sparks of Western Michigan University also discusses communication disorders among the elderly. She suggests goals assuring that the current prevalence of significant hearing loss and speech or language problems in the elderly should not increase and that the disability of the resulting social isolation should decrease. (#396)

Access to Health Care

To carry out the national objectives, greater access to preventive care is necessary, according to many testifiers. (#142) Private insurance and Medicare policies about reimbursement for preventive services constitute a large part of the problem, but Marine points out that available services often are poorly coordinated. (#370)

Richards discusses barriers to cancer screening in older adults. They include transportation difficulties, lack of insurance coverage for screening and prevention, and difficulty in cancer self-detection due to physical losses (visual, musculoskeletal) and concurrent debilitating diseases. One way to overcome these problems, she says, is to conduct screening procedures at geriatric day-care centers, retirement centers, and senior centers. (#183)

Another way to address the access problem, according to Richards, is through Medicare versions of prepaid health plans, known as Medicare health maintenance organizations (HMOs). In addition, social health maintenance organizations (SHMOs) integrate health care with psychosocial, environmental, and informal supports to reduce dependency. The SHMO is geared to coordination of services and to maximizing the functional capacity of older adults. Richards suggests objectives to increase the availability of Medicare HMOs and SHMOs and to increase public awareness of this option. (#183)

Several witnesses spoke about educational efforts that should be undertaken to sensitize those who work with the aging to problems that may arise in later years and ways to deal with them. Miner feels that formal course work in geriatrics should be mandatory for those entering health care fields. In addition, primary care providers should be better educated about conditions in the elderly that suggest referral to mental health services and about their needs for emotional support and personalized caring. (#468) Paul Hunter and his colleagues believe that students in the health professions should have experience in facilities for the elderly. (#612)

Current efforts in health promotion and aging are hampered by the limited involvement of medical care providers, according to Robert Newcomer and Rena Pasick of the University of California, San Francisco. This can be improved through changes in Medicare reimbursement rules, minimum standards for professional training, and better definitions of the roles of all health providers. (#482)

Several testifiers stated that Medicare should reimburse a greater variety of services, especially preventive services, than it does now. (#062; #074; #336; #612) Richards states, "Unfortunately, a very tidy summary of the preventive services most needed in this age group can be found in a publication, The Medicare Handbook, under a category entitled 'What Medicare Does Not Cover'."¹⁶ Richards suggests that the following items should be reimbursable: dental services; nutritionist's services, especially for those with multiple health problems; home care pharmacists to monitor multiple medications; mental health services; long-term care costs; periodic health and screening examinations; the costs of eyeglasses and examinations to prescribe them; breast examinations; mammography; and Pap smears. (#183)

Data and Information Needs

The American Association of Retired Persons (AARP) notes that the 1990 Objectives include relatively few objectives pertaining specifically to older adults. The AARP believes that this omission is due to gaps in data collection systems and measurement techniques. It recommends that the Public Health Service focus resources on expanding data collection for assessing health status and health risk in older adults. Data are needed on the use of preventive services and reimbursement for such services; accidents and injuries (especially in-home fires); misuse of alcohol or drugs (including prescription drugs); suicide; and use of mental health services by the elderly. (#767)

Walter Bortz of the Palo Alto Medical Foundation suggests that data are needed to show how preventive strategies work in older people and how health behavior is affected by the negative stereotype of aging. (#508)

Richards also believes that "while there is growing evidence that health promotion pays off in improved quality of life, we must convince policymakers that prevention also saves scarce health dollars." She recommends the researching of long-term questions: for example, do older adults with arthritis who begin a regular exercise program require institutionalization less often or at a later age than those who do not exercise? She suggests an increase in the number of projects doing follow-up to measure the long-term effects of health promotion. (#183)