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Key Concepts

Aging, like so many health care issues, has a language of its own. Here, we define some of the main issues you are likely to encounter in your reporting.

7 Pillars of Aging

Advance directive

Ageism

Age-related sleep disorders

Aging as a social construction

Aphasia

Arthritis

Assistive technology

Balance and vertigo

Balancing Incentive Program

Biological warranty period

Blue zones

Brain plasticity

Capacity

Caregiver Advise, Record, Enable (CARE) Act

Cognitive health

Conscious aging

Cultural competency

Dual eligibles

Dimensions of aging

Dementia Friendly Communities

Elder abuse

Elder Economic Security Standard Index (Elder Index)

Elder guardianship

EQUIPPED (Enhancing Quality of Provider Practices for Older Adults in the Emergency Department)

Fall risk assessment

Filial piety

Frailty

Geriatric syndromes

Green houses

Health literacy

Health-Related Quality of Life (HRQoL)

Healthspan

Hearing loss

Life course perspective

Life expectancy

Life span

Long-term services and supports (LTSS)

Longevity

Longevity gene

Meaningful use

Mild cognitive impairment

Nationwide Health Information Network

Naturally Occurring Retirement Communities

Nurses Improving Care for Healthsystem Elders (NICHE)

Observation care

Office of the National Coordinator (ONC)

Older Americans Act

Older Americans Independence Centers (OAIC)

OpenNotes

Osteopenia

Osteoporosis

Palliative care

Person-centered care

Person-environment Interaction

Physician-assisted death vs. euthanasia

Physician-assisted suicide

Program of All-inclusive Care for the Elderly (PACE)

Quality Indicator Survey (QIS) process

RE-AIM Framework

Regenerative Medicine

Resilience

Social construction of aging

Social portfolio

Stages of caregiving

Sundowning

Supercentenarians/Centenarians

Supplemental Poverty Level

The Two Midnight Rule

Village model of aging in place

Visitability

Well-being

7 Pillars of Aging

Aging is the greatest risk factor for most chronic diseases, affecting both morbidity and mortality. Chronic diseases impact the aging process. So it made sense for scientists at the National Institutes of Health to get together and share research across centers, agencies, and labs.

People are living longer, but are often sicker with multiple chronic diseases simultaneously. Scientists agree there’s an urgent need to extend our health span — how long we live with no disease, or with well controlled diseases.

The trans-NIH Geroscience Interest Group (GSIG) collaborates to better understand aging mechanisms, links between aging and chronic disease and recommends pathways to identify and develop therapies or preventative approaches for age-associated diseases. They developed what’s come to be known as the “Seven Pillars of Aging.” These are key themes regarding the processes that promote aging. They are not seven

independent factors driving aging; rather, they are highly interwoven processes, and understanding the interplay between these seven pillars is critical.

The seven pillars are:

  • Adaptation to stress

  • Epigenetic’s

  • Inflammation

  • Macromolecular damage

  • Metabolism

  • Proteostasis

  • Stem cells and regeneration

Citation: Kennedy, et. al, Cell 159(4) · November 2014)

According to researchers, “By understanding how aging enables pathology, new therapeutics will arise for multiple chronic diseases, providing an opportunity to extend human health span by targeting aging directly.”

The article was published in the November 2014 issue of Cell. I wrote about the April 2016 New York City geoscience summit here.

Advance directive

What kind of care do you want at the end of your life?

Advance directives allow people to answer this question by setting out their preferences in a living will or a do-not-resuscitate order or by giving the power of medical decision-making to a friend or family member through a durable power of attorney for healthcare.

The idea behind advance directives makes sense, intuitively.  Of course, it’s better to be prepared for what might come up at the end of life than be caught unaware when a crisis is at hand.  Of course, it makes sense for a person to have conversations with family and physicians about their values and goals of care at life’s end rather than leaving essential wishes unexpressed.

But end-of-life planning isn’t nearly as simple as it may seem on the surface.  With illness, people’s perspective may change.   What may have seemed intolerable when a person was healthy and independent may seem acceptable when they become more frail and dependent.   Treatments that may have been refused under living wills prepared years or months earlier may suddenly seem desirable and necessary.

These kinds of changes are well documented in the medical literature and Drs. Jerome Groopman and Pamela Hartzband discuss them intelligently in a recent article in ACP Internist, published by the American College of Physicians.  The physicians are both on the faculty at Harvard Medical School and co-authored the book “Your Medical Mind:  How to Decide What Is Right for You.”

In their article, the doctors write of a 64-year-old woman with cancer who was ready to end treatment and die but who was persuaded by her family to undergo chemotherapy that proved life-saving.   The woman had an advance directive that specified no “heroic measures” in the event her cancer grew again.  Yet when that happened eight years later, she insisted that everything possible be done to keep her alive.

“Why do patients often deviate from their advance directives?” Groopman and Hartzband ask.  Their answer: “They do so because they cannot accurately imagine what they will want and how much they can endure in a condition they have not experienced.”

For this reason and because it’s very difficult to anticipate the particulars of medical situations people may encounter, advance directives often are not especially useful to surrogate decision-makers or physicians.

“Despite the prodigious effort devoted to designing, legislating, and studying of advance directives, the consensus of medical ethicists, researchers in health care services, and palliative care physicians is that the directives have been a resounding failure,” said Muriel Gillick, a geriatrician at Harvard and an end-of-life care researcher quoted in Groopman and Hartzband’s article.

Gillick is among the growing ranks of end-of-life care experts who now recommend that people have regular, ongoing conversations with family, friends and physicians about their end-of-life preferences rather than relying on advance directives.

That raises the question “who pays for these conversations” and that’s exactly what the misguided national debate over “death panels” was all about.  At stake was whether Medicare would start paying physicians for talking to patients about end-of-life care options during annual medical checkups, as suggested in a version of the health reform bill passed by the U.S. House of Representatives.  The lack of reimbursement for these conversations is a key reason why they don’t occur as often as they should.  (Doctors’, patients’ and families’ unease over discussing about end-of-life issues is another key reason.)

For resources on advance directives, see this list at MedLine Plus, this page on the American Medical Association’s web site, and this page on the website of National Healthcare Decisions Day.  For a description of legal and policy issues related to advance directives, see this write-up from Charles Sabatino of the American Bar Association’s Commission on Law and Aging.

A newer type of advance directive known as “physician orders for life sustaining treatment” has also been getting attention and we’ll look at how it works in a tip sheet appearing on this site soon.    Advance directives are also now being used for psychiatric care; for more information consult the National Resource Center on Psychiatric Advance Directives.

Ageism

Like other “isms” such as racism and sexism, ageism refers to prejudice and discrimination against people who share a common characteristic – in this case, old age.

The term was coined in 1968 by Dr. Robert Butler, the first director of the National Institute on Aging.

A chapter in Global Population Ageing:  Peril or Promise?, a recent report from the World Economic Forum, suggests that there are four types of ageism:  personal, institutional, intentional and unintentional.

Personal ageism occurs when we make assumptions based on conscious or unconscious biases against older people.  An example might be assuming an older person in a wheelchair is less than competent mentally.

Institutional ageism occurs in settings as diverse as workplaces, hospitals, and movie theaters.  Examples include bias against hiring older workers, hospital beds that older people can’t get up on easily, or films that depict older people as irritating, decrepit and pitiable.

Often, ageism takes the form of minimizing the value of older people.   Dr. Bob Arnot encountered this while caring for his dad and wrote about it in the January 2012 issue of Today’s Caregiver magazine.  Arnot is a physican and television correspondent who was the chief medical correspondent for NBC News.

Arnot described attempts to intervene on behalf of his dad, who had suffered an earlier heart attack.  He writes:  “I pressed and pressed to make sure that he was on the right kinds of medications and got a lot of pushback from his doctor, like ‘Oh, he is old and it kind of does not matter.’” 

This is altogether too common in medical settings, as is clear from a reader’s comment on the New York Time’s New Old Age blog in response to a post on surgery in the elderly.

“My father, in his early 90's, had no sign of mental confusion until he had surgery to "fix" his incontinence – ‘fix’  is in quotes because afterwards his incontinence was worse. He developed a brain infection while convalescing from which he almost died because his doctors didn't think there was anything wrong – aren't all old men delusional? – until we insisted they do something. He physically recovered but mentally was never the same.”

Donald Hall, one of America’s foremost poets, wrote eloquently about growing old and experiencing ageism in the Jan. 23, 2012 issue of the New Yorker:

“Sometimes, the reaction to antiquity becomes a farce. I go to Washington to receive the National Medal of Arts, and arrive two days early to look at paintings. At the National Gallery of Art, Linda pushes me in a wheelchair from painting to painting. We stop by a Henry Moore carving. A museum guard, a man in his sixties, with a small pepper-and-salt mustache, approaches us and helpfully tells us the name of the sculptor. I wrote a book about Moore, and knew him well. Linda and I separately think of mentioning my connection but instantly suppress the notion – egotistic, and maybe embarrassing to the guard. A couple of hours later, we emerge from the cafeteria and see the same man, who asks Linda is she enjoyed her lunch. Then he bends over to address me, wags his finger, smiles a grotesque smile, and raises his voice to ask, ‘Did we have a nice din-din?’”

For an in-depth look at ageism, see Ageism in America, a 2006 report from the International Longevity Center. 

The Age Discrimination Act of 1975 prohibits age discrimination in programs that receive federal financial assistance. The Age Discrimination in Employment Act of 1967 prohibits job discrimination against people 40 and older.  The Older Workers Benefit Protection Actamended ADEA to protect older workers’ employees benefits and define conditions under which they could be changed.

Age-related sleep disorders

Sleep problems in the elderly are fairly common, but frequently go undiagnosed. Factors affecting sleep range from retirement-related lifestyle changes to chronic health problems. Additionally, older adults tend to have multiple health problems and take multiple medications, one or all of which can affect sleep patterns. Poor sleep is also linked with increased mortality.

While some changes in sleep patterns may just be a normal part of aging, researchers found  that other disturbances are linked to health issues such as restless leg syndrome, sleep apnea, or other pathological issues that are not part of the normal aging pattern.

Pharmacologic treatment of sleep disorders in older adults is common, but comes with its own set of problems. Older adults metabolize drugs differently than do younger people, which can cause serious cognitive and physical side effects. Daniel J. Buysse, MD, Professor of Psychiatry and Clinical and Translational Science, University of Pittsburgh School of Medicine points out that all sleep medications are associated with falls in the elderly. Changes in cognitive function due to brain atrophy are also linked to sleep-dependent short-term episodic memory in the elderly.

More information:
University of Maryland Medical Center 
Scripps Health 
Medline Plus

Aging as a social construction

While aging itself is a biological process, what it means to be "young" or "old" is socially constructed. This means that there is no inherent cultural meaning to the biological process of aging. Rather, cultures instill youth and age with meanings. The social construction of aging is perceived differently around the world, with different groups applying different understanding of the process.

Frequently, the average life expectancy in a given region bears on what age counts as "old." For example, in the United States, where the average life expectancy is over 78 years, people are not considered "old" until they are in their sixties or seventies. However, in Chad the average life expectancy is less than 49 years. People in their 30s or 40s are already middle-aged or "old." These variations in people's perceptions of who should or should not be considered elderly indicate that notions of youth and age are culturally constructed. There is no such thing as a universal age for being considered old.

Japanese perceptions of elders differ significantly from public perceptions of old age in the United States. Western societies tend to place an increased value on youth to the point that many people take extreme measures to appear younger than their biological years.

Individuals sometimes take drastic action to control the appearance of their age so that others can perceive them to be younger. Significantly, these social interactions occur in a social environment that values youth. In this light, people try to appear younger to increase their sense of social value.

Aphasia

Aphasia is a communication disorder that results from damage to the parts of the brain that contain language (typically in the left half of the brain). Aphasia is always caused by injury to the brain-most commonly from a stroke, particularly in older individuals; however other diseases or damage to the part of the brain that controls speech, like brain tumors or progressive neurological conditions can also cause aphasia.

Aphasia may cause difficulties in speaking, listening, reading, and writing, but does not affect intelligence. Individuals with aphasia may also have other problems, such as dysarthria, apraxia, or swallowing problems, according to the American Speech-Language-Hearing Association.

There are four main types:

  1. Expressive aphasia - you know what you want to say, but you have trouble saying or writing what you mean

  2. Receptive aphasia - you hear the voice or see the print, but you can't make sense of the words

  3. Anomic aphasia - you have trouble using the correct word for objects, places, or events

  4. Global aphasia - you can't speak, understand speech, read, or write

Most people with aphasia undergo speech and language therapy to help regain lost abilities. While many people eventually can compensate somewhat, most never fully regain their pre-aphasia communication skills, according to the Mayo Clinic.

Researchers are exploring drug therapy as an experimental approach to treating aphasia. According to the NIH, some studies are testing whether drugs that affect the chemical neurotransmitters in the brain can be used in combination with speech-language therapy to improve recovery of various language functions. Several medications, such as memantine (Namenda) and piracetam, have shown promise in small studies. But more research is needed before these treatments can be recommended, according to the National Institutes of Health.

Other research is focused on using advanced imaging methods, such as functional magnetic resonance imaging (fMRI), to explore how language is processed in the normal and damaged brain and to understand recovery processes. This type of research may advance knowledge of how the areas involved in speech and understanding language reorganize after a brain injury. The results could have implications for the diagnosis and treatment of aphasia and other neurological disorders.

A relatively new area of interest in aphasia research is noninvasive brain stimulation in combination with speech-language therapy. Two such brain stimulation techniques, transcranial magnetic stimulation (TMS) and transcranial direct current stimulation (tDCS), temporarily alter normal brain activity in the region being stimulated.

The American Stroke Association offers a tip sheet for family and friends of those with the condition, with suggestions on how to help their loved one cope.

Arthritis

When writing about older adults and arthritis, it’s helpful to understand the differences between the various forms and how each affects the body.

The National Arthritis Foundation defines arthritis as “a complex family of musculoskeletal disorders consisting of more than 100 different diseases or conditions that destroy joints, bones, muscles, cartilage and other connective tissues, hampering or halting physical movement.”

Osteoarthritis is the most common, affecting about 34 percent of adults over age 65. It is characterized by joint stiffness and transient to severe joint pain. It is prevalent in weight-bearing joints such as knees and hips and can affect the hands, back and neck, according to the National Institute of Arthritis and Musculoskeletal and Skin Diseases.

Rheumatoid Arthritis (RA) is an auto-immune disease which causes the body to attack its own tissues, especially the synovium, a thin membrane which lines the joints. The attacks result in painful fluid build up in the joints and inflammation throughout the body. It commonly affects the hand, but can also strike other joints.

About 1.3 million adults (1 percent) in the United States have RA, a disease which affects both sides of the body symmetrically. [If symptoms appear on one side of the body, they appear on the other as well]. Women are three times more likely to develop RA then men. It is considered a chronic disease and there is no cure. Common treatments include non-steroidal anti-inflammatory drugs (NSAIDs) to reduce inflammation and symptoms and disease-modifying anti-rheumatic drugs or agents that may put RA in remission. Older adults may experience some side effects of long-term NSAID use such as gastrointestinal bleeding, which has serious health repercussions. 

Disease modifying anti-rheumatic drugs (DMARDs) are a standard treatment when NSAIDs alone are not enough, but may also have serious side effects and seem to lose efficacy during long-term treatment.

The American College of Rheumatology (ACR) recently published revised recommendations for use and monitoring of DMARDs after several new therapies were approved which treat the disease itself, rather than only addressing pain and inflammation.

Gout is another form of arthritis that occurs when uric acid builds up and forms tiny crystals instead of passing through the body normally. When crystals form in joints, they become very painful, swollen, and stiff. Gout often begins in the big toe, but can also affect ankles, knees, and other major joints.

Arthritis can make activities of daily living (ADLs) difficult to perform and may affect the ability of an older person to age-in-place.

Assistive technology

Any device that helps older people negotiate their lives at home, work, or in the community can be classified as “assistive technology.”

Think of canes, walkers, hearing aids, scooters, and units that amplify sound from a telephone or a television.  Think of orthopedic shoe inserts, furniture with built-in lifts, grab bars in a bathroom shower and “reachers” that help older people take things off a high-up shelf.

Next Avenue, a website for Baby Boomers sponsored by PBS and affiliated stations, published a useful classification of various types of “assistive technology” recently on its website.  That description, prepared by the Administration on Aging, is reprinted below.

  • Adaptive switches. Modified switches that seniors can use to adjust air conditioners, computers, telephone answering machines, power wheelchairs and other types of equipment. These switches might be activated by the tongue or the voice.

  • Communication equipment. Anything that enables a person to send and receive messages, like a telephone amplifier.

  • Computer access. Special software that helps a senior access the Internet, for example, or basic hardware, like a modified keyboard or mouse, that makes the computer more user friendly.

  • Education. Audio books or Braille writing tools for the blind come under this category, along with resources that allow people to get additional vocational training.

  • Home modifications. Construction or remodeling work, like building a ramp for wheelchair access, that allows a senior to overcome physical barriers and live more comfortably with a disability or recover from an accident or injury.

  • Tools for independent living. Anything that empowers the elderly to enjoy the normal activities of daily living without assistance from others, like a handicapped-accessible bathroom with grab bars in the bathtub.

  • Job-related items. Any device or process that a person needs to do his or her job better or easier. Examples might include a special type of chair or pillow for someone who works at a desk or a back brace for someone who does physical labor.

  • Mobility aids. Any piece of equipment that helps a senior get around more easily, like a power wheelchair, wheelchair lift or stair elevator.

  • Orthotic or prosthetic equipment. A device that compensates for a missing or disabled body part. This could range from orthopedic shoe inserts for someone who has fallen arches to an artificial arm for someone whose limb has been amputated.

  • Recreational assistance. New methods and tools to enable people who have disabilities to enjoy a wide range of fun activities. Examples include swimming lessons provided by recreational therapists or specially equipped skis for seniors who have lost a limb as a result of accident or illness.

  • Seating aids. Any modifications to regular chairs, wheelchairs, or motor scooters that help a person stay upright or get up and down unaided or that help to reduce pressure on the skin. This could be something as simple as an extra pillow or as complex as a motorized seat.

  • Sensory enhancements. Anything that makes it easier for those who are partially or fully blind or deaf to better appreciate the world around them. For instance, a telecaption decoder for a TV set would be an assistive device for a senior who is hard of hearing.

  • Therapy. Equipment or processes that help someone recover as much as possible from an illness or injury. Therapy might involve a combination of services and technology, like having a physical therapist use a special massage unit to restore a wider range of motion to stiff muscles.

  • Transportation assistance. Devices for elderly individuals that make it easier for them to get into and out of their cars or trucks and drive more safely, like adjustable mirrors, seats and steering wheels. Services that help the elderly maintain and register their vehicles, like a drive-up window at the department of motor vehicles, would also fall into this category.

Who pays for these items? Medicare will pay most of the cost for devices that it considers “durable medical equipment.”  States also pay for some items, and the Center for Aging Services Technology (CAST) looked at what they’ll cover for in this 2011 report.  

For a somewhat dated but still helpful overview of assistive technology and older adults, see this publication by researchers from the University of North Dakota prepared for the North Dakota Family Caregiver Project.

Balance and vertigo

Three out of four older people have problems with balance. It may manifest as feeling dizzy or unsteady, or feeling as if their surroundings are moving. According to the National Institutes of Health, many balance issues are caused by disturbances of the inner ear. The part of the inner ear responsible for balance is the labyrinth, which is made of bone and soft tissue. To maintain the body's position, the labyrinth interacts with other systems, such as the eyes, bones and joints.

A balance disorder may be caused by viral or bacterial infections in the ear, a head injury, or blood circulation disorders that affect the inner ear or brain.  They can also result from medication side effects, or problems in visual, skeletal, nervous or circulatory systems. The Centers for Disease Control and Prevention estimates that one out of six older adults has impaired vision; one out of four has impaired hearing; and one out of four has loss of feeling in the feet. Some balance disorders can begin suddenly and with no obvious cause. 

Vertigo – the feeling like you or things around you are spinning – is a common symptom of balance disorders. Benign paroxysmal positional vertigo (BPPV), also called positional vertigo, is a brief, intense episode of vertigo that occurs because of a specific change in the position of the head and is common in older adults.

Ménière's disease is a balance disorder that can happen at any age. A person may experience vertigo, transient hearing loss, tinnitus or a feeling of fullness in the ear. It has no known cause.

Lightheadedness or feeling faint, known as presyncope, is also common in older adults. Chronic physical conditions such as heart disease or diabetes are often involved.

Balance disorders frequently lead to falls and fall-related injuries such as hip fractures. The CDC says that about one-third of adults ages 65 years and older fall each year. Among older adults, falls are the leading cause of injury-related deaths.

Balancing Incentive Program

This grant program is one of several incentives under the Affordable Care Act which makes it easier for people to access Medicaid home and community-based services.  Since 2011, eligible states can apply for grants to help balance their Medicaid long-term care system so that it provides more community-based services instead of institutional services. States receive additional federal funding through an enhanced federal Medicaid match of either 2 percent or 5 percent, with greater incentives going to states with greater needs to improve their systems.

Biological warranty period

For individual species, terms such as longevity, life span or average life expectancy are generic and do not convey why a species' life span has limits. That is best understood in the context of competing species and the ecological food chain, or what they call the “marketplace.”

Similar to a product warranty, which provides a limited time frame where obvious failures are not anticipated by engineers, a biological warranty implies that failures of biological origin occur when an individual’s survival extends beyond the species’ normal life history – conception, embryogenesis, development, and sexual reproduction.

Researchers say that this is typically the termination of reproductive competence for females [menopause] or the equivalent age for males (andropause) in humans. Afterward, people live on “borrowed time,” as it were. If the net accumulation of damage to the basic molecular building blocks of life eventually exceeds the maintenance and repair capacity of the body, this renders the individual vulnerable to forces of morbidity.

"Humans may have their own personal agendas, but after the biological warranty period, our genetic prime directive to 'go forth and multiply' has been exhausted," they noted. "In other words, by definition, the termination of the biological warranty period coincides with the early onset of aging, and without a fundamental intervention in programming, vitality can only be expected to go downhill from that point.”

This concept is courtesy of the Gerontological Research Group, physicians, scientists, and engineers from UCLA and other institutions who seek to slow and ultimately reverse human aging.

Blue Zones

The average life expectancy in the United States is 78.2 years. So why do some people routinely remain healthy well into old age, living to 90, 100, or beyon with few serious problems?  Why does it occur more often in some population pockets throughout the world and not others? Researchers have long sought to find the answers in these communities, known as blue zones. 

According to the Los Angeles Times,  there were 720,000 centenarians in the U.S. In 2016. By 2050, it's projected there will be more than 1 million. Researcher Dan Buettner and colleagues identified five pockets around the world where people live longer and better: 

  • Barbagia region of Sardinia – Mountainous highlands of inner Sardinia with the world’s highest concentration of male centenarians. 

  • Ikaria, Greece – Aegean Island with one of the world’s lowest rates of middle age mortality and the lowest rates of dementia.

  • Nicoya Peninsula, Costa Rica – World’s lowest rates of middle age mortality, second highest concentration of male centenarians. 

  • Seventh Day Adventists – Highest concentration is around Loma Linda, Ca. They live 10 years longer than their North American counterparts. 

  • Okinawa, Japan – Females over 70 are the longest-lived population in the world.  

What is it about these areas that foster ultra-longevity? In his book and subsequent Blue Zones Project,  Buettner explained that while residents in these parts of the world have nine things in common which many explain it:

  • They move - they live lives that encourage natural exercise and movement, like walking

  • They have a sense of life purpose, which research shows may add years to a person's life.

  • They follow the 80 percent rule – and stop eating when they feel 80 percent full. 

  • They eat a primarily plant-based or Meditteranean diet, with beans or fish as a central source of protein. Meat is eaten rarely and in small portions as this USA Today story explains.

  • They know how to de-stress. They use yoga, meditation, prayer, time out, and other methods to shed stress. 

  • They drink regularly in moderation (except Adventists)–  Almost all drank 1-2 glasses of wine daily. It should be noted that study results and experts disagree on the role of wine in healthy aging. A recent, widely reported study said "maybe not."

  • They belong to a faith-based community. This was common among nearly all centenarians Buettener interviewed. Research links social connectedness to increased life expectency

  • Loved ones come first – often many generations live together, and families take priority over work. 

  • They belong to the right tribe, as this story in the Duluth News Tribune explains. That means surrounding themselves with other happy, healthy people.

This WBUR story describes Buettner's research and what he found out about diet and nutrition. This journal article delves into more of the science behind the these common components. Buettner's brother and fellow researcher Tony, presented Blue Zone Project's findings to The Aspen Institute  last year. 

By the way, the term Blue Zones has no underlying scientific meaning; it was apparently coined when researchers circled the five longevity regions  on a map in blue marker. 

Brain plasticity

Brain plasticity refers to the ability of the brain to modify its own structure and function following changes within the body or in the external environment. The large outer layer of the brain, known as the cortex, is especially able to make such modifications.

Brain plasticity is at the root of normal brain function, such as our ability to learn and modify our behavior. It is strongest during childhood — explaining the fast learning abilities of kids — but remains a fundamental and significant lifelong property of the brain. 

Adult brain plasticity has been clearly implicated as a means for recovery from sensory-motor deprivation, peripheral injury, and brain injury. It has also been implicated in alleviating chronic pain and the development of the ability to use prosthetic devices such as robotic arms for paraplegics, or artificial hearing and seeing devices for the deaf. According to the Society for Neuroscience, there is increasing understanding of the role that brain plasticity plays in psychiatric and degenerative brain disorders.    

Scientists now know that the organization of brain circuitry is constantly changing as a function of experience. These changes are referred to as brain plasticity, and they are associated with functional changes that include phenomena such as memory, addiction, and recovery of function. Recent research has shown that brain plasticity and behavior can be influenced by many factors, such as drugs, hormones, maturation, aging, diet, disease, and stress. Understanding how these factors influence brain organization and function is important not only for insight into both normal and abnormal behavior, but also for designing treatments for behavioral and psychological disorders ranging from addiction to stroke.

Aging is associated with progressive losses in function across multiple systems, including sensation, cognition, memory, motor control, and affect. The traditional view has been that functional decline in aging is unavoidable because it is a direct consequence of brain machinery wearing down over time. In recent years, an alternative perspective has emerged, based upon decades of research in neuroscience, experimental psychology, and other related fields. This perspective argues that as people age, brain plasticity processes with negative consequences begin to dominate brain functioning. Four core factors — reduced schedules of brain activity, noisy processing, weakened neuromodulatory control, and negative learning — interact to create a self-reinforcing downward spiral of degraded brain function in older adults. This downward spiral might begin from reduced brain activity due to behavioral change, from a loss in brain function driven by aging brain machinery, or more likely from both. 

These combined, interrelated factors promote plastic changes in the brain that result in age-related functional decline. Studies of adult brain plasticity have shown that substantial improvement in function and/or recovery from losses in sensation, cognition, memory, motor control, and affect should be possible, using appropriately designed behavioral training paradigms. Brain plasticity shows the ability of the brain to change throughout life by forming new connections between brain cells, and to alter function. For a long time, it was assumed that as we become older, the connections in the brain became fixed, and then it was just a matter of time that we started “losing” brain cells. However this assumption is being aggressively challenged by recent studies showing that the brain never stops changing.

Caregiver Advise, Record, Enable (CARE) Act

This is state legislation that supports family caregivers when loved ones are discharged from hospitals or skilled nursing facilities. It was created to help more than half of the 42 million U.S. family caregivers who perform medical or nursing tasks for their loved ones.

The CARE Act specifies that

  • the name of the family caregiver is recorded when a loved one is admitted into a hospital or rehabilitation facility

  • The family caregiver is notified if the loved one is to be discharged to another facility or back home

  • The hospital or rehabilitation facility must provide an explanation and live instruction of the medical tasks – such as medication management, injections, wound care and transfers – that the family caregiver will perform at home

“Post acute care is much more than ADLs and IADLs,” said Susan Reinhard, AARP’s vice president of public policy at the recent Gerontological Society of America annual conference in Orlando, Fla. “Many families are responsible for complex conditions from multiple medication to wound care to ventilators. Unfortunately, too many are discharged with just a sheet of instructions and no real training.”

The CARE Act identifies family caregivers and includes patient-centered /family-centered care process. It offers anticipatory guidance for family caregivers expected to perform medical/nursing tasks and gives nurses and other health and social service professionals support to do what their professional standards of practice require them to do.

Importantly, it encourages providers to anticipate patient and family questions and proactively support them, which leads to a reduction in hospital readmissions, according to AARP.

Eighteen states have passed or are considering the law as of November 2015, including:

  • Oklahoma
  • California
  • New Mexico 
  • Colorado
  • Nevada
  • New Jersey
  • West Virginia
  • Virginia
  • Mississippi
  • Arkansas
  • Connecticut 
  • Maine
  • Indiana
  • New Hampshire
  • Oregon
  • Illinois
  • New York
  • Rhode Island

Some state laws are already in effect; others, in early, 2016 – one story angle might include an analysis of pre-and post- law readmissions data and interviews with family caregivers who received medical instruction. Updates for the states can be found here.

Capacity

According to the Center for Elders and the Courts, capacity may involve many areas of functioning, including physical, mental, cognitive, emotional, and behavioral. It is not a fixed or static condition. People can have capacity for different activities and tasks, and capacity can vary across time, situations and location. In all states, the law presumes that a person over the age of majority has capacity. The legal aspects of capacity have been extensively explored and described in the context of guardianship of minors, adults with disabilities, and older adults with diminished capacity. State guardianship laws vary in their legal standards for diminished capacity, but the majority of states require that a person has some type of disabling condition that is causing the person's inability to make decisions about and handle critical personal or financial affairs.

The concept of capacity is relevant across the spectrum of legal issues and transactions. State statutory and case law have established standards of capacity for different types of legal transactions, including health care decision making. Determining capacity in older adults can be difficult and often requires gathering information from many sources, including family members, medical care professionals, mental health care professionals, adult protective service workers and other involved parties. Several tools have been developed to assist judges, lawyers and court-based professionals in assessing the capacity of older persons.

Cognitive health

We often refer to the “cognitive health” of an older adult, but what does it encompass? According to this article by Medscape editor Laura A. Stokowski, R.N., M.S., cognitive health in the elderly should be defined not just as the absence of disease, such as Alzheimer’s disease, but rather as the development and preservation of the multidimensional functional structure in the brain that allows the elderly to maintain social connectedness, an ongoing sense of purpose, and the abilities to function independently, to permit functional recovery from illness or injury, and to cope with residual functional deficits.

The nine elements of cognitive health are: language, thought, memory, executive functions, perception, judgment, attention, remembered skills (such as driving), and the ability to live a purposeful life. Preserving these functions can literally make the difference between leading an independent or a dependent life.

Advancing age is the most important risk factor for worsening cognitive health, cognitive impairment, and dementia. Research has consistently found that certain factors can maintain cognitive health or slow cognitive decline. These include higher educational attainment, higher socioeconomic status, emotional support, better baseline cognitive function, good cardiovascular health, moderate alcohol use and regular physical activity. 

Conscious aging

The Conscious Aging movement, also known as Conscious Eldering, works to help older adults shift their attitudes and thinking away from self-limitation, isolation and fear, towards inclusiveness, compassion, and expansiveness. It holds that this time of life can be one of passion, engagement and service in the community – and it is up to each individual to determine how this might occur.

Conscious aging champions believe that there is a huge difference between being “old” and being an elder, and that the latter is something urgently needed in the world. Conscious Aging puts forth the idea that the senior years are a prime opportunity for personal growth and fulfillment – and that becoming a true “elder” is the apex of life’s journey.

They also believe the elder role is deliberately chosen and is one which requires physical, psychological and spiritual preparation in support of the “wholeness” of the person – that this is the hallmark of a true elder.

A major part of this work involves an examination of one's life and an understanding of how apparently negative events often lead to positive outcomes. Inner work is also essential to relieve oneself of the burden of resentment and anger that can accumulate over a lifetime, according to Harry R. Moody, AARP’s director of academic affairs.

Additional resources

Cultural competency

Culturalal competency is imperative in today's diverse society. Health professionals must understand the effects of a patient's culture on their interaction with the health care system. This is especially important when it comes to older adults, and specifically, immigrant and refugee older adults. Their beliefs, traditions, and influences must be be addressed in a culturally competent manner and with sensitivity to avoid unintended negative consequences, according to the University of Minn. School of Social Work. 

For example, those from some cultures may mix herbal remedies with prescription and over-the-counter medications, without understanding potential side effects. Others may resist lifestyle changes because they interfere with family needs or traditional activities. Still others may feel a fatalistic sense about their health, or treat disease or death as the will of a “higher power,” rather than as something they have some control over. 

According to  the National Library of Medicine, "Culture" refers to integrated patterns of human behavior that include the language, thoughts, communications, actions, customs, beliefs, values, and institutions of racial, ethnic, religious, or social groups. “ ompetence" implies having the capacity to function effectively as an individual and an organization within the context of the cultural beliefs, behaviors, and needs presented by consumers and their communities.

Culturally and linguistically appropriate services are respectful of and responsive to the health beliefs, practices and needs of diverse patients. The percentage of Americans who are racial and ethnic minorities and who speak a primary language other than English continues grow rapidly. Organizations are looking to meet the challenges of serving diverse communities and provide high quality services and care. The Office of Minority Health has a fact sheet on national cultural and linguistic standards that were developed to address disparities throughout the health care system.

The Administration on Aging has put together this toolkit for health professionals: there is valuable information here to help journalists understand some of the challenges about addressing language and culture. 

The Kaiser Family Foundation has a report on the wide disparities in income and assets of those on Medicare by race and ethnicity; For an explanation on why culture matters, check out this brief from the Robert Wood Johnson Foundation.

Dual eligibles

"Dual eligibles" are people covered by both Medicare and Medicaid. They are sicker and poorer than the population as a whole and they use a disproportionate amount of health care. Many require long-term care in a nursing home or other setting.

More than nine million people fall in this coverage category and costs for their care totaled $319.5 billion in 2011, according to an Oct. 2011 brief from the Robert Wood Johnson Foundation and the Urban Institute.

Because dual eligibles rack up unusually large medical expenses and have high hospital readmission rates, they’ve become an important focus of efforts to trim health care costs and deliver care more effectively.

Health reform legislation created a special office within CMS to address issues concerning dual eligibles. This includes developing new ways of providing care coordination and addressing perverse incentives that contribute to fragmented care, poor quality care, and cost-shifting. The new office works closely with states across the country and the Medicare and Medicaid Innovation Center.

Learn about the CMS’ office’s strategies and priorities in this Sept. 2011 testimony by its director, Melanie Bella, to the Senate Finance Committee.

Read more: Medicare-Medicaid dual eligible under scrutiny (USA Today) and Red tape hampers care for patients who are poor and disabled (Los Angeles Times).

The Kaiser Family Foundation has published a fact sheet on dual eligibles, available here.

The Alliance for Health Reform held a briefing on dual eligible for reporters in June 2011.  MedPac took a close look at this population several years ago; its description is still worth reading.

The Care Continuum Alliance recently published a paper outlining essential elements of programs that seek to coordinate and integrate care for dual eligibles.

The Scan Foundation looked at state strategies to better manage care for dual eligible in this recent report.

The Center for Health Care Strategies, Inc. also has published a series of papers on integrating primary, acute, behavioral and long-term care services for the dual eligible population.

UPDATE:   On July 18, 2012, a hearing hosted by the U.S. Senate Special Committee on Aging examined concerns about the government’s plans to enroll dual eligibles in managed care plans and other types of care coordination.  Several experts had said beforehand they worried that Medicare and Medicaid were rushing too quickly into these arrangements.

At the hearing, Dr. Robert Berenson, a former Medicare official now at the Urban Institute, testified: “It is reasonable to proceed with demonstrations of state‐based initiatives given the great interest in the states…However, the Initiative is far too large and needs to be substantially reduced with much more attention to the statutory requirement for high quality evaluations that permit a reasonably accurate assessment of the impact on spending and on quality of care for the affected beneficiaries.”

Kaiser Family Foundation president Drew Altman looked at recent developments in a June column carrying the header “Duals:  The National Health Reform Experiment We Should Be Talking More About.”  Note several new resources mentioned in Altman’s piece. 

Yet another new resource is a health policy brief on care coordination for dual eligibles from Health Affairs and the Robert Wood Johnson Foundation.

Dimensions of aging

We usually think of aging in chronological years, but in gerontology, that is only one of four “dimensions” of aging. According to Sociology: Understanding and Changing the Social World, University of  University of Minnesota Libraries Publishing, there is also  biological aging, when physical changes like arthritis or heart disease make us slow down in our later years. Psychological aging refers to changes which include mental functioning and personality. The fourth dimension, social aging, refers to changes in a person’s roles and relationships, both within their networks of relatives and friends and in formal organizations such as the workplace and houses of worship. Although social aging may differ from from person to person, it is also very influenced by the perception of aging that is part of a society’s culture—including those involving mental functioning and personality that occur as we age. It’s important to note that these dimensions are not always the same. Someone on their 60s can look or act much younger than someone in their 50s.  

Dementia Friendly Communities

The UK-based Dementia Friendly Communities program focuses on improving inclusion and quality of life for people with dementia in England, Wales and Northern Ireland. 

The goal is to increase awareness and understand among community residents  about dementia; encourage people with dementia and their caregivers to seek help and support; to help them feel included in their community, be more independent and have more choice and control over their lives.

A dementia-friendly community is one in which people with dementia are empowered to have aspirations and feel confident, knowing they can contribute and participate in activities that are meaningful to them. 

According to Alzheimer’s Society UK, many villages, towns and cities are already taking steps towards becoming dementia-friendly. For dementia-friendly communities to succeed, the views and opinions of people with dementia and their caregivers must be at the heart of any considerations or decisions.

Confidence was identified as a major barrier. A dementia-friendly community empowers people with dementia to have high aspirations and feel confident, knowing they can contribute and participate in activities that are meaningful to them. The Society has identified 10 key areas of focus:

  1. Involving people with dementia and their caregivers in in shaping communities

  2. Breaking down the stigma of dementia and increasing understanding of the disease

  3. Offering accessible and appropriate community activities

  4. Acknowledge positive contributions and potential those with dementia can make to their communities

  5. Ensure access to early diagnosis and post-diagnostic support.

  6. Provide practical support that allows people with dementia to engage in community life

  7. Support people with dementia wherever they live through community based solutions

  8. Provide consistent and reliable travel options

  9. Create or modify easy to navigate physical environments

  10. Promote respectful and responsive businesses and services that understand and help people with dementia conduct businesses.

Elder abuse

Elder abuse involves intentional harm to an older person or harm incurred through neglect.  The most common types of abuse involve financial or sexual exploitation, abandonment, physical threats or violence, neglect, and the infliction of emotional or psychological suffering, according to the National Center on Elder Abuse at the Administration on Aging.

Think of a vulnerable older woman whose caregiver empties out her bank account, or a cognitively compromised homebound older man whose estranged family never visits, leaving him entirely alone and without basic necessities. Think of someone in a nursing home whose painful bed sore isn’t adequately treated or who is attacked by a mentally ill resident living at the same facility.

How often do such problems occur? It’s not entirely clear, but recent research indicates that 11 percent of Americans 60 and older – nearly 6 million people – may suffer some type of abuse or neglect each year. Only a small fraction of cases are reported as shame and secrecy surround these experiences.

Most at risk are older people who are socially isolated, in poor health and cognitively compromised, especially when a caregiver has a mental health or substance abuse problem.  As can easily be imagined, the consequences of abuse are severe, and older people are much more likely to enter a nursing home or die after undergoing this type of experience.

Laws regarding mandatory reporting of elder abuse vary by state. At the state level, adult protective services are responsible for dealing with cases of older adults who are abused, neglected and exploited. But funding for adult protective services hasn’t kept pace even as the demand for services and complexity of cases has increased in recent years, according to a March 2011 GAO report.

The first national legislation to address this elder abuse, the Elder Justice Act, was enacted in 2010 along with the Affordable Care Act but implementation was delayed as funding remained elusive.  (The first funding request came in President Obama’s fiscal 2012 budget. $747 million has been authorized but not yet allocated.) In June 2012, the Secretary of the U.S. Dept. of Health and Human Services announced that it would make available $5.5 million in grants to fund innovative programs designed to prevent elder abuse.  Recipients of those grants were due to be named at the end of September 2012.

Resources for reporters writing stories about this topic include the National Center on Elder Abuse, National Committee for the Prevention of Elder Abuse, Elder Justice Coalition,  International Network for the Prevention of Elder Abuse, Center of Excellence on Elder Abuse & Neglect, University of California, Irvine,  National Adult Protective Services Assn.,  National Academy of Elder Law Attorneys. Also, here’s a handy list of numbers in every state that people should call when and if they suspect a case of elder abuse.
Related story: Protecting Mom & Dad's money: What to do when you suspect financial abuse, Consumer Reports, January 2013

Elder Economic Security Standard Index (Elder Index)

Elder Economic Security Standard Index (Elder Index) is a state-by-state measure of income needed by older adults to maintain independence and meet their daily living costs including affordable and appropriate housing and health care, without public or private assistance. The development and use of the Elder Index promotes a measure of income that respects the autonomy goals of older adults, rather than a measure of what we all struggle to avoid—poverty. It was developed by the Gerontology Institute at UMass Boston and Wider Opportunities for Women (WOW).

Elder guardianship

Elder guardianship, or elder conservatorship, is a legal relationship created when a court appoints an individual to care for an elderly person who is no longer able to care for him or herself. The appointed guardian has certain duties and responsibilities to the elderly person.

Why might someone need a guardian?

It may be in the older person’s best interests to have a court-appointed guardian if they are unable to properly manage their own care – such as medications or finances. It is then up to the guardian to make personal and/or financial decisions. Some incapacitated individuals can make responsible decisions in some areas of their lives but not others. In such cases, the court may give the guardian decision-making power over only those areas in which the incapacitated person is unable to make responsible decisions (a so-called "limited guardianship"). In other words, the guardian may exercise only those rights that have been removed from the ward and delegated to the guardian.

Every state has its own guardianship processes and requirements but generally an elder guardian is the spouse, adult child, other relative or in some cases, a representative of the state or local agency. In recent years, an entire service industry of private professional guardians has grown out of the increasing demand for guardians. Each state has a public guardianship program, funded by state or local governments, to serve incapacitated adults who do not have the means to pay for the costs associated with guardianship and do not have family or friends who can serve in this role.

According to the National Guardianship Association, five major issues that pose particular challenges for the court:

  • the determination of capacity

  • costs associated with the administration of guardianships

  • training and education standards for judges and court staff

  • court monitoring of guardianships

  • the collection of data.

Once the court appoints a guardian, that guardian has complete control over the ward's property and finances. Guardians can block family visits, determine where the ward will live, and sell property. In addition, guardians charge fees for their services that are payable from the elderly person’s bank account. When a senior gets caught up in the guardianship system, it can be very difficult to get out.

Several high profile cases – including those documented by AHCJ member Barbara Peters Smith, have highlighted the use of guardianships and conservatorships as a means to further exploit older adults.

The situation was becoming so bad in Florida that Gov. Rick Scott signed a law in March 2016 instituting changes to its public guardian system. The law creates an Office of Public and Professional Guardians that is required to create standard practices and rules for public guardians. The office also has enforcement power to revoke a guardianship.

EQUIPPED - Enhancing Quality of Provider Practices for Older Adults in the Emergency Department

This multi-part quality improvement initiative combines education, electronic clinical decision support and individual provider feedback to influence prescribing and improve medication safety for older adults. The goal is reducing use of potentially inappropriate medications (PIM).

The initiative was developed by an interdisciplinary team of ED physicians, geriatricians, gerontologists, clinical pharmacists and quality improvement nurses in the Department of Veterans Affairs; it’s an ongoing program in eight VA emergency departments: Bronx, NY, Durham, NC, Ashville, NC, Nashville, TN, Murfreesboro, TN, Atlanta, GA, Birmingham, AL, Montgomery, AL

According to Emory University, one of the program sites, “the project aims to decrease the use of PIMs, as identified by the Beers criteria, prescribed to veterans aged 65 and older at the time of ED discharge. Interventions include provider education; informatics-based clinical decision support with electronic medical record-embedded geriatric pharmacy order sets and links to online geriatric content; and individual provider education including academic detailing, audit and feedback, and peer benchmarking."

As US Medicine pointed out,  knowing the right drug and the right dose for an older patient is important in any emergency department (ED). It’s especially critical for the VHA, with 45 percent of patients receiving care being age 65 or older, according to VA researchers.

Read more here:  Emory University one of the original sites, In a follow up study, Melissa B. Stevens, MD, of the Atlanta VAMC and assistant professor of medicine at Emory University School of Medicine concluded, "a team approach, combined with education and order sets, can significantly reduce the use of these medications.” .

Other sites saw similar drops in PIMs, said Stevens, despite some differences in the specifics of the intervention’s implementation.  EQUIPPED is more of a QI initiative than a research study, which gives practitioners more flexibility. However, all project sites include three primary areas of intervention:

  • Provider education – including tools for group didactic session, ED journal clubs and individual provider academic detailing

  • Informatics based clinical decision support – with templates for electronic medical record (EMR) embedded geriatric pharmacy order sets and links to online geriatric content

  • Individual provider performance feedback including audit and feedback, and peer benchmarking

Fall risk assessment

Falls are among the most common and serious problems for older adults. They’re associated with increased mortality, morbidity, reduced function, and premature nursing home admissions, as well as diminished quality of life. Older adults are frequently not aware of their risks of falling, and physicians can also overlook those risks, which sometimes only become evident after the fact. According to the fall prevention task force, a collaboration between the American Geriatrics Society, British Geriatrics society and the American Academy of Orthopedic Surgeons Panel on Falls Prevention, both incidence and severity of fall-related complications increase after age 60. More than one-third (35 percent) of otherwise healthy, community-dwelling people over age 65 fall annually. After age 75 rates are even higher

They recommend a comprehensive assessment for any patient at risk of falling, and development of a tailored multifaceted fall prevention program.  Depending upon severity of risk, various assessments are used:

The 4-Stage Balance Test and 30-Second Chair Stand are part of the CDC's STEADI Toolkit for Health Providers (Stopping Elderly Accidents, Death, and Injuries).  STEADI also offers a variety of fall risk information, including reports on fall risk factors and integrating fall awareness into a healthcare practice.  The other tests were devised by various gerontological researchers and have been shown to be effective at indicating fall risk. 

A medication risk assessment is also recommended as part of an overall fall risk assessment. Taking four or more medications significantly increases the risk for falling because both the number and intensity of side effects increases with multiple medication use. Drug interactions can cause side effects. Additionally, older people metabolize medications differently than younger people, which can increase the risk for falling.

Filial piety

Filial piety is a Confucian virtue of respect for one's parents, elders, and ancestors. In more general terms, filial piety means to be good to one's parents, to take care of one's parents, to engage in good conduct not just towards parents but also outside the home so as to bring a good name to one's parents and ancestors.

Filial piety plays a key role in caregiving among Chinese families. Some studies point to increased depression and stress among Chinese Americans while others find that filial piety serves as a protective function to reduce the negative effects of stressors and to enhance the positive effects on caregiving burden.

In China the concept is so strong that the government mandated that adult children regularly visit their elderly parents or risk fines or even jail. Other cultures around the world also embrace similar concepts of honoring and caring for their elders. But in the U.S. and elsewhere, modern life is taking a toll on this tradition. 

In the U.S. a related concept of filial responsibility extends to parents’ financial debts. In 29 states and Puerto Rico with filial responsibility laws on the books, adult children may be held legally responsible for their care under certain circumstances, such as when parents are ailing and without sufficient financial resources to take care of themselves.

Until recently, these statutes have been largely ignored. However, according to insurance giant Northwestern Mutual, several recent court decisions indicate that there might be renewed interest in enforcing them.

Frailty

They look “as if a puff of wind could blow them over.”

What a beautiful – and unforgettable – way to portray older people who have become frail.

Linda P. Fried, M.D., M.P.H., dean of the Columbia University Mailman School of Public Health, described them this way to The Washington Post for an article on frailty – a medical condition that affects the elderly and that doesn’t get sufficient attention.

Fried and colleagues described the telltale characteristics of frailty in 2001 in the Journal of Gerontology:

“There is a growing consensus that markers of frailty include age-associated declines in lean body mass, strength, endurance, balance, walking performance, and low activity and that multiple components must be present clinically to constitute frailty. Many of these factors are related and can be unified, theoretically, into a cycle of frailty associated with declining energetics and reserve.”

In other words, frail people are those whose bodies are wearing down and whose reserves of stamina and energy are being depleted, making them more vulnerable to all kinds of adverse outcomes.

Marlene Cimons describes this trajectory in her Washington Post article, quoting Ava Kaufman, a Bethesda, Md., geriatrician:

“Because it typically worsens over time, frailty often leads to more serious consequences, such as a disabling fall, even death. Frail people are, in fact, at higher risk of falls, and have a much more difficult time recovering if they become ill or enter the hospital. ‘Putting a frail person in the hospital often is the beginning of the end,’ Kaufman says.”

How many older people are classified as frail? Fried estimated that “about 4 percent of men and 7 percent of women older than 65 were frail” in her 2001 study, Cimons tells us. After the age of 85, that rises to about 25 percent.

Can this group of vulnerable elders be helped? Yes, and exercise is often recommended. As Sara Espinoza, M.D., M.Sc., a geriatrician at Johns Hopkins University School of Medicine, notes in a 2005 review:

“In a group of nursing home patients whose average age was 87, Fiatarone et al showed that a program of resistance training increased muscle strength more than 100%, muscle size in the lower extremities by 3%, and gait velocity by 12%. These findings were all statistically significant compared with those of a control group, which showed either marginal increases or declines in these areas. Training was also associated with increased mobility and spontaneous physical activity.”

The study referred to above appeared in 1994 in the New England Journal of Medicine.

A more recent review, published in 2008 in the American Journal of Nursing, noted that professionals who work with frail older adults – including those residing in nursing homes – often underestimate how much they can do. The next year, in the journal PLOS One, researchers from Canada established that exercise benefits older adults “across all grades of frailty” and “conferred its greatest benefits to improvements in health status in those who were more frail at baseline.”

Findings like these challenge our view of frail adults as beyond remedy. They’re not. With careful assessment and help from physicians, social workers, nurses, and physical therapists, their functioning can be improved and their lives made easier.

When frailty becomes severe, however, palliative care is probably in order, as this 2006 article in the Journal of the American Medical Association notes. For more details on frailty in older adults, see an accompanying write-up, also in 2006 in the Journal of the American Medical Association

Geriatric syndromes

It’s common for older people to fall, faint, have trouble swallowing, develop bed sores, or become frail, dizzy, confused or incontinent, often without a clear underlying medical reason.

Medical experts have developed a name for this.  It’s called “geriatric syndrome.”

Dr. Sharon Inouye, a professor of medicine at Harvard Medical School, and several colleagues took a close look at geriatric syndromes four years ago in the Journal of the American Geriatrics Society.

“The term ‘geriatric syndrome’ is used to capture those clinical conditions in older persons that do not fit into discrete disease categories,” they wrote.  “Many of the most common conditions that geriatricians treat, including delirium, falls, frailty, dizziness, syncope and urinary incontinence, are classified as geriatric syndromes.”

The authors go on to define common features of geriatric syndromes:

“They are highly prevalent in older adults, especially frail older people.  Their effect on quality of life and disability is substantial.   Multiple underlying factors, involving multiple organ systems, tend to contribute to, and define, geriatric syndromes.”

Risk factors for geriatric syndromes are shared and represent “the accumulated effect of impairments in multiple systems,” the authors note.   Age itself is a key contributor, along with cognitive impairment, problems performing tasks of daily living – getting dressed, bathing, preparing food, and more – as well as difficulty with walking.

What are the implications?

Many physicians and nurses aren’t sure how best to treat geriatric syndromes.  Interventions that target these conditions successfully aren’t common employed, the authors write.

Since these syndromes are complex, multiple medical providers may need to work together and multiple strategies tried to address their impact.  But Medicare payment policies  don’t encourage this.

Among geriatric syndromes, falls have received the most attention and delirium is now becoming more commonly recognized as a serious problem.

For an easy-to-understand look at geriatric syndromes, see this write-up at the American Geriatrics Society Foundation for Health in Aging web site.

The Centers for Disease Control and Prevention has helpful information about the impact of falls in the elderly and strategies to prevent them. 

Dr. Inouye is a leading expert on delirium and helped develop the Hospital Elder Life Program (HELP) to prevent this alarmingly common consequence of hospitalization in the elderly.  See this write-up of HELP from the Commonwealth Fund for more information.

Green House movement

As reported in this tip sheet on senior housing alternatives, Green Houses are more “homelike” alternatives to nursing homes or large, multi-unit assisted-living facilities. Green Houses, which have been around since the mid-1990s and have spread to at least two dozen sites nationwide, are laid out with a central living/dining/activities area surrounded by 10 or 12 private bedrooms.

Dedicated staff serve residents in need of chronic care at the assisted living/nursing home level 24/7. According to the Robert Wood Johnson Foundation, which is funding expansion of this care model, “At the center of The Green House model are skilled nursing assistants called shahbazim who manage residents' care, with support from nurses and therapists — a reversal of the traditional nursing home model.”

The Green House Project cited several advantages to this model, including:

  • A real home environment

  • Respect for flexible routines, personal preferences

  • Nurtures a familial experience around a common dining table

  • Welcomes friends and family members

  • Encourages personal growth and enables elders to continue to pursue their interests and passions.

  • Lowers cost – studies find this model saves $1,300 to $2300 in Medicare and Medicaid costs vs traditional nursing homes

More information

  • This RWJF Policy Brief looks at the need for different elder care housing models

  • The New Jewish Home is building the first Green House model in New York City. Check out their FAQ’s

  • Jane Brody took a look at this model for The New York Times

  • Ina Jaffe reported on the model for NPR

Health literacy

The Institute of Medicine defines health literacy as “the ability to understand health information and to use that information to make good decisions about health and medical care.” Understanding health information can be overwhelming for anyone. The Agency for Healthcare Quality and Research (AHRQ) reports that some 80 million adults struggle with low health literacy in 2003.

Older adults are unduly affected by poor health literacy, struggling to manage multiple chronic conditions and juggle multiple medications. Trouble understanding what doctors or other providers say, following written instructions, properly adhering to their medications, or filling out health insurance forms are all serious barriers to optimal outcomes - often leading to poorly made health decisions, increased hospitalizations and greater mortality.

Health literacy requires multiple cognitive processes that can challenge adults of any age. For seniors, the addition of deteriorating physical factors like hearing or vision loss, reduced comprehension and slower information processing only add confusion and misunderstanding.

According to the National Library of Medicine:

  • 71 percent of adults older than age 60 have difficulty using print materials

  • 80 percent have difficulty using documents such as forms or charts

  • 68 percent have difficulty interpreting numbers and performing calculations.

People 65 and older make nearly twice as many physician office visits per year than adults aged 45 to 65. However, an estimated two-thirds of older people are unable to understand the information given to them about their prescription medications.

With an estimated U.S. population of 71.5 million adults over age 65 by 2030, the issue of low health literacy has become increasingly important.

The National Action Plan to Improve Health Literacy encourages health providers to use strategies such as picture or video-based information, plain talk, teach back, simplified consent forms, and to undergo health literacy training. It recommends that older adults have a family member or close friend accompany them to appointments and be present when interacting with providers.

Several national, state and local programs provide materials and training to enable community organizations to conduct health literacy workshops with seniors and others in need. 

Health-related quality of life (HRQoL)

Health-related quality of life is “an individual’s or group’s perceived physical and mental health over time.” (CDC)

HRQOL encompasses prevention, treatment, and aspects of a person’s life that affect physical or mental health. According to the CDC, this may include health risks and conditions, functional status, social support and socioeconomic status of individuals. It can be difficult to pinpoint more specifically, since the meaning of “quality of life” varies so broadly among individuals.

In communities, HRQOL encompasses resources, conditions, policies and practices that influence a population’s health status and perceptions. This helps to determine burden of preventable disease, injuries, and disabilities, which guide local, state and national policy interventions, programs and health objectives.

Adding HRQOL indicators in community health assessment studies offers health agencies outcomes that are meaningful to the broad community, identifies population disparities in HRQOL, and helps to prioritize subgroups with unmet needs to improve community quality of life.

Various models are used to measure HRQOL. You may be familiar some indicators if you have ever completed the “Healthy Days” assessment – a form which asks about your health status and any functional or daily activity limitations. Information from this and other evaluations are aggregated into city, state and federal databases to determine and track personal and population health status, issues and trends. Other analyses of HRQOL include patient-reported outcomes, well-being assessments and participation measures. These indicators are tracked by Healthy People 2020.

Healthspan

The news raced around the world:  for the first time, scientists had slowed the aging process in genetically engineered mice by ridding their bodies of a special category of cells, known as senescent cells.

The mice had been programmed to die from heart disease and so they weren’t expected to live longer.  But while alive, it appeared they wouldn’t be subject to some of the declines associated with aging that might otherwise occur.

“Their healthspan was extended,” gerontologist Darren Baker of the Mayo Clinic, told Wired magazine. “They were healthier until the time they died.”

This is a concept reporters covering aging need to be familiar with.

Think of it this way: Someone’s lifespan represents the period of time that they are alive, the span between birth and death.  Someone’s healthspan is the amount of time they are healthy during that period.

The promise of healthy aging is that our healthspans will be extended, even if our lifespans are not.   In other words, we’ll live longer without disability, disease and other ailments, enjoying more years of good health and all the opportunities that this brings.

There’s a measure for this, known as “years of healthy life,” used to assess the health of populations.   It’s used in Europe and it’s being used in the United States on a national basis through Healthy People  2020.

One of the promises raised by the field of anti-aging medicine  is that healthspans will be extended.  Here’s an example of how marketers are using this concept to pitch their products and services, from colon cleansing to so-called “superfoods.” The web is full of similar examples.  On a slightly different note, take a look at a site called Fight Aging! that assumes a scientific mantle to promote  the promise that people can extend their  healthy life expectancies. 

This is not to imply that strategies to enhance healthy aging – and, by definition, extend people’s healthspans – are wrongheaded.  Indeed, a growing body of research shows that eating well, getting exercise, not smoking, consuming alcohol in moderate amounts and other habits can make a real difference in how people age.   A decade ago, the World Health Organization concluded that healthspans could be extended by 5 to 10 years across the globe if people stopped practicing unsafe sex, started controlling high cholesterol and high blood pressure, and addressed obesity, among other health issues.

Hearing loss

Hearing loss tends to worsen with age, and that can lead to other health problems. According to the CDC, 30 percent of adults 65-74 years old, and 47 percent of adults age 75 or older, have a hearing impairment.  Men seem to suffer more frequently than women, but for both genders, hearing loss means more than just difficulty using the phone or enjoying a television show.

Older adults with hearing loss may have trouble understanding verbal instructions from health providers, something that could result in problems like medication errors or not following care plans correctly. Older drivers may not hear horns, railroad crossing signals, emergency sirens, or other warning sounds - which could lead to accidents.

There are two main types of hearing loss:

Sensorineural loss is damage to the inner ear or auditory nerve and is usually permanent; conductive loss means sound waves are not reaching the inner ear, and can be a result of something as simple as earwax buildup or more serious, like a ruptured eardrum. Treatment or surgery can usually restore conductive loss.

Presbycusis is hearing loss which gradually develops with aging. Often the first sign is inability to hear higher-pitched sounds. It commonly affects people over 50, many of whom are likely to lose some hearing each year. Other causes of hearing loss include disease, trauma, medications or long-term exposure to loud noises. Tinnitus, which is a symptom of hearing loss, not a disease, is a frequent complaint of older adults. They hear a ringing, roaring, clicking, hissing, or buzzing sound that may come and go, in one or both ears.

Older people who can't hear well may become depressed or withdraw from others to avoid frustration or embarrassment in social situations. Sometimes older people are mistakenly thought to be confused, unresponsive, or uncooperative when it's really because they don't hear well. Many people are reluctant to admit hearing loss and avoid seeking help. However, according to The Better Hearing Institute, untreated hearing loss is linked to:

  • irritability, negativism and anger

  • fatigue, tension, stress

  • social rejection and loneliness

  • reduced alertness and increased risk to personal safety

  • impaired memory and ability to learn new tasks

  • reduced job performance and earning power

  • diminished psychological and overall health

Patients with diabetes are more than twice as likely as those without the disease to have hearing loss, according to several studiesThe American Diabetes Association says that high glucose levels can damage small blood vessels and nerves in the inner ear over time. People with pre-diabetes are 30 percent more likely to have hearing loss than those with normal blood sugar.

Aging baby boomers, long exposed to loud concert music, MP3 players, and sounds from jackhammers, lawn equipment or even firecrackers are already losing their hearing, it will get worse, as this Huffington Post article explains.

Untreated hearing problems may lead to permanent deafness, so experts advise undergoing regular hearing checkups, and mentioning any possible issues to their care provider.

Life course perspective

According to the World Health Organization, health in old age is determined by patterns of living, exposures and opportunities for health protection within structural, social, and cultural contexts. The life-course perspective recognizes that aging takes place within a socio-historical context that provides different resources to individuals based on gender, socioeconomic status and race/ethnicity. The lifelong impact of differences in access, as well as individual choices, can create disparities in health and well-being in later life. 

To be most effective, programs targeting older people’s health must work with those seeking to improve the lifestyles, environmental risk exposures and opportunities for health protection at earlier ages. This is especially true for the prevention of those disorders that have their origins in earlier life, such as osteoporosis, vascular diseases and most cancers. 

Life expectancy

The average number of years that a person can expect to live. This figure is often adjusted for an individual’s sex, race, age, and other demographic considerations.

The U.S. Centers for Disease Control and Prevention publishes life expectancy tables for the population at birth, age 65 and age 75 broken down by age and sex. The U.S. Census Bureau also publishes life expectancy data.

The average life expectancy for a baby born in the United States has been rising for much of the past century and recently topped 78 years – an all-time high, according to the most recent CDC data. But there are significant disparities. Notably, women live five years longer than men, on average, and whites of both sexes live longer than blacks. Of all groups, black men have the lowest life expectancy.

Longer life expectancies generally reflect reductions in infant mortality and improvements in medical care. As people live longer, new questions arise about their roles in society, the best ways to ensure their ongoing health, the nature of retirement, and the cost of programs targeting the elderly, among many other issues.

Residents of several other nations live longer than Americans, and there are concerns that the growing prevalence of obesity and diabetes here could actually begin to reduce life expectancies in the years ahead.

A relatively new concept in this field is “healthy life expectancy” – the average number of years that a person can expect to live in full health, free of disease or injury. The World Health Organization is promoting the measurement of “healthy life expectancy at birth” as an important global indicator of health.

Life span

The amount of time that someone survives between birth and death.

A key question for aging researchers is whether the life spans of humans have a maximum upper limit determined by the biology of aging. Some researchers are convinced this is not the case, and are seeking ways to actively reverse aging – and extend people’s life spans – through dietary restrictions, biomedical engineering or other means. One group active in promoting research is the Methusaleh Foundation.

Scientists are studying “supercentenarians” – people who live to the age of 110 or more – for clues about factors that contribute to or promote exceptional life spans in humans.

A French woman who lived to the age of 122, Jeanne Calment, is the oldest known human, according to the Gerontology Research Group. With improved medical care and advances in public health, more people are living to a very old age than ever before in human history and life spans have gradually lengthened over the past several hundred years.

Long-term services and supports (LTSS)

Long-term services and supports (LTSS) help older adults and people with disabilities accomplish everyday tasks like bathing, getting dressed, fixing meals, and managing a home.

As our population ages, the number of individuals needing this kind of help is projected to double. Long-term services and supports for the elderly and younger populations with disabilities are a significant component of national health care spending. According to the National Health Policy Forum, we spent $219 billion, or almost 10 percent of all personal health spending, for these services in 2012. About two-thirds were paid for by Medicaid.

Often the individual’s disability or condition results in the need for hands-on assistance or supervision over an extended period of time. Medicaid plays a key role in covering LTSS to aged and disabled individuals. As the largest single payer of LTSS in the United States, federal and state Medicaid spending accounted for $133.5 billion or 42.1 percent of all LTSS expenditures in 2011 ($317.1 billion). LTSS are also a substantial portion of spending within the Medicaid program relative to the population served, accounting for over one- third (35.6 percent) of all Medicaid spending. Of the 66 million total enrolled Medicaid population, an estimated 4.2 million (or 6.4 percent) Medicaid beneficiaries received LTSS in 2010.

Medicaid funds LTSS for eligible beneficiaries in both institutional and home and community- based settings, though the range of services offered differs substantially by state. States must offer certain Medicaid institutional services to eligible beneficiaries, yet the majority of Medicaid home and community-based services (HCBS) are optional for states.

The Affordable Care Act contains certain provisions that allow states to more easily expand access to LTSS. Key programs include:

A comprehensive 2013 Congressional Budget office report looks at the rising demand for LTSS. This report includes some excellent stats and graphs that reporters can use as a jumping off point to look at projected growth and future needs in their own communities.

Longevity

The amount of time a person can expect to live under ideal circumstances – ideal nutrition, healthcare, physical activity, social circumstances, and so on.

Helping people live as long as possible, or achieve longevity, by adopting healthy habits is the focus of a small library of books – some based on good science, some less so. Included are titles such as “The Longevity Prescription: The 8 Proven Keys to a Long and Healthy Life,” by Dr. Robert Butler, a famous gerontologist and former head of the National Institute on Aging, and “You: Staying Young, The Owners Manual for Extending Your Warranty,” by celebrity physician authors Michael Roizen and Mehmet Oz ().

The field of anti-aging medicine similarly extends a promise of extended longevity to adherents, though many therapies and practices marketed by anti-aging practitioners are unproven and of questionable benefit.

Scientists are pursuing many avenues of research related to longevity. Some have been studying “centenarians” -- people who live to the age of 100 years or more and who therefore have achieved longevity. Meanwhile, others have been exploring whether there is a “longevity gene” that could be manipulated with drugs to help extend long life. This is a controversial field, with different camps of researchers taking different positions.

Longevity gene

Humans have searched for a "fountain of youth" since before the time of Ponce de Leon. Now scientists may be on track to find a so-called "longevity gene." SIRT3, part of a class of proteins known as sirtuins, help stem cells cope with stress. A study in mice by researchers at the University of California, Berkeley points to potential for their findings to someday help scientists find targeted treatments for aging-related degenerative diseases. Researchers were able to turn back the molecular clock of older mice when their blood was infused with the proteins – triggering stem cell's rejuvenating potential similar to that found in younger mice.

Scientists have long known of specific genes which affect healthy aging. While this research may have future application for targeted disease treatment, other researchers point out that practical use is still a long way off. Focusing on things we can control now, such as improved chronic disease management, diet and exercise, is still the best way to promote healthy aging.

Resources:

Meaningful use

Meaningful use sets specific objectives that eligible professionals and hospitals must achieve to qualify for Centers for Medicare & Medicaid Services (CMS) Incentive Programs.
Among the requirements is using certified electronic health record (EHR) technology to:

  • improve quality, safety, efficiency and reduce health disparities

  • engage patients and families

  • improve care coordination, population and public health

  • maintain privacy and security of patient health information

It is hoped that compliance with these regulations improve clinical outcomes, increase transparency and efficiency, empower individuals and provide more robust data on health system use.

Mild cognitive

At the close of the last century, scientists at the Mayo Clinic identified a condition they called mild cognitive impairment (MCI), typically characterized by worse-than-usual memory problems associated with aging.

It’s still little known to the general public and services for people with MCI remain few and far between.

While estimates of MCI’s prevalence differ, it’s relatively safe to say that 10 percent to 15 percent of people age 65 and older have this condition. Of those, about 50 percent will develop some type of dementia within five years.

Another surprisingly large group of older people – up to 40 percent in some studies – who initially appear to have MCI will turn out to have normal cognitive aging when they’re re-tested or other medical concerns such as depression, hearing problems, thyroid dysfunctions, metabolic syndrome, and vitamin B-12 deficiencies are addressed.

This reflects the reality that diagnosing MCI isn’t a sure thing. The accuracy of diagnoses depends on which tests are given, how often, and under what conditions, and involves both subjective and objective criteria.

Often, MCI is discussed as if it’s on the dementia spectrum, representing the earliest stage of Alzheimer’s disease or other related conditions. This is understandable because large numbers of people with MCI do develop Alzheimer’s down the road. But because basic biological mechanisms associated with Alzheimer’s remain under investigation, it’s not been proved definitively that MCI is the pre-clinical manifestation of this disease. Also, there are various types of MCI, and not all are equally associated with Alzheimer’s.

If the line between MCI and mild to moderate Alzheimer’s disease seems unclear, think of it this way. By definition, people with MCI retain most of their ability to function day-to-day and are not seriously compromised. When their independence, their ability to work or their ability to follow routines is jeopardized, a diagnosis of dementia may be warranted.

Similarly, the line between MCI and normal cognitive aging sometimes may seem blurred. Here, experts say the difference is one of degree. While it’s normal to have more problems remembering names with age, it’s not normal to forget the names of people close to you and remain unable to remember them after some time has passed. Also, MCI affects memory more broadly than normal, age-related memory loss.

Red flags that indicate the need for a medical evaluation include “asking questions or making comments repetitively … getting lost in familiar places … not remember names of people that you know well … not remembering something after a reminder … (and) not remember important, meaningful events soon after they happened,” according to a new book by researchers at the University of Toronto, “Living with Mild Cognitive Impairment.”

There are no interventions that can treat MCI, nor any proven methods of preventing it. But that doesn’t mean the situation is hopeless: There are ways of maximizing functioning, even once this condition becomes apparent. Some will sound familiar – eating well, getting regular exercise, remaining intellectually and socially engaged – and others are more specific to this ailment, such as structured memory exercises.

Recent research from the Mayo Clinic has shown that MCI is more common among men than women, and that men with only a high school education are more at risk for developing MCI than are women with similar education levels.

Resources on mild cognitive impairment are available from the Alzheimer’s Association, the Mayo Clinic, Baycrest (a research campus at the University of Toronto) and the Family Caregiver Alliance, among other organizations.

UPDATE: Some experts are concerned that people diagnosed with mild cognitive impairment will undergo widespread screening and receive unnecessary treatments that don’t actually prevent or slow Alzheimer’s disease but that do have the potential for significant side effects. For a just-published piece warning of this danger, see this Sept. 12, 2012, write-up at the Australian website The Conversation.

Nationwide health information network

A set of common standards, services and policies that allow for secure exchange of information over the Internet. These protocols securely move patient information from paper to electronic format. Sharing of electronic health records enable providers in any facility or geographic location  to improve and expedite care coordination while better controlling costs. The NHIN is an underpinning of a national health information exchange, one of the primary goals of the Health Information Technology for Economic and Clinical Health (HITECH) Act. 

The NIHN falls under the purview of the Office of the National Coordinator for Health Information Technology (ONC) at the Department of Health and Human Services. ONC is leading the effort to implement and use the most advanced health information technology available to enable electronic health information exchange.

Naturally occurring retirement communities

NORCs are one successful living model that helps seniors age-in-place. NORCs are communities or buildings where a large proportion of residents are older, and live independently. They are not comprehensive senior-only housing or retirement communities per se, and were not designed as such. Nor were they set up to specifically address seniors’ health or social service needs.

Commonly, NORCs include older residents who have remained in their own homes or apartments while younger residents migrated from the neighborhood. They could also be age-friendly communities or housing complexes that attract older residents who are intent to live out the rest of their lives there.

NORCs are found in cities, suburbs, and rural areas. Numerous NORC programs work to coordinate health care, social services, recreation, and educational opportunities; all with the goal of assisting older people to remain in their own homes and on their own for as long as possible.

Private philanthropy groups as well as federal, state, and local funds support NORC programs. The Administration on Aging website has an overview of the past several years of Congressional funding for NORC programs. There are also several useful resources and links on their site.

As described by the United Hospital Fund of New York, NORC programs bring together social workers, nurses, and residents “to address the needs of seniors in the community.” Although services and projects vary by community, most include:

  • Social work services. This includes a broad range of supports to individuals and caregivers.

  • Nursing services. This includes individual care to older adults managing chronic conditions (such as referrals for reimbursable skilled care services and coordinating medical care with physicians) and activities that address health issues affecting many community residents.

  • Educational and recreational activities. NORC program activities – lectures, concerts, classes, field trips, card games, cultural activities, discussion groups, and more – are diverse and designed to engage the broad range of seniors in the community.

  • Opportunities for community engagement. Senior residents make NORC programs possible through their roles as program advisors and ambassadors, fundraisers, teachers, and peer counselors, among others.

  • Ancillary services. These reflect the unique needs of each community and are intended to advance the broader goals of the NORC program. Examples of ancillary services are transportation, housekeeping, and social adult day programs.

Further reading:

This article from Next Avenue provides a good primer on NORCs and several key support programs. The value of NORCs is discussed in a study by Kristina Guo, et. al., in Ageing International.

How are urban environments set to handle the coming aging boom? Buffel, Phillipson, and Scharf analyze age-friendly urban environments in this article from Crticial Social Policy, and Housing as a Platform for Improving Outcomes is discussed in this report from The Urban Institute.

Nurses Improving Care for Healthsystem Elders (NICHE)

This is a widely adopted nurse-driven program that helps hospitals and healthcare organizations improve the care of older adults. The idea is to provide sensitive and outstanding care to all patients 65 and over.

The NICHE program is designed to upgrade the quality of care for older adult patients by increasing awareness of geriatric issues, improving staff competence in nursing care of the elderly, and supporting the implementation of hospital geriatric protocols. The program provides guiding principles and tools to change the culture of healthcare facilities and achieve patient-centered care for older adults. Using NICHE guidelines, the entire caregiving team works together to provide the most coordinated, effective care possible.

To date, 620 hospitals and healthcare facilities in 46 states, Canada, Bermuda, and Singapore have received NICHE designation. This certification demonstrates a facility’s commitment and ongoing progress to improve quality, enhance the patient and family experience, and support the hospital and other health care organization's efforts to better serve its communities.

For more on NICHE:

Observation care

When is a hospital patient not really a hospital patient?

When he or she is classified as being in observation care.

This little known category of care has come under the spotlight recently as advocates have raised questions about its growing use and the impact on seniors with Medicare coverage.

Observation care is meant to apply to patients who aren’t sick enough to be admitted to inpatient wards but who aren’t well enough to be sent home without extra testing, monitoring and oversight.  A good example: People with chest pain who aren’t clearly having a heart attack but who appear in considerable distress.

The problem is that hospitals have been keeping some patients in observation care well beyond the 24- to 48-hour period typically recommended by Medicare. (Fear of audits and withheld payments is one motivation, and fear of being penalized for readmissions is another. See the articles listed below for more details.) In some cases, patients have stayed in hospitals for a week or longer, only to learn after the fact that they were considered an “observation” patient, not an inpatient.

This matters because seniors don’t qualify under Medicare for post-acute skilled nursing care unless they’ve been admitted to the hospital for at least three days. Also, seniors in observation care pay more for some drugs, and incur other extra, unwanted expenses.

I wrote one of the earliest stories about observation care for the Chicago Tribune back in 2009, when confusion over this practice was just beginning to mount.

The Center for Medicare Advocacy filed a lawsuit challenging Medicare’s increasing use of observation care in November 2011.

Susan Jaffe’s articles about observation care for Kaiser Health News are a valuable contribution to the literature on this topic. Take a look at this piece from September 2010 and another from June 2012 where she reported on a new Health Affairs study by researchers from Brown University:

“The researchers analyzed medical records and hospital claims for 29 million people in traditional Medicare from 2007 to 2009. They found that observation stays increased 25 percent to about one million in 2009. They also found that observation patients remained in the hospital longer, with 45,000 patients in 2009 staying at least 72 hours – an 88 percent hike since 2007 – and well past Medicare’s recommended 24 to 48 hours.”

(State by state information about observation care can be found at the end of Jaffe’s piece.)

Also worth looking at is Anna Wilde Mathew’s February 2012 story on observation care in The Wall Street Journal

Recently, Health Affairs published a new article on observation care units – special areas in a hospital devoted to observation care. Researchers concluded that appropriate use of these units could result in health care savings of more than $3 billion annually by preventing inappropriate hospitalizations and easing pressure on emergency rooms.

MSNBC covered observation care in a January 2014 piece in which CMS officials refused to be interviewed.

In another noteworthy development, the Center for Medicare & Medicaid Services is considering possible changes to its policies vis a vis observation care and has solicited input. See California Healthline’s September 2012 coverage of the basic issues and that development here.

Office of the National Coordinator (ONC)

The Office of the National Coordinator for Health Information Technology (ONC) leads the administration’s health IT efforts and is charged with coordination of nationwide efforts to implement and use the most advanced health information technology and the electronic exchange of health information. ONC is organizationally located within the Office of the Secretary for the U.S. Department of Health and Human Services (HHS). The position of National Coordinator was created in 2004, through an Executive Order, and legislatively mandated in the Health Information Technology for Economic and Clinical Health Act (HITECH Act) of 2009.

The ONC has provided funding for a number of health IT programs, including the development of the Nationwide Health Information Network (NwHIN)—a set of standards, services, and policies that enable the secure exchange of health information over the Internet. The NwHIN is NOT a physical network — it sets the standards, services, and policies which help transition health care from a paper-based patient record system to a securely stored and shared electronic process that follows the patient. This improves clinical decision making and has uses beyond direct patient care, such as measuring quality of care.

Media Contact: Peter.Ashkenaz@hhs.gov; 202-260-6342; Fax: 202-690-6079

Older Americans Act

This groundbreaking legislation, enacted in 1965, was the first national initiative to address a widespread lack of community-based services for older adults.

It created an infrastructure that endures to this day, providing funding for local Area Agencies on Aging, state agencies on aging, and the national Administration on Aging, now part of the U.S. Department of Health and Human Services.

(For a historical overview of programs serving older Americans, see this resource from the Administration on Aging.)

Currently, the national aging network consists of 56 state units on aging, 629 Area Agencies on Aging, 244 tribal organizations that deliver services to seniors, and two aging organizations representing Native Hawaiians. There is a geographic directory of services.

Services funded through the Older Americans Act help millions of seniors get regular meals at home, attend senior centers, receive government benefits to which they’re entitled, obtain help going to and from doctors’ appointments, qualify for caregiving support services, manage chronic diseases, get job training, and more.

Anyone age 60 or older qualifies for services delivered through the Older Americans Act except caregiver support services, which are available to those age 70 and older.

The act was up for reauthorization in 2011, but Congress put off that challenge until after the start of 2012.

On Jan. 6, 2012, Senator Bernie Sanders (I-Vt.) announced plans to introduce a comprehensive reauthorization bill. Sanders is chair of the Senate Subcommittee on Primary Health and Aging, which has jurisdiction over this Older Americans Act.

In a press release, Sanders announced several proposed changes to the act:

"Under one of the major initiatives in the reauthorization measure, the Bureau of Labor Statistics would be instructed to improve how it calculates inflation for the elderly by more accurately reflecting out-of-pocket expenses for health care and prescription drugs. A cost-of-living measure tailored to the real-world lives of seniors could be used to make more accurate annual adjustments in Social Security benefits, for example…

The bill, which will be formally introduced after Congress reconvenes later this month, also would clarify the legal definition of "economic security" to encompass the income necessary to pay for housing, health care, transportation, food, long-term care, and other basic needs.

The measure also would streamline and strengthen the meals program, authorizing a 50 percent boost in funding. The bill would help modernize senior centers by creating a pilot program and community planning grant program. The legislation also devotes more help for seniors looking for jobs."

The National Council on Aging has called reauthorization “a prime opportunity to reshape and modernize aging services in this country.” But the financial environment in which this debate is taking place is grim: steep budget cuts being contemplated nationally and in the states could prove devastating for programs for older Americans.

See this issue brief on funding for the Older Americans Act. In fiscal 2011, federal funding for the program totaled $1.5 billion.

Here are the basics on the Older Americans Act.

The National Council on Aging has extensive materials on its website.

The Administration on Aging also has extensive materials on the OAA and community forums where reauthorization was discussed extensively.

The Leadership Council of Aging Organizations has a helpful fact sheet.

Another resource is the National Association of States United for Aging and Disabilities.

Older Americans Independence Centers (OAIC)

The program was established in honor of Claude D. Pepper ,the late Congressional Representative,to create centers of excellence in geriatrics research and research career development. Their goal is to increase scientific knowledge leading to better ways to maintain or restore independence in older persons. Currently 15 centers, support biomedical research leading to maintenance of functional independence into older age

The National Institute on Aging supports the OAICs to develop and enhance research and education at institutions with strong programs in aging research. This support addresses key research problems, technological limitations, and faculty development needs for future generations of appropriately-trained researchers. The Centers conduct cutting-edge research and offer a number of services for older Americans. Each center has a research focus such as frailty, disease prevention, or translational research.

A listing of the currently active OAICs, their achievements, and other pertinent information can be found on the National Pepper Center Website .

The goal is to foster multidisciplinary research to integrate basic and clinical science, education, and health services research relevant to the health care problems of older adults.

One of the more interesting components is the Pepper Center Integrated Aging Studies Databank and Repository . Here you will find over 20 interventional or observational studies in older cohorts with their associated data and stored specimens. Datasets include extensive assessments of physical and cognitive function, body composition, and quality of life, and many of the stored specimens include skeletal muscle biopsies. There is also a study of healthy aging that can be a great source of reference data for studies in older clinical populations. The Pepper Coordinating Center publishes an annual report that describes the investigators, pilot studies, other research projects, and publications associated with each Center

Recently, the National Institute on Aging and the Patient-Centered Outcomes Research Institute awarded funding to a consortium involving all the Centers to conduct a large-scale effectiveness trial of tailored interventions to prevent serious fall-related injuries in older adults. In addition to clinical trials, the Centers are also partnering with the HMO Research Network and the NIH-funded Centers for AIDS Research in two separate projects to expand the reach of aging in large healthcare systems and in HIV-infected populations, respectively.

Common among all these initiatives is the Centers’ role of providing resources to conduct research through secondary analyses, ancillary studies, and pilot awards, as well as access to experts and potential mentors in aging research.

OpenNotes 

OpenNotes is a national effort designed to give patients access to the visit notes written by their doctors, nurses, or other clinicians. The program began in 2010, when 100 primary care doctors from medical institutions across the United States began sharing notes online with their patients. Each site was part of a 12-month study to explore how sharing doctors’ notes may affect health care. The evidence from this study suggests that opening up visit notes to patients may make care more efficient, improve communication and, most importantly, may help patients become more actively involved with their health and health care.

More than 11 million Americans have access to their visit notes through the OpenNotes program. The concept of OpenNotes is to make sure that everyone involved in the medical encounter — including the patient — has access to the same information either electronically or via print out. Results show that patients are more compliant with medication and feel more in control of their care. According to this study in the Annals of Internal medicine: OpenNotes helps patients better remember what is discussed during clinical visits and share notes with their caregivers. This helps caregivers stay more up to date with care and enact recommended treatment plans.

Physicians and other clinicians find that OpenNotes enhances patient communication and education, better prepares patients for visits and helps them stay healthier or better manage their chronic conditions. Sharing their notes enables physicians and other clinical providers to enhance patient communication and education, help patients better prepare for their visits and help to reduce health care costs through improved communication, medication adherance and more efficient use of a clinician's time.

Not all physicians are comfortable with note-sharing, however. Some cite concerns about creating confusion, needless worry or privacy violations. This article looks at some of the pros and cons of note sharing between clinicians and patients. For a deeper dive into the issue, check out this episode of the Diane Rehm show.

Osteopenia

Low bone mass that is not low enough to be osteoporosis. Family history, insufficient calcium or Vitamin D are risk factors for osteopenia. Not everyone who has low bone mass gets osteoporosis but it does increase the risk of developing it. Some researchers argue that limiting the clinical diagnosis of osteoporosis solely to a T-score-based criterion (the official convention in the U.S.) creates uncertainty about the use of the term "osteoporosis" to diagnose older women and men who have T-scores >−2.5, but either have already sustained low-trauma fractures or are recognized as having high fracture risk based on absolute fracture risk calculations.

Osteoporosis

Those with reduced bone strength are at an increased risk for fractures, which is called osteoporosis. The diagnosis is based exclusively on bone mineral density T-scores that are ≤−2.5 at the spine or hip. As many as half of all women and a quarter of men older than 50 will break a bone due to osteoporosis, according to the National Institute of Arthritis and Musculoskeletal and Skin Diseases.

Pallative care

This is a unique medical specialty that takes a holistic, integrated approach to provide patients with relief of symptoms and and cope with the stress of a serious illness.  An interdisciplinary team − physicians, social workers, nurses, therapists and others – work together on common treatment goals, managing the patient’s pain, easing transition from one setting to another and addressing the family’s concerns. 

Palliative care does not have to wait until the patient is in hospice or dying. It is appropriate at any age and at any stage in a serious illness and can be provided along with curative treatment. It can help to manage symptoms such as nausea, shortness of breath, fatigue, depression, and sleep issues; it also provides a way for patients to exert more control over their own care by improving understanding of treatment options and working collaboratively to determine treatment goals. 

At AHCJ 2014 in Denver, Daniel Johnson, M.D., F.A.A.H.P.M., National Physician Lead for Palliative Care, Care Management Institute, Kaiser Permanente; Director Emeritus at Life Quality Institute; and Faculty Associate at University of Colorado Center for Bioethics and Humanities, took part in a panel on palliative care. He offered some tips on how journalists can improve coverage of this issue, as well as story ideas that might warrant further attention.  

Person-centered care

The Institute for Person-Centered Care at the University of Buffalo defines it as a process that "moves decision-making directly to the individual despite frailty, cognitive impairment or the location in which services are provided. PCC includes the valuable input of care partners and integrates all aspects of daily life creating environments where people can truly thrive and grow.” 

Person-centered care differs from patient-centered care – which is visit-based – because person-centered care is based on accumulated knowledge of the entire care team, including family caregivers. This forms the foundation for better recognition of health problems and needs over time and facilitates appropriate care for these needs in the context of other needs.

This approach sees the person as an individual, rather than as a collection of symptoms and behaviors to be controlled. It considers the whole person, taking into account each individual's unique qualities, abilities, interests, preferences and needs. 

Person-centered care focuses not just on treatment for the person’s illness or condition, but on:

  • the person’s strengths, rather than their limitations
  • the person’s interests—what’s important to them
  • activities that are truly meaningful to them
  • close and continuous contact with others (real relationships), and
    the rewards of being interdependent, not dependent.

It also takes into account a person’s preferences for such things as:

  • when and what they eat
  • when they want to sleep and bathe
  • what they want to wear
  • what they want to do with their time, and
  • their end of life (to be hospitalized or not, for example, or to receive treatment such as CPR, intubation, or a feeding tube).

The National Quality Forum seeks to promote person- and family-centered care across the health care landscape:

  • Improve patient, family, and caregiver experience of care related to quality, safety, and access across settings.
  • In partnership with patients, families, and caregivers, and using a shared decision-making process, develop culturally sensitive and understandable care plans.
  • Enable patients and their families and caregivers to navigate, coordinate, and manage their care appropriately and effectively.

Person-environment interaction

One way to view the process of development and change during adulthood. Person-environment interaction suggests that all aspects of human behavior and performance are the result of the interaction or transactions between individuals and their environment. Therefore, successful adaptation and adjustment during adulthood require persons to be selective in their choice of stimuli, responses and behavior, and to compensate for changes in ability or health that result from the aging process in order to optimize their behavior and performance.

Physician-assisted death vs. euthanasia

Coverage of a new California law that legalizes physician-assisted death was all over the map. While most media made a point to clearly describe the nuances and criteria of the law, others sometimes played a little looser with the terminology, as in this wire story from Agence France-Press (via MSN) about was then still a California bill – referring to it as a “euthanasia bill.” That’s irresponsible, according to a spokesperson for the Hastings Center, a nonpartisan bioethics research institute.

Here’s the difference:

Physician-assisted death: the practice of a physician providing the means for a patient to end his own life, usually with a prescription for barbiturates that the patient takes himself; sometimes also called physician-assisted suicide.

Euthanasia: painlessly killing or permitting the death of individuals who are ill or injured beyond hope of recovery.

Voluntary active euthanasia: hastening one’s own death by use of drugs or other means, with a doctor’s direct assistance.

Passive euthanasia: hastening death by withdrawing life-sustaining treatment and letting nature take its course.

Involuntary euthanasia: causing or hastening the death of someone who has not asked for assistance with dying, such as a patient who has lost consciousness and is unlikely to regain it.

According to Hastings, state-of-the-art palliative care remains the standard of care for any end-of-life suffering, and last-resort options should only be considered when such treatments are ineffective. A more politically and ethically acceptable alternative to legalizing physician-assisted death may be to expand other “last resort” options.

In the United States, most jurisdictions have prohibited physician-assisted death, either with specific statutory provisions or judicial applications of more general statutes. Common understanding of the word “suicide” equates it with mental illness and irrational behavior, and the medical obligation is to prevent it if at all possible. Dying patients who see their lives being destroyed by illness sometimes come to view death as the only way to escape their suffering and, therefore, as a means of self-preservation – the opposite of suicide.

The public remains deeply divided on the question of whether to permit physician-assisted death. In most surveys, approximately two-thirds of the U.S. population of approve of it as an option for terminally ill patients with intractable suffering. But when the question of legalization comes to a vote, it is usually closer to 50/50. This split probably reflects the inherent tensions in the debate. On the one hand, most people know of cases of severe suffering, even with excellent palliative care, where the need for some predictable escape is very compelling. On the other hand, there are real fears that physician-assisted death could be used as a detour from effective palliative care, or as a way to eliminate the suffering of vulnerable patients by eliminating the sufferer.

Suffering can go beyond physical to include psychological, social, existential, and spiritual dimensions. The medical profession acknowledges that such unacceptable suffering sometimes exists when a physician talks with a patient about stopping life supports. But when there is no life support to stop, the medical profession tends to be judgmental of both the physician and the patient about not trying hard enough with standard palliative measures.

Data collected by the Oregon Health Department show that the practice is stable and relatively rare, accounting for approximately one in 1,000 deaths in Oregon, hospice utilization is among the highest in the nation, and there is a statewide program to record patients’ wishes about cardiopulmonary resuscitation, called Physician Orders for Life-Sustaining Therapy (POLST).

Oregon is one of only three states with legalized physician-assisted suicide via legislation (Vermont and Washington are the others.) Montana and New Mexico have legal physician-assisted suicide via court ruling. However, New Mexico's statutes continue to list assisted suicide as a fourth-degree felony.  Other states are considering so-called “Death with Dignity” legislation.

A last resort response to some of the more complex and difficult cases is for physicians to sedate a patient to the point of unconsciousness to enable the person to escape otherwise intractable physical suffering at the end of life. The American Medical Association in July 2008 stated that “it is the ethical obligation of a physician to offer palliative sedation to unconsciousness as an option for the relief of intractable symptoms” at the end of life when “symptoms cannot be diminished through all other means of palliation.”

The AMA has consistently opposed physician-assisted death, arguing that allowing physicians to participate in assisted suicide would cause more harm than good. “Physician-assisted suicide is fundamentally incompatible with the physician’s role as healer, would be difficult or impossible to control, and would pose serious societal risks,” it said.

More resources:

  • University of Rochester Medical Center: Its Division of Medical Humanities and Bioethics page includes links, resources, and a newsletter.

  • American Academy of Hospice and Palliative Medicine: Its position statement on physician-assisted death gives background and guidelines for evaluating a request.

  • Oregon Department of Human Services’ Public Health Division: Maintains a gateway page on the state’ Death with Dignity Act. Includes annual reports, reporting requirements, publications, and FAQs.

  • Pro/Con.org: Has posted findings from several public opinion polls on physician-assisted death.

  • AHCJ coverage on end-of-life care includes an interview with Nancy Berlinger, of the Hastings Center and a panel discussion on the topic during the 2015 conference.

Physician-assisted suicide

Two states – Oregon and Washington – allow terminally ill patients to end their lives with the aid of a physician. A petition drive to put the issue before voters is underway in Massachusetts, and a bill that would legalize physician-assisted suicide was re-introduced in February in Vermont after failing to gain traction last year.

Voters in Michigan and Maine have adopted the opposite stance, refusing to let patients end their lives with the aid of doctors. Some say Hawaii, whose legislature shelved a bill allowing physician-assisted suicide in February also falls in this category, but others argue that the state has laws that permit the practice.

This is the single most divisive cultural issue in America, according to Gallup’s 2011 Values and Beliefs Poll, released in March. That polling organization found that 45 percent of Americans consider physician-assisted suicide “morally acceptable” while 48 percent deem in “morally wrong.”  The second most controversial issue is abortion, with 39 percent of Americans calling it an acceptable practice and 51 percent calling it unacceptable.

Proponents argue that allowing terminally ill patients to end their lives on their own terms is respectful of a person’s autonomy and allows that individual to die with dignity. Compassion & Choices is a leading advocate for this option. Opponents, including the Catholic Church and some disability rights groups, call physician-assisted suicide a form of state sanctioned murder and a violation of physicians’ Hippocratic Oath.

Oregon was the first state to pass a ballot initiative in 1994 allowing physician-assisted suicide;  after several challenges, the law was upheld by voters in 1997. Several protections are included in the act:  patients must request a lethal prescription in writing, wait 15 days after the request is approved and then ask again. If a doctor suspects depression is factor in the person’s decision, he or she can order a psychological evaluation. Witnesses are required for at various points of the process, and at any point a patient may change his or her mind.

Fears that large numbers of people would take their lives in Oregon and Washington, leading to broader acceptance of voluntary euthanasia  haven’t materialized. Paula Span of the New Old Age blog at The New York Times reported recently that in 2010 in Oregon, 96 people asked for lethal medications and 59 people used them to end their lives. In Washington,  the trend was similar:  87 people requested prescriptions while 51 actually committed suicide with the drugs.

Program of All-inclusive Care for the Elderly (PACE)

This care model is built around the concept of providing community-based care and support for older adults with chronic care needs, rather than institutional-based care. 

PACE provides the entire continuum of care and services to eligible seniors, helping them to maintain their independence at home for as long as possible. Services include adult day care, medical care, home health and personal care, meals, prescription drugs, specialty care including therapy, dental , vision and hearing, respite care, hospice and nursing home care when needed. 

PACE is a Medicare program and Medicaid state option. Individuals age 55 or older who are state-certified to need nursing home care but are able to live safely in their community — and live in a PACE service area — may qualify for the program.   

For more information, check out this fact sheet from PACE, or contact the National PACE Association.

Quality Indicator Survey (QIS) process

The Quality Indicator Survey (QIS) process is one of the two types of CMS-approved surveys (along with the traditional standard survey) to determine compliance with Medicare/Medicaid requirements. The QIS uses a resident-centered approach to systematically review specific nursing home requirements and provides guidance to the surveyors to objectively investigate any regulatory areas that are triggered. 

The QIS uses Quality of Care and Quality of Life Indicators (QCLIs) to improve consistency and accuracy of the identification of quality of care concerns. The QIS uses a structured process of resident, family and staff interviews as well as structured and focused record reviews. The QIS also uses customized software to guide surveyors through the investigations.

RE-AIM Framework

This is a model for planning, executing, and evaluating efforts to implement population-level changes in the health and well-being of older adults. REAIM stands for Reach, Effectiveness, Adoption, Implementation, and Maintenance. It’s designed to help state and local leaders understand the prevalence of behavioral health problems, and assist program leaders in selecting, implementing, and assessing effective prevention and early intervention programs and practices.

The goal of RE-AIM is to encourage stakeholders to identify essential elements that improve the implementation and sustainability of programs and practices:

  • Reach the target population

  • Effectiveness or efficacy

  • Adoption by target staff, settings, or institutions

  • Implementation consistency, costs and adaptions made during delivery

  • Maintenance of intervention effects in individuals and settings over time

According to this issue brief from the Substance Abuse and Mental Health Services Administration, (SAMHSA) and Administration on Aging (AoA), paying attention to the RE-AIM elements increases the likelihood of improving the health of the entire population. Organizations that successfully implement evidence-based practices are attentive to and perform well in the five RE-AIM elements.

Encouraging stakeholders to pay more attention to essential program elements will also pay off with the sustainable adoption and implementation of effective, generalizable, evidence-based interventions. In contrast to the availability of information regarding intervention efficacy, there is no widely-available systematic framework to evaluate potential for translation and public health impact. To fill the research-practice gap, behavioral scientist Russell Glasgow, M.S., Ph.D., visiting professor at the University of Colorado, Denver School of Medicine and colleagues designed an evaluation framework to expand assessment of interventions beyond efficacy to multiple criteria that have real-word public health impact but are not often addressed through traditional research studies

Regenerative Medicine

Regenerative medicine has been around since the 1950s — think organ and bone marrow transplants — but the rapidly aging population is putting more pressure on science and medicine to keep people healthier longer and to develop permanent solutions for people with life-threatening conditions.

Scientists are creating living, functional tissues to repair or replace tissue or organ function lost due to age, disease, damage, or congenital defects by stimulating previously irreparable organs to heal themselves. They’re also growing new tissues and organs in the lab and replacing them when the body can’t heal itself.

Lack of donated organs means thousands die on waiting lists every year before a match is found. According to the NIH,

  • tissue-engineered skin is now commonly used to treat burns, for diabetic ulcers, and for skin replacement.

  • a tissue-engineered bladder, derived from a patient’s own cells, can be grown outside the body and successfully transplanted.

  • Tissue engineered products help with bone and connective tissue growth, replace damaged knee cartilage and are being used in heart bypass surgery and to treat cardiovascular disease. Stem cells are culled from sources including bone marrow, embryos, umbilical cords and adult tissue. Clinical trials are underway with the hope of curing or treating many previously incurable conditions like macular degeneration, ALS, Parkinson’s disease, multiple sclerosis, and blood disorders.

As this article explains, much of the controversy over stem cell use has quieted; scientists around the world are working as fast as they can to develop solutions to treat chronic, debilitating conditions without the need for a lifetime of medication or suffering. Several institutions are investigating the use of regenerative medicine to address Alzheimer’s and other dementias. If successful, this could significantly impact the cost and burden of long term care in the U.S.

Research is underway at many major academic institutions and teaching hospitals, including:

Resilience

It’s an important part of healthy aging. Resilience is generally defined as how people cope with and bounce back form stress, adverse events and major life changes - such as chronic disease, death of a partner, moving from one’s home or loss of a job. 

The affects of adversity on health and function in later life can vary significantly between individuals. It is how, and how well, they cope with common stressors that determines resilience. The Resilience Solutions Group at Arizona State University defines the core components of resilience as: 

  • optimism

  • flexibility

  • determination

  • sustainability

  • diversity

  • balance

  • connectedness

Focusing on positive outcomes, adapting to change, having strength of purpose, remaining healthy over time, having a range of possibilities, maintaining psychological composure and having close ties with family and friends all contribute to resilience as we age.  

Older adults are more resilient in many ways than younger people. Clinical psychologist Nancy Pachana, Deputy Head of the School of Psychology at the University of Queensland, said in an interview with the Australian Psychology Society "Older adults bring with them a lifetime of experience and this can be applied to difficulties that come up later in life." For example, older adults often cope better with the loss of a spouse than younger adults because late adulthood is the expected time for such a loss to occur, with friends often in similar situations. In comparison, younger people may find themselves isolated and lacking in coping resources. 

As this article in Canadian Psychology points out,, "humans have sometimes astonishing capacities to minimize or contain the long-term costs of stress, thereby maintaining a resilient physiology and helping to ensure a long and healthful life. These capacities are attributable in part to lifestyle choices that limit exposure to stress, in part to adaptive appraisal and coping strategies that reduce the impact of stress exposure, and in part to efficient restorative processes that rebuild physiological reserves. Improvement in any of these domains would be expected to have an impact on health and resilience. Thus, although aging is inevitable, engaging human strengths in the face of contemporarystressors can considerably slow the accrual of bodily wear and tear. 

Or, as Paula Span (paraphrasing Justice Potter Stewart), wrote, “it’s hard to define, but we know it when we see it.”

Social Construction of Aging

The creation of social norms and symbols that encapsulates the aging process. While aging itself is a biological process, what it means to be "young" or "old" depends on the specific culture.  

Aging is perceived differently around the world. Frequently, the average life expectancy in a given region affects what age counts as "old." For example, in the United States, where the average life expectancy is over 78 years, people are not considered "old" until they are in their sixties or seventies. However, in other parts of the world  age 50  — or younger— is old. These variations in people's perceptions of who should or should not be considered old supports the idea that youth and age are culturally constructed. 

There is no universal age for being considered old. Cultures treat their elderly differently and place different values on old age. Many Eastern societies associate old age with wisdom, so they value old age much more than their Western counterparts. In Japan, adult children are expected to care for their aging parents in ways different than in the United States. Sixty five percent of Japanese elders live with their children and very few live in nursing homes. Japanese cultural norms suggest that caring for one's parents by putting them in a nursing home is akin to neglect. Western societies tend to place an increased value on youth — so much so that many people take extreme measures to appear young. The desire to appear younger than one's biological years is frequently reinforced in the media, including advertising, marketing, on television and in movies.

Social portfolio

A method of enhancing one's pathway through mid to late life phases; it was first proposed by Gene D. Cohen, considered  one of the founding fathers of geriatric psychiatry, a  founder the American Association for Geriatric Psychiatry,  first editor of the American Journal of Geriatric Psychiatry and a former acting director of the National Institute on Aging.

The social portfolio consists of an individualized list of vital activities that one can engage in along dimensions of low- and high-mobility and individual or group pursuits. It is based upon what Cohen cites as the reality of active and selective engagement in late life versus stereotypical and inaccurate theories of disengagement. Its creation is an activity that an individual engages in through an active review of one's lifelong personal assets. Ideally, individuals assemble their portfolios with the participation of others who know them well. The social portfolio is meant to be diversified and include "insurance" in the form of vital activities that can be engaged in even in the face of disability or loss. These articles, from The Harvard Press,  and the Washington Post archives, further explain how to put this concept put into practice.

Stages of caregiving

You may be familiar with the stages of grief, but do you know about the stages of caregiving?

Nearly two-thirds of older adults with long-term care needs, about 65 percent, rely exclusively on family and friends for assistance, according to the Family Caregiver Alliance. Almost another third (30 percent) supplement family care with paid providers. The organization estimates that half of older adults who need long term care but lack available family caregivers will end up in a nursing home; only 7 percent of those with family caregivers end up institutionalized.

Caregiving evolves through several stages–it may be referenced as four or five, depending on the source – and each brings its own unique challenges, rewards and needs.

Stage 1: Getting started

According to the United Way of Dane County, Wisconsin:

Stage 1 Caregivers

  • perform no ADLs

  • devote about 3.5 hours/week to caregiving.

  • Level 1,2, and 3 caregivers are likely to report old age as their care recipient’s main challenge

Caregivers — usually the spouse, adult daughter or daughter-in-law — may have slipped into the role because they are there. They started going along on medical appointments, helping manage finances, or preparing meals. Adult children may experience a sense of role reversal. Weekends may fill up doing parents’ chores — although mom or dad might insist they’re fine.

Stage 2: Involved and Searching

Stage 2 Caregivers

  • perform 4 IADLs

  • 0.4 ADLs

  • devote 9.8 hours/week to caregiving

Caregivers start moving from reactive to proactive, as they transition into their role as primary caregiver. This could happen over many months, a year, or more. Loved ones are often resistant at this stage to hire outside help, and may be in denial about their declining abilities.

Other family members and friends should be tapped to pitch in whenever possible, so the entire caring burden is not on one person. Respite care should be a consideration at this stage too. More than half of all caregivers work full time. Twelve percent work part-time, and 9 percent have had to quit their jobs because of caregiving. Many who quit said they would not have made that choice if flexibility in working conditions had been available, according to the Pinellas County, Florida Area Agency on Aging.

Stage 3: Increasing Intensity

Stage 3 Caregivers

  • perform 4.3 IADLs

  • 2.2 ADLs

  • devote 12 hours/week to caregiving

  • assist their care-recipients with prescription medication

  • spend 20 or more hours weekly if caring for someone with Alzheimer’s or dementia

Caregivers frequently manage multiple disabilities and conditions, which may be accompanied by chronic pain. Use of formal caregivers, including home health aides and therapists, along with more frequent trips to the physician or hospital, become more common. Caregivers need to make sure they take time out for themselves to avoid burnout or injury, advises the AAoA.

Stage 4: Being Overwhelmed

Stage 4 Caregivers

  • perform 5.2 IADLs and

  • 2.9 ADLs, and

  • devote 33.1 hours/week to caregiving.

  • Most stage 4-5 caregivers obtain assistive devices such as a bathing bench or magnifying lens for reading, and have made home modifications for care-recipients.

  • Level 4-5 caregivers have reported health concerns related to caregiving.

  • High percentage of level 4-5 caregivers make work-related adjustments.

Caregiving is all encompassing as physical and/or mental health deteriorates, or a sudden trauma such as a fall or stroke, occurs. Caregivers may be “on duty” more than 60 hours a week, including frequent middle-of-the-night disturbances due to wandering, pain, or other issues by the care recipient. Caregivers are often exhausted, and feel isolated. Despite their best efforts, the level and extent of care may not be adequate. It is often the time to consider other options, like nursing home care.

Stage 5: Letting Go

Stage 5 Caregivers

  • perform almost 6 IADLs

  • over 4 ADLs

  • devote 87.2 hours/week to caregiving.

  • are more likely to provide care to stroke patients

Caregivers have almost no extra time for friends/family as well as vacations, hobbies or their own social activities.

They

  • need help managing stress and finding time for themselves.

  • report experiencing financial hardship, and are the least likely to be employed full or part-time.

  • Spend more money on the person they care for than caregivers at other levels.

With the well-being of their loved one and themselves at stake, the decision to move the older adult to institutionalized care may be made at this stage. It’s a difficult decision that caregivers must come to terms with – that often includes feelings of guilt, relief, and loneliness.

This stage of caregiving also includes resolving relationships, making sure end-of-life decisions are complete, talking openly about hospice care and death with the loved one and medical team when the time comes.

Each stage is different for every caregiver and may be condensed or stretched out over time, depending on the older adult’s health needs. However, the consistent message that comes through is for caregivers to regularly take time for themselves – for a day, a weekend, or longer – to mitigate burnout, recharge their batteries and remain health and able to care for their loved one. This report from AARP is an excellent resource for more insights on caregiving issues.

Sundowning

You may have heard of the term “sundowning” when reporting on patients with Alzheimer’s disease or other dementias. Becoming more familiar with the concept can add additional understanding, context and depth to your stories.

The National Institute on Aging defines sundowning as the restlessness, agitation, irritability or confusion experienced by some people with Alzheimer’s disease that begins or worsens as daylight begins to fade. This is often around the time of day that tired caregivers need a break. The situation may continue into the night, making it hard for people with Alzheimer’s to fall asleep and stay in bed. As a result, they and their caregivers may have trouble getting enough sleep and functioning well during the day.

The Alzheimer’s Foundation of America points out that most sundowning behavior starts appearing in mid-stage dementia and slowly worsens as the disease progresses.

It’s not clear what causes sundowning, but researchers think it may have something to do with how the disease affects the biological clock of a person with Alzheimer’s. It may interfere with normal sleep/wake cycles, leading to disturbances and confusion. Other hypotheses for the cause include pain, hunger, depression and boredom. As Martha Sparks, Ph.D., a psychotherapist and an assistant professor of psychiatry at Mt. Sinai Health System in New York City writes in this article, up to 20 percent of people with moderate to moderately severe dementia experience sundowning.

Sundowning seems get worse if a person’s surroundings are noisy, cluttered or there are too many people around. Sometimes shadows cast by the setting sun can cause confusion too. Additionally, if the person is overstimulated or overtired, it can increase late afternoon and early-evening restlessness. Coffee, caffinated sodas and alcohol all seem to make the situation worse. Too much going on in a given day can also lead to the person becoming overtired and irritable.

According to Anthony Komaroff, M.D., a physician and professor at Harvard Medical School, sundowning is more likely to occur in an unfamiliar environment and is also frequently reported among hospitalized elderly patients, even if they don’t experience the condition at home. Sundowning should be taken seriously, since it can lead to falls or other injuries. Medication may help, but can also result in other unwanted side effects.

The Alzheimer’s Foundation has these coping tips for caregivers.

Supercentenarians/centenarians

They are the oldest of the old, an elite club of people who’ve lived to the age of 110 or more.

They’re called “supercentenarians” and there are 69 of them across the planet, according to the Gerontology Research Group, a network of doctors, scientists and engineers committed to reversing human aging.

This group of super-agers popped briefly into the news recently when one of its members, Jiroemon Kimura of Kyota, thought to be the world’s oldest living man, celebrated his 115th birthday. See a video clip from ABC News here.

Of course, what everyone wants to know is what it takes to live so long. “It is all thanks to the grace of God,” Kimura said, quoted in The Inquisitr. “I have nothing but gratitude for the life I’ve been given.”

Eating small portions of food also may have had something to do with it, suggested Kimura, who has 7 children (two are deceased), 14 grandchildren, 25 great-grandchildren, and 13 great-great-grandchildren.

Worldwide, 65 women and 4 men are recorded as supercentenarians by the Gerontology Research Group.

Centenarians – people who live to the age of 100 or more – have also been a subject of considerable interest for many years. The United States has more centenarians than any nation on earth – one in every 10,000 residents, according to the U.S. Census Bureau.

Surviving to the age of 100 appears to be “a complex combination of genetics, environment, lifestyle and luck,” wrote Dr. Thomas Perls, director of the New England Centenarian Study at Boston University, in a 2006 article.

Another notable study of centenarians is based in Okinawa, Japan, whose aging population is known for a relative absence of chronic disease and an extended “healthspan.” (See key terms for a definition of this term.)

Barbara Juncosa of Scientific American wrote about centenarians and scientists’ search for clues to healthy aging and extended longevity in 2008. The Wall Street Journal ‘s Robert Lee Hotz also examined the topic that year and included information from another valuable source: the Longevity Genes Project at Albert Einstein College of Medicine in New York.

The end of the Journal article strikes an important cautionary note, observing that healthful habits may help people reach old age, but it’s not clear they will push someone past the century mark:

“Earlier this year, researchers at the U.K.'s University of Cambridge and the Medical Research Council reported that people who exercise regularly, don't smoke, limit their alcohol intake and eat five servings of fruit and vegetables a day live, on average, 14 years longer than people who didn't.

Yet, there is little evidence of an abstemious lifestyle among the 450 people between the ages of 95 and 110 enrolled in the Longevity Genes Project at Albert Einstein College of Medicine. There are no vegetarians. At least a third of them were obese in middle-age. A third have been smoking tobacco for 40 years or more, despite health warnings. ‘I have a woman who recently celebrated 91 years of cigarette smoking,’ says Dr. (Nir) Barzilai (head of the Longevity Genes Project). ‘She is 106 now.’”

New York magazine took an engaging look at Jewish centenarians in the Big Apple here and had the whackiest cover ever. (Scroll down the article and you’ll see it on the left. It’s the bearded man in the baby carriage.)

Supplemental Poverty Level

The official poverty measure, in use since the 1960s, estimates poverty rates by looking at a family's or an individual's cash income. The SPM is a newer measure that adds more complexity by incorporating additional items such as tax payments and work expenses in its family resource estimates. Thresholds used in the SPM are derived from Consumer Expenditure Survey expenditure data on basic necessities (food, shelter, clothing and utilities) and take into account geographic differences in the cost of housing. 

Unlike the official poverty thresholds, the supplemental poverty thresholds are not used to assess eligibility for government programs. Instead, SPM serves as an additional indicator of economic well-being and provides a deeper understanding of economic conditions and policy effects. Research files and data are available for public use. Kaiser Family Foundation has a state-by-state analysis. Check out this Forbes commentary which takes Vox to task about their coverage of Paul Ryan’s interpretation of poverty.

The Two Midnight Rule 

Medicare reimburses hospitals very differently depending on whether the patient is admitted or not. Similar services could be covered under part “A” (hospitalization) or part “B” (general medical insurance).

Once a patient is admitted, inpatient care is reimbursed under a single “prospective payment” system – one sum for all services provided to the beneficiary during the stay regardless of how long that stay is (with some exceptions). This includes costs such as X-rays, room charges, pre-operative testing, nursing services, and drugs. This occurs only if the patient stays for at least two midnights.

According to CMS, “surgical procedures, diagnostic tests and other treatments (in addition to services designated as inpatient-only), are generally appropriate for inpatient hospital admission and payment under Medicare Part A when the physician expects the beneficiary to require a stay that crosses at least two midnights and admits the beneficiary to the hospital based upon that expectation.”

Medicare pays considerably more for short inpatient stays than for observation or outpatient services; patients pay only a single deductible for inpatient care. The two midnight rule also determines reimbursement for beneficiaries who may require additional care in a skilled nursing facility. The rule mandates that the person must have had a hospital stay of at least three days prior to skilled nursing admission.

One ongoing problem with this rule is that CMS auditors have the right to review inpatient admissions and determine whether that admission was medically reasonable and necessary. If the auditor decides that care could have been provided on an outpatient basis, then the claim is denied. This potentially leaves hospitals, and ultimately patients, on the hook for thousands (or tens of thousands) of dollars.

Hospitals can try to recover some costs by resubmitting claims for some of these services under Medicare’s outpatient payment structure. Patients end up being charged much higher copays, out of pocket, and direct fees that they assumed were covered under part A. Hospital and professional associations and patient advocacy groups have blasted the two-midnight rule as arbitrary and argue that it undermines providers’ medical judgment.

Further reading:

  • This excellent policy brief  from Health Affairs offers extensive background and explains the rules, reimbursement processes, and controversy.

  •  Medicare’s explanation of inpatient coverage.

  •  A brief from The Advisory Board Company describing the continuing tug of war between CMS, hospitals and patients.

  •  Summary of a draft bill from House Ways and Means health subcommittee Chair Kevin Brady (R-TX) that would overhaul the rule and create a new payment structure for short lengths of stay. The committee is expected to take it up again in 2015.

  •  Additional Core topic resources on Medicare and Medicaid payments.

Village model of aging in place

A “Village” takes a consumer-oriented approach that aims to promote aging in place through a combination of member supports, service referrals, and member engagement. 

Villages are grassroots organizations that provide community-dwelling older adults with a combination of nonprofessional services, such as transportation, housekeeping, and companionship, as well as referrals to existing community services, sometimes at a reduced rate. Unlike Naturally Occurring Retirement Communities (NORCs) and other home and community-based models, Villages are initiated and governed by their members. Villages charge annual dues rather than fees for individual services. Many also rely on grants to make up the cost difference. 

Beacon Hill Village in Boston established the first community model in 2001; since then, dozens more have sprung up around the U.S. According to AARP, “this consumer-driven and person-centered approach can help delay or even prevent the need for institutional care." The Village-to-Village Network a national peer-to-peer network that helps guide establishment and management of these communities, lists 205 existing villages, 150 others are in development. This article from The Atlantic’s CityLab looks some of the benefits a village model can provide.&

Visitability

An international movement to change home construction practices so that virtually all new homes, whether or not designated for residents who have mobility impairments, offer a few specific accessibility features.  The three key features that are promoted are: at least one zero-step entrance on an accessible route leading from a driveway or public sidewalk, all interior doors providing at least 31¾ inches (81 cm) of unobstructed passage space and at least a half bathroom on the main floor.

Well-Being

Well-being integrates mental health and physical health resulting in more holistic approaches to disease prevention and health promotion. The CDC considers it a valid population outcome measure beyond morbidity, mortality, and economic status that tells us how people perceive their life is going from their own perspective, Well-being is associated with self-perceived health, longevity, healthy behaviors, mental and physical illness, social connectedness, productivity and factors in the physical and social environments.

Well-being can provide a common metric that can help policy makers shape and compare the effects of different policies and can be useful for multiple stakeholders involved in disease prevention and health promotion. There is no consensus around a single definition of well-being, but there is general agreement that at minimum, it includes the presence of positive emotions and moods (e.g., contentment, happiness), the absence of negative emotions (e.g., depression, anxiety), satisfaction with life, fulfillment and positive functioning. For public health purposes, physical well-being (e.g., feeling very healthy and full of energy) is also viewed as critical to overall well-being.

Because well-being is subjective, it is typically measured with self-reports. Among the instruments used that help measure well-being are:

There is no sole determinant of individual well-being, but in general, well-being is dependent upon good health, positive social relationships, and availability and access to basic resources (e.g., shelter, income).

Numerous studies have examined the associations between determinants of individual and national levels of well-being. Many of these studies have used different measures of well-being (e.g., life satisfaction, positive affect, psychological well-being),

In general, life satisfaction is dependent more closely on the availability of basic needs being met (food, shelter, income) as well as access to modern conveniences (e.g., electricity). Pleasant emotions are more closely associated with having supportive relationships.5

Other factors associated with well-being include

  • Genes and personality: At the individual level, genetic factors, personality, and demographic factors are related to well-being.

  • Age and gender: Depending on which types of measures are used age and gender also have been shown to be related to well-being. While and women generally have similar levels of well-being, this pattern changes with age.

  • Income and work: income correlates only modestly with well-being, based on the types of measures used. Associations between income and well-being (usually measured in terms of life satisfaction) are stronger for those at lower economic levels, but studies also have found effects for those at higher income levels

  • Relationships: Having supportive relationships is one of the strongest predictors of well-being, having a notably positive effect.