Addressing the Needs of Older Adults in Tarrant County
Submitted by: The Center for Community Health Development Texas A&M Health Science Center School of Rural Public Health May 13, 2009
Table of Contents Introduction ................................................................................................................................... 2 Profile of Older Adults in Tarrant County................................................................................ 3 Older Adults’ Perspectives .......................................................................................................... 6 General Concerns and Comments ......................................................................................... 7 Education ................................................................................................................................... 7 Income ........................................................................................................................................ 7 Health ......................................................................................................................................... 8 Income ............................................................................................................................................ 8 Health Care Expenditures ..................................................................................................... 13 Education and Literacy .............................................................................................................. 15 Implications for Accessing Needed Services ...................................................................... 17 Health ........................................................................................................................................... 18 Life Expectancy and Mortality .............................................................................................. 19 Chronic Disease ...................................................................................................................... 21 Heart Disease, High Blood Pressure, and Stroke ........................................................... 22 Arthritis ................................................................................................................................ 23 Diabetes ................................................................................................................................ 25 Alzheimer’s Disease ........................................................................................................... 26 Injuries .................................................................................................................................. 27 Mental Health ..................................................................................................................... 29 Potential Solutions ...................................................................................................................... 31 Evidence‐Based Programming ............................................................................................. 31 CDSMP ................................................................................................................................. 31 Healthy IDEAS .................................................................................................................... 31 A Matter of Balance ............................................................................................................ 32 Long‐Term Care Coverage ................................................................................................ 33 Conclusion ................................................................................................................................... 35 References .................................................................................................................................... 37
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Introduction The United States is on the brink of a population revolution. By 2030, the proportion of the U.S. population aged 65 and older will double to about 71 million older adults, or one in every five Americans (see figure below). The far‐reaching implications of the increasing number of older Americans and their growing diversity will include unprecedented demands on public health, aging services, and the nation’s health care system. The nation’s health care spending alone is projected to increase by 25 percent due to these demographic shifts (Centers for Disease Control and Prevention, 2009). America’s older adult population also is becoming more racially and ethnically diverse. At the same time, the health status of racial and ethnic minorities lags far behind that of non‐minority populations. Figure 1: National Population Projections of Older Adults through 2050
Tarrant County is not immune from this expected growth and increase in aging services demand. The table below outlines the projected growth of older adults in Tarrant County for the next thirteen years. The proportion of older adults aged 60 and older is expected to increase from 11.9 percent in 2007 to nearly 17 percent by 2020. Older minorities are of further concern. The United Way and Area Agency on Aging 2008 – 2010 Area Plan notes that comparing the percent of the population comprised of minorities for all ages, versus those ages 60 and higher, minority representation is likely
to grow as the population ages. From the projections outlined in the table below, the proportion of minorities among adults aged 60 and older is expected to increase from 24 percent in 2007 to nearly 40 percent in 2020. In addition, when looking at the poverty rate for all ages in Tarrant County, the rate is higher for the total population than for the subset of those ages 60 and higher. This could have implications on mean household wages, which could impact tax revenues to support social programs geared toward older adults. This could also impact funding priorities for local foundation and corporate funders. Table 1: Forecast of 60+ Population in Tarrant County, 2007‐2020 2007 2010 2015 2020 Total Population, recent estimate* 1,702,205 1,746,082 1,909,469 2,047,553 Total 60+ 202,255 229,740 281,818 347,494 Total 85+ 15,999 17,401 18,977 20,593 Anglo, 60+ 153,949 168,187 189,731 209,892 African American, 60+ 19,376 22,757 30,028 39,515 Hispanic, 60+ 19,710 25,555 39,822 62,346 Other, 60+ 21,600 13,241 22,237 35,741 Total Minority, 60+ 92,087 137,602 48,306 61,553 Poverty, 60+ 17,596 19,987 24,518 30,232 Source: North Central Texas Council of Governments
Local and state‐level service agencies will need to be prepared to address the increasing needs of this growing older adult population in the coming years. By investing now in developing infrastructure critical to supporting the most common needs of older adults, Tarrant County will be able to excel in meeting the needs of current and future older residents. This report is intended to provide one starting point for this effort. It focuses on the current status of older Tarrant County residents, their perceived needs, and potential areas for focusing resources that will provide the greatest benefit and payoff in meeting the needs of older Tarrant County residents. Special focus is placed on examining the educational, economic, and health‐related concerns common to older residents.
Profile of Older Adults in Tarrant County This section outlines who older Tarrant residents are and where they live. The U.S. Census Bureau estimated that approximately 139,914 adults aged 65 years and older resided in Tarrant County (average 3‐year estimate between 2005 and 2007). Women tend to live longer than men in general (Satariano, 2006), so it was expected that there were more female than male older residents in Tarrant County, with 58.3 percent of older adults being female. (U.S. Census 3 year estimates, 2005‐2007)
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Living arrangements are an important aspect of older adult well‐being. Co‐habitants provide a source of social support and interaction; whereas living alone as an older adult has been associated with an increased prevalence of mental health issues (including depression), severity of chronic disease burden, and decreased quality of life. Further, having another person in the residence serves as an additional resource in the event an older adult needs reminders or assistance with taking medications, or even accessing emergency medical services if ever needed (such as calling 9‐1‐1 if the older adult were to suffer a bad fall). Three‐year census estimates between 2005 and 2007 indicated that nearly 43 percent of Tarrant County residents aged 65 and older were living alone. Conversely, according to estimates from the North Central Council of Governments, 56.5 percent of older adults in Tarrant County are still married. Studies have shown marriage, specifically, to be a protective factor for a number of common issues related to health and well‐being, including increased active life expectancy, relatively higher levels of physical functioning, and increased likelihood of engaging in healthy behaviors (such as complying with prescribed medical regimens and getting appropriate health screening exams (i.e., mammography, colonoscopy, etc.; Satariano, 2006). Figure 2: Marital Status of Older Adults in Tarrant County
60+ Tarrant County Relationship Status 1.5% 3.5% 13.8%
56.5% 24.7%
Married
Widowed
Divorced
Separated
Never Married
The figure below outlines the relative distribution of older adults through the county. The older residents of Tarrant County are quite geographically stable, with over 90 percent living in the same place or house as in the previous year, and an additional 5.5 4
percent having moved but still living in the county. (U.S. Census 3 year estimates, 2005‐ 2007). Figure 3: Distribution of Older Adults across Tarrant County
(Source: U.S. Bureau of the Census)
Older Tarrant County residents represent a diverse group of individuals. Census estimates indicate that approximately 78 percent of older residents are White, non‐ Hispanic, while 9.4 percent are Black or African‐American, and 8.8 percent are Hispanic or Latino. An additional 2.8 percent were Asian or Asian‐American. This diversity is expected to increase overtime. Projections from the North Central Council of Governments predict the proportions of older adults belonging to a minority racial or ethnic group to increase substantially over the coming years, as is indicated on the chart on the next page.
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Figure 4: Race/Ethnicity Projections of Older Adults for Tarrant County
60+ Tarrant County Population Projections by Race/Ethnicity 350,000 300,000 250,000
Total Population 60+
200,000
Anglo Total Minority
150,000
African American Hispanic
100,000
Other
50,000 0 2007
2010
2015
2020
Education and socioeconomic status are both key indicators of the resources an older adult has available. While both are discussed in detail later in this report, it is noteworthy to point out here that nearly 10 percent of older Tarrant residents live below 150% of the federal poverty level and a quarter (24.1%) do not have a high school education. Further details about these topics and their implications are discussed in later sections. With this brief overview of Tarrant County’s older population in mind, gaining a sense of these residents’ perceptions of their community, with specific focus on the needs, resources, strengths and weaknesses they perceive, strengthens one’s understanding of the current situation within the county.
Older Adults’ Perspectives In early 2009, the Center for Community Health Development at the Texas A&M Health Science Center School of Rural Public Health conducted a series of community discussion groups, each discussion lasting approximately an hour, to gain a sense of residents’ perceptions of the community, its strengths and weaknesses, and issues and potential resolutions to these identified issues within the community. One such session focused on the older adult community. While held in only one part of Tarrant County, it was noted that about a third of the participants were from areas outside of this general neighborhood. Still, the comments and concerns expressed by these participants are not representative of the entire county. The participants’ responses, however, do provide
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one direct source of feedback from older residents. Their concerns are outlined below, categorized into the following sub‐groups: comments and concerns about education, income, health, and more general concerns.
General Concerns and Comments •
Overall, a great community for senior citizens
•
Senior center located in a place familiar to many long‐time residents
•
Senior center is a wonderful resource, with the city council and chamber of commerce being very involved; also, a high degree of volunteerism at the center
•
Senior center needs to market itself better to become more visible to the many seniors that may be unaware of the center; one suggested outlet included marketing via 2‐1‐1
•
There is also a neighborhood association that allows seniors to help each other
Education •
Haltom City Library is a great resource in the community
•
Local organizations provide regular health fairs to provide information about health‐related topics
•
The United Way offers classes about using computers, learning about diabetes, and other useful topics
Income •
Upon retirement, income (or rather the loss of income) becomes a major concern
•
Some begin losing weight because they can no longer afford food
•
Meals on Wheels and the Red Cross provide resources for seniors in need, and Senior Citizen Services offers assistance with preparing meals
•
Local places of worship assist in times of crisis, such as helping to remodel a kitchen after a house fire
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•
There is inadequate access to transportation between communities, causing older adults to become “stuck” – they become unable to make a trip to the doctor or other locations; there are no nearby sources of healthcare
•
Medical care and medications are expensive
•
The Red Cross provides a source limited transportation
•
There are many seniors that would benefit greatly from the senior center, but are not active enough, or resourced enough, to make the trip
•
Shortage of affordable housing for seniors, as well as the population in general
•
Also in need of need funding for assistance with home and yard maintenance
•
Lighthouse for the Blind Mid Cities Care Corp provides some assistance, such as building ramps at homes
•
The fire department assists with changing light bulbs and installing fire alarms
•
Seniors in the area are also increasingly becoming victims of crime and fraud; however, the police department is very supportive and responsive to concerns
Health •
Fire department very helpful and responsive (a quick and effective response to a neighbor who suffered a fall was highlighted)
•
No doctors/health care providers in the area
•
Malnutrition, diabetes, and nutrition appear to be concerns
•
Difficulty accessing and affording medications
These comments and concerns help to frame a discussion about the current and likely future needs of older Tarrant County residents. The responses above are not unique to these residents, and similar issues and potential solutions can be found elsewhere. Many of these solutions, tailored to meet the unique situations present in Tarrant County, should prove fruitful and represent a source of investment where returns are likely to be great in improving the health and quality of life for Tarrant’s older residents and, likely, younger residents as well.
Income Income is one critical component related to older adult quality of life, risk of morbidity and premature mortality. Most older adults are retired from working; however, they still require money for housing, food, health care, medications, and other necessities of life. Older adults have a variety of sources of income, including earnings (if still working), income from assets, pensions, and public support.
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Social security provides a floor to ensure a minimum amount of income for most older adults. The figure below outlines the sources of income for Older Americans over the past 30 years. Figure 5: Sources of Older Adult Income, Nationwide
In 2006, aggregate income for the population age 65 and over came largely from four sources. Social Security provided 37 percent, earnings accounted for 28 percent, pensions provided 18 percent, and asset income accounted for 15 percent. Ninety percent of people age 65 and over live in families with income from Social Security. Sixty percent are in families with income from assets, and almost one‐half (45%) with income from pensions. About one‐third (36%) are in families with earnings and 1 in 20 are in families receiving public assistance (Federal Interagency Forum on Aging‐related Statistics, 2008). As shown in the chart above, since the early 1960s, social security has provided the largest share of aggregate income for older Americans. The share of income from pensions increased rapidly in the 1960s and 1970s and more gradually since then. The share of income from assets peaked in the mid–1980s and has generally declined since then. The share from earnings has had the opposite pattern—declining until the mid‐
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1980s and generally increasing since then, indicating that older adults may be remaining in the workforce longer than in the past. Among older Tarrant County residents (aged 65 and older), income sources break down in similar categories‐ 39.3 percent have earnings from active employment, and 49.8 percent have retirement/asset income. 92.1 percent are receiving social security income. 5.2 percent are receiving supplemental social security income and 1.9 percent are receiving funds from a public assistance program (U.S. Census Bureau, 2009). Nearly 10 percent of older Tarrant residents live at or below 150% of the federal poverty level. This suggests there may be a gap among older adults that are not receiving adequate income, but are ineligible or not enrolled in public assistance programs. Projections forecast (as outlined below) this number of older residents living in poverty to increase as the proportion of older adults increases among the population. Addressing this issue will no doubt become an increasing challenge for the policy makers and residents of Tarrant County in the coming years. Figure 6: Projections of Older Adults Living in Poverty, Tarrant County
Projected Number of Tarrant County Residents Aged 60+ in Poverty 35,000 30,000 25,000 20,000 15,000 10,000 5,000 0 2007
2010
2015
2020
Upon closer examination, specifically the break‐down of sources of income for older adults across different income levels nationwide, one can see that as income level decreases, the proportion of older adult income coming from public sources (i.e., social security and other public sources of funding) increases (see the figure below). In the lowest quintile, public sources of income account for 91 percent these older adults’ total
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income, compared to only 18 percent for those in the highest quintile (Federal Interagency Forum on Aging‐related Statistics, 2008). Figure 7: Sources of Income Among Older Adults by Quintile of Total Household Income, Nationwide
Tarrant County is no exception in the impact of income on older adults’ health and well being. Twenty percent of households with older adults reported an individual needed dental care but did not receive it in the last year. Primary reasons for not getting dental care were cost and lack of insurance coverage. Some households cannot afford to make changes to their home that would make it safer and easier to move around in for an older family member with a disability. The majority of older adults live in adequate, affordable housing. However, for some older adults, costly or physically inadequate housing can pose serious problems to their physical or psychological well‐being. Nationwide, 41 percent of households with people age 65 and over had one or more of the following types of housing problems: housing cost burden, physically inadequate housing, and/or crowded housing. This is the highest level since 1985. By comparison, the occurrence of such problems among all U.S. households was 37 percent (Federal Interagency Forum on Aging‐related Statistics, 2008). The prevalence of housing cost burden, or expenditures on housing and utilities that exceeds 30 percent of household income, has increased for all U.S. households but is more prevalent among the households with people age 65 and over. Between 1985 and 2005, housing cost burden for households with older people increased from 30 percent
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to 38 percent, compared with increases across all U.S. households from 26 percent in 1985 to 33 percent in 2005. Physically inadequate housing, or housing with severe or moderate physical problems such as lacking complete plumbing or having multiple upkeep problems, has become less common. In 2005, five percent of households with people age 65 and over had inadequate housing, compared with eight percent in 1985. In contrast, six percent of U.S. households overall reported living in physically inadequate housing during 2005 compared with eight percent in 1985 (Federal Interagency Forum on Aging‐related Statistics, 2008). In Tarrant County, more than 8,500 households with an older adult with a disability are estimated to need modifications to their home, such as a wheelchair ramp or grab bars. Many households with older adults cannot afford to make repairs to their home. Nearly two‐thirds (61%) of households with older adults indicated that they could not afford to make needed repairs to their home (the costs of which are rising nationwide – see below). This means an estimated 47,000 households cannot afford to make home repairs as needed for older adults in their home. Finally, many adults past retirement age want to work. An estimated 9,500 households in Tarrant County have a member past retirement age who wants or needs to work (United Way of Tarrant County, 2005). Figure 8: Percentage of Older Adults Reporting Problems With Housing
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Health Care Expenditures As indicated earlier, older adults consume the most health care of any age group. Most older adults qualify for some source of health care benefits. Medicare exists to cover most older adults with basic hospital and primary care coverage, but does not provide coverage for a number of health needs, such as long‐term care and prescription drugs (unless enrolled in a Medicare Part D plan). Long‐term care services for the elderly is one of the 10 most serious problems facing Tarrant County. From a list of 33 issues affecting residents, long‐term care services were identified by community leaders as the ninth most serious problem facing Tarrant County over the next three years (United Way of Tarrant County). To assist with additional coverage needs, Medicaid is available to those meeting certain income criteria. Further, 24.6 percent of older Tarrant residents are veterans and eligible for additional health care benefits from the VA (U.S. Census Bureau, 2009). As the number of older adults increases, so does overall consumption of health care resources. The associated increase in Medicare and Medicaid expenditures will prove to be a challenge in the coming years to policy makers at the local, state, and federal levels. The chart’s below illustrate the increasing cost of providing medical care to older adults and this increasing cost’s burden on the overall American economy. Medicaid expenditures consume more than one in four dollars collected by the State of Texas, and continue to escalate as the State’s population ages and as the incidence of chronic diseases, such as diabetes and obesity, increases. Texans who are older and/or disabled consume a disproportionate share of Medicaid resources. Only 21 percent of the State’s beneficiaries are aged, blind, and/or have a disability, but they account for 61 percent of program cost (Texas Association of Area Agencies on Aging, 2008). Figure 9: Average Annual Health Care Dollars for Medicare Enrollees Nationwide
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Figure 10: Percent of GPD Spent on Older Adult Programs as Percent of GDP, 1962‐2082 (projected)
Source: Congressional Budget Office, June 2008
As is illustrated above, the proportion of gross domestic product projected to be spent on Medicare and Medicaid is estimated to increase to near 20 percent. This increase will no doubt put additional strain on funding sources and may not be sustainable under current funding policy. New approaches will be needed to address the health care needs of older adults. One such approach may be increase expenditures on health promotion and disease prevention efforts. As will be discussed later, chronic disease burden is proportionally high among older adults. This category of disease is not curable, and there is typically no vaccine or other preventive medical procedure. Thus, a person with one or multiple chronic illnesses (as is fast becoming the norm) will spend years in treatment, which will likely include regular visits with a health care provider, multiple prescription medications, and reduced productivity and active years of life lost, and the possible need for extended long‐term care. One approach taking hold is in the increased funding and dissemination of evidence‐ based programming aimed at preventing and increasing self‐management of chronic diseases and related health issues. Another is the increased realization of the potential for long‐term care insurance, which covers extended stays in long‐term care facilities, to offset or supplement possible Medicaid dollars (such services are not typically covered by Medicare). Examples of these efforts will be discussed further towards the end of this report.
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Education and Literacy Educational attainment influences socioeconomic status, which in turn plays a role in well‐being at older ages. Higher levels of education are usually associated with higher incomes, higher standards of living, and above‐average health. It also serves as a protective factor in navigating the health care system. As such, it is a critical area to consider when assessing needs of older adults (Federal Interagency Forum on Aging‐ related Statistics, 2008). Overall, educational attainment among older adults has increased over the past century (see below). In 2007, 76 percent of older adults had a high school diploma, compared to only 24 percent in 1965. However, this increase in educational attainment has not been uniform. Men are more likely to have a Bachelor’s degree than women (25% compared to 15%). There are also disparities along racial and ethnic boundaries. Older minorities are less likely to be high school graduates or have a Bachelor’s degree than their non‐Hispanic, White counterparts (Federal Interagency Forum on Aging‐related Statistics, 2008). Figure 11: Educational Attainment of Older Adults Nationwide
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Figure 12: Educational Attainment of Older Adults by Race/Ethnicity, Nationwide
Among older Tarrant County residents, 21.4 percent did not receive a high school diploma, compared to the statewide average of 32.1 percent for older adults. Further, 20.9 percent received a Bachelor’s degree or higher, compared to 18.5 percent statewide. However, when compared to the overall average educational attainment across Tarrant County, older residents tend to be less formally educated than the average resident (only 16.8% do not have a high school diploma and over 27.8% have at least a Bachelor’s degree)—the chart below highlights the trend in educational attainment for Tarrant county (U.S. Census Bureau, 2009).
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Figure 13: Educational Attainment for Tarrant County Residents, Total Population vs. Older Adults Only
Educational Attainment for Tarrant County 35.0% 25.6%
25.0% 20.0%
29.8%
28.7%
30.0%
26.8%
27.8% 23.2%
21.3% 16.8%
15.0% 10.0% 5.0% 0.0% Less than high school High school graduate Some college or graduate associate's degree Total Population
Bachelor's degree or higher
60+ Only
Source: North Central Council of Governments
Another component to consider is language barriers. Language barriers can lead to a lack of communication between older adults (and caregivers) and health care professionals, serve as a barrier to understanding medical regimens (i.e., how and when to take medications), and may lead to misunderstanding about their disease(s) and course of treatment. Not all older adults in America (or Tarrant County, for that matter) speak English fluently. Across Texas, 13.9 percent of older adults do not speak English very well. Further, 23.4 percent live in a multi‐lingual household. In Tarrant County, 7.9 percent of older adults do not speak English very well and 86.1 percent speak English only in household, leaving 13.9 percent who live in multi‐lingual households (U.S. Census Bureau, 2009). Further, in 2005, a United Way needs assessment found that 23.5 percent spoke a language other than English at home.
Implications for Accessing Needed Services The medical and health care industry is complicated and is not considered user friendly. The industry has a unique language, complex streams of funding, and policies and procedures that are inconsistent from one health system to the next—and, in some cases, within a health system (i.e., PPO vs. HMO). Navigating such a system can lead to confusion, misunderstanding, and stress among older adults. In worse case scenarios, it can also lead to misunderstandings of prescribed medical regimens, prescription errors, and other types of medical errors. A high literacy level among older adults, specifically health literacy, is seen as a protective factor against medical errors and issues in interacting with the health care
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system. High health literacy also facilitates increased ability to access health care and related services. This is particularly the case among non‐English speaking older adults. Targeting improving health literacy and providing assistance where language barriers exist is one needed area of assistance by area older adults. Older adults are proportionately less likely to have basic health literacy than any other age group. Nationwide, almost two‐fifths (39%) of people age 75 and over have a health literacy level of below basic compared with 23 percent of people age 65–74 and 13 percent of people age 50–64. Further, current levels of health literacy among people age 50‐64 suggest fewer people 65 and over will have below basic levels of health literacy. This is important because poor health literacy is associated with cognitive decline among those ages 80 and over, a group that is increasing in size (Federal Interagency Forum on Aging‐related Statistics, 2008).
Health Health is a primary concern for older adults. Improved health is directly related to improved health status and health outcomes, better measures of quality of life, improved life expectancy, and increased longevity. Unfortunately, older adults are at high risk for chronic illness, negative impacts due to accidents (i.e., falls), and poor mental health. The health of older adults overall is of significant importance to the population in general, as well. Older adults consume more health care than any other age group. The cost incurred for health care by older adults increases with age, number of chronic conditions, and minority status. For example, older adults with annual incomes of less than $10,000 averaged $16,766 in health care expenditures. Compare this figure with the average health care expenditure of $10,676 for those older adults with annual incomes greater than $30,000 (Federal Interagency Forum on Aging‐related Statistics, 2008). Therefore, the health of older adults deserves further attention. This section aims to provide an overview of the health‐related issues of older adults in Tarrant County. It will discuss the specifics related to older adults regarding overall health status, health risks and behaviors, healthcare expenditures, chronic disease burden, injuries, and the implications these factors on the social networks of older adults. Overall Health Status Asking people to rate their health as excellent, very good, good, fair, or poor provides a common indicator of health easily measured in surveys. Health ratings of poor tend to correlate with higher risks of mortality. The proportion of people reporting good to excellent health decreases among the older age groups. For men, 78 percent of those age 65–74 report good or better health. At age 85 and over, only 63 percent of men report good or better ratings. This pattern is also evident among women and within race and ethnic groups (see chart below). However, regardless of age, older non‐Hispanic white
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men and women are more likely to report good health than their non‐Hispanic black and Hispanic counterparts (Federal Interagency Forum on Aging‐related Statistics, 2008). Figure 14: Self‐reported Health Status among Older Adults, Nationwide
Life Expectancy and Mortality Americans are living longer than ever before. Over the past several years, life expectancies have increased markedly. Currently, people who survive to age 65 can expect to live an average of 18.7 more years, almost 7 years longer than people age 65 in 1900. The life expectancy of people who survive to age 85 today is 7.2 years for women and 6.1 years for men (see below) (Federal Interagency Forum on Aging‐related Statistics, 2008).
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Figure 15: Life Expectancy of Older Adults at Ages 65 and 85, Nationwide
Life expectancy varies by race, but the difference decreases with age. In 2004, life expectancy at birth was 5.2 years higher for White, non‐Hispanic people than for Black or African‐American people. At age 65, White, non‐Hispanics can expect to live an average of 1.6 years longer than Black or African‐Americans. Among those who survive to age 85, however, the life expectancy among Black or African Americans is slightly higher (7.1 years) than White, non‐Hispanic Americans (6.7 years) (Federal Interagency Forum on Aging‐related Statistics, 2008). Conversely, death rates in the U.S. population have declined during the past century. In 2004, the leading cause of death among people age 65 and over was diseases of heart (heart disease‐1,418 deaths per 100,000 people), malignant neoplasms (cancer‐1,052 per 100,000), cerebrovascular diseases (stroke‐346 per 100,000), chronic lower respiratory diseases (284 per 100,000), Alzheimer’s disease (171 per 100,000), diabetes mellitus (146 per 100,000), and influenza and pneumonia (139 per 100,000). Note that all, but one of the top causes of death are chronic illnesses. Further, the burden of chronic disease morbidity remains high among older adults (see graph below). Between 1981 and 2004, age adjusted death rates for all causes of death among people age 65 and over declined by 18 percent. Death rates for heart disease and stroke declined by approximately 44 percent. Age adjusted death rates for diabetes increased by 38 percent since 1981, and death rates for chronic lower respiratory diseases increased by 53 percent (Federal Interagency Forum on Aging‐related Statistics, 2008). For Tarrant County, heart disease, cancer and diabetes combined accounted for 62.1 percent of all deaths in 2004. 20
Figure 16: Chronic Disease Burden among Older Adults, Nationwide
Heart disease and cancer are the top two leading causes of death among all people age 65 and over, irrespective of sex, race, or Hispanic origin. Other causes of death vary among older people by sex and race and Hispanic origin. For example, men have much higher suicide rates than those of women at all ages, with the largest difference occurring at age 85 and over (45 deaths per 100,000 population for men compared with 4 per 100,000 for women). Non‐Hispanic white men age 85 and over have the highest rate of suicide overall at 50 deaths per 100,000(Federal Interagency Forum on Aging‐related Statistics, 2008). Chronic illnesses, mental health, and accidents/injuries will be discussed in more depth over the following paragraphs.
Chronic Disease The major chronic disease killers — heart disease, cancer, stroke, and diabetes — are an extension of what people do, or not do, as they go about their daily lives. Eighty‐eight percent of those over 65 years of age have at least one chronic health condition. Health damaging behaviors — particularly tobacco use, lack of physical activity, and poor eating habits — are major contributors to the nationʹs leading chronic diseases. Clearly, promoting healthy behavior choices, through education and through community policies and practices, is essential to reducing the burden of chronic diseases (Centers for Disease Control and Prevention, 2009). The following paragraphs provide detailed information about the current state of chronic disease burden among older adults.
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Heart Disease, Stroke, and High Blood Pressure Heart disease, high blood pressure, and stroke encompass a broad range of diseases affecting the circulatory system. These diseases, combined, are responsible for a large proportion of morbidity and premature mortality among older adults. About 82 percent of people who die of coronary heart disease (CHD) are age 65 or older. There is an increased mortality among women with CHD. This is due, in part, to the trend of women having heart attacks at older ages than when men do, and they are therefore more likely to die from them within a few weeks. In 2006, 1,760,000 Americans were discharged from short‐stay hospitals with a first listed diagnosis of CHD; 55 percent were age 65 or older (American Heart Association, 2009). Stroke, a condition that occurs when the flow of blood to the brain is disrupted, is a leading cause of serious, long‐term disability in the United States. About 86 percent of stroke deaths occur in people age 65 and older. In 2006, 889,000 Americans were discharged from short‐stay hospitals with a first listed diagnosis of stroke; 68 percent were age 65 and older. There is also a gender and racial disparity in survivability of a stroke in older adults. The percent that passed away one year following a first stroke is estimated to be: at age 70 and older 24 percent of white men, 27 percent of white women, 25 percent of black men and 22 percent of black women. The incidence of stroke or TIA (transient ischemic attack, or so‐called “baby stroke”), in white men is 6.1 percent for ages 55–64, and 12.2 percent for ages 65–74. For white women, the incidence is 4.8 percent for ages 55–64, and 9.8 percent for ages 65–74. For black men, the incidence is 13.1 percent for ages 55–64, and 16.2 percent for ages 65–74. For black women, the incidence is 10 percent for ages 55–64, and 15 percent for ages 65–74 (American Heart Association, 2009). High Blood Pressure, defined as systolic pressure of 140 mm Hg or higher or diastolic pressure of 90 mm Hg or higher, taking antihypertensive medicine or being told twice by a professional that you have high blood pressure, is a risk factor for stroke, kidney disease, and coronary heart disease. It is also very prevalent among older populations. At ages 55–64, 53.7 percent of men and 55.8 percent of women are diagnosed with high blood pressure. This figure increases to 64.7 percent of men and 69.7 percent of women at ages 65–74, and 64.1 percent of men and 76.4 percent of women at age 75 and older (Centers for Disease Control and Prevention, 2005). Specifically for Texas, following the lead of national estimates, heart disease is the leading cause of death, accounting for 43,452 deaths or approximately 28 percent of the stateʹs deaths in 2002. Stroke is the third leading cause of death, accounting for 10,548 deaths or approximately seven percent of the stateʹs deaths in 2002(National Vital Statistics Report 2004). There are a number of risk factors associated with CHD and stroke. According to Behavioral Risk Factor Surveillance System (BRFSS) survey results in 2005, adults in Texas reported having the following risk factors for heart disease and stroke: 24.3 percent had high blood pressure, 34 percent of those screened reported
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having high blood cholesterol, 8 percent had diabetes, 17.9 percent were current smokers, 62.4 percent were overweight or obese (Body Mass Index greater than or equal to 25.0), and 28.4 percent reported no exercise in the prior 30 days (Centers for Disease Control and Prevention, 2005 & 2006). In 2004, heart disease and stroke accounted for nearly 35.6 percent of all deaths reported in Tarrant County (Texas Department of State Health Services, 2004). Mortality is only one piece of the equation, however. The burden of these chronic illnesses and associated risk factors is a large source of potentially preventable medical care expenditure. For example, in Tarrant County, a single stroke in 2000 was estimated to cost an average of $12,716 – $15,150 (United Way of Tarrant County, 2005). Following survival of a stroke, heart attack or similar condition, comes potentially lengthy rehabilitation and loss of potential years of active life.
Arthritis Arthritis is a leading cause of physical disability across the Nation. It is also a leading co‐morbidity among older adults already suffering from one or more other chronic conditions. The prevalence of arthritis is on the rise. In 2007, 57 percent of older adults were told by a health care provider that they have arthritis. This is up nearly five percent from 2001, when 51.6 percent older adults indicated they were told they had arthritis. The prevalence of arthritis is expected to continue to increase (see below) (Centers for Disease Control and Prevention, 2005& 2006). Figure 17: Percent of Older Adults with Arthritis, Nationwide
Source: BRFSS, CDC
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Figure 18: Projected Increases in Arthritis Prevalence, Nationwide
Arthritis can be a painful and debilitating condition, creating a barrier to being physically active and, therefore, the ability to maintain physical function and a healthy body composition. In 2007, 55 percent of older Texans had arthritis. Among them, 74 percent were overweight or obese, and 21 percent were physically inactive (i.e., were getting no physical activity). Nationwide, among adults with arthritis, 21 percent report they are inactive and another 39 percent are insufficiently active. Further, 37 percent are obese and another 37 percent are overweight. Thirty‐six percent report fair or poor health(Centers for Disease Control and Prevention, 2005 & 2006). As indicated earlier, arthritis is a common co‐morbidity among older adults already diagnosed with one or more other chronic conditions. Below is a sample of how commonly diagnosed arthritis is among older adults with pre‐existing chronic illness: •
Of adults with diabetes, 801,000 (47%) also have arthritis.
•
Of adults with heart disease, 596,000 (54%) also have arthritis.
•
Of adults with high blood pressure, 1,946,000 (42%) also have arthritis.
•
Of adults with high cholesterol, 1,860,000 (40%) also have arthritis.
•
Of adults who are overweight, 1,358,000 (24%) also have arthritis.
•
Of adults who are obese, 1,373,000 (32%) also have arthritis.
•
Of adults who are inactive 770,000 (33%) also have arthritis.
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Diabetes Diabetes is a serious, costly, and increasingly common chronic disease. According to estimates from the American Diabetes Association, the total annual economic cost of diabetes in 2007 was estimated to be $174 billion. Medical expenditures totaled $116 billion and were comprised of $27 billion for diabetes care, $58 billion for chronic diabetes‐related complications, and $31 billion for excess general medical costs. Indirect costs resulting from increased absenteeism, reduced productivity, disease‐related unemployment disability, and loss of productive capacity due to early mortality totaled $58 billion. This is an increase of $42 billion since 2002. This 32 percent increase means the dollar amount has risen over $8 billion more each year. The 2007 per capita annual costs of health care for people with diabetes is $11,744 a year, of which $6,649 (57%) is attributed to diabetes. One out of every five health care dollars is spent caring for someone with diagnosed diabetes, while one in ten health care dollars is attributed to diabetes (American Diabetes Association, 2009). Early detection, improved delivery of care, and better self‐management are the key strategies for preventing much of the burden of diabetes. Seven million persons aged 65 years or older (20.1% of all people in this age group) have diabetes. If not properly managed, diabetes can lead to a range of complications. Diabetes is associated with an increased risk for a number of serious, sometimes life‐threatening complications and certain populations experience an even greater threat. Good diabetes control can help reduce your risk, however many people are not even aware that they have diabetes until they develop one of its complications. For example, adults with diabetes have heart disease death rates about 2 to 4 times higher than adults without diabetes, the risk for stroke is 2 to 4 times higher and the risk of death from stroke is 2.8 times higher among people with diabetes. People with diabetes are more susceptible to many other illnesses and, once they acquire these illnesses, often have worse prognoses. For example, they are more likely to die with pneumonia or influenza than people who do not have diabetes. Finally, persons with diabetes aged 60 years or older are 2‐3 times more likely to report an inability to walk one‐quarter of a mile, climb stairs, or do housework, or to use a mobility aid compared with persons without diabetes in the same age group. In 2007, 23.2 percent of older Texans were diagnosed with diabetes. The burden of this disease was not distributed equally along racial/ethnic lines. More than 34 percent of older minorities were diagnosed with diabetes, while only 17.5 percent of White, non‐ Hispanic older Texans had been diagnosed (Texas Diabetes Council, 2009). Overall, the prevalence of diabetes in Texas is beginning to overtake national averages significantly (see below).
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Figure 19: Prevalence of Diabetes—Texas vs. Nationwide
Alzheimer’s Disease Approximately 5 million Americans have Alzheimer’s disease (AD). Unless a cure or prevention is found, that number will increase to 14 million by 2050. One in eight persons over 65 and nearly half of those over 85 have AD. An estimated 280,000 Texas have Alzheimer’s disease. Alzheimer’s is a very expensive disease with direct and indirect costs of AD and other dementia’s amounting to more than $148 billion annually. The average lifetime cost per patient is $174,000. Half of all nursing home residents suffer from Alzheimer’s disease or a related disorder. The average cost for nursing home care is $42,000 per year but can exceed $70,000 per year in some areas of the country (Texas Alzheimer’s Association, 2009). Almost 10 million Americans are caring for a person with Alzheimer’s disease or another dementia; approximately one out of three of these caregivers is 60 years or older. More than 7 of 10 people with Alzheimer’s disease live at home. Almost 75 percent of the home care is provided by family and friends. The remainder is “paid” care costing an average of $12,500 per year. Families pay almost all of that out‐of‐pocket. In 2005, it was estimated that unpaid caregivers of people with Alzheimer’s disease and other dementias provided 8.5 billion hours of care valued at almost $83 billion dollars. More than half the states in the United States provide more than a billion dollars in unpaid care each year. For Texas, the unpaid costs of care giving are estimated to be $5.8 billion (Department of State Health Services, 2009). Providing support for these unpaid caregivers, whether it be financial or respite support, could prove to be an outstanding social and economic investment. Additionally, supporting adult day cares
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appears to be an expressed need of Tarrant County residents. Adult day care needs are going unmet for many residents in Tarrant County. Fewer than half of the households surveyed by the United Way in Tarrant County who indicated they need adult day care were receiving the service. This is similar for the entire state of Texas. It is estimated that 25 new adult day care centers are needed in Tarrant County (United Way of Tarrant County, 2005).
Injuries Another health issue older adults commonly face is the impact of falls and other injuries. As one ages, their body’s structure and ability to heal begin to change, making recovery from injuries more and more difficult.. Further, such injuries can lead to an increased chance of becoming disabled and requiring a greater level of care from family and more formal caregivers. As such, prevention and mitigation of falls should be another focus of protecting older adults from premature morbidity, loss of years of active life, and mortality. Two sources of injuries in older adults will be discussed in more detail: accidental falls and elder abuse.
Falls Unintentional falls are a threat to the lives, independence and health of adults ages 65 and older. Every 18 seconds, an older adult is treated in an emergency department for a fall, and every 35 minutes someone in this population dies as a result of their injuries. Although one in three older adults falls each year in the United States, falls are not an inevitable part of aging. Among older adults, falls are the leading cause of injuries, hospital admissions for trauma, and deaths due to injury. In 1999, about 10,097 seniors died of fall‐related injuries. Fractures are the most serious health consequence of falls. Approximately 250,000 hip fractures, the most serious fracture, occur each year among people over age 65. These consequences of accidental falls prove expensive. In 2000, the total direct cost of all fall injuries for people 65 and older exceeded $19 billion. The financial toll for older adult falls is expected to increase as the population ages, and may reach $54.9 billion by 2020 (adjusted to 2007 dollars). According to Centers for Disease Control and Prevention calculations, in 2000, traumatic brain injuries (TBI) and injuries to the hips, legs, and feet were the most common and costly fatal fall injuries, and accounted for 78 percent of fatalities and 79 percent of costs. Injuries to internal organs caused 28 percent of deaths and accounted for 29 percent of costs from fatal falls. Hospitalizations accounted for nearly two thirds of the costs of nonfatal fall injuries, and emergency department treatment accounted for 20 percent. On average, the hospitalization cost for a fall injury was $17,500. Fractures were both the most common and most costly type of nonfatal injuries. Just over one third of nonfatal injuries were fractures, but they accounted for 61 percent of costs or $12 billion. Hip fractures are the most frequent type of fall‐related fractures. The cost of hospitalization for hip fracture averaged about $18,000 and accounted for 44 percent of direct medical costs for hip fractures (Centers for Disease Control and Prevention, 2009).
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Many of these falls and resulting injuries can be prevented. Strategies to prevent falls among older adults include exercises to improve strength, balance, and flexibility; reviews of medications that may affect balance; and home modifications that reduce fall hazards such as installing grab bars, improving lighting, and removing items that may cause tripping (Centers for Disease Control and Prevention, 2009).
Elder Abuse Elder abuse is gaining attention from researchers and policy makers alike. According to the best available estimates, between 1 and 2 million Americans age 65 or older have been injured, exploited, or otherwise mistreated by someone on whom they depended for care or protection, and these number are on the rise. Estimates also show that for every one instance of reported elder abuse, there are likely to be five unreported instances (NCEA). The National Center on Elder Abuse defines seven different types of elder abuse: physical abuse; sexual abuse; emotional abuse; financial exploitation; neglect; abandonment; and self‐neglect. Neglect is the most common form of elder maltreatment in domestic settings. Of the non‐self neglect reports that were substantiated in 1996, 55 percent involved neglect. Physical abuse accounted for 14.6 percent in the same year, while financial or material exploitation represented 12.3 percent of the substantiated reports. In 1996, 66.4 percent of the victims of domestic elder abuse were white, while the remaining 33.6 percent were minorities (National Council on Elder Abuse, 2009). The 1998 National Elder Abuse Incidence Study funded in part by AoA found the following: • •
• •
551,011 persons, aged 60 and over, experienced abuse, neglect, and/or self‐ neglect in a one‐year period; Almost four times as many new incidents of abuse, neglect, and/or self‐neglect were not reported as those that were reported to and substantiated by adult protective services agencies; Persons, aged 80 years and older, suffered abuse and neglect two to three times their proportion of the older population; and Among known perpetrators of abuse and neglect, the perpetrator was a family member in 90 percent of cases. Two‐thirds of the perpetrators were adult children or spouses (MHMR of Tarrant County, 2009).
Within Tarrant County, confirmed cases of elder abuse have also been on the rise, evidenced by the chart below. Between 2001 and 2003, the total number of validated investigations by Adult Protective Services grew by nine percent, with nearly 1,500 older adults being victimized. Elder abuse may be physical, sexual, emotional or neglectful. It may involve abandonment, and financial and material exploitation.
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Figure 20: Reports of Domestic Elder Abuse, Tarrant County
Mental Health Depression Depressive symptoms are an important indicator of general well‐being and mental health among older adults. People who report many depressive symptoms often experience higher rates of physical illness, greater functional disability and higher use of health care services. Between 8 to 20 percent of older adults living in the community and up to 37 percent in primary care settings suffer from depressive symptoms. These symptoms can range from depressive illness (major depressive disorder, dysthymic disorder, or bipolar disorder) to depressive symptoms that fall short of meeting full diagnostic criteria for a disorder and is associated with an increased risk of developing major depression (subsyndromal depression). In any of these forms, however, depressive symptoms are not a normal part of aging. In contrast to the normal emotional experiences of sadness, grief, loss, or passing mood states, they tend to be persistent and to interfere significantly with an individualʹs ability to function. Depression often co‐occurs with other serious illnesses such as heart disease, diabetes, or cancer. Due to these co‐occurring conditions health care professionals may mistakenly conclude that depression is a normal consequence of these problems—an attitude often shared by patients themselves. These factors together contribute to the underdiagnosis and undertreatment of depressive disorders in older people. Depression can and should be treated when it occurs and many effective therapies are available. If left untreated, depression impairs one’s enjoyment of life and may increase disability. It can also delay recovery from or worsen the outcome of other co‐occurring chronic illnesses.
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Like in other comparable areas, older Tarrant County residents are experiencing depression, chronic nervousness or anxiety. Between 8 to 20 percent of older adults in the community and up to 37 percent in primary care settings suffer from depressive symptoms.(Centers for Disease Control and Prevention, 2009) Based on the results of the 2005 survey, it is estimated that at least 8,000 households in Tarrant County have older adults who are experiencing depression, chronic nervousness or anxiety. Among those who are experiencing these problems, more than half of those surveyed indicated that the available services in Tarrant County did not support or only partly supported their needs (United Way of Tarrant County, 2005).
Suicide Risk factors for suicide among the elderly differ from those among the young. Older persons have a higher prevalence of depression, a greater use of highly lethal methods and greater social isolation. From 1980–1998, the largest relative increases in suicide rates occurred among those 80–84 years of age. The rate of suicide is higher for elderly white men than for any other age group, including adolescents (Centers for Disease Control and Prevention, 2009). Again, Tarrant County is no exception. As illustrated in the figure below, the rate of suicide for males skyrockets in older males than in other age and gender groups. Suicide accounted for 1.6 percent of all deaths in Tarrant County in 2004 (Texas Department of State Health Services, 2004). Figure 21: Incidence Rate of Suicide by Age Group, Tarrant County
Source: http://www.tarrantcounty.com/ehealth/lib/ehealth/Suicide00‐01.pdf
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Potential Solutions A large number of premature deaths and years of active life lost can be prevented. Nearly 40 percent of deaths in America can be attributed to smoking, physical inactivity, poor diet, or alcohol misuse‐behaviors practiced by many people every day for much of their lives. Adopting healthy behaviors such as eating nutritious foods, being physically active, and avoiding tobacco use can prevent or control the devastating effects of many of the nationʹs leading causes of death regardless of oneʹs age (Centers for Disease Control and Prevention, 2009).
EvidenceBased Programming Stanford Chronic Disease Self Management Program (CDSMP) One approach aimed at changing these behaviors is the self‐management evidence‐ based programming being developed at Stanford University. Over 1,000 people with heart disease, lung disease, stroke or arthritis participated in a randomized, controlled test of this programming, and were followed for up to three years. Researchers looked for changes in many areas: health status (disability, social/role limitations, pain and physical discomfort, energy/fatigue, shortness of breath, psychological well‐ being/distress, depression, health distress, self‐rated general health), health care utilization (visits to physicians, visits to emergency department, hospital stays, and nights in hospital), self‐efficacy (confidence to perform self‐management behaviors, confidence to manage disease in general, confidence to achieve outcomes), and self‐ management behaviors (exercise, cognitive symptom management, mental stress management/relaxation, use of community resources, communication with physician, and advance directives). Those who participated in the Program, when compared to those who did not, demonstrated significant improvements in exercise, cognitive symptom management, communication with physicians, self‐reported general health, health distress, fatigue, disability, and social/role activities limitations. They also spent fewer days in the hospital, and there was also a trend toward fewer outpatients visits and hospitalizations. These data yield a cost to savings ratio of approximately 1:10. Many of these results persist for as long as three years (Lorig, Ritter, Stewart, et al., 2001).
Healthy IDEAS Another evidence‐based program showing promise is Health IDEAS, which addresses depression in older adults. Depressive symptoms are an important indicator of general well‐being and mental health among older adults. Evidence shows that structured depression prevention and intervention models, if applied with fidelity, can decrease the risk or delay the onset of depression and reduce the suffering it causes. Of particular interest, especially in today’s climate of overstretched budgets and limitations on mental health care insurance benefits, are disease self‐management programs. These programs are designed to prevent further disease progression and decline in functioning by teaching people how to effectively manage their illness, thereby improving quality of life
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and reducing the need for more costly medical services (Hollon, Thase & Markowitz, 2002). Healthy IDEAS (Identifying Depression, Empowering Activities for Seniors) is a community‐based program designed to detect and reduce the severity of depressive symptoms among older adults with chronic health conditions and functional limitations. The presence and severity of depressive symptoms determines the scope and duration of the intervention. There are four main program components of Healthy IDEAS: screening and assessment of depressive symptoms; education about depression and self‐ care for clients and family caregivers; referral and linkage to medical and mental health care professionals; and behavioral activation. All clients undergo screening for depressive symptoms and receive education about the disorder, effective treatment, and self‐care (National Council on Aging, 2009). Recent pilot data from a study in Houston demonstrated promising results of further expanding this programming throughout its service area. Approximately one in four (27 %) of all clients screened for depression reported significant depressive symptoms on the Geriatric Depression Scale (GDS). For Healthy IDEAS eligible clients, there were statistically significant improvements in mean GDS scores at six months (9.0 vs. 5.5), with scores above 6 indicative of mild depressive symptoms and 10 or above indicating moderate to severe depressive symptoms. A statistically significant percentage of clients reported a reduced level of pain, with more clients reporting no pain or milder pain than when they began the program. Significant improvements were also noted from baseline to six months in the percentage of clients who could make an appointment to get help with depression, identify symptoms of depression, and know what to do if their depression worsened (self‐management self‐efficacy). A higher percentage of clients at six months (56.6 %) reported little or no interference of their physical or emotional health with their social activities, compared with baseline (26.4 %). Of those who completed a six month survey, almost all (95 %) reported receiving help with their depression and all of them were satisfied with the services they received. The program was also piloted locally in Tarrant County. Of 22 clients with GDS scores of 5 or higher, 18 agreed to participate in the pilot program (including 3 caregivers). Promisingly, after 90 days of follow‐up, 12 of the clients (67%) had decreased GDS scores, and 3 maintained their baseline score. (Tarrant County Area Agency on Aging, Personal Communication)
A Matter of Balance There is currently an effort to disseminate A Matter of Balance (an evidence‐based program designed to prevent and mitigate unintentional falls among older adults) throughout the State. The Texas Falls Prevention Coalition provides some supplemental funding, training and evaluation services to the dissemination of this program within the aging network statewide. Recently, the Tarrant County Area Agency on Aging joined the Texas Falls Prevention Coalition in offering this class (Texas Falls Prevention
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Coalition, 2009). A Matter of Balance is a structured group intervention, which utilizes a variety of activities to address physical, social, and cognitive factors affecting fear of falling and to learn fall prevention strategies. The activities include group discussion, problem‐solving, skill building, assertiveness training, videotapes, sharing practical solutions and exercise training. During the class, participants learn to: •
•
•
•
View falls and fear of falling as controllable (involves changing behavior with a focus on building falls self‐efficacy, i.e. the belief that one can engage in an activity without falling); Set realistic goals for increasing activity (by instilling adaptive beliefs such as greater perceived control, greater confidence in one’s abilities, and more realistic assessment of failures); Change their environment to reduce fall risk factors (uses a home safety evaluation and action planner to reduce fall risk hazards in the home and community); and Promote exercise to increase strength and balance
Each of the eight sessions is two hours in length including a break for light refreshments. Early sessions focus on changing attitudes and self‐efficacy before attempting changes in actual behavior. The exercise component, which begins in the third session, takes about 30 minutes of the session to complete (MaineHealth, 2009).
Medication Management Improvement System (MMIS) Older adults benefit more from taking medications than any other age group. However, older adults are also more vulnerable to medication‐related problems than any other age group. A recent study by Medco Health Solutions, a prescription benefit manager, found that medication errors were seven times more likely to occur in those aged 65+ than in younger adults. The more physicians the older adult sees, the more prescriptions he/she fills and the more errors that occur. Annually, there are about 177,000 emergency room visits related to adverse drug events (injuries resulting from medication use) among older adults. Although those aged 65+ compose just 12 percent of the US population, they account for about 25 percent of emergency room visits and 50 percent of hospitalizations related to adverse drug events. Studies estimate that 70 percent of these ER visits and 88 percent of these hospitalizations were preventable. The estimated annual cost of adverse drug events exceeds $177 billion. (National Council on Aging, 2009) The MMIS is a collaborative approach to identifying, assessing, and resolving medication problems in community‐dwelling older adults. These system targets potential medication problems include both drug use and symptoms associated with specific adverse drug effects. The process, which includes consultation with a specially trained clinical pharmacist and an interdisciplinary care‐management team and a follow‐up with the client’s physician, adheres to periodically updated guidelines
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established by a Geriatric Advisory Panel composed of pharmacists, physicians, social workers, and nurses. Medication errors among community‐dwelling older adults are numerous. The MMIS focuses on identifying and resolving the four most common that researchers have determined are amenable to a collaborative staff and pharmacist intervention in homecare programs. They are: 1. unnecessary therapeutic duplication (e.g. generic and brand name of same drug); 2. falls, dizziness, or confusion possibly caused by inappropriate psychotropic drugs; 3. cardiovascular medication problems related to dizziness, continued high blood pressure, low blood pressure, or low pulse; and 4. inappropriate use of non‐steroidal anti‐inflammatory drugs (NSAIDs) in those with risk factors for peptic ulcer. Home health staff using usual practices can address these problems during a typical home health stay to identify problems with a high likelihood of clinical significance would warrant further re‐evaluation by the prescribing physician. In the original home health intervention, a computerized algorithm identified patients at potential risk, based on a medication inventory and an assessment of vital signs and patient reported symptoms such as confusion, recent falls, and dizziness. After the initial risk assessment, staff members collaborated with a pharmacist to develop an intervention plan. Strategies to resolve the problems included assessing patient adherence, coupled with education and counseling, as needed; and contacting the prescribing physician to re‐evaluate medication use.
Long‐Term Care Coverage In order to stem the rising tide of Medicaid expenditures, Texas should consider programs that invest in solutions that divert residents from the Medicaid program, delay entry into Medicaid, and emphasize less costly community‐based services. Given strains on publicly funded systems, there is a need for younger adults (Texans in this case) to plan for long‐term care costs. A Baby Boomer who purchases a long‐term care insurance policy may relieve the State of Medicaid expenditures up to his policy limit. For example, if the Project assists 100 Boomers (who meet Medicaid income guidelines) to purchase long‐term care insurance policies, and they draw a maximum benefit of $150,000 each, the Project will contribute to $15 million in foregone Medicaid outlays. Putting this into perspective, the average cost of Medicaid for an adult Texan is $6,116, the average cost of services through the Community Based Alternatives (CBA) program is $1,286 per month, and the average cost of nursing home Medicaid is $108 per day. This assumes the policy holder has an income that is within Medicaid guidelines. Not all policyholders will meet this criterion. Another important consideration is that long‐ term care insurance policies are not standardized, and maximum benefits vary widely; however, there is potential in examining this issue further as one possible element to the solution of increasing health care expenditures with a growing older adult population (Texas Association of Area Agencies on Aging, 2008).
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Transitional Care Another possible route to consider advocating is the idea of transitional care. Transitional care is defined as a set of actions designed to ensure the coordination and continuity of health care as patients transfer between different locations or different levels of care within the same location. Representative locations include (but are not limited to) hospitals, sub‐acute and post‐acute nursing facilities, the patientʹs home, primary and specialty care offices, and long‐term care facilities. In the course of an acute exacerbation of an illness, a patient might receive care from a primary care provider or specialist in an outpatient setting, then transition to a hospital physician and nursing team during an inpatient admission before moving on to yet another care team at a skilled nursing facility. Finally, the patient might return home, where he or she would receive care from a visiting nurse. Each of these shifts from care providers and settings is defined as a care transition. Transitional care is based on a comprehensive plan of care and the availability of health care practitioners who are well‐trained in chronic care and have current information about the patientʹs goals, preferences, and clinical status. It includes logistical arrangements, education of the patient and family, and coordination among the health professionals involved in the transition. Transitional care, which encompasses both the sending and the receiving aspects of the transfer, is essential for persons with complex care needs. Examining how this may be implemented in local health systems to create seamless and efficient transitions for older residents with health care needs may be a worthwhile endeavor.
Conclusion Tarrant County, along with the rest of the nation, will soon be facing the challenge of an aging population. These older adults will be diverse in their demographic make‐up, as well as in their health care and activities of daily living needs. While Federal and State level policy makers are working on addressing these needs, local policy makers and funders have the best sense of what is needed locally and, more importantly, what is the best approach to meet these needs. By approaching the issue of the aging population proactively and informed, policy makers can start addressing these needs today. Many of the issues older adults tend to face can be mitigated or prevented in earlier stages of life. Supporting the dissemination and sustainability of evidence‐based health promotion programming (such as the chronic disease self management program, Healthy IDEAS, A Matter of Balance, and the Medication Management Improvement System all discussed above) can help prevent chronic diseases, mental health, and injuries from taking a larger toll on health care and social resources. Examining and advocating long‐term care insurance policies among the younger cohort of older adults may save countless dollars in Medicaid expenditures. Supporting informal caregivers, such as family and friends, can help reduce the stress these individuals face day‐to‐day. Considering the huge volume of volunteer labor supplied by these individuals, supporting informal caregivers and giving them the
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resources they need to continue (including respite care, financial support, etc.), will in the long‐term save countless health care dollars. Finally, examining how one can improve the efficiency of the health systems in place to better facilitate care transitions for improving quality of care and patient safety among older adults may improve quality of life and health‐related outcomes.
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References American Diabetes Association. (2009). Diabetes Statistics. Accessed April 24, 2009. Available at: http://www.diabetes.org/diabetes‐statistics.jsp. American Heart Association. (2009). Heart Disease and Stroke Statistics, 2009. Accessed April 24, 2009. Available at: http://www.americanheart.org/ downloadable/heart/1240250946756LS‐ 1982%20Heart%20and%20Stroke%20Update.042009.pdf Centers for Disease Control and Prevention. (2009). CDC Website Accessed April 24, 2009. Available at http://www.cdc.gov. Centers for Disease Control and Prevention. (2005). National Health and Nutrition Examination Survey. Accessed April 24, 2009. Available at: http://www.cdc.gov/nchs/nhanes.htm. Centers for Disease Control and Prevention. (2005, 2006). Behavioral Risk Factor Surveillance Survey. Accessed April 24, 2009. Available at http://www.cdc.gov/brfss. Federal Interagency Forum on Aging‐related Statistics. (2008). Older Americans 2008: Key Indicators of Well‐Being. Accessed April 24, 2009. Available at: http://www.agingstats.gov. Hollon, S, Thase, M, Markowitz, J. (2002). Treatment and Prevention of Depression. Psychological Science in the Public Interest, 3(2), 39‐77. Lorig KR, Ritter P, Stewart AL, Sobel DS, Brown BW, Bandura A, González VM, Laurent DD, Holman HR. (2001). Chronic Disease Self‐Management Program: 2‐Year Health Status and Health Care Utilization Outcomes. Medical Care, 39(11),1217‐1223. MaineHealth. (2009). A Matter of Balance: Managing Concerns About Falls. Accessed April 24, 2009. Available at: http://www.mmc.org/mh_body.cfm?id=432. MHMR of Tarrant County. (2009). Aging and Geriatrics. Accessed April 24, 2009. Available at http://scf.mhmrtc.org/poc/view_doc.php?type=doc&id=4717& cn=12. National Center on Elder Abuse. (2009). Why Should I Care About Elder Abuse? Accessed April 24, 2009. Available at: http://www.ncea.aoa.gov/NCEAroot/ Main_Site/pdf/publication/NCEA_WhatIsAbuse.doc National Council on Aging. (2009). Center for Healthy Aging. Accessed April 24, 2009. Available at: http://www.healthyagingprograms.org.
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Satariano, W. (2005). Epidemiology of Aging. Sudbury, MA: Jones and Bartlett Publishers. Texas Alzheimer’s Association. (2009). Facts: Statistics about Alzheimer’s Disease. Accessed April 24, 2009. Available at: http://www.alz‐austin.org/disease/statistics.htm. Texas Association of Area Agencies on Aging. (2008). White Paper on Medicaid Diversion. Texas Department of State Health Services. (2004). 2004 Health Facts for Texas, Public Health Regions and Counties. Accessed April 24, 2009. Available at: http://www.dshs.state.tx.us/chs/cfs/cshdpa04.shtm. Texas Diabetes Council. (2009). Diabetes Data: Surveillance and Evaluation. Accessed April 24, 2009. Available at: http://www.dshs.state.tx.us/diabetes/tdcdata.shtm. Texas Falls Prevention Coalition. (2009). Texas Falls Prevention Coalition Homepage. Accessed April 24, 2009. Available at: http://www.srph.tamhsc.edu/research/ texashealthylifestyles/tfpc/index.html. United Way of Tarrant County. (2005). 2005 Community Assessment. Accessed April 1, 2009. Available at: http://www.unitedwaytarrant.org/OurWork/ CommunityAssessmentLinks/tabid/239/Default.aspx. United States Census Bureau. (2009). American Factfinder. Accessed April 2, 2009. Available at: http://factfinder.census.gov.
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