About Medical Care for The Elderly
Aging seniors and their families are often confounded by the complexity of issues facing the elderly (including declining income, increased debt, poor investment returns, declining health, medical crises, complex insurance programs, long term care challenges, etc…). This book (published in 2014) takes a comprehensive approach to address these challenges and provide solutions.
by Thomas Day
Featuring Dr. Rob Stall
This Information is brought to you courtesy of Healthcare Resources Home Health
The American Perspective on Aging and Health
Americans' Attitudes on Aging
American society in general glorifies youth and fears or even despises old age. This is not the case in many other societies where age is associated with wisdom, knowledge and special status.
We see evidence of this bias towards older Americans especially in the media. In films and on TV old people are very often depicted as weak, indecisive, bumbling or even comic. We laugh at their misdeeds and forgive their mistakes knowing in the back of our minds that they are old and can't help themselves. We view them not as capable as younger people. It is rarely that we see older people depicted as decisive, strong or as leaders. We see this same attitude with large corporations and government employers. At a certain age, employees are encouraged or expected to "retire" to a new phase of their lives where they are not required to work for a living any longer. Retirement is presumably a reward for many years of dedication and hard work, but the underlying philosophy is more likely based on the idea that older workers are no longer productive or useful.
As Americans age we fear the deterioration of our bodies and the possible lack of security due to low income — a byproduct of old-age. Some people in our country fight old age through cosmetic surgery, use of supplements, aggressive weight-loss programs or through overzealous physical training programs. Other people accept old age gracefully and adapt as well as they can. Still others refuse to grow old and resist aging by adopting social strategies such as denial, refusal to participate in life or becoming belligerent. (The angry old codger image)
Instead of taking the role as leaders in their families or in the community as is the case in some countries, the elderly in our country, even after successful careers in earlier years, simply become invisible. They waste their prodigious talents traveling, entertaining, socializing, watching TV or playing golf. They are rarely asked to assume responsible roles in the community. And unlike other cultures, older Americans often abandon themselves to control by other people, often their children and their health care providers. Instead of taking responsibility for their own decisions they will rely on children or others to make decisions for them. Many of them seem to enjoy the role of becoming dependent on others. And it is all too often the case that family and others pander to this submissive role of the elderly and we begin treating them like children.
This generally accepted perception of aging in our country has resulted in the elderly themselves and in the community at large regarding older people as less valuable than younger people. The assumption is that the elderly have lost the ability to think clearly, to learn new things and they are generally incapable of any physical activity other than walking or sitting. This attitude also carries over into the health treatment that older Americans receive.
The Older Person's Attitude towards His or Her Own Health
Many elderly buy into the notion that they themselves are no longer useful and as a result make little attempt to keep themselves healthy and active. After all, they are getting closer to the end of their lives and have no desire to try new things or to challenge themselves or to eat or exercise properly.
There is a great deal of anecdotal and research evidence that demonstrates older people can learn, can retain memory and can be actively involved in business and in the community. The lack of physical exercise, social involvement and mental stimulation in older Americans often leads to these people losing the ability to use their minds and their bodies. The older person's negative attitude towards aging becomes self-fulfilling.
Many reason that they have missed their opportunities in life when they were younger and it's too late to start over. As a result, many older people are intimidated by new ideas or by technology such as computers, not because they are incapable but simply because of their attitude. The idea of not being able to "teach an old dog new tricks" is in most cases an excuse. Obviously this mindset of failure and inability to perform becomes self-fulfilling. Not surprisingly, depression and suicide are more common in the elderly than in the younger population.
The negative attitude towards aging on the part of an older person has a direct impact on that person's health. Many studies show that people who are physically active have less joint pain, lower blood pressure, less depression, fewer heart attacks and a lower incidence of cancer. Proper nutrition also has the same affect on the aging process; it delays the onset of debilitating illness or disability.
According to James S. Marks, M.D., M.P.H., Director of the National Center for Chronic Disease Prevention and Health Promotion
"…. Research has shown that poor health does not have to be an inevitable consequence of growing older. Death is inevitable, but, for many people, it need not be preceded by a slow, painful, and disability- ridden decline. Our nation will continue to age — that we cannot change — but we can delay and in many cases prevent illness and disability."
A study in 2000 from the Journal of the American Geriatric Society reports that inactive women at age 65 have a life expectancy of 12.7 years whereas highly active, non-smoking women at 65 have a life expectancy of 18.4 years. A report from the CDC indicates that very few older Americans get 30 minutes or more exercise for five days a week or more. The report states that up to 34% of adults age 65 to 74 are inactive and up to 44% or almost half of adults age 75 are inactive. A study From the US Preventative Services Task Force reveals that regular exercise can reduce life-threatening falls in the elderly by 58%. Another study showed that regular exercise reduced pain and increased function in joints of older Americans suffering from osteoarthritis. (Reduced the need for pain medications) Yet another study found that strength training was as effective as medication in reducing depressive symptoms in older adults. Other studies from the Department of Health and Human Services support the idea that older people who are responsible for their own health and their own health decisions are healthier than people who rely on others to make decisions for them.
Lack of activity and poor nutrition often lead to obesity. More than any other problem facing older people, obesity can have the worst effect on their health. It leads to joint degeneration, heart problems, stroke, congestive heart failure, diabetes and a whole raft of other chronic medical conditions. And obesity among all ages is becoming a national crisis.
Another health problem with the elderly is the overuse of alcohol, cigarettes and addictive medicines such as pain killers or tranquilizers. It is assumed by the elderly and by their family that long-term use of these substances has gotten to a point where it would be pointless or impossible to get the elder person to discontinue or cut back on their use. In other words older people are no longer useful so let them have their bad ways. "Everyone dies at some point; what does it matter what causes the death." For instance it is assumed that smoking has already done its damage and little could be achieved in stopping. Actually recent evidence indicates that no matter what the age, cessation of smoking can reduce the incidence of chronic lung disorders and improve lung function even after a few weeks.
No one knows the extent of abuse of alcohol or other addictive substances among the elderly simply because no definitive studies have ever been done and older abusers remain hidden and invisible to the public. Again this is reflective of our society's attitude towards the elderly. It is commonly felt, especially by doctors who prescribe addictive medications, that we should,
"Let them have their vices, it gives them comfort and relief from pain and they are old and are going to die anyway".
Because of this public attitude many elderly people waste the remainder of their lives living in alcohol or drug induced stupor. And their health suffers as well due to lack of activity and poor nutrition.
The average 75-year-old suffers from at least three chronic medical conditions and takes five or more medications. Oftentimes older people have resigned themselves to a life of suffering and pain. They are not particularly interested in changing or improving their medical condition but are simply waiting out the rest of their life. These people often exhibit a phenomenon known as "the reluctant patient". They will not listen to medical advice, they have little interest in their own health and they often don't take their medications properly or they overdose. Doctors and other health professionals treating reluctant patients don't get the information they need in terms of symptoms or progression of treatment. The patient will typically lie about his or her condition. It requires a greater understanding from medical professionals and encouragement or sometimes forceful intervention from family to help the reluctant patient understand his or her attitude and participate in his or her medical treatment. The result can often be improved health and a greater quality of life.
Families or others involved with an elderly person must recognize the all too common attitude of worthlessness, defeat and resignation from elderly loved ones and take corrective action. They should encourage and possibly even prod the older person to be stimulated mentally, socially and physically — to be actively involved; to give him or her a purpose for living. But families should also be very careful not to become patronizing or controlling but be genuinely supportive in this process. Here are some ideas.
- Make sure an elderly loved one has challenging activities throughout the day instead of simply watching TV or viewing videos. This might include trips to interesting places, visiting senior centers, providing challenging games or puzzles, doing volunteer work, providing an opportunity to be involved in church work, offering stimulating conversation or working on an adult education class or college degree.
- If the person is interested, encourage him or her to become involved in handcraft, genealogies, creative design, writing, scrap booking or other challenging home oriented activities.
- Give them responsibility for taking care of pets such as a dog, a cat or a friendly bird. In addition, if feasible, allow them to care for plants as well. This strategy is used often in nursing homes to reduce depression in the elderly and to actually improve their health as well. It really works.
- If a caregiver for an older person cannot be present, make arrangements to enroll a loved one in adult day care. These providers often offer the same strategies we are talking about here.
- Provide opportunities for family and friends to come by and visit and encourage or even arrange such encounters.
- Provide opportunities for the older person to interact, teach and nurture children such as grandchildren or children in a day care center. This is an extremely effective strategy for helping the older person feel that he or she has a meaningful existence. And it has a dramatic impact on improving and maintaining health.
- Design or arrange an exercise program and come up with a way to encourage the older person to follow it.
- Understand the nutrition needs of an older loved one, especially the need for vitamins and minerals including iron. Get some books on the subject or go to the Internet. Make sure the person takes care of him or herself and eats properly. Fixing special meals, providing treats, getting takeout or going out to dinner can be fun and exciting for anyone regardless of age. Many elderly people neglect their own nutrition. Poor nutrition can cause all kinds of mental and physical problems in the elderly.
- Make sure an older person has opportunity to look good and have nice clothing. Make sure the person gets out in public, and tries dining out or going to a public event and can feel good about his or her appearance.
Aging and the Attitude of Health Care Providers
It is natural that health care providers such as doctors, pharmacists or nurses will have the same attitude towards aging as other Americans. Without proper geriatric care training, these people can fall into the same trap of treating the elderly differently from younger people. According to the Alliance for Aging Research,
"In recent years evidence has been mounting to suggest that, at all levels in the delivery of healthcare, there is a prevailing bias -ageism – that is at odds with the best interests of older people. This prejudice against the old in American healthcare is evidenced by scores of recent clinical studies, surveys and medical commentaries, many of which are referenced here. In this report, we outline five key dimensions of the ageist bias in which U.S. healthcare fails older Americans:
• Healthcare professionals do not receive enough training in geriatrics to properly care for many older patients.
• Older patients are less likely than younger people to receive preventive care.
• Older patients are less likely to be tested or screened for diseases and other health problems.
• Proven medical interventions for older patients are often ignored, leading to inappropriate or incomplete treatment.
• Older people are consistently excluded from clinical trials, even though they are the largest users of approved drugs."
A fictional story, often used in the training of geriatric physicians, goes this way:
A 90 year old man meets with his doctor and complains about pain in his right knee. The doctor tells him, "Well Henry, what do you expect? You're 90 years old."
Henry replies, "But doctor my left knee is the same age as my right knee, there's no pain and it feels just fine!"
Many in the health-care profession consider old age to be a disease itself. Any medical problems are inappropriately attributed to old age as if it were a medical condition. And since there is no cure for old age, appropriate tests and treatment are never performed. Thus, medical problems that may not be related to age and may just as frequently occur in younger people are often not treated. As an example a recent survey of physicians involved in the health-care of the elderly reported that 35% of the doctors considered hypertension a result of the aging process and that 25% of them felt that treating an 85-year-old for symptoms of hypertension would cause more harm than the benefits it would produce.
Consider these real-life examples.
A 71 year old woman has surgery on her shoulder for a bone spur that is causing her considerable pain. The surgery is successful and she goes through several months of physical therapy to help her recover. But she is not recovering as expected. She continues to experience pain that radiates through her entire back. Her physical therapist does not know how to help her and attributes her failure to recover to old age. She visits her family care doctor at least twice over the next six months complaining of extreme tiredness and lack of energy. Her skin color is gray and she does not look healthy. Finally she visits her doctor and insists he check her for some problem since she is not recovering from the surgery and she feels awful. After her insistence he does a CBC blood lab and discovers she is severely anemic. He puts her in outpatient care and gives her four units of red blood cells and puts her on iron supplementation. Within two weeks the pain has disappeared and within a month she has recovered fully from the surgery. Numerous tests are done but there is no explanation for the anemia. Six months later she is healthy and active and her cheeks are ruddy. When she asks her doctor why he did not suspect anemia he tells her that she has never had anemia and based on her history he would never expect her to develop it. (He obviously has no training in geriatric care.) He then tells her, in an obvious contradiction of his previous position, that older people sometimes fail to absorb iron. Ironically, she defends the action of her doctor and does not feel he acted inappropriately.
Susan and John have been married for 46 years. Susan has always demonstrated a tendency for depression but it has generally been kept under control with medication. John's health begins to deteriorate and within a year he is dead. Several months after her husband's death, Susan is exhibiting signs of severe depression. She is given ever-increasing levels of various antidepressants but they have no effect. She is also exhibiting signs of a psychosis and is inflicting wounds upon herself. The family puts her in an assisted-living facility but they are unable to deal with their aberrant behavior. Her son who lives in New York decides to bring her to live with him and he admits her to a hospital in New York City . Tests indicate she is suffering from severe hypothyroidism and she is put on appropriate treatment. (Apparently no health practitioner had to this point suspected there may be another condition contributing to the depression other than old age.) The low thyroid undoubtedly was a significant factor in the development of her depression. But treatment of the depression is not addressed in the hospital and it has progressed considerably. She is transferred to a nursing home and wrongly diagnosed with dementia and placed in the dementia unit. She is deteriorating rapidly, she continues to abuse herself and she refuses to speak or acknowledge anyone. Within a few months she will probably be dead. At this point an experienced geriatric care physician steps forward and correctly diagnoses her condition as clinical depression. She is hospitalized for six months and undergoes aggressive treatment for depression. They also discover she is severely malnourished and correct that problem as well. She has now moved back into the home of her son. She is a normal functioning person and is even volunteering to work in the local library. The elderly health care system almost dropped the ball on this one.
A 65 year old woman, who has been active all of her life, has a small stroke which leaves her with some discomfort and pain in her right arm but does not limit her in any other way. She is anxious and nervous about her condition and the possibility of another stroke and the doctor prescribes pain pills and Valium to help her with her anxiety. Over a period of 15 years, she becomes addicted to Valium and does little else except sit in front of the TV all day long. She makes sure she maintains contact with a doctor who will provide her need for Valium. (No doctor or pharmacist would allow this abuse to go on with a younger person without intervention. Older people are often ignored and allowed their vices.) Early on, her family can see the problem and they decide to intercede. On the advice of friends they contact the geriatric care unit at a local university hospital. A geriatric care physician is alarmed at her addiction and insists they wean her off of the mood altering drug. He is willing to treat her and help her. She refuses to cooperate and in deference the family backs off. Over a period of 15 years she gets no exercise except for trips to the bathroom or trips to the living room to visit occasionally with her family. But family and grandchildren over the years visit less and less often.
After many years of sitting in the same position her knees deteriorate and she finds it difficult to walk. In order to avoid getting up from her chair to walk to the bathroom, she drinks very little fluid and becomes chronically dehydrated. This does not help her mental or physical condition. She has the joints in both knees replaced but does no exercise and the combination of the invasion of muscle tissue and lack of use of her legs causes muscles around her knees to atrophy. No follow-up is done by the orthopedic surgeon to make sure she remains active, after all she is old. She can now barely walk at all. She spends her final three years confined to one room in her daughter's house, refusing the use of a wheelchair and refusing to go anywhere beyond the bathroom.
In this case a general lack of concern by all involved demonstrates the apathy of family and the healthcare community to making sure elderly people can experience a meaningful existence in their remaining years. Had this been a younger person, say in her 40's, everyone involved would have been more aggressive in helping her solve her addiction and in making sure she had a better quality of life.
What Should You Expect At Your Age? A Lot!
Dr. Rob Stall is passionate about the area of geriatric health care. He is a board certified geriatrician and maintains a private practice as well as being medical director for a number of health care facilities. In addition to his practice, Dr Stall has a popular monthly radio program and he speaks frequently to local groups about care for the aged.