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Healthy Aging: Confronting a Worldwide Challenge
by William Kanapaux
Geriatric Times May/June 2002 Vol. III Issue 3
Health care and policy leaders from across the globe convened last month in Madrid, Spain, to discuss an event without parallel in human history: the aging of the world population.
The Second U.N. World Assembly on Ageing, which took place April 8 through 12, brought world leaders together to adopt a plan of action and long-term strategies for addressing aging issues. Non-governmental organizations (NGOs) associated with the United Nations held their own NGO World Forum on Ageing in Madrid on April 5 through April 9. Six thousand representatives addressed issues ranging from health care to economic development and housing.
Much has changed since the first World Assembly was held in Vienna 20 years ago. The United Nations projects that by 2050 the number of people in the world 60 years and older will, for the first time in human history, exceed the number of children 14 years and younger. This demographic shift has already occurred in the world's industrialized regions, and developing countries are catching up quickly.
The World Health Organization (WHO) said that in order to meet this challenge, countries and organizations must enact "active aging" policies and programs that enhance the health, independence and productivity of older citizens. "The time to plan and to act is now," according to a discussion paper released by the WHO prior to the Madrid gathering.
The proportion of people age 60 and older is growing faster than that of any other age group. According to the United Nations, the world's population of older people is growing by 2% each year and is expected to outpace other age groups for at least the next 25 years. The fastest growing age group in the world is the oldest-old, those aged 80 years and older. By 2050, the oldest-old will account for one-fifth of older individuals.
In the United States, 16% of the population in 2000 was 60 years or older. By 2050, that proportion is expected to rise to 28%. Other developed countries face an even greater challenge. In Spain, for instance, in 2000, 22% of the population was 60 years or older. That proportion is projected to jump to 43% by 2050. In Japan, the proportion of the population older than 60 years is expected to rise from 23% to 38%.
Developing countries face a more difficult challenge. While industrialized nations grew wealthy before their populations began to age, developing countries must meet the service demands of an aging population before any substantial increase in wealth occurs. This will leave major gaps in the services and supports available to older adults.
The Challenge at Home
While the likelihood of experiencing major disabilities increases dramatically with old age, an aging population does not necessarily equal a more disabled one.
According to the WHO, the United States has experienced a significant decline in age-specific disabilities over the last 20 years. The declining disability rates since 1982 resulted in a $17.3 billion savings in nursing homes' costs in 1994 alone. It has been estimated that each $1 investment in programs that encourage moderate physical activity results in a savings of $3.20 in medical costs.
"Health systems need to take a life course perspective that focuses on health promotion, disease prevention, equitable access to primary care and a balanced approach to long-term care," the WHO's "Health and Ageing" discussion paper urged. "If people live longer with fewer disabilities than originally projected, dire predictions of an 'explosion in health care costs' are not likely to happen."
Training Issues
The United States has the infrastructure in place to promote and maintain good health for older adults, but several obstacles stand in the way of providing those services. A primary concern is that most family practitioners and internists are not trained in geriatrics, leaving a wide gap between what patients need and what professionals know.
Few of the nearly 700,000 primary care physicians currently in practice have geriatric training, Patricia Barry, M.D., M.P.H., executive director of the Merck Institute of Aging & Health, told Geriatric Times. The United States has fewer than 7,000 board-certified geriatricians, she added, with demand far outpacing supply.
Experts project that in the next 20 to 30 years, 30,000 geriatricians will be needed. Medical schools have begun to address the need for geriatric training, but these schools graduate only about 16,000 doctors a year. That leaves more than 600,000 physicians who are poorly prepared for the health care needs of an aging population, Barry said.
Barry addressed the issue in Madrid as part of an NGO World Forum panel on "Preparing Healthcare Professionals for Population Ageing and Longevity."
Results of a survey of 250 physicians commissioned this year by the Merck Institute found that more than half of the primary care physicians who responded felt that their colleagues were not as comfortable as they might be in diagnosing and treating medical problems generally found among older Americans.
These results, released March 26, confirmed that many primary care physicians are probably not providing optimal geriatric care, Barry said.
To help address the gap, the Merck Institute, which was founded last June and is funded by the Merck Company Foundation, a philanthropic division of the pharmaceutical firm Merck & Co., has developed a series of tool kits based on an assessment of needs in the primary care setting. The tool kits, part of the Practicing Physician Education Project, are available free on the Institute's Web site.
So far the Institute has tool kits covering memory loss, urinary incontinence, depression and falls. Future kits will address sensory impairments (primarily hearing loss and vision problems) and health promotion.
It is important that health care professionals know how to diagnose and manage health syndromes that are common with older patients, Barry commented. Good geriatric care helps to maintain health and avoid disability, a major challenge as life spans increase.
"It's not getting old that's the problem," she said, "it's getting disabled."
The tool kits are designed to address these issues. For instance, data show that falls resulting in a hip fracture make it more likely that the patient will fall again. Health care professionals need to be aware of this and focus on ways to prevent additional falls.
Other problems may have a domino effect that can lead to disability. For instance, urinary incontinence is very limiting in terms of social activities. Left untreated, it can lead to a cycle of social isolation and physical inactivity. This, in turn, lays the foundation for future disability.
The biggest challenge is getting the message out to physicians and other health care professionals who are already in practice. Barry told GT, "We need support from within the professions themselves."
Changing behavior in the practice setting is a challenging task. Rather than a "darkroom with slides" approach to continuing education, Barry hopes to find more innovative and interactive ways to bring the knowledge of quality geriatric care into daily practice.
Computerized systems allow for change at the practice level, she said. Guidance from the tool kits, for instance, can be programmed into existing systems. For example, a reminder to screen for sensory impairments can pop up for older patients who are making a first visit.
Policy Concerns
Policy decisions will have a tremendous impact on the way health care professionals are able to respond to the medical needs of older patients.
One area of concern is Medicare. A March 17 article in The New York Times reported that a significant number of doctors are refusing to take new Medicare patients because fees for those patients are too low. In January, the federal government imposed an across-the-board 5.4% cut in reimbursement for services to Medicare patients. It was the largest rate reduction in the history of the program, and more cuts are expected. The American Academy of Family Physicians told The New York Times that 17% of family doctors are no longer accepting new Medicare patients as a result.
The Medicare program currently covers 40 million people, a number that is expected to double in the next 30 years. As doctors continue to opt out of the program, older Americans will find it more difficult to receive proper care. The lack of a prescription benefit in the Medicare program also poses a challenge for older Americans.
Further, many Americans fall through the cracks of the health care system. Nearly 40 million Americans are currently without health insurance, meaning that a large segment of the population is not receiving care that might otherwise prevent or lessen health care problems later in life. And the Medicaid program, which has served as the safety net for low-income seniors, is no guarantee either.
On March 14, Barbara Lyons, Ph.D., deputy director of the Kaiser Commission on Medicaid and the Uninsured, told the U.S. Senate's Special Committee on Aging that the more than 4 million seniors who receive Medicaid are at risk of losing a significant portion of their benefits as states struggle with budget shortfalls. According to Lyon's testimony, the vast majority of Medicaid spending for seniors -- 83% -- is not required by federal law.
The Global View
The Madrid meetings represented the first time that the aging issue has been addressed as a large global event involving multiple levels of discourse: political, civil and professional.
United Nations-sponsored forums of this magnitude serve as catalysts, Irene Hoskins, senior technical officer in the Ageing and Life Course Programme at the WHO, told GT. According to Hoskins, the message that the WHO and other organizations want to convey is that older people are a force to be reckoned with. They now are able to live longer lives in better health and be major contributors to society.
One thing that the Europeans are learning, Hoskins said, is to make sure that older people remain in the labor force longer. Ten years ago, early retirement was the trend. Now these countries are trying to change that with incentives for older people to continue working in order to postpone pensions and other income-security benefits.
However, Hoskins added, that move opens a Pandora's box of issues. Employers have to think about ways of addressing the needs of an older workforce, not the least of which is staying healthy.
Another area that deserves attention in the United States is the aging of immigrant populations, Hoskins said. Health care providers will need to consider the needs and requirements of different ethnic and cultural groups as first-generation immigrants begin to age. In particular, language skills for large groups such as Hispanics and Asians will be in high demand.
Declaration of Human Rights
Robert N. Butler, M.D., president of the International Longevity Center-USA, called for the World Assembly to develop a "Declaration of the Rights of Older Persons." Butler wrote a proposed document declaring that abuse of older people should be considered a human rights violation.
Those abuses include "physical, sexual, emotional and financial abuse occurring in their homes as well as in institutions such as nursing homes" and "discrimination in the delivery of services otherwise available to other members of the society." The center distributed the document, which was published in the April issue of The Gerontologist, at the Madrid meetings.
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