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Every non-profit or academic institution focused on aging in America (e.g. AARP, Older Women’s League, American Society on Aging, etc.) supports the American Care Act. It’s great news that the Supreme Court ruled the law was constitutional. With this ruling, insurance companies will no longer be able to deny coverage, or charge more because of a pre-existing condition, or force women to pay higher premiums than men. Preventive care will continue to be covered at no cost, and seniors will continue to save money on prescription drugs (5.3 million Medicare Part D beneficiaries have already saved $3.7 billion on prescriptions since the law was enacted).

The ACA is a major step toward ensuring affordable and quality health coverage for millions of working families, elders, and children. Therefore, it is surprising to me that many Americans don’t believe the ACA will help them. A Kaiser Family Foundation report found that people believe young adults and children are likely to benefit from the new law, but not themselves or their families. Thirty-seven percent of respondents felt the law will make no difference in their lives, thirty-one percent felt they will be worse off.

Where are these answers coming from? Is it that a case being brought to the Supreme Court is enough to reduced people’s opinions of the law? Who are the individuals against the ACA…do they understand the implications for American’s health system and the American people’s well-being?

The ACA is in no way perfect, but many of the laws are designed specifically to help older people acquire and pay for comprehensive health care. An AARP article lists the number of ways the law supports older adults:

  • Insurance companies cannot drop you if you become sick or disabled
  • They cannot have lifetime dollar limits on your coverage
  • Medicare recipients receive annual wellness visits, preventive services, and immunizations at no additional cost
  • As mentioned, people with Medicare Part D now receive discounts on prescription drugs while in the doughnut hole. The Part D discounts will gradually increase until 2020, when the doughnut hole will close
  • In 2014, insurers can no longer deny coverage if you have a preexisting condition
  • In 2014, insurance “exchanges” will provide better access and options to self-employed people, small businesses and others who are unable to find affordable coverage

The Supreme Court’s decision is a significant move in the right direction. It will help the United States build a health care plan for our future that is on par with what other developed nations provide already: Affordable health care coverage as a right, not a privilege.

The winter edition of the American Society on Aging’s publication “Generations” focuses on medications and older adults. The writers and guest editor did a great job of synthesizing information on medications and their usage for a non-clinician. I was most struck, however, with the overarching message that we actually know very little about medications’ true effects on elders. A particular article highlighting this point was titled “Medicating Elders in the Evidence-Free Zone” by John P. Sloan.

In Sloan’s work he asks us to take a step back from the escalating debate around the growing health care and drug costs in America, and to consider the drugs themselves. “The newest shift in prescribing,” he writes, “is the shift from drugs that treat conditions to drugs that prevent them – particularly in elders.” Drugs are being prescribed for older adults to treat chronic illnesses and help them feel and function better, but many drugs are also taken with the goal to prevent illness and prolong life. Sloan provides an example: A 90-year-old woman is told she has low bone density and is prescribed a drug to help. Before leaving the office, she asks her doctor how long it will take for the medicine to have a beneficial effect. The doctor tells her it will take 2 to 3 years before they’ll see any noticeable improvement. Knowing her life expectancy to be not much longer than 3 years, she wonders about the benefits of preventative medicine for someone her age.

This example raises number of questions for the reader:  Do the frailest, oldest-old want to prolong their life and prevent future illness? If so, at what cost and with what negative side-effects? Are we confident preventative medicines will help this population?

Sloan addresses the last question in his article and I was startled by the answer. Older, frail adults are members of what has been called an “Evidence-Free Zone.”  Drug trials, which are the only support for prescribing preventative medications, do not include older adults, frail individuals, people with more than one chronic illness, or people taking multiple medications. Consider this for a moment. Drug trails, so they are safe for participants and accurately testing a drug’s effects, cannot include complicated people. Older adults, however, are the most heterogeneous and complicated group when it comes to their medical care and conditions.

The author states point blank, “When an older person takes a medication, no one has any idea what is going to happen.” This is because of the four “Absurdities of Prevention in Frailty”:

  1. You can’t predict the outcomes of a drug in people whose biology is unpredictable.
  2. Clinical trials never include frail elders because frailty by definition includes multiple pathologies.
  3. Older people are less likely to benefit from preventative medicines.
  4. Preventative medicines, even if safe in everyone else, are just riskier in frail elders.

Drug trials also do not test for outcomes that may matter most to older people like functional status, cognition, mood, quality of life, and caregiver burden. Geriatric patients, who use our medical system most, may be surprised to find little is known about them and their health. I know I was. The good news is geriatricians and medical researchers are aware of the problem. They continue to investigate the best ways to help older adults age well and provide helpful information for the rest of us so we can stay informed about caring for ourselves and our loved ones as they age.

The Fall 2011 Generations issue is all about rituals. The journal’s content was on my mind as I gathered with family and friends this Thanksgiving. I began thinking beyond the fun and food, and looked more toward the larger meaning of holiday events. What are our cultural and family traditions, and how did my grandparents benefit from developing these rituals?

The significance of our family traditions mattered not only to my grandmother, but to the rest of us as well. She started our “Thanksgiving Brunch” years ago when her children began splitting time between their spouse’s families and their own during the holidays. It was important for her that the whole family get together during the holidays and without the stress of having to be in two places at once. Many of the rituals we perform during Thanksgiving (the time we eat, the food we serve, the location where we gather, the family photo) started with my grandmother and added meaning to the holidays.

But what meaning did our Thanksgiving rituals hold for her? Cooking the Thanksgiving brunch for our family could be seen simply as habit. Yet consider how this made my grandmother feel: making the meal reminded her of the personal, familial, and cultural roles she’s held over the years.  As I think back on it now, she had a specific Thanksgiving ritual. The same food was prepared year after year. Only when the food was ready did she greet everyone (don’t bug her while she’s cooking!). She’d watch her family interact and get their share of the meal before she took any food for herself. When she finally sat down at the table, the eating could begin. Even in later years when she was no longer the cook (and assumed the role of supervisor), her ritual was still performed every Thanksgiving.

Older adults often perceive rituals as a way to build successful families and strengthen relationships. Researchers show that the most positive aspects of holiday rituals are maintaining family contact, togetherness and sharing, making memories, and communication. My grandmother knew that even when she passed away we would keep these holiday rituals alive and continue to see each other for brunch every year. In times of change or struggle, rituals become extremely important because of the continuity, order, and predictability they provide to families. In the final years of my grandmother’s life, keeping to the holiday traditions provided structure for us and for her as we began accepting the inevitable. Our holiday activities over the years left an emotional imprint on everyone involved, allowing each family member to recall positive memories from these events.

For older adults and those of us who study them, rituals provide insight into the lives they hope to live, the types of social and cultural settings they find meaningful, and the experiences they wish to share and turn into their legacy. So when family gets angry because you forgot to bring the cranberry sauce this year, consider why breaking this tradition would make them so upset. Rituals, particularly for those in later life, connect people to something bigger through shared experiences and the meaning that they create. “It’s not Thanksgiving without cranberry sauce!”

The 2011 OWL Mother’s Day report  starts with a very strong statement: “Health care for all is a women’s issue…” Why would this be? Men also need and use our health system. Yet, the case is made for how women’s lives are affected by health care coverage or a lack there of. Women play a large role in managing care for sick family members, most often providing this care themselves. Widows can often be left impoverished if their husbands’ chronic illnesses dwindled savings accounts and assets. In late life, women find themselves 60% more likely to need help with basic daily activities (i.e. eating, dressing, bathing) compared to men. This paints a picture in our minds: Grandma spent her 60’s and 70’s caring for grandpa. He had heart problems and diabetes but she made sure he took his medications, got to his appointments, and was cared for till the end. Now in her 80’s, grandma finds herself sick, poor and alone in a big, empty house. Since women’s life expectancy continues to exceed that of men’s, this story is all too familiar.

“After a lifetime of caring for others, older women often need affordable care but find that the costs are high and their options are severely limited.” I’ve described to you a common late-life situation for women. Let’s keep this image in our minds as we discuss how the Affordable Care Act (ACA) aims to support Americans as they age. People, like grandma, find themselves skipping preventative services because Medicare requires them to pay a 20% co-payment. This cost is found to be a disincentive for approximately half of Medicare beneficiaries who do not use preventative services available to them.  Grandma lives on a fixed income of $1,000/month from Social Security (the average benefit is $1,177) and this means that paying a $30 co-pay to see her doctor gives her $30 less for grocery shopping that month. She isn’t feeling sick, so she prefers to spend the money on food. This begs the question: Should she have to make that choice?

 
The good news is changes to our health care system are happening over the next few years and should support people in old age. Below I’ve highlighted some of the changes but please read the full report or see this great summary of the Health Reform Law from the Kaiser Family Foundation for more details.

Health Insurance Reforms

  • Medicaid will be expanded to cover 16 million Americans (all legal residents up to 133% of the federal poverty level will be eligible)
  • Retroactive cancelling of insurance because of accidents or sickness, denying coverage because of pre-existing conditions, and basing premiums on health status, gender and genetics will all be prohibited
  • Insurance companies must devote at least 80 – 85% of premium dollars received to medical benefits and quality improvement and they must provide justifications for any excessive rate increases, making this information available to consumers

Medicare

  • People who reach the “donut hole” on prescription drug coverage will get a large discount on drugs and biologics and this discount will grow each subsequent year.  The hole will be closed in 2020
  • Beneficiaries will receive a free annual exam, free flu and pneumonia shots, and any covered service that is given a grade A or B by the U.S. Preventive Services Task Force must be provided at no cost
  • Medicare payments will be reduced for hospitals that have high HAC rates (hospital-acquired conditions) and incentives will be provided to hospitals that improve their transitional care and partner with community services to reduce readmission rates

Long-Term Care 

  • The Community Living Assistance Services and Support (CLASS) Act will provide a voluntary long-term care insurance program available to all working Americans. When an individual becomes eligible and needs long-term care services an average cash benefit of $50/day will be given to help them pay. Beneficiaries have control over their own care, so this includes paying family or friends who provide help at home.
  • Home and Community Based Services (HCBS) aim to provide a network of services within state and local areas to meet the needs of elders aging in place. A new protection called under HCBS will attempt to prevent “spousal improverishment” by only counting the ill spouse’s income when determining eligibility.
  • Nursing home care will be improved as the ACA aims to make the system, procedures, staffing and care more transparent and regulated. The Elder Justice Act is a part of this, in an attempt to identify and prevent elder abuse.

In the United States everyday people are providing 85% of needed long-term care for their family members and friends. These roles are generally unpaid and at the expense of their own careers, health, and well-being.  Rather than creating a health system that works, we have created a system that to a large extent depends on informal caregivers yet still costs us 17% of GDP.  The ACA is not a perfect system and will not be fully up and running for a few years. Still, it is a step in the right direction and will expand coverage to 95% of the population and support those who care for the people they love.

If you find yourself bombarded with mixed messages or feeling confused about the new health care changes, I encourage you to at minimum read the OWL Mother’s Day report’s appendix. Here the authors address a number of major myths about the Affordable Care Act and answer some common questions about the policies and coverage.

I’m not a medical doctor but I hear so many older adults say things like “I can’t find my keys, am I getting Alzheimer’s?” or “My sunglasses were right on my head!  I hope I’m not losing it.”  I feel the record needs to be set straight. Cognitive illnesses are a growing concern for older Americans. The increasing number of delirium and dementia cases among elders have advanced the general public’s awareness of these issues. That’s great but don’t let it confuse you into thinking you and everyone around you has a problem (After reading below if you are legitimately concerned you should get the opinion of a medical professional right away).

Forgetfulness comes with age and you may now have a harder time remembering. But when you get tested for dementia they are not exactly checking to see how forgetful you are. Can you draw an analog clock showing it is 2:35? Will you know how much change you’d receive paying for a $1.95 pack of gum with a $5? Can you name 12 different animals? As you can see, these questions have nothing to do with how often you misplace your keys. John Hopkins Medicine tells us that doctors consider both your short and long-term memory loss AND one or more of the following:

  • aphasia – language problems
  • apraxia – organizational problems
  • agnosia – unable to recognize objects or tell their purpose
  • disturbed executive function – personality and inhibition

Dementia is a progressive decline in memory and at least one other cognitive area (attention, orientation, judgment, abstract thinking and personality). Types of dementia all involve structural damage to the brain. Dementia is rare in under 50 years of age and the incidence increases with age; 8% in >65 and 30% in >85 years of age. Alzheimer’s Disease is a type of dementia.

Delirium is an acute disorder of attention, memory and perception and is preventable and treatable.  It is typically of short duration but severe, and is believed to either disrupt brain metabolism or brain chemistry, both of which can significantly affect brain functioning. The diagnosis is unfortunately missed in more than 50% of cases.

Mild Cognitive Impairment (MCI) is a condition involving problems with memory or another mental function (for example language) severe enough to be noticeable but not serious enough to interfere with daily life. This can progress to dementia and the risk of progression to dementia is elevated for people with stroke, depression and a high burden of other medical conditions.

If you want to do more to help, the Alzheimer’s Association’s Walk to End Alzheimer’s is happening in the next few months all around the country. I know I’ll be walking to increase knowledgeable awareness about dementia and delirium and to raise money to help find a cure (or even just a better understanding) of these heart-wrenching diseases.

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