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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.

Today the University of Massachusetts Boston has made the fourth edition of “The Guide for Elders: Planning that Protects You and Your Assets” available for free online. The Guide which started in 1993 and has continued to be revised over time (most recently in 2010) hopes to be a resource for older adults so they know what steps to take to get and keep their affairs in order. There are “increasing numbers of reports of elderly people being abused, exploited, or victimized in ways that rob them of their life savings and their dignity. Those cases involving financial exploitation saw elders victimized by friends, neighbors, and even family members.”

Financial and health care matters are often confusing and the Guide provides their readers with clear descriptions and scenarios to illustrate problem areas. After reading the Guide you should be able to answer a number of questions: Why do I need a power of attorney, health care proxy, or will? When should I consider entering a nursing home? What can I do if I get “ripped off,” or if I am the victim of a crime or abuse?

Although not intended as a substitute for individual counsel and assistance, the Guide will allow you to prepare and determine if your situation needs additional professional advice. As clearly stated in the introduction, “Elders need to know what steps they can take to avoid being victimized and what they should do when and if it happens to them. This Guide’s…emphasis is on prevention and avoidance of problems, with the recognition of the old adage that an ounce of prevention is worth a pound of cure.”

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.

In the field of gerontology, long-term care planning is a very hot topic. I can’t pick up an aging newspaper or journal without some mention of this issue. That is not to say I am surprised by the attention it gets. One of the most startling facts I learned in class was that unpaid caregivers provide services valued at $450 billion per year!

Long-term care (LTC) is an essential expense and while many dream of a healthy retirement filled with vacations and relaxation, this is far from the reality. Most people will grow old and frail and need LTC during their retirement years. Unfortunately, most are not planning for it and the government is cutting back on affordable options that could help. Though Americans are not planning for LTC, they are worried. A California poll on this issue found that two-thirds of people don’t know how they will be able to afford LTC. They are just as concerned about this expense as the cost of their future healthcare. So if people are aware of the problem, why the inaction? Perhaps it’s because they don’t know where to begin. What affordable options do they have so they can age with dignity and independence, living how they want in the place they choose?

Information to Consider:

What is Long-Term Care = when you are not able to complete personal care or other daily activities on your own. This is most often the result of a chronic illness or disability. In some cases, the illness or disability may include cognitive impairment.

How Much Care Do You Need = about two-thirds of today’s elders will need LTC support. Women need care longer (on average 3.7 years) than men (on average 2.2 years), mostly because women typically live longer.

Who Will Provide Support = help comes from 3 sources: (1) family and friends (2) agencies with certified staff or (3) hiring help on your own. For many, a blended approach to LTC is needed.

How Do You Plan and Pay = the National Care Planning Council has a detailed guide to planning for your LTC needs. This 7 step plan involves understanding the care settings and available government programs, who you should call on for help, how you can pay for services, and how you can protect your assets. More information about the public and private sources for funding LTC can be found on the Department of Health and Human Services website.

Getting Started:

It may be daunting to see all the steps and options to consider. I’m asking you to start thinking about this decades before it’s needed! Perhaps having the following conversations is a better starting point for some of us. Begin thinking about LTC and your own life. Then when you do your research, you’ll be aware of your personal needs and desires.

(1) Talk with your spouse, adult children, friends, or siblings about whether they might care for you if I became ill or disabled. Tell them how you feel about relying on their help.
(2) Ask your family doctor whether you might be at higher risk for needing long-term care someday based on your medical and family history or lifestyle risk factors.
(3) Talk with a financial planner, insurance agent, attorney, or other financial advisor about how you would pay for long-term care services if you need them.

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.

While on a recent phone conversation with my best friend we got to talking about her parents and their (in her opinion) impulsive purchase. They were in North Carolina on vacation and bought a plot of land. They plan to build a house on it over the next couple of years and by the time they retire it will be ready for them to move in. Being a gerontology student and always thinking about long-term care needs, I babbled on for a few minutes about universal design. If they intend to build this home and stay in it for as long as possible, I told my friend, then they should consider their future needs.

Recent statistics show that about 80% of baby boomers want to remain in their homes for as long as possible (and Obama’s new Affordable Care Act may help them do just that with the Community Living Assistance Services and Supports (CLASS) program and the expansion of Home and Community-Based Services. A story for another time). If you start planning for it now, you don’t have to have oodles of money to build a house from scratch like my friend’s parents. Let me share with you what I feel are the key components of universal design and home modifications:

  • Think About Daily Activities – when modifying your home to support you in old age focus on making it easy to perform basic activities like bathing, cooking, or getting into and out of your home. Examples:
  1. Install grab bars in the bathroom
  2. Replace doorknobs or faucet handles with lever handles
  3. Install handrails on both sides of any staircases inside or outside your home (or consider ramps)
  4. Create some easy access storage in the kitchen such as a pull-out pantry or adjustable shelves
  • Consider the Age of Your Home – Most older adults live in homes that are over 20 years old and these can have some issues as you age. Some updates to your home can help you age in place. Examples:
  1. Install proper insulation, storm windows, and air conditioning so you have good heating and ventilation
  2. Create 36-inch wide doorways throughout the house for easy access with a wheelchair or walker
  3. Move outlets 18-inches off the floor so you’ll be able to reach them without much bending
  4. Put your laundry on the main floor (definitely get it out of the basement!)
  • Make Safety a Priority – Think about your aging parents. What parts of their home make you nervous? The clutter, the dim lighting, the slippery bathroom? These may also become a safety concern for you one day. Examples:
  1. Get rid of throw rugs (they are very hazardous!)
  2. Place non-slip strips in the bath tub, the kitchen and on any outdoor or indoor stairways
  3. Install bright lighting inside and outside the home, and make sure switches are easy to use and access
  4. Rearrange your furniture so there is plenty of space to move around a room

There are many companies out there that will sell you some pretty sleek looking products. You definitely do not need to spend that kind of money, but I think some people fear their home will look like a hospital if they integrate basic universal design.  Just remember this is entirely up to you, your tastes and your budget. If you start planning for it now and modify your home over time the benefits could greatly outweigh the costs. Below are some resources if you are interested in learning more:

National Resource Center on Supportive Housing and Home Modification

  • Comprehensive list of online resources
  • Directory for finding services in your area

US Department of Health and Human Services

A few weeks ago we had an expert in longevity come to campus and discuss the field’s cutting edge research. He started his talk asking the class of 20 or so students, ‘Who wants to live to 100?’ I immediately raised my hand and then surprisingly noticed that I was the only one. He smiled and asked me why.

I have longevity on both sides of my family, with my grandmothers and a some of their siblings reaching well into their 90’s. They had their wits about them till the very end and had very few chronic illnesses. It seems only natural that I will also live a long time and, with modern health care, reach 100.  But when he asked the other students why they did not share my enthusiasm, I realized my experience was unique.

Most students said they envisioned people in the 90’s and 100’s as immobile, sickly, mentally ill individuals. Overwhelmingly, this was their experience with aging family members. Yes, they wished to live in good health for as long as possible, but in their minds good health did not extend into the oldest ages.

Research on centenarians tells us that if you do make it to 100, you are most likely exceptionally healthy. “Time’s research found that today’s centenarians are mostly very healthy people. ” And your genetics do not necessarily define your future. Genetics play a role but keeping mentally and physically active, eating right, refraining from smoking or excessive drinking, and continuing to be social and optimistic can really increase your chances of living a long life.

Some people don’t want to live without fast food, alcohol, and a sedentary lifestyle. They may feel that the benefits of living longer aren’t worth it. But I would ask those people to consider how their health may be in the decades before reaching 100. One must consider that this lifestyle could mean you’ll be immobile, sickly, mentally ill in your 70’s and 80’s. No matter how long you expect to live, taking care of yourself now will benefit you later. I think this is what students should keep in mind as they observe their grandparents in old age. You are not destined to their fate.

I too must keep this in mind. My genes do not ensure me a spot among the centenarians if I don’t stay as healthy and active as my grandmothers did.

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