As my father turned 95 years old on May 15th I reflected on what a wonderful portrait of aging he has become. His journey through life has been an interesting one. Born of immigrant parents and poor, he was always taught how important it was to be educated. He excelled in high school as a football player and was accepted on full scholarship to Columbia University. He was All American at Columbia and was drafted by the Chicago Bears. While playing for the Bears and helping them to 3 national championships he completed his studies at Northwestern University to become a dentist. He served as a Lieutenant in the US Navy where he was a dental officer and then went on to practice dentistry for nearly 45 years. Today he is the oldest living Chicago Bear and on his birthday received a phone call from them letting him know that a video about him was posted on their home page, http://www.chicagobears.com.
I have learned so much from watching my father over the years. His values of integrity, humility and passion for always doing your very best have ruled my life. I also consider him my personal laboratory on aging. The Spring of his 90th year he tilled and planted his vegetable garden. A few months later he fell on the steps and never told anyone that he knew he had a broken rib – one of those painful events he learned to live with during his days of low protection football. Three nights later when he collapsed in his bedroom he was rushed to the hospital and diagnosed with a punctured lung. After being in bed at the hospital for several days he was sent to a “rehab” unit where he had what was called “geriatric” rehab. For one hour per day he had rehabilitation and spent the rest of the day in his room where he remained immobile. He was discharged home one week later with delirium and on a walker. He lost his mobility while in the hospital and has never gotten it back. This was an avoidable loss of function. He has some dementia and lives at home with 24 hour assistance. His gait and balance are impaired and he continues to use a walker. The delirium was managed by a loving family and wonderful paid caretakers who provided structure and meaning to his days. Although his dementia sometimes takes over, medication and loving caregivers keep his cognition at the highest level of his potential. His sense of humor continues and his stories and recall are often amazing.
Another thing I have learned watching him through these past years is how difficult it has been to have medical care for him without having to go out to the providers’ office which requires at least two people to assist in getting him down the stairs and out the door. Rather than have a nurse check on a symptom that might be handled in the home with communication to the provider, my father must have a face-to-face with the provider. In this day and age when we have far fewer primary care providers than we need and more people aging every day, this problem will only become more difficult. We must find ways to use the right provider, at the right time with the right care if we are to keep people at home with the best quality of life they can have. My father has a good quality of life because he has a significant support system. Most older people are not this fortunate and have poor access to appropriate care. Our older population is growing and more people will be living to 95 and beyond like my father. Their lives have been journeys of good times and bad times. When they are in the twilight of their lives, we must assure that they can stay safe with the right care at the right time wherever they are. I have no doubt I will learn more from my father during whatever time we have left together.
An article and video interview with Dr. Siegal was featured on May 15th and is available on the Chicago Bears website. http://www.chicagobears.com/news/article-1/Oldest-living-Bears-player-turns-95-years-young/b2201539-1e40-42ed-b963-f4e9d37eb241
May is Older Americans Month!
As the number of people over the age of 65 continues to grow with the aging of baby boomers and increased longevity, the need for accessible, coordinated and collaborative primary care for this population also grows. The older population (65+) numbered 40 million in 2010, and the number of Americans aged 45-64 who will reach 65 over the next two decades increased by 31% over the past ten years. Over one in every eight, or 13.1%, of the population is an older American, and persons reaching age 65 have an average life expectancy of an additional 18.8 years (20.0 years for females and 17.3 years for males). Older people have a higher prevalence of chronic disease that needs to be managed, are more prone to experience falls and related injuries, and more rapidly lose function resulting in the need for long term care. Most older persons have at least one chronic condition and many have multiple conditions. 1
The complexity of caring for this diverse older population means that we need a healthcare workforce prepared to address these challenging healthcare needs. The primary care setting is the hub for not only the management of chronic disease, but also the prevention of avoidable function loss and the coordination of care as people move in and out of different healthcare settings as their healthcare needs change. There is a need for primary care providers to have the access to resources that enhance their ability to deliver this kind of care. Effective primary care depends on high functioning, interprofessional teams which utilize evidence-based practice to achieve quality outcomes. There is, however, a crisis in primary care. By 2020 there will be a shortage of as many as 45,000 primary care physicians.
The 2008 Institute of Medicine (IOM) report, Retooling for an Aging America: Building the Healthcare Workforce 2, underscores that our current healthcare system is ill-equipped to deal with this pending crisis. The report lays out
the demographics, health status, and long-term needs of this population, and the challenges in caring for the aging population. It recommends that all healthcare professionals be trained to care for older adults and that there needs to be increased recruitment and retention of geriatric specialists in all fields of practice.
Geriatricians can address the healthcare concerns of older adults, but there simply are not enough physicians prepared as geriatricians to meet this need. Recent workforce projections estimate that 150,000 physicians will be needed in the next 10-15 years to meet the goal of providing primary care access to all U.S. citizens.3 This workforce projection will be particularly acute for primary care physicians since only 2% of all new physicians chose primary care for their career path in 2008.4 NPs provide high quality and cost effective care, produce outcomes comparable to physicians, and provide care that covers 80-90 percent of the services physicians provide.5,6
In 2010 President Obama addressed the House of Delegates at the American Nurses Association to announce a number of investments to expand the primary care workforce. It included increasing funding for nurse/NP-run clinics to “work well for nurses and doctors, and to improve the quality of care for patients”.7 Nurses have been providing care to vulnerable and medically underserved populations through Nurse Managed Health Clinics since the 1960’s. Many of these sites are Federally Qualified Health Centers (FQHCs), which have traditionally served families with children, and they have recently been certified as medical homes.
It is time for sweeping regulation to allow NPs to practice independently and provide these essential services to the growing number of people needing primary care. In order to maintain older adults at their highest level of function, manage chronic disease and keep them safe in the community, there needs to be adequate access to quality primary care. Nurse Practitioners can provide this care and must be allowed to be full partners practicing independently in team based primary care.
1. Administration on Aging. A Profile of Older Americans: 2011. U.S. Department of Health and Human Services. 2011. (Online accessed March 18, 2012)
2. Institute of Medicine. Retooling for an Aging America, Rebuilding the Healthcare Workforce. Washington, DC: National Academy Press. 2008.
3. Association of American Medical Colleges. The Complexities of Physician Supply and Demand: Projections Through 2025. 2008.
4. Hauer, K. et al. Factors Associated With Medical Students’ Career Choices Regarding Internal Medicine. Journal of the American Medical Association. 2008. 300(10):1154-1164
5. Mezey,M. et al. Experts recommend strategies for strengthening the use of advanced practice nurses in nursing homes. Journal of the American Geriatrics Society. 2005. 53(10):1790-1797.
6. Lenz,E. et al. Primary care outcomes in patients treated by nurse practitioners or physicians: Two-year follow-up. Medical Care research and review. 2004. 61(3):332-351.
7. White House. Remarks by the President to the American Nurses Association. 2010. http:/whitehouse.gov/the -press-office/remarks-president-a-joint-session-congress-health-care.
Everyone involved in care of older adults and their families should be sure to read the lead article on dementia on the front page of yesterday’s NY Times (April 4, 2013). While not a surprise to many of us who have worked in geriatrics, predictions for the number of people who have dementia now, and will develop dementia by 2040 are staggering. Of great importance in the article are the emotional and financial consequences for the family members who face providing long term care for their loved ones with dementia.
A priority of anyone providing care to older patients is to keep them at optimum physical and mental function. Depression is one of the most under recognized and under treated conditions in older adults. Keeping the older adult’s attitude and frame of reference positive can prolong the quality of healthy aging. I came across the following story which I thought said all of this so well.
A 92-year-old, petite, well-poised and proud man, who is fully dressed each morning by eight o’clock, with his hair fashionably combed and shaved perfectly, even though he is legally blind, moved to a nursing home today. His wife of 70 years recently passed away, making the move necessary. After many hours of waiting patiently in the lobby of the nursing home, he smiled sweetly when told his room was ready.
As he maneuvered his walker to the elevator, I provided a visual description of his tiny room, including the eyelet sheets that had been hung on his window. “I love it,” he stated with the enthusiasm of an eight-year-old having just been presented with a new puppy.
Mr. Jones, you haven’t seen the room, “Just wait”.
‘That doesn’t have anything to do with it,’ he replied. “Happiness is something you decide on ahead of time. Whether I like my room or not doesn’t depend on how the furniture is arranged … it’s how I arrange my mind. I already decided to love it.”
“It’s a decision I make every morning when I wake up. I have a choice; I can spend the day in bed recounting the difficulty I have with the parts of my body that no longer work, or get out of bed and be thankful for the ones that do. Each day is a gift, and as long as my eyes open, I’ll focus on the new day and all the happy memories I’ve stored away just for this time in my life.”
Old age is like a bank account. You withdraw from what you’ve put in. So, my advice to you would be to deposit a lot of happiness in the bank account of memories!
‘Remember the five simple rules to be happy:
1. Free your heart from hatred.
2. Free your mind from worries.
3. Live simply.
4. Give more.
5. Expect less.
When Alice* was 35 years old, her children contracted mumps. She soon got the virus as well, and it led to a profound hearing loss in her right ear. For 47 years, she relied solely on her left ear for hearing. As she approached her 80th birthday, age-related changes affected the hearing in her “good ear,” so she eventually got a hearing aid for that side. Yet the combination of one hearing aid and one essentially nonfunctional ear was not adequate for Alice’s busy social life and full-time academic career. So at 82 years of age, she received a cochlear implant.
Cochlear implants are devices that electrically stimulate the auditory nerve, allowing the individual to perceive sound. They have an inner portion which is surgically placed inside the head, and an external portion which usually sits behind the ear. The external portion looks a lot like a behind-the-ear hearing aid. Visit the National Institutes of Health to learn more about how cochlear implants work.
Some people have few problems adjusting to their cochlear implant(s). For those who struggle, I’m told it can be a confusing and frustrating experience. It is a time-consuming process, as people need to re-train their brains to identify and comprehend important sounds, and to “ignore” insignificant sounds. For example, Alice was unable to differentiate environmental sounds from one another, making refrigerators, lawn mowers, and speech sound similar to one another for the first few weeks. But Alice was exceptionally motivated. She would take off her hearing aid when she was home, to force herself to use the cochlear implant side. After a few months, she was able to fully comprehend speech with that side. And now that she had access to higher frequencies, she could hear her grandson’s little voice for the first time.
It is difficult to explain how inspiring this story is to me. At 82 years of age, Alice not only underwent elective surgery, she also managed to re-train the way her brain had been working for the past 47 years. Alice accepted the age-related changes happening to her body and said, now how can I improve my life? To me, that is the true definition of healthy aging.
For more information on hearing loss and older adults, visit the National Institute on Deafness and Other Communication Disorders.
Julianne Remus is a Research Assistant at the Hartford Institute for Geriatric Nursing and a Masters Candidate in Communicative Sciences & Disorders at New York University.
*Names have been changed
By Dr. Tara Cortes, Executive Director of the Hartford Institute for Geriatric Nursing
In order to meet the growing demand of an aging population, control the cost of care, increase the quality of services delivered and improve the quality of life we need to prepare a workforce who has some knowledge in geriatrics. Education and healthcare are intertwined in such a way that investment in one results in growth and development in both. The time is now. We need to focus and invest in developing a workforce of both professionals and non-professionals who can meet this demand across the continuum of health care.
We have only about 7,000 prepared geriatricians and this number is falling with the trend predicting less that 5,000 by 2040. Physicians are just not going into geriatric practice. Only about 5,700 of the 155,000 Nurse Practitioners are prepared in geriatrics. Hopefully the new Adult Gerontological Advance Nurse master’s preparation will push more advanced practice nurses into the field with some knowledge of care for older people. There are ~55,000 social workers prepared in geriatrics. Over the next 30 years that number needs to double. Other professions which need to increase the workforce prepared in geriatrics are physical therapy, occupational therapy, pharmacy, and psychiatry. In addition, the demand for direct care workers – home health aides, personal care aides, and certified nursing aides is estimated to be at 5 million by 2020 – up 2 million from today. And finally it is estimated that there are about 43 million unpaid family caregivers providing care to someone 55 years or older and this number is growing. These caregivers are at risk for not only physical and emotional problems, but also financial and family issues.
This grim picture of an underprepared workforce to care for a population 65 years and older which is growing by 10,000 people a day calls us to action. We must continue to invest in educating students, practicing professionals, and community based workers and resources to understand the uniqueness of aging. We must also stand up for proposals that protect the care of this vulnerable aging population. With quality and coordinated care from a diverse workforce prepared to care for older adults we can control costs and ensure that our older Americans age with dignity.