Recent Advances in Geriatric Medicine: Volume 2: An Interdisciplinary Approach to Geriatric Medicine

The Basis of Geriatric Medicine

HISTORY OF GERIATRIC MEDICINE

Due to a relatively small population of older adults throughout history geriatrics was not particularly studied in detail. It was not until the 20th century that breakthroughs in medicine and advances in health, occupational safety, and standards of living allowed for the explosive increase of the older adult population. In 1909, the word geriatrics was first coined by Ignatz Nascher. In 1909, the average life expectancy in the U.S. was 52.2 years. It was nearly 25 years after Nascher coined the word geriatrics that the average life expectancy in the U.S. crossed over 60 years of age.

In the 1970s, greater interest in geriatrics bloomed. It became a focus for researchers and clinicians. In 1974, the National Institute on Aging was founded (incidentally the average U.S. life expectancy in 1974 was 72.1 years of age). In an interesting comparison, the field of geriatrics blossomed in the U.K. soon after the end of WWII (substantially earlier than the U.S.). However, the increase in life expectancy in the U.K. was remarkably similar to the increase in life

expectancy in the U.S. throughout the 20th century. It can be speculated that the U.K. was proactive in anticipating the needs of the older adult population. Conversely, it could be assumed that the U.S. was slower to respond to the increasing older adult population.

In the 1980s, fellowships for physicians in geriatrics increased dramatically. The field of psychology saw a renewed interest in aging and brain function/behavior. The psychological community avoid the field of aging due to the negative implications of aging research that stemmed from G. Stanly Hall’s 1922 book Senescence. These changes in medicine and psychology reflect advances in geriatric nursing in the previous decades. During the 1960s and 70s, nursing formalized geriatric nursing and joined the forefront of geriatrics. In the 21st century, the rise in the population of older adults has made geriatrics a factor in all branches of medicine and clinical practice. In fact, many clinicians find that the majority of patients are over the age of 65. Now is the time of the geriatrician.

BASIS OF AGING

Currently, many theories exist to explain aging and the disorders common to aging. Many theories are specific to one particular aspect of aging. There are some pan-aging theories. In the subsequent chapters there will be more elaborate discussions of such theories. It becomes more imperative that different clinicians and researchers have an understanding of how recent advances influence new theory-based approaches to treatment.

For example, the Third Congress on Biogerontology [1] identified seven different points and prediction upon the soma theory and its role in modern geriatrics:

Ageing results from the gradual accumulation of damage in somatic cells and tissues and accordingly longevity is regulated by the efficacy of somatic maintenance and repair. This is now confirmed by a wide range of experimental studies, including comparative studies on repair capacity and stress resistance.

Germline immortality may be secured by enhanced mechanisms for maintenance and repair of germ cells, a strong example of this being the action of telomerase. Stem cells occupy an interesting position between germ- line and terminally differentiated somatic cells, and there is interesting data beginning to accumulate on intrinsic ageing of tissue stem cells, such as those of intestinal epithelium.

Trade-offs are predicted to exist between key life-history traits such as fertility and longevity, a prediction shared with the pleiotropy theory developed by George Williams. There are many documented instances where such trade-offs have been observed but there are also some intriguing examples where the existence of trade- offs is yet to be demonstrated.

Since the central mechanism of ageing is predicted to be the accumulation of random molecular damage, a key prediction is that the ageing process is inherently stochastic. There is growing evidence to support this and it appears likely that further studies on the role of intrinsic chance variations in ageing will be necessary in order to understand the variability of the senescent phenotype.

Multiple, complex systems contribute to the underlying causes of ageing. This requires the development and application of new ‘systems biology’ methods, including in silico models, in order to address the potential synergism between different candidate mechanisms.

The theory predicts that ageing results from evolutionary optimisation of the life history, subject to a number of intrinsic and extrinsic constraints imposed by ecological and physiological factors. This provides a series of interesting problems in terms of understanding how optimality principles have helped to shape organisms’ life cycles.

The theory suggests that there may be significant opportunity for organisms to have evolved plastic responses to allow them to cope with variable environmental conditions. A good example is the calorie-restriction response in rodents, which the disposable soma theory suggests might have its origins in evolving a plastic response to periods of interrupted food supply.

FUTURE DIRECTIONS

One new and rather germane topic currently in discussion is just who is a geriatrician [2]? This discussion originated as the global population of older adults continued to expand. Now clinicians must cope with a diverse array of older adults as well as conditions and factors. Questions to be asked are what type of population should be the focus: community-dwelling or assisted-living? Young-old or old-old? Chronological age or functional age? Clearly this is not a debate that can be settled in one session let alone one book. The goal of this book is to discuss recent advances in the treatment and interactions with the geriatric population.

As the geriatric population becomes diverse so do the people who work with and study older adults. This book attempts to elucidate on the myriad of different disciplines currently involved in geriatrics. In this book physicians, academics, scientists as well as speech-language pathologists, physical therapists, and the cornerstone of care, nursing (among other disciplines), address the advances and new areas of interest in these broad fields. This will provide the reader with a greater appreciation of the interdisciplinary field of geriatric medicine.

CONFLICT OF INTEREST

The author confirms that author has no conflict of interest to declare for this publication.

ACKNOWLEDGEMENTS

Declared none.

REFERENCES

Health and Economic Consequences of Aging in US

INTRODUCTION

As individuals age, decline in functional status leads to an increasing need for personal care assistance with activities of daily living (ADLs) required to take care of oneself, such as bathing, toileting, eating, and dressing and instrumental activities of daily living (IADLs) such as cooking, grocery shopping, managing finances or medication. One recent study shows that after accounting for changes in sociocultural, economic and environmental factors between 1982 and 2009, successive cohorts of older adults are becoming more disabled over time [2]. It has been projected that by 2030 there will be over 21 million elderly limited in their activities and need assistance for a progressively long period of time.

In the U.S., the vast majority of personal care that allows older people to live in their communities is provided by family members as unpaid care. The combined effects of increasing older share of the population and greater life expectancy, the demand for long-term care services provided by unpaid caregivers will continue to increase. Due to private insurance policies in the U.S. professional caregiving is

not always provided. However, the traditional supply of unpaid caregivers is shrinking due to the gap between population growth rates of the elderly and people aged 25 to 54, particularly women who predominantly provide personal care. Beginning from 2025, the number of people aged 65 and over will exceed the number of women aged 25-54 (Fig. 1). Due to increasing participation of women in the workforce (except long-term care workforce), marriage and reproductive trends (such as smaller family sizes) are restricting women’s availability to care for family members. Outside of the U.S. these demographic changes are similar to many European countries. All these social and demographics changes will pose significant challenges to the elderly, policymakers, healthcare providers and planners to meet the care needs of older Americans and improve the lives of the family members who care for them.

Fig. (1))

Source: U.S. Census Bureau, Population Division, National Population Projections, Summary Files, "Total Population by Age and Sex, December, 2014.

The aging in general, and long-term care services in particular, will represent an overwhelming economic burden to the society and the healthcare system, including the public health system such as Medicare, Medicaid and other government sponsored programs. The other aspects of economic burden due to population aging include increase in Social Security payments, out-of-pocket medical care expenditures and cost for supplemental coverage for Medicare beneficiaries. The increasing number of people on Medicare and the aging of the Medicare population are expected to raise both the total and per capita Medicare spending. The current Medicare spending of $540 billion is expected to rise to $1 trillion by 2024. Since 2005, the rate of Medicare spending has been increased faster than the GDP in areas including skilled nursing facility (SNF), outpatient hospital, hospice, and lap services. This increased Medicare spending is contributed by the increase in Medicare population from 20 million in 1970 to 80 million in 2030.

The current study assesses the health and economic dimensions of the population aging in the U.S. The first part of this chapter discusses the logic that suggests the potential challenges for families and healthcare systems to meet the care needs of older Americans and the second part reviews the economic burden of aging in general and long-term care and Social security benefits in particular.

Formal versus Informal Care

In contrast to acute care, the vast majority (75%) of long-term care is unpaid or informal assistance provided by family and friends. As the older share of population is growing and people are living longer with chronic disabling conditions, particularly dementia, long-term care needs will become more challenging for families. Family caregivers are essentially the backbone of the delivery of long-term care needs of the elderly in the U.S. In general, adult children constitute the largest share of caregivers (42%) followed by spouse (25%), who provide assistance on personal care (e.g. bathing, toileting, dressing, and eating) and other instrumental activities (e.g. transportation for doctor appointment, bill payment, cooking, etc.). Although elderly who use informal care also use formal care (e.g. paid care from paraprofessional workers or nursing assistants) to supplement care needs. The following sections will focus on the availability and constraints of informal caregivers as long-term care is predominantly provided by the informal caregivers.

Availability of Informal Caregivers and Constraints

Informal caregivers of older adults are predominantly women. Informal caregivers and family caregivers are used to refer to individuals such as family members, partners, friends and adult child who provide care to older adults who have difficulty in performing activities of daily living in home and community setting. Estimates of number of informal caregivers in the U.S. vary depending on the definitions used for caregivers and care recipients as well as the types of care provided. For example, there are about 66 million informal and family caregivers who provide care to an elderly who is ill and disabled in the U.S. and about 27 million family caregivers provide personal assistance to adults with a disability or chronic illness [3]. Due to demographic transition and changes in socioeconomic circumstances, there will be a widening gap between care needs of the elderly and the availability of informal or family caregivers who can provide that care. This raises a concern for growing unmet care needs, a heavier burden on caregivers and increased demand for paid care. The combined effects of delayed childbearing, longer life expectancy, lesser proportion of middle-aged women who provide care contribute to unmet care needs and increased burden to the family caregivers. Furthermore, most of these middle-aged women in caregiving age are being "sandwiched’ in their roles towards their children and aging parents. Wiemer and Beanchi [4] found that there was a 20% increase in the share of women who provide care to their children and aging parents between 1988 and 2007. Various other factors such as divorce, low fertility, and higher life expectancy will contribute to the fact that an increasing proportion of older adults aged 75 and over will have to live without an adult child or spouse [5].

Dual Pressures of Informal Caregiving and Employment

Caregiving in the U.S., 2015 highlights those workers with caregiving responsibilities for an adult with a disability or illness make up a substantial proportion of the labor force. About 60% of family caregivers caring for an adult also work for a paid job during their caregiving experience in 2014-an estimate of 24 million working caregivers of adults. These caregivers are more likely to be female (66%) than male (55%). About 63% of them were caring for an individuals aged 65 or older. In addition to their full-time job, on average, caregivers provide 34 hours per week on caregiving and many of them provide assistance to individuals with higher care needs. For example, about 28% of caregivers reported helping their care recipients with three or more activities of daily living (e.g. eating, bathing, dressing etc.) and more than half (about 54%) reported performing skilled nursing care (e.g. medication management). Caregivers in the age groups of 20 to 34 are more likely (73%) to engage in full-time (40 hours per week) employment compared to caregivers in any other age group which indicates that these young caregivers are facing the dual challenges of keeping their jobs and caregiving for an ill or aging family members. Although less prevalent, about 17% percent of caregivers are self-employed to better meet the care needs and work flexibility. Self-employed caregivers are more likely to be male, live with care recipients and report working fewer hours compared to caregivers work for an employer. The Employment pattern indicate that about 68% of Hispanic caregivers are in labor force compared with 60% of African American and 56% of White.

Providing uncompensated care for a family member while working full-time can be stressful. More than one-third of employed caregivers view that their caregiving situation is stressful emotionally and the lack of affordable supports services make it difficult to continue caring family members in the home or community setting. Balancing the dual responsibilities becomes particularly challenging for caregivers who lack the level of support services needed and unable to pay for the paid care. It is also common that caregivers need to adjust their work schedule (especially those involve in intensive caregiving) and take time off to meet the care needs of their care recipients. Furthermore, caregivers those who are employed full-time and could not afford to hire paid help, may have to leave the labor-force entirely and have to face financial stress due to loss of earnings and retirement benefits. Evidence suggests that higher-hours caregivers (e.g. providing 21 hours per week) are more likely (29%) to leave the labor market compared to caregivers (7%) who provide less than 20 hours per week. Some caregivers also report the experience of employment discrimination due to caregiving responsibilities. Typically caregiving for disabled elderly include assistance provided with limitations in activities of daily living (ADL) such as bathing, eating, dressing, toileting etc. and instrumental activities of daily living (IADLs) such as medication management, grocery shopping, cooking, transportation etc. (Table 1).

Table 1 Examples of Activities of Daily Living (ADL) and Instrumental Activities of Daily Living (IADL).

Caregiving With and Without Dementia

Caregiving experience is commonly perceived as a chronic stressor and caregivers most often experience negative psychological, behavioral and psychosocial effects which impact their quality of lives and general health [6]. For example, a recent study based on a nationally representative data, found that caregivers who provide care for 14 hours per week or more for more than two years are twice more likely to develop cardiovascular risk of cardiovascular disease compared to demographically matched adults who were not caregivers [7]. Another study found that becoming a caregiver can also increase the risk of developing depression among caregivers who provide care at least 14 hours per week or more. In 2013, about 40 million family caregivers provided 37 billion hours of care