“Aging Americans are the elephant inside the demographic pyramid.”
There are too many old people in America and not enough geriatricians to care for them all, said leading elder care professionals at the Association of Health Care Journalists Conference in Boston, MA.
The rift between the growing elder population and the declining number of physicians trained in geriatrics will only grow larger in the coming years, said Sharon Levine, M.D., a professor in the Department of Medicine Geriatrics at Boston University School of Medicine.
“Aging Americans are the elephant inside the demographic pyramid,” said Levine.
With the population of those 85 and older increasing at four times the rate of other Americans, an estimated 30,000 geriatricians will be needed by the year 2030. Levine explained that this target can be hit only if 1,200 medical students enter geriatric medicine fellowship programs each year for the next two decades.
However, such entrance levels are far from likely. Only 75 medical school graduates entered geriatric fellowships in 2010, according the The American Geriatrics Society. That number was down from 1,120 in 2005.
Levine insists that dwindling interest in geriatrics is due, in large part, to increasing medical school debt and significantly less earning potential. In 2010, a geriatrician’s median salary was $183,523. That was almost six thousand dollars less than the average salary of a family physician, and close to $22,000 less than the average salary of a general internist. Geriatricians must train at least one year longer than their colleagues in primary care.
Currently, there are currently 3.8 geriatricians for every 10,000 older Americans. Elderly living in the Sun Belt and New England have the more geriatricians per capita in their regions than elderly patients in other parts of the country.
Life Matters Media co-founder Mary F. Mulcahy, M.D., published her research about the racial and economic inequalities in the U.S. health care system for PBS. She continues to spread the message of advance care planning.
“Racial disparities and inequities in American healthcare are evident in daily life, but regrettably they are also prominent in death. In these final days of Black History Month, it is imperative to reflect on the final days of all African-Americans and the choices they have within our health care system. These are the choices they aren’t taking, and the phenomenon serves as a means of further disenfranchisement from the medical community at large.
“The National Center for Health Statistics reports that African-Americans in home health care and nursing homes are half as likely as whites to have an advance directive, such as a living will or a do-not-resuscitate (DNR) order. This disparity leaves African-Americans at risk for unwanted medical procedures, unnecessary pain and family strife.”
Nursing homes continue to be the most intensive and expensive form of long-term care, which often includes 24-hour medical supervision, the AP reports. The average cost of a semi-private room in 2011 was $81,000, according to a survey by MetLife. A private room can cost more than $90,000, as the average daily rate for a private room in a nursing home rose more than 4 percent in 2011.
Most seniors will not require extended nursing home care. However, Medicare does not cover less intensive care options, such as in-home help with meals and chores.
“The issue is that these are long-term costs and almost all of it comes out of pocket,” said John Migliaccio, director of research for Metlife’s Mature Market Institute. “It’s important to have some idea about what it will cost dad, mom or your husband to get the care they need.” Only some 5 percent of adults have long-term care insurance to help pay for these services. Some policies can cost $8,000 a year.
“Advance care planning is a dynamic process that evolves over time as a person’s health goes from well, to ill, to ultimately terminal,” LMM co-founder Mary F. Mulcahy, M.D., wrote for The Huffington Post. “Medical advances have led to few cures of illness, have prolonged the experience of living with chronic illness and have prolonged the process of dying.”
A panel of health care and financial experts provided end of life planning advice to a packed room of seniors at The Breakers at Edgewater Beach Wednesday. The event served adult children caring for aging parents and seniors beginning to make end of life plans.
Dr. Leslie K. Eldridge, the executive director of the senior living facility, hosted the event and questioned the panel, which included Julie Fohrman from North Shore Geriatric Care Management and Kathy Sprau of Sprau Advocate Group.
Most questions pertained to changes the Affordable Care Act will usher in during 2014 and Medicare benefits. Eldridge acknowledged that she hears a story of someone working in crisis mode every day due to lack of planning and understanding of current policies.
“This is a topic that is on everyone’s mind these days,” said Sprau. ”There are so many questions and I think it is incredibly difficult to find information. You have the Internet and I don’t know if people know to go there.”
The audience was clearly engaged and would have asked questions for hours if allowed. The Breakers is planning another event in the coming months.
Victor Schwartz, 86, said he thought the event was very informative. “People always have these questions about how they protect their grandmother, their mother or someone that they have very close ties with.”
The National Institute of Medicine will soon convene experts to review federal policies and hospital practices to aid improvements in care for dying patients and their families.
“During the last century and more, death has evolved from a common family event centered in the home to a medical event occurring in a distant medical facility overseen by trained experts and administrators,” the Institute reported when announcing the study, “Transforming End-of-Life Care.”
The committee’s findings will lead to a report on the current state of end of life care in the U.S. The far-reaching study will address delivery of medical care and support, doctor-patient communication, advance care planning and financial reimbursements. The committee will focus especially on demographic and cultural changes.
The committee will also review the Institute’s 1997 report, “Approaching Death: Improving Care at the End of Life,” which sought to increase understandings of care and the need for improvement.
Silicon Valley’s MercuryNews reports that recommendations from the private nonprofit arm of the National Academy of Sciences often make their way into laws and federal agency policies.
First meetings will occur February 20 and 21, 2013, at the National Academy of Sciences building. The committee is chaired by Dr. Philip A. Pizzo, from the Stanford University School of Medicine, and Dr. David M. Walker, of the Comeback America Initiative.
As more than 76 million baby boomers approach retirement age, some have had to become caregivers for parents and sidestep vacation and retirement plans. Advances in medical technology have allowed the elderly to live longer than ever, so now many boomers must adjust.
According to data from the National Alliance for Caregiving, some 66 million Americans are unpaid family caregivers. Two-thirds of those caregivers are female, and most are around 48-years-old. Fourteen percent simultaneously care for their own child.
In 2009, AARP estimated the economic value of their unpaid contributions was approximately $450 billion, as many provide care for more than 40 hours a week.
CNN recently published a feature on adults with rerouted lives due to caregiving responsibilities. Karen Jones, 61, a retiree from Virginia Beach, Virginia, is one such individual. ”I never thought I would be doing this,” Jones said. She takes care of her parents, both in their 90s, who live down the street.
“Travel plans now include very expensive trip insurance so I can rush back to take care of them,” she said. “An extended trip to Scotland to visit my husband’s relatives has been put off twice because it’s hard to leave my parents for a month at a time.”
She has no siblings nearby and has had a strained relationship with her parents. Jones said she’s cleaning up her karma and “putting old hurts to right.”
Megan K. McAvoyexplained in a new article forThe Huffington Post that caring for parents is “a labor of love,” because women must carve out time between getting kids to sports practice, succeeding career-wise and putting dinner on the table.
Some women experience loneliness and isolation caused by the emotions involved in caring for a parent. Seeing a parent ingest high doses of medications, making decisions with siblings, working and financial costs take a serious toll on the caregiver.
According to McAvoy: “The compound physical and emotional impact of caregiving over a lifetime results in a large percentage of women who need care themselves. Yet, nearly half of women ages 75 or older are living alone, compared to less than one-quarter of men. The challenge becomes finding the resources to get care for yourself after you have given it for so long.”
McAvoy, a financial representative, advises families to have early conversations about caregiving and long-term care insurance, although such insurance won’t replace loved ones.
So why do so many children choose to become caregivers? Ellen Breslau, editor-in-chief and senior vice president of Grandparents.com, insiststhat many children take upon the caregiving role because it offers peace of mind. ”They will naturally feel more comfortable with you than with non-family members, which can impact the caregiving and their well-being.”
“It is also a time to give back to your parents in a way that is unique,” she told CNN. “They raised you and cared for you, and now the cycle has come full circle to a point where you can do the same for them.”
Physicians and nurses at Boston medical centers cited a lack of training as the main reason why they rarely provided spiritual care for their terminally ill cancer patients, even though most patients considered it important to their end of life care.
A new study published in the Journal of Clinical Oncologyreports that out of the 204 physicians from four medical centers who participated in the three year study, just 24 percent reported providing spiritual care. Among the 118 nurses, only 31 percent reported providing care.
“I was quite surprised that it was really just lack of training that dominated the reasons why,” senior author Dr. Tracy Balboni, an oncologist at the Dana-Farber Cancer Institute in Boston and researcher of spirituality, told Reuters Health.
Spiritual care may range from prayer with a physician or nurse to recommendations for a hospital chaplain.
Spiritual care “is considered by patients to be an important aspect of end of life care and is also associated with key patient outcomes, including patient quality of life, satisfaction with hospital care, increased hospice use, decreased aggressive medical interventions, and medical costs,” Balboni said.
Even though current palliative care guidelines encourage medical practitioners to mind religious and spiritual needs that arise during a patient’s end of life care, most medical practitioners remain silent. Ninety-four percent of patients with advanced cancer had never received any form of spiritual care from physicians.
Spiritual care may become more common in the future, however. “There was a time when nurses and physicians may have said, ‘That’s not my job,’ but I think the tides are changing,” said palliative care researcher Betty Ferrell of City of Hope, a cancer research center in Duarte, California.
“I think we are realizing we can no longer ignore this aspect of care,” Ferrell told Reuters. She’sa professor of nursing who was not involved in the new study.
Study researchers suggest more spiritual care training for physicians and nurses. The study found only 13 percent of doctors and nurses reported having such training. However, those who received training were almost 11 times more likely to provide spiritual care to their patients than those who had not.
Cancer patients who talk with their physicians about how they want to die are less likely to opt for aggressive end of life treatments in the last two weeks of life, according to a new study published in the Journal of Clinical Oncology. Instead, these patients end life more comfortably at home or in hospice care, and as a result spend much less on hospital care.
“Aggressive care at the end of life for individual patients isn’t necessarily bad, it’s just that most patients who recognize they’re dying don’t want to receive that kind of care,” said Dr. Jennifer Mack, lead author of “Associations Between End-of-Life Discussion Characteristics and Care Received Near Death: A Prospective Cohort Study.”
The researchers studied more than 1,200 patients with stage IV lung or colorectal cancer who survived at least one month from the time of diagnosis, but died during the 15-month study period. Using interviews of the patients and/or their caregivers and a comprehensive medical record review, the researchers determined if and when the patients had discussions with their doctors about end of life.
Researchers found that 88 percent had end of life discussions, but more than one-third of those took place less than a month before the patient died. Those patients who had end of life discussions documented in the medical record but did not recall them in the patient or surrogate interviews were more likely to have chemotherapy within the last 14 days of life, or acute intensive or hospital care within the last 30 days of life.
Patients who reported having the discussions with doctors were almost seven times more likely to end up in hospice than those who didn’t have those talks. Hospice focuses on comfort care and pain management for terminal patients, instead of treatment.
“A lot of patients don’t want (aggressive treatment), but they don’t recognize that they’re dying or that this is relevant for them,” said Dr. Camilla Zimmermann, head of the palliative care program at University Health Network in Toronto. She wasn’t involved in the study.
She told Reuters: “The earlier you discuss these things, the more options you have. If you wait too long, you end up having these discussions with someone you don’t know, that you just met, in an inpatient setting,” instead of with your primary doctor.
According to Mack, ”If we start these conversations early, then patients have some time to process this information, to think about what’s important to them (and) to talk with their families about that.”
In 2010, Medicare paid $55 billion for doctor and hospital bills during the last two months of patients’ lives- more than the budget for the Department of Homeland Security, according to CBS News. Twenty to 30 percent of those medical expenses may have had no meaningful impact on the patients’ health.
Reuters is reporting data from the Dartmouth Atlas of Health Care, which found that 32 percent of total Medicare spending goes to caring for sick patients in their last two years of life.
National guidelines recommend patient-physician talks begin soon after a terminal cancer diagnosis. Researchers found that physicians initiated end of life discussions an average 33 days before death.
As the nation’s large baby boomer population continues to age, some childless seniors are wondering who will take care of them at the end of life. The Sacramento Bee’sAnita Creamer highlights such individuals in a new feature focusing on the struggles childless seniors face in planning for their future.
Creamer spoke with Karen Spencer, 60, who didn’t marry until she was in her late forties. Like more than 20 percent of her generation’s women, she’s one of the 15 million boomers who never had children.
“I have nieces and nephews who would show up, but I don’t want them to feel like it’s necessary to take care of me,” said Spencer who lives in Granite Bay, California with her 68 year-old husband Mike Twigg. “Either I go into assisted living, or I stay in my home with somebody taking care of me. That would be my intention with the long-term care insurance.”
Although she has some savings and a long-term care insurance policy, she worries about the non-monetary situations that could arise, such as the need for home repairs, hospital advocacy and family visits.
“These are issues that we’ll have to grapple with as a country,” said Lynn Feinberg, an AARP policy expert on caregiving. “When somebody needs long-term care, they typically turn to their children.”
There is an increasing reliance on fewer family members to take care of older relatives. ”The expectation on a nephew to care for his elderly aunt as well as his own parents and children presents a real challenge,” said Feinberg.
In 2000, there were more than 35 million Americans 65 and older. By 2030, there will be 72 million.
Creamer describes this issue as a women’s issue, because two-thirds of the 11 million boomers who’ve already lost their spouses are female. Experts aren’t quite sure what will happen to frail seniors without children on whom to rely.
“Even so, both baby boomers and their elders indulge in a rather startling lack of planning for their care needs in old age,” Creamer writes. A recent Centers for Disease Control study shows that only 37 percent of older adults who aren’t in nursing homes or hospice care – and only 15 percent of all adults – have completed legal proxies to specify who can make decisions on their behalf.
Dr. Larry Weiss, founder of Reno’s Center for Healthy Aging, and Feinberg suggest a “Golden Girls” scenario becoming increasingly popular. Small group of seniors are starting to live together, sharing expenses and caring for one another.
Last year, The New York Times’ Paula Span wrote about childless seniors and their quality of life. She interviewed Dr. Merril Silverstein, a gerontologist at the University of Southern California, who found that people at least 75 years old with trouble walking across a room weren’t receiving less care than those who were parents. They also didn’t score lower on measures of psychological well-being.
“The popular idea was that without children, you’d be in a whole heap of trouble,” Dr. Silverstein said. “But there’s not a whole lot of empirical evidence showing that.”
Seniors can stay in their homes
Henry Cisneros and Jane Hickie, of the Stanford Center on Longevity, offer some advice on how seniors could stay in their homes if necessary changes happen within them.
American housing design standards have undergone few changes since 1964, Hickie said last month at the Northwestern University Buehler Center on Aging. Home construction then was based on measurements of able-bodied men who were in military service during World War II. “The problem is that these design standards don’t fit a population that is shorter, less flexible, fatter, has less muscle mass and is just not as strong as younger people who were the basis for those standards.”
Contrasting colored lining on steps and furniture, better lighting and guide lights can help seniors continue to live in their own homes.
Spencer likes the idea of staying in her home and being surrounded by friends. Spencer and a life-long friend talk about staying in the same neighborhood and eventually traveling together.
Home remodeling can improve eldercare, said former Secretary of Housing and Urban Development Henry Cisneros at a recent lecture at Northwestern Memorial Hospital. The event was sponsored by Northwestern University’s Buehler Center on Aging, Health and Society.
Both Cisneros and Jane Hickie, of the Stanford Center on Longevity, insisted that more seniors can stay in their homes if necessary changes happen within them.
With such a large number of Americans moving to advanced age, Cisneros said, the issue of where they will live is taking on increasing urgency. “While there’s a tendency to think about aging as an eventual destination to a nursing home, in fact, only about four percent of Americans ever end up in an institutional setting like that,” Cisneros said. Most seniors live relatively independently, in their homes or some apartment-like setting.
In 2000, there were more than 35 million Americans 65 and older. Cisneros calculated that in 2030, there will be 72 million. By 2050, there will be 89 million, because life expectancy is increasing.
Contrasting colored lining on steps and furniture, better lighting and guide lights can help seniors living in their own homes, Cisneros said. “A lot of this goes in the framework of disability structures and universal design,” he explained of the changes, which he called “cost-effective.”
“Older Americans are suburban Americans,” said Hickie. “As one ages there is a greater tendency to live alone and frailty does increase.” Therefore, Hickie recommended that housing designs should change to reflect seniors’ needs.
American housing design standards have undergone few changes since 1964, Hickie said, when construction was based on measurements of able-bodied men who were in military service during World War II. “The problem is that these design standards don’t fit a population that is shorter, less flexible, fatter, has less muscle mass and is just not as strong as younger people who were the basis for those standards.”
Independent for Life: Homes and Neighborhoods for an Aging America is available now.