Just a few generations ago, a much smaller percentage of the US population lived into advanced old age and even fewer lived long with serious disabilities and illnesses. Those who lived with serious disabilities in their advanced years usually lived with multigenerational families providing support. Now, most Americans will live beyond age 65, and most will do well for a time and then live for some years with declining capabilities. The number of older adults living with frailty and disability will nearly double between 2012 and 2035. Eventually, 70 percent will become dependent upon others for daily tasks for an average of about two years. Additionally, 46 percent of women older than age 75 live alone, with no live-in help. At this critical moment, public health perspectives can help to describe this substantial threat as it is arising and to propose and implement strategies to prevent or mitigate the suffering. Improvement activities need population-based data, public-spirited consideration of options and priorities, and commitment to the public’s well-being.
To be sure, most Americans will be in good health and able to live independently without assistance as they pass their 65th birthday. The prevention-oriented initiatives of the public health sector—including those that target tobacco use and promote healthful food consumption and routine physical activity—will continue to help prolong their well-being.
But most older adults will eventually have substantial health challenges and progressive disabilities that will require assistance and adapted environments. Yet, the US has done astonishingly little to prepare for older adults’ needs in their last years of life. A recent simulation showed that, by 2029, most middle-class people who are age 65 and older will be unable to afford the housing and health care they need. In many states, the large number of people who rely on Social Security income will make too much money to be eligible for Medicaid but too little to pay for such essentials as housing, food, and personal care. Already, wait times for senior home-delivered food service are often more than six months; and wait times for affordable housing often go beyond the expected lifespan for disabled older adults.
The Important Roles Of Public Health
The well-being of older adults with significant disabilities and frailty depends less upon the existing public health programs that focus on changing individual behaviors and more upon improving the conditions within the community—housing stock, personal care workforce, flexibility of employers regarding caregiving, transportation arrangements, availability of senior food delivery, and so on. Those in the health care sector are increasingly screening patients for the social determinants of health. But once identified, people needing help face remarkable gaps in meeting these identified needs. No physician can prescribe food delivery when the community has a long waiting list, nor housing when none is available.
This is, in part, where the public health sector comes in. Public health officials can use their respected positions, as well as their experience in addressing a wide range of health issues, to shape the conditions in communities to be more routinely supportive to older adults. Specifically, public health practitioners and the Centers for Disease Control and Prevention could take these actions:
- Provide data that reflect the experiences of frail and disabled elders and their families. Public health departments routinely track the demographic, socioeconomic, and health-related characteristics of residents of the communities they serve. However, they have rarely focused attention on the experiences of older adult populations and their caregivers. National surveys are too thin to apply to localities, medical records are both inaccessible and inadequate in characterizing disabilities, and no other data sources are generally available. Without such information, policy makers are in the dark about many of the needs of this population.
- Review and adapt public health work underway. Public health departments manage scores of programs including those designed to prevent infectious and chronic disease and assist in emergency preparedness. However, many of these programs have not been adapted to address the specific needs of older adults. For example, special steps are needed to ensure the safety of frail, older adults when a weather-related emergency occurs.
- Convene service providers, data holders, stakeholders, and older adults to review community performance in eldercare, set priorities, and monitor efforts to improve deficiencies. Public health officials are often trusted, independent voices with the ability to unite people from diverse sectors to better understand and solve identified problems facing older adults.
- Drive public and policy maker attention to the urgent call for planning for this demographic change, including highlighting improved societal arrangements for encouraging private savings and for expanded access to public benefits and programs, all of which require years of lead time. At present, for example, many cities have wait times lasting more than six months for senior home-delivered food service. For accessible and affordable housing, the wait times can be a few years long or more. Most retirees do not have income or assets sufficient to support them in retirement, even before developing substantial costs for supportive care. Public health officials should be able to identify and promote evidence-based policies that can be scaled and spread to improve health with sensitivity to controlling costs.
Public health perspectives and tools are designed for these tasks, but rarely are they used to address the needs of this segment of the older adult population.
Mobilizing The Public Health Response
Florida has modeled one encouraging way to bring public health tools to bear on aging. That state has started an “Age-Friendly Public Health” pilot, with the Florida Health Department in the lead and 37 county health departments participating. Participating counties represent 65 percent of both the state’s population and its age 65-and-older population. The county public health departments are producing county-specific data reports, adapting their emergency preparedness plans, linking with elder services organizations in their areas, and working toward better policies and programs to meet the needs of older adults. Drawing on experiences from the Florida model and others, the Trust for America’s Health and The John A. Hartford Foundation jointly developed a “Framework for an Age-Friendly Public Health System.”
However, public health initiatives and the use of public health expertise to meet the challenges has been quite limited. The Centers for Disease Control and Prevention does not yet have a unit or funding to support healthy aging and adequate supportive services during declining health. Some local public health agencies have developed limited falls prevention and immunization outreach programs, although usually with little sustained funding or staffing. The governors of California, Massachusetts, Florida, and New York have pledged that their states will become more “age friendly,” although the meaning of that phrase varies from state to state.
Every month that goes by without the mobilization of the public health community increases the likelihood of preventable suffering and deaths from inadequate attention to eldercare in public health emergency planning, inability to tolerate heat or cold in poor housing, lack of adequate food, obstacles to mobility, substance misuse, social isolation, and unsafe living conditions.
The Urgency Of Acting Now
The situation for frail elders, families, and governments will be dire within a dozen years if leadership and resources do not shift to meet population needs. The US will have so many older adults unable to find housing and buy food, even before they encounter serious disabilities. Families and governments will confront economic realities that will demand the balancing of the prevention of suffering on the one hand with the aversion against increasing taxation on the other. Having the opportunity to live into old age should be a source of great joy. Older adults should not have to envision being hungry, homeless, and alone.
Planning now can avert the suffering and much of the adverse effects upon ensuing generations. The mission of public health organizations and personnel is to improve the health and safety of our nation. They have the skills, tools, and expertise to shape the planning and changes needed. The lead time on implementing better financing, services, and environment is substantial, so the time for action is now.
Source: Health Affairs