Public Health and Older Georgians:

Transcription

1 Public Health and Older Georgians: A Road Map for Research, Training, and Outreach Georgia Population Age 65 And Over Source: U.S. Census 2,000,000 1,907,837 1,500,000 1,409,923 1,000, , , , , ,000 30,342 43,632 52,427 66,376 80, , , , , , , The aging of the population is one of the major public health challenges of the 21st century... Julie L. Gerberding, MD, MPH, Director Centers for Disease Control and Prevention Institute of Gerontology College of Public Health The University of Georgia Technical Report #UGAIG

2 The aging of the population is one of the major public health challenges of the 21st century... the prevention of diseases and injuries is one of the few tools available to reduce the expected growth of health care and long-term care costs. Julie L. Gerberding, MD, MPH, Director Centers for Disease Control and Prevention

3 Message from the Institute Director On July 1, 2005, the Institute of Gerontology became an integral academic unit of the College of Public Health at the University of Georgia. In addition to the Institute s current mission of research, teaching, and outreach on aging and older adults, the Institute is charged with a leadership role to highlight and address public health issues among older Georgians. We look forward to this charge, as most, if not all, of the work at the Institute since its inception in 1965 is pertinent to the public health of older adults. This brochure highlights some of the priority issues relating to health and health status of older Georgians. Information includes changes and distributions of at-risk older Georgians, a sampling of pertinent public health issues, preventive opportunities, caregiver support, and end-of-life care. The information was written and compiled by Dr. Anne Glass, the Institute s Assistant Director, who has extensive experience in health care systems. Demographic distribution information maps and graphics are presented in conjunction with Dr. Doug Bachtel from the Department of Housing and Consumer Economics and a member of the Faculty of Gerontology. This brochure also contains gerontological resources and expertise at the University of Georgia that are pertinent to the public health issues of older Georgians. These resources include training opportunities at the University and University System, research and training consortia, and clinical laboratories that are contributing in geriatric diagnostic, intervention, and maintenance functions. A glossy poster, which is a handy guide for public health professionals, is available to highlight contents of this brochure. Detailed information on the mission of the Institute, Faculty of Gerontology, training and research programs, and publications can be obtained at the Institute s web site: We very much welcome the opportunity to be involved in public health research, training, and outreach for older adults. We look forward to productive interaction with colleagues and departments within the College of Public Health and other institutions. We want to share our resources and expertise with colleagues to contribute to the public health and quality of life of older adults. Leonard W. Poon of Public Health and Psychology Director, Institute of Gerontology Chair, Faculty of Gerontology August 2005 i

4 Table of Contents Public Health and Older Georgians... 1 Demographic Portrait... 1 State Map 1: Percent of Total Population Age Sixty-Five or Older By County: State Map 2: Percent of Population Age Sixy-Five or Older Living Below The Povery Line... 3 Table 1: Age 65+ Population Characteristics... 4 Table 2: Selected Population Characteristics of Old-Old... 4 Table 3: Top 10 Counties by Race/Ethnicity as a Percent of Total Population Age State Map 3: Older Georgians At Risk... 6 A Sampling of Public Health Issues... 7 Chronic Diseases and Conditions Identification and Management... 7 Cardiovascular Disease... 7 Diabetes... 8 Arthritis... 8 State Map 4: Death Rates Caused by Stroke... 9 Prevention Opportunities Influenza and Pneumococcal Immunizations Falls State Map 5: Death Rates Caused by Falls Driving and Motor Vehicle Accidents Medication Management Caregiver Support Graph 1: Medicare Enrollees Age 65 and Over Receiving Personal Care End-of-life Care Table 4: Summary of Last Acts National Report Card on End-of-Life Care Looking Toward the Future Who Will Provide Care? State Map 6: Aged Dependency Ratio: Graph 2: Georgia Population Age 65 and Over From 1870 and Projected Into Summary Institute of Gerontology at The University of Georgia Training Opportunities Research Opportunities Resources at the UGA Institute of Gerontology Faculty of Gerontology References ii

5 Public Health and Older Georgians Our population is aging in numbers never before seen. This trend presents opportunities as well as an ongoing public health challenge for the United States and for Georgia. This report is designed to provide an overview of public health and aging in Georgia. It highlights key demographic and health issues and captures relevant data at this point of time. This information may be useful to agencies and policy makers in helping to focus resources on these critical areas. Another goal of this report is to offer current and potential students an idea of the wide variety of challenges that face society as the population ages. Finally, relevant opportunities and professional activities associated with the Institute of Gerontology are summarized. The field of aging and public health is still developing, but the overall goal could be stated as helping to maximize function and well-being as we grow older (Albert, 2004). Accomplishing this goal requires consideration of the older person holistically within an environment, which includes attention to the living situation, support system, and personal preferences, as well as in the context of the multiple medical conditions that may be present. This comprehensive approach is a step beyond the traditional healthcare focus on solving a specific acute condition during a patient visit without fully examining the broader picture. Such an approach is essential to facilitating effective and comfortable living as we age. Demographic Portrait Georgia is a relatively young state, with 785,275 people aged 65 and above 9.6% (U.S. Census, 2005) of the population, compared to 12.4% for the nation (Greenberg, 2004). Only two states have lower percentages of their population in this age group (Alaska and Utah). Georgia s median age is 33.4 vs for the United States. However, the older population is growing: From 1993 to 2003, the percentage increase in the Georgia population aged 65+ was 18.7%, almost twice as high as the national rate of increase of 9.5% (Greenberg, 2004). Georgia had the eighth highest increase among all states in net internal migration of older adults from 1995 to 2000 (He & Schachter, 2003) The median age has increased two years just since 1990 when it was The percent change of 85.3% projected for Georgia s 65+ population between 2002 to 2020 ranks it fifth highest in the nation (Gibson, Gregory, Houser, & Fox-Grage, 2004), and is higher than the national figure of 58.4%. By 2030, 16% of Georgia s population will be age 65 or above (U.S. Census, 2005). While Georgia may be a relatively young state, there are counties in the state that have high percentages of older adults. (See State Map 1 on page 2.) Most importantly, the challenges of the aging population are significant in Georgia because of several demographic conditions. Older adults with lower incomes, less education, and who lack resources, generally have a more difficult time. Older adults who are at most overall risk include those who are: Of advanced age (especially 85+) Living alone Women Non-white Rural A review of the demographics demonstrates that Georgia has conspicuous representation among these sub-groups. See, for example, State Map 2 on page 3. Some people may fall into more than one of these sub-groups, placing them in double or even triple jeopardy. 1

6 Percent Of Total Population Age Sixty-Five Or Older: 2000 GA: 9.6% US: 12.4% 1.8% to 9.5% 9.6% to 12.3% 12.4% to 25.9% Percent Population Age 65+= (Pop. Age 65+/Total Pop.)*100 for each county Source: US Census Bureau 2 State Map 1

7 Percent Of Population Age Sixty-Five Or Older Living Below The Poverty Level: 2000 GA: 13.0% US: 9.6% 4.5% to 9.5% 9.6% to 12.9% 13.0% to 38.8% Percent Of Population Age 65+ Below Poverty Level= (The Number 65+ In Poverty/Population 65+)*100 for each county Source: US Census Bureau State Map 2 3

8 Table 1: Selected Age 65+ Population Characteristics in Georgia and the U.S. Age 65+ Population Characteristics Georgia State Rank U.S. Minority/Ethnic Population (%), Rural Population (%), Bachelor Level Ed. or Higher (%), Household Income Age 65+ (median), 2002 $23, $26,332 Poverty Status, 2002: At/Below Poverty (%) % of Poverty (%) Source: Gibson, Gregory, Houser, & Fox-Grage, Georgia has a particularly diverse population: A large total African American population - only two states have higher numbers 153,815 (19.5%) of those aged 65+ are African American Almost 40% of those 65+ are living below or within 200% of the poverty level The fifth highest percent of African American Medicare beneficiaries (19%) Fast growing Hispanic (census data show it has one of the fastest growing Hispanic populations in the country) and Asian American populations Awareness of our diverse population is important because African American and Hispanic adults are much more likely to have chronic diseases such as high blood pressure and diabetes (Moore & Moir, 2004), and are more likely to die from these conditions at greater rates than whites (Georgia Department of Human Resources, 2004). In addition, the rate of poverty in African Americans aged 65+ is 27.8% compared to 10.0% of their white peers (Boatright & Bachtel, 2004). Georgia is also remarkable for some characteristics of the old-old population. Of particular note is the extremely low ratio of men to women age 85 and above, which is the lowest in the nation, and the high percentage of women age 80 and above who live at or below poverty level (see Table 2). Table 2: Selected Population Characteristics of Old-Old Population Characteristics Georgia State Rank U.S. Men per 100 Women Age 85+ (#), Women Aged 80+ Living At/Below Poverty (%), 2002 Source: Gibson et al,

9 Table 3: Top 10 Counties by Race/Ethnicity As A Percent Of Total Population Age 65+ Total 65+ # By Race % Of Total 65+ African American Hancock County 1, % Talbot County % Stewart County % Randolph County 1, % Calhoun County % Macon County 1, % Taliaferro County % Baker County % Clay County % Warren County 1, % Asian American Gwinnett County 31,599 1, % Clayton County 13, % Columbia County 7, % DeKalb County 53,224 1, % Cobb County 42, % Liberty County 2, % Fulton County 68, % Barrow County 4, % Richmond County 21, % Camden County 2, % Hispanic Gwinnett County 31, % Chattahoochee County % DeKalb County 53,224 1, % Whitfield County 8, % Hall County 3, % Liberty County 2, % Clayton County 13, % Atkinson County % Cobb County 42, % Talbot County % White Towns County 2,409 2, % Union County 3,728 3, % Dawson County 1,491 1, % Gilmer County 3,082 3, % Fannin County 3,766 3, % Forsyth County 6,940 6, % Rabun County 2,730 2, % Dade County 1,820 1, % Catoosa County 6,322 6, % Murray County 2,922 2, % Source: 2000 U.S. Census data 5

10 OLDER GEORGIANS AT RISK Catoosa Dade Whitfield Murray Walker Gordon Chattooga Floyd Bartow Fannin Gilmer Pickens Cherokee Union Lumpkin Dawson Forsyth Towns Rabun White Habersham Stephens Banks Franklin Hall Jackson Madison Hart Elbert Polk Haralson Carroll Heard Paulding Douglas Coweta Cobb Gwinnett Barrow Clarke Oconee De Kalb Walton Fulton Rockdale Clayton Morgan Newton Henry Fayette Jasper Putnam Butts Spalding Oglethorpe Wilkes Lincoln Greene Taliaferro Columbia Warren McDuffie Richmond Hancock Glascock Troup Meriwether Pike Lamar Monroe Jones Baldwin Upson Bibb Wilkinson Harris Talbot Crawford Twiggs Taylor Peach Muscogee Houston Bleckley Chattahoochee Marion Macon Schley Pulaski Dodge Dooly Stewart Webster Sumter Wilcox Crisp Quitman Randolph Terrell Lee Ben Hill Turner Clay Irwin Calhoun Dougherty Worth Tift Burke Jefferson Washington Jenkins Screven Johnson Emanuel Laurens Treutlen Candler Bulloch Effingham Montgomery Evans Wheeler Toombs Tattnall Chatham Bryan Telfair Liberty Jeff Davis Chatham Appling Long Coffee Bacon Wayne McIntosh Early Miller Baker Mitchell Colquitt Cook Berrien Atkinson Pierce Brantley Glynn Lanier Ware Seminole Decatur Grady Thomas Brooks Lowndes Clinch Charlton Camden Camden Echols Older Georgians at Risk Counties at Risk Highest Risk Higher Risk Moderate Risk State Map 3 Lower Risk Lowest Risk 6

11 State Map 3 on page 6 shows the counties with populations most at risk, based on consideration of 1) their percentage of population aged 65 and above, 2) the percent of those individuals living at or below the poverty level, 3) the percent living alone, and 4) the percent with less than a high school education. A Sampling of Public Health Issues Affecting Older Georgians Most older people enjoy many years of health and activity. They may continue in the work force or enjoy an active retirement. Some volunteer much of their time and are a tremendous resource. Many are among the 92,265 grandparents in Georgia (Casey Family Programs, 2002) who have taken on the responsibility of raising their grandchildren. However, there are many challenges that can accompany the aging process, including the following areas of particular importance in Georgia from a public health perspective: Chronic Diseases and Conditions Identification and Management Prevention Opportunities Medication Management Caregiver Support End-of-life Care Chronic Diseases and Conditions Chronic diseases and conditions become increasingly major considerations with age, as at least 80% of older people have at least one chronic condition and 50% have two or more (Moore & Moir, 2004). More than a quarter of older adults have heart disease and over half have high blood pressure (National Center for Health Statistics, 2004b). Georgia has high rates of obesity overall (22% - 11th in the nation). and among older Georgians, 38% are overweight and another 22.4% are considered obese (Georgia Department of Human Resources, 2005). Nearly 30% (28%) of Georgians report no physical activity 11th in the nation and this percentage increases to 37% of those 65+ being sedentary (Welch, Gazmarariam, Schuessler, Hawley, & Oster. 2003). At the same time, only 39% report receiving the recommended level of physical activity, ranking Georgia 45th nationally. This combination of overweight and lack of activity is dangerous. Chronic diseases and conditions have high costs it is estimated they consume 75% of our healthcare dollars (Centers for Disease Control and Prevention [CDC], 2004a) and nearly 95% of the healthcare expenditures among older people (Moore & Moir, 2004). Some chronic diseases can be prevented by lifestyle choices. At the very least, there are steps individuals and communities can take to help manage these conditions to improve quality of life. Thus, identification and education are essential. Of the many serious conditions that affect older Georgians, including cancer and Alzheimer s disease, three will be highlighted here: cardiovascular disease, diabetes, and osteoarthritis all of which can be improved by individual and community interventions such as exercise and eating healthy. Cardiovascular Disease Deserving special attention in Georgia are heart disease and strokes, which are both included in the category of cardiovascular disease (CVD). CVD is the number one killer in Georgia, causing 39% of all deaths (Mertz, Jones, Griffith, & Powell, 2002). Over three-quarters of the CVD-related deaths occur in people aged 65+ (Wilson & Bricker, 2004). In 1999, Georgia had the tenth highest CVD mortality rate among all states, and had a particularly high stroke death rate (see State Map 4 on page 9). For strokes, Georgia had the sixth highest death rate (Mertz, Jones, Griffith, & Powell, 2002). Strokes account for 18% of cardiovascular disease deaths. CVD death rates are higher for African Americans than for whites. 7

12 Risk factors for cardiovascular disease include overweight, high blood pressure, lack of exercise, and smoking. CVD is another area that can be improved through lifestyle choices, including regular exercise, healthy eating, and not smoking. Stroke Symptoms Everyone should know the symptoms of a stroke, because emergency medical help is essential. Sudden numbness or weakness of the face, arm or leg, especially on one side of the body Sudden confusion, trouble speaking or understanding Sudden trouble seeing in one or both eyes Sudden trouble walking, dizziness, loss of balance or coordination Sudden, severe headache with no known cause If you realize someone near you is experiencing any of these symptoms, please get emergency help right away. Medical attention is important even if the symptoms last only a few minutes indicating a mini-stroke or transient ischemic attack (TIA). Diabetes Diabetes is a serious and growing health problem; it is the sixth most common cause of death in Georgia and the death rate from diabetes has been increasing for almost two decades (Jack, Mbadugha, Mertz, Wu, & Powell, 2003). It is estimated that over 10% of adult Georgians have diabetes, but about a third of these individuals are unaware that they have it. Type 1 diabetes, in which the body stops producing insulin, accounts for five to ten percent of all diabetes, and most often begins in childhood. It is Type 2 diabetes, which is associated with overweight and can often be managed with diet and exercise, which is increasing dramatically, accompanying the increase in obesity in our population. The prevalence of diabetes in the state has grown about 8% each year from 1994 to 2001, and it is more common among older people, affecting more than 15% of those over 60. It is also more frequent in women and African Americans. Regular treatment can reduce the risk of many complications by up to 50%, but for the treatment goals that have been set nationally, Georgia has only met three thus far: receipt of diabetes education, two or more hemoglobin A1C tests/annually, and receipt of aspirin therapy (Jack et al, 2003). Compounded by racial disparities, many Georgians aged 65+ with diabetes are not receiving the recommended treatment and monitoring. For example, only 13% of those 65+ are receiving annual quantitative urine protein tests as recommended, even though individuals in this age group are more likely to be at high risk for kidney disease. Arthritis Osteoarthritis is the nation s leading cause of disability, and it hits older people particularly hard, affecting almost half (48.9%) of those age 65 and above, compared to 7.8% of those aged and 30.2% of those aged It affects more women (24.7%) than men (17.9%) (CDC, 2005b). In Georgia, over one in four (26.7%) have been told by a healthcare professional that they have arthritis, ranging from 5.5% of those aged 18 24, to 59.9% of those aged 65+, which is higher than the national average of 47.8% cited above. It affects more women (30.1%) than men (23.2%) and is highest in southern Georgia and lowest in metro Atlanta (CDC, 2005c). Georgia has 2.91% of the doctor-diagnosed arthritis cases nationally, with states ranging from 0.14% in Wyoming to 9.69% in California. Estimated costs 8

13 Death Rates Caused By Stroke Population Age Sixty Or Older Ten Year Cumulative Rates: GA: to to to 1,071.5 Source: GA Division Of Public Health Stroke Death Rates= Number Age 60+ Dying From Stroke for each county per 100,000 Pop. Age 60+ State Map 4 9

14 related to arthritis and other rheumatic conditions in Georgia in 1997 were $1,488 million in direct costs, and $1,022 million in indirect costs, for a total of $2.5 billion (CDC, 2004b). Total hospital charges for arthritis hospitalizations in Georgia exceeded $317 million in 2000 (Welch et al, 2003). If trends continue, the CDC predicts arthritis will affect twice as many people 65 and older by Prevention Opportunities Among the opportunities for prevention of health problems in the older population, three will be highlighted here. Use of immunizations for influenza and pneumonia, fall prevention, and issues of driving safety are high priority for receiving attention and action. In the U.S., unintentional falls and motor vehicle accidents account for more than half of all unintentional injury deaths among older people more than 16,000 deaths each year (Stevens & Dellinger, 2002) and unintentional injuries were the ninth leading cause of death among those aged 65+ in 2002 (National Center for Injury Prevention and Control [NCIPC], 2005). Influenza and Pneumonia Immunizations While vaccination programs have made great strides in overcoming childhood diseases, influenza and pneumonia are still the fifth leading cause of death in Georgians aged 65+ (Georgia Division of Public Health, n.d.). This risk is of particular concern because the vaccinations now available can prevent individuals from getting the disease or lessen the severity and duration if they do. The influenza vaccination must be obtained annually, while the pneumococcal vaccination is good for several years. The Centers for Disease Control and Prevention (CDC) note: Eliminating persistent racial and ethnic disparities in infl uenza and pneumococcal vaccination coverage for people 65 years of age and older is a priority for CDC and the whole of DHHS. African Americans and Hispanics have signifi cantly lower infl uenza and pneumococcal immunization coverage rates compared to the rest of America s seniors. (CDCa, 2005:35). In Georgia, more than a third of those 65+ do not get the flu shot, and females, African Americans, and those with lower incomes all have lower rates (Welch et al, 2003). There has been progress. Among persons aged 65+, national influenza vaccination levels have increased from 33% in 1989 to 66% in 1999, surpassing the Healthy People 2000 goal of 60%. However, Georgia is lagging behind other states, with 59.3% of people aged 65+ receiving the influenza vaccination in Georgia ranks 48th in the nation (Kaiser StateHealthFacts, 2002). Falls More than one out of three older adults fall each year and falls are the most common cause of nonfatal injuries and hospital admissions. Almost a third of those who fall suffer injuries that reduce their independence and mobility (American Public Health Association [APHA], 2005a). Falls are also the leading cause of injury deaths, and Georgia s rate of fall injury deaths is particularly high. According to CDC data, the unintentional fall death rate among men age 65+ ( ) was 38.8, compared to 29.7 for the U.S. For women during this period, Georgia s rate was 36.3, compared to 26.4 for the U.S. (National Center for Injury Prevention and Control, n.d.). All death rates are per 100,000 population. State Map 5 on page 11 shows the cumulative fall death rates in Georgia by county for Every hour an older adult dies as the result of a fall. National Center for Injury Prevention and Control, 2001 Older adults are at risk for falls for many reasons. Balance and strength may decline, and, with increasing frailty and/or cognitive impairment, hazards existing in the home may take a toll. Side effects of medications can also make elders more susceptible. Even those who fall without injury are affected, as a fear of falling can lead to avoiding activity. 10

15 Death Rates Caused By Falls Population Age Sixty Or Older Ten Year Cumulative Rates: GA: to to to Source: GA Division Of Public Health Fall Death Rates= Number Age 60+ Dying from Falls for each county per 100,000 Pop. Age 60+ State Map 5 11

16 Of special concern are those falls resulting in hip fractures. Hip fractures increase exponentially with age and can launch an older adult on a tragic downward spiral. National data show that of those who sustain hip fractures, half are unable to walk without assistance, up to 25% of formerly community-dwelling older adults remain institutionalized for at least a year, and 10 to 20% will die within six months. (NCIPC, n.d.) There are now about 250,000 hip fractures in people aged 65+ every year, and by 2040, the number of hip fractures in the U.S. is likely to exceed 500,000. In 2002, the rate of hip fractures was 525 in men, and 1,127 in women, for a total of 877 (all rates per 100,000) (Moore & Moir, 2004). The Healthy People 2000 goal was 607 per 100,000. In Georgia, there were a total of 7,112 hospital discharges for ICD-9-CM Code 820 (fracture of the neck of the femur) in 2000 (Bennett-Burkholder, 2002). That number of fractures is almost three percent of the total in the U.S. Home safety evaluations and modifications can help prevent falls. In addition, regular exercise to increase lower body strength can build muscles and bones, and exercise such as Tai Chi has been proven to help some people with balance. Careful review and monitoring of medications can also be beneficial. Driving and Motor Vehicle Accidents Nationally, death rates from motor vehiclerelated injuries in 2002 were much higher for males of all ages compared to their female cohorts. Among women, the highest rate was 19.3 deaths per 100,000 resident population for females aged 75 to 84. For males, high rates were seen among young men, particularly males aged 20 to 24, whose rate was The rates among males level off during the middle age period, but start to increase in the group (35.3) and especially in the 85+ age group, where the rate peaks at 51.7 (National Center for Health Statistics, 2004a). Data analysis has shown that, compared to drivers between the ages of 16 to 34, older drivers are less likely to be involved in accidents in which someone else died, and crashes caused by older drivers are more likely to kill the older driver (NCIPC, 2005). Both older drivers and older passengers are more likely to die if injured in a motor vehicle accident; their recovery from injuries is often compromised by existing medical conditions. In Georgia, for example, among those who were injured in 2003, 4% of those 75+ died, compared to 1.1% of those under the age of 65 (Georgia Department of Motor Vehicle Safety, 2004). Many factors affect older drivers, including their mobility, such as the ability to turn to see behind them, and declining reflexes and vision. Failure to yield is the primary contributing factor in fatal crashes for those aged 75+, reported in half the cases in Georgia in 2003, compared to 6.6% of cases involving drivers under age 65 (Georgia Department of Motor Vehicle Safety, 2004). Many older drivers do self-limit their driving to compensate for their limitations driving only in the daytime and when the weather is good. However, a particular problem in Georgia is the older drivers who must drive on high-risk rural roads due to lack of accessible public transportation, and the distances they must travel to get to shopping and health care. The fatal crash rate for drivers aged in rural counties is almost double the rate for drivers in the same age group in the five Atlanta metropolitan counties. Many people see their right to drive as important to their self-esteem. More education and research are needed to promote safe driving by older drivers and to provide appropriate evaluation and guidance to help older people stop driving when they can no longer do it safely. Medication Management Medications are a fact of life for many older adults. Older adults make up 12 to 13% of the population nationally, but they account for about 34% of prescribed medications and about 12

17 30% of over-the-counter medications (Moore & Moir, 2004). At least 84% had at least one prescription medication in the past month, and nearly half (47.6%) had three or more prescription drugs (National Center for Health Statistics, 2004a). All of this medication use can be a huge boon to older adults dealing with chronic and acute health problems. However, there are many serious issues with medication use and older adults. These issues include body changes that affect absorption and elimination of medications. Older adults are also more likely to have multiple medical conditions and multiple physicians, leading to multiple medications; such polypharmacy increases their risks of adverse drug events. Another significant problem is under-use and noncompliance; nearly 25% of older adults skip doses or do not fill prescriptions because of cost. Those who do not take their medications as prescribed are 76% more likely to significantly decline in health overall, compared to those who take all their medications as prescribed (APHA, 2005b). There is also a lack of research with older patients, so actual medication effects on them are not well understood. adjustments about their jobs because of caregiving responsibilities (NAC/AARP, 2005). The 22 million households involved in caregiving for someone 50 + in 1997 are projected to rise to 39 million by 2007 (Family Caregiver Alliance, n.d.) The graph on the following page ( Distribution of Medicare Enrollees ) demonstrates the significant amount of care provided by family and friends; this informal support system cares for about two-thirds of the individuals who have personal care needs without outside assistance. Many older caregivers suffer from chronic illness themselves, and with the added stress of caregiving, they have a 63% higher death rate than their peers who do not have caregiving responsibilities (Moore & Moir, 2004). In Georgia, almost one in five adults (17%) report having primary responsibility for caring for someone other than a child who cannot take care of themselves. They reported spending an average of 43 hours a week providing this care more than a full time job (Peach State Poll, 2004). Falls, restlessness, confusion, loss of memory, constipation, sleep disorders, weight loss, bowel changes, incontinence, and dizziness can all be signals of possible medication problems. Unfortunately, sometimes adverse drug events are wrongly attributed to aging itself. Because the effects of medications can be so significant for older people, every use of a medication should be carefully considered in terms of the risk versus the potential benefit. Caregiver Support For the first time in history, many people will now spend more years taking care of their parents than they did taking care of their children. Nearly one out of four households provides care to someone age 50 or above. In addition, 59% of caregivers also work outside of the home; almost two-thirds (62%) report having to make some Caregiving can be very rewarding but it can also place the caregiver under tremendous strain. Caregivers often think they can and should do it all themselves, but there may come a time when some help and support from outside is essential. It is important to take care of the caregiver in order for the caregiver to keep going. Ways for caregivers to take care of themselves include asking for help from family and friends, 13

18 Graph 1 Source: website. as well as making use of community services. Everyone needs a little break occasionally, but too many try to keep going alone, leading to stress, depression, health problems, and in some cases, even elder abuse or neglect. A recent caregiver study (NAC/AARP, 2005) showed that the greater the level of caregiver burden, the stronger the impact the caregiving has on the caregiver s perceived health. A sense of not having a choice about taking on the caregiver role was also associated with emotional and physical health strains. In addition, the caregiving may go on for several years. The same study showed a mean length of care was 4.3 years, with 29% reporting caregiving for five years or more. End-of-Life Care Most people state a preference for dying at home, but nearly 75% of deaths occur in institutions half in hospitals, and, increasingly, in nursing homes (20 to 25%). Only 25% die at home. A national report card (Last Acts, 2002) by state showed that provision of end-of-life care in Georgia, and in the rest of the nation, is mediocre at best. The report card categorized the performance of each state on twelve indicators, such as the quality of the state s advance directive policies, the percent of deaths at home, and the percentage of those 65 and above who used hospice in the last year of life. Based on their performance, states were placed in five groups for each indicator and assigned a grade, with A being the best (see Table 4 on page 15). 14

19 Table 4: Summary of Last Acts National Report Card on End-of-Life Care # of States Indicator Mean (Range) Georgia Receiving A/B Mean not reported 3.5 = B A: 7 Quality of state advance ( ) (3.5 to 4.0) B: 12 directive laws, 2002* Deaths at home, 1997, % People 65+ who used hospice in last year of life, 2000, % Median days in hospice, 2001, No. Hospitals reporting pain management programs, 2000, % Hospitals reporting hospice programs, 2000, % Hospitals reporting palliative care programs, 2000, % People 65+ with 7+ ICU* days during last 6 months of life, 2000, % Nursing home residents in persistent pain, 1999, % Strength of state pain policies, 2001* General and subspecialty primary care physicians certified in palliative care, 2000, % Full-time nurses certified in palliative care, 2000, % 24.9 ( ) 19.3% = D (15 < 30%) 21.5 ( ) 24.2% = D (12.5 < 25%) 25.3 ( ) 25.4 = D (15 < 30) 42.3 ( ) 40.4% = C (40 < 60%) 23.5 ( ) 14.6% = E (0 < 20%) 13.8 (0 54.5) 10.5% = E (0 < 20%) 10.1 ( ) 12.0% = C (7.6 < 12.1%) 42.2 ( ) 44.4% = C (35 < 45%) Mean not reported ( ) +1 = D (0 to +2) 0.33 (0 0.97) 0.14% = E (0 to 0.17%) 0.41 ( ) 0.33% = C (0.30 to 0.49%) *ICU=Intensive Care Unit Source: Last Acts, 2002 A: None B: None A: None B: 1 A: None B: None A: None B: 6 A: None B: None A: None B: None A: 5 B: 10 A: None B: 1 A: 7 B: 9 A: 5 B: 9 A: 5 B: 10 There is a lack of communication about end-of-life care and available resources are underused. More effort must be made to expand palliative care programs, to educate patients and their families about their options, and to help families and health care providers honor patients wishes for end-of-life care. 15

20 Looking Toward the Future... By 2030, the number of older Americans will double compared to 2000, representing about 20% of the total population. There is less growth right now because of the relatively low birth rate during the Depression years; the major growth will come between 2010 and The growth is dramatic in Georgia as well (see Population Graph on page 18). Minority populations will grow even faster and will increase by 2030 to 26.4% of older adults, up from 17.6% in The estimated national percentage increases in 65+ by race, from 2000 to 2030 (Greenberg, 2004) are: African Americans 164% American Indians, Eskimos & Aleuts 207% Asians and Pacific Islanders 302% Hispanics 342% White 77% Who Will Provide Care? If you are in the healthcare field, chances are high that you will be working with older patients. Older adults comprise only 12-13% of the population but they consume a third of all physicians patient care hours projected to increase to almost 40% by 2020 (HRSA, 2003) and were responsible for almost half (45%) of the hospital days of care in 2002 (DeFrances & Hall, 2004). Extra training to serve this population more effectively could benefit much of the healthcare workforce. There is also a care gap in the making. The health workforce is aging and many professionals will be retiring about the same time that demand for services is increasing (HRSA, 2003). In addition, the number of older people who need long term care whether at home or in a facility will grow dramatically along with the increase in life expectancy. Who will provide the care? In the next 30 years, the older population will double, but the women aged the traditional caregivers will only increase by 7%! State Map 6 on page 17 portrays the aged dependency ratio for Georgia s counties. The state ratio is 15 people aged 65+ per every 100 persons in the workforce traditionally considered ages 18 to 64 which is lower than the national average of 20.1 per every 100. However, there are many counties in which the ratio surpasses the national average and these are many of the same counties already facing significant challenges such as high rates of poverty. Many are also among the 144 of Georgia s 159 counties that contain areas or populations that are designated as medically underserved. Large numbers of persons 65+ signal potential problems for decision makers attempting to deliver services, particularly in rural communities. Georgia spent $147 per capita in Medicaid long-term care expenditures in This amount compares to the national figure of $288 (Gibson et al, 2004), placing Georgia 48th in the nation. Overall, a shift toward more community-based care is expected in all states. As the major payor for nursing home care, Georgia Medicaid continues to fund the institutional side of long term care more heavily than home and community-based services (HCBS), but the proportion of Medicaid long term care spending going to HCBS increased from 15.8% in 1996 to 25.5% in 2002 (Summer, Friedland, Mack, & Mathieu, 2004). The percentages spent on HCBS stretch from 10% in Louisiana to 73% in Oregon. The 2000 state ratio of home health aides in Georgia was 65 home health aides per 1,000 population age 85+, which is the fourth lowest in the country. To maintain even this ratio in 2025 will require 4,373 additional aides (Summer et al, 2004). 16

21 Aged Dependency Ratio: 2000 GA: 15.0 US: to to to 44.7 Aged Dependency Ratio= (Pop. Age 65+/Pop. Age 18-64)*100 for each county Source: US Census Bureau State Map 6 17

22 Graph 2 Graph 2 GEORGIA POPULATION AGE 65 AND OVER FROM 1870 AND PROJECTED INTO 2030 Source: U.S. Census 2,000,000 1,907,837 1,500,000 1,409,923 1,000, , , , , ,000 30,342 43,632 52,427 66,376 80, , , , , , , Summary Our population is aging at a rate never before seen in history. More and more people will live to be The number of centenarians those over 100 is projected to grow from over 50,000 now to as many as a million by 2050! Chronic health conditions can plague individuals at all ages, and are far more prevalent among those aged 65 and above a fast growing population yet our health care system continues to focus on acute care rather than chronic care management. Thousands of older persons ultimately suffer from frailty and dementia, with families stressed over caregiving, yet we lack a clear-cut comprehensive system of support. There are not enough traditional caregivers, both informal and formal, to keep up with the growth in the elder population. We spend more per capita on health than any other country (National Center for Health Statistics, 2004a), but our chronic care management and end-of-life care are only mediocre. The issues are many and the challenges are great. In all areas, additional research and education are desperately needed to better understand how to help older adults with the identification, treatment, and management of their chronic health problems, and their later years of life. How we as a state, a nation, and a world, will answer these challenges will reveal much about our society. 18

23 The Institute of Gerontology at the College of Public Health The Institute of Gerontology (formerly named Gerontology Center) was initiated in 1964 as an all-university institute charged with instruction, research, and outreach associated with aging and the aged. The Institute moved administratively to the College of Public Health in 2005, and this move provided an important opportunity to address public health issues among the older population and older Georgians in particular. The issues described in this report highlight public health challenges that will affect the lives of us all. How can we be better prepared? Training Opportunities Gerontology education and training is essential for many jobs and would be of benefit in almost any field, given the fast growing older population. The College of Public Health at The University of Georgia offers two types of training in public health and aging. Graduate Certificate of Gerontology. Since 1974, the Institute of Gerontology at the College of Public Health has offered a Graduate Certificate in Gerontology to graduate students in any department or college. It may also be earned by nondegree students who wish to pursue the certificate only. The certificate courses help students prepare to tackle the challenges of our aging population, whatever their interest. Their career paths can include: Students complete a total of 18 semester hours of graduate level courses to meet the requirements of the Certificate Program. Courses are selected from three major clusters - Biology/Physiology, Psychology, and Sociology - in addition to a mandatory course, Seminar in Aging. Three hours may be chosen from a list of elective courses and three hours are devoted to gerontology research or practicum. Detailed information including frequently asked questions and application forms can be found at onlinepublications.php. Master of Public Health (MPH). Students can acquire a specialty in aging training through the MPH program at the College of Public Health. For example, a student can have a gerontology speciality within the concentration in Health Policy and Management. Students will complete 15 hours in the MPH core course requirements, 12 hours in Health Policy and Management requirements, and 17 hours in electives drawing from courses contained in the Graduate Certificate of Gerontology catalog. Detailed information can be found at mph-hpm.htm. Adult Education Architecture Biology Business Clothing Design Consumer Economics Counseling Health Policy Health Promotion and Education Housing Law Medicine Nursing Nutrition and Food Science Pharmacy Psychology Public Health Social Work 19

24 Post Doctoral and Sabbatical Training. Opportunities are available to continue post-doctoral training and research at The University of Georgia Institute of Gerontology. Application details can be found at edu/studentprograms/postdoctoral.php. In addition, the Institute offers opportunities for continuing education and adult education in a variety of related topics for older adults in the community, university staff and alumni, and the general public. The Institute is also involved in efforts to help increase and improve training for the workforce. Inquiry on any of the training programs can be directed to Dr. Anne Glass, Assistant Director, aglass@geron.uga.edu. index.php. (For more information, contact the Institute of Gerontology to request the publication, The Georgia Centenarian Study: A Study of Longevity and Survival of the Oldest Old, published by the Institute in 2005.) Phases I and II of the study focused primarily on behavioral and social science factors associated with longevity and survival of cognitively-intact and community-dwelling centenarians, octogenarians, and sexagenarians. Phase III expands the research to both community-dwelling and institutionalized centenarians in the population. The study strives to focus on a population-based sample of centenarians. Further, the study was expanded to provide a balance of biomedical and psychosocial predictors of longevity and survival. As this project is currently underway, there are not yet results to share. However, the data, cell lines, and brain material will be available for collaborative comparison and research in The impetus of the current project came from the NIA Strategic Plan which articulated four major goals that NIA will pursue in the years to come. The four projects being conducted in the current NIA-funded Program Project ( ) can contribute to the eventual realization of these goals: 20 Research Opportunities The Georgia Centenarian Study. The Centenarian Study (1988 to 2007) is a study of longevity and survival of the oldest old, led by the Institute Director, Leonard W. Poon. This is the keystone research project at the Institute which combines faculty expertise in aging at the Institute of Gerontology with researchers from nine different universities from across the nation. This research has been funded by the National Institute of Mental Health and now by the National Institute on Aging. History and details about the three phases of research that began in 1988 can be found at Project 1 tests the viability of four homologues of yeast longevity genes. Findings from Project 1 can contribute to the following NIA goals of (a) understanding healthy aging processes, (b) unlocking the secrets of aging, health, and longevity, and (c) identifying genes associated with aging, longevity, age-related diseases, and behavior. Project 2 tests hypotheses on relationships between senile plaque/neurofibrillary tangle counts, brain infarcts, functional abilities, cognitive measures, the presence of dementia and markers of neurocognitive reserves in centenarians. Findings from this Project can contribute to the NIA goal of characterizing normal cognitive and brain function of the oldest-old.

25 Project 3 tests hypotheses on predictors of functional capacity, which has been shown to be an important determinant of utilization of health care resources, mortality, and institutionalization in the elderly. This Project has the potential to contribute to a number of NIA goals, including the definition of biological and environmental factors that maximize cognitive, sensory, and physical functions. This Project also aims to take advantage of the core physical health information collected on sensory, musculoskeletal, blood chemistry, mental health, and diseases of centenarians and their impact on functional capacity in comparison to control subjects in their 60s and 80s. This information can contribute to the dissociation of changes of normal or usual aging from those of diseases and disorders. Project 4 tests hypotheses of predictors that differentiate centenarians who are independent, healthy, and experience a sense of well-being from those who are dependent, unhealthy (frail), and do not experience a sense of well-being. This Project can contribute to the NIA goal of identifying social, psychological, and lifestyle factors that promote health, well-being, and longevity. This Program Project is a multi-disciplinary population-based study of centenarians in North Georgia. The long-term goal is to elucidate the roles of biological, psychological, and social factors that are pertinent to the survival and functioning of this population. Probability sampling frames were developed and employed to select representative samples of centenarians and of younger control populations residing in a set of designated counties in Georgia. Projects 1 and 2 focus on biomedical aging mechanisms among centenarians and Projects 3 and 4 concentrate on psychosocial mechanisms. The specific aims are to: Assess the underlying genetic structure of our population and test initially the viability of four homologues of yeast longevity genes (LAG1Hs, PHB1Hs, c-h-ras1, and GRP78) to human longevity. (Project 1) Test hypotheses on the relationship between advanced aging and cognitive impairment by evaluating relationships among plaque/tangle counts, brain infarcts, functional ability, and cognitive measures on those participants who are willing to donate their brains. (Project 2) Test hypotheses on neuropsychological, sensory, neuromuscular, blood chemistry, mental health, and disease correlates of functional capacity among centenarians. (Project 3) Test hypotheses on the impact of distal (life events, past achievements) and proximal (individual, social, and economic resources) influences on behavioral skills and developmental outcomes (levels of adaptation) among centenarians. (Project 4) How We Are Accomplishing the Goals: The Program Project contains four projects that focus on the same population of centenarians so that hypothesis testing on the inter-relationships among biomedical and psychosocial factors could be maximized. Five cores are employed to support the four projects. Projects- (1) Genetic Contributions to Longevity (2) Neuropathology (3) Functional Capacity (4) Developmental Adaptation Cores- (a) Administrative (b) Sampling & Subject Ascertainment (c) Recruitment & Data Acquisition (d) Cell, Blood, & DNA Bank (e) Data Management & Analysis The Institute of Gerontology at The University of Georgia is the lead institution in this Program Project. Collaborating institutions are: Louisiana State University (genetics), Boston University, Emory University, and University of 21