For too long, gerontological research has focused on the functional losses that occur with age. We have lost sight of the fact that most older people function very well and report good or excellent health. Despite the physiological losses and psychosocial stresses often associated with advanced age, many older people have the vitality and resilience to function at a high level. Data collection should consider the positive aspects of aging rather than purely functional decline, illness, and mortality. Similarly, there needs to be a growing recognition of the ability of individuals to improve over time; thus, data sets should be conceptualized to track individuals as they increase in functioning,
Extending longevity and compressing morbidity
A major policy issue concerns the relationship between changes in the mortality experience of the elderly population and coincident changes in the underlying experiences of morbidity and disability.
In 1900, a man reaching age 65 could expect to live 11 years longer, and a 65-year-old woman could expect to live 12 years longer. By 1984, men who were 65 could expect to live 14.5 years longer, and women who were 65 could expect to live 18.7 years longer (National Center for Health Statistics, 1986c). This “longevity revolution” has affected even the very old, as the past two decades have resulted in dramatic reductions in mortality rates for both men and women over age 80.
The important question, however, is the quality of the extra years of life for the elderly. Are the extra years ones of vigor and independence, or of frailty and dependence? Will future increases in longevity be associated with increased dependency, or will active life expectancy increase (“compression of morbidity”) as health promotion and disease prevention strategies become increasingly effective (Rowe, 1985)?
“The initial assertion that as mortality decreases, morbidity will also decrease has recently been challenged by studies suggesting that increases in the life span of the elderly are not accompanied by decreases in morbidity and may in fact result in a more dramatic increase in the need for health services. ” (Rowe, 1985: 828). While federal statistics have documented changes in pollutant life expectancy over the twentieth century, there are no national data on whether the period of vitality has also changed. Thus, it is not known whether the actual number or proportion of the last years of people who passed in good health increased, stayed the same, or decreased over the period when life span increased. Chapter 4 discusses this issue in detail.
Transitions from morbidity to disability and mortality
The World Health Organization has proposed a model (Manton, 1986a) that describes the links between mortality, disability, and morbidity (discussed in detail in Chapter 4). While it is clear that the overall mortality experience of the older population has an underlying pattern of morbidity experience in which individuals accumulate specific illnesses and losses of capacity, the specific interactions between the development of illness and the subsequent development of disability have not been elucidated. It is particularly important to recognize that many different disease processes can lead to or contribute to identical functional impairments. For a particular individual, several coincidental disease processes interact in complex ways to result in disability. This interaction is often strongly influenced by other factors, particularly in the psychosocial sphere.
The marked variability of health status in the elderly and the uncertain relationship between the presence of disease processes, their functional consequences, and eventual mortality underlie the importance of an approach to the elderly that allows for analysis of the transitions that individuals make from one functional or health state to another. It is clearly inadequate to focus solely on mortality, hospitalization, or institutionalization as endpoints, and it is increasingly important to detect changes in function as they occur and to develop sensitive measures of the severity of disease processes. It is particularly important in studies of health status transitions to maintain a perspective that detects improvements over time, rather than simply losses of function.
This approach may be more difficult in older patients than in their younger counterparts, because there appears to be a very short recall period for health interactions in the elderly. In addition, self-reported data on some measures of functional status, such as those called instrumental activities of daily living, may not be adequate. Studies should be conducted to determine whether the inaccuracy of these self-report data is a function of age or age-related diseases, such as those that impair cognitive function.
The Need for Acute and Chronic Care
In recent years, the dramatic increase in Medicaid spending on nursing home care has led to a progressive focus on the long-term care needs of older adults and the search for alternatives to costly institutionalization. The critical importance of acute care among the elderly appears to have been underestimated: more than 40 percent of health care expenditures for the elderly are spent on acute care (Waldo and Lazenby, 1984). Moreover, the common practice of identifying the type of care provided by the site in which it is provided is increasingly misleading. On the one hand, many older people in acute care facilities receive chronic care. Some are admitted to an acute care hospital in order to access a long-term care facility, and some are admitted to a hospital because of a worsening chronic condition. On the other hand, with the implementation of prospective payment and diagnosis-related groups in Medicare, acute care hospitals tend to refer patients to long-term care facilities earlier than before.
Many nursing homes are now faced with providing acute care, including acute postoperative care, in facilities not designed for such care and by staff who are often insufficiently trained. In monitoring the progress of patients through the health care system, it is becoming increasingly important to know not only the location in which care is provided, but also the specific nature of the care. Many nursing homes today are faced with providing acute care, including acute postoperative care, in facilities not designed for such care and by staff who are often inadequately trained. In monitoring the progress of patients through the health care system, it is becoming increasingly important to know not only the location in which care is provided, but also the specific nature of the care.
Many nursing homes today are faced with providing acute care, including acute postoperative care, in facilities not designed for such care and by staff who are often inadequately trained. In monitoring the progress of patients through the health care system, it is becoming increasingly important to know not only the location in which care is provided, but also the specific nature of the care.