Mr. Jacob Reingold 

Director, Hebrew Home for the Aged, Riverdale, N.Y.

Geriatric Care: Ethical and Practical Considerations

The world's population of elderly people is increasing more rapidly than its birth rate. In 1990, 28 nations had at least two million inhabitants age 65 or older; China led with 63.4 million and the United States was high on the list with 31.6 million. This dramatic growth has far-reaching implications for long term care. Today the elderly enter long-term care facilities at a more advanced age, and with greater infirmities than they did ten years ago. When I first entered the field, a 100-year-old resident was a rarity. Today at the Hebrew Home, we have over twenty-one residents over 100 years old.  By the year 2000, there will be over 50,000 Americans in their late 90's and even older.

What do these statistics mean? This burgeoning population of the elderly will be grossly underserved unless our healthcare system is drastically changed.   In the United States there are only two medical schools with geriatric divisions and they have difficulty recruiting students. There is not only a scarcity of physicians, but the field of geriatrics lags far behind other specialities in areas from nutrition and social work to psychiatry and nursing.

A direct result of this shortage is the dearth of information available about the physiology and psychology of the elderly. Many doctors today prescribe the same medication, at the same dosage, to both 40-year-old and 85-year old patients without taking into account either their physical differences or the harmful effects such a dosage could have on the 85-year-old patient. Not enough is known about the aging body and mind, and more research is needed to identify the special medical needs of the elderly. Specific treatments, procedures and protocols must be developed for treating the aged, just as for the treatment of children. Currently, we see far too many incoming residents at the Hebrew Home suffering from unnecessary, avoidable complications, such as overmedication and malnutrition.

This situation is compounded by the complications of treating the cognitively impaired. Elderly people with Alzheimer's or other dementias cannot communicate effectively. It takes highly trained specialists to understand their needs and diagnose and treat their illnesses.  We have found that when cognitively-impaired residents are transferred to hospitals for procedures unavailable at their nursing homes, the experience is traumatic and they often return with additional problems.

The case of an 88-year old resident of a nursing home in the New York area, graphically illustrates this point.  Mrs. K., a mildly demented woman, developed pneumonia and was transferred to a nearby hospital.  Her pneumonia was effectively treated.  Nonetheless, she received inappropriate care for her age and condition.  Due to her disorientation and loss of hearing, it was difficult for Mrs. K. to answer the questions of medical staff resulting in an incomplete medical profile. She returned to her nursing home after two weeks having lost twelve pounds and with a feeding tube in place though she had no eating problems when she entered the hospital. She was also very confused, suffered from numerous pressure sores and wore a diaper though she had not been incontinent before her hospital stay.

In our quest to answer some of the questions posed in treating the elderly, the Hebrew Home created a Research Division.  In one study, we found that the same light therapy used to treat the depression associated with Seasonal Affective Disorder is effective in treating Alzheimer's and other dementias. Residents participating in our light therapy program are calmer and more focused and their sleeping patterns become more regulated.  However, so little is known about geriatric physiology that we do not yet know why light therapy is effective.

There is no doubt that we need to know more as a geriatric healthcare crisis seems imminent. Currently, four million Americans suffer from Alzheimer's disease, and it is projected that by the year 2050, 14 million will be afflicted.  Alzheimer's is the fourth leading cause of death among Americans, taking more than 100,000 lives a year. However, the US government spends only $1 for every $320 the disease costs American society. US government investment in other diseases with similar economic and social costs, such as heart disease, cancer and AIDS, is four to seven times higher.  The implications are alarming. More research on Alzheimer's disease is needed to find treatment for what Lewis Thomas, former chancellor of Memorial Sloan-Kettering Cancer Center, called "the disease of the century."

To this end, the Hebrew Home and The New York Hospital Cornell Medical Center are the joint recipients of a $2.5 million grant from the Starr Foundation to study neurological disease in the elderly. The Starr Program for Neurogeriatric Studies will explore new ways to diagnose, correct and prevent neurological diseases, primarily Alzheimer's disease.

Though healthcare reform is now the national mantra of the United States and a high priority internationally, there is an staggering lack of long-term planning for old age, both within the family and on a national scale. Aging and death are issues that we are reluctant to confront.

Societal denial of aging is reflected by the diminished status that the aged occupy in our lives. No longer seen as a repository of wisdom or revered for their life experience, the elderly today are perceived as an expensive burden for which the rest of us are forced to pay.  One indication of this perception is the American national debate on "entitlements" and "shared sacrifice."  To many, the American retirement program, Social Security, is tantamount to another welfare program rather than the guaranteed return of money earned and accrued by our elderly population throughout their lives. 

One segment of the population increasingly hard hit by a lack of realistic long-term planning is the "sandwich generation," people in their 50's and 60's who are perhaps grandparents themselves. Not only are they grappling with the issues of retirement and healthcare in their own lives, but they are also responsible for these same issues in the lives of their parents.

In our society we do not make long-term provisions for old age, nothing is done until a crisis develops, and by then it is too late for rational planning. The expense of this head-in-
the-sand approach is staggering. The Wall Street Journal recently reported that the last two weeks of an elderly person's life can cost over $50,000 for hospitalization alone. Rather than applying band-aids to this painful situation, we should concentrate on developing expanded preventive and community care as well as wellness programs for the aged.

One way to keep costs down and also keep our elderly in optimal health is through community healthcare programs. At the Hebrew Home, we help the elderly to remain in their own homes for as long as possible, as healthily as possible. We offer a comprehensive range of programs, stressing preventive care and wellness.

There are currently 2,200 medical and social adult day care centers in the United States.  These programs provide an array of services for participants: clinical and therapeutic recreation, transportation and meals for the physically frail and/or those with dementia, socialization and health maintenance.  Some programs, including the Center at the Hebrew Home, make clinical specialties available to participants.

The Hebrew Home developed one of the first, short term residential respite programs, providing much-needed "time off" to caregivers. Short-term residents receive all medical, rehabilitative, social and other services provided to our long-term care residents leaving caregivers free for up to four weeks.

Our Long-Term Home Health Care program is available to individuals who qualify for nursing home care but prefer to live at home. Nurses and nurses' aides visit regularly to monitor and evaluate the health of the participants; they also help with daily activities such as bathing, dressing and cooking and provide companionship.

It is difficult for the elderly to receive all the medical services they need while living at home. At the Hebrew Home, we have developed an Outpatient Health Service providing general health care, visits with medical specialists, laboratory and diagnostic procedures, rehabilitation therapy, nutritional counseling and social services in one convenient location. Patients are assigned a primary care physician, who heads a team of geriatric specialists in coordinating and planning care. The goal of the program is to manage existing health problems and prevent new ones.

If enough community service is provided, the elderly can remain in the community longer and live healthier lives at less cost. If they do enter a geriatric facility, they will not be suffering from the avoidable conditions we currently encounter. In addition, most residential medical treatment could be made available at nursing homes, cutting down the number of hospital transfers needed, again saving money and maintaining the best health care possible for residents.

Another solution is publicly-funded assisted living arrangements for the elderly, which provide many more services than a traditional retirement community, yet allow residents greater autonomy than a nursing home. River House West at the Hebrew Home is one of the first models of federally subsidized housing in the United States. The apartment complex has a manager, a part-time social worker,  meal plans, social activities and a tenant emergency call system, in addition to the Hebrew Home's medical facilities which are right at hand. Such housing is currently in short supply in the United States.

By providing a continuum of care via preventive community programs; through careful planning and a clear-sighted understanding of the issues of aging; and with adequate professional resources, society and government can once again recognize aging as a fruitful, satisfying time of life - the culmination of a lifetime of growth and experience.