Caring for the Very Old

By Hannah Wallace October 31, 2005

With the nation's largest 65-plus population and the second-largest 85-plus population, Florida will be the first in the country to deal with the tidal wave of the very old. This makes Kathy Black, Hartford Geriatric Social Work Faculty Scholar and assistant professor at the University of South Florida Sarasota-Manatee School of Social Work, both worried and optimistic.

A research associate with the newly formed USF Center for Research in Healthcare Systems and Policies, Black is passionate about planning for the health and other needs of this and future generations of elders. For her, health is about much more than an annual physical. It's about mental, emotional, spiritual and physical well-being, and she believes the best and longest-lasting results can only be achieved by making economic, social and policy changes at every level.

How do the elderly fare in Sarasota and Manatee counties? Sarasota County is the second-largest county in the state for the 85-plus age group (Charlotte ranks first), and these are the frailest elders, who are also more likely to be living in poverty. The 85-plus group is growing faster than all other age groups. When we think of caregivers, the attention is on the middle-aged woman with kids on one side and parents on the other; that's not the case here.

Throughout the state, about 25 percent of the 65-plus [population] are caregivers. In the broader Manatee area, about half of these caregivers were caring for elderly parents. Some 65-plus are caring for people in their 90s and 100s. That's off the charts. The implications of that, we don't even know yet. Florida is really ahead of what the rest of the country will be facing down the road.

Did your research indicate gender or racial disparities among the elderly? At 85-plus, women greatly outnumber men. Men at every age group are more likely to be married, and women are more likely to be widowed. Older women are more disadvantaged because they don't have the work history the next generation will have, and the Social Security system is tied into work history. Chances are, these women worked at lower paying jobs with huge gaps for taking care of children.

Racial disparities are also huge. There's a large and growing body of research that indicates that race and ethnicity really matter and are associated with health status, healthcare accessibility and quality. People of color fare poorly on many health outcomes, and it is at an older age that the cumulative effects of a lifetime of inequalities come to fruition. Many people of color don't make it to old age, because of a lifetime of blue-collar jobs, poor diet and less insurance coverage along the way. Those who do are likely to have worse health.

Less than 5 percent of Sarasota and Manatee counties' elderly are of color, but they are more likely to be poor than other elders. And we do need to be thinking of the cohort to come. Florida is one of the highest growing states in ethnic diversity. We need to be culturally sensitive as far as language and many first-generation immigrants' distrust of the Western healthcare system.

Are there business opportunities in serving the elderly?b For people who are in the business of supporting caregivers and those elderly trying to live independently at home, there's a huge market. Both Sarasota and Manatee counties are severely underserved in affordable assisted living. Florida has more assisted-living beds than nursing home beds, but the bulk of those beds are expensive. Many more people who need it can't afford it, and without affordable assisted living, people can be prematurely placed in a higher and more expensive level of need.

We also have a great shortage of healthcare professionals-physicians, nurses, social workers-trained in geriatrics. Geriatrics is a very unique area. You absolutely have to look at the geriatric patient in a holistic way or you risk doing things piecemeal. For example, an estimated 50 percent of people 80 and above have dementia, and both dementia and depression are largely underdiagnosed and undertreated.

Alcoholism among elders is a huge issue, often undetected and undiagnosed. The other big one is medication overuse, everything from polypharmacy and doctor hopping. Some opportunities are there for intervening to promote mental health. The next cohort, the baby boomers, are very interested in living life to the fullest and interested in maintaining mental health. There's perhaps a market there for people to promote cognitive and mental skills.

What does the future look like for upcoming generations of elderly? Eighty percent of people 65 and older have at least one chronic condition. By 75, they have two or more. Florida is the seventh-highest state for prescription drug costs; the second-highest for Medicaid prescription drug expenses for elders. You can't cure all health problems, but you can manage them-50 percent or more of your health is in your hands. I think there's going to be a growing interest in lifestyle interventions to prevent health problems.

This cohort of elders had a more paternalistic relationship with their physicians, but the next generation has a more collaborative one. Baby boomers have a more holistic view of health; they partner more with their physicians, research drugs online and make their own decisions. Each generation is more educated, and each successive generation will reap better health benefits. I am hopeful.

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