Aging Well: What Works for Older Persons in the Community • BEATRICE RUTH BURGESS MEMORIAL LECTURE • JoAnn Damron-Rodriguez, LSCW, PhD • University of California, Los Angeles 33rd Summer Institute on Aging Living Well, Staying Well, Aging Well West Virginia University June 8, 2011
Mountain Mama, Bring Me Home 1918 to present
Youth is a Gift of Nature Age is a Work of Art Chinese Proverb
Overview of Our Considerations • Future of Aging • Preparing Practitioners • Challenges to Wellness • Promoting Wellness • Programs that Work for Wellness
OUR AGING WORLD: CHANGING THE SHAPE OF THE AMERICAN POPULATION • THE FUTURE OLDER POPULATION WILL: • BE MORE EDUCATED AND DIVERSE • BE CHALLENGED TO MANAGE CHRONIC ILLNESS • DEMAND SERVICE CHOICES • HAVE FEWER FAMILY CAREGIVERS
Boomers Living Longer • Greater expectancy of a long life • Due to advances in public health, health care and healthier lifestyles • 1900 – 47 years • 2011 – 78 years • West Virginia Aging • 3rd highest in USA • Over 15% “When I’m 64: How Boomers Will Change Health Care ”, American Hospital Association, May 2007
Cohort view of the world shaped by: Compositional Characteristics Structural Characteristics Historical period • e.g., educational system, workplace, family • e.g., gender, ethnic, life expectancy, cohort size • e.g., events, opportunities, constraints Swing Generation (G.I. Generation) 1900-1926 Silent Generation 1927-1945 Baby Boomers 1946-1964 Baby Bust (Gen X) 1965-1976 Echo Boomers (Gen Y) 1977-1994
Ageism • Relates to considering one group of people as essentially different from themselves • Similar to racism and sexism. • Names and terms to designate the other • Differentiate illness from aging • We incorporate these beliefs into who we are • Robert Butler, M.D., Pulitzer Prize Winner
Do Ageist Attitudes Hurt You? • Older individuals apply negative age stereotypes to themselves, they have: • a greater cardiovascular response to stress • and worse health behaviors, such as higher tobacco use (Levy, Slade, Kunkel, & Kasl, 2002). • these outcomes have been linked to the risk of cardiovascular events (Levy, Hausdorff,Hencke, &Wei, 2000; Levy & Myers, 2004) • When younger people hold negative stereotypes earlier in life they have consequences for health in later life. • greater likelihood of experiencing cardiovascular events up to 38 years later than individuals with more positive age stereotypes. (Levy, Zonderman, Slad & Ferrucci, 2009)
An Active Aging Framework Active aging Emphasis on autonomy/choice with aging A model of viewing aging as a positive experience of continued growth and participation in family, community, and societal activities, even when accompanied by decline in some capacities
FIGURE 1.1 The Determinants of Active Aging SOURCE: World Health Organization, Active ageing: A policy framework (WHO: 2002). Reprinted by permission of the World Health Organization.
Rowe and Kahn’s Successful Aging Model “Healthy Aging” Managing Chronic Conditions “and injury and promoting health” “optimizing” Source: Marshall, V.M. & Altpeter, M. (2005). Cultivating social work leadership in health promotion and aging: Strategies for active aging interventions. Health&Social Work, 30(2), 135-144.
II. Considering The Preparation of Practitioners for the Future Aging Workforce
Retooling for an Aging America: Building the Health Care Workforce Institute of Medicine, 2008 www.nap.edu. • The health needs of the older population need to be addressed comprehensively; • • Services need to be provided efficiently; • • Older persons need to be active partners in their own care.
Three-Pronged Approach to Building Capacity • Enhance geriatric competence of general workforce in common problems • Increase recruitment and retention of geriatric specialists and caregivers • Implement innovative models of care
Learning Objectives based on the Hartford Geriatric Social Work & Nursing Competencies • Use educational strategies to provide older persons and their families with information related to wellness and disease management 2. Include older adults in planning and designing programs. 3. Promote use of research (including evidence‑based practice) to evaluate and enhance the effectiveness of social work practice and aging related services.
4. Advocate with and for older adults and their families for building age‑friendly community capacity and enhance the contribution of older persons. 5. Address the cultural, spiritual, and ethnic values and beliefs of older adults and families including rural distinctiveness.
Geriatric Social Work Competency Scale II Please use the scale below to thoughtfully rate your current skill: 0 = Not skilled at all (I have no experience with this skill) 1 = Beginning skill (I have to consciously work at this skill) 2 = Moderate skill (This skill is becoming more integrated in my practice) 3 = Advanced skill (This skill is done with confidence and is an integral part of my practice) 4 = Expert skill (I complete this skill with sufficient mastery to teach others) 0 1 2 3 4 Not skilled Beginning skill Moderate skill Advanced skill Expert skill
Enhance the developmental, problem solving, and coping capacities of olderpeople and their families Promote the effective and humane operating of systems that provide resources and services to older people and their families; 3)Link older people with systems that provide them with resources, services and opportunities; and 4)Contribute to the development and improvement of social policiesthat support persons throughout the lifespan. Source: Berkman, Dobrof, Damron-Rodriguez & White (1997) Geriatric Social Work Defined:
Geriatric Social Work: Addressing Key Issues of Older Persons and Their Families in Today’s Delivery System Consumer Direction (Choice, Quality and Satisfaction) Family Caregiving (Family Caregiver Acts) Community Care (HCBS, Olmstead Decision) Addressing Diversity (+ Ethnic Elders)
Leading Causes of Death, Age 65+ (2001) • Heart Disease 32% • Cancer 22% • Stroke 8% • Chronic respiratory 6% • Flu/Pneumonia 3% • Diabetes 3% • Alzheimer’s 3% CDC-MIAH 2004; CDC/NCHS Health US, 2002
Underlying Risk Factors – “The Actual Causes of Death” Behavior% of deaths, 2000 • Smoking 19% • Poor diet & nutrition/ 14% Physical inactivity • Alcohol 5% • Infections, pneumonia 4% • Racial, ethnic, economic ? disparities
Threats to Health and Well-being Among Older Adults • 35% age 65 - 74 report no physical activity • 46% age 75+ report no physical activity • 24% - obese • 33% - fall each year • 34% - no flu shot • 45% - no pneumococcal vaccine • 20% - prescribed “unsuitable” medications
Chronic diseases account for75%of the $1.4 trillion we spend on health care $245 billionan average of $1,066 per person 1980 $1.4 trillionan average of $5,039 per person 2001 $2.8 trillionan average of $9,216 per person 2011 95% of health care spending for older adults attributed to chronic conditions Mensah:www.nga.org/Files/ppt/0412academyMensah.ppt#21 Heffler et al. Health Affairs, March/April 2002.
What’s the health and health care picture for Boomers? By 2030 • More than 6 of every 10 will be managing more than one chronic condition • 14 million (1 out of 4) will be living with diabetes • >21 million (1 out of 3) will be considered obese • Their health care will cost Medicare 34% more than others • 26 million (1 out of 2) will have arthritis • Knee replacement surgeries will increase 800% by 2030 “When I’m 64: How Boomers Will Change Health Care ”, American Hospital Association, May 2007
Threats to Health Among )lder Adults 73% age 65 - 74 report no regular physical activity 81% age 75+ report no regular physical activity 61% - unhealthy weight ~35% - fall each year 20% - clinically significant depression; age group at highest risk for suicide 32% - no flu shot in past 12 months 35% - never had pneumococcal vaccine 20% - prescribed “unsuitable” medications Also at greatest risk for fire-related injuries, and traumatic brain injury (age 75+) modifiable Sources: State of Aging and Health, 2007; www.cdc.gov/nchs; www.cdc.gov/ncipc/olderadults.htm
RURAL ELDERS VS. URBAN43 of 55 West Virginia Counties Rural • Higher proportion older persons (20% vs. 15%) • More likely to be poor • Only 8 of 410 counties in Appalachia equal to national income average or above • More likely to have less education • More likely to own their home • More likely to report health as fair or poor
Rural Health • Score lower (than urban and suburban)on 21 of 23 major health indicators • Smoke more • WV rank 46 • Exercise less • WV rank 32 • Eat less nutritional diets • WV rank 46 • Centers for Disease Control and Prevention (CDC) email@example.com
Boomers are provide a substantial amount of caregiving • Many serve as caregivers • >70% have at least one living parent • 25 million live with an aging parent • 13 million provide parental caregiving “When I’m 64: How Boomers Will Change Health Care ”, American Hospital Association, May 2007
Health Risks Associated with Caregiving Schulz, R. & Beach, S.R. (2009). Caregiving as a Risk Factor for Mortality: The Caregiver Health Study. JAMA, 282(23), 2215 – 2219. Increased stress and chronic stress Comprise in in physiological functioning (e.g., decrements in immunity) Less likely to engage in preventive behaviors Increased risk for serious illness An independent risk factor for mortality
IV. Considering Wellness Promotion As A Primary Focus of Aging Practice and Services
Focus on the Positive Side of Aging • Much emphases on the “negative” aspects of aging • Public health perspective: focus on strengths to compensate for deficits
“Health Promotion” • At the individual level: • People gain the skills to maintain and improve their health by adopting beneficial health behaviors • Draw on social supports • Learn to change or cope with their environments • At the community level • Improve those environments through increased access to health care • Adequate housing and transportation • Safe neighborhoods
West Virginia Cultural Strengths Rural Beatitudes Healing in the Hills Mountain State Geriatric Education Center WVU Center on Aging Hilda R. Heady, MSW Blessed are the rural for they are self-reliant and true collaborators. Blessed are the rural for they value family and friendly folks. Blessed are the rural for they value individualism, modesty and independence. Blessed are the rural for they all deserve a good life and quality health care.
What is a Health Behavior? • Actions and habits that relate to: • PRIMARY • Health promotion and prevention • SECONDARY • Health maintenance and restoration • TERTIARY • Health treatment
What Theory Can Guide Us to Change Health Behaviors? • Social Cognitive Theory • Emphasizes personal factors (e.g., beliefs) • Physical and social environmental factors • Strong emphasis on self-efficacy • Occurs in social context • Formal health care providers • Informal social network members • Physical environment
Self-Efficacy • Key construct in social cognitive theory (Bandura, 1977) • Confidence in accomplishing a specific action • Enhances or impedes motivation to act • Remember only 30% of physical and cognitive aging is attributable to genetic heritage. • We influence the rest…..
Social Cognitive Theory Applied to Chronic Illness • Illness management skills are learned and behavior is self-directed • Motivation and self-confidence (self-efficacy) are important determinants of patient’s performance • Social environment can either help or hinder • Monitoring and responding to changes in disease state improves adaptation
Definition of Self-Management of Chronic Illness (CI) • Self-care behaviors that individuals do: • In order to keep the illness under control • To minimize its impact on physical health and functioning • To cope with the psychosocial components and/or impact of the illness • Most prevalent chronic illnesses entail a significant self-management component
SOCIAL COGNITIVE MANAGEMENT PRINCIPLES APPLIED TO CHRONIC ILLNESS MANAGEMENT Assess and Specify Problem/Target Behavior Provide Follow Up Collaboratively Support Set Goal(s), Identify Barriers & Motivators Provide Personalized Coping Skills as Needed Source: Glasgow, R.E., Wagner, E.H., Kaplan, R.M., et al., 1999, page 163
Evidence-based Health Promotion • Is a process of planning, implementing, and evaluating programs adapted from tested models or interventions • Uses an public health (population) perspective • Emphasizes both prevention and treatment • Uses an ecological approach • A special thank you to Mary Altpeter, PhD, University of North Carolina, Institute on Aging and The National Council on Aging
Evidence-Based Change! • Credit to: • Administration on Aging • Centers for Disease Control and Prevention • AHRQ , NIH, SAMHSA and other federal agencies • John A. Hartford Foundation • Atlantic Philanthropies • Retirement Research Foundation • Archstone Foundation • Regional Foundations • States, localities, regional and community-based organizations
Stanford University’s Chronic Disease Self-Management Programs (CDSMP) CDSMP is available in: Arabic, Bengali, Chinese, Dutch, French, German, Hindi, Italian, Japanese, Korean, Norwegian, Punjabi, Somali, Tamil, Turkish, Vietnamese and Welsh (Russian and Tagalog coming soon)
The EBHP “Movement” • 2001: Demonstration projects (4) • 2003: Model projects (14) served 5,000 people • Programs included CDSMP, Falls, Depression, Physical Activity, Medication Management, and Nutrition • Documented fidelity and focus on evaluation • Produced replication reports • 2006: “Choices for Independence” moves into 24 states • 2007: Challenge grants (4 more states) • 2010: AoA ARRA Projects: 48 states/territories
Crosscutting Themes of Evidence-based Health Promotion Programs • Individual level • Use of effective self management • Assessment, goal setting, action planning, problem solving, follow-up • Social and familial context • Use of peer support, peer health mentors, professional support, role modeling, sharing and feedback, reinforcement • Cultural context • Saliency, appeal and adaptation to community norms, language, customs, beliefs Adapted from Nancy Whitelaw presentation, AHRQ Conference, 2006
Challenges of Evidence-Based Health Promotion: • Requires knowing where to find and how to understand/judge the “evidence” • Feels like standardization of programs rather than site-specific tailoring • Tools and processes are unfamiliar • Difficult to build community support – many prefer “home grown” to “off the shelf” Adapted from: Nancy Whitelaw, Director, NCOA Center on Healthy Aging