Aging is a Aging is a Health Disparity Health Disparity Maria Torroella Carney, MD, FACP Maria Torroella Carney, MD, FACP Commissioner Commissioner Nassau County Department of Health Nassau County Department of Health April 28, 2010 April 28, 2010 2 2 nd nd Annual Best Practices Annual Best Practices Conference Conference The Institute for Healthcare The Institute for Healthcare Disparities Disparities @ Hofstra University @ Hofstra University
Transcript
Aging is a Aging is a Health DisparityHealth Disparity
Maria Torroella Carney, MD, FACPMaria Torroella Carney, MD, FACPCommissionerCommissioner
Nassau County Department of HealthNassau County Department of HealthApril 28, 2010April 28, 2010
22ndnd Annual Best Practices Conference Annual Best Practices ConferenceThe Institute for Healthcare DisparitiesThe Institute for Healthcare Disparities
@ Hofstra University@ Hofstra University
Aging in America Aging in America in the in the
Twenty-first Twenty-first CenturyCentury
““It is our contention that official It is our contention that official
government forecasts of survival, life government forecasts of survival, life
expectancy and aging for the US expectancy and aging for the US
population may have been significantly population may have been significantly
underestimated.”underestimated.”
Aging in America in the Twenty-first Century: Demographic Forecasts from the MacArthur Foundation Aging in America in the Twenty-first Century: Demographic Forecasts from the MacArthur Foundation Research Network on an Aging Society; The Milbank Quarterly, Vol 87, No 4, 2009 (pp842-862)Research Network on an Aging Society; The Milbank Quarterly, Vol 87, No 4, 2009 (pp842-862)
U.S. Population U.S. Population Distribution Distribution 1950-2050 1950-2050
Projection of US Population 65+ is to Projection of US Population 65+ is to DoubleDouble
2000 to 2030 (in millions) 2000 to 2030 (in millions)
Source: Source:
U.S. Census U.S. Census Bureau, Aug. Bureau, Aug. 20082008
US Population US Population by Ageby Age
>18 Yrs.
25.7%
18 – 64 Yrs.
61.9%
65 +
12.4%
1 out of 8
US Residents currently
is 65 +
US Population All Ages, by Race & Ethnicity
75.14%
12.32%
3.78%
12.55%
0%
10%
20%
30%
40%
50%
60%
70%
80%
2000
Per
cen
t Po
pula
tion
White Black Asian and Pacific Islander Hispanic (all Races)
Source: U.S. Census Bureau, “Fact Sheet-American Fact Finer-Summary File 1 (SF 1) and Summary File 3 (SF 3)”; Published May 2000
Nassau CountyNassau County
Nassau CountyNassau County
15% of Nassau Residents 65 +
1,334,544 Residents: 10.1% Black & 10% 1,334,544 Residents: 10.1% Black & 10% HispanicHispanic
Nassau County Nassau County Population by Population by Race/EthnicityRace/Ethnicity
Percent of Nassau County Population by Ethnicity
10.0%
90%
Hispanic
Non-Hisp
Percent of Nassau County Population by Race
79.3%
10.1%4.7% 5.9%
White
Black
API
Other
0.0%
10.0%
20.0%
30.0%
40.0%
50.0%
60.0%
70.0%
80.0%
White Black Asian/PI Hispanic
2000 US and Nassau County Population by Race & Ethnicity
Nassau County
U.S.
MessageMessage
Nassau County is undergoing a rapid Nassau County is undergoing a rapid demographic shiftdemographic shift
Population is aging & significantly older Population is aging & significantly older than 10 years agothan 10 years ago
Population continues to be more Population continues to be more ethnically, racially and economically ethnically, racially and economically diversediverse
Data indicates these trends will continueData indicates these trends will continue
Poverty Distribution in Poverty Distribution in Nassau CountyNassau County
5.2% of Nassau County Residents are in Poverty
68,631 Residents
3.9%
10.7%
4.9%
12.4%
0.0%2.0%4.0%6.0%8.0%
10.0%12.0%14.0%
Percent
White Black API Hispanic
Race or Ethnicity
Percent in Poverty within Each Race or Ethnicity
Series1
White 3.9% Black 10.7% Asian Pacific 4.0% Hispanic 12.4%
Nassau County Poverty Nassau County Poverty Levels Levels
by Race/Ethnicity by Race/Ethnicity
Nassau County Population Nassau County Population 65+ 65+
use, high risk sexual behavior)use, high risk sexual behavior) Clinical Care – 3rdClinical Care – 3rd Social and Economic Factors – 2ndSocial and Economic Factors – 2nd Physical Environment – 32Physical Environment – 32ndnd
Environmental Quality Environmental Quality Built Environment Built Environment
Source: Robert Wood Johnson Foundation in partnership with University of Wisconsin Population Source: Robert Wood Johnson Foundation in partnership with University of Wisconsin Population Health Institute County Healthy Rankings 2010Health Institute County Healthy Rankings 2010
Access to Health Care in Access to Health Care in NassauNassau
CentersCenters 6 Hospices 6 Hospices 21 Home Health Care Agencies21 Home Health Care Agencies 12 Long Term Care Agencies12 Long Term Care Agencies 8 Prenatal Care Assistance Programs8 Prenatal Care Assistance Programs 4 Community Health Centers4 Community Health Centers 12 HIV Testing Sites12 HIV Testing Sites Urgent Care Centers expandingUrgent Care Centers expanding
Nassau Health Care Nassau Health Care Providers Providers
Over 8,000 PhysiciansOver 8,000 Physicians 2666 Primary care2666 Primary care 5368 Specialists5368 Specialists
Source: CDC Website. Life expectancy at birth in 2000 by race and sex and Health, United States 2008, table 26 American Journal of Public Health Publications, Vol. 96, No.9, September 2006.
US & New York State Life US & New York State Life ExpectancyExpectancy
71
72
73
74
75
76
77
78
79
80
81
Total Male Female
Life
Expe
ctan
cy (Y
ears)
US NY
US Life Expectancy at Birth by Race and US Life Expectancy at Birth by Race and SexSex
Source: CDC Website. National Vital Statistics Reports, Vol. 58, No.1, August 19, 2009
Comparison of Life Expectancy for Males & Comparison of Life Expectancy for Males &
FemalesFemales Between Most & Least Between Most & Least Socioeconomic Deprivation Groups Socioeconomic Deprivation Groups
Disparities between Socioeconomic Groups
60
65
70
75
80
85
1980-82
1998-2000
1980-82
1998-2000
1980-82
1998-2000
Both Sexes Males Females
Lif
e E
xpec
tan
cy (
Yea
rs)
Most Deprived
Least Deprived
Source: International Journal of Epidemiology 2006; 35:969-979
US Life Expectancy: Singh & US Life Expectancy: Singh & SiahpushSiahpush
Significant increasing gap in Most Deprived SEG– Males Life Expectancy
58.5% Residents 65+ are 58.5% Residents 65+ are OverweightOverweight
Source: Nassau County Department of Health, “Nassau County Behavioral Risk Factor Report Survey”; Published March 2007.
Obesity Trends* Among U.S. Obesity Trends* Among U.S. AdultsAdults
BRFSS, 1985BRFSS, 1985(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data <10% 10%–14%
Obesity Trends* Among U.S. Obesity Trends* Among U.S. AdultsAdults
BRFSS, 1990BRFSS, 1990(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data <10% 10%–14%
Obesity Trends* Among U.S. Obesity Trends* Among U.S. AdultsAdults
BRFSS, 1997BRFSS, 1997(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data <10% 10%–14% 15%–19% ≥20%
Obesity Trends* Among U.S. Obesity Trends* Among U.S. AdultsAdults
BRFSS, 2000BRFSS, 2000(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data <10% 10%–14% 15%–19% ≥20%
Obesity Trends* Among U.S. Obesity Trends* Among U.S. AdultsAdults
BRFSS, 2005BRFSS, 2005(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%
Obesity Trends* Among U.S. Obesity Trends* Among U.S. AdultsAdults
BRFSS, 2007BRFSS, 2007(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%
As we age, we are As we age, we are more likely to live with more likely to live with chronic disease.chronic disease.
Average Rate of Diabetes Hospitalizations by Age Nassau County, 2004-2006
African-Americans are about African-Americans are about two timestwo times more more likely & Hispanics are about likely & Hispanics are about one and one-half one and one-half timestimes more likely than their white counterparts more likely than their white counterparts to have Alzheimer's and other dementias.to have Alzheimer's and other dementias.
Although whites make up the vast majority of the Although whites make up the vast majority of the more than five million people with Alzheimer's and more than five million people with Alzheimer's and other dementias, African-Americans and Hispanics other dementias, African-Americans and Hispanics are at higher risk for developing the disease. are at higher risk for developing the disease.
Alzheimer's Association's® Alzheimer's Association's® 2010 Alzheimer's Disease Facts and Figures2010 Alzheimer's Disease Facts and Figures
Health Insurance for the Health Insurance for the AgingAging
MedicareMedicare By 2030, it is projected that 300,000 people will live to age 100+By 2030, it is projected that 300,000 people will live to age 100+
Some families have 3 generations enrolled in MedicareSome families have 3 generations enrolled in Medicare
Medicaid Medicaid
Nassau County Dept. of Social Services has identified 57,000 eligible andNassau County Dept. of Social Services has identified 57,000 eligible andmostly enrolledmostly enrolled
Many physicians do not accept Medicaid patients. Patients rely on Many physicians do not accept Medicaid patients. Patients rely on hospitalhospital
emergency departments for primary care.emergency departments for primary care.
Many enrollees do not understand how to navigate within their MedicaidMany enrollees do not understand how to navigate within their MedicaidManaged Care organization.Managed Care organization.
Privately InsuredPrivately Insured
Predictors for Placement in Predictors for Placement in Nursing HomeNursing Home
AgeAge
CaucasianCaucasian
Living aloneLiving alone
FemaleFemale
Daily Living Activities’ Dependence: toileting, feeding, bathing, dressing Daily Living Activities’ Dependence: toileting, feeding, bathing, dressing
Cognitive impairmentCognitive impairment
Socio-demographic Socio-demographic
Lack of potential sources of support Lack of potential sources of support
Hospitalization or prior Nursing Home admissionHospitalization or prior Nursing Home admission
Characteristics Predicting Nursing Home Admission in the Program of All-Inclusive Care for Elderly People, Friedman SM et al. The Gerontologist vol 45;2:157-166.Characteristics Predicting Nursing Home Admission in the Program of All-Inclusive Care for Elderly People, Friedman SM et al. The Gerontologist vol 45;2:157-166.Predicting Nursing Home Admission in the US: A Meta-analysis. JE Gaugler et al. BMC Geriatr 2007;7:13.Predicting Nursing Home Admission in the US: A Meta-analysis. JE Gaugler et al. BMC Geriatr 2007;7:13.
““We Don’t Carry That”We Don’t Carry That”
Only 25 percent of pharmacies inOnly 25 percent of pharmacies inpredominantly non-whitepredominantly non-whiteNeighborhoods had opioidNeighborhoods had opioidsupplies that were sufficientsupplies that were sufficientto treat patients in severe pain, asto treat patients in severe pain, ascompared with 72 percent ofcompared with 72 percent ofPharmacies in predominantlyPharmacies in predominantlywhite neighborhoods.white neighborhoods.
RS Morrison et al. “We Don’t Carry That” – Failure of Pharmacies in Predominantly Nonwhite RS Morrison et al. “We Don’t Carry That” – Failure of Pharmacies in Predominantly Nonwhite Neighborhoods To Stock Opioid Analgesics. N Engl J Med 2000;342:1023-6Neighborhoods To Stock Opioid Analgesics. N Engl J Med 2000;342:1023-6
Geographic: Geographic: Transportation resources; shortage of accessible physiciansTransportation resources; shortage of accessible physicians
Cultural Cultural
Socioeconomic Socioeconomic
Organizational:Organizational:Lack of interpreters; wheelchair accessibility; lack of universal Lack of interpreters; wheelchair accessibility; lack of universal designdesign
Psycho-social:Psycho-social: Stigma; denial, fear, lack of advocacyStigma; denial, fear, lack of advocacy
Physician-Patient Communication Physician-Patient Communication BarriersBarriers
Speech or language articulationSpeech or language articulation Foreign languageForeign language Time constraintsTime constraints Inability of physician or patient to meet face Inability of physician or patient to meet face
to faceto face IllnessIllness Altered Mental StatusAltered Mental Status Medication EffectsMedication Effects Psycho-social factorsPsycho-social factors Gender differencesGender differences RacialRacial or cultural differencesor cultural differences
JAOA Vol 105, No 1, Jan 2005, pp13-18JAOA Vol 105, No 1, Jan 2005, pp13-18
Kleinschmidt KC. Elder Abuse: A Review; Ann Emer Med 1997 Oct; 30 Kleinschmidt KC. Elder Abuse: A Review; Ann Emer Med 1997 Oct; 30 (4):463-72(4):463-72
Elder Abuse Risk FactorsElder Abuse Risk Factors A Major precipitating factor: Family A Major precipitating factor: Family
Domestic Violence Grown OldDomestic Violence Grown Old Cycle of Family ViolenceCycle of Family Violence Lack of Financial ResourcesLack of Financial Resources Psychopathology in AbuserPsychopathology in Abuser Lack of Community SupportLack of Community Support Caregiver StressCaregiver Stress
National Center of Elder Abuse; US Administration on Aging National Center of Elder Abuse; US Administration on Aging 8/21/20078/21/2007
jeopardyjeopardy Language barriersLanguage barriers Unfamiliar with American institutionsUnfamiliar with American institutions Lack of transportationLack of transportation Financial difficulties Financial difficulties Stigma/shame in asking for helpStigma/shame in asking for help Importance of Keeping Individual Problems from Importance of Keeping Individual Problems from
OutsidersOutsiders Mistrust of Mainstream ServicesMistrust of Mainstream Services
Falicov CJ. The Latino Family Life Cycle.Falicov CJ. The Latino Family Life Cycle.
Sanchez YM. "Elder mistreatment in Mexican American communities: The Nevada and Sanchez YM. "Elder mistreatment in Mexican American communities: The Nevada and Michigan experiences.” Michigan experiences.”
So DW, Gilbert S, Romero S. "Help-seeking attitudes among African American college So DW, Gilbert S, Romero S. "Help-seeking attitudes among African American college students." students."
Cultural Norms and Values Cultural Norms and Values about Family and Elderlyabout Family and Elderly
African Americans – kinship, African Americans – kinship, extended family networksextended family networks
Asian-hierarchical by age and Asian-hierarchical by age and gender, family networks - Respectgender, family networks - Respect
Hispanic/Latinos-respect to eldersHispanic/Latinos-respect to elders Native Americans –elderly repository Native Americans –elderly repository
Cultural Diversity at End Cultural Diversity at End of Lifeof Life
Emphasis on Individualism versus Emphasis on Individualism versus CollectivismCollectivism
Definition of FamilyDefinition of Family Common views of gender roles, child-Common views of gender roles, child-
rearing practices, care of older adultsrearing practices, care of older adults Views of Marriage and relationshipsViews of Marriage and relationships Communication patternsCommunication patterns Religious and spiritual-belief systemsReligious and spiritual-belief systems Views of physiciansViews of physicians Views of sufferingViews of suffering Views of afterlifeViews of afterlifeCultural Diversity at the End of life: Issues and Guidelines for Family Physicians. HR Cultural Diversity at the End of life: Issues and Guidelines for Family Physicians. HR
Searight. Am Fam Physician 2005 Feb 1;71(3):515-522.Searight. Am Fam Physician 2005 Feb 1;71(3):515-522.
Advance DirectivesAdvance Directives
Health Care Proxy Health Care Proxy Living WillLiving Will Do Not ResuscitateDo Not Resuscitate At Home Do Not ResuscitateAt Home Do Not Resuscitate MOLST: MOLST:
Medical Orders for Life–SustainingTreatmentsMedical Orders for Life–SustainingTreatments
40% Elderly white 40% Elderly white compared to compared to
16% of Elderly blacks 16% of Elderly blacks have advance directiveshave advance directives
Cultural Diversity at the End of life: Issues and Guidelines for Family Physicians. HR Searight. Am Fam Physician 2005 Feb 1;71(3):515-522.Cultural Diversity at the End of life: Issues and Guidelines for Family Physicians. HR Searight. Am Fam Physician 2005 Feb 1;71(3):515-522.
A’s of AgingA’s of Aging
AwarenessAwareness
Alert to a problemAlert to a problem
Access CareAccess Care
AdvocacyAdvocacy
NOWNOW Life expectancy is shorter in Blacks & Life expectancy is shorter in Blacks &
HispanicsHispanics
Lifespan has improved over time; however, Lifespan has improved over time; however, at a slower rate for more deprived at a slower rate for more deprived populationspopulations
Aging in itself poses challenges. These Aging in itself poses challenges. These challenges are exacerbated in minority and challenges are exacerbated in minority and socioeconomically deprived populations socioeconomically deprived populations
FutureFuture More Research on Health Disparities in Aging is More Research on Health Disparities in Aging is
neededneeded Additional medical Geriatric; health education and Additional medical Geriatric; health education and
training training Enhance Screening at earlier ages for at risk Enhance Screening at earlier ages for at risk
populationspopulations Increase Education and Awareness Programs Increase Education and Awareness Programs Utilize Medical Reserve Corps for Outreach Utilize Medical Reserve Corps for Outreach Educate Health professionals, insurance companies, Educate Health professionals, insurance companies,
hospitals on the importance of Health Literacy hospitals on the importance of Health Literacy EducationEducation
Expansion of Medicare – Ideal Expansion of Medicare – Ideal Health Care Reform to comeHealth Care Reform to come
