Introduction: Advances and Challenges in Care of Older People with Chronic Illness

This issue of Generations reviews the current approach to several common chronic medical illnesses in older adults and practice innovations to improve the care of older people with chronic illness. The ability of modem medical care to successfully treat acute infections, trauma, and other medical emergencies has allowed many Americans to live into old age, when the focus of medical treatment is now largely on the management of chronic illness. Chronic illnesses are common among older adults, and it is not unusual for individuals to simultaneously have several. In the case of chronic illness, the focus of treatment is seldom on cure, but rather on slowing the progression and limiting the resulting functional limitations. The articles in this issue document that much is known about the successful treatment of many individual chronic illnesses common among older people. The care of older people with multiple chronic illnesses is less well studied.Further, the U.S. healthcare system and Medicare continue to devote most of their available resources to treatment of the acute complications or late-stage outcomes of chronic illness. Few resources are applied to slowing the progression or preventing the complications of chronic illness. CHRONIC ILLNESS According to a common definition, chronic illnesses are "conditions that last a year or more and require ongoing medical attention and/or limit activities of daily living" (Hwang et al., 2001). Chronic conditions are more common in adults age 65 and over than in younger adults (Figure I). Common chronic illnesses in older adults include the following: hypertension, coronary heart disease, congestive heart failure, arthritis, hearing and vision disorders, diabetes, stroke disease, and cancer (National Center for Health Statistics, 2004). Eighty-four percent of individuals age 65 and over have at least one chronic illness, and 62 percent have two or more (Anderson and Horvath, 2004). For example, among older adults with hypertension, only 17 percent have hypertension alone, while the other 83 percent have at least one other chronic condition (Anderson and Horvath, 2004). Although the burden of chronic illness (referring to the consequences of the disease-the proportion of people disabled) is greater among older women, this situation is related to the longevity of women. Age-specific rates of chronic illness are comparable among men and women (Anderson and Horvath, 2004). Across all age groups, white populations have a slightly higher prevalence (46 percent) of chronic illness than do black (37 percent) or other racial groups (32 percent) (prevalence refers to the number of people who have a condition at a given time). However, black Americans are 1.5 times as likely as whites to report impairment of activities of daily living. The prevalence of chronic illness is similar across all family income levels (Anderson and Horvath, 2004). The burden that chronic illness places on the individual, families, and society is significant. Chronic illnesses, specifically heart disease, cancer, stroke, chronic lung disease and pneumonia, diabetes, and Alzheimer's disease, are among the leading causes of death in U.S. adults (National Center of Health Statistics, 2003). Living with chronic illness over many years can result in chronic pain, loss of function and independence, and increased reliance on family and friends for support. As the number of an individual's chronic conditions increases, the prevalence of functional limitations is more common (Figure 2). When surveyed, one-third of older adults reported being in fair or poor health (Burton and Kasper, 2006). The cost of medical care for older adults with chronic illness is financed by Medicare, Medicaid, private insurance, and out-of-pocket expenditures. The impact of chronic illness on medical expenditures is best illustrated by the large portion of Medicare spending directed to adults with multiple chronic illnesses. …