Technology and Aging in America

June 1985

NTIS order #PB86-116514
Recommended Citation:

Technology and Aging America (Washington, DC: U.S. Congress, Office of Technology

Assessment, OTA-BA-264, June 1985).

Library of Congress Catalog Card Number 84-601137

For sale by the Superintendent of Documents

U.S. Government Printing Office, Washington, DC 20402
Foreword

Rapid technological change in American society has been accompanied by accelerating growth of

the population over 65. Older persons now outnumber teenagers in the United States; by 2025 the ratio

will be more than 2 to 1 and the older population will have notably larger proportions in the oldest

ages. New challenges will face the public and private sectors in both responding to the needs and utilizing the resources of older Americans.

This assessment was requested by the Senate Special Committee on Aging and the House Select Committee on Aging. A letter of endorsement was received from the House Committee on Education and

Labor. The study focuses on the functional status of the elderly and ways in which technology can assist

them to maintain their independence and enhance their quality of life. Recent significant improvements

in longevity of the elderly have led to rising prevalence of chronic diseases that impair their ability to

function independently.

The report discusses five chronic conditions that severely affect older persons-steoarthritis, dementia, osteoporosis, hearing impairments, and urinary incontinence. The potential health improvements

from behaviors that may delay the onset of chronic diseases, the need for increased biomedical research

into the causes of these diseases, and methods to encourage behaviors that promote health are also

reviewed. Special attention is given to the potential impact of telecommunications in the home and community in promoting self -health care among the elderly. The importance of medication for management

of chronic impairments is also assessed, but much remains unknown about the particular effects of

drugs on older persons. The report stresses the need for a coordinated approach to long-term care and

improved technologies to assess health and functional status. A wider range of options for supportive

services and settings would more appropriately respond to the different needs among the older population. Because Federal and State reimbursement policies influence the availability of health and longterm care services, changes in reimbursement criteria can promote such options.

The housing and living environment of the elderly are also described. Federal programs that subsidize rental housing for the elderly could pay greater attention to coordination of community-based services

with these housing programs. New design standards that promote safety and improve the elderly’s ability

to be self-sufficient are also stressed. Modern construction technologies more easily allow existing singlefamily units to be renovated for the elderly. Shared housing, residential care facilities, accessory units,

and other types of residences would expand the housing choices available to older Americans. The study

also evaluates the impact of changes in workplace technology, Job security may be weakened in some

industries, while in others it can enhance job performance, safety, and security for older workers. Telecommunications are making the “electronic cottage” a reality and older persons may be able to take

advantage of emerging opportunities for home-based work arrangements. Finally, the retraining of older

workers would encourage continued employment or provide new employment possibilities.

OTA was assisted in the preparation of this study by an advisory panel of individuals representing

a wide range of backgrounds, including geriatrics, health policy, biology, gerontology, demography, economics, academia, private industry, labor, and advocacy organizations. More than 80 reviewers drawn

from universities, governmental agencies, and the private sector provided helpful comments on draft

reports.

OTA expresses sincere appreciation to each of these individuals. As with all OTA reports, the content is the responsibility of the Office and does not necessarily constitute the consensus or endorsement

of the advisory panel or the Technology Assessment Board.

Director

. . .

Ill
Technology and Aging in America Advisory Panel*

Robert Binstock, Panel Chair

Director, Policy Center on Aging, Brandeis University

Raymond Bartus

Group Leader of Geriatrics

Medical Research Division

Lederle Laboratories

Robert Berliner

Dean

School of Medicine

Yale University

Robert N, Butler

Chairman

Department of Geriatrics and Adult

Education

Mt. Sinai Medical Center

Robert Clark

Associate Professor

Department of Economics and Business

North Carolina State University

Lee L. Davenport

Senior Vice President-Chief Scientist, emeritus

GTE Corp.

Ken Dychtwald

president

Dychtwald & Associates

Caleb Finch

Professor of Biological Sciences and

Gerontology

University of Southern California

Velma Murphy Hill

Director

Civil and Human Rights Division

Service Employees International Union

Robert L. Kane

Senior Researcher

The Rand Corp.

Paul A. Kerschner

Associate Director for Programs, Legislation

and Development

American Association of Retired Persons

Maggie Kuhn

Founder and National Convener

The Gray Panthers

“Panel members’ affiliations are listed at the time the assessment began.

Matt Lind

Vice President

Corporate Planning and Research

The Travelers Insurance Co.

Robert G. Lynch

Vice President

Marketing Planning

GTE Corp.

Mathy D. Mezey

Director

Teaching Nursing Home Program

University of Pennsylvania

Hamish Munro

Professor of Medicine and Nutrition

Tufts University

Bernice Neugarten

Professor of Education and Sociology

Northwestern University

Sara Rix

Director of Research

The Women’s Research and Education

Institute

Pauline Robinson

Research Professor of Gerontology

University of Southern California

John W. Rowe

Chief of Geriatrics

Beth Israel Hospital

Bert Seidman

Director

Department of Occupational Safety, Health

and Social Security

AFL-CIO

Jacob Siegel

Senior Researcher

Center for Population Research

Georgetown University

NOTE: OTA appreciates and is grateful for the valuable assistance and thoughtful critiques provided by the advisory panel members. The views expressed

in this OTA report, however, are the sole responsibility of the Office of Technology Assessment.

iv
OTA Project Staff—Technology and Aging in America

H. David Bantal and Roger C. Herdman, Assistant Director, OTA

Health and Life Sciences Division

Gretchen S. Kolsrud, Biological Applications Program Manager

Robert A. Harootyan, Project Director

David McCallum,2 Project Director

Debora E. Burch, Research Analyst

Susan Clymer, Research Analyst

Robert M, Cook-Deegan, Senior Analyst

Catharine Maslow, Research Analyst

Eleanor Pitts, Research Assistant

Gloria Ruby, Analyst

Louise A. Williams, Senior Analyst

Phyllis Avedon, Project Editor

Special Contributor s

John Grana, Deputy Director, Center for Health Information, Project HOPE

Zaven Khachaturian, Chief, Physiology and Aging Branch, National Institute on Aging

Sheila Taube, Chief, Biochemical Diagnosis Section, National Cancer Institute

Support Staff

Fatimah Scott3 and Elma Rubright, Administrative Assistant

Teri Miles4 and Linda Rayford, Secretary

R. Bryan Harrison, Office Automation Systems Analyst

Major Contractor s

G. Becker, Aging Health Policy Center, University of California, San Francisco

T. Borzilleri, Consultant on Economics and Aging

C. Paul and S. Coberly, Andrus Gerontology Center, University of Southern California

M. Kohrs, Consultant on Nutrition and the Elderly

B. Lessard, Consultant on International Aspects of Aging

R. McGandy, Human Nutrition Research Center on Aging, Tufts University

J. Ouslander and Associates, Consultants on Urinary Incontinence in the Elderly

B. Skurdenis, Research Consultant, Western Gerontological Society

Related Activities and Products

“The Impact of Technology on Long-Term Care,” a workshop jointly sponsored by OTA, Project

HOPE, and the National Health Policy Forum (held February 1983)

Impacts of Neuroscience, OTA Background Paper

Management of Hearing Impairment in the Elderly, OTA Background Paper

Technologies for Managing Urinary Incontinence, OTA Case Study

1Assistant Director until August 1983.

‘Project Director until September 1983.

3Administrative Assistant until August 1983.

Secretary until October 1983.
Contents

Chapter Page

I. Executive Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

2.Introduction: Technological Change and the Older U.S. Population . . . . . . . 33

3. Selected Chronic Conditions, Technology) and Biomedical Research . . . . . . . 61

4. Health Promotion/Disease Prevention and Nutrition in the Elderly . . . . . . . . 119

5.Medications and the Elderly . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 137

6. Information Technology and the Health of an Aging Population . . . . . . . . . . 159

7.Technologies, Functional Impairment, and Long-Term Care. . . . . . . . . . . . . . 185

8.Health Care Costs and Access to Technology for Older Persons . . . . . . . . . . 249

9.Technology, Housing, and the Living Environment of the Elderly. . . . . . . . . 277

10. Workplace Technology and the Employment of Older Adults ..., . . . . . . . . 335

Appendixes

A.Morbidity and Mortality Data. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 369

B. The Cell Biology of Aging . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 413

C. Nutrition Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 421

D.Biotechnology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 447

E. Workplace Technology and the Employment of Older Adults. . . . . . . . . . . . . 458

F. Glossary of Terms and Acronyms for Technology and Aging in America . . . 479

G.List of Contractors. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 485

Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 489
Chapter 1

Executive Summary
Contents

. .

Introduction . ... , . . . . . . . ., . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . , . . . . . . . . . . . . . . .

Definitions and FOCUS . . . . . . . . . . . . ..., . . . . . . . . . . . . . . . . . . . . . ..., . . . . . . . . . . . .

Changes in Health Status . . . . . . . , . . . . . ..., . . . . , . . . . . . . . . . . . . . . . . . . . . . . . . .

Population Aging and Changes in Selected Chronic Conditions . . . . . . . . . . . . . . . . .

Health Promotion/Disease Prevention and Nutrition . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Medications and the Elderly . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Changes in Health Services . . . . . . . . . . . . , . . . . . . . . . , . . . . , . . . . . . . . . . . . . . . . .

Information Technology and Health Care of the Elderly . . . . . . . . . . . . . . . . . . . . . . , .

Functional Impairment and Long-1’erm Care . . . . . . . . . . . . , . . . . . . . . . . . . . . . . . .

Health Care Costs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Social Changes in the Living Environironment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Housing and the Living Environment . . ., . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Work-Related Changes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Workplace Technology and the Employment of older Adults . . . . . . . . . . . . . . . . . . . . .

Conclusion . , . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . , . . . . . . . . . .

Figures

Page

3

7

7

7

10

13

15

15

18

21

22

23

24

27

30

FigureNo. . Page

1. Number of Teenagers and Older Persons, United States, 1970-,2050 , . . . . . . . . . . . . 3

2. Fertility Rates per 1,000 Women Aged 15 to 44 Years, United States, 1930-82 . . . . 5

3. Infant and Neonatal Mortality Rates, United States, 1930 -82., . . . . . . . . . . . , . . . . . . . 5

4. Crude and Age-Adjusted Death Rates, United States, 1930 -82. . . . . . . . . . . . . . . . . . . . 6
Chapter 1

Executive Summary

Introduction

This century is witnessing unprecedented demographic and technological changes in American

society. There have been significant gains in life

expectancy, both at birth and at the older ages.

Declining fertility rates have “aged” the U.S.

population, and there have been major improvements in health status.

By 1980, for the first time in the history of the

United States, 50 percent of all Americans were

over 30. Today there are more persons over 65

than there are teenagers. The elderly population

has grown from 4.0 percent of the total in 1900

to mm-e than 11.5 percent in 1983. The number

of those over 65 is projected to grow from today’s

27 million-to an estimated 39.3 million by 2010,

when they will constitute almost 14 percent of

the Nation’s population.

More significantly, between 2010 and 2020 the

older population is expected to increase by more

than 12 million, when the first wave of the baby

boom cohort becomes the elderly boom of the future. By 2025 there will be more than twice as

many older Americans as teenagers (see fig. 1).

These demographic trends are due in large part

to technological changes since 1900-changes

whose pace is accelerating. This technological

revolution has major implications for all aspects

of society.

During this century, improved technologies

have increased life expectancy at birth from an

average of 47 years in 1900 to more than 74 years

in 1982, These technological improvements in-

‘For purposes of this assessment, the elderly population is generally defined as all persons aged 65 and over, although in designated cases the age identifier can be as low as 40 years or as high

as 85 years (the very old).

Technology” is broadly defined here to include the development

of knowledge and its application to solving practical tasks and problems; it also refers to such factors as biomedical research into the

causes of arthritic conditions, as well as wheelchairs used by persons suffering from severe arthritis. Technology can be “soft” (research and knowledge) or “hard” (products of research), and “high”

(complex) or ‘(low” (simple),

elude advances in public hygiene and sanitation,

reductions in the prevalence of infectious diseases

through immunization and antibiotics, and the

continued improvement and accessibility of general health care to all persons. The effects of these

advances have been most noticeable at the earliest ages, where dramatic improvements have increased the probability of surviving beyond the

first year of life. Almost four-fifths of all babies

born this year can expect to live to age 65; only

two-fifths of babies born in 1900 could expect

to do 80,

More recent technological advances have

helped reduce mortality rates at the older ages.

During the past 15 years, sharp reductions in

death rates from two major killers-heart disease

Figure l.— Number of Teenagers (Aged 13 to 19) and

Older Persons (Aged 65 and Over), United States,

1970-2050 (number in millions)

Number 7 0

60

50

40

2050

Year

SOURCE: Population Reference Bureau, Population Today, vol. 12, No. 1, January

1984.

3
4 ● Technology and Aging in America

and stroke—have caused mortality rates among

the elderly to plummet. Death rates fell more

sharply during this period than during any 15-

year period in U.S. history. More than half of the

improvement in life expectancy for the elderly

since 1950 has occurred in the past decade. Recent age-specific mortality rates indicate that this

accelerating pace of improvement in life expectancy at older ages will continue for the foreseeable future. The most dramatic changes are the

increases in the proportions of people surviving

to the oldest ages (i.e., 75 or 85 years). Other technologies may lead to changes in the aging of cells

that could have consequences for the human life

span)

3 as discussed in chapter 2.

The ‘(newness’) and swift pace of these gains

in” life expectancy at older ages signify a new era

in the changing demographic structure of the

United States that has important consequences

for all aspects of society. This era is also characterized by rapid technological advances in the

ability to plan fertility4 (e.g., oral contraceptives,

intrauterine devices), enabling individuals to more

closely realize their childbearing preferences. The

post-World War II baby boom was abruptly succeeded by the “baby bust” of the last decade. Fertility has been as important a factor as mortality

in determining the changing age structure of the

Nation’s population. Among the significant and

unprecedented demographic changes of recent

decades are:

●

●

dramatically lower fertility rates among

women of childbearing age, a trend that

began in the late 1950s and recently stabilized

at a rate below replacement level (see fig. 2);

similarly dramatic reductions in infant and

neonatal mortality rates5 over more than half

‘(’Life span” is the biological upper age limit that a human can

potentially reach, currently considered to be about 120 years.

4’Fertility is a measure of the number of live births within a

population, such as “number of births per 1,000 women aged 15-

44”. Fertility measures do not account for stillbirths and aborted

pregnancies, whether induced or spontaneous.

The current U.S. infant mortality rate of 10.9 (deaths to infants

under 1 year of age per 1,000 live births) ranks 14th in the world,

The lowest rates are 6.5 in Finland and 6.8 in Sweden, while many

developing countries have rates well above 100 (e.g., 134 in Nigeria and 153 in Liberia). Thus, the relative possible improvement in

the U.S. infant mortality rate is very small when compared with

rates in most other countries.

●

a century that are approaching an expected

minimum possible level (see fig. 3); and

sharp declines in the age-adjusted death

rates6 of the total population since 1930 (see

fig. 4).

In combination, these demographic trends have

produced an aging population that is characterized by accelerating increases in life expectancy

at the oldest ages. Moreover, the gains in life expectancy at birth and at older ages have consistently been greater for females than males; there

are now 5 million more older women than older

men in the United States.

The effect of technology on population structure is expected to continue. For example, the median age, which rose only 0.6 years between 1960

and 1980, is expected to rise by 3.3 years between

1980 and 2000. That this significant demographic

shift will occur during such a short interval

underscores the increasing pace of population

aging in the United States. Potential consequences

include changes in the structure of families, more

older persons living alone (four-fifths of them

women), more older workers, and a growing market for services and products to the elderly. In

general, this profound demographic transformation is likely to change both the resources older

persons have to offer and the allocation of resources offered to them.

These changes may occur even faster than is

currently anticipated. Previous demographic

projections have underestimated the rate of

change in population aging due in part to difficulties in anticipating the development of new

technologies and their short= and long-term effects on fertility and mortality.7 The phenome-

‘In contrast to “crude rates, “ ‘(age-adjusted” rates control for the

effects of age-structure differences in a population over a period

of time. Analogous to the use of “constant dollars” in economic analyses, they are the best indicators of actual change in demographic

rates over time.

The Bureau of the Census projections for the older population

have consistently underestimated the number of older persons in

future decades. For example, in 1977 the bureau attempted to account for changing mortality rates among the elderly by increasing its 1975 projections of the older population for 2000 from 28.8

million to 31.9 million. The latest revisions are for almost 34.1 million elderly in 2000. In less than a decade the projections of this

population have been increased by 18 percent in response to the

most recent effects of technological advances in health and medical care.
Ch. I—Executive Summary 5

130

120

0

0

0. 80

T

) 70

6(

Figure 2.—Fertility Rates per 1,000 Women

Aged 15 to 44 Years, United States, 1930-82

130

120

110

100

90

80

70

60

0

0

1940 1950 1960 1970 1980 1990

1930

Year

SOURCE: National Center for Health Statistics, “Annual Summary of Births, Deaths, Marriages, and Divorces: United

States. 1982.” Monthly Vital -. —..., Statistics Report, vol. 31, no. 13, DHHS publication No. (PHS)83-1 120 (Hyattsvine, MD: Public Health Service, October 1983).

>. -

0

0

0“

70 

60

50

40

30

20

10

0

Figure 3.—infant (Under 1 Year) and Neonatal

(Under 28 Days) Mortality Rates, United States, 1930-82

7 0

0

1930 1940 1950 1960 1970 1980 1990

Year

SOURCE: National Center for Health Statistics, “Annual Summary of Births, Deaths, Marriages, and Divorces: United

States, 1982,” Monthly Vital Statistics Report, vol. 31, no. 13, DHHS publication No. (PHS)83-1 120 (Hyattsville, MD: Public Health Service, October 1983).
6 Technology and Aging in America

Figure 4.-Crude and Age-Adjusted Death Rates,

United States, 1930.82

1,300

1,200

1,100

1,000

900

800

700

600

500

0 0

1930 1940 1950 1960 1970 1980 1990

Year

SOURCE: National Center for Health Statistics, “Annual Summary of Births, Deaths, Marriages, and Divorces: United

States, 1982,” Monthly Vital Statitics Report, vol. 31, no. 13, DHHS publication No. (PHS)83-1 120 (Hyattsville, MD: Public Health Service, October 1983).

nal pace of current changes is readily apparent

in other areas of technology. For example, a

microprocessor measuring less than 3 inches on

a side now has the capability of a computer that

20 years ago was the size of an average business

office. The rate of increase in storage capacity of

computer memory chips has been exponential,

rising from the 1-bit chip in 1970 to today’s current chip with more than 250,000 bits; recent development of an experimental l-million-bit chip

indicates that its commercial mass production is

only a few years away. Dramatic technological

changes such as these have future consequences

that can only be partly envisioned. Similarly, although the societal effects of technological change

and the aging of the population are only partly

foreseeable, they are likely to be felt in various

ways:

● Changes in health status. The prevalence of

chronic illnesses and attendant functional im -

●

●

●

pairments among the elderly will rise as the

proportions of those in the oldest subgroups

increase.

Changes in health services. The need for

social and health care services (i.e., long-term

care) for chronic conditions will grow, as will

the demand for medical care for treatment

of acute illnesses.

Social changes in the living environment.

Significant changes are expected in family

structure, living arrangements, and the housing environment of the elderly; more older

persons will live alone, and people over 55

will be more likely to have a very old parent

still alive.

Work-related changes. older workers may

be particularly vulnerable to the impact of

new methods of production and workplace

technologies, and to changes in the skills required of the labor force.
Ch. I—Executive Summary . 7

This assessment describes the reciprocal rela- summarizes the major components of this study

tionship between technology and aging in Amer- and highlights its major findings. Selected issues

ica by focusing on these four general topics. arising from each area are presented for congresChanges in these areas are interdependent and sional consideration. Full development of the

offer both broad challenges and striking oppor- issues and possible congressional options are contunities to society. The balance of this chapter tained in chapters 3 through 10.

Definitions and focus

In keeping with congressional requests and the

advice of the Technology and Aging Advisory Panel, the term technology is broadly defined in this

assessment. It is viewed as both a collection of

devices or gadgets (i.e., hard technology) and the

development of knowledge or an organizational

system (i.e., soft technology). The two types of

technology form the ends of a continuum. Within

the continuum, the most relevant types of technology have been selected for each of the substantive areas. Knowledge and research are thus

stressed in some instances, and hardware and devices in others.

Another dimension of technology is its degree

of complexity, which can range from simple “lowtechnology” devices such as stair safety treads to

complex “high-technology’l equipment such as the

computerized axial tomography (CAT) scan used

for medical diagnosis. The range of technological complexity and types leads to different approaches and findings for each major subject of

this assessment, which accordingly covers a variety of issues and options for congressional consideration.

A general theme, however, prevails throughout. The most important variable in this assessment of the relationship between technology

and aging is the physical and mental functioning of older persons. Most people do not fear

‘(growing old” so much as they fear becoming

chronically ill or frail The “vitality’) of older

people-their ability to remain functionally independent, or to be minimally dependent on

various types of assistance-is the fundamental

characteristic that determines their quality of

life at home, in the workplace, and within the

community. The extent to which various technologies can improve the ability of older persons

to maintain this vitality is a major focus of this

report.

Changes in health status

population aging and changes in diseases of the heart and blood vessels have also

begun to change as a result of diet, personal hab - selected chronic conditions * its, and improved health care. If these trends conThe second half of the 20th century has seen tinue, several predictions can be made:

a dramatic shift in the types of diseases afflicting ●

people, especially in technologically advanced

countries. The incidence of many infectious dis- ●

eases has fallen sharply as sanitation has improved and vaccines have been developed; many ●

of the remaining infectious diseases can be effectively treated with antibiotics. Death rates from

● These issues are examined in detail in chs. 2 and 3 and app. A.

life expectancy at older ages will continue to

rise, as will the median age of the population;

diseases whose incidence rises with age will

become more prevalent;

environmental, behavioral, and dietary factors affecting health may become more important because individuals will live through

longer periods of exposure and have more

time to develop symptoms; and
8 ● Technology and Aging in America

. new and unexpected medical problems may

appear.

As death rates from vascular diseases decline,

the prevalence of other chronic health conditions

such as dementia, arthritis, cancer, deafness, poor

vision, and other currently incurable and unpreventable ailments is likely to increase. The progression from infectious to cardiovascular to

other chronic conditions has followed the path

of clinical ignorance; the disorders that are now

most common are those about which the least

is knowm Far more is understood about the

cause of tuberculosis (now rare) than about the

causes of Alzheimer disease* (the most common

disorder causing dementia among the elderly).

There are four general strategies for dealing

with chronic health conditions:

 treatment of acute episodes of illness arising

from underlying chronic illness;

● long-term medical treatment or long-term

care;

● prevention; or

● research to improve diagnosis, treatment,

and prevention.

Each of these strategies is influenced by Federal policy; a balanced approach is required for

effective control of chronic disease. Current Federal policy tends to favor acute care over preventive strategies, long-term care, or research. In

surveying the conditions that most affect the

elderly population of the United States, OTA, with

the assistance of the Technology and Aging Advisory Panel, chose five conditions as especially

worthy of review, using the following seven

criteria:

●

●

●

the condition is an important cause of death

and disability among the elderly population

due to severity or prevalence;

the condition is chronic and persistent among

the elderly;

the impact on caregivers, including family

members and friends, is a significant

hardship;

This assessment uses the term “A1zheimer disease” (instead of

the more familiar “Alzheimer’s disease”) in accord with recommended usage by the American Academy of Neurology and the

American Neurological Association and their respective journals.

● the condition contributes to functional impairment and the demand for long-term care,

a major focus of this assessment;

● easily readable and up-todate summaries of

the state of science and medicine regarding

the condition are not readily available;

● technology is relevant to correction of or

compensation for the condition; and

● Congress has recently demonstrated a special

interest in the condition.

The five chronic conditions reviewed are de

mentia, urinary incontinence, hearing impair

ment, osteoporosis, and osteoarthritis

Dementia was selected because Alzheimer disease and other dementing illnesses will become

overwhelming health problems unless means for

prevention or treatment are found. These diseases are severe, affect an important aspect of

human function–mental ability-and are the

most common determinants of need for long-term

care. There are as yet no reliable or specific

means of accurately diagnosing dementing disorders, although improvements have been rapid

in recent years. Further, these disorders are probably not single entities, but combinations of related but biologically distinct diseases that have

not yet been scientifically differentiated.

The main policy options relating to Alzheimer

disease and dementia thus concern long-term care

for demented patients and biomedical research.

Although the ultimate solutions to dementing illness must come from research, they are not likely

to be achieved in the short term, despite recent

advances in knowledge of these conditions; the

problem of caring for demented patients for the

final years of their lives will be very great for a

number of years to come. The social and economic value of successful research in this area

is enormous.

Urinary incontinence is a growing problem

among the elderly, and is another major reason

for institutionalization. It is a common symptom

of different neurological, endocrine, vascular, and

urological diseases that can now be treated with

technologies ranging from absorbent pads to sophisticated mechanical devices and surgery. Difficulty persists in diagnosing the condition among

the noninstitutionalized elderly, who often do not
Ch. I—Executive Summary ● 9

seek medical attention or do not admit to what

can be an embarrassing problem. Because many

of the relevant technologies are just coming to

fruition, incontinence should be far more effectively treated or managed in the future. g

Discussion of the problem of incontinence and

potential policy issues centers on the substantial

delay in developing appropriate technologies, as

well as possible drawbacks of present technologies. Improvements in this area could notably

reduce the nursing home population and permit

families to directly care for their incontinent dependents for a longer period of time. Equally important would be the great improvement in the

quality of patients’ lives.

Hearing impairments affect almost 30 percent

of all older Americans; 23 percent of those aged

65 to 74 and almost 40 percent of those over 75

suffer some hearing loss. Most hearing impairments of the elderly cannot be corrected with

available medical or surgical techniques, but technologies such as hearing aids and assistive listening devices can compensate for some forms of

hearing loss. But the adaptation of appropriate

technology to specific hearing defects of patients,

especially elderly patients, has had limited success. The potential for improvement of hearing

is substantial if diagnosis is made early enough,

if patients can be convinced of the value of correction, and if industry can adapt to better serving patients’ needs .10 Technological innovation in

this area promises to be rapid over the next

decade.

Federal policy issues include assurance of patient safety in public places (e.g., mandating

alarms that can warn those with hearing impairments of danger), reimbursement policy for Medicare and Medicaid (which currently offer little

support for those with hearing impairments), increased regulation of the hearingdevices industry, and sponsorship of training and research.

Osteoarthritis, which affects 16 million to 20

million older Americans, is the largest single cause

VT’his subject if more fully discussed in the forthcoming OTA case

study on “Technologies for Managing Urinary Incontinence”

(January 1985).

1’JFor a detailed review, see the forthcoming OTA background

paper on “Management of Hearing Impairment in the Elderly”

Uanuary 1985).

of disability among the elderly. Radiologic evidence of osteoarthritis is found in over four-fifths

of persons over 70. Technological issues related

to osteoarthritis include a relative lack of basic

scientific knowledge about the biology of cartilage, a need for preventive strategies, the potential for reducing pain and suffering for a large

proportion of patients, and the enormous expense

of current therapies, particularly joint replacement surgery. Like dementia, osteoarthritis is in

need of expanded research that could lead to discoveries for effective prevention and cure.

Osteoporosis is a disease process involving

thinning of bones. Its most devastating consequences are fractures of the vertebrae and long

bones, which are especially common in elderly

women. Fractures of the hip often result in death

or extended periods of rehabilitation, chronic impairment, or nursing care. Current evidence suggests that osteoporotic fractures are amenable to

prevention by such methods as increasing calcium

intake and postmenopausal administration of estrogens, but a definitive preventive protocol has

not been established because the various regimens used in routine practice have not yet been

rigorously compared.

SELECTED ISSUES*

Effective treatment or prevention of these five

chronic disorders is needed, and adaptation of

technology to compensate for the ravages of

chronic disabilities will be increasingly in demand

in future years. For conditions that can be ameliorated by existing technologies, such as some

types of hearing impairments and incontinence,

the availability, application, and improvement of

such technologies is a priority. Other policy considerations include possible oversight to promote

increased awareness and sensitivity to the extent

of chronic illnesses among the elderly and the possibilities for their management.

Research on chronic diseases, however, provides the only possibility for their ultimate elimination. For this reason, two general issues merit

congressional attention:

*For brevity, only the most important issues for congressional

consideration are presented in this chapter. These and other issues,

each with a number of options, are discussed in greater detail in

their respective chapters. See ch. 3 for further discussion of the

issues in this section,
10 . Technology and Aging in America

Should Congress increase support for basic

and clinical biomedical research and for longitudinal studies on aging and chronic

diseases?

Should Congress exercise more or less control over the extent, direction, and selection

of problem areas of basic biomedical research

related to aging?

Health promotion/disease prevention

and nutrition *

An increasing body of evidence demonstrates

that preventive measures begun early and maintained throughout life can significantly reduce the

prevalence of acute and/or chronic disease in old

age. Preventive measures are considered here in

the context of persons over 65, while recognizing the importance of preventive measures

throughout life.

Until recently there was consensus among

health professionals, and among the elderly themselves, that after 65 it was too late to think seriously about prevention of disease or disability.

These attitudes are slowly changing, and health

promotion is now justified on the basis of rising

life expectancy after age 65 (on average, currently

more than 14 years for men and 18 years for

women more sophisticated definitions of health

that recognize variability among and between age

groups, and recent improvement in cardiovascular disease mortality due to preventive efforts

(e.g., control of hypertension and elimination of

smoking).

The goals of health promotion/disease prevention vary with personal circumstances. For those

who are ill, the hope is to maximize function and

prevent deterioration; the goal of those who are

well is to prevent disease or disability at any age.

MORBIDITY, MORTALITY, AND RISK FACTORS

RELATED TO CHRONIC DISEASES

Diseases of the heart, malignant neoplasms (cancer), and cerebrovascular disease (stroke) accounted for three-fourths of all deaths among the

elderly in 1981. The incidence of these major diseases remains high, but death rates from most

*These issues are examined in detail in ch, 4 and app. C.

have decreased for the elderly. As more older persons survive acute episodes of stroke and coronary heart disease, the prevalence of these diseases rises. Because the burden of morbidity in

the older population is rising, this assessment examines the risk factors 1l that are correlated with

these diseases and chronic conditions.

CORONARY HEART DISEASE AND STROKE

A cluster of risk factors correlates both with

coronary heart disease (CHD) and stroke, Hyper=

tension, or high blood pressure, is the most

powerful predictor of risk for CHD; more than

half of persons with myocardial infarction and

three-fourths of patients with stroke have concurrent hypertension. *z Limited findings indicate

that control of moderate and high diastolic hypertension in older individuals is associated with reduced mortality and morbidity from CHD and

stroke, but the benefits of treatment of isolated

systolic hypertension remain unclear and are

under investigation.

Cigarette smoking is highly correlated with

mortality from cardiovascular disease; it is also

a significant factor in morbidity, exacerbating hypertension (nicotine constricts the blood vessels).

Hypertension, in turn, is another risk factor for

CHD and stroke. Unfortunately, the elderly often

succumb to the myth that smoking cessation is

effective only for younger age groups. Now that

those who reach 65 can expect to live an average of 16 more years, the benefits of not smoking are substantial. Programs and research on

smoking cessation should be expanded to give

greater emphasis to their impact on older individuals.

Despite gaps in knowledge, it appears that exercise can benefit the elderly in reducing their

risk of CHD and stroke. Some gerontological studies indicate that carefully developed exercise

regimens for older people can reduce blood pressure and pulse rate at rest while also increasing

ll Risk factor 5 are characteristics that indicate an increased

likelihood of developing a given condition. They are based on statistical probabilities in large populations rather than on causal relationships or the certainty that an individual will develop a specific

disease or condition.

12Hypertension in the elderly is defined as blood pressure greater

than 140/90mm Hg or isolated systolic blood pressure greater than

160, with normal diastolic blood pressure.
Ch. I—Executive Summary 11

Photo credit: Dennis Deloria, Dancers of the Third Age, Dance Exchange, Washington, DC

Properly developed exercise programs can benefit one’s health at any age.

aerobic capacity. Exercise reduces fat and increases lean body mass, and can promote healthy

bone. Yet exercise carries certain risks and, especially for the elderly, should be gradually initiated

according to individual health characteristics. The

risks depend on a number of factors—general

health, past exercise habits, age, type and amount

of exercise, and intensity of exercise. Nevertheless, when weighed against the hazards of not

exercising, the benefits clearly outweigh any risks.

More information needs to be developed regarding the relative risks and benefits of different

levels of exercise for older persons, particularly

those suffering from chronic conditions.

Although stress is a normal part of life, little

documentation exists regarding the prevalence,

types, and effects of stress on older persons. A

possible indicator of stress is the prevalence of

depression, the most common mental problem

among older people. Depression is one symptom

of the inability to cope with stress, which can

cause various types of health impairment. Stressreduction techniques—such as exercise, meditation, and relaxation+an reduce the physical and

psychological effects of stress. Biofeedback techniques can also help minimize the negative consequences of stress. In severe cases, prescription

drugs are also effective treatments.

As with exercise, a considerable body of knowledge remains to be developed regarding the specific characteristics of stress and its consequences

for the elderly.
12 . Technology and Aging in America

Nutrition, including intake of liquids, appears

to have special significance for older persons.

Poor nutrition results in a lack of essential

vitamins and nutrients, which leads to physiological deficiencies. Poor nutrition can also be

manifested in an excess of certain nutrients that

are related to obesity, 13 to higher risk of diabetes,

and to higher levels of cholesterol—all of which

are risk factors for CHD and stroke. Insufficient

intake of liquids can lead to dehydration, which

is often undetected for long periods, Among the

elderly, changes in metabolism and physical activity can significantly alter the intake, absorption,

and effective utilization of various nutrients.

There is as yet too little information, however,

on which to base Recommended Dietary Allowances (RDAs) specifically for the elderly population. It is particulary difficult to discern the longterm subclinical deficiencies that may be related

to the aging process.

Current Federal policy, as implemented under

the older Americans Act, is designed to improve

the nutritional status of the older population

through the congregate meals and meals-onwheels programs. Existing evaluations of these

programs are methodologically flawed and provide insufficient information about the programs’

effectiveness in reaching the at-risk poor and

minority elderly. Future evaluations should also

focus on the nutritional value of the food actually

consumed rather than on just the food that is

prepared.

Impaired glucose tolerance is symptomatic of

diabetes mellitus, which is in turn a risk factor

for cardiovascular disease. Moreover, diabetes is

strongly associated with obesity, especially as age

increases. Drug therapy can reduce glucose levels

and promote management of diabetes, but its efficacy in CHD prevention is unclear. Dietary restrictions are also used in management of CHD, but

little is known about possible ways to prevent or

minimize its incidence.

High serum cholesterol levels, which are related to diets high in saturated fats, have recently

been linked with atherosclerotic diseases of the

13Obesity is generally defined as weight that is 20 percent higher

than specified in standardized tables according to sex, age, and

height. Obesity itself is associated with numerous risk factors for

CHD and stroke.

blood vessels. A study of men aged 35 to 59 with

very high levels of cholesterol who were given

drug therapy to reduce those levels found a significantly lowered incidence of CHD. However,

no direct causal effect can be inferred concerning the effect of reduced dietary levels of saturated fats for those with moderately elevated cholesterol levels, since the research involved men

with high levels of cholesterol who were treated

with drugs. More clinical and longitudinal investigations are required to clearly understand

the relationship between diet and moderately

high levels of cholesterol in the older population.

CANCER

Cancer, the second leading cause of death

among the elderly, is associated with risk factors

such as smoking and diet, although it remains difficult to establish specific causal links from available analyses. If detected early enough, cancers

of the prostate, breast, lung, rectum, and colon

can be effectively treated. Regular medical checkups and self+xamination are very important factors in early detection of cancer. Unfortunately,

some studies indicate a reluctance among the

elderly to seek screening services, particularly

gynecological examinations for older women. This

may be due to ignorance or lack of information

about new technologies and the possibilities for

treatment of many diseases, including some cancers. Careful monitoring of changes in the body

is important, because multiple presentations of

illness in the elderly can mask the existence of

some diseases and make early detection difficult.

FRACTURES

Osteoporosis is the cause of about two-thirds

of hip fractures in older people, especially women. Research to prevent osteoporosis is centered

on the effectiveness and possible risks of estrogen

replacement therapy after menopause, supplemental doses of calcium for women both before

and after menopause, and the role of exercise in

bone-strengthening. Up to 40 percent of the

elderly report suffering a fall. Two-thirds of these

are estimated to be preventable, and as many as

half may be caused by environmental factors such

as loose rugs, poor lighting, slippery surfaces inside and outside the home, broken stairs, or lack

of grab-bars in bathrooms and other high-risk
Ch. l—Executive Summary . 13

areas. The likelihood of falls is increased by

underlying physical conditions such as Parkinson’s disease, seizures, cerebrovascular disease,

and conditions that cause fainting or dizziness

(including inappropriate use of drugs). Sensory

loss in hearing and vision also increase the risk

of falls.

The incidence of falls and the severity of their

consequences for the elderly could be reduced

by better diagnosis and treatment of these chronic

conditions and efforts to eliminate environmental

hazards. Concerted efforts are required to sensitize the general public and the elderly themselves to the possibilities for greatly reducing the

risk of falls, and the suffering and expense they

can cause.

DENTAL DISEASE

An often overlooked problem for the elderly is

dental disease. In 1971, about 45 percent of Americans over 65 were estimated to have lost all of

their teeth. Loss of teeth is associated with poor

dental hygiene, a diet high in starches and simple sugars, and lack of regular dental care. Dental diseases, including those of the gums and bone,

can have significant consequences for the general

health of the elderly. Yet in 1981 approximately

half of all older persons who had teeth had not

visited a dentist in the previous 5 years.

Improved monitoring of dental health for the

elderly and the application of new technologies

for prevention and treatment of dental disease

should be fostered. Medicare reimbursement is

not provided for any preventive dental services,

which may be a reason for the extent of inadequate dental care among the elderly.

SELECTED ISSUES

Each of these areas of health promotion/disease

prevention and nutrition requires additional information and research regarding their long-term

effects on the well-being of older persons. Understanding the interaction of individual health behaviors and environmental influences for promoting health into the older ages may provide new

suggestions for preventing, coping with, or at least

delaying the onset of chronic diseases. A substantial research effort over an extended period

of time is needed to achieve this definitive

knowledge.

Most current RDAs do not differentiate between subgroups over age 50. The same RDA is

supplied for all ages past 50, regardless of nutritional need. In general, RDAs fail to take into account the age-related physiological, behavioral,

and pathological changes that can affect the nutritional needs of those over 65. Certain nutrients

are especially relevant to the aging process and

should be stressed in research on elderly nutrition; these include calcium, vitamin D, B vitamins,

vitamin A, zinc, sodium, and fats.

other specific issues for congressional concern

include these questions:

●

●

●

Does research on health promotion interventions for the elderly indicate that these interventions are cost effective?

Should Medicare reimbursement categories

be reconsidered with a view to increased reimbursement for health promotion/disease

prevention interventions?

How might Congress obtain more accurate

and standardized evaluations of Federal food

assistance programs in order to improve their

general efficacy and their ability to reach specific target groups?

Medications and the elderly*

Drug treatment is an important medical technology for older individuals. Those over 65 use

30 percent of all prescription drugs—twice as

many as the average user. More than four-fifths

of all noninstitutionalized older people use overthe-counter medications. The safety of using medications, availability of information about drugs,

and new technologies that might improve how

drugs are delivered and used are influenced by

Federal policy.

As disease prevalence rises with age, drug use

increases. The elderly use the everyday drugs

consumed by the general population for colds,

acute infections, and headaches. Chronic diseases

such as arthritis, hypertension, and cardiovascular disorders, which are especially common in old-

“This issue is examined in detail in ch. 5.
14 . Technology and Aging in America

er people, determine the use of another group

of drugs that includes diuretics, anti-hypertensives, anti-inflammatory agents, and cardiac

drugs.

THERAPEUTIC EFFECTIVENESS OF DRUGS

IN THE ELDERLY

When carefully administered, drugs improve

the condition of most elderly patients. Drugs are

usually the most cost-effective way to treat chronic disease or manage its effects. Such benefits,

however, can have unanticipated negative effects

on some older people. The elderly have a higher

incidence of drug side effects and drug interactions than younger age groups. Many problems

of drug use among the elderly are due to altered

metabolism, the presence of multiple diseases, and

increased susceptibility to side effects. The effects

of these factors are exacerbated when older persons take improper combinations of drugs, often

unbeknownst to their doctors or pharmacists.

Few drugs are tested for side effects and therapeutic effectiveness specifically in the elderly.

Recent studies of how drugs are distributed and

metabolized in the body show significant differences between older and younger populations.

These differences are based on age-related biological changes that affect the body’s ability to

process, store, and excrete drugs. It is not yet

universally recognized, however, that the elderly

require different drug treatment than younger

adults.

The presence of multiple chronic diseases and

their treatment with multiple drugs lead to a

higher incidence of adverse drug reactions and

adverse drug interactions. The threshold of toxic

blood concentration is lower for the elderly for

many drugs, leading to increased probability of

overdose, This may be due to altered pharmacokinetics 14 in combination with increased susceptibility to adverse drug effects.

While adverse drug reactions and interactions

account for 3 percent of all hospital admissions,

they account for 12 to 17 percent of hospital admissions for those aged 70 to 90. Adverse effects

are especially common for drugs used to treat

14 pharmacokinetics defines how drugs are distributed and

metabolized in the body.

cardiovascular and psychiatric diseases, both of

which are prevalent among the elderly. Adverse

drug reactions among the elderly are estimated

to cost $3 billion per year.

Side effects of drugs may be more common

among ambulatory patients than among hospital

patients. Reporting of adverse effects is less reliable for ambulatory patients, and drug errors

are more common outside the hospital. Increased

prevalence of home care may exacerbate the

problem of adverse drug effects and noncompliance with prescription instructions.

EDUCATION IN PROPER USE OF DRUGS

Appropriate use of drugs by the elderly can be

facilitated in a number of ways, Improved education of health care providers, including physicians, can instill knowledge about proper use of

drugs and increase awareness of the special biological and physiological characteristics of older

patients, An experimental method now under

way uses trained personnel to visit physicians to

educate them about common prescription errors.

There is wide agreement on the need to improve physicians’ awareness of drug therapy

problems among older patients. A large study

found that efforts to change physician habits reduced Medicaid costs significantly. The cost of

educational materials and personnel for educating physicians was $93 per physician per year,

which resulted in estimated annual savings of

$205 per physician in Medicaid reimbursements.

Patient education is essential for the practical

management of chronic conditions because the

long duration of illness requires active patient participation. Information transfer is more difficult

with older patients than the general population,

however, especially for two groups-very old persons who are less educated and those who are

confused. Heightened sensitivity among health

providers to the need for adequate patient education could improve the efficacy of treatment;

enhanced awareness among older patients could

diminish anxiety and aid in the treatment process.

TESTING AND SURVEILLANCE

Although drug testing in elderly patients is not

specifically mandated for inclusion in clinical trials
Ch. l—Executive Summary ● 1 5

performed for Food and Drug Administration approval, the recent trend has been to include more

older patients. But there are no specific guidelines

or regulations for assuring that clinical trials take

account of the special drug needs of the elderly,

in part because such requirements would complicate analytic procedures. Elderly subjects would

have to be representative of the older population

and its wide variety of chronic conditions. The

high prevalence of disease among the elderly increases the “noise” level in drug reaction data,

compounding the difficulty of detecting problems.

To compensate for this factor, more elderly patients must be included in tests; this increases development costs and makes analysis more difficult.

Increased use of postmarketing surveillance

could contribute to establishing drug safety and

efficacy; monitoring of actual drug use would help

to identify unknown adverse reactions. Premarket test results could be supplemented by these

procedures and safety would be encouraged by

intensive surveillance. There are, however, problems with using postmarketing surveillance to assure safety; current methods of reporting adverse

effects, for example, are unreliable.

Because older people often have multiple disorders that can be treated in a multiplicity of

ways, and because of the plethora of potentially

effective drugs that can be used, optimal treatments are often not apparent. Comparative

studies of different treatment combinations for

a set of conditions are often not available. The

standard method for dealing with such uncertainty is the randomized clinical trial, the development of which was a major advance in modern medicine. Careful studies of different treatments under controlled circumstances could

establish the best regimens.

Federal savings from support of randomized

clinical trials might be obtained through reduced

incidence of side effects from current treatment

methods and by preventing unnecessary complications. The magnitude of savings, however, cannot be estimated because there is inadequate

knowledge about the potential improvement in

health that might arise from different treatments.

Also, increased support for clinical trials is likely

to be quite costly, and could divert Federal funding from basic biomedical and other forms of research.

SELECTED ISSUES

It is clear that considerable information is

needed about issues surrounding drug use by the

elderly. The Federal Government is directly or indirectly involved in a number of these issues. Considerations for congressional review include the

following:

●

●

●

●

changes in health services –

Should Congress require premarket testing

and/or postmarked surveillance of drugs specifically in older population subgroups?

How might Congress encourage improved

education of both health care providers and

older persons themselves regarding drug use

by the elderly?

Should Congress require improved labeling

of over-the-counter medications to warn of

possible dangers in their use by older

persons?

Should Congress extend funding for randomized clinical trials for drug treatments for diseases that are prevalent in the elderly?

Information technology and and home health care are developed. Although

health care of the elderly* information technology, particularly in computers

and communications,15 has had substantial impact

Ability of the elderly to use information tech- on the health care system, relatively little attennology and to participate more directly in their

health care is of growing interest as new ap- 15F~r purposesof this report, information technolo~v is defined

preaches to health promotion, disease prevention, as the application of computers and telecommunications systems

to the creation, storage, manipulation, and dissemination of infor-

*This issue is examined in detail in ch. 6. mation,
76 . Technology and Aging in America

tion has been devoted to applying this technology to the specific health needs of the older population, who stand to benefit significantly from its

applications. This report thus focuses on the potential use of health information technology for

both current and future cohorts of older persons.

The elderly of the year 2000 will have considerably higher educational levels, and be more likely

to be familiar with and to use information technology than those presently over 65. The difference in attitudes toward such technology will be

even more dramatic when the baby boom cohorts, now aged 25 to 40, become eligible for

Medicare early in the 21st century.

Although there is a dearth of computer applications of information technology for elderly persons in general, various computer-based technologies have been developed to assist the severely

disabled and those suffering from chronic medical problems. Such prosthetic technologies include programmable wheelchairs, voice-activated

robots that can literally “serve” paralyzed persons,

and a variety of rehabilitation aids. Many of these

technologies, however, are as yet either experimental, relatively expensive, or primarily applicable in health care settings.

New computer applications are expected to

have widespread use in assisting those who are

less impaired, including most older persons. The

decade of the 1980s promises significant advances

in the availability and use of personal computers

for a multitude of functions that will aid all age

groups in the population. Some of these new technologies will be especially beneficial to older persons who have decreased functional abilities and

restricted mobility. Today, about half a million

older persons are confined to bed; about 2 million have mobility problems around the home;

and almost 3 million require the assistance of

another person to perform activities of daily living. Information technology can enrich and improve the services that traditional health care

institutions and professionals provide by disseminating information directly to older persons in

their homes. This information could include methods for maintaining and improving health or ways

to access needed services, and could be readily

provided on video displays or in print, both to

those at home and to wider audiences at senior

centers, community centers, and congregate

housing complexes.

USE OF INFORMATION TECHNOLOGY

BY THE ELDERLY

There has been little study of the ability of older

persons to use computers, and still less of their

ability to use computers for health care. The little empirical evidence available indicates that—

contrary to stereotypical views of the elderly—

most older individuals are quite receptive to computer technologies. Demonstration projects have

shown that older persons, after preliminary instruction, have a high degree of interest in using

personal computers. Some older people enjoy programming and working with applications software, such as spreadsheets; others prefer recreational computer games and communicating by

means of computers adapted to their capabilities.

Because the older population is heterogeneous,

particularly in terms of functional ability, some

older persons require specially adapted computers. Although they vary widely in cost at this stage

of development and marketing, computer consoles with larger keyboards and video display

screens with larger displays are available to compensate for the sensory and functional impairments of some older persons.

Information technology can be used by the

elderly for health purposes in two major ways.

One is computer-assisted health instruction,

which is a logical extension of self-care/self-help.

It is estimated that at least 25 self-help programs

for the elderly are now in operation, most of them

developed by nonprofit organizations, but very

few of these use computer programs. Most

computer-assisted health instruction programs

are used in health care settings to instruct patients, such as diabetic and post-stroke patients,

who have specific problems. The steady growth

of software for educating the general public about

health maintenance and disease management outside of traditional care settings, and the trend

toward specialized programs for subgroups of the

population, signal the eventual evolution of homebased computer programs for the elderly. The

relevance of this technological trend for use by

and for the elderly is not yet widely recognized

by either the private or public sector, but the mar-
Ch. l—Executive Summary ● 1 7

ket is expected to change rapidly during the next

5 years.

Self-help for health maintenance and disease

management can also be indirectly assisted by existing computer technologies. Homes can be computer-monitored to assure proper heating, to control a variety of appliances, to provide wake-up

services, and give audible reminders at medication times. Computers can be programmed to instruct older persons or their family caregivers on

special diets, rehabilitation practices, and other

medically related practices that promote their

health. The safety of dependent older persons can

be enhanced by alarm systems that notify central monitoring stations of trouble in the home.

The alarm can be activated at any time by the individual or by an automatic signal if the monitoring unit is not reset within a predetermined

amount of time. These and other technologies increase the ability of dependent older persons to

remain in their homes and to be less dependent

on personal care assistance.

A second important way in which the elderly

can use information technology is by assisting

health professionals to monitor the care of older

persons. The use of home computers to augment

professional care may enable chronically ill people to remain in their homes and reduce the need

to make difficult visits tomedical offices or to have

care providers visit them at home. Blood pressure,

pulse rates, body temperature, and heart electrical activity can now be sensed and measured by

“smart” sensors that incorporate microprocessors.

This type of personal home health monitoring system can provide daily appraisals of the patient’s

vital signs and store the data in a longitudinal record that can be used to monitor changes in those

measurements. It can also include a voice chip

for giving simple instructions and programmed

advice for certain types of health regimens.

Measurements of other physical functions have

recently been developed for use in rehabilitating

handicapped patients. Some of these measurements have the potential for computer-based

processing, and may also be applicable for

monitoring the health status of older persons who

are acutely ill or severely impaired. An interactive telecommunications system between the

patient’s home and the health care provider’s office could be established to facilitate medical

monitoring.

ACCESS TO HOME COMPUTERS

There are no data on the age of individuals who

own or have access to personal computers in the

home, and estimates of future penetration of the

market vary widely. Estimates of the proportion

of U.S. homes that will have computers by 1990

range from one-fourth to two-thirds. It is only certain that the market will greatly expand, especially

as unit prices decline and program capabilities increase. The extent to which this growth will reach

the older market is unclear.

There are a number of barriers to the use of

information technology for health purposes by

the elderly. One problem is the cost of the technology, which currently ranges from several hundred to several thousand dollars for a basic home

computer system. Additional costs for software

increase the economic burden. Another factor is

the incompatibility of equipment among a great

variety of systems, making the decision to purchase a particular unit more difficult. The elderly

with functional impairments have unique access

problems in that they often find it difficult to use

computers designed for the general public, and

the costs of custom-designed units remain high.

Self-health information and computer instruction technologies are themselves emerging fields,

and as such are diverse and unsettled. In some

cases, programs are developed by transient “entrepreneurs” who lack subject knowledge and are

often forced out of the market. Other programs

have excellent material that is developed by individuals who have expertise in subject content

and computer technology. Most available software programs have not been evaluated. The

serious issue of establishing criteria for evaluating

computer-assisted instructional material is just beginning to be addressed.

SELECTED ISSUES

Because the application of information technologies to self-health care for the elderly is new,

there has been little direct Federal involvement

in the past. Some Federal demonstration program
18 . Technology and Aging in America

funds have been used to develop information system models for nursing homes. A more concerted

Federal effort has supported research and development of information dissemination technologies

for the handicapped, some of which are useful

for older persons who are functionally impaired.

Some executive agencies are now supporting

demonstrations of home-based information technologies for health promotion; other agencies are

considering funding investigations of the use of

microcomputers and computer games to improve

the social interaction and mental functioning of

the elderly.

Additional research is needed on the role of information technologies in health maintenance and

disease prevention for the elderly. This research

should include evaluations of the quality of health

instruction programs designed for older persons,

problems in accessibility and use of computers

by the elderly, and the cost-effectiveness and efficacy of information technologies for reducing

the amount of personal home care required.

The major issues for congressional oversight in

this area are:

●

●

To what extent, if any, should the Federal

Government be involved in activities concerning the safety, cost, liability, and efficacy of

computer-assisted health instruction programs for the elderly?

Given existing authority, how can the Federal Government encourage the private sector to voluntarily develop appropriate health

instruction technologies for the elderly that

meet basic standards for quality?

Functional impairment and

long-term care *

Most older persons are able to carry on their

regular daily activities in a variety of environments, but the incidence of chronic conditions

and prevalence of functional impairments increase notably at the oldest ages. These problems

are the major reasons for the long-term care

needs of both the elderly who are institutionalized

and those who live in the community. As the number of Americans over 65 rises, the correspond-

*These issues are examined in detail in ch. 7.

ing rise in the number of “very old’’ —those over

85–will dramatically increase the need for longterm care services, This need will be exacerbated

by the new prospective payment system under

Medicare, which is expected to limit hospital

length-of-stay and encourage early release of older patients, many of whom will still require rehabilitative or other types of long-term care at

home.

Long-term care services are provided by nursing homes, board and care facilities, and home

health care agencies. In some communities additional services are provided in adult day care facilities, hospice programs, and congregate housing facilities. Little information is available about

differences in the services that agencies provide

or the types of older persons served, in part because of differences among State programs that

support community-based long-term care services. It is known, however, that a wide range of

services is provided to a great variety of older

clients, and that there is both lack of coordination and duplication of services in many communities.

EXTENT OF NEED FOR LONGTERM CARE

In general, community-dwelling persons over

85 are six times more likely than those aged 65

to 74 to be dependent in basic or instrumental

activities of daily living 16 and to need the assistance of another person. As the proportion of very

old persons in the older population increases, the

demand for long-term care services will grow.

Greater strains will be placed on families and

other informal caregivers, who currently provide

up to 80 percent of long-term care for the elderly.

This level of informal support is expected to

change for a number of reasons:

The older the person, the less likely he/she

is to have a spouse to provide assistance; this

is especially true for women over 85.

The higher the number and severity of functional impairments, the lower the likelihood

16Basic activities of daily living include dressing, eating, bathing~

toileting, walking, and getting in or out of bed. Instrumental activities, also called home management activities, generally refer to tasks

such as shopping, cooking, doing house and yard chores, handling

money, and driving.
Ch. I—Executive Summary 19

that family and friends can provide the degree of assistance required.

● Because most family caregivers are women,

the increasing proportion of adult women in

the labor force will reduce the number available to provide informal support to an elderly

parent.

Greater demands will be placed on existing longterm care agencies to respond to the changing

characteristics of the older population and its informal support network. Yet the complexity, fragmentation, and limited scope of long-term care

services in most communities make it difficult for

individuals and their families to understand what

formal services and alternatives are available. The

problem can be particularly troublesome for dependent older persons who are alone. One of the

greatest fears of the elderly is that they may

become frail and dependent on others, even

though assistance might be readily available. This

concern can be ameliorated by a logical and wellcoordinated national system of long-term care

services that includes expanded use of technologies in the health care setting, the home, and the

community.

TECHNOLOGY AND LONGTERM CARE

Technology has not been widely used in longterm care services for the elderly. Identification

of appropriate technologies for this population

requires accurate assessment of their needs. Such

assessment is hindered by the fact that Federal

and State programs, which regulate and fund

more than half of all long-term care services in

the United States, influence the kind of needs that

are recognized. By emphasizing medical and

skilled nursing care, these programs tend to

obscure the need for other types of supportive

services.

Although existing medical technologies can treat

some of the chronic conditions that cause functional impairment, most chronic conditions are

not curable. Given the lack of effective cures or

prevention, effective management of chronic

conditions becomes important. This can often be

achieved with appropriate drug therapy, personal

care services, and use of technologies that compensate for decreased function (e.g., prostheses,

assistive devices such as walkers, chair lifts, vision and hearing aids). Many of these assistance

methods need further development to expand

their usefulness. While biomedical research generally focuses on acute conditions that cause

death, expanded research on the chronic conditions that cause functional impairment could

result in effective treatments or prevention strategies, as well as prosthetic or management technologies that promote independence and decrease

the need for long-term care.

Alternative approaches to maintaining independence or compensating for functional impairments are needed, such as assessment technologies, assistive devices, and rehabilitation

techniques. Assessment technologies can play a

significant role by focusing on the various chronic

conditions that lead to functional impairments and

the types of resources available to assist the individual. But the prevailing emphasis on medical

and skilled nursing care has limited the use of

assessment technologies, both in long-term care

institutions and in the community. At the same

time, the new Medicare prospective payment system for hospital care, based on Diagnosis Related

Groups (DRGs), will encourage the earliest possible release of older patients, which increases the

importance of adequate discharge planning and

use of appropriate assessment technologies. Yet

physicians and other health care providers generally lack training in the use of such measures,

and there is disagreement about the reliability and

validity of existing assessment technologies.

Assistive devices are available to compensate

for some impairments in hearing, vision, walking, and other functions. Various other devices

can assist the moderately impaired in preparing

food, eating, performing household chores, and

managing other activities of daily living. These

devices range from simple and inexpensive to

complex and quite expensive. In most cases their

costs are not reimbursable under Medicare or

Medicaid provisions; this factor can limit their use

by older persons, Other factors restricting their

use include lack of information about available

devices, the difficulty of selecting appropriate

devices for individuals with multiple impairments,

and negative attitudes of elderly individuals, their

families, and many health care professionals

about the usefulness of the products.
20 ● Technology and Aging in America

Photo credit: M. Holtby, ‘Seniors’ Resource Center, Jefferson County, CO

Assistive devices helped the impaired elderly to remain active.

Another growing need is the availability of rehabilitation devices and techniques for posthospitalization care in the home. The implementation of DRGs under Medicare is likely to increase

the need for medical technologies that can be used

for outpatient and in-home rehabilitation. The

need for new devices to assist in the rehabilitation of older persons will grow, but their cost and

complexity may limit their availability. As with

assistive devices, negative attitudes toward the

rehabilitation potential of older persons may restrict the use of those devices that are available.

PREVALENCE OF MENTAL AND

PHYSICAL IMPAIRMENT

Some elderly individuals have mental condi=

tions that can cause functional impairment or increase their degree of physical dependency. The

degree of physical and mental impairment is related to need for long-term care and the risk of

institutionalization. About half of all residents of

nursing homes and board and care facilities have

some degree of mental confusion. But the proportions of these individuals who are functionally impaired because of mental confusion and the proportions who are impaired by both physical and

mental conditions are not known. Nursing home

residents are more likely to have severe mental

confusion and to be highly dependent in the basic

activities of bathing, eating, and toileting. Some

data on nursing home residents show a high statistical association between mental confusion and

degree of physical impairment, particularly in the

areas of severe incontinence and inability to bathe

or feed oneself. Persons with both mental and

physical impairments usually require 24-hour

care, which is a great burden for most caregivers.

There appears to be a critical threshold of physical and mental impairment, beyond which family

caregivers can no longer effectively care for the

dependent person and are usually forced to rely

on institutional care. Despite the great difficulties

that families and health care providers must face

in caring for these highly impaired individuals,

little public or private sector attention has been

given to the development of devices and care techniques that might help resolve the more severe

problems.

Although most patients who are severely impaired mentally and physically may require skilled

nursing care, some need only 24-hour supervision and personal care services. Yet existing

health care reimbursement programs encourage

admittance of these persons to nursing homes

rather than to less restrictive and usually less

costly board and care facilities. Similarly, individuals who need personal care and supportive services at home may not receive the care they need

or may receive unnecessary health care services

because of Medicare and Medicaid funding regulations. Negative attitudes about the concept of

custodial care, and fears about the cost of providing nonmedical long-term care services for the

functionally impaired elderly, also limit the availability of these services.

USE OF AVAILABLE TECHNOLOGIES

Most long-term care services are labor-intensive, and formal and informal providers receive

little training in the use of devices and techniques

to facilitate caregiving. Increased development

and use of these technologies could lessen the

burden of caregiving, allow elderly persons to remain at home longer, and decrease staff turnover

in long-term care facilities. Technologies to assist

patients and caregivers are used more extensively

in Europe than in the United States. Western

European countries generally provide a greater

range of supportive environments and residential facilities to assist impaired individuals and

their caregivers.

Few medical care technologies have been used

in long-term care facilities or in the home. The
Ch. l—Executive Summary 21

recent implementation of the Medicare prospective payment system and increased emphasis on

the provision of health care services at home

should broaden the demand for home-based medical care technologies. This trend is expected to

grow, as is demand for sophisticated medical and

nursing care technologies in nursing homes. Increased use of these technologies outside the hospital will depend to a large extent on public and

private reimbursement policies for costs of nursing home and home care services, and on the

availability of skilled health care personnel trained

to use these technologies and to teach the patient

and the family to use them.

These changes will require better methods of

patient assessment and increased coordination of

the caregiving network to promote a continuum

of care based on categories of need among different groups of patients. Efforts to improve service delivery have included techniques for coordinating services at the community level, case

management systems, and organizational approaches that provide a range of services through

a single local agency. Development of a more coordinated system of services could enhance the

ability of some elderly individuals to remain at

home and to plan effectively for their own longterm care.

SELECTED ISSUES

Because the demand for long-term care services is expected to continue its rapid growth, additional information will be required to develop

and evaluate alternative approaches to caregiving for functionally impaired older persons. A fundamental need is expanded basic research on the

chronic physical and mental conditions that cause

impairment. Given the prevalence of existing conditions, additional research is needed for development, utilization, and evaluation of technologies

to meet the needs of the long-term care population. Devices and techniques to assist older persons with multiple impairments and mental confusion need to be developed. Accordingly, more

information is needed on the relationship between mental confusion and functional impairment, and on the impact their severity has on the

demand for different types of long-term care. Improved methods are needed to reliably assess the

extent of chronic conditions and impairments as

well as the devices or techniques that can best

ameliorate them.

Most of these research areas are related to

other issues for congressional review regarding

the growing need for long-term care. These

include:

●

●

●

Should Congress promote the expanded development and use of comprehensive assessment technologies for the community-dwelling and the institutionalized elderly?

Should Congress mandate additional funding

for long-term care serices-based on degree

of functional impairment-delivered in the

home and in care settings other than nursing homes?

Should Congress implement policies to increase the use of assistive devices and rehabilitation technologies in the home and in other

long-term care settings?

Health care costs *

Health care spending has been rising and will

continue to do so under present policies, but the

growth in numbers of those over 65–particularly

those over 75—will intensify demand for acute

and long-term care services. Recent data indicate

that about one-third of all health care expenditures are by the elderly, and that up to 30 percent of all Medicare payments are made for care

of persons in the last year of life. But the growth

of the elderly population is not the main reason

for the rapid escalation in health care costs, which

have been increasing at almost three times the

general rate of inflation during the past 5 years.

Health care expenditures in 1982 totaled more

than $322 billion, an increase of almost 30 percent since 1980. In 1983 total health expenditures

rose an additional 10 percent and reached $335

billion-comprising more than 11 percent of the

gross national product. The dramatic increases

are largely due to intensification of services, expanded availability and use of costly diagnostic

and treatment services and technologies, and the

rising cost of labor. This excessive inflation in

health care costs has led to concerted efforts to

*This issue is examined in detail in ch. 8.
22 “ Technology and Aging in America

contain spending, which have far-reaching implications for older Americans.

DEMAND FOR HEALTH CARE

Demand for health care by older persons is influenced by physical, psychosocial, and economic

factors. The increased use of services by some

older persons is usually due to their increased

burden of illness. The remarkable recent decreases in mortality among those over 65 have

not been accompanied by similar decreases in

morbidity. Moreover, older persons tend to

underreport symptoms of chronic conditions.

Some studies have shown an average of three

correctable problems per elderly patient; many

of these problems could have been identified

earlier by using functional assessment measures

or by using greater care in taking the patient’s

history.

While most older persons are functionally independent, many require health care for chronic

conditions that increase in prevalence with age.

Spending for health services represents a major

problem for both elderly individuals and the Federal Government. Medicare provides an important health care subsidy for those over 65, but

it is by no means comprehensive—many necessary services and technologies that affect health

and functional status, such as dental services,

eyeglasses, and hearing aids are not reimbursable.

The growing need for long-term care as age rises

means that increasing proportions of the elderly

population whose financial resources become

depleted have to rely on public means-tested

programs such as Medicaid and Supplemental

Security Income for the cost of long-term care

services, Private financing mechanisms such as

“medigap”17 or other types of private insurance

do not provide adequate supplemental protection.

The few private insurance policies that are available for long-term care, especially for nursing

homes or skilled care at home, are extremely

selective for participation and very expensive. Yet

one-fourth of all health expenditures by the

elderly are for nursing home care, of which pub17 Wiedigap insurance has been developed by the private sector to

help patients cover the cost of medical expenses not reimbursable

by Medicare.

lic programs (primarily Medicaid) pay about onehalf. The increases in these costs show no sign

of abating, as more expensive technologies become

available and the need for care grows within the

aging population.

COST-CONTAINMENT EFFORTS

Cost-containment efforts to date have not been

effective in controlling overall health spending,

whether by individuals, the Federal Government,

or third-party payers. Most approaches have focused on hospital care and rate-setting, as in the

new Medicare prospective payment system. The

response of the health industry has been increased shifting of services to ambulatory settings (e.g., outpatient and rehabilitative care) or

shifting costs to other Federal programs, other

insurers, and consumers. Attempts to shift a

greater share of costs to consumers in order to

minimize overutilization of health services have

tended to reduce the number of persons seeking

care, but have not changed use-patterns after a

diagnosis has been made. Cavitation approaches

have been most successful in encouraging the

substitution of lower cost services for expensive

hospital care. Recent experiments are extending

the cavitation concept to include supportive social

services.

The coordination of services and benefits

among Medicare, Medicaid, and other public

programs that influence health care remains a

problem in access to care for the elderly. Poor

coordination can increase costs because the most

appropriate services are not provided; better coordination may increase utilization and overall

costs, but can also improve the quality of care and

reduce the need for acute care. The incremental

costs and benefits of each action must be

evaluated.

As has been noted, attempts to control Medicare costs through prospective payments could

affect quality of care for patients in hospitals

awaiting placement in long-term care institutions.

Premature discharge may result in multiple admissions and shifting costs to home care, increasing overall costs for these patients as they are

cycled back and forth between inadequate community settings and the hospital.
Ch. l—Executive Summary ● 2 3

Other reports have addressed cost-reduction

questions related to changes in eligibility, benefits,

and financing mechanisms for the existing Medicare program. Recent Congressional Budget Office reports explore options to increase revenues

or decrease outlays as well as potential schemes

to tie deductibles to income level. This assessment

concentrates on the cost-containment issues in

Medicare and Medicaid as they relate to the aging

of the population, the demand for health services

and long-term care, and changes in technology.

SELECTED ISSUES

The volatility of health care costs in recent years

has spurred considerable research and evaluation

at all levels of government and in the private sector, but significant gaps in knowledge remain regarding such questions as how to maintain quality

and access to care while promoting cost-effectiveness and cost reductions. More information is

needed on the range of factors that affect the use

of health and long-term care services by the

elderly. Research is needed on how to improve

measures of health outcome, better strategies for

educating consumers, and alternative methods for

financing health care and long-term care.

Specific issues regarding health care cost-containment strategies and their effects that are likely

to face Congress include:

●

●

●

●

Should Congress strengthen the quality assurance mechanisms for health care services

because of possible adverse effects of cost

containment?

How might Congress stimulate coordination

among preventive social, long-term care, and

acute care services to promote efficiency and

reduce costs for unnecessary types of care?

What types of function-enhancing technologies can be encouraged to reduce the need

for health care services?

Should Congress act to increase coordination

among Federal and State programs to avoid

unintended interprogram cost-shifting?

Social changes in the living environment

Housing and the living environment *

The housing environment takes on greater

significance as people age-especially in terms

of lifestyle continuity, neighborhood familiarity,

physical security and safety, and emotional sustenance. Although the older population has the

highest percentage of home ownership, physical

housing deficiencies and excess cost burden also

tend to be higher among many subgroups of the

elderly. Resolving these problems may require

new and specific types of Federal assistance. Of

particular concern is the growing number of very

old persons who live alone, especially those who

have functional impairments. For these individuals, informal supports from family and friends

often mean the difference between institutionalization and continued residence in their homes.

New technologies and services, when combined,

could provide increased assistance for maintaining independence in the household, especially as

the availability of informal support shrinks.

ELDERLY HOUSEHOLDS AND HOUSING TENURE

During the last two decades, the number of

elderly households has risen proportionately

more rapidly than the number of elderly persons.

Changes in living arrangements, especially the

growth in numbers of older persons living alone,

have contributed to this trend. The proportion

of U.S. households headed by an older person has

increased from 15 percent in 1950 to more than

one-fifth today. Marital status and living arrangements have also changed since 1960, due in large

part to sex differences in life expectancy. More

than four times as many older women as men live

alone; more than three-fourths of older men but

● These issues are examined in detail in ch. 9.
24 “ Technology and Aging in America

less than two-fifths of older women are married

and living with their spouse. Most recently, the

proportions of older men and women who live

with nonrelatives have decreased. This trend is

particularly evident among women over 85, who

are also far more likely to live alone or to be

institutionalized.

Approximately three-fourths of all elderly

households are owner-occupied, of which fourfifths are owned mortgagefree. The growth of

housing ownership by the elderly has continued

unabated since World War II. Since 1980, despite

an increase of more than 1 million elderly households, there has been a net decrease in the number of renter-occupied elderly households. Although Federal housing programs and subsidies

for the elderly have been directed at rental units

for low-income persons, there is growing awareness of the particular problems of—and possible

opportunities for-elderly homeowners.

HOUSING PROBLEMS AND FEDERAL PROGRAMS

Housing tenure of the elderly tends to correlate

with various social and demographic characteristics related to need for assistance. Rented units

are far more likely than owned units to be occupied by one person. Because single-person units

among the elderly are highly likely to be occupied

by women, they are also twice as likely to have

households with incomes below the Federal poverty level. Renter-occupied units are also more

than twice as likely to have physical and maintenance deficiencies Elderly owner-ccupied

households, which also have these types of deficiencies, may also face the problem of excess

housing cost burden, especially for those elderly

persons on fixed incomes who still have a mortgage indebtedness.

Federal housing policies to assist the elderly

have concentrated on the problems of low-income

renters through major programs such as Section

8 rental subsidies, low-rent public housing, and

Section 202 rental housing for the elderly. But

these housing programs for the elderly have been

narrowly directed toward building construction

and provision of rental units, with little attention

to special design features that respond to the

physical and psychosocial needs of older persons.

In the past, the design of some federally subsidized high-rise housing projects for the elderly

increased the likelihood that the residents would

become isolated, injure themselves, or be victims

of crime. Also, only limited Federal efforts have

been directed at preserving the housing stock or

promoting rehabilitation of elderly dwelling units–

either rented or owned.

Until recently, no attention was given to the

coordination of housing programs with services

needed by elderly residents. The need for services is growing as the older population ages and

as the first cohorts of elderly tenants in public

housing and Section 202 projects “age in place.”

A similar process is occurring in suburban neighborhoods, where the number of elderly residents

is growing rapidly. These new cohorts of old and

very old homeowners and renters have greater

needs for assistance in transportation, household

chores, dwelling maintenance, and access to community-based services. The preponderance of

older persons living alone and the lack of available support from family and friends-especially

for those over 75+xacerbate these problems and

increase the degree of assistance needed.

HOUSING OPTIONS FOR THE ELDERLY

Federal housing programs need to recognize the

heterogeneity of the older population and to induce development of a range of housing options

that provide varying levels of support. Existing

rental unit subsidy programs could be better integrated with congregate services and community programs for the elderly. They could also encourage housing alternatives such as shared

housing. Shared housing programs provide income to older homeowners while supplying rental

space at affordable prices, Other advantages of

such programs are efficient utilization of excess

housing space, reduction of social and physical

isolation, and provision of informal supports for

older persons. Intergenerational shared housing

promotes interaction and assistance between generations.

Other housing options include accessory apartments or “echo” (elder cottage housing opportunity) housing. Accessory apartments are usually

created within single-family residences. The

house is converted to accommodate a separate

apartment with little or no change in the home’s
Ch. I—Executive Summary . 25

outside appearance. Preservation of neighborhood character is an important element in the

acceptability of accessory apartments in most

communities. Modular bathroom and kitchen

units have made such conversions more efficient

and less costly. Echo housing units, also called

‘(granny flats,)’ are compact, efficiently designed,

temporary structures that are erected in backyards of family homes and designed for use by

elderly relatives. The standard unit is a modular

three-room house of about 600 square feet.

Despite their efficiency and low cost, these

housing options for the elderly face opposition

in local communities that seek to preserve singlefamily zoning laws. These neighborhoods are the

most likely sites for echo housing and accessory

apartments, but are also the most likely to resist

changes to the single-family nature of the neighborhood. Yet the Census Bureau estimates that

there are more than 2.5 million accessory apartments in the United States. Echo housing, which

cannot be concealed within an existing unit, is far

less prevalent.

In addition to federally subsidized housing for

the elderly, other types of congregate housing

have been developed by the private sector. Life

care, continuing care) and residential care communities are analogous terms for communities

in which older persons pay a large entrance fee

and a monthly service fee to live in a unit within

a complex that typically provides supportive and

health care for the remainder of the person’s life.

There are more than 100,000 elderly residents

in 300 such complexes in the United States, some

of which have already experienced financial trouble. Financing problems usually arise because of

unsold units, lack of initial capital, and underestimates of actuarial cost factors for providing

Lifetime care to the residents. Fewer than 15 States

have laws governing the operation of life care

communities and no Federal protections exist.

Some of the newest housing developments provide residential care, but do not offer lifetime care

contracts to prospective residents.

other supportive environments include board

and care homes that range in size and type. Some

have only a few residents and others are large

residential care facilities. They also differ in the

types of residents they accommodate and the

types of supportive services they provide, with

some caring for mentally impaired and frail individuals, many of them elderly. Most board and

care homes are State-licensed and a majority of

their residents receive public income maintenance

subsidies. More information is needed about the

range of facilities that exist and the types of residents they can accommodate. It appears that

some persons who are in need of long-term care

can be well served in such facilities rather than

in more costly nursing homes.

IN-HOME TECHNOLOGIES

Many possibilities exist for applications of technologies in the home to assist older persons in

maintaining independence and adapting the environment to meet their needs. These technologies,

in conjunction with appropriate design of the

dwelling unit, can enhance the older person’s

“environmental fit” and competence, both of

which enable him to control his environment.

New, relatively inexpensive technologies allow

housing to be readily adapted for the impaired

or retrofitted with improved safety and communication features. Low technologies include simple ones that promote mobility, such as safety

treads on stairs and in bathtubs, handrails and

grab bars, and ramps. Many simple technologies

can mitigate the common problems of reduced

vision and decreased grip strength in the elderly—

including door handles in place of door knobs,

special controls for major appliances, jar openers,

adaptive utensils, and other household gadgets.

Various dressing, bathing, and grooming aids are

available to compensate for the impaired person’s

decreased tactile ability and lessened agility, particularly from arthritis. Zipper pulls, “velcro”

fasteners, and hand-held shower sprayers are a

few examples.

High technologies are more complex and have

widespread applications in the home. Especially

helpful are communications technologies, such as

automatic alarm and telephone dialing systems

for emergency help (including electronic monitors

that detect falls or injuries), portable telephones,

and other security devices. Electronic safety systems are available to “program” appliances to shut
—

26 . Technology and Aging in America

Photo credt: Roger Austin, Peterborough Development Corp.

Supportive housing environments can promote the independence of elderly residents.

off after predetermined lengths of time or to monitor and control heat, air-conditioning, and lighting. In-home computers can provide various selfinstruction programs for medication, nutrition,

and other self -care assistance. They can also provide “catalogs” of products for in-home comparison shopping. Modems for personal computers

will enable older persons to communicate for a

wide range of purposes, such as banking and billpaying from the home; some health monitoring

can be accomplished with interactive computers.

Interactive television and “videotex” telecommunications allow individuals to compare, select,

and purchase a wide range of goods and services

without leaving the home.

OTHER HOUSING OPPORTUNITIES

New financing instruments provide other possibilities for enhancing the older person’s housing options. New equity-based financing instru=

ments can help some elderly homeowners

increase their income and remain in their homes.

Reverse mortgages typically allow elderly homeowners to convert up to 80 percent of their home

equity into monthly income for a specified period

of years. The homeowner retains ownership, but

reduces his equity in the home over time. As

currently offered, most reverse mortgages require repayment of the full loan amount (the total

of disbursed monthly payments plus accumulated

interest) at the end of the loan period (usually 5

to 12 years), New instruments may soon be marketed that will not include the payback requirement at the end of the loan period, but still allow

the older person to remain in the house.

A second type of home equity conversion is the

sale-leaseback plan, in which the older homeowner sells his house to an investor in return for

the right to lease back the house for the rest of

his life. The typical sale-leaseback plan includes

a downpayment to the elderly seller, who carries

an interest-bearing note for the balance of the

purchase price, paid in monthly installments over

a period of years related to the seller’s life expect-
Ch. l—Executive Summary . 27

ancy. Advantages to the seller are the right to remain in one’s home for the rest of one’s life, to

pay a fair rental, to receive full price for sale of

the house, and to earn interest on the note. The

buyer’s advantages include depreciation of the

rental property, income tax deductions, and any

appreciation in the house’s value over time. Either

of these procedures for home equity conversion

requires consumer protections and counseling for

the parties involved.

SELECTED ISSUES

The range of housing problems and options for

the elderly is expected to grow because of the increasing number of homeowners and the heterogeneity of the older population. Research into

these options should include more extensive analyses of shared housing, accessory and echo housing, board and care homes, and life care communities. Too little is known about each of these

options, the types of consumer safeguards that

may be required, and the potential role of the Federal Government in promoting their availability

for the elderly. Home equity conversion plans require greater review and the opportunity to develop new instruments in response to consumer

demand and requirements for consumer protection. The range of in-house technologies should

be evaluated by appropriate Federal agencies for

safety and efficacy.

This research can be supported by direct Federal involvement or by incentives to the private

sector, especially the housing and finance industries. The growing involvement of the private sector in development of retirement and life care

communities, in manufacture of modular housing, and in the production and marketing of hundreds of in-home devices attests to this potential.

The following questions suggest areas for possible congressional consideration:

Should the Federal Government expand existingpqgrams that assist low-income elderly

homeowners who have housing deficiencies

and excessive cost burdens?

How might Congress encourage utilization of

technologies that promote the independence

of older persons who are either slightly impaired or restricted in managing major activities in the home?

Should Congress provide support for public

and private sector efforts to develop new

housing construction and desi~ technologies

that assist older persons in the home?

Should Congress promote the expansion of

public and private housing alternatives for

older Americans?

Work-related changes

workplace technology and the

employment of older adults*

The structure of the American economy has

undergone major changes since the mid-1800s,

when it was agriculturally based and farm workers constituted two-thirds of the labor force. The

United States had become an industrial nation by

the 1920s, when more than two-fifths of all jobs

were in manufacturing industries and only about

I in 10 workers remained in farming. During the

20th century the mechanization of farming and

the automation of manufacturing have ushered

● These issues are examined in detail in ch. 10.

in a new economic era increasingly characterized

by service sector occupations. only 3 percent of

today’s labor force is employed in on-farm agriculture, while 23 percent are in manufacturing,

and more than 60 percent are in the service and

trade sectors. These changes are expected to continue as the economy becomes increasingly dominated by the electronics revolution and the service sector jobs it creates.

TRENDS IN LABOR FORCE PARTICIPATION

OF THE ELDERLY

These trends have been accompanied by the

aging of the U.S. population and a marked decline

in the labor force participation rate of persons

38-800 0 - 85 - 2
28 . Technology and Aging in America

over ss. Workers now 4S and over may be particularly vulnerable to the latest changes in the

work force. Older workers are primarily located

in industries and occupations that were growing

when they entered the labor market; many older

workers are employed in manufacturing, which

expanded in growth through the 1940s. Manufacturing and related industries-and their share

of the labor force—began to decline in importance

during the 1950S) by which time the earlier young

cohorts of workers in these industries were

‘(aging in place.”

The explosion of workplace technologies during the last two decades has threatened the previously secure future of these older workers. Although there is no direct evidence that significant

numbers of older workers have been displaced

by workplace technologies (e.g., union seniority

rules in many manufacturing trades tend to protect older workers from unemployment), there

is concern that future cohorts of older workers—

those who are now aged 35 to 45—will face such

possibilities. Recent advances in medical technologies, computers, and robotics18 have led to the

development of new occupations in a variety of

high-technology medical care services and in computer programming, operation, and repair–jobs

from which workers over 45 are likely to be excluded due to lack of appropriate skills. To remain employed, some older workers may need

to accept low-skilled, low-paying jobs, or receive

extensive on-the-job training. The likelihood that

unemployed older workers will find employment

at their previous pay level is expected to be significantly diminished.

EFFECTS OF TECHNOLOGY IN THE WORKPLACE

It is becoming increasingly likely that the pace

of technological change in the workplace will present problems for older workers of the 1990s and

the turn of the 21st century unless they are

trained for positions in the growth sectors of the

labor force. Although projections vary, one set

indicates that by the year 2000 employment in

service occupations will comprise about 85 per18There are an estimated 7,000 industrial robots now In use in

the United States. Some 200,000 are projected to be in place in all

types of industries and work settings by 1990; this figure may reach

1 million by 2000.

cent of all jobs. Jobs in manufacturing will have

declined to about 11 percent of the total. Meanwhile, as technologies evolve, many jobs in declining industries are either being replaced by automation or disappearing. Jobs in the manufacturing,

farming, and private household service sectors,

which have high proportions of older workers,

are declining most rapidly.

Technology may adversely affect older workers’ potential to keep these jobs, but it is also likely

to improve working conditions, promote safety,

and expand opportunities for other workers over

45. Technology is creating new jobs in many industries that currently have high proportions of

older workers who can be retrained for these

positions (e.g., steel factory floor foremen have

been trained to operate computerized control

centers instead of supervising “from the floor”).

New service industry jobs and more clerical jobs

may offer security to some older workers whose

skills will remain in demand. And the possibility

of doing today’s jobs in tomorrow’s ‘(electronic

cottage)’ (the computer-based office at home) may

provide opportunities for older workers who

want to work on a part-time or flex-time basis

and/or obviate daily travel to work (clerk typists

and stockbrokers, for example). Nevertheless,

older workers will need to compete with younger workers who may seek similar flexibility in

their job structures. The continuing influx of

women into the labor force will intensify this competition.

Technology can benefit older workers who

have physical impairments. Assistive devices,

computers, robots, and other workplace technologies can compensate for waning physical

strength, dexterity, eyesight, or hearing and can

help improve employment prospects for those not

ready for retirement. Workers of all ages can be

protected by technologies that replace physically

hazardous jobs or those involving dangerous

chemicals and materials. There is evidence of

long-term health hazards from certain dangerous

jobs—hazards that are usually manifested in

chronic conditions later in life. These health conditions are cited as reasons for early retirement

by a significant number of older retirees. Replacing these jobs and providing opportunities for

other work are likely to help older workers who

choose to remain in the labor force.
Ch. I—Executive Summary ● 2 9

RETRAINING OF OLDER WORKERS

Retraining of adult workers will grow in importance as changes occur in the nature of jobs and

the composition of the labor force. Few training

or retraining opportunities are currently available

to older workers, especially those with little education and in low-skilled occupations. This situation is likely to change as the population ages and

fewer young workers are available for the work

force. Indeed, the demographic trend toward

greater proportions of older workers may coincide nicely with the projected creation of new jobs

in geriatric occupations, such as geriatric service counselors and health rehabilitation technicians. Other projections indicate that the aging

of the population, combined with the higher educational levels of future older populations, will

increase retraining opportunities and the prevalence of second and third careers in a person’s

lifetime. Retraining could then be far more common and a repeated element in the lives of most

workers, regardless of age.

other types of technological changes will influence the number of persons who choose to retire

into a healthy and economically secure future.

Current changes in the workplace, in pension

planning opportunities, in health promotion, in

the home, and in the management of chronic conditions later in life may support a continued trend

toward early retirement. In 1983, 17 percent of

men over 65 were still in the labor force, compared with almost 50 percent in 1950; for women

in that age group, the change was from 10 percent in 1950 to 8 percent in 1983 (less dramatic

reductions occurred for men over 55, but an increase from 27 to 42 percent occurred for women

aged 55 to 64 during the same period). If these

retirement trends continue and life expectancy

improvements accelerate as in the recent past, the

falling ratio of workers to retirees will place evergreater pressures on the Social Security system.

In sum, technology can both hinder and enhance the ability of the older worker to continue

working. Although present circumstances do not

warrant immediate large-scale concern, the future growth of technology and its effects on workers will need scrutiny by policymakers to improve

the quality of worklife and provide job security

for aduh workers who wish to remain in the labor

force as long as possible. Adequate income maintenance must also be targeted for congressional

oversight, on the assumption that retirement patterns, whether voluntary or involuntary, will continue at their current level.

SELECTED ISSUES

As is the case with medical advances, accelerating technological change is most evident in the

workplace. Although projections abound regarding the changing nature of the occupational structure during the next 15 years, there is very little

accurate information available on either current

or potential impacts on older workers. Moreover,

little information exists on whether older workers are, in fact, displaced by technology or whether certain technologies instead enhance their employment opportunities. More research is needed

on the functional capabilities of older workers and

the precise reasons for the retirement decision.

Informed policy will require specific data on the

relationship between older workers’ attitudes and

their actual employment behavior, including the

role of factors such as flex-time and part-time

work opportunities, possibilities for retraining,

amount of retirement income expected, social

characteristics, and technological applications in

the work environment (i.e., the workplace or the

home).

The foIIowing questions reflect some of the

immediate concerns that arise for congressional

review about technological impacts on older

workers:

●

●

●

Should Congress encourage the use of assistive devices and electronic technologies in

the workplace to enable older workers with

physical limitations who wish to remain in

the work force to do so?

Should Congress devote Federal resources

and provide incentives to the private sector

to retrain older workers for needed skills?

How might Congress respond to the desires

of some older retired persons for alternative

work options such as flex-time, part-time, and

electronic cottage employment opportunities?
——. —

30 Technology and Aging in America

Conclusion

This review of the relationship between technology and aging has stressed the importance of

functional ability and the vitality of older Americans for maintaining their independence, maximizing their options, and improving their quality

of life. The ongoing aging of the U.S. population

is likely to increase the demand for long-term care

and the need for increased assistance as the growing proportion of those over 75 face a combination of incapacitating and largely unavoidable infirmities. Some existing technologies can mitigate

these problems and others may arise to prevent

or delay their onset.

Technology has also been the major factor in

the growth of the older population and its increased longevity. The mortality rates of all

elderly subgroups have entered a new era of accelerated improvement, indicating even greater

gains in numbers than had been anticipated.

Technology can respond to these trends by providing knowledge and ways to apply that knowledge in the workplace, the home, the health care

setting, and the community to enhance the wellbeing of the elderly. At the same time, the swift

pace of technological change poses new challenges

to society in responding to the effects of such

change. Among the challenges are:

● continual adaptation and retraining for new

skills in the workplace;

● providing home environments that promote

functional independence;

● encouraging greater involvement of individuals in their own health maintenance;

. assuring that those in need of assistance and

supportive services are appropriately served;

and

. utilizing the many resources of older

Americans.

It is clear that a major challenge into the 21st

century will be the maintenance of the health and

functional ability of the older population, particularly as the proportions in the oldest ages rise to

unprecedented levels. In so doing, society will

share the countless benefits that a healthy and

vital older population can contribute.
Chapter 2

Introduction:

Technological Change and

the Older U.S. Population
Contents

Page

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33

Approaches to Technology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33

Aging and Technology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33

Organization of the Report . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34

Major Areas of Concern . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34

Demographic Background . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35

Definitions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35

Demographic Projections of the E1derly Population . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38

Demographic Trends. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40

The Growth of the Older Population . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40

Changes in Average Life Expectancy ...., . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41

The Aging of the older Population . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41

Trends in Life Expectancy by Sex and Race . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43

Major Causes of Death in Old Age . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47

Future LifeSpan and Prevalence of Chronic Diseases . . . . . . . . . . . . . . . . . . . . . . . . . . . 48

Implications of Chronic Disease and Disability . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51

Severity of Chronic Conditions and Patterns of Institutionalization . . . . . . . . . . . . . . . . 52

Chronic Conditions Among the Community-Dwelling Elderly . . . . . . . . . . . . . . . . . . . . . 54

Socioeconomic Characteristics and Sources of Assistance . . . . . . . . . . . . . . . . . . . . . . . . 55

Chapter preferences . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56

Tables

Table No. Page

l. Growth of the Population Aged 55 and Over, by Selected Age Groups, 1900-2050. . 39

2.Life Expectancy at Birth and at Age 65, by Race and Sex, United States,

Selected Years, 1900-82 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42

3. Relative Distribution of the Population Aged 65 and Over, by Selected Age Groups,

Selected Years, 1960-2020 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42

4. Average Annua] Percent Change in Age-AdjustedDeath Rates forPersonsAged 65 and Over,

by Sex and Age, United States, Selected Periods of Years, 1940-80 . . . . . . . . . . . . . . . 44

Figures

Figure No. Page

5. Schematic Representation of Cohort Data and Period Data . . . . . . . . . . . . . . . . . . . . . 37

6. Age-Adjusted Mortality Rates for the Population Aged 65 and Over, by Sex,

United States, 1940-80 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43

7. Average Life Expectancy at Birth, by Race and Sex, United States, 1900-80. . . . . . . . 44

8. Average Life Expectancy at Age 65) by Race and Sex, United States, 1900-80 . . . . . . 45

9. PopulationPyramids, by Age and Sex, United States, 1960-2030 . . . . . . . . . . . . . . . . . 46

10. Past, Current, and projected Ideal Survival Curves for the Population, United States,

Selected Years, 1900-80 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49

11. Projections of the Nursing Home Population Aged 65 and Over,

United States, 1980-2050 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53

12. Limitation of Activity Due to Chronic Conditions, by Degree of Limitation

and Selected Age Groups, 1981 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54
Chapter 2

Introduction: Technological Change

and the Older U.S. Population

Introduction

Technology, in conjunction with economic, demographic, and social factors, affects the nature,

impact, and course of social change. It plays, and

will continue to play, a pivotal role in the aging

of the U.S. population. The myriad approaches

to understanding the interactive nature of technological, demographic, social, economic, and political processes are often onedimensional or narrowly focused, yielding parochial conclusions that

take inadequate account of the effects that different variables have on each other.

Approaches to technology

In this report technology is viewed as complex

and varied, not only in how it evolves, but in how

it is applied to societal problems and goals. The

broad scope of technology is exemplified by descriptions of its different forms, such as ‘(hard”

or ‘(soft ,“ and “high” or “low.” It can be a process

(soft technology) such as research and the development of new knowledge, or products (hard

technology) such as sophisticated new medical instruments and surgical procedures-which are

also high technology-or simple in-home assistive

devices and gadgets, which are low technology.

Technology can, for example, be manifested in

the ways in which health services are organized

or new implements and devices created and utilized. ’ In this report, the term technology encompasses each of these levels, types, and applications

of knowledge to solving problems and accomplishing tasks.

The relationship between technological change

and the welfare of society involves decisions about

‘Another view is provided by physician and educator Lewis Thomas, who has proposed a three-level paradigm of technology: 1) nontechnology, such as personal supportive care services for dependent persons; 2) halfway technology, such as devices that compensate

for disabilities (e.g., hearing aids, pacemakers, wheelchairs]; and 3)

decisive technology, such as basic research and science.

what in fact constitutes a problem,z Because these

decisions include judgments about what is “good,”

the development of knowledge and its technological applications not only arise from cultural

values but are themselves social institutions. Modern technology surpasses that of earlier periods

in its power, scope, and pace of change. Its societal consequences are thus becoming both more

profound and more pervasive, intensifying the importance of understanding and anticipating technological impact and change.

Aging and technology

The interaction between technology and society

presents both opportunities and challenges to individuals and social institutions. Will technological change enhance the ability of older persons

to work or to perform daily activities of living,

or will it instead limit their capacity to be selfsufficient? The rapid growth in numbers of older

Americans is focusing increased attention on the

social and economic costs or benefits of technology for the elderly, and for society as a whole.

New types of housing units and their design

may minimize or exacerbate the difficulties faced

by older individuals who are functionally impaired. Improved biomedical technologies to treat

acute illnesses will present new questions about

the value of life and the choices made about living and dying. Advances in health care that reduce the incidence of chronic disease are likely

to require decisions about allocation of resources

and whether access to health care services is a

right or a privilege. The list of relevant issues is

long and complex, but it is clear that none of these

changes is independent of the others.

2

In discussing the cultural aspects of technology and its use in

solving problems, economist John Galbraith defined technology as

the “systematic application of scientific or other organized knowledge to practical tasks” (8).

33
34 ● Technology and Aging in America

During this century, the application of technologies in the workplace, the home, the hospital,

and the environment has led to great improvements in life expectancy and health across all age

groups, particularly the youngest. Most recently,

medical and other technologies have accelerated

the improvement of life expectancy among the

oldest age groups. Technological developments

have also improved contraceptive efficiency, contributing to the notably low birth rates of the

1970s. The annual fertility rate of American

women aged 15 to 44 was lower during the last

decade than in any previous periods

In combination, these changes in fertility and

mortality will hasten the aging of the American

population during the next few decades During

the last 20 years the population aged 66 and over

has grown twice as fast as the population under

65. The pace of technological change accelerated

dramatically during this period, raising innumerable questions about the interaction of technology with the growing older population,

This assessment recognizes that technology involves the development of knowledge and its application to issues of aging in a variety of contexts,

such as:

3

Fertility rates measure the frequency of live births within a given

population, such as “number of live births per 1,000 women aged

15 to 44.” These rates do not account for stillbirths and aborted

pregnancies, whether induced or spontaneous.

4The aging of the population means an increasing proportion of

the total population in the older (over 65) relative to the younger

(under 65) ages. It is also measured by median age, the age at which

50 percent of the population is older and 50 percent is younger.

the biology or chemistry laboratory, where

new biotechnologies may enhance understanding of cellular aging and disease

processes;

the health care setting, where new diagnostic and treatment methods may prolong increasing numbers of lives;

the workplace, where efficiency and productivity are new challenges for adult workers

and for policymakers concerned with their

physical, economic, and psychological wellbeing;

the home, where functional independence is

likely to be enhanced by new devices, information technologies, and differently organized long-term care service delivery systems; and

the community, where public services, transportation systems, information technologies,

and long-term care programs may enhance

functional ability, or promote disease prevention, health promotion, and expanded options

in daily living.

An examination of each of these broadly defined contexts led to the identification of issues

that are of Federal concern in budgetary, regulatory, and oversight activities. Options that correspond to these issues, which will grow in importance as the elderly become a larger proportion of the U.S. population, are presented for

congressional review.

Organization of the report

Major areas of concern It should be noted that this assessment does not

focus on acute illness and its treatment in the

Four major areas were selected for attention elderly, which would considerably expand its

in this assessment. Their importance, both direct scope. Treatment of acute illness has already reand indirect, is evident in existing Federal policy, ceived extensive study, including other OTA

programs, regulations, and budgetary activities assessments of medical technologies and acute

related to older Americans. These areas are: health cares This assessment concentrates on

●

●

●

●

chronic conditions and biomedical research; chronic health condition, biological factors and

functional impairment and long-term care;

housing and the living environment; and ‘The OTA Health Program has published a series of case studies

and technical memoranda on specific medical technologies for acute

employment and the workplace. illness (22).
Ch. 2—Intrduction: Technological Change and the Older U.S. Population 35

functional impairments of the elderly because of

their growing significance to the independence

of older persons and their ability to carry on var

ious activities in the workplace, the home, and

the community. Some of these areas are discussed in this chapter; many more are included

in the chapters that follow.

The table of contents for this report indicates

the breadth of subjects covered in the four general subject areas cited. Each chapter deals with

the implications of technology and aging in a particular area. General themes include organization,

financing, efficacy, regulation, safety, quality, education, and research. The congressional issues and

options that conclude each chapter reflect many

of these themes (e.g., the efficacy of medications

for the elderly, the organization of long-term care,

and the quality of housing and its design for the

elderly). Areas for additional research are identified separately. Studies on the socioeconomic,

attitudinal, behavioral, and other social scientific

characteristics of the older population are not emphasized in the research priority sections unless

they have a direct bearing on questions related

to technological change.

Chapter topics were chosen in response to congressional requests and upon the advice of the

project’s Advisory Panel. The intent of this assessDemographic background

Definitions

These definitions are central to discussion of

the demographic aging of the American population and the future implications of current trends

in U.S. population growth and change.

AGING AND THE AGED

For purposes of this report, the elderly are defined as all persons aged 65 and over (or ‘(over

65”). Although”65 is a chronological definition of

the onset of old age, there is no scientific “marker”

of old age. In the United States and most Western industrialized countries, 65 years is the age

of eligibility for full retirement income benefits.

Some countries vary in this regard. In Japan the

ment is not to provide a comprehensive review

of all aspects of technology and aging, but rather

to examine the most important technological factors related to the physical and mental health status—and independence-of the older population.

Appendixes are included to provide detailed

data and background information for several important areas, including morbidity and mortality,

labor force participation, and biotechnology. The

appendixes amplify information that is provided

in the chapters.

The following section reviews the demographic

phenomenon known as the aging of the American population. It discusses the changing characteristics of the older population and major

trends in mortality and morbidity. Technological

change and its relevance to these trends is assessed in relation to the report’s four general subject areas, which give rise to key policy issues.

Where appropriate, the experiences of other

Western industrialized countries with similar

characteristics are cited as instructive models that

may suggest possible policy options for the United

States. Detailed comparisons of aging and public

policy in these nations are, however, not included

in this assessment.

eligibility age for women is 55 and for men is 60;

in Norway neither men nor women become eligible for full benefits until age 67. Age 65 was established as the eligibility age for full Social Security

benefits at the US. retirement program’s inception in 1935.6

It is important to note, however, that aging is

a gradual biological process that differs among

individuals; people do not suddenly “become old”

at 65, Indeed, the older population tends to be

6Age 65 has a historical basis; for example, it was used by Germany’s Chancellor Bismarck in the late 19th century to establish

eligibility for military pensions. Although the Chancellor lived past

80, one of his intentions appears to have been to limit the number

of pension beneficiaries in an era when average life expectancy at

birth was less than 45 years,
36 . Technology and Aging in America

more, rather than less, heterogeneous in its

social, political, economic, health, and other

characteristics than those under 66. A chrono=

logically based label is convenient for defining

population groups, but is a poor descriptor of

biological function or need for various types of

assistance. Further ambiguity is seen in the different age criteria for the “elderly” in Federal programs and public statutes. Federal housing assistance programs for the elderly use age 62, while

programs under the Older Americans Act are

available to those 60 and over. The Internal Revenue Service allows an elderly credit on personal

income taxes for Americans 65 and over, but the

one-time capital gains allowance from the sale of

a primary residence is available to anyone over

55. The Age Discrimination in Employment Act

(ADEA) protects workers 40 and over, although

no inference is made that workers in their 40S

are “old. ” Thus, social values and policy-relevant

definitions concerning old age vary widely, and

often depend on the issues, programs, needs, and

constituents involved.

“The aged” as a group must be distinguished

from “aging” as a process that varies both in different species and across subgroups within the

same species. The great variation in average life

expectancies across species is illustrated by the

fact that mice live an average of 3 years and humans an average of 74 years. There is growing

evidence that aging and the incidence of diseases

associated with age also vary within species.

These differences are associated with genetic factors, biological differences, environmental influences, and, for humans, socioeconomic status. For

example, average life expectancies at birth range

from as low as 45 in some developing countries

(Gambia, Niger, and Somalia) to as high as 76 in

some developed countries (Norway, Sweden, and

Japan). In the United States, the average life expectancy at birth for a white female (78.7 years)

is almost 12 years greater than for a black male

(66.5 years).7

Given these variations, definitions of “the elderly”

based on chronological age are artificial. Individ7Data on racial categories used in this report are technically differentiated as “white” or ‘(black and other.” For convenience, “black”

is used in the text, rather than “black and other. ”

ual variation within each age group is great. Although it is convenient and often necessary to

use chronological age (e.g, in formulating pub

lic policy), such boundaries must be used with

caution when making inferences about the

elderly as a group. Both technology and aging

can affect individuals or subgroups of the same

chronological age differently, depending on such

other factors as their functional capabilities and

the social or environmental characteristics that

influence their interaction with society.

Because the over-65 group is so heterogeneous,

some segments of this report identify those between 65 and 74 as the young-old and those 75

and over as the old-old. When it is necessary to

make still finer distinctions, persons over 85 are

referred to as the very old. In certain policyrelated issues, such as older workers’ employment

and the ADEA, the “elderly” can also include those

40 to 64; these exceptions to the report’s basic

definitions are noted as they occur.

The aging of a population is a gradual process

in which the proportions of adults and elderly increase while the proportions of children and adolescents decrease. This results in a rise in the median age (i.e., the age at which 50 percent of the

total population is older and so percent is younger). Aging occurs when fertility rates decline or

remain constant, while mortality rates remain

constant or improve, especially at the older ages.

COHORT V. PERIOD DATA

In discussing population aging and demographic

trends, two main types of data can be utilized:

period data and cohort data. period, or “crosssectional)” data describe variables or events that

occur across a population within a specified time

period. Cohort data, by contrast, follow the experiences of a particular population group over

a long time period. The major difference is that

period data present a “snapshot” of different age

groups in a short time period or at one point in

time, while cohort data provide a “lifetime picture” of a particular group over many years (see

fig. 5).

The most useful cohort in demography is the

“birth cohort”–a group of individuals born within

a certain time period, usually a calendar year or
Ch. Z—Introduction: Technological Change and the Older U.S. Population ● 3 7

Figure 5.—Schematic Representation of Cohort Data and Period Data

85+ Period data

80-84 (cross-sectional

75-79

70-74 -

65-69 The cohort

60-64 born 1896-1900

(aged 40-44 in 1940) 55-59 “

50-54 “

 45-49

a 40-4 4 -

35-39 -

30-34 -

25-29 -

20-24

15-19

10-14

5-9 “

I 1 1 t I t i I 1 I 1 J

1940 1945 1950 1955 1960 1965 1970 1975 1980 1985

Year

NOTE Birth cohort data describe the events expetienced over time by a group born in the same year(s), ie , as the group "ages" period data describe the events across age

groups at one point m time

SOURCE Office of Technology Assessment

a 5-year interval.a The experiences of this birth

cohort can be “followed” through its lifetime. Each

birth cohort experiences a set of events over time

that is characteristic of its aging and the historical period during which this aging occurs, the

consequences of which are called “cohort effects. ”

Cohort analysis is important in gerontological

study because it measures change within a group

over time, as in panel or longitudinal studies. Because actual birth cohort data are not readily

available for long time periods, age-specific crosssectional data over many years are often used to

approximate the cohort experience. But they do

not provide comparable information.

Most events in a population are influenced by

both cohort and period effects. For example, the

‘k’or example, persons aged 64 in 1984 belong to the 1920 birth

cohort. A birth rohort can also be defined for a longer period of

time k’flr example, the 1915-19 birth cohort was aged 61 to 6.5 in

1 :)80

educational attainment of the elderly in 1980 is

largely a result of the educational attainment of

the pre-1915 birth cohorts during their “schoolage years.” Successive birth cohorts had higher

levels of education (a period effect). As the cohorts

aged and became part of the future elderly population, the average level of the total older population’s educational attainment increased. In this

way, earlier period effects are combined with

the aging of the birth cohorts to yield new crosssectional data at a later time. For example, from

1970 to 1980 the proportion of persons over 65

who had completed 1 or more years of high

school increased sharply from 30 to more than

so percent. This large change was primarily due

to the cohort effect of a more highly educated

group aged 55 to 64 who had entered the over65 category by 1980.9

‘r’he difference between cohort and period effects is illustrated

b}’ more detailed comparison of the data on educational attainment.

In 1970 on]j 30 percent of all persons o~’er 65 had completed 1
38 “ Technology and Aging in America

For certain analyses, cross-sectional and cohort

data are combined to create “synthetic cohorts,”

which are hypothetical groups that substitute for

real birth cohorts. A synthetic cohort is created

by using cress-sectional demographic data and applying them to a birth cohort over its future lifetime. These hypothetical cohorts are the basis for

the most commonly used life expectancy tables.

Synthetic cohorts are essential because a real

cohort’s mortality experience requires observations dating back 100 years, and such data are

not generally available. The fertility and mortality characteristics of synthetic cohorts are the

basis for most population projections developed

by Federal agencies. The role of these characteristics in creating synthetic cohorts is an important factor in evaluating projections of the future

elderly population.

Demogaphic projections of the

elderly population

The two major U.S. national population projections are provided by the Bureau of the Census

and by the Social Security Administration (SSA).

The SSA projections are primarily used for future

planning of the Social Security system and its longterm financing obligations. The Census Bureau

projections include all age, sex, and race subgroups of the total population and are the most

commonly used population forecasts. The word

“forecast” is used intentionally to emphasize that

demographic projections are not predictions.

(continued from p. 37)

or more years of high school, compared with 55 percent of those

25 to 64. By 1980, the survivors of the 1970 cohort of persons over

65 had become the over-75 group. In 1980, 28 percent of those over

7.5 had 1 or more years of high school. Because most persons do

not add to their formal education after age 30—much less after age

65—the educational level of this elderly cohort did not change as

it aged during the 1970-80 decade. The cohort effect produced a

slight decrease in 1980 in the proportion of those over 65 with 1

or mom years of high school (probably due to bias in educational

level of the cohort survivors or a statistical artifact).

Period (i.e., cross-sectional) data provide different information.

By 1980 more than 50 percent of all persons over 65 had completed

1 or more years of high school, an increase of 20 percentage points

for that age group between 1970 and 1980. The major reason for

this increase in the period rate was the movement of the cohort

aged 55 to 64 in 1970 into the over-65 category in 1980. The younger

age group brought with it notably higher educational attainment

levels, thereby increasing the average for the new over-65 group

in 1980 (i.e., not the same birth cohort).

Projections are developed in three “series” that

differ according to the basic demographic assumptions used to create the synthetic cohorts

that form the “new” populations. The three series

use low, middle, and high estimates of each type

of age-specific vital rate for l-year birth cohorts

(called the cohort component methodl”).

The accuracy of demographic projections has

improved during the last few decades with the

application of more sophisticated methodologies.

The most recent projections use the latest population base from the final counts of the 1980 census,

revised by estimates of the population as of July

1, 1981 (see table 1). In general, the middle-series

assumptions are considered the most likely to occur, and the low and high assumptions define a

reasonable rate of error around the middle series.

Each of these components will vary from expectations because of unpredictable cultural, economic, and biological factors.

The least predictive component is fertility,

which is most likely to be influenced by exogenous factors (e.g., economic conditions, government policy), to be controlled by personal choice,

and to be influenced by the adequacy of contraceptive methods. The “baby boom” following

World War II was not projected for the 1945-60

period, either in terms of the birth rate or the

number of years during which fertility remained

high. Nor was the precipitous decline in fertility

since the early 1960s expected. Both of these fertility trends have an impact on the short- and longterm changes in the aging of the population.

Mortality is less difficult to estimate, barring no

major short-term deviations in age-, race-, and sexspecific trends in death rates. However, recent

changes in health and medical care technologies

have added an element of uncertainty to age-specific mortality rates for cohort projections. Assumptions about changes in age-specific death

rates have been lower than reality in most projections during the past 30 years (19). The unprecedented increases in life expectancy at the oldest

‘The “cohort component method” separately projects age-specific

fertility, mortality, and immigration rates for each l-year birth

cohort, using the three alternative levels of each demographic component. These “scenarios” are then played out over the remaining

lifetime of each birth cohort to yield the projections for future

decades.
Ch. 2—introduction: Technological Change and the Older U.S. Population ● 3 9

000000000000000 0

000000000000000 0

~1--l-l--vlvl-v~~v~v~-- -

. . . . . . . . . . . . . . . .

. . . . . . . . . . . . . . . .

. . . . . . . . . . . . . . . .

. . . . . . . . . . . . . . . .

. . . . . . . . . . . . . . . .

. . . . . . . . . . . . . . . .
40 . Technology and Aging in America

ages during the 1970s were not anticipated in projections during that time.1*

Net immigration figures tend to be most easily

estimated, given the relationship of immigration

rates to Federal policy, quotas, and registration

procedures. However, immigration rate assumptions do not take account of the high annual total

of undocumented immigrants who enter the

United States. Estimates of their numbers vary

greatly because no accurate data are available.

These factors illustrate the need for caution in

the use and interpretation of population projections. The longer the interval covered by a projection, the greater the degree of uncertainty and

error in the estimates. Each successive year following the decennial census compounds the inaccuracy of the estimates for the basic populations in the projections. Projections of the

numbers of older people are more reliable than

those that yield percentage figures; percentages

1 IProjectlons based on the increased rates of decline in age-specific

mortality rates for the older population subgroups (by age, race,

and sex) during the 1968-77 period yield a total older population

in 200t) that is almost 4 million persons more than was officially

projected by the Census Bureau in 1977–an underestimate of more

than 10 percent. The most recmt official projections have been adjusted upward to account for this dramatic change.

Demographic trends

Among the population changes experienced by

the United States during this century has been

unprecedented growth in the number and proportion of older Americans. Demographic aging,

its changing pace, and the technological factors

that have both created it and responded to it point

to substantial challenges and opportunities for

American society. Improved understanding of

these trends is important in enabling both the

public and private sectors to anticipate and thus

respond appropriately to the needs of future cohorts of elders and to benefit from the resources

they possess.

The most significant demographic trends are:

● rapid growth of the over-65 population during most of this century and its continued

high rate of growth during the next 50 years

depend on the number of persons in every other

age group, which depend largely on fertility

trends over time (the least predictable variable

for projections).

projections of elderly households are even less

reliable, because household formation and size

are influenced by factors such as marital status,

income, health, extended family structure, tax policy, and other variables that are themselves difficult to project. A final source of potential inaccuracy in projections is the base population (or

baseline data) from which future cohorts are developed. As shown in chapter 9, for example, the

1979 estimates of tenure (i.e., owners v. renters)

for elderly households were very different from

the totals enumerated by the 1980 census .*2

Taking these caveats into consideration, the following section reviews the demographic trends

that have had the greatest influence on the aging

of the U.S. population, and looks at current projections of the older population.

lz~ew household p~jections based on 1980 census COUntS halre

not been officially generated; because the most recent official projections use 1978 estimates from the Current Population Survey,

the potential for error remains strong.

●

●

(the aging of the baby boom generation, resulting in the “elderly boom” during 201o to

2025);

changes in life expectancy at birth and at the

older ages, especially the most recent increases in the rate of improvement for the

very old; and

aging of the older population itself, with the

fastest rates of growth among the oldest subgroups (sometimes referred to as an “aging

implosion”).

The growth of the older population

In 1900 only 4 percent of the total U.S. population was over 65. By 1980 this proportion had

risen to 11.2 percent and the number of older

Americans exceeded 25 million (see table 1). In
Ch. 2—Infroductiort: Technological Change and the Older U.S. Population . 47

1983 the elderly population was estimated to have

surpassed 27 million, and to account for 11.6 percent of the total. The growing proportion of older

persons has boosted the median age significantly

in less than three generations—from just under

23 years in 1900 to over 30 by 1980.

This growth in the number and proportion of

the elderly is expected to continue, but at a slower

pace, through the end of the century. The most

recent projections indicate that the ranks of the

elderly will increase by at least 30 percent by the

year 2000, when they will constitute more than

13 percent of the total population. By recent

standards, this projected growth is relatively

small, due largely to the effect of the small birth

cohorts and relatively high infant mortality rates

during the Depression and World War II period

of 1925-45. Both of these factors will limit the

number of older persons in future decades (when

net immigration is held constant).

The effect of the baby boom birth cohorts on

the future older population will be felt after 2010,

when America’s elderly boom begins. By 2020,

the elderly population is expected to exceed 51

million and to account for more than Ii’ percent

of the Nation’s population .13 The projected increase in numbers of older Americans between

2010 and 2020—more than 12 million—is only

slightly less than the number of those expected

to join the over-65 population during the entire

30-year period from 1980 to 2010 (see table 1).

Changes in average life expectancy

During most of this century, gains in the life

expectancy of Americans have occurred because

of improvements in public sanitation, hygiene,

control of infectious diseases, prenatal maternal

and postnatal infant care, and, since the 1940s,

antibiotics. These improvements have sharply reduced infant mortality, which began to fall in the

early 1930s, resulting in higher survival ratios for

successive birth cohorts.

Iq’hese prolecte~ figures are based on the most recent middk’-

series assumptions: 1.9 total births per woman by 1985 and constant thereafter; life expectancy at birth increasing to almost 80 years

for whites by 2050 and for blacks b~f 2080; and net annual immigration of 450,000 persons,

only 41 percent of infants born in 1900 survived to reach age 65; by 1980 this proportion

had risen to more than three-fourths .14 In 1900)

average life expectancy at birth was 47,3 years;

those who reached 65 could expect to live another

11.9 years. By 1983, average life expectancy at

birth had increased by more than 27 years—to

74.7. The change in life expectancy at age 65,

however, has been far less impressive for most

of this century. In 1983 this figure was just 16.8

years, on average, for those aged 65—an increase

of only 4.9 years since 19000

More notable is the recency of the increase in

life expectancy at older ages. The average life expectancy of those aged 65 in 1950 was 13.9

years—only 2 years higher than in 1900, reflecting an improvement of only 17 percent during

the entire half-century (see table 2). Since 1950,

however, the corresponding figure has already

risen by 2.9 years (to 16.8 for 1983), a 20-percent

improvement in just 33 years. Yet this dramatic

improvement in old age survivorship masks still

more recent advances in age-specific mortality.

Of the 2.9 years gained since 1950, 1.6 years

were added between 1970 and 1983. This increase is the largest change ever recorded in life

expectancy at age 66 in such a short period of

tim~more than one-half of the total gain since

1950 occurred in the last 13 years of this 33-year

period.

The aging of the older population

This improvement occurred at the same time

that the older population itself was aging, most

notably since 1960. The growth of the very old

population coincides with improvements in medical technologies, especially lifesaving measures

in acute care (e.g., coronary bypass surgery and

cardiac pacemakers) and life-sustaining technologies (e.g., diagnosis and treatment of hypertension). The survival of increasing proportions to

the very old ages also coincides with the establishment of the Medicare program, which gave

older people greater access to medical technology.

Iq]nfant mor~]it}, has dropped sharplv from 56 deaths per 1 /00~

life births of infants under I year of age in 1935 to a rate of about

11 in 1982 (24).
42 ● Technology and Aging in America

Table 2.–Life Expectancy at Birth and at Age 65, by Race and Sex, United States, Selected Years, 1900-82

(average number of years remaining)

Total White Black and other

Both Both Both

Age and year sexes Male Female sexes Male Female sexes Male Female

At birth:

1900 . . . . . . . . . . . . . . . . 47.3 46.3 48.3 47.6 46.6 48.7 33.0 32.5 33.5

1950 . . . . . . . . . . . . . . . . 68.2 65.6 71.7 69.1 66.5 72.2 60.8 59.1 62.9

1960 . . . . . . . . . . . . . . . . 69.7 66.6 73.1 70.6 67.4 74.1 63.6 61.1 66.3

1970 . . . . . . . . . . . . . . . . 70.8 67.1 74.7 71.7 68.0 75.6 65.3 51.3 69.4

1980 . . . . . . . . . . . . . . . . 73.7 70.0 77.5 74.4 70.7 78.1 69.5 65.3 73.6

1981 . . . . . . . . . . . . . . . . 74.1 70.3 77.9 74.7 71.0 78.5 70.3 66.1 74.5

1982 . . . . . . . . . . . . . . . . 74.5 70.8 78.2 75.1 71.4 78.7 70.9 66.5 75.2

At age 65:

1900 . . . . . . . . . . . . . . . . 11.9 11.5 12.2 — 11.5 12.2 – 10.4 11.4

1950 . . . . . . . . . . . . . . . . 13.9 12.8 15.0 – 12.8 15.1 – 12.5 14.5

1960 . . . . . . . . . . . . . . . . 14.3 12.8 15.8 14.4 12.9 15.9 13.9 12.7 15.2

1970 . . . . . . . . . . . . . . . . 15.2 13.1 17.0 15.2 13.1 17.1 14.9 13.2 16.4

1980 . . . . . . . . . . . . . . . . 16.4 14.1 18.3 16.5 14.2 18.5 15.5 13.5 17.3

1981 . . . . . . . . . . . . . . . . 16.7 – — — — — — — —

1982 . . . . . . . . . . . . . . . . 16.8 — — — — — — — —

SOURCES: National Center for Health Statistics, Health: Ur)/tedStates, f98Z, DHHSpublication N0.(PHS)83-1232, Public Health Service (Washington, DC: U.S. Governmerit Printing Office, 1982); and4’Annual Summary of Births, Deaths, Marriages, and Divorces: United States, 1982J’Morrth/y Vita/ Statistics Report 31:13,

DHHS publication No. 83-1120 (October 1983) and 32:4, DHHS publication Supplement No. 83-1120 (Hyattsville, MD: Public Health Service, August 1983).

Table 3 shows the increasing proportion of

those over 85 in the total older population since

1960 and the expected growth of the very old

population through 2020. In 1960 about 1 in 20

older persons was over 85; by 1980 that proportion had grown to 1 in 11 (8.8 percent). During

the same period the proportion aged 65 to 74 fell

from 66 to 61 percent of the total. Because of the

small birth cohorts during the 1926-35 Depression period, the 65 to 74 group is expected to be

just one-half of the total older population at the

turn of the century, while those 75 to 84 are likely

to constitute more than one-third of all elderly

persons, and those over 85 to reach their highest

proportion, close to 15 percent.

Despite the possibility of small errors in these

projections, the “implosion,” or aging of the

older population itself, promises to be as important as the sheer growth in total number of older

persons. The positive and negative impacts on

society of the growth of this aging elderly population, brought about in large part by increasingly

rapid technological change during the last halfcentury, will inevitably spawn additional new

technologies.

The dimensions of this dramatic transformation

and its implications for society are not easily comprehended. Recent changes in the age composition of the older population tend to obscure the

Table 3.—ReIative Distribution of the Population Aged 65 and Over, by Selected Age Groups,

Selected Years, 1960-2020a

Population age 65 and over Percent distribution by age group

Number

Year (in millions) Percent 65-74 75-84 85 and over

1960 ....., . . . . . . . . . . . . . . . . . . . . . . . . . . . 16.6 100% 66.4%0 28.O% 5.60%

1980 ....., . . . . . . . . . . . . . . . . . . . . . . . . . . . 25.5 100 61.0 30.2 8.8

2000 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35.1 100 50.5 34.8 14.7

2020 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51.4 100 57.9 27.8 14.3

aprojections for years 2000 and 2020 are based on middle-series assumptions

SOURCE: U.S. Bureau of the Census, Projections of the Population of the United States: 1982-2050 (Advance Report), Current Population Reports, Series P-25, No. 922,

October 1982.
Ch. Z—Introduction: Technological Change and the Older U.S. Population . 43

actual improvement in elderly survivorship when

data are reported for the older population as a

whole. This problem is avoided by using age-specific, as well as age-adjusted, death rates .15

From 1940 to 1978 the age-adjusted death rate

for the elderly decreased by more than 37 percent—n percent more than indicated by unadjusted rates for the same period. Similarly, ageadjusted death rates for older women and men

decreased by greater proportions than indicated

by the overall rate (5). These age-adjusted declines

in mortality among the older age groups for both

sexes are primarily due to the improved technologies that have contributed to the growth of the

very old population.

When plotted on an annual basis, elderly death

rates for the 1955-67 period form a plateau, with

relatively little change in real mortality rates (i,e,

age-adjusted) in the older population. But during

the 1968-80 period, sharp reductions in elderly

mortality rates occurred. Average annual reductions in age-adjusted death rates for this period

were 1.5 percent for older males and 2.1 percent

for older females. The nature of this recent trend

in real mortality decreases among the elderly is

shown in figure 6. The post-1967 mortality

declines among the elderly have been greater

than for any previous period in American history, and suggest a new era characterized by

continued decreases in age-adjusted elderly

death rates during the rest of the century (see

also table 4).

Trends in life expectancy

by sex and race

Figure 7 shows that sex differences in age-specific life expectancy have become increasingly

greater than racial differences since the 1930s.

Life expectancy at birth for women has inFigure 6.-Age-Adjusted Death Rates for the

Population Aged 65 and Over, by Sex,

United States, 1940-80

90.0

70.0 -

60.0

I

‘ \

* -

30.0 I I 1 I

1940 1945 1950 1955 1960 1965 197019751980

Year

SOURCE: US Senate, Special Committee on Aging, Developments in Aging 1983,

Volume 1, Washington, DC, Feb 29, 1984. Based on unpublished tabulations by L Fingerhut, National Center for Health Statistics

creased far more rapidly than for men; the most

dramatic improvements have been for black

women, whose life expectancy at birth surpassed that of white men for the first time in

1967. This demographic change began at the

turn of the century, when female survivorship

rates started to improve more rapidly than male

survivorship rates. In 1900 life expectancy at birth

was distinguished by a great disparity between

blacks and whites, rather than between the sexes,

as shown in figure 7. By the 1930s the life expectancy of black women clearly began to accelerate

relative to that of men of both races. By 1980

black women’s life expectancy approached that

of white women, who have the highest level. As

a whole, newborn girls can now expect to live,

on average, 8 years longer than newborn boys. 16

This life expectancy difference by sex is consistent with the rates in many industrialized

countries, particularly those of Northern Europe.

Average life expectancies at birth in Denmark,

15 Age-asjusted demographic rates providetrue indicatiors rates provide true indicators of agespecific change, because they control for the effects of changes in

population age composition that can have a biasing effect on vital

rate data over time. The age-adjusted rates for two or more points

in time are directly comparable, because they indicate hat the rates

Would be if the populations had the same age composition at those

points in time, Measures using age-adjusted rates in demography

are the same as measures using “constant dollars” in economic researrh. The “base year” for age-adjusted rates is usually 30 to 40

years earlier in order to show a definite trend over time,

16Note that life expectancy figures are derived from life table calculations that utilize age-specific period death rates by race and sex.

The life table ‘(population” begins with a synthetic (or hypothetical)

birth cohort whose mortalityf experience over its entire “future lifetime” is based on current age-, sex-, and race-specific death rates.

It is possible that these rates for the synthetic cohort of overestimate e

the mortality experience of the real birth cohort as it ages during

the next 85 years, thus underestimating actual improvdernents in future life expectancy.
44 . Technology and Aging in America

Table 4.—Average Annual Percent Change in Age”Adjusted Death Rates for Persons Aged 65 and Over,

by Sex and Age, United States, Selected Periods of Years, 1940-80 i

Years

Sex and Age 1940-54 1955-67 1968-80

Males:

Age 65 and over . . . . . . . . . . . . . . . . . . . . . . . . . -1.1 “/0 0.2%0 – 1 .7%

65-69 . . . . . . . . . . . . . . . . . . . . ., . . . . . . . . . . . -0. 7 0.1 -2.1

70-74 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . -1. 0 0.2 -1. 6

75-79 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . -1.1 0.2 –1.7

80-84 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . -1. 3 -0. 4 -1. 3

85 And over.... . . . . . . . . . . . . . . . . . . . . . . . . -1. 5 0.9 -1.4

Females:

Age 65 and love -2. 0 -1. 0 -2. 3

65-69 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . -2. 3 -1.1 -2. 3

70-74 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . -2. 2 -1. 3 -2.1

75-79 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . -1. 9 -1. 2 -2. 6

80-84 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . -1. 9 -1.1 -2.3

85 And over . . . . . . . . . . . . . . . . . . . . . . . . . . . . -1.3 0.0 -2.1

a Age adjusted to the United states population aged 65 and Over as Of 1940

SOURCE: National Center for Health Statistics, “Changes in Mortality Among the Elderly: United States, 1940-78’’ Supplement to 1980.’ Vital and Health Statistics,

Series 3, No.229, DHHS publication No. (PHS)64-1406a, Public Heatth Service (Washington, DC: U.S. Government Printing Office, 1964)

Figure 7.–Average Life Expectancy at Birth,

by Race and Sex, United States, 1900-80

1900 1910 1920 1930 1940 1950 1960 19701980

Year

SOURCE: National Center for Health Statistics, VitaL Statistics UnitedStates,

1980.’ Life Tab/es, vol. II, sec DHHS publication No. (PHS) 84-1104

(Hyattsville, MD Public Healh Service, May 1984)

Sweden, Norway, the Netherlands, and other European countries are slightly higher (by l.0to 1,5

years) than in the United States, and have similar differences in life expectancies by gender. But

most of these industrialized countries have life

expectancies at age 65—both average and for men

and women—that are either equal to or slightly

below those of the United States. This anomaly

is partly explained by the older age structure of

most of these European countries relative to that

of the United States, as measured by median age

or by the proportion of the total population over

75.17 The Sex differences in life expectancy at

birth suggest that the united States can expect

continued discrepancy between the survival ra”

ties of men and women, even as the proportion

of older women increases in future years,

The sex- and race-specific changes in life expectancy during the last half-century have greatly affected the composition of the older population.

By 1983 there were over 5 million more women

than men over 65, a ratio of 3 older women to

every 2 older mem As recently as 1960 this ratio

was 5 to 4. This discrepancy increases notably

for the very old; among those over 85 there are

almost 6 women for every 2 men (42 men for

every 100 women. There are no indications that

this general pattern will change for the ensuing

decades into the 21st century.

Yet the rate at which women’s life expectancy

at birth and, in particular, at age 65 increases relative to that for men is not expected to grow at

‘The proportions of persons over 75 in most Northern European

countries range from 0.5 to 2.3 percent higher than in the United

States, a demographically large difference, Higher age-specific death

rates at the oldest ages partly explain the similarity in life expectancy at age 65 between these countries and the United States. But

higher life expectancies at birth, despite the older age structures,

indicate that both female and male life expectancies at ages under

65 are usually higher than in the United States.
Ch. 2—Introduction: Technological Change and the Older U.S. Population “ 45

the same pace that it has for the last four decades (14). As shown in table 2 and figure 8, the

1970-80 increases in life expectancy at age 65 have

been only slightly lower for white men than for

white women, while slightly higher for black men.

In general, older men and women are now benefiting similarly from the recent decreases in

death rates from most causes of mortality, but

the large sex differentials in life expectancy at

birth and at age 65 remain.

These trends in age-specific mortality for both

sexes indicate that more people will not only be

living to older ages, but will also be living considerably longer after age 65 than ever before in the

United States. A visual image of how the demographic structure of the U.S. population is expected to change emphasizes the potential impact

of these trends. Although not directly representative of the most recent projections from which

table 1 was developed, figure 9 presents a recent

set of population pyramids 18 based on projections

made in 1980. The baseline data for the projections assumed higher total fertility rates, lower

l~Popu]~tlO1l p\~rar11i~5 ~re ~r~ptrk re[]reserltat ions of th[: S~X and

age composition of a population, using either I- or 5-}war age inter~’als for each sex to age 85 and m er. The diiigranl is called a pJrrarnid beCa USe the st I’ucturr of most populations in earlier periods

closel~r resembled the tapering form of a pyramid, i~rith decreasing

numhers and proportions in surce.ssi~wl~’ older age groups. ‘1’he

measure used for the horizontal axis can he either iIIMolute nunl -

lwrs, as in fig, 9, or percentag(’s of the IOtiil.

Figure 8.—Average Life Expectancy at Age 65, by Race and Sex, United States, 1900-80

.

1900 1910 1920 1930 1940 1950 1960 1970 1980

Years

SOURCE’ Off Ice of Technology Assessment, based on data from the National Center for Health Statistics, Vital Statistics of the United States,

1980 Life Tables, VOl II, sec 6 DHHS pub No. (PHS) 84-1104 (Hyattsvllle, MD: Public Health Service, May 1984)
46 Technology and Aging in America

t

—----- r
Ch. 2—introduction: Technological Change and the Older U.S. Population ● 4 7

ultimate life expectancies, and higher levels of net

immigration than more recent projections. The

aging of the populations in these pyramids, as

depicted by the degree to which they become

“squared” in ensuing decades, is less than the most

recent projections would anticipate. They therefore reflect the minimum aging that is expected

to occur in the U.S. population structure during

the next 50 years.

The “wave” of the large baby boom cohort in

1960 (ages 0 to 9 in the pyramid) continues to exert its influence as it ages into the years 2010-30.

The squaring of the population’s structure is accompanied by the rapid rate of growth in numbers of older women in successive decades. Even

if mortality rate reductions at the older ages become similar for both sexes in ensuing years, the

current higher survival ratios of women over 55,

who presently outnumber men in this age group

by almost 7 million, will produce higher numbers

of surviving women for at least the next 30 to 40

years.

Major causes of death in old age

Dramatic percentage decreases in death rates

have been occurring in all older age subgroups,

as shown in table 4. Indeed, persons reaching 85

can expect to live, on average, beyond 92. As is

true of mortality declines for the elderly in general, the major contributor to these decreases in

death rates of the very old has been the age-specific decline in cardiovascular deaths. As has been

noted, there is no clear evidence to explain these

dramatic improvements among all older age

groups, but the most likely factors include:

●

●

●

recent technological advances in the care of

acute illnesses that might otherwise have led

to death;

improved monitoring and control of risk factors such as high saturated fat and cholesterol diets, cigarette smoking, and hypertension; and

changes in long-term care of the chronically

impaired, both in institutions and in the community.

Underlying these newly emerging improvements in life expectancy at the older ages are recent declines in age-specific mortality from acute

episodes of infectious diseases (e.g., pneumonia

and influenza) and the major chronic diseases, especially diseases of the heart and cerebrovascular

diseases (stroke). The latter two disease categories, plus malignant neoplasms (cancers), currently account for three out of every four deaths

among the elderly, 19 an overall proportion that

has remained unchanged since World War II.

However, the relative proportion of deaths from

each of the three leading causes of elderly mortality has changed over the last 30 years, in part

explaining the recent improvements in life expectancy at older ages.

HEART DISEASE MORTALITY

Coronary heart disease remains the Nation’s

leading cause of death, both among the elderly

and in the total population. Although 46 percent

of all deaths among persons over 65 in 1980 were

due to cardiovascular diseases, age-specific death

rates from these causes have steadily declined

among the elderly during the past three decades,

particularly since 1970. Between 1970 and 1979,

the death rate from heart disease for persons 65

to 74 declined 22.7 percent-the most substantial decrease ever recorded in a decade for this

disease category and this age group. For those

75 to 84, the decrease was 14.5 percent; the over85 age group had an 18.7-percent decrease during this same period. The relative risk of death

from heart disease increases with age, even

among the elderly. In 1980, heart disease accounted for less than 41 percent of deaths for persons 65 to 74, but almost 49 percent of deaths

among those over 85,

The variations in heart disease mortality within

these age groups by race and sex are noted in appendix A, In general, proportional improvements

have been highest for women and blacks, except

for increases among blacks 75 to 84.

19’Cause of death” data utilized by the National Center for Health

Statistics (NCHS) are based on information contained in death certificates. In general, the cause of death in NCHS tabulations reflects

the underlying cause or event that led to death. This cause may

differ from the “immediate” cause of death that is reported on the

death certificate (e.g., a death from a skull fracture due to an automobile accident would usually be reported as due to the accident

rather than the skull fracture). In 1978 nearly 75 percent of all death

certificates listed more than one condition and 15 percent had four

or more. Cause of death data generally indicate the underlying condition, but not the complicating ones that may have contributed

to the death (23).
48 ● Technology and Aging in America

There are no definitive explanations for the

heart disease mortality differences within or between the racial groups. Similar differences are

also seen in other causes of death and in morbidity rates. Some gerontological studies show

that elderly blacks face the “double jeopardy” of

old age and minority status; the problems of aging

are compounded for minorities by lifelong confrontations with lower social, economic, psychological, and physical health status. These disadvantages are reflected in their greater incidence of

chronic and acute disease throughout life.

These health and social disadvantages disappear

only among the very old, as shown by lower death

rates by sex for blacks in the over-85 group. One

hypothesis suggests a “leveling effect,” which reduces race differences in health and functional

ability at the oldest ages (18). Mortality differences

change in the same manner; beyond age 75,

blacks have higher life expectancies than whites

(19).20 For heart disease mortality, this leveling effect occurs beyond age 85.

CEREBROVASCULAR DISEASE MORTALITY

Cerebrovascular disease (stroke) is a major

cause of death for the very old. Although only

7 percent of deaths to persons aged 65 to 74 are

due to strokes, this proportion reaches 14 percent for those over 85. However, remarkably

high rates of decrease in deaths from strokes

among the elderly occurred during the 1970s,

averaging 3 to 5 percent per year.

Key factors in reducing death rates from stroke

are increased awareness, diagnosis, monitoring,

and control of hypertension and levels of serum

cholesterol. Recent reports from longitudinal

studies suggest that improvements in diet, exercise, and other lifestyle habits also contribute to

falling death rates from stroke (see ch. 4).

20Caution is advisable in discussions of race differences in death

rates among the elderly, especially the very old. Age-reported data

for blacks are likely to be less accurate than for whites at the oldest

ages, due in part to less accurate birth records for older blacks.

Death rates for older blacks have been found to be understated.

Thus, differences in data on elderly mortality rates by race are likely

to be artificially greater than in reality (15),

CANCER DISEASE MORTALITY

Cancers accounted for 19 percent of all deaths

among the elderly in 1980.21 Age-specific rates of

this second leading cause of death among older

persons (and among the general population) have

increased in recent years, primarily due to a notable rise in the rates of lung cancer for older men

and women of all races. In 1980 lung cancer

among women aged 65 to 74 replaced breast cancer as the leading cause of female cancer mortality. older black men have the highest rates of

death from cancer among those over 85. In contrast, older black women have had lower or very

similar mortality rates from all cancers when

compared with older white women.

Recent studies of racial differences in the incidence of specific types of cancers among the

elderly from 1973 to 1978 show a leveling effect

between race, age, and incidence of most cancers

among older men (16). No clear pattern of cancer incidence by race and age was discerned for

women.

Although death rates from cancer increase by

age within the older population, the increases are

small when compared with those for deaths due

to heart disease. The likelihood of dying from

cancer decreases with age; although 26 percent

of all deaths among persons 65 to 74 in 1980

were due to cancer, this proportion sharply decreases-to just 10 percent-among those over

85. Cancer is far more likely to be a killer of the

young-old than the very old.

Future life span and prevalence of

chronic diseases

Because the elderly are becoming an ever-larger

proportion of the U.S. population, their physical

and mental health status is an increasingly important concern. Although recent decreases in death

21The proportion of deaths from cancer among persons over 65

is lower than for those 45 to 64. For the 45 to 64 age group, the

proportion of deaths from heart disease is lower and the proportion of deaths from cancer is higher than for the elderly. Among

persons 25 to 44, accidents are the major cause of death, followed

by cancer and heart disease,
Ch. 2—/ntroduction: Technological Change and the Older U.S. Population ● 4 9

rates from heart disease and stroke among older

Americans have ushered in a new period of increased old-age longevity, this quantitative increase has not been matched by qualitative improvements in the health status or functional

abilities of the older population.

Chronological age continues to be directly associated with greater risk and incidence of most

chronic diseases and functional impairments. Despite reductions in mortality rates from acute

episodes of heart disease and stroke, the prevalence of chronic conditions associated with these

and other diseases persists among the elderly. As

populations age, they face an increasing prevalence of major mental diseases such as schizophrenia, affective disorders, brain syndromes

associated with senile brain disease (e.g., Alzheimer disease) and arteriosclerosis, and epilepsy. This

trend has been called the “rising pandemic of

mental disorders and associated diseases” (11).

Pessimistic reviews of the prevalence of mental diseases in aging populations may be accurate

in the short-term, but there is disagreement about

their long-term persistence, their age of onset,

new technologies that may alleviate or prevent

them, and the consequences that can be expected

at older ages in future decades (9).

There is general agreement that although notable life expectancy improvements should be

achieved during the next two generations, there

is an upper limit for human longevity (1,12), based

on the belief that most types of human cells have

an internally determined limit to the number of

times they can reproduce (10). Some theorists accordingly suggest that mortality is not necessarily

linked to disease and that future technologies to

control or eliminate disease will not yield an everincreasing or even a major increase in human life

span .22

22It is important to distinguish between the terms “life span” and

life expectancy , ” which are sometimes confused in discussions regarding longevity. Life span is best described as the biological upper age limit that any member of a species could possibly reach.

Current estimates suggest a human life span of 110 to 115 years.

AS explained earlier in this chapter, life expectancy is a statistical

measure of the expected average number of years to be lived for

different subgroups of a population. For example, life expectancy

at birth in 1983 was 74.7 years; for black males it was 65.2 years,

while for white females it was 78,8 years. These two different

constructs should not be used interchangeably.

Other researchers estimate that the control or

elimination of all major chronic diseases could

produce a 20-year increase in life expectancy before biological limits on longevity take effect (10).

As the “ideal curve” in figure 10 indicates, this

scenario presents a maximum life expectancy at

birth of no more than 86 years, because most of

what has been called “premature death” from

chronic diseases has already been eliminated. The

large decreases between 1970 and 1979 in older

age mortality are sometimes viewed as the beginning of the final “era” of improvement in life expectancy, whether at birth or at age 65.

Figure 10.—Past, Current, and Projected Ideal

Survival Cures for the Population, United States,

Selected Years, 1900-80

100

 7 5

50

2 5

0

0 10 20 30 40 50 60 70 80 90 100

Age

00

75 -

50 - 1900

25 -

I I 1 1 I

‘O 10 20 30 40 50 60 70 80 90 100

Age

SOURCE. Adapted from Fries, 1980; and Strehler, 1975.
50 “ Technology and Aging in America

Scenarios of the future also offer varying interpretations of the burden of chronic disease in

the older population. One holds that although

chronic disease incidence may increase, the average age at onset of these diseases and their disabling effects will increase faster than will life expectancy, producing a “compression of morbidity”

in which the average period of chronic disease

and disability in old age will be less than current

levels. People would be ill or impaired for shorter

periods of time before biological senescence led

to death (7).

Another scenario projects longer average periods of disability and chronic illness in the future,

based on the assumption that recent lifesaving

and other health care technologies have had a

greater impact on longevity than on the incidence

of chronic disease, Increases in life expectancy

would be accompanied by considerably longer periods of ill health and disability (-9).

Still other models of aging find no clear evidence

of an absolute limit on the longevity of human

cells or on their ability to reproduce. Proponents

of this view feel that all deaths are due either to

accidents or disease, rather than to biological senescence (12). Most reviews of available data indicate that recent advances in life expectancy at

the oldest ages are due to technological advances

in the diagnosis and treatment of chronic diseases and that the potential is high for further

improvement in longevity from the control of

chronic diseases

The experience of other countries with higher

life expectancies, where the incidence and prevalence of the major killer diseases are notably different, is instructive. For example, Japan has a

higher average life expectancy at birth than the

United States (76.3 years as compared with 74.7),

due in large part to much lower heart disease incidence and attendant mortality rates. But the major cause of death in Japan is stroke, which is

ranked third in the United States. If Japan were

to reduce its incidence of stroke to a level similar to that of the United States, additional years

would be added to already high Japanese life expectancy. Similarly, if the United States could decrease its incidence of heart disease to Japanese

levels, even greater increases in American life expectancy could be achieved.

If senescence rather than diseases were in fact

a major killer, life expectancy at the oldest ages

would not be showing such great improvement.

Reductions in the rate of aging of cells, as demonstrated in nonhuman clinical and cellular studies, could possibly delay the age of onset of chronic disease as well as significantly increase life

expectancy (21). If future technologies reduce

the rate of human cellular aging then significant

increases in human life expectancy and life span

could occur with no corresponding increase in

the period of morbidity among the elderly (26).

Some researchers hold that we are on the threshold of major gains in human life expectancy because of prospects for identifying specific genes

related to longevity23 (30). New technologies may

yield methods for improving the efficiency of the

immune system. One method would control the

problem of autoimmunity, in which the body’s

immune system attacks the “good” cells along with

the “bad. ” Another approach contends that accumulated damage to DNA, the message center

of the cell, results in decreased rates of DNA repair as humans age. New methods and technologies for improving the DNA repair rate for longer

periods of time may, some researchers suggest,

be a major step toward increased longevity. Another possible life span extension method is the

nutritional restriction diet. Current studies on

mice indicate that the rate of aging can be reduced and life span increased in mice that receive

carefully restricted diets. The application of technologies such as antioxidant and membrane

stabilization processes, altering neuroendocrine

hormone balance by hypophysectomy (surgical

alteration or removal of the pituitary gland), or

drug therapy have also been hypothesized as life

extension methods (3).

Some theorists suggest that combinations of

two or more of these proposed technologies can

yield 20= to 30-year increases in life span during

the next generation. Recent work in these areas

of life span extension and changes in rate of aging

is provocative, but fails to answer questions about

the application of animal study results to humans.

23The example in humans is a part of the sixth chromosome that

is considered the center of the immune system. It is known as the

major histocompatibility complex and is being studied to understand

its relationship to rates of cellular aging and immune functioning.
Ch. Z—Introduction: Technological Change and the Older U.S. Population ● 51

The long-term effects of applying such methods

to humans remain unknown. Other questions

concern the time period in which such applications or their effects, if any, could occur for

human populations.

Recent data indicate that the age of onset and

the prevalence of chronic conditions among the

elderly have not changed in accord with recent

increases in average life expectancy at age 65

(2,17). Because there is as yet no way to prevent

(or effectively treat or cure) major chronic diseases such as osteoarthritis and Alzheimer disease, there is little reason to postulate declining

incidence of these disabling conditions among

elderly cohorts in the near future (see ch. 3). And

as the older population ages in ensuing decades,

the prevalence of these conditions could also rise.

Contrasting views hold that the data do not accurately account for today’s healthier behaviors

among portions of the younger population, as suggested by data on one subgroup of young persons that show lower blood pressure, serum cholesterol, and cigarette consumption levels than

their parents’ generation (4). Proponents of this

belief argue that if healthy behaviors were encouraged among all age groups, healthier future

cohorts of elderly persons would result (6).

Investigation of the implications of these behaviors for their possible long-term effects on health

(e.g., heart conditions or osteoarthritis) and functional ability (e.g., Alzheimer disease) is in its infancy (see ch. 4). But if projected gains in life

span and/or average life expectancy were to be

achieved within onegeneration, these dramatic

changes would take place just as the baby boom

cohort “comes of age” as the elderly boom of the

2010=25 period. The implications of this possibility are profound in terms of both added productivity among the elderly and increased demands

on societal resources.

Implications of chronic disease and disability

These emerging technological and demographic

trends have important and varying implications

for Federal policies related to the provision of

health care, social services, long-term care, and

income supports to the elderly. The demand for

these types of supports and the resources and

capabilities that increased numbers of older per

sons contribute to society will depend on the nature of the population aging process and the pe

riod of morbidity that can be expected Additional impacts from these changes in technology and

aging will involve the marital status, living arrangements, extended family size, work and retirement patterns, and other characteristics of future elderly populations characterized by higher

life expectancies.

Given current indications, the following characteristics and consequences of an aging American population and anticipated technological

change are likely to dominate Federal aging policy debates for the short-term future to the turn

of the century:

●

●

●

the growing prevalence in the older population of certain chronic physical and mental

conditions, and functional impairments resulting from them, especially among the very

oId;

in contrast to the predominance of the current acute-care medical model, a growing

need to develop appropriate programs to

care for persons with chronic conditions, including provisions for needed social as well

as medical services;

developing options and evaluating the relative costs, both public and private, for different modes of long-term care in different

settings;

questions regarding appropriate medications

and evaluations of their positive or negative

effects on older persons;

the possible role of healthier behaviors in reducing the incidence or severity of chronic

conditions and maximizing the quality and

productivity as well as length of life at older

ages;
52 . Technology and Aging in America

●

●

●

●

●

●

●

the role of informal v. formal social, health,

and medical supports in responding to current and future long-term care needs of the

elderly;

the need for institutionalization in caring for

those severely ill, highly dependent elderly

and disabled persons who require the highest

levels of 24-hour skilled nursing care;

continuing pressure to contain the costs of

medical, social, and long-term care services

while maintaining their quality and accessibility for all persons;

the increasing interest in and development

of information technologies that can help the

elderly in self-health care and maintenance

of functional ability;

the ability to respond to the preferences of

most older people to live as independently

as possible in comfortable, safe, convenient,

and familiar residential settings for as long

as possible;

a growing range of housing options and technological choices that can respond to the desires and needs of older persons with various

levels of functional impairments to carry on

their daily activities; and

the trends in labor force participation and

functional status among the elderly and the

potential for workplace technologies to either

displace older workers or provide expanded

opportunities for new or continued employment.

An important challenge in relation to these

issues is the need to recognize the heterogeneity

of the older population in terms of the attitudes,

preferences, social characteristics, and health status of its members. It will also be important for

Federal policy to carefully anticipate the growing numbers and proportions of older persons

who will be most ‘(at risk” of chronic disease and

related disabilities. These “at risk” individuals will

either require institutionalization or need some

level of supportive health and social services in

the community.

The following section focuses on the relevance

of health, functional impairment, and the environment of the elderly to highlight the interdependent aspects of these characteristics and their

impact on the lives of older Americans. The other

chapters of this report present detailed information on these areas.

Severity of chronic conditions and

patterns of institutionalization

In 1983 there were more than 1.3 million older

Americans in nursing homes—5 percent of the

over-65 population.24 This is twice the proportion

of elderly persons who lived in nursing homes

in 1960. This increase is largely due to the aging

of the older population itself and, in particular,

to the prevalence of very old women who are widowed. These women are at high risk of institutionalization because they are most likely to live alone,

to have no informal support network, and to be

poor (i.e., eligible for Medicaid reimbursement for

nursing home care; see chs. 7 and 9). If current

age-specific trends persist, greater rates of institutionalization among the elderly can be expected

as the population continues to age, At any one

time, about 10 percent of the over-75 population

are institutionalized. More than 1 in 5 (23 percent)

of those over 85 are in institutions.

Recent projections, using revised 1977 baseline

data, show an increase of 83 percent in the elderly

nursing home population (to 2.2 million residents)

by the year 2000, According to these projections,

the very old will become an ever-growing portion of all older persons in nursing homes (see

fig. 11). By 2020, when the young-old cohort of

the elderly boom is 65 to 74, there could be 3 million elderly persons in nursing homes, more than

one-half of whom would be over 85. By 24)40, as

the elderly boom cohorts reach the very old

ages, the numbers of nursing home residents

could skyrocket to 6 million or more, threefifths

of whom would be the very old. Revised estimates that reflect the most recent aging trends

would yield even higher numbers.

The median entry age of nursing home residents has increased steadily since 1960 to the current age of 80. The median age of residents is 83.

Although the young-old are largely able to avoid

nursing homes, the growth of the old-old and

their much higher risk of institutionalization will

24Persons over 65 account for approximately 85 percent of all nursing home residents, a figure that has changed little during the last

25 years.
Ch. 2—introduction: Technological Change and the Older U.S. Population ● 53

Figure 11 .—Projections of the Nursing Home Population Aged 65 and Over,

United States, 1980-2050

6

5

4

‘ 3

2

1

0

85 and over

75-84

65-74

2.60

1.69

1980 1990 2000 2010 2020

3.02

2030

4.90

2040

5.39

2050

SOURCE: U S. Senate, Special Committee on Aging, Developments in Aging: 1983, Volume 1, Washington DC Feb 29.1984

Based on most recent revised estimates of the 1977 population base, U.S. Bureau of the Census Series P-25, ‘No.

917-1977, estimated, and Series P-25, No. 922, October 1982. Middles Series Projections; and the National Nursing

Home Survey (1977), National Center for Health Statistics.

be a major Federal concern in future years.

unless the incidence of severe mental and physical disabilities related to increased prevalence

of chronic diseases among the very old decreases, and assuming that the aging of the older

population continues, a greater share of the total

older population of the future can be expected

to require either 1) full-time skilled nursing

care, primarily in institutions or 2) increased

custodial and other forms of long-term care in

the community. In fact, some estimates show

that twice the number of persons now in nursing homes are in need of some type of long-term

care in the community (2).

One consideration for Federal policy is the extent to which some proportion of this highly

dependent population could be either equally or

better cared for in a different residential setting.

There is no consensus on the proportion of the

institutionalized elderly who could be ‘(released”

from nursing homes. Estimates of those who

could receive alternative forms of care or who

are considered unnecessarily institutionalized

range from none to more than 40 percent (29,32).

The difficulties with such estimates lie in the different assumptions that are made regarding the

institutional population’s characteristics and the

relationship of these characteristics to the types

of care required. There is little evidence on which

to base estimates of the numbers of current nursing home residents who could be cared for in

other settings, in part because of a dearth of information on alternative settings and types of formal long-term care (see ch. 7).

Nonetheless, three categories of characteristics

are the strongest predictors of nursing home residency: 1) dependency in toileting and eating, 2)

dependency in bathing and dressing, and 3) mental disorders (31). These highly interrelated predictors are particularly applicable for the very old

and those who live alone. For example, the risk

of mental confusion increases notably in the oldest ages and is sometimes the reason that individuals are unable to feed, bathe, or dress themselves. Estimates from national surveys and other

sources indicate that, despite the primary diagnosis for admittance, about one-half of all elderly

nursing home residents suffer some degree of

mental confusion. Other data indicate that the degree of dependency among nursing home residents has increased, along with median age, since

1960.
54 ● Technology and Aging in America

Chronic conditions among

the community-dwelling elderly

The community dwelling elderly, who comprise

95 percent of Older Americans, have a much lower prevalence of severe limitations and dependency than the institutionalized older population.

In 1981 the most commonly reported chronic conditions for this great majority of the older population were arthritis (46 percent), hypertension (37

percent), hearing impairments (28 percent), and

heart conditions (28 percent) (27). Although more

than 85 percent of the noninstitutionalized elderly

reported one or more chronic conditions in various surveys over the past 20 years, fewer than

half of those who had such conditions reported

any degree of activity limitation because of them

(25). Most older persons thus continue to be independent and active members of the community.

Yet the extent of limitation among the elderly

is notable when compared with other segments

of the population, as shown in figure 12. Only 14

percent of the total noninstitutionalized population in 1981 reported some form of activity limitation (4 percent were limited in a major activity

such as work). Among those 45 to 64, the total

proportion whose activities were limited by

chronic conditions was 24 percent. Both the prevalence and the severity of chronic conditions and

their associated disabilities increase in old age.

Fewer than one-third of those who are limited

Photo credit: Suzanne L. Murphy

The great majority of older Americans are active and

contributing members in their community.

Figure 12.—Limitation of Activity Due to Chronic

Conditions, by Degree of Limitation and Selected

60

50

40

 3 0

20

10

0

Age Groups, 1981

 Unable to carry major activity

Limited in amount or kind of activity 53%

Limited, but not in major activity

.

470/~

140%

4

240%

n

7

All 65+ <25 25- 45- 65- 75+

ages 44 64 74

SOURCE: U.S. Senate, Special Committee on Aging, Developments in Aging 1983,

based on National Center for Health Statistics, 1981 Health Interview

Survey, unpublished.

in the 45 to 64 age category are unable to carry

on a major activity, but among those over 65, the

proportion rises to almost two-fifths; among those

over 75 the proportion exceeds two-fifths (see fig.

12). Beyond age 85, some 60 percent of the

community-dwelling elderly report activity limitation from a chronic condition and more than

one-half of these persons are unable to carry on

a major activity.

The severity of physical and mental limitations

from chronic conditions is thus a critical problem–for the elderly in general and the very old

in particular. The sharp increase in prevalence

of dysfunctions among the very old is especially

noticeable for osteoarthritis, heart conditions,

hearing and vision impairments, and urinary

incontinence. Technological applications that

can eliminate or mitigate the incidence of either
Ch. 2—introduction: Technological Change and the Older U.S. Population 55

the underlying chronic conditions or the limitations they present would yield major improve

ments in preserving the independence of older

persons and their ability to function in the workplace, at home, and in the community.

Assistance for the functionally impaired who

need help is provided by formal services, informal care from family and friends, or technologies

in the home. Chapters 7 and 9 provide detailed

reviews of these subjects, which are briefly discussed in the following section.

Socioeconomic characteristics and

sources of assistance

Coinciding with the growth of the old-old and

very old segments of the elderly population is the

growth in numbers of older Americans who live

alone. This trend is almost entirely attributable

to the increase in the number of very old surviving women. In 1982 one-half of all older women

were widowed, compared with only 12 percent

of all older men. These proportions rise significantly among those over 75—to 69 percent for

women and 22 percent for men (see ch. 9). Conversely, among all women over 75, only 22 percent were married and living with their spouse

in 1982; for men, the corresponding figure was

70 percent.

A consequence of these differences is that women over 75 are far more likely to be living alone

than men—45 percent of women as opposed to

19 percent of men. These differences in marital

status and living arrangements, coupled with

older women’s greater life expectancy, mean that

very old women are far more likely to live alone

and, therefore, are less likely to have informal

assistance from a spouse or other person in the

home. By 1995 more than 55 percent of all

elderly households are expected to consist of persons living alone or with nonrelatives; four-fifths

of this population will be older women.

These trends indicate that the elderly are likely

to require a greater variety of housing types and

living environments than exist today. Higher proportions of single-person households, especially

among the very old, are likely to increase the demand for congregate types of housing, residentialcare complexes, and life-care communities. The

functional status of the growing older population

and their need for assistance will influence this

demand for more supportive types of living arrangements. The ability of some elderly subgroups to pay for such environments and support services may be limited by low incomes. This

is particularly relevant for the short-term future

as increasing proportions of the elderly reach the

oldest ages with little more than Social Security

for their monthly incomes.

older women are clearly at greatest risk of poverty. Low rates of labor force participation among

women 45 to 64 in previous decades, compounded by low average income levels of those

women who were in the labor force, indicate that

greater numbers of old-old and very old women

are likely to have incomes below the Federal poverty level for the next two decades. In 1982, 14,6

percent of all older persons were living below the

poverty level. Twice as many older women who

lived alone (28.7 percent) were in this category.

Black women are especially vulnerable in this regard. Almost one-half of all black women over 72

had incomes below the poverty level, a rate five

times that of their white male counterparts.25

Almost 70 percent of black women who live alone

have incomes below the poverty level (28). These

differences are expected to persist for the remainder of this century.

Certain older Americans in fact face “quadruple

jeopardy” in terms of higher risks of chronic disease, functional impairment, poverty, and living

alone—those who are: 1) very old, 2) women, 3)

widowed, and 4) black. Thus, the burdens of old

age are far greater among the very old, especially

among women and minorities. Although these

elderly individuals are most likely to suffer impairments from chronic conditions, they are least

likely to have informal supports or the resources

to pay for formal care at home, And very old

women who are widowed are a growing propor25Older women in general have Social Security retirement incomes

that are considerably lower than those of older men. Women’s tradi -

tionally lower wages provide a much lower earnings base for calculation of Social Security retirement income benefits. Very old black

persons, particular} women, are highly likely to receive only the

minimum benefits.
56 Technology and Aging in America

tion of the older population. If these trends con=

tinue, during the rest of this century a growing

proportion of the older population in need of

care is likely to rely on publicly subsidized

sources of assistance, whether in long-term care

institutions or in their own homes and the corn=

munity.

The following chapters review the range of agerelated issues that can be addressed by various

types of technologies. Cost+effective technologies

that improve the health and functional status of

the elderly may help reduce the anticipated increases in per capita public and private health expenditures. Delaying the onset of major chronic

diseases and improving their treatment or prevention will greatly enhance the functional independence of the elderly, making their lives more

productive and meaningful. Technological adapChapter 2 references

1. Burch, P., “What Limits the Life Span?” Population

and the New Biology, B. Benjamin, P. Cox, and J.

Perl (eds.) (New York: Academic Press, 1974), pp.

31-56.

2. Butler, R., “A Generation at Risk,” Across the Board

37-45, July/August 1983.

3. Cutler, R., “Life-Span Extension,” Aging: Biology

and Behavior, J. McGaugh and S. Kiesler (eds.)

(New York: Academic Press, 1981).

4. Feinleib, M. “Changes in Life Expectancy since

1900,” Circulation, Supplement 111, 52:16-17, 1972.

5. Fingerhut, L,, “Changes in Mortality Among the

Elderly, United States, 1940-1978,” Vital and Health

Statistics, National Center for Health Statistics,

Series 3, No. 22, DHHS publication No. (PHS) 892-

1406 (Washington, DC: U.S. Government Printing

Office, March 1982).

6. Fries, J., “The Compression of Morbidity,” Milbank

Memorial Fund Quarterly 61(3):397-419, summer

1983.

7. Fries, J., “Aging, Natural Death, and the Compression of Morbidity,” hr. Engl. J. Med. 303(3):130-135,

July 1980.

8. Galbraith, J., The New Industrial State, 3rd. ed.

(New York: New American Library, 1979).

9. Gruenberg, E., “The Failures of Success,” Milbank

Memorial Fund Quarter& 55(1):3-24, winter 1977.

tations of the living environment can assist older

persons in adjusting to environmental demands,

thereby promoting their independence and safety

in the home and in the community. Longer years

of life and new technologies for the workplace

could provide opportunities for some older persons to fulfill their desires for a longer worklife

or for second and third careers. Others may

choose to expand their leisure and recreational

activities in retirement.

In combination, these technological changes can

enhance the well-being of older persons and maximize their ability to remain independent and active members of society. The U.S. Congress and

Federal Government could directly and indirectly

assist in this effort. The issues and options at the

end of each ensuing chapter set forth some of the

considerations for congressional review.

10. Hay flick, L., “The Limited In Vitro Lifetime of

11

12

13.

Human Diploid Cell Strains,” Experimental Cell Research 37:614-636, 1965.

Kramer, M., “The Rising Pandemic of Mental Disorders and Associated Chronic Diseases and Disabilities, ” Acta Psychiatric Scandinavia, vol. 62,

Supplement 285:382-397, 1980.

Leaf, A., “Long-Lived Populations: Extreme Old

Age,” J. Am. Geriat. Soc. 30(8):485-487, 1982.

Manton, K., “Changing Concepts of Morbidity and

Mortality in the Elderly Population,” Milbank

Memorial Fund Quarter@ 60(2):183-244, spring

1982.

14. Rose, M., “The Evolutionary Route to Methuselah)”

New Scientist 103(1414):15-18, July 26, 1984.

15. Rosenwaike, I., Yaffe, N., and Sagi, P,, “The Recent

Decline in Mortality of the Extreme Aged: An Analysis of Statistical Data,” Am. J. Pub. Hlth. 70(10):

1074-1080, October 1980.

16. Satariano, W., Albert, S., and Belle, S., “Race, Age

and Cancer Incidence: A Test of Double Jeopardy)”

J. Gerontol. 37(6):642-647, November 1982.

17. Schneider, E., and Brody, J., “Aging, Natural Death,

and the Compression of Morbidity: Another View,”

N. Eng). J. Med. 309(14):854-856, October 1983.

18. Shanas, E., “Self-Assessment of Physical Function:

White and Black Elderly in the United States,” Sec-
Ch. 2—Introduction: Technological Change and the Older U.S. Population ● 5 7

ond Conference on the Epidemiology of Aging, S,

Hayes and M. Feinleib (eds. ) (Bethesda, MD: National Institutes of Health, publication No, 80-969,

July 1980), PP. 269-285.

19. Siegel, J., “Review of Official National Demographic

Projections, ” report prepared for the Office of

Technology Assessment, contract No. 333-8300,

October 1983.

20. Siegel, J., “Recent and Prospective Demographic

Trends for the Elderly Population and Some Implications for Health Care, ” Second Conference on

the Epidemiology of Aging, S. Haynes and M. Feinleib (eds. ) (Bethesda, MD: National Institutes of

Health, publication No. 80-969, July 1980), pp.

289-315.

21. Strehler, B., “Implications of Aging Research for

society,” Proceedings of the 58th Annual Meeting

of the Federation of American Societies for Experimental Biology, 1974 34(1):5-8, 1975.

22. U.S, Congress, Office of Technology Assessment,

Abstracts of Case Studies in the Health Technology Case Study Series (Washington, DC: U.S. Gov -

ernment Printing Office, November 1984).

23. U .S. Department of Health and Human Services,

National Center for Health Statistics, “Advance Report of Final Mortality Statistics, 1981, ” Monthy

Vita/ Statistics Report 33:3 Supplement, DHHS publication No. (PHS) 84-1120 (Hyattsville, MD: Public

Health Service, June 1984).

24. U.S. Department of Health and Human Services,

National Center for Health Statistics, “Annual Summary of Births, Deaths, Marriages, and Divorces:

United States, 1982, ” Monthly Vital Statistics Report 31:13, DHHS publication No. (PHS) 83-1120

(Hyattsville, MD: Public Health Service, October

1983).

25. U.S. Department of Health and Human Services,

National Center for Health Statistics, “Current Estimates From the National Health Interviewr Survey

United States, 1981, ” Vital and Health Statistics,

Series 10, No. 141, DHHS publication No. (PHS) 83-

1569 (Washington, DC: U.S. Government Printing

Office, October 1982).

26. U.S. Senate, Committee on Finance, Subcommittee

on Savings, Pensions, and Investment policy,

“Trends in U.S. Life Expectancy, ” Hearing, 98th

Cong., 1st sess., July 15, 1983 (Washington, DC:

U.S. Government Printing Office, 1983).

27. U.S. Senate, Special Committee on Aging, Developments in Aging: 1983, Volume I, 98th Cong., 2d

sess. (Washington, DC: U.S. Government Printing

Office, February 1984), p. 45.

28. U.S. Senate, Special Committee on Aging, ibid., pp.

25-28.

29. U.S. Senate, Special Committee on Aging, ‘(The Federal-State Effort in Long-Term Care for Older

Americans: Nursing Homes and ‘Alternatives ’,”

Hearing 95th Cong., 1st sess., Aug. 30, 1978 (Washington, DC: U.S. Government Printing Office,

1978),

30. Walford, R., Maximum Life Span (New York:, W. W. Norton 1983).

31. Weissert, 1$’., and Scanlon, W., ‘(Determinants of

Institutionalization of the Aged, ” Working Paper

No. 1466-21 (Washington, DC: The Urban Institute,

November 1982).

32. Weissert, W’., “Innovative Approaches to LongTerm Care and Their Evaluation, ” paper prepared

for the Project HOPE and OTA Conference on the

impact of Technology on Long-Term Care, February 1983.
Chapter 3

Selected chronic Conditions,

Technology, and Biomedical

Research
Contents

Page

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61

Dementia: Social Problem , Medical E

and Federal Burden . . . . . . . . . .

Causes and Prevalence . . . . . . . . .

Effects on Patients and Their Fami

Clinical and Scientific Background

Federal Roles Regarding Dementia

Urinary Incontinece . . . . . . . . . . .

.

Enigma,

. . . . . . . . 63

. . . . . . . . 63

ies . . . . 64

. . . . . . . . 64

. . . . . . . . 65

.. .,..., 66

Definition, Prevalence, and Causes

of Incontinence . . . . . . . . . . . . . . . . . . . . . 70

Treatment . . . . . . . , . . . . . . . . . . . . . . . ... , . . 72

The Cost of Incontinence . . . . . . . . . . . . . . , . 76

Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77

Hearing Impairment in the Elderly , . . . . . . . . . 78

Prevalence . . . . . . . . . . . . . . . . . . . . . . . . . . . . 78

Types and Causes of Hearing Loss

Among the Elderly . . . . . . . . . . . . . . . . . . . . 80

Impacts of Hearing Impairment . . . ... , . . . . 82

Treatment of Hearing Impairment . . . . . . . . . 82

The Service Delivery System. ... , . . . . . . . . . 86

Funding for Treatment of Hearing

Impairments . . . . . . . . . . . . . . . . . . . . . . . . . . 87

Federal Government Programs for the

Hearing Impaired Elderly . . . . . . . . . . . . . . . 88

Osteoarthritis . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89

Definitions and Prevalence . . . . . . . . . . . . . . . 90

What is osteoarthritis . . . . . . . . . . . . . . . . . . . 90

Risk Factors . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91

Diagnosis . . . . . . . . . . . . . . . , . . . . . . . . . . . . . . 91

Prevention of Disability and Treatment . . . . 92

Quackery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 94

Social Factors . , ., . . . . . . . . . . . . . . . . . . . . . . 94

Osteoporosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . 95

Magnitude of the Clinical and Social Problem 95

Biology and Physiology . . . . . . . . . . . . . . . . . . 96

Page

Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97

Treatment andPrevention . . . . . . . . . . . . . . . 97

Summary . . . . . . . . . . . . . . . . . . . . ., . . . . . . . . 100

Policy for Basic Biomedical Research . . . . . . . . 100

Congressional Role in Supporting

Research on Aging . . . . . . . . . . . . . . . . . . . . 101

Reasons for Supporting Biomedical

Research on Aging ,. .,.,., . . . . . . . . . . . . 103

Resource Allocation: Who Decides What . . . 105

Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 110

Congressional Issues and options

Regarding Basic Biomedical Research . . . . . 110

Chapter 3 References . . . . . . . . . . . . . . . . . . . . . 111

Tables

Table No. Page

5. Common Reversible Causes of Dementia . . 66

6. Types of Incontinence. . . . . . . . . . . . . . . . . . 71

7. Treatments for Urinary Incontinence .,... 73

8. Causes of Conductive and Sensori-Neural

Hearing Impairments . . . . . . . . . . . . . . . . . . . 81

9. Treatments for Arthritis . . . . . . . . . . . . . . . . 92

Figures

Figure No. Page

“13. Percent of Adults Aged 25 to 74

With Hearing Impairment, by Frequency

of Tone in the United States, 1971 -75..... 79

14. Physiology of the Human Ear . . . . . . . . . . . 80

15. Diagram of Knee Joint . . . . . . . . . . . . . . . . . 91

16. National Health R&D, 1972 and 1982,

as Related to Total R&D Cost

and Total Health Cost . . . . . . . . . . . . . . . . . . 102

17. National Support for Health R&D

by Source, 1972-83 . . . . . . . . . . . . . . . . . . . . 103
Chapter 3

Selected Chronic Conditions,

Technology, and Biomedical Research

Introduction

Improved sanitation, health care, environmental

protection, and greater affluence all contribute

to extending the average length of human life.

Technology is an essential element of each of the

factors that improve health and extend life. Modern sanitation methods, for example, are based

on scientific evidence of their potential effectiveness and the technological innovation that makes

the transport and treatment of sewage affordable.

New medical technologies that extend life include

the use of drugs to successfully treat hypertension, thus reducing mortality from heart disease

and stroke, and sophisticated devices, like computer-assisted X-ray machines, that permit more

rapid and specific diagnosis.

The second half of the 2~h century has seen

a dramatic shift in the types of diseases afflicting people, especially in economically developed

countries. The incidence of many infectious diseases has fallen sharply as sanitation has improved and vaccines have been developed; many

of the remaining infectious diseases can be effectively treated with antibiotics. Death rates from

diseases of the heart and blood vessels have also

begun to change as a result of diet, personal

habits, and improved health care. If trends contilme, several predictions can be made:

● life expectancy will continue to rise,

● diseases whose incidence rises with age will

become more common,

● environmental and dietary factors affecting

health may become more important because

individuals will live through longer periods

of exposure and have longer to develop symptoms, and

● new and unexpected medical syndromes may

appear.

Each of these factors may boost the number of

people affected with chronic health conditions.

Dementia, arthritis, deafness, poor vision, and

other currently incurable ailments are likely to

rise in importance as death rates from vascular

disease decline and the prevalence of various

cancers shifts (see app. A). There are four general strategies for dealing with chronic health conditions:

●

●

●

●

treatment of acute episodes of illness arising

from underlying chronic illness;

long-term treatment or long-term care;

prevention; or

research to improve diagnosis, treatment,

and prevention.

Policies regarding each of these interventions,

except routine medical care, are discussed elsewhere in this assessment. Medical care for acute

episodes of chronic illness and other aspects of

hospital and ambulatory health care are discussed

only briefly in this report because they are covered in both OTA reports on Medicare and in

reports by other Federal agencies. Certain aspects

of medical care, however, are covered in chapter 8.

Long-term care is discussed in chapter 7 and

prevention in chapter 4. Questions regarding Federal policy on biomedical research on aging are

addressed in the final section of this chapter.

An important result of the rise of chronic disease is the likely increase in prevalence of conditions that lack both cures and means of prevention and that become more common with age,

such as osteoarthritis and Alzheimer disease. The

shift from infectious to cardiovascular to other

chronic conditions has followed a path of progressively greater clinical ignorance: those disorders that are now becoming more common are

those about which we know the least. We know

far more about the cause of tuberculosis than

61
62 ● Technology and Aging in America

about the causes of Alzheimer disease. The most

common causes of death and disability among

Americans over 65 are reviewed in chapters 1,

2, 7, and in appendix A, which covers morbidity

and mortality. The conditions selected for special

review by OTA staff and the advisory panel for

this assessment were chosen on the basis of several criteria:

●

●

●

●

●

●

the condition is chronic and persistent;

easily readable and current summaries of the

state of science and medicine regarding the

condition are not readily available;

the elderly population is specifically affected

due to severity or prevalence;

technology is relevant to correction of or

compensation for the condition;

the condition contributes to the demand for

long-term care, in line with the emphasis of

the current assessment; or

Congress has recently demonstrated a special

interest in the condition.

The conditions identified by OTA staff and advisory panel members as most meriting discussion

were dementia, urinary incontinence, hearing impairment, osteoporosis, and osteoarthritis, Visual

impairments, diabetes mellitus, certain cancers,

liver disease, and chronic lung disorders were also

considered, but omitted due to limitations of

space, which also dictated that the reviews be succinct and focused on policy.

Dementia was selected because Alzheimer disease and other dementing illnesses will soon

become overwhelming health problems unless

means for prevention or treatment are found.

These diseases are severe, affect an important

aspect of human function—mental ability—and

are the most common determinants of need for

long-term care. There are as yet no reliable or

specific means of accurately diagnosing dementing disorders, although improvements have been

rapid in recent years. Further, these disorders are

probably not single entities, but combinations of

related but biologically distinct diseases that have

not yet been scientifically differentiated. The policy options relating to Alzheimer disease and dementia thus relate to long-term care for demented

patients (see ch. 7) and to biomedical research.

Although the ultimate solutions to dementing illness must come from research, they are not likely

to be achieved in the short term, and the problem of caring for demented patients for the final

few years of life cannot be avoided in the near

future.

Urinary incontinence is a common problem. It

is a symptom of many neurological, endocrine,

vascular, and urological diseases that can now be

treated with technologies ranging from absorbent pads to sophisticated mechanical devices. Because many of the relevant technologies are just

coming to fruition, incontinence will be far more

effectively treated in the future. Discussion of the

problem of incontinence centers on the substantial delay in bringing technology to bear on the

problem, and on possible drawbacks of present

technologies. Improvements in this area could revolutionize nursing home care, and permit families to care for their incontinent dependents for

longer periods before the patients become unmanageable. Even more important, great improvement can be made in individual patients’

lives.

Hearing impairments affect 24 percent of

those 65 to 74 and almost 40 percent of those over

75 in the United States. Many forms of hearing

impairment can be improved by technological intervention—hearing aids and other devices. But

the adaptation of appropriate technology to specific hearing defects of patients, especially elderly

patients, has had only limited success. The potential for improvement of functional hearing impairments is substantial if patients can be convinced of the value of correction and if industry

can adapt to better serving patients’ needs. Technological innovation in this area promises to be

rapid over the next decade. Federal policy issues

include assurance of patient safety in public

places (mandating alarms that can warn those

with hearing impairments of danger), reimbursement policy for Medicare and Medicaid (which

currently offer little support for those with hearing impairments), regulation of the hearingdevices industry, and sponsorship of training and

research.

Osteoarthritis, which affects 16 million to 20

million older Americans, is the largest single cause

of disability among the elderly. Technological
Ch. 3—Selected Chronic Conditions, Technology, and Biomedical Research c 63

issues related to osteoarthritis include a relative

lack of basic scientific knowledge about the biology of cartilage, a need for preventive strategies, the potential for reducing pain and suffering for a large proportion of patients, and the

enormous expense of current therapies, particularly joint replacement surgery. Like dementia,

osteoarthritis is in need of discoveries that could

lead to effective prevention and cure.

Osteoporosis is a disease process involving

thinning of bones. Its most devastating consequences are fractures of the vertebrae and long

bones, which are especially common in elderly

women. Fractures of the hip often result in death.

Current evidence suggests that osteoporotic fractures are amenable to prevention by such methods

as increasing calcium intake or postmenopausal

administration of estrogens, but the definitive

preventive protocol has not been established because the various regimens used in routine practice have not yet been rigorously compared. Federal policy centers on the need for support of

research to determine optimum prevention and

treatment methods, basic biomedical research,

and oversight of elevating the dietary standards

for calcium (Recommended Dietary Allowances)

to conform to the requirements of older women.

In conjunction with this assessment, longer separate reports, with additional scientific and technical background, are being issued by OTA on the

impacts of neuroscience, technologies for managing urinary incontinence, and the management

of hearing impairments.

This chapter summarizes OTA findings regarding each of the five selected chronic conditions,

and discusses Federal policy with respect to biomedical research on aging.

Dementia: social problem, medical enigma,

and Federal burden

Dementia is one of the most important disorders leading to chronic disability among older

Americans. It affects fewer people than osteoarthritis, and is not a major direct cause of death

like cancer or cardiovascular disease. In epidemiological studies, however, life expectancy is reduced by half among demented patients, making

it the fourth or fifth highest cause of death among

older people. Yet the effects of dementia are so

devastating to the patient and his or her family,

and its prevalence is increasing so rapidly, that

one medical authority, Lewis Thomas, has called

it the “disease of the century. ”

Causes and prevalence

Dementia is a serious social problem, a difficult

medical enigma, and a major Federal expense. The

loss of intellectual and other “higher” functions

that is referred to as dementia can be caused

by many different diseases and environmental

insults.

The most common type of dementia is Alzheimer disease, which accounts for 50 to 7S percent

of all cases. Up to 20 percent of patients with

dementia have a disease that is treatable, and

proper treatment can improve mental function

in many cases.1 Another 15 to 25 percent have

dementia due to cardiovascular disease, stroke,

or an accumulation of “mini-strokes. ” Another

common cause is inappropriate drug treatment

for other illnesses; many drugs used to treat cardiovascular diseases, psychiatric diseases, and insomnia lead to poor mental function. Mental function often improves when the offending

medication is withdrawn, and failure to distinguish drug-induced dementia from true irreversible dementia can resuh in unnecessary mental

confusion and inappropriate care. A substantial,

but unquantified, number of older people suffer

from transient confusion that spontaneously

Kommon treatable causes of dementia include drugs, depression,

and some cardiovascular and endocrine ailments.
64 . Technology and Aging in America

resolves or abates with medical treatment of

another condition. Such acute confusional states

pose a different set of medical problems than does

chronic dementia; acute dementia is not explored

further in this discussion. There are many causes

of irreversible dementia, but the functioning of

affected patients is generally similar regardless

of cause; daily care techniques are thus also similar. Because stroke as a cause of dementia is, in

general, treated as is stroke causing other symptoms, a scientific review of this type of dementia

is not included here. In contrast, Alzheimer disease is the largest single cause of irreversible

dementia, and little is known about its cause or

means of prevention.

Alzheimer disease, first described in 1906 by

German physician Alois Alzheimer, leads to progressive loss of brain functions over a period of

years. The cause is unknown and there is no effective standard medical treatment.

Alzheimer disease affects between 1.2 million

and 4 million Americans; its true prevalence cannot be accurately determined because of variations in regional and historical methods of diagnosis of dementing illnesses. The term “Alzheimer

disease,” for example, was until recently restricted

to those cases beginning before the arbitrary age

of 65. Best estimates suggest that severe dementia affects approximately 2.5 percent of those over

65, and moderate and mild dementia probably afflicts another 2.5 to 10 percent. The disease becomes more common with age, affecting 20 to 30

percent of those over 80. More than half of all

nursing home residents suffer from dementia.

Effects on patients and their families

The patient is usually aware of intellectual decline in the early stages of the illness. As the disease progresses, the patient loses touch with the

outside world, first through loss of memory and

intellectual functions, then through loss of personality and speech, and finally through loss of

the ability to recognize even close relatives and

spouses.

The effect of dementia on family and friends

is devastating. Families care for the vast majority

of patients with dementia. For the most part, only

those in the final stages of severe dementia are

placed in nursing homes or other institutions of

long-term care. Families and friends are estimated

to attend to 80 percent of the long-term care

needs of patients in the United States (see chs.

7 and 9).

Beyond the financial and medical burdens imposed by those who develop this disease are the

severe emotional strains faced by families and

friends. The progressive intellectual deterioration

of a close loved one is a tragic experience that

can only be fully understood by those who have

gone through the process; it has been described

by one family member as a “funeral that lasts for

years.” The arduous task of caring for patients

with dementia is tellingly described in a book

called The 36-Hour Day,

Clinical and scientific background

The clinical changes of Alzheimer disease are

associated with physical and biochemical changes

in the brain. Accumulations of abnormal proteins

and other material are found in “plaques” in the

cerebral cortex of the brain, as are accumulations

of abnormal fiber-like proteins within nerve cells.

Specific populations of nerve cells in the nucleus

basalis of Meynert, near the base of the brain,

die for unknown reasons. The death of these

cells is postulated to be related to the clinical

symptoms.

Patients die with this disease, not of it. Patients

with dementia have only half the usual life expectancy for a given age; not because it kills in

and of itself, but because patients become susceptible to other diseases as a consequence of being unable to take care of themselves and because

of immobility caused by the end stages of the disease. At present, its cause is unknown, and there

are no means of prevention. The absence of effective medical intervention has diminished the

incentives to physicians to provide accurate and

welldocumented diagnosis; if the cause of illness

does not affect treatment choices, there is less reason to identify it. Greater awareness of the fact

that up to 20 percent of dementia is treatable

could improve physician attention to accurate

diagnosis of dementia. Growing public awareness
7Ch. 3—Se/ected Chronic Conditions, Technology, and Biomedical Research . 65

of Alzheimer disease has drawn medical attention to the disorder, yet one of the most important reasons for accurate diagnosis is often overlooked–families of patients know that something

is wrong, but do not know what. The specific

diagnosis of organic brain disease is unwelcome,

but may reduce the anxiety and guilt felt by patients’ families by identifying the problem as an

organic brain disease rather than a problem of

family or interpersonal dynamics.

The widespread belief in dementia as a normal

concomitant of aging has historically served to

lessen physician interest in the disease. The problem of diagnosis has been further hampered by

physicians who inaccurately ascribed dementia

to atherosclerosis or other cardiovascular dysfunction. Diagnostic methods are now changing

rapidly, and heightened awareness has led to a

dramatic increase in specific diagnosis by physicians. Nevertheless, there is great uncertainty

about the real prevalence of Alzheimer disease.

Although there is a genetic form of the disease,

which runs in families (much like such genetic

diseases as Huntington disease), it is not yet certain how many cases of Alzheimer disease are of

the familial type; estimates of the number of patients who have a genetic form vary from fewer

than 10 percent to more than 60 percent. Determining the genetic basis of Alzheimer disease is

an important objective for research, especially if

a marker for the disorder could be found to aid

in diagnosis in affected families. Various causes

of the disease have been postulated, including

unusual infectious agents (’(slow viruses”)) aluminum toxicity, reaction of the body against itself

(autoimmune disorder), and various biochemical

abnormalities. Many research leads are promising, but none are yet conclusive.

Federal roles regarding dementia

The basis of Federal concern about Alzheimer

disease is not only in its prevention and treatment,

but in payment for the care of patients. Because

dementing illnesses account for admission of most

nursing home residents, they are a major aspect

of long-term care and institutionalization (see ch.

7). The Health Care Financing Administration has

estimated that the Federal Government spends

over $6 billion annually in nursing home costs

alone for those affected with Alzheimer disease

(approximately 30 percent of the total Federal

outlay—1982 data). An additional $2 billion to $4

billion in Federal funds are spent each year on

acute hospital, home, and rehabilitative care for

these patients.

Federal concern about Alzheimer disease is intensifying as its prevalence increases with the

rapid growth of the oldest segments of the American population, The magnitude of health care

costs, especially for long-term care, has focused

new attention on the scientific and medical need

to study this disease.

Concern among physicians, researchers, and

other health care professionals has led to rapid

advances in the study of Alzheimer disease in the

last decade. A significant factor has been the creation of the National Institute on Aging (NIA),

which has made a major commitment to the study

of dementia. In 1984, for example, NIA earmarked

$3.S million to establish up to five “centers of excellence” for the study of Alzheimer disease in

response to congressional appropriations, The National Institute of Neurological and Communicative Diseases and Stroke (NINCDS) and the National Institute of Mental Health (NIMH) have also

increased research on dementia. Total Federal research funds on Alzheimer disease for 1984 are

estimated at $36.4 million to $37.8 million, up

from $3.8 million in 1976. Recent discoveries of

specific nervewell loss, of the nature of the anatomic abnormalities, possible infectious agents,

and of biochemical changes have all emerged

from federally funded research during the last

decade.

Recent findings in neuroscience have led to experimental drug therapies directed at particular

chemical nerve~ell connections in the brain.

There has been preliminary success with drugs

that allow the neurotransmitter acetylcholine to

work longer at its anatomic site. The neuropeptide vasopressin has been shown to improve memory slightly in some patients with Alzheimer disease. The drug naloxone, which is used to treat

some forms of acute opiate overdose, has also

been reported effective in one small study, but

following studies have not shown a significant effect. Tests have begun on drugs that might in-
—

66 . Technology and Aging in America

crease the efficiency of releasing acetylcholine

into its active site by altering calcium metabolism

and other biochemical pathways. Federal policy

regarding support of randomized clinical trials

of various therapies will affect the pace at which

effective drug treatments are identified and accepted by the medical community. Preliminary

findings offer hope for at least a partially effective symptomatic treatment. Solving the problem

of dementia may well depend on developing effective means of prevention, which will, in turn,

depend on understanding its cause and the mechanisms of its progression.

There is also a role for the Government inpwtecting those who have Alzheimer disease. For example, who is to decide when it is proper to conduct research on a demented patient? The patient

is by definition not able to give informed consent,

which requires understanding of the purpose and

process of experimentation. Obtaining informed

consent can be a barrier to scientific investigation of just those treatments that are so needed.

The dual role of the Federal Government in both

preserving civil rights and supporting most biomedical research suggests that informed consent

for Alzheimer disease research maybe an emerging Federal issue.

Treatment and prevention of this dread disease

can only come from investment in neuroscience

research (see table 5). The United States has a social, financial, and medical stake in the solution

of this major health problem. The Federal Government already sponsors research, pays for

acute care and diagnosis through Medicare, and

is responsible for long-term care through Medicaid. Cost savings in health care for the rising

population of demented patients depend on finding new, effective, and inexpensive treatments for

dementia and determining methods of prevention

for Alzheimer disease and other dementing illnesses.

Table 5.—Common Reversible Causes of Dementia

Drugs:

● Sleeping pills and sedatives

● Other psychopharmaceuti cals

● Anti-Parkinson’s drugs

● Other neurological drugs

● Anti-hypertensive drugs

● Other cardiovascular drugs

● Opiate analgesics

c Many others

D@#VWSiOfl and psychosis

/nfectlons:

● Cold s

● F l u

● Lung (pneumonia)

● Brain

● Brain membranes

● Bloo d

● Kidney

● Digestive tract

c Many others

Stroke (often at least ~arfia//y reversible):

● Blood clots in or around the brain

● Occlusion of blood vessels feeding the brain

Heart failure

Disorders of endocrine function:

● Thyroid hormone

● Parathyroid hormone

● Hormones and substances affecting blood volume control

● Stress-related hormones

● Others

Nutritional disorders:

● Vitamin BI~ deficiency

● Folate deficiency

● Protein deficiency

Anemia

Metaboiic and eiectrviytic imbalances:

● Calcium

● Sodium

● Potassium

● Others

Trauma:

● Head injury

● Shock

Toxicity:

. Occupational exposure

. Environmental exposure (lead, carbon monoxide)

● Household exposure (pesticides)

SOURCE: Office of Technology Assessment.

Urinary incontinence

Urinary incontinence is detrimental to the phys- rupts the lives of 5 million to 10 million Ameriical health, psychological well-being, and social cans, their families, friends, and caregivers and

functioning of those afflicted. This condition dis - is most common among those over age 65. Incon-
Ch. 3—Selected Chronic Conditions, Technology, and Biomedical Research ● 6 7

●

☛

●

●

●

●

●

●

Alzheimer disease affects 5 to 15 percent

.

recent events. Difficulties in speechand

those over 65 (1.2 million to 4 million Amer. word-finding; loss of the ability to "think

icans). through complex interpret com -

Alzheinwr disease is common with ad- .: plex stimuli soon follow. The first signs

vancing age, affecting more than 20 percent noted can however, vary greatly among pa- ..’a

of those over age 60. . tients.

Alzheimet disease imposes severe financial “&~ 2. This is followed by worsening cognitive

medical, and emotional stresses on families: deterioration and personality changes, often

–A full diagnostic evaluation cost $300 to

$2,000. , . . . tation as to time and place. The patient’s

–Families bear fractions of diagnostic speech often remains fluent and grammattherapeutic costs, and almost half of the ical‘ -; -but the content of what is said is often

overall cost of king-term care directly out-. inappropriate or eisconected from realit y

of-pocket. patient shows complete loss o f

–Families suffer loss of a ~~, ‘ ‘ r abilities, leading to a state o f

:

. ,

often leading to sudden and substantial vegetation. This includes the inability to

duction in income, - speak or Recognize even close relatives, and

Alzheimer disease accounts for an estimated . complete loss of “world knowledge.” ‘ . .

30 to 50 percent of those in nursing homas. .:. It is highly probable that what is now called

Alzheimer disease is the most frequen~ ca- @“ ‘. ..disease” or “senile dementia of the

of institutionalization for long#.4mn @re.

~“ .

.

‘- type’’ isagroupofseveral distinct disFederal funds fw kmg-tem WUX? kI 1~ ‘#4p different causes and mechanisms .

$12 billion ($lo.xbmon from Medicaid, $@# ~ : is trem@dous variation in the duration

billion from Medicare, and $1.1 billion from : its mte of progression. Younger

the Veterans Administration). The@ c@% ~@hts tend to have more severe cases which

under present arrangements, wilI escalate to more rapidly. Alzheimer disease can

$24 bmon by 1935, and $43_ by 19%% ~km a few years to a few decades.

Alzheimer disease accounts for 30 to 50 nw

,,

functions over a period of years. Its clinical pro- cific regions of the brain, and are rare-in

gression is uswdly divided into three stages: other diseaseIs.

1. Mild cognitive deterioration is quite~ None of the pathologic changes is unique to

to distinguish from normal funatkm, and is Al#@ner disease. The pathologic diagnosis is
68 . Technology and Aging in America
Ch. 3—Selected Chronic Conditions, Technology, and Biomedical Research ● 6 9

to Other diseases such M Syst@ti hlpllt! W, but the eff~ is so minor that it may not

erythematoms or myasthenia grwis. ix? Gi@ical(y rekwmt.

A biochemical abermtion of ctdoium nmtabo- . .

lism may kacl to insuffkient release of neurw -~rn~~-~develap~ent~fn

transmitter. tit?~ run?

There may be a &order of glycolytic Mow ~ , j ,l@earch may yield a specific diagnostic test

cheroical @.hWZyS (pyruvate dehydrogenasd .f@ Alzheimer disease. Such a test could deleading to decreased cakium influx into the . X from biochemical tests on tissue from

cell and insufficient x@ease of neurotrms- bmiin biopsies, chemical metabolizes in ceremitter. b?twpinal fluid, or monwlonal anti~dies to

Disorders of neurotransmitttws other than ~@s that are possibly specific to Alzheiacetyicholine maybe involved as well, Those . %q#r diiwme.

suggested include: ‘;@ vw of nerve-cell impiants (scwdled brainadl

—somatostatin, tmnsplants) is promising, but many technical

—norepinephrhe (from the locus Cerulew), ~bstacles remain. The treatment has worked

—vasopredn, and fnanimakl with a disease resembling Parkin-

_eROUS OPi@i peptides. TM last is ~. WJ%%% disease, and human grafts have grown

ported by clinical reports of improvement swxmsfully in experiments conducted in

by treatment with nakxcme, a chemical ‘$aandinavia. The human experiments have

blocker of opiate receptors. w yet been clinically useful, and many prob-

~_ regarding what tissue to use as a source What potentiaf thmaptea are under in- ofimdantabb nerve cxdk? must be solved. Sucveatigation? ~ WM&II implant therapy for Alzheimerdisease

●

●

●

●

●

●

●

●

●

Infuse drugs that simulate the actions of ace- ‘%!@o awai~ knowledge of the nerve cds that

tylcholine directly into the fluid surrounding *dto be replaced.

the brain. Four patients, in a recent trial, re~ ● ~~erm of the bi~he~~ and ne~.

ceived such drugs from a pump implanted in transmitter defects may allow specifically tarthe patient% body and families reported hug geted therapy, based on the physiology of me

provement or stabilization of symptoms. dfected parts of the brain. One promising aveStimulate acetykholine synthesis (lecithin, nu~ to learning about this is through develchoiine)-not very successful to date. opment of animal models based on finding

Administer piratwtam, a drug which improves Qh#micals that specifhdly destroy certain

some aspects of mental function, alone or in - of the brain or particular types of nerve

combination with other drugs. C+#@@.

Use drugs that mimic the effect of acetyi- @ ~~r~ding a muse or causes (whether

choline, either alone or in combination. viruses, other infectious agents, or environStimulate acetylcholine release with 4-amino- Ih@mtd toxins) may permit effective prepyridine and related agents. wmtion.

Increase the duration of action of acetykho- * klentifkation of genet.io markers, anaiogous

Iine by inhibiting breakdown by anticholine- @Mlmseknawn for sickie celi disease or Hunsterase drug therapy. The best example is ~~&_, WOUM prove useful for mphysostigmine. wwtigating the putative molecular defect, as

Chelate aluminum to prevent toxicity W@ wdi as helping in diagnosis of members of

fluoride, tetracycline, or deferoxamine. j: ,,

, ..:~- families for family and personal

Use nakxone to block opiate receptors. $ J: - ~ use vasopressin to improve memory. : ~ “f- ~ . - ., --w ~, maybe possible, based on

Breathe hyperbaric oxygen (not very #t#’!- : ~,” :.3+ .%

genes in other species (e.g.,

Cessful). ‘ speUse ergoloid mesylates (HYdergine+mly mar- -

‘

*of ~m genes, if any, that predisginally effective, used widely in Europe). ~ “ P “ E may also be possible to

if them treatments, those af&cthga&kho- deliberately engineer netie celh @th needed

line have shown moderate, but Wxmsistent im- characteristics to replace or supplement cells

provmnent, Ergoioid mesylates administration that have died.

has been shown to have an efiect in numerous
———.—— — . —

70 . Technology and Aging in America

tinence also constitutes a costly health problem:

the U.S. Surgeon General estimates that $8 billion is spent on incontinence in this country each

year (37). Because it is often difficult for affected

individuals and their families to cope with the condition at home, incontinence may play a pivotal

role in the decision to enter a long-term care facility.

Despite the availability of many effective forms

of treatment, incontinent persons are rarely

evaluated thoroughly enough to determine the

precise causes of the condition and are therefore

not treated optimally. Some estimate that up to

one-third of incontinent patients could be completely cured (38,73). Several factors contribute

to the deficiency in care of incontinent persons

in this country, including: 1) lack of knowledge

about the specific diagnosis and optimal treatments for different types of urinary incontinence;

2) reluctance of affected individuals to seek medical help because of embarrassment, social stigma,

and the misconception that it cannot be treated

(’largely because of lack of awareness of available

treatments); and 3) scant, inconsistent Federal and

State reimbursement policies for urinary incontinence treatment and products, especially for the

noninstitutionalized.

This section briefly explores these barriers to

adequate medical care for incontinent persons,

looks at the technologies available for treatment,

and proposes some ways in which the government might act to reduce the magnitude of the

medical, social, and economic impact of urinary

incontinence in this country.

Definition, prevalence, and causes

of incontinence

Urinary incontinence is defined as an involuntary loss of urine sufficient in quantity and frequency to be a social or health problem. The

severity ranges from occasional dribbling to total

loss of control over excretion of both urine and

stool (fecal incontinence is much less common and

is not discussed in detail here). Between 10 and

20 percent (2 million to 4 million)2 of communitydwelling elderly have some degree of incontinence. The prevalence increases to between 40

and 50 percent of those elderly in nursing homes

(600,000 to 700,000). In comparison, between 1

and 5 percent of those under age 65 (2 million

to 10 million) have a persistent problem with incontinence.

Data subdivided by severity for communitydwelling elderly persons are scarce but British

studies suggest that 5 percent are severely affected (one or more episodes daily) and 9 percent

are less severely affected (68). More than twothirds of affected individuals (or over one-third

of the total patient population) in nursing homes

have more than one episode a day (59). Although

incontinence of both urine and stool is relatively

uncommon in community dwelling persons, close

to 50 percent of those in nursing homes who are

incontinent of urine also have episodes of fecal

incontinence (46,59). Most patients with both

kinds of incontinence also have severe impairments of mental and/or physical functioning.

Disorders of the lower genitourinary tract,

disorders of innervation and neurological control

over genitourinary function, lack of mental awareness of the need to void, and limitations in mobility or environmental factors (e.g., restraints or drugs) Can all contribute to the development and

persistence of incontinence. The many types of

urinary incontinence can be divided into two general categories, acute and persistent (see table 6),

for which the causes and the clinical approaches

are distinct.

Acute incontinence refers to the sudden onset

of episodes of involuntary urine loss that are usually associated with an acute illness, or environmental factors that impair the mental or physical ability to reach a toilet or toilet substitute.

Especially common in hospitalized elderly, acute

incontinence can be precipitated by impairment

of mobility (as with hip fracture) or some type

of bed restraints; such patients may recognize the

need to void but may not be able to obtain timely

help in getting to the toilet. other causes of acute

incontinence include: acute urinary tract infections with bladder inflammation; metabolic dis-

‘Accurate, consistent prevalence data for urinary incontinence

are scarce, especially for community dwelling persons, because of

underreporting due to social stigma, reluctance to seek medical help,

and lack of diagnosis. The figures given here are therefore rough

and probably underestimates.
Ch. 3—Selected Chronic Conditions, Technology, and Biomedical Research ● 71

Table 6.—Types of Incontinence

Definition Causes Population(s) affected

Acute:

Incontinence of sudden onset Acute illnesses associated with one or more of the Elderly, usually in acute

associated with an acute following: (a) immobility and/or environmental factors that hospitals.

illness (and/or other factors) diminish the ability to get to and use a toilet, (b)

that subsides once the acute impaired mental function that diminishes toileting

condition has been resolved ability, (c) fecal impaction.

or other factors have been Acute urinary tract infections.

removed, Drugs: (a) those that increase urine flow (e.g., diuretics),

(b) those that inhibit bladder contractions and cause

urinary retention and overflow (e.g., anticholinergics),

(c) those that decrease mental awareness (e.g.,

sedatives, hypnotics).

Metabolic—increased urine flow (polyuria) associated

with poorly controlled diabetes.

Established:a

Stress:

Leakage of small amounts of Weakened supporting tissue surrounding bladder outlet Women, especially

urine with increases of intra- and urethra associated with: (a) lack of estrogen in those over age 40.

abdominal pressure (e.g., postmenopausal women, (b) previous vaginal

coughing, sneezing, laughing, deliveries, (c) previous pelvic surgery (e.g.,

exercise). hysterectomy).

Urge:

Leakage of urine caused by Neurological disease such as stroke, dementia, Men and women of any

inability to delay voiding long Parkinsonism, muliple sclerosis, spinal cord diseases. age; most common

enough to reach the toilet Genitourinary disorders such as unstable bladder in the elderly.

after urge to void is felt. (“detrusor instability”), bladder stones, diverticuli of

urethra and bladder, atophic urethritis, vaginitis

(females), chronic cystitis, mild outflow obstruction

(usually males).

Overflow:

Leakage of small amounts of Hypotonic or acontractile bladder associated diabetic Older men with

urine associated with neuropathy, spinal cord injury, or drugs such as prostatic

obstruction to urine flow. anticholinergics (which inhibit bladder contractions), enlargement.

smooth muscle relaxants, narcotics, and alcohol. Diabetes.

Anatomic obstruction associated with prostatic

enlargement or urethral stricture.

Functional:

Inability or unwillingness to Impaired mobility. Elderly in acute

reach a toilet in time. Impaired mental function. hospitals and

Inaccessible toilets (or caregivers). nursing homes and

Psychological disorders such as depression, psychosis, those with acute or

anger or hostility. severe psychiatric

illness.

a Incontinence is persistent and unrelated to an acute illness.

SOURCE: J Ouslander, R. Kane, S. Vollmer, and M Meneres, “Medical Devices for Urinary Incontinence: A Case Study,” prepared for the Office of Technology Assessment,

contract No. 333-6550, December 1983.

orders that increase urine flow, such as diabetes;

fecal impaction that may mechanically obstruct

normal bladder emptying or cause reflexive involuntary bladder contraction; and a variety of

drugs. Drugs that can induce urinary incontinence include: diuretics that increase urine flow;

sedative, hypnotic, and antipsychotic drugs that

may diminish mental awareness of the need to

void; and drugs that influence lower urinary tract

functioning, such as anticholinergic drugs (that

inhibit the bladder from contracting) and certain

antihypertensive drugs (that decrease resistance

in the bladder outlet) (36,64).

Persistent or established incontinence (i.e.,

repeated episodes not associated with an acute

condition) can be divided into four types:

1. Stress incontinence usually occurs in women,

especially those whose musculature has been

weakened by multiple vaginal deliveries or
72 ● Technology and Aging in America

pelvic surgery. It involves the leakage of small

amounts of urine with increased abdominal

pressure such as that associated with exercise, straining, coughing, laughing, or sneezing.

2. Urge incontinence involves leakage of varying amounts of urine because of inability to

delay voiding before reaching a toilet. It can

be, but is not always, caused by a variety of

genitourinary and neurological disorders

such as involuntary bladder contractions, or

local irritation of the bladder or the urethra.

3, Overflow incontinence involves leakage of

small amounts of urine and is caused by

anatomic obstruction to bladder emptying (as

by an enlarged prostate in men) and/or impaired ability of the bladder to contract (as

with diabetes, spinal-cord injuries, and certain drugs).

4. Functional incontinence occurs in those individuals who have chronic impairments of

either mobility or mental function, are unable

to use a toilet independently, or are unable

to maintain continence because of psychological disturbances. This type of incontinence

may also be induced by iatrogenic factors

such as medication or environmental barriers

(e.g., restraints).

Treatment

Determining the appropriate treatment for an

individual with urinary incontinence requires a

thorough evaluation of all relevant factors—

genitourinary, neurological, psychological, and

environmental—that could be causing or contributing to the condition. Unfortunately, health professionals commonly do not recognize incontinence, especially among community dwelling

older persons, or fail to note it as a problem and

therefore do not pursue an evaluation (59). The

problem is compounded by the reluctance of

many afflicted individuals who are too embarrassed to seek medical help or believe that nothing

can be done about it.

Fewer than 5 percent of incontinent patients

in a nursing home setting are estimated to have

had any specific evaluation of their incontinence

(59). Many could benefit from such an evaluation

because it could lead to a cure or to treatment

that significantly ameliorates their incontinence.

Some experts estimate that one-third of incontinent patients can be completely cured and most

others could be kept comfortable and dry with

appropriate management technologies (38,73). Unfortunately, there have been very few studies on

the relative efficacy of various treatments for different types of incontinence. Only a handful deal

specifically with the elderly and most report on

fewer than 10 patients (72).

When treated inadequately or inappropriately,

incontinence can lead to skin breakdown and

recurrent urinary infections. In addition, inadequate treatment can exacerbate the incontinence

and thus increase the psychosocial impact, leading

to further loss of self-asteem and withdrawal

from social activities that may exacerbate isolation and depression. Studies in Great Britain indicate that incontinent individuals often are reluctant to utilize services available to them such as

incontinence nurses, incontinence clinics, and

laundry services (e.g., 67,68,74,75).

Many technologies are specific to a particular

type or types of incontinence and attempt to cure

the problem (e.g., artificial sphincters, electric

stimulators, drugs, training procedures, and surgery). Diagnostic evaluation is thus critical to the

appropriate use of these treatments. other treatment technologies are nonspecific and palliative

rather than curative (bed pads, undergarments

and, in some situations, catheters). In general,

these technologies should be used as a last resort

after diagnostic evaluation has excluded treatable

conditions.

The various types of technologies for the treatment of urinary incontinence, along with their

mechanisms of function and appropriate uses, are

described in table 7. In order to discuss their advantages and disadvantages, these technologies

are divided into four categories in the discussion

that follows: devices, surgery, drug treatment,

and training procedures. Again, little is known

about the relative efficacy and long-term cost effestiveness of the various treatments for urinary

incontinence.
Ch. 3—Selected Chronic Conditions, Technology, and Biomedical Research 73

Table 7.—Treatments for Urinary Incontinence

Examples Mechanism Uses

Devices:

To collect urine before leakage occurs:

Catheters A flexible tube is placed directly in the bladder and Inability to empty bladder (urinary

drains urine into a collecting bag. Can be used retention) that cannot be corrected by

continually or intermittently. surgical or drug treatment. (This may

or may not be associated with overflow

incontinence.)

Incontinence associated with healing

skin lesions.

To collect urine after leakage occurs:

NASA (female) Outflow is trapped and drained into a collecting Any type of incontinence.

Condom catheters bag.

(male)

Bed pads Pad protects individual and mattress from contract Any type of incontinence especially,

with urine. These pads are disposable or reusable. useful as adjunctive therapy with other

treatments.

Prevent or delay urine outflow:

Artificial sphincters

Inflatable cuff

Silicone-Gel

prosthesis

Periurethral Teflon

Electrical stimulators

External clamp

(male)

Pessary (female)

Other treatments:

Surgical procedures:

Bladder-neck

suspension

Prostatectomy

(transurethral

resection and

suprepubic)

Therapeutic bladderneck transection

Selective bladder

denervation

(cystolysis)

Therapeutic bladder

distension

Correction of other

genitourinary

pathology (e.g.,

bladder tumor or

stone).

Inflatable cuff is surgically implanted around

urethra and inflated to prevent urine outflow.

Silicone-gel is inserted to replace existing urethra.

Teflon paste is injected into tissues surrounding

urethra.

Device inserted into vagina; produces electric

impulses that (a) cause contraction of pelvic floor

musculature (b) inhibit bladder contractions.

Penis is clamped to prevent urine flow.

Device is inserted into vagina, supporting tissues

below bladder and around urethra.

Incontinence associated with sphincter

weakness (usually stress incontinence

or postprostatectomy)

Incontinence associated with pelvic

floor muscle weakness or bladder

instability.

All types of male incontinence.

Female incontinence associated with

prolapsed pelvic structures (usually

stress incontinence).

Urethra and bladder neck are restored to a more Female stress incontinence.

normal intra-abdominal position.

All obstructing portion of prostate is removed. Male overflow incontinence associated

with anatomic obstruction.

Bladder neck is surgically incised.

Nerves to upper bladder are cut so that there is no

muscle control of bladder dome, but sphincter

mechanism is intact.

Bladder is distended under anesthesia for at least

two hours to a pressure close to systolic blood

pressure.

Removal of irritative or obstructive factors.

Urge incontinence associated with

bladder instability.

Urge incontinence associated with

bladder instability.

Urge incontinence.

Urge incontinence associated with

bladder instability.

Overflow incontinence associated with

outflow obstruction.

Drugs:

Propantheline Diminish bladder contractions. Urge incontinence associated with

(Probanthine) bladder instability.

Imipramine (Tofranil)

Oxybutrin (Ditropan)

Flavoxate (Urispas)

Ephedrine (Sudafed) Strengthen bladder outlet Stress incontinence associated with

sphincter weakness.
—

74 . Technology and Aging in America

Table 7.—Treatments for Urinary Incontinence—continued

Examples Mechanism Uses

Phenypropronolamine

(Ornade)

Estrogen (Premarin) Increases supporting tissue around urethra. Stress incontinence.

Oral or topical

Bethanechol Promotes bladder contraction. Overflow incontinence.

Urecholine)

Training procedures:

Habit training

Bladder retraining

Pelvic floor

exercises

Biofeedback

Behavioral

modification

Caretaker determines individual’s pattern of

incontinence and gets him/her to toilet

according y.

Caretaker establishes routine of fluid

administration and toileting with progressive

lengthening of toileting intervals to increase

bladder capacity or re-initiate normal voiding.

Exercises to strengthen pelvic muscles.

With specialized equipment, patient is trained to

inhibit bladder contractions or contract pelvic

muscles.

Caretaker rewards incontinent individual for staying

dry.

Urge. incontinence.

Functional incontinence.

Urge incontinence.

After catheter use.

Overflow incontinence after

overdistension injury.

Stress incontinence.

Mainly urge incontinence associated

with bladder instability and stress

incontinence associated with sphincter

weakness.

Incontinence associated with

underlying mental or emotional

disorders; some forms of functional

incontinence.

SOURCE: J. Ouslander, R. Kane, S. Vollmer, and M. Medical, “Medical Devices for Urinary Incontinence: A Case Study,” prepared for the Office of Technology Assessment,

contract No. 333-6550, December 1983.

DEVICES

Four major types of devices are currently in

use: bedpads and undergarments, catheters, electrical stimulation, and artificial sphincters.

Bedpads and undergarments range from those

that are completely disposable to those with

launderable components. Most acute care hospitals and long-term care institutions use “blue pads”

for managing incontinence despite their relatively

low absorbency and lack of odor control. More

innovative forms, like the Kylie @ pad that is

launderable and draws moisture away from the

body, have been marketed widely in the United

States only recently. The efficacy of these products in diminishing complications of incontinence

such as skin irritation and urinary tract infection

has not yet been carefully assessed.

The three types of catheters commonly used

are chronic indwelling catheters, intermittent

bladder catheterization, and, for men, external

catheters. A chronic indwelling catheter is placed

in the bladder and attached to plastic tubing that

drains urine into an externally worn collection

bag, This type of catheter can induce serious complications, however; urinary tract infection is the

most common. It should only be used in patients

with urinary retention that cannot be treated surgically, pharmacologically, or by intermittent

catheterization, and for patients with skin conditions that are worsened by contact with urine.

There is evidence that indwelling catheters are

overused in managing urinary incontinence, especially in elderly patients in long-term care facilities (10 to 30 percent of incontinent cases),

probably because of the relatively low cost and

convenience for the staff (50,53,57,61)69). Intermittent self-catheterization has a lower incidence

of infection and other complications in younger

patients (51), although its relative efficacy in the

elderly has not been studied; this method also requires training on the part of the caregiver and/or

patient. External (condom) catheters, used exclusively in men, may reduce infection but require

frequent changing, often fall off, and may result

in local skin irritation.

The National Aeronautics and Space Administration (NASA) has also developed an external

female urine-collection device for use of women
Ch. 3—Selected Chronic Conditions, Technology, and Biomedical Research ● 75

astronauts. This and a similar adhesive device developed by private industry are still in the developmental stage for application to older women

in the general population; both have already received approval by the Food and Drug Administration (FDA). The adhesive device has been marketed on a limited basis; the NASA product is

scheduled for release onto the retail market in

November 1984 under a nonexclusive licensing

agreement with a small manufacturing company

headed by the inventor of the device.

Electrical stimulation involves an external device that intermittently stimulates musculature

associated with voiding to induce muscle contraction and maintain continence. This technique is

most useful for incontinence due to stress and

bladder instability (40,41)42)43), Between 50 and

80 percent of individuals treated in this way derive some short-term benefit from the treatment.

The long-term effects of chronic electrical stimulation are unknown, however, and the patient must

be willing and able to manage the device.

While artificial sphincters appear to improve

or cure incontinence in 40 to 80 percent of patients treated (relatively few patients receive

such implantations), there are several associated

complications. The most common problems are

erosion of the sphincter cuff into the urethra, persistent infection, and mechanical failure. Favorable results have been obtained with prostheses

consisting of injections of silicone gel or Teflon”,

but there is again the risk of urethral erosion and

Teflon” particles have shown a tendency to migrate to other major body organs.

SURGERY

Surgery is an essential treatment for certain

types of incontinence and is effective, but not

essential, for other types. An anatomic obstruction to urine flow (e.g., an enlarged prostate in

men), for example, can lead to recurrent infection and even renal failure, necessitating surgery

to relieve the obstruction. Yet surgery may not

cure the incontinence and may even induce a different type of incontinence. Pathologic conditions

in the lower genitourinary tract that irritate the

bladder or urethra (e.g., bladder tumors, bladder

stones, and diverticuli of the urethra or bladder)

and cause incontinence can also be treated surgically. The most common surgical procedure for

incontinence is bladder-neck suspension in women

in which the bladder neck and urethra are repositioned to relieve stress incontinence. The success

rate is generally reported as 70 to 90 percent

(54,62,63,65,66). There have been no conclusive

studies on the efficacy of surgery relative to other

treatments for stress incontinence.

DRUG TREATMENT

Although drugs can be used to treat overflow,

stress, and urge incontinence (36,56)64), they may

be inappropriate for the elderly or have undesirable side effects. For example, cholinergic drugs

used to treat overflow incontinence that promote

bladder contraction may actually worsen incontinence in the elderly by creating urinary frequency and urgency; in addition, some of these

drugs may cause cramping, diarrhea, and increased bronchial secretions. Drugs used to treat

stress incontinence that promote muscle contraction around the bladder outlet may exacerbate

hypertension. The topical and oral estrogens that

are used in elderly women to strengthen the

tissues around the bladder outlet may also exacerbate hypertension and increase the risk of cancer of the uterine lining. The most common and

effective drug treatment involves substances that

reduce bladder contraction to treat urge incontinence. Most studies show these drugs to be effective in 50 percent of the patients. Many, however, can have undesirable side effects, including

dry mouth, constipation, and blurred vision. Unfortunately, there have been few studies comparing the efficacy of these drugs with other

methods.

TRAINING PROCEDURES

“Training procedures” are broadly defined here

to include pelvic-floor exercises, biofeedback bladder retraining, habit training, and behavior modification. Many of these have been reported as

successful in managing various types of incontinence (47)71). Patients must have adequate cognitive function to use the pelvic-floor exercises

(strengthening associated muscles by repeated

contraction), biofeedback bladder retraining

(learning to control muscle contraction, requiring specialized equipment and personnel) or blad-
—

76 . Technology and Aging in America

der retraining (learning progressively to extend

periods between voiding). Habit training involves

developing a toilet schedule and can be used with

patients who have mental and physical impairments. Behavior modification is similiar to habit

training but incorporates positive and negative

reinforcers and is used mainly for bed-wetting

children and chronically mentally ill patients

(39,60). Most studies of the efficacy of training

procedures have involved some type of bladder

retraining or habit training for urge incontinence

and have found SO to 80 percent of subjects cured

or substantially improved (44,45,47,48,49,52).

Again, there have been few studies of the relative efficacy of training compared with other

treatments.

The cost of incontinence

The costs of incontinence go far beyond economic considerations. Withdrawal from social

activities, psychological distress, burden on the

family and caregivers, and the influence on the

decision to institutionalize are all important potential effects of incontinence that are difficult

to quantify (55). In one study of stress in caregivers of frail elderIy community dwelling persons, difficulties with toileting and incontinence

were highly correlated with caregiver burden

(55). Since the Federal Government plays an important role in assisting with medical costs, however, it is important to discuss the cost of incontinence and current Federal reimbursement

policies.

The variety of incontinence products are discussed in detail in a separate OTA case study,

“Technologies for Managing Urinary Incontinence. ” One of the report’s major conclusions is

that promotion of these products has been targeted largely toward physicians and other health

care professionals rather than toward the consumer. As a result, incontinence products are not

widely available at the retail level and public

awareness of the variety of treatments available

is scant,

Two large paper-products firms have entered

the market for disposable incontinence products,

however, and have launched consumer-oiented

advertising campaigns that may help destigmatize

incontinence and lead to competitively low prices.

Unfortunately, these promotional efforts, which

emphasize management of incontinence through

the use of undergarments, may lead consumers

to believe that this is the most appropriate treatment. For other technologies such as catheters,

electrical stimulators, and artificial sphincters, the

delays and difficulties in obtaining FDA approvals

could constitute a barrier to entry into the market for manufacturers. The case report points out

that the Federal Government, as a disinterested

party, could effectively promote consumer education about the importance of medical evaluation and the variety of treatments available.

FINANCIAL COSTS

The actual expense of incontinence management and the Federal role in providing financial

assistance to care recipients is important since this

can affect access to health care. Moreover, loss

of productivity of both those afflicted and their

caregivers can be substantial, It is important to

note that, as has been mentioned, very few incontinent nursing home patients receive a specific evaluation of their condition. Although an

extensive urologic evaluation for incontinence can

be costly (about $600) and involve highly specialized personnel and equipment, it may save money

overall by curing or mitigating the condition

through more specific, effective treatment (58),

and bring immeasurable improvement to the

quality of life of both the patient and the caregiver. Research into the most practical and costeffective methods of diagnosing different types

of incontinent patients is sorely needed.

The U.S. Surgeon General has estimated that

$8 billion is spent on incontinence in this country annually (37); the basis of this estimate has

not been detailed, however. A recent report (58)

divides estimates of the overall annual costs of

incontinence in nursing homes in the united

States into “firstarder costs” (i.e., the costs of managing incontinence without the costs of any complicating conditions) and “seconderder costs” (i.e.,

the costs associated with managing complications

of incontinence and its treatment).

If only first-order costs are considered, incontinence adds between $3 and $11 to the daily cost

of caring for a nursing home patient. The range
Ch. 3—Selected Chronic Conditions, Technology, and Biomedical Research ● 7 7

of cost is due to differing costs of various management techniques. of the three components of

these costs (labor, laundry, and supplies), the labor involved in handling an incontinent patient

is the major contributor,

Assuming that there are approximately 600,000

nursing home patients with some degree of urinary incontinence and that, in threequarters of

these patients, the incontinence is of sufficient

severity that catheters or other specific management techniques are used, the yearly first-order

costs of incontinence in U.S. nursing homes can

be estimated at between $0.5 billion and $1.5 billion. This represents between 3 and 8 percent of

the total expenditure on nursing home care in this

country (58). The costs of incontinence in the

community are much more difficult to estimate

and no studies have addressed these costs in

detail.

First-order costs were estimated to be lowest

for patients with indwelling catheters. Yet for

these same patients the second-order costs were

highest because of the high incidence of urinary

tract infection associated with continuous use of

these devices. A conservative estimate of the

second-order costs of incontinence is between

$2,000 and $3,000 per patient per year. The National Institute on Aging is currently funding a

study on methods to reduce complications associated with indwelling catheters in order to reduce second-order costs and possibly render

these catheters less costly alternatives to other

treatments in the nursing home setting.

PAYMENT

Except for diagnostic evaluation and services

delivered as part of an acute hospitalization,3

Medicare coverage for incontinence products is

quite limited. Part B of the plan only pays for a

prosthetic device that replaces an inoperative

body organ or function thereof. Thus sphincters

or ileostomy bags would qualify, but catheters,

bedpads, and undergarments would not. Medicare also does not pay for most bedpads and

undergarments used outside of the hospital.

3Nleciicare co~wrage of acute hospital costs under Part A changed

draznaticallj with the introduction of diagmosis-related groups i n

october I %43. The all-inclusite price will not specifically pay for

an incontinence dm’ice.

Coverage for urinary incontinence products

under Medicaid varies from State to State. Undergarments and other disposable products are least

likely to be considered medical equipment and are

therefore the least likely treatments to be covered.

Medicaid covers these products in some States,

such as New York, California, Florida, Illinois, and

Michigan. In other States, such as New Jersey,

these products are not covered. Even in those

States in which Medicaid covers the products, the

type and extent of coverage vary considerably.

Furthermore, State requirements for coverage

and payments change frequently.

Given present fixed reimbursement rates in

most States, the first-order costs of incontinence

($3 to $11 per day) represent 7 to 27 percent of

the daily per diem provided by Medicaid (about

$41 per day in California for 1984). The result is

often reluctance of nursing homes to accept incontinent patients. Several States have developed

or are developing case-mix reimbursement strategies that recognize the rising costs of incontinence; the emphasis, however, is on managing

such patients rather than on treatment to improve

their condition.

Moreover, second-oder costs, as for treatment

of skin breakdown or urinary tract infection, are

largely covered by Medicare. The financial incentive for nursing homes is therefore to use the

cheapest treatment in terms of first-order costs

(e.g., an indwelling catheter) regardless of possible resultant complications. An experiment conducted by the National Center for Health Services research is currently testing the effects of

paying nursing homes an incentive to accept incontinent patients and a bonus if they improve

their functional condition (70).

Conclusion

Urinary incontinence afflicts a significant percentage of our elderly population with detrimental effects on their physical health, psychological

well-being, and social functioning, and constitutes

a costly health care problem. There are several

barriers to effective treatment, including lack of

knowledge about the most effective treatment for

particular types of incontinence, lack of public

awareness of the variety of technologies available
78 . Technology and Aging in America

(many curative), social stigma, and limited access reducing or removing these barriers could reduce

to health care due to minimal, inconsistent gov- the impact on affected individuals and their careernment reimbursement for most of incontinence givers, as well as reduce costs through decreased

treatments and products, especially for the non- institutionalization and reduced use of other

institutionalized. Improving the quality and avail- health care resources.

ability of treatment for urinary incontinence by

Hearing impairment in the elderly4

Hearing loss is a major problem for the elderly.

National surveys show that hearing impairment

is the third most prevalent chronic condition

among the noninstitutionalized elderly, exceeded

only by arthritis and hypertensive disease (93,94).

As the older population grows, the number of

hearing impaired individuals will increase rapidly.

Because the over-75 population has a very high

prevalence of hearing impairments and is growing at a faster rate than the elderly population

as a whole, the total number of hearing impaired

elderly individuals will rise dramatically. At present, more than 7 million elderly persons have significant hearing impairments. If current rates persist, there will be more than 10 million hearing

impaired elderly persons by the year 2000.

Hearing impaired individuals include both

those who are deaf and those who are hard of

hearing. Hard of hearing refers to a degree of

hearing impairment that interferes with comprehension of speech, although partial auditory

function remains. Deaf refers to a degree of impairment that renders hearing nonfunctional for

the ordinary purposes of life (90).

Only a small proportion of the elderly with

hearing impairments are deaf, but even the partial loss of hearing that is often associated with

aging can limit independence and negatively affect quality of life for the elderly. Hearing loss

restricts the individual’s ability to interact with

others and to give, receive, and interpret infor4This section summarizes an OTA background paper, Management of Hearing Impairment in the Elder(v, which draws heavily

on G. Becker, R. M. Flower, L. E. Glass, and R. J. Newcomer, The

Management of Hearing Impairment in Older Adults and American Speech-Language-Hearing Association, Management of Hearing

Impairment in Older Adults, OTA contract No. 333-8970.0, 1984.

mation. Sound is important for self-protection and

identification of hazards in the environment.

Ultimately, hearing loss can affect mental and

physical health, decreasing the ability of some individuals to function independently and increasing the need for formal and informal long-term

care services.

Prevalence

The prevalence of hearing impairment is measured by two methods, interviews and audiometric

testing. The interview method underestimates the

prevalence of hearing impairment because many

individuals, particularly the elderly, are not aware

of their hearing loss or may deny or minimize its

severity. Audiometric testing results in more accurate information about prevalence and also

measures hearing at specific frequency levels; this

is important because hearing acuity in the elderly

varies greatly according to frequency. Audiometric tests that measure hearing of pure tones,

however, underestimate the extent of dysacusis,

a condition that is widespread among the hearing impaired elderly. Individuals with dysacusis

can hear pure tones but have difficulty understanding speech because of deficits in auditory

discrimination (84).

Prevalence of hearing impairment by age, gender, race, income, and institutional status is discussed here. These data reflect prevalence of

hearing impairment in the total population but

may not apply in a given geographic area. For example, the prevalence of chronic ear infections

among certain ethnic groups in Alaska and in the

Southwest increases the prevalence of hearing impairment in these areas, Similarly, in areas where

high-noise industries are concentrated, hearing
Ch. 3—Selected Chronic Conditions, Technology, and Biomedical Research . 79

loss is much more prevalent among the working

age and older populations.

AGE

Interview surveys indicate that the prevalence

of hearing impairment rises sharply with age,

from less than 2 percent of those under 17, to

about 12 percent of those 45 to 64, 24 percent

of those 65 to 74, and about 39 percent of those

over 75 (92). The severity of hearing impairment

also increases with age (91).

Audiometric testing indicates that hearing impairment varies according to the frequency of the

sound. As figure 13 indicates, the elderly have

much greater hearing loss for high-frequency than

low-frequency sounds. While most speech is in the

frequency range of 500 to 2,000 hertz, sounds

such as S, T, K, and P are heard at higher frequencies, and elderly persons with hearing impairments are often unable to hear these sounds.

GENDER

Interview surveys show that elderIy men have

a higher prevalence of hearing impairment than

elderly women. For example, one study found

that 29 percent of men ages 65 to 74 had hearFigure 13.—Percent of Adults Aged 25 to 74 With Hearing Impairment, by Frequency of Tone in the United

States, 1971-75.

100

5 0

40

30 28,2

20

10 I 7.6

16.8

4.7

2.62.0

59.8

43.1

25-34 35-44 45-54 55-64 65-74

Age

SOURCE National Center for Health Statistics, Basic Data on Hearing Level of Adults 25-74, Off Ice of Health Research Statistics and Technology, 1980
80 ● Technology and Aging in America

ing impairments compared with only 20 percent

of women in that age group. Among those over

75, 44 percent of men but only 35 percent of

women have hearing impairments (92). Some

scholars suggest that these differential rates result from men’s longstanding exposure to noise

in heavy industry and other work-related situations.

Audiometric testing indicates that elderly men

have a higher prevalence than women of hearing loss at high frequencies. One study showed

that 49 percent of men over 65 had a moderate

to severe hearing loss at 4,00 hertz, compared

with only 17 percent of women over 65. Elderly

women, however, have a slightly higher prevalence of hearing loss at low frequencies (95). The

reasons for these differences are not known.

RACE

Interview surveys indicate a lower prevalence

of hearing impairment among black persons of

all ages than among whites. For example, blacks

age 65 to 74 (bath sexes) showed an impairment

rate of 18 percent, while whites in the same age

group showed a rate of 25 percent (92). Audiometric testing shows that elderly blacks have a

lower prevalence of severe hearing impairments

than elderly whites, but a higher prevalence of

moderate hearing impairments (95).

INCOME

Persons with low family incomes have higher

rates of hearing impairment than their wealthier

counterparts. For example, one interview survey

found that the rate of impairment among persons

65 to 74 with annual family incomes below $3,000

was 30 percent. For the same population group

with incomes in excess of $15,000, the rate was

20 percent. with only minor variation, this inverse relationship to income is sustained for all

age categories (92).

INSTITUTIONALIZATION

The prevalence of hearing loss among the institutionalized elderly is greater than among the

noninstitutionalized elderly (88). Moreover, a recent study of an institutionalized older population (80) pointed out the inadequacy of self-reports

for accurately assessing hearing impairment.

Residents of a home for the aged were interviewed about their hearing and were given audiometric tests, Fifty percent of the residents acknowledged a hearing loss, but audiometric

testing showed that 75 percent had hearing impairments; 8 percent of the residents reported

hearing loss when there was no audiometric

evidence of impairment, while 33 percent reported normal hearing but actually had clinically

significant loss. These findings suggest that audiometric testing should be a routine procedure for

elderly individuals admitted to long-term care facilities.

Types and causes of hearing l0SS

among the elderly

Types of hearing impairment include conductive, sensori-neural, mixed, and central hearing

impairments. These types are based on the site

of structural damage or blockage (see fig. 14). ConFigure 14.—Physiology of the Human Ear

q

Malleus

h I

Incus

Ear drum / Stapes —.

 8th Crania l

\

nerve

\

I

tube

I Middle I

Outer Ear I Ear I Inner Ear

In the healthy ear, the outer ear gathers sound waves and

directs them to the ear drum, where three bones-the

malleus, incus, and stapes—transmit the vibration to the

cochlea. In the cochlea delicate hair cells translate the

vibration into electrical current that passes through the 8th

cranial nerve to the auditory centers of the brain.

SOURCE OTA From an original by V Friedman, Washington University Medical Center

at St Louis.
Ch. 3—Selected Chronic Conditions, Technology, and Biomedical Research 87

ductive hearing impairment involves the outer

and/or middle ear. Sensori-neural impairment

involves damage to the inner ear, the cochlea,

and/or fibers of the eighth cranial nerve. A mixed

hearing impairment, as the term implies, is one

that comprises both conductive and sensori-neural components. A central processing disorder 

a hearing impairment that influences the understanding of spoken language; the elderly person

may hear the words but be unable to make sense

out of them as a result of disorders of the auditory

pathways in the brain.

Hearing impairment causes an inability to hear

environmental sound without amplification. Hearing impairment is sometimes also characterized

by an inability to discriminate or understand

speech sounds even with amplification. This

distortion of sound, which is common among

the hearing impaired elderly, can result in the

complaint, "I can hear you, but I can’t understand you. ”

Tinnitus is often an accompanying complaint

of those who have hearing loss. It is a ringing or

buzzing in the ears or head, the cause of which

is unknown. The prevalence of tinnitus increases

with age, and is more common in women than

men (84). Another problem often seen in older

persons with hearing loss is recruitment, an inability to tolerate loud sounds. This condition can

interfere with satisfactory use of a hearing aid.

Causes of conductive and sensori-neural hearing loss are listed in table 8. The most common

type of hearing loss in the elderly is prebycusis,

a sensori-neural loss resulting from changes in

the inner ear. These changes can include decreased numbers of hair cells or nerve fibers in the

cochlea and fibrous changes in the small blood

vessels that supply the cochlea. Some researchers believe that presbycusis is associated with normal aging, while others believe it results primarily from disease conditions. Not all elderly

individuals have presbycusis, and some people in

their 90s and older retain acute hearing.

THE ONSET OF HEARING IMPAIRMENT

The onset of hearing impairment can occur

before birth or in early childhood before language

is acquired, during early or middle life, or durTable 8.-Causes of Conductive and Sensori.Neural

Hearing Impairments

Causes of conductive hearing impairments:

External blockage: buildup of wax or presence of a foreign

object in the ear, which is very common in the elderly.

Perforated eardrum: a hole or tear in the eardrum, which can

occur as a result of injury, sudden pressure change, or

infection.

Genetic and congenital abnormalities: malfunction and/or

malformation of the outer and/or middle ear.

Otitis media: middle ear infection and accumulation of fluid.

Otosc/erosis: disease process affecting the mobility of the

middle ear bones, which is thought to be hereditary.

Causes of sensor-nural hearing impairment:

Presbycusis: literally, “old hearing.” The term has been used

to describe hearing impairment that occurs with old age.

Presbycusis may be sensory, neural, metabolic, or vascular in nature.

Hereditary hearing loss: includes a great variety of disorders

that affect the sensori-neural mechanism and are usually present at birth.

Trauma-induced: caused by a severe blow to the head, an accident, or a stroke or brain hemorrhage that affects the

ear, auditory pathways, and brain centers.

Tumors: acoustical neuromas and tumors that invade the

eighth nerve.

Noise damage: brief or continued exposure to high-intensity

sound, which irreparably damages the hair cells.

Vascular incidents: related to hypertension, heart disease,

or other vascular problems that may alter blood flow to

the inner ear.

Drug-induced hearing loss: drugs such as aspirin, and some

antibiotics, diuretics, and certain powerful anti-cancer

drugs can damage the hair cells or other vital parts of the

inner ear.

Viral and bacteria/ illness: such as mumps, meningitis, or encephalitis, and rubella contracted by expectant mothers,

are some common disease processes that are well-documented as etiologies for hearing impairment.

Meniere’s disease: characterized by fluctuating hearing loss,

dizziness, and tinnitus, the possible causes range from

allergy to hypothyroidism and diabetes.

SOURCE: American Speech and Hearing Association, “Management of Hearing

Impairment in the Elderly,” prepared for OTA under contract No,

333-8970.0, 1984

ing later life. People who have been deaf since

childhood have had time to adjust to their hearing losses and to develop behaviors to cope with

the social isolation resulting from deafness (77),

but additional problems acquired late in life may

seriously affect their functioning. For example,

poor vision in old age may interfere with lipreading techniques the individual has used successfully throughout life.

The elderly who become hearing impairedl ate

in life present different problems because they

must acquire an entirely new and complex system of communication in order to maintain social
82 . Technology and Aging in America

interaction. Little information is available about

the special problems of acquired hearing impairment among adults, and particularly the elderly.

Impacts of hearing impairment

Hearing impairment causes social and psychological difficulties by interfering with the individual’s ability to communicate with family and

friends. This can lead to withdrawal, social isolation, and depression. Loss of hearing interferes

with the elderly person’s ability to compensate

for other losses that can occur with aging, such

as loss of relationships due to the death of spouse,

siblings, and friends, loss of a familiar home or

community, and worsening health and mobility.

Lack of easy communication means decreased

access to new people, new activities, and new

services.

Hearing impairment limits access to information that is normally available through personal

communication, telephone, radio, and television.

For elderly individuals who have both hearing and

visual impairments, access to information is often

severely Iimited, and some research indicates that

restricted access to information can contribute

to the progressive development of confusion; further research is needed in this area.

Perhaps more important than any actual confusion related to hearing loss is the widespread

assumption that elderly persons who are hearing impaired are also confused. In a study conducted in a hospital, health care professionals described their impatience with elderly persons

with hearing losses. Several respondents said the

method they used in interactions was to “scream

at them. ” This behavior was considered acceptable since the patients were old, “and probably

senile, too” (76).

DENIAL OF HEARING IMPAIRMENT

Many elderly individuals deny they have a hearing problem despite significant evidence to the

contrary. Negative social attitudes about hearing

impairment and growing old encourage denial,

Hearing impairment is not visible, and in=

visibility facilitates denial In addition, hearing

impairment in the elderly is often characterized

by very gradual onset that can make the impairment difficult to recognize.

For elderly persons with one or more lifethreatening illnesses, hearing impairment may

seem insignificant by comparison. The onset of

depression and withdrawal associated with hearing impairment may be slow and insidious and

may appear unrelated to hearing loss. Accidents

that occur as a result of the elderly person’s inability to receive aural cues are frequently ambiguous as to cause. Similarly, difficulties in communication and social relationships may not be

attributed to hearing loss, even when the loss is

acknowledged. As a result, hearing impairment

is often not seen as important by the elderly, their

families, and health care providers. Denial of hearing impairment and failure to recognize its impact on independent functioning are clear obstacles to effective treatment.

Treatment of hearing impairment

Treatment of hearing impairment includes

methods to: 1) prevent hearing impairment or

reduce its severity, 2) improve the individual’s

communicative competence through amplification

or other electronic and mechanical devices, 3)

adapt public facilities to accommodate the special

needs of hearing impaired people, and 4) help people to manage their hearing problems by providing information about devices and other compensatory strategies to reduce communication

handicaps.

Potential treatments for hearing impaired people are the same regardless of age, The suitability

and effectiveness of each approach, however, differs considerably among the various age groups,

because of the type of hearing loss most frequently encountered and because of other physical,

psychological, and social characteristics of each

age group.

PREVENTION

Prevention is an obvious first approach to treatment. At present, too little is known about the

causes of hearing loss associated with aging to allow effective preventive measures. Dietary factors and circulatory changes have been impli-
Ch. 3—Selected Chronic Conditions, Technology, and Biomedical Research ● 8 3

cated, if not as direct causes, at least as

accelerators of deterioration in the auditory system. More vigorous research efforts might identify specific factors that would ultimately lead to

precise prevention strategies.

Some hearing impairments in older people result from preventable problems that began earlier

in life, such as untreated infections and exposure

to noise. Better health care throughout life and

effective noise control procedures could ultimately reduce the prevalence and severity of hearing

loss among older people.

Some drugs damage auditory mechanisms. The

best known ototoxic drugs are the “aminoglycosides,” a class of antibiotics that includes streptomycin; these drugs may be lifesaving but can

adversely affect hearing. Aspirin can also be

ototoxic, though probably only in the high dosage levels sometimes used in the treatment of arthritis. Aspirin-induced hearing loss is usually reversible if it is recognized early and dosage is

reduced. Too little research has been done on the

mechanisms of ototoxicity and the essential chemistry of ototoxic agents. Educational efforts have

been effective in informing most physicians of the

hazards of streptomycin, but the ototoxicity of

other drugs is frequently not recognized.

MEDICAL AND SURGICAL TREATMENT

The likelihood of curing hearing impairments

in the elderly with available medical or surgical

treatment is limited because they are almost

always sensori-neural losses most of which are

currently not treatable. The exceptions include

removal of acoustic tumors, and surgical treatment of Meniere’s disease.

The cochlear implant is a relatively new treatment for sensori-neural hearing loss. This electronic device is surgically implanted in the inner

ear to pick up sound waves, change them to electrical signals, and carry them past the cochlea to

the auditory nerve (82). The purpose of the implant is neuroelectrical simulation of natural hearing, but full attainment appears far in the future.

The sound produced by available implants has

been described as fluctuating grating noises and

buzzes that are not the same as normal sound

(85), and users need extensive training to learn

to interpret the sound. Research to improve the

cochlear implant continues in the United States

and other countries.

In its present form, the cochlear implant is not

appropriate for most elderly hearing impaired

people who usually have partial. hearing loss

rather than the profound deafness for which the

device is now used. In the future, as the cochlear

implant is improved through research and testing,

it may become an important treatment option for

sensori-neural hearing loss among the elderly.

TECHNOLOGIES TO COMPENSATE FOR

HEARING IMPAIRMENT

Since only a small proportion of the hearing impaired elderly can benefit from medical or surgical treatment, other approaches to treatment

are needed. These approaches do not change the

underlying condition but provide methods to compensate for hearing loss and maintain adequate

communication. Such methods include the use of

personal listening devices and amplification systems, adaptations of the telephone system, and

signaling and alarm systems.

Hearing Aids—Hearing aids are amplification

devices designed to compensate for partial hearing loss. They have benefited thousands of individuals, allowing them to function in communication situations that otherwise would have

been impossible. Yet only about 13 percent of all

persons with hearing impairments use hearing

aids. The elderly are more likely to use hearing

aids than younger people: about 20 percent of all

hearing impaired persons over 65 use hearing

aids, and those with more severe impairments are

more likely to use them (91).

Deterrents to the use of hearing aids include

problems in instrument design and performance,

social and psychological factors, and cost. Hearing aids do not restore normal hearing for most

users. The quality of sound is mechanical, and the

amplification of distracting background noise is

a problem for users of all ages.

Some specific hearing deficits that are common

in the elderly, such as more severe hearing loss

at high frequencies and distortion of sound due

to abnormalities in the sensory cells, require tai-
84 ● Technology and Aging in America

loring of the hearing aid’s operational specifications. Sound processing techniques are available

to make these adaptations, but most of these techniques are not widely used, partly because of the

difficulty of identifying the precise deficits experienced by each individual (85). Audiologists are

trained to evaluate hearing deficits, but many

elderly individuals buy hearing aids from hearing aid dealers without seeing an audiologist.

Moreover, even when a comprehensive evaluation is done, the audiologist or hearing aid dealer

may have difficulty selecting the appropriate

hearing aid because of the lack of reliable technical information about different brands and

types of hearing aids (79).

Social and psychological factors that discourage

use of a hearing aid include reluctance to call attention to the hearing impairment and disappointment with the quality of sound provided by the

hearing aid. Individuals who once had normal

hearing often expect that a hearing aid will return their hearing to normal, and the disappointment they experience in trying to adjust to a

hearing aid can create significant acceptance

problems. Some experts believe that the elderly

have more difficulty adjusting to hearing aids than

younger people because of so-called age-related

inability to adjust to something new, but it is also

possible that many elderly individuals are not

using their hearing aids because the aids are inappropriate for their hearing impairments.

other Personal Listening Devices.—Three

other personal listening devices can compensate

for hearing loss: audio loop systems, FM amplification devices, and infrared amplification devices.

These devices transmit sound directly from the

source to the listener, thus eliminating background noise that interferes with hearing. They

have been used primarily in classrooms and public facilities, such as theaters and churches, and

are often called “large room systems,” but they

are now being used by individuals for interpersonal communication and TV and radio listening.

This use is particularly appropriate for the elderly

because they usually have partial rather than

complete hearing loss, and in many cases these

devices can provide satisfactory amplification.

Moreover, no training is needed to learn to use

these devices. Audio loop systems, FM amplification devices, and infrared amplification devices

can also be used with the hearing aid to eliminate

bothersome background noise.

The Use of Devices for Public Access: The Rehabilitation Act of 1973 prohibits discrimination

against disabled individuals by any program, activity, or facility receiving Federal assistance. The

law requires that these facilities be accessible to

people with all kinds of handicaps, including hearing impairment, but the emphasis has primarily

been on adapting facilities for people with mobility problems. This has occurred even though

the costs of providing access to the hearing impaired with technologies such as FM and infrared

amplification devices are usually minimal compared with the costs of major modifications in architecture. While public funding has been

available for architectural modification% the

costs of improved accessibility for the heap

ing impaired have been paid primarily by

the private sector.

Telecommunications Systems. -Inability to use

the telephone is one of the most common problems of hearing impaired individuals. For the

elderly, particularly the great number who live

alone, the telephone is a link to the outside world;

inability to use the telephone can compromise

safety and interfere with independent functioning.

Hearing over the telephone is difficult even for

those with mild hearing loss because telephone

signal transmissions omit very low- and high-frequency sounds that are important for understanding speech. Line noises and other sound distortions also interfere with the quality of sound

transmission. In the future, as the need grows to

transmit more conversations over limited channels, this problem may become worse. Methods

for increasing channel capacity involve omitting

parts of the speech message that are considered

unimportant, but the standards for what is unimportant are based on the hearing ability of younger persons with normal hearing. Research is

needed to document the effect of these omissions

on the hearing ability of elderly and other hearing impaired individuals (78).

Devices to assist hearing impaired individuals

to use the telephone include amplifiers that can

be built into the telephone handset or attached
Ch. 3—Selected Chronic Conditions, Technology, and Biomedical Research . 85

to the side of the telephone, and telecoils that are

built into hearing aids to pickup electronic signals

directly from the telephone receiver, bypassing

the hearing aid microphone. The Telecommunications for the Disabled Act of 1982 requires that

all telephones installed in “essential places” such

as hospitals, hotels, and similar public facilities

be compatible with hearing aids. Because there

are no comparable requirements for hearing aids,

however, aids can now be sold that are not compatible with these telephones.

For individuals with severe hearing impairments, other devices are available or in the development stage. These devices include:

● teletypewriters (TTYs) that allow individuals

to type a message that is carried over phone

lines,

● Teletex and Viewdata information retrieval

systems for transmitting text and simple

graphics to a television receiver, and

● Picturephone and Vistaphone devices that

transmit a visual image of the speaker over

an ordinary telephone line and allow communication through lipreading or manual

sign language.

It is not known how many elderly individuals use

or could use these devices. The TTYs and Viewdata systems require that the speaker type all

messages. The Picturephone and Vistaphone are

only helpful to those who communicate through

lipreading or sign language. Since few elderly individuals use these methods of communication,

the usefulness of these devices for the hearing

impaired elderly is limited.

The development of effective computerized

speech recognition systems could greatly simplify

telephone use for the hearing impaired. These

systems convert spoken words into printed output that could be displayed on a screen attached

to the telephone. Currently available speech recognition systems have major limitations: they recognize only a few words and sometimes confuse

words, and their performance varies widely from

speaker to speaker. Future refinements of this

technology could facilitate telephone use for the

hearing impaired elderly.

Signaling and Alarm Systems.—Signaling and

alarm systems that convert sound to visual or tactile signals are important for the safety and independence of hearing impaired persons. Flashing

lights and vibrating devices that signal the ringing of a fire alarm, smoke alarm, telephone, doorbell, or alarm clock substitute for sounds the person cannot hear. Tactile Paging Devices use radio

signals to generate vibrations in a portable receiver carried by the hearing impaired individual.

One serious block to use of these devices by the

elderly is lack of awareness of devices that could

be helpful. Information about these devices is

available within the informal deaf community,

which is primarily comprised of younger individuals who have been deaf since childhood or

early adulthood, and their families. The elderly,

however, are seldom part of the informal deaf

community, so they lack access to this source of

information. Since the elderly usually do not receive comprehensive aural rehabilitation services,

they do not learn about available devices from

hearing specialists.

Aural Rehabilitation.—Aural rehabilitation

services are designed to help individuals communicate more successfully with or without the use

of a hearing aid or other personal listening device. These services are usually provided by audiologists and are briefly described here:

● Hearing aid orientation includes instruction

in the care and maintenance of the aid and

earmold, practice inserting the earmold and

batteries, and instruction in the use of amplification in a variety of listening situations.

● Auditory training involves systematic training in the use of residual hearing. The individual is taught to recognize and differentiate

sounds and intonational patterns that give

clues about the content and meaning of

speech. This training is presently used almost

exclusively with children, but the elderly,

who usually have some residual hearing,

could also benefit from this approach.

● Speechreading is the use of visual cues to facilitate understanding speech. It is similar to

lipreading but involves attention to facial,
.

86 ● Technology and Aging in America

●

throat, and body positions in addition to lip

movements (81,87). Few elderly individuals

are taught speechreading techniques, even

though these techniques are particularly effective for individuals who have only partial

hearing loss. Cued speech is a method of communication that supplements speechreading

and is being used with elderly individuals in

a few places in the United States. Cued

speech involves the use of hand signals and

hand positions that clarify the lip and facial

positions associated with speech sounds.

Counseling can address negative attitudes

that interfere with rehabilitation. It can help

to develop strategies to manage social situations and other life activities in ways that will

lessen the handicap (81). The elderly are particularly likely to believe that their hearing

losses are hopeless, and some elderly individuals suggest that services be directed

toward a younger person who could derive

greater benefit. Counseling can help to overcome these feelings.

Despite the potential benefits of aural rehabilitation, few elderly individuals receive these services. Reasons for this include lack of awareness

of the value of the services by the elderly and

their families, the cost of the services, and the historical focus of hearing professionals on the needs

of profoundly impaired children.

Environmental Desigm-Building design characteristics affect the behavior of sound and the

relative ease or difficulty of hearing. For example, hard-surfaced walls and floors reflect sound,

creating reverberations that interfere with hearing, while sound-absorbent wallcovering materials

decrease reverberations (83). While much is

known about design characteristics that affect

hearing, this information is seldom applied in

buildings used by the elderly. Reduction of reverberations and background noise in these facilities

could ameliorate some of the problems of those

with hearing loss.

The service delivery system

SERVICE PROVIDERS

Hearing services for the elderly are provided

primarily by physicians, audiologists, and hearing aid dealers. Although few hearing impairments of older people respond to medical or surgical treatment, some elderly persons see a

primary care physician as a first step in treatment.

Depending on their symptoms, they may be referred to a specialist, who is usually an otolaryn -

gologist. Physician evaluation is important to identify impairments that are medically treatable, but

physicians usually receive little training in the

management of hearing impairments and alternative approaches to compensate for hearing

loss.5

Audiologists are nonmedical specialists trained

in the identification and evaluation of hearing impairment and rehabilitation of individuals with

hearing deficits. Audiological evaluation includes

assessment of hearing threshold sensitivity,

speech discrimination ability, and residual auditory function. Audiological testing helps to determine the type of hearing aid needed, and some

audiologists dispense hearing aids. Audiologists

also provide hearing aid orientation and counseling for hearing impaired persons, families, and

health care providers in a variety of settings.

Hearing aid dealers sell hearing aids and hearing aid accessories, such as batteries, earmolds,

and spare cords, and may also repair hearing aids.

They often receive as little as 1 week’s training

from hearing aid manufacturers and much of this

training focuses on sales management.

The National Hearing Aid Society (NHAS) offers

a 20-week home-study course, but many dealers

do not take the course. Moreover, an expert panel

review of the home-study course found many deficiencies including incorrect, oversimplified, and

outdated information. The review panel concluded that the home-study course was “not only

inadequate but potentially dangerous. It is dangerous in the same way that ‘quack’ medicine is

dangerous . . . it postpones or prevents adequate

evaluation, diagnosis, and treatment of hearing

loss and its accompanying pathology” (89).

5Otolaryngologists receive some training in hearing measurement

techniques and amplification, but few otolaryngologists receive extensive training in sophisticated aspects of auditory processing and

its relationship to communicative ability. Their training focuses pri.

marily on medical diagnosis for and medical/surgical treatment of

conditions affecting the ear, nose, throat, head, and neck, and on

facial, cosmetic, and reconstructive plastic surgical techniques.
Ch. 3—Selected Chronic Conditions, Technology, and Biomedical Research ● 8 7

The National Hearing Aid Society confers the

title “certified hearing aid audiologist” on dealers

who pass the NHAS home-study course. This title can lead consumers to believe that the dealer

possesses expertise that he does not have. The

Federal Trade Commission (FTC) has proposed a

rule that would prohibit the dealer’s use of the

term “certified hearing aid audiologist .“ The use

of this term by dealers is already prohibited in

several States.

The most valuable aspect of the dealer’s role

in the hearing aid delivery system is that of a prosthetic dispenser. Dealers are trained and qualified

to make earmold impressions, to fit the final earmold product and the hearing aid for comfort,

and to provide hearing aid wearers with basic instruction concerning the operation and care of

hearing aids. They are generally not qualified to

provide the comprehensive auditory evaluation

needed by the hearing impaired elderly.

Many elderly individuals enter the service delivery system through a hearing aid dealer. When

they are fitted with hearing aids without consulting an audiologist they risk purchasing an aid that

is of no value to them.

Speech therapists, social workers, psychologists,

nurses, and other caregivers sometimes provide

physical, emotional, and “informational” support

to the hearing impaired elderly. These professionals often know very little about treatments,

devices, and rehabilitative approaches that might

ameliorate the hearing loss. The education of all

human services professionals should include information about the causes and treatment of

hearing impairments in the elderly.

FEDERAL REGULATION OF THE DELIVERY SYSTEM

Some aspects of hearing aid sales are regulated

by the Food and Drug Administration. The FDA

requires that the consumer must give the hearing aid dispenser a written statement from a physician, certifying that the hearing loss has been

evaluated and that the individual may be a candidate for a hearing aid. However, consumers

who are over 18 may sign a form waiving the requirement of a physician’s evaluation. There is

no objective information about the number of aids

that are dispensed on the basis of these waivers,

but it has been informally estimated that in some

communities up to 80 percent of all aids are

dispensed through waivers.

FDA regulations also require that the customer

receive an instructional brochure describing the

use and care of the aid, sources of repair and

maintenance, and a statement that the hearing

aid may be only part of a rehabilitative program

that may also involve speechreading or auditory

training. The regulations require a warning to

dispensers and purchasers that certain conditions

make medical consultation advisable prior to purchase of an aid.

While the FDA regulations were intended to

address safety and effectiveness, they offer no

assurance that any hearing aid that is sold will

benefit the purchaser. Furthermore, in providing a waiver for even the requirement of physician evaluation prior to sale, the regulations

surrender all semblance of quality control. Regulations that thus purport to offer consumer protection, but do not in fact do so, may be more

dangerous than no regulations at all.

During the mid-1970s the FTC initiated a major effort to develop regulations for hearing aid

sales. Recommended regulations, published in

1978, included restrictions on in-home sales, marketing of used hearing aids, and the use of testing

programs to identify potential customers. The regulation that was most vigorously contested by the

hearing aid industry would allow a hearing aid

purchaser or renter to cancel the sale or rental

within 30 days and receive a refund. These recommended regulations were strongly supported

by consumer advocates and organizations for the

hearing impaired, but no regulations have been

promulgated as of october 1984, a full eight years

after the rules were proposed. The FTC is presently sponsoring a survey of hearing aid users,

and results of the survey will be used by the commissioners to determine the current need for regulations,

Funding for treatment of

hearing impairments

Hearing services for the elderly are paid for by

government programs, such as Medicare and

Medicaid, private insurance, and direct out-of-
88 ● Technology and Aging in America

pocket payments. Medicare pays for medical and

surgical hearing services provided by physicians,

and some services provided by audiologists, but

only when authorized by a physician. Medicare

does not pay for audiological evaluations related

to the prescription of hearing aids. Purchase of

hearing aids and other assistive listening devices

are also not covered by Medicare.

Hearing aids are the most common treatment

for hearing impairment in the elderly, and lack

of Medicare funding for hearing aids has a severe

effect on the provision of effective treatment.

Many elderly individuals purchase hearing aids,

but few are also willing and able to pay for an

audiological evaluation that could specify an

appropriate aid. Without this evaluation it is likely

that the hearing aid will be ineffective.

Medicaid pays for medical and surgical hearing services provided by a physician to low-income patients. some services provided by audiologists are covered by Medicaid in most States,

and Medicaid pays for hearing aids in about half

of the States. A major problem in many States that

have Medicaid reimbursement for audiological

services and purchase of hearing aids is that the

reimbursement rates are so low that providers

refuse to serve Medicaid patients. Another problem with reimbursement for hearing services by

both Medicare and Medicaid is the complexity of

Federal and State regulations that govern reimbursement, especially for audiology services.

Private insurance companies cover some hearing services, but each insurance policy is independently negotiated, and it is difficult to specify

exactly which hearing services are covered by

which insurers for which groups of beneficiaries.

Most policies reimburse for hearing services provided by physicians and some hearing services

provided by audiologists, but routine evaluations

to detect hearing loss and services related to degenerative hearing loss are not covered. Hearing

aid evaluations and hearing aids are also not

covered.

Since Medicare and private insurance do not

pay for audiological evaluation or purchase of

hearing aids or other assistive listening devices,

the elderly must pay for these services and devices themselves or do without.

Federal Government programs for

the hearing impaired elderly

Hearing impairment among the elderly is a Federal Government concern because of its impact

on the safety and quality of life of elderly people

and because of the need for publicly funded

health and social services for the hearing impaired. Federal initiatives to address these concerns have included funding for research and

some hearing services, legislation to guarantee access to public services and facilities for the hearing impaired, and regulation of hearing aids.

While these initiatives have benefited hearing impaired individuals of all ages, there is a need for

programs that address the specific problems of

the hearing impaired elderly.

The prevalence of hearing loss in the elderly

far exceeds that of most chronic diseases and disabilities of later life, but the magnitude of this

problem has not been reflected in the amount of

research that has been conducted in pathology,

prevention, treatment, and rehabilitation. Most

hearing-related research has been directed toward the most severe hearing problems and particularly the problems of deaf children. In contrast to children, however, hearing impairment

in the elderly is often mild or moderate, instead

of severe, yet it is very widespread; it is often progressive; it usuaIly has a gradual onset and is frequently not recognized for some time; and finally,

hearing impairment in the elderly often coexists

with other health problems that complicate treatment and limit the effectiveness of available assistive devices. Research is needed on causes of

hearing impairment in the elderly and appropriate treatment methods.

Denial of hearing impairment is a continuing

obstacle to treatment. public education to increase

awareness about the extent and type of hearing

impairments among the elderly is needed,

Few of the hearing impairments of the elderly

respond to medical or surgical treatment, and the

most effective method of treatment available at

present is the use of devices and techniques that

compensate for hearing loss. The elderly, their

families, and health care providers need information about the kinds of devices that are available

to compensate for hearing impairment.
Ch. 3—Selected Chronic Conditions, Technology, and Biomedical Research ● 8 9

Assistive listening devices have been developed

in the United States primarily by universities with

rehabilitation programs and by commercial manufacturers. Marketing of new devices has been

a problem, and testing procedures for devices

have been inadequate. In some industrial countries such as Sweden, development, funding, dissemination, and repair of devices are considered

a national responsibility, In the United States the

Veterans Administration (VA) has a comprehensive program of device development, testing, and

patient services, but outside of the VA, the delivery system is splintered and often ineffective. Extension of the VA model of services could stimulate device development and improved service

delivery.

Osteoarthritis

osteoarthritis is one of the most important

causes of chronic disability in the United States

and other developed countries. The disease is

found in all organisms with bony skeletons’ (98).

Although it is not a disease of modernity-evidence of it has been found in the skeletons of

Neanderthal Man and even some dinosaurs—because the incidence of osteoarthritis rises with

age, and because its prevalence increases as individuals live longer, it has become much more

common in recent years. This rising prevalence

may give osteoarthritis the “highest morbidity rate

of all mankind’s diseases” (98). Some evidence of

the disease has been found in 90 percent of people by age 40 (in autopsy studies), but it causes

symptoms only in a minority at that age.

Variations in diagnostic criteria render statistics on incidence and prevalence uncertain, as

they are for many other disorders. All estimates,

however, indicate that the process that underlies

osteoarthritis occurs in almost everyone if they

live long enough, and that symptoms become increasingly prevalent and more intense with age.

The disease is severe enough in 16 million to 20

million Americans to cause symptoms (97,105).

Some form of arthritis other than rheumatoid ar6

Sharks, which do not have bony skeletons, but do have cartilaginous ones, are evidently immune to the ravages of osteoarthritis,

A final concern is the failure of the hearing impaired elderly to utilize aural rehabilitation services. Although hearing loss in the elderly is often

mild or moderate, it is not simple, and its effects

can be very serious. Government initiatives to increase the use of aural rehabilitation services

could include increased funding and simplification of the complex requirements for these services under Medicare and Medicaid. In addition,

public education programs are needed to increase

awareness of the potential benefit of these services among the hearing impaired elderly and their

families.

thritis was reported as affecting 47.5 percent of

those over 65 in 1981 (see Appendix A: Morbidity

and Mortality Data) and osteoarthritis would constitute the vast majority of such cases. Osteoarthritis causing severe or moderate pain was noted

in 6.6 percent of those 65 to 74 in the National

Health and Nutrition Examination Survey (this includes only those cases for which patients reported symptoms) (112). Had older age groups

been surveyed, the prevalence would have been

far higher. Other surveys have found evidence

of the disease in patients to dramatically increase

with age; changes in joint X-rays can be found in

only 4 percent of those aged 18 to 24, but in 85

percent of those 75 to 79 (105). Of those showing some X-ray evidence of the disorder, 23 percent reported moderate or severe symptoms. The

prevalence of osteoarthritis is higher in white

populations and lower in blacks, American Indians, and Asians living in Asia.

Osteoarthritis is a major factor in health care

costs and patient morbidity, but, like dementia,

is not a direct cause of death. osteoarthritis

causes an estimated 46 million visits to physicians,

3.7 million hospital days, 185 days spent in bed

away from the hospital, and loss of 68 million

workdays per year in the United States (104). The

Arthritis Foundation estimated the total costs of

all forms of arthritis at $13.3 billion in 1983 (96),
 . Technology and Aging in America

of which osteoarthritis accounted for approximately 60 to 70 percent (more than $7 billion).

Although it is only one of hundreds of causes of

arthritis, it affects far more individuals than any

other cause.

Osteoarthritis should not be confused with

rheumatoid arthritis; only osteoarthritis is reviewed in this report. Rheumatoid arthritis is the

second most common form of arthritis, affecting

an estimated 6 million to 7 million people, but its

prevalence in many younger age groups makes

it less a disease of aging. Its cause is thought to

be disrupted immune function, and is quite distinct from the process underlying osteoarthritis.

Definitions and prevalence

Arthritis means inflammation of the joint,7 of

which osteoarthritis is one cause, Other names

for osteoarthritis include “degenerative joint disease, “ “osteoarthrosis, 8 and “hypertrophic arthritis. ” These alternative labels reflect a degree

of medical disagreement about the disease process, but the debate over proper terminology is

not germane to public policy regarding the condition itself. OTA has selected “osteoarthritis” because it is the most common term. Osteoarthritis,

as used here, refers to the combination of biochemical and anatomical changes in the joint that

cause symptoms in at least one joint.

Medical definitions of the disease are subject

to some controversy. Most physicians consider

the diagnosis if there is pain or stiffness and Xray evidence of joint damage. There is disagreement, however, about the X-ray changes that indicate osteoarthritis. Some physicians look for

unusual bone formations (osteophytes) around

the affected joint. others do not make the diagnosis without evidence of joint narrowing and

changes in the bone underlying affected joints.

What is osteoarthritis?

Osteoarthritis is the symptomatic disruption of

joint function. Functional impairment arises from

the biological changes described in this section,

which provide an introduction to the biology and

anatomy underlying osteoarthritis.

Joints are fluid-filled spaces lined by cartilage

and separating bones; those found on the limbs

(legs and arms) are adapted to permit easy movement. Limb joints are most affected by this disease, especially those responsible for weight-bearing (hips and knees), the vertebrae, and (for

unknown reasons) the joints closest to the tips of

the fingers.

Arm and leg joints are composed of a fluid-filled

cavity, surrounded by a fibrous capsule (see fig.

15). The surfaces that move against one another

are composed of cartilage. The cartilage sits over

bone. The cartilaginous surfaces are extremely

well adapted to ease of movement; they are four

times as slippery as Teflon ”, one of the most frictionless artificial surfaces (98). Disruption of the

health of the cartilage tissue can reduce this ease

of movement, leading to joint stiffness. Irritation

of surrounding tissues leads to the symptom of

pain, osteoarthritis is one of the causes of ill

health of the joint cartilage.

Many types of injury to cartilage can lead to

changes similar to those seen in osteoarthritis

(102). Such changes include degeneration of the

cartilage, faulty attempts at repair, anatomic clefts

and blisters, and even complete exposure of

underlying bone. Injury can be caused by imposed immobility, removal of tissues that support

the joint, and extreme compression. The similarity

of normal cartilage repair to osteoarthritis has led

some to hypothesize that the disease is an abnormal response to constant minor injury.

Joint cartilage relies on adjacent tissues for its

health. The surface of joint cartilage is coated with

special long chains of sugars and proteins. Biochemical changes of these coatings have been associated with damage to cartilage, and can reduce

the slipperiness of the surfaces, causing increased

friction and yet more tissue damage.

Because cartilage does not contain blood vessels,g it gets its nutrients and other factors from

the surrounding soft tissues and, more importantly, underlying bone. Proper cartilage repair apT’rem: arthro-(joint) + -itis (inflammation).

‘From: osteo-(bone) + arthro-(joint) + asis (process)

‘Blood Vessels appear to be prevented from growing into cartilage

by a molecule that is produced by the cartilage,
Ch, 3—Selected Chronic Conditions, Technology, and Biomedical Research 91

Figure 15.-Diagram of Knee Joint X-Ray Photograph X-Ray Photograph

of Arthritic Knee Joint of Normal Knee Joint

—Bone

-Cartilage

-Synovial fluid

Capusule

SOURCE: National Institute of Arthritis, Diabetes, and Digestive and Kidney Diseases

pears to require access to cells in the bone marrow (102). The repair process may be sensitive

to influences from other tissues as well, including

hormones (thyroid-stimulating hormone and somatomedin have been postulated) and other

chemical messengers (growth factors, growth

suppressors, and certain nucleotides have all been

suggested) (98)102), Osteoarthritis can, over a long

period, lead to severe joint deformity, enlargement of surrounding tissues, and immobility.

Risk factors

The most important risk factor for arthritis is

age, which cannot be controlled. Other uncontrollable factors include (105):

● body type (risk is increased in stocky individuals, decreased in tall thin people);

. race (risk is increased in Caucasians over

blacks, Asians, and American Indians);

● diabetes (which may be partially controllable

when due to obesity) (98); and

● genetic traits (one possible form is influenced

by sex chromosomes; another involves many

genes).

There are also some controllable risk factors:

● obesity (many studies support this, but some

do not) (98);

● occupation (risk is increased in coal miners,

dock workers, and dominant hands of weavers, but not in pneumatic hammer drillers);

and

● exercise.

one possible risk factor, exercise, deserves special mention. Many orthopedic surgeons fear that

the current popularity of jogging and other vigorous exercises may exacerbate osteoarthritis. It

would be ironic if strategies that could prevent

some deaths (e.g., from cardiovascular disease and

stroke) were to worsen disability due to osteoarthritis. There is ample evidence that overexercise

can worsen the condition of those who have the

disease. Evidence that exercise can precipitate it,

however, is unclear. Studies of marathon runners

did not show more osteoarthritis of the hip, and

studies of soccer players showed some indications

of the disease, but other signs and symptoms

were absent (105). Whether osteoarthritis can be

caused by exercise thus remains an important

unanswered question.

Diagnosis

The diagnosis of osteoarthritis is made by correlating symptoms of pain and stiffness with Xray evidence of changes in joints. other causes

of arthritis must be eliminated by history, physical examination, and laboratory tests. Such other

causes include infection, deposits of mineral crystals (from gout or other metabolic disorders), and

some systemic diseases. one problem in making

38-800 0 - 85 - 4
92 “ Technology and Aging in America

the diagnosis is that some patients wait for prolonged periods before seeing a professional. Another problem is that physician and patient perceptions of the severity of the illness may differ.

one study found that while physicians’ and patients’ judgments of the degree of disability agree

for low levels, physicians may underrate the disability at higher levels (where such error may

make a greater difference) (107). The authors

point out that this can erode mutual trust, and

can lead to a paradox in that the physician believes that treatment is successful, but the patient

does not.

Prevent of disability and treatment

The Arthritis Foundation notes that patients

with osteoarthritis wait an average of 4 years before seeking medical attention from a physician.

This is unfortunate, because the progression of

the disease can be retarded, and its symptoms

ameliorated by routine treatments (table 9).

CHANGING THE PATIENT’S ENVIRONMENT

AND HABITS

Some symptoms of osteoarthritis can be prevented by treatment and directed programs of

exercise and physical therapy. Some simple interventions can greatly retard the progression of the

disease. Use of a cane can, for example, reduce

the stress placed on the hip during walking by

a factor of 2 or 3 (113). Changing the environment

by adapting beds and chairs for easier entry and

exit, and arranging living space to avoid use of

stairs can greatly diminish the demands on the

individual, and can minimize the need for movements that exacerbate the disease (113).

Weight reduction is often recommended to reduce the weight strain placed on knees and hips.

Job changes away from physically demanding occupations may reduce joint wear and tear, and

altering sports activities may be necessary to prevent acceleration of joint degeneration.

Devices that compensate for diminished function, especially of the hand and major joints of

 the legs, could greatly improve the independent

and relatively normal functioning of those affected by osteoarthritis. There appears to have

been little attention given, for example, to designTable 9.—Treatments for Arthritis

Assistive devices:

● Canes and devices that facilitate walking

● Special utensils

● Adapted furniture

. Special stairways

● Enlarged keyboards

. One-floor architecture

Physical therapy:

● Balanced program of rest and exercise

● Special movement and relaxation therapy directed at

specific joints

● Weight loss

Drug thearapy:

● Aspirin

● Nonsteroidal anti-inflammatory agents

● Others (steroids, etc.)

Surgical therapy:

● Hip joint replacement

● Bone reshaping (osteotomy)

● Joint debridement

Future possibilities:

● Specific hormones or growth factors active on joint

cartilage

● Joint surface replacement

● Cartilage transplantation

● Improved joint replacement techniques and

replacements for joints in addition to the hip

● More and better assistive devices

SOURCE: Off Ice of Technology Assessment.

ing computer keyboards to make them accessible to the millions of Americans whose hand mobility is restricted by this disease.

PHYSICAL THERAPY

Treatment of osteoarthritis involves balancing

joint movement with protecting the joint from excessive movement. This implies the need for a

proper balance between exercise and rest. Weight

bearing and movement are imperative for proper

cartilage repair (98), but overexercise is a wellknown cause of excess disability. Physical therapists, physiatrists (physicians engaged in physical therapy), and other providers can be effective in reducing muscle spasm and in training

patients to exercise and rest specific joints.

DRUG THERAPY

There are several drug therapies for osteoarthritis. The most common is the use of high doses

of aspirin. Aspirin has the unusual characteristic of being both a painkiller and an anti-inflammatory agent, which makes it suitable for treating
Ch. 3—Selected Chronic Conditions, Technology, and Biomedical Research “ 93

both the process that causes pain (inflammation),

and the pain itself. Aspirin may also directly affect some biochemical processes involved in cartilage repair, thus improving the repair process.

But because it can cause digestive disturbances,

ringing in the ears, and other adverse effects, and

some patients have violent reactions to it, aspirin

cannot be used by all patients. Further, recent

reports based on animal studies suggest that some

effects of aspirin can inhibit proper healing of arthritic joints (101)108). Such studies have not yet

been extended to research on humans, hence

their relevance to standard therapy is not yet

clear.

Among the other drugs used in treating osteoarthritis, the most common is a class of drugs called

nonsteroidal anti-inflammatory drugs. These reduce joint inflammation and can prevent some of

the resulting pain and stiffness. Many such agents

are widely prescribed, including indomethacin

(Indocin”), ibuprofen (Motrin@), naproxen (Naprosyn@), and others. These drugs are, in general,

reserved for patients who cannot tolerate aspirin.

They are more costly than aspirin, and have significant side effects (109). Several drugs in this

group have recently been withdrawn from the

market because of side effects, and two others

are currently under investigation by FDA. Development of safer anti-arthritic drugs in this class

is a high priority in the laboratories of many pharmaceutical manufacturers.

Steroid drugs are not generally used for routine

treatment because of the many possible side effects, but they can be effectively used by local

injection for flare-ups, or before surgery.

SURGERY

Total joint replacement is a relatively new technique, made possible by technological advances

in low-friction materials, biocompatible plastics

and metals, and development of cements that can

function in bone. The joint most commonly replaced is the hip, but some centers are also performing knee replacement surgery, and surgery

on other joints, such as fingers and shoulders, on

an experimental basis.

More than 60 percent of the 75)000 total hip

replacements done in the United States annually

are done in those over 65, mainly because of osteoarthritis (110). Hip replacement is now a routine procedure, which can reduce pain, improve

mobility, and has a low risk of failure. The risk

of death during the operation is less than 1 percent, and the risk of infection is similarly low. Included in the l-percent risk are clot formation

in leg veins (clots can cause severe problems if

they break off and pass through the heart to the

lungs). Temporary urinary retention is found in

15 to 30 percent of patients. A major conference

on the subject at the National Institutes of Health

(NIH) concluded that hip replacement “when done

for incapacitating pain and dysfunction . . . gives

a predictably excellent result in the vast majority

of patients” (110).

The same conference found that present technology results in 90 percent of devices remaining functional 10 years after surgery (110). The

main complication of total hip replacement is loosening of the apparatus. Fracture of the device occurs in approximately 0.5 percent of cases. A

search for improved cements to keep the devices

in place, and development of devices that do not

require cement (by allowing bone growth into the

device) are underway (105). New technologies also

may permit detection of loosening by detecting

sounds of the device under stress (111). Surgical

replacement of hips and other joints is effective,

but expensive.

It is estimated that $700 million was spent in

1979 for hip replacements alone, 59 percent of

which was done to replace joints affected by osteoarthritis (103). The rising numbers of elderly

in the U.S. population, especially of those who are

very old, suggests a rapid increase in this total

unless means of preventing osteoarthritis can be

found. The potential for cost growth as more joint

replacements are done is a topic of concern for

health policymakers. There are large numbers of

potential recipients, and as the technology advances, such surgery may well become more attractive to a larger proportion of those with

osteoarthritis or osteoporosis, This raises the

prospect of difficulty in establishing criteria for

deciding who should be entitled to joint replacement, establishing publicly acceptable mechanisms for rationing or otherwise constraining

access to joint replacement through Federal pro-
 ● Technology and Aging in America

grams, or continued cost escalation driven by

demand.

Osteotomy involves reshaping the bone to reduce stress, or to provide a more favorable anatomic orientation of the joint. It is now less commonly used because of the advent of total joint

replacements. joint debridement is removal of unwanted tissue from the joint space, and can help

when there is free cartilage or bone irritating the

joint. Hip surface replacement is also being tried

for some cases of arthritis, mainly in younger patients (106),

POSSIBLE FUTURE DEVELOPMENTS

Future prevention and therapy of osteoarthritis

may include new drugs to promote cartilage

growth and regeneration, production of growth

factors and hormones through biotechnology, improved joint replacement, regrowth or replacement of joint surfaces, and development of devices to compensate for diminished function,

Increased attention to this potentially large market by companies that produce devices could also

greatly improve the functioning of arthritic individuals. Designers of chairs, stairways, beds,

telephones, and computer keyboards are likely

to adapt their designs for use by the growing

numbers of those affected by arthritis. Development of “smart” technologies to assist in daily

activities should prove highly marketable to this

large subpopulation.

Quackery

A major problem in arthritis treatment is the

proliferation of quack remedies and consumer

fraud. The Consumers Union notes that “quackery thrives best on human illnesses for which

there is no cure” (99). The persistent and unremitting symptoms of pain and stiffness also spur the

search for remedy, or the promise of it. The large

number of affected individuals encourages promoters to try to tap this potentially lucrative market. Both chronic discomfort and high prevalence

contribute to the problem of quackery. Further,

the episodic nature of the illness can breed personal anecdotes of “successful” treatments, when

an individual happens to take action just at the

time the symptoms are naturally subsiding.

one additional factor can render arthritis victims vulnerable to the attractions of useless substances, devices, and procedures: the patient’s

perception that traditional medicine has failed.

This can be exacerbated by the frequent disparity

between the patient own measure of discomfort

and that acknowledged by medical practitioners.

The Arthritis Foundation has variously estimated the amount spent on false or unproven

remedies as $950,000 and $1.8 million (96,97).

Quackery can take many forms:

 drugs;

● chemical mixtures (often containing hormones);

● diets;

 special “clinics”;

● devices; and

● “therapeutic” jewelry (e.g., copper bracelets,

gold, etc.).

Examples of useless or unproven remedies include DMSO, a common chemical solvent, which

has been heavily promoted for relief of arthritic

symptoms, despite a lack of verifiable effects. Copper bracelets were popular for a time, and one

patently fraudulent device, the “Vryllium Tube,”

consisted of $0.02 worth of salt and sold for $250.

Special clinics in Mexico and the Dominican Republic have catered to the desperation of arthritis

victims, and special diets and diet books can be

found in profusion (99).

The creative marketing techniques sometimes

used by American drug companies, encourage unenlightened self-medication. Promoting agents to

the public for relief of arthritis symptoms can lead

to inaccurate self-diagnosis, and, in the words of

a 1977 FDA panel, “Consumers who self-treat with

an over-the+ ounter pain reliever for these diseases, without first seeking medical attention, may

be risking irreversible damage to joints and other

tissues” (99).

Social factors

As with any other chronic condition, optimal

patient functioning relies not only on physiologic

change and medical intervention but also on social

variables and public policy:
Ch. 3—Selected Chronic Conditions, Technology, and Biomedical Research ● 95

R is clear that patient motivation, patient com- among other factors, may be as important deterpliance, education level, socioeconomic status, minants of disability as are the biologic activity

arrangement of health care resources in the of the disease or the extent to which that biologic

community, payment mechanisms, public and activity may be controlled by medicinal agents

patient education programs, and family support, (loo).

Osteoporosis 10

Introduction

Osteoporosis (“porous bone”) is a major chronic

disorder of older people. It is defined as a condition in which total bone mass is decreased while

bone volume is unchanged; therefore the density

of the bone decreases. This thinning of the bone

increases its fragility and makes it more susceptible to fracture. Activities and stresses that would

not harm normal bone can result in fractures of

osteoporotic bone. Loss of bone mass occurs in

all people as they age, but the rate of loss is higher

in women for about 10 years immediately following menopause, This period of rapid loss causes

women to be especially subject to fractures and

the secondary problems that ensue.

This predisposition to fracture makes osteoporosis of significant importance to individuals over

40 and to the health care system.

Magnitude of the clinical

and social problem

Osteoporosis is an important cause of morbidity

and mortality in the elderly. It appears to be the

underlying cause of about two-thirds of hip fractures in older people (132). The incidence of hip

fractures due to osteoporosis was estimated to

be 98 per 100)000 people in the United States in

1977 (130)132); their total annual cost (acute care

only) was estimated to be about $800 million. The

total cost of osteoporosis in the United States has

been estimated at $3.8 billion annually, and osteoporosis affects 15 million to 20 million Americans

(145)!

Greater life expectancy and rising health care

costs are expected to sharply increase the costs

This section written by Sheila Taube, Ph .D , as part of the ,XIH

Grants ,Associates Training Program,

related to hip fractures. The total number of patient days spent in general hospitals as a result

of hip fractures now ranks 10th among conditions

counted (131). Fractures of the wrist are also a

problem in people with osteoporosis and can result from relatively minor stresses. Vertebral fractures are common; it is estimated that 25 percent

of white women have at least one vertebral fracture by the age of 60 (122). Most of these fractures are compression fractures—’’crush fractures” —in which the vertebra simply collapses

from the weight of maintaining the body in the

upright position. Vertebral fractures often go

unrecognized as fractures but may cause considerable pain. The pain frequently is not restricted

to the area of the fracture, but can be felt in other

areas, such as the abdomen.

The immediate medical and surgical problems

posed by these fractures frequently foreshadow

a significant impact on the individual’s lifestyle.

A number of studies of patients who suffered hip

fractures (117,122,125,131) indicate a 16- to 40-

percent increase in mortality within the first year.

Only about 50 percent of patients are likely to return to pre-fracture mobility; approximately onethird enter nursing homes and remain there permanently (127,129,131). Mortality rates related to

hip fractures were found to be higher in older

patients (over 80), males, and patients with dementia or confusion (131). Of those patients who

were living at home prior to the fracture and ultimately returned home, about 20 percent had to

spend some time in a nursing facility during the

interim (127,131). This nursing care tends to incur considerable expense, which is generally not

fully reimbursed by public or private health insurance. The social problems are also significant

because the patient is separated from his or her

friends, family, and regular activities, which can
 . Technology and Aging in America

cause depression and other psychological

problems.

Direct costs of osteoporosis include diagnostic

tests, drugs, surgery, prosthetic devices, physical therapy, long-term care, and social rehabilitation. The indirect costs include productivity decreases from lost labor and its impact on the gross

national product, although most osteoporotic patients are older women who are no longer in the

work force.

Biology and physiology

Bone consists of a soft protein framework that

is hardened by deposition of calcium salts. It is

a dynamic tissue that is constantly being remodeled (reshaped and renewed) throughout a person’s life. Bones provide the skeletal structure for

the body and also serve as a repository of minerals such as calcium, magnesium, phosphorus, and

sodium, which are required for a variety of the

body’s functions. This remodeling of bone is accomplished by simultaneous resorption (removal

of structural components) and formation (redeposition). Any condition in which resorption exceeds formation results in decreased bone mass.

Resorption and formation are usually tightly

coupled so as to maintain bone structure and

function. This coupling appears to be a localized

phenomenon; the cells responsible for the resorption and formation processes are active in the

same bone surface at the same time. The resorbing cells are called osteoclasts, and the forming

cells are called osteoblasts. The two cell types together are considered to be a “remodeling unit.”

Turnover of bone is high when there are many

“remodeling units” present and low when there

are few. The relative rates of activity of the two

cell types determine whether there is net gain or

loss of bone mass.

An individual’s total bone mass generally

reaches a maximum in the second to fourth decade of life and then begins to decline, The initial

rate of decline is the same for both men and women, about 0.5 percent per year. When women enter menopause, however, the rate of bone loss

increases to 1.0 to 1.5 percent per year for about

10 years and then begins to slow again to a rate

similar to that in men (138,141). The rate of bone

loss differs for different parts of the skeleton

(138). Bones most affected include the metacarpal (the bones between the wrist and the fingers),

the neck of the femur (that part of the thigh bone

which forms the hip), and the vertebrae. Different

bones lose mass in different ways; bones of the

spine are more prone to losing their internal

structure, while those in the limbs become thin

near the edges.

The cause of age-related bone loss is not clear.

It appears that the rate of resorption is increased,

but it has been difficult to find a consistent cause

underlying this increase. The metabolic interactions involved in bone turnover are complex, and

normal function depends on a balance of calcium

intake, absorption into the blood, deposition in

bone, and excretion. These processes are controlled by hormones (particularly parathyroid and

adrenocortical hormones) and by vitamin D and

its derivatives. They are also affected by dietary

components other than calcium, such as protein,

phosphorus, fiber, and others.

Specific parameters that have been examined

have not provided consistent correlations between metabolic changes and increased bone loss.

There has been no direct evidence that increases

in parathyroid hormone levels associated with age

are any greater in osteoporotic patients (120).

There appears to be no relationship between the

degree of bone loss and the age of onset of menopause (128). There have been no consistent

changes in adrenocortical function documented

in osteoporotic individuals, although suggestions

have been made that subtle changes in function

of the pituitary, adrenal, or gonadal glands might

play a role in osteoporosis (128). Osteoporotic patients generally have lower body weight and less

muscle mass than nonosteoporotic controls, but

the significance of this observation is unclear

(118,128). It is possible that tall thin people can

less afford to lose bone mass than stockier people.

Current research is directed toward a better

understanding of the molecular aspects of bone

remodeling, Growth factors have been identified

that stimulate osteoblasts (the cells responsible for

bone formation). Human skeletal growth factor,

for example, may couple bone formation and resorption and may be involved in osteoporosis

(144). Attempts are being made to define the cells
Ch. 3—Selected Chronic Conditions, Technology, and Biomedical Research . 97

and molecules that affect activity of both the

osteoblasts and the osteoclasts (135). With this

knowledge, it may then be possible to manipulate

the system to maintain the balance of activity necessary to prevent bone loss. Much of the current

molecular research is on bone cells in culture, a

technique only recently perfected; it will take time

to relate findings in these experimental situations

to events actually occurring in the body.

Diagnosis

The diagnosis of osteoporosis can present major difficulties. The diagnosis is made by exclusion; the doctor must determine that the patient

has no other causes of bone loss, such as underlying metabolic disorders, metastatic cancer, malnutrition, or drug-induced disorders. The condition is frequently undiagnosed until a fracture

occurs. Vertebral fractures are often detected by

accident when a patient has an X-ray taken for

some unrelated problem. Once fractures have occurred, examination usually reveals considerable

bone loss. To make the diagnosis of osteoporosis,

the physician must first exclude other possible

causes of bone loss; if any specific disorders affecting bone are found, appropriate treatment is

initiated. If no underlying cause is found, the condition is considered to be osteoporosis.

In order to attempt to prevent fractures resulting from bone loss, it must be possible to detect

this loss early and to measure the rate of loss.

Standard radiographic procedures are not sensitive enough to detect the early stages of the disease because 30 to 40 percent of the bone must

be lost before osteoporotic changes can be detected by these techniques. Nevertheless, films of

the spine and hand can aid in the differential diagnosis of osteoporosis by identifying other diseases,

and are sensitive enough to detect later stages of

osteoporosis. The characteristic changes in vertebral osteoporosis that distinguish this disease

from other bone diseases generally occur in the

lower portion of the spinal column (below the

sixth thoracic vertebra, at the midchest level).

Changes seen higher in the spine are usually due

to other causes, such as cancer, trauma, or infection. The particular vertebral shape changes

are also characteristic of osteoporosis; for example, the vertebral bodies may become increasingly

biconcave and wedge-shaped. Other shape

changes indicate that other disorders may be

present. Similarly, hand films can provide clues

for differential diagnosis since changes seen can

distinguish between osteoporosis and underlying

hormonal imbalances (137).

X-ray measurements are only useful once

changes have occurred; a procedure that could

detect very early losses and identify individuals

at risk would be of far greater value. More sensitive methods for measuring bone density are being developed. Photon absorptiometry is a sophisticated method that employs a highly focused

beam of light at one frequency to examine the

total mass of bone in the path of the light. This

technique is only useful for examining peripheral

bones (in the arms and legs) and is not yet available at all medical centers. Dual photon absorptiometry, a modification of this technique, can be

used to examine the spinal column but its availability is even more limited. Quantitative computerized axial tomography (CAT) scanning of the

spine can be used to make careful density measurements of spinal bones, but is expensive and

not widely used. All of these techniques are being improved in terms of precision and reduction

of X-ray dose, but usefulness for routine screening must still be assessed. As yet there are no

reliable markers in blood or urine that can be

used to quantitate bone loss; some blood tests indicate metabolic disorders, but these do not measure the condition of specific bones.

Treatment and prevention

The ability to measure bone loss prior to fracture is likely to have important implications for

prevention and treatment. The pattern of bone

loss may provide physicians with clues concerning other underlying disorders as well as with

prognostic information.

Treatment of osteoporosis is complex primarily because it involves care of problems arising

from the underlying bone loss, that is, fractures

and their sequelae. As discussed earlier, hip fractures are a major occurrence; surgical repair of

the fracture or replacement of the hip is required.
98 Technology and Aging in America

Surgical techniques and prosthetic devices have

improved, and death rates now appear to correlate more with age and predisposing disease than

with common complications of surgery such as

infections and embolisms. Total hip replacement

is sometimes required. Fractures and the necessary immobilization following surgery further

complicate the osteoporosis because lack of exercise results in further bone resorption and predisposes the individual to formation of clots in

blood vessels.

Vertebral compression fractures cause pain,

postural changes, and increased strain on the

muscles of the torso. Treatment for pain and postural problems can include bed rest, analgesics,

and orthopedic braces of various sorts. Bed rest

must be balanced with a need for exercise because of the complications of immobility mentioned above, but rest may be necessary to remove the stress on the spine. Painkillers must be

used carefully as well, because of side effects such

as constipation and disorientation. orthopedic

braces can be very uncomfortable, but they do

relieve the pressure on the spine and permit

somewhat more mobility. Younger patients tolerate the rigid supports better than older patients.

There are exercises that can be performed safely

to relieve pain, but these should include only extension exercises; flexion can cause more pain and

may result in new fractures (140).

A major treatment issue concerns the measures

that can or should be taken to prevent further

fractures once it is clear that clinical osteoporosis

is present. Most studies indicate that Iost trabeculae of bone (the spiny meshwork inside the bone)

cannot be replaced, but significant research is being performed to determine how to decrease the

rate of bone resorption, As more information is

gained concerning the normal metabolism of

bone, attempts are being made to enhance bone

formation or decrease resorption. These include

use of mineral supplements, vitamin therapy, hormonal therapy, and exercise. Aside from wide acceptance of calcium supplements, few, if any, of

the “treatments” are accepted universally as effective. This is because more definitive studies are

required to prove cause-and-effect relationships,

or efficacy of treatments (121).

A consensus conference at NIH addressed the

question of defining optimum treatment of osteoporosis in April 1984, and concluded that carefully monitored estrogen therapy, calcium supplementation, vitamin D administration or

exposure to sunlight, and exercise are all potentially effective methods of treatment (145).

Vitamin D increases both bone resorption and

formation. Experience with this vitamin and its

analogs (all involved in calcium and bone metabolism) is limited, and the studies are inconclusive.

The best results have been obtained with an activated form of vitamin D, but levels must be monitored with care since too high a dose can increase

bone resorption (150), In general, vitamin D

should be used carefully because it is easy to attain toxic levels.

Sodium fluoride (NaF) has been shown to increase bone mass, but the bone has unusual crystal structure and decreased elasticity. In addition,

joint pain and severe gastrointestinal problems

occur in as many as 50 percent of patients (139).

Calcium supplements given with NaF result in

more normal bone structure, but there are still

side effects in one-third to one-half of patients,

and it is not certain that the increased bone mass

is associated with fewer fractures. A large clinical trial of NaF treatment is currently underway

under sponsorship of NIH.

Hormone treatments may also prove effective

in treating osteoporosis. Preliminary studies using

parathyroid hormone or its active fragment have

not been encouraging; both resorption and deposition increased (136). Use of estrogen, a female

sex hormone, has received a great deal of attention. Most researchers now agree that estrogen

therapy for the first few years following menopause slows the rate of bone loss to that of men

or premenopausal women. why female sex hormones affect bone physiology is not clear, Nevertheless, empirical studies support a consensus that

low doses of estrogen” are beneficial in terms of

bone formation and resorption, and in preventing fractures of the hip, in the arm, and above

11When given cyclically with progestins and periodic withdrawal

of both hormones to allow bleeding, analogous to uses for contraception and menstrual regulation.
Ch. 3—SeLected Chronic Conditions, Technology, and Biomedical Research 99

the wrist. (124,133,149). When to terminate treatment has not been agreed upon, and the minimum effective dose is under investigation (123).

Another controversy arises over the dangers of

estrogen treatment—the increased risks of both

blood clotting and cancer of the lining of the

uterus (endometrial carcinoma). For women who

have had hysterectomies, estrogen therapy appears to be relatively safe because the risk of endometrial carcinoma is removed. A newly uncovered aspect of estrogen therapy, however, is

encouraging; the overall mortality of women dying from all causes is lower for those treated w-ith

estrogen than for those who are not (116). The

questions about estrogen use as a routine measure in postmenopausal women cannot be answered without more long-term prospective studies. These studies are difficult to perform because

women have to be followed over many years (perhaps as long as 20 or 30 years), and there are ethical questions as well. The relative risks and costs

of osteoporosis and endometrial carcinoma have

been compared (148), and it has been suggested

that if osteoporosis is already present, the risks

of further deterioration are greater than for endometrial carcinoma. Because the issue has not

been resolved to everyone’s satisfaction, estrogen

therapy has not been recommended as a regimen

and its use is being evaluated on a case-by-case

basis. FDA has, however, approved estrogen for

treatment of osteoporosis at the physician’s discretion, and carefully monitored estrogen therapy was recommended for white women at the

NIH Consensus Conference (145).

one recent finding may change treatments for

osteoporosis. Thiazide diuretics, used in the treatment of heart failure and hypertensions, appear

to be associated with reduced numbers of bone

fractures among women taking them (147). Further investigation of this phenomenon may lead

to a new strategy for treatment.

Calcium intake and absorption are widely accepted as important in preventing osteoporosis

(134). Calcium alone is considered effective in

slowing bone resorption, but the amount of calcium in the diet decreases as people grow older

because of changes in the foods they eat (121),

In addition, absorption from the gut appears to

decrease. The cause of this decrease is not clear,

Increasing the intake of calcium does appear to

increase the total amounts of absorption, and calcium is not toxic in the amounts necessary to provide adequate absorption (143). However, there

are some contraindications to calcium supplements: decreased blood flow through kidney (diminishing kidney filtration rate), or hyperparathyroidism, but these conditions can be assessed

prior to prescribing supplements.

Proper calcium intake should be maintained as

people age, and this may require supplementation of the normal diet. In order to achieve absorption of the recommended amount of calcium

(800 to 1,000 mg per day), it is probably necessary to consume 1.5 to 2 times this amount (still

within the safe limits). Active forms of vitamin

D that enhance calcium absorption from the intestine are under investigation by the FDA, and

may prove useful in preventing osteoporosis. Calcium may not be the only mineral involved in osteoporosis. Zinc deficiency has also recently been

associated with osteoporosis, but its the link to

the thinning of bone has not been established

(115).

Another critical element in maintaining bone

health is exercise, specifically weight-bearing exercise. Bone mass decreases when physical activity is reduced. Studies of immobilized subjects

have indicated that loss of bone begins very soon

after immobilization, and on full bed-rest the calcium loss is about 200 to 300 mg per day (about

one-fourth to one-third of the Recommended Dietary Allowance) (119). Exercise has been shown

to increase bone mass in normal individuals during recovery from immobilization (146) and in

women after menopause (114, 142). Once osteoporosis has been diagnosed, the exercise program

should be carefully designed to avoid stress to

fragile bones.

Although this discussion has concentrated on

treatment efforts aimed at further reducing bone

loss and fractures once osteoporosis has been

diagnosed, some comments also apply to prevention of the disease. Studies to date suggest that

bone mass must be built and maintained prior to

the fifth decade of life and that the greater the

bone mass at its peak, the more the individual can

afford to lose before the bone becomes subject
— —.. — —

 ● Technology and Aging in America

to fracture (121). Women especially should be

sure to eat calcium-rich foods and to carefully

assess their diets to assure proper calcium intake. 12 Nutrition is a complex science, and calcium

absorption and excretion are affected by other

components of the diet such as protein (high protein increases calcium excretion) and fiber [effects

are not clearly understood yet) so that an individual’s entire diet must be analyzed to assure

proper nutrition. It is also important for women

to maintain muscle and bone mass through regular exercise. The NIH Consensus Conference recommended that women take 1,000 to 1,500 mg

calcium daily, starting well before menopause

(145).

To determine the extent to which age-related

bone loss can be retarded by calcium supplementation, studies must be performed over a period

of time that is long enough to permit accurate

rates of loss to be calculated. Studies are needed

to assess calcium absorption under different conditions, i.e., high concentrations of calcium, effects of other nutrients, etc. Prospective longitudinal studies are required to establish a firm

relationship between calcium nutrition in early

life and development of peak bone mass as well

as the relationship between peak bone mass and

later susceptibility to fracture. The longitudinal

12Wood sources of calcium in food are dairy products, and vegetables such as parsley, soybeans, and spinach. For those who cannot tolerate milk easily, yogurt is an acceptable substitute. Calcium

supplements are readily available as over-the-wounter products,

studies necessary to prove cause and effect are

almost impossible to carry out because of the long

time span over which observations and measurements must be made. However, some of the necessary evaluations could be included in ongoing

longitudinal studies such as the Baltimore Longitudinal Study on Aging. One longitudinal study,

sponsored by NIH, started in 1967. Those in the

study are just now entering the age of susceptibility to osteoporosis.

Because the various methods of preventing or

treating osteoporosis have not been rigorously

compared for relative efficacy (126), there is a

clear need for randomized clinical trials.

Summary

Osteoporosis affects a significant number of

elderly individuals. The morbidity and mortality

associated with fractures are costly in terms of

hospital care, long-term care, and rehabilitation,

and the social costs to the individual and his or

her family are substantial, although they cannot

be precisely measured. Although research on

bone physiology suggests the availability of preventive measures and treatments to those who

are susceptible to osteoporosis, most prevention

methods still require confirmation by research.

Earlier diagnosis is considered important to a better prognosis, and such new technologies as photon absorptiometry make earlier diagnosis possible.

Policy for basic biomedical research

Provision of health care for the increased numbers of older individuals in American society will

involve activity in many sectors: prevention of disease, promotion of health, good nutrition, delivery of health care, diagnosis and treatment of diseases, and research into all of these. This section

focuses on that segment of the Federal Government’s activity related to biomedical research.

In light of the aging of the American population, those diseases that are more common in the

elderly will affect a higher proportion of the total

population, Research on aging and diseases that

affect older people will therefore become progressively more important, and funds expended in this

area are likely to benefit more individuals. The

Federal Government devotes 27 percent of its

funds to services for older citizens and disburses

$53.5 billion for Medicare and Medicaid, the two

largest health care programs for older Americans

(154). In the most recent inventory of Federal research specifically on aging (but not including all

research on diseases common in older people),

a task force found Federal spending for biomed-
Ch. 3—Selected Chronic Conditions, Technology, and Biomedical Research . 101

ical research on aging was $177 million in 198013

(163). The agency supporting the largest amount

of research on aging was the National Institute

on Aging (NIA), which spent $42.3 million, or 24

percent of the total. These figures do not, however, include all research on such disorders prevalent among the older population as stroke,

atherosclerosis, or arthritis. In terms of other

disorders, such as dementia, NIA has taken the

lead. Research figures on the diseases for which

most research is performed at institutes other

than NIA would significantly expand the totals.

Precise figures cannot be given because surveying research on diseases important to the elderly

population would entail making difficult judgments about which diseases to include, and would

necessitate another, much larger, inventory

effort.

It is clear, however, based on research expenditures compared to health care costs, cited in

other sections of this chapter, that research on

several chronic conditions of older Americans is

relatively neglected. Federal research expenditures on Alzheimer disease, for example, total less

than $40 million, compared to $8 billion to $10

billion Federal outlays for acute and long-term

care, and roughly equal contributions from private sources.

While there is no complete accounting of the

resources devoted to research on all diseases of

importance to the older American population, it

is possible to make rough estimates of the relative Federal costs of health care and biomedical

research for the total population. In 1982, costs

of health care were $322 billion nationwide, accounting for 10.5 percent of the gross national

product. In this same year, estimated total Federal and non-Federal funding for health research

and development was $9.2 billion, or 2.9 percent

of total spending on health care. Appropriations

for the National Institutes of Health (NIH) were

$3.6 billion, or 1.1 percent of the total spending

for health care nationwide. NIH sponsors the vast

majority of federally sponsored biomedical re13This inventory was done primarilv bv computer search of

. . abstracts for aging-related terms. This procedure would miss many

basic science and clinical projects relevant to diseases highly prevalent in the older population that not did not include such terms,

search (comprising 37 percent of all health research, and 69 percent of Federal support for

overall biomedical research). An approximate figure for relative Federal spending for health care

v. biomedical research might thus be estimated

by comparing NIH funding to spending for federally funded health care through the two largest

programs, Medicare and Medicaid. In 1982, these

two health programs disbursed $83 billion from

Federal sources. The NIH budget would constitute

4.4 percent of this total (see fig. 16).

Federal funding for biomedical research has remained fairly constant in real dollars over the past

decade, but has declined as a proportion of health

care costs from 3.9 percent in 1972 to 2.9 percent in 1982. Funding for biomedical research has

also failed to keep pace with overall trends in research and development: the proportion of dollars

going to biomedical v. other types of research declined from 12.4 percent in 1972 to 11.7 percent

in 1982. The proportion of funding for health research provided by the Federal Government declined from its 1977-79 peak of 41 percent of all

health research support to 36 percent in 1982,

and is now approximately the same as the Federal share a decade ago (when it was also 36 percent) (see fig. 17).

There is no method of determining an optimal

level of Federal spending for biomedical research

overall or even for a particular disease or class

of diseases. There is no competitive market that

can establish an equilibrium among spending for

prevention, diagnosis, treatment, delivery, and research. In the absence of such a self-correcting

mechanism, decisions about the relative levels of

support are made administratively, based on a

calculus of mixed economic, biological, ethical,

medical, and political considerations.

Congressional role in supporting research on aging

The growth of biomedical research in the

United States has depended on action by Congress

to authorize and fund the Federal agencies responsible for performing and coordinating research, especially at NIH, The NIH budget has

grown from $48,000 in 1933 to $55 million in

1953 to $4.3 billion in 1984. This growth has oc-
— . .

102 ● Technology and Aging in America

Figure 16.– National Health R&D, 1972 and 1982, as Related to Total R&D Cost and Total Health Cost

Total R&D Cost

1972 $28.5 billion

Health R&D $3.5 (12.40/o)

> Health R&D) $9.2 (11.7%)

Total Health Cost

 Health R&13 $3.5 (3.9%)

National Expenditures for Health,

Total R&D, and Health R&D, 1971-81

1972 ’73 ’74 ’75 ’76 ’77 ’78 ’79 ’80 ’81 ’82

est.

1982 $317.0 billion

est.

-Health R&D $9.2 (2.90/o)

SOURCE NSF and NIH

SOURCE HCFA, with adjustments of R&D (and theretore of totals) to conform to NIH data

curred as a consequence of wide acceptance

among congressional leaders of the importance

of biomedical research. In 1974, Congress created

a new institute at NIH, the National Institute on

Aging, “for the conduct and support of biomedical, social, and behavioral research and training

related to the aging process and the diseases and

other special problems and needs of the aged”

(Public Law 93-296).

NIA has taken a clear lead in research on some

disorders. For example, it supports the largest

effort on Alzheimer disease and dementia. NIA

obligated $9.3 million out of a total of $22.3 million spent on Alzheimer disease in fiscal year

1983. This proportion will further expand with

the substantial increase of funds designated for

research on Alzheimer disease and related disorders in fiscal year 1984 ($36.4 million to $37.8

million). NIA was intended to focus its efforts on

the disorders and problems of older Americans.

NIA coordinates research among the various institutes, and incorporates biological and social

science research into a national research plan on

aging.

NIA has convened panels of experts to formulate planning for national research on aging. Their

most recent report entitled, A National Plan for

Research on Aging (165), has played a pivotal role

in determining current research priorities.

Congress has supported growth at NIA over the

past decade. The appropriations figures itemized

below show the rise in funding for NIA. Although

these figures have not been adjusted for inflation,

they do show an increase in the proportion of NIH

funding devoted to aging research. But because

NIA remains the second smallest of the institutes,

the increase at NIA has little proportionate impact on overall NIH funding allocation. (For example, the 1983 appropriation of $91.6 million for

NIA compares with $595.7 million for the National

Heart, Lung, and Blood Institute (NHLBI) and

$962.6 million for the National Cancer Institute.)

Appropriations for the National Institute on Aging

(millions of dollars)

Fiscal year 1976 . . . . . . . . . . . . . . . . . . . . ... .$ 19.3

Fiscal year 1977 . . . . . . . . . . . . . . . . . . . . . . . . 30.0

Fiscal year 1978 . . . . . . . . . . . . . . . . . . . . . . . . 37.3

Fiscal year 1979 . . . . . . . . . . . . . . . . . . . . . . . . 56.9

Fiscal year 1980 . . . . . . . . . . . . . . . . . . . . . . . . 70.0

Fiscal year 1981 . . . . . . . . . . . . . . . . . . . . . . . . 75.6

Fiscal year 1982 . . . . . . . . . . . . . . . . . . . . . . . . 81.9

Fiscal year 1983 . . . . . . . . . . . . . . . . . . . . . . . . 91.6

Fiscal year 1984 . . . . . . . . . . . . . . . . . . . . . . . . 112,3

SOURCE Fiscal years 1976-82 NIH Data Book, NIH publication No 83.1261, final year

1983 and 1984 Congressional Record H 8445, Oct 20, 1983
Ch. 3—Selected Chronic Conditions, Technology, and Biomedical Research 103

Figure 17.—National Support for Health R&D by Source, 1972-83

(Dollars in Millions)

$11,000

10,000

9,000

8,000

7,000 [

Totals m current and

constant (1972) dollars

6,000 -

0

’72 ’73 ’74 ’75 ’76 ’77 ’78 “79 “80 “81 ’82 “83

$5,107

5,000 “

$4,443 $4,701 1 1 %

 11% 1 2 %

4,000 $3,536 $3,750

13% 2 8 %

2 9 %

3,000 -

13% 270/ 0

2 6 %

2 8 %

2 0 %

2 0 %

2,000 -

2 3 %

2 5 % 24%

1,000

3696 35% 39% 40% 40%

$5,606

10%

2 9 %

2 0 %

4 1 %

1972 1973 1974 1975 1976 1977

$6,268

1 0 %

290/0

20%

41%

1978

$7,117

10%

19%

—

4 %

1979

$8,529

$7,899 9%

t

9%

34%

31%

20% 18%

4 0 % 3 9 %

1980 1981

prel

$10$341

$9,214 9% Other

90/0

,

39% Industry

370/0

Other

17% ‘60’0 Federal

37% 36% NIH

1982 1983

est proj

aConstant dollars based on biomedical R&D price Index 1972–1 982 Projected to 2260 for 1983, based on percentage Increase In estimated GNP implicit price deflator

SOURCE: National Institutes of Health (164).

NHLBI provides most of the support for research on cardiovascular and respiratory diseases,

disorders that are responsible for most deaths

among older populations. The National Institute

of Arthritis, Diabetes, and Digestive and Kidney

Diseases (NIADDK) expends most of the funds that

support work on arthritis and osteoporosis, conditions that are major causes of disability among

the elderly. The National Cancer Institute funds

research on cancer, one of the most feared killers

of older Americans,

Reasons for supporting

biomedical research on aging

HEALTH AS A JUSTIFICATION FOR

BIOMEDICAL RESEARCH

The most compelling reason for supporting biomedical research is the future health of the American population. Investment in research now is

a means of conferring improved health on present and future Americans, and providing information for use by all populations in the world.

The primary product of research is information that is freely available to all—that is exclusive

to no particular group. This aspect of research

places it in a category economists call “public

goods.” For example, a successful treatment of arthritis would improve society as a whole by decreasing demand for social services, and by improving the quality of life of countless individuals

who cannot now be identified. Much as we all

benefit from free access to information about

weather, we are all better off for knowing how

to prevent ill health. Most biomedical research is

funded by the Federal Government because market mechanisms cannot serve to adequately allocate resources to long-term research. Market

mechanisms fail, in part, because of both the high

degree of uncertainty associated with basic research and the general applicability of many research results (a company does not gain relative

advantage from investment if all companies can

apply the results of its research). Progress in research is most rapid when there are many groups

investigating closely related topics, and when research information is freely disseminated, another
 ● Tecnologh and Aging in America

reason that private corporations cannot support

research as easily as the public sector. An individual company’s incentive to invest in research

is reduced to the extent that it cannot control its

use and dissemination: wide dissemination yields

greater research efficiency overall, but provides

less direct benefit to the sponsoring company.

Further, no single company can support a research program large enough to assure a balanced

program of research in large scientific areas.

Since World War II, the Federal Government has

adopted the responsibility for supporting basic

biomedical research because of this absence of

an adequate market mechanism.

The main justification for basic biomedical research is future reduction of mortality and morbidity. Reduced illness can reduce overall health

care costs through:

●

●

●

●

●

●

●

●

●

more effective prevention;

reduction in the severity of disability leading

to increased productivity;

prolongation of productive life span;

improved diagnosis allowing more specific

treatment or prevention;

reduction in the cost of a particular disorder

(e.g., poliovirus vaccine reduced the need for

supportive therapy of the victims of poliomyelitis);

improved function in individuals permitting

less use of medical care (e.g., treatment of

cardiovascular illness permitting patients to

remain at work, while also improving their

quality of life);

replacement of expensive treatment by a

cheaper form (e.g., replacement of some surgery by new drugs for peptic ulcer disease,

or replacement of coronary bypass surgery

by drugs or catheter surgery);

reduction in the number of useless therapies,

incorrect diagnoses, or errors in treatment;

and

improved delivery of services.

Historical analysis suggests that each of these

justifications for biomedical research can be supported in particular instances. Research can also,

however, increase health care costs through:

● increased life span leading to a longer period

of incurring health care costs for any particular condition;

increased life span leading to acquisition of

more disabilities;

replacement of a lesser health cost with a

greater health cost (e.g., those who would

have died from polio have lived long enough

to develop arthritis, coronary artery disease,

and dementia14);

discovery of new treatment modalities (e.g.,

new treatments for disorders that would previously have gone untreated, such as drug

treatments for certain cancers);

discovery of new methods of diagnosis (thereby incurring increased costs required to confirm or eliminate treatment alternatives);

development of more complex therapy (e.g.,

multiple drug therapy for cancer in place of

a single drug);

requirement of testing for effective prevention (e.g., requiring a laboratory test for monitoring drug treatments);

increasing medical errors by making diagnosis, treatment, or prevention more complex;

or

increasing the complexity of health care provision, thus requiring new capital outlays,

new types of service providers, and more

specialized education.

Basic biomedical research does not, therefore,

necessarily lead to savings on health care costs

in all cases. The goal of biomedical research is

health, not parsimony. Federal investment in biomedical research can assure future generations

of improved health, but reduction in the cost of

health care is not guaranteed. Even improved

health is not guaranteed, although it becomes increasingly probable as more resources are devoted to biomedical research.

ECONOMIC JUSTIFICATIONS FOR

BIOMEDICAL RESEARCH

Future Savings in Health Care Costs.—

While the most widely accepted reason to support biomedical research is the promise of better health in the future, there are also economic

14 Prevetion of polio, therefore, may actually increase lifetime

health care costs for any particular individual. However, those who

would have died of polio would also have been prevented from contributing to society. Premature mortality, conversely, may actually

reduce health care costs but increase overall costs to society. Dead

people cost less, but neither can they contribute.
Ch. 3—Selected Chronic Conditions, Technology, and Biomedical Research ● 105

arguments for supporting basic biomedical research. In addition to the possible savings in

health care costs for some technologies, several

other economic results can follow from progress

in biomedical research.

Restoration of health can also permit a return

to normal life, including contributing to economic

or industrial productivity. Many studies of cost/

benefit analysis relating to health take this factor into account. In the case of many older Americans, however, many of their activities are not

included in standard economic calculations of productivity because they are retired. In such cases,

cost/benefit analysis may underestimate the total

benefits to society. Further, if the “human capital” approach of calculating lost wages were to

be rigorously applied to health care resource allocation and research priority setting, resources

would be preferentially assigned to younger

working populations.

Industrial Applications.-One of the most exciting new developments in industry is biotechnology, The new biological technologies promise

to become an important part of the international

economy (161). The new industrial techniques

comprising biotechnology all grew from biomedical research. Applications of biomedical research

have thus spun off into the fields of environmental protection, food production, food processing,

energy production, and even submarine detection. Such industrial changes constitute national

returns on investment in biomedical research.

These alone might provide sufficient justification

for the investment, and at least provide additional

reasons for funding basic research at the national

level.

The health care industry is one of the largest

in the United States, accounting for 10.5 percent

of the gross national product. The health industry is highly labor-intensive, employing large numbers of service workers. Health care is one economic sector promising to produce many new

jobs in the coming decades.

one important force driving the growth in

health care is new biological and medical knowledge. New knowledge has led to new technologies

for enhancing health and for industrial production. Examples of industries based, at least in part,

on knowledge derived from biomedical research

include pharmaceuticals, diagnostic device manufacture, hospital equipment production and distribution, and new biotechnology firms. Those

employed include scientists, technicians, physicians, nurses, pharmacists, educators, social workers, administrators, and government regulators.

REASONS FOR SUPPORTING RESEARCH

SPECIFICALLY ON AGING

NIA was created in response to a need perceived by Congress to focus research specifically

on aging. This perception arose from the demographic pressures of anticipated growth in the

older American population, the potential increase

in health costs due to increasing numbers of

chronically ill persons in this population, and neglect of research on aging (Public Law 93-296).

Several functions distinguish research on aging

from other biomedical and social science research.

Older individuals have biological characteristics

that differ from younger cohorts. Examples cited

in this report include their special susceptibility

to side effects of drugs, increased incidence of

particular disorders, and vulnerability to concurrent diseases and multiple organ failure. Older

people are also more likely to suffer functional

impairments for those conditions that they have,

and are thus more vulnerable to limitations on

their independence. The reasons underlying the

reduction in functional reserve 15 that occurs in

many organs are not known, and the fundamental processes that cause the phenomenon of aging

are not understood. The primary goal of research

on aging is resolution of these problems.

Resource allocation:

who decides what

Congress determines funding levels for NIH and

other research agencies through its budget process. As part of this process, decisions must be

made about:

● how much research money is devoted to research overall;

15 Functional reserve is the ability of a tissue or organ to respond

to new stresses without affecting the individual. A good example

is the heart’s response to vigorous exercise that diminishes with age.
——

106 ● Technology and Aging in America

●

●

●

●

●

how many resources are given to biomedical

v. other varieties of research;

allocation among the various institutes;

division within the institutes into intramural

or extramural research (that done at NIH or

elsewhere);

division into basic research and clinical research;

duration of support for each grant;

division within the institutes into programs

for disease groups or scientific areas; and

allocation among research projects, training,

investigator grants, institutional grants, clinical projects, technology transfer, development of applications, public information dissemination, and special activities.

Congressional debate about proper mechanisms

for funding of biomedical research has intensified

in recent years. Concerns have been expressed

about how to properly allocate funds, how to organize research, and how to determine how much

research should be in basic science and how

much devoted to other activities (e.g., promoting

development of new treatments, supporting clinical trials of new drugs or treatments, or disseminating information about health).

CRITERIA FOR ALLOCATION DECISIONS

There are at least four important determinants

of successful biomedical research. Each of these

is advocated by different groups in support of

funding for a particular area of science or focused

on a particular disease or group of disorders.

Scientific opportunity is important in productivity of any research. one cannot successfully

study even the most important health problems

if there are no scientific techniques with which

to address the relevant questions. The study of

bone diseases, for example, was inhibited until

recently by the absence of tissue culture methods for studying bone and cartilage cells. Study

of Alzheimer disease is still hampered by absence

of an adequate animal disease model. In some instances, such scientific roadblocks can be creatively circumvented; in other cases, the barriers

resist scientific inquiry. Scientists can, for example, develop new instruments or tests that permit information-gathering directly from affected

patients (e.g., noninvasive new technologies for

visualizing the living human brain), but cannot

deliberately cause Alzheimer disease in animals

or laboratory cells in order to study it.

The process of peer review by scientists has

arisen to measure the scientific validity of individual grants or programs, thus promoting efficiency in research. Peer review is by no means

flawless; studies have shown that there may be

a substantial factor of luck and reviewer bias in

some methods of peer review (162). Eliminating

the peer review process would, however, sacrifice evaluation of factors that are not attributable

to luck. Peer review might be improved, but is

unlikely to be replaced, because there appears to

be no other effective means of identifying scientific priorities.

Personnel and environment are also essential.

Those doing the research must be properly

trained, have access to necessary equipment, and

have an environment of support from peers. In

several areas there is a shortage of personnel

trained to do research on a particular topic, which

makes research less robust than it could be. Few

medical researchers are trained to do computer

research, for example, and still fewer Federal

sources of fellowship provide support for training them. Many of the arguments in favor of functional assessment and prevention initiatives, cited

in chapters 4 and 7, presuppose training and support of new researchers in these areas.

The environment for doing the research must

provide needed support services and an intellectual atmosphere conducive to productive enquiry.

Evaluation of both the adequacy of institutional

support and aptitude of the individual researchers is another aspect of peer review.

One important reason for sponsoring intramural research at NIH and for the support of

“centers of excellence” is the enhanced productivity achieved by concentrating groups of researchers close to one another. For example, it

is not uncommon at many major research universities to find ready exchange of ideas at seminars,

lectures, and through informal laboratory interchanges. This rapid and easy diffusion of ideas

causes spread of new techniques into diverse

fields, proliferation of approaches to scientific

questions, and intensification and broadening of

research training. There is thus a “critical mass”
Ch. 3—Selected Chronic Conditions, Technology, and Biomedical Research . 107

phenomenon associated with biomedical research: it is most productive where there is a sufficient number of highly qualified scientists available to exchange ideas. Not all research, however,

is conducted at major research universities. Some

scientists are more productive when left on their

own, and many important ideas arise from those

who take a completely fresh approach to a scientific problem, without being restrained by the

ideas of those around them. There are different

research styles, just as there are different styles

of management.

Importance of solving a problem is a factor in

allocating resources for research. Those problems

that cause the most social disruption, the greatest number of deaths, or the highest levels of disability are those that society most wishes to solve.

The “burden of illness” can be measured by numbers of people affected, severity of disability, public fear of developing a disorder, and untoward

social and health effects associated with a given

disorder. For example, cardiovascular diseases are

the most frequent causes of mortality among the

elderly; the severe symptoms of stroke and dementia cause distress for the patient and his or

her family; arthritis causes chronic pain for a vast

number of individuals, but kills few; and the prospect of cancer provokes widespread fear. Each

of these aspects of disease bears on the political

and administrative calculus of deciding how to

distribute research dollars. Recent congressional

debate has focused on how best to organize distribution of funds to NIH, Some prefer distributing funds along scientific lines (for research in

neurobiology, metabolism, genetics, or for basic

cell biology), while others favor increasing the

focus on particular diseases or disease groups.

Duration of grant support: the length of time

a research project is supported affects how science is performed. Shorter periods of grant support permit greater flexibility of resource allocation at the national level because long-term grants

obligate funds in future years that cannot be redirected to new projects. Shorter grants also,

however, require scientists to apply for funds

more often, thus detracting from their primary

function of investigation. Short-term grants also

increase the paperwork associated with research

support because of the necessity of filing more

grant applications during the same period than

would be needed for long-term commitments.

Long-term grants also permit more stable assurance for research personnel and stable development of coordinated research programs. Decisions about grant duration at the national level

thus balance the advantages of flexible yearly research priority assessment against the need to

provide stable and reliable support for scientific

investigation.

SPECIFIC CONGRESSIONAL INVOLVEMENT

IN BIOMEDICAL RESEARCH

Congress creates new research institutions, annually authorizes and appropriates funding for

research, and has control over some aspects of

how funding is allocated. Congress makes decisions about resource allocation at three levels:

● Congress determines how much total funding to set aside for all biomedical research

at the Federal level.

● Congress may also choose to play a role in

allocating funds among the various institutes .16

● Congress may also ensure execution of particular projects or research plans.

The level of congressional involvement varies

from allocating money to be used at the discretion of the Secretary of Health and Human Services (usually delegated to the Director of NIH) to

specific funding for particular types of grants.

Specific congressional involvement differs among

disease groups, scientific areas, and executive institutions that support research. There have been

historical variations in the intensity and specificity

of congressional action. Examples of general actions include creation of the NIH and the larger

institutes. Less general was the creation of NIA,

which was intended to encourage research in an

area of perceived neglect. Specific actions are

common in support of particular diseases or disease groups. For example, there were several proposals for research specifically on Alzheimer dis -

16ongress must specifically authorize and fund the ,National Cancer Institute and the ,National Heart, Lung, and Blood Institute because of the character of the legislation that created these two largest

institutes at NIH. Other institutes are authorized under an “umbrella”

authorization that provides spending authority if authorization has

not passed Congress,
708 . Technology and Aging in America

ease in the most recent session of Congress.

Decisions about congressional involvement in determining research priorities involves debate

about the criteria named earlier: scientific opportunity, personnel, and social importance. It also

involves judgments about the administrative costs

of particular actions, and who is best able to decide questions of a particular type. In general,

Congress is best at ascertaining the social and personal costs of a particular problem, while scientists, through the peer review process, are expert

in assessing scientific validity. Congress can direct resources to important problems, and scientists can emphasize the importance of using the

tools available.

Judgments about proper allocation of resource

funding are thus political in that they can involve

resolution of sometimes conflicting contentions.

There may often be no one right answer. When

there is only one right answer, it may not be possible to identify it. The present system of allocating research funds incorporates the tension

between the expertise of scientists, who assess

scientific opportunity and research priority in a

given area, and Congress, which establishes overall funding and general research priorities.

EXAMPLE OF CONGRESSIONAL POLICY DEBATE:

A PROPOSED ARTHRITIS INSTITUTE

A prominent example of congressional debate

about research policy surrounds creation of a

new institute for the study of arthritis and musculoskeletal disorders, which was under consideration as this report was written (151,152,

158,160).

Those opposed to creation of a new institute

cite increased administrative costs that would detract from money available for basic research

(such costs are estimated by the Office of the Director of NIH at $4 million) (156) and express concern that proliferation of the number of institutes

at NIH will make the organization difficult to manage. Those in favor of creating a new institute assert that research on arthritis is relatively neglected, and the presence of a new institute would

focus scientific attention on this severe medical

and social problem and facilitate efforts to garner support for arthritis research in Congress

(thus increasing total funding for research, rather

than merely reallocating funds from other areas)

(159).

Proponents of the arthritis institute point out

that spending is 22 times higher per affected patient for cancer research and 12 times higher for

heart research than for arthritis research (153).

By these same criteria, however, mental illness

could be considered even more underfunded than

arthritis, yet the presence of a National Institute

of Mental Health (NIMH) has not remedied this.

Some believe, in this context, that funding for

NIMH would have been greater if NIMH had not

been separated from NIH in the late 1960s (155).

Differences here center on whether creating an

institute at NIH in fact attracts increased resources for the topics investigated at that institute. The historical analysis in the upcoming Institute of Medicine study of the NIH (see below)

may provide information that can contribute to

resolving this issue.

Within the field of arthritis research, there is

debate about the current distribution of funding.

Some aver that funding is now too focused on immunology and away from basic cartilage and bone

research. They advocate increasing research on

the major causes of disability of osteoporosis and

osteoarthritis with less emphasis on rheumatic arthritis and immunological disorders. Others counter that scientific opportunities in bone and cartilage research are restrained by the absence of

adequate scientific methods and shortage of

trained researchers in this area. They point out

that research on immunological mechanisms has

been extremely productive, and should continue

to be so. Those favoring research on osteoarthritis

counter that the productivity of immunological

research is due to availability of Federal funding

for it, and that bone and cartilage research would

have been equally productive if it had been as well

supported over the last decade.

Such debates highlight the difficulties of allocating funding in the absence of a natural market. Targeting of research on particular diseases

emphasizes the importance of the problems to be

addressed, while targeting on particular methods

of scientific approach or organ system stresses

scientific opportunity. In most cases, these values

do not conflict, but when they do, there are usually good arguments on both sides of the debate.
Ch. 3—Selected Chronic Conditions, Technology, and Biomedical Research ● 109

Congress is then forced to make an administrative decision fraught with a high degree of uncertainty. High levels of spending for heart and cancer research arose from congressional action and

concerted public efforts persistently pursued

since the 1950s. The present high level of scientific achievement in these fields and the industrial spinoffs (biotechnology and medical technology) of such research are the beneficial effects

of more than two decades of committed Federal

support. Whether creation of an institute for the

study of arthritis and musculoskeletal disorders

will achieve its goals of scientific excellence and

amelioration of disability may depend as much

on the consistency of support from Congress over

the next decade as on the establishment of a new

institutional home for musculoskeletal research.

The status of a new institute for the study of

arthritis, musculoskeletal, and skin diseases is

uncertain as this assessment is written. The Senate and House of Representatives of the 98th Congress passed S. 540 authorizing the creation of

such an institute, but the bill was vetoed by President Reagan on october 30, 1984.

ANOTHER EXAMPLE: PROGRAMS FOR

PREVENTION RESEARCH AND EDUCATION

Concern that research on disease prevention

and health promotion has been relatively neglected prompted Congress to mandate Associate

Directors for Prevention Research at the National

Cancer Institute, National Institute on Child Health

and Human Development, and the Office of the

NIH Directopr, in addition to the one already in

place at the National Heart, Lung, and Blood Institute. The function of these new offices would

have been to assure that research on prevention,

health-promoting behavior, epidemiology, and disease causation was given high priority at the respective institutes.

In addition, passage of S. 771 authorized a revision and extension of the Office of Health Promotion and Disease Prevention of the Public

Health Service. The bill included provisions to

create a network of centers for health promotion

and disease prevention, The centers were to perform basic applied research in preventive health.

The bill contained authorization sufficient to support 13 center grants in fiscal years 1985, 1986,

and 1987, The arguments for this new legislation

in the structure of NIH were similar in type, although different in detail from those urging establishment of the arthritis institute. These other

health research bills were also vetoed on October

30, 1984.

ORGANIZATION OF THE NATIONAL INSTITUTES

OF HEALTH: IOM STUDY

The proposed institute on arthritis is only one

of many changes in NIH debated over the past

decade. As a result of this debate, the organization of the National Institutes of Health is being

studied by the Institute of Medicine (IOM). The

results of this study, The Organizational Structure of the National Institutes of Health, was

released on November 15, 1984. The study

focused on criteria for creation of institutes, how

to support solid basic science, and how to best

respond to medical needs and social burdens

(157).

The study has three components:

●

●

●

a historical review of how institutes were

formed, how association with or dissociation

from NIH has affected different institutes,

and how institutes have split or had new

functions added to existing institutes;

a survey of the current organization of NIH,

including how priorities are set and a review

of potential additions to NIH, and review of

proposed alternative organizational structures; and

an analysis of alternative means of organizing NIH, including criteria for goal setting,

decisionmaking, priority setting, and budget

authority.
— . — — —

110 ● Technology and Aging in America

Conclusion

The prevalence of major chronic diseases is expected to rise over the next decade. If current

trends continue, dementia, hearing impairments,

urinary incontinence, osteoporosis, and osteoarthritis will continue to increase in incidence and

prevalence as the population ages and as the average age at death continues to rise. Effective treatment for prevention of these disorders is needed,

and adaptation of technology to compensate for

the ravages of chronic disabilities will be more

and more in demand in the future. For conditions

that may be ameliorated by existing technologies,

such as hearing impairment and incontinence, application of such technologies is a priority. Research on chronic diseases, however, provides the

only possibility for ultimately eliminating them.

Congressional issues and options

regarding basic biomedical research

Support for basic biomedical research is growing rapidly. It has resulted in the creation and

growing budget of the National Institute on Aging

and support of research in other NIH institutes

and Federal agencies on diseases prevalent among

the older population. Such research has not, however, attained the status or level of support enjoyed by other groups of disorders, such as cancer or heart disease. Increasing efforts by private

citizen organizations such as the Alzheimer Disease and Related Disorders Association and the

Arthritis Foundation have begun to change this,

encouraging Federal policymakers to invest more

research dollars in studying the diseases that

cause severe disability among older Americans.

Such increases in funding can be achieved by

diverting funds from other areas of basic

biomedical research, by increasing total funding

for biomedical research, or by a combination of

these strategies.

Issue 1: Should Congress increase support

for basic and clinical biomedical research on aging?

Options:

1.1;

1.2:

Congress could continue present levels of support

for aging research.

Congress could increase support for basic biomedical research on aging by devoting a larger

share of the NIH budget to it.

1.3: Congress could increase support for basic biomedical research on aging by devoting more overall Federal funds to it.

Some believe that present levels of funding for

aging research are adequate, and that devoting

increased funds to this area could detract from

research now going on in other areas. Others believe that the growing proportion of the older segment of the American population will necessitate

a commensurate increase in knowledge about the

biology of aging and about conditions highly

prevalent in older Americans.

If Congress chooses to support more research

on aging, it can take one of three general courses:

either increase the overall NIH budget, earmarking more funding for aging, increase the proportion of the NIH budget devoted to aging research,

or a combination (the combination would conform to recent trends).

Issue 2: Should Congress exercise more con=

trol over the direction of basic biomedical research?

Options:

2,1: Congress could delegate major decisions regarding biomedical research to the Director of NIH,

the Public Health Service, and the Department

of Health and Human Services.

2.2: Congress could increase its level of involvement

in selected areas, such as general aging research,
Ch. 3—Selected Chronic Conditions, Technology, and Biomedical Research 111

2.3:

creation of new institutes, and mandating new

programs.

Congress could increase its level of involvement

by changing the methods of authorizing and appropriating funds for NIH.

Examples of option 2.2 would include the proposed new institute on arthritis and musculoskeletal disorders, new centers of excellence for

Alzheimer disease, earmarking of funds for particular types of disease-oriented research, and

mandating programs for disease prevention and

health promotion. Examples of 2.3, involving

regular reauthorization and appropriation of each

institute and increased oversight of institute programs, were at the heart of debate about the

original version of H.R. 2350 in 1983, before a

compromise was reached with competing bills.

The basic arguments were those noted above in

the discussion about the specificity of congressional involvement in basic research policy and

in the discussion about the proposed arthritis institute.

Increased congressional involvement in research policy would tend to favor more sensitivity

to the needs of diseaseariented interest groups,

which may represent the needs of their constituents; leaving administrative decisions to the present NIH hierarchy favors attention to scientific

opportunity as assessed by peer review.

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“Treatment of Primary Osteoporosis With Fluoride and Calcium,” J. Am. Med. Assoc. 243:446-

449, 1980.

Sinaki, M., “Postmenopausal Spinal Osteoporosis

Physical Therapy and Rehabilitation Principles, ”

Mayo C]in. Proc. 57:699-703, 1982.

Smith, D. M., Khairi, M. R. A., Norton, J., and

Johnston, C. C., Jr., “Age and Activity Effects on

Rate of Bone Mineral Loss,”J. C]in. Invest. 58:716-

721, 1976.

Smith, E. L., Reddan, W., and Smith, P. E., “Physical Activity and Calcium Modalities for Bone

Mineral Increase in Aged Women,” Med. Sci.

Sports Exercise 13:60-64, 1981.

U.S. Department of Health and Human Services,

Food and Drug Administration, “Report on Over

the Counter Preparations,” Fed. Reg. 44:16175-

16178, 1979.

U.S. Department of Health and Human Services,

National Institute of Arthritis, Diabetes, and

Digestive and Kidney Diseases, “Arthritis, Rheumatic Diseases and Related Disorders,” Special Report to Congress, 1982.

145. Office of Medical Applications of Research, National Institutes of Health, U.S. Department of

Health and Human Services, osteoporosis, Consensus Development Conference Statement, vol.

5, No. 3, 1984.

146, Vogel, J. M., and Whittle, M. W., “Bone-Mineral

Content Changes in the Skylab Astronauts,”

Amer. Jour. Rheumato], 126:96-97, 1976.

147, Wasnich, R. D., Benfante, R. F., Yano, K., et al.,

“Thiazide Effect on the Mineral Content of Bone,”

N. Engl. J. Med. 309:344, 1983.

148. Weinstein, M. C., “Estrogen Use in Postmenopausal Women-Costs, Risks, and Benefits,” N.

Engl. J. Med. 303:308-316, 1980.

149. Weiss, W. S., Ure, C. L., Ballard, J. H., et al., “De150

creased Risk of Fractures of the Hip and Lower

Forearm With Postmenopausal Use of Estrogen,”

N. Engl. J. Med. 303:1195-1198, 1980.

Whedon, G. D., “Recent Advances in Management

of Osteoporosis,” Phosphate and Mine;afs in

Health and Disease, S. G. Massry, E. Rity, and H.

John (eds.) (New York: Plenum Press, 1980).

Biomedical research policy

151.

152.

153.

154.

155.

156.

157.

158.

159.

Arthritis Foundation, policy statement, 1983.

Arthritis Foundation, policy statement, 1982.

Arthritis Foundation, Annual Report, 1982.

Borzilleri, T., “The ‘Graying’ of the Federal Budget:

Income and Expenditures of the Elderly,” prepared under contract for the Office of Technology Assessment, October 1983.

Goodwin, F., Address to Institute for Alternative

Futures, April 1983.

Salans, L. B., Response to a Question, Departments of Labor, Health and Human Serw”ces, Education, and Related Agencies: Appropriations for

1984, 1983.

Stoto, M., Study Director, Institute of Medicine,

National Academy of Sciences, December 1983.

Sun, M., “A New Arthritis Institute Nears Approval, ” Science 217:610-612, 1982,

Sun, M., “Mary Lasker’s Latest Pet Project,” Science 217:611, 1982.

160. U.S. Congress, House debate on H. R. 2350, Nov.

17, 1983.

161. U.S. Congress, Office of Technology Assessment,

Commercial Biotechnolo~: An International

Analysis, OTA-BA-218, January 1984.

162. U.S. Congress, Office of Technology Assessment,

“Appendix B: Grants, Contracts, and Peer Review

on NSF Grants)” Technology Transfer at the Na -

tional Institutes of Heakh-A Techm”cal Memoran -

dum, OTA-TM-H-lO, March 1982,

163. U.S. Department of Health and Human Services,

“Inventory of Federally Supported Research on

Aging,” Administrative Document, March 1982.

164. U.S. Department of Health and Human Services,

Public Health Service, National Institutes of

Health, Office of Program Planning and Evaluation and Division of Research Grants, NIFl Data

Book, 1983, NIH publication No. 83-1261, June

1983.

165, U.S. Department of Health and Human Services,

Public Health Service, National Institutes of

Health, National Institute on Aging, Toward an

Independent Old Age: A National Plan for Research on Aging, NIH publication No. 82-2453,

September 1982.
Chapter 4

Health Promotion/Disease

Prevention and Nutrition

in the Elderly
Contents

Page

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 119

Contents Of Prevention . . . . . . . . . . . . . . . . . . . . . . , . . . . . . . . . . . . . . . . . . . , . . . . . . . . . . . . 120

Definitions and Wellness and Functional Dependence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 120

Morbidity and Mortality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 121

Risk Factors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . , . . . . . . . . . . 121

Risk Factors Associated With Coronary Heart Diease and Stroke . . . . . . . . . . . . . . . . . 122

Risk Factors Associated With Cancer . . . . . . . . . . . . . . . . . . . . . . . ..., . . . . . . . . . . . . . . 125

Risk Factors Associated With Fractures . . . . . . . . . . . . . . . . . . , , . . . . . . . . . . . . . . . . . . . 126

Risk Factors Associated With Sensory Loss . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 127

Risk Factors Associated With Dental Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 128

Nutritional Deficiencies. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ,. . . . . . . . . . . . . . . . . . . . . 128

Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 129

Congressional Issues and Options . . . . . . . ., . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 130

Technical Memorandum ..., . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ., , . . . . . . . . . . . 133

Chaper 4 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ., . . . . . . 133
Chapter 4

Health Promotion./Disease Prevention

and Nutrition in the Elderly

Introduction

People are living longer, and an increasing body

of evidence is demonstrating that preventive

measures begun early in life and maintained

throughout life can significantly reduce the prevalence of acute and/or chronic diseases in old age.

These measures include diet modification, regular

exercise, smoking avoidance, and periodic medical screening, especially for blood pressure and

cancer. At the same time, because of increases

in life expectancy during the last 50 years, a generation of persons is growing up with the knowledge that if they practice healthy life behaviors,

they are likely to live 70 or more years. Efforts

to extend knowledge of behaviors that promote

health and prevent crippling and chronic disease

at older ages are thus becoming more important.

Behavior alone cannot ensure longevity; however,

the social and economic context is extremely important. People who cannot afford nourishing

food, adequate housing, and essential medical

care cannot live healthy lifestyles even if they

know how to do so.

Because the focus of this study is the elderly,

this chapter primarily treats preventive measures

for persons 65 or more years of age. This is done,

however, in full recognition of the importance of

prevention throughout life.

Until recently there was consensus among

health professionals, and among the elderly themselves, that after 65 it was too late to think seriously about prevention of disease or disability.

For example, a 65-year-old would already have

sustained too much lung damage through excessive smoking to justify quitting, or atherosclerosis

would have progressed too far to make it worthwhile to undertake exercise and dietary modifications that might reverse the condition. These attitudes are slowly changing, and health promotion

is now justified for several reasons:

●

●

●

●

●

●

increasing life expectancy after 65 (half of

those who reach 65 will live to be at least 80);

more sophisticated definitions of health that

recognize variability among and between age

groups;

better understanding of the importance of

chronic disease and disability as major threats

to health in the elderly and of the relationships between chronic disease and preventable risks;

the recent improvement in cardiovascular

disease mortality due in part to preventive

efforts (e.g., control of hypertension);

the desire of many older people to continue

working (73 percent of persons over 65

would prefer to continue some kind of parttime work if they could (this percentage

drops significantly for full-time work and for

persons over 75) (26); and

growing uncertainty about Social Security

and pension plans that reinforces the desire

to stay healthy and continue to work.

In implementing health promotion strategies,

both the efficacy and goals of the intervention and

the time in the life cycle are important, The efficacy of prevention is often difficult to demonstrate because of the problem of measuring the

nonoccurrence of events (19). Preventive steps

should be taken early in life in order to show effect in old age; this long time lag makes proving

causality difficult. Also, many efficacious programs can increase functional independence or

decrease chronic disease incidence; these parameters are more difficult to measure than death

rate changes. For people who are ill, the goal of

health promotion/disease prevention is to maximize function and prevent deterioration, while

for those who are well the goal is the prevention

of disease or disability irrespective of age. The

goals of risk prevention are quite different for

119
120 . Technology and Aging in America

a 50-year-old than they are for an 80-year-old, and to promote the maximum functional independare further complicated by the overall health of ence of which the individual is capable.

the individual. At any age, however, the goal is

Types of prevention

Prevention is usually divided into three components: primary, secondary, and tertiary. Primary prevention refers to preventing the occurrence of disease or injury. Secondary prevention

refers to early detection and intervention, preferably before the condition is clinically apparent.

The aim of secondary prevention is to reverse,

halt, or at least retard the worsening of a condition. Tertiary prevention refers to minimizing the

effects of existing disease and disability by surveillance and maintenance designed to prevent

complications and premature deterioration (21).

This traditional taxonomy is difficult to apply

to specific cases and fits poorly into the chronic

disease situations that characterize the elderly.

A condition may be both a preventable disease

(a problem on its own) and a precursor (risk factor) to a subsequent condition. For example, falls

are not only common in older age groups but also

constitute a risk factor for hip fracture. Hypertension is a medical condition that should be treated

because it is a risk factor for stroke, heart disease, and kidney disease. When primary prevention of hypertension (e.g., control through diet

modification) succeeds, it becomes tertiary prevention; control of hypertension is, in turn, a primary prevention strategy for stroke and arteriosclerosis (19). Control of diet (weight) is primary

prevention for diabetes, which is, in turn, a risk

factor for arteriosclerosis and stroke. And reducing arteriosclerosis can lower the incidence of

stroke. Thus a particular risk factor can be a primary, secondary, or tertiary risk factor, depending on the disease.

Definitions of wellness and functional dependence

Of Americans 65 and over, more than half (56

percent) perceive their health to be excellent or

good (26). More than 60 percent of adults 18 to

64 and more than 70 percent of those over 65

believe that health status has improved for older

Americans. (’This improvement may be associated

with the evidence of increases in life expectancy.

See Appendix A: Morbidity and Mortality.) Despite

disagreement as to the validity of these selfratings, there is evidence that they are useful

measures of health status. Objective definitions

of wellness or health are, however, difficult to

develop.

The World Health Organization defines health

as ‘(a state of complete physical, mental, and social

well-being and not merely the absence of disease

or infirmity.”

Providers and scientists interested in health promotion/disease prevention have found this definition difficult to follow in practice. The linkage

of functional dependence with health promotion

provides a more fruitful approach. Functional dependence is defined as the inability to attend to

one’s own needs, which generally include the basic activities of daily living: walking, eating, personal hygiene, shopping, dressing, laundry, meal

preparation, paying bills, and recreational and

social activities. Dependence may result from

changes that accompany natural aging, but is

more likely a correlate of disease or a related pathological condition. Dependence can often be prevented, reversed, or reduced (14).

Several measures for assessing the degree of

functional independence of the elderly have been
Ch. 4—Health Promotion/Disease Prevention and Nutrition in the Elderly ● 121

developed. The older Americans Resources and

Services (OARS) assessment battery yields information on five functional activity areas. Another

approach uses both clinical and epidemiologic criteria to specify health goals and professional services appropriate for 10 different age groups from

Morbidity and mortality

Today’s leading causes of death—both in the

general population and among those over 65–

are diseases of the heart, malignant neoplasms

(cancer), and cerebrovascular disease (stroke). As

noted in chapter 2, these three conditions accounted for three out of every four deaths among

the elderly in 1981. Death rates for stroke among

the elderly decreased more rapidly during the

past 30 years than those for heart disease, especially since the early 1970s, when stroke mortality fell sharply. Death rates for heart disease,

which are also falling, showed a rapid decline between 1968 and 1978. In contrast, death rates for

some cancers are rising, especially for cancer of

the respiratory tract, and in men, genital and colon cancer. Overall cancer mortality among elderly

Risk factors

A risk factor is a characteristic that can identify an individual as having an increased likelihood

of developing a given condition. Risk factors are

based on statistical probabilities in populations

rather than on causal relationships or the certainty that an individual will develop a specific disease or condition. Nevertheless, knowing the risks

associated with particular diseases can provide

an opportunity for disease prevention or reduction.

Appropriate interventions are not possible without knowledge of risks. Some risk factors can be

modified, while others are intrinsic to an individual. For example, personal habits and body weight

can be changed, but age and genetic characteristics cannot. In certain circumstances, the effects

birth to 75 years and over. A third method stresses

functional independence defined from activities

of daily living scales. These assessment measures

are discussed further in chapters 7 and 9 and in

the Technical Memorandum at the end of this

chapter.

women actually fell slightly between 1950 and

1978, but the incidence of lung cancer in women

is rising.

The incidence of other leading causes of death

such as pneumonia, influenza, arteriosclerosis,

hypertension, and diabetes mellitus has fallen in

recent years. Although the incidence of many of

these killers has decreased, their prevalence has

risen because the elderly are now more likely to

survive stroke and coronary heart disease. The

level of chronic disease in the elderly population

is therefore rising. Because this burden of morbidity in the population is growing, it is important to examine the risk factors that are correlated

with these diseases and chronic conditions.

of changeable characteristics become irreversible.

Excess weight, for example, may be changeable

at any age, yet the effects of obesity on risk of

heart disease may be unchangeable at a given

point. Unfortunately, the relationship between

risk and specific interventions to reduce risk has

not yet been well researched in the elderly, but

enough is known about the effectiveness of certain prevention strategies to argue for their implementation.

The choice of which risk factors to modify

should, in part, be made on philosophical and ethical bases. Because the cost of morbidity (especially

chronic disease in the elderly), both in human suffering and economic terms, is an area of growing concern, another approach to health promo-
122 ● Technology and Aging in America

tion is to assess which risks, if reduced, are most

likely to significantly reduce human suffering and

medical costs.

Risk factors associated with

coronary heart disease and stroke

A number of risk factors correlate with both

coronary heart disease (CHD) and stroke. One

group, underlying physical conditions, includes

hypertension, high levels of cholesterol, and impaired glucose tolerance. Another type, behavioral risk factors, includes smoking, lack of exercise,

poor diet, and stress. Despite the lack of a direct

cause-and effect relationship between risk factors

and CHD or stroke, it is clear that the risk of a

coronary event increases exponentially as the

number of risk factors increases (37).

HYPERTENSION

High blood pressure is the most powerful predictor of risk for CHD; more than half of persons

with myocardial infarction and three-fourths of

persons with stroke have concurrent hypertension. There is a strong association between increasing blood pressure and advancing age: 33

percent of persons in their 6@ have elevated pressure, compared with 11 percent of those in their

30s (19).

Hypertension in the elderly is defined as blood

pressure greater than 140/90 mmHg, or systolic

blood pressure greater than 160 with normal diastolic blood pressure. Although persons over 75

are often underrepresented or excluded from research, limited findings indicate that control of

moderate and high diastolic hypertension is also

associated with reduced mortality and morbidity

from CHD and stroke.

Isolated systolic hypertension (systolic pressure

above 160 mmHg accompanied by diastolic pressure below 90 mmHg), which is found in 25 to

30 percent of persons over 75, is correlated with

a twofold to threefold increase in mortality from

CHD and stroke. The benefits of treatment are

still under investigation; if therapy proves to be

efficacious, treatment of this condition may reduce death rates or prevent these two diseases

(33).

SMOKING

Cigarette smoking plays a significant role in

mortality from cardiovascular disease. It is a significant factor in morbidity, exacerbating hypertension, which, in turn, is a risk factor for cardiovascular disease and stroke. Nevertheless, the

elderly and persons working with and for them

appear to share the belief that smoking cessation

efforts are primarily of concern and importance

to younger age groups (25). This is a false assumption for several reasons:

●

●

●

●

Many elderly people live more than 10 and

often 20 to 25 years beyond age 65. Many

benefits of smoking cessation, such as increased pulmonary function, are experienced

immediately, and others, such as reduced risk

for lung cancer, begin as few as 2 years after

smoking cessation. Increased life expectancy

of the elderly thus justifies efforts to promote

smoking cessation programs.

Nicotine constricts blood vessels, thereby

raising blood pressure (which is already elevated, on average, in older groups). For many

elderly persons, elimination of smoking can

effectively reduce their risk of stroke, which

is the third leading cause of death for those

over 65.

Respiratory function can be improved immediately, even in patients with emphysema. Improvements in breathing are enhanced if a

medically supervised program of moderate

exercise is coupled with smoking cessation.

Smoking reduces the ability to taste food. Because loss of this ability contributes to poor

nutrition in the elderly, smoking can exacerbate poor eating habits.

Notwithstanding these cogent reasons for smoking cessation, most nonsmoking programs and

research on smoking cessation are targeted to

persons in younger age groups. Although these

programs are important because of the great benefits of smoking cessation at younger ages, they

should be expanded to give greater emphasis to

their impact on the elderly.

EXERCISE

Although some research has shown an association, a definitive and direct link between physical exercise and reduction in risk of CHD and
Ch. 4—Health Promotion/Disease Prevention and Nutrition in the Elderly . 123

stroke has not been established. In addition, because research subjects have typically been

younger men, evidence is still lacking for women

and the elderly.

Despite gaps in knowledge of the benefits of exercise for the elderly in reduction of risk of CHD

and stroke, several things are known about the

effects of exercise that warrant implementation

of moderate exercise programs. Regular exercise:

increases lean body mass and reduces body

fat (this effect has been associated with reduced CHD and diabetes in older persons);

increases glucose tolerance (reduces the occurrence of diabetes or improves the functioning of those who are diabetic, a risk factor for CHD);

increases the strength and speed of contractility in the heart muscle;

increases oxygen uptake from the blood into

the heart and skeletal muscles; and

decreases heart rate and demand on the

heart during rest.

Since exercise reduces other CHD and stroke risk

factors, programs that encourage exercise in all

age groups are important. Exercise can reduce

the emotional tension associated with various diseases. In a study of men 50 and over, a 15-minute

walk reduced neuromuscular tension more effectively than a dose of tranquilizer (10,11,12,17).

Exercise also reduces other CHD risk factors.

It increases the proportion of high density lipoproteins (HDLs) relative to low-density lipoproteins

(LDLs),’ but the effect is temporary; exercise must

be performed at least every other day to maintain the reduction in LDLs and triglycerides.

Blood-pressure reduction is more likely to occur

in individuals with moderately elevated blood

pressure and more likely to affect diastolic than

systolic blood pressure. Enforced physical inactivity results in increased systolic blood pressure,

increased total peripheral resistance, increased

Iiigh-densit)’ lipoproteins ha~’e two important functions: 1 ) they

coat the inside of the artery walls and provide a protectiIre layer

to pretent fatty deposits from twikiing up; 2) they help dissoh’e fattj.

deposits when they occur, Lo\ldensitjr lipoproteins are responsi~e

to dietary habits and form dangerous deposits on the walls of blood

t’essels; 1,D1,s are the primarj’ culprits in clogg(?d arteries anci

atherosclerosis Thus the risk of (;HD is reduced if the proportion

of HDLs to LflLs is relati\7el~r high.

Photo credit: Paul Conklin, Dancers of the Third Age,

Dance Exchange, Washington, DC

Carefully developed exercise programs can benefit

adults of all ages.

serum levels of cholesterol, and glucose intolerance, all of which are, in turn, risk factors for

CHD.

Notwithstanding its beneficial aspects, exercise

can have certain risks. Risks and complications

depend on a number of factors—the general

health of the individual, past exercise habits, and

age, as well as type, amount, and intensity of exercise. However, most authorities agree that the

majority of adults under 65 do not need prior

physical examinations before beginning a carefully developed, progressive exercise program.

When weighed against the hazards of not exercising, the benefits clearly outweigh any risks (15).

STRESS

Stress is a normal part of life, but the inability

to cope with it can cause health impairment. Two

simple techniques, meditation and relaxation, can

38-800 0 - 85 - 5
124 Technology and Aging in America

reduce the physical and psychological effects of

stress. Meditation techniques have been found to

reduce blood pressure and residual muscle tension and increase oxygen intake. There is an impressive body of research to substantiate the

beneficial effects of relaxation training. These include reduction of elevated blood pressure, heart

rate, and gastric motility, increased cardiac output and respiratory efficiency, and aerations in

brain-wave patterns (increased ratio of alpha

waves to beta waves in EEGs) (25).

NUTRITION

Poor nutrition can be characterized by a lack

of essential vitamins and nutrients, leading to deficiencies, or by an overabundance of certain nutrients that can be associated with higher risk for

diabetes and high levels of cholesterol, both of

which are risk factors for CHD and stroke.

obesity (usually defined as greater than 20 percent over standardized tables of ideal weight for

age and height) is associated with increased risk

of hypertension, high cholesterol, and glucose intolerance. It is not clear, however, whether the

risk factor is current obesity or a history of

chronic obesity. If a longstanding history of

obesity is shown to be correlated with CHD, an

intervention program in the elderly might not be

useful because the effects of the earlier obesity

would be irreversible.

Diets low in saturated fats and high in vegetables

and fiber are recommended for prevention of

CHD. These diets can reduce blood pressure in

normal subjects (31,32), but whether the incidence of CHD is reduced is unclear (19). Per capita consumption of foods high in cholesterol and

saturated fats has decreased since the early 1960s,

while consumption of foods high in unsaturated

fats and fiber, like fish and vegetables, has increased (38). This change in dietary habits may

have contributed to the recent drop in serum cholesterol levels and perhaps to declining CHD mortality. Large doses of the B vitamin, niacin, may

reduce blood lipid levels (9) and seem to be helpful

in reducing recurrent nonfatal myocardial infarction (7)$

2Myocardia1 infarction is death of tissue in the heart muscle due

to insufficient delivery of blood or oxygen, usually due to obstruction of a blood vessel.

High sodium intake has long been associated

with high blood pressure (8), but there is as yet

no conclusive evidence for a causal link. A recent

epidemiological study of over 10)000 individuals

aged 18 to 74 found that significant decreases in

the consumption of calcium, potassium, vitamin

A, and vitamin C were the nutritional characteristics that distinguished hypertensive individuals

from those with normal blood pressure (24). Low

calcium intake was most consistently correlated

with hypertension. While these results do not

prove causal effects, they do suggest directions

for future research.

DIABETES AND IMPAIRED GLUCOSE TOLERANCE

Impaired glucose tolerance has been implicated

as a risk factor for cardiovascular disease because

of the high incidence of vascular complications

in persons with diabetes mellitus. Fasting levels

of blood glucose and the prevalence of adult-onset

noninsulindependent diabetes rise with age. This

change in blood glucose homeostasis is due in part

to the age-related decrease of metabolically active lean body mass accompanied by an increase

in fatty tissues. Because of these age-related

changes, Williams (39) estimates that more than

half of the population over 70 would be diagnosed

as having diabetes according to the criteria used

to evaluate younger adults in the oral glucose tolerance test. Standards for younger persons thus

cannot be universally applied to the elderly.

Obesity is strongly correlated with impaired glucose tolerance: 80 percent of adult-onset diabetics

are obese or have a history of obesity, and 60 percent of persons with 125 pement or more of ideal

body weight have impaired glucose tolerance

tests. Dietary guidelines developed by the American Diabetes Association (2) focus on the restriction of caloric intake and moderate increase in

energy expenditure, Because diabetics have two

to three times the risk of dying from atherosclerotic CHD as nondiabetics (3), a reduction in total

and saturated fat calories is also recommended,

and drug or insulin treatment may be necessary

to reduce glucose levels. The efficacy of this treatment in the prevention of CHD is not proven, but

trends suggest a favorable prognosis with longterm management of diabetes (19).
Ch. 4–Health Promotion/Disease Prevention and Nutrition in the Elderly ● 125

CHOLESTEROL

The link between lowered cholesterol levels and

CHD became definitive only recently, although

large studies have shown a consistent association

between the intake of foods high in saturated fats

and both the level of serum cholesterol and morbidity and mortality rates for atherosclerotic diseases. The National Heart, Lung, and Blood Institute confirmed this link in a study in which men

35 to 59 with very high levels of cholesterol were

given drug therapy to reduce cholesterol. The incidence of CHD was significantly reduced in the

men given the drug (37).

REHABILITATION

Rehabilitation or tertiary prevention after CHD

usually includes exercise regimens with drugs,

stress reduction, and various other techniques

undertaken to prevent the recurrence of heart

attacks. Research in these areas often excludes

the elderly. The benefits of intensive rehabilitation after CHD are less well substantiated than

the benefits of rehabilitation after stroke.

Interventions to minimize the effects of stroke

and help patients to function independently are

very important. The mean survival time after the

occurrence of stroke is 7 years; 30 percent of patients survive 11 or more years. Results from the

Framingham study indicate that following stroke,

33 percent remain dependent for activities of

daily living, 20 percent require assistance with

walking, and 15 percent require institutionalization. The remaining 35 percent are functionally

independent. This level of functional disability is

a significant drain on resources, both public and

private.

Intensive rehabilitation after stroke is neither

effective nor beneficial for all patients. Those who

are unconscious during acute stroke are likely to

remain dependent, while those who remain conscious and are able to walk unaided immediately

after the stroke generally exhibit spontaneous

functional recovery. Rehabilitation in a specialized stroke unit results in greater functional recovery; 52 percent of such patients exhibited

functional independence as opposed to 32 percent of patients given traditional rehabilitation on

the medical wards, and did so in a shorter period

Photo credit: Suburban Hospital, Bethesda, MD

Medically monitored physical activities are one form

of rehabilitation or tertiary prevention.

of time (average stay of 55 v. 75 days). The patients selected for this study had remained conscious during acute stroke, but exhibited developing or established hemiplegia (paralysis of one

side of the body); they represent patients likely

to survive but unlikely to recover spontaneously.

Thus, the degree of impairment from stroke is

a useful criterion for patient grouping. In addition to functional improvement, there are psychosocial! and quality-of-life benefits (19).

Risk factors associated with cancer

Cancer is the second leading cause of death

among the elderly. Several risk factors have been

identified. For example, 30 percent of all cancer

deaths may be attributed to smoking (13). Although it is not possible to accurately quantify

the role of diet in cancer, 40 percent of cancer

deaths among women and 57 percent of those

among men may be associated with diet (13,27).

There are synergistic effects between smoking

and alcohol, but the effect of tobacco is far more

important. Mortality from cancer of the cervix

is decreasing, largely due to increased periodic

screening with Pap smears. Cancers of the breast,

ovaries, and endometrium account for 29 percent

of all female cancer mortality (13 percent of total

mortality).
126 Technology and Aging in America

Lung, colorectal, and prostate cancers are the

most prevalent cancers among men; women are

more at risk for breast, lung, and colorectal cancer, respectively. some cancer death rates for

elderly men have continued to increase, but the

increase in rates for elderly women is a more recent phenomenon. This is especially true of lung

cancer rates for women, probably due to the

higher prevalence of smokers among women of

recent generations, And although the incidence

of cervical cancer has declined in the general

population, it has not declined in women past

menopause. Because older women may not visit

gynecologists for regular checkups, primary care

physicians should screen for cancer or, at least,

refer women to gynecologists for evaluation (19).

Several types of cancers can be treated successfully if detected early enough. These include prostate (periodic physical exam), and breast and colon (discussion follows). Some evidence indicates

a reluctance among the elderly to seek screening services or diagnosis; this is especially true

of women who are at increasing risk of breast,

cervical, and uterine cancer with advancing age.

Some of this reluctance is due to misinformation

about the possibilities for effective treatment.

BREAST

Breast sel-examination is an effective, inexpensive way to increase the chance of early detection of breast cancer; 80 to 90 percent of primary

breast cancers are detected by women themselves

(19). The few self-examination programs that exist have concentrated on easy-to-reach populations, usually in work settings, leaving the relatively high-risk woman over 65 effectively out of

reach. Only a few programs have been developed

for these women. Some older women appear to

be more reluctant to examine themselves and may

not respond to certain teaching settings. Programs

to educate them in self-examination techniques

need to be tailored to their values and expectations. Annual mammography and physician examinations for women over 40 are associated with

improved early diagnosis and significant decreases in cancer mortality.

There is a significant association between obesity

and cancer of the breast and uterus in women,

and cancer of the colon and prostate in men. High

fat intake is also associated with breast cancer and

prostate cancer, perhaps due to the effect on

estrogen metabolism, imbalances of which are

associated with increased risk of certain cancers.

COLORECTAL

The colon and rectum are the leading sites for

overall mortality from cancer in those over 75.

The 10-year survival rate for persons with localized cancer is 67 percent, compared with 36 percent for nonlocalized cancer. Since only 41 percent of all colorectal cancers are detected at a

localized stage, early detection of this form of cancer is a high priority for prevention programs.

The guaiac test, and other simple tests of occult bleeding from the digestive tract, can be used

in screening for colon and rectal cancers. But fewer persons over age 70 (27 percent) accepted an

invitation to take a screening test than did younger

persons (38 percent) in a recent study, although

rates were low for both groups (19). The International Workshop on Colorectal Cancer recommends that the elderly undergo sigmoidoscopy

every 3 to 5 years to screen for cancer (19).

Several dietary factors have been associated

with cancer of the gastrointestinal tract. The dietary recommendations of the American Cancer

Society (1984), though based largely on epidemiological and some experimental data, are meant

to help reduce the risk of gastrointestinal and certain other cancers. These recommendations include: avoid obesity; reduce intake of fat, alcohol,

and salt-cured, smoked, or nitrite-cured foods;

and eat cruciferous vegetables and foods high in

fiber and vitamins A and C.

Risk factors associated with fractures

The most important risk factors for fractures

are osteoporosis and falls. The incidence of fracture rises dramatically with age: among women

75 to 79, the incidence of hip fracture is 6 per

1,000; among those 85 to 89 the incidence in-
Ch. 4—Health Promotion/Disease Prevention and Nutrition in the Elderly ● 127

creases to 21.4 per 1,000; and among women over

90 the incidence rises to 48.6 per 1,000 (19).

OSTEOPOROSIS

Osteoporosis is estimated to cause about twothirds of hip fractures in older people. The incidence of hip fractures resulting from osteoporosis

was estimated at 98 per 100,000 in 1977, at a total

annual cost for acute care of some $800 million.

The number of hospital patient days resulting

from these fractures is ranked both among conditions counted, The mortality rate from falls is

estimated at 20 to 30 percent, with an additional

13 percent of survivors who never return to independent ambulation (23). Because 90 percent

of fractures in older women are associated with

little or no trauma, and in fact may occur simply

because of osteoporosis (19), prevention of osteoporosis could sharply reduce the incidence of

fractures among the elderly.

current osteoporosis-prevention research centers on the effectiveness and possible risks of estrogen therapy after menopause, supplemental

intake of calcium by women both before and after

menopause, and the role of exercise in bone

strengthening. Although estrogen replacement

therapy after menopause seems to inhibit bone

resorption, it has also been associated with increased risk of cancer of the uterine lining. Calcium absorption declines with age and can decrease by 30 to 50 percent by age 80 (18). The

theoretical daily intake of calcium needed to

counteract bone loss has been suggested as 1)000

mg for premenopausal women and 1,500 mg for

postmenopausal women (18).

Blood levels of vitamin D, which promotes intestinal absorption of the calcium and phosphate

involved in bone mineralization, are often deficient in the elderly and can be up to 50 percent

lower than those of younger controls. These low

serum levels of vitamin D may be due to reduced

intake, reduced intestinal absorption, and/or decreased exposure to the sunlight that drives synthesis of the vitamin in the skin (30).

New evidence indicates that bone mineral content can be increased in older women by exercise. In a study of women whose mean age was

84, one group exercised (nonstrenuous exercise,

sitting in a chair) 30 minutes a day, three times

a week. This control group gained bone mineral

content while an inactive group lost bone mineral

content. Physical activity at any age may thus have

a significant effect in reducing the effects of osteoporosis and the likelihood of fracture (34).

(For further details see section on osteoporosis in

ch. 3).

FALLS

The U.S. Public Health Service estimates that

two-thirds of falls by the elderly ma-y be preventable. The risk of fracture associated with falls increases with age, especially for women.

Falls are caused by both environmental and

physical factors. As many as half of the falls sustained by the elderly may be caused by such environmental factors as loose, torn, or frayed rugs,

poor lighting, icy sidewalks, or broken stairs. Poor

vision (which is sometimes correctable), underlying physical conditions such as Parkinson’s disease, seizures, cerebrovascular disease, and conditions that cause fainting or dizziness, also

contribute to the incidence of falls. The incidence

of falls could be reduced by more extensive diagnosis and treatment of these disease conditions

and efforts to eliminate environmental obstacles.

Inappropriate or excessive medication-especially of sedatives, hypnotics, psychotropic, anticonvulsives, and antihypertensive agents—often

causes falls. In one study, 93 percent of patients

who were observed to fall between 10:00 p.m.

and 6:00 a.m. had taken a barbiturate (19).

Risk factors associated

with sensory l0SS

VISION

The prevalence of unattended treatable eye

pathology rises dramatically after age 60, exceeding 85 percent of the elderly aged 65 to 74. Refractive problems increase less rapidly than cataracts,

and cataract correction may be unduly delayed.

Screening for glaucoma, which is effective, may

be ignored by the elderly. The fragmentation and

lack of coordination of services for the elderly,

the needy, and the blind and partially sighted constrain the correction of visual problems among

the older population (19).
128 ● Technology and Aging in America

TASTE

Age-related changes in, for example, the gastrointestinal tract may impair food intake, digestion, and absorption of certain nutrients (see app.

C). The sense of taste itself changes with age,

and this can lead to malnutrition. Compounding the

risk of malnutrition is the fact that current Recommended Dietary Allowances (R.DAs) of various

nutrients consider the elderly as a single 51-andover age group, despite wide disparities in individual and age-related nutritional needs.

HEARING

Hearing loss affects the ability to function independently, affects communication, and can lead

to a medical diagnosis of cognitive impairment.

The prevalence of hearing impairment is 28 percent in persons over 65 and about 40 percent in

those over 75 (see OTA background paper on

Management of Hearing Impairments in the

Elderly). Although many hearing impairments are

not correctable with current technologies, simple hearing aids to amplify speech can be very

effective in some cases. Hearing aids are expensive, difficult to adjust, not reimbursed by Medicare, and often fraudulently marketed; all of these

factors lead to neglected, treatable hearing problems in the elderly.

Risk factors associated

with dental disease

In 1971 about 45 percent of Americans over 65

were estimated to have lost all of their teeth (36).

Nutritional deficiencies —

Dental caries and periodontitis are the justification for 90 percent of extractions. Dental disease

can limit the food choices and eating practices of

the elderly and damage their self-image and social

confidence. Clinical studies done in the 1940s

reported a high prevalence of vitamin C and Bcomplex deficiencies among edentulous (lacking

natural teeth) elderly, but need to be updated

(16,22).

Both nutritional and hygienic practices have

been implicated in dental disease. The intake of

starches and simple sugars is known to aggravate

decay and increase the risk of loss of teeth (4).

Intake of simple sugars increased during the early

years of this century, while intake of the more

nutritious complex carbohydrates declined from

43 percent (1909) to a current 29 percent of dietary food energy (28). Periodontal disease, or recession of the gum and resorption of the bone

surrounding the roots of the teeth, is probably

related to general age-related loss of bone mass

(see section on osteoporosis); possible prevention

and treatment of this disease through dietary calcium supplements warrants further exploration.

Despite the impact of dental disease on the

elderly, 48 percent of those who still have teeth

have not visited a dentist within the last 5 years

(6). Because routine dental examinations are not

covered by Medicare or most private health insurance, a major obstacle for the elderly may be

cost .

There are few reliable data on the prevalence

of frank or “subclinical” nutritional deficiencies

among the elderly. However, it is known that the

elderly are particularly susceptible to malnutrition because of the physiological and behavioral

changes of aging, and increased prevalence of

chronic disease. For example, age-related changes

in the gastrointestinal tract may impair intake,

digestion, and absorption of certain nutrients.

Psychosocial changes associated with aging, such

as senile dementia, isolation, and depression may

also suppress appetite and increase the risk of nutrient deficiency (see app. C).

Subclinical malnutrition is difficult to diagnose,

both because physicians may not be aware of it

and because not enough is known about adequate

nutritional levels for the elderly. Current RDAs

for the elderly are based on survey and research

data from younger groups that have been extrap-
Ch. #—Health Promotion/Disease Prevention and Nutrition in the Elderly ● 129

elated to the entire over-50 population, which is

an extremely heterogeneous group. Direct study

of the special nutritional needs of those in age

groups over 65 is needed to provide better standards for medical care, food assistance programs,

and national nutrition surveys.

The Federal Government has attempted to ameliorate the problem of malnutrition among “high

risk” segments of the population, including the

elderly, through federally sponsored food assistance programs (see table C-8 in app, C). An estimated 1.9 million elderly persons are now enrolled in congregate and home-delivered meal

programs (29), but the food stamp program remains the largest program affecting noninstitu -

tionalized elderly persons (l). In fiscal year 1981,

for example, an average of 22.4 million people received food stamps each month. Because currently available evaluations of federally funded food

assistance programs that serve the elderly are inconsistent and flawed, they yield little information about dietary and health benefits of these

programs. There is general agreement, however,

that they are not reaching certain target groups,

especially minorities and the socially isolated (see

app. C).

Conclusions

The central issues in health promotion and disease prevention strategies for the elderly are the

efficacy and the cost effectiveness of particular

interventions. Further, many of the risk factors

require behavior modification and are ultimately

the personal responsibility of the individual. Improved quality of life is also important in that

many interventions, while they do not significantly alter health statistics, have an effect on functional independence. This quality-of -life factor is

often not considered in the present structure of

Medicare/Medicaid reimbursement.

The overriding Federal issue is the reimbursement structure of the present Medicare/Medicaid

system. At present, reimbursement is principally

for acute care, and payments are prohibited for

all or most preventive services (exceptions: immunization against pneumococcal pneumonia and

Photo credit’ Suzanne L Murphy

Federally subsidized congregate meal programs for the

elderly help assure adequate nutrition and promote

social interaction.

The Federal Government could effectively promote preventive nutrition through intensified

public education. Inasmuch as eating habits are

established early in life and many risk factors for

age-related conditions are cumulative throughout

adulthood (as for CHD and osteoporosis), such nutrition education should be targeted to all adults,

not just the elderly.

short-term rehabilitation). Many relatively inexpensive preventive measures are not reimbursed,

yet the consequences of not applying these measures in fact increase overall Medicare costs. A

rethinking of reimbursement categories may,

therefore, be in order. Preventive services that

are directly linked to reduction in need for acute

care but are not presently reimbursed include:

 Periodic screening. Among the preventive

measures effective here are screening for hypertension, and breast and colorectal cancer.

Mammography exams are not reimbursed,

but acute care for breast cancer is. The occult blood test, a very simple and inexpensive test for detection and early diagnosis of

colorectal cancer, is not reimbursed. Bloodpressure control is an achievable goal because hypertension is easily detected and
130 ● Technology and Aging in America

●

●

●

●

●

usually correctable. Although treatment of

hypertensives must be carefully monitored

to avoid iatrogenic problems, reduction in

blood pressure is a significant factor in 1owering stroke and overall mortality rates in the

elderly population. The prevalence of hypertension in persons aged 65 to 74 dropped

from 49 to 41 percent in the 1960s and 1970s;

the CHD death rate in this group showed a

similar decline during this period (35).

Long-term care. There is only minimal reimbursement for tertiary prevention, which

could aid in increasing functional independence and thus reduce costs of long-term care

and related services (see discussion in ch. 7)

(25,35).

Vision. Refraction is not reimbursed, yet

visual problems are a major component of

falls. (Trauma related to falls is reimbursed).

Drug and alcohol abuse, Treatment is not

generally reimbursed. when untreated, these

conditions can lead to nutritional problems

and to increased mental confusion that mimics senile dementia (see OTA Case Study on

the Effectiveness and Costs of Alcoholism

Treatment for “Medical Technology and

Costs of the Medicare Program”),

Hearing. Hearing loss can be a risk factor for

injuries and falls, and purchase of hearing

aids is not reimbursed (for further information, see the OTA Background Paper on Management of Hearing Impairments in the

Elderly).

Dental care. Lack of dental care has both direct effects on health—the occurrence of periodontal disease-and indirect effects in that

the individual’s opportunity to maintain adequate nutritional levels is compromised. Lack

of teeth, or poor teeth, may also lower self-

-esteem,

Medicaid does pay some of these preventive

costs, but eligibility criteria differ from State to

State. Billions are being spent for acute care, yet

relatively little reimbursement is allocated to prevention, which could potentially reduce these

acute care costs. Some evidence of potential savings exists, but there is no available hard evidence

of potential levels of cost reduction. Measures for

research on the degree to which prevention could

reduce acute care costs in the elderly are thus

sorely needed. (Note: A proposal for a separate

health promotion/disease prevention section of

the National Institutes of Health has recently been

passed by the House. See ch. 3.) The irony is that

while some research is underway, growing numbers of Americans are failing to avail themselves

of proven preventive measures —e.g., smoking

cessation, diet modification, exercise—and in so

doing, increasing the likelihood that they will

someday need acute care. The obvious goal is to

keep people healthy and functionally independent until they die at a “late” age. How to allocate

health care delivery and research resources for

prevention is an important component of achieving this goal.

Improving the nutritional status of the elderly

clearly calls for establishing nutritional RDAs for

subgroups of people over 50, Once these data are

available, educational efforts targeted to both the

elderly and health care providers can be more

effective. But there is little accurate or reliable

information on the dietary benefits that these programs provide for the elderly, In general, participants are nutritionally better off than nonparticipants, but food programs are not always reaching

target groups, especially the poor and minority

elderly.

Congressional issues and options

There is growing evidence that the ameliora- especially among the elderly, to reduce the prob -

tion of specific risk factors can reduce the in- ability of other causes of morbidity and mortalcidence of the three leading causes of mortality— ity, such as falls and fractures. Many of these

coronary heart disease, cancer, and stroke. It is measures can not only reduce the incidence of

also known that specific actions can be taken, specific diseases but can improve the quality of
Ch. 4—Health Promotion/Disease Prevention and Nutrition in the Elder/y . 131

life. At present, Medicare reimbursement is principally for acute care and prohibits payment for

all or most preventive services (exceptions: immunization against pneumococcal pneumonia and

short-term rehabilitation). Although many relatively inexpensive preventive measures are not

reimbursed, the consequences of not applying

these measures are usually more costly to the

Medicare system. These measures include screening for hypertension and for breast, cervical, prostate, and colorectal cancers; refraction for visual

problems; treatment of drug and alcohol abuse;

provision of hearing aids; and dental care.

ISSUE 1: Does research indicate that health

promotion interventions are cost effective?

Research on the cost effectiveness of various

health promotion/disease prevention strategies is

in its infancy. options available to Congress

include:

Options:

1. 1: Congress could maintain the status quo.

1.2: Congress could increase its level of involvement

in aging research and stipulate that cost effective -

ness be a part of new health promotion research

within the National Institutes of Health.

The advantages and disadvantages of greater

or lesser congressional support of biomedical research and greater or lesser direct involvement

with the direction of such research are discussed

in chapter 8. Inasmuch as some research is being undertaken in health promotion, more evidence of the cost effectiveness of various interventions will emerge even if the status quo is

maintained. But if Congress were to stipulate that

some of this research be devoted to potential savings in the cost of acute care because of health

promotion interventions by the prevention offices

within NIH, reformulation of Medicare reimbursement categories could proceed more swiftly.

ISSUE 2: Should Medicare reimbursement

categories be reconsidered with a

view to increased reimbursement

for health promotion/disease prevention interventions?

Direct links between particular interventions

and the occurrence of morbidity and mortality,

and the costs of these interventions compared to

those for acute care, are not clearly established.

It is known, however, that the potential for cost

savings in acute care is significant.

Options:

2.1: Congress could maintain the status quo.

2.2: Congress could adopt option 1.2 above and stip -

ulate that results from these studies be considered by the Prospective Payments Commission.

In maintaining the status quo, research in health

promotion would continue and some of these research results might be incorporated into clinical practice activities. For example, research could

be initiated to determine the cost effectiveness

of fixed-fee payments to physicians who carry out

specific preventive services. If the second option

were to be adopted, Congress could ensure that

results were considered as soon as they became

available. One advantage of this approach is that

in the case of some health promotion interventions (e.g., cancer screening and correction of vision and hearing problems), it may be relatively

easy to quickly demonstrate that simple interventions for specific conditions are cost effective by

comparison to later costs for acute care. one disadvantage of this option is that the mandate for

the Prospective Payments Commission would

have to be changed, since it currently is concerned only with hospital costs.

ISSUE 3: How could Congress obtain more accurate and standardized evaluations

of Federal food assistance programs

in order to improve their efficacy?

Most currently available evaluations of Federal

food assistance programs fail to use representative samples, longitudinal data, and biochemical

tests to accurately establish the nutritional status

of participants and possible benefits of the program meals. Many examine neither the efficacy

of the mandated nutrition education nor the

qualifications of the meal program staff. Findings

of many evaluations are consequently limited, inaccurate, and cannot be compared with those of

other evaluations.

Options:

3.1: Congress could require standardized evacuation

techniques for Government-contracted surveys
132 Technology and Aging in America

3.2:

3.3:

of food assistance programs. Such techniues

would involve standardized biochemical and anthropometric (and, impossible, lotuch”nal) determinants of nutritional status, representative

samples, and better evaluations of both program

staffs and the quality of the nutrition education

offered to program participants.

Congress could establish funding incentives or

other sponsorship for private investigators who

use such standarzied techniques.

Congress could mandate that the Health and Nu -

trition Examination Survey (HANES) include age

groups over 74 and that it include a sample of

elderly foodprogram participants to be compared

with the general population.

Presumably, investigators contracted by the

Government would improve their techniques for

evaluating food assistance programs after seeing

the flaws of past evaluations. Conversely, the lack

of accurate, comparable data about such a large

government program may be serious enough to

warrant development of specific guidelines and

requirements for federally contracted evaluations

that would create a pool of comparable information. There is a dearth of reliable data on the efficacy of the programs in terms of nutritional impact, nutrition education, and the level of food

management training required of meal-site employees.

ISSUE 4: How could Congress approach the

failure of the meal programs to

reach certain target groups

Many surveys find that food assistance programs, including food stamps, are inadequate to

reach some of the target groups specified in the

programs’ original congressional mandate, For example, persons aged 60 to 64 are at present ineligible for food stamps and most meal programs

operate only 5 days a week. While low-income

groups seem to be represented among participants, minorities and the socially isolated are not

well represented. This could be due to public ignorance of the programs, inaccessibility of the

programs to these underrepresented target

groups, or voluntary lack of participation.

Options:

4.1:

4.2:

4.3:

4.4:

Congress could require the Administration on

Aging to develop guidelines and materials for targeting educational information on food assistance

programs to the most needy groups.

Congress could require that local programs actively seek out the most needy, especially within

the underrepresented target groups, within a given community.

Congress could mandate quotas for target groups

according to local demographic characteristics of

each program site or area,

Congress could mandate that the Administration

on Aging and the National Institute on Aging

pare and disseminate health and nutrition education materials to consumers.

There is disagreement as to whether lack of participation in meal programs is a result of ignorance of the programs or lack of mobitity. Efforts

to educate would be costly but might encourage

the most needy in the community to gravitate

toward the food assistance programs. There is

some evidence that some active intervention on

the Government’s part is necessary in both education and mobility to ensure that these mandated

target groups are served.

RESEARCH PRIORITIES

Current Recommended Dietary Allowances

(RDAs) for the elderly fail to take into account the

age-related physiological, behavioral, and pathological changes that can affect their nutritional

needs. Certain nutrients are especially relevant

to the aging process and should be stressed in research on elderly nutrition; these include calcium,

vitamin D, B vitamins, vitamin A, zinc, sodium,

and fats.
Ch. 4—Health Promotion/Disease Prevention and Nutrition in the Elderly . 1 3 3

Technical memorandum

The OARS assessment battery yields information on

five functional activity areas:

●

●

●

●

●

social resources, quantity and quality of relationships with friends and family, and availability of

care in time of need;

economic resources, adequacy of income and resources;

mental health, extent of psychiatric well-being,

cause of existing disorder, if any;

physical health, presence of physical disorders,

participation in physical activities; and

activities of daily living, capacity to perform

various instrumental and physical (or bodily care)

tasks that permit individuals to live independently

(for other measures, see ref. 20).

Another approach uses clinical and epidemiologic criteria to identify specific health goals and professional

services appropriate for 10 different age groups from

birth to 75 years and over. For example, the goals for

the elderly (60 to 74 years) are as follows:

● to prolong the period of optimum physical/mental/

social activity,

● to miminize handicapping and discomfort from

onset of chronic conditions, and

● to prepare in advance for retirement.

The professional services are:

Chapter 4 references

1. Akin, J. S., Giulkey, D. K., and Popkin, B. M., “Participation of the Elderly in Food Stamp and Feeding Program, ” seminar presented to Human Nutrition Information Service, Consumer Nutrition

Division, U.S. Department of Agriculture, Sept. 28,

1983.

2. American Diabetes Association, ‘(Principles of Nutrition and Dietary Recommendations for Individuals With Diabetes Mellitus, ” Diabetes 28:1027-

1030, 1979.

3. Arky, R., Wylie-Rosett, J., and E1-Beheri, B., “Examination of Current Dietary Recommendations

for Individuals With Diabetes Mel]itus,” Diabetes

Care 5:59-63, 1982.

4. Bierman, E. L., “Carbohydrates, Sucrose and Human Disease, ” Am. J. Clin. iVutr. 32:2712-2722,

1979.

●

●

●

●

professional visits with the healthy adult at age

60 and every 2 years thereafter, including the

same tests for chronic conditions as in older middle age, and professional counseling regarding

changing lifestyle related to retirement, nutritional requirements, absence of children, possible loss

of spouse, and probable reduction in income as

well as reduced physical resources;

annual immunization against influenza;

annual dental prophylaxis; and

periodic podiatry treatments as needed (5).

Another approach that stresses functional independence has the following criteria:

the ability to perform activities of daily living, i.e,

bathing, dressing, toileting, transfer, continence,

and feeding;

degree of mobility of the individual, including the

capacity to move about within the home, the immediate neighborhood, and the larger community;

mental state of the individual: cognition, psychological level of functioning, and the ability to cope

emotionally with problems of daily life; and

nature of the social and economic environment

and the degree of support it offers (20).

5. Breslow, L., and Somers, A. R., “The Lifetime

Health-Monitoring Program: A Practical Approach

to Preventive Medicine,” New Eng. J. Med. 296(11):

601-608, 1977.

6. Cohen, J. B., and Logan, E., “Health Promotion/Disease Prevention for Elders: The State of the Art, ”

contract prepared for OTA, September 1983.

7. Coronary Drug Project Research Group, “Clofibrate and Niacin in Coronary Heart Drug Disease,”

.J.A,M.A. 231:360-381, 1975.

8. Dahl, L. K., “Salt and Hypertension,” Am. J. Clin.

Nutr. 25:231-244, 1972.

9. Darby, W. J., et a]., “Niacin, ’’Nutr. Rev. 32:289-297,

1975.

10. deVries, H. A., “Tranquilizer Effect of Exercise: A

Critical Review,” The Physician and Sports Medicine 9(1 1):47-55, November 1981.
— — —.

134 ● Technology and Aging in America

11. deVries, H. A., “Physiological Effects of an Exercise Training Regimen Upon Aged 52-88, ” J. Gerontolo~v 25:325-336, 1970.

12. deVries, H. A., “Physiological Effects of an Exercise Training Regimen Upon Men Aged 52-88, ” J.

Gerontology 25(4):325, October 1970.

13, Doll, R., and Pete, R., “The Causes of Cancer: Quantitati~re Estimates of Avoidable Risks of Cancer in

the United States Today,” JNCI 66:1191-1308, 1981.

14. Filner, B., and Williams, T. F., “Health Promotion

for the Elderly: Reducing Functional Dependency, ”

background paper prepared for HealthLv People,

the Surgeon General’s Report on Health Promotion

and Disease Prevention, DHFXV publication No. 79-

55071A, 1979.

15. Franks, P., Lee, P. R., and Fullarton, J. E., “Lifetime

Fitness and Exercise for Older People, ” A background paper prepared for the Administration on

Aging, Aging Health Policy Center, IJniversity of

California, San Francisco, April 1983, pp. 52-53.

16. Greene, H. F., Dreizen, S., and Spies, T. D., “A Clinical Survey of the Incidence of Impaired Masticator Function in Patients of a Nutrition Clinic,” J.

Am. Dent. Assoc. 39:561-571, 1949,

17. Haskell, W., “Physical Activity in Health Maintenance, ” W’awvs of Heahh, D. Sobel (cd. ) (New York:

Harcourt, Brace, Jovanovich, 1979).

18. Heaney, R. P., et a]., ‘(Calcium Nutrition and Bone

Health in the Elderly,” Am. J. C/in. A’utr. 36:986-

1013, 1982.

19. Kane, R. L., Kane, R. A., and Arnold, S. B., “Prevention in the Elderly: Risk Factors, ” paper prepared for the Conference on Health Promotion and

Disease Prevention for Children and the Elderly,

Foundation for Health Services Research, Sept. 16,

1983.

20. Kane, R. A., and Kane, R. L., Assessing the Elderly:

A Practical Guide to Measurement (Lexington, MA:

Lexington Books, 1981).

21. Last, J. M. (cd.), Maxcy-Rosenau Public Health and

Preventive Medicine, llth ed. (New York: Appleton-Century Crofts, 1980), pp. 3-4.

22. Mann, A. W., Mann, J. M., and Spies, T. D., “A Clinical Study of Malnourished Edentulous Patients, ”

J. Am. Dent. Assoc. 32:1357-1368, 1945.

23. Marks, J. L., “Osteoporosis: New Help for Thinning

Bones,” Science 207:628, 1980.

24. McCarron, D. A., Morris, C. D., Henry, H. J., and

Stanton, J. L., “Blood Pressure and Nutrient Intake

in the United States,” Science 224:1392-1398, 1984.

25. Minkler, M., and Fullarton, J., “Health Promotion,

Health Maintenance, and Disease Prevention for

the Elderly,” background paper for the 1981 White

House Conference on Aging, prepared for the Office of Health Information, Health Promotion, Physical Fitness and Sports Medicine, 1980.

26. National Council on the Aging, Inc., Aging in the

803: America in Transition, a sur~ey conducted for

the National Council on the Aging, Inc. by Louis

Harris & Associates, Inc. (Washington, DC: National Council on the Aging, Inc., November 1981).

27. National Research Council, Committee on Diet, Nutrition, and Cancer, Diet, Nutrition, and Cancer

(Washington, DC: National Academy of Sciences,

1982).

28. National Research Council, Food and Nutrition

Board, Recommended Dietajy Allowances, 9th re~.

ed. (Washington, DC: National Academy of Sciences, 1980).

29. Opinion Research Corp. and Kirschner Associates,

“An Evaluation of the Nutrition Services for the

Elderly, ” t’olume ZIZ: llescripti~’e Report, conducted

for the Administration on Aging of the U.S. Department of Health and Human Services, May 1983.

30. Parfitt, A. M., et al., “Vitamin D and Bone Health

in the Elderly, ” Am, J. Clin. Nutr., 36: 1014 -103I,

1982.

31. Puska, P., and Nissinen, A., et al., “Controlled, Randomized Trial of the Effect of Dietary Fat on Blood

Pressure, ” Lancet 1:1-9, 1983.

32. Rouse, I. L., et al., “Blood-Pressure-Lowering 13 ffect of a Vegetarian Diet: Controlled Trial Normotensive Subjects,” Lancet 1:5-10, 1983.

33. Rowe, J. W., “Systolic Hypertension in the Elderly,”

Alew Eng. J. Med. 309(20):1246-7, 1983.

34. Smith, E. L., Reddan, W., and Smith, P. E., “Physical Activity and Calcium Modalities for Bone Mineral Increase in Aged Women, ” Med. Sci. Sports

Exerc. 13:60-64, 1981.

35. Somers, A. R., and Weisfeld, V. D., “The Challenge

of Health Promotion for the Elderly, ” paper presented to Western Gerontological Society, 29th Annual Meeting, Albuquerque, NM, Apr. 18, 1983.

36. U.S. Department of Health and Human Services, National Center for Health Statistics, “Edentulous Persons in the U. S., 1971)” N.C.H.S. Series 10(89), 1974.

37. U.S. Department of Health and Human Services,

“Arteriosclerosis 1981,” Volume 2: Report of the

Working Group on Arteriosclerosis of the National Heart, Lung, and Blood Institute, NIH publication No. 82-2035, September 1981.

38. Walker, W. J., “Changing U.S. Life Style and Declining Vascular Mortality—A Retrospective, ” Ne\\r

Eng. J. Med. 308(11):649-651, 1983.

39. Williams, T. F., “Diabetes Mellitus, ” Clin. Endo.

Metab. 10:179-194, 1981.
Chapter 5

Medications and the Elderly
Contents

Page

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 137

Use of Medications Among the Elderly . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 137

Biologic Differences in Drug Effects and Metabolism Older People . . . . . . . . . . . . . . 140

Altered Metabolism and Tissue Sensitivity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 140

Characteristics of Drug Use . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 141

Side Effects and Adverse Drug Interactions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 141

Patient Compliance with Drug Prescriptions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 143

Issues Specific to Drugs Affecting Mental Function. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 145

Need for Increased Education of Health Care Providers . . . . . . . . . . . , . . . . . . . . . . . . . 145

Use of Over-the-counter Drugs . . . . . . . . . . . . . . . . . . . . . . ., . . . . . . . . . . . . . . . . . . . . . 146

Patient Information on Drugs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 146

Congressional Issues and Options . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 148

Chapter 5 References . . . .:. . . . . . . . . .

Tables

Rible NO.

10. Comparison of Inflation Factors for

11. Age-Related Changes Altering Drug

Figures

Figure No.

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .153

Page

Prescription Drugs and Other Goods ... , . . . . . 140

Metabolism and Sensitivity. . . . . . . . . . . . . . . . . . 140

Page’

18. Percent Change in Prices From Previous Year . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 139
Chapter 5

Medications and the Elderly

Introduction

Drug treatment is an important medical technology that is especially important to the elderly

population. Medications are widely used by older

Americans, and Federal policy directly affects the

availability of drugs for general use. The safety

of using medications, availability of information

about drugs, and new technologies that might improve how drugs are delivered and used are covered in the following chapter.

Congress has demonstrated an interest in issues

related to use of medications by older Americans.

A joint hearing was held in June 1983 by the Senate Special Committee on Aging and the Subcommittee on Health and Long-Term Care of the

House Select Committee on Aging entitled “Drug

Use and Misuse: A Growing Concern for Older

Americans” (70). That hearing covered many of

the issues raised in this chapter.

A number of other medical technologies from

this report have been excluded because they are

covered in other OTA reports. One area deserves

special mention—that of medical devices. There

is a vast potential for medical devices that improve

IThe definition of technology used bey OTA is “a drug, dm’ice, or

medical or surgical procedure used in medical care. ”

function and enhance independence among disabled elderly individuals. Some of these devices

are reviewed in the section on Long-Term Care

in chapter 7. others have been assessed in recent

OTA reports, such as Technology and Handicapped People, as noted below, or are currently

the subject of other OTA projects. Devices specifically relevant to urinary incontinence and

hearing impairments are reviewed in case studies

on those subjects to be published separately.

Among the current OTA assessments that cover

relevant technologies, such as diagnostic and therapeutic procedures, are:

●

●

●

●

●

●

Federal Policies and the Medical Devices Industry (october 1984),

Medical Technology and the Costs of the

Medicare Program (July 1984),

Postmarketing Surveillance of Prescription

Drugs (November 1982),

Medical Technology Under Proposals To Increase Competition in Health Care (october

1982),

MEDLARS and Health Information Policy—

A Technical Memorandum (September 1982),

and

Technology and Handicapped People (May

1982).

Use of medications among the elderly

More than four out of five Americans over 65

now suffer from one or more chronic diseases

(86 percent–see chs. 7 and 9 and app. A). About

85 percent of the noninstitutionalized elderly and

95 percent of those in hospitals, nursing homes,

and other institutions take medications on a regular basis (39). Although those over 65 constitute

11 percent of the population, they use 30 percent

of prescription drugs (54,64), more than twice as

many as the average user (7,39). An average of

10 different drugs is prescribed for an elderly patient during each hospital stay; the usual number of prescriptions for those in nursing homes

is 4 to 7 (54). The average number of prescriptions for those who use drugs and are over 65

rose from 13.4 per year in 1967 to 17.9 in 1977;

90 percent of these prescriptions are for longterm use to treat chronic medical conditions (37).

137
—.

138 ● Technology and Aging in America

As disease prevalence rises with age, drug use increases. older individuals take medications for

several types of illnesses. They use the everyday

drugs used by the general population for colds,

acute infections, and headaches. Such chronic diseases as arthritis, hypertension, and cardiovascular disorders, which are especially common in

older people, determine the use of another group

of drugs that includes diuretics, anti-hypertensives, anti-inflammatory agents, and cardiac drugs

(60).

Elderly women suffer disproportionately from

drug-related problems. They live longer, are more

likely to live alone (almost twice as likely as men),

and have lower average incomes and a higher

prevalence of disability than men. Each of these

factors complicates drug therapy. The oldest

women are the most vulnerable to adverse reactions and other untoward consequences of using

drugs.

Drug use improves the condition of most elderly

patients; drugs are used because they work. Patients are better off because useful drugs are

available, and drugs are ‘(probably the most costeffective modality of chronic disease management” (36). While the rate of inflation for medical costs overall during the last decade has been

far greater than for the economy as a whole,

pharmaceutical prices have risen more slowly

than the Consumer Price Index (CPI) (19). Inflation for pharmaceuticals has exceeded the CPI in

recent years (fig. 18), but the average inflation

over the past decade remains favorable (table 10).

Pharmaceutical therapy is not only medically effective but can also produce savings by diminishing morbidity and forestalling the need for more

expensive forms of medical treatment. For example, the use of cimetidine ragamet~ for duodenal

ulcer disease led to an estimated 26-to 70-percent

cost savings for Medicaid in Michigan in the first

year of its use, primarily by substituting for surgery in some patients (18). It is not clear that this

figure can be extrapolated specifically to the elderly population, because the study included all age

groups, but the potential for cost savings over the

short term has been demonstrated for the general population in this study. In another example, lithium treatment of manicdepressive illness

has saved an estimated $4 billion over the last decade, according to the director of the National Institute of Mental Health (56).

Use of drugs to treat diseases for which there

has never previously been effective therapy can,

however, increase health care costs, if their cost

is higher than previous modes of therapy. Treatments requiring extensive drug therapy may also

increase overall costs.

Many issues concerning the cost effectiveness

of drug therapy, proper indications for drug use,

and regulatory practices vis-a--vis the drug industry are not directly relevant to this report, because they do not specifically affect the older population. Although these issues are important for

older Americans because they use more drugs,

policy changes would not be directed at improving the lot of the elderly per se. The balance of

this chapter thus deals with those aspects of drug

therapy that do specifically affect the older American population. The issues to be discussed include metabolic and clinical differences between

older and younger individuals, drug testing regulations, and patterns of drug use unique to the

elderly.

Older Americans pay more for prescription

medications than does the general population.

Those over 65 pay an average of $93 per year

for prescriptions, compared to $79 for those .55

to 64 and $27 for those 19 to 24 (27). Cost differences are especially marked in the heaviest users:

3.3 percent of those over 65 pay more than $250

per year for prescription drugs, compared to 2.2

percent of those 55 to 64 and 0.5 percent of those

19 to 24 (27). Some contend that these figures substantially underestimate the economic impact of

drug use among the elderly, because such figures

do not capture over-the~ounter medications, and

do not measure the impact of a substantial minority of elderly patients who have medication

bills far in excess of $250 (37). The important topic

of reimbursement policy for prescription drugs

under Medicare has been omitted because it has

been analyzed in detail in a recent report which

gives potential costs of changes in Medicare reimbursement policy and cost estimates for a variety of options (65).

Many of the problems of drug use among the

elderly are due to altered metabolism, the pres-
Ch. 5—Medications and the Elderly ● 139

14

12

12

11

Ic

9

8

7

~ 6

al o

zQ 5

4

3

2

1

0

–1

- 2

- 3

Figure 18.— Percent Change in Prices From previous Year (based on table 10)

I1 ; i

!

\

/

I

\

\

I I

/

/

/

/

/

\

\

/

/

- \dl

1974 195 19’8 1977 1978 1979 1980 1981 1982 1983

1

\

\

\
140 ● Technology and Aging in America

Table 10.—Comparison of Inflation Factors

for Prescription Drugs and Other Goods

Prescription Drug Consumer Price index

Year Price index for ali goods

1967 . . . . 100.0 100.0

1968 . . . . 98.3 104.2

1969 . . . . 99.6 109.8

1970 . . . . 101.2 116.3

1971 . . . . 101.3 121.3

1972 . . . . 100.9 125.3

1973 . . . . 100.5 133.1

1974 . . . . 102.9 147.7

1975 . . . . 109.3 161.2

1976 . . . . 115.2 170.5

1977 . . . . 122.1 181.5

1978 . . . . 131.6 195.4

1979 . . . . 141.8 217.4

1960 . . . . 154.8 246.8

1981 . . . . 172.5 272.4

1962 . . . . 192.7 289.1

1983 . . . . 213.8 298.4

SOURCE: Bureau of Labor Statistics, cited by Palumbo, 1984 (55).

ence of multiple diseases, the use of multiple

drugs, and increased susceptibility to side effects.

Biologic differences in drug effects

and metabolism in older people

Drugs are tested for side effects and therapeutic effectiveness in the general population, yet are

used most often by the elderly, in whom they may

act in a manner not always detected in studies

of the general population. Recent studies of pharmacokinetics-the study of how drugs are distributed and metabolized in the body—and pharmacodynamics—the study of how drugs act—show

significant differences between older and younger

populations. These differences are based on fundamental biological age-related changes that affect the body’s ability to process, store, and excrete drugs (table 11).

Biological differences between older and younger patients are analogous to the differences between adults and infants. It has been said that just

as it took many years to recognize that infants

are not simply “smaller” adults and must be

treated differently, it is not yet universally recognized that the elderly require different treatment than younger adults (33).

Table 11.—Age=Related Changes Altering Drug

Metabolism and Sensitivity

1. Body composition

L.

.

Iv.

v.

A. Decreased lean body mass

B. increased proportion body fat

C. Decreased total body water

D. Decreased blood albumin (small change)

Heart and blood vessels

A. Decreased heart response to stress

B. Increased size of heart

C. Diminished vessel elasticity

D. increased total vascular resistance to blood flow

E. Decreased oxygen delivery to selected organs

Kidneys

Liver, brain, and muscles (small change)

Kidneys

A. Decrease in number of blood filtering units (nephrons)

B. Decreased blood flow through kidneys

C. Decreased filtering and clearance rate of blood components

D. Decreased ability to adapt to maximum loads

Digestive organs

A. Slowed stomach emptying

B. Diminished acid secretion

C. Decreased peristalsis

D. Decreased absorption (small change)

Liver

A. Altered drug metabolism (slowed oxidation, especially

in men, conjugation relatively unaltered)

B. Diminished blood flow (small change)

VI. Nervous system

A. Decreased threshold for depressant medications

B. Decreased coordination and short-term memory (small

change, unless another disorder is also present)

C. Diminished blood flow to brain and nerves (slight, in

absence of vascular disease)

D. Slowed velocity of conducting impulses in nerves

E. Slowed reflexes

Vii. Lungs

A. Decreased lung elasticity

B. Decreased effective surface area for oxygen exchange

C. Decreased effective breathing volume

D. Decreased rate of expelling air

E. Decreased clearance of irritants (ciliary movement)

Viii. Endocrine organs

A. Decreased sex hormones (in general, with a few exceptions)

B. Decreased response to sugars

C. Many other alterations, too numerous to list, including

stress hormones, regulators of metabolic rate, and

body volume regulation

SOURCE: Lamy, 1982 (33), as modified by OTA with the assistance of J. Rowe,

Altered metabolism and

tissue sensitivity

Older adults have significantly altered drug reaction and metabolism (7)20,33)36)38)43). They

also have a higher percentage of fatty tissue com-
Ch. 5—Medications and the Elderly 141

pared to lean body mass, which causes increased

effective concentrations of water-soluble drugs

and prolonged retention of fat-soluble drugs. Hepatic metabolism of drugs, particularly oxidative

processing in older males, is altered with age,

which may lead to reduction of the required dose

of drugs so processed. Decreased kidney function

with age leads to prolonged retention of drugs

in the body, often lowering the dose of a drug

required to achieve useful concentrations, or necessitating an increase in the time between doses.

Decreased blood albumin causes increased effective plasma concentrations of many drugs.

Tissue sensitivity to drugs may also increase or

decrease with age, depending on the tissue, the

patient, and the drug. Many of these changes lead

to a need for reduced doses of drugs. The clinical effect of many benzodiaepine drugs (common

sedative agents) in older patients, for example, is

more intense than in younger patients with similar blood concentrations (47).

Prescription sleeping pills provide striking examples of how altered biological characteristics

can necessitate adapting the treatment to the older patient. Common sleeping pills, also called minor tranquilizers or hypnotics, are fat-soluble

chemicals that are retained longer in older patients: flurazepam (Dalmane@

, a hypnotic agent)

stays in an elderly patient for an average of 1

week (64), and the effective half-life of diazepam

(Valium@, a related anti-anxiety agent) averages

90 hours in those over 80, compared to 20 hours

in those under the age of 20 (23). These prolonged

retention times have led geriatric pharmacologists

to urge the prescription of shorter acting drugs

at lower doses.2 Although it is twice the recommended geriatric dose, the usual 5 mg dose of Valium (dizepam) is one of the most commonly

prescribed drugs for those over 65 in a private

prescription service (29), and more than 13 million prescriptions for Dalmane® (flurazepam)

were given to the elderly last year (64). Such figures do not indicate that the drugs are not useful,

but do suggest that prescription patterns are not

The use of \ery short-acting hypnotic agents is also prohlematir,

in that patients may’ awaken from ‘(rebound insomnia” if the drug

is metabolized and cleared rapidly. Resolution of proper practirr

in prescribing h~’pnotic agents thus awaits further inqoirjr.

optimally tailored for the needs of the older population.

Characteristics of drug use

Those over 65 use more drugs than any other

age group (36,43). Many chronic disorders such

as arthritis or hypertension are treated with more

than one drug. Many older people have multiple

chronic diseases, each of which may be treated

by drugs. There are more than 43,000 pharmaceutical products on the market, containing 1,900

separate chemical entities (39). The scant attention given to use of drugs peculiar to the elderly

in medical practice is due in part to the fact that

much drug information (e.g., information in the

Physician’s Desk Reference) is based on Food and

Drug Administration (FDA) requirements for drug

certification. At present, FDA drug approval does

not require special attention to effects on elderly

patients. (See “Drug Testing” below.)

Side effects and adverse

drug interactions

The elderly have a higher incidence of drug side

effects and drug interactions (2,20,33,38). The

threshold of toxic blood concentration is lower

among the elderly for many drugs, leading to increased probability of overdose. The presence of

multiple chronic diseases and their treatment

with multiple drugs lead to a higher incidence of

adverse drug reactions and adverse drug interactions (36,43,58). This may be due not only to

altered pharmacokinetics, but also to possibly increased susceptibility to adverse effects of drug

usage resulting from altered inherent susceptibility among older people.

A recent study of adverse drug reactions and

interactions, which showed that they accounted

for 3 percent of all hospital admissions, found this

figure to be much higher for the elderly–12 to

17 percent of hospital admissions for those 70 to

90. Of those suffering adverse drug reactions, 40

percent are over age 60 (cited in 54). Conclusions

from the studies that have been performed cannot be generalized to the total American elderly

population because they have been small and

local. Generation of aggregate data on hospital ad-
142 ● Technology and Aging in America

missions due to drug reactions is one benefit that

may accrue from increased use of computerized

medical information systems, and may permit

more accurate policy determinations.

Adverse effects are especially common for

drugs used to treat cardiovascular and psychiatric

diseases and so are used especially heavily by the

elderly. Adverse drug reactions among the elderly

have been roughly estimated to cost $3 billion per

year (cited in 54).

Some assert that side effects-of drugs may be

more common among ambulatory patients than

among hospital patients (33). Reporting of adverse

effects is less reliable for ambulatory patients, and

drug errors are more common outside the hospital. Increased home care may exacerbate the

problem of adverse drug effects and noncompliance with prescription instructions.

A different type of problem in geriatric drug

use is the frequency of drug interactions. Drug

interactions can occur between the drug and the

patient (due to individual susceptibility), between

the drug and numerous diseases (metabolism of

drugs for one disorder altered by another disorder), between the drug and drugs for other disorders, and between the drug and a patient’s diet.

Interactions between drugs and diet can cause

problems in several ways (34). Drugs can affect

dietary intake; certain antacids, used to quell

stomach complaints, also lead to decreased absorption of phosphate, vitamin BI (thiamine), and

iron (needed to make red blood cells) (42). Laxatives, often used to prevent constipation, can prevent the absorption of fat-soluble vitamins involved in blood coagulation and bone metabolism

(see section on Nutrition inch. 4). Dietary habits

can also influence the efficacy of drugs; diets high

in yeast, liver, fish, whole grains, and certain

vegetables can inhibit the effectiveness of drugs

for Parkinson disease. Diets high in vitamin K,

such as spinach, cheese, and liver, can reduce the

efficacy of some drugs used to prevent blood clot

formation (42). Foods high in the chemical tyramine,

found in cheese, wine, and chocolate, can cause

dangerous elevation of blood pressure for those

taking some types of antidepressant medications.

Such problems are not unique to older patient

populations, but each of these drug groups is used

more by elderly individuals (42).

Although many drug interactions cannot be

avoided, the increase of “polypharmacy, ” the simultaneous use of multiple drugs, highlights current deficiencies in the use, retrieval, and storage of medical information. The problem of

predicting and reporting drug interactions is an

example; one computer analysis of drug prescriptions showed the potential for harmful drug interactions to be far in excess of those clinically

reported (8). Present methods of monitoring adverse drug effects raise questions of whether untoward reactions are markedly underreported or

whether the computer model is incorrect; both

explanations may be partially valid.

Technology can be useful in identifying drug

interactions. A recent study that used a computerized prescription information service found that

using the computer did not reduce the number

of prescriptions with potential problems, but did

shorten the time period needed to recognize and

begin dealing with the problem (30). The application of sophisticated “artificial intelligence” to

medical monitoring, in which computer programs,

such as the RX program developed at Stanford

University, (9,10) continuously investigate the patient record data base of a hospital or region, looking for possible medical effects from the use of

a particular drug or group of drugs, is likely to

be a major improvement. Such data analysis depends, however, on gaining access to statistics on

the incidence of drug side effects in the population. Innovations arising from increased use of

information technologies, such as “smart cards”

or improved patient-centered information systems may enhance the ability to identify drug

reactions and interactions. The present system,

which relies largely on user, manufacturer, or

physician reporting, requires that someone notice

a causal relationship, and is especially unreliable

when there is a long time lag between the start

of drug administration and the development of

an adverse effect (8,67). Development of effective

methods of monitoring drug use in actual clinical practice may prove important in development

of drugs for the elderly population. (See Drug

Testing below.)
Ch. 5—Medications and the Elderly ● 143

Photo credit Giant Food, Inc

Pharmacists use the computer to spot potentially harmful drug use that can occur

when people unknowingly mix medications.

Patient compliance with

drug prescriptions

Elderly patients often fail to use drugs exactly

as prescribed; 59 percent of patients in a recent

survey showed some “error” in drug use (54). The

most common error is omission (39), The probability of error rises among women, patients who

live alone, those over 75, and those who use a

great number of drugs or must take drugs frequently (54). Deviance from prescription instructions is also more likely among those who have

numerous diseases, who have poor vision or hearing (17), and whose socioeconomic status is low.

Diminished mobility (difficulty in getting to the

pharmacy to fill prescriptions) and inattention

from medical care providers may also contribute

to noncompliance (39).

Compliance with drug prescriptions is probably

not affected by aging per se, but may be diminished by social and biological factors that become

more common with age. If nothing else, the

greater number of medications taken by older

people increases the probability of deviating from

instructions for at least one prescription,

The treatment of chronic diseases with drugs

taken over long periods clearly requires persistent patient and family participation and the strong

motivation of both patients and providers; these

factors may not be receiving sufficient attention

at present in the medical community (39). Difficulties in communication between physicians and

patients may be intensified by older people’s difficulty in hearing, understanding, or remembering instructions on drug use (17).
144• Technology and Aging in America

Some noncompliance is deliberate. The tremendous variation in reported rates of deliberate noncompliance ranges from 7 to 43 percent (69); one

study found that 70 percent of “errors” were intentional (12). yet the high rates of deviation from

prescription instructions do not always portend

ill outcomes. Compliance rates vary tremendously, depending on drug type (69), and may at times

be due to a judgment of appropriate treatment

by the patient. Another study showed the most

common reason for not taking medications to be

thepatient's perception that he or she did not “like

or need” them, which accounted for far more deliberate disuse than cost or presence of side effects (69). These two reasons accounted for 71.6

percent of patient-reported failure to follow a

prescription. To the extent that patients can accurately determine their own needs for medication, such “noncompliance” may be intelligent. For

example, some inappropriate prescriptions for excessive doses of hypnotic/anti+mxiety drugs, such

as Valium® and Dalmane@

, may be partially corrected by patients taking fewer pills than directed.

Noncompliance with prescriptions, however, is

not generally laudable. Misuse of drugs, whether

deliberate or unintentional, can lead to serious

adverse effects, and, as noted above, to preventable hospitalizations.

“Child-proof” containers may be difficult to open

(15,39,41,44), and can thus cause compliance

problems. New packaging for over-the-counter

medications, instituted in reaction to the deliberate alteration of Tylenol® capsules, may also

make opening difficult for older people. However,

such protective packaging can also be a blessing

in preventing accidental or poorly conceived ingestion of drugs by patients with poor mental

function (41), patients whose arthritis affects their

hands are particularly likely to have difficulty

opening child-proof containers, and should have

easy -to-open containers ordered by their physicians.

Correct administration of drugs is especially difficult in patients afflicted with dementia and psychiatric illness, for whom expectation of patientinitiated accuracy of drug administration is a vain

hope. For these patients, the involvement of other

family members is essential (41). The use of medication “boxes,” with drugs arranged for time of

day and date by a family member or health professional can help; as can the use of charts with

examples of the appropriate pill taped to the proper column. Prescription labels in lay language in

large type on containers of different colored pills

can also help avoid mistakes .There is great opportunity here also for technological innovation.

New products relying on “smart” electronics to

keep track of proper times for dispensing particular drugs are under development. One simple device in a relatively inexpensive bottle cap sounds

an alarm when it is time to take the medication

(Med-Tymer, Boston Medical Research, 1983).

Other systems under development could dispense

multiple medications on different schedules and

notify patients when it is time to take a particuPhoto credit: Boston Medical Research, Inc.
Ch. 5—Medications and the Elderly ● 145

lar pill. This would be helpful to all patients requiring multiple medications, and would be particularly welcome for patients with diminished

mental function (although others would have to

fill the prescriptions and program the mechanisms).

Issues specific to

mental function

DEMENTIA CAUSED BY

drugs affecting

DRUGS AND DEPRESSION

Depression may cause or complicate dementia

(loss of higher mental functions) in 8 to 23 percent of patients who receive a diagnosis of irreversible dementia. This is partly due to inaccurate

diagnosis, and partly to an increased prevalence

of depression among demented patients (4 I). Further, drugs used to treat other diseases can cause

dementia. Many drugs that block the effect of acetylcholine, 3 either as a primary effect or as an unwanted side effect, are used in the treatment of

Parkinson disease, insomnia, hypertension (46),

colds (32), depression, and psychosis (14). The rare

syndrome of “atropine psychosis)” a severe form

of mental reaction to certain anti-cholinergic

drugs characterized by psychotic symptoms, may

tempt a physician to treat the psychosis with

drugs that can further worsen the patient’s symptoms (14). Much more common, however, is mild

confusion induced by over-the-counter or prescription drugs that have mild or moderate anticholinergic actions.

Drug-induced dementia is even more common

as a cause of reversible dementia than depression

(25). Drugs are thus the most common cause of

this syndrome, which carries the awkward title

of “pseudodementia” (20). Sedatives and hypnotic

drugs often diminish intellectual function in patients at all ages, and are especially likely to do

so among older people.

Drugs given to correct other conditions, such

as heart disease or hypertension, can also cause

loss of mental functions by altering blood flow

3Acet~vlcholine is a molecule used to communicate between neme

cells, and is implicated in memory processes. LcIss of brain cells that

use it is found in some diseases, such as Alzheimer disease, that

lead to dementia. Blocking of acetylcholine, ~tith drugs called anticholinergic drugs, might, therefore, lead to exacerbation of dementia

and increase in confusion in susceptible patients,

to the brain or by directly acting on brain cells.

These effects are rare in younger age groups, but

increase with age.

DRUGS USED FOR MANAGEMENT EASE,

RATHER THAN PATIENT BENEFIT

There is some evidence that psychopharmaceuticals are used to make nursing home patients

easier to manage, rather than to improve their

medical condition. One study found that a small

minority of physicians (1.3 percent) with large

nursing home practices prescribed a large proportion (37 percent) of the anti-psychotic medications dispensed in the nursing homes sampled;

the 14 percent of physicians who had 10 or more

nursing home patients prescribed 81 percent of

the anti-psychotic drugs (57). The prevalence of

anti-psychotic drug use in this study varied widely—more than three-hundredfold—among nursing homes. Usage increased with nursing home

size, and was inversely related to the ratio of nursing home staff to patient (57), suggesting that antipsychotic medications may be used as a substitute for personnel in some institutions,

Need for increased education of

health care providers

One way to improve the manner in which drugs

are used is to educate the physicians who prescribe them. Such education includes not only instilling knowledge about proper use of drugs, but

also increasing awareness among practitioners

about the special biological and physiological characteristics of older patients. studies suggest that

physicians may base more of their prescription

decisions on drug advertisements than on scientifically verified studies (3). In response to this

finding, a group seeking to promote appropriate

prescription habits has borrowed the techniques

used by pharmaceutical companies to promote

the use of their drugs—using trained personnel

to personally visit physicians to educate them

about common prescription errors [4). Such methods are experimental, and some have questioned

the appropriateness of this approach (45), but

there is wide agreement on the need to improve

physicians’ awareness of the importance of the

vicissitudes of drug therapy among older patients.
146 ● Technology and Aging in America

Recent data show that the use of physician advisors can be especially effective in changing physicians’ prescribing habits (59). A large recent

study found efforts to change physician habits to

be cost effective in saving funds for Medicaid.

Costs of educational materials and personnel for

educating physicians were $93 per physician per

year, compared with $205 saved from Medicaid

funds. The program was especially effective for

those physicians who were the heaviest prescribers, and was received well by the physicians involved (61).

Use of over-the-counter (OTC) drugs

Many elderly people use OTC drugs: 70 percent

of those 65 and over use some OTC medication

regularly (64). Physicians are often unaware that

their patients are taking OTC agents, either because patients do not inform them, or because

they fail to ask (13). The most common drug in

this class is aspirin, which is often used to treat

the pain and inflammation associated with arthritis (13,35). Aspirin is one of the cheapest and most

effective remedies for arthritis, but is also associated with ear and vision toxicity, loss of control of body heat, confusion, nausea, diarrhea, and

gastrointestinal bleeding (13). Some patients, who

also have asthma and nasal polyps, can have lifethreatening reactions to aspirin. Yet aspirin is ubiquitous; more than 200 products contain it, and

some of them are not clearly labeled (13).

Another common side effect of OTC medications is confusion. Many nonprescription drugs

contain agents that block the effects of acetylcholine. Many nonprescription sleeping pills and

anti-cold remedies contain agents that can induce

confusion.

The special biological and sociological characteristics of older populations may indicate a need

for caution in converting drugs from prescription to over-the-counter status. For those drugs

that are used primarily by older people, special

attention to the incidence of side effects in the

older subpopulation may be in order when deciding to make medications available to all consumers.

patient information on drugs

The need for active patient participation in

treatment of chronic diseases requires improved

methods of teaching patients about their treatments. In a recent FDA survey, 58 percent of patients received information on how to take their

medication, but 75 percent received no information regarding potential side effects (48). Physicians in a recent survey believed that their patients were either very well (32 percent) or

adequately (56 percent) informed about their

medications (40), yet other studies show patients

are often ignorant of important facts about their

therapy (48). Patients rarely ask physicians about

their drugs, but instead ask nurses, clerks, family,

or friends (50). The transfer of information to patients is worse for older patients than for the

general population, and especially poor for one

group-old and less educated women (49).

Poorly informed patients are unable to make

rational decisions, and may experience unnecessary drug interactions. Lack of information from

health professionals leaves patients vulnerable

to the advice of uninformed or ill-informed acquaintances and family members. Some of the

problems in communication may stem from the

reluctance of patients to ask physicians for information: in the FDA survey, only 2 percent of the

patients asked their physicians about their medications (48). Heightened sensitivity to the need for

adequate patient education among health providers could improve the efficacy of treatment;

greater assertiveness on the part of patients could

diminish anxiety and aid in the treatment process by improving patient awareness of potential

adverse reactions and contraindications.

The recently formed National Council for Patient Information and Education (NCPIE) is addressing the need for increased involvement of

patients in their treatment by encouraging patients to ask questions of their physicians. Current NCPIE strategy is to sponsor television and

mass media advertisements (52). Other patient-information activities include community programs

at the Albany College of Pharmacy, the University of Maryland, and the University of Michigan,
Ch. 5—Medications and the Elderly ● 147

and in Los Angeles, San Francisco, and Osceola,

FL (39). Many other communities not noted in national publications are also known to have developed special patient education programs for the

elderly.

Accompanying certain prescription drugs with

information for patients became an area of Federal concern in 1981, when the FDA mandated

the inclusion of information with prescriptions

for cimetidine, clofibrate, propoxyphene, and

seven other drugs. This requirement was reversed by Executive Order 12291 shortly after the

start of the Reagan Administration in February

1981, although inserts are still required for several medications such as isoproterenol inhalants

and contraceptives.

The delay in implementation of Executive Order 12291 coincided with the start of the voluntary American Medical Association’s Patient Medication Information program, in which physicians

are to distribute patient information on drugs to

their patients at the physician’s expense. A recent

survey showed that 22 percent of physicians who

prescribe medications were participating in the

program; 50 percent of physicians did not know

about the program, and a small minority of older

male physicians disagreed with AMA policy in distributing patient-information leaflets (31).

Another program of patient education undertaken by the American Association of Retired

Persons (AARP) has been especially effective.

“Medication Information Leaflets for Seniors” accompany each prescription emanating from several mail prescription services available to AARP’s

14 million members, who order more than 5 million prescriptions per year. The inserts, in leaflet form, explain the reason for taking the drug,

how to administer it, what information the physician needs to properly prescribe it, contraindications and potential interactions with food and

other drugs, and potential side effects. An early

survey of recipients showed that although 24 percent of people either did not notice them or did

not receive them; of those who did, 90 percent

found the leaflets useful, 95 percent read them,

and 76 percent kept them for possible future reference. Fears that providing patients with information about their prescription would increase

anxiety were allayed by finding that 40 percent

of those responding “felt better” about their medications, and 56 percent “felt no different” after

receiving the leaflets (21,53). The package inserts

were more extensively used for anti-hypertensive

medications than for anti-arthritic agents or minor tranquilizers (51). The AARP drug leaflet is

currently being comprehensively evaluated to determine its effect on patient attitudes, perceptions,

and behavior (6).

Patient package inserts may be especially helpful to older patients. A large and extensive Rand

Corp. study of patient package inserts sponsored

by the FDA found that older patients read them

more often, resulting in a small but detectable increase in patient knowledge about medications

(26). Patient package inserts can thus be useful,

although questions remain about patients’ judgments of risk. Patients remember less about side

effects than other aspects of the leaflets (26) and

some patients have difficulty in accurately assessing the relative seriousness of risks (28).

Patient education need not be restricted to leaflets included with the drug. Several pharmacies

have taught classes, trained educators, arranged

for educational programs, or written leaflets for

their older patrons. Computer networks, as noted

in chapter 6, may also encourage information networks on topics related to health. National and

local press also serve an important function in

highlighting new developments relevant to drug

use.
148 ● Technology and Aging in America

Congressional issues and options

Background

DRUG TESTING

The FDA’s drug approval process begins with

laboratory discovery of a drug’s action. Once a

potentially useful new chemical activity has been

discovered, tests of efficacy and toxicity are performed on animals. At this point, the manufacturer applies to the FDA for certification of the

New Chemical Entity (NCE) to be tested in humans

as an Investigational New Drug (IND). The agent

is then tested for safety in a small number of relatively healthy volunteer patients, and long-term

toxicity is measured in animals. This is called

Phase I testing.

If preliminary tests are successful, phase II

trials—larger clinical trials—are undertaken in a

small number of patients (100 to 300) to establish dosage range and efficacy, and as a further

measure of safety. Phase III is usually the final

stage of testing and involves carefully controlled

trials and field testing in larger numbers of patients (500 to 3)000). Although the FDA can request further testing, the agency cannot require

it. Adverse effects may be detected by the clinical trials; the probability of detecting a harmful

effect depends on the number of patients tested,

the frequency of the reaction, and the duration

of the study (67).

Elderly patients, who consume a large proportion of most types of drugs (7,38), are not specifically mandated for inclusion as patients during

clinical trials performed for FDA approval. The

trend in recent years has been to include more

older patients in clinical trials (63), but there are

no specific guidelines or regulations for assuring

that clinical trials take account of the special drug

needs of the older population.

There are several reasons that inclusion of

greater proportions of older patients might complicate clinical trials. volunteers and patients used

in early trials must be relatively healthy to assure

safety of the testing procedure. Although a more

representative patient mix could be incorporated

into later testing, elderly patients are likely to have

several diseases, making it difficult to ascertain

whether a new sign or symptom is in fact due

to drug use rather than to a new disease or a new

manifestation of an existing condition. And many

older patients take other drugs, making it difficult to identify the particular drug that might be

causing a problem. The high prevalence of disease among the elderly increases the “noise” level

in drug reaction data, compounding the difficulty

of detecting problems. In order to compensate for

this factor, more patients must be included in

tests; this pushes up development costs and makes

analysis more difficult.

problems in current methods of drug testing

have been underscored by recent episodes of adverse reactions to antidiabetic drugs, and nonsteroidal anti-inflammatory agents for treating arthritis. The problem for these agents was lack of

testing in populations similar to those that used

the drugs in routine practice, although this was

not necessarily due specifically to a dearth of

older patients in the test groups. Both classes of

drugs are used more often in the elderly, however, and representatives of each of these drug

classes were recently removed voluntarily from

the market by their manufacturers in the United

States because of newly discovered adverse effects that were not found in premarket testing.

Such problems might be minimized in the future

by increased attention to premarket testing in representative populations, which in many cases will

involve inclusion of older individuals.

It is important to note that testing of drugs in

patients over 65, if it is to be realistic, must be

done in populations that have numbers and types

of illnesses, average ages, and sex and racial balance similar to those groups that would actually

use the drugs in practice (71).

The most difficult aspect of testing drugs in

elderly populations is assuring safety, The pharmacokinetic and pharmacodynamic differences

between the elderly and younger cohorts are more

likely to lead to overdose than to underdose, and

the increased incidence of side effects among older populations adds to this risk. Modification of

current regulations regarding drug testing in the

elderly could focus on issues of safety, In connec -
Ch. 5—Medications and the Elderly 149

tion with this, the FDA has recently proposed

guidelines for testing of drugs in older populations. The guidelines stress including older patients in late (Phase III) clinical trials and analyzing clinical trial data with attention to effects of

aging (62). The proposed guidelines focus on the

most dramatic known differences between older

and younger population groups, and do not emphasize questions of bioavailability, dosage forms,

or tissue sensitivity of new agents specific to older

patients (67). One potential problem with establishing adequate guidelines is likely to be determination that a truly representative population

of older patients has been tested (71). Identification of drug interactions is especially difficult, but

also important in older patient populations because of the larger average number of agents that

such patients take simultaneously. In addition, it

may prove difficult to test the safety of the longterm drug use in older patients who often take

drugs for chronic conditions over months or

years. Long-term administration of drugs for

older patients may expose adverse effects that appear only after cumulative use that would have

been absent in tests for premarket approval. The

FDA will continue to seek advice on how to establish guidelines that satisfy both public demand for

safety and industrial concern over increased costs

of drug development and increased regulation

(63).

COSTS OF DRUG DEVELOPMENT

The cost of clinical testing is the largest single

hurdle between drug discovery and routine clinical use (16). A 1978 report estimates that development of a new drug costs an average of $54

million per drug marketed, which includes the

cost of testing drugs that never reach the market (22). A more recent estimate is $70 million.

The costs of new drug development vary widely, depending on the nature of the drug. Antibiotics cost less than $20 million to develop, because efficacy is easy to demonstrate, and animal

models of infectious disease are readily available.

Psychopharmaceuticals, in contrast, cost more

than three times as much to develop—approximately $70 million each—largely because of costs

of clinical testing and the absence of applicable

animal models of drug action (11,19).

These high development costs have led to calls

for reducing the cost of clinical trials. It is important to rationalize the conflicts between patient

safety and expeditious approval. Additional costs

could lead to a reduction in the rate of introduction of new and useful drugs, but loosening safety

requirements might be costly in patient health

and welfare. Increased drug testing in the elderly

might increase the costs of clinical trials, and thus

of drug development. Such cost increases could

range from adding tests of pharmacokinetics in

older people, as suggested by the proposed FDA

guidelines, which would require only a few added

tests, to extensive epidemiological surveys, pharmacodynamic studies, and tests of potential drug

interactions that would cost substantially more.

Increased use of postmarketing surveillance

could contribute to establishing drug safety and

efficacy, and have the added benefit of focusing

attention on the special problems of the elderly.

Drugs could be monitored in actual use, thus identifying currently unknown adverse reactions, and

adverse effects detectable by present methods

might be found more quickly. Premarket test results could thus be supplemented, and premarket

requirements might even be reduced in some instances; representative sampling of the elderly

would be assured because monitoring would reflect actual clinical use. Safety would be encouraged by intensive surveillance. There are,

however, problems with using postmarketing surveillance to assure safety; current methods of

reporting adverse effects, for example, are unreliable (67). This may be crucial because safety

is one of the most important reasons for the stringency of FDA clinical trial protocols. There is

strong pressure to err on the side of safety, because the agency has limited power to recall drugs

once they are approved (19,39,67).

Monitoring of actual drug use is an important

element of drug regulation in several countries.

The international nature of pharmaceutical marketing suggests that monitoring of drug use is an

important area for potential international cooperation that could benefit all countries involved.

Some other nations already rely more on postmarketing surveillance than does the United

States. Some of this increased reliance on postmarketing surveillance is ascribed to the presence
150 . Technology and Aging in America

of central or national medical care delivery systems that increase physician-government contact

and allow easier governmental access to patient

and physician records (66). Because such mechanisms are not in place in the United States, effective postmarketing surveillance would require

establishment of new means of monitoring drug

effects in clinical use.

Postmarked surveillance is not, however, solely

a means of reducing the need for premarket testing; postmarked surveillance is also a mechanism

for assuring safety independently of premarket

approval practices. There are strong arguments

for retaining current procedures for premarket

testing of effectiveness and safety. The stringently

controlled clinical trials now required improve the

quality of evidence used in making treatment decisions: new drug therapies are instituted only after

careful analysis, in contrast to many other treatment modalities. Elimination or reduction of the

current premarket approval process could result

in proliferation of poorly verified treatments.

ISSUE 1: Should Congress require special testing of drugs in older population

groups before approval for marketing?

FDA requires demonstration of safety and efficacy before approving a drug or device for marketing. At present, this does not include explicit

mention of testing in older population groups.

Several drugs used primarily in older populations

have recently been withdrawn from the market

because of concern for patient safety, Yet testing

of drugs in older patients adds costs because such

patients have more complicated medical histories.

This complexity determines that more patients

must be analyzed to assure sensitivity in demonstrating efficacy or safety.

Options:

1.1: Congress could continue present regulatory requirements.

Many believe that present mechanisms of approval of drugs and medical devices are adequate

for assuring public safety.

1.2: Congress could encourage inclusion of drug

testing among older populations by oversight of

FDA .

This would entail obtaining assurances that interpretation of current legislation would be

changed to include emphasis on the needs of the

older population. The emphasis on testing drugs

could be changed, for example, by requiring pre -

market testing of agents intended for use in those

conditions identified as highly prevalent among

older populations.

1.3: Congress could create new legislation to mandate

drug testing among older populations.

This option would entail defining those conditions for which special testing is needed, and definition of the population to be protected.

Option 1.1 would retain the status quo for drug

testing. Options 1.2 and 1.3 would be intended

to protect a special population group at risk of

developing adverse reactions from drugs, but

would do so at increased cost to pharmaceutical

and medical device manufacturers, The guidelines

proposed by FDA should entail minimal increased

cost (62), but more stringent requirements would

increase costs further. Increased development

costs might lead to fewer new agents being developed, increased risk for investors, and disincentives for established companies to manufacture such products or for companies to newly

address the affected markets. Nevertheless, cost

savings to other groups, including the Federal

Government, might occur if the incidence of adverse side effects could be diminished. Savings

would result from preventing disability and lost

productivity, as well as from avoiding those health

care expenditures due to adverse effects of drugs.

ISSUE 2: Should Congress require increased

postmarketing surveillance of drugs

already approved?

Options:

2.1: Congress could continue present patterns of

postmarketing surveillance.

2.2: Congress could encourage increased use of

postmarketing surveillance.

This option could include oversight of FDA activities, mandating new requirements for manufacturers and new authorities for FDA. These

could be done either independently of or in combination with options discussed under drug

testing.
Ch. 5—Medications and the Elderly 151

Mandating increased use of postmarketing surveillance for drugs and medical devices could be

effective in monitoring the safety of such products in actual use. This is relevant to the general

population, but especially relevant to older patients, in whom the risks of adverse effects, interactions, and complications are higher. Increased use of postmarketing surveillance would

entail establishing better mechanisms for reporting adverse reactions, and might require altering

FDA legislation to permit FDA to withdraw drugs

found to be unsafe in actual use. One potential

problem in this area is access to and analysis of

drug information in Federal data systems. The

Computerized On-line Medicaid Pharmaceutical

Analysis and Surveillance System (COMPASS) at

FDA, for example, is intended to permit rapid

epidemiologic surveys of drug reactions, but has

been fraught with technical problems. The National Institute on Aging, with the American Association of Retired Persons and the Andrus Foundation, is supporting research on computerassisted epidemiologic research on drug effects

at Harvard Medical School (6). If Congress chooses

to encourage postmarketing surveillance of drug

use, more resources for epidemiologic data acquisition and information processing may be required; current university research may help determine the feasibility of monitoring for drug

effects on a national scale.

Implementation of requirements for postmarketing surveillance would raise development costs

for each drug and device, and thus might reduce

the incentives for innovation, as also noted in the

discussion of drug testing.

A more comprehensive discussion of postmarketing surveillance, which focused on the general

population rather than the special needs of the

older population, appeared in the OTA publication: Postmarketing Surveillance of Prescription

Drugs, which also included specific legislative options (67).

ISSUE 3: Should Congress encourage improved

patient education regarding use of

medications?

Options:

3.1: Congress could refrain from taking action.

3.2:

3.3:

3.4:

Congress could encourage FDA to issue patient

package inserts on medications especially prone

to misuse among older populations.

Congress could mandate inclusion of patient

package inserts on medications determined to be

especially prone to misuse by older patients.

Congress could encourage Department of Health

and Human Services activities in the area of patient education.

This could include public service messages, research support, and developement and dissemination of booklets.

Increased patient education on medications is

intended to prevent misuse by providing information to consumers. It can be accomplished by

voluntary mechanisms, such as those of the NCPIE,

AMA, and AARP mentioned above; through executive action, as taken by the Carter Administration and revoked by the Reagan Administration; or by legislative mandate.

Those who believe that voluntary programs

already under way are sufficient see no role for

increased Federal intervention. Federal requirements would increase costs for those affected by

such requirements. Mandating patient package

inserts for medications, if supplied by the manufacturer, would increase distribution and production costs. Requiring patient education through

other means, such as through physicians, pharmacists, or other health professionals, would increase the costs of their services. Increasing production and distribution costs could adversely

affect incentives for innovation, as noted under

other options. Increasing costs of health care

would raise Federal outlays for such services.

Conversely, cost savings might also be possible

by preventing adverse side effects, interactions,

and complications, as well as by reducing the

number of hospital admissions for drug-related

problems.

ISSUE 4: Should Congress encourage improved

education of health care providers

regarding older patients?

The special biological and social characteristics

of older patients have been widely noted, yet little attention has been devoted to educating physicians and other health care providers about
152 ● Technology and Aging in America

these characteristics (5). Increased knowledge of

pharmacological differences between older and

younger patients is one of many high priorities

for educating health professionals about the

special needs of the older population (1,24). Professional education has the potential to become

one of the most effective methods of preventing

future problems in drug use, and might also save

some health care costs associated with drug reactions, complications, and interactions. Some

educational programs directed at physicians have

already been shown directly to reduce Medicaid

expenditures for medications, even without taking into account the indirect savings from avoiding adverse reactions (61).

The Federal role in educating health professionals is less prominent than State and local

statutes regarding certification of practitioners

and proper medical practices. There is, however,

a Federal role in supporting training programs

for basic and clinical research and through reimbursement policies affecting delivery of health

care. The problem of insufficient knowledge and

education about gerontology and geriatrics is

global, affecting social as well as medical fields.

Actions regarding this issue are thus only discussed; congressional options are part of a larger

option of general education regarding geriatrics

and gerontology in chapter 2 and other chapters

of this report.

ISSUE 6: Should Congress require improved

labeling of over-the-counter medication?

Options:

5.1: Congress could refrain from taking action.

5.2: Congress could encourage action by FDA to require such labeling through oversight of FDA

activity.

5.3: Congress could require FDA action by new legislation.

Improved labeling of over-the-counter medications, especially aspirin and drugs with mental

side effects, would allow consumers to avoid

agents that contain ingredients to which they

know they are sensitive. Special notice of changes

in drug ingredients marketed under the same

name might be beneficial in some instances.

Special labeling might include warnings to specific classes of individuals, such as those subject

to aspirin reactions or susceptible to drug-induced

dementia. It could also encompass prominent

listing of potentially hazardous reactions to ingredients. Such labeling might increase manufacturing and distribution costs, increasing the price of

a product needed in high quantities by several

groups of patients, especially those afflicted with

osteoarthritis. Potential cost increases, however,

might be defrayed in part or entirely by reduced

incidence of aspirin reactions and side effects

resulting from unknowing ingestion of compounds

that cause confusion in susceptible patients.

ISSUE 6: Should Congress authorize and fund

more randomized clinical trials for

drugs and treatments prevalent

among older Americans?

Options:

6.1: Congress could refrain from mandating funding

of more clinical trials.

6.2: Congress could direct the Health Care Financing

Administration (HCFA) or the National Institutes

of Health (NIH) to support more randomized clinical trials, especially for those conditions requiring multiple agents or for conditions highly preva -

lent in the older population.

6.3: Congress could encourage or require third-party

payers (e.g., health insurers) to fund some clinical trials.

Older people are susceptible to multiple disorders, and often have conditions that can be

treated in a multiplicity of ways. Treatments for

such disorders as hypertension, osteoarthritis,

and osteoporosis are common in the geriatric population, and yet optimal treatments for these conditions are often not apparent because of the

plethora of potentially effective drugs and other

treatments. Comparative studies of different treatment combinations are often not available. The

large number of non-steroidal anti-inflammatory

drugs, for example, have not been directly compared for relative overall efficacy, incidence of

adverse side effects, and comparative appropriateness for patient subgroups. Several members

of this group of drugs have not been compared

with aspirin, the most common drug used for osteoarthritis, Drugs from this class have been
Ch, 5—Medications and the Elderly • 153

recalled for unanticipated side effects noted in

clinical use after approval for marketing, and two

additional agents are currently under investigation by the Secretary of Health and Human Services. Clinical use of the different agents is a topic

of current medical controversy.

The standard method for dealing with such controversies is the randomized clinical trial, the

acceptance of which marks one of the major advances of modern medicine. Careful studies of different treatments can be compared under controlled circumstances to establish the utility of

competing regimens, and may also determine the

lack of substantial differences between different

modalities of treatment (68).

Increased support for such trials, however, is

likely to be quite costly. Supporting these trials

from the NIH budget might detract from more

basic biomedical research. Supporting trials

through HCFA has been suggested, but would reChapter 5 references

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quire a new allocation of resources within HCFA

or increased overall funding for the agency. Increased support for trials could also be obtained

through partial or full reimbursement by thirdparty payers.

Savings from such research might be obtained

both for the Federal Government and third-party

payers through reduced incidence of side effects

due to present suboptimal levels of treatment and

by preventing unnecessary complications. The

magnitude of savings, however, cannot be estimated because there is insufficient knowledge

about current therapeutic practices and the potential for improvement in health that might arise

from rationalizing treatment.

A more complete discussion of the issues surrounding clinical trials can be found in the OTA

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151-181.

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T. Crook and G. Cohen (eds.) (New Canaan, CT:

Mark Powley & Associates, Inc., 1981).

Institute of Medicine, Aging and Medical Education (Committee chairm;n: Paul B. Beeson), Publication IOM-78-04 (Washington, DC: National Academy Press, 1978).

25. Jarvik, J., and Reisberg, B., “Drugs Prescribed To

26

Treat Cognitive Dysfunction,” Physician’s Handbook on Psychotherapeutic Drug Use in the Aged,

T. Crook and G. Cohen (eds.) (New Canaan, CT:

Mark Powley & Associates, Inc., 1981).

Kanouse, D. E., Berry, S, H., Hayes-Roth, B,, et al.,

Informing Patients About Drugs (Washington, DC:

Rand Corp., 1981).

27. Kasper, J. A., “National Health Care Expenditures

Study, ” Prescribed Medicines: Use, Expenditures,

and Sources of Payment, Data Review 9, National

Center for Health Services Research, U.S. Department of Health and Human Services, Hyattsville,

MD, April 1982.

28. Keown, C. F., “Risk Judgments and Intention Measures After Reading About Prescription Drug Side

Effects in the Format of a Patient Package Insert)”

Journal of Consumer Affairs, 17:277-289, 1983.

29. Knapp, D., Food and Drug Administration, Public

Health Service, U.S. Department of Health and Human Services, 1982: “Geriatric use of drugs,”

“Geriatric use of drug products lacking adequate

evidence of effectiveness, ” and “Geriatric use of

drugs with psychiatric effects,” papers prepared

by FDA, not published because statistical analysis

was not conclusive. The points made in this chapter do not depend on such statistical analysis.

30. Koepsell, T. D,, Gurtel, A. L., Diehr, P. H., et al.,

“The Seattle Evaluation of Computerized Drug Profiles: Effects on Prescribing Practices and Resource

Use,” Am. J. Pub. Hlth., August 1983.

31. Lampe, K. F., “Physician Interventions,” presented

at the Drug Information Association workshop on

Geriatric Drug Use-Clinical and Social Perspectives, Washington, DC, Feb. 27, 1984.

32. Lamy, P, P., “Drug Prescribing for the Elderly,”

Bull. N.Y. Acad. Med. 57:718-730, 1981.

33. Lamy, P. P., “Comparative Pharmacokinetic Changes

and Drug Therapy in an older Population, ” J. Am.

Geriat. Soc. Suppl. 30:s11-s19, 1982.

34. Lamy, P. P., ‘

(Effects of Diet and Nutrition on Drug

Therapy)” J. Am. Geriat. Soc. Suppl. 30:s99-s112,

1982.

35. Lamy, P. P., “Over-the-Counter Medication: The

Drug Interactions We overlooked, ” J. Am. Geriat.

SOC. th.qlp]. 30:s69-s75, 1982.

36. Lamy, P. P., “Therapeutics and an Older Population: A Pharmacist’s Perspective, ” J. Am. Geriat.

SOC. Suppl. 30:s3-s5, 1982 .

37. Lamy, P, P., response to OTA draft document,

March 1984.

38. Lee, P. R., and Lipton, H. L., “Drugs and the

Elderly, ” contract report, University of California

at San Francisco, August 1983.

39. Lipton, H. L., and Lee, P. R., “Drugs and the Elderly,” Administration on Aging Background Paper, draft, Office of Human Development Services,

U.S. Department of Health and Human Services,

September 1982,

40. Louis Harris & Associates, “Patient Information

and Prescription Drugs: Parallel Surveys of Physicians and Pharmacists,” March 1983.

41. Mace, N. L., and Rabins, P. V., The 36-Hour Day

(Bakimore: Johns Hopkins University Press, 1981).

42. McGandy, R., et al., USDA Human Nutrition Research Center on Aging, Tufts University, “DrugNutrient Interactions,” Nutrition and Aging, contract report for the Office of Technology Assessment, October 1983.

43. McGlone, F. B,, “Therapeutics and an Older Population: A Physician’s Perspective,” J. Am. Geriat. Soc.

Suppl. 30:s1-s2, 1982.

44. Medical Economics Co., “Medication Mistakes and
Ch. 5—Medications and the Elderly ‘ 155

Noncompliance,” Practical Guide to Geriatric A4edications (Oradell, NJ: Medical Economics Co. Book

Division, 1980), pp. 93-138.

45. Melmon, K. L., and Blaschke, T. F., “The Undereducated Physician’s Therapeutic Decisions, ” IV. Engl.

J. Med. 308:1473-1474, 1983.

46. Mendels, J., “Antidepressants,” Physician’s Handbook on Psychotherapeutic Drug Use in the Aged,

T. Crook and G. Cohen teds.) (New Canaan, CT:

Mark Powley & Associates, Inc., 1981).

47. Meyer, B. R., “Pharmacodynamic Risk Factors in

Geriatric Drug Use,” presented at the Drug Information Association workshop on Geriatric Drug

Use--Clinical and Social Perspectives, Washington,

DC, Feb. 28, 1984.

48. Miller, R. W., “Doctors, Patients Don’t Communicate,” FDA Consumer, DHHS publication No. (FDA)

83-1102, reprinted July/August 1983.

49. Moore, S. R., Kalu, M., and Yavaprabbas, S., “Geriatrics and Gerontology,” Drug Intel]. Clin. Pharm.

17:920-3, 1983.

50. Morris, L. A., Grossman, R., Barkdoll, G. L., Gordon, E., and Soviero, C., “Patient Receipt of Prescription Drug Information, ” OPE Study 67, September 1983.

51. Morris, L. A., and Olins, N. J., “Utility of Drug

Leaflets for Elderly Consumers,” Am. J. Pub. Hlth.,

1984.

52. National Council for Patient Information and Education, press releases and Task Force Reports,

1983.

53. Olins, N. J., press releases from the American Association of Retired Persons, Alexandria, VA, 1983.

54. Ouslander, J. G., “Drug Therapy in the Elderly,”

Annals Int. Med. 95;711-722, 1981.

55. Palumbo, F., University of Maryland, Baltimore,

personal communication, March 1984.

56. Paroles, H., opening address, “Practical Approaches

for Meeting the Mental Health Needs of the Elderly,” Project HOPE, Millwood, VA, March 1983, pp.

23-24.

57. Ray, W. A., Federspiel, C. F., and Schaffner, W.,

“A Study of Anti-psychotic Drug Use in Nursing

Homes: Epidemiologic Evidence Suggesting Misuse,” Am. J. Pub. H]th. 70:485-491, 1980.

58. Reidenberg, M. M., “Drug Interactions and the Elderly,”J. Am. Geriat. Soc. Supp]. 30:s67-s68, 1982.

59. Schaffer, W., Ray, W. A., Federspiel, C. F., and Miller, W. O., “Improving Antibiotic Prescribing in Office Practice,” J.A.M.A,, Oct. 7, 1983.

60. Simonson, W., Medications and the Elderly (Rockville, MD: Aspen Publications, 1984).

61. Soumerai, S. B., and Avorn, J., ‘(Benefits and Costs

of an Experimental Academically Based ‘Detailing’

Program To Improve Drug Therapy Decisions of

Office-Based Physicians, ” October 1983.

62. Temple, R., “Discussion Paper on Testing of Drugs

in the Elderly,” FDA memorandum, Sept. 30, 1983.

63. Temple, R., “FDA Clinical Guidelines for Geriatric

Testing)” presented at the Drug Information Association workshop on Geriatric Drug Use—Clinical and Social Perspectives, Washington, DC, Feb.

28, 1984.

64. Thompson, T. L., Moran, M. G., and Nies, A. S.,

“Psychotropic Drug Use in the Elderly,” N. Engl.

J. Med. 308:134-138, 194-199, 1983.

65. Trapnell, G. R., National Health Insurance Issues:

the Cost of a National Prescription Program (New

York: Health Issues, sponsored by Roche Laboratories, 1979).

66. U.S. Congress, General Accounting Office, FDA

Drug Approval—A Lengthy Process That Delays

the Availability of Important New Drugs, HRD-80-

64, May 28, 1980.

67. U.S. Congress, Office of Technology Assessment,

Postmarketing Surveillance of Prescription Drugs,

OTA-H-189 (Washington, DC: US. Government

Printing Office, November 1982).

68. U.S. Congress, Office of Technology Assessment,

The Impact of Randomized Clinical Trials on

Health Policy and Medical Practice-A Background

Paper, OTA-BP-H-22 (Washington, DC: U.S. Government Printing Office, August 1983).

69. U.S. Department of Health and Human Services,

Alcohol, Drug Abuse, and Mental Health Administration, National Institute on Drug Abuse, Treatment Research Report: Drug Taking Among the

Elderly, DHHS publication No. (ADM)83-1229,

1982.

70. U.S. Senate, Special Committee on Aging, U.S.

House of Representatives, Select Committee on Aging, and the Subcommittee on Health and LongTerm Care, S. Hrg. 98-392, Drug Use and Misuse:

A Gro~”ng Concern for older Americans, June 28,

1983.

71. Williams, T. F., “Setting the Agenda for Geriatric

Drug Research,” presented at the Drug Information Association workshop on Geriatric Drug Use—

Clinical and Social Perspectives, Washington, DC,

Feb. 27, 1984.

38-800 0 - 85 - 6
Chapter 6

Information Technology and the

Health of an Aging Population

Introduction

The “information revolution” has profoundly affected business and commerce, recreation, education, security, and social interaction. Until very

recently, this revolution has had little apparent

effect on most of our health institutions and practices. Yet information technology has changed

the entire health system and is a distinctive element in all fields of health. These fields and contributions include:

●

●

●

●

●

●

●

medical education—access to biomedical data

bases;

public health and biomedical research-computer modeling and statistical analysis;

health care delivery-construction of diagnosis-related groups;

patient care—access to computer-assisted diagnostic systems;

information management—medical information systems;

occupational health—epidemiological analyses; and

patient education-computerized health risk

appraisal instruments.

Although the rate at which information technology has been incorporated into the health care

system has been less rapid than predicted 10 or

20 years ago, it is now clear that it will be an increasingly important part of this system at all

levels.

1A previous OTA report has defined information technology to

include “communications systems such as direct broadcast satellite, two-way interactive cable, low-power broadcasting, computers

(including personal computers and the new hand-held computers),

and television (including video disks and vrideo tape cassettes)” (62).

Because of space limitations and the importance of the computer

as an access tool to health information, this report more narrowly

defines information technology as ‘(the application of computers and

telecommunication systems to the creation, storage, manipulation,

and dissemination of information. ”

Relatively little attention has been devoted to

applying information technology to the specific

health needs of the older population, which

stands to benefit significantly from its various applications. Information technology can enhance

functions diminished by the aging process in the

“healthy” elderly, improve health care for those

with acute and chronic medical problems, and enrich the health care services that traditional health

care institutions and professionals provide. It can

also disseminate information on maintaining and

improving health and on the availability of services in new environments such as home and community centers.

Because there are as yet few examples of the

application of information technology to the

health needs of the older population, this chapter

focuses on the potential use of information technology. The contribution of information technology to specific health fields, such as patient care

and public health, can be extended to their gerontological components. Technological limitations

will be overcome in time. The scarcity of current

information technology specific to the elderly

underscores another focus of this chapter—the

future elderly. There are profound differences

in responsiveness to any technology, including information technology, depending on age. In 10

to 20 years, the elderly are likely to have a completely different view of information technology

than their counterparts have today. The difference will be even more dramatic when the “computer generation” becomes eligible for Medicare,

In this context, it is important to recognize the

heterogeneity of the older population. Older Americans vary widely in such areas as financial status,

health status, and levels of enthusiasm, Many older people look upon computers as another of life’s

opportunities and challenges (33), while others

159
160 ● Technology and Aging in America

find it difficult to adapt to the lifestyle changes

they can bring.

This chapter restricts the definition of information technology to computers and telecommunications, and focuses on information technology as

used by elderly individuals for their health care,

either alone or, most often, in conjunction with

a physician and other health professionals.

Information technology can be used both to

promote preventive behaviors and to help manage chronic conditions. Discussion of its role in

the health of America’s elderly is important for

a number of reasons. The use of information technology by the patient for health purposes has received minimal attention to date, although a large

body of literature, including reviews, has looked

at information technology in terms of other health

fields, albeit without an age-related focus. OTA

has produced two such publications, Computer

Technology in Medicated Education and Assessment

(64) and Policy Implications of Medical Information Systems (65).

As the U.S. population ages, more people will

need assistance in functioning, particularly at

home. The number of elderly people confined to

bed, barring unforeseen changes in disease patterns, is expected to rise from 458,000 in 1977

to 658,000 in 2000. The number of those needing

help in getting around their own homes will rise

from 1.9 million to 2.7 million during this period,

and a similar increase is expected in numbers of

those who are limited in carrying out some activities of daily living (19). Some 2.8 million elderly

now need the help of someone else to carry out

one or more of their daily activities (70). When

adapted to the specific needs of the elderly, information technology can be a primary source

of such assistance.

The growth of the elderly population will intensify demands on the U.S. health care system,

producing significant increases in hospitalization,

the use of hospital-based services, and nursing

home care (19). By directly assisting with home

health care and providing access to information

concerning care for the elderly, either at home

or on an ambulatory basis, information technology can reduce today’s heavy reliance on highcost institutional services.

Information technology is expected to increase

the role of the elderly in their own care by improving their access to health information and

services. Such technology will be used at home,

in physicians’ offices, clinics, or in hospitals by

the elderly, either alone or with the assistance of

others, including health professionals. One form

of information technology, networking, z has the

potential to greatly improve their social interaction, mental health, and access to health and other

information.

This chapter discusses what is known about information technology and its use by the elderly

for health purposes, including the cost of providing the technology. Two major factors underlie

such use by the elderly—their ability to use information technology and the extent to which

they participate in their health care.

‘Networking (computer networking) is the transmission of data

either to human users or to other computers through connections

that link a telecommunications system. In this way, computers can

transmit data throughout the Nation and the world, sharing work

and data among groups of linked computers.

The elderly’s ability to use information technology

The ability to use information technology such

as the computer varies considerably with the

older individual. Those with active minds are

likely to relish the acquisition of new knowledge:

a computer club in Menlo Park, CA, teaches elderly members to program computers as well as to

operate them (33). The Elderhostel program at

Reed College, which is limited to persons over 62.
Ch. 6—information Technology and the Health of an Aging Population ● 161

offers a hands-on introduction to personal computers as one of its summer residential academic programs for older adults (49).

Even the less adventurous older person may

welcome operating a computer for health purposes. The level of computer literacy needed to

obtain health information need not be high, and

the older individual often has assistance; in a community setting, other people are usually available

to help. Home use could be facilitated by a family

member, neighbor, or a paid or voluntary visitor. Difficulties with independent use of the new

technologies may thus be limited to a small segment of the elderly population. Although more

than 60 percent of those over 85 have major limitations in activity, this proportion is lower at

younger ages. The size of this group is further

reduced by the fact that with the exception of

visual, neurological, and muscular problems, most

of the limitations of those over 85 generally would

not constrain their use of a computer terminal.

There has been little study of the ability of older individuals to use computers in general and

still less about their ability to use computers for

health care. Available evidence indicates that

some elderly people enjoy programming and applications software, such as spreadsheets, and

others enjoy recreational computer games and

communicating by means of computers adapted

to their capabilities.

.

A 1980 study of computer communication and

the elderly found them highly receptive to using

the computer and appreciative of the control that

it afforded them. Interactive communication with

other users was preferred over computer games

by the subjects, who were residents of an urban

retirement hotel. Their favorite game was highly

interactive and simulated personal communication. The system required a number of modifications for the older users, including a large display

screen and large characters on the keyboard. The

presence of a trained computer demonstrator in

a small group setting during the initial stages

facilitated the learning process. The researchers

concluded that additional modifications to the

hardware, such as color-coded keys, would increase user satisfaction (18).

A more recent examination of computer use by

the elderly was conducted during a series of

workshops held in 1983 in Washington, DC, and

surrounding suburban areas (38). A total of 200

individuals, ranging in age from 60 to 95, attended

at least one of 14 workshops. The study population was recruited from educational programs

for the elderly sponsored by churches, nursing

homes, and recreational centers. The response

was extraordinarily enthusiastic. To the surprise

of the researchers, these older computer users

obtained the greatest satisfaction from the programming portion of the workshop. They were

apt learners and had the patience required for

the task. The participants also enjoyed applications software, such as spreadsheets, but were

not interested in most computer games. The study
162 ● Technology and Aging in America

indicates that at least one segment of the elderly

population—those who are active and enthusiastic—are more than ready for the computer age.

Another study found that the “frail elderly” can

also benefit from information technology. A study

of 50 elderly nursing home residents, whose

average age was 85 and who had moderate mental and physical impairments, found that these

frail elderly were able to participate in computer

games that had been especially adapted for them.

Adaptations included slowing down the game so

that residents with such handicaps as impaired

vision or hearing, tremors, or hemiplegia could

enjoy winning. Most of those who were asked to

participate were willing and eager to try the computer games; all were willing to try them a second time. The study points out that visual symbols in video games for the elderly must be large

and well defined and auditory clues distinct and

clear, and that these can be used to exercise and

improve memory, enhance hand and eye coordination, and increase ability to concentrate on a

task (77).

Although most of today’s elderly, or, for that

matter, most of today’s middle-aged, have had

little experience with computers, the evidence,

though scant, indicates that they are receptive to

using the new technology, either “as is” or when

tailored to their needs, The elderly of the future

are likely to be more open to using computers

because of exposure to them throughout their

lifetimes.

The development of new computer and communications technologies for those who are functionally limited is taking place at an astonishingly

rapid pace. Computers incorporating features to

counteract eyestrain or more serious vision problems are now available commercially. Oversized

video displays are relatively inexpensive, but keyboards with large keys are usually custom built

and costly (50). Other approaches include enlarging the letters on present keyboards or colorcoding letters when only a few input commands

are needed.

Display interaction-the use of light pens to obtain information from a computer—is potentially

useful for elderly individuals who find it difficult

to use a keyboard. The light pen, used in conjunction with a softwaredriven menu that appears

on the screen, is pointed at the item of interest

in the menu, which is then displayed on the

screen. Even severely functionally limited elderly

people can make contact with a computer by utilizing a sophisticated light pen that need not make

physical contact with the screen in order to activate the computer. The pen is under development

for those handicapped by high-level spinal cord

injuries and cerebral palsy, or for amputees,

among others (28).

Another substitute for a keyboard is the touchsensitive terminal. The user simply touches a sensitized television screen’s computer-generated

menu to obtain audio and visual information.

Hewlett-Packard is marketing a touch-sensitive

system, Bell Laboratories has installed one at Epcot Center for use as an information system by

visitors, and Boston’s Sheraton Hotel uses one to

provide information to its guests on in-hotel services and activities. Many homes are expected to

have them by the mid-1980s.

Voice-activated systems that enter data and receive output on microcomputers are rapidly improving in both price and performance, with

accurate representation of speech likely by the

1990s (62). Although the capability of current systems to recognize speech is limited, computers

can be programmed to recognize a specific voice

and follow simple commands.

Another new technique, the transparent access

approach, is being used to give handicapped people access to standard hardware and software

programs (73). The approach allows a specialized

modular design of input and output devices for

the handicapped but gives access to software and

hardware designed for the general public.
Ch. 6—information Technology and the Health of an Aging Population ● 163

The elderly and self-care

The use of information technology for health

purposes by older individuals is also bounded by

the extent of their involvement in their health

care, either through selfware or through self-help

groups. About 75 percent of all health care is estimated to be self-care (41), which substantially

eases pressures on the health care system.

Self-care and self-help, as information-based

health care activities, are becoming increasingly

recognized as legitimate sources of care in the

United States (21). Although definitions of these

concepts vary, self-care can be generally defined

as ‘(actions that we as individuals perform on behalf of our own, our family’s, or our neighbor’s

well-being” (72).

An individual’s interest in being in control of

his or her own health care is often considered

to be the basis of self-care. This concept can be

applied to all levels of health care, including care

provided through the use of high technology (40).

It also applies to care taken in consultation with

health professionals; this application has received

the greatest degree of approval from health professionals and appears to be the most appropriate for an elderly population.

Self-help groups are ‘(clusters of persons who

share a common condition, and who come together to offer one another the benefit of their experience and mutual support” (72). Broadly defined, these groups may total several hundred

thousand in the united States (37). A recent inventory which used a more restrictive definition

identified more than 2,000 U.S. programs offering medical self-care instruction (21).

Self -care encompasses a broad variety of activities, ranging from: 1) daily health practices, such

as brushing teeth; to 2) increasing one’s knowledge about health through such sources as magazines, pamphlets, and health fairs, and acting

upon the information received; to 3) assuming

tasks traditionally found in a health professional’s

realm of practice. This last mode of self% are usually requires formal training in which health skills,

such as measuring blood pressure and heart rate,

are learned (15).

The delegation to patients of certain tasks usually performed by professional caregivers has

long been routine. Diabetics of all ages test their

urine and give themselves insulin injections; persons with angina medicate themselves with nitroglycerin. Physicians and the Federal Government

encourage women to undertake periodic self-examinations for breast cancer (66). Patients undergoing continuous ambulatory peritoneal dialysis

are directly involved in their treatment at home

(60). Health education programs, usually initiated

by consumers, disseminate a wide variety of skills,

such as showing parents how to obtain throat cultures from their children, and teaching women

how to take a pap smear or do a pelvic exam.

Computer and communications technologies are

expected to play an increasingly important role

in enhancing the ability of people of all ages to

perform tasks traditionally done by professionals.

Although self-care and self-help programs afford wide opportunities for improving general

health, many serious issues remain unresolved.

These include questions on the degree of commercial involvement in the programs and the

extent of professional involvement and support.

Participants may feel that there is too much professional input into some programs; physicians

are often concerned about the lack of a significant professional component (15). Additional

issues include the political implications of certain

programs, and problems of evaluating the effectiveness of any program in improving health (21).

Few self-help programs are designed specifically

for the elderly, but many existing programs appear to be appropriate for their needs. An important factor in the growth of self-help groups has

been the shift in disease patterns from acute to

chronic illness. Chronic disease requires greater

reliance on the individual, who must actively and

continuously modify his or her lifestyle in order

to cope with the burden imposed by the disease.

Self-help groups are singularly suited to the care

of chronic diseases, and many such groups (e.g.,

the Reach for Recovery Program of the American Cancer Society and the Cardiac Rehabilitation

Group of the American Heart Association) have
I&# . Technology and Aging in America

been established, largely as a result of private

funding. Although the prevalence of chronic disease among the elderly is high, few organizations

have as yet “taken cognizance of the special needs

of the elderly” (15).

Self-care is also well suited to health promotion

and disease prevention in terms of health risktaking behavior. Selfware education can reduce

the probability of disease, disability, or premature

death from a number of illnesses in which lifestyle

has been shown to play a role. The unique circumstances of the elderly make it essential that

self-care education be structured to accommodate

their specific requirements and expectations, yet

little has been accomplished in this area.

Preliminary estimates from a large-scale effort

to identify self-care and self-help programs in the

United States found at least 25 self-care programs

specifically focusing on training or activities for

the elderly. Many other programs for the elderly

include self-care as part of the curriculum. The

programs vary in sponsorship and setting, target

group, method of implementation, type and size

of staff, and goals and activities (21). Data on the

use of information technology in these programs

are not yet available (20).

Futurists contend that the use of computers and

telecommunications will promote a change away

from specialist care to self-care (43,56). At the

same time, enhanced interest by consumers in

self-care and their greater awareness of health

and the value of health information will be important factors in their decisions to use information technology for health purposes.

The Federal Government has played a relatively

minor role in promoting self-care and self-help

among the older population. The National Institute on Aging (NIA) published an excellent pamphlet on self-care and self-help for the elderly in

1980 (72), and both the National Institute of Mental Health and NIA have provided grants to train

paraprofessionals to help organize self-help

groups among older people.

Also NIA recently began the funding of research

into the nature of older people’s behaviors and

attitudes (68) in using three levels of health care.

The emphasis will be on self-care and informal

care and their relevance to health and disease in

older people, regardless of whether the behaviors

have in fact been found by epidemiological studies

to be “risk behaviors.”

NIA has also begun accepting proposals under

the Small Business Innovation Development Act

for self-care research projects for the elderly. The

projects are aimed at increasing the self-sufficiency and sense of well-being of older individuals by

enabling them to gain confidence in their ability

to prevent and manage many of their health conditions. One project would develop a blood pressure self-care modality based on systematic training and education in dietary, exercise, and

relaxation techniques. participants would be compared in their ability to control or modify their

blood pressure with their counterparts in a conventional medication program (Grant Application

to the Small Business Innovation Program, 8/83).

Information technology for health purposes

Computer-assisted health instruction

The use of computer-assisted health instruction

is a logical extension of self-care/self-help. The

growing use of information technologies for educating the public about maintaining health, and

preventing or treating disease, is rapidly increasing the number of software programs on health

education and management-diet, exercise, drug

interactions, etc.—that can be run on a home computer (8).

The relevance of this technological phenomenon for use by and for the elderly has not yet

been widely recognized in either the private or

public sector, however. The use of information

technologies, particularly the microcomputer,

could help the elderly maintain independent liv-
Ch. 6—Inforrnation Technology and the Hea/th of an Aging Population ● 165

ing, and is likely to be particularly effective when

used in conjunction with physicians and other

health care providers.

Current efforts to develop such technology specifically for use by the elderly are hampered by

lack of interest and lack of funding, but a few

projects are underway. A specialty group associated with the American Association of Medical

Systems and Informatics, for example, has a specific interest in health assessment of the elderly

and automated systems for this age group. Their

focus is on information systems support for older

Americans, with an emphasis on health promotion and disease prevention, and on developing

a computer-assisted personal health management

system for promoting the concept of wellness of

the elderly (12).

Although very little computer-assisted software

health instruction material is being developed specifically for the older population, health software

is being produced by all sectors, including the forprofit, not-for-profit, not-for-profit with for-profit

sponsorship, and by firms or academic institutions with a wide variety of expertise. A relatively

large number of such products has been developed for mainframe computers, and the number

of such programs for microcomputers is beginning to grow. The rapid expansion of personal

computer capabilities has catalyzed the development of software packages to the extent that the

Office of Disease Prevention and Health Promotion of the Public Health Service publishes a list

of health promotion software for health educators, other health professionals, and individuals

interested in developing good health habits. Topics include basic living skills, general health information, health risk appraisals, stress management, and nutrition and diet (70). Most of the

software programs, which are not evaluated, are

marketed by for-profit firms and few are inexpensive. The issue of costs and individual application of information technology, including software, is discussed later in this chapters

As in any new product area, problems abound.

The field is diverse and unsettled. In some cases,

3A computer monthly has also published an article listing a number of commercially available nutrition, diet, and fitness software

programs (23).

programs are developed by transient “entrepreneurs” who lack subject knowledge and are often

forced out of the market. A large number of colleges and universities have developed health instruction materials and are marketing or planning

to market their products. Most available software

programs have not been evaluated, but the serious issue of establishing evaluation criteria is beginning to be addressed (32).

TYPES OF INSTRUCTIONAL PRODUCTS,

DEVELOPERS, PRODUCERS, AND SETTINGS

Private sector health software programs vary

widely in both content and price—from nutritional programs that cost as much as $700 (69) to

weight control and nutrition programs that help

users balance meals and create weekly menus for

$39.95 (55). Diabetics, for example, can purchase

$100 software programs that focus on their daily

fluctuations of blood sugar and insulin.

In the nonprofit sector, the Kellogg Foundation

is funding the development of health education

and promotion software for use by adolescents

and their families, primarily in clinic settings.

Topics include alcohol and drug abuse, stress

management, smoking, diet and exercise, human

sexuality, and family communications (10). The

program is being systematically developed, tested

with control groups, and evaluated; a preliminary

report on its effect on the health knowledge, attitudes, and behaviors of adolescents is scheduled

for early 1985.

Manufacturers of the Apple computer have

sponsored the development of a number of health

information programs at Ohio State university.

When one such program, “Kardia,” which describes risk factors for heart attack, was assessed

by patients in the waiting room of a family practice clinic, 95 percent found it acceptable. patients

had to access the program and interact with the

material presented; 91 percent said that it was

both helpful in providing an understanding of

health and very easy to use (17).

A software package developed at the Abbott

Northwestern/Sister Kenny Institute, in cooperation with a firm with expertise in microcomputer

courseware technology and educational methodology, illustrates how information technology can
166 ● Technology and Aging in America

be adapted to the needs of a particular population, in this case hospital patients with low back

pain. The Institute is a major medical center that

is both an acute care facility and a rehabilitation

center; a considerable proportion of its patients

suffer acute and chronic low back pain. The software takes the physical status, learning readiness,

and motivation of the patient, and the resources

of the health care facility into account. The microcomputer is accessible to patients at all hours, so

that patients can use it when they are not in pain,

and is portable so that the keyboard can be used

easily from a wheelchair or at bedside. Segments

of the course are short to accommodate to the

patient’s comfort level and attention span. Upon

leaving the hospital, the patient better understands the problem and has received instruction

for lifestyle adaptations to protect himself from

further injury. The courseware is currently being marketed through the Institute and a computer consulting firm (16).

A computer-based education program for patients with rheumatoid arthritis, written at the

University of Connecticut School of Medicine, is

one of the few programs that has an evaluation

component (78). The program’s initial evaluation

found that participants demonstrated more positive changes in knowledge, self-reported compliance behaviors, and affect than did a control

group. The interactive program is stored on a

mainframe computer located at the university’s

health center, where it can be accessed by telephone from terminals located at any site, and is

written in lesson format. Although the program

was not developed for the elderly, it does make

some provisions for them. A planned software

program on osteoarthritis will have several access features for older patients, such as a largetype option, a cutout template that is blocked off

and color coded for different functions, and, possibly, a speech synthesizer (57).

The use of computers for in-hospital health education appears ready for major expansion. The

American Telephone & Telegraph Co. (AT&T) is

exploring the potential for developing computerized health educational materials with Johns Hopkins Hospital and other facilities. Little detailed

information is yet available about the project,

which is in the planning stage, but it may utilize

video disks, and a software program instructing

patients in post-heart attack management maybe

developed (51).

Software packages for health hazard/health risk

appraisals (HHA/HRA) are also proliferating. The

HHA/HRA is a technique for health promotion

in which the user fills out a questionnaire and

then receives information on his or her health

status and recommendations for change. The appraisal rates the user’s chances of becoming ill

or dying from selected diseases by comparing selfdescribed health-related behaviors and personal

characteristics to mortality statistics and epidemiological data (74). The appraisal is designed to

motivate individuals to change their lifestyle and

improve their health (22), but because it generates a statement of probability and not a diagnosis, it can present problems (26). Many consumers

lack the expertise needed to distinguish between

risk factors and diagnosis and may not understand the information they receive. Thus some

researchers contend that computer-assisted appraisals are best when part of a comprehensive

program that might include face-to-face interaction with health professionals and written explanatory materials (47).

Few HHA/HRAs have been developed for the

elderly population, although a number of instruments are available to health professionals for use

in assessing the general functioning of their

elderly patients (36)42). Numerous self-administered scales have been developed to measure psychological conditions in the aged (36), and computer games could be devised to measure various

aspects of aging, such as cognition (35).

Because many database and methodological

problems are associated with the construction of

health risk appraisals, their use is controversial

(74). Even when coupled with programs known

to decrease the prevalence of risk indicators, it

is not known whether appraisals will in fact yield

dividends of healthier, more productive people

and reduced expenditures related to illness, disability, and premature death (26). As is the case

with many health care technologies now in use,

their role and value have yet to be fully evaluated.

There are also unique problems associated with

using health risk appraisal instruments for today’s
.

Chapter 6

Information Technology and the

Health of an Aging Population
Contents

Page

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ~ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 159

The Elderly's Ability to Use information Technology. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 160

The Elderly and Self-Care . . . . . . . . . . . . . , . . . . . . . . . . . . . . . . . . . . . . . . , . . . . . . . . . . . . 163

Information Technology for Health Purposes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 164

Computer-Assisted Health Instruction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 164

Computer-Assisted Patient-Health Professional interactions . . . . . . . . . . . . . . . . . . . . . . . 167

Access to Computer-Assistecl Information and Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 171

Federal Activities . . . . . . . . . . . . . . . , . . . . . . . . . . . . . . . , . . . . . . . . . . , . . . . . . . . . . . . 173

Research Needs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 174

Conclusions . . . . . . ... , . . . . . . ... , . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 174

Congressional Issues and options . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 175

Chapter 6 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 179
Ch. 6—information Technology and the Health of an Aging Population Ž 169

instruction as by a therapist (1), there is also concern that some programs may simply delay recovery in some cases (76).

The elderly, particularly the home-bound elderly,

could profit from the availability and accessibility

of computer-assisted mental health instruction.

Home computer use could greatly enhance their

ability to obtain reliable assistance with psychological problems and anxieties that are often overlooked and untreated. Effective computer-assisted

instruction in the mental health field, as in all

health fields, will require the guidance of professionals in the development, use, and evaluation

of self-help programs.

Information technology can also assist health

professionals with the care of the dependent

elderly, who are a minority of the over-65 population, yet use a disproportionate amount of this

age group’s health services. Frail individuals

would benefit from the availability of personal

health software that combines diet, exercise, and

stress monitoring. They could establish their own

biochemical profiles to determine efficacy and

safety of particular drugs for themselves (9), and

develop diets appropriate for their health maintenance.

Some members of the older population have

multiple chronic health problems that require extensive care and treatment (70). Some 77 percent

of the elderly have annual Medicare reimbursements of less than $500, but 8.8 percent have

average Medicare payments of more than $3,000

(7).

Computer-assisted health care that complements professional care may enable chronically

ill people to remain in their homes when they

wish to do so. About 45 percent of the noninstitutionalized elderly presently face limitations caused

by chronic disease. Although this proportion is

not likely to change dramatically, the total number of those limited by chronic disease is projected

to rise sharply as the over-65 population grows

from 27 million in 1983 to 35 million in 2000. The

oldest group of elderly—those over 75, who need

the most care—is growing even more rapidly. In

1965, 37 percent of Medicare’s elderly enrollees

were over 75; by 1981, this proportion had risen

to 41 percent (58).

A number of factors point to an increase in the

proportion of the chronically ill population who

may choose home care over institutional care in

the future. An estimated 15 to 20 percent of today’s institutionalized elderly could be living at

home if home health services were available and

reimbursable. Such services are gradually becoming reimbursable through a number of funding

sources, such as Title XX of the Social Security

Act and Title III of the Older Americans Act, Services are also becoming available as a result of the

phenomenal growth in segments of the home

health care industry. According to the National

Homecaring Council, the number of homemaker/

home health aide service programs has grown

from 300 in 1972 to more than 5,000 in 1984 (45).

Moreover, advances in medical technology now

allow services to be provided at home that once

required an institutional setting (2). Reductions

in size and complexity have made many machines

portable. By the late 1980s, consumers are expected to spend at least half a billion dollars annually for electronic devices to be used in the

home for health monitoring and disease prevention (9), Use of these devices will be limited, however, by the need for accurate diagnosis of illness,

which requires training and knowledge to interpret the results of the instrumentation (46). Telecommunication equipment connecting patients

and health professionals will facilitate their interaction and enhance the quality of care.

Increases in the supply of U.S. physicians may

counteract the need for computer-assisted professional care, since one reason for such care is

physicians’ disinterest in making house calls. Government estimates indicate an aggregate surplus

of physicians by 1990 that will persist into the

21st century (71). Nonetheless, the specific services needed for the homebound elderly may not

be available. These projections also point to a

shortage of general psychiatrists by 1990 and a

near balance in the numbers of family practitioners and osteopathic general practitioners at that

time. But the projections did not analyze geriatrics, nor did they account for geographic variation in physician-population ratios. Thus, a surfeit

of physicians would not ensure adequate numbers to meet the special needs of either the elderly

in general or the homebound elderly in particular.
—.— — .

170 . Technology and Aging in America

Among the health information surveys now

available at home is “CompuServe, ” which gives

subscribers access to a medical “bulletin board”

that includes listings of health professionals, and

affords physicians an opportunity to exchange information. Future applications of such technologies to the needs of specific patients, particularly

homebound patients, are likely to be extensive.

Instructions on patient care can be programmed

for use in the home by the patient or a family

member when needed, which may enable home

health agencies to reduce the number of home

visits by nurses and other health professionals.

One exciting application would redefine the term

“house call” by connecting homebound patients

with physicians’ offices; physicians and other

health professionals would then be able to make

electronic house calls.

Few of these efforts have been directed at the

needs of the elderly, but research in such fields

as rehabilitative medicine provides insight into the

potential for using information technology to give

older individuals special care. Adapting technologies for the elderly can be extremely difficult

because this population is so heterogeneous, and

because the introduction of a technology into

their lives must often be accompanied by an educational effort to convince the patient of its

utility.

An interactive system of medical monitoring between the patient’s home and the professional’s

office can be designed in a variety of ways. For

example, the computer periodically calls patients

and prints out routine questions. If the response

is abnormal, unusually slow, or not given, the

computer notifies the appropriate health professional. In a similar system, “Lifeline,” which is now

operational, the patient wears a lightweight transmitter that is electronically linked to a health care

institution 24 hours a day. To call for help, the

user presses a button on the transmitter, sending

an electronic signal to the health care institution’s

computer. The computer identifies the user, notes

the time of the signal, and personnel monitoring

the system use the information stored in the computer to determine if help is needed. The system

automatically sends a signal to the computer if

it is not reset twice each day.

Other examples of medical technologies that can

be connected to computers, thereby assisting

health professionals with patient care, include

analog signals from both mechanical and electrical devices that can be converted to digital signals

for transmission to health professional computers.

If desired, the health professional can transmit

information back to the patient or directly to the

device, Future medical technologies may operate

digitally as do products currently in use, such as

watches and bathroom scales, thereby eliminating the need for conversion of signals from analog

to digital systems.

“Smart” sensors—those incorporating microprocessors-currently sense and measure blood

pressure, pulse rates, body temperature, and electrical activity of the heart, Measurements of other

physical functions have been developed for use

in rehabilitating handicapped patients; those that

have the potential for computer-based processing may be applicable for monitoring the health

status of segments of the older population. For

example, a patient with a spinal cord injury who

has returned home from the hospital can be monitored for the number of times and length of time

he or she is out of bed by means of a pressuresensitive ribbon switch located under the mattress

and a strip chart recorder (30). A protocol for

computer-based monitoring of such chronic problems has been developed that would enable a physician to monitor the patient’s movements (54).

Periodic measurements of the movements of a

partially bed-bound elderly patient would assist

a physician in evaluating the patient’s progress.

Computer technology can enable hospital-based

approaches for managing chronic diseases to be

expanded to the home. A study of cirrhotic ambulatory patients found that they were able to

systematically measure and communicate medically and behaviorally significant information (54).

A health aide telephoned the data to a laboratory,

where they were entered into a computer terminal and analyzed. The method can be used with

many chronically diseased patients, and helps involve them in assessing—and potentially managing—their chronic diseases. When adapted for direct linkage to a computer and utilized for an

elderly population, the rapid processing of data
Ch. 6—information Technology and the Health of an Aging Population ● 171

provided by ambulatory patients from their

homes can promote continuity of care approaching that provided in hospitals.

Various computer and communication technologies can be used within the home setting for

health purposes without involving consultation

with health professionals. Computers that monitor such household functions as turning lights,

radios, and televisions off and on, and provide

wake-up service by voice synthesizers that speak

pre-programmed messages (52) could be programmed to remind elderly persons of medication times, instruct them on diet and medical care

practices, and remind them of physician and

other health professional visits. Devices could be

programmed to track medicinal intake and periodically dispense medicines. A bedside automated

programmable dispensing machine has been developed for use in hospitals (s) that may be adaptable for use in the home (6).

Access to compute-assisted

information and care

Information technology is expected to enhance

the independence of the older population, including the home-bound elderly, but the extent to

which older individuals will have access to computer-assisted information and care is conjectural.

For example, their current level of access to the

type of information technology known as intersite networking is not known at present. In intersite networking, a home or office terminal and

modem are connected to a mainframe by means

of a telephone or cable; the “Lifeline” system and

arthritis self-care program are two examples.

AT&T has conducted preliminary experiments in

providing health information in a home setting

by networking homes to regional mainframes, but

as is traditional in the private sector, information

is proprietary and the company has released only

scanty information on the developmental process.

The number of elderly who have access to terminals or microcomputers in the home is not

known, essentially because the age of individuals

owning or having access to personal computers

has not been determined. Estimates of the projected penetration of U.S. homes by computers

vary widely. A 1983 study estimates that approxA .

Photo credit: Lifeline Systems, Inc., Watertown, MA

One type of home-based alarm system is

directly linked with a central computer.

imately one-fourth of U.S. households will have

personal computers by the late 1980s, and a 1979

study by the University of California estimates

that at least half of the projected 97 million

households in the United States will have them

by the end of the decade (8). A third study expects this proportion to exceed two-thirds (8,39).

OTA has calculated that by 1986 there will be almost 5 million personal computers used in the

home (62). Estimates of the current number of

home computers in households also vary substantially. The Wall Street Journal estimates the number as 4.2 million, the InfoCorp at 5.5 million, and

Future Computing and the Yankee Group, market research firms, estimate the number as approximately 7.5 million (39).

Although prices for home computers have declined steadily, a major constraint to their access

by the older population may be cost. A 1982 report on prices of personal computers found a

range from several hundred to several thousand

dollars (62). Hand-held computers sold for a few

hundred dollars. Although they are deficient in

a number of characteristics, such as size of display

area, hand-held computers could be designed to

connect with other hardware devices and to be

linked over a phone line to a larger system in a

physician’s office, clinic, or community organization.
172 • Technology and Aging in America

Prices for personal computers of similar capability are continuing to fall. It is currently possible to purchase a Commodore 64 with a disk drive

at a discount store for about $400, which is less

than the price of most color television sets. A

“Home Teller” program initiated by the Madison

National Bank in Washington, DC, offers an installment purchase plan for the Commodore 64;

by maintaining a $1)000 interest-free balance and

paying $15 a month, a customer can access his

or her banking information and own the computer in 36 months. The Chemical Bank in New York

and California’s Bank of America offer similar

plans (4). As soon as the bank customer receives

the computer, it can be used for other purposes,

including health purposes.

There is little consensus on future computer

prices. Software programs for personal computers continue to improve and their prices to decline, but whether this trend will continue is

unclear. Perhaps the greatest unknown at this

time is the future price of telecommunication

services. The price effects of the breakup of

AT&T have yet to be determined.

Whatever the future costs of computers, software, and telecommunication services, some

members of the elderly population will not find

them affordable or attractive, even for health purposes. Although income levels vary widely among

those over 65, the elderly tend to be concentrated

at the lower end of the income distribution, as

shown in table E-II in appendix E. Nonetheless,

income, as but one measurement of monetary

assets, does not indicate total financial worth.

Both savings and committed expenditures will influence the purchase of information technology.

Many members of the older population own their

own homes and have either paid off their mortgages or are doing so at low interest rates. Their

health expenditures, however, are higher than

those of any other age group.

Many members of the elderly population will

have access to software programs in libraries or

community settings, and those who are still employed are likely to find computers in the workplace. Current estimates by International Data

Corp. establish the ratio of computer terminals

to office workers at 1:5; by the end of the next

decade the ratio is expected to be 1:2.

A major obstacle to accessing computer-assisted

instruction and care is the incompatibility of

equipment. Software programs are usually written for specific microcomputers. The fact that

they cannot be transferred between different

machines, a problem for users of all ages, is particularly acute for those over 65 because of the

scarcity of programs for their use.

Older individuals who have functional limitations have additional access problems in that they

often find it difficult TO use computers designed

for the general public. More than 11 million visually impaired Americans of all ages (most are

over 55) find it difficult or impossible to read information on conventional display screens (3).

About half of all Americans who have hearing loss

in one or both ears are over 55 and are often

unable to understand spoken messages on the terminal or from a computer terminal; many cannot hear the “beeps” some computer programs

produce. Many older individuals whose mobility

is restricted also find it difficult to reach the equipment or have trouble with keyboard control.

Awareness of the need for special equipment

for the handicapped has risen significantly in recent years (73). For the most part, specialized

equipment to enable handicapped individuals of

all ages to use information technology has not

been produced by mass market manufacturers

because the demand for such technology has been

difficult to demonstrate. Available demographics

do not delineate the true number of elderly individuals with specialized needs because older people with functional limitations are not accurately

represented in the census or other surveys. Many

of those who have limitations cannot respond to

surveys because of their limitations-e.g., deafness. Of greater importance is the complexity of

payment arrangements for adaptive computer

technologies. In almost all cases they have not

been considered health devices by Medicare and

Medicaid. The availability of appropriate private

insurance coverage depends on a number of factors, including employment and State laws.

Until now, specialized equipment has been manufactured by “thin” market manufacturers or has

been custom-made, and is not inexpensive (11).

Advances in the field are so rapid, however, that

it is impossible to forecast the size and configura-
Ch. 6—information Technology and the Health of an Aging Population . 173

tion of the market in even the very near term.

For example, only one company manufactured

key guards in January 1984. By April 1984, there

were seven brands of key guards on the market.

significant developments in alleviating some of

the problems of the functionally disabled are the

improvements in standardizing the connections

between adaptive devices and commercially available computers and in providing access to standard software programs for those using assistive

devices.

whether it is Government’s role to intervene

on behalf of those older persons who would benefit from the accessibility to health services that

computer and telecommunication services would

afford is a matter of resource allocation.4 At this

time of Federal financial constraints, Federal resources are not sufficient to provide all technologies to all people who need them. Money that

is applied in one area of technology limits that

available for other areas. Conversely, it is appropriate for the Government to assist with providing goods and services that the private sector cannot. important considerations in making decisions

concerning information technology for the aged

include:

1. the degree to which encouraging independent living for the elderly is a priority of Federal resource allocation policy,

Z. the cost effectiveness of information technology, and

3. the extent to which information technology

will encourage independent living for the

elderly.

Federal activities

The level of Federal involvement with information technology and the aged has been minimal.

The National Institute on Aging (NIA) of the National institutes of Health (NIH) has sponsored the

development of information systems in nursing

homes in its teaching nursing home program.

OTA has been able to identify several projects that

4A recent OTA report provides a comprehensive view of the Government’s role in technology for the handicapped (63).

the Federal Government may sponsor that directly address the use of information technology by

the elderly for health purposes. One project, still

in the planning stage, will investigate the use of

microcomputers and computer games to improve

elderly people’s mental and social interaction. It

may be submitted to NIA under the Small Business Innovation Development Act (public Law 97-

219). Under the same program, the NIA has received a number of proposals for automatic drug

dispensing systems that utilize computer technology.

The use of information technology would be appropriate for other programs for the elderly now

under consideration. In planning for a national

health promotion campaign for the aged, the Office of Disease Prevention and Health Promotion

of the U.S Public Health Service and the Administration on Aging are sponsoring a project aimed

at identifying effective ways to communicate

health information, particularly on nutrition and

fitness, to older people, emphasizing actions that

promote health and prevent disease. A current

NIA grant and contract solicitation calls for grant

applications for research projects designed to

identify specific modifications of the social environment, including the home, that may improve

the health of middle-aged and older persons (67).

Listed as a possible area of investigation is research on technological changes that can be introduced into homes to maintain independent living for frail, older people. In addition, a special

grant announcement soliciting proposals to demonstrate and evaluate the impact of covering prevention services in the Medicare program was

published in the Federal Register on August 12,

1983. The announcement calls for studies of Medicare reimbursement for a package of prevention

services, including health education/promotion

services.

The Federal Government has been involved in

other fields that have relevance to information

technology for the elderly. For example, the Government has played a role in the research, development, and diffusion of information technologies

for the handicapped (63). As has been noted, information technology developed for the handicapped can in many cases be used by the elderly.
174 ● Technology and Aging in America

The Federal Government has also played a part information technology developed to instruct rein information technology for education in gen- tarded children, such as memory aids, could be

era] and for special education (62). Some of the adapted for use by the elderly.

Research needs

To make the most effective use of information

technologies (computers and communications

technology) for the elderly requires investigating

areas that range from the physical sciences to the

social sciences. Current research needs include:

●

●

●

●

The effectiveness of selfware/self-help, health

education and the specific techniques of HHA/

HRA, and home care in promoting and maintaining health and monitoring health care

among the elderly. Computer-assisted programs in these areas need special attention

with respect to both development and evaluation.

The economic implications of self-care and

self-help.

The ability of various subgroups (by age, by

general health status, and by disability) within

the elderly population to use computer and

telecommunications technology.

The development of new and adaptation of

current computer and telecommunications

technology to the needs of particular subgroups of the older population, according to

age, general health status, and disability.

Conclusions

A major consideration in formulating policies

regarding information technology to be used by

an elderly population is matching technologies to

users. “Appropriate technology”s is a Clear need

‘In a previous report, OTA used the term “appropriate technology” to refer to technology that is developed or adapted in response

to the needs, desires, and capabilities of disabled people and applied appropriately. The same concept of appropriate technology

is used here to refer to appropriate technology for elderly people.

It is also recognized, however, that the elderly are an extremely

diverse group that includes many older individuals for whom there

may be no need to adapt the technology used for the general public (63).

Methods of involving the elderly in the development and delivery of information technology,

Methods of encouraging the development

and transfer of current and future computer

and communications technology to the older

population. Of particular importance are

proper interactions between the public and

private sector to ensure equitable access of

elderly persons to information technology,

especially those with functional limitations.

Methods of reducing financial barriers (within reasonable restraints) to the acquisition of

appropriate information technology by the

older population.

The application of artificial intelligence to

interactive computer programs.

The evaluation of software programs for

safety, effectiveness, and instructional strategy (discussed further in the Congressional

Issues and Options section at the end of this

chapter).

in many cases. Also important are the reactions

of society and its institutions to existing and future

technological capabilities and its willingness to assume financial responsibility for diffusion of various technologies.

As has been stressed throughout this chapter,

society has thus far placed little emphasis on the

research and development of information technologies specifically for use by the elderly, either

alone or in conjunction with health professionals.

The preceding list of research needs testifies to

the absence of rigorous information. Interest in
Ch. 6—information Technology and the Health of an Aging Population Ž 175

this area, which has been lacking in the field of

information science, is now beginning to surface.

Professionals who work with the elderly have begun to realize the assistance that information technology can afford their clientele. Awareness of

the potential of information technology in assisting with the health of the elderly population, and

cooperation among information scientists, gerontologists, and other pertinent specialists are both

very much in their infancy.

The information technology that is available has

been developed for other populations, such as the

general public, the business community, health

care organizations, or the handicapped. Much of

it can be adapted to fit the needs, desires, and

capabilities of the elderly. Although it is sparse,

there is convincing evidence that older people can

benefit from using computers. Indeed, many of

today’s older individuals are completely comfortable with the new technology. The elderly of the

future will find computers much “friendlier,” in

both a technological and a social sense.

Information technology can be used by those

over 65 for health purposes in two major ways.

One is computer-assisted health instruction. The

use of computer-assisted health instruction for

the population in general is new, and scant attention has been paid to developing programs for

specific populations, such as the elderly. Although

the market is growing, the number of software

programs currently available is very small, and

few have been evaluated. The market is complex

in terms of the vendors of such programs. Some

programs are developed and distributed by forprofit firms whose substantive knowledge of the

subject matter or ability to produce a quality product may be questionable. Other programs are being developed under the aegis of university programs and subsequently marketed. A minute

proportion of such programs specifically address

the needs of those over 65.

Information technology can also be used to assist health professionals in monitoring the care

of older adults. Many available and emerging technologies can be adapted for interactive use by the

elderly and health professionals. Yet there remains too little recognition of this potential use,

either by manufacturers of the equipment or by

their distributors.

Society is on the verge of applying concepts developed in other areas to the needs of the elderly.

The time is thus propitious for developing policies that will make a significant contribution to

the research, development, and diffusion of information technology appropriate for use by and

for older individuals. The appropriate utilization

of information technology by the elderly is not,

however, inevitable. A key consideration in formulating policies regarding information technology to be used by those over 65 is society’s

commitment to the use of present and future

technological capabilities. Although it is an

avowed goal of Federal policy to keep the elderly

out of institutions and promote their independence, there are substantial costs involved in the

research, development, and diffusion of information technology for the older U.S. population.

These costs need to be evaluated against “helping the senior members of society continue as

viable participants in its processes” (48).

Congressional issues and options

ISSUE 1: Should Congress assume major re- not require new legislation because sufficient ausponsibility for assuring the quality thority has already been written into law. Rather,

of computer-assisted health instrue desired actions could be stimulated by congestion for the elderly? sional interest or oversight.

These policy options are intended to assure the The principal question to be addressed is the

quality of computer-assisted health instruction for extent to which the Federal Government should

the older population. Most of the alternatives do be involved in activities concerning the quality of
176 ● Technology and Aging in America

computer-assisted health instruction for the elderly.

The use of the technology for all age groups, and

particularly the older population, is in a very early

stage of development. It is not yet a viable means

of promoting, maintaining, or monitoring the

health of the older population. But beneficial

health-related software programs for this population can be forthcoming if adequately fostered.

Because of the possible physical and financial vulnerability of those over 65, the quality and credibility of the content of health-related software

programs for this age group require attention.

The Government’s role could depend on the

types of computer-assisted health programs for

the elderly, which vary along a number of parameters. Of particular relevance for the quality issue

are the specificity and uniqueness of a program’s

content, Quality and accuracy of information are

necessary to all computer-assisted health education, including gener~ instructions on broad subjects, such as good health habits, the nutritional

value of foods, and HHAs/-lRAs. Quality assumes

still greater significance in software programs that

instruct individuals on managing specific health

conditions with counseling, drugs, or medical devices. Quality is also an essential component of

an individualized software program that instructs

a person on the care of his or her particular medical problem. Because, however, such programs

usually require continuous consultations with and

revisions by a health professional, some aspects

of quality control are informally in place.

Options:

1.1: The private sector could assume responsibih”tyfor

the quality of the content of health instructional

software for the elderly.

Although computer-assisted health instruction

is not a new technology, there is as yet no formal mechanism in the private sector to oversee

the safety and effectiveness of the content of software programs. Computer-assisted health instruction has been used for a number of years for the

education of health professionals. In the early

1970s a number of software programs for the

general public appeared on the market, but most

were of poor quality and did not achieve commercial success, Interest in the technology has

resurfaced with the diffusion of microcomputers

into clinics, offices, schools, community centers,

and homes. It is conceivable that, if left undisturbed, market forces might eventually eliminate

quality deficient health instructional software programs. But today’s potential market for computerassisted instruction is large and poorly informed.

The rapid diffusion of the microcomputer

throughout society has given millions of people,

including older people, access to computerassisted health instruction that did not exist 10

or 15 years ago, As the number of people with

access to computers soars in the future, the number of users who lack the expertise to properly

evaluate the content of instructional programs

will also rise.

Government involvement in generalized descriptive programs that do not differ from published materials would be hard to justify because

of the protection afforded publications by the

First Amendment. But reputable developers of

computer-assisted health instructioniil material attempt to produce programs that do not mimic

published matter. The nature of the computer allows for an interactive exchange between the user

and the program, which is rarely possible between the reader and a book or other publication. proficient software developers thus attempt

to invoke active user participation in constructing their software programs. Whether the Government can assume a role with respect to the

quality of interactive instructional software programs has not been determined.

A serious issue arises about actions to be taken

in cases where incorrect or inexact information

is used in software programs that instruct individuals how to manage mental health problems

and how to use drugs or medical devices to manage medical conditions. such information may adversely affect the health status of the user. Because of its general role of protector of the public

and its specific role of user of and payer for health

technology, the Government is concerned with

issues of safety and effectiveness. And the Goverment has found it necessary to assure the safety

and effectiveness of health technologies, such as

drugs and medical devices, on which the life or

death of the user may depend.
Ch. 6—information Technology and the Health of an Aging Population ● 177

1.2:

1 .2,a:

Congress could encourage Federal involvement

in validating the quality of the content of health

instructional software for the older population.

Congress could require that the Food and Drug

Administration(FDA) regulate the safety and effectiveness of the content of all health instructional software for the elderly.

The FDA is currently responsible for regulating the safety and effectiveness of all new drugs

and certain medical devices before they are marketed. There is also legal precedent for the FDA

to classify certain types of software as medical

devices (34). Although manufacturers of medical

devices are required by law to conduct tests of

safety and effectiveness using FDA guidelines, the

definition of effectiveness employed by FDA has

limited utility for evaluating the health effects of

medical devices under general conditions of use.

On the one hand, FDA considers a device to be

effective when, on the basis of well-controlled investigations or other valid scientific evidence, the

device is shown to have the effect claimed by the

manufacturers under the specified conditions of

use (21 U.S.C. 260(c)(3)). On the other hand, the

Health Care Financing Administration (HCFA)

judges the effectiveness of a medical device in

terms of its ability to improve health. Thus some

devices approved by FDA for marketing purposes

are not covered by HCFA for payment under

Medicare or Medicaid (79).

The FDA does not have a policy governing the

regulation of software used in computer-assisted

health instructional programs, but the FDA Task

Group on Computers and Associated Software as

Medical Devices is studying the issue (31). The

problem is determining which types of programs

can be considered medical devices. Preliminary

decisions are that information management systems and programs that merely transfer information, such as databases, are not medical devices

and thus not subject to FDA regulation. Software

that describes self-testing, diagnosis, or treatment

may be considered to be a medical device except

in cases where the software merely copies instructions, i.e., serves as an “automated” book. If

the content has been manipulated in any way and

concerns diagnosis or treatment, current thinking holds that the software may be considered

a medical device.

l.2.b: Congress could charge another established governmental body, or create another governmen -

tal body, with responsibility for regulating the

safety and effectiveness of the content of software for health instructional material not concerning drugs or medical devices for the elderly

or for all health instructional software.

There is no Federal agency, including the FDA,

specifically charged with evaluating surgical and

medical procedures, including therapeutic counseling, before such services are performed. The

quality of the service is governed by the governmental licensure and professional certification of

the providers of the service, and the professional

accreditation of the providers’ educational facilities. Medicare coverage also serves as a minor

control of the safety and efficacy of surgical and

medical procedures as well as drugs and devices

used for the elderly (61). HCFA requires a determination-a coverage decision-f the safety and

efficacy of technologies before it will reimburse

providers for their use with Medicare beneficiaries.

The FDA does not currently have the expertise

to regulate medical products other than drugs and

devices. However, as noted previously, the agency

is considering the issue of regulating instructional

software. The staff could be expanded to include

professionals who have the requisite expertise,

or professionals from other agencies who have

content knowledge could be consulted. Creating

a separate body for this one purpose runs counter

to current administrative philosophy and operations.

1.3: Congress could stimulate the development of

standards for assessing the safety and effectiveness of content of software for computer-assisted

health instruction programs for the older popula -

tion. (This option is independent of options 1.1

and I.2).

Recognized formal standards for use in evaluating the science base or the instructional strategy embedded in computer-assisted health instructional programs for the elderly have not

been developed by either the public or the private sector. The director of the Office of Disease

Prevention and Health Promotion has decried the

lack of a science base and evaluation of the soft-
178 ● Technology and Aging in America

ware used for health education programs (44). He

notes that “many programs have been written by

persons with inadequate background in health or

health education, and are not being properly reviewed.” Moreover, the quality of the instructional

notebooks of computer-assisted health programs

for the older person has received little attention.

Because the way in which information is presented affects the use of the information, a program needs logic and completeness. The task is

timely and costly. Although there is a need to address the problems associated with the development of health instructional software, the field

is too new to have created voluntary standards

to cope with such rapid technological change. 6

At the present time there is marginal activity

among members of the academic community in

establishing standards to evaluate the quality of

health instructional software (14,32). As has been

noted, the FDA is classifying types of software as

to their standing as medical devices. At the same

time, the FDA is developing standards for assessing those software programs that are classified

as medical devices. However, the standards to be

used by the FDA in future evaluations are expected to be limited to assessment of the algorithm, or computing method, used in structuring the software program and in implementing

the program. If an algorithm relies on various

tests of predictive accuracy, including both sensitivity and specificity, the program should perform satisfactorily. However, as a 1981 report by

the General Accounting Office (GAO) points out,

assessment of an algorithm does not always assure that the science content of a software program is accurate. GAO noted a number of cases

in which FDA had evaluated a software program

and the medical devices were defective because

the software program used by the manufacturer

in the medical device was based on calculations

unacceptable to the scientific community (59).

Even if the FDA were to expand and modify its

evaluation methodology, the FDA process for developing standards has proven very cumbersome.

6 Voluntary standards are generally established by private sector

bodies and are available for use by any person or organization, private or governmental (OMB Circular A-119, revised, Oct. 26, 1982).

For example, no mandatory performance standards have been developed for Class 11 medical

devices since Congress passed the Medical Device

Amendments of 1976. Indeed, the 1981 GAO report notes the need to develop alternatives to

FDA’s performance standards so that assurance

can be given within a reasonable period of time

that the software of medical devices in general

operates as expected.

Neither current nor proposed FDA activities

preclude the development and use of standards

by the private sector, which has initiated many

standards in the health field. voluntary standards

can be used in various ways, In some cases, voluntary standards are used solely by their developers,

usually an industry, to guide the development of

its products and services. In other cases, they

have formed the basis of governmental standards;

e.g., accreditation standards of the Joint Commission on the Accreditation of Hospitals (JCAH) are

the basis for Medicare’s conditions for hospital

participation in the program. JCAH’S accreditation standards are also used by the private sector to assure the quality of hospital care.

Many professional groups and private enterprises are involved in the research and development of software programs for health instruction

purposes, and their number is growing. There

is, however, insufficient official communication

among the organizations, and no one type of organization has taken the lead in developing voluntary standards for use in evaluating the quality

of the content of health instructional software.

One way in which Congress could encourage

the process of developing criteria for use in

evaluating health instructional materials for the

elderly is to encourage the convening of a conference or workshop on the problem. Participants

could represent all interested parties, including

manufacturers of computers and software, software programmers, researchers in computer science and education, health professionals, educators, consumers, and relevant Government bodies. The conference would illustrate congressional

recognition of the need for evaluation standards,

initiate a process for their development, and facilitate the cooperation of those with expertise in

their formulation.
Ch. 6—information Technology and the Health of an Aging Population c 179

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Chapter 7

Technologies, Functional

Impairment- and Long-Term Care
Contents

Page

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 185

What is Long-Term Care . . . . . . . . . . . . . . . . . 185

The Need for Long-Term Care . . . . . . . . . . . . 185

Government Involvement in

Long-Term Care . . . . . . . . . . . . . . . . . . . . . . 186

Technology and Long-Term Care. . . . . . . . . . 187

The Influence of Federal Funding Mechanisms

on the Long-Term Care System. . . . . . . . . . 188

Functional Impairment andthe Need for

Long-Term Care . . . . . . . . . . . . . . . . . . . . . . 189

Functional Impairment in the Elderly

Population . . . . . . . . . . . . . . 4 . . . . . . . . . . . . 190

Causes of Functional Impairment . . . . . . . . . . 191

Long-Term Care Services . . . . . . . . . . . . . . . . . . 194

Informal Long-Term Care . . . . . . .....+... . 194

Formal Long-Term Care Services

and Settings . . . . . . . . . . . .....+... . . . . . . 195

Issues in Long-Term Care Settings

and Services. . . . . . . . . . . . . . . . . . . . . . . . 204

Technologies in Long-Term Care . . . . . . . . . . . . 207

Assessment Technologies . . . . . . . . . . . . . . . . . 207

Assistive Devices and Rehabilitation

Techniques . . . . . .......................212

Technologies for Caregivers . . . . . . . . . . . . . . 220

Long~Term Care Delivery Systems . . . . . . . . . 225

Findings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 232

Research Priorities. . . . . . . . . . . . . . . . . . . . . . . . 234

Issues and Options. . . . . . . . . . . . . . . . . . . . . . . . 235

Use of Assessment Measures . . . . . . . . . . . . . 235

Functional Impairment. . . . . . + . . . . . . . . . . . . 235

Rehabilitation Technologies . . . . . . . . . . . . . . . 236

Service Delivery Systems . . . . . . . . . . . . . . . . . 237

Technical Memorandum: Federal Programs

Funding Long-Term Care Services . . . . . . . 237

Medicare . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 237

Medicaid . . . . . . . . . . . . . . . . . . . + . . . . . . . . . . 238

TitleXX . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 239

Title III. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 239

Supplemental Security Income . . . . . . . . . . . . 239

Veterans Administration . . . . . . . . . . . . . . . . . 240

Chapter preferences . . . . . . . . . . . . . . . . . . . . . 240

Tables

Table No. Page

12. Public Expenditures on Long-Term Care

Service by Program, Fiscal Year 1980. . . . . 187

13. Number of Individuals and Rate per 1,000

Who N&d the Help of Another Person

in One or More Selected Activities

by Age: United States, 1979 . . . . . . . . . . . . . 192

14.Most Frequent Preexisting Health Conditions

and Functional Dependencies. . . . . . . . . . . . 193

15. Elements of Long-Term Care

in the Home . . . . . . . . , . . . . . . . . . . . . . . . . . 201

16. Examples of Assistive Devices for the

Functionally Impaired Elderly . . . . . . . . . . . 213

17. Behavior Problems of Patients

Cited by Families . . . . . . . . . . . . . . . . . . . . . . 223

Figures

Figure No. Page

19. Dependency in Basic Physical Activities

Be cause of a C hronicHeakhProblem,

by Type of Activity and Age:

United States, 1979 . . . . . . . . . . . . . . . . . . . . 191

20.Dependency in Home Management

Activities Because of a Chronic Health

Problem, by Type of Activity and Age:

United States, 1979 . . . . . . . . . . . . . . . . . . . . 192

21. Source of Support for the Disabled

Elderly, Cleveland, OH, 1975 . . . . . . . . . . . . 194

22. Percentage Distribution of Nursing Home

Expenditures in the United States, 1979... 197

23. Percent of Nursing Home

Residents Who Need Assistance

With Basic Physical Activities, 1977 . . . . . . 197
Chapter 7

Technologies, Functional

Impairment, and Long-Term Care

Introduction

Long-term care for the elderly includes a variety of health and social services provided for individuals who need assistance because of physical or mental disability. The increasing number

of elderly persons in our society, particularly

those over 85 who most frequently need longterm care, is expected to intensify the demand

for services and place additional strain on agencies, delivery systems, and funding programs.

This chapter examines Federal concerns in longterm care, the needs of the disabled elderly, and

technologies appropriate for addressing those

needs and improving services and service delivery. These technologies include:

assessment technologies to identify functional

impairments and facilitate matching of the individual with long-term care services;

technologies to maintain or increase independent functioning, including assistive devices and rehabilitation services;

technologies to assist formal and informal

caregivers; and

service delivery systems to improve access

to appropriate long-term care.’

Discussion focuses on problems that impede the

use of available technologies and

opment of new technologies.

What is long-term care?

limit the develAlthough there is no single accepted definition

of long-term care, it is generally agreed that the

goal of long-term care is to maintain or improve

the ability of the individual to function as independently as possible and that services will be

needed over a prolonged period, even if they are

only needed intermittently. Medical care is seen

as an essential component of long-term care, but

a variety of other services are also considered important (44).

Long-term care is generally concerned with

functional impairments, such as limitations in the

individual’s ability to move around independently;

to feed, dress, or bathe himself; or to perform

housekeeping functions such as shopping, cooking, or cleaning. While acute care is most often

directed toward treating or curing disease, longterm care is generally directed toward compensating for functional impairment and maintaining or improving the functional capacity of the

individual.

In the past, definitions of long-term care have

often encompassed only services provided in institutional settings such as nursing homes and

extended-care facilities, but most recent definitions include a broader range of services that may

be provided in an institution or in the home or

the community (68,109). The following definition,

developed for the 1981 White House Conference

on Aging, emphasizes the broad range of services and the kinds of individuals served:

Long-term care represents a range of services

that address the health, social, and personal care

needs of individuals who, for one reason or another,

have never developed or have lost the capacity

for self-care. Services may be continuous or intermittent, but it is generally presumed that they

will be delivered for the “long-term, ” that is, indefinitely, to individuals who have demonstrated

need usually measured by some index of functional incapacity (130).

Although long-term care services are needed by

some disabled individuals of all ages, this chapter

addresses only the long-term care needs of the

elderly.

The need for long-term care

Estimates of the number of elderly individuals

who need long-term care services depend on the

definition of long-term care that is used and the

185
——.— — — — —

186 ● Technology and Aging in America

kinds of impairments that are seen to create a

need for long-term care. About 7 percent of individuals 65 to 74 and more than 40 percent of

those over 8.5 have functional impairments that

may indicate a need for long-term care. Many of

these individuals are not using formal long-term

care services: some receive assistance informally

from family or friends; others live in communities that lack the formal services they need. Some

elderly individuals cannot pay for services and

are not eligible for those provided by government

programs. others are not aware of available services or simply prefer not to use formal long-term

care services.

At present there are almost 1.3 million elderly

individuals in nursing homes at any one time.

Another 150,000 to 200,000 elderly individuals

are residents of board and care facilities (88), and

many elderly persons are receiving one or more

long-term care services in their homes or communities.1 Adult day care facilities, hospice programs, and congregate housing facilities also provide long-term care services in some communities.

The need for formal long-term care services is

expected to increase dramatically in the future

as a result of rapid growth in the number of

elderly individuals in the population (see ch. 2).

One researcher has estimated that the number

of elderly individuals in nursing homes will rise

by more than 50 percent by the year 2000 (29),

requiring construction of up to 10,000 new nursing homes. Demand for other long-term care facilities and services can be expected to increase

proportionately, Factors that would alter these

projections are changes in the prevalence of

chronic disease and functional impairment among

the elderly and in the ability and willingness of

family and friends to provide long-term care services informally.

over the past 50 years, advances in public

sanitation, hygiene, and medical care have lowered

mortality from infectious diseases, and individuals

who might have died earlier of these causes now

live long enough to develop functional impair1 in 1980, about 890,000 elderly individuals received home health

care services funded by ,Medicare, and about 140,000 elderly individuals received ,Medicaid funded home care services (126). There

are no reliable estimates of the number of elderly individuals who

paid privately for home care services.

ments related to chronic diseases. Medical treatment has also lowered mortality from heart attacks, strokes, and some cancers, but there is

currently no evidence that the onset of chronic

disease and functional impairment has been postponed (98). Future medical advances that reduce

mortalit y for the elderly may result in greater .

numbers of elderly individuals with chronic diseases that lead to functional impairment (81), thus

increasing the need for long-term care. Yet medical research focused specifically on the chronic

conditions that cause functional impairment could

result in methods of treatment or prevention that

would significantly decrease the number of elderly individuals needing long-term care (29,81).

Changes in regulations for government programs that fund acute care services can also affect demand for long-term care. For example, recent changes in Medicare reimbursement for

hospital care are increasing the demand for longterm care services. The prospective reimbursement system based on diagnosis-related groups

(DRGs) instituted October 1, 1983, has created incentives for early discharge of hospital patients.

Many elderly individuals who are discharged

earlier from hospitals need continuing convalescent care in nursing homes or in the community.

Technologies that have been available primarily

in hospitals are also needed in alternative settings

in the community to care for these individuals.

Government involvement in

long-term care

Current government involvement in long-term

care includes funding and regulation of many

long-term care services through Federal programs

such as Medicare, Medicaid, Supplemental Security Income (SS1), the Title XX Block Grant, Title

III of the older Americans Act, and services provided through the Veterans Administration (VA).

(These programs are described in the technical

memorandum at the conclusion of this chapter.)

State and local governments participate in funding and regulation of services provided through

these Federal programs and also fund and regulate some long-term care services of their own.

Public spending for Federal programs providing

long-term care services in fiscal year 1980 is summarized in table 12.
.

Ch. 7—Technologies, Functional Impairment, and Long-Term Care ● 187

Table 12.—Public Expenditures on Long”Term Care Service by Program, Fiscal Year 1980a

Total reported Percentage distribution by programb

expenditures in U.S. Title Ill Supplemental

(thousands of Older Americans Security Veterans

Service category dollars) Medicaid Medicare Act Income Title XX Administrationc

Tota l $13,454,224.2d

76,3% 6.9% 5.2% 2,7% 5.4% 3.5%

Nursing hom e 8,586,008.0 92.3 3.6’ — 4.1

Board and care

—

., 505,991.4 – — — 73.1 4.0 22.9

Adult day care 20,585.9 3.3 – — — 96.7

Home healt h

—

775,383.3 18,2 80.8h — — 1,0

Personal care and

—

housekeeper chor e 667,602.4 32.6 – 6.3 — 61 .1’

Communit y

—

462,147,2 – — 45.2 — 54.8k —

“Less than 0.05 percent.

aThese programs se~e individuals of ail ages, not OnlY the elderly

bEach of these ~rograms is described in the technical memorandum at the conclusion of the chapter.

cExpenditures for fiSCal year 1979

dThis column does not total because some se~ices that are not discussed in this chapter and services for retarded adults are nOt included,

expenditures for calendar year 1979

fNursing home ombudsman sewices—$3,789,0 thousand.

presidential care and treatment services.

hExpenditures for calendar year 19m

ilncludes sewices repofled under the follo~lng categories: homemaker, chore, and home rnanagefllent,

Jlncludes access, community (other than legal), and in-facility services.

klncludes sewices repo~ed under the following categories: special se~ices for the blind, education and training, transportation, health related, Spt?Cid SefViCeS fOr

the disabled, other, socialization, transitional case management, protective services for adults, placement, housing, improvement, counseling, recreational, diagnosis

and evaluation, and emergency

SOURCE: Cohen, 1983 (25).

Rising public expenditures for long-term care

services are a major concern of government at

all levels. Public spending for long-term care has

increased sharply over the past 20 years and is

expected to continue growing as a result of increases in the number of elderly persons, expansion of services, and escalating health care costs.

For example, more than one-third of all Medicaid expenditures are now for nursing home care.

Despite Federal and State efforts to contain costs,

expenditures for nursing home care continue to

grow (119), threatening the capacity of the Medicaid program to provide other benefits for indigent elderly and nonelderly recipients.

In addition to rising costs, another major governmental concern in long-term care is the availability of appropriate services for the disabled

elderly. Although there is currently no comprehensive Federal policy on long-term care, the programs cited earlier reflect government intent to

provide for some of the long-term care needs of

the elderly. Relevant public policy issues include:

● availability of long-term care services in local

communities;

. access to these services, including information and referral, and funding;

●

●

●

appropriate matching of the needs of the individual and the services provided;

provision of services in the least restrictive

setting; and

quality of available services.

Government concern for controlling public expenditures in long-term care appears to conflict

with government efforts to assure access to appropriate long-term care services (81). Increased

use of technology can address both concerns. Biomedical research on chronic disease and rehabilitation technologies that help to maintain or improve independent functioning may decrease the

need for long-term care, thus limiting costs and

improving quality of life for the elderly. Assessment technology and technologies to assist caregivers and improve the service delivery system

can lead to more appropriate treatment and more

efficient use of available resources.

Technology and long-term care

Technology has traditionally been given very

little emphasis in long-term care. The importance

of functional impairments in causing the need for

long-term care has been cited repeatedly in re38-800 0 - 85 - 7
188 ● Technology and Aging in America

search reports and government publications, but

the role of technology in compensating for functional impairments has received relatively little

attention, Assessment technologies to identify

functional impairments have not been widely

used outside research and demonstration projects

and specialized geriatric assessment centers.

Long-term care providers, including nursing

homes and informal caregivers such as family and

friends, have not generally used available technologies to facilitate caregiving and improve

quality of care.

The influence of

on the long-term

Some specific reasons for the lack of emphasis

on these technologies are discussed later in this

chapter. One common factor that limits the use

of these technologies is the overriding emphasis

on medical care and skilled nursing care in the

Federal programs that fund long-term care services. By defining need in terms of medical and

skilled nursing care, these programs tend to obscure other needs, including the need for technologies to identify and compensate for functional

impairments and assist caregivers and the need

for alternative forms of care.

Federal funding mechanisms

care system

At present Medicare and Medicaid pay almost

half the total cost of nursing home care in this

country, and more than half of all nursing home

patients are paid for in part by these public programs.z It is estimated that Medicare and Medicaid also pay for more than half of all home care

in this country (94). As a result, Medicare and

Medicaid regulations that define eligibility for

services affect a very large proportion of those

receiving long-term care.

In addition to defining eligibility requirements,

Medicare and Medicaid regulations define the

kinds of services covered, the kinds of agencies

certified to provide reimbursed services, and minimum standards for the number and qualifications of personnel employed by these agencies.

State governments can add to Federal requirements, and some agencies provide services and

staffing above Medicare and Medicaid guidelines,

but because cost containment is a constant concern, many agencies limit their services and staffing to Medicare and Medicaid requirements. Even

individuals who pay privately for long-term care

services may be affected by Medicare and Medicaid regulations because the agencies that pro-

‘Using 1976 data, the General Accounting Office estimated that

54 percent of elderly nursing home residents were receiving some

Medicaid support (119); other data indicate that the figure may be

as high as 75 percent (134).

vide services to them are often structured and

staffed to meet these requirements.3

Medicare and Medicaid were enacted in 1965

primarily to provide medical care for the elderly

and the poor, with emphasis on acute care in the

hospital and the physician’s office. Medicare coverage for nursing home care was designed to provide skilled nursing care immediately following

hospitalization. Medicaid coverage for long-term

care was intended to assure adequate health care

services for low-income persons but not to provide supportive or custodial care.

Since their inception, both programs have been

stretched to provide some services that are not

medically related, but the emphasis remains on

medical care. Eligibility for Medicare-funded nursing home care depends primarily on medical diagnosis and the need for skilled nursing care, and

Medicare-funded home care services are healthrelated services authorized by a physician. Eligibility for most nursing home and home care services funded by Medicaid depends on medical condition.

3Alhough some facilities, agencies, and providers do not provide

services for any Medicare or Medicaid reimbursed patients and so

are not affected by Medicare and Medicaid regulations, most facilities serve both Medicare or Medicaid patients and individuals who

pay privately for their care. In these agencies, the services and staff

available to private-pay patients are often determined indirectly by

Medicare and Medicaid regulations.
Ch. 7—Technologies, Functional impairment, and Long-Term Care ● 189

Because Medicare and Medicaid fund such a

large proportion of long-term care services, the

emphasis on medical diagnosis and medical treatment in these programs tends to define the kinds

of long-term care needs that are recognized and

the services and technologies that are available.4

Physician services and prescribed medical treatment are obviously very important for impaired

elderly individuals, and accurate medical diagnosis is essential for planning medical and nonmedical care, but evaluation of appropriate technologies for this population requires recognition

of needs for both medical and nonmedical forms

of care. The following examples illustrate how the

emphasis on medical and skilled nursing care in

Federal funding programs can lead to inappropriate treatment and distort data on the need for

long-term care.

4Ntany long-term care agencies have been created since Medicare

and Medicaid came into effect and have designed their programs

to serve Medicare and Medicaid patients and conform to relevant

Federal regulations.

%urveys based on a review of patient records cannot pick up these

instances of inappropriate treatment because patient records must

be written to show that the patient needed services that are reimbursable under Medicare and Medicaid, or payment will be denied.

Only an independent assessment of patient needs could provide accurate data.

Functional impairment and the need

for long-term care

Despite the emphasis on medical diagnosis and on their own. The important factor in determinmedical care in the existing long-term care sys- ing the need for long-term care, including both

tern, virtually all research on the long-term care formal and informal services, is the functional

needs of the elderly shows that medical diagno- status of the individual; i.e., which functions he

sis is usually not a good predictor of the need for or she is able to perform and which functions he

services. Individuals with the same diagnosis vary or she needs help with (50,68,140).

greatly in their need for long-term care. For example, some individuals with heart disease, chronic In fact, the elderly often measure their own

respiratory disease, or degenerative osteoarthritis health in terms of functional impairment. They

need to be in a nursing home; others manage well may say that they are in good health when they
— .

 . Technology and Aging in America

Photo credit: Phylis Eisen

Many elderly individuals function independently

despite underlying chronic conditions.

are able to function independently in spite of

underlying chronic diseases (68). Likewise, they

may fear the frailty and dependency associated

with functional impairment more than specific

diseases (.53). While chronic diseases often cause

functional impairment, it is functional impairment

that most often leads to a need for long-term care.

The distinction between chronic disease and

functional impairment is very important in identifying long-term care needs and technologies that

are appropriate for addressing these needs. Technologies that do not affect underlying disease conditions but improve the functional status of the

individual can decrease the need for long-term

care. For example, devices or techniques that

allow an individual to bathe, dress, and feed

himself will decrease his need for long-term care

services. In contrast, medical treatments that alter

disease conditions but do not improve functional

status will not affect the need for long-term care.

Thus, an individual with heart disease, hypertension, and degenerative osteoarthritis may need

assistance in functioning only because of the osteoarthritis; medical treatment to control the

hypertension will not affect his current need for

long-term care services.

Precise medical diagnosis is essential for the

treatment of disease, and diagnoses are available

for many elderly patients, yet they often do not

specify the disease conditions that are causing

functional impairment. Diagnosis related to functional impairments is important for planning

treatment because while long-term care patients

often have several diagnoses, including some

presently incurable diseases, the condition that

is causing the need for long-term care may be

curable. For example, incontinence, which has

been cited as the cause of nursing home placement for many patients, may often be treatable,

allowing the possibility that the patient could return home even when his other chronic disease

conditions are unchanged. 6

Functional impairment in the

elderly population

The extent of functional impairment among the

noninstitutionalized elderly is illustrated in the following graphs which show the rates of dependency in six basic physical activities (fig. 19), and

in home management activities (fig. 20). These illustrations highlight the relationship between increasing age and functional impairment. Rates of

dependency for each activity at least double between each age category and triple between ages

75 to 84 and over 85. The very old, those over

85, are from 5 to 10 times more likely to need

assistance with these activities than the youngold, those who are 65 to 74.

Among the noninstitutionalized elderly, more

than 425,000 individuals are bedridden, including

about 1 percent of those 65 to 74 and more than

5 percent of those over 85. About 800,000 individuals over 65 either have a device to control

bowel or bladder function or have other trouble

with bowel or bladder control; this figure includes

about 2 percent of those 65 to 74 and about 11

percent of those over 85 (129).

Overall estimates of the number of noninstitutionalized individuals who need assistance from

another person in some daily activity are shown

in table 13, which again illustrates the dramatic

increase in need for assistance with increasing

age. Almost 44 percent of those over 85 need or

are receiving assistance with some daily activities.

As the number of individuals in this age group

6Medical diagnosis related to functional impairment could also provide valuable information for government planning and policymaking since the need for most long-term care services is dependent on the prevalence of disease conditions that cause functional

impairment. Although the annual Health Information Survey conducted by the National Center for Health Statistics provides data

on the prevalence of acute and chronic conditions and the

prevalence of disability and impairment, there is currently no way

to identify which acute and chronic conditions are causing disability

and impairment because medical diagnoses related to specific impairments and disabilities are generally not available.
Ch. 7—Techno/ogies, Functional Impairment, and Long-Term Care ● 191

Figure 19.—Dependency in Basic Physical Activities Because of a Chronic Health Problem,

Walking

Bathing

Dressing

Toileting

Getting in

bed or out

of a bed

or chair

Eating

Age

18-44

45-64

65-74

75-84

85+

18-44

45-64

65-74

75-84

85+

18-44

45454

65-74

75-84

85+

18-44

45-64

65-74

75-84

85+

18-44

45-64

65-74

75-84

85+

by Type of Activity and Age: United States, 1979

Number per 1,000 persons

259.7

m

172.9

~ , .

116.6

104.9

I’11.3

72.5

75-84 ~

37.6

SOURCE” U.S. Department of Health and Human Services, Public Health Service, National Center for Health Statistics, “Americans Needing Help To

Function at Home,” No. 99, Sept. 14, 19S3.

grows, the need for formal and informal longterm care services will increase rapidly.

Causes of functional impairment

Many acute and chronic diseases and mental

and emotional disorders can limit the ability of

the older individual to function independently.

(The prevalence of chronic disease in the elderly

is discussed in app. A.) Chronic diseases with especially high prevalence among the elderly include

heart disease, hypertension, arteriosclerosis, osteoarthritis, diabetes, and diseases of the urinary

system. In some individuals these diseases result

in inability to perform basic self-care and home

management activities. Vision and hearing impairments are also very common among the elderly

and frequently cause functional impairment. 7

The functionally impaired elderly include both those who become

disabled after age 65 and those who were disabled at earlier ages

but are now over 65. This latter group can be expected to increase

significantly as a result of biomedical advances that prolong the lives

of developmentally disabled and physically handicapped individuals.
————

192 ● Technology and Aging in America

Figure 20.—Dependency in Home Management Activities Because

of a Chronic Health Problem, by Type of Activity and Age:

Needs help with any home

management activity

Needs help with shopping

Needs help with chores

Needs help with handling

money

Needs help with meals

United States, 1979

Number per 1,000 persons

18-44

45-64

65-74

75-84

85+ 399.0

18-44 ~ 3.9

18-44136

18-44

45-64

65-74

75-84

85+ 175.5

18-44

45-64

65-74

75-84

85+

!2.8

224.7

SOURCE: U.S. Department of Health and Human Services, Publlc Health Service, National Center for Health

Statistics, “Americans Needing Help To Function at Home,” No. 92, Sept. 14, 19S3.

Table 13.–Number of Individuals and Rate per 1,000 Acute conditions that can cause functional imWho Need the Help of Another Person in One or More

Seiected Activities by Age: United States, 1979 pairment among the elderly include those resulting from untreated infections and drug interacNeeds help of another person tions. The complex relationship between the need

Age Number in thousands Rate per 1,000 for acute medical care and long-term care among

45-64 . . . . . . . . . . . . 1,357 31.2 the elderly is not discussed in this chapter, but

65-74 . . . . . . . . . . . . 1,043 69.2

75-84 . . . . . . . . . . . . 1,101 160.3

it should be noted that the need for long-term care

85+ . . . . . . . . . . . . 674 436.5 for an elderly individual is often first recognized

SOURCE: U.S Department of Healh and Human Services, public Health service. when the individual is hospitalized for an acute

National Center for Health Statistic% “Americans Needing Help To

Function at Home,” Advancedata, No. 92, Sept. 14, 1983. medical condition. Once this condition has been
Ch. 7—Technologies, Functional Impairment, and Long-Term Care ● 193

treated, it becomes obvious that the individual is

not able to function independently and may have

needed long-term care services even before the

acute condition developed.

Mental and emotional conditions that cause

functional disability include organic conditions

such as Alzheimer disease and multi-infarct demeritia, and functional disorders such as depression. It is estimated that 5 to 15 percent of individuals over 6.5 have Alzheimer disease (123),

and 2 to 7 percent have clinically diagnosed cle -

pression (36). Estimates of the extent of undiagnosed depression in the elderly are much

higher.

The relationship between mental and emotional

conditions and functional impairment in elderly

individuals has received little research attention,

but a recent study by Brody and Kleban (15) compared functional impairment in three groups of

elderlv individuals: those with normal mental .

functioning, those with a history of diagnosed

functional mental illness for which inpatient or

outpatient treatment had been received, and

those with senile dementia. The chronic diseases

and functional disabilities of these groups are presented in table 14.

The researchers point out that although almost

all the subjects had one or more chronic conditions, the mentally normal group was basically

independent in self-care and home management

activities; the group with functional mental dis -

orders was somewhat more dependent, with a

significant proportion needing help with home

management activities; and the individuals with

senile dementia were most dependent, with a

large proportion needing help with personal care

and almost all needing assistance with home management activities. Dementia was highly correlated with functional impairment.

Other studies also indicate a correlation between dementia and functional impairment. For

example, special tabulations of survey data on

nursing home and community dwelling older persons indicate statistically significant correlations

between impaired cognitive ability and incontinence of bowel or bladder (Pearson correlations

ranged from 0.63 to 0.73) (86). These data agree

with findings of Ouslander, et al. (75), that the

majority of incontinent patients in seven nursing

homes studied were also cognitively impaired. Patients with frequent incontinence were significantly more likely to be cognitively impaired than

those with occasional incontinence.

The relationship between mental confusion and

functional impairment is a very important consideration in the development of technology for

long-term care because technologies that are appropriate for individuals who are not confused

are often inappropriate for those who are confused. Organic brain disease is known to cause

a progressive decline in the individual’s mental

functioning and self-care abilities: patients become

Table 14.—Most Frequent Preexisting Health Conditions and Functional Dependencies (percentage by groups)

Senile Senile

Preexisting health conditions Normal Functional dementia Dependent in Normal Functional dementia

Arthritis . . . . . . . . . . . . . . . . . . . . . 66 63 56 Toileting . . . . . . . . . 0 0 35

Foot trouble. . . . . . . . . . . . . . . . . . 45 35 35 Feeding. . . . . . . . . . 0 0 26

Visual impairment. . . . . . . . . . . . . 33 56 56 Dressing . . . . . . . . . 2 5 50

High blood pressure . . . . . . . . . . 33 41 53 Grooming . . . . . . . . 0 7 47

Circulation problems . . . . . . . . . . 31 26 62 Home mobility . . . . 0 2 29

Hearing impairment . . . . . . . . . . . 27 43 26 Bathing . . . . . . . . . . 2 16 79

Diabetes . . . . . . . . . . . . . . . . . . . . . 25 9 24 Cutting toenails. . . 16 44 91

Elimination problems . . . . . . . . . . 22 52 59 Telephoning ... , . . 0 2 62

Digestive problems. . . . . . . . . . . . 14 33 38 Shopping (food) . . . 16 35 97

Nervous breakdown . . . . . . . . . . . 0 40 0 Food preparation. . 2 9 79

Housekeeping . . . . 10 23 88

Laundry . . . . . . . . . . 8 26

Transportation . . . . 8 30 94

Taking medications 2 5 82

Handling finances . 4 14 97

NOTE: Data for normal and functional groups obtained from subjects data about dependencies of senile dementia group obtained from collaterals.

SOURCE: Brody and Kleban, 1963 (16),
194 . Technology and Aging in America

increasingly forgetful and confused and eventually may become unable to dress, bathe, and feed

themselves because they cannot remember how;

they become incontinent because they cannot find

the bathroom or remember how and when to use

a bathroom. About 50 percent of nursing home

residents have symptoms of confusion, but it is

not known how many or what proportion of

these individuals are unable to care for themselves as a result of confusion and how many are

functionally impaired as a result of other chronic

physical conditions. Some individuals may be

functionally impaired as a result of both mental

confusion and physical conditions. Identifying the

cause of functional impairment is crucial for the

appropriate use of rehabilitation technologies

with these patients.

Long-Term care services

The existing long-term care system includes

services provided informally by family and friends

and formal services provided in institutions, in

the community, and in the patient’s home. The

following description of the kinds of individuals

who are receiving services and the characteristics of the agencies and caregivers provides a

background for the identification and evaluation

of technologies appropriate for these patients,

agencies, and caregivers.

Informal long-term care

Families play a predominant role in providing

long-term care services for the elderly. A 1975

study by the General Accounting Office (GAO) of

the elderly population in Cleveland, OH, concluded that families were providing more than

50 percent of all long-term care services received,

and that as the impairment level of the individual increased, so did the proportion of services

provided by the family. For the extremely impaired group, families provided 80 percent of

needed services (115).

While the spouse and adult children of the

disabled elderly are the most frequent source of

informal support, other relatives and friends also

provide assistance: of the 87 percent of elderly

subjects in the Cleveland study who identified an

individual as their primary source of help, most

cited adult children or their spouse, but a significant number named a brother or sister, another

relative, or a friend (114) (see fig. 21).

Informal support provided by family and friends

can help to avoid or delay institutionalization, and

Figure 21.-Source of Support for the

Disabled Elderly, Cleveland, OH, 1975

SOURCE: U.S. Congress, U.S. Comptroller General, General Accounting Office,

Apr. 19, 1977 (114).

elderly persons who live alone are at greater risk

of nursing home placement. The GAO study

found that of those persons who were institutionalized during the following year, none had been

living with spouse or adult children, and threefourths had been living alone (115). Similarly, a

study of severely disabled elderly people receiving services from a home care agency in Philadelphia showed that none of the individuals lived

alone: 46 percent lived with their children, 20 percent lived with a spouse, and 34 percent lived with

other relatives and friends (18).
Ch. 7—Technologies, functional Impairment, and Long-Term Care ● 795

Several recent reports suggest that the increase

in numbers of working women may limit the

availability of family members to care for the impaired elderly (11)96)113). Although no statistics

are available to test this hypothesis, a study of

the attitudes of elderly women, their daughters,

anci granddaughters found that the daughters,

and particularly the granddaughters believe that

the elderly should be able to depend on their families to help them. At the same time, the respondents agreed that working daughters should not

quit their jobs in order to care for elderly parents

(16). These findings are significant because

daughters provide the great majority of informal

supports to elderly parents.

The availability of technologies to lessen the

burden of caregiving could increase the ability

and willingness of families to keep elderly

relatives at home. These technologies include:

●

●

●

●

●

assistive devices that increase the ability of

the impaired individual to perform some

functions independently;

devices and procedures that help with lifting,

turning, transferring, bathing, dressing, and

feeding functionally dependent persons;

devices and procedures to assist with the

problems of the mentally confused individual, such as wandering, forgetfulness, being

up all night, and the catastrophic emotional

reactions that characterize some Alzheimer

disease patients;

home care systems to provide services the

caregiver cannot provide and to teach caregiving procedures; and

respite care systems provided in the home

or community that temporarily relieve the

caregivers of their responsibilities.

Technologies to facilitate physical care ma-y be

particularly important for the spouse and adult

children of the impaired elderly because these individuals are often elderly themselves and may

have chronic conditions that limit their energy,

strength, and capacity to provide physical care.

Several recent reports have also documented the

value of support groups in providing information

and emotional support for caregivers. These technologies are discussed later in this chapter.

Formal long-term care services

and settings

Formal long-term care services are provided in

nursing homes, board and care facilities, and in

the elderly person’s home. Adult day care, hospice

care, respite care, and congregate housing services are also available in some communities. These

services are often said to form a continuum of

care arranged to reflect the elderly person’s increasing need for assistance. At one end of the

continuum are inpatient facilities providing 24-

hour skilled nursing care, and at the other end

are community agencies that provide supportive

services such as meals-on-wheels, chore services,

and transportation for the elderly. In between are

board and care facilities that offer personal care

on a 24-hour basis and home health agencies that

provide skilled nursing care and personal care in

the home.

The continuum of care concept reflects a combination of two underlying questions about the

individual’s need for care. The first is whether

the individual needs 24-hour care; that is, can the

individual safely be alone at all? The second question concerns exactly what kind of care the individual needs: skilled nursing care, personal care,

or supportive care. Skilled nursing care includes

medically prescribed treatments such as tube

feedings, dressings, catheterization, and monitoring of medical conditions that can only be done

by a trained nurse. Personal care includes services such as bathing, dressing, feeding, and assisting the patient to get up and get to the bathroom,

while supportive services include shopping, housekeeping, chore service, and transportation.

In the past, few formal long-term care services

were available in the home, and individuals were

sometimes admitted to nursing homes for skilled

nursing care or personal care even when they did

not need 24-hour care. In some communities this

is still true, but in other communities skilled nursing care, personal care, and supportive services

are available both in institutional settings and in

the home. The availability of home care services

makes it increasingly important to carefully assess

the individual’s need for 24-hour care. Provision
195 ● Technology and Aging in America

of appropriate long-term care services depends

on matching of available resources with the individual’s need for 24-hour care and/or skilled

nursing care, personal care, or supportive care,

Ideally, a wide range of long-term care services

would be available in each community, and elderly

individuals could select the services they need.

In fact, some services are not available in certain

jurisdictions, and some are available only to those

able to pay privately. Even ‘when services are

available in the community, it is often difficult for

the elderly and their families to find out about

them. Physicians and other health care professionals are frequently unaware of available services (24). Decisions about long-term care are often

made in an atmosphere of crisis that is compounded by lack of information about available

resources and lack of coordination of long-term

care services at the community level.

NURSING HOMES

At present, there are approximately 20,000

nursing homes in the United States, providing

beds for about 1.5 million residents, about 85 percent of whom are elderly. About 5 percent of

those over 65 are residing in nursing homes at

any one time, This number includes less than 2

percent of those 65 to 74, but more than 20 percent of those over 85 (125).

Nursing homes provide 24-hour care, skilled

nursing services, and personal care in an institutional setting, Care is given by nurses or by nursing assistants supervised by nurses with written

orders from a physician. In addition to skilled

nursing care and personal care, nursing homes

provide a type of sheltered housing, including

room and board, housekeeping, and meal service, and 24-hour supervision. For some patients,

this combination of sheltered housing, supportive

services, and 24-hour supervision is more important than any specific nursing services available

in the facility.

Funding for Nursing Home Care.—More than

half the cost of nursing home care is funded by

government programs, primarily Medicaid. As figure 22 illustrates, the remaining 47 percent is paid

by patients and their families (45 percent) and by

private insurance (less than 2 percent).

Residents.—Nursing home residents are most

often admitted on the basis of medical diagnosis

and need for nursing care. According to the National Nursing Home Survey, primary diagnoses

on admission include cardiovascular diseases (4o

percent), mental disorders such as senile psychosis, chronic brain syndrome, senility, mental

retardation, and alcoholism (20 percent), diabetes

(6 percent), arthritis and rheumatism (4 percent),

hip fracture (2 percent), cancer (2 percent), and

other (26 percent). Functional impairments are

seldom formally evaluated on admission, but the

survey indicates that most nursing home residents

need assistance with basic physical activities (see

fig. 23). More than 20 percent of nursing home

residents required help with all six activities

(128).8 A comparison of nursing home residents

and disabled elderly individuals in the community

shows that three characteristics strongly predict

nursing home placement: 1) dependency in toileting or eating, 2) dependency in bathing and dressing, and 3) mental disorders (1381.

Nursing home residents are not a homogeneous

group. They include: 1) terminally ill patients who

have been discharged from a hospital because no

further hospital care is needed; 2) individuals admitted from a hospital for recuperation and rehabilitation following surgery or a fracture; and

3) individuals who are medically stable but functionally impaired, due to chronic physical or mental conditions. About one-third to one-half of nursing home residents are discharged within 3

months (51,65); these tend to be individuals who

have been admitted from a hospital with a diagnosis of cancer, stroke, or hip fracture. A 1981

study indicates that about one-half of these shortstay patients died either in the nursing home or

in the hospital shortly after discharge from the

nursing home; 41 percent returned home, and

13 percent were transferred to another health

care facility. In contrast, individuals who stay

longer in the nursing home are more often admitted from home and include a higher propora Some evidence suggests that nursing home residents are now

more dependent and more functionally impaired than in the past

(119), This trend will accelerate as hospitals discharge sicker patients to nursing homes in response to the Medicare prospective

payment system. Results of the 1985 National Nursing Home Survey

can be expected to document this change.
Ch. 7—Technologies, Functional Impairment, and Long-Term Care ● 197

Figure 22.—Percentage

o1979

Medicaid

5 < 3

of Nursing Home Expenditures in the United

/

Insurance and other 1.4

t +

Other 38 ~ I

States,

Medi~~re 2.3 ~

Veterans Administration 1.9 —

SOURCE: GAO, 1983 (119),

Figure 23.—Percent of Nursing Home Residents Who Need Assistance With Basic Physical Activities:

United States, 1977

Mobility I

66?Z0

Bathing I

. ‘: ‘.. 86’3/0

Dressing I

.; J. 690/o

Toileting 1

Bowel and

bladder control 450/0

Eating ~sz”f o

SOURCE: Dtil-fS, 1981 (128),
198 ● Technology and Aging in America

Photo credit: Gretchen Kolsrud

Many nursing home residents are medically stable,

but require long-term care because of

functional impairments.

tion of those with mental disorders; one-fourth

of long-stayers had a primary diagnosis of mental disorder or senility compared with only 3 percent of short-stayers (51). These long-stay patients

constitute the largest proportion of nursing home

residents at any particular time.

Different subgroups of nursing home residents

need different types of care and different technologies for appropriate treatment. For example,

terminally ill patients might be best cared for with

methods based on the hospice model, which emphasizes pain+ontrol technologies and emotional

support systems; individuals admitted for rehabilitation need assistive devices, physical and occupational therapies, and effective linkage with

community agencies for continued care following discharge. Among the long-stay patients, appropriate technologies depend partly on the mental status of the patient; for mentally competent

patients, technologies to maintain or improve

physical functioning are appropriate. For those

who are mentally impaired, environmental design

technologies, cognitive therapies, and technologies

to maintain physical health are more appropriate.

For the new group of patients who are discharged

early from hospitals as a result of the Medicare

prospective reimbursement system, appropriate

technologies may be monitoring equipment and

nursing care systems now used primarily in hospitals.

Some nursing homes provide technologies and

systems of care appropriate to the different needs

of unique subgroups of patients, but many nursing homes provide a relatively uniform system of

care for all patients. This is due partly to lack of

comprehensive assessment procedures to identify individual needs and partly to insufficient staff

to provide individualized systems of care, Professional nurses who are trained to assess patient

needs and plan individualized treatment are often

in short supply in nursing homes and also perform many other functions in the facility, such

as skilled medical treatments, supervision of

largely untrained nursing aides, and time+ onsuming recordkeeping required by Federal and

State regulations.

Recent research that identifies subgroups of

nursing home residents (47,51,62)63,64,65)66)

provides a strong knowledge base for defining

distinct care needs of these subgroups, but this

research is based on retrospective analysis, and

it is not known how effectively nursing home patients can be identified as belonging to one subgroup or another at the time of admission. In addition, there is no consensus about whether

patients with similar needs are best cared for in

separate facilities, separate sections of the same

facility, or mixed in with other kinds of patients

as they usually are now. Further research is

needed to clarify these issues.

Research on care systems designed for confused

patients is particularly needed. Although about

50 percent of all nursing home residents have

symptoms of mental impairment and some nursing home residents have longstanding emotional

and behavioral problems, such as psychiatric conditions, alcoholism, and drug abuse, most nursing homes are not structured or staffed to meet

the needs of these patients (95). Within the existing care system, mentally and emotionally

impaired patients require more staff time than

physically impaired patients (39)128). Some care

providers believe these patients can be more

easily and effectively cared for in a setting designed specifically to meet their needs.
Ch. 7—Technologies, Functional Impairment, and Long-Term Care ● 199

Research on appropriate patterns of care for

nursing home residents is currently funded

through two Teaching Nursing Home Programs,

one sponsored by the National Institute on Aging

(NIA) and the other sponsored by the Robert

Wood Johnson Foundation. NIA has awarded

grants to five programs, each emphasizing treatment of specific disease conditions or functional

impairments (124). The Robert Wood Johnson

program is sponsoring affiliations between 11

nursing schools and local nursing homes (23). In

addition to these programs, a few long-term care

facilities have received public and private funding for the development of model nursing home

services (58). objectives of all these programs include investigation of disease processes in the

elderly, evaluation of functional assessment measures, and development of treatment approaches.9

Training opportunities for physicians, nurses,

social workers, and other caregivers are provided.

As these programs develop, models of care for

specific subgroups of patients will be developed

and refined.

BOARD AND CARE FACILITIES

Board and care facilities include a wide range

of residences that provide room and board and

some degree of protective supervision on a 24-

hour basis. Unlike nursing homes, these facilities

are not considered medical care institutions. Nursing care is generally not provided, but residents

may receive assistance with some personal care

activities such as bathing or dressing. Supportive

services, such as cooking, cleaning, and laundry

are also proivided. Although board and care residents may have private rooms, they generally do

not have private apartments because of the need

for 24-hour supervision.

There are now about 30,000 board and care facilities in the United States, serving about 350)

000

individuals, including elderly, mentally retarded,

and mentally ill residents. Although no exact

figures are available, it is estimated that about onethird to one-half of board and care residents are

elderly. (Some of the elderly are mentally retarded

and mentally ill, and some of those who are classified as mentally ill or mentally retarded are over

Wwatment goals include rehabilitation and discharge of some patients and lifelong supportive care for others.

65.) Board and care facilities range in size from

small adult foster homes and group homes to

large residential care facilities and some retirement homes. Each State recognizes and licenses

certain types of board and care facilities; although

each State has some unlicensed board and care

facilities, a recent study shows that 85 percent

of all facilities are licensed (88).

Funding for Board and Care. -About one-third

of residents pay privately for care. Among the

other two-thirds, many receive Federal Supplemental Security Income (SS1) payments and use

this income to pay for their care, In addition,

States are allowed to supplement the Federal minimum SSI benefits, and by 1983, 34 States and the

District of Columbia provided supplements for

persons living in board and care facilities (52,131).

Residents.—Although very little information is

available about the characteristics of elderly residents of board and care facilities, a recent study

of residents of these facilities in seven States indicates that some residents needed assistance with

basic self-care activities, such as bathing (26 percent), dressing (11 percent), walking (9 percent),

and using the toilet (4 percent). Larger percentages of residents needed assistance with home

management activities such as laundry (64 percent), cleaning, (55 percent), managing money (46

percent), shopping (43 percent), and taking medicine (43 percent). Chronic physical conditions of

residents included degenerative joint diseases (36

percent), circulatory and heart disorders (25 percent), hearing impairments (22 percent), and respiratory diseases (14 percent). Perhaps more significant is the large percentage of residents with

mental impairments. The researchers found that

about 40 percent of the residents were mentally

ill, disoriented, or exhibited memory impairmerit. *O About 28 percent of the residents had previously resided in an institution for the mentally

ill, while 21 percent had lived in a nursing home (31).

These data reflect a seriously disabled population with extensive physical and mental impairments. While no research is available to verify the

IQne-third of residents were assessed as mentally ill. ,~nother

one-third of residents were disoriented or exhibited mental impairment. These tm’o groups overlapped, and one of the researchers

has estimated that 40 percent of all residents were in one or both

subgroups (104).
200 ● Technology and Aging in America

primary reasons that residents need board and

care services, it is likely that the high prevalence

of mental illness, disorientation, and memory impairment explains much of the need for care.

These confused and mentally ill residents are

more likely to require supervision and assistance

with laundry, cleaning, managing money, and taking medicine rather than personal care such as

bathing, dressing, and walking. (It is interesting

to note that the study did not find any residents

who were incontinent or needed assistance with

eating, the two primary risk factors for nursing

home placement.)

The cost of board and care facilities varies

widely but is generally one-third to one-half the

cost of nursing home care. Despite this relatively

low cost, several problems limit demand for board

and care homes; these include the generally poor

reputation of these kinds of facilities11 and lack

of available information about the facilities, the

services offered, and the cost of care. In addition,

the pervasive emphasis on medical v. nonmedical

forms of care in our society and the availability

of Medicaid funding for nursing home care but

not board and care limit demand for these facilities. The major factor restricting the supply of

board and care homes is the low levels of reimbursement for providers (88).

Since the cost of care in most board and care

facilities is substantially less than nursing home

care, it is important to consider whether some

nursing home residents could be cared for in

board and care facilities. Both settings provide 24-

hour supervision, and while some nursing home

residents need skilled nursing care that is not

available in board and care facilities, many actually receive little or no skilled nursing care. For

these individuals, many of whom are the long-stay

patients discussed earlier, board and care homes

might provide a long-term care option that is

cheaper and less personally restrictive than living for many years in a nursing home.

Technologies appropriate for the board and

care population include:

llThe American Bar Association has recently finalized a model

state statute for board and care facilities that includes standards

for physical environment, staff qualifications, resident rights, and

administrative sanctions for noncompliance.

●

●

●

assessment technologies to identify individuals who can be best served in these kinds

of facilities;

assistive devices to improve the physical functioning of residents; and

technologies for caregivers, including devices

and care methods appropriate for mentally

impaired residents.

In addition, improved information systems are

needed to increase awareness of this long-term

care option among the elderly, their families, and

health care providers.

HOME CARE

Long-term care services provided in the home

include medical, social, and supportive services

designed to maintain the individual in the community and compensate for impaired functioning. Most medical and social services that are available in nursing homes can also be provided to

individuals at home, but three problems restrict

the use of these services: 1) lack of home care

services in some communities, 2) lack of coordination of home care services in many communities, and 3) limited public funding for supportive

services in the home. In this section, home care

services are defined, and appropriate use of home

care services is discussed. Because much attention has been focused on whether the availability of home care services can decrease the use

of nursing homes, this question is also discussed.

Funding for Home Care Services.—Public funding for home care services is provided through

Medicare, Medicaid, the VA, the Title XX Block

Grant, and Title III of the Older Americans Act.

Medicare and Medicaid fund primarily health care

services, and complex regulations govern the

kinds of services that are reimbursed. The Title

XX Block Grant and Title III of the Older Americans Act fund primarily supportive services (see

the technical memorandum at the conclusion of

this chapter). Private insurance pays for some

skilled nursing, physical therapy, and speech therapy provided in the home. Individuals and families also pay privately for home care services, but

since these services are purchased independently

from both agencies and individuals, little information is available about the kinds and cost of

services used.
Ch. 7—Technologies, Functional Impairment, and Long-Term Care ● 201

Clients.—Home care services are listed in table

15. The kinds of elderly individuals who use home

care can be inferred from the wide variety of

services that are available. Some patients have

been recently discharged from the hospital and

require nursing care and supervision of medical

treatments. In fact, increasingly complex and

sophisticated medical treatments, such as intra -

venous fluid replacement, antibiotic therapy,

chemotherapy, enteral and parenteral nutrition,

hemodialysis, and continuous ambulatory peritoneal dialysis, can now be provided in the home.

Other patients need rehabilitation services such

as physical or speech therapy that may have been

started in the hospital but can continue in the

home. Supportive services such as home delivered

meals, homemaker, and chore services may be

needed by the same individuals who need skilled

nursing care or rehabilitative services and also

by another large group of individuals with functional impairments that restrict their ability to

shop, cook, or care for their homes.

Table 15.—Elements of Long=Term Care in the Home

Skilled nursing care: Medically oriented care provided by a

licensed nurse to include monitoring of acute and unstable chronic medical conditions, evaluation of the patient’s care needs, injections, care of wounds and bed

sores, tube feedings, and clearing of air passages. Skilled

nursing care is usually authorized by a physician,

Physical therapy: Rehabilitative therapy provided by a qualified physical therapist.

Speech therapy: Therapy provided by a qualified speech therapist to improve or restore speech.

Occupational therapy: Therapy provided by a qualified occupation therapist to improve functional abilities.

Medical social services: Assessment, referral, and counseling services related to the medical care needs of the

patient.

Home health aide services: Assistance with simple, healthrelated tasks, such as medications and exercises, and personal care services provided under the supervision of a

licensed nurse.

Personal care: Assistance with basic self-care activities such

as bathing, dressing, getting out of bed, eating, and

using the bathroom.

Homemaker services: Household services such as cooking,

cleaning, laundry, shopping, and escort service.

Chore services: Household repairs, yard work, and errands.

Home-delivered meals: Meals delivered to the home for individuals who are unable to shop and/or cook for themselves.

Telephone reassurance: Regular telephone contact to individuals who are isolated and often homebound.

Home Care Services as a Substitute for Nursing Home Care.—It has been believed for many

years that home care services could help to maintain impaired elderly individuals in their homes

and avoid nursing home placement. Although this

belief offers the hope of cost savings and has been

used as an argument for increasing home care

services, a recent GAO study of demonstration

programs offering expanded home care services

found that these services did not reduce utilization of nursing homes. GAO concluded:

For some subpopulations of the elderly, providing home care services may decrease the use of

nursing homes. However, more work, including

the refinement of assessment tools, is needed to

better define and identify individuals for whom

nursing home use can be reasonably decreased

(118).

The development and increased use of assessment

technologies is discussed later in this chapter.

one reason that home care services do not reduce utilization of nursing homes is that many

individuals who are at risk for nursing home

placement need 24-hour care because they cannot be safely left alone or because they need

assistance many times a day at widely separated

time intervals. Formal home care services are seldom available on a 24-hour basis because of cost,

and in many communities, publicly supported

home care services are limited to only a few hours

a day. As a result, if the individual lives alone or

if no family member is available on a 24-hour

basis, institutional care may be necessary.

As indicated in the example, formal home care

services are not an appropriate long-term care option for elderly individuals who are too confused

to remain safely alone and have no one to stay

with them when the home care provider leaves.

Increased use of comprehensive assessment technologies could help to identify individuals for

whom board and care facility or a nursing home

is a more appropriate long-term care option than

home care.

:

Frantic calls were received at several nursing

homes from a middle-aged seeking nursing home bed for his 73year old mother. She

had little income, had broken her hip and was

SOURCE: Office of Technology Assessment.
202 Ž Technology and Aging in America

●

●

●

●

●

assessment technologies to identify patient

needs and appropriate care methods;

patient-care devices that have been used in

hospitals but can be adapted for use in the

home, and methods for teaching the elderly

and their families to use these devices;

assistive devices to decrease functional impairment, and techniques for training individuals to use these devices;

environmental design technologies to accommodate the functional impairments of elderly

individuals; and

improved service delivery systems to increase

awareness and appropriate access to home

care services.

In addition, the information technologies discussed in chapter 6 could be used to meet some

of the home care needs of the impaired elderly.

For example, interactive television could be used

to provide training in the use of devices and to

answer questions about medical treatments provided in the home.

ADULT DAY CARE

Adult day care centers provide health and social

services for impaired elderly individuals. Services

vary among programs but frequently include supervision, personal care, group activities, meals,

recreation, and exercise in addition to medical and

medically related services such as physical therapy and speech therapy, Availability of these services in a centralized setting is convenient for both

clients and health care providers (106), Two types

of adult day care have been identified: 1) rehabilitation-oriented programs designed primarily

to provide medical care and physical therapy, and

2) multipurpose programs designed to provide

social stimulation for impaired and isolated elderly

individuals and respite for the families who have

been caring for them (13?). The number of adult

day care facilities in the United States has increased from fewer than 20 in 1970 to between

700 and 800 at present (l).

Funding for Adult Day Care. -Clients and their

families often pay for some or all of the cost of

adult day care themselves. Adult day care is an

optional Medicaid service; as of 1984, eight States

were providing Medicaid reimbursement for

adult day care (127). In addition, 35 States provided adult day care with title XX funds, and several States provide adult day care services through

demonstration projects funded under the Medicaid waiver program (24). Medicare does not

cover adult day care programs, although some

medical and physical therapy services provided

for adult day care clients are covered by Medicare.

Clients.—SeveraI studies have examined the

characteristics of adult day care clients. A 1976

study of four programs showed that 56 percent

Photo credit: Suburban Hospital, Adult Day Care Program, Bethesda, MD

Adult day care programs can provide socialization and

group activities in addition to medically related

services such as physical therapy.
Ch. 7—Technologies, Functional Impairment, and Long-Term Care ● 203

of the participants were severely dependent in

activities of daily living, requiring assistance in

eating, transferring (moving from bed to chair

and chair to bed), or toileting, or were incontinent; another 16 percent were moderately impaired, requiring assistance with bathing or dressing, but not eating, transferring, or toileting (106).

Another study comparing clients at an adult day

care center with residents of a nursing home and

individuals living independently in an apartment

facility for the elderly found that the day care

clients were most disabled in physical health,

mental health, and activities of daily living, while

the residents of the nursing home were most

limited in socioeconomic areas, such as informal

social supports and financial resources (85). A

third study found that day care clients were generally less impaired than nursing home residents,

but of the 25 most impaired day care clients, only

2 were living alone (111). These findings suggest

that adult day care can be an appropriate resource for severely impaired individuals as long

as they have sufficient informal supports and financial resources to maintain themselves at home

when they are not at the day care center.

Technologies appropriate for adult day care include assessment technologies to identify elderly

individuals who could be cared for in these settings and information systems to increase awareness of this long-term care option among the

elderly, their families, and other service providers.

Some adult day care programs are designed specifically for mentally impaired individuals, with

emphasis on consistency in program and staff to

limit daily changes that are confusing to clients

and environmental design that allows maximum

independence without compromising safety (95).

Evaluation of the efficacy and cost of these programs is needed. Treatment methods for mentally

impaired individuals that have been developed in

adult day care settings may provide a model of

care for these patients that can be used in other

long-term care settings.

HOSPICE

Hospice programs provide supportive services

for individuals with terminal illness. Hospice is

a method of care, not a place, and hospice care

can be provided in a hospital, nursing home, or

in the patient’s home. Services include nursing

care, medical social services, homemaker, home

health aide services, and counseling for the patient and the family. In addition, short-term inpatient care is often available for crises. The technology of pain control is central to the hospice

concept, and emphasis is on quality of life rather

than aggressive medical treatment and prolongation of life.

The first hospice was established in this country in 1973, and by 1983 there were an estimated

1,100 to 1,200 hospice programs in the United

States (49). Medicare benefits have been available

for hospice care since November 1, 1983. Up to

6 months of hospice care can be covered.

Because hospice care is believed to be less expensive than hospitalization, Medicare coverage

of hospice care may result in cost savings (121),

but some experts question whether these savings

will materialize. A recent study compared terminal

cancer patients treated in a hospital-based hospice

program with those who received conventional

care. Hospice patients reported more satisfaction

with their care than conventional care patients,

but the cost of hospice care was the same or

greater than the cost of conventional care. No significant differences were found between the

groups in survival time, pain symptoms, or days

in the hospital. While the conventional care patients spent more days in nursing homes than

hospice patients, the majority of both groups died

in the hospital; only 3 percent of the hospice patients and 7 percent of the conventional care patients died at home. Although hospice programs

are designed to decrease the number of invasive

diagnostic and curative treatments, the data show

little difference between the two groups on these

variables (49). These results raise questions about

the real differences between hospice care and

conventional care. Further research is needed, including comparison of methods, costs, and outcomes in hospices based in different settings, such

as hospitals, nursing homes, and home care

agencies.

Hospice care is a resource for terminally ill patients currently being cared for in nursing homes

or in the community. Identification of terminal

patients can present a difficult diagnostic proce-
204 ● Technology and Aging in America

dure for certain subpopulations, and the development of more precise guidelines and diagnostic criteria is needed. Improved service delivery

technologies are also needed to make information

about the hospice alternative available to appropriate patients and their families.

RESPITE CARE

Respite care is temporary care provided for the

impaired elderly to relieve the primary caregivers.

Respite care can be provided in nursing homes,

board and care facilities, or in the individual’s

home, and can range from several hours up to

a week or longer. Public funding for formal respite care programs is available in some communities through the Title XX Block Grant and Title

111 of the older Americans Act. There is no Medicaid funding for respite care under the general

program, but respite care is part of 15 of the 26

approved Medicaid 2176 waiver programs for the

elderly (138). (See the technical memorandum at

the end of this chapter for a description of the

Medicaid 2176 waiver program.) In addition,

home health care, personal care, and homemaker

services funded through Medicare, Medicaid, Title

XX, and Title III may be used by some families

as respite care, since caregivers are able to leave

the home when the aide or homemaker is present,

CONGREGATE HOUSING

Congregate housing for the elderly, which is discussed in chapter 9, is included here because the

design features and supportive services available

in some congregate housing facilities compensate

for the functional impairments of elderly residents and thus postpone or avoid the need for

other long-term care services. Physical design

features such as emergency call buttons, grabbars in the bathroom, and safety features on

ovens have been built into many publicly and privately funded congregate housing facilities for the

elderly. Some of these facilities also provide optional supportive services such as meals and

housekeeping that can eliminate the need for

shopping and some home management activities.

Alarm systems in each apartment provide psychological security for physically impaired individuals. Opportunities for socialization and

recreational activities in the facility can help to

maintain emotional well-being.

Most congregate housing facilities in this country have been built within the past 20 years. Over

time, administrators at these facilities have had

to deal with the increasing physical and mental

impairments of their aging residents. In some facilities, residents have been required or encouraged to move out when their functioning decreased below the level established for admission.

1n other facilities, these residents are not required

to move, and in some facilities, increased services have been provided to help compensate for

impairments and maintain independent functioning.

Both physical and mental impairments of residents can limit their ability to function adequately

in congregate housing. Physical problems such

as severe illness, the need for frequent monitoring of medication, and being bedridden interfere

with the individual’s ability to live independently,

and residents with these problems usually transfer to other long-term care settings. Mental and

emotional problems, incontinence, and accident

proclivities are also seen as very disruptive by

managers and other residents, but individuals

with these problems often do not see the need

to move (13), which can create difficult administrative problems for managers.

In summary, congregate housing is an appropriate long-term care option for some physically

impaired individuals. The level and type of impairment that can be safely accommodated depends on the availability of supportive services

and physical design features for the handicapped

in each facility. Congregate housing is usually not

an appropriate option for mentally impaired individuals because of the lack of 24-hour supervision. Federal policy initiatives to increase the

availability of congregate housing and encourage

provision of services for physically impaired residents are discussed in chapter 9.

Issues in long-term care settings

and services

Several general issues related to long-term care

services and settings are discussed in this section,

including the comparative cost of care in various

settings and the perception of settings as distinct

caregiving systems.
Ch. 7—Technologies, Functional Impairment, and Long-Term Care “ 205

COMPARATIVE COSTS OF CARE

Accurate comparison of the cost of various longterm care services is difficult because costs vary

from one city to another and from rural to urban areas. Within communities, costs vary depending on the agency providing the service and

the source of payment. For example, Medicare

usually pays considerably more for specific services than Medicaid. Cost comparisons are further

complicated by the inclusion of room and board

in the cost of some long-term care services, such

as nursing home care, but not in the cost of other

services, such as home care and adult day care.

Despite these difficulties, some generalizations

can be made about relative costs of care.

In general, nursing home care costs more than

other forms of care because the per diem rate

is relatively high and most patients receive care

for extended periods. Private patients usually pay

the highest rate, followed by VA and Medicare

patients, and then Medicaid patients. For calendar year 1979, the average per diem rate was

$63.73 for VA patients, $38 for Medicare patients,

and $23.59 for Medicaid patients (24). The cost

of care in board and care facilities varies widely,

but is generally one-third to one-half the cost of

nursing home care. In early 1980, the average cost

in board and care facilities was about $10 a day

(88). In comparison, the average daily cost of hospital care was $226 in 1979 (120), and the average Medicare reimbursement for hospital care

was $182 per day (126).

The cost of home care depends on the type of

services provided and the source of payment.

Medicare payments for home care are relatively

high. Reimbursement guidelines for the year ending June 30, 1980, were: skilled nursing care,

$41.80 (urban) and $38.05 (rural); home health

aide visits, $33.00 (urban) and $27.70 (rural) (116).

Medicaid payments for home care services are

generally much lower. For example, in Colorado

in 1980, one home care providet received $45 for

a skilled nursing visit under Medicare but only

$28 from Medicaid) and $10.24 for a home health

aide visit under Medicare but $4 from Medicaid

(117). In Washington, DC, in 1980, Medicaid paid

$23.75 to $27.63 for skilled nursing visits, $8.61

to $10,50 per hour for personal care, and $2.90

per hour for homemaker services (117).12 No information is available about the cost of home care

services paid for by individuals.

These figures indicate that the Medicare rate

for a single skilled nursing visit is similar to the

Medicare rate for a day of nursing home care.

Since the cost of home care does not include room

and board and other living expenses, the overall

cost of care for an individual who needs daily

skilled nursing care at home can be higher than

the cost of nursing home care. Most home care

patients do not, however, require or receive daily

skilled nursing visits; the nurse may go out once

or twice a week or less, with intervening visits

of a less expensive home health aide. Home care

is thus usually less expensive than nursing home

care. The Medicare reimbursement for a home

health aide visit was about 75 to 85 percent of

the Medicare reimbursement for a day of nursing home care, and also does not include the cost

of room and board. The Medicaid payment for

1 hour of personal care in the home in Washington, DC, was about one-third to one-half the average per diem Medicaid payment for nursing home

care nationwide.

The cost of adult day care varies according to

the type of program. Those with a rehabilitation

emphasis cost about twice as much as programs

with a social emphasis, and some adult day care

costs the same or more than nursing home care.

A 1976 study of four adult day care programs

with a rehabilitation emphasis showed that the

average per diem cost was $52 a day, but with

a wide range of $18.54 to $88.17 (106). Adult day

care clients seldom attend every day, however.

The same study found that average attendance

was 70 days per person per year with a range

of 48 to 114 days between the four sites (106).

As a result, the overall monthly cost of adult day

care is significantly less than nursing home care

and may be similar to the cost of a board and care

facility.

The cost of hospice care and respite care depends on the kinds of services used and the frequency of utilization. At present, Medicare reim1211 is like]}, that the lower Medicaid reimbursement rates discourage pro~’iders from ser~ing Medicaid recipients
206 . Technology and Aging in America

bursement for hospice care is limited to $53.17

a day for a maximum of 6 months.

Congregate housing is considerably less expensive than other long-term care services. In federally subsidized housing, residents who are eligible for section 8 subsidies pay 30 percent of their

income for rent. Monthly rent for other elderly

individuals can range from $400 per month up

to $1,200 to $1,500 or more, depending on the

facility and the amenities provided.

A recent study focused on costs and outcomes

for individuals receiving services in four settings—nursing homes, geriatric day hospitals

(adult day care centers), board and care facilities,

and senior centers. Applicants were screened and

statistical methods were used to develop subgroups of similar individuals receiving services

from each type of agency .13 After 9 months, no

consistent significant differences were found between subgroups on a wide variety of outcome

measures, including utilization of skills for independent living, community integration, unmet

service needs, and living conditions. There were,

however, significant differences in the cost of

care. Considering total expenses for individuals

in each subgroup, the adult day care was most

expensive (about $48 per day),14 followed by nursing home (about $40 per day), senior center (about

$34 per day), and board and care (about $31 per

day). These figures include the costs of acute care

services, formal and informal long-term care services, and living expenses in the community. When

only the cost of formal long-term care services

is calculated, the order is changed: nursing homes

are slightly more expensive than adult day care

and more than twice as expensive as board and

care facilities, while senior center services were

least expensive (102).

Although these data were derived through a

complex analysis of patients and services provided

in a limited number of settings in Pennsylvania

13Many app]icant5 t. each agency were not included in this stud y

because their needs and/or characteristics were different from those

of individuals in the identified subgroups. The authors emphasize

that their results are on{v applicable to the kinds of individuals they

studied.

14The adu]t dav care services discussed here were rehabilitationoriented servic& provided in a hospital as opposed to socially

oriented services that are much less costly.

and Delaware, they raise important questions

about the differences between services and costs

of care in various long-term care settings.

SETTINGS AND SERVICES AS DISTINCT

CAREGIVING SYSTEMS

Long-term care services are most frequently described using a model in which each of a variety

of agencies provides unique services appropriate

for specific subgroups of patients. Current funding mechanisms and most long-term care decisionmaking systems assume that this description

represents reality. In this system, only those technologies appropriate to each subgroup of patients

would be used in certain agencies.

An alternative model of long-term care includes

many agencies, each providing a wide range of

services to a broad mix of patients with a variety

of needs. The discussion of long-term care settings and services in this chapter indicates that

this model more accurately represents current

reality. Increased use of technology in this model

is more difficult and more expensive because

many different kinds of technologies will be

needed in each setting. For example, technologies

that are appropriate for residents of a single nursing home could include hospice care techniques

and pain-control technologies; a wide range of

assistive devices and rehabilitation services, including physical, occupational, and speech therapy; technologies for caregivers; patient monitoring devices; and environmental design technologies.

The cost of making these technologies available

in the nursing home would be very high.

The question of whether it is more effective to

provide a unique set of services in each setting

or a wide range of services to a variety of patients

depends not only on the relative costs of increasing the use of technology. It also depends on the

feasibility of dividing patients into subgroups and

the impact on patient morale and quality of care

of moving patients when their needs change.

Three questions relevant to these issues can be

raised:

● Can available assessment measures effectively identify care needs for a large proportion of long-term care patients, including both

the services the patient needs and those he

does not need?
Ch. 7—Technologies, functional Impairment, and Long-Term Care . 207

● How frequently do the needs of individual

patients change, resulting in the necessity for

different services and technologies?

● What is the impact on patients of moving

them when their needs change?

Anecdotal evidence suggests some negative effects

of moving patients, including increased disorientation in a new setting and lowered morale as a

result of separation from friends and a familiar

setting. Balancing these negative effects against

Technologies in long-term

Assessment technologies

Assessment technologies include both formal

assessment measures used to evaluate the individual and knowledge about how and when to

use these measures and how to evaluate the

results. Effective assessment procedures are important both for good patient care and for sound

public policy. Planning appropriate long-term care

for a disabled elderly individual requires an understanding of the condition of the individual and

the complex interaction of physical, mental, social,

and environmental factors that result in functional impairment and create the need for longterm care services. Similarly, sound public policy decisions about the administration and financing of long-term care services require reliable and

valid information about functional impairments

and the need for services in the elderly population (140).

CURRENT USE

A large number of assessment measures have

been developed over the past 25 years in the

United States, and are being used in long-term

care research, demonstration projects, and

specialized geriatric assessment centers. Most of

these measures emphasize the functional status

of the individual, and some also assess social and

environmental factors that affect the need for

long-term care services. Experts in gerontology

and long-term care agree that comprehensive

functional assessment is essential for the evaluation of elderly individuals for long-term care purthe positive aspects of receiving care in a setting

uniquely structured to meet one’s needs is an

issue that requires further research. The relative

ease and lower cost of increasing the use of technology in a long-term care system with each

agency providing a unique set of services is only

one factor in the decision about which model of

long-term care services is most beneficial for patients.

care

poses and that formal assessment measures are

important tools for gathering the necessary information, yet most physicians and other longterm care service providers are not using these

tools.

The failure of physicians and long-term care

providers to use comprehensive assessment measures may be based in part on lack of knowledge

about these technologies. Perhaps more important is the fact that Medicare and Medicaid eligibility for most long-term care services is not based

on a comprehensive functional assessment of the

patient, and no standard assessment is required

for individuals who pay privately for long-term

care services. Thus physicians and long-term care

providers are not required to use comprehensive

assessment measures and are often reluctant to

spend the additional time needed to complete the

assessment.

Failure to use comprehensive assessment measures can result in failure to identify treatable conditions. For example, a recent study of incontinence in nursing home patients (75) found that

50 percent of the residents were incontinent, but

only 14 percent of these incontinent patients had

this problem listed by their physicians, and very

few were receiving any treatment for it, While

identification of incontinence would result from

a thorough medical evaluation, many nursing

home residents do not receive thorough evaluations, Use of a comprehensive assessment measure

by the physician or another health care professional could increase the probability of identifying these conditions.
208 ● Technology and Aging in America

Many research projects and demonstration programs have used comprehensive assessment measures to identify appropriate long-term care services for elderly individuals. For example, one

study evaluated the use of comprehensive assessment for frail elderly individuals living at home

and awaiting placement in a nursing home; as a

result of the assessments, about 60 percent were

recommended for and assisted in receiving longterm care outside a nursing home, including 23

percent who received supportive services at

home, and 30 percent who were placed in supervised boarding homes (140). Other studies have

demonstrated the use of comprehensive assessment measures for identification of inappropriate

use of services and unmet needs in the community and for patient planning and treatment

evaluation in nursing homes (38,48,140).

There is as yet no consensus on the validity of

studies showing positive results of the use of comprehensive assessment measures. Some experts

believe that the state of the art in assessment technology may not be sufficiently developed to provide positive results (17). One recent study indicates that the use of comprehensive assessment

measures is effective in improving patient outcome only in certain groups of patients (91a).

ongoing research at specialized geriatric assessment centers around the country can be expected

to clarify these questions.

ASSESSMENT MEASURES

Although an enormous number of variables are

related to functional impairments and long-term

care needs, it is generally agreed that the most

important can be grouped in a few general categories or domains, including: 1) need for medical treatment, 2) physical functioning, 3) mental

functioning, and 4) social functioning and environmental fit. In each category, evaluation of the

residual strengths of the individual is as important for long-term care decisionmaking as the

identification of deficits and problems. In the following sections, variables in each of the categories

and problems with measurement are discussed.

Measurement of Need for Medical Tmatment.—

Most assessment instruments designed for impaired elderly individuals include an evaluation

of specific medical care needs, such as the need

for tracheotomy, respiratory therapy, or intravenous medications. The need for frequent physician services, skilled nursing care, physical therapy, occupational therapy, and speech therapy

is also usually evaluated. This information is important because the availability of needed medical care services in the community and in longterm care institutions may affect appropriate

placement of the individual. No problems in the

assessment of information in this category have

been noted (140).

Measurement of physical Functioning. -Assessment instruments designed to evaluate physical functioning include measures of general physical health, such as bed days, restricted activity

days, and predicted life expectancy; measures of

self-care activities, such as bathing, dressing, and

feeding; and measures of home management and

independent functioning, such as shopping, cooking, using a telephone, taking medications, and

managing money. Although many of the same activities are included in several measurement instruments, differences in wording and scales may

mean that results using different instruments may

not be comparable and some instruments may be

more useful in certain settings than others (43).

Several conceptual problems in the measurement of physical functioning have been noted.

First, the functional ability of elderly individuals

is known to vary from day to day as a result of

fatigue, acute illness, and other factors, making

it difficult to arrive at a single measure of physical functioning. Second, both motivation and opportunity affect physical functioning (43), and

there may be a need to distinguish between those

who are unable to perform a certain function

under any circumstances, those who are not

motivated to perform the function, and those who

do not have an opportunity to perform the function, such as nursing home residents who do not

need to cook and often are not allowed to shower

without assistance. Third, functional ability can

sometimes be improved with the use of assistive

devices, and assessment measures differ in the

way that functioning with the use of an assistive

device is handled (43).

Assessment measures have been used extensively in the National Long-Term Care Channeling Demonstration Program described later in this
Ch. 7—Technologies, Functional Impairment, and Long-Term Care ● 209

chapter. Preliminary findings on the use of these

measures indicate several areas of physical functioning that are not adequately evaluated with

available measures. These include: 1 ) deficits in

vision, hearing, and speech that can have a major impact on the ability to function independently, 2) the relative ease or difficulty with which

an individual performs a certain function, and 3)

the individual’s potential to perform a certain

function in a different setting or with rehabilitation training (77). Each of these issues is important for the evaluation of an indiviudual’s need for

long-term care services.

Measures of Mental Functioning.—Assessment

instruments havee been developed to measure

three main aspects of mental functioning: cognitive functioning, affective functioning, and general mental health. Measures of cognitive functioning focus on orientation to person, place, and

time; personal and current information; attention;

comprehension; and memory. Measures of affective functioning focus primarily on depression,

and measures of general mental health generally

screen for psychiatric illnesses (43).

Valid assessment of mental functioning is even

more difficult than assessment of physical functioning, partly because of problems in defining

conditions such as ‘(confusion, ” “dementia, ”

“disorientation,” and “depression” [84)140). In addition, mental functioning in the elderly is often

affected by acute and chronic illnesses and by

medications prescribed for these illnesses (43); as

these physical factors change from day to day,

mental functioning may also change. It is also difficult to separate cognitive impairment from depression since some depressions have symptoms

like dementia in the elderly (43). For these reasons, the reliability and validity of measures of

mental functioning have been difficult to establish. It has been suggested that the available measures of mental functioning should be used only

as gross screening tools for identifying individuals

who need more intensive evaluation (140).

A major problem in using measures of mental

functioning in long-term care is that the relationship between impaired mental function and a

need for long-term care services has not been

established. It is known that some individuals with

considerable memory problems are able to function safely in their familiar home environment,

while others who perform well on tests of memory may be subject to occasional or continuous

confusion or agitation that limits their ability to

function independently (140).

Some recent research indicates that severity of

functional impairment may be related to the loss

of specific cognitive functions. One study suggests

that individuals with primary losses in memory

and orientation had less severe functional impairment, while those with primary losses in attention and recognition were more severely impaired

(133). Commonly used mental status measures

that emphasize memory and orientation may

therefore not distinguish accurately between

those who are able to care for themselves and

those who need assistance with self-care as a result of mental impairment (142). Increased understanding of the relationship between loss of specific cognitive functions and the need for longterm care services is important for identifying individuals who need care, designing appropriate

care systems, and estimating the future size of

the long-term care population.

Measurement of Social Functioning and Environmental Fit.—Evaluation of social and environ -

mental functions affecting the impaired individ -

ual is important for decisionmaking in long-term

care (43,140). Informal support provided by family and friends often allows mentally and physically impaired individuals to remain at home

rather than be placed in a nursing home. Similarly, the characteristics of the individual’s environment, including the physical layout and any

rules, regulations, or external constraints will

often affect his well-being and his ability to function independently (43).

Despite the recognized importance of social supports and environmental characteristics for the

impaired elderly, it has been difficult to develop

valid assessment tools to measure these factors.

Although the general concepts of social functioning, social supports, and environmental fit are

clearly related to long-term care needs, it is difficult to specify the aspects of these concepts that

are most relevant to long-term care decisionmak -

ing. In addition, interpretation of results is complicated by lack of norms and by important differences in the way that individuals react to social
210 ● Technology and Aging in America

and ernvironmental realities (12,43), For example,

some individuals may be satisfied with much less

social interaction and fewer social activities than

others. Similarly, rules and environmental constraints that are experienced as very restrictive

by some individuals may have a neutral or positive

effect on others. objective measurement of the

complex interaction between the individual’s preferences and expectations and the reality of his

physical and social environment is difficult,

Kane and Kane (43) have discussed measurement tools in three categories: social interactions

and resources, personal coping and subjective

well-being, and environmental fit. Some measures

in each of these categories have been developed

for use in long-term care decisionmaking, while

others were designed for use with the well elderly

or for individuals of all ages. Measures of social

interactions and resources generally include items

about the existence and location of family and

friends, frequency and quality of intergenerational contacts, and other social activities. Measures of personal coping and subjective well-being

include scales on life satisfaction, morale, happiness, adaptability, and coping skills. The third

category, environmental fit, includes measures to

describe the individual’s environment, rules, regulations, and programmatic aspects of his living

situation, and the fit between his characteristics

and aspects of his environment.

Multidimensional Measures. -Multidimensional

assessment measures are designed to provide information about many different aspects of client

functioning, including physical, mental, social, and

environmental. Examples include: the Sickness

Impact Profile (SIP), developed to assess the outcome of health care; the Older Americans Resources and Services instrument (OARS), developed at Duke University and used in a GAO study

in Cleveland, OH; the Comprehensive Assessment

and Referral Evaluation (CARE), developed for the

United States-United Kingdom Cross-National

Project; and the Patient Appraisal and Care Evaluation (PACE), developed by four universities for

use in the management of patients and for administrative and research purposes (43).

Issues of reliability and validity have been particularly troublesome with multidisciplinary measures, particularly questions about inter-rater reliability and how to evaluate the validity of these

measures. Several general issues affecting the use

of multidisciplinary measures and all geriatric

assessment technologies are discussed here.

ISSUES IN ASSESSMENT TECHNOLOGY

which Instrument to Use.—The large number

of available assessment tools presents a difficult

choice for geriatric practitioners. Many of these

measures have been developed for research or

demonstration projects. Measures developed for

research and demonstration programs are often

too long to be practical for widespread use by geriatric practitioners.ls In addition, researchers have

often devised new instruments or adapted existing instruments to precisely serve the purpose

of their projects; this increases the number of

available instruments and does not help to test

the validity or reliability of existing measures (20).

Assessment can serve a variety of purposes, including description, screening, diagnostic and

treatment planning, monitoring changes, and preiqt has &n estimated that under the existing payment structure

family physicians, general practitioners, and internists cannot be

expected to spend longer than 5 additional minutes in assessment

of their elderly patients (45).
Ch. 7—Technologies, Functional Impairment, and Long-Term Care ● 211

dieting outcome; certain assessment measures are

believed to be more appropriate for one purpose

than another (43). A concise pamphlet for practitioners on available assessment tools and appropriate uses is needed.

Incentives for Use.—As described earlier, there

is little incentive for widespread use of assessment

measures. Comprehensive functional assessment

is generally not required for public funding of

long-term care services, and neither Medicare nor

Medicaid provide reimbursement for the physician’s time spent in functional assessment. Required use of a comprehensive functional assessment measure as part of eligibility determination

for publicly funded long-term care services would

create an incentive for use of these measures. A

1977 report by the Institute of Medicine has recommended this approach:

The Federal Government should reimburse for

long-term care provided to the functionally dependent elderly . . . Eligibility for Federal reimbursement of long-term care should be based on

a comprehensive assessment process (41).

Functional assessment is “recommended to serve

a ‘gatekeeper’ function for long-term care services as well as to assure appropriateness of care

for the individual patient” (41).

Selection or development of a comprehensive

functional assessment instrument for determining eligibility for publicly funded long-term care

services would require choices about the most important factors to measure and the most appropriate structure and wording for the test instrument. The required use of such an instrument

would, however, eliminate uncertainty about

which one to use, and repeated use of the same

instrument would allow for extensive evaluation

of reliability and validity and subsequent refinement of the instrument.

Physicians and other long-term care providers

now spend considerable time on forms to establish eligibility of patients and clients for publicly

funded long-term care services. A comprehensive

functional assessment measure might be substituted for other currently required forms. Since

public funds pay such a large proportion of longterm care services, agencies required to use an

assessment measure for publicly funded services

might gradually extend the use of this measure

to privately funded services as well.

The Value of Scoring.—Some assessment measures result in numerical scores on individual sections or an overall score on all sections of the test.

These scores are used to indicate degree of impairment in physical or mental functioning, or the

extent and kind of services needed, and can also

be used to measure improvement or deterioration in an individual patient. In some States, scores

on comprehensive assessment measures are used

to determine eligibility for certain long-term care

services; for example, in New York State elderly

individuals who score over 180 on a comprehensive functional assessment measure are eligible

for Medicaid-funded nursing home placement

(140).

Although scoring has been used extensively for

research and administrative purposes, there is

great concern about the validity of this process.

Little information is available about the relative

importance of various aspects of functioning. It

has been pointed out that these scoring systems

often assume that “the items being scored consist of a systematic, ordinal set of characteristics

of a single phenomenon (e.g., total physical functional disability, total mental disability, total physical plus mental disability, etc. ) (140). In fact:

The items being scored are rarely if ever of an

ordinal nature, (and) there is no basis for assuming an ordinal relationship (between items) in

which a given score would represent a given degree of total mental function and a specific higher

score would represent a predictably proportionately better level of total mental functioning (140).

The use of overall scores for the evaluation of an

individual patient tends to obscure information

about specific problem areas, but scores on selected test items can be used the way the results

of lab tests are used, to indicate the presence or

absence of a problem that requires further analysis (140).

Who Should Do the Assessment. -Comprehensive functional assessment involves two steps: collection of the necessary information and analysis of the information. Each of these procedures
212 Ž Technology and Aging in America

can and is being done in various settings by individuals with or without special training in geriatric assessment, by physicians, social workers,

or nurses, and by teams of health care professionals, each collecting and analyzing information

in his area of expertise. Information can also be

collected and analyzed by computer. The decision

about who should do the assessment depends on

numerous factors that interact:

the purpose of the assessment,

availability of funding for collection and analysis of the information,

availability of trained staff to do the

assessments,

degree of confidence in the reliability and

validity of the assessment instrument, and

beliefs about the role and importance of clinical judgment in the collection and analysis

of the information.

Some experts have suggested that since many

physicians have been reluctant to spend the time

needed for comprehensive assessment, these

assessments should be available through geriatric assessment centers in local jurisdictions. At

present, comprehensive functional assessment

measures are sometimes used for research and

administrative purposes without the additional

evaluation of a trained professional, yet it is generally believed that adequate patient care and

long-term care planning require clinical judgment.

In fact, some experts believe that assessment

measures should only be used as general screening tools to identify individuals who need further

evaluation by trained professionals. Others believe

that formal assessment tools are not needed for

patient care when a trained professional is available to evaluate the patient; even in this case, however, assessment measures can help remind the

clinician of important factors to evaluate. In addition, the common language of the assessment

measure provides a method for teaching geriatric care and communicating between disciplines

(91).

The role of the patient and his preferences has

received relatively little attention in discussions

of comprehensive assessment measures. Since patient motivation and expectations are known to

affect response to chronic disease and impairments, this issue needs more attention. In this

context, adequate procedures for maintaining

confidentiality of patient records are especially

important since information about all aspects of

the patient’s functioning is available on the assessment form.

Assistive devices and

rehabilitation techniques

Technologies to maintain or increase the independence of the elderly include assistive devices

and rehabilitation techniques that compensate for

functional impairment. For some individuals the

appropriate use of these technologies will postpone or eliminate the need for institutionalization

or extensive home care services; for others the

use of assistive devices and rehabilitation techniques can reduce the burden of care on family

and friends. In nursing homes and board and care

facilities, these technologies can improve the quality of life for residents by maintaining some level

of independent functioning and decreasing the

need for staff assistance.

The goal of rehabilitation is to maintain or restore independent functioning, rather than to

cure disease. For the elderly, this approach is particularly important because many of the diseases

that affect the elderly are not curable at present.

Rehabilitation technologies can help an individual to function independently despite underlying

disease conditions. Even relatively small improvements in functioning can make a difference in selfcare ability. For example, a stroke victim who can

learn to transfer from bed to wheelchair and

wheelchair to commode can be independent in

many self-care activities (140). Similarly, an individual with severe tremor due to Parkinson’s disease can continue to feed himself using devices

such as splints and special eating utensils, thus

avoiding the need to be fed and associated feelings of dependence and loss of control.

REHABILITATION TECHNOLOGIES

Many assistive devices have been developed to

compensate for functional impairment. They

range from such simple devices as a long-handled

soaper to help an individual with limited arm mo-
Ch. 7—Technologies, functional Impairment, and Long-Term Care 213

tion to bathe himself to such highly sophisticated Sources of information about assistive devices

devices as voice-controlled robots for bedridden include computerized data systems and catalogs

patients that are being developed by the Veterans produced by public agencies and private manuAdministration/Stanford University Robotic Aid facturing and retail companies. ABLEDATA, a

Project (32). Some examples of assistive devices computerized data base sponsored by the Nato compensate for common impairments of the tional Institute for Handicapped Research, curelderly are shown in table 16. rently lists more than 6,000 products for disabled

Table 16.-Examples of Assistlve Devices for the Functionally Impaired Elderlya

Impairment Simple devices Complex devices

Vision Lighted magnifying glass Electronic reading machine that converts

Large-print books printed material to speech

Hearing Hand-held speaking tube or horn Infrared hearing system that transforms

an audio signal via infrared light beam

to a receiver worn by the listener, thus

suppressing background noise that is a

problem for hearing aid users (57)

Speech Manual communication board; the in- Electronic communication board with

dividual points to a symbol or what he memory and print-out capability. The

wants to say individual uses a switch to activate a

cursor on the board to indicate words

or messages (19). Portable speech synthesizer (8)

Memory Pad to keep notes for reminders Clock radio system that verbalizes

reminders and automatically controls

some appliances . .

Mobility Braces and splints Computerized electrical impulse device to

stimulate muscles and allow paralyzed

persons to walk (40)

Canes, walkers, and wheelchairs Voice-controlled, electric wheelchair that

can open doors and manipulate

switches (8)

Ramps Electric chairlift for stairs

Upper extremity weakness Reachers and grippers Prosthetic control system using electronic

Levers to facilitate turning door knobs sensors and mechanical transducers to

and faucet handles operate a prosthetic arm (8)

Bathing Shower or bathtub chair Hydraulic bath lift

Long-handled soaper Horizontal shower (19)

Dressing Velcro fasteners No complex devices known

Clothing that opens in’ front

Eating Utensils with built-up handles Automatic feeding machine (56)

Toileting Bedside commode Commode with automatic toilet flusher,

warm water bidet and hot air drying in

a push-button unit (19)

Shopping Shopping cart for a wheelchair user Shopping by computer

Prepackaged, freeze-dried meals

Cooking Suction gripper to hold a jar to be opened Robot that can prepare meals (56)

Environmental control Switches and controls on extension cords Computerized remote environmental conthat can be reached by the patient trol system to allow a bed or chairbound patient to adjust lights, radios,

TVs, thermostats, and other electrically

controlled appliances (19)

a these devices were selected to illustrate the kinds of assistive devices that are available. Thousands of other devices are also availabfe.

SOURCE: Office of Technology Assessment.
214 ● Technology and Aging in America

persons of all ages. other computerized data systems include “Accent on Information,” a proprietary system developed by Raymond Cheevers,

and “Automated Retrieval of Information on

Assistive Devices” (ARIAD), developed and maintained by Louisiana Tech University (108). Several catalogs list assistive devices for the elderly.

For example, A Catalogue of Products and Services To Enhance the Independence of the Elderly,

compiled at Drexel University, lists more than 250

products, including appliances, special clothing,

and communications devices (5). The American

Association of Retired Persons and the Western

Gerontological Society are completing a catalog

of about 400 devices that assist older persons to

live independently at home. The catalog will be

published in early 1985 (54).

In addition to assistive devices, many rehabilitation techniques are used by physiatrists (physicians who specialize in rehabilitation), physical

therapists, occupational therapists, nurses, and

other health care professionals to assist disabled

persons to maintain or improve their functioning. Rehabilitation techniques are included in this

section with assistive devices because they are alternative technologies for maintaining independence and because the effective use of assistive devices often depends on the simultaneous availability of rehabilitation services and procedures

(55). Like assistive devices, rehabilitation techniques can be simple procedures such as teaching

a stroke victim and his family how to lay out his

clothes to allow him maximum independence in

dressing, or complex procedures such as the use

of electronic sensing devices to provide biofeedback to a disabled person who is not able to sense

the position of his feet or arms.

Appropriate rehabilitation technology for any

individual depends on an evaluation of functional

impairments and residual function; that is, which

functions the individual is not able to perform and

which abilities and functions he retains. Assessment of the individual should determine the need

for a simple device or a more complex one. often

both a device and rehabilitation services are

needed, For example, a person with degenerative

joint disease may need both a cane or walker and

physical therapy in order to maintain mobility.

Successful use of rehabilitation technologies depends as much or more on matching the individual and the appropriate technology as it does on

the existence of sophisticated devices and rehabilitation techniques (26).16

CURRENT FEDERAL INVOLVEMENT IN RESEARCH

AND DELIVERY OF REHABILITATION TECHNOLOGIES

Many Federal Government agencies have programs of research, evaluation, or funding of rehabilitation technologies. Most of these are

directed toward the needs of disabled individuals

of all ages and focus on certain types of devices,

a particular step in the process of designing and

evaluating devices, or provision of devices and

rehabilitation services to individuals.

The National Institute of Handicapped Research

(NIHR) 17 is the lead agency responsible for initiating, funding, and coordinating Federal research

to benefit disabled persons of all ages. NIHR’s longrange plan, submitted to Congress in January

1981, included recognition of the special needs

of the disabled elderly and a commitment to relevant research. NIHR currently funds 21 Rehabilitation Research and Training Centers, including

two focused specifically on the needs of the elderly:

one at the University of Pennsylvania and the

other at Rancho Los Amigos Rehabilitation Hospital, in affiliation with the Ethel Percy Andrus

Gerontology Center and the School of Medicine

of the University of Southern California (122,135).

Federal funding for some assistive devices and

rehabilitation services for the elderly is available

through Medicare and Medicaid, and to a limited

extent through State rehabilitation agencies supported in part by grants from the Rehabilitation

Services Administration. The VA is a major provider of assistive devices and rehabilitation services for disabled veterans of all ages and is the

Nation’s largest purchaser of assistive devices (69).

Inhere is continuing debate about how to allocate research and

delivery resources between simple, relatively inexpensive devices

and technologically sophisticated devices. This debate at a policy

level tends to focus more on devices than on the needs of the individual (34).

ITNIHR was created by the Rehabilitation, Comprehensive serV -

ices, and Developmental Disabilities Amendments of 1978 (public

Law 95-602) which moved the existing research programs of the

Rehabilitation Services Administration in the Department of Health,

Education, and Welfare (now, the Department of Health and Human

Services) to the Office of Special Education in the Department of

Education.
Ch. 7—Technologies, Functional Impairment, and Long-Term Care “ 215

The VA funds research in rehabilitation technology for disabled persons of all ages through its

Rehabilitation Engineering Research and Development Program (122).

FACTORS AFFECTING THE USE OF REHABILITATION

TECHNOLOGIES BY THE ELDERLY

Despite the availability of thousands of assistive

devices and rehabilitation techniques, several

problems limit the use of these technologies by

the

●

●

●

●

elderly:

The elderly often have several functional impairments associated with multiple chronic

diseases. Devices and techniques appropriate for one impairment may not be usable

because of other impairments the individual

has.

Cognitive impairment can interfere with

an elderly individual’s ability to use an assistive device or respond to a rehabilitation

technique.

Negative stereotypes about the elderly and

their potential for rehabilitation limit the interest and enthusiasm of rehabilitation specialists, and sometimes the elderly and their

families, for obtaining and using rehabilitation technologies.

Limited availability of skilled rehabilitation

personnel in long-term care settings restricts

access to assistive devices and rehabilitation

services.

Other problems limit the use of rehabilitation

technologies by disabled persons of all ages. These

include difficulties with production, marketing,

funding, and repair of assistive devices. Lack of

effective methods for getting devices from inventors to individuals who need them is a major

obstacle to the use of these technologies (122).

The Impact of Multiple Impairments.—Many

elderly individuals suffer from multiple chronic

diseases with resulting functional impairments,

and this affects the kinds of assistive devices and

rehabilitation techniques they can use effectively

(19). Rehabilitation technologies are often designed to compensate for impairment by substituting another function, yet this substitution of

one ability for another is difficult when multiple

impairments are present in the same individual.

For example, an elderly individual who cannot

walk because of an amputation, hip fracture, or

osteoarthritis may not have the stamina to use

crutches or a walker because of cardiovascular

or respiratory disease. Similarly, an elderly blind

person with paralysis of an arm due to stroke or

decreased tactile sense due to diabetes will not

be able to use braille to read.

Assessment of all the individual’s functional impairments and residual strengths is a prerequisite

for matching the individual and appropriate devices and services. Locating devices for an individual with a specific combination of impairments

often requires a wide knowledge of available devices or a time-consuming search through catalogs. Although data are not available, it is likely

that many assistive devices purchased for elderly

individuals with multiple impairments are not

used because the individual lacks the residual abilities needed to use the device.

Physiological changes that occur with normal

aging can also restrict the use of rehabilitation

technologies. These changes include decreases in

visual acuity and hearing ability, decreases in

touch sensitivity and fine motor control, decreased

grip strength, and decreased capacity of the body

to respond to environmental extremes (4). While

these changes may not limit the functioning of

the healthy elderly individual, they lessen capacity to compensate for impairments resulting from

acute and chronic disease. For example, decreased

grip strength may not interfere with the functioning of the healthy elderly person but can hamper

the ability of a mobility-impaired individual to use

a cane or grab-bars effectively. Awareness of the

physiological effects of normal aging is essential

for the design of rehabilitation technologies for

the elderly.

The Impact of Confusion on the Use of Rehabilitation Technologies.–Although only a small

percentage of all elderly persons have symptoms

of confusion or organic brain disease, large percentages of the long-term care population are affected, including up to 50 percent of nursing

home residents and 20 percent of community

dwelling elderly over 80, The impact of confusion on their ability to use rehabilitation technologies has received little research attention, al-
216 . Technology and Aging in America

though anecdotal evidence indicates that it is an

important factor.

A recent study of patients in rehabilitation facilities in Canada (99) showed that confused patients did not respond well to standard rehabilitation techniques. After a year 59 percent of notconfused patients had returned home, but only

16 percent of the severely confused patients had

done so. The authors conclude:

The standard rehabilitation approach depends

on the patient learning ways to deal with the

disability and practicing techniques taught by the

therapist, Intellectual dysfunction impairs learning ability. Accordingly, it is not surprising that

our data demonstrate this approach is not more

effective than a standard supportive approach in

which spontaneous improvement can occur.

The authors recommend the development of rehabilitation methods specifically for confused patients.

Confusion restricts the ability of the disabled

elderly person to learn to use assistive devices

such as walkers, hearing aids, or simple devices

to help in dressing, bathing, or eating. Sometimes

it is even difficult for the confused person to

remember what the device is for. Failure to assess

cognitive functioning may result in the purchase

of assistive devices that are inappropriate for the

patient.

Research findings about the effectiveness of rehabilitation technologies are also affected by the

existence of mental confusion in the long-term

care population. Formal research that does not

distinguish between patients who are confused

and those who are not may reach ambiguous conclusions, reflecting a mixture of positive results

with one group of subjects and negative results

with another group. Similarly, informal evaluations by long-term care providers who use rehabilitation technologies may produce neutral or

negative results because many patients are too

confused to learn to use the devices or respond

to the rehabilitation techniques. As a result, providers often become discouraged about the efficacy of these technologies in general. Formal research that is clearly structured to differentiate

between confused and not-confused subjects can

help to identify technologies appropriate for these

two groups of patients.

Negative Attitudes About the Rehabilitation

Potential of the Elderly.—The belief that the

elderly deteriorate inevitably, both physically and

mentally, is widespread in our society, and affects

the elderly, their families, health care professionals, and long-term care providers. The sense of

hopelessness resulting from this belief is a significant barrier to the use of rehabilitation technologies.

As a result of these negative stereotypes, many

elderly persons resist thinking of themselves as

old and deny impairments that they think make

them seem old. They may refuse to use assistive

devices such as canes, walkers, and hearing aids

that call attention to impairments even though use

of these devices might help to maintain independent functioning. Other elderly persons, especially

those who are recovering from a debilitating

acute illness, accept the negative stereotypes

about the inevitable deterioration and adopt a

sense of hopelessness about recovery (19). In this

state of mind, they are unlikely to respond well

to rehabilitation services.

Family and friends of disabled elderly persons

can bean important source of motivation and concrete assistance in obtaining assistive devices and

helping the individual to install or learn to use

them. Family members can help locate rehabilitation services, provide transportation, and encourage the disabled individual to cooperate with

the rehabilitation plan, but family and friends

who accept the stereotyped view that deterioration is inevitable are unlikely to offer encouragement and assistance in obtaining these services.

Health care professionals and rehabilitation

specialists often share society’s negative view of

the elderly. Most physicians and nurses prefer

younger patients and those whose ailments are

curable (87), and some rehabilitation counselors

also exhibit bias against the elderly (110). These

negative attitudes result in lack of enthusiasm for

the rehabilitation of the elderly and relative lack

of rehabilitation research and services for this age

group (61). Nevertheless, a recent study of rehabilitation in the very old patient (76) showed significant improvement in 79 percent of the 97

patients studied, all of whom were over 85. Interestingly, a computer search of U.S. literature

failed to find any previous study of rehabilitation

results with very old patients (76).
Ch. 7—Technologies, Functional Impairment, and Long-Term Care ● 217

Photo credit: Gretchen Kolsrud

Many elderly patients can improve significantly

with appropriate rehabilitation services.

The authors of a 1983 report emphasize the importance of well-designed research and clinical

trials on rehabilitation of the elderly. They state:

We want to avoid the self-fulfilling prophecy

that shows elderly persons at poor risk for rehabilitation because statistics show less good results

when, in fact, fewer therapies were offered in

the first place (46).

They point out that evaluation of the rehabilitation potential of elderly patients is difficult when

so few of them are ever offered rehabilitation at

all.

Limited Availability of Skilled Rehabilitation

Personnel in Long-Term Care Settings.—Most

rehabilitation services and technologies for the

elderly are provided in hospitals by physiatrists,

physical therapists, occupational therapists,

speech therapists, and nurses. As home care services have expanded, some of these rehabilitation

specialists have begun working outside the hospital setting. As yet, however, too few are available to meet the needs of nursing home residents

and community dwelling elderly. For example, occupational therapists are trained to evaluate functional impairment, locate or design appropriate

assistive devices, and teach individuals to use

them. Of the 35,000 members of the American

Occupational Therapy Association, fewer than

3,000 work with elderly patients, and most of

these work in hospitals.

Medicare funding for rehabilitation services

outside the hospital is restricted by complex regulations about who provides the service and in

which setting. Moreover, the patient must show

improvement; services needed to maintain functioning are not reimbursable. Medicaid funding

for rehabilitation services is available in some

States, but coverage is limited, and the level of

reimbursement is usually considerably below customary charges for these services.

Rehabilitation services for nonelderly adults are

often provided and paid for by State rehabilitation agencies. These agencies receive 80 percent

Federal funding as mandated by the Rehabilitation Act of 1973 and provide extensive services,

including physical and mental rehabilitation, income maintenance during rehabilitation, transportation, counseling, mobility training for the

blind, and telecommunication, sensory, and other

assistive devices (122).

Although the Rehabilitation Act of 1973 includes

no age criteria, it specifies that services be directed toward making the disabled person employable. This focus on employability has resulted

in the virtual exclusion of the elderly from these

services (71); figures from the Rehabilitation Services Administration for 1978 show that of the

290,213 persons who received rehabilitation services through federally funded State rehabilitation

agencies, only 2.2 percent were over 65 (14).
278 ● Technology and Aging in America

The Rehabilitation, Comprehensive Services,

and Developmental Disabilities Amendment of

1978 (public Law 95-602) extended eligibility for

federally funded rehabilitation services to severely disabled individuals who do not have employment potential. Mandated services include architectural modifications of homes and other living

environments, attendant care, physical therapy,

and assistive devices to help disabled individuals

to function as independently as possible within

their families or communities and to prevent or

postpone institutionalization (139).

This focus on independent living services would

seem to address the needs of the disabled elderly,

except for two continuing problems. First, although some funds have been appropriated to set

up rehabilitation programs for independent living, no funds have yet been appropriated to pay

for the mandated services. Secondly, the elderly

are in direct competition with younger disabled

persons for services under these programs. Given

the traditional focus of rehabilitation agencies on

younger persons, the obvious need for rehabilitation services in the younger age group, and funding limitations, it is unlikely that the disabled

elderly will receive substantial benefits from these

programs without a significant redirection of financial and staff resources.

problems in Production, Marketing Funding

and Repair. -Ongoing difficulties in the production, marketing, funding and repair of assistive

devices also restrict the use of these technologies

by the disabled elderly. These problems include:

Inadequate Production and Marketing of

Needed Products: Many potentially useful devices are invented but never produced or

marketed because companies are reluctant

to invest in the manufacture of devices without an identifiable market for the product

(7,55). In many cases the number of disabled

people who can actually benefit from a certain device is relatively low, potential users

are often difficult to identify (33), and small

companies that are frequently the source of

innovative products may lack the financial or

staff resources to launch the kind of marketing campaign needed to reach potential users.

Lack of Information About Available Technologies: Lack of information about assistive

●

devices and rehabilitation techniques is an

ongoing problem. Although computerized

data systems and catalogs of devices have

been developed to solve the problem, the information gap persists. Researchers complain

that it results in frequent instances of “reinventing the wheel” (10, 107). Disabled individuals, their families, and service providers continue to have difficulty finding out about

appropriate technologies. Meanwhile, companies with innovative products and services

struggle to find ways to make their products

known to service providers and the disabled

(34).

Lack of Financial Resources to Pay for Assistive Devices and Rehabilitation Services:

Three financial factors restrict purchases of

rehabilitation technologies. First, disabled individuals as a group have lower than average income and are often unable to pay for

these devices and services (55,122). Second,

many devices are unexpectedly expensive because of the high costs of designing and marketing products to this relatively small group

(33). Third, the many public and private agencies and programs that pay for rehabilitation

technologies have uncoordinated and inconsistent definitions of who is eligible and what

devices and services will be paid for.18 Decisions about whether a device is covered

under a certain program may vary from one

part of the country to another, and can be

made retroactively, so that neither the disabled individual nor the provider knows in

advance whether the device or service will

be paid for. In addition, the amount of payment for a specific device or service may be

less than the full cost, and some devices are

not covered at all (69). OTA has found that

as a result of the lack of coordination among

funding sources, “users and providers are either unable to take advantage of available

technologies or must spend enormous amounts

~aAvaj]abi]jty of funding for specific devices influences their production and use. Under some public programs, such as Medicare

and Medicaid, such funding is authorized only when the devices

are deemed “medically necessary. ” Hearing aids, glasses, dentures,

and communications devices are not covered by Medicare because

they are not considered medically necessary, although they do compensate for functional disabilities of disabled persons (122). In some

cases, disabled persons find themselves with an inappropriate device because it is the only one that is funded (55,73).
Ch, 7—Technologies, Functional Impairment, and Long-Term Care ● 219

of time providing the coordination needed to

best assist each individual” (122).

● Lack of Available Repair Services for Assistive

Devices: Difficulties in obtaining repair services for devices such as hearing aids and

wheelchairs limit their usefulness. Repairs

frequently take weeks or even months and

are often costly. Replacement parts are hard

to find, and for someone who is dependent

on the device for an important functional

disability, the time spent waiting for repair

of the device can be very difficult (27).

INITIATIVES TO INCREASE THE AVAILABILITY

OF REHABILITATION TECHNOLOGIES

Evaluative Research.—More research on the efficacy, safety, and cost of commonly used devices

such as wheelchairs and hearing aids is needed,

as are comparisons of outcomes when devices are

used alone or in combination with rehabilitation

training. Evaluation of rehabilitation technologies

is one focus of the National Institute of Handicapped Research, The Veterans Administration,

with its large population of disabled elderly veterans and its ongoing programs in both research

and the provision of devices and services, also provides an ideal setting for evaluative research.

Assessment. -Accepted, valid, functional assessment measures are a prerequisite for evaluation

of rehabilitation technologies and appropriate

matching of individuals and technologies. Especially significant factors to measure are multiple

functional impairments, mental impairments, and

psychosocial factors that affect the capacity of the

individual to use available technologies.

Public Education About Device.—Initiatives to

increase awareness of available rehabilitation

technologies include advertising of specific products and public service advertising about the importance of rehabilitation technologies in maintaining independence and well-being. Advertising

of specific products is clearly the responsibility

of private industry, and some advertising of this

kind, i.e., incontinence supplies, is currently

underway in major national markets. Development of advertising for assistive devices has been

difficult because the elderly tend to reject agerelated product identifications (2). The design of

advertising messages that emphasize both age and

disability is even more difficult, and media advertising directors have been reluctant to accept advertising for assistive devices because of anticipated negative reactions toad content. Although

advertising for some types of assistive devices appears in magazines directed to the elderly and

those with a health care focus, these publications

do not reach all the individuals who might benefit from rehabilitation technologies or the families who often assist in obtaining them.

Public service advertising is an option that has

not yet been tried. Advertising could emphasize

the importance of assistive devices in maintaining independence and counter the widespread belief that using these devices implies that an individual is old, useless, and unattractive. Although

the potential impact of this approach remains

speculative, it is relevant to consider the positive

effect on attitudes and demand for hearing aids

when president Reagan first appeared in public

with a hearing aid. Ads could refer to available

sources of information about specific devices and

encourage careful evaluation of both the needs

of the individual and the appropriateness of the

device chosen.

Awareness of Health Care and Service Pre

viders—hitiatives are needed to increase awareness of rehabilitation technologies among health

care professionals and other service providers,

such as physicians, nurses, social workers, physical therapists, occupational therapists, speech

therapists, and staff members at senior centers,

senior nutrition programs, and senior housing facilities. Although some of these individuals may

have received training in some rehabilitation technologies, few have any knowledge of the wide

range of technologies available. Retailers of assistive devices are generally untrained or trained

through inservice programs provided by the manufacturers of the devices. They may develop expert knowledge about the devices they carry but

rarely receive training in assessment techniques.

The development of training programs for

health care professionals and service providers

has been a major focus of the two Rehabilitation

Research and Training Centers in Aging funded

by NIHR. Curricula and audiovisual aids for training in rehabilitation of the elderly are being de38-800 0 - 85 - 8
220 “ Technology and Aging in America

signed to increase knowledge about the elderly

and to counter negative attitudes about rehabilitation potential, but the impact of these training

programs has been limited by staff and funding

restrictions at the centers, which were established

only 3 years ago.

Rehabilitation counselors in State rehabilitation

agencies generally have training in both assessment and rehabilitation technologies but lack

funding and appropriate goals for working with

the elderly. Increased funding for independent

living services mandated by the Rehabilitation,

Comprehensive Services, and Developmental Disabilities Amendment of 1978 is needed. Realistic

goals for rehabilitation of the elderly are also

needed. In addition to goals such as increased independence and self-care, it is important to recognize the roles the elderly can fill as volunteers

in the community and caregivers in their own

families (9).

Assistive Device Centers.—’’Aids Centers,” located throughout Sweden, enable disabled persons to look at assistive devices, try them out, and

consult with rehabilitation specialists about which

devices would be most helpful (35). In the United

States, the Department of Justice maintains a Sensory Aids Center to evaluate and customize technological aids for its visually impaired and deaf

staff members (112). In Sun City, a retirement

community in Arizona, residents have organized

a lending service for health care and rehabilitation appliances. Financial support is also available

through the community for prostheses, glasses,

and hearing aids (93) Development of assistive device centers in other locations would increase access to rehabilitation technologies by the elderly.

Funding. -Increased funding for rehabilitation

technologies through Medicare and Medicaid is unlikely at present because of budget limitations, and

without increased funding, coverage cannot be

extended to new categories of assistive devices.

Nevertheless, development of nationally consistent standards for Medicare and Medicaid coverage would facilitate provision of devices.

The need for increased public funding for

assistive devices and rehabilitation services is not

clear at present. The use of these technologies

is limited primarily by lack of information, negative attitudes, and lack of a professional group

with responsibility for assessment and matching

of individuals and rehabilitation technologies for

the elderly. Lack of funding discourages purchase

of some expensive and technologically sophisticated devices, but many devices are relatively inexpensive, and recent reports tend to refute the

idea that most of the elderly are poor (4). It is not

clear how many elderly persons would be unable

to pay for these devices if they knew about them

and believed that the devices would help to maintain independence.

Technologies for caregivers

Technologies for caregivers include devices and

procedures to facilitate and improve caregiving,

Long-term care has traditionally been labor-intensive, with little emphasis on technology. Few

labor-saving devices are used, and caregivers, including both informal caregivers and paid personnel, often receive little or no training in efficient methods of care. As a result, staff turnover

is very high in long-term care facilities, and families and other informal caregivers become overburdened and exhausted.

Many technologies have the potential to facilitate long-term care. In this section, technologies

to assist caregivers with three types of care are

reviewed: 1) care for individuals with medical or

skilled nursing care needs, 2) care for physically

impaired individuals, and 3) care for mentally impaired individuals.

CARE FOR INDIVIDUALS WITH MEDICAL OR

SKILLED NURSING CARE NEEDS

In the past few years, medical treatment that

was previously provided only in hospitals has become increasingly available outside the hospital.

This change has been spurred by the hospital utilization review process that discourages unnecessary hospitalization and by the availability of

reimbursement for home health care through

Medicare, Medicaid, and private insurance. The

new Medicare prospective reimbursement system

(DRGs) is increasing the need for medical services outside the hospital. Medical care devices and

skilled nursing care are needed in the home and

in nursing homes for patients who are discharged

earlier from hospitals and continue to need medical treatment.
Ch. 7—Techrmlogjes, Functional Irnpairment, and Long-Term Care ● 221

At present most nursing homes primarily provide personal care and supportive services under

the supervision of a registered nurse. *g Patients

who are acutely ill or need complex medical treatment are sent to the hospital because most nursing homes do not have the resources to provide

the required treatments. As hospitals respond to

the prospective reimbursement system, nursing

homes are being pressured to accept patients who

19A~ of 1 g7g only I 5 percent of nursing home staffs were registered nurses (RN;), compared with 46 percent of hospital staffs,

resulting in a nurse-to-patient ratio of 1 to 49 in the nursing home

compared with 1 to 4-5 in the hospital (68). RNS in nursing homes

are responsible for supervision of nursing tides and many other

administrative tasks in addition to medication-monitoring and medical treatments.

Photo credit: Gretchen Kolsrud

Rehabilitation services can lessen the burden

on caregivers by maintaining function even

in the very frail elderly patient,

need more acute care and more complex care

than has been provided in the past.

Technologies to provide more complex medical care in nursing homes include diagnostic and

monitoring equipment and devices for sophisticated medical treatment. In addition, ancillary

personnel with training in the use of these technologies will be needed. It has been suggested that

geriatric nurse practitioners and nurse clinicians

are well qualified to provide skilled and acute care

services in nursing homes (67).20

The availability of medical technologies and

qualified nursing personnel is primarily dependent on payment levels and reimbursement policies of Medicare, Medicaid, and private insurance

companies. At present, payment for nursing home

care is generally not high enough to cover the cost

of sophisticated medical technologies and highly

trained personnel. Cost-based reimbursement policies with increased allowance for medical devices

and skilled personnel would create an incentive

for nursing homes to upgrade the level of care

they can provide, but would also increase the cost

of nursing home care. Federal and State initiatives

to limit reimbursement for nursing home care restrict the provision of acute and skilled care services that may be required by the patient group

that is discharged earlier from hospitals under

DRGs.

To a great extent, nursing homes can choose

the patients they admit (see ch. 8). Without increased reimbursement for medical technologies

and skilled nursing personnel, nursing homes are

unlikely to admit patients with acute and skilled

care needs because they do not have the resources to care for them. This creates severe

hardship for patients who need ongoing medical

care in an institutional setting and for hospitals

forced to choose between discharging patients

without adequate continuing care or keeping patients they are not being paid for.

Although the availability of medical care technologies and skilled nursing care in the home has

‘The geriatric nurse practitioner is a nurse with a master’s degree in gerontologic nursing and training in managing patient care,

providing routine physical care and physical tests, and acting as

liaison with the patient’s physician. In addition, the geriatric nurse

practitioner can provide staff training in the use of medical care

technologies (42).
222 ● Technology and Aging in America

increased greatly in the past few years,21 demand

for home health care will continue to rise as a

result of the Medicare prospective reimbursement

system. Primary concerns here are the continuing availability of highly trained nurses to provide skilled care and the existence of efficient

mechanisms for testing and approving medical

technologies for use in the home. Medical device

regulation, which is the subject of several recent

government reports22 is not discussed here. The

availability of skilled health care professionals to

provide assistance and training for the patient and

the family in the use of sophisticated medical devices is an important factor in the successful use

of these technologies.

CARE FOR PHYSICALLY IMPAIRED INDIVIDUALS

Physically impaired elderly persons may require

assistance with personal care activities such as

bathing, dressing, eating, toileting, and mobility.

Technologies to assist with these functions include

devices that increase the ability of the elderly person to function independently (discussed in the

previous section of this chapter), devices to assist

the caregiver directly, such as machines to lift and

move patients, and techniques to facilitate physical care.

Although many devices and techniques for caregivers are available, they are not widely used, and

caregivers are often unaware of these technologies. Two factors interact to perpetuate this situation: First, caregiving is not generally recognized as a skill in our society. The focus is on

curing rather than skilled caregiving (60). Second,

and related to the first factor, is the relatively low

status of most caregivers, It has been pointed out

that:

Zlln cont~a~t to the nursing home situation, payment is availab]e

for many medical care devices and skilled nursing visits in the home.

In fact, Medicare reimbursement for one skilled nursing visit approaches the cost of a day of nursing home care in some parts of

the country, although the nursing homes also provides 24-hour personal care, room and board, laundry service, and other supportive

services.

‘%AO, “Federal Regulation of Medical Devices-Problems Still to

Be Overcome,” September 1983; House Subcommittee on Oversight

and 1nvestigations, “Medical Device Regulation: The FDA’s Neglected

Study,” April 1983; and Office of Technology Assessment, “Federal

Policies and the Medical Devices Industry,” OTi%-H-23(1 (Washington, DC: CJ.S. Governrnent Printing Office, October 1984).

Photo credit: Gretchen Kolsrud

This automatic chair lift is used to raise the patient

comfortably into the whirlpool bath.

Caring roles are for the most part performed

by women with limited education, training, and

professional identification and prestige, These are

low paying jobs with virtually nonexistent status

(60).

Even when these low-status caregivers develop

effective caregiving techniques, there is little

recognition of their skills or diffusion of the techniques to other caregivers.

Nurses, occupational therapists, and physical

therapists are skilled in developing caregiving

techniques for specific patients, but relatively few

occupational therapists and physical therapists

are employed in long-term care settings. Nurses

provide training for nursing assistants in nursing homes and for home health aides and homemakers in home care agencies. Nevertheless, the

lack of recognition for caregiving as a skill and

the low status of caregivers limit the extent and

effectiveness of this training.

Family members and other informal caregivers

are particularly unlikely to know about and use

available devices and techniques. In many cases,

the informal caregiver is the elderly spouse, who
Ch. 7—Techrfologies, Functional Impairment, and Long-Term Care ● 223

has particular difficulty lifting and moving the patient in order to bathe or dress the patient or get

him or her into a wheelchair. In fact, some nursing home placements occur when the caregiver

has fallen or injured himself/herself trying to lift

or move the patient. Packaging of information

about devices and techniques for informal caregivers in a form that is easy to understand and

use is an important priority in long-term care.

Many devices for physical caregiving are designed

for use in an institutional setting, and there is a

need for devices developed specifically for home

and the informal caregiver.

CARE FOR THE MENTALLY IMPAIRED INDIVIDUAL

A large proportion of nursing home and board

and care residents are mentally impaired, and

many families are caring for severely confused

elderly individuals at home, yet there has been

relatively little attention paid to caregiving technologies appropriate for these individuals. The

focus of Federal funding programs on physical

illness and medical treatment has tended to

obscure the care needs of mentally impaired individuals, but recent interest in Alzheimer disease

has resulted in a growing literature on caregiving techniques for all mentally impaired patients.

Some of this information is new, but much of it

reflects existing knowledge of long-term care providers who have developed expertise in caring for

these patients.

Effective care for mentally impaired individuals

involves techniques for handling a variety of dif -

ficult problems. Table 17 lists the problems cited

by families caring for mentally impaired individuals with Alzheimer disease, multi-infarct dementia, and other organic brain diseases (82). Technologies to address three of these problems,

forgetfulness, agitation and catastrophic emotional reactions, and wandering, are discussed

here.

Forgetfulness. —Increasing forgetfulness is characteristic of mentally impaired individuals and

ranges from forgetting where one left certain objects to forgetting one’s spouse and children and

forgetting how to dress, eat, and use the bathroom. Memory training techniques have been

tested with some evidence of short-term gain but

little lasting improvement (143). Further research

on a variety of approaches to maintaining memory function is needed.

For individuals with severe forgetfulness, caregivers can often help to maintain orientation with

reminders about the date, the time, and other

daily information. Several simple devices can also

be useful. Labels on objects can remind the individual of the name of the object and illustrate its

use with a simple drawing. Signs on doors, especially bathroom doors, can also be helpful. In one

facility when a patient is so confused that he cannot answer any questions about himself, a colorTable 17.—Behavior Problems of Patients Cited by Families

Number of Number of families Number of families

families reporting reporting behavior to

Behavior responding occurrence (

0

/0) be a problem (o/o)

Memory disturbance. . . . . . . . . . . . . 55 55 (1000/0) 51 (930/0)

Catastrophic reactions. . . . . . . . . . . 52 45 (87) 40 (89)

Demanding/critical behavior . . . . . . 52 37 (71) 27 (73)

Night waking . . . . . . . . . . . . . . . . . . . 54 37 (69) 22 (59)

Hiding things. . . . . . . . . . . . . . . . . . . 51 35 (69) 25 (71)

Communication difficulties. . . . . . . 50 34 (68) 25 (74)

Suspiciousness . . . . . . . . . . . . . . . . . 52 33 (63) 26 (79)

Making accusations . . . . . . . . . . . . . 53 32 (60) 26 (82)

Meals . . . . . . . . . . . . . . . . . . . . . . . . . 55 33 (60) 18 (55)

Daytime wandering . . . . . . . . . . . . . . 51 30 (59) 21 (70)

Bathing . . . . . . . . . . . . . . . . . . . . . . . . 51 27 (53) 20 (74)

Hallucinations . . . . . . . . . . . . . . . . . . 49 24 (49) 16 (42)

Delusions . . . . . . . . . . . . . . . . . . . . . . 49 23 (47) 19 (83)

Physical violence . . . . . . . . . . . . . . . 51 24 (47) 22 (94)

Incontinence . . . . . . . . . . . . . . . . . . . 53 21 (40) 18 (86)

SOURCE: P. V. Rabins, et al., Journal of the American Medical Association, 246(3) ”333-335, July 16,1962. Copyright 1982, American

Medical Association.
—

224 ● Technology and Aging in America

ful poster is placed outside his room, giving his

name and some information about his family and

his past and providing staff and visitors something

real to talk to the patient about (136).

Little information is available about effective

techniques for maintaining the individual’s memory of how to care for himself (bathing, eating,

toileting, etc.). This is partly because in many longterm care settings, no distinction is made between

patients who need help with these functions because of mental impairment and those who need

help because of physical impairment, and staff

members tend to provide the same kind of assistance for both groups. Informal caregivers often

provide physical assistance instead of using techniques that support the individual’s ability to perform self-care functions himself. Research on effective techniques for maintaining memory of

self-care functions is needed.

Agitation and Catastrophic Emotional Rem

action&—Agitation and catastrophic emotional reactions are major problems for caregivers. These

behaviors are related to memory loss because the

individual becomes agitated and angry when he

cannot remember or understand people and

events in his environment. Although there are no

devices to cope with this problem, medication can

be used. Unfortunately some medications that are

frequently used for this purpose also reduce alertness and other cognitive functions.

Certain caregiving techniques and systems can

decrease the frequency and severity of agitation

and catastrophic reactions. Informal and paid

caregivers can learn to divert the individual’s attention from upsetting issues or events and to

avoid presenting the individual with tasks he is

not able to perform (82). In addition, caregivers

can be aware of the impact of daily events on the

mentally impaired individual. For example, in the

institutional setting, mentally impaired individuals

may become agitated when shift changes or visitors to the facility cause high levels of activity and

noise. An understanding of the effect of these

events on the confused person can result in environmental and scheduling changes that decrease

the frequency of catastrophic emotional reactions.

Wandering. –Wandering is a difficult problem

for families and long-term care facilities because

mentally impaired patients, particularly those

with Alzheimer disease, are often physically

healthy and able to wander away quickly, becoming lost and endangering their safety. As a result,

they require constant supervision.

Some mentally impaired wanderers believe they

are going to a specific place or accomplishing a

specific job, while others seem to wander aimlessly, drawn from one stimulus to another (105).

This behavior often increases when the individual becomes agitated, and one study has suggested

that wanderers may be individuals who had a lifelong pattern of responding to stress with activity, such as walking or pacing (70).

Methods for preventing wandering have included the use of drugs, which often have side

effects that worsen the individual’s physical and

mental condition, “protective devices” that involve

tying the patient to a chair, and locked doors that

prevent the individual from leaving a certain area.

In a long-term care institution, the availability of

a locked nursing unit allows the wanderer to

move around freely within the unit; the locked

unit is, however, very restrictive for other residents who are not confused (28). For the informal caregiver, living in a totally locked space with

a mentally impaired individual can be extremely

stressful.

Technologies for wanderers include devices,

programs, and environmental design to allow

some freedom of movement while maintaining

the caregiver’s sense of certainty about where the

individual is. Some long-term care facilities have

installed electronic monitoring systems that activate an alarm at the nurses station when a patient wearing the signaling device goes through

a monitored doorway, These devices cost up to

$1)000 per monitored door. other facilities have

installed special door knobs and locks that can

easily be opened by mentally normal patients,

staff, and visitors, but not by mentally impaired

patients. Programs for wanderers include frequent structured and unstructured opportunities

for physical exercise, such as exercise groups and

walks with staff or visitors. Environmental design

technologies include living areas and outdoor

spaces structured with pathways that allow the

individual to wander within an overall enclosed

space.
Ch. 7—Technologiesj Functional Impairment, and Long-Term Care ● 225

SUPPORT GROUPS FOR CAREGIVERS

Support groups for informal caregivers have

been formed in many communities. Most of these

groups are designed primarily to provide emotional support by encouraging caregivers to discuss the complicated feelings and difficult decisions involved in caring for impaired elderly

individuals. In addition, support groups allow for

sharing information about mental and physical

impairments, available resources, and techniques

of caregiving (37). Although there has been very

little emphasis on technologies for informal caregivers, these groups could provide an opportunity

for exchanging information about available devices. By providing emotional support and information for informal caregivers, support groups

can help to decrease stress and may increase the

willingness and capability of families to maintain

impaired individuals at home.

PROGRAMS FOR PHYSICALLY AND MENTALLY

IMPAIRED INDIVIDUALS

Effective systems of caregiving include not only

devices and procedures for physical care but also

a program of social and recreational activities.

While these activities provide diversion and entertainment, they can also increase the patient’s involvement with others and with his environment.

Activities designed to foster a sense of usefulness,

involvement, and responsibility can help to overcome feelings of helplessness that are common

among long-term care patients, Examples of these

activities include:

●

●

●

●

●

resident councils and other self-government

activities;

formal and informal opportunities for individuals to assist other patients, such as the

Retired Senior Volunteer Program (RSVP)

that has been set up in some nursing homes

to recognize and support volunteer efforts

of patients for other patients;

group projects to benefit the nursing home

or a community agency, such as the “Rock

and Roll Jamborees” held in some nursing

homes to benefit the Heart Association;

opportunities to care for plants or gardens;

and

pet visitation programs.

Photo credit: Gretchen Kolsrud

In Montgomery County, MD, 4-H clubs have trained

parakeets to be given as pets to nursing

home residents.

By supporting the patient’s sense of active involvement and competence, these activities can increase self-esteem and counter feelings of helplessness and dependency that undermine motivation for independent functioning and self-care.

Long-term care delivery systems

Methods of providing long-term care services

for the elderly include organizations and funding mechanisms for developing and coordinating

resources and matching the needs of the individual with appropriate services and facilities, such

as nursing homes, board and care facilities, home

care, adult day care, hospice, and congregate

housing. Some or all of these services are available in most communities, but the complexity and

fragmentation of long-term care services at the

community level make it difficult to connect

elderly individuals with the services they need.

Decisions about long-term care are often extremely traumatic for the elderly and their families. These decisions are frequently put off until

a crisis point is reached because of the intense
226 ● Technology and Aging in America

emotional issues that are involved. The elderly

fear loss of independence and the possibility that

they will have to move from a familiar home environment. Families may experience a combination

of sadness about the elderly individual and guilt

that they are unable or unwilling to provide the

care that is needed. Within this complex emotional environment the fragmentation of the service

delivery system at the community level compounds the trauma to the elderly individual and

the family.

This section discusses the existing service delivery system, and alternative methods for linking the individual with appropriate long-term care

services.

THE PATCHWORK OF SERVICES

In most communities Iong-term care services

are provided by a variety of public and private

agencies with differing eligibility requirements,

services, and funding mechanisms, resulting in

what one author has called a “patchwork array

of services” (24). The services are generally not

coordinated. overlapping services and gaps in

available services are common, and there is often

no single source of information about what services are available. As a result, it is difficult for patients, their families, physicians, and other health

care and social service providers to locate appropriate services. When impaired elderly individuals

need several long-term care services from different agencies, coordination can be very difficult (3,132).

The fragmentation of agencies and services at

the community level is partly a result of the way

these services have developed over time. New

agencies have been created in response to specific needs, and there is often no comprehensive

plan for how the new services will mesh with existing services in the community.

Another and perhaps more important cause for

the fragmentation is the complexity and lack of

coordination of regulations controlling government programs that fund these services. As stated

earlier, government funding programs have a

substantial impact on the kinds of services that

are available at the community level. Although

some private agencies do not accept any government funding, most agencies and long-term care

facilities provide at least some government-funded

services, and as a result, their services and eligibility requirements usually reflect government

regulations. Government regulations about services that are “reimbursable” often define which

services are available in the community because

agencies tend to develop and provide those services that will be paid for. Similarly, regulations

about the qualifications of agencies that are certified for reimbursement through government

programs often define the kind of agencies that

will be developed.

Unfortunately, the government programs that

have such a major impact on long-term care services are themselves uncoordinated. A 1977 GAO

report described four Federal programs that provided funding for home care services at that time:

Medicare, Medicaid, Title XX of the Social Security Act, and Title III of the older Americans Act.

The report concluded that “the various Federal

home health programs defy coordination” (115).

Since that time, new regulations have tended to

increase the complexity of these programs, 23

Other Federal, State, and local programs that

affect the availability of long-term care services

include Social Security, Supplemental Security Income (SS1), benefits available through the Veterans Administration, and programs developed

and funded by State and local health departments

and social service departments, Each of these government programs has differing eligibility requirements, benefits, and funding mechanisms,

increasing the complexity of the long-term care

system at the community level and limiting access to appropriate services by the elderly.

METHODS FOR IMPROVING COORDINATION AND

ACCESS TO LONGTERM CARE SERVICES

The fragmentation of the long-term care system has been noted for more than 20 years

(21,100), and several methods have been developed to improve coordination and access to services. These include: 1) efforts to coordinate agencies and services at the community level, 2) case

Zsstate and ]Oca] re~lations also affect eligibility, benefits, and

funding for three of these programs; Medicaid, Title 111 of the older

Americans Act, and the Title XX Block Grant.
Ch. 7—Technologies, Functional Impairment, and Long-Term Care ● 227

management approaches designed to locate and

coordinate services for the individual, and 3) efforts to provide a full range of long-term care

services within a single agency or program. These

methods are reviewed briefly here, and government initiatives to increase the role of individuals

in planning their own long-term care are discussed.

Each of these methods can be seen as an attempt to rationalize the system at the community

level. While each is effective in some ways, they

cannot change the underlying problem, which is

the lack of coordination in the major Federal programs that regulate and finance long-term care.

Coordination of Agencies and Services at the

Community Level.—Methods to improve coordination at this level can include:

●

●

●

●

●

formal mechanisms for exchanging information between agencies, such as the regular

meetings of long-term care providers now

held in some communities;

development of a directory of all long-term

care services available in the community;

development of a centralized information and

referral service;

mutual referrals and cooperation in handling

individual clients (case conferencing); and

joint planning and policymaking to avoid du -

plication and gaps in available services.

In the past, efforts to coordinate services have

been organized by public agencies, such as the

health department or the department of social

services, or by a private agency or voluntary association founded for this purpose. This remains

the pattern in some communities; in others, the

Area Agency on Aging (AAA) has become the lead

agency for coordination of services. one of the

mandated functions of the AAAs, which were established by the older Americans Act, is coordination of community services for the elderly (3);

in some communities AAAs have provided funding and organizational support for each of the approaches listed above.

Efforts to coordinate services have been only

moderately successful in most communities; inflexible Federal and State regulations, that often

cause much of the complexity in the system, have

been a limiting factor. Moreover, community

agencies may resist coordination because of a

commitment to existing agency structure and policies, C)ne author has pointed out that successful

coordination of agencies and services is a timeconsuming and expensive process requiring a

leader who is “a super-being with optimum political skills, administrative competence, missionary

fervor, and familiarity with the entire range of

professional interventions and management techniques” (21).

Case Management Program&-A second method

for coping with the fragmentation of the longterm care system and improving access to appropriate services is case management, a system for

“developing and coordinating client care plans and

monitoring the treatment process” (125). In the

context of the complex array of long-term care

services, it is the function of the case manager

to assess the needs of the client, develop a plan

of care, and arrange services to implement the

plan. Many State and local communities have

established case management programs, and a

1980 study by Andrus Gerontology Center identified more than 300 such programs. Most of these

programs, however, did not coordinate a comprehensive range of services; some coordinated

only social services, while others coordinated

mainly health care services (125).

Case management was a major component of

several long-term care demonstration projects

funded by the Federal Government in the 1970s24

These projects were designed to test whether

home and community based long-term care services could substitute for nursing home care, and

the case manager was responsible for assessing

the client’s needs and referring the client to

appropriate services. All of the projects also provided new home care services or new funding for

services that were already available. Evaluation

of the effectiveness of the case management approach in these projects is difficult because

changes in client outcome could have resulted

24 of ~me demonstration projects are ACCESS, in Monroe

County, NY; the Alternative Health Services Project in Georgia; the

Community Based Care Systems for the Functionally Disabled in

Washington State; the Wisconsin Community Care Organization;

and Triage, in Connecticut.
-.

228 ● Technology and Aging in America

from the case management, the new long-term

care services, or both. None of the projects included a research design to test the efficacy of

case management in reducing fragmentation of

long-term care services for the clients (125).

In 1980, the Department of Health and Human

Services and the Administration on Aging jointly

funded the National Long-Term Care Channeling

Demonstration Program specifically to evaluate

the effectiveness of case management in reducing fragmentation of services. Ten States are participating in the program to test two models of

case management. Five States are using the “basic”

channeling model that includes assessment of client needs, care planning, and arrangement of

appropriate long-term care services. The “complex” channeling model being tested in five other

States includes the basic case management functions plus several additional features: the case

manager has authority over the amount and duration of noninstitutional health and social services

the client receives, and the cost of services for

all clients is capped at a level equal to 60 percent

of the cost of nursing home care in the demonstration area. The Channeling Demonstration Program will run from 1982 to 1985, and result are

expected to provide definitive answers about the

effectiveness of case management in facilitating

client access to appropriate long-term care services (79).

The Facilitator and the Gatekeeper.—The functions of the case manager in long-term care demonstration projects (including the channeling program) illustrate two different approaches to

service delivery. In some demonstration programs

and the “basic” channeling model, the case manager functions primarily as a facilitator, assisting

clients to obtain appropriate services. In other

demonstration programs and the “complex” channeling model, the case manager also functions as

a gatekeeper, controlling and limiting access to

services, especially high-cost services such as institutional care. Although there has been little discussion in the literature of the relationship between these two roles, they seem to involve

inherent internal inconsistencies for the case manager who must decide whether to arrange for all

the services the client needs or to focus on limiting

costs. For the individual client who needs certain

long-term care services, the facilitator approach

could be expected to result in provision of those

services. It is not clear whether the same services would be provided when the gatekeeper approach is used. Comparison of the results of the

two models of channeling may help to resolve this

question.

The distinction between these two approaches

reflects the two primary concerns of government

in long-term care: concern with cost control and

concern with providing access to appropriate

services for the elderly. In the absence of a comprehensive national long-term care policy, the

relative emphasis on these concerns can be expected to vary from one government program to

another and from one community to another in

a manner that is in many instances both confusing and inequitable.

Targeting.—Targeting of long-term care services to the most impaired individuals combines

the facilitator functions of assessment and identification of needs and the gatekeeper functions

of controlling and limiting access to services.

Many analysts of the long-term care system have

emphasized the importance of targeting services

in order to control costs while providing essential services (80,118). While the concept of targeting represents a merging of the facilitator and

gatekeeper functions, its implications require further definition. Decisions about the kind and

amount of services that will be provided with government funding are a matter of public policy,

and the concept of targeting does not in itself

answer the difficult questions about resource

allocation or resolve the ambivalence of government about its central concern in long-term care.

Use of Computerized Information Systems.—

The complexity of agencies, services, funding

mechanisms, and client needs at the community

level suggests a possible application for computerbased information systems in long-term care.

Computers are now being used in health and

social service agencies for applications such as

recordkeeping and program analysis, and some

service providers have begun to use computerized

information systems to aid in matching individual needs and available long-term care services

(72). OTA has not assessed the efficacy of this ap-
Ch. 7—Technologies, Functional Impairment, and Long-Term Care ● 229

preach, but it appears to provide an improved information base for long-term care decisionmaking. Concerns about the impact of this approach

on client autonomy and confidentiality of client

information should be resolved prior to implementation of these systems.

Provision of a Comprehensive Range of LongTerm Care Services Through a Single Agency or

Program-A third method for increasing the coordination of long-term care services and facilitating client access to services is provision of a

comprehensive range of long-term care services

by a single agency or program. The Veterans

Administration is the largest and best known example of this approach, Other examples are social/

health maintenance organizations and agencies

offering life care contracts. Recently hospitals

have become more involved in the provision of

long-term care services. Each of these agency

types is discussed briefly with emphasis on its effectiveness in overcoming the fragmentation of

long-term care services.

The Veterans Administration OTA).–The VA

provides an extensive system of long-term care

services including nursing home care, board and

care, and home care. Adult day care, hospice, and

respite care are also available in some areas (80).

Institutional services are provided in VA Medical

Centers and domiciliary care facilities, while home

care services provided by the VA are most often

available in areas near the VA Medical Centers

(79). 25 Eligibility for VA services depends on a

complex system of entitlements focused first on

the presence of service-connected disability and

secondly on measures of need and ability to pay

(97). Although there has been little emphasis on

targeting mechanisms, increased targeting of services is an option being considered in response to

the increasing number of veterans eligible for VA

services. The VA employs a large number of social

ZSThe i’~ also contracts with private nursing homes and cOmml.Inity home care agencies to provide services when VA facilities are

full or when there are no VA facilities in a given geographical area.

These contracted services are not relevant to this discussion of services actually provided by a single agency, but it is interesting to note

that when the VA contracts with community agencies for services

it cannot provide, it experiences many of the same problems in coordination of services that have been described in the beginning

of this section. At present, there is ongoing discussion and debate

within the VA about how the VA can best coordinate its services

with non-t’A services in the community.

workers who are responsible for patient assessment and coordination of services within the VA

system and for contracted services in the community (80).

Although analysis of VA long-term care services is beyond the scope of this report, two points

are relevant to the functioning of the VA as a delivery system. First, the cost of VA long-term care

services such as nursing home and home care

programs is higher than similar services provided

by other government or private agencies (97). It

is unclear whether these higher costs are related

to the level of care needed by VA patients, the

quality of care provided by the VA, or possible

inefficiencies in the VA system of delivering services. Second, many elderly individuals who are

eligible for long-term care through the VA choose

instead to use non-VA services, relying on Medicare, private insurance, and personal funds to pay

for these services (97). The reasons for this choice

are not known, but some possibilities are: 1) lack

of VA facilities near the individual’s home and

reluctance of the individual to leave his community; 2) the belief of some individuals that VA services are inferior to similar services provided by

the private sector; and 3) a perception of the VA

as a large, impersonal bureaucracy in which the

preferences of the individual might be disregarded. Further analysis of these issues is needed

to clarify the advantages and disadvantages of

service delivery in the VA model.

Social/Health Maintenance Organizations (S/HMOS).

—S/HMOs are agencies that provide a comprehensive range of long-term care services using management and reimbursement principles developed

by HMOS (health maintenance organizations) to

deal with the fragmentation of services in the

community and avoid unnecessary hospitalization

and nursing home care. Cost control is a major

focus of the S/HMO. Clients pay a predetermined

monthly rate and are thereby eligible for services they need including acute medical care, nursing home care, adult day care, home health care,

housekeeping, and chore services.

On Lok is a San Francisco agency that has been

using HMO principles to provide a comprehensive range of long-term care services in the Chinatown-North Beach area since 1979 (101). On Lok’s

own research indicates that their clients used less
230 Technology arid Aging in America

hospital care and less nursing home care than a

comparison group and that measures of physical health and functional status indicated more

improvement in the On Lok group than the comparison group (74). The On Lok cost per client

per day in 1981 was $37.68, which includes all

medical and social services but not the cost of

housing, food, or other living expenses. Although

accurate comparison is difficult, the Medicaid rate

for skilled nursing home care in California at that

time was $36.88 per day, which does not include

costs of hospitalization, physician’s services, or

physical therapy. If the cost of these services is

included, On Lok estimates that the true cost of

care for patients in skilled nursing facilities would

be comparable to On Lok’s cost plus the housing

and living expenses of On Lok clients (101).

While there is some question about the validity

of the results of the On Lok research because of

the comparison group used, there is considerable

interest in the S/HMO approach. At present, several S/HMO sites are being developed by Brandeis

University as part of a 3-year demonstration project funded by the Health Care Financing Administration. Evaluation of the results of this project

is expected to provide information about the efficacy of the S/HMO approach for delivering services and improving client access to appropriate

care (118).

Some researchers believe that the S/HMOs will

reduce the cost of long-term care by substituting home health and nonmedical home care services for hospital and nursing home care (30). The

Federal Office of Management and Budget (OMB)

disagrees and expects that S/HMOs will raise the

cost of long-term care and create a precedent for

providing nonmedical services that are not currently covered by Medicare and Medicaid (89).

Life Care Communities-Life care communities

are long-term care systems that provide a continuum of services for elderly residents, including

homes or apartments for independent living,

home care services, and infirmary or–in many

instances—nursing home care. Hospital care is

usually not provided, but individuals are guaranteed that they can return to the life care community following hospitalization.

There are about 275 life care communities in

this country, providing housing and care for

about 90,000 elderly people (6). Most life care

communities are privately owned, and many are

run by religious organizations. Elderly individuals

are usually admitted while they are still able to

function independently. Payment of the initial

membership fee and a monthly fee guarantees

the individual long-term care for the rest of his

life. Because the membership fee and monthly

fees are often very high, this type of long-term

care has been used primarily by relatively wealthy

individuals, but religiously based and nonprofit

life care communities do admit some low and

moderate income individuals. Sometimes Medicare or Medicaid reimbursement is available for

home care or nursing home services provided in

these communities.

Life care communities allow the elderly individual to select a system of long-term care before

he needs any services, thus increasing his sense

of control over his future. In addition, the availability of a range of services within the same community eliminates the need to move to a completely new environment when services are needed,

thereby avoiding the trauma that is often associated with moves.

Despite these positive indications, reported financial and management problems of some life

care communities have dampened enthusiasm for

this long-term care option (59). Poor financial

planning, often related to lack of accurate statistics about life expectancy for residents, has led

to several bankruptcies (92), and a recent report

has pointed out the need for improved actuarial

planning (141). About one-third of States have

laws governing life care communities, and other

States are considering legislation (78). Legislation

to protect the financial investment of residents

and at the same time encourage the development

of life care communities could make this option

available to more elderly individuals.

Many of the Nation’s largest nursing home

chains have begun to diversify into housing and

home care services for the elderly. In testimony

before the Senate Subcommittee on Aging, July

14, 1983, Arnold Richman, chairman of Merid-
Ch. 7—Technologies, Functional Impairment, and Long-Term Care . 231

ian Health Care, described his company’s recent

involvement in the provision of home care services including skilled nursing care, homemaker

and chore services, and respite care. The company has developed housing for the elderly and

is considering development of a retirement community with rental apartments for the elderly and

a nursing center that would provide board and

care services and skilled nursing care. Mr. Richman stated:

While it is difficult for a proprietary provider

of services to be a direct provider of life care services, we believe there is a significant untapped

need for the rental concept which does not have

associated with it the large entry or endowment

fees typically associated with life care (90).

Evaluation of the potential role of profit-making

organizations in the development of life care communities to serve low and moderate income

elderly is needed. Such an evaluation should focus

on the cost of care and the effectiveness of this

approach in reducing the fragmentation of longterm care services.

Hospital-Based Service Delivery System s.—With

the advent of government-initiated cost control

programs, particularly the Medicare cost-based

reimbursement system (DRGs), hospitals have become more involved in developing and coordinating long-term care services. The cost control systems limit reimbursement to the hospital when

the patient no longer needs acute care, but most

hospitals are reluctant to discharge patients without appropriate plans for continuing care. In order to provide discharge options for their patients,

some hospitals are developing or acquiring nursing homes, home care agencies, adult day care

centers, and community outreach services, while

others are establishing formal transfer agreements between the hospital and these long-term

care agencies.

Advantages of hospital-based service delivery

systems are: 1) the prominence of hospitals in the

community which makes them a well-known center for service delivery, and 2) the availability of

physicians in the hospital to provide and supervise long-term care. Lack of physician involvement in nursing homes and home care agencies

has been a major concern for many years, and

affiliation of long-term care agencies with hospitals offers the possibility of alleviating this problem (22). Provision of long-term care services within the hospital system could also allow easier

transitions for patients between acute and longterm care settings.

In many communities, empty hospital beds are

driving up the cost of hospital care. Affiliation

with long-term care agencies provides a guaranteed source of patients for some of these hospitals. Other hospitals are using empty beds to provide long-term care in the hospital. This approach

could lessen the need to build new nursing homes

and decrease costs associated with empty hospital beds. In some rural areas, Medicare reimbursement is now allowed for these “swing beds” that

can be used for acute or long-term care services

depending on current need (22).2’

One disadvantage of hospital-based service delivery systems is that the hospital is a medical care

facility, and hospital coordination of service delivery can result in overemphasis on medical care

and lack of social or nonmedical services, The fact

that reimbursement is more often available for

medical care than for social services is an additional incentive for hospitals to provide primarily medical services. This tendency to medicalize

the long-term care system is a problem because

of the relatively high cost of medical care compared to social or nonmedical services and because in some instances nonmedical services are

more appropriate for the patient. Further analysis of the impact of hospital-based service delivery systems on the kinds of services provided and

the cost of care will be needed as this method of

coordinating long-term care services is more

widely used.

Government Initiatives To Increase the Role of

Individuals in Developing Their Own Long-Term

Care Plans. -This option has thus far received

very little attention for several reasons. First, longterm care is frequently seen as medical care, and

planning is seen to require medical expertise. SecZeMedicare and Medicaid regulations and some State and ]OCal regulations prohibit hospital pro~tision of long-term care services and

acquisition of long-term care facilities to avoid restraint on competition between local agencies.
232 Technology and Aging in America

end, individuals who need long-term care services are often treated as if they were so mentally

and physically disabled that they cannot make

long-term care plans for themselves. Third, there

is a sense of crisis that surrounds long-term care

decisionmaking and interferes with the deliberate

consideration of individual preferences and alternatives for care. Finally, the complexity and fragmentation of long-term care services make it difficult for individuals to understand what alternatives are available.

In fact, information reviewed in this chapter indicates that functional impairments rather than

medical conditions are most apt to cause a need

for long-term care services and that increasing

proportions of individuals in each older age group

need assistance with personal care and housekeeping services. To the extent that functional impairments and the resulting need for long-term

care services can be anticipated by the elderly,

it is possible that some individuals could plan for

these services.

Government initiatives to encourage and assist

individuals to plan for their own long-term care

could focus on public information programs to

increase awareness of:

●

●

●

●

functional impairments and their impact on

the need for long-term care services,

the potential for rehabilitation of the elderly

and the role of assistive devices in maintaining and increasing independent functioning,

the kinds of long-term care services that are

available, and

the importance of housing and living arrangements in postponing the need for more formal long-term care services.

Clearly the development of a more rational and

coordinated system of long-term care services

would also help individuals to plan long-term care

for themselves.

One of the greatest fears of the elderly is becoming frail and dependent on others, Government

initiatives to encourage elderly individuals to plan

for themselves may help to alleviate this fear and

assure them continuing control of their lives.

Findings

The need for long-term care is expected to increase dramatically in the future as a result of

several factors:

●

●

●

growth in the number of elderly individuals,

particularly the very old who frequently need

long-term care services,

decreasing age-specific mortality that results

in larger numbers of elderly individuals living longer with chronic diseases and functional impairments, and

changes in medical practice and reimbursement-mechanisms that result in limiting inpatient care and the length of hospital stays

and promoting delivery of health care services in the home and the community.

Increasing need for long-term care will place

strain on families, existing agencies, and service

delivery systems. Public and private expenditures

for formal long-term care services which have

grown rapidly in the past 20 years, will continue

to rise.

Technology has not been widely used in longterm care. Identification of technologies that are

appropriate for this population requires a needs

assessment, but this assessment is complicated because government programs that regulate and

fund more than half of long-term care services

in this country tend to define the kind of needs

that are recognized, emphasizing medical and

skilled nursing care and obscuring the need for

other forms of care. Survey data collected from

agencies serving Medicare and Medicaid patients

reflect this influence.

In contrast to this emphasis on medical and

skilled nursing care, research indicates that longterm care services are most often needed as a result of functional impairment; that is, limitations

in the individual’s ability to function independ-
Ch. 7—Technologies, Functional Impairment, and Long-Term Care ● 233

ently. Medical treatment can cure some of the

conditions that cause functional impairment, but

other conditions are not curable at present. Biomedical research has been focused primarily on

conditions that cause death, but conditions that

cause functional impairment are not necessarily

the same as those that cause death. Research on

conditions that cause functional impairment could

result in effective treatments and decreased need

for long-term care.

In the absence of effective medical treatments,

alternative approaches to maintaining independent functioning are needed, such as assessment

technologies to identify functional impairment

and assistive devices and rehabilitation techniques

to compensate for functional impairment. Use of

these technologies has been limited because of the

focus on medical and skilled nursing care, and

because physicians and other long-term care providers lack training in their use. Reimbursement

for the use of assessment technologies is limited,

and there is disagreement about the reliability and

validity of existing assessment measures. Factors

restricting the use of assistive devices include lack

of information about available devices, the difficulty of selecting appropriate devices for individuals with multiple impairments, and negative attitudes of elderly individuals, their families, and

many health care professionals about the rehabilitation potential of the elderly.

Some elderly individuals have mental conditions

that cause functional impairment and a need for

long-term care. While it is known that about half

of residents of nursing homes and board and care

facilities have mental conditions that cause confusion, it is not known how many of these individuals are functionally impaired as a result of

confusion, how many are functionally impaired

as a result of other chronic conditions, and how

many have both physical and mental conditions

causing impairment. The development of devices

and care techniques for confused patients has received little attention although families and formal long-term care providers often have great dif -

ficulty caring for these individuals.

Because of the emphasis on medical and nursing care in the Federal programs that regulate and

fund long-term care services, alternative care systems such as board and care facilities and personal care and supportive services in the home

are often not available. Physically and mentally

impaired patients who need 24-hour supervision

and personal care services but not skilled nursing care are often admitted to nursing homes although they might be cared for in less restrictive

and less costly board and care facilities. Similarly,

individuals who need personal care and supportive services at home may not receive the care

they need or may receive health care services

they do not need because of Medicare and Medicaid funding regulations. Negative attitudes about

the concept of custodial care and fears about the

cost of providing nonmedical long-term care services for the functionally impaired elderly also limit

the availability of these services.

Most long-term care services are labor-intensive, and formal and informal providers receive

little training in the use of devices and techniques

to facilitate caregiving. Increased development

and use of these technologies could lessen the

burden of caregiving, allowing some families to

keep elderly relatives at home longer and decreasing staff turnover in long-term care facilities.

Few medical care technologies have been used

in long-term care facilities or in the home. Recently, as a result of the implementation of the Medicare prospective reimbursement system and increased emphasis on the provision of health care

services at home, medical care technologies that

have been available only in hospitals are being

used more often in the home. This trend is expected to grow, and demand for sophisticated

medical and nursing care technologies in nursing homes is also expected to grow. The increased

use of these technologies outside the hospital is

dependent on the availability of funding and

skilled health care personnel trained to use these

technologies and to teach the patient and the

family to use them.

Long-term care services are provided by nursing homes, board and care facilities, and home

care agencies. In some communities, adult day

care facilities, hospice programs, and congregate

housing facilities also provide services. Little information is available about differences between

agencies in the services they provide and the

kinds of individuals they serve, and it often appears that most agencies provide a wide range
—— —

234 ● Technology and Aging in America

of services to a variety of patients with very different needs. Increasing the use of technology in

these agencies would be difficult and expensive

because so many different technologies would be

required to meet the varied needs of patients

served by each agency.

An alternative is to classify patients according

to need and to provide a unique set of technologies and care systems in each agency. The feasibility of this alternative depends on whether patients can be realistically grouped according to

need and whether available assessment technologies can accurately classify patients in this way.

When patient needs change frequently, the negative effect of moving can outweigh the positive

effect of appropriate technologies in the new setting. These issues

Research

require further evaluation.

priorities

Lack of coordination among the Federal programs that regulate and fund long-term care services contributes to the fragmentation of services

at the community level, making it difficult for the

elderly, their families, and health care professionals to arrange appropriate services and increasing the sense of crisis that surrounds longterm care decisionmaking. Efforts to improve

service delivery have included techniques for coordinating agency services at the community

level, case management systems, and organizational approaches that provide a range of services through a single local agency. Development

of a more coordinated system of services could

enhance the ability of some elderly individuals to

plan effectively for their own long-term care.

Research priorities related to the development, ●

utilization, and evaluation of technologies to

meet the needs of the long-term care population

include: s

●

●

●

identification of the primary causes of func- ●

tional impairment and biomedical research

to find cures or treatments that alleviate the

functional impairment;

development of assistive devices and reha- ●

bilitation techniques for elderly individuals,

particularly those with multiple impairments;

evaluation of the relationship between mental confusion and functional impairment and

the impact of mental confusion on the need

for long-term care;

identification of assistive devices and rehabilitation techniques that are effective with

confused individuals;

assessment of devices and techniques to facilitate caregiving;

evaluation of the reliability and validity of

available assessment measures in classifying

patients according to service and technology

needs; and

comparison of the cost and quality of care

effects of providing a variety of technologies

in each long-term care agency v. moving patients to settings that provide a unique set

of services and technologies to meet specific

needs.
Ch. 7—Technologies, Functional Impairment, and Long-Term Care ● 235

Issues and options

Use of assessment measures

Issue I: Should Congress encourage the use

of comprehensive assessment technologies?

Options:

1.1: Congress could maintain current levels of support

for the use of comprehensive assessment measures in demonstration projects.

1.2: Congress could increase funding for evaluation

and consensus development on effective assessment measures.

1.3: Congress could increase funding for training

health care professionals and other long-term care

providers in the use of comprehensive assessment

technologies.

1 .4: Congress could mandate reimbursement through

Medicare and Medicaid for physicians and other

long-term care providers for comprehensive

assessment.

1.5: Congress could mandate reimbursement for comprehensive assessment provided in Geriatric

Assessment Centers.

1.6: Congress could make eligibility for publicly

funded long-term care services dependent on the

results of a comprehensive functional assessment

measure.

Comprehensive evaluation of the physical, mental, and social functioning of the impaired elderly

individual is important for identifying medical

care needs, functional impairments, and appropriate technologies and long-term services. Federal initiatives to provide training and reimbursement for health care professionals and other

long-term care providers in the use of available

assessment measures can be expected to increase

utilization. Mandated use of comprehensive assessment measures to determine eligibility for federally funded long-term care services would have

a much greater effect, ultimately leading to increased awareness of the multiple factors involved in the need for long-term care and the

variety of technologies and services that are appropriate for this population.

Functional impairment

Issue 2: Should Congress mandate funding

for long-term care services based on

functional impairment?

Options:

Z. I: Congress could maintain current emphasis on eligibility for services based on need for medical and

skilled nursing care.

2.2: Congress could expand existing programs to include eligibility for long-term care services on the

basis of functional impairment.

2.3: Congress could create a new program to fund

long-term care services for functionally impaired

individuals who do not need continuous medical

or skilled nursing care.

Research has demonstrated the importance of

functional impairments in causing the need for

long-term care services, but, as a result of the emphasis in Federal funding programs on medical

and skilled nursing care, some elderly individuals

with functional impairments are not eligible for

the services they need. Providing reimbursement

for services based on functional impairment

would increase the number of eligible individuals

and probably increase overall costs. The availability of funding for nonmedical services could, however, encourage the development of alternative

care systems such as board and care facilities and

personal care and supportive services in the home

that are significantly less costly than medical and

skilled nursing care. These alternative care systems could emphasize the use of technologies for

caregivers and environmental design technologies

that limit the impact of functional impairments.

Since it is not known how many nursing home

residents and home care clients need skilled nursing care and how many need only personaI care,

supportive services, and supervision, no reliable

estimate can be made of the number of individuals who could be cared for with lower cost, alternative services.
236 ● Technology and Aging in America

Rehabilitation technologies

Issue 3: Should Congress implement policies

to increase the use of assistive devices?

Options:

3.1: Congress could maintain current levels of support

for the use of assistive devices.

3.2: Congress could increase funding for assistive devices through existing programs, extending coverage to devices that support independent functioning, but are not currently considered medically necessary, such as glasses, hearing aids, dentures, communication devices, lifeline devices, and

devices to alter the home to compensate for functional impairments.

3.3: Congress could create a new program to supply

assistive devices, modeled after programs currently in effect in Sweden.

3.4: Congress could fund a demonstration project to

evaluate the efficacy of “Aids Centers” in providing and repairing assistive devices.

3.5: Congress Could provide support for

improve the matching of individuals and devices,

such as:

3.6:

a.

b

c.

d.

The use of assessment technologies to identify

needs and appropriate devices.

Training to increase understanding of the use

of assistive devices among long-term care providers, including physicians, nurses, social

workers, and staff at senior centers and nutrition sites. This could encompass training about

the kinds of devices that are available, the effectiveness of devices in mmpensatirg for functional impairment, and appropriate referrals

for patients who need devices.

Training to increase awareness of the special

needs of the elderly among professionals already involved in providing assistive devices,

such as physical therapists and occupational

therapists.

Increased emphasis on services for the elderly

through State rehabilitation agencies. (These

agencies receive 80 percent Federal funding

through the Rehabilitation Act of 1973.)

Congress could fund a public education program

targeted to the elderly and their famiZies on the

nature of functional impairments and use of assistive devices in compensating for impairment,

Such a program could focus on countering negative attitudes about the use of assistive devices.

Issue 4:

Options:

Should Congress support initiatives

to increase the use of rehabilitation

services for the functionally impaired

elderly?

4. 1: Congress could maintain current levels of support

for rehabilitation services for the elderly. (It is expected that rehabilitation services will be provided

more extensively because these services are exempt from Medicare DRGs.)

4.2: Congress could increase support for rehabilitation

4.3;

4.4:

4.6:

. .

services through Medicare by eliminating restrictions on reimbursement for services that maintain functioning and limitations on the frequency

of reimbursable services.

Congress could increase support for rehabilitation

services through Medicaid by fiscal policies that

encourage States to reimburse prow”ders at higher

rates.

Congress could mandate the provision of rehabilitation services in nursing homes as a condition

for Medicare certification and encourage States to

impose the same requirement for certification under

Medicaid.

Congress could increase funding for training of

rehabilitation professionals and other long-term

care providers, including:

a. training to counter negative attitudes about the

rehabilitation potential of the elderly,

b. training in the use of assessment measures to

identify the need for rehabilitation servicies, and

c. training in techniques for rehabilitation of the

functionally impaired elderly.

4.7: Congress could fund a public education program

targeted to the elderly and their families on the

nature of functional impairment and the potential of rehabilitation services for improving functional capacity and compensating for impairments.

The use of rehabilitation technologies to compensate for functional impairment is limited by

negative attitudes of the elderly, their families,

and health care providers about the rehabilitation potential of those over 65, lack of training

for providers, and limitations on reimbursement

for services to maintain functioning and devices

to compensate for functional impairment. Federal

initiatives to increase training for providers and

reimbursement for a wide range of rehabilitation
Ch. 7—Technologies, Functional Impairment, and Long-Term Care ● 237

technologies will increase use, resulting in improved functioning for many elderly individuals

and decreased need for long-term care services.

Demonstration of the effectiveness of these technologies can be expected to decrease negative attitudes that now restrict use.

service delivery systems

Issue 5: Should Congress support initiatives

to improve services delivery?

Options:

5;1: Congress could maintain current support for coordination of services at the community level including funding for Area Agencies on Aging and Medicaid waivers that allow case management as a

reimbursable service.

5:2: Congress could create a federally funded case

management system modeled after the Channeling Demonstration Program.

5.3: Congress could provide more flexible funding and

other financial incentives to encourage the development and use of a comprehensive range of longterm care services provided by single agencies

such as hospital and nursing home based service

systems, WHMOS, and life care communities.

5.4: Congress could consolidate Federal funding for

long-term care services into a single program,

combining funding from Medicare, Medicaid, the

Title XX Block Grant, Title III of the Older Americans Act, and the VA.

The lack of coordination of Federal programs

that fund long-term care is an important cause

of fragmentation of services at the community

level, but combining these programs into a single

Federal long-term care program (option 5.4)

would require major changes in legislation, regulations, and agency structures at the Federal,

State, and local level. In the absense of these

substantial changes, Federal support for systems

to coordinate services at the community level can

help to decrease fragmentation and improve access to appropriate services. Such systems include

local provider groups, information and referral

systems, case management, hospital or nursing

home based service systems, S/HMOs, and life

care communities.

Technical memorandum: Federal programs funding

long-term care services

Medicare

Medicare, authorized by Title XVIII of the Social

Security Act, pays for acute care services (hospitalization and physician’s services, etc.) and some long-term

care services for elderly and disabled beneficiaries.

Almost all elderly persons are covered by Medicare.

NursingHome: Medicare pays for up to 100 days of

skilled nursing care within each benefit period with

substantial copayments after the first 20 days. (A benefit period begins the day an individual is admitted to

a hospital or nursing home and ends when he or she

has been out of the hospital or nursing home for 60

consecutive days [25]). Custodial care is not covered.

In 1980, Medicare paid $337 million for skilled nursing care for elderly individuals. This represented less

than 1 percent of total Medicare expenditures and

about 2 percent of all spending for nursing home care

(126).

Board and Care Facilities: Not covered.

Home Care: Medicare funds skilled nursing care,

physical therapy, speech therapy, occupational therapy, medical social services, and home health aide

visits with the authorization of a physician.z’ Under

Medicare regulations home health aides can provide

personal care but can only perform homemaker services such as cleaning and changing beds when these

services can be shown to prevent or postpone institutionalization. No chore services are provided. In 1978,

a majority of the home care visits funded by Medicare

were skilled nursing visits (55.7 percent), while 30.7

z>A]] home cam se~ces funded by Medicare must be authorized by a ph.vsician, and the physician is supposed to determine the extent and nature of

all services provided. Nevertheless, a recent GAO study found that home care

agencies were generally planning the services and most physicians were not

aware of the services they had authorizti. In fact, 50 percent of the physicians interviewed wem not seeing the patients for whom they had authorized

home care services, and very few physicians were aware of the cost of these

services (1 16).
238 ● Technology and Aging in America

percent were home health aide visits, and 10 percent

were physical therapy visits (116). Medicare regulations specify that home care services can be covered

only when the recipient is homebound; it has been

very difficult, however, to define homebound, and

services have been funded for some elderly individuals

who are able to leave home (116).

Medicare outlays for home care services increased

from $287 million in fiscal year 1976 to $964 million

in fiscal year 1981 (116), and the number of Medicare

home care visits has doubled in the past 10 years;

nevertheless, funding for home care services accounts

for only about z percent of Medicare expenditures

(118). There is no patient deductible for home care

services under Medicare, so these services are free to

the patient (116).

Adult Day Care: Medicare pays for skilled nursing,

physical therapy, and occupational therapy provided

in the adult day care setting, but does not cover adult

day care as such.

Hospice: As of October 1, 1983, Medicare funds

hospice care for terminally ill beneficiaries with a life

expectancy of 6 months or less. Reimbursement has

been limited to $46.25 per day per patient, but legislation to raise this amount was approved on November

9, 1984 (P.L. 98-617).

Respite Care: Medicare home health care services

may be used by some families for respite care (116).

Congregate Housing: Not covered.

Medicaid

Medicaid is a Federal-State program authorized by

Title XIX of the Social Security Act. It pays for acute

and long-term care services for low-income individuals, including the elderly. Because regulations governing Medicaid programs are determined by each

State, within the Federal guidelines, there are significant variations between States in eligibility requirements and available services, States can limit services

to individuals with incomes below a set level or they

can provide services for the “medically needy,” i.e.,

individuals whose income is below the set level only

after their medical expenses have been deducted.

Nursing Home: The Federal Medicaid program

defines two types of covered nursing home care:

skilled care, provided in a skilled nursing facility (SNF),

includes services that are needed on a daily basis, must

be provided in an institution, and require the skills

of professional or technical personnel; intermediate

care, provided in an intermediate care facility (ICF),

is health-related care for individuals who require services that are above the level of room and board and

must be provided in an institution. In the SNF, a professional nurse must be on duty 24 hours a day. In

an ICF, a professional nurse must be on duty only during the day shift (25).

Although Federal regulations are quite specific,

States vary greatly in their use of these two levels of

care. Some States, like California and Connecticut, consider almost all the care they provide skilled care,

while others, like Iowa and Oklahoma, provide almost

all intermediate care. Since it is unlikely that the types

of care needed by nursing home residents varies

greatly between States, variation in the use of the SNF

and ICF categories probably results from differences

in State policies that implement the Federal Medicaid

regulations (25).

In fiscal year 1980, Medicaid paid $7.9 billion for

nursing home care. This represents more than onethird of all Medicaid expenditures and about 45 percent of all spending for nursing home care (119). The

Federal Government pays from 50 to 78 percent of

State Medicaid costs for services and up to 50 percent

of administrative costs. In recent years, Federal payments to the States have been capped at lower levels

than previously (e.g., 96 percent of fiscal year 1982

dollars were available in 1983).

Board and Care Facilities: Not covered.

Home Care: Under Federal Medicaid guidelines,

States are required to provide skilled nursing care and

home health aide services, while other services such

as personal care services, physical therapy, speech

therapy, and occupational therapy are optional (25).

Currently 18 States are covering personal care services including bathing, dressing, feeding, and some

housekeeping services if related to a medical need (25).

Services must by ordered by a physician, and home

health aide services and personal care services must

by supervised by a licensed nurse (138),

Medicaid expenditures for home care have been

relatively low (1.4 percent of total Medicaid spending

in fiscal year 1980) (25), and States vary widely in the

extent to which Medicaid is used to fund home care

services. In fiscal year 1980 New York accounted for

40 percent of all recipients nationwide, almost half of

all Medicaid home care expenditures, and 90 percent

of Medicaid expenditures for personal care (25). Medicaid payments for home care services are generally

much lower than Medicare payments, and it is likely

that the lower Medicaid reimbursement rates discourage providers from serving Medicaid recipients.

Medicaid 2176 Waiver Program: A 1981 amendment

to the Social Security Act waived some of the requirements for Medicaid-funded home care services, allowing States to set up demonstration projects to offer

home and community-based services not previously

paid for by Medicaid. Services provided through the

2176 waiver program could be offered on less than
Ch. 7—Technologies, Functional Impairment, and Long-Term Care • 239

a statewide basis, so that projects could be set up in

certain geographical areas and targeted to specific

groups of recipients. Waiver projects must be approved by the Secretary of Health and Human Services, and total spending must be no higher than without the waiver project. Medicaid waiver applications

approved by mid-1983 include 26 programs for the

elderly, and many of these programs include home

care services: 16 programs include homemaker services, 11 include personal care, 7 include home health

care, and 5 include chore services (138).

Adult Day Care: Adult day care is an optional Medicaid service, and as of fiscal year 1984, eight States

provided Medicaid reimbursement for adult day care.

Several States provide adult day care through the 2176

waiver program (25,127).

Hospice: Hospice care is not currently funded by

Medicaid, but New York State has requested an administrative decision by the Health Care Financing Administration to make reimbursement available under existing legislation.

Respite Care: Home care services covered by Medicaid are used by some families for respite care.

Congregate Housing: Not covered.

Title XX

Title XX of the Social Security Act was converted to

“Title XX Block Grants to States for Social Services”

in 1981 (118). Title XX grants are used by States primarily for social services for elderly and nonelderly

individuals, and there is considerable variation between States in services provided.

Nursing Home: Not provided.

Board and Care Facilities: Some States provide

limited funding for geriatric foster care with title XX

funds (25).

Home Care: Home care services provided in some

States with title XX funds include homemaker, chore

services, and homedelivered meals, but GAO has estimated that in the States they studied, less than 13 percent of title XX funds were spent for these home care

services (25). It is difficult to specify what percentage

of title XX home care services were used by elderly

persons, but one author has estimated that in fiscal

year 1980 between $723 million and $1.593 billion in

title XX funds were spent on long-term care services

for the elderly. States vary widely in the use of these

funds. For example, it is estimated that California spent

about 40 percent of all title XX funds for long-term

care (25).

Adult Day Care: Although more than 95 percent of

publicly funded adult day care was paid for with title

XX funds in fiscal year 1980, and almost all States provided some adult day care with title XX funds, total

title XX expenditures for adult day care were relatively

limited. It is estimated that less than 3 percent of all

title XX expenditures for long-term care for the elderly

were spent on adult day care (25).

Hospice: Not covered.

Respite Care: No information available,

Congregate Housing: Housing subsidies are not provided, but services for residents on congregate housing facilities are provided with Title XX funds in some

jurisdictions. Examples include homemaker and transportation services.

Title III

Title III of the Older Americans Act provides funds

for a variety of services for the elderly, including

homedelivered and congregate meals, transportation,

homemaker, and home health aide services. The Administration on Aging allocates title 111 funds to States

primarily on the basis of the proportion of the State’s

population aged 60 and over compared with the proportion of that age group in the national population

(25).

Nursing Home: Not covered.

Board and Care Facilities: Not covered.

Home Care: Home care services funded through title 111 include home-delivered meals, shopping and

escort services, telephone reassurance, homemaker,

home health aide, and residential repair (25). The GAO

estimates that $43 million of title III funds were spent

on home care services for the elderly in fiscal year

1980 (118).

Hospice: Not covered.

Respite Care: Home care services provided with title 111 funds are used by some families for respite care.

In addition, some localities provide specific respite care

services with title III funds. No accurate figures are

available on spending for respite care nationally.

Congregate Housing: Housing subsidies are not provided, but services for residents of congregate housing facilities are provided with title 111 funds in some

jurisdictions. Examples include congregate meals and

recreation services.

Supplemental Security Income (SSI)

SS1 is the Federal program enacted in 1972 to provide minimum monthly payments to aged, disabled,

and blind individuals who have incomes below the

minimum standard. Since SSI is a cash benefit, it can

be used by recipients to pay for long-term care services, but low benefit levels limit the kinds of services

that can be purchased.
240 ● Technology and Aging in America

Nursing Home: Not covered. When SS1 recipients are

admitted to a nursing home, their SS1 grant is reduced

to a maximum of $25; if they have other income, the

SS1 benefit is reduced to zero.

Board and Care Facilities: Many residents of board

and care facilities receive SS1 payments and use this

income to pay for their care. In addition, States are

allowed to supplement the Federal minimum SS1

benefits, and by 1983, 34 States and the District of

Columbia provided supplements specifically for persons living in board and care facilities (52,131),

Home Care: Not covered.

Adult Day Care: Not covered.

Hospice: Not covered.

Respite Care: Not covered.

Congregate Housing: Not covered.

Veterans Administration (VA)

The VA provides a wide range of long-term care

services for eligible veterans. The complex eligibility

criteria for services are not discussed here.

Nursing Home: In fiscal year 1982, about 15,000 veterans were cared for in VA nursing homes with an

average daily census of about 8,400 (132a). About 62

percent of these individuals were 65 or over (80). In

addition, about 31,500 veterans were paid for in nonChapter 7 references

VA community nursing homes with an average daily

census of about 9)500 (132a). About 56 percent of these

individuals were over 65 (80).

Board and Care Facilities: The VA operates 16 large

board and care facilities with an average daily census

of about 7,000. In addition, the VA places veterans in

smaller board and care homes. In fiscal year 1982, approximately 13,500 veterans were living in about 3,00

supervised board and care homes: approximately 30

percent were over 65 (132a). (State veterans homes

also provide domiciliary care and some nursing home

care.)

Home Care: The VA provides home care services to

homebound veterans through 30 VA medical centers.

In fiscal year 1983 it was estimated that medical, nursing, social, and rehabilitation services would be provided for about 5,600 veterans. Veterans who do not

live near one of the 30 medical centers do not have

access to VA-funded home care services.

Adult Day Care: Recent legislation authorizes VA

provision of adult day care through VA facilities or

through contracts with non-VA providers.

Hospice: The VA operates one hospice program in

Los Angeles (80).

Respite: VA home care services are used by some

families for respite care.

Congregate Housing: Not covered.

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Chapter 8

Health Care Costs and Access

to Technology for Older Persons
Contents

Pag e

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 249

Health Spending of Young and Old. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 251

Technology, Aging, and Other Factors Affecting Health Expenditures . . . . . . . . . . . . . . 252

Selecting Appropriate Technologies for Older Persons . . . . . . . . . . . . . . . . . . . . . . . . . . . . 257

Appropriate Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 257

Use of Health Care Technologies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 258

Appropriate Providers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 259

Cost-Containment Strategies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 259

Federal and State Efforts to Contain Costs of Institutional Care . . . . . . . . . . . . . . . . . . . 261

Cavitation Approaches . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 263

Technology and Coordination of Federal Health Programs . . . . . . . . . . . . . . . . . . . . . . . . . 263

Federal Health Programs. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 264

Hospital Backup . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 264

Information Technology for Coordination of Heahh Programs . . . . . . . . . . . . . . . . . . . . 266

Financing Alternatives for Health and Long-Term Care. .....,... . . . . . . . . . . . . . . . . . . 266

Findings and Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 268

Research Priorities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 269

Congressional Issues and Options . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 270

Chapter preferences . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 272

Tables

Table No . Pag e

18. Average Annual Compound Rates of Growth of Benefits and Enrollees,

Fiscal Years 1978-82 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 254

19. Factors Accounting for Growth in Expenditures for Selected Categories

of Total Systems Cost, 1971-81 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ., . . . 255

20. Relative Contributionof Different Factors to the Total Increase

in Real Expenditures for Physician Services . . . . . . . . , . . . . . . . . . . . . . . , . . , . . . , . . . 256

21. Average Utilization of Health Services by Elderly Medicare Beneficiaries,

by Type of Supplementation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 260

22. Formal Long-Term Care Expenditures in Hospital Care Nursing Home Care,

and Community-Based Care, by Source of Funds . . . . . . . . . . . . . . ., . . . . , . , . . . , . . . 265

Figures

Figure No. Pag e

24. Percentage Distribution of Personal Health Care Expenditures by Source

of Funds and Age Group, Calendar Year 1978 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 252

25.Per Capita Personal Health Care Expenditures for the Aged, by Source

of Funds and by Type of Care, Calendar Year 1978 . . . . . . . . . . . . . . . . . . . . . . . . . . . 252

26. Factors Accounting for Growth in Total Health Costs, 1971-81 . . . . . . . . . . . . . . . . . . 253
——

Chapter 8

Health Care Costs and Access

to Technology for Older Persons

Introduction

Health care costs, including long-term care expenditures, have grown rapidly over the last three

decades, increasing from $12.7 billion (4.4 percent of gross national product (GNP)) in 1950, to

$322.6 billion (10.5 percent of GNP) in 1982 and

an estimated $357 billion in 1983. Total health

care expenditures are projected to reach 12 percent of GNP by the year 2000 or sooner (10,15).

Growth in per capita health care costs, augmented

by the growth in numbers of the U.S. population

over 65, has produced an impending crisis in the

funding of Medicare and Medicaid, major payers

for health service to the elderly.

Technological development in recent decades

has increased the effectiveness and sophistication

of health care. It has also increased its costs, The

relationships between cost, technology, and financing are complex, in some cases not well understood, and require continuing investigation.

Although new medical technologies’ have raised

the cost of care—by expanding the types of problems that can be diagnosed and treated–they

have also provided more efficient strategies for

the management of acute and chronic disease and

functional disability. Depending on how it is applied, the same technology can be either costsaving or cost-enhancing. Exercise electrocardiography, for example—a noninvasive diagnostic

test for coronary heart disease—can be cost-saving if it is used to screen candidates for invasive

diagnostic evaluation, thereby reducing the number of invasive tests. If it is simply added to the

diagnostic workup for patients for whom invasive

testing is already planned, it increases the cost

of care. The net effect of technology on the cost

of care therefore depends on both the technology and the ways in which it is used.

1OTA defines medical technologies as cirugs, dm~ices, and nledi -

cal and surgical procedures used in medical care, and the organizational and support systems within which they are produced.

If the growth of health expenditures can be contained at levels comparable to the general rate

of inflation, these expenditures will halt their encroachment on the Nation’s resources. How much

health care is enough, who is responsible for paying, to what extent equality of access should be

assured, and other ethical questions combine with

questions of necessity and appropriateness to

create an exceedingly complex set of issues that

apply to all age groups of consumers and all payers for care. This chapter emphasizes issues related to technology and the aging of the U.S. populatim in the context of the demand for fiscal

restraint.

Control of escalating health care spending is a

priority in light of current and projected Federal

deficits as well as the growing costs of employee

health plans and personal expenditures for care.

Because those over 65 use more health services

than any other age group and the Federal Government has assumed significant responsibility

for funding these services, the kinds and costs

of care for the elderly are a particular congressional concern. Instituting effective controls over

costs of covered benefits as well as total health

spending thus deserves increased attention.

Congress has paid some attention to slowing the

growth of these costs. Direct attention has been

given to controlling Federal expenditures for

Medicare and Federal contributions to Medicaid.

Total savings may be reduced by cost shifting to

third-party payers and individuals, or from one

Federal program to another. Entitlement programs are primary concerns because their costs

are less easily controlled than other Federal health

activities.

Access to health-related technologies—for those

over 65 and for the poor of all ages—has also been

a major congressional concern. Recognizing that

249
250 ● Technology and Aging in America

the cost of technologies can be a strong deterrent

to their availability and use, Congress has legislated programs to assist these people with the purchase of health care. Medicare is the largest Federal health care financing program. Medicaid is

a federally aided, State-run, means-tested (eligibility based on income) program that provides

health benefits for the categorically needy, including the poor elderly. The Veterans Administration (VA) provides resources for the care of older

veterans. In addition, the Federal Government

provides funding for health resource programs

(e.g., block grants to States, health planning) designed to improve the distribution, supply, and

cost effectiveness of these services.

Federal policy for health and long-term care has

in part shaped the development of technology,

the settings in which it is used, and access to it

for those over 65. The rate of adoption, and hence

the availability of a new technology, is strongly

influenced by whether or not it is eligible for

reimbursement and whether it is regulated by

health planning activities. Because reimbursement

has been more liberal for inpatient procedures,

hospital-based care has been encouraged. Recent

changes have encouraged more outpatient diagnostic and surgical procedures. The implementation of prospective payment under Medicare,

as discussed earlier and in this chapter, may shift

the more acutely ill patients and the technologies

for their care to outpatient clinics, nursing facilities, and home care settings. More sophisticated

technology and personnel may thus be required

in these settings which, in turn, may increase the

cost of care in them.

Because Federal payments for health care represent about one-third of total hospital revenues,

one-third to one-half of physician payments, and

about half the cost of long-term care, changes in

Federal reimbursement strategies may induce

changes in the use of technology throughout the

health care system. To the extent that other payers do not adopt similar strategies and providers

are able to maintain full practices without participating in Federal programs, older persons who

depend on these programs may suffer reduced

access to health care technologies. Even under

cost reimbursement policies for acute care, a

number of technologies are identified elsewhere

in this report that would be beneficial to the over65 age group but maybe currently underutilized,

This results, in part, because of their cost and the

lack of reimbursement under Federal and State

programs. Coverage for additional services could

increase overall costs, but there is potential for

limiting the increase by achieving greater functional independence.

Federal and federally assisted State programs

provide acute and long-term care for the elderly.

Medicare, Medicaid,z income support programs,

services through block-granted programs, and VA

programs are among the efforts to provide care

for those over 65. Using these benefits to access

the proper mix of acute and chronic health care,

as well as appropriate supportive and social services, can be difficult. Lack of continuity of services can sometimes lead to inappropriate and poor

quality of care and increased costs due to duplicated services and the loss of functional independence.

A number of observers have identified mismatches between Federal and private health benefits and the needs of an aging population

(9,39,40). The success of the Medicare program

in providing access to acute care technologies has

contributed to the recent declines in mortality for

those over 65. However, as noted in chapters 2

and 3, decreasing mortality has not been accompanied by comparable declines in morbidity in the

older population, and the elderly therefore carry

a larger burden of illness (36). Growing numbers

of older individuals with multiple health problems

will continue to increase the demand for technologies to prevent and manage chronic disease and

for long-term care (10,14). Policymakers focusing

on cost containment must recognize that the

changing needs of the population served by Medicare have increased Medicare costs and stimulated spillovers into other Federal programs, most

notably Medicaid. This mismatch between needs

and benefits has resulted in increased out-of-pocket spending by individuals as well. Increased costs

may deter older users from seeking needed care

for correctable problems (e.g., blood-pressure

‘Many older persons requiring long-term care come to depend

on Medicaid benefits by “spending down” enough to become eligible, i.e., by liquidating assets and exhausting their finances on highcost, long-term care.
Ch. 8—Health Care Costs and Access to Technology for Older Persons “ 251

control, vision problems, and routine health evaluations for chronic disorders), potentially resulting in greater ultimate costs for acute and restorative care.

The financial burden of long-term care is a particularly severe problem for those over 75 because the risk of needing prolonged care increases

with age. Few benefits are provided by Medicare,

and private insurance is largely unavailable to protect against this eventuality. Medicaid is the only

safety net and provides benefits only after personal resources are exhausted. Depletion of resources may have the additional effect of eliminating future opportunities for community care.

Should a patient’s condition improve or the availability of new technologies permit a transition,

the patient might no longer have a residence or

lack the means to be financially independent.

This chapter provides an overview of factors

affecting health expenditures and cost-containment efforts. Included are a comparison of spending by those over 65 and by younger age groups;

the contribution of technology, aging, and other

factors to growth in health care costs; the goals

for appropriate use of technology; the characteristics of older health care consumers that influence their use of services and technologies; costcontainment activities and some of their implications for cost and quality of care; and the need

for better coordination among Federal programs.

The hospital backup problem is explored as an

example of the impact of poor coordination on

costs and quality of care. The potential for better access to information as a means to improve

coordination and outcomes is also discussed. The

major issues are then detailed, and options are

presented for congressional consideration.

Health spending of young and old

Health care spending differs significantly among

various age groups. In 1978, those under 19 (31

percent of the U.S. population) accounted for 12

percent of the $168 billion health care expenditure, while those 19 to 64 (58 percent of the population) accounted for 59 percent, and those over

65 (11 percent of the population) accounted for

29 percent of the total. This higher per capita

spending by older age groups results from increased contact with the health care system and

an increased number of services required per

visit.

Sources of payment also differ by age group.

Public and private health benefits provided by

government, industry, and direct purchase of insurance have grown for all age groups. Private

insurance and personal expenditures are the major sources of payment for younger persons

(about 70 percent), while government (Federal,

State, and local) finances the greater proportion

of the care provided for those over 65 (about 63

percent) (14), as shown in figure 24.

Hospital care represents the major expenditure

for all age groups, but its relative importance increases with age. Physician services rank second

to hospital care for younger persons and third

after hospitals and nursing homes for the older

population. Nursing home use is dominated by

those over 65, and represents one-fourth of total

health expenditures in this age group. Dental visits

consume a smaller proportion of the health care

budget for those over 65, but the average charge

is higher than for those under 65. Annual per capita expenditures for prescription drugs and sundries increase threefold between the under-19 age

group ($41) and the over-65 age group ($133) (14).

The growth of the older population will continue to exert pressure on Federal programs, but

acceleration of health spending is a problem for

individuals of all ages, their insurers, and their

employers. Although Medicare and Medicaid provide an important subsidy affording some financial protection for the elderly, these programs do

not eliminate the need for significant out-of -pocket outlays (see fig. 25). Many necessary services,

such as eyeglasses, hearing aids, and extended

nursing home care, are not covered by Medicare.

Also, private supplemental (“medigap”) insurance

to cover deductibles is purchased by more than

38-800 0 - 85 - 9
252 Technology and Aging in America

Figure 24.—Percentage Distribution of Personal

Health Care Expenditures by Source of Funds

and Age Group, 1978

$19.9 billion

I 1

i u

$98.6 billion

720/o

Under 19 19-64

Age group

$49.4 billion

n

370/0

%

65 and over

SOURCE: Fisher, 1980 (14).

63 percent of the elderly, and another 14 percent

receive Medicaid assistance (21). The value placed

on protection against health expenses is underscored by the fact that personal income does not

correlate with insurance premiums paid. In 1981,

the out-of-pocket per capita expenditure of $914

for health services (excluding costs for insurance

premiums) by those over 65 represented 11 percent of their per capita income. Recent estimates

indicate that this proportion may reach 14 or 15

percent in 1984.

Technology, aging, and other factors

affecting health expenditures

Much attention has been given to the increase

in demand for health services resulting from the

growth in the older population, especially the

Figure 25.-Per Capita Personal Health Care

Expenditures for the Aged, by Source of Funds

and by Type of Care, 1978

$2,026

Other

public

programs

I

$366

$792

$30

Total Hospital care Physicians’ All other

services

SOURCE: Fisher, 1980 (14),

growth in numbers of those over 75. The elderly

need and use more medical services. Yet the

growth of this high-risk group accounts for only

a small amount of the increase in total personal

health care expenditures. Most of this increase

has been brought about by general inflation; the

increased cost of capital, labor, and supplies; inflation of medical care prices in excess of general

inflation; and changes in the types and quantities

of services provided—’’service intensity ’’—often

used as a proxy measure for increased technology (11,15,46,48). Intensification of services includes not only the introduction of new technology but also increased labor intensity and more

frequent use of existing technology. This section
Ch. 8—Health Care Costs and Access to Technology for Older Persons ● 253

explores the contribution of technology and aging

of the population relative to other factors fueling the growth of health expenditures.

Among the economic, policy, and social factors

to which analysts have attributed the growth in

real spending (15,37,46,48) are:

●

●

●

●

●

payment mechanisms:

—third-party payers that insulate patients

and physicians from true patient costs, and

—fee-for-service and cost-based reimbursement methods that lack incentives to control costs;

technological innovation:

—product innovations that expand range of

services, and

—process innovations that can increase costs

and quality of care;

increased use of existing technology;

population factors:

—shifts in age-sex characteristics,

—increases in real income, and

–psychological factors such as the value of

good health and a reluctance to forego heroic care; and

health resources:

-cost and supply of facilities,

-cost and supply of equipment, and

-cost and supply of manpower.

An analysis of health expenditures and costs between 1971 and 1981 shows that real increases

in services accounted for 28.6 percent (fig. 26) of

the increase in expenditures during that period

(15). In specific terms, a recent study by the Congressional Budget Office found that the major increase in program outlays was due to increased

benefits per user rather than to either increased

enrollees in the program or increased proportions

of those enrollees receiving services (table 18).

Some of the increase in per capita costs reflects

a growing burden of care due to the aging of the

population (37 percent of those enrolled in Medicare were over 75 in 1966; this proportion rose

to 41 percent in 1979), but utilization rates increased significantly even in the same age group

(e.g., a 27-percent increase in hospital discharge

rates in enrollees 65 to 66 between 1967 and

1976), suggesting higher utilization rates overall

(45).

Medical technology is the primary factor in the

increase in health expenditures. Analyses of the

impact of medical technology on health care costs

can be addressed in the aggregate or from a techFigure 26.-Factors Accounting for Growth in Total Health Costs, 1971.81

Total national health expenditures Personal health care spending

lmplicit price deflator for Implicit price deflator for total

national health expenditures systems cost (health prices in

(health prices in excess of excess of overall inflation)

overall inflation)

NOTE: Health industry specific factors are shaded, Total systems cost is personal health care spending.

SOURCE: Freeland and Schendler, 1983 (15).
—.

254 ● Technology and Aging in America

Table 18.—Average Annual Compound Rates of

Growth of Benefits and Enrollees, Fiscal Years 1978-82

(in percent)

Aged Disabled All

enrollees enroliees a enrollees

Hospital insurance:

Total benefits . . . . . . 18.4

Number of enrollees 2.3

Proportion of

enrollees receiving

reimbursement . . . 2.1

Benefits per user . . . 13.4

Supplementary medical insurance:

Total benefits . . . . . . 20.7

Number of enrollees 2.3

Proportion of

enrollees receiving

reimbursement . . . 2.9

Benefits per user . . . 14.7

SOURCE: Congressional Budget Office, 1983 (45).

19.3

1.7

1.1

16.1

24.0

2.2

2.0

19.0

18.5

2.2

2.0

13.7

21.2

2.2

2.9

15.3

nology-specific perspective. The aggregate analysis is useful although it ignores the patient benefits derived from technological innovation. The

technology-specific approach is helpful in establishing the cost effectiveness of a particular technology or class of technologies but ignores the

overall impact on systems costs. Both kinds of

analyses are important in assessing the structure

and funding of health and long-term care. A recent OTA study on technology and the Medicare

program (48) found that in the aggregate, technology-related factors—more services per enrollee and the increase in costs of those services in

excess of general inflation-accounted for about

30 percent of the growth in Medicare costs per

enrollee between 1977 and 1982. These factors—

service intensity and excess medical price inflation—are influenced by other factors as well as

technology. At best, they provide an oblique view

of the impact of technology on costs of care.

Even recognizing the limitations of aggregate

techniques and that available reports encompass

all age groups, an analysis of total personal health

expenditures is useful for evaluating the differential effects of technology and population factors on expenditures for hospital care, physician

services, dental services, and nursing home care

(table 19). General inflation accounted for about

50 percent of the increase in all categories of service. The technology-related factors discussed

above accounted for about 35 percent of the increase in expenditures for hospital care and physician services, but less than 20 percent of the increase for dental care and nursing home services.

Utilization factors are related to population aging, reflecting older Americans’ increased burden

of illness, and to other factors that induce demand, as discussed later in the sections on cost

containment and consumer characteristics. Aggregate population growth has been constant

across different services, as would be expected,

at about 7 percent. Per capita visits exhibit wide

variability, ranging from —3.4 percent for physician visits to +18 percent for hospital outpatient

services to +20 percent for nursing homes. Because these statistics reflect the net effect for all

age groups, differences in utilization trends for

different age groups should be noted. Visits to

physicians and hospital discharges have been decreasing for younger age groups. Physician visits

for persons over 65 have remained relatively constant while hospitalization rates, measured by

both surgical and total discharges, have been increasing. Average lengths of stay have been decreasing for all age groups but remain longer for

those over 65. The relative importance of the utilization-related factors would thus be greater in

the over-65 age group.

The increase in costs for physician care between 1970 and 1979 was analyzed from a different perspective (37). The effect of technology

was calculated indirectly as the residual, after

accounting for other factors thought to be causally related to expenditure increases.3 This residual was 11 percent (see table 20). Population

aging was considered directly and accounted for

15 percent of the increase, due to increases in

the size of high-risk groups such as the very old.

Variables which influence demand for and access

to care—physician-population ratio and insurance

for physician services-accounted for 40 percent

of the increase.

Whe independent variables selected for this regression study emphasized factors that might cause changes in health spending. The

studies by Freeland and Schendler (15) and by (48). OTA decomposed expenditures into their component parts rather than attempting to identify causal factors. This illustrates the influence of

underlying assumptions in these types of analyses.
Table 19.-Factors Accounting for Growth in Expenditures for Seiected Categories of Totai Systems Cost, 1971-81a

Community hospital care Nursing home Total

Factors accounting for “how” Inpatient expensesb

Outpatient Physicians’ Dentists’ care excluding systems cost

medical care expenditures rose Inpatient days Admissions exPenses b services services ICF-MR (personal health care)

Economy-wide factors:

1. General inflation . . . . . . . . . . . . . . . . . . . . . 51.7% 51.7%0 41 .60/0 58.1 0/0 58.60/o 53.00/0 56.80/0

2. Aggregate population growth . . . . . . . . . . 7.2 7.2 5.6 8.1 8.2 7.4 7.9

“Health-sector spacific” factors:

3. Growth in per capita visits

or patient days . . . . . . . . . . . . . . . . . . . . . . 4.2 8.6 17.9 -3.4 14.2 19.8 NA

4. Growth in real services per visit

or per day (intensity) . . . . . . . . . . . . . . . . . 25.2 20.8 25.3 27.4 17.6 13.1 NA

5. Medical care price increases relative

to general price inflation . . . . . . . . . . . . . 11.7 11.7 9.6 9.8 1.4 6.7 7.0

Addenda: Growth in real services

per capita. . . . . . . . . . . . . . . . . . . . . . . . . . . . . —

Total . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

— — — — 28.3

100.0 100.0 100.0 100.0 100.0 100.0 100.0

= Not available.

tota systems cost is called personal health care In Gibson and Waldo (1982).

bcommunity hospital expenses are split into inpatient and outpatient expenses using the American Hospital Association (1982) procedure.

csee table A-13 for price variables.

SOURCE: Freeland and Schendler, 1983 (15).
256 . Technology and Aging in America

Table 20.- Relatlve Contribution of Different Factors

to the Total Increase in Real Expenditures

for Physician Services, 1970-79

Percent

Factors increase

Physician-population ratio. . . . . . . . . . . . . . . . . . . . 22

Total population growth . . . . . . . . . . . . . . . . . . . . . 19

Age distribution of population . . . . . . . . . . . . . . . . 15

Insurance for physician’s services . . . . . . . . . . . . 15

Per capita income . . . . . . . . . . . . . . . . . . . . . . . . . . 9

Specialty mix. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

Prices of practice inputs (other than M.D.) . . . . . 8

Residual (technology) . . . . . . . . . . . . . . . . . . . . . . . 11

Total . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 100

SOURCE:Adaptad from Sloan and Schwartz, 1983(37).

An analysis of the grow thinthe use and costs

of home care showed that the average rate of increase in expenditures was 31 percent per year

from 1971 to 1980. This increase is attributable

to the growth in the number of individuals served

(59 percent) increases in the number of visits for

those served (7.4 percent), and rises in costs and

charges for each visit (39.1 percent). Older patients use home health services at higher rates

(34.8 per 1,000 v. 23.4 per 1,000) but received

fewer visits (23.1 visits per person v. 26,1 visits

per person) compared to the disabled (51). The

increase in the number of persons served is in

part due to the increased numbers of persons

needing care, but is also strongly influenced by

the growth in the number of home care agencies

and changes in reimbursement policy. Although

costs and charge increases are the technologyrelated elements, they also reflect a number of

factors unrelated to technology.

The availability of home care is clearly an influential factor. There were 3,959 home health

agencies certified to receive Medicare reimbursement as of June 1983. These include Visiting

Nurses Associations, official health agencies (State

and local government), hospital-based programs,

proprietary agencies, private nonprofit programs,

and rehabilitation and skilled nursing home-based

programs.

Home care is likely to continue to grow and become more sophisticated with home health agencies, hospitals, and nursing homes diversifying to

include more comprehensive outpatient services,

including medical equipment for home use, particularly as reimbursement policy encourages

earlier hospital discharges. New Federal policies

during the last two decades have encouraged this

growth. They include (34):

●

●

●

●

●

●

1965—Medicare/Medicaid bills were enacted

that provide limited home health care reimbursement.

1968—Home care was required as an alternative to skilled nursing home care for Medicaid participation.

1972—The coinsurance requirement for

Medicare Part B was eliminated.

1980—Medicare dropped the requirement

for prior hospitalization and eliminated the

limit on the number of visits deductible.

1982—The Tax Equity Financing Reform Act

(TEFRA) permitted reimbursement for some

hospice care.

1983—Prospective payment for hospital care

was enacted and encouraged earlier discharges.

This brief review of several analyses of the

growth in health spending illustrates the difficulty

in establishing quantitative estimates of the causal

factors and their relative importance. Different

conclusions can be reached, depending on the

technique and the variables selected for analysis.

These studies do establish that technical innovation, increased utilization due to greater need, and

increased access are major components. Technology appears to be more important in the acute

medical care arena, whereas utilization factors

have been more important in long-term care, including nursing homes.

Dental care is an interesting special case in considering the impact of technology, relative to

other factors, on cost of care. Expenditures for

dental care grew at an annual rate of 13.1 percent during the 1970s, reflecting increased per

capita utilization, new technical innovations such

as high-speed drills, and growth in complex orthodontic and periodontal procedures, Yet inflation

in dental prices contributed only 1 percent to the

increase, even though the dental Consumer Price

Index (CPI) increased at an annual rate of 7.6 percent; price inflation in both hospital care and physician services was much higher. This suggests

that dentists absorbed a greater proportion of the

increased cost of operation.
Ch. 8—Health Care Costs and Access to Technology for Office Persons ● 257

Dental services are financed in large part by

out-of-pocket expenditures, although dental insurance benefits are rapidly expanding. The absence

of third-party reimbursement and an ample supply of dentists to allow competition have been suggested as reasons for lower price inflation for this

service. Better productivity (high-speed drills increase the number of cavities that can be filled

per visit), the effectiveness of fluoridation, and

other preventive dental procedures may also have

contributed to constraining cost growth (13,15,

26)29).

Employee health plans are currently adding

dental benefits. In some cases, dental benefits are

being substituted for mental health benefits (used

by fewer beneficiaries); this spreads benefit outlays over more beneficiaries (Employees Benefit

Plan Review, 1981, cited in 15). older persons who

depend on Medicare as their primary health insurer may thus enter the system with better dental health and practices, but also may be accustomed to greater insurance coverage, which could

increase the pressure to add dental benefits or

create a market for dental insurance in this population.

The benefits of improved access to health technologies for those over 65 have occurred primarily as a result of the enactment of Medicare and

other Federal programs. In 1966 medical care—

particularly hospitalization-became affordable to

many older persons for the first time. Their initial demand for hospitalization displaced younger

persons until additional capacity was built. Inpatient care has continued to grow while physician visits have remained fairly constant, partly

in response to reimbursement policy.

The challenge is to find the most efficient technologies as well as the most effective. Technologyspecific approaches are most useful for this task,

but the results must be effectively applied to

achieve the goal of improved efficiency. OTA studies have assessed the impact of specific technologies and stressed the importance of assessing

both their costs and benefits. Case studies on technologies for hearing impairments and managing

incontinence are being published in conjunction

with this report. Additional case studies on preventive, diagnostic, and therapeutic technologies

such as cervical cancer screening, X-ray procedures, and joint replacement have also been done

(see 47).

Selecting appropriate technologies

for older persons

Appropriate care ●

●

Consensus about the goals of care for older persons is important in considering how to contain ●

costs and also in setting performance objectives

for the care system. Geriatricians have begun to ●

focus on what constitutes appropriate care for

those over 65, which will influence the selection ●

of technologies and the settings in which they are

broadened approach to health assessment,

application of appropriate medical care for

acute and chronic disease,

acceptance of the legitimacy of death,

allowance of sufficient time for recovery,

attention to care in the least restrictive environments, and

continuity of care, including health and social

services.

used. The factors that influence selection of ap- The geriatrician’s primary concern is not econ - propriate care include the following (19,38): omy, but appropriateness. Appropriate may,

● emphasis on preservation and restoration of in fact, lead to economy as long as cost controls

functional ability, are considered simultaneously. The original goals

 building and maintaining a support system, of the Medicare program were developed to ad-
258 . Technology and Aging in America

dress problems in access to services and technology for older Americans who were inadequately

served by private insurance. The focus on access

problems gave rise to the cost-reimbursement approach that, in part, has fueled the rise in costs

of care and in some cases the inappropriate application of technology. The elderly are again unprotected against certain expenditures for needed

care. Policy alternatives must seek to balance concerns for access and quality with efficiency and

economy as incentives for developing health care

and health financing technologies. The ways in

which older consumers use services must also be

considered. Appropriate utilization is a key factor in maintaining fiscal solvency and quality of

care.

use of health care technologies

Demand for and access to health care technologies by older consumers are influenced by physical and psychosocial factors as well as economic

factors. These factors are important in understanding how clients respond to care providers’

recommendations. They are also important in

evaluating cost-containment schemes designed to

reduce overutilization of health care services by

the elderly. Cost+containment strategies that shift

costs too heavily to older patients can cause many

of them to delay care. Long delays can result in

increased disability and higher costs, but overutilization will increase costs and not improve outcomes. Providers must recognize these factors in

responding to older patients and selecting technical interventions. Some of the factors are agebased and can be expected to grow in importance

in future cohorts of older persons. Others may

be related to experiences and opportunities that

can change dramatically in future cohorts due to

general trends or specific educational efforts.

The clinical nature of illness in geriatric patients

is different. Some diseases occur only in the

elderly and classic symptoms may be replaced by

nonspecific problems such as refusal to eat, falling, incontinence, dizziness, acute confusion, and

weight loss or failure to thrive. The chronic nature of diseases and the frequency of multiple disorders are also important in this age group (3).

The nature of some diseases makes their symptoms difficult to distinguish from generally accepted effects of aging. In addition, nonphysiologic factors such as the older person’s perceived

seriousness of symptoms, denial of illness, ahernative explanation of symptoms (e.g., just getting

old), and access to treatment influence the decision to seek or delay care (2,25). Several studies

have shown severe underreporting of symptoms

by older persons (1,3,4,22,56).

Underdiagnosis of correctable functional (both

physical and mental) and medical problems in the
Ch. 8—Health Care Costs and Access to Technology for Older Persons . 259

elderly is supported by the recent experience of

the Geriatric Assessment Units, which have found

an average of three correctable problems per patient (18). Many of the conditions identified in

these studies do not require sophisticated diagnostic technology, but could be identified with

careful evaluation of symptoms. This burden of

unreported illness supports the validity of studies

reporting delayed care-seeking behavior of the

elderly (3,8,41). older persons seem less likely to

exaggerate their health problems than younger

persons, and their complaints are more likely to

be based on important underlying diseases.

The response of health professionals may reinforce the patient’s denial of and failure to report

functional disabilities. Health professionals may

focus on specific diseases, rather than the functional status, of an older individual. Vision, hearing, and dentition problems are examples of neglected areas in primary care. The 1971-75 Health

and Nutrition Examination Survey (HANES) found

those 56 to 74 were more likely to receive an EKG

or chest X-ray but were less likely to have a vision or hearing test than younger persons. Anecdotally, older patients complain that health professionals fail to listen and follow up on their

specific functional complaints (18).

Appropriate providers

In addition to appropriate goals of care and appropriate consumer response, the types of providers may influence the cost, selection of technologies, and the efficacy and efficiency of care.

The team care approach is accepted as the ideal

strategy. Members of the care team that must respond to the broad spectrum of needs for the frail

elderly can include physicians, nurse practitioners, physician assistants, nurses, social workers,

occupational therapists, physical therapists,

speech therapists, and home health aides. These

providers can also be specially trained in the care

of geriatric clients.

The impact of team care on the cost of care is

influenced by management of the care team, the

range of specific client problems, and the casemix that exists within a particular care setting.

In general, highest efficiency can be achieved by

matching patient needs with the least expensive

provider having the requisite skills. The actual

cost saving can be eroded by administrative costs

of using additional providers and, as with technologies, other provider services can be additive

rather than a substitute for more expensive care.

Skills, licensure, legal requirements, and communication among team members must be carefully considered to assure maximum efficiency.

Cross-training of certain geriatric providers may

be one approach to providing care more efficiently. For example, if a particular client’s primary

needs are for social services but there is also a

need to monitor or administer medication, an appropriate training program might be designed to

certify some social workers to carry out this function. Nurses already provide some social service

assistance while providing nursing care. Training programs to enhance these skills might improve the efficacy of intervention.

Cost-containment strategies

A number of approaches focusing on economic

incentives for consumers and providers, controlling prices, assuring appropriateness of care, and ●

limiting expansion of facilities and services have

been tried or discussed for controlling health care

expenditures (43,45,48,49). These include: ●

● direct price controls,

● changes in reimbursement strategies from

cost-based to various types of prospective

payment,

utilization review programs and Professional

Standards Review Organizations to review

the appropriateness of care,

health planning and certificate-of-need programs designed to control capital expenditure,
260 “ Technology and Aging in America

use of coverage policy to limit reimbursement

to effective technologies,

increased cost-sharing and coinsurance for

Federal program beneficiaries to discourage

“overutilization,”

stimulation of more competition among

health care providers and insurance plans,

and

contracting and preferred-provider approaches to channel patients to lower cost

providers.

Regulatory actions have been the principal approach to cost containment to date. Capping payments (e.g., Economic Stabilization Program, Section 223) has not controlled long-term cost

increases. The diagnosis-related group (DRG) casemix approach (Public Law 98-21) for prospective

payment has recently been legislated for Medicare

hospital reimbursement. Health planning and

peer review strategies to reduce the development

of excess capacity and encourage appropriate utilization may have been responsible for decreases

in length of stay in hospitals but have not been

sufficient to control overall expenditures. Some

attempts to rationalize coverage policy based on

technology assessments have not been effective,

in part due to lack of central direction and data

deficiencies for Medicare intermediaries (48).

A 1980 study found that cost-sharing decreases

utilization of physician and hospital services for

some patients (21,30), and that lack of supplemental coverage results in cost-shifting for those with

chronic conditions (21). The reduction in physician services for Medicare beneficiaries was

found to occur primarily in patients without

chronic impairments (22 percent) and in the number of persons seeking physician services. Persons with chronic conditions (78 percent), who

most intensively need care, were unaffected (21).

In the same study, the number of hospital admissions was lower in the group without supplemental insurance, as shown in table 21. Utilization patterns and costs of services were similar once

patients entered the system. Patients with public supplementation were the highest users, possibly due to poorer health status.

The effects of the direct cost of services on utilization and health have not been evaluated in persons over 65. Preliminary results from the Rand

Health Insurance study (5) show that in younger

populations free care resulted in significantly

higher utilization rates, but improved health outcomes were not demonstrable for broadly defined

physical and mental health measures. Two improved outcomes were identified–better bloodpressure control and improved corrected vision,

suggesting that cost can deter persons from seeking needed care for some chronic conditions and

that improved access to care can be beneficial for

conditions with established treatment regimens.

They’ also suggest that unlimited access to care

can result in overuse of services without resulting

in better general health. Future analyses of the

data from this study will provide useful information about the use and benefit of health services

for the nonelderly population studied. Extrapolation of these results to those over 65 must be

Table 21.—Average Utilization of Health Services by Elderly Medicare Beneficiaries,

by Type of Supplementation, 1976

Annual physician visits

No chronic Some chronic

Type of supplementation conditions conditions Annual hospital days

No supplementation: Medicare only. . . . 1.66 6.72 2.51

(100%)’ (100%) (1 OO%)

Private supplementation . . . . . . . . . . . . . . 2.30 6.23 2.79

(139%) (93%) (111%)

Public supplementation: Medicaid . . . . . 2.71 8.92 4.41

(1630/o) (1330/0) (1760/o)

a The num~rg {n parentheses Irlctlcate the average utilization rate for a group relatke to the Utilization rate amon9 those

beneficiaries who do not supplement their Medicare coverage.

NOTE: Calculations baaed on tabulations from the 1976 Health Interview Survey.

SOURCE: Link, Long, and Settle, 1960 (21).
Ch. 8—Health Care Costs and Access to Technology for Older Persons Ž 261

done with caution because health problems and

utilization of services may be quite different in

older persons.

Advocates of increased beneficiary cost-sharing

and pro-competition approaches suggest that current reimbursement systems—government and

private insurance programs that insulate the consumer from the true cost of service-promote the

use of excessive health services and promote higher fees by providers (24,43,45). Use of these approaches is aimed at reducing unnecessary services and making patients more prudent shoppers

for medical care. Prudent buying by health consumers remains a largely uninvestigated proposition and presumes the ability of the patient to distinguish between unnecessary and essential

services (48). Some researchers have suggested

that health care is not “an ordinary article of

commerce” (35), suggesting that it should be

treated differently in the marketplace for technical and ethical reasons. Others have suggested

that there are inherent problems in enabling patients to be prudent shoppers at the point of purchase (6) because:

● consumers are poorly informed,

● consumers cannot accurately assess the care

they get,

● consumers confront the system in times of

crisis, and

● consumers sacrifice other things to pay for

health care.

Periodic multiple-choice schemes in which selection of benefits is tied to the purchase of insurance removes the purchase decision from a crisis

situation. However, appropriate selection of

health insurance benefits requires a great deal

of information. Also, because insurers are faced

with the problem of adverse selection (those who

are most frail purchase more coverage), the risk

may not be spread over both high and low users.

Channeling patients to lower cost providers

through preferred-provider organizations or contracting may be effective in reducing the costs

of care. The restriction of freedom of choice, however, places increased responsibility on the government and insurers to ascertain that incentives

to reduce visits or ancillary services do not adversely affect the quality of care.

In evaluating policy options, the total care impact of alternative strategies for meeting the projected increase in demand for health and longterm care services should be explored. In addition to operating and administrative costs for services, such other factors as capital costs and program startup costs should be considered.

Federal and State efforts to contain

costs of institutional care

CONTAINING HOSPITAL COSTS

Current cost-containment activities have focused on reduction of the costs of institutional

care—hospital and nursing home services. Prospective payment for hospital services is being

phased in for Medicare, cost-control mechanisms

have been enacted for a number of State Medicaid programs, and some States have instituted cost

controls on all payers. It is hoped that because

of the importance of Medicare revenues to hospitals, prospective payment for Medicare alone

will reduce costs overall,4 rather than cause a shift

of cost to other individuals or other payers. Prospective payment systems become more effective

in influencing the way hospitals deliver service

when all sources of payment are covered. But

cost-shifting will not be tolerated indefinitely by

non-Medicare payers.

The Medicare prospective payment system calculates costs on a per-case basis using DRGs to

adjust for differences in the type and severity of

cases. The case-mix adjustment reduces incentives

for avoiding more difficult and costly cases. Still,

prospective payment may encourage an increase

in the number of admissions, particularly in the

number of those with lower care requirements.

Older patients are more likely to require more

intensive services and longer periods for recovery. Current DRG categories may not adequately

account for differences in severity of illness. The

incentive to reduce the level of services for a patient argues for careful monitoring of the quality

of care.

The scope of services covered is not comprehensive–at least during the phase-in period. Capital costs, teaching costs, and outpatient costs are

4

For a complete discussion, see (48) and (49).
 . Technology and Aging in America

not covered, providing an incentive for hospitals

to shift costs to these categories. There are also

incentives for shortening lengths of stay, but these

may increase the use of outpatient services not

covered under the system.

Prospective payment should reduce the use of

ancillary services and encourage the adoption of

cost-saving technology. The impact of prospective payment on medical technology will be

stronger if capital costs are ultimately included,

but even here the impact must be considered on

a case-by-case basis (48).

States are also actively involved in trying to control the cost of hospital care. A publication by the

Senate Special Committee on Aging provides an

overview of these activities (53). Revenue caps,

rate and budget review, DRGs, price competition,

cavitation approaches, and channeling patients

to specific providers are some of the mechanisms

being tried. States with mandatory rate-setting

programs did have slower growth of per capita

hospital expenditures. New programs are being

implemented in response to the Omnibus Reconciliation Act of 1981. The results of these efforts

on costs, quality of care, use of technology, and

health care providers, if they are documented,

can provide useful information to guide Federal

policy.

CONTAINING LONGTERM CARE COSTS

Most approaches to slowing the growth of longterm care costs have attempted to limit access to

nursing homes or substitute lower cost community-based services for more expensive nursing

home care.

The number of nursing home beds available can

affect utilization and cost. Licensed nursing home

beds, estimated to number about 1.4 million in

1980, are operating at very highoccupancy rates

—90 percent and more. Control of the number

of nursing home beds has been used to limit Medicaid nursing home expenses by some States (44).5

Growth in numbers of beds is limited by the certificate-of-need policies in the States. For example, between 1976 and 1980, the number of beds

%x GAO rqmrt for discussion of State Medicaid Policies for Funding Nursing Home Care (44).

increased by 3 percent per year (44). For the 1978-

81 period, aggregate nursing home days and the

population over 75 also increased by 3 percent

per year. Shortages in nursing home beds in some

regions impede access for some beneficiaries and

may increase the days spent in hospital waiting

for nursing home placement,

The feasibility of providing long-term care in

noninstitutional settings has been clearly demonstrated for certain subgroups of the elderly. Evaluation of the cost and effectiveness of these programs has been difficult because of design

problems. In general, savings in total system costs

have not been demonstrated. Most agree that

services delivered are valuable, but targeting

strategies have not focused on those who are both

functionally disabled and socially isolated—those

who are most likely to become institutionalized

(55). The National Channeling Demonstration Programs are focused more directly on targeting, cost

containment, and case management, to test whether a managed system of long-term care can produce more favorable results than the current system (7). The research and evaluation design for

these studies has also been strengthened with the

goal of producing definitive results (32).

SECTION 2176 WAIVERS

Section 2176 of the Omnibus Reconciliation Act

of 1981 amended the Social Security Act to permit States to more freely experiment with home

and community-based care. The requirements

that aggregate spending not increase and that

these services directly substitute for nursing

home care make it illegal to use home and community services as an add-on. The problems with

targeting services to those at risk for nursing

home care have been discussed above. Difficulties

in predicting what expenditures might have been

without the waivers wilI make evaluation of cost

savings from these programs difficult. Lack of

adequate measures of patient outcomes or comparison groups also will inhibit cost-effectiveness

evaluation (55). Programs such as these do, however, create incentives for new efficiencies in providing community-based services that are considered more desirable than nursing home care for

many reasons that are not cost related.
Ch. 8—Health Care Costs and Access to Technology for Older Persons ● 28.3

Cavitation approaches

Since 1972, health maintenance organizations

(HMOs) have been able to enter either reasonablecost or risk-based contracts for both inpatient and

outpatient services for Medicare beneficiaries.

The Health Care Financing Administration has established several cavitation demonstration projects for acute care services. Preliminary data indicate that better management of care and financial incentives have controlled costs and improved

effectiveness (17,32). Cost savings were achieved

by offsetting the increased use of ambulatory and

home care services by reduced use of hospitals

(12,32). HMOS that owned and operated ambulatory clinics, home health agencies, hospitals, and

nursing homes show the most marked shift away

from institutional services (32,54).

A new model combining acute and long-term

care services is the social/health maintenance organization (S/HMO]. The linking of acute and longterm care provides an opportunity to capture cost

savings over the whole continuum of care and

encourages the least intensive level of care (32).

This model is currently being developed and evaluated through the Florence Heller School at Brandeis University. Fears about the budgetary effects

of waivers necessary to implement this program

delayed its implementation.

CONTAINING PHYSICIAN COSTS

Reducing the costs of Federal payments for physician services requires reducing utilization, paying lower fees, increasing beneficiary cost-sharing, or some combination of these. Setting lower

fee schedules for Medicare or constraining fee

increases beyond the current requirement could

reduce the number of physicians who accept assignment. Assignment means that the physician

is reimbursed directly for 80 percent of the cost,

and the beneficiary pays the 20-percent coinsurance. About 50 percent of physicians currently

accept assignment. For nonassigned services, the

beneficiary is responsible for the entire cost and

can then be reimbursed by Medicare for 80 percent of allowable charges (which are usually significantly lower than the billed charges). Hence,

for nonassigned services, physicians can shift the

difference between allowed and billed charges to

the consumer.

In addition, more private cost-sharing for existing benefits under Medicare Part B, which covers physician services, has been proposed by the

current Administration. Higher premiums to covera higher percentage of operating costs (48,52)

as well as coinsurance rates and deductibles could

also augment revenues. Higher premium costs

would have less effect on reducing service utilization but would shift costs to beneficiaries and

distribute them over the entire Medicare population (48).

G1ncreases cannot exceed the iMedicare Economic Index.

Technology and coordination of

Federal health programs

The potential for cost-shifting between the programs and for noncomplementary policies and incentives can affect both the cost of and access

to appropriate technologies and services. For example, new computer and information technologies can facilitate coordination and improve the

cost effectiveness of Federal health programs. A

number of Federal programs influence the ability

of those over 65 to purchase services and technology. These include cash and in-kind service

benefits that are age-based entitlements and those

that serve specific groups, such as the socially and

economically disadvantaged, or veterans, including those over 65. From the standpoint of access

to health and long-term care services and technologies, Federal and federally assisted programs
264 . Technology and Aging in America

that influence the quality and distribution of services and technologies as well as private insurance

benefits are also important.

Federal health programs

The following major programs are cited to illustrate the complex interaction of Federal programs in affecting access to health services and

technologies.

INCOME SUPPORT

Improved socioeconomic status, reflected in

higher general standards of living, and better access to health care have been associated with improved health and functional status (23,42). While

Medicare provides an important subsidy for

health care, the elderly still have substantial outof-pocket expenses for health services and technology. Income support programs such as Social

Security and Supplemental Security Income may,

therefore, affect health status and health program

costs.

IN-KIND HEALTH BENEFITS

Medicare provides acute hospital and skilled

nursing care benefits (Part A) to most persons

over 65; supplementary medical insurance (Part

B) for physician and outpatient services is

an elective option. Medicaid, in 52 federally assisted, State-run programs, supplements this coverage for the poor, and in some States for those

who are needy due to increased health care expenses. Medicaid also provides a “safety net” for

those who require extended nursing home care.

SOCIAL SERVICE PROGRAMS

Social and supportive services are provided

through Social Service Block Grants and Title III

of the Older Americans Act. Services vary from

State to State but can include homemaker, chore

services, transportation information and referral,

congregate meals, and home-delivered meals.

VETERANS ADMINISTRATION (VA) PROGRAMS

The VA provides comprehensive benefits to veterans with service-connected disability and to

all veterans over 65 on the basis of need and availability of resources (public Law 91-500). Currently, many veterans choose to use private services

and be reimbursed through Medicare. The number of veterans over 65 who are eligible for both

VA and Medicare benefits is expected to triple

(from 3.5 million to 9 million) by 1990. Applications for VA health benefits have increased significantly (the rate of increase in the number of

applications per 1)000 veterans was over 30 percent during fiscal year 1983) (16). Some of this

increase may be due to recent changes in the

Medicare program. More specific examination of

the rates for veterans over 65 is needed.

HEALTH SERVICES AND

HEALTH RESOURCE PROGRAMS

Health services and resource programs provide

Federal support to the medically underserved and

aid in manpower development, health planning,

and community and preventive health services.

Activities under these programs can affect the

availability of services and technologies through

health planning activities and health care expenditures. These programs interact with State-specific

certificate-of-need programs that regulate the supply of certain technologies and services (e.g., institution-based home care, dialysis, therapeutic

and diagnostic equipment), and particularly the

supply of hospital and nursing home beds.

Actions taken in any of these programs can produce unintended effects in others. Cost-shifting,

changes in the number and characteristics of persons seeking services, and impaired access to services and technologies, either financially or geographically, can occur. Lack of adequate data on

use and the factors that affect it often hinders

efforts to evaluate potential effects of policy

changes.

Hospital backup

The problems in delivery of long-term care that

result in a patchwork of services have been discussed in chapter 7. The coordination between

acute and long-term care adds further complexity, as does the interaction between public and private health and long-term care financing alternatives (discussed later in this chapter). Cost

containment may create additional stresses that

can result in cost shifting and, without adequate
Ch. 8—Health Care Costs and Access to Technology for Older Persons ● 265

safeguards, affect the quality of care. The problem of the backup of patients in hospitals is an

example.

Certain policies have been effective in reducing the length of hospital stays. Utilization review

quickly identifies those patients who no longer

need hospital care. Because out-placement of

these patients can be difficult, the Medicare provision for nursing home care—instituted to contain costs—is underutilized because beds are not

available. 7 The result is a large number of hospital days that are not necessary for medical reasons. The cost of these “administratively necessary days” (ANDs) in 1980 ($3.7 billion) was slightly

greater than the amount spent on communitybased care in that year, as shown in table 22.

The Medicare nursing home benefit is seldom

used, Medicare pays for only about 2 percent of

nursing home days of the elderly, and an average stay is 28 days compared to the allowed 100

days. Medicaid (40 percent) and private payments

(58 percent) are the major sources of nursing

home revenues (50). Higher quality standards,

retrospective denial of claims, and difficult reg-

~ursing homes can selectively admit patients based on care needs

and reimbursement status and thus still maintain high bedoccupancy rates.

ulations related to accounting for allowable costs

make Medicare participation less attractive for the

limited benefits. The availability of Medicare nursing home benefits depends on: 1) existence of a

skilled-level nursing facility (SNF)—a function in

large part of Medicaid policy; 2) Medicare participation by the SNF—a function of the similarity

of Medicaid and Medicare rules, certification,

types of patients, and reimbursement policies; and

3) interest on the part of nursing homes in participating.

Until the enactment of prospective, case-based

payment, delays in nursing home placement were

problems for the Federal budget, rather than for

providers and patients. Nursing home users were

operating at 95-percent occupancy rates and hospitals at 75-percent occupancy rates; because

Medicare funding was seldom terminated, patients simply received hospital care at hospital

costs after their medical condition was stabilized.

New incentives have been created for hospitals

to rapidly discharge patients. But no incentives

have been created to encourage nursing homes

to accept Medicare patients. The availability of

beds for these patients is a function of the relative attractiveness of Medicare and the State Medicaid program policies, as well as care requirement for individual patients. The short supply

Table 22.—Formal Long-Term Care Expenditures in Hospital Care, Nursing Home

Care, and Community. Based Care, by Source of Funds, 1980

Hospital patients awaiting Nursing Community

nursing home placement home based

Federal:

Medicare . . . . . . . . . . . . . . . . . . . . ... , . 1,568 455 1,042

Federal Medicaid . . . . . . . . . . . . . . . . . . 419 5,694 85

Federal Title XX . . . . . . . . . . . . . . . . . . . — — 809

AOA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . — 724

Veterans Administration . . . . . . . . . . . . 1,562 359 723

Other Federal . . . . . . . . . . . . . . . . . . . . . 104 21 135

State and Local:

State Medicaid . . . . . . . . . . . . . . . . . . . . 354 4,788 73

State Title XX . . . . . . . . . . . . . . . . . . . . . — — 420

Other State . . . . . . . . . . . . . . . . . . . . . . . 198 — 211

Local government . . . . . . . . . . . . . . . . . — — 17

Private:

Insurance. . . . . . . . . . . . . . . . . . . . . . ., . 902 129 740

Business/philanthropy. . . . . . . . . . . , , . 29 129 162

Consumers . . . . . . . . . . . . . . . . . . . . . . . 209 8,869 1,377

Total . . . . . . . . . . . . . . . . . . . . . . . . . . . 5,345 20,444 6,518

SOURCE: U.S. Department of Health and Human Services, Office of the Inspector General, Long-Term Care: Serv/ce De//very

Assessment, Report to the Secretary (2 VOIS.) unpublished, N. Zimlich, December 1981. For detailed explanation of

estimates see Volume 11: Technical Report.
266 ● Technology and Aging in America

of nursing home beds makes access highly variable and difficult in most areas (15).

Current provisions of DRGs account for ANDs

in that they have been factored into the base

rates. No additional reimbursement will be made

for patients waiting to be placed in nursing

homes. Many of these patients are poor and require a great deal of care. The care requirements

make them poor candidates for home care and

because they are poor, they probably cannot afford private care. Careful review of appropriateness of out-placement will be required.

Information technology for

coordination of health programs

The rapid advance of information technologies

offers opportunities for better coordination of

programs through more effective data collection

and dissemination of information to consumers,

providers, administrators, and policymakers.

While information is only one element in the coordination process, it is essential in monitoring its

impact and formulating policy. Chapter 6 reviewed the uses of innovative information technologies to improve patients’ ability to participate

in their own care through education and patientheld health information. Educational technologies

Financing alternatives for

Medicare is the major form of health insurance

for those over 65, supplemented by private ‘(medigap” insurance. Gaps in Medicare coverage for

the elderly exist in preventive services, dental

care, and particularly long-term care. Many of the

elderly are not poor and tend to want to save for

emergencies (27). The need, resources, and desire for protection imply a market for mechanisms that would provide financial protection for

these older persons. Protection against catastrophic long-term care expenses has been discussed most often, but some attention to the

structure of medigap insurance is underway and

deserves increased attention as a means of fillcan also be applied to improve consuming behavior through helping patients choose between service and coverage alternatives.

Artificial intelligence and computerasisted

learning strategies can assist providers in coping

with the complex problems of disease and functional disability, and can also be applied to promote efficiency in health care programs and improve strategic planning activities, Technologies

such as the “smart card” (a magnetic information

storage card) provide new opportunities to capture

patient-based data on the utilization of services

and their cost, Artificial intelligence can assist in

analyzing information for complex resource-allocation deisions. Electronic information-sharing

can improve the ability of multiple providers to

act in concert to address individual and community needs. State-of-the-art data collection and analytical tools can enhance the effectiveness of utilization review for both quality of care and cost

control.

Confidentiality and protection against abuse

must be carefully considered as new applications

are developed. The design of effective administrative mechanisms that can use information

effectively also requires further development before the maximum benefit of these new technologies can be achieved.

health and long-term care

ing benefit gaps and reducing medical care costinflation (28).

Among the mechanisms proposed for accumulating resources for long-term care are a publicly

supported national program, private insurance,

and subsidized personal savings programs (e.g.,

tax-deferred savings).

A compulsory national long-term care insurance

program would be one way of providing comprehensive universal coverage. This approach avoids

the problems of participation by only those who

are at greatest risk of needing care (adverse selection). Fear of increasing inflation of health and u
Ch. 8—Health Care Costs and Access to Technology for Older Persons 287

long-term care costs and concomitantly increasing government expenditures has hindered full

consideration of this approach.

The need for a compulsory national insurance

program is partly based on the failure of the private insurance market to provide individual coverage (33). Reasons that have been given for lack

of interest of private insurers include:

●

●

●

●

●

●

cost of coverage relative to income of target

population;

lack of understanding by elderly consumers

of their risk and insurance needs (many think

they are already protected);

existence of a public “safety-net” for those

who are poor or become poor;

difficulty in predicting the cost of benefits,

including lack of reliable data on which to

base estimates of utilization and costs;

difficulty in distinguishing between skilled

nursing, intermediate care, and custodial

care; and

regulatory barriers.

The barriers fall into two major categories—

technical barriers to the design of an insurance

product and barriers to marketing this product.

The technical barriers in designing and administering benefits are similar to the problems that

face public programs that pay for long-term care.

Public programs have not yet been able to contain the growth of expenditures.

The problems of cost containment, price inflation, overutilization of benefits, and the inability

to predict length of care and appropriate level of

care are major concerns for private insurers. In

addition, private insurers provide benefits that

are marketable and must attract insurers who

represent an appropriate balance between users

and nonusers. Most existing insurance policies for

long-term care are focused on nursing home care

and provide only limited expansion of Medicare

benefits. Some have very limited home care benefits and only a few cover levels of care below

skilled nursing.

One approach suggests creating a policy with

an idemnity benefit (set-dollar reimbursement) of

$37 per day for up to 3 years of nursing home

care (27) to be marketed to those over 65. The

premiums for the policy were calculated to be

about $450 to $550 per year. However, insurance

industry estimates of premium costs have been

substantially higher. Although these premium

costs would strain the health care budgets of

many when added to current out-of -pocket spending, some older consumers might consider the potential benefits to be worth the extra cost. For

this group it may be an attractive alternative to

spending down for Medicaid eligibility. Also,

premium costs could be reduced substantially if

consumers purchased coverage before age 65.

Benefits of additional private coverage for longterm care could accrue to both individuals and

government. Such coverage could reduce the burden on Medicaid because a substantial portion of

Medicaid beneficiaries were not initially poor;

spending down and transferring assets have made

them eligible. Tighter Medicaid restrictions on

asset transfers may stimulate increased demand

for private insurance protection. The existence

of a personal-protection alternative could also

alleviate some of the ethical and political problems in increasing the stringency of spending

down and greater emphasis on tapping of family

resources before becoming eligible for Medicaid

benefits.

Insurance regulation varies from State to State

and can therefore act as a barrier to the sale of

long-term care insurance. The variability in State

programs makes it difficult for national companies to design and administer long-term care insurance products.

Incentives for personal savings to defray the

cost of future care have also been suggested. Taxdeferred savings programs for this purpose could

be offered along with current tax-deferred savings programs for retirement income; the number of persons who could afford such an investment might be relatively limited, although many

have purchased individual retirement accounts.

The budgetary impact for such a program would

have to be carefully analyzed.

Three major kinds of medigap insurance policies are currently available: 1) individual policies

that pay deductible and coinsurance for Medicarecovered services at Medicare rates; 2) individual
268 Technology and Aging in America

policies that pay deductibles and coinsurance

based on what the insurance company determines as reasonable charges (usually higher reimbursement); and 3) group insurance’ policies, usually as a continuation of employee benefit plans

after retirement, that provide major medical benefits as well as deductibles and coinsurance. The

premium-to-benefit ratios are reasonable in most

cases and relatively fair, but may duplicate Medicare coverage or each other and provide little additional protection. Since the benefits are usually

determined by Medicare policy, they do not make

coverage a great deal more comprehensive. Voluntary savings programs would have to provide

tax savings in addition to those provided by cur-

*Lower group rates are expected from such insurance plans, as

exemplified by group health insurance rates for persons under 65,

because of lower administrative costs and better risk spreading.

Findings and

Health care spending has

conclusions

been growing and will

continue to grow under present policies, but the

growth of the over-65 population-particularly

the over-i’5 segment—will increase demand for

acute and long-term care services. The growth

of this population group is not the main reason

for the rapid escalation in health care costs, Increased costs due to inflation (even surpassing

general inflation) and intensification of services

have been much more significant factors; increasing costs have led to efforts to contain spending

that have far-reaching implications for older persons. While most individuals over 65 can maintain functional independence, many require

health care for chronic conditions that increase

in prevalence with age. Spending for health services represents a major problem for the Federal

Government, individuals, and families.

Medicare currently provides an important

health care subsidy for those over 65 but is by

no means comprehensive—many necessary services that affect their health and functional status,

such as dental services, eyeglasses, and hearing

aids are not reimbursable. A growing problem is

rent programs. Rewards for prudence such as

sheltering other assets from Medicaid spenddown requirements might be included to enhance

the attractiveness of such programs.

A major barrier to the development of private

financing mechanisms is that elderly consumers

do not understand their health care risks and/or

their insurance coverage (20,27). Many think they

are adequately protected through Medicare and

medigap insurance. The strong preference for

first-dollar coverage for acute care and the high

cost of such coverage may also limit the amount

of money available for additional insurance or savings (27). Although the development of alternatives to government financing seems desirable in

improving access to care, significant changes in

attitudes and incentives of both insurers and consumers will be required for these mechanisms to

become viable.

the cost of long-term care for those who are disabled. Eventually, many older persons come to

depend on public means-tested programs for longterm care after their personal resources are exhausted. Private financing mechanisms, including

medigap insurance and private insurance for

long-term care, are not sufficient to provide adequate supplemental protection.

Demand for health care by older persons is influenced by physical and psychosocial factors as

well as economic factors. The increased use of

services by some of those in this age group may

result from an increased burden of illness. The

remarkable decrease in mortality in the over-65

age group has not been accompanied by a similar decrease in morbidity. Studies also indicate

that older persons tend to underreport symptoms

and may be more likely to delay seeking care.

They attribute symptoms to “just getting older.”

Health professionals may reinforce this behavior

by not dealing adequately with functional disabilities. Recent experience in Geriatric Assessment

Units found an average of thrwe correctable problems per patient; many of these problems could
Ch. 8—Health Care Costs and Access to Technology for Older Persons ● 269

have been identified through a careful health history without sophisticated diagnostic tests.

Cost- containment efforts to date have not been

effective in controlling overall health spending.

Most approaches have focused on hospital care

and rate-setting. The response has been increased

utilization or shifting of services to ambulatory

settings or shifting costs from Federal programs

to other insurers and consumers. Increasing direct consumer costs to reduce overutilization has

been shown to reduce the number of persons

seeking care, but not to change use patterns after

a diagnosis has been made. Cavitation approaches

have been most successful in encouraging the

substitution of lower cost services for expensive

hospital care. Recent experiments are extending

the cavitation concept to include supportive social

services.

The coordination of services and benefits between Medicare and the State Medicaid programs,

as well as among other Federal, State, and local

programs that influence health care, remains a

problem in access to care for the elderly. Poor

coordination may even increase costs because the

most appropriate services are not provided. Better coordination can increase utilization and overall costs, but can also improve the quality of care.

The incremental costs and benefits of each action

must be evaluated.

The hospital backup problem described in this

chapter is an example of conflicting program requirements and, in certain geographic areas, lack

of skilled-nursing beds leading to increased costs.

Shifting financial incentives through prospective

payment under Medicare could affect quality of

care for patients in hospitals awaiting placement

in long-term care institutions. Premature discharge may result in multiple admissions and

shifting of costs to home care, thereby increasing overall costs for these patients as they are

cycled back and forth between inadequate community settings and the hospital.

O ther reports have addressed questions related

to changes in eligibility, benefits, and financing

mechanisms for the existing Medicare program

to cover increasing costs. Recent Congressional

Budget Office reports (45,46) explore options to

increase revenues or decrease outlays as well as

potential schemes to tie deductibles to income.

Research priorities

Health services research has the potential to

provide valuable information for improving the

cost effectiveness of the delivery of health services. There are significant gaps in knowledge at

present. Some efforts are constrained by technical problems; others are limited by the resources

that have been allocated for this purpose. Many

of the questions have not been adequately studied in any age group. In other areas, persons over

65 have been excluded from the study population (e.g., The Rand Health Insurance Study).

Results from the community-care demonstration

activities and the 2176 waiver programs may provide useful information for directing Federal

policy.

Additional information is needed in the following areas to direct Federal policy on containing

health care costs and improving health care and

supportive services for older persons:

●

●

●

●

●

●

●

●

●

●

●

factors affecting the use of health and social

services by older persons,

the effect of cost-sharing on the use of services by and the health status of older persons,

evaluation of economic incentives on provider-prescribing behavior,

effectiveness and cost effectiveness of alternative strategies for the care of chronic disease and functional impairments,

evaluation of alternative strategies for coordinating services and benefits,

cost effectiveness of alternative quality-assurance mechanisms,

development of methods to effectively educate older consumers in the prudent use of

health services,

development of improved health-outcome

measures for older persons,

exploration of methods to apply capitationpayment approaches to multi-provider

systems,

development of better assessment tools to

identify health and social service needs, and

refinement of case-mix measures based on

severity of illness for patients with multiple

diagnoses.
—.—

270 ● Technology and Aging in America

Congressional issues and options

ISSUE 1: Should Congress strengthen quality

assurance mechanisms for health

care services because of the potentially adverse effects of cost containment?

Options:

1.1

1.2

1.3

1.4

1.5

Congress could strengthen the requirements for

review of quality care.

Congress could establish a monitoring system to

identify adverse patient outcomes that maybe attributable to reductions in level of care and mandate the Prospective Payment Commission to evaluate the implications.

Congress could require refinement of the DRGs

according to age group (as a proxy measure for

severity of illness) or other surrogate measures

for severity of illness or the presence of multiple

diagnoses.

Congress could mandate making information on

care and its consequences more accessible to patients, including requiring a patient ombudsman

in hospitals.

Congress could require that HCFA have applications for Professional Review Organizations reviewed by outside experts to assure adequate

plans for monitoring quality of care.

While incentives to reduce the number and

types of services may be effective in encouraging more prudent and economical plans of care,

these incentives may also lead to skimping for

heavy-care patients. Older patients are more likely

to require more intensive services and longer periods for recovery. Current reimbursement policy recognizes this in two ways: 1) it provides

higher rates of reimbursement for patients over

70, and 2) provides for quality of care reviews

through Professional Review Organizations

(PROS). However, because analyses were performed on the total hospital population, significant differences between age groupings may have

been obscured. Since both the payment system

and quality assurance mechanisms are not yet

fully implemented, their effectiveness cannot be

evaluated. But the proposed regulations and

administrative structures should be evaluated for

adequate quality-assurance safeguards. The data

that will be necessary to guide future policy decisions must also be considered.

Options 1.1 and 1.3 imply action before the current system is implemented. The age break of 70

years was identified empirically. Option 1.2 would

provide a system to identify problems if they occur. Option 1.4 would enhance the patient’s ability

to avoid situations that could place him in jeopardy. Option 1.5 would provide additional assurance that quality of care as well as cost of care

considerations are adequately represented in PRO

functions. All of the proposed options would increase the cost of quality-assurance programs, but

savings could also accrue from the prevention of

complications.

ISSUE 2: Should Congress act to increase

coordination of Federal health and

social service programs and to increase liaison with State-run programs to avoid unintended interpr0-

gram cost shifting?

Options:

2.1

2.2

2.3

2.4

2.5

2.6

Congress could establish additional Federal-level

coordinating mechanisms.

Congress could consolidate Federal agency and/or

program responsibilities.

Congress could delegate responsibility for coordination of Federal programs to States and localities.

Congress could establish a client-based information system so that total per capita spending can

be monitored on a representative sample of beneficiaries.

Congress could encourage the dissemination of

information to individuals and strengthen coordination through enhanced consumer decisionmaking.

Congress could provide increased support for existing coordination efforts through the Administration on Aging, the Area Agencies on Aging, and

State-run health programs.

Current efforts aimed at coordination have not

eliminated conflicting program requirements and

regulations. The financial impacts of lack of coordination are largely unknown, but cost shifting
Ch. 8—Health Care Costs and Access to Technology for Older Persons . 271

between Federal programs and between Federal

and State programs is known to occur. Enhanced

coordination could occur at the Federal level (options 2.1 and 2.2), at the State and local level (option 2.3), or at the individual patient level (option

2.5). Better information on the use and costs of

services provided by all health and social services (option 2.4) could lead to better planning, but

would introduce higher costs of data collection

and could raise problems related to confidentiality

of information. Increased activity through existing

structures (option 2.6) could be effective but more

attention to linkages in certain areas (e.g., housing programs and Veterans Administration programs) seems appropriate. Better coordination

could reduce costs through the provision of more

appropriate services but could also increase demand for services overall and thereby increase

total costs.

ISSUE 3: Should Congress stimulate coverage

for preventive services, long-term

care, and function-enhancing technologies as a way of substituting

lower cost services?

Options:

3.1

3.2

3.3

3.4

3.5

Congress could increase benefits for prevention

and treatment of chronic disorders in addition to

current acute care benefits.

Congress could increase benefits for prevention

and treatment of chronic conditions and limit program liability for acute care services.

Congress could establish additional optional coverage through social insurance.

Congress could encourage additional optional coverage by creating incentives for private insurance

coverage for these services.

Congress could provide incentives for personal accumulation of resources for additional benefits

(e.g., tax-deferred savings).

The addition of benefits to the Medicare program (option 3.1) or restructuring benefits (option 3.2) could lead to a less functionally dependent older population. Little evidence exists on

whether this would lead to cost savings. In the

short run, costs would likely increase. The provision of other types of optional coverage (options

3.3 and 3.4) is another approach to providing additional benefits. Technical, marketing, and regulatory barriers have inhibited private insurers’

development of appropriate mechanisms to distribute risks. Social insurance schemes would likely require additional Federal resources. Personal

accumulation schemes (e.g., tax-deferred savings

plans, home-equity conversion) have been proposed by some (option 3.5), but these would be

most effective for moderate and upper income

persons. Alternative methods for the poor and

near-poor would therefore be required if equity

of access

ISSUE 4:

is to be maintained.

Should Congress act to alleviate the

number of patients in hospitals

waiting for discharge to lower levels

of care?

Options:

4. I Congress could make Medicare and Federal @de4.2

4.3

4.4

4.5

lines more consistent to increase the number of

beds available for recuperation of Medicare patients.

Congress could relax legislative restrictions for

designation of swing beds (classifying unused hospital beds as skilled-nursing beds) in hospitals.

Congress could exempt hospitals from certificateof-need requirements for adding home health

services.

Congress could encourage more active dischargeplanning efforts.

Congress could encourage the building of additional skilled-nursing beds in shortage areas.

Making more Medicare nursing home beds available (options 4.1, 4.2, and 4.5) would increase the

use of this benefit, thereby increasing program

costs. Some savings from a reduction of hospital

payments could occur in those cases where extended lengths of stay produce “outlier payments”

(payments in addition to DRG reimbursement for

extremely long stays). Also, patients requiring intense community services because of lack of informal support might be cared for more economically. Better access to home and community

services (options 4.3 and 4.4) could reduce pressure and outlier costs for hospitals but would increase the cost of home care benefits.
272 ● Technology and Aging in America

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— —. —— —

274 . Technology and Aging in America

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Chapter 9

Technology, Housing, and

the Living Environment

of the Elderly
Contents

Pag e

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 277

Demographic Influences . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 277

Changes in Households . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 277

Marital Status . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 278

Living Arrangements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 280

Housing Status of the Older Population . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 282

Tenure of Elderly Households . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 282

Housing Deficiencies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 283

Housing Expenditures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 285

Recent Changes in Expenditures and Deficiencies. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 286

Housing and Environmental Fit of the Impaired Elderly . . . . . . . . . . . . . . . . . . . . . . . . . . . 288

Age, Impairment, and the Housing Environment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 288

Impairment and Disability. ...,.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 288

Prevalence of Disability . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 290

Evolution of Federal Housing Policy for the Elderly. ......,, . . . . . . . . . . . . . . . . . . . . . . 294

General Housing Policy and Federal Programs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 294

Federal Housing Programs for Older Americans . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 294

Impact of Federal Housing Programs on the Elderly . . . . . . . . . . . . . . . . . . . . . . . . . . . . 300

The Macro-Environment of Housing for the Elderly . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 301

Characteristics of Elderly Single-Family Housing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 301

The Micro-Environment of Housing for the Elderly . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 315

Technological Applications in the Home . . . . . . . . , . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 315

Concluding Remarks . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..., . . . . . . . . 324

Research Priorities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 325

Issues and Options . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..., , . . . . . . . . . . . . . 325

Chapter 9 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 327

Tables

Table No. Page

23.All Households and Households With an Elderly Head: United States, 1950-82 . . . . . 278

24. Marital Status of the Population Aged 65 and Over, by Age and Sex: United States,

1970 and 1982 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .“. . . . . . . . . . . . . . . . . . . . . . . . . 279

25. Living Arrangements of the Population Aged 65 and Over, by Age and Sex:

United States, 1970 and 1981 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 280

26. Elderly Headed Households, by Tenure: United States, 1979 and 1982 . . . . . . . . . . . . 282

27. Housing characteristics of Elderly Headed Households: United States, 1979 . . . . . . . 283

28. Deficiency Criteria for Physically Inadequate Housing: United States, 1981 . . . . . . . . 284

29. Incidence of Housing Deficiencies and Excess Expenditures: United States, 1979 . . . 285

30. Persons Needing Help in Basic Activities of Daily Living and Persons in Nursing

Homes, by Selected Ages: United States, 1977 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 291

31 .Noninstitutionalized Persons With Activity Limitation Due to Chronic Conditions,

and Persons Dependent in Selected Basic Activities of Daily Living (ADLs), by Age:

United States, 1977 , . . . . . . . . . . . . . . . . , , . . . . , . , . . . . . , . . . . . . .; . . . . . . . . . 291

32. Mopility Limitations Due to Chronic Conditions Among Noninstitutionalized Persons,

by Age: United States, 1977 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 292

33, Summary of Housing Units for the Elderly Currently Subsidized by Selected Federal

Housing Programs: United States, 1981-82. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 296

Figure

Figure No. P a @

27. Schematic Diagram of the Competence and Environmental Press Model: Behavioral

Outcomes of Person-Environment Interaction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 289
Chapter 9

Technology, Housing, and the

Living Environment of the Elderly

Introduction

Major demographic and technological changes

in housing and living arrangements of older

Americans in the recent past signal new challenges for Federal housing policy in the future.

Understanding the effects of these trends for

the elderly is particularly relevant because of the

growing importance of the residential environment as persons age. Questions of safety, security, satisfaction with life, and maintenance of independence are only a few of the issues that have

a bearing on Federal policy in housing, technological change, and the elderly (see, e.g., 43). Moreover, as the elderly population itself ages, greater

challenges arise for assuring that the very old are

not only adequately housed but also properly

served (74).

Issues surrounding ‘(housing and the elderly”

go beyond the physical dwelling itself. The status

of older persons in terms of their housing and

living arrangements is intricately related to their

socioeconomic, marital, familial, psychological,

and physical status. Whether directly or indirectly, Federal housing policy affects central aspects

of the older individual’s well-being.

Demographic influences

Changes in households

Although it is clear that ever larger numbers

and proportions of people are surviving to age

65 and beyond, the composition of this population must be considered when assessing the housing needs of the elderly. Among the key factors

are age, sex, marital status, and living arrangements.

This chapter discusses the demographic, social,

and technological developments that have helped

create the current Federal role in housing policies affecting the elderly. It includes a synopsis

of the major Federal housing programs that have

an impact on the older population, their relative

contribution to providing or subsidizing housing

for this special group, and their current status

or level of activity. It also provides an analysis of

potential future needs in Federal housing policy

and in achieving the explicit goal of assuring “safe

and decent housing” for all persons and families,

as first stated in the Housing Act of 1937.

More recent Federal legislation sets out the special nature of the housing needs of the elderly,

especially the desirability of coordinating housing with a variety of community services. Increasingly, the emphasis is on maximizing and maintaining the residential independence of older

persons, particularly those who are frail, disabled,

poor, and/or living alone. Technological innovations in residential settings and development of

new service delivery systems, ranging from low

to high technologies, are already being applied

toward these goals.

It is also important to distinguish between persons and households as demographic variables.

The household is the best unit of analysis for discussing housing concerns, since it is the consuming entity and reflects the actual number of dwelling units that are occupied. During the decade

of the 1970s, the over-65 population grew by 28

percent, to 25.7 million persons. In contrast, the

rate of growth for the total population was only

277
—.

278 ● Technology and Aging in America

11 percent; this age-specific growth differential

has existed for most of this century. (See ch. 2

for a complete discussion of these trends.) Moreover, during the 1970-80 period the aging of the

older population itself was shown by the 33-percent increase in the over-75 population, and the

even more marked increase of 61 percent in persons over 85.

This impressive growth in numbers of persons

only forms the underlying basis for assessing

housing demand by the elderly. The change in

numbers of households is more relevant. According to the Annual Housing Survey of the Bureau

of the Census, by 1980 there were 16.5 million

households maintained by a person over 65. This

figure is about one-fifth of all U.S. households,

a proportion that has been increasing since world

War II, Thus, while the number of older persons

doubled between 1950 and 1980, the number of

households headed by older persons increased

even more—by a factor of 2.5 (from 6.4 million

to 16.5 million). Table 23 shows these trends from

1950 to 1982.

Table 23 also shows the variability of decennial

percent changes in both total and elderly households, which reflects the wide variation in fertility rates of earlier decades. The low fertility rates

of the 1930s lessened the demographic potential

for future household formation. The cohort born

between 1930 and 1934 exerted relatively little

influence on household formation in 1959 (i.e.,

when these individuals reached age 25 to 29, a

major life-cycle stage for household formation).

Similarly, when this cohort reaches age 65 to 69

Table 23.—All Households and Households

in 1999, they will add a relatively small number

and proportion to the total of elderly households.

Therefore, despite the higher decennial rates

of growth in elderly households since 1950, the

rate of increase has both varied and slowed. In

1950, fewer than 15 percent of U.S. households

were headed by elderly persons; this figure rose

to 19.6 percent in 1970 and to almost 21 percent

in 1982. The earlier increases in elderly households were largely due to the increased likelihood

of older persons maintaining independent households and the general trend toward greater survivorship in old age.

The trend in household growth among the elderly is expected to slow during the rest of this century (66). Issues related to quantity or supply of

housing for older persons are likely to be less crucial than questions regarding its financing, maintenance, and distribution. Also, new issues regarding the integration of housing policy with public

services, especially long-term care, will become

increasingly important.

Marital status

Increased emphasis on quality of the living environment and service coordination is predicated

on the differences in types of households within

the older population. Age-based differences in

marital status and living arrangements of the older population have remained quite stable during

the last two decades, but sex-based differences

have changed somewhat. Table 24 shows the diswith an Elderly Head: United States, 1950-82

(numbers In millions)a 

All households Households with elderly headb

Total Percent change Percent change Percent

Year number preceding decade Number preceding decade of total

1950 . . . . . . . . . . . . . . . . . 43.4 —% 6.4 —0/0 14.70/0

1960 . . . . . . . . . . . . . . . . . 52.6 21.2 9.4 46.9 17.9

1970 . . . . . . . . . . . . . . . . . 62.9 19.6 12.3 30.9 19.6

1980 . . . . . . . . . . . . . . . . . 80.7 28.3 16.5 34.1 20.4

1982 . . . . . . . . . . . . . . . . . 83.5 — 17.3 — 20.7

aFigUres are for the noninstiturionalizedpOpUht)On.

bEkj@y hewj of household Is a person aged 65 of ~def.

SOURCE: Data derfved from U.S. Bureau of the Census, Currant Populat(orr Reports, Series P-m, Nos. 361 and 366, and Series P-25, No. 605; Current Housing f?eporfs,

Annual Housing Survey, 1960.
Ch. 9–Technology, Housing, and the Living Environment of the Elderly • 279

Table 24.–Marital Status of the Population Aged 65 and Over, by Age and Sex: United States, 1970 and 1982

(percent distribution)

Male Female

Year and marital status Age 65+ Age 65-74 Age 75+ Age 65+ Age 65-74 Age 75+

1970: 8

Never married . . . . . . . . . . . . . . 7.5% 8.00/0 6.60/0 7.7% 7.80/o 7.5%

Married, spouse present . . . . . 69.9 75.2 60.4 33.9 43.5 19.1

Married, spouse absent . . . . . . 3.2 2.8 3.9 1.7 1.6 1.9

Widowed . . . . . . . . . . . . . . . . . . 17.1 11.3 27.7 54.4 44.0 70.3

Divorced . . . . . . . . . . . . . . . . . . . 1,3 2.7 1.4 2.3 3.0 1.3

Total , . . . . . . . . . . . . . . . . . . . 100.0 100.0 100.0 100.0 100.0 100.0

1982: b

Never married . . . . . . . . . . . . . . 4.4 4.9 3.3 5.6 5.3 6.1

Married, spouse present . . . . . 77.6 81.5 70.2 38.5 49.3 2.4

Married, spouse absent . . . . . . 2.4 2.5 2.3 1.7 2.0

Widowed . . . . . . . . . . . . . . . . . . 12.4 7.5 21.7 50.4 38.3 d::

Divorced . . . . . . . . . . . . . . . . . . . 3.2 3.6 2.4 3.8 5.1 1.8

Total . . . . . . . . . . . . . . . . . . . . 100.0 100.0 99.9 100.0 100.0 100.0

algro figures are based on total civilian resident Population.

bl~z figures Me b~d On total civilian resident population, excluding persons Who are lnstltutlonallzd.

SOURCE: U.S. Bureau of the Census, Current Population Fiepms, Series P-20, Nos. 212 and 3S0.

tribution of marital status within the older population by age and sex in 1970 and 1982.

Most noticeable are the similarities within the

sexes and the age groups for both years. Although

not shown, data for 1960 had similar relative differences. Those differences in marital status that

do exist are found between the sexes and age

groups within either year. For example, although

widowhood is perceived as an increasing problem for older women, the proportion widowed

actually declined between 1970 and 1982. For all

older women, widowhood was 4 percentage

points lower, at 50.4 percent in 1982. To the extent that widowhood reduces quality of life in

older age (2,48,49), the overall status of older

women has improved slightly. By a similar difference of 4.5 percent, the proportion of women

over 65 who are married with spouse present has

increased to 38.5 percent.

In 1982, 12.4 percent of older men were widowed, a proportion one-fourth that of their female

counterparts. Over three-fourths of the men were

married with spouse present. Even for men over

75, 70 percent were still in that category, compared with only 22 percent of women in that age

group. Thus, while recent trends have been toward increases in proportions married for both

sexes and all older age groups, the lifestyle “advantage” for older men has actually improved proportionally.

But increasing numbers of older women are becoming widowed, especially when compared to

men. Between 1970 and 1982 the number of widowed older women rose by 1.7 million (to 8.1 million), even though the proportion in that category

was 4 percentage points lower. In contrast, there

has been an actual decline in the number of widowed older men—from 1,42 million in 1970 to

1.34 million by 1980. The proportion of all widowed older men was almost 5 percentage points

lower by 1982 (90).

Thus, the numbers of widowed older women,

while increasing, are doing so at a decreasing rate.

There has been no significant change in numbers

of older men widowed during the last 12 years.

Because life expectancies at birth, at age 65, and

even at age 85 are higher for women, their increase in total numbers has been greater, thereby

enhancing both the positive and negative changes

that have occurred in their marital status. ’

The growth in the total number of older men

was almost entirely comprised of those who were

IThe total population of older males grew by 2.1 million between

1970 and 1982, while the total female older population gained almost

twice that amount (3.9 million) during the same period.
280 ● Technology and Aging in America

married with spouse present. Almost 8 percent

more older men were in this category in 1982

than in 1970, a gain of 2.2 million. In contrast,

the additional 2 million women who were married with spouse present represented only onehalf of the total increase in older women from

1970 to 1982. The other 1.9 million were either

never married, widowed, divorced, or separated.

Various factors account for these differences.

As noted above, age- and sex-specific differences

in life expectancy continue to have an impact on

the sex composition of the older population, although their respective rates of increase have

slowed. Moreover, husbands are, on average, 3

to 4 years older than their wives, thereby increasing the “risk” of female widowhood by increasing the average age differential between spouses.

Finally, even among married older persons, who

have higher life expectancies in general, wives still

have notably higher life expectancies than husbands (66).

Living arrangements

These demographic influences and their social

impacts are also seen in the living arrangements

of the older population. Data for 1970 and 1981,

shown in table 25 (comparable 1982 data are not

yet available), indicate the changes in–and the

differences between–the living arrangements of

older men and women. A notable change since

1970 has been the dwindling proportions of both

men and women who live with someone other

than a spouse, especially those over 75. The proportion of all older men living with someone else

dropped from 14.2 to 9.1 percent. Even more dramatic is the decrease in older women living with

someone else, which fell from more than 27 percent in 1970 to less than 20 percent in 1981. The

largest decrease was for women over 75: from

more than one-third to less than one-fourth. The

likelihood that very old women will be living alone

has thus increased substantially since 1970.

In 1981, 79 percent of men 65 to 74 were living with a spouse, compared with only 47 percent of women in that age group (who also

showed an increase since 1970, but a less dramatic increase than for men). A more profound difference is found for the over-75 population. Almost two-thirds of these men lived with their

spouses in 1981, but fewer than one-fifth of all

women over 75 did so. The effect of differences

in life expectancy between the sexes on the living arrangements of the elderly is, therefore,

much greater for the very old population.

Among all older women, almost 39 percent lived

alone in 1981, 5 percentage points higher than

in 1970. The comparable figure for older men was

Table 25.—Living Arrangements of the Population Aged 65 and Over, by Age and Sex:

United States, 1970 and 1981 (percent distribution)a

Male Female

Year and living arrangement Age 65+ Age 65-74 Age 75+ Age 65+ Age 65-74 Age 75+

1970:

In households . . . . . . . . . . . . . . 95.5% 96.40/0 93.7% 95.0% 97.6% 91.1%

Living alone . . . . . . . . . . . . . . 14.1 11.3 19.1 33.8 31.6 37.0

Spouse present. . . . . . . . . . . 69..9 75.2 60.4 33.9 43.5 19.1

With someone else . . . . . . . 11.5 9.9 14.2 27.4 22.4 35.0

Not in households . . . . . . . . . . 4.5 3.6 6.3 5.0 2.4 8.9

Total . . . . . . . . . . . . . . . . . . . . 100.0 100.0 100.0 100,0 100.0 100.0

1981:

In households . . . . . . . . . . . . . . 96.2 97.9 92.9 93.8 97.8 88.3

Living alone . . . . . . . . . . . . . . 13.8 11.1 19.0 38.8 34.2 45.1

Spouse present . . . . . . . . . . . 74.1 79.0 64.8 35.5 47.3 19.3

With someone else . . . . . . . 8.3 7.8 9.1 19.4 16.2 23.8

Not in households . . . . . . . . . . 3.8 2.1 7.1 6.3 2.2 11.7

Total . . . . . . . . . . . . . . . . . . . . 100.0 100.0 100.0 100.0 100.0 100.0

aF19Ure$ ~e for the total clvlllan resident Population.

SOURCE: Siegei, 1983; baaed on data from U.S. Bureau of the Census, Current Popu/at/on Repofis, Series P-20, various nos.
Ch. 9—Technology, Housing, and the Living Environment of the Elder/y ● 281

less than 14 percent. More than four times as

many women as men over 65 lived alone in 1981

(i.e., more than 6.0 million women v. fewer than

1.5 million men).

Women over 65 also have higher risk of institutionalization than their male counterparts. While

the proportion of all older men who are “not in

households” 2 declined from 1970 to 1981 to 3.8

percent, the proportion of older women in that

group increased to 6.3 percent. As in the case of

widowhood, women face a much greater risk of

institutionalization at the oldest ages (75 and over)

and the difference has been increasing; their rate

of institutionalization increased from 8.9 percent

in 1970 to 11.7 percent in 1981. This change is

correlated with the growth toward a much higher

proportion of very old women who live alone (45

percent in 1981 v. 37 percent in 1970).

Elderly women who are likely to be institutionalized are also likely to be very old, widowed, living alone, and poor. Although these factors contribute to the likelihood of functional dependency

and institutionalization (99), an encouraging trend

is the recent decline or leveling in the proportion

of both men and women aged 65 to 74 who are

institutionalized. This change can be partly explained by the recent increases in proportions

married and living with their spouses.

The most recent trends in both marital status

and living arrangements among elderly men and

women thus indicate four general changes:

1. There is an increase in the proportions of older men and women who are married and living with their spouses. These trends are

equally evident for both young-old and veryold males, as well as for young-old females.

For very-old women, no change in proportion who are married with spouse present

has occurred during the last decade.

2. Smaller proportions of older men and women, across all age subgroups, are living with

3.

4.

someone other than their spouses. This trend

is particularly evident among very-old

women,

Institutionalization rates for the younger subgroup of older persons (the young old) have

decreased, especially for elderly men. But

among the very old, these rates have increased, notably so for women.

The proportion of older men who live alone

has remained constant, but the proportion

of older women living alone has markedly increased.

Most of these trends are expected to persist in

the foreseeable future, Between 1980 and 1995

little change is anticipated in the proportions of

elderly men and women who are either single or

married and living with a spouse. Nor are the proportions of older men who live alone or with

someone other than a spouse expected to change

significantly (89).

The one clear change expected over the next

15 years is an increase in the proportion of socalled “nonfamily” households among elderly

women, i.e., those who live alone or with nonrelative. Corresponding to this shift will be a decline in the proportion of households headed by

elderly women living with other relatives (from

more than 54 percent in 1981 to 50 percent by

1995), In general, over 55 percent of all households maintained by elderly persons in 1995 are

expected to consist of persons living alone or with

nonrelative) four-fifths of which will be headed

by women (89).

The changes are more dramatic for the o\wr75 population. In 1981, two-thirds of all households headed by a person over 75 were single-person or nonfamily households, which are projected

to remain at that level through 1995. Women are

expected to comprise almost 84 percent of these

single and nonfamily households in the over-75

population.

“[’he category “not in househokk” corresponds to “in group

quarters, ” which includes the “institutionalized, ” of whom 96 percent am in nursing homes and the remainder in other types of group

quarters,

3Bureau of the (;ensus estimates and projections for “nonfanlll)

households do not inrlud~> persons who are iIlstitLltio[~iilize(i
282 . Technology and Aging in America

Housing status of the older population

These demographic trends among the elderly

indicate the need for new approaches by the Federal Government to the housing needs of the older

population. The data reviewed here underscore

the dual growth in both family units and singleperson elderly households since World War II.

This growth in U.S. households maintained by

elderly persons was accompanied by increases in

the numbers and proportions of older persons

in institutions (i.e., nursing homes and personal

care homes, including domiciliary and board and

care facilities). These institutions and their residents are not included in the count of households,

but they currently house approximately 1.4 million elderly residents—more than 2% times their

number in the mid- 1960s. The following sections

are restricted to the housing situation of the noninstitutionalized elderly.4

Tenure of elderly households

Among the 16.5 million “elderly households” in

1980, approximately 12.3 million were owneroccupied and only 4.2 million were renter-occupied. This relatively high rate of homeownership

among the elderly has been increasing since

World War II. By 1970 over two-thirds of all elderly households were owned; by 1979 the proportion had increased to almost 72 percent (tables

26 and 27). Included in the growth of elderly

homeownership is an increase in the prevalence

of manufactured or mobile housing units. By 1980

over one-fifth of all elderly homeowners resided

in this type of housing (56).

The growth in ownership during the 1970s has

continued during the 1980s. By 1982 the number of elderly-headed households reached 17.3

million, of which 76 percent (13.2 million) were

owner-occupied and 24 percent (4.1 million) were

renter-occupied (90). Thus, not only did the number of elderly-headed households increase by 1.1

million units in just 3 years, but the entire net

growth was in owner-occupied households. The

same period showed a net decrease in elderly

%ee chs. 2 and i’ for details on the types of older persons most

likely to be institutionalized and the types of care provided.

renter-occupied households: from 4.6 million in

1979 to 4.1 million in 1982.

It should be noted that some of this change is

due to underestimates from the 1979 Annual

Housing Survey (AHS) data. The 1979 AHS sample

used baseline data from the 1970 census of population for its estimates of persons and households. Compared with 1979, the survey data estimates for 1982 have been adjusted upward in

accord with 1980 census counts for persons and

households. 5 If the average 2 percent adjustment

from the 1980 census base is applied to the 1979

survey data, more accurate estimates of change

can be developed (see table 26).

By adjusting the 1979 survey data as shown in

table 26, the 1979-82 increase in total elderly

households was 0.8 million units. Using these adjusted figures, the number of elderly owneroccupied households increased by 1.4 million and

the number of renter-occupied households decreased by 0.6 million. (Estimates of the inaccuracy of owner/renter distribution in 1979 are not

available).

An ever-growing number and proportion of

elderly households are owner-occupied. This is

one of the most important facts regarding the

housing status and problems of older Americans,

because housing tenure (i.e., whether owned or

rented) of the elderly tends to be associated with

These most recent 1980 census-based adjustments resulted in

a 2-percent increase, on average, in the civilian noninstitutional population, as well as in the number of families and households that

are used for estimates from census survey data since 1980.

Table 26.—Elderly Headed Households, by Tenure:

United States, 1979 (unadjusted and adjusted) and

1982 (numbers in millions)

1979

Household tenure Unadjusted Adjusted 1982

Total households . . . . 16.2 16.5 17.3

Owner-occupied . . . 11.6 11.8 13.2

Renter-occupied . . . 4.6 4.7 4.1

SOUflCE: OTA adjustments based on U.S. Bureau of the Census, Current Pop-da.

tion Repotis, Series P-20, Nos. 352 and 381,
Ch. 9–Technology, Housing, and the Living Environment of the Elderly ● 283

Table 27.—Housing Characteristics of Elderly Headed Households: United States, 1979 (numbers in thousands)

Owner-occupied Renter-occupied

Housing characteristics Number Percent Number Percent

Total households. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11,609 71 .60/0 4,605 28.40/o

Median household income . . . . . . . . . . . . . . . . . . . . . . . . . . . $8,904 $6,500

Poverty status . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1,741 15.0 1,289 28.0

Median value of house/median gross rent . . . . . . . . . . . . . . $38,900 $ 168

Single-person household . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4,302 37.1 3,032 65.8

Two-or-more person household . . . . . . . . . . . . . . . . . . . . . . . 7,307 62.9 1,573 34.2

Unit built before 1940. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4,891 42.1 1,950 42.3

Unit Iacks some or all plumbinga . . . . . . . . . . . . . . . . . . . . . . 321 2.8 269 5.8

aSee table 28 for details

SOURCEAdapted from 1980 AHS survey data; Struykand Turne~ 1982 (71)

various social and demographic characteristics related to need for assistance. Furthermore) the development, applicability, and accessibility of new

technologies in the dwelling unit may involve different approaches for owned v. rented units.

Those elderly who rent their dwelling units are,

in general, more likely to need government assistance to achieve decent, safe, and sanitary housing. Differences exist not only between renters

and owners, but also between owners who still

have a mortgage indebtedness and owners who

do not. Table 27 shows some of the general differences between elderly households that are

owner- v. renter-occupied.

These 1979 data illustrate the general differences in housing status that persist today among

the older population. Almost 72 percent of all

elderly headed households in 1979 were owneroccupied;6 of these, 63 percent contained two or

more persons and 37 percent contained only one

person. In contrast, elderly renter-occupied units

comprised less than 30 percent of the total, and

fully two-thirds of these were occupied by only

one person. Renter-occupied households were almost twice as likely as owner-occupied households to have incomes below the poverty level,

Housing deficiencies

Housing adequacy can be similarly differentiated. There is a high association among such characteristics as living alone, poverty status, and various other factors related to housing adequacy.

The estimates in table 26 imply that the proportion of owneroccupied units in 1982 had increased to 76 percent, but this figure

may be slightly high.

As noted earlier, elderly persons who live alone

are more likely to be women, very old, poor, and

inadequately housed; they are also more likely to

have inadequate diets, need social supports and

services, and be in ill health than are those who

live with one or more other persons.

Compounding the difficulties for those who live

alone, especially renters, are problems related to

the housing units themselves. The data in table

27 show that renters not only have lower median

household incomes, they are also twice as likely

to be living in a unit that lacks some or all plumbing (although there are a greater number of owner-occupied units with inadequate or missing

plumbing). Elderly rental units are also more than

twice as likely to have two or more dwelling deficiencies than are elderly owned units (103).

Analysis of AHS data shows that among all

elderly renters in poverty in 1979, almost onethird were in units with one or more physical deficiencies. Table 28 shows eight major physical

deficiency categories that are used by the Department of Housing and Urban Development (HUD)

for the AHS. These criteria emphasize the severity of the housing deficiencies that are included

in the data cited above. Following the example of

other analyses, table 28 lists two groups of deficiencies, ‘(structural” and “maintenance” (71).

Because of the requirements for the two categories under “maintenance deficiencies” (e.g., at

least three of four common area problems), it is

reasonable to assume that their prevalence is

understated in available housing survey data.

Many units with some structural deficiencies, including local municipal building code violations

and safety hazards, might not be included in the

more stringently defined AHS data.

38-800 0 - 85 - 1 0
284 . Technology and Aging in America

Table 28.—Deficiency Criteria for Physically inadequate Housing:

United States, 1981

Type of deficiency Description of deficiency

Maintenance deficiencies:

Physical structure. , ., . . . . . . . Has at least three of five structural problems:

Common areas . . . . . . . . . .

Structural deflciencies:

Plumbing . . . . . . . . . . . . . . .

Kitchen . . . . . . . . . . . . . . . . . . . .

. leaking roof;

● open cracks/holes in interior walls or ceilings;

• holes in floors;

• peeling paint or broken plaster over 1 square foot of an

interior wall;

● evidence of mice/rats in the last 90 days.

, For a multi-unit building has at least three of four:

● no working light fixtures in common hallway;

● loose, broken, or missing stairs;

● broken or missing stair rails;

● no elevator in buildings of four or more stories.

, Lacks or must share some or all plumbing facilities:

. hot and cold piped water;

● flush toilet;

● bathtub or shower.

Lacks adequate provision for sewage disposal:

● connection with public sewer;

● septic tank;

● cesspool;

● chemical toilet.

Lacks or must share some or all kitchen facilities:

● sink with piped water;

• a range or cookstove;

• a mechanical refrigerator.

Electrical . . . . . . . . . . . . . . . . . . Lacks electricity.

Has at least three electrical deficiencies:

● one or more rooms without a working wall outlet;

. fuses blown or circuit breakers tripped three or more

times in the last 90 days;

● exposed interior wiring.

Heating. . . . . . . . . . . . . . . . . . . . Has unvented gas- or oil-burning room heaters.

SOURCE: Adapted from Struyk and Turner, 19S2 (71); based on l+UD AHS criteria.

In 1979, 11.5 percent of all elderly households

that received no Federal housing assistance (i.e.,

not federally regulated) had at least one physical

deficiency. Among renter-occupied elderly households the comparable figure was 17.2 percent;

among owner-occupied households without a

mortgage, the prevalence was 10.1 percent and

only 6.5 percent for owners with mortgages. Note

that about 80 percent of all elderly homeowners

do not have mortgages. Thus, generalized data

on older homeowners are biased toward the characteristics of those without mortgage indebtedness, thereby providing inadequate information

about elderly homeowners with mortgages.

Some of the highest incidence of housing deficiencies are found among the elderly in poverty,

regardless of tenure status; almost one-third of

poor elderly owners and renters occupy dwellings with at least one deficiency. Housing problems are especially acute for the most vulnerable and isolated elderly. Forty percent of

unassisted elderly households in rural farm areas

and small towns occupied physically deficient

dwelling units in 1979. In contrast, 22 percent of

elderly households in urban areas of nonmetropolitan counties and only 12 percent of those in

metropolitan counties were in that category.’

Moreover, within each of the three tenure

groups (renters, owners without a mortgage, and

owners with a mortgage), black households (all

7A metropolitan county is generally defined as any county with

at least one central city of 50,000 or more population, as well as

any contiguous county that is economically and socially integrated

with the metropolitan county that contains the central city.
Ch. 9–Technology, Housing, and the Living Environment of the Elderly ● 285

ages) had the highest incidence of dwelling disrepair. Forty-six percent of all black renteroccupied households were physically deficient in

1979, compared with only 13 percent for all other

renter households. The same comparisons exist

for mortgaged owner-households (25 percent for

black households v. only 4 percent for white) and

nonmortgaged owners (36 v. 8 percent, respectively).

Housing deficiencies are thus not only higher

among elderly than nonelderly households, they

are particularly severe among Americans who are

also poor, black, and/or renters. These differences

have remained constant since the early 1970s, despite the overall improvement in the housing quality for the elderly vis-a-vis the nonelderly population (71).

Housing expenditures

Relative housing expenditures of the elderly are

also higher. A generally accepted index of excess

housing expense, adopted by HUD, uses the following criteria:

Excessive housing expense burden occurs when:

● for renters, gross rent (contract rent, plus

utilities paid by the tenant) reaches more

than 30 percent of gross household income;

● for owner-occupants, direct expenditures for

housing (excluding those for major maintenance and improvements) reach more than

40 percent of gross household income.

Among unassisted households in 1979, excess

expenditures were incurred by over 18 percent

of elderly households and 15 percent of nonelderly households. However, notable differences exist

in the distribution of the expenditure burden

within the two age groups (table 29). Among

nonelderly households, 33 percent of the renters

and 8 percent of the owners with mortgages had

excess housing expenditures. For elderly households, the corresponding figures were dramatically higher: 55 percent for renters and 25 percent for owners with mortgages. The overall rates

by age group are closer, because fewer than 20

percent of all elderly homeowners have a mortgage, compared with more than 60 percent of the

nonelderly. Thus, in terms of both absolute and

Table 29.—incidence of Housing Deficiencies and

Excess Expenditures: United States, 1979

(percent distribution)

Age group and Physical Excess

tenure status deficiencies expenditures

Nonelderly households:

Total . . . . . . . . . . . . . . . . . . . . . . . . . 7.60/o

Renters . . . . . . . . . . . . . . . . . . . . 13.2

Owners with mortgage . . . . . . . 3.1

Owners without mortgage . . . . 7.9

In poverty . . . . . . . . . . . . . . . . . . . . 26.3

Renters . . . . . . . . . . . . . . . . . . . . 28.7

Owners with mortgage . . . . . . . 17.1

Owners without mortgage . . . . 26.2

Elderly households:

Total . . . . . . . . . . . . . . . . . . . . . . . . . 11.5

Renters . . . . . . . . . . . . . . . . . . . . 17.2

Owners with mortgage . . . . . . . 6.5

Owners without mortgage . . . . 10.1

In poverty . . . . . . . . . . . . . . . . . . . . 29.0

Renters . . . . . . . . . . . . . . . . . . . . 31.0

Owners with mortgage . . . . . . . 33.6

Owners without mortgage . . . . 27.4

Owners with mortgage:

Black . . . . . . . . . . . . . . . . . . . . . . . . 24.7

Other . . . . . . . . . . . . . . . . . . . . . . . . 3.8

Owners without mortgage:

Black . . . . . . . . . . . . . . . . . . . . . . . . 36.5

Other . . . . . . . . . . . . . . . . . . . . . . . . 8.3

Renters:

Black . . . . . . . . . . . . . . . . . . . . . . . . 46.0

Other . . . . . . . . . . . . . . . . . . . . . . . . 13.3

15.20/o

33.4

7.9

1.7

70.8

86.5

73.2

18.2

18,4

55.3

25.3

4.5

41.0

74.9

74.9

17.7

44.3

22.6

7.2

4.4

57.8

55.0

SOURCE: Adaptad from Struyk and Turner, 19S2 (71); data are only for households

not receiving housing assistance.

relative figures, those renters in both age groups

who do not receive any housing assistance are

far more likely to be burdened with excessive

housing costs.

Other differences in housing expenditures exist. Poverty status, combined with lack of housing

assistance, is clearly a major reason for excess

housing expenditures for both the elderly and the

nonelderly. Among all impoverished nonelderly

households, 71 percent experienced excess housing costs in 1979, especially the renters (87 percent). over 73 percent of poor, nonelderly owners

with mortgages also had excessive costs (compared with only 18 percent for their nonmortgaged counterparts). The largest differences among

the nonelderly exist in the rates for the poor compared with the total population, regardless of

household tenure. Only 8 percent of all owners

with mortgages and a mere 2 percent of those

without mortgages had excess expenditures. But
286 . Technology and Aging in America

one-third of all nonelderly renter-occupied households were in this predicament,

Although elderly renters and mortgaged households, on average, have notably higher rates of

excess expenditures than nonelderly households,

these differences are either reversed or nonexistent when specifically comparing only the poverty level households of the two age groups.

Among all impoverished renters, the elderly

households were less likely to have excess expenditures than the nonelderly, in part because of

smaller dwelling requirements and available Federal subsidies. The expenditure rates for owneroccupied households in poverty were virtually the

same between the two age groups (70).

poverty-level households of all ages, occupied

by renters or owners with mortgages, have by

far the highest levels of housing expense burden.

Thus, among those who do not receive housing

assistance, the cost of housing weighs most heavily on those with the least resources. Black households, young and old, are the most vulnerable,

especially black renters, who had both the highest rates of physical deficiencies (46 percent) and

of excess housing expenditures (58 percent).

Thus, for households not receiving housing

assistance, the risks of housing inadequacies and

excessive costs are distributed differently among

subgroups of the population:

●

●

●

●

Among all households, renters are most likely

to face physical deficiencies in their units.

Among all renters, those who are black, poor,

and/or elderly are more likely to live in physically inadequate housing.

In contrast to the nonelderly, impoverished

elderly owners with mortgages are most likely to be in housing with physical inadequacies, followed by impoverished elderly renteroccupied households.

Except for owners without mortgages, the

poor of all age groups are highly likely to

have excess housing expenditures. Over onehalf of renter-occupied elderly households

were burdened by excess housing costs.

Recent changes in

expenditures and deficiencies

While higher proportions of older Americans

have consistently had excess housing expenditures, the relative change in this burden during

the late 1970s was generally lower for the elderly

than for the nonelderly (71). From 1974 to 1979,

the incidence of excess housing expenditures increased by 38 percent among all nonelderly and

29 percent among all elderly households. The notable exception was for elderly owners with mortgages. Although comprising only one-fifth of all

elderly homeowners, those with mortgages had

an increase in housing expense burden of 61 percent (for nonelderly mortgagees the increase was

52 percent). Elderly renters had a notably lower

increase of 26 percent in the incidence of excess

housing expenditures.

The greatest increase in cost burden was for

owners without mortgages: 67 percent for the

elderly and 89 percent for the nonelderly. Lowincome elderly and nonelderly households had

distinctly lower net cost increases from 1974 to

1979, except for owners without mortgages.

These data indicate that owners without mortgages, in all age groups and regardless of poverty

status, experienced the greatest increases in excess housing costs during the late 1970s.

An additional problem occurred for elderly

owners with mortgages: a notable increase of 14

percent in households occupying units that were

physically deficient (3 percent for the nonelderly).

Indeed, for the elderly and nonelderly groups, the

only increases in incidence of deficiencies were

for owner-occupied households with mortgages.

Renters and mortgage-free owner households of

all ages had decreases of up to 31 percent in physical housing deficiencies.

Clearly, the trend is toward better quality housing for most households, except for poverty-level

elderly owner-occupants with mortgages. The

1974-79 increase in the incidence of physical deficiencies in their units was an extremely high 72

percent. These households of older persons are
Ch. 9–Technology, Housing, and the Living Environment of the Elderly . 287

least likely to either undertake or afford regular

maintenance or major repairs. As a result, these

dwellings–already likely to be among the oldest

housing stock–suffer the consequences of this

neglect.

Among elderly households themselves, some

further differences exist in housing quality and

excess expenditures. Available data from the AHS

indicate that owner-occupied households maintained by persons over 70 have higher incidence

of physical deficiencies as well as excess expenditures than households headed by those 65 to 69.

These differences exist for both mortgaged as well

as mortgage-free elderly households. For example, 10 percent of mortgaged owners over 70 v.

4 percent of those 65 to 69 were in physically deficient housing in 1979. For those without mortgages, the proportions were 11 and 9 percent, respectively. Similar age-based differences were

found with respect to excess expenditures, particularly among owners with mortgages. Excess

costs were experienced by 28 percent of heads

of household over 70 and by 23 percent of those

65 to 69 (71).

Among elderly renters, 50 percent of households headed by persons 65 to 69 and 58 percent

of households headed by those over 70 had excess housing expenditures. The one exception to

these differences is for physical deficiencies,

where 19 percent of households headed by younger elderly and 16 percent of those headed by persons over 70 were in physically deficient units.

These survey data suggest some additional generalizations about trends and changes in the housing status of older Americans. Among households

not receiving housing assistance, the following

major trends occurred from 1974 to 1979:

● Overall, housing quality improved for most

elderly as well as nonelderly households,

especially poor renters and owners without

mortgages.

● Elderly households without mortgages had

the highest increase in the incidence of excess housing costs.

●

●

●

These two trends imply that improvements

in the quality of housing among the elderly

have been “bought)” in part, at the cost of

greater expenditures for both renters and

mortgage-free households.

Among all tenure groups, only elderly

owners with mortgages had a net increase

in the incidence of physical deficiencies, compounded by a high increase in excess expenditures.

Among elderly owners, the older the head

of the household the greater the degree of

both housing deficiencies and excess expenditures.

Thus, elderly households as a whole are less

well housed and burdened by greater excess expense than nonelderly households. But such a

generalization ignores even more important differences that are relevant to Federal housing policies, especially those concerned with targeting

resources where they are most necessary.

One implication is that careful targeting of public policy for housing assistance could go beyond

the current emphasis on low-income renters, both

elderly and nonelderly. Notably vulnerable are

those older homeowners who have both mortgage indebtedness and household incomes below

the poverty level. They number up to 280,000

households, one-third of which are in physically

deficient units. Moreover, most of these deficient

dwelling units were built before 1940) and many

need major structural repairs and greatly improved maintenance.

Even though the monthly mortgage amount

may be small relative to the average for newer

mortgages, it is sufficiently burdensome to this

group of poverty-level householders to place them

among the three-fourths with excess expenditures. Thus, the clear dilemma for this subgroup

of the older population is their high probability

of living in deficient and possibly dangerous housing, while being the least likely to afford improvements to the dwelling unit.
288 . Technology and Aging in America

Housing and environmental fit of the

impaired elderly

Another aspect of the housing situation of elders

concerns not only the quality and cost of housing, but its viability as a supportive environment

for older persons who have limitations in functional abilities or suffer from chronic impairments.

Congress and the Federal Government have exhibited growing concern since the early 1960s for

functionally limited or disabled persons.’ However, such concern has primarily been for rehabilitation programs directed toward those who

are considered employable (e.g., largely through

vocational education and training programs).9 Far

less concern has been shown for developing support for older disabled persons who are not likely

to be in the paid labor force.

Only in the last decade, after considerable pressure from advocacy groups, has Federal legislation been created to broaden the scope of assistance and protection for disabled persons of all

ages. An example is the 1978 amendments to the

Rehabilitation Act, one section of which emphasized and affirmed the civil rights of all disabled

Americans. Two other examples are the 1976

amendments to the Architectural Barriers Act and

amendments to the Housing and Community Development Act, both of which attempted to assure

equal access to federally owned, operated, and

subsidized commercial or residential buildings.

But most programs for the disabled remain targeted toward employment opportunities, income

maintenance, and health care (83). Few are specifically oriented toward promoting independent living; those that are have only recently been developed and implemented in a haphazard and

slow manner. Notwithstanding such limitations,

these recent efforts attempt to promote the max-

%ee ch. 7 for a more detailed discussion of functional limitation

or disability, chronic conditions, and other factors related to phys.

ical and mental impairments among the elderly.

‘Major legislative initiatives in this regard were the Education of

the Handicapped Act and its Amendments, the Rehabilitation Act

of 1973 (and especially, its 1978 Amendments), and the Vocational

Education Act of 1963.

imum independence of disabled and elderly persons by providing financial assistance and incentives for self-care and services in the least

restrictive environment,

Age, impairment, and the

housing environment

The evolution of Federal programs benefiting

the disabled and elderly occurred in part because

of the growing recognition that physiological aging is often accompanied by decrements in functional abilities (32). Recent legislative objectives

pay more attention to the problems of functional

impairment among the elderly. But definitive

information on the functional problems of the

elderly in their housing environment is limited.

Descriptive, but sometimes inconclusive or contradictory, research on aging and the environment has been developed on issues such as the

neighborhood (25,59), types and quality of housing (44), and institutional living (34,96). Federal

housing and aging programs respond only in part

to these issues, even though they have become

increasingly relevant to older people. As the older

population itself continues to age, the challenge

grows for assisting older persons to maintain independence in their housing units and the community.

Their demographic and household characteristics can either enhance the ability of older persons to live independently in their own homes or

exacerbate problems they encounter in daily activities. For instance, informal supports from

family or other household members often substitute for public agencies or technological applications in the home to assist older persons who are

frail or unable to independently carry on activities of daily living.

Impairment and disability

The impact of functional limitations is best understood by distinguishing among the concepts
Ch. 9—Technology, Housing, and the Living Environment of the Elderly ● 289

of “impairment, “ “disability,” and “handicap” (83).

Impairments are physical or mental abnormalities

that can be identified or diagnosed. (Chs. 3,4, and

7 discuss impairments that are particularly evident in the elderly.) An impairment, such as

chronic hypertension or severe arthritis, may become a disability if it interferes with the person’s

ability to perform one or more functions. In this

sense, disability relates most closely to functional

limitation and can be specified in terms of a person’s problems in performing regular activities

of daily living. These activities can range from personal care (basic) tasks, such as bathing and dressing, to instrumental tasks, such as working, shopping, or driving an automobile. 10 One or more

disabilities are considered a handicap only in

terms of the social and environmental context of

the disabled individual. When a disability cannot

be overcome by technological intervention (e.g.,

anti-hypertensive drugs or prosthetic devices),

formal or informal supports (e.g., family assistance or home chore services), or other types of

assistance, it becomes a handicap (100).

But determining when such a handicap is present is often difficult. The same disability can be

a handicap in one environment but not in another, as well as for one individual but not for

another in the same environment. This dilemma

is one reason that accurate measurement of functional limitations must include many domains, including social resources, personal feelings of wellbeing or control, and environmental fit (36). For

example, a person disabled by severe arthritis

may be handicapped in a two-story house but not

in a single-level one. In addition, the values and

attitudes of disabled persons concerning their impaired status and the nature of their living environments will affect their feelings of constraint

or degree of handicap.

This approach has been well developed in studies on the psychosocial aspects of institutions for

older people, particularly nursing homes. Kahana

(34) developed a model of “person-environment

congruence” to explain how behavior varies in

response to the physical, social, and psychologi-

‘Xh. 7 discusses such activities as “basic physical activities” or

“home management activities.” These terms are used interchangeably with those in this chapter, such as “activities of daily living”

(ADL) or “instrumental activities of daily living” (lADL).

cal milieu of the institutional residential environment. others have developed similar person-environment interaction models that can be more

generally applied to other residential situations.

In the latter, the range of possible behaviors and

responses of the individual is greater, because

control and adaptation are more probable. The

optimal environment is one that “fits” or is congruent with the needs of the individual.

For older persons with some degree of functional impairment, environmental congruence becomes more difficult to achieve. This problem has

been conceptualized as “competence and environmental press” (45). “Competence” represents the

individual’s functional capacities in terms of

health, perception, cognition, and motor skills.

“Environmental press” is a type of environmental

stress or demand placed on the individual that

activates behavior. The relationship between the

individual’s competence and the environment’s

press creates a broad spectrum of adaptive behaviors. The more competent the individual, the

greater the ability to respond positively to environmental press. A schematic diagram of this interaction is shown in figure 27.

Figure 27.—Schematic Diagram of the Competence

and Environmental Press Model: Behavioral

Outcomes of Person-Environment Interaction

High

Low

I

t

Weak Strong

Environmental press

SOURCE: Adapted from Lawton and Nahemow, 1973 (45).
290 . Technology and Aging in America

But it is difficult to determine when environmental press is strong enough to induce functional dependence in the older person (i.e., when he

or she moves from the marginal to the maladaptive behavior situation in fig. 27).

Although these interrelations are situation-specific, they suggest broader applications for the

older population as a whole. In general, chronically disabled persons are likely to become increasingly dependent as they age; this is a function of lowered physiological reserve and increased

prevalence of multiple disabilities (100). This likelihood, combined with the knowledge that the social supports and physical environment of the

elderly can be altered, indicates the need for increased efforts to implement home-based supportive strategies.

Prevalence of disability

Assessing or measuring the extent of functional

disability among the noninstitutionalized elderly

is imprecise, in part because of the nebulous and

contextual distinction between disability and

handicap. Two important benchmarks of the difference between the institutionalized and noninstitutionalized elderly are their relative rates and

degrees of functional disability and dependence

on others for supportive care (99), As noted in

chapter 7, institutionalized elders are highly likely

to suffer from at least one mental or physical impairment. An estimated 50 to 60 percent of elderly

persons in nursing homes have some degree of

organic mental disorder, primarily dementia of

the Alzheimer type. Almost 9 out of 10 institutionalized older persons have at least one chronic

impairment. From the perspective discussed

above, they are disabled persons with inadequate

environmental supports in the general community (high environmental press), which necessitates some type of institutional care.

The characteristics of institutionalized older

persons contrast with those of community dwelling individuals in terms of person-environment

congruence. Although the data are by no means

satisfactory, differences in impairment levels between these two groups of elderly persons can

be discerned. Two of the most common survey

measures of disability are the ‘(activities of daily

living” (ADL) and the “activity limitation” scales.

The ADL measure appears in a number of functional assessment instruments used in community

studies, clinical evaluations, and needs assessment

surveys for aging program development. The

ADL scale measures whether the individual needs

help in performing six basic activities: eating,

dressing, transferring (to/from bed or chair),

bathing, toileting, and maintaining continence.

The original ADL scale (37) is often used in conjunction with the measures of “instrumental ADL”

that indicate need for assistance in preparing

meals, doing housework, going shopping, or handling money.

Risk of nursing home admission is most highly

associated with dependency in a number of ADL

tasks. An analysis of merged data from the 1977

National Nursing Home Survey (NNHS) and the

1977 National Health Interview Survey (NHIS) indicated that major predictors of nursing home

residency included: 1) dependency in many ADLs

(especially the basic ones of eating, toileting,

bathing and/or dressing); 2) a diagnosed mental

disorder; 3) poverty; and 4) lack of a spouse/

widowhood .11 These conclusions can be compared

with the findings of other studies that functional

impairments increase dramatically with age, especially among persons over age 85. (For detailed

data, see ch. 7.)

When this information is combined with other

data from surveys of older persons who are living in nursing homes, different characteristics

emerge in terms of the degree, extent, and types

of functional impairments that exist among the

young old, old old, and very old subgroups in the

older population. Table 30 summarizes one aspect

of these differences.

This information adds another perspective to

the demands that functional impairments make

on elderly persons in the community. The residential environment and the types of support that

can be provided to mitigate these impairments

take on increasing importance as a person’s age

1lThese merged data allowed comparison between a nationally

representative sample of the community dwelling elderly population and a sample of nursing home patients comprised largely of

those who were “residents” for more than 3 months (i.e., longstayers). Most “admissions” to nursing homes are short-stayers whose

chronic impairments are different (47,99).
Ch. 9–Technology, Housing, and the Living Environment of the Elderly • 291

Table 30.—Persons Needing Help in Basic Activities

of Daily Living and Persons in Nursing Homes,

by Selected Ages: United States, 1977

(percent distribution)

(A) (B)

Percent with Percent in

basic ADL nursing Ratio of

Age group dependency homes “B,, t. "A"

65-74 . . . . . . . . . . . 3.50/0 1 .4 ”/0 .40

75-84 . . . . . . . . . . . 11.3 6.4 .56

85+ . . . . . . . . . . . . 35.1 2.6 .61

~hese figures include all persons who reside in either the community or in nursing homes and who are dependent in one or more basic ADL tasks.

SOURGE: Health Care Financing Administration, January 1981 (91).

approaches 85. One inference from these data is

that, all things being equal, the risk of institutionalization is not as great for those elderly who are

impaired in instrumental ADL (e.g., shopping or

housework) as compared with basic ADL tasks.

It is for impairments in instrumental ADL that

families, community resources, social services,

and various technologies are most likely to provide assistance.

This conclusion is corroborated by studies of

“burnout” by family caregivers of functionally impaired elderly. A “crisis threshold” appears to exist, at which point the stress on family caregivers

becomes too great and institutionalization of the

disabled parent or spouse is highly likely (102).

When incontinence or the inability to feed oneself

becomes severe, or other basic physical or mental abilities are greatly diminished, the supports

(informal, formal, or technological) maybe insufficient to permit continued residence in the home.

Other measures of functional disability also

show greater prevalence among the elderly. Degree of “limitation in activity,” generally disaggregate by “major” and “nonmajor” activities, is a

commonly used measure. There are limitations

to the inferences that can be made from these

data, because of questions concerning how older

retired persons may interpret the word “major”

(paid work is the most common referent for “major activity”). Although the incidence of major limitations among the retired elderly may be underreported, the NHIS data indicate a consistent

relationship between increasing age and the prevalence of activity limitations and ADL dependency

(table 31).

In 1981, 47 percent of all noninstitutionalized

persons over age 65 had some kind of limitation

in their daily routine. Of these persons with limitations, 86 percent were limited in a major activity, i.e., paid work or housekeeping (93). Thus, 4

of every 10 elderly people have some degree of

major restriction in their environment, and this

ratio increases dramatically for the very old (63

percent; table 31). The chronic conditions primarily responsible for these activity limitations are

arthritis/rheumatism, heart conditions, visual impairments, and hypertension; these are followed

in prevalence by diabetes and hip or leg impairments.

The ability to cope with such restrictions often

depends on one or more of the following: 1) the

availability of persons who can provide assistance,

2) technologies and devices that assist the individual to perform tasks, and 3) environmental design that reduces the impacts of these restrictions.

According to 1979 data, the need by older persons for assistance in “any one” of seven basic

ADLs (i.e., an unduplicated count) increases dramatically with age. For all older persons in the

community, 9 percent need some type of assistance to perform any one of the basic activities.

Within the older population the proportion grows

dramatically from 5 percent of those 65 to 74 to

Table 31 .—Noninstitutionalized Persons With Activity Limitation Due to Chronic

Conditions, and Persons Dependent in Selected Basic Activities

of Daily Living (ADLs), by Age: United States, 1977 (percent)

All ages 45-64 65-74 75-84 85+

With activity limitation . . . . . . . . . . . . . . . . . . . . 13.5% 23.0°/0 38.6°10 48.4% 63.2%

Dependent in at least one ADLa . . . . . . . . . . . . 0.7 0.7 2.2 5.8 15.0

Dependent in four ADLs. . . . . . . . . . . . . . . . . . . 0.1 0.1 0.4 0.6 3.7

%he activities of daily living (ADL) in these data include bathing, dressing, eating, and toileting

SOURCE: Health Care Financing Administration, January 1981 (91).
292 . Technology and Aging in America

35 percent for persons over 8512 (94). Slightly

higher proportions are found for persons needing

assistance in instrumental, or home management,

activities (10.5 percent of all older persons in the

community, ranging from 6 percent of the 65 to

74 group to 40 percent of those over 85).

Therefore, based on an estimated elderly noninstitutionalized population of 26 million persons

in 1983 and the NCHS 1979 survey data noted

above, more than 2.3 million older Americans living in the community need assistance in performing a basic ADL such as bathing, dressing, or walking. More than 2.7 million need assistance with

instrumental activities such as shopping, household chores, etc. Although the data do not account

for the relationship between the two groups of

tasks, most persons needing assistance with basic

activities are probably included in the number requiring home management help. As discussed

later in this chapter, such assistance can be from

persons who provide informal supports, formal

services, technologies in the home and community, or some combination of these.

The restrictions faced by most older persons

do not, in general, confine them to their homes.

Problems with mobility and the need for assistance increase both by age and by distance from

the home. In 1977, just over 8 percent of all older

persons in the community needed help in getting

around outside their neighborhood. Within their

neighborhoods, 6 percent required mobility assistance and less than 3 percent needed help getting

around within the dwelling unit. Table 32 indicates the positive relationship of distance from

home and increasing age with need for mobility

assistance among the elderly.

Two other mobility limitations should be considered regarding older persons living at home.

Although table 32 shows that their prevalence increases outside the home, mobility restrictions in

using stairs around or within the home are especially problematical for the elderly. They are a

major contributor to falls among the elderly, who

are highly vulnerable to them; the elderly account

‘These figures increase for rates based on assistance needed in

“one or more” ADLs (i.e., a duplicated count): 7 per 100 age 65 to

74, 16 per 100 age 75 to 84, and 44 per 100 age 85 and over. These

rates cannot be translated into unduplicated population figures.

Table 32.—Mobility Limitations Due to Chronic

Conditions Among Noninstitutionalized

Persons, by Age: United States, 1977 (percent)

Mobility limitation 65+ 65-7 4 75-84 85+

Outside the neighborhood. .8.4 4.6 12.0 30.6

Within the neighborhood . . . 6.0 3.1 8.3 24.4

Within the house. . ........2.6 1.4 3.5 10.8

SOURCE: NCHS, unpublished data, 1963.

for more than two-thirds of all deaths from falls

in the United States. Special tabulations from the

1978 AHS indicate that almost 10 percent of those

older persons sampled had specific mobility limitations in “going up or down stairs, ” compared

with only 4 percent who had problems “getting

around inside the dwelling” (54). The same AHS

tabulations showed that 3 percent of the elderly

were limited in their ability to “use equipment in

the dwelling” (e.g., kitchen, bathroom, etc.). Overall, 13 percent of the AHS respondent sample had

at least one limitation in “personal mobility” (54).

These data from various sources lead to the following generalizations about the functional abilities of older noninstitutionalized persons and the

implications regarding their living environments:

●

●

●

●

Available indices of functional impairment indicate that dependence in basic ADLs (especially eating and toileting) is much greater for

institutionalized older persons, as is mental

confusion. Such dependency increases greatly for persons over 85.

Risk of institutionalization is related to person-environment congruence; the older the

person is, the more likely that this congruence will not exist for the community-dwelling elderly (in independent households). This

risk is exacerbated for those who are poor

and who live alone.

Dependence in instrumental ADLs, such as

shopping and housekeeping, is more likely

to be mitigated by different types of support,

such as those from family and friends, formal services, and assistive devices.

Past survey data suggest that among the 26

million older persons living in the community in 1983:

—2,3 million needed some type of assistance

in performing one or more basic ADLs (personal care);
Ch. 9—Technology, Housing, and the Living Environment of the Elderly Ž 293

—2.7 million needed some type of assistance

in performing instrumental (home management) activities;

–persons dependent in basic ADLs are highly likely to also be dependent in instrumental ADLs, but not necessarily vice-versa;

—10.5 million had some type of limitation in

a major activity, and an additional 1.7 million were limited in a minor activity;

—mobility limitations are less prevalent than

other types of functional impairments, except for using stairs (affects 2.6 million) and

traveling outside one’s neighborhood (affects 2.1 million); and

—approximately 780,000 had a notable limitation in using household appliances and

equipment.

● Except for the measure of general activity

limitation, the prevalence of functional impairments (basic and instrumental ADLs, mobility, etc.) is highly correlated with increasing age. In general, prevalence of such

impairments:

–doubles from age 65-74 to 75-84; and

—triples from age 75-84 to 85 and over.

● These rates of major functional impairment

by age are 11⁄2 to 2 times higher for black

older men and women.

The various problems with everyday tasks that

the elderly face can have a profound influence

on their sense of worth and well-being, and their

ability to maintain an independent lifestyle. The

prevalence data presented above are based on

measures that include only those older persons

who need assistance, experience limitations in certain activities, and have problems with mobility.

It is not possible, given existing data and resources, to estimate the additional number of

older persons who may have marginal levels of

functional impairment or who do not readily admit such problems, incapacities, or needs.

The aforementioned prevalence data are likely

to reflect the minimum degree of functional impairment among older persons who are not institutionalized. The importance of promoting

housing environments that ameliorate these problems is, therefore, that much greater. But these

supportive environments require very different

levels of commitment and assistance from both

formal and informal sources, as well as physical

characteristics that can promote person-environment congruence.

As noted earlier in this chapter, most informal

supports for noninstitutionalized elders come

from available family members, especially spouses

and daughters (31,64). It is also clear that such

support is far more readily available for instrumental tasks than for personal care requirements,

since the former can often be provided by friends

and neighbors as well as family members (1,85).

Most of the research consistently finds that approximately four-fifths of all supportive care is

provided by these informal caregivers and the remainder by formal service agencies (64; also, see

ch. 7).

Some research also indicates that a hierarchy

exists in the composition of the informal support

network. When available, spouses are the primary and usually the sole providers of assistance,

followed by a daughter or other close family

member. Friends and neighbors tend to be primary caregivers only when family support is unavailable, and if the recipient is a long-time

neighborhood resident (69). Finally, for the great

majority of community-dwelling elderly who do

not have major functional impairments in personal care activities, little or no help is provided.

When help is needed, it is most likely to be for

light housework, heavy chores, and shopping (4).

It remains unclear to what extent the application of technology to the physical housing environment and technological applications within the

house mitigate the need for supportive assistance.

As the remainder of this chapter indicates, the

existing type, design, and nature of housing occupied by most older persons does not provide

the kind of supportive environment that many

older persons need in order to carry on daily

activities with a minimum of dependence on caregivers. In general, Federal housing policies and

programs have not been developed to encourage,

much less provide, such supportive environments

for older persons,
294 • Technology and Aging in America

Evolution of Federal housing policy for the elderly

The role of the Federal Government in assisting

older Americans with their housing requirements

has its roots in the evolution of Federal involvement in housing policy for all age groups. As in

many other areas of public concern and government assistance, housing policies specifically for

the elderly are a relatively recent development

in the history of U.S. housing assistance programs.

General housing policy and

Federal programs

The involvement of the Federal Government in

housing ranges from direct provision of dwelling

units for specified populations to indirect incentives and benefits provided through the Internal

Revenue Code (e.g., Federal income tax deduction

for mortgage interest paid by homeowners and

tax incentives for housing developers). This chapter briefly reviews only the most relevant components of Federal housing policies and programs

involving the elderly.

The Federal Government first became involved

in housing during World War I, when 5,000 units

were constructed primarily to provide housing

for defense workers. The project was costly and

inefficient, and ended with the Armistice. During the post-Depression period, Federal involvement in housing was resurrected. As part of the

National Industrial Recovery Act, the Federal Government subsidized the construction of low-rent

housing to assist the unemployed, the poor, and

the housing industry itself (24).

The genesis of public housing was the Housing

Act of 1937 that, as noted at the beginning of this

chapter, established the general goal of Federal

involvement to assist local units of government

in providing “safe and decent” housing for lowincome families. The Federal Government was no

longer involved in direct management and construction of public housing units. Moreover, the

Act of 1937 primarily served the “submerged middle class” (12) by providing temporary housing

during the economic recovery. During the period

following World War H, public housing increasingly became the domain of the long-term poor,

as the new middle class benefited from FHA mortgage insurance programs and the GI Bill.

The changed nature of Federal public housing

goals was reflected in the National Housing Act

of 1949, which developed the first major statement for a national housing policy oriented

toward urban renewal, slum clearance, assistance

to the poor, and subsidies to the housing construction industry, Indeed, the construction of public

housing was designed to be efficient, high-density,

standardized, and adequate for an average family

with children. No distinctions were made for

other possible groups of tenants or types of units.

Not until the mid-1950s was Federal legislation

for assisted housing specifically targeted toward

the elderly.

Federal housing programs for

older Americans

During the 1950s, Federal legislation began to

reflect attention to the growth of the older population and some of the special problems faced

by older Americans. One arena for this awareness

was public housing. The Housing Act of 1956 was

the first to make explicit reference to the elderly

as a special subgroup. The Act included four relevant provisions that:

●

●

●

●

expanded the definition of “family” to include

single persons over 65 in the eligibility

criteria;

allowed local public housing authorities to favor elderly persons (“families”) in tenant selection;

allowed certain private institutions to assist

with mortgage payments for persons over 60

who had low-incomes;13 and

eased FHA mortgage insurance qualification

criteria for those over 60, recognizing them

as a special group.

This expansion of public housing legislation for

older persons coincided with growing national

Whia provision of the 1956 Housing Act was the first step toward

future legislation that encouraged private sponsorship arrangements

for development of low- and moderate-income housing for the

elderly.
Ch. 9—Technology, Housing, and the Living Environment of the Elderly • 295

awareness of and response to the elderly as a special group in need. Passage of the Medicare program in 1965, after more than a decade of effort,

was one example of such attention to older Americans (30,50). During this period, however, the

elderly themselves were not a homogeneous political force with a strong group consciousness (3).

Yet they were often generally characterized as

the “deserving poor” and, in a sense, used as a

moral force for enacting social programs that

might not otherwise have been politically feasible if proposed for the population as a whole.

Housing legislation for the elderly may have

been especially favorable in this regard, since public housing projects for the nonelderly were often

viewed as undesirable or threatening to the neighborhoods adjoining them. During the 1960s, HUD

attempted to institutionalize the decentralization

of public housing by applying funding pressure

on suburban governments to accept low-income

projects. Similar to the introduction of Medicare

as a political compromise for a universal national

health insurance program (30), public housing exclusively for the elderly “appears to have been

a convenient compromise for many [congressional]

committees” (52).

Local public housing authorities were far more

likely to propose and win community approval

for projects oriented toward the elderly, especially in neighborhoods that required changes in zoning ordinances. Cost considerations for both public housing authorities and private sponsors also

made elderly housing projects attractive because

they were exempt from the density and net area

coverage limits of nonelderly housing. For many

communities, low- and moderate-income housing

for the elderly was an acceptable and even welcome alternative to other types of public housing (42).

The following synopsis indicates the extent of

Federal involvement in housing programs that

benefit the elderly. Because communities have

generally favored HUD-subsidized housing for the

elderly over other types of public housing, most

new construction of subsidized housing in the last

decade has been for projects intended solely for

elderly occupants. But the two HUD programs

specifically for the elderly (Section 202 and Section 231) have, overall, provided a relatively small

number of dwelling units. Table 33 summarizes

the various housing programs and their impact

on older persons. There are no Farmers Home

Administration (FmHA) assistance programs solely

targeted for older persons, except for one part

of the Section 504 program (as described below).

It is important to note that Federal housing legislation has a very complex history. Most of the

programs have been revised, changed, canceled,

resurrected, or altered from their original legislation by congressional, regulatory, or executive

action. The brief review presented here only highlights their characteristics.

DEPARTMENT OF HOUSING AND

URBAN DEVELOPMENT PROGRAMS

Low-Rent Public Housing.–As noted earlier, public housing began with the Housing Act

of 1937, and is the oldest housing program of the

Federal Government. It has provided the greatest number of units for the elderly, who currently

occupy about 45 percent of all low-rent public

housing units. Local housing authorities, assisted

by HUD funding, create and manage this housing for families and older persons who meet local

income eligibility standards. Tenants’ rents cannot exceed 30 percent of their adjusted incomes14

(33).

This program is still active, but has recently experienced difficulty in finding acceptable sites for

new units and in subsidizing the operating costs

of existing units (44,81). It provided over 500,000

low-rent units for the elderly in 1982.

Section 8 Rental Subsidies—Another major

form of Federal housing subsidy is the Section 8

program created by the Housing and Community

Development Act of 1974. It guarantees payment

of a per-unit subsidy to owners of rental property occupied by qualified tenants (i.e., those with

incomes below 80 percent of the median in the

metropolitan area). The subsidy pays the difference between 30 percent of the tenant’s income

and the HUD-established “fair market rent .“ The

1

4

’’ Adjusted income” is based on a variety of factors such as size

and type of household, age of the head-f-household, number of

dependents, cash benefits, and other factors.
296 . Technology and Aging in America

Table 33.–Summary of Housing Units for the Elderly Currently Subsidized by

Selected Federal Housing Programs: United States, 1981-82

Estimated number

Of occupied Of units occupied Elderly units as

units by the elderly percent of total

HUD programs: a

Public housing. . . . . . . . . . . . . . . . . . . 1,121,972 500,885 44.60/o

Section 8. . . . . . . . . . . . . . . . . . . . . . . . 1,211,211 630,11 lb52.0

Section 202. . . . . . . . . . . . . . . . . . . . . . 58,773 58,773 100.0

Section 236. . . . . . . . . . . . . . . . . . . . . . 386,754 71,800 19.0

Section 231.... . . . . . . . . . . . . . . . . . . 44,088 44,088 100.0

Section 221(d)(3)

Rent supplement . . . . . . . . . . . . . . . 81,252 6,195 8.0

BMIR . . . . . . . . . . . . . . . . . . . . . . . . . 113,960 259 0.2

Section 232.... . . . . . . . . . . . . . . . . . . 147,336C

147,336 100.0

Total. . . . . . . . . . . . . . . . . . . . . . . . . . 3,165,346 1,459,447 46.1

FmHA programs:d

Section 502..... . . . . . . . . . . . . . . . . . 1,119,091 26,363 2.4

Section 504:

Loans . . . . . . . . . . . . . . . . . . . . . . . . . 51,296 NA NA

Grants . . . . . . . . . . . . . . . . . . . . . . . . 39,269 39,269 100.0

Section 515.... . m . . . . . . . . . . . . . . . . 116,102 39,475 34.0

Total . . . . . . . . . . . . . . . . . . . . . . . . . . 1,325,758 NA NA

aFigUreSfOrHuD prograrnsrepresentunits currently insured asofJune 1982, whethertheprogram iSaCtive OrinaCtive. These

are not cumulative figures over the history of each HUD program. bFlgureSdOnOt lncludesectionzoz households receiving Section 8subsldies.

cThe “units” for this program are nursing home beds.

dFigUreSfOrFrnHA programs arecumulatlve as of September 1981.

SOURCE: Adapted from Congressional Research Service, 1982 (79~ and Cohen 1983(16)

owner-developer may be either a profit-making

or nonprofit sponsor. Where Section 8 subsidies

are provided for elderly housing, the units are

generally developed through the Section 202 program. These rental units may be newly constructed,

existing, or substantially rehabilitated.

The Section 8 rental subsidy program remains

active) with more than 50 percent of the beneficiaries (over 630,000) being elderly households.

Currently, there are problems with cost inflation

of rental subsidies for new construction units

(versus those for existing units) and undesirable

long-term commitments of Federal subsidy funding. These problems are being considered in proposed legislative amendments.

Section 202 (and Section 236) Elderly Rental Housing Mortgage and Rent Subsidies.—

The Section 202 program was first authorized by

the Housing Act of 1959, phased out in 1969, and

renewed by the Housing and Community Development Act of 1974. The original program provided 50-year direct Federal loans at 3 percent

interest to nonprofit sponsors of multi-unit housing built specifically for low- and moderate-income elderly (age 62 and over) and handicapped

persons. Over 45)

000 units were developed before

the program was temporarily replaced by Section

236 under the Housing Act of 1968.

The latter program (Section 236) required mortgages at market rates, with no occupancy restrictions as to type of household. Federal interest

reimbursement to the developer reduced the real

interest rate; the amount of the subsidy was based

on the number of low-income tenants served. Section 8 replaced Section 236 in 1974, although a

few new starts have occurred since then from

commitments made prior to that time. Because

Section 236 only subsidizes mortgages, rapidly increasing operating costs and relatively small increases in rental income have troubled these projects. Currently, about 72)000 units under Section

236 assistance (19 percent of the total) are occupied by elderly households.

The reauthorization of Section 202 in 1974

changed the financing period to 40 years, with

interest rates that approximate the market rate.
Ch. 9—Technology, Housing, and the Living Environment of the Elder/y • 297

Subsequent amendments limit the interest rate

to 9.25 percent for nonprofit sponsors of these

projects. The 1974 reauthorization was important

because it:

●

●

●

●

●

promoted greater heterogeneity of tenants

by encouraging a mix of low- and moderateincome households;

encouraged a more equitable distribution by

increasing the number of units constructed

in nonmetropolitan areas or away from central city core neighborhoods;

coordinated with the Section 8 rental subsidies to promote affordable housing for lowincome elderly households;

called attention to the special design features

that are important in units for the elderly;

and

broadened the definition of ‘( family,” specifically for the elderly, to include two or more

older persons living together (who need not

be related) or one older person plus an “essential person” who provides assistance.

These changes and new emphases made the

combined Section 202/Section 8 program more

attractive to State and local public housing authorities, as well as to nonprofit sponsors (44). One

remaining shortcoming in the program is the continued under-representation of small communities in nonmetropolitan areas in development of

Section 202 or other HUD-subsidized housing.

FmHA housing programs have not filled this void,

in part because the sponsor qualification criteria

of both HUD and FmHA15 limit the likelihood that

small town and rural nonprofit entities can be

eligible sponsors for such projects (29).

In mid-1982 the Section 202 program was providing almost 59,000 units for the elderly and

handicapped. ” Recently, the program has become

more responsive in providing the supportive environments needed by many older persons, including cooperative demonstration programs that incorporate congregate social services into the

housing. However, recent legislative proposals

‘Whe criteria tend to favor projects with so or more units, supportive services, secure financing, and prior experience with such

housing development—all of which are less likely for nonmetropoli -

tan area sponsors.

‘Whese figures are for “currently” insured or subsidized units.

They are not “cumulative” numbers since the program was initiated.

(e.g., ‘the Housing and Urban-Rural Recovery Act

of 1983) have been designed to phase out Section

202 over the next few years, with restructuring

of financing and other program changes anticipated for 1985. Nonprofit sponsorship, flexibility

in unit-cost limitations to account for design features that accommodate the elderly and handicapped, and increased attention to shared housing are features of these legislative changes (81).

Section 231 Rental Housing Mortgage Insurance.—The Housing Act of 1959 also authorized the Section 231 mortgage insurance program.

Federal insurance was provided for market-rate

loans obtained by either nonprofit or profit-making sponsors of rental housing (new construction

or substantial rehabilitation) for people in middleand higher-income ranges; at least so percent had

to be occupied by the elderly or handicapped.

These units tended to be “upscale” in design and

quality. Special services and facilities for the

elderly were encouraged.

A number of these projects were developed as

“retirement centers” or “life care communities”

that provided many supportive services, including

medical and nursing care when necessary. These

projects usually required large “entrance fees” for

those advantages, reinforcing the selective bias

toward the more wealthy. The entrance fee

charge was prohibited in 1963 as a sign of Federal commitment to those most in need of assistance. The program has suffered a very high failure rate through default or foreclosures.

Although still “active,” Section 231 is not emphasized as an important component of Federal

housing policy. In mid-1982 there were over

44,000 units occupied by the elderly; 9 out of 10

are in urban areas.

Section 221(d)(3) Below Market Interest

Rate Subsidies and Rent Supplements.--The

Section 221(d)(3) program was created by the

Housing Act of 1954 and was the precursor of

the Section 236 program. It has had minimal impact in providing housing assistance to the elderly.

The program initially provided mortgage insurance for multi-family rental housing for low- and

moderate-income tenants, but in 1961 it added

interest rate subsidies for developers. The subsidies created a “Below Market Interest Rate” (BMIR)
—.

298 . Technology and Aging in America

by paying the difference between 3 percent and

the market interest rate financing obtained by the

housing sponsor. No income limits were used to

restrict occupancy, but not until 1964 did the program permit elderly persons living alone to be eligible tenants. Also, rent supplements were made

available to low-income households.

The program has been phased out since enactment of Section 236 and, subsequently, the Section 8 rental subsidy program. Currently, a few

hundred elderly units are assisted under the BMIR

program, and 6,000 units receiving rent supplements are occupied by the elderly (8 percent of

the total).

Section 232 Nursing Home Mortgage Insurance.—The Section 232 program subsidizes

the construction of nursing home and intermediate care facilities by providing mortgage insurance for their construction or renovation. Facilities must be built for at least 20 patients who

require skilled nursing or intermediate care. Eligible sponsors are profit-making or nonprofit corporations that meet all State licensing and regulatory requirements for nursing home development, By

1981 the Section 232 program had provided mortgage insurance for more than 1,300 facilities that

contained over 147,000 beds for elderly patients.

FARMERS HOME ADMINISTRATION PROGRAMS

In contrast to most HUD programs, which tend

to favor metropolitan areas and medium-sized cities, programs of the FmHA are limited to communities of no more than 20,000 persons that are

located within nonmetropolitan counties and communities of less than 10,000 persons within metropolitan counties.

Section 502 Rural Low-Interest Homeownership Loans.—The Section 502 program provides direct low-interest Federal loans to low- and

moderate-income families for the construction,

purchase or rehabilitation of housing. The housing must conform to FmHA standards, and the

loan recipients must be unable to obtain financing at affordable rates in their area. For very lowincome households, an “interest credit” subsidy

can be obtained that reduces the interest on the

loan to as low as 1 percent, but the recipient must

clearly be able to afford the property’s mortgage,

taxes, maintenance, and other payments to be eligible for this special subsidy.

Since its inception in 1965, the Section 502 program has provided over 1.3 million loans. It currently assists over 1.1 million households, only

2.4 percent of which are elderly. Given the higher

prevalence of physical deficiencies in elderly occupied housing in rural areas (29), it is unclear

why greater numbers have not been recipients

of the rehabilitation loans. One suggested explanation is that the incomes of most rural elderly

households are too low to qualify for these loans,

even the lowest cost ones with the interest credit

advantage.

Section 504 Rural Home Repair Loans.—

This program was developed to help very lowincome households who cannot qualify under Section 502. Section 504 provides home repair loans

at 1 percent interest and a payback period of up

to 20 years. The maximum loan amount is $5,000

and must be used for repairs that improve the

safety and sanitation of the dwelling. Allowable

repairs include those for the foundation, roof,

heating, water, and septic systems. Another common use of the loans is to repair or add kitchen

or toilet facilities.

Direct grants for similar repair needs can be

specifically provided to persons aged 62 and over

whose incomes are so low that they cannot repay

the costs of the repairs. Although the FmHA does

not maintain age-specific data across its programs,

Section 504 grants for elderly rural homeowners

(80 percent of all rural elderly own their own

homes) totaling $24 million were obligated in 1981

(81). Also, it has been estimated that 60 percent

of the FmHA home repair loans are made to elderly rural homeowners (78).

Section 515 Rural Rental Housing Loans.

—Although originally legislated to serve the

elderly exclusively, since 1966 the Section 515

program has included families of all ages. It provides direct loans for the construction, purchase,

or extensive rehabilitation of multi-unit rural

rental housing for low- or moderate-income families, including the elderly and the handicapped.

Sponsors can include individuals, public agencies,

profit-making corporations, and nonprofit organ-
Ch. 9–Technology, Housing, and the Living Environment of the Elderly ● 299

izations. Interest rates vary depending on type

of sponsor and proportion of units devoted to lowincome tenants (nonprofit sponsors can receive

loans at rates as low as 1 percent). Moreover, a

certain number of units in the project can qualify for rental assistance supplements from either

the HUD Section 8 program or a similar one through

the FmHA.

The FmHA estimates that approximately 34 percent of all Section 515 assisted units are occupied

by elderly households (16); about one-half of those

units receive rental supplement assistance.

OTHER HUD HOUSING ASSISTANCE PROGRAMS

Section 312 Housing Rehabilitation

Loans.—Authorized by the Housing Act of 1964,

the Section 312 program provides direct Federal

loans to property owners for housing rehabilitation that will bring the dwelling into compliance

with area building codes. Thus, the rehabilitation

work is often extensive in nature (in 1977 the

average loan was over $7)500). The loans carry

a 3 percent interest rate and a maximum payback

period of 20 years. Applicants must be unable to

obtain private financing on comparable terms in

their local area. Priority is given to applicants with

low or moderate income. However, the program

is available only to homeowners in areas where

other Federal programs such as urban renewal

or Community Development Block Grants (CDBG)

are under way. Because of these requirements,

the program tends to be available only in certain

areas of larger cities. Delays in the approval process, contractor payments, and other administrative problems have plagued the program (44).

Another problem, similar to that with the Section 502 program, is the bias against low-income

elderly applicants who may be considered high

risks for paying back the loan. This concern for

a client’s ability to repay the loan has grown because the program’s most recent reauthorizations

by Congress require that all new loans be funded

from repayments and recoveries from existing

loans. Precise data on the proportion of older persons receiving these loans are not available. Selected studies indicate that consistently less than

one-sixth of all loans are given to the elderly, a

figure that is notably below their proportion of

all homeowners. A sampling of program reports

in 1975-76 showed that less than 20 percent of

the loans were made to either the elderly or the

handicapped (70). In 1977, about 16 percent of

the loans went to homeowners aged 65 and over

(44). Figures for more recent years suggest even

lower proportions of loans went to elderly households. In 1980 and 1981, about 16 percent of the

loans were made to homeowners aged 62 and

over (86).

Community Development Block Grants

(CDBG).–The CDBG program provides considerable resources to communities for various development efforts aimed at improving housing and

neighborhoods in urban areas. Authorized by the

Housing and Community Development Act of

1974, the program awards HUD block grants

through State allocation procedures to the governments of selected major cities and urban counties. Two-thirds of CDBG funds are targeted for

these “entitlement” cities in metropolitan counties; less than one-third of the funds are earmarked for cities with less than 50,000 population. As with other HUD programs, exact data are

unavailable on the proportion of CDBG funds that

benefit the elderly. Some project funds have

helped to build or renovate senior centers (less

than 1 percent of all CDBG funds in 1981), and

considerably more funding has been used to

create centers for the handicapped, to renovate

public housing, remove architectural barriers,

and undertake other activities that indirectly benefit older persons (86).

Housing rehabilitation efforts comprise a major portion of CDBG funding; 38 percent of the

total in 1981. One study of project reports indicated that up to one-third of all rehabilitation

grants were made to elderly households (70).

Along with other possible sources of assistance

for housing rehabilitation, such as Section 312 and

Section 502, the CDBG program can provide considerable resources for older homeowners who

meet program eligibility criteria. Questions remain, however, about the accessibility of these

rehabilitation programs to older homeowners

who are marginally poor or who are in commu -
300 . Technology and Aging in America

nities that may not be targeted under CDBG entitlements or FmHA criteria.

Impact of Federal housing

programs on the elderly

The evolution of Federal housing legislation

since the Housing Act of 1937 indicates the public commitment to provide adequate housing for

those least able to afford it. The concept of Federal housing assistance has expanded, from the

first programs that directly provided public housing to the current broad array of programs that

provide indirect assistance to different population

subgroups in many types of housing. The programs reviewed above exemplify this variety of

assistance and indicate the efforts that have been

made to recognize and serve the special housing

needs of older Americans.

The following generalizations can be made concerning the approach and responsiveness of these

programs to helping older persons meet their

housing needs:

●

●

●

Most Federal housing programs subsidize the

construction or substantial rehabilitation of

multi-unit rental housing for income-eligible

families through interest rate subsidies, rental cost reimbursement, and mortgage insurance for housing sponsors (not for housing

consumers).

Efforts to respond to the housing needs of

older Americans have involved both construction and rehabilitation approaches, but

their impact has been disappointing in comparison to the demand for such assistance.

For example, the Section 202 and public housing programs have never met suggested annual production goals (e.g., the 1971 White

House Conference on Aging set a target of

120)

000 new units of elderly housing per

year), Annual production has never come

close to that rate, as seen in table 33.

Relative to the long history of Federal housing policy, only recently has greater attention been given to preserving the housing

stock through rehabilitation loan programs

for owners of single-family housing as well

as multi-unit dwellings.

●

●

●

●

●

Federal housing program changes during the

1960s promoted the inclusion of elderly persons, both single and married. Yet restrictive

eligibility criteria continued to disproportionately exclude certain subgroups of the elderly, particularly those who were unrelated but

sharing a dwelling unit and those who were

located outside of central city and metropolitan areas.

Until recently, Federal housing programs

paid little attention to special design and service needs of older persons. In some instances,

the design of federally subsidized housing,

particularly high-rise public housing, increased the likelihood that older persons

would become isolated, injure themselves, or

be victims of crime (53).

These tenant eligibility and architectural design problems were either lessened or eliminated in the Section 202 reauthorization in

1974 and subsequent amendments. However,

the number of subsidized units that are available to the elderly remains woefully inadequate, and prospects for the future do not

indicate a major increase in production. In

most communities, waiting lists of prospective elderly tenants generally range from 11⁄2

to 3 times the number of units that are available and often require a 5- to 10-year delay.

Insufficient attention has been paid to the

aging of the people who comprised the first

cohorts of tenants in public housing and Section 202 projects. As the survivors among

these early tenant cohorts become increasingly dependent for assistance in daily activities, their existing housing environments

may be unable to provide the types of support required for independent living.

Problems in the lack of supportive environments for the very old go well beyond federally assisted housing projects. They involve

the even greater numbers of impaired or

marginally independent elderly who are in

unassisted independent housing in the community.

Because many of these housing problems for

the elderly are generic, increased attention is being paid to policies that can encourage supportive

environments for all older persons, whether in
Ch. 9—Technology, Housing, and the Living Environment of the Elderly • 301

federally assisted or independent housing. The

following sections discuss the variety of elderly

housing options that exist in the community and

The macro-environment

Although the various Federal housing programs

provide subsidized rental units for about 1.5 million older persons (see table 33), approximately

90 percent of the elderly live independently in

the community (sometimes called “nonprogrammatic” housing). As shown in table 26, over threefourths of these elderly households are owner-oc -

cupied. This is due in part to other Federal and

State policies (e.g., income and property tax laws)

that have encouraged private sector housing development and private ownership of housing. Attitudinal surveys indicate that older persons who

are in good health, and who can afford to do so,

strongly prefer to maintain independent households (63,65), The prevalence of elderly, owneroccupied households-over one-fifth of all owned

housing units—attests to this preference. Federal

policy that either subsidizes elderly housing construction programs or supports older homeowners can directly influence the ability of older persons to remain independent and active in their

communities—the macro-environment.

Characteristics of elderly

single family housing

The elderly have the highest rate of homeownership among all age groups. As in the general

population, single-family housing predominates

among these older households. Nine out of ten

owner-occupied elderly units are single-family

residences. But in contrast to the general population, elderly homeowners are notably more likely to live in housing that was built before 1940;

40 percent of elderly owners, but only 22 percent of nonelderly owners, live in units that predate 1940. Older houses tend to be less energy

efficient, require more repairs, and have larger

average room size than newer housing. It is thus

more likely that older homeowners have greater

housing repair and maintenance burdens than do

suggest ways in

to assist older

ronment.

which technologies can be applied

persons in their housing enviof housing for the elderly

younger homeowners (70). The very old are especially at risk of such burden, because they are

most likely to be on fixed incomes and to be in

the oldest housing. Many elderly homeowners

avoid major home repairs. Undermaintenance is

one of the most commonly used methods of “dissaving” (i.e., false economizing) by elderly

homeowners, especially those living in houses that

predate 1940. Avoiding maintenance or needed

repairs is one way that older homeowners on limited incomes are able to continue paying for more

essential goods and services.

These older homeowners are increasingly likely

to be located in the suburbs of metropolitan

areas, *7 especially those adjacent to central cities

where the single-family housing stock is the oldest. As with the elderly who entered subsidized

rental housing during the 1960s, homeowners in

suburbia are also “aging in place. ” As suburban

housing ages, increasing numbers and proportions of pre-elderly suburban homeowners are

reaching age 65 and over. The rate of increase

from 1970 to 1976 for all suburban households

headed by an older person was more than three

times the rate for central cities—31 percent in

suburbia versus 10 percent in central cities. For

older homeowners, the increase in suburbia was

36 percent, compared with 17 percent in central

cities (27). These trends have continued into the

1980s and are not expected to change so long

as ownership and maintenance of single-family

houses remain economically practical for the majority of older Americans.

While suburban elderly homeowners and renters tend to have higher median incomes than their

central city counterparts, there is little difference

between them in the prevalence of chronic con17A Suburb is commo~}, defined to include all areas within a Stand- “

ard Metropolitan Area that are outside the limits of a central city

(as defined by the U.S. Bureau of the Census).
.—.—

302 ● Technology and Aging in America

ditions, sensory impairments, and mobility limitations. Lack of an automobile or an inability to

drive presents a greater burden for the elderly

in suburbia, where the impact of minimal public

transportation is made worse by the distances required to travel for essential services, shopping,

and other routine tasks or needs. Maintaining the

independence of the suburban elderly involves

greater attention to their mobility problems outside the home environment. Recent estimates indicate that almost 1 million older persons (excluding about 750,000 who are homebound or

bedridden) have mobility limitations in the macroenvironment beyond their immediate neighborhoods, Home health care and supportive service

programs, combined with paratransit services for

necessary trips outside the home, respond to the

growing needs for assistance by elderly homeowners living in single-family suburban housing.

The preponderance of single-person elderly

households, even in suburbia, compounds this

need for supportive environments and services.

EXCESS HOUSING SPACE

The prevalence of single-family housing among

the elderly also raises questions regarding excess

housing space. While “overcrowding” is generally

defined as greater than one person per room, no

definitive criteria exist that objectively measure

the existence of excess space or “overhousing.”

Overhousing is a relative concept that cannot simply be measured in terms of numbers of persons

and rooms. For the elderly, lifecourse changes in

family composition and living arrangements, and

the consequent increase in proportions of singleand two-person households, are the primary reasons for excess space in existent housing. A suggested measure of overhousing incorporates an

economic variable that compares one’s existing

housing space to the amount of space one would

be willing to “purchase” at current rental costs

(79). The comparison is made with renter households in similar income groups to assess the marginal utility of purchasing such excess space. One

set of estimates based on this type of comparison

using AHS data found that, in 1979, 2.3 million

single-person, elderly owned households occupied

five or more rooms. But based on comparisons

with renter households of similar income levels,

less than 500,000 single-person elderly households

“should” have occupied that many rooms. According to these criteria, about 4 million elderly

households (about one-fourth of the total) were

considered overhoused in 1979. The proportions

overhoused increased with increasing income

levels and were notably more prevalent in metropolitan than in nonmetropolitan areas (79).

These data suggest the existence of a prospective pool of elderly homeowners who might consider alternatives to their current housing situation, as discussed further below. The feasibility

of such options for the elderly will be based, in

part, on the economic constraints (or advantages)

of their existing housing, the cultural values that

support single-family housing choices, and the

marginal costs or rewards of changing one’s existing housing.

SHARED HOUSING

Shared housing, or homesharing, includes a variety of living arrangements in which two or more

unrelated individuals share a large apartment or

house, as well as meals and some chores. Common living areas, including kitchen facilities, are

shared; residents have private bedrooms and usually share semiprivate bathrooms. For many elderly homeowners, it is an ideal way to retain ownership, remain in familiar surroundings, reduce

isolation, gain assistance with daily activities, and

supplement a limited income. For homesharers,

it provides less expensive housing in established

neighborhoods, daily companionship, and an opportunity to help others.

Homesharing has occurred for decades on an

informal and naturally occurring basis. Estimates

from national survey data indicate that in 1980,

2.5 percent of all elderly households contained

one or more nonrelative (76). The U.S. Bureau

of the Census estimates that up to 270,000 older

persons are currently in some type of shared

housing arrangement. With the recent growth in

numbers of owner-occupied, single-person households among the elderly, greater attention is being given to promoting shared housing arrangements through matching programs sponsored by

various social service agencies.

Notably successful programs include Operation

Match in the Washington, DC, metropolitan area,
Ch. 9—Technology, Housing, and the Living Environment of the Elderly ● 303

Project Match in San Jose, CA, and Homesharing

for Seniors in Philadelphia and Seattle. These programs are operated by local public agencies, federally subsidized nonprofit organizations, and

local voluntary or religious groups, During the

past 10 years, more than 200 shared housing units

specifically for low-income elderly persons have

been developed by community-based or religious

groups. There are also an estimated 200 programs

in the United States that currently provide individual homesharing matching services for the

elderly. 18

The projects range from agency-sponsored

group homes that usually have 4 to 10 residents

who share a large home to individualized arrangements that match an older homeowner with a

boarder. In sponsored housing owned by an

agency or private investor, the resident usually

pays monthly rent in return for a private bedroom, private or semiprivate bath, meals, and

laundry service. Limited transportation services

may also be provided. Individual homesharing arrangements may be far less structured than agency-based group homes, depending on the needs

and desires of the individuals involved. For example, the boarder can pay rent, provide services to the homeowner in lieu of rent, or some

combination of the two.

For most types of homesharing, formal agreements are generally written to assure that no misunderstandings occur regarding the rights and

responsibilities of the parties involved. The nature

of homesharing makes the matching process an

important and labor-intensive endeavor (17).

Proper screening of applicants, both homeowners

and sharers, requires intensive interviews and

background checks to ascertain the expectations,

personality traits, health, and economic status of

the persons who apply. Homeowners might have

unrealistic expectations about services to be provided by the boarder, while potential renters

might not understand their responsibilities and

constraints. A major goal of the matching process is to minimize possible conflicts and maximize

a successful and enduring relationship between

18Detai]ed information on such groups is availahle from the Shared

Housing Resource Center in Philadelphia, P A .

the homesharers. Mutually positive interdependence is a key factor in successful homesharing

arrangements.

Properly developed and sustained, shared housing promotes greater economic and personal security for older homeowners, while providing affordable rental housing for other older persons

or for younger individuals seeking temporary

housing. Although far fewer in number, intergenerational arrangements are often successful because of the types of assistance that younger persons can provide in the home (e.g., chores, routine

maintenance) and the stability and support that

older persons can provide to young people.

Whether intergenerational or intragenerational,

homesharing arrangements may be particularly

suitable at those times in the lifecourse when major changes have occurred. For older persons,

widowhood, divorce, or other types of social support losses can be ameliorated by homesharing.

For young persons just entering college or the job

market, shared housing arrangements can provide an affordable and congenial living environment. Similar advantages are gained by older persons in intragenerational shared housing.

Another advantage of shared housing is its efficient use of existing housing stock, with no

major construction or renovation costs (80). Communities can benefit from the expansion of affordable rental housing that homesharing provides,

while preserving the single-family nature of the

neighborhood. In essence, homesharing generally

replaces family members who are no longer part

of the household. Thus, it need not be viewed as

a major cause of increased population density in

residential neighborhoods or of significant increases in the need for public facilities and resources. An added communal benefit is the continued economic and functional independence of

the community’s older homeowners and the likelihood that homesharing will enhance the informal support system for those older persons who

need assistance in the activities of daily living.

When carefully developed and administered to

maximize the likelihood of long-term matches, to

assure the safety of all persons involved, and to

retain the existing nature of the neighborhood,

shared housing can benefit the old, the young,

and the community at large.
304 • Technology and Aging in America

HOUSING CONVERSIONS AND ACCESSORY

APARTMENTS

A variety of housing options that do not involve

a shared household are included in the category

of housing conversions, all of which promote the

use of existing housing stock. Most common

among them are:

●

●

●

extensive rehabilitation of abandoned residential dwellings to bring them in compliance

with local zoning and safety codes;

conversion of nonresidential buildings into

multi-unit residential dwellings for the elderly; and

conversion of existing single-family houses

into dwellings with two or more units, or accessory apartments.

Each type of housing conversion has different

benefits and constraints. Housing construction

and design technologies can play a central role

in the economic feasibility of such conversions,

but local customs and zoning ordinances can be

just as important to the possibility of their development (82). The attitudes of older persons for

whom these conversions are intended also play

a significant role in their potential success.

Rehabilitation of Abandoned Dwellings.--

The feasibility of converting abandoned residential dwellings depends largely on the ability of

community-based organizations to promote such

projects. They are generally feasible only where

government subsidies are available to organizational sponsors or where the real estate market

is sufficiently strong for private investors to be

involved. Government subsidies for this type of

conversion usually take the form of low sale

prices for abandoned buildings whose ownership

has been relinquished to the municipality through

tax delinquencies. Public auctions of abandoned

buildings in need of rehabilitation generally yield

low sale prices in return for commitments by the

purchasers to renovate the building and bring it

up to fire and safety codes. Conversion projects

with organizational sponsors (e.g., religious or

secular nonprofit groups) are facilitated by coordination with local public housing agencies or quasipublic housing development programs to assure

that the conversions satisfy all local zoning and

housing code requirements.

Photo credit: Suzanne Larronde

Rehabilitation of abandoned residential dwellings often

requires government/private sector cooperation.

The economic feasibility of conversions for

homesharing purposes is based on various factors. They include:

●

●

●

●

●

●

tax credits or other incentives by local municipalities;

applicability of modular construction technologies for such dwellings;

lowered construction and rehabilitation costs

in units with existing infrastructure (e.g.,

structural, electrical, and plumbing systems);

cost savings from use of shared kitchen, living, and bath facilities;

adequate rental income from multiple tenants; and

assistance of local agencies in finding and selecting tenants.

While these inducements are strong, relatively

few rehabilitation conversions of abandoned

dwellings have been undertaken specifically for

developing shared housing. The tenuous nature

of the process and the limited availability of suitable locations or structures constrict the potential market for such conversions. Rather, abandoned dwellings have been more suitably converted by younger persons seeking affordable and

conveniently located housing in central city areas.

With relatively low purchase prices, abandoned

residential dwellings offer home ownership opportunities to younger families who are able to

invest time and labor to rehabilitate the unit.
Ch. 9–Technology, Housing, and the Living Environment of the Elderly ● 305

For most homesharing purposes, such rehabilitation involves a degree of speculation that is generally not warranted unless a number of the incentives listed above are available. The key factors

are economic feasibility and the existence of an

organizational sponsor to promote and undertake

this type of extensive rehabilitation for homesharing purposes.

Conversion of Nonresidential Buildings.--

Since the early 1970s, when real estate values in

both central city and suburban areas began to appreciate rapidly, older nonresidential buildings became feasible for conversion to multi-unit, highdensity residential use. The rapid growth of single- and two-person households–both young and

old—during the last two decades created a large

pool of prospective owners and renters who prefer living in proximity to urban amenities, job locations, service agencies, and public transportation

(59).

The changing economic and commercial basis

of many central cities left older manufacturing

and commercial buildings empty or underutilized.

In some urban core areas, conversion of nonresidential buildings coincided with governmentsubsidized urban renewal programs that were

aimed at revitalizing a central city’s daytime commercial and nighttime entertainment and residential functions, For similar reasons as those noted

in the previous section, the conversions were economically attractive to commercial developers.

The 1970s were a period of rapid growth in

“theme areas” of cities that catered to the young

professional market of consumers for housing,

retail facilities, and entertainment. The first era

of conversions included the development of specialized shopping and entertainment facilities, followed by the growth in multi-unit residential

dwellings. The latter were sometimes created

from buildings that were warehouse or manufacturing facilities. Their solid structural, plumbing,

electrical, heating, and other components generally provided a sound infrastructure that would

have cost much more if newly constructed. Retrofitting of existing infrastructure components is

one economic advantage of conversions. In general, older nonresidential buildings require

weatherization, insulation, and updating of the

heating and cooling systems. Their size and open

spaces often permit considerable flexibility in designing interior units for residential purposes.

Units for single- or two-person households, which

might comfortably occupy from 800 to 1,200

square feet of space, are especially feasible in such

projects.

The earliest multi-unit conversions were marketed for young urban households. However, as

the proportions of older people in central city

areas grew and their housing desires leaned

toward smaller, more convenient, and affordable

settings, the use of central urban buildings for

rental or condominium units designed especially

for elderly households also became feasible. Studies during the 1970s confirmed the potential of

central city nonresidential buildings for providing new housing that was safe, responded to the

needs of older persons for proximity to shopping,

services, and public transportation, and provided

a homogeneous residential environment with

some degree of informal supports (8,60). Without government subsidies, the majority of these

multi-unit rental buildings must cater to the

elderly households that have moderate incomes.

Elderly renters, who are most likely to have low

incomes, are unlikely to afford such housing

unless Section 8 or other subsidies are available

to reduce out-of-pocket monthly costs. Even

where Section 231 mortgage insurance was available to subsidize this type of conversion, the units

developed were largely for “retirement centers”

that rarely included low-income residents,

Thus, conversions of nonresidential buildings

into units for the elderly are usually undertaken

by profit-making developers and are generally targeted toward middle or higher income consumers. Compared to suburban areas, where the higher income elderly are concentrated, the central

urban location of most nonresidential buildings

limits the potential elderly market that is available. The indigenous central city elderly population is most likely to be poor and in need of rental

housing. Thus, these conversions would be more

feasible for poor elderly residents if government

housing subsidies were available to promote the

development of lower cost rental units.

Single-Family Housing Conversions and

Accessory Apartments.--One of the more com -
306 ● Technology and Aging in America

mon types of housing conversion is the creation

of an additional apartment within an existing single-family house. These are generally called “accessory apartments, ”19 to emphasize their characteristics as separate living quarters created

within existing houses. The Census Bureau estimates that there are 2.5 million accessory apartments in the United States (18)77), although some

sources would yield higher estimates (68). One

reason for the lack of accurate data is the often

circumspect nature of these additions, many of

which violate local housing ordinances and zoning laws that only permit single-family housing

in a neighborhood. Door-to-door surveys in singlefamily neighborhoods would undoubtedly yield

greater numbers of such secondary units than are

known to local authorities.

Conversion to an accessory apartment generally involves building a self-contained independent

unit, usually with a separate entrance, that includes a separate kitchen, bathroom, bedroom,

and living room. Although most conversions of

this type are undertaken covertly because of existing restrictions in local housing codes, they are

feasible because the exterior appearance of the

single-family house remains unchanged. The accessory unit is often added in a basement or one

part of a large home, with a private entrance from

the side or rear of the house. Thus, most homes

with these added units retain their single-family

appearance.

While accessory apartments may be developed

to provide rental income for an owner-occupant,

the units are often developed to provide independent living quarters for a parent or other relative (hence, the term “mother-in-law apartment”).

Recently, these units have gained attention as a

potential source of added income for elderly

homeowners. Given the degree of overhousing

that exists among elderly homeowners,20 especially single-person households in suburban areas,

conversions to accessory units are an alternative

to homesharing. This alternative may be more at-

~9Accessory apartments are also sometimes called “secondary

units” or “mother-in-law apartments.”

Wensus data indicate that almost two-thirds of all elderly

homeowners are part of one- or two-person households in homes

with at least five rooms. This group numbers about 7.3 million

elderly households.

tractive to elderly homeowners who wish to retain their privacy and independence, and similarly

attractive to potential renters (elderly or nonelderly) who would prefer separate living quarters at

an affordable rent.

Today, conversions to create accessory apartments are more technically feasible than ever before, because modular room and wall units are

available at somewhat lower cost and higher quality than many units built on site. Because the basic

infrastructure for plumbing, electricity, heating

and cooling, exterior walls, and interior walls

already exists, the cost of conversion to an accessory apartment is generally much lower than the

cost of constructing totally new units. Modular

or factory-constructed bathrooms that include

cabinets, bathtubs, shower stalls, toilets, and fixtures in one unit are available. Individual modular

bathtub, shower, and cabinet units have also become increasingly popular. Onsite construction

labor costs are usually lower for installing factory prebuilt units. Modular kitchens are also now

available, some of which have integrated wall and

cabinet systems that include all major appliances

(23). The range of options in factory-assembled

units permits flexibility as well as cost savings.

In the few communities where they have been

studied, accessory apartments have generally

been well-received by residents of all ages and

socioeconomic levels (28). In one analysis of three

suburban communities where accessory apartments have been permitted under local zoning

law changes, about 12 percent of the single-family

homes in each area had accessory apartments.

Residents in communities with affluent homeowners were particularly pleased that persons were

living in many of the houses while the owners

were away for extended and frequent trips. It was

also shown that homes with accessory apartments

were unlikely to have a negative effect on

neighborhood housing values, but absentee ownership of any type of single-family housing, either

with or without an accessory apartment, was

more likely to create lowered values (28). Thus,

in some communities that legally authorize accessory apartments, the permits require that the

houses be owner-occupied. Some communities

also require that either the homeowner or the

tenant(s) be age 65 or over. Such restrictions are
Ch. 9–Technology, Housing, and the Living Environment of the Elderly • 307

intended to maintain the stability of the communities in which accessory apartments are permitted. Moreover, in the three communities studied, the average length of tenancy in the accessory

apartments was approximately 5 years, a relatively long period for rental households.

These results may not always be duplicated, depending on the type of community and housing

stock in which the conversions occur, as well as

the general demand for rental units. In one demonstration program recently undertaken to convert two-story houses to duplex units, the results

were mixed. The older dwellings in which the secondary units were constructed required more extensive rehabilitation and time than is the case

for converting a basement into an apartment. Because it was a government-assisted demonstration program, there were numerous required approvals, resulting in delays in obtaining financial

assistance. The older homeowners incurred debts

and inconvenience for periods longer than anticipated. Because of their costs, these conversions

required more years of rental payments to yield

a net profit on the conversion costs incurred by

the elderly owners. The results, while promising,

would have been far better had the long delays

not occurred (9).

Thus, while not foolproof, accessory apartments provide a likely source of additional housing for persons needing rental quarters, while also

adding to the income of single-family homeowners. In most communities, secondary units neither change the appearance of the neighborhood

nor detract from housing values. Because of these

attributes, the potential for accessory apartment

development is strong, but not until some of the

myths surrounding this type of housing are corrected and public attitudes are changed. When

properly developed and integrated within existing

single-family communities, accessory apartments

can directly benefit elderly households, both owners and renters alike. Continued growth in the

number and proportion of accessory apartments

in most areas of the United States, especially older

suburbs, can be expected during the next two or

three decades as demand for rental housing

grows.

DETACHED ACCESSORY HOUSING:

THE ELDER COTTAGE

Another housing option for the elderly is a relatively small, free-standing cottage that is factorybuilt and erected on a preformed foundation.

These cottages are generally known as “granny

flats,” a term borrowed from Australia where the

original units were developed. They are also

known as “echo” (elder cottage housing opportunity) housing or, more simply, elder cottages.

Granny flats are designed for installation in the

side or backyards of existing single-family homes.

Their potential use has grown as new construction technologies have improved their appearance, quality, and energy efficiency.

These small homes range in size from 500 to

800 square feet and contain one or two bedrooms.

They are either totally built and assembled at the

factory or built in modular sections that are easily

assembled on the site. In the United States, one

Pennsylvania company offers three basic cottage

models that range in price from $15,000 to more

than $22)

000, plus foundation, installation, transportation, and utility connection costs (14). Factory production techniques using template guides

for cutting and assembling all sections have improved the quality of the total unit. Exterior wall

boards with high insulation value are usually combined with vinyl or aluminum siding, inner wall

batt insulation, weatherstripping, magnetic door

seals, and double-pane windows (and storm windows) to promote energy efficiency and comfort

levels that are suitable for elderly persons. The

modular construction of these homes includes all

major kitchen appliances, cabinets, and bathroom

fixtures. The modular units, or even an entire assembled house can be transported to the site,

where the house is erected on a prebuilt foundation with all water and utility lines installed.

The housing unit can be installed, and all required

plumbing and utility connections completed, in

1 or 2 days.

Because elder cottages are intended for the

elderly, door openings are designed for wheelchair accessibility; entry ramps in place of stairs

are optional provisions. Although usually defined

as “temporary” housing for zoning purposes (simi-
308 . Technology and Aging in America

Photo credit: The Coastal Colony Corp., 1983

The “elder cottage” is one example of a free-standing granny flat.

lar to mobile homes), elder cottages are constructed to last permanently. But they are designed to be easily disassembled, removed from

the foundation, and moved to another site. Such

technological and design specifications enhance

their feasibility as temporary structures while

maximizing the quality of the environment for

those older persons who may have functional impairments and mobility restrictions.

Other technological advances can make factorybuilt elder cottages even more responsive to the

individual needs and desires of older residents.

New applications of existing computer design

technologies could lead to the availability of

consumer-designed housing that takes advantage

of the economies of factory-built housing. An example is the “Burroughs house” in Sweden, which

can be designed in sections as small as 4 feet by

8 feet. First, a normal blueprint is drawn to the

specifications of the consumer. Then, an electronic pencil or eye traces over the blueprint, which

is electronically sent to the factory where the

modular units are constructed (35). In this way,

elder cottages that respond to the desires of the

residents could be individually designed (e.g.,

from a range of options for room size and layout),

built at a centralized factory, and shipped to dispersed geographic areas. Given the limited size

of the cottages, adapting the interior living space

to meet the consumer’s desires would give these

units broader appeal and greater marketability.

As with accessory apartments, however, the

greatest challenge to the development of elder cottages is resistance of local communities to this

type of secondary housing in traditionally singlefamily neighborhoods. Local zoning restrictions

are the key barriers to the spread of such housing. It appears, however, that some of the resistance is dissipating. In recent years, some States

(e.g., California, Pennsylvania, Arizona, and New

York) have enacted different types of legislation

that “authorize” local communities to permit con-
Ch. 9—Technology, Housing, and the Living Environment of the Elderly • 309

struction of granny flats in single-family neighborhoods or in rural areas. As the esthetic and

physical qualities of elder cottages improve, local

communities may be more likely to permit their

construction. In communities where they are currently allowed, the rental of elder cottages is often

restricted to family members. In this way communities protect themselves from development

of accessory units that might become commercial rental property. Because granny flats are temporary structures, local codes often require that

they be disassembled when the unit is no longer

occupied by the family member(s). While such requirements preserve the limited scope of granny

flats and increase their acceptability in singlefamily neighborhoods, the cost of removal (about

$8,000) adds to their total cost and, therefore, reduces their feasibility.

According to existent information, communities

that allow granny flats in single-family neighborhoods have had very few requests for permits

(95). Where they have been built, no negative effects in housing values, esthetics, crowding, or

other consequences have been discerned. Elder

cottages, when carefully constructed to assure

their quality and designed with roofing, siding,

and other materials that correspond to the neighborhood’s existing housing, can provide an economical, safe, independent, convenient, and supportive housing environment for older persons.

But the current market for granny flats appears

to be very limited and selective, especially when

contrasted with the millions of accessory units

that have been constructed in the United States

during the past decade. Even in Australia, where

granny flats were first developed, less than 600

have been erected. In the United States, investment in construction of granny flats, despite recent advances in modular technologies, requires

significant capital outlay, uses valuable open

space, and usually includes restrictions on permanence of the structure. Conversion to accessory apartments requires fewer risks, lower costs,

and less inconvenience. Thus, the relative advantages of granny flats over accessory units are dif -

ficult to ascertain, except in special circumstances

where a detached unit is particularly desirable.

CONGREGATE AND ASSISTED HOUSING

Congregate or assisted housing describes various types of housing complexes that can be defined and described as service-integrated group

living or assisted independent living. The term encompasses multi-unit complexes that provide their

residents with some degree of supportive services, the most common of which is one or more

meals served daily in a central area (7). The fundamental feature is a supportive environment that

can be flexible in meeting the diverse needs of

the elderly, especially as they reach the oldest ages

when chronic conditions and impairments are

more likely to limit their independence (see chs.

3 and 7). The ideal congregate housing setting follows the earlier-discussed model of environmental

congruence. Flexibility is another ideal aspect,

particularly the ability of the environment to meet

the needs of the residents as they age. Congregate

housing is thus considered to best approximate

an accommodating environment whose supportive elements can be called on as the needs of individual residents increase over time and they require greater assistance in activities of daily living

(6).

publicly sponsored Congregate Housing.

—Until recently, the Federal Government has not

been a strong proponent of supportive housing

for the elderly. The traditional approach of HUD

has been to concentrate only on construction of

housing complexes through its subsidy programs

for developers and renters—the so-called ‘(bricks

and mortar” orientation. But as demands grew

for more supportive environments for those older

persons who were in subsidized housing complexes (e.g., public housing, Section 202), HUD

eventually entered into cooperative agreements

with other Federal agencies to integrate social and

long-term care services with physical housing programs. These funding initiatives have supported

demonstration programs that provide a range of

congregate services in Section 202/8 assisted housing for the elderly. The total effort is, however,

small in comparison to the number of potential

residents who could benefit from congregate programs and the range of services that could be provided to maximize the supportive nature of the

housing environment.
310 ● Technology and Aging in America

As the proportions of old-old and very-old residents in elderly housing complexes grow (i.e., aging in place), numerous services in addition to

daily congregate meals are usually required.

Among these are medical and health care services, housekeeping and chore services, meals on

wheels, increased security, transportation outside

the neighborhood, education programs, and recreational activities. Ironically, reductions in Federal subsidies for congregate housing programs

are occurring at a time when the older population is itself aging and the need for these supportive services is growing. The surviving members

of the first cohorts of elderly residents in Section

202 housing are now the very old. Yet, the environments that 20 years earlier may have provided

adequate safety and support for the young old

have certainly become less “friendly” to these

very-old residents. Indeed, even the best efforts

of the Federal Government in the current period

of economic restraints would not meet the broad

range of needs for this type of supportive housing environment.

In order to accommodate this growing demand

for assisted living, new design features that promote the supportive nature of the physical environment can be combined with the provision of

more services to help older residents remain in

their current living environment. But there is no

single Federal agency that is responsible for initiating, developing, and implementing this type

of supportive housing environment for the elderly. Because of both the limited Federal involvement and the growing awareness of the elderly

housing market, private developments aimed at

middle-income elderly households have become

increasingly prevalent, especially as current government subsidies for congregate housing are being reduced or eliminated. But most of these new

units are beyond the economic reach of poor and

near-poor elderly households who must still rely

on government assistance to find adequate housing. A notable gap remains between the poor and

nonpoor elderly in access to affordable living environments that provide a high degree of supportive services.

Privately Developed Residential Complexes for the Elderly.–The service-rich characteristic of congregate housing is exemplified by

new, privately sponsored housing complexes that

are popularly referred to as “life care communities)” continuing care retirement communities,”

or “residential care complexes.” These communities typically consist of apartments in a congregate setting and/or single-family cottages in a cluster arrangement that most often include recreational facilities, a nursing home, acute care clinic,

and a range of supportive services for their residents. A broad array of congregate services are

offered, including daily meals, laundry services,

homemaker chore services, and transportation assistance. Life care communities are established

to encourage the continued independent lifestyle

of the residents while also assuring them of longterm care (including nursing) and supportive services as the need arises.

Residential care complexes require an “entry”

or “endowment” fee when the resident enters the

facility, plus a monthly “service” fee that covers

the unit’s rental costs and those ancillary services that are included at no extra charge, The

units are not purchased by the resident, but the

entry fee “guarantees” lifetime occupancy. Most

facilities also guarantee that the resident will receive all types of long-term care, including nursing care, without additional cost. Some facilities,

especially those with lower entry fees, assess additional charges for services such as nursing home

care. Although facilities may include acute care

clinics, the charges for these services or for hospitalization (i.e., outside the facility) are borne by

the resident in addition to the entry and monthly

fees. In 1983, entry fees ranged from $20,000 to

more than $100)000 for an individual (the cost

for couples is usually 15 to 20 percent higher),

while monthly fees averaged $600 for a single person and $850 for a couple (87). The large range

in costs, especially for entry fees, reflects differences in the location, amenities, scope of services

(particularly nursing home coverage), and sponsorship of residential care communities.

Current estimates indicate that about 100,000

elderly Americans are living in approximately 300

life care communities, most of which are operated by nonprofit organizations affiliated with

religious denominations. This fact has made life

care communities an attractive option because of

the expected security and trustworthiness asso-
Ch. 9–Technology, Housing, and the Living Environment of the Elderly • 311

ciated with these types of sponsoring organizations. The older person is investing a large initial

fee on the good faith that the sponsor will provide the housing and all services during the resident’s lifetime. However, some life care communities have already broken their contracts and

some sponsors have gone into bankruptcy. In

some of these instances, clearly fraudulent practices led to losses of lifetime savings for many residents. In others, the sponsors had underestimated

the actuarial characteristics of prospective residents, resulting in higher than anticipated costs

for supportive and nursing services for chronically ill residents. These costs were in excess of

the income generated from the entry fee pool and

the monthly fees (87).

one result of these failures has been the reevaluation of the actuarial assumptions for both morbidity and mortality that are used in determining

fees. In many of the first-developed communities,

new residents are paying substantially higher entry fees than earlier residents, and annual increases in monthly fees at some facilities have

greatly surpassed the rate of increase in the general cost of living. As noted above, in some continuing care retirement communities, nursing

home care is not included in the life care contract.

Rather, the contract specifies extra fees that

would be charged when the resident requires

skilled nursing care or placement in the community’s nursing home.

These adjustments in the costs and contract obligations of life care communities emphasize their

newness and the need for the industry to more

carefully develop such lifetime plans, which involve critically important actuarial projections

(101). The elderly consumer is also warned to

scrutinize the features of the life care contract,

as well as the reputation and past performance

of the sponsor. While the great majority of life

care communities are successful and continue to

provide the expected services, caution on the part

of the consumer remains important in an industry that has few, if any, Federal or State regulatory safeguards.

OTHER TYPES OF CONGREGATE HOUSING

Two other types of congregate housing are particularly relevant to the elderly: nursing homes

and board and care facilities. These types of housing are distinguished by the relative dependence

of their elderly residents, as compared to those

in life care communities or elderly housing complexes. The elderly in nursing homes and board

and care facilities do not maintain individual

dwelling units and have little responsibility for

daily chores. This type of housing is often called

“domiciliary,” in reference to the types of personal

care and protective oversight that are provided

to the residents. Because the residents and characteristics of these two housing categories were

discussed in chapter 7, they are only briefly reviewed here.

Nursing Homes.—In the United States, there

are more than 23,000 facilities that provide nursing and related types of 24-hour care, Over 5,000

of these homes provide skilled nursing care. Currently, about 5 percent of the older population,

or more than 1.3 million persons over 65, are residents of nursing homes at any one time. But about

20 percent of all older persons will live in a nursing home sometime in their lives. The elderly comprise more than 85 percent of all nursing home

residents, whose average age is 83, Almost half

of the total cost of nursing home care is paid by

Medicaid, with additional small percentages paid

by Medicare and by private insurance (about 2

to 3 percent by each).

The health, functional, and social characteristics of nursing home residents differ markedly

from those of the community dwelling older population. Nursing home residents are far more likely to be mentally impaired, to suffer from urinary

incontinence, and to be dependent in eating, bathing, dressing, and other basic activities of daily

living (99). They are also more likely to be widowed or single; hence, less likely to have informal support from a spouse or other family

members.

Differences among nursing home residents are

also discernible in terms of their length of residency. Recent studies indicate that between onethird and one-half of all nursing home residents

stay for less than 3 months (i.e., “short-stayers”);

about one-half of these persons died in the nursing home or shortly after discharge, usually to

a hospital (47). Those who stay for 4 or more

months are highly likely to be “long-stayers” who
312 • Technology and Aging in America

remain in the nursing home for well over a year.

These individuals are far more likely than shortstayers to be mentally impaired and dependent

in one or more basic activities of daily living (see

ch. 7 for detailed characteristics of nursing home

residents and the types of care they need).

The ability of nursing homes to respond to the

many needs of their elderly residents depends in

large part on the number of staff available, their

training, qualifications, and experience in geriatric care, and their attitudes about elderly residents who typically have a high degree of dependency (91). These are crucial elements for quality

of care in nursing homes. Another important factor is the living environment and its ability to provide psychological as well as physical support to

the residents. Design and technological features

that enhance safety, security, privacy, convenience, and attractiveness can promote the health

and well-being of nursing home residents. Many

of these features, some of which can also be incorporated in independent community-based

housing, are described in the following section

on micro-environments for the elderly.

Because nursing home residents typically have

decrements in the senses, special attention to

barrier-free environmental design is highly important. Declines in vision and hearing acuity of

the average elderly nursing home resident require

various adjustments in the physical environment

that ameliorate the problems associated with

these sensate losses. For vision, degeneration of

the cornea can lead to severe loss of acuity, particularly in color discrimination. Peripheral field

loss from retinal disease or glaucoma leads to

“tunnel vision,” resulting in poor orientation but

generally good color acuity. Cataract and corneal

disease result in varying degrees of clouding and

distortion, with poor vision in bright light or areas

with high surface glare. The effects of these conditions can be reduced by specific environmental

adaptations. Heightened color intensity and contrast (e.g., accent stripping) would assist those

who have peripheral loss, but such color cueing

is generally not useful for persons with corneal

degeneration. However, the use of oversized letters on nonglare surfaces and luminous, well-diffused indirect lighting will most likely benefit all

persons suffering from vision loss. For those who

are blind, raised letters, braille, and auditory cues

are the obvious environmental requirements to

reduce the degree of dependence of the nursing

home resident.

Hearing loss, which affects about 30 percent of

all older persons and a significantly higher proportion of the very old (who are most likely to

be institutionalized), can also range from mild to

severe .21 Presbycusis (progressive loss of hearing

due to various causes), tinnitus (persistent ringing in the ear), and other forms of hearing loss

can restrict the ability of nursing home residents

to carry on daily activities. For these persons,

visual and tactile cues are helpful in managing

environmental demands. Flashing lights to indicate when telephones ring or emergency alarms

sound can provide an added measure of safety.

Amplification devices for televisions, radios, and

telephones increase their usefulness for the hearing impaired. Hearing aids that amplify sound at

the outer ear are of limited value for many forms

of hearing loss in the elderly, which are often due

to neural degeneration in the inner ear that cannot be overcome by amplification in the outer ear.

For persons with tinnitus, the characteristic ringing sounds may only be exacerbated by hearing

aids, Background noise that interferes with conversational hearing can be reduced with appropriately placed carpeting, drapes, and other soundabsorbing materials.

Thus, more attention should be paid to visual

and tactile environmental cues for the hearing impaired, especially those in nursing homes. Meanwhile, recent improvements in the technology of

cochlear implants that restore very limited sound

receptivity in the inner ear for deaf persons hint

at possible future applications for large numbers

of elderly people with hearing impairments caused

by neural loss. These implants, recently approved

by the Food and Drug Administration for use in

the United States, hold promise for future application if their performance can be greatly improved

and their cost reduced.

The general loss of tactile, motor, and ambulatory abilities among very-odd nursing home resiZIAdditiOna] information on hearing loss among the elderly is provided in ch. 3 and in the forthcoming OTA Background Paper on

Management of Hearing Impairment in the Elderly.
Ch. 9–Technology, Housing, and the Living Environment of the Elderly • 313

dents is another area in which environmental design and technologies can provide assistance (39).

Among the most common and least costly technologies are replacement of door knobs with door

handles to greatly reduce the difficulty that many

elderly persons have in gripping and turning door

knobs. Door handles require less dexterity and

twisting torque of the hand and wrist (19,40).

They can also be used without gripping the handle; an open or closed hand, the forearm, or even

an elbow can usually be used to push the door

handle down. Similar problems with other types

of fixtures are ameliorated by push-pull controls

for plumbing fixtures and electrical controls (e.g.,

for persons severely afflicted with arthritis, toggle switches are far easier to operate than knobs).

Other environmental technologies that are especially useful in nursing homes are changes in floor

surface texture and color to denote differences

in patient rooms, common areas, and staff areas.

Nonskid surfaces and graspable handrails at proper heights for older persons and those in wheelchairs are low-technology applications that enhance the safety of nursing home residents. Safety

grab bars, handrails, and raised toilet seats are

also low cost but highly effective safety additions

for bathrooms. In all cases, nursing homes can

be designed to reduce the incidence of falls by

avoiding steps wherever possible and using ramps

to promote ambulation of patients and wheelchair

access. Adequate indirect lighting, nonglare surfaces, and color cueing, as noted above, are especially important in these institutional settings.

Assistive devices such as wheelchairs are particularly relevant to nursing home residents, who

comprise just under one-half of all users (84). But

the technology of wheelchairs has changed slowly

in recent decades, with most changes being refinements of existing features to make them more

lightweight, durable, portable, and comfortable.

For example, electrically self-propelled chairs have

been refined to promote their safety, reduce their

weight, improve the manual controls, and extend

the length of time between battery charges. The

next generation of wheelchairs will be the computerized version that permits the user to send

instructions to the drive mechanism through a

sensing device that detects specific movements

of the head (61). The chair will also travel sideways as well as forward and backward. Its anticipated purchase cost is between $5,000 and

$6,000, as compared with $400 to $900 for manual wheelchairs and $2,000 to $3,000 for regular

power-driven chairs, As wheelchairs are improved and become more useful for greater numbers of older people, the potential number of

wheelchair users in nursing homes should grow.22

However, the purchase or rental costs of these

improved wheelchairs may deter their use, in part

because of limited Federal or State reimbursements for those costs and the need to medically

certify that such technological advantages are

warranted.

Regardless of market trends in high-technology

wheelchairs, nursing home environments must

accommodate the needs of all wheelchair users.

Proper design of patients’ rooms, especially to promote the independence of the wheelchair user

in moving within the room, to the bathroom, into

common areas, and in transferring from bed to

wheelchair, is a fundamental requirement. As

with other tasks, nursing home design should be

predicated on the assumption that most residents

are highly restricted in mobility and dexterity,

thereby incorporating designs for extra-wide

doorways, open cabinets, accessible shelves,

closets with low racks, adjustable beds, and

sturdy ergonomically designed furniture to properly respond to these physical limitations.

For the less mobile or self-sufficient resident,

nursing homes can utilize other assistive devices.

Nursing staff must often assist patients in transferring from bed to wheelchair and wheelchair

to toilet or bathtub. Various portable lift devices

are available that help assure the safety of the patient and the nursing staff in undertaking such

tasks, especially when dealing with physically frail

older persons in high-accident risk areas such as

bathrooms. Similarly, electrically controlled beds

allow relatively easy adjustments in vertical height

and horizontal position to ensure the comfort,

safety, and dignity of the patient. A number of

other general design and device applications are

‘Wne informal evaluation of wheelchair use among older nursing home residents attempted to determine why some persons who

were still able to walk used wheelchairs. A frequently mentioned

reason was that wheelchairs were far quicker than walking slowly,

or using a cane or walker (22).
—

314 Ž Technology and Aging in America

useful in both the nursing home and independent

housing. Most of these are noted in the section

on the micro-environment of housing for the

elderly.

Board and Care Homes.--The category “board

and care” includes a wide range of group homes

that provide some type of supportive care to their

residents. Estimates of the number of homes and

residents vary greatly, because the definition of

what constitutes such a facility remains nebulous.

Indeed, of the 118 domiciliary care programs recently surveyed by the Administration on Aging,

none identified their facilities as a board and care

home (most used terms such as residential care

or continuing care). In general, however, these

homes are distinguished from other group quarters in that they provide room, board, and some

form of nonmedical and nonnursing personal

assistance. The latter is often referred to as “protective oversight” to emphasize the need for assistance with activities of daily living for many residents of such facilities.

Since each State individually licenses board and

care homes, there is great variation in the types

of facilities and resident populations that are included in national figures. The best estimate is

approximately 30,000 board and care homes in

the United States in 1981, with an additional

300,000 ‘(boarding” homes in which residents primarily receive only sleeping quarters and some

meals (92). An estimated 285,000 persons over 65

represent four out of every five board and care

residents (72). As noted in chapter 7, these residents tend to be moderately dependent in basic

or personal care tasks, and highly dependent in

instrumental activities such as laundry, shopping,

managing money, and cleaning. Board and care

home residents also have above-average rates of

poverty and mental impairment. Similar but less

severe dependency seems to exist for residents

of boarding homes (as distinguished from board

and care facilities), but accurate national data are

unavailable since boarding homes are generally

not regulated or licensed. For that reason, it appears that boarding home residents are particularly vulnerable to fraud or abuse (62,75).

Because of their residents’ characteristics, board

and care facilities receive a significant portion of

their income from residents who receive Supplemental Security Income (SSI) payments for the

poor or disabled.23 Those facilities that care for

the more frail and dependent elderly (including

those who are mentally impaired) are continually

challenged to provide a decent, safe, and sanitary

living environment for their residents. Many of

the design features noted above for nursing

homes could be incorporated in board and care

facilities. But, because they are unlikely to receive

Federal or State reimbursements for their services, board and care facilities are limited in their

ability to undertake major physical changes in the

design of the home. Thus, most facilities only meet

minimum local fire and safety codes; few provide

environmental features that encourage independence of the residents or promote a psychologically

healthy and stimulating atmosphere.

Increased attention to the growing board and

care population of older persons is needed if supportive housing opportunities are to be made

more available to the elderly. In order to achieve

this goal, the definition of what constitutes a

board and care home could be standardized, as

could be some type of Federal reimbursement or

subsidy for costs incurred in caring for those who

might otherwise be institutionalized. For the latter to occur, minimum design and safety standards for multi-unit homes could be promulgated

to inspire healthier environments for elderly residents of board and care facilities.

The different types of congregate facilities briefly reviewed above attest to the growing variety

of housing opportunities for most segments of the

older population. Whether publicly subsidized or

privately developed, congregate housing facilities

are the most promising types of accommodative

living environments for the elderly who have reduced or limited functional capabilities. Congregate facilities become more important as the average age of residents increases in multi-unit

complexes designed for the elderly. Yet, there is

no national system by which these housing opZgWhen av~b]e, dab from a 19S4 survey of SS1 recipients, undertaken by the Social Security Administration, should provide information on the levels of care available to SS1 recipients in different

types of living arrangements, including various types of board and

care facilities.
Ch. 9—Technology, Housing, and the Living Environment of the Elderly ● 315

portunities are coordinated or the average con- plexes–will continue into the next century. As

sumer can be informed about them. The growth the U.S. population ages and the complexity of

of private and public housing opportunities— these housing opportunities grows, appropriate

ranging from accessory units to shared housing monitoring, regulation, and consumer protection

to comprehensive life care retirement com- will become more important.

The micro-environment of housing for the elderly

As noted in previous sections of this chapter,

person-environment congruence becomes more

important and more difficult to achieve as people age–another example of both the increasing

heterogeneity and associated functional dependency with advancing years. The ability of the

environment to accommodate and respond to the

needs of its aging resident is often overlooked (41).

It is usually assumed that what worked for persons aged 40 will provide the same environmental

supports for persons aged 80. But this report has

noted the changes in functional abilities that generally occur with increasing age and the need for

appropriate responses to ameliorate the negative

effects of those changes on the lives of older

Americans.

The characteristics of the residential environment—its design, organization, and amenities—

can have a profound effect on the ability of older

individuals to function adequately on a daily basis

(10,11). For purposes of this report, the “microenvironment” is defined as the immediate residential environment in which the individual lives, and

includes the physical and esthetic elements that

contribute to a person’s quality of life. As expressed in the aforementioned HUD program

goals, the microenvironment should provide safe,

decent, and sanitary living quarters for all residents. For those older persons whose functional

capabilities are reduced, these goals increase in

relevance. Housing technologies and design factors can contribute significantly to providing not

only the minimum standards for adequate housing, but an environment that fosters independence and promotes safety and convenience as well

(21). This section reviews some general housing

technologies that respond to these goals and provides examples of their applications in the home.

Technological applications

in the home

New technologies for the home environment

are continually being developed, many of which

can add a measurable degree of convenience and

safety to residents’ daily lives. For the elderly with

functional disabilities, some of these technologies

can mean the difference between increased dependency on others for informal and formal support and the ability to maintain one’s independence (5). The potential advantages are especially

important to the growing number of older persons who live alone. It is not only the fear of being dependent, but also of not being able to seek

help at critical moments that most concerns people as they reach the oldest ages. Technological

applications in existing and new housing can provide a measure of security and safety that helps

dispel these fears.

GENERAL IN-HOME APPLICATIONS OF

TECHNOLOGY AND DESIGN

Among the many general technological or design applications in the home, a few low- and hightechnology features stand out as the most important and feasible for the elderly, whether they

are renters or homeowners. These are discussed

in the following section.

General Safety Features.— Safety is a fundamental issue as persons age and functional disabilities become greater. Injuries and deaths from

falls and fires are the most common dangers in

the home life of older Americans. In the United

States, the elderly account for one-fourth of all

accidental deaths—more than twice their proportion of the total population. Falls are the leading

cause of accidental deaths among the elderly. InS8-800 O - 85 - 11
316 ● Technology and Aging in America

deed, persons over 65 account for more than twothirds of all deaths from falls in the United States

(15). The high risk of injury and death from falls

has discernible implications for public policy; the

economic consequences of falls in the elderly

alone are estimated to be between $2.5 billion and

$4 billion per year.

Risk of Falls.—There are a number of low

technologies and simple design adaptations that,

if implemented nationally on a large scale, would

greatly reduce the risk of falls and their consequences for the elderly. Adding buffers to hard

or sharp surfaces is one general approach. Properly installed carpeting, appropriately secured

scatter rugs, upholstered furniture, and rounded

edges on outside corners of walls, counters, tables, and other furniture lessen the likelihood of

falls and the degree of injury when falls do occur. These measures may not prevent major injuries in older persons suffering from severe

osteoporosis, but most elderly would benefit from

such precautions. Care in the use of walkers,

canes, and other ambulatory aids is necessary,

since these assistive devices can themselves be the

cause of falls. Abrupt changes in floor surface

levels are dangerous, especially where there are

no environmental cues such as changes in color

or texture of floor coverings (15). A common example is the step-down room with a one- or tworiser step that is not easily seen by persons with

reduced visual acuity. Another hazardous element

in housing design is the door that opens directly

onto a stair tread with no initial landing. The most

common of these is found in standard house construction with doors that open directly onto basement stairways.

Stairs themselves are a major source of falls

among the elderly. Most of these falls are due to

tripping rather than slipping. The major problem

is inappropriately designed or marked stair treads

and landings. Elderly persons with arthritis or

other causes of restricted mobility and agility have

difficulty with normal riser heights when ascending a stairway. Reduced agility in the joints increases the risk of catching the front of the foot

on the stair tread extension, or “nosing” (the portion of the tread that extends beyond the vertical

riser), creating a forward fall on ascent. On descent, the short depth of the stair tread often results in “overstepping)” which usually leads to a

backward fall against the stairway. Deeper treads

(11 inches is ideal) with lower risers (6 to 7 inches

high) are the best environmental solutions to this

problem. Another risk factor in stairway falls are

handrails that are inappropriately designed or installed at the wrong height for the average older

person. Because the average older person has lessened ability to grip large surfaces, handrails

should be small in circumference and designed

to fit the partially closed palm. Their ideal height

is 36 inches, the same as that for door handles

and electrical switches. Stair safety is also enhanced with tread edge markings on both the bottom and top edges of the stair tread. Falls due to

overstepping on descent are due not only to short

tread depth but also to the poor visibility of the

tread edge when looking down from above. A

mixed blessing is provided by nonslip strips for

stair treads. While they reduce the chance of slipping, they sometimes create forward falls when

the foot stops abruptly on descent. Carpeted stairways should be carefully secured at all edges, especially at the nosing and the back of the stair

tread, In all cases regarding stair safety, proper

illumination will minimize glare, reduce confusing shadows, and maximize tread edge visibility.

A considerably more expensive technology is

the chair lift. It entails a fairly expensive addition

to the home, requiring a well-anchored glide track

along one side of the stairway, on which an electrically powered chair moves. In some States and

local jurisdictions, electric chair lifts must conform to local building codes, generally those that

apply to elevators. Depending on type of model

and width of stairway, the basic cost of a chair

lift for a straight stairway ranges from $2)200 to

$3,500. Stairways with bends and landings add

to the complexity and cost of this technology.

Other general safety features to prevent falls

in the home include the removal of thresholds

across door openings to reduce the likelihood of

tripping. This hazard is often overlooked, but can

be especially dangerous when adjoining surfaces

are slippery or of contrasting texture. Added danger occurs when a threshold abuts loose or frayed

carpeting, which increases the risk of tripping.

The elderly, in particular, should avoid high gloss

flooring that can be slippery when wet and un-
Ch. 9—Technology, Housing, and the Living Environment of the Elderly ● 317

forgiving on impact from a fall (e.g., ceramic tile

floors).

Risk of Fire.—Fire safety is a second major

concern in the elderly’s living environment. Although local fire codes vary, institutional settings

and multi-unit residential complexes are generally required to have fire retardant and nontoxic

materials wherever possible, smoke detectors, full

sprinkler systems, accessible fire extinguishers,

and fire alarms with flashing lights as well as bells

or sirens. Clearly marked exits within specified

distances from any resident’s room, fire-resistant

metal entry doors for all rooms, alarm-activated

firebreak doors in hallways and common areas,

and battery-powered emergency lighting are also

generally required. Inspection and enforcement

of these types of fire code requirements remain

a problem in many communities, especially those

with high proportions of older institutional dwellings that were constructed before such codes

were developed,

Building requirements are far less stringent for

single-family residences. Local jurisdictions are

increasingly likely to require smoke detectors in

all new construction and retrofitting in previously

built multi-unit complexes or in single-family units

that are sold. Because the elderly are highly vulnerable to injury or death from fires, added precautions are especially relevant in their microenvironment. Fire safety would be enhanced with

emergency lighting, maximal use of fire retardant

and noncombustible materials, and smoke detectors with alarm buzzers and signal lights. The

detectors should be installed in all hallways, adjacent to bedrooms and the kitchen, and in basements, Hand-held fire extinguishers in strategic

locations (e.g., bedroom, kitchen) are an additional

safety measure. Where feasible, safe egress

through windows can be enhanced with step

stools to reduce the risk of falls in attempting to

climb over a sill.

Fire prevention is improved by behavioral precautions. Avoidance of smoking while seated in

upholstered furniture and in bed are fundamental prohibitions. Care in the use of all appliances

is also important. For those who may be forgetful, self-monitoring appliances are a recent advantage. An example is the iron that shuts itself off

if overheated, tipped over, or left in one position

for a preprogrammed time. Similar technologies

are becoming available for major kitchen appliances such as range tops and ovens (see subsection on kitchens).

Emergency Response Systems.—General

safety features go beyond those related to preventing falls and fires. Electronic emergency

alarm systems (e.g., ‘

(Lifeline”) are increasingly

available at reasonable cost. The most common

type utilizes a personal transmitter that is either

hand-held or worn on the body, usually on a belt

or as a pendant. In an emergency, as in a fall or

heart attack, the transmitter can be activated to

send a signal to a central home unit that is interfaced with the telephone. The home unit then

automatically dials a centralized control center

that is monitored either by a person or a computer at all times. Most central monitors are currently located in hospitals or in residential care

facilities. In many systems the emergency autodial unit includes a ‘(line-seizure” mechanism that

automatically takes over a phone line that may

already be in use for a normal call. The central

computer can receive several calls simultaneously;

it automatically decodes each call to identify the

home from which it came and records the time

and date of the emergency call.

State-of-the art systems also have special signal

codes to indicate the type of emergency involved

(51). The signal codes indicate whether the source

of the signal was the transmitter (most likely indicating a fall, heart attack, or similar episode),

the emergency button on the auto-dialer unit (suggesting the person is ambulatory), or a smoke detector or appliance (indicating excessive smoke

or fire). The central monitor automatically dials

the home unit to confirm that it was activated,

at which time the monitoring staffperson calls the

home number. If the phone is not answered within a specified time or number of rings, then the

appropriate emergency assistance is contacted.

The sensitivity of the system and the possibility of accidentally relaying a signal require care

in the use and monitoring of all calls. Some systems are programmed to internally verify daily

that the system is not malfunctioning by automatically dialing each home unit to assure it is work-
--

318 Ž Technology and Aging in America

ing. The home units also have automatic battery

operation in the event of power failures or if accidentally unplugged. When in the battery-powered mode, a signal is sent to the central computer

and the staff monitor will then call the home to

ascertain the problem.

These emergency response alarm systems can

be installed in most homes and are especially valuable for persons who are prone to heart attacks

or other acute episodes. In some communities,

hospitals encourage their use as one element of

discharge planning. Monthly charges for these

types of service begin at $35 per dwelling unit,

depending on the complexity of the system (46).

Available information suggests that emergency response systems are of great value to those elderly

who are most vulnerable: those with a history of

acute illness and who live alone. Physical safety

and the feelings of security that assistance is

readily available are the most commonly cited

benefits that these systems provide for elderly

users who consider them well-worth the cost.

Telecommunications Safety and Convenience Devices.—Along with response systems

for emergencies, a new generation of high-technology telecommunications devices are being developed that provide a much wider array of services oriented toward home safety, security, and

convenience. One example is a system that employs microprocessors linked to one or more telephones to gather and monitor information provided by sensors located throughout a house.

These systems (e.g., “Sensaphone”) can monitor

the home’s heating, ventilation, and air-conditioning around the clock and automatically change

room temperatures by preprogrammed instructions. The system also monitors the home’s electrical use, its appliances, and possible sources of

inefficiency, Loud sounds emanating from any

room that has a sensor can be detected. The most

sophisticated units can also use infrared detectors to discern, at predetermined periods of time

(e.g., at night), movements inside or outside the

house, or windows or doors that are opened.

These security detectors can be linked with automatic dialers, similar to the emergency response

systems, to notify authorities when assistance is

needed.

Other telecommunications devices are creating

opportunities for home-based safety or self-health

care instruction (see ch. 6). Although in its infancy

and relatively expensive for most residential applications, interactive telecommunications may

soon replace programmed videotape or computer

disk instructional devices (73). one-way information systems are generally known as “teletext”

services. These involve television signal broadcasts of information that are accessible to individuals at home through a home-based decoder.

With the appropriate keypad, the user can select

the programmed information for viewing through

the television. Teletext currently offers viewers

a variety of programs in news, sports, entertainment, health instruction, consumer information,

and other services.

Interactive systems with two-way communications are in their infancy. They are generically

called “videotex” systems. These two-way information systems will offer a range of services in

one unit, News, shopping, and banking services

by telecommunications are expected to be the

first applications for general in-home use (73).

Videotex not only provides one-way information,

but also allows the user to respond through the

network system, which usually involves telephone

or cable television lines (or a combination of the

two). Community-based trials have demonstrated

the usefulness of videotex in providing homebased electronic “catalogs” of consumer goods and

in ordering merchandise through a home terminal. Videotex is a limited form of a comprehensive computer system that will automatically monitor and run all major aspects of the modern

home—the “smart house” of today, These features

are only the “first generation” of a new technology that may have significant impacts on the way

people work, shop, and play in the future.

For the functionally impaired elderly, such systems offer new opportunities to maintain their

independence through home-based information

retrieval, teleshopping, and banking. Other potential applications include the ability to monitor

a patient’s vital signs and communicate them to

a clinic or physician’s office (26). The patient

would in turn receive information from the physician, Interactive communications of this type
Ch. 9—Technology, Housing, and the Living Environment of the Elderly ● 319

may reduce the burden of difficult trips for medical examinations.

Pharmaceutical prescriptions also may be transmitted through this system, which could include

detailed records of all prescribed and over-thecounter drugs being used by the patient. Indeed,

the problem of “polypharmacy” (see ch. 5) in the

elderly has grown as the population has aged and

more drugs have become available. New methods to monitor drug intake would reduce the likelihood of negative side effects from improper

combinations of drugs. Computer-based monitoring systems could also be used to “read” a patient’s

pharmacy records stored on a microprocessor

embedded in a magnetic strip of a plastic card

that can be carried by the patient. The magnetic

strip would be machine-readable and accessible

to any physician or pharmacist, who would regularly enter new data about the patient. This type

of monitoring could significantly increase the safety of pharmaceutical decisionmaking by helping

assure that a patient is not receiving improper

combinations of drugs.

Currently, these types of telecommunications

systems are in development and trial phases. The

expense of the technologies and their specialized

components make them impractical for general

use by most older persons. But they hold promise for future applications that are clearly suitable for the elderly. Contrary to some negative

stereotypes, older persons are both willing and

able to learn how to use telecommunications

equipment (13). The key factor in the learning

process for the elderly is the functional advantage that the computer provides, whether for instrumental or entertainment activities. older persons are also more likely to welcome computers

if the keyboards have larger keys and the display

screens are enlarged and their glare reduced. If

they perform useful functions at reasonable cost,

personal computers will be used by older persons,

even nursing home residents who have moderate

mental and physical impairments (20,97). Thus,

as they become more affordable and user-friendly,

home computers and other telecommunications

devices should grow in popularity and accessibility among the elderly.

The Kitchen. –Microprocessors also have had

a valuable impact on kitchen safety and convenience for the elderly. New appliances provide various programmable functions to assure that

foods are both preserved and prepared appropriately. Touch-sensitive controls eliminate some

of the problems that arthritic older persons have

with knobs or dials. But these new controls tend

to have poor features for the sight-impaired. Lettering and numbers are generally too small and

of limited contrast for easy viewing. on the other

hand, the ability to better control temperature

settings and to use timing features make these

appliances more convenient and safe. Whether

“soft touch” push pads or dials, appliance controls

for the elderly should assure sufficiently large lettering and should be located at the front of the

appliance; never on the back panel. on ovens and

ranges, for example, controls on back panels are

more difficult to see and present greater danger

of burns from contact with heating elements or

flames.

Wherever possible, design elements that respond to the characteristics of the elderly should

be incorporated in kitchen designs. Ovens and

ranges should be located at counter height to minimize bending and reaching (19). Small countertop ovens are particularly convenient because

they are at the correct height and are often the

most efficient size for preparing one- or twoperson meals. Other low-technology or design factors that add to the convenience and safety of kitchens include roll-out shelves in base cabinets,

bottom shelves that are at least 10 inches above

the floor (4 inches higher than normal), turntables

(“lazy Susans) in corner cabinets, and rounded

edges on all counter and cabinet edges. For the

average older person, ideal counter heights are

32 to 35 inches (about 3 inches lower than most

counters) and the bottoms of kitchen sinks should

be approximately the height of a person’s palm

when standing. Counters and cabinets should be

approximately 2 feet deep for ease of access to

items on shelves. Maximum height for the highest shelves should be 70 inches, Nonglare lighting

over counters and sinks adds safety to food preparation.

Various assistive devices also promote the ability

of impaired older persons to function independently in the kitchen. These include electric can

openers, jar cover openers (mounted under a
320 ● Technology and Aging in America

Photo credit: Comfortably Yours, Maywood, NJ

Turning handles can be used on appliance and faucet

knobs to enhance an older person’s grip and leverage.

counter or hand-held), special grip enhancers that

fit over handles of pots and pans, food preparation timers with large numerals, and long-handled

“reachers” (similar to those used in stores) for getting hard-to-reach objects.

The Bedroom.--One of the simplest changes

in bedrooms is to raise the height of the bed for

easier access and egress by older persons with

limited joint mobility. Bolster rails that can be

securely fastened to either end of the bed frame

rails promote safety in getting in or out of bed.

Nightstands should be slightly higher than the bed

and lighting switches should be at the base of

table lamps or mounted above the head of the

bed. Touch-sensitive, metal base lamps are another convenient option. A telephone should be within easy reach from the bed, as should any emergency response transmitters.

As in all rooms, scatter rugs should be securely

anchored or have nonskid backing. Closets are

more convenient with track-sliding doors, dual

height clothes rails, open shelves from the floor,

and roll-out drawers for selected items. Design

features that minimize the need to bend, stoop,

or reach should be the guiding principles in bedroom design for the elderly (55). Simple devices

also are available to assist older persons in dressing. Among the more common are long-handled

zipper pulls, hand “extenders” for pulling on hosiery, and the use of “velcro” fasteners instead

of buttons or zippers.

The Bathroom.— The bathroom is one of the

most dangerous areas in the micro-environment

of the elderly. Bathrooms are a frequent site of

falls by the elderly and the characteristic hard

surfaces contribute to the severity of injuries.

More attention has been paid to promoting safety

for the elderly in bathrooms than in any other

part of the micro-environment (38). Numerous

low-technology adaptations to existing bathrooms

are feasible. Among the most common and worthwhile is installation of strategically placed and

well-anchored grab bars on a bathtub’s inner and

end walls (using counter-sunk bracing), and over

the outer side (with U-shaped, “locking” extenders). Grab bars should be made of stainless

steel or high-impact heavy gauge plastic. Bathtubs

should have nonskid surfaces; newer tubs are

manufactured with such surfaces, but older ones

usually need nonskid strips or rubber mats.

Adjustable shower heads that move 2 to 3 feet

along a vertical glide rail are convenient for older

persons who have mobility and dexterity impairments. Push-pull or lever types of controls for

water mixers and shower diverters are more convenient than other types of fixtures. Tub chairs

that have adjustable heights, secure backs, and

nonslip leg tips are recommended for those who

find it difficult to remain standing for a shower

or to rise up from a bath. For the more severely

restricted, tub chairs with side transfer seats are

available as well. Another option is a step-in

shower stall made of molded fiberglass that includes a sturdy, built-in seat and movable shower

head (57). All bathtub and shower areas should

be well-illuminated.

Use of the toilet can be made safer by adding

assist rails on either side to help prevent falls. As

with the bed, some older persons have difficulty

in sitting on or rising from the average toilet seat
Ch. 9–Technology, Housing, and the Living Environment of the Elderly • 321

Photo credit: Comfortably Yours, Maywood, NJ

Well-anchored grab bars for bathtubs ar

an important safety feature for the elderl

e

y.

height of 16 inches. Various types of adapters are

available to increase the height from 2 to 5 inches

to ease this problem. Unless there is an emergency response system, a telephone or other signal

device that can be reached from the tub or toilet

is advisable for older persons prone to falls, dizzy

spells, or heart attacks. Tiled or linoleum floor

surfaces in bathrooms should be kept as dry as

possible to minimize the risk of slipping. Ideally,

bathrooms for the elderly should have well-secured wall-to-wall carpeting or large scatter rugs

with nonskid rubber or vinyl backing.

Many of these features represent adjustments

to conventional bathrooms. New bathroom designs based on ergonomic principles and design

standards could be a major step forward. Some

attempts have been made to undertake such studies and designs, but to date none have become

generally available to the public. A model bathroom for the elderly and handicapped has recently been developed by the Design Research CenPhoto credit: Comfortably Yours, Maywood, NJ

Properly installed assist rails for toilets can be adjusted

for appropriate height and width.
322 . Technology and Aging in America

I

Photo credit: Design Research Center, University of Wisconsin-Stout

Prototypes of new bathroom designs are intended to promote the safety of older persons.

ter at the University of Wisconsin-Stout, As shown

in the photographs, the design is unique and attempts to provide a far more user-friendly environment for the elderly. Lighting is indirect and

nonglare. All hard surfaces are rounded and the

entire room is carpeted to cushion falls. The color

of the carpeting contrasts with the walls and fixtures to promote orientation for the visually impaired. The configuration of fixtures and the sturdy swing-out chair permit use at the sink and for

transfer into the nonconventional bathtub. All

shelves are within easy reach of the seated or

standing person; the need to bend is eliminated.

The bathtub represents a significant departure

from conventional design, Rather than require an

older person to step over the normal 13-inch outer side of the tub (with or without grab bars), the

Wisconsin design allows a person to sit in the

open-sided tub, which is at chair height and has

a built-in padded seat and back support. The bather sits, raises his legs, and rotates his body into

the tub, much like getting into bed. A horizontally movable grab bar is used to raise the tub’s

circular outer side. This “bathing tube” is the

enclosure for the water, which enters from shower heads above or a recessed “fountain” (i.e.,
Ch. 9—Technology, Housing, and the Living Environment of the Elderly ● 323

Photo credit: Design Research Center, University of Wisconsin-Stout

The prototype bathtub design reduces the risks of falls

from slipping and bending.

faucet). Push-pull and slide controls for water volume and temperature are located on the grab bar,

with an auxiliary set at the foot of the tub that

can be operated with the feet. The recessed fountain allows the bather to test the water temperature before turning on the shower heads. When

finished bathing, the water drains out around the

base upon which the person is seated (or reclining) and the bathing tube side slides back into the

unit so the bather can swing out to the seat or

step onto the floor.

The other unique design idea is a toilet that

keeps the body raised higher than in conventional

units. The seat is placed at an angle that permits

the user to maintain a squatting position that aids

in defecation. A swingdown support bar opposite

the seat provides additional safety and comfort.

The angle of the seat is also more convenient for

male urination. The Center has developed alternative designs for toilets, including a simpler one

that involves a hydraulic-assisted seat to aid in

lowering and raising one’s body, along with side

support rails for added safety.

While these bathroom designs have not been

adopted commercially, they hold promise for further investigation and modification. For example,

recent marketing for newly designed tubs stress

built-in back supports and recessed fountains in

place of potentially dangerous faucets that extend

into tubs. The University of Wisconsin designs

and technologies represent a conscientious attempt to create a safer and more friendly environment in the most hazardous room for older

persons.

The Living Areas.—Numerous environmental

design adaptations have been mentioned above

that apply throughout the home. Loose and frayed

rugs are particularly dangerous, as are glossy or

slippery floor surfaces. Door handles, recommended for all nursing homes, can be quite expensive to install in one’s home. But there are

available a number of adaptive handle-shaped devices made of metal or plastic that can be snugly

fitted over existing door knobs to provide the

needed lever action. Numerous specially designed

utensils such as scissors, gardening tools, screw -

drivers, eating utensils, and writing implements

have extra-large and slightly curved handles to

aid in gripping. Plastic, rubber, or high-density

foam pieces that can be slipped over the handles

of regular utensils are a less expensive alternative.

Upholstered chairs with hydraulic or mechanical lift mechanisms under the seat cushions aid

those with joint motion difficulty in sitting on or

rising from the chair. Telephones with large buttons and adapters for controlling the volume in

the hearing piece are commonly available. Energyefficient windows with crank handles allow ease

of use for ventilation as well as passive solar

heating. In fact, an important element in housing design for the elderly is energy efficiency and

safety in monitoring the heating and cooling systems to prevent conditions that lead to hypotherPhoto credits: Comfortably Yours, Maywood, NJ

Various door knob adapters can be used, including

ones that convert knobs into handles or provide

grooved grip-enhancers.
—

324 ● Technology and Aging in America

mia or hyperthermia, to which the elderly are

particularly vulnerable.

Numerous other housing design elements, lowtechnology adaptations, and high-technology systems could be discussed (58,67). Clearly, the individual can do much to foster a safer and more

convenient micro-environment without excessive

expense. He can also invest considerable amounts

to develop a computer-based living system that

performs a multitude of functions—the so-called

“smart house” that would combine systems such

as Lifeline, Sensaphone, teletext, videotex, and

other microelectronic applications into a total integrated system.

Other recent high-technology applications are

in robotics, which are primarily being applied in

manufacturing (see ch, 10). Also being developed

are robots that perform various household functions. The current prototypes are most useful for

assisting severely impaired persons such as paraplegics. However, even the most well-developed

robots today require considerable programming

to perform basic tasks. Experimental (and costly)

mobile robots exist that can respond to selected

voice commands and perform a limited range of

functions. Further development of these prototypes could lead to a time when they become

much less expensive, far more appropriate for

tasks of daily living, and generally available for

use in the average household.

Whether the issue is high-technology robots,

home-based computers, housing design elements,

or low-technology adaptations and assistive devices, there is a need for greater public awareness

of the possibilities for promoting the functional

independence of the elderly. At the same time,

the network of public agencies and private organizations involved in the field of aging could also

be better informed, Finally, the private manufacturing sector should be made more aware of the

significant and growing market for products and

services designed to meet the environmental

needs of the elderly.

Concluding remarks

This chapter has reviewed the broad range of

factors that have an impact on the housing and

living environment of the elderly. As the older

population itself ages, the proportions of older

persons living alone, experiencing housing problems, or dealing with functional impairments are

likely to increase during the next three decades.

New responses to assist the elderly in maintaining their independence will be needed if the projected increases in nursing home populations are

to be kept at a minimum. The maintenance and

energy burdens of older housing tend to fall on

those elderly homeowners who are least able to

pay those costs, while elderly renters (who tend

to be poor) are faced with both shrinking housing opportunities and rising rental costs. These

trends are occurring at a time when Federal housing programs and subsidies are being eliminated

or curtailed. The elderly and the poor are the two

groups that are most vulnerable to these changes

in Federal support for housing.

The growing need for congregate housing facilities presents opportunities for public and private involvement across a range of housing types

that can respond to the heterogeneous characteristics of the older population and their needs

for supportive living environments. Excess housing space can be better used to serve both elderly

homeowners and those seeking decent, affordable

rental housing through developments such as

shared housing, accessory units, and granny flats.

Board and care facilities may become more important in providing both housing and protective

oversight to many older persons who do not require skilled nursing care. The many types of life

care and residential care communities being developed attest to the market for this kind of

macro-environmental support. The cost of such

housing opportunities varies greatly, depending

on sponsor, location, and services provided. But

the physical and psychological security provided

by congregate facilities responds to one of the ma-
Ch. 9–Technology, Housing, and the Living Environment of the Elderly • 325

jor concerns of persons as they age, Maintaining

one’s independence, promoting a healthy lifestyle,

and being assured of long-term care and supportive services are the key attractions of residential

care complexes.

Opportunities to remain independent in one’s

home are also possible by attention to adaptations,

design factors, technologies, and behaviors that

promote safety and security. These range from

nonskid treads and appropriately designed stairways to “smart” appliances and totally new bathroom designs. As with all aspects of technology,

their possible applications in the micro-environment of the elderly will depend on their usefulness, cost, and adaptability in existing living environments.

Research priorities

The following items, while not exhaustive, indicate the types of research on housing and the

living environment of the elderly that would be ●

beneficial in development of public policy:

. accurate assessment of the functional abilities

of older persons in tasks of daily living, the

●

physiological bases of functional impairments, and the range of adaptive behaviors

that are developed to compensate for limitations in functional ability; ●

. changes in household composition of the oldold and very-old subgroups of the elderly and

their implications for future demand for formal and informal supports in the living envi- ●

ronment;

. attitudes of the elderly and nonelderly concerning the types of housing opportunities

that should be available and the respective

roles that can be played by the government

and the private sector in providing those

options;

housing problems confronting elderly renters

and mortgaged homeowners who have

household incomes below or near the Federal poverty level;

the market for the full range of elderly congregate housing facilities and strategies for

promoting their development, including a

wide array of accompanying services;

ways to promote development of new models

and designs of living environments for the

elderly that better respond to their physical

capabilities as well as their limitations; and

development of improved projections of

changes in household composition and housing demand of the older population, and ways

by which this demand could be met.

Issues and options

ISSUE 1: Should the Federal Government

expand existing programs that assist

low-income elderly homeowners

who have excessive housing deficiencies and excessive cost burdens?

Options:

1.1 Congress could avoid making changes in current 1.3

programs that assist this subgroup of older

homeowners.

1.2 Congress could mandate additional investigation

of the housing problems of poor elder& homeowners and the ways in which these problems

could be mitigated by the Federal Government.

Particular attention could be focused on possible

biases against homeowners living in small communities in metropolitan counties that are not

likely to benefit under CDBG or Section 312

programs.

Congress could appropriate significant funding increases in the Section 312 program (perhaps in

conjunction with the Community Development

Block Grant program) that provides low-interest

loans to qualified homeowners for rehabilitation
326 ● Technology and Aging in America

1.4

1.5

of their housing. This expansion could greatly increase the number of loans available and/or increase the subsidies for lower interest rates on

such loans. The subsidies could be modeled after

the interest credit provided under Sections 502

and 504.

Congress could amend the Section 312 rehabilitation loan program to permit outright grants or

interest-free loans to low-income elderly homeowners for removing physical deficiencies in their

housing. Other amendments could broaden the

availability of the loans to areas that may not have

CDBG or urban renewal programs,

Congress could legislate new amendments to the

Internal Revenue Code to permit tax incentives

(deductions or credits) for expenses incurred by

low-income older homeowners in correcting certified housing deficiencies.

ISSUE 2:

Options:

Should Congress support the use of

specific technologies in the home

that assist slightly impaired older

persons in carrying out their daily

activities?

2,1

2.2

2.3

2.4

2.5

Congress could avoid further involvement in promoting or subsidizing specific home-based technologies or self-help devices for the elderly.

Congress could indirectly support the use of technologies in the home by encouraging or mandating that the Consumer Product Safety Commission

(CPSC) monitor and evaluate the range of available products and self-help or assistive devices

targeted toward elderly persons living at home.

Such CPSC evaluation would discourage consumer

fraud and indirectly provide consumer protection.

Congress could require specific safety standards

on products used in the home to assist both the

well elderly and those who are frail. These standards could be based on evaluations of product usefulness, safety, cost, and degree of complexity.

Relatively low-cost technologies that can be easily

added in the home to promote safety, such as stair

treads, grab bars, and other alterations, could be

encouraged by Congress through amendments to

housing rehabilitation programs and in coordination with social service programs under the Older

Americans and Social Security Acts. Selected technologies could be specified for these purposes.

Congress could promote the use of more costly

or complex technologies such as electronic devices

(e.g., alarm systems), telecommunications, and

similar devices for use in the homes of older per2.6

sons. Such Federal support could involve consumer information programs, tax incentives, social

service coordination, or direct cost subsidies.

Congress could limit Federal involvement by only

subsidizing the use of selected assistive devices

that are not now considered medically reimbursable under Medicare, such as hearing aids and

corrective lenses. The Medicare reimbursement

criteria would include medical evaluation and certification of need.

ISSUE 3:

Options:

How could Congress encourage utilization of technologies that promote

the independence of older persons

with functional impairments and

major activity limitations?

3.1

3.2

3.3

3.4

Congress could maintain existent housing and social service policies that generally favor those who

are functionally independent.

Congress could require increased utilization of

technologies for functionally impaired older

people in federally subsidized housing through requirements under the Section 202 or Section 8

housing programs. Coordination with Tit/e XX and

OAA social service programs would also be necessary, as well as development of standardized

functional assessment technologies.

Congress could expand the scope of such assistance to include similar utilization of in-home devices for all older persons who require assistive

devices to maintain their independence in the

community and the home (functional assessment

technologies are assumed from option 3.2).

Congress could indirectly support efforts to increase the utilization of in-home assistive devices

for the functionally impaired elderly through public information programs and the coordination or

advocacy activities of social service agencies.

ISSUE 4:

Options:

Should Congress provide increased

support for public and private

sector efforts to develop and utilize

new housing construction and design technologies that assist older

persons to maintain their independence in the home?

4. I Congress could maintain its current level of support through existing Federal housing programs

and incentives to the private sector.
Ch. 9—Technology, Housing, and the Living Environment of the Elderly ● 327

4.2

4,3

Congress could expand the scope of existing Federal housing rehabilitation loan programs (e.g.,

Section 312) or encourage the expansion of community-based grants (for low-income persons)

through the CDBG program to promote the redesign and retrofitting of existing dwelling units. The

programs could focus on structural changes that

are required to permit older persons who ha have

become functionally disabled to remain in their

homes (e.g., design changes such as ramps,

doorway openings, counter heights, etc., for those

who become confined to wheelchairs) .

Congress could promote similar redesign by

developers of specialized housing complexes for

impaired older people through tax incentives, Federal loan subsidies through HUD and FmHA

programs, or other financing assistance.

ISSUE 5:

Options:

5.1

5.2

5.3

5.4

Should Congress encourage and assist the expansion of housing alternatives that promote the continued

functional independence, social wellbeing, or financial welfare of older

persons?

5.5

Congress could encourage increased levels of

funding for research and demonstrations that investigate the feasibility of various housing alternatitives such as accessory units, granny flats,

shared housing, board and care, and congregate

housing. Cost-effective methods to develop such

alternatives could also be investigated, including

modular construction, conversion of commercial

structures, and use of manufactured housing.

Congress could utilize existing information on the

prevalence of single- family housing among older

homeowners, especially low-income persons living

alone, to support construction of accessory units

Chapter 9 references

5.6

1. Atchley, R. C., The Social Forces in Later Life, 3d 5.

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2. Berardo, F., “Survivorship and Social Isolation:

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as rental apartments. New construction and

retrofitting technologies, such as factory-built

modular bathroom and kitchen units, could be

encouraged to control costs while expanding the

housing stock for both older and younger persons.

Congress could earmark specific sums for funding the expansion of shared housing programs

through coordinated efforts under Title XX, OAA,

and HUD. Other support could be provided

through programs such as Section 312 to subsidize

necessary rehabilitation of existing houses to make

them safe and sanitary for shared housing use.

Such efforts could be linked with communitybased development of long-term care programs

to encourage informal supports along with formal

services.

Congress could subsidize, through direct HUD and

FmHA funding assistance and indirect tax

incentives, private sector conversion of dormant

commercial and industrial space into rental units.

Special consideration could be given to those

projects that are for central city and rural areas,

that meet Federal design requirements for

elderly/handicapped residents, and that

encourage the provision of congregate services.

Federal assistance similar to that described in

option 5.4 could be made available to promote

board and care facilities that meet additional requirements for assisting functionally impaired (but

not ill) older persons through long-term care and

congregate services.

Congress could promote the development of various home equity conversion options (e.g., reverse mortgages, sale leasebacks) for older homeowners. Included in such legislation would be

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10

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34

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40. Koncelik, J. A., ‘(Elements of Geriatric Design: The

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42. Lawton, M. P., Planning and Managing Housing

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43. Lawton, M. P., Enttironment and Aging (Monterey, CA: Brooks/Cole, 1980).

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46. Lifeline Systems, Inc., Watertown, MA, persona]

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47. Liu, K., and Palesch, Y., “The Nursing Home Population: Different Perspectives and Implications

for Policy, Health Care Financing Review 19(3):

15-23, 1981.

48. Lopata, H. Z., Widowhood in an American City

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49. Lopata, H. Z., Women as Widows: Support Systems (New York: Elsevier, 1979).

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51. Ministry of Community and Social Services,

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53. Newman, O., Defensible Space (New York: Macmillan Publishing, 1972).

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55. Parsons, H. M., “Residential Design for the Aging, ”

Human Factors 23: 39-58, 1981.

56. Pastalan, L. A., “Demographic Characteristics, ”

Journal of Housing for the Elder[v l(l): 85-87,

spring/summer 1983.

57. Raschko, B. B., Housing Interiors for the Disabled

and Elderly (New York: Van Nostrand Reinhold,

1982).

58. Redden, M. R., and Stern, V. W. (eds.), Technology for Independent Living 11, proceedings of the

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59. Regnier, V., “Neighborhoods as Service Systems,”

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(Stroudshmg, PA: Dowden, Hutchinson & Ross,

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60. Regnier, V., and Bonar, J., “Recycled Buildings for

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61. Research Institute of America, High Technology

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64. Shanas, E., “The Family as a Social Support System in Old Age,” The Gerontologist 19(2): 169-174,
—

330 ● Technology and Aging in America

April 1979.

65. Shanas, E., Townsend, P., Wedderburn, D., Friis,

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70. Struyk, R. J., and Soldo, B. J., Improving the Elder~y’s Housing (Cambridge, MA: Ballinger Publishing, 1980).

71. Struyk, R. J., and Turner, M., Changes in the

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72. Teresi, J., Holmes, M., and Holmes, D., Sheltered

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Chapter 10

workplace Technology and the

Employment of Older Adults
Contents

Page

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 335

Technology, Older Adults, and Employment Opportunities. . . . . . . . . . . . . . . . . . . . . . . . . 336

Technology and Job Opportunities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 337

The Future . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 341

Technology, Retraining, and Older Adults . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 349

Benefits From Training and Retraining. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 350

Costs of Training and Retraining . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 350

Methods of Training and Retraining . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 351

Factors Affecting Participation of Older Persons in Retraining Programs , . . . . . . . . . . 352

Case Study Examples of Retraining . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 353

The Future . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 354

Technology, Health, and Physical Capacity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 355

The Future . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 356

Priority Areas for Research . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 357

Issues and Options . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 358

Technical ,Memorandum A: Workplace Devices . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 359

Technical Memorandum B: Industries in Detail . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 363

Technical Memorandum C: Training Methods. . . . . . . . . . . . . . . . . . . . . . . ..., , . . . . . . . . 364

Technical Memorandum D: Projected Job Growth Rates in High-Technology Industries 364

Chapter IO References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 365
Chapter 10

workplace Technology and the

Employment of Older Adults

Introduction

The structure of the American economy has

undergone major changes since the mid-1800s.

In 1850, the largest sector of the economy was

farming, which employed 64 percent of the labor force. Each farm worker of that era produced

enough food for four people. As the mechaniza -

tion of farm work progressed, more food could

be grown and harvested by fewer workers. Machines such as the cotton gin, tractor, plow, and

reaper revolutionized productivity to the point

that although only 3.1 percent of today’s workers are farmers, each farmer provides enough

food for 78 people (37).

By the 1900s the mechanization of farming had

substantially lowered the prices of many products. Spinning and weaving machinery, for example, combined with the cotton gin to reduce cotton prices. The concomitant decline in need for

farm labor pushed workers into urban areas,

where factory employment was available. By

1920, two of every five jobs were in the manufacturing industry, and the share of farm employment had fallen to 11 percent (37).

Today, the concentration of jobs in the economy is shifting once again; manufacturing jobs are

giving way to service sector employment. During the manufacturing boom of the 1920s, service employment accounted for only 11 percent

of the work force. In the 1980s, the growing number of two-earner families has spurred interest

in dining out, traveling, and a range of other support services for busy families. As a result, new

jobs in the service sector abound, and the proportion of jobs in this sector rose from 11 percent in 1920 to 22 percent in 1982. At the same

time, the emphasis on efforts required by occupations within these industries has shifted from

physical to mental as machines take over many

manual functions.

Today, workers 45 and over (hereinafter called

‘(older workers”) are largely located in the industries and occupations that offered good job prospects at the time they chose their careers. Older

workers are concentrated in manufacturing industries, which, though declining during the

1950s, continued to hold the largest proportion

of workers. Both service and trade were then expanding. The country was experiencing growth

and workers expected bright futures.

The unprecedented, explosive pace of recent

changes in workplace technologies may, however,

be threatening future job security of older work -

ers. Advanced production technologies, computers, and robotics were not available when today’s

older workers were training for careers. New

computer and technology-dependent jobs are becoming an increasingly larger share of the total

job pool. Thus, workers lacking in appropriate

technical skills have a decreasing number of

employment opportunities. To remain employed,

some older workers may be forced into lowskilled, low-paying jobs. Others may receive ex -

tensive on-the-job training but may be forced to

retire. Older workers who lose their jobs are likely to have difficulty finding new employment at

previous pay levels.

Technology may also oust older workers from

jobs in declining industries and occupations. New

technology in these industries is making some jobs

obsolete as machines substitute for human labor.

The most rapidly declining industries are in manufacturing, and many of the declining occupations

are in private household services and farmingall of which hold high proportions of older

workers.

But just as technology threatens some older

workers’ chances of continuing in jobs they cur335
336 . Technology and Aging in America

rently hold, it may be a boon for others. Technology is creating additional jobs in many of the

other industries and occupations in which older

workers are concentrated, and new service sector and clerical jobs may provide opportunities

to some older workers. These growing industries

and occupations may also signal opportunities for

part-time work, which is a goal of many older

workers. It is also a goal of women of all ages,

whose number in the labor force is rapidly increasing and who may be a source of competition

for these jobs.

Technology can be particularly helpful to older

workers who have physical impairments, by offering them assistive devices to compensate for

waning physical strength, eyesight, or hearing.

Use of these devices can improve employment

prospects for those not ready for retirement.

Technology can also benefit workers who are

involved in physically hazardous jobs or who

work with dangerous chemicals or materials. Machines are likely to replace many workers who

once risked disease, disability, or death from years

of exposure, freeing them to take less hazardous

jobs.

As the requirements of many jobs change, continuous training and skill updating are becoming

necessary components of work. Few opportunities for retraining of workers are available today,

but it seems that older workers, for a variety of

reasons, have even fewer training or retraining

opportunities offered to them. This practice could

change in the future, however, as the work force

ages and as retraining becomes more common.

Technology can thus both help and hinder older

workers’ ability to continue working. If, on the

one hand, current trends in innovation and implementation of mechanization continue, technology is likely to reduce opportunities for older

workers or, at best, be neutral, On the other

hand, technology has the potential to expand opportunities for older workers and to improve

their working conditions. The future growth of

workplace technologies and their impact on older

workers are likely to require scrutiny by policymakers to improve the quality of worklife and

provide job security for the total labor force.

Technology, older adults, and

employment opportunities

Workplace technologies vary from simple tools

and implements for individual workers to complex production systems that involve thousands

of workers. The effects of technologies are equally varied–they eliminate old jobs and create new

ones, enhance working conditions for some and

act as barriers to employment for others.

Employment and the effects technology may

have on an individual’s work and work opportunities can be examined in relation to the economy’s various segments: nine industrial sectors,

each of which contains up to nine classes of occupations that in turn include various types of

jobs. Technology can influence work in any or

all of these categories.

Each of the potential effects of technology may,

in turn, have an effect on workers over 40.

1 Little research has been conducted on the special

problems faced by older workers as a result of

new and changing technology, but the current

state of technological change does not appear to

be a major concern for older adults.

‘For purposes of this study, most of which is focused on workers over 45, older workers are defined as employees aged 40 and

over, because this is the age: 1) at which protection from discriminatory hiring and firing practices begins under the Age

Discrimination in Employment Act (ADEA) of 1978; 2) at which many

workers begin to notice changing occupational opportunities; 3) designated in much of the research literature as older employees; and

4) of those aged 40 to 45 in 1980 who will be 60 to 65 in 2000, the

period generally covered in this study.
Ch. 10—Workplace Technology and the Employment of Older Adults ● 337

Technology and job opportunities

LABOR FORCE PARTICIPATION TRENDS

OF OLDER WORKERS

Patterns of labor force participation of workers 4.5 and over have been changing steadily since

the early 1900s. For men, labor force participation has declined across all older age groups over

time. Between 1940 and 1983, participation of

men 45 to 54 fell from 96 to 91 percent, participation of men 55 to 64 dropped from 87 to 70

percent, and the proportion of men over 65 in

the labor force declined dramatically from 45 to

17 percent.

Patterns for women have taken a different

course. The composition of the labor force has

changed to include far more women; 43 percent

of today’s U.S. workers are women. In 1940, 24

percent of women aged 45 to 54 worked outside

the home; this figure rose to 62 percent in 1983.

The participation of women aged 55 to 64 also

increased—from 19 to 42 percent—while participation of those over 65 remained relatively steady

at 7 percent in 1940 and 8 percent in 1983.

According to 1983 data, large numbers of men

and women over 65 were in the labor force but

overall participation rates obscure substantial

variation among more detailed age groupings. Although participation for men over 65 was shown

to be 17 percent, 25 percent of those 65 to 69

were working compared with 17 percent of those

70 to 74 and only 8 percent of those over 75. The

pattern is similar for older women. Aggregate

data show participation rates to be 8 percent; this

consists of 15 percent for women 65 to 69, 8 percent for those 70 to 74, and 3 percent for women

over 75. This age-based trend is similar within

each racial group.

Although participation rates of workers over

45 have fallen since early in the century, the numbers of those working have increased. In 1950,

approximately 22 million workers were over 45;

by 1983 the number of workers in this age group

totaled almost 32 million. The 55-to-64 age group

reached 12 million in 1983 (up from 8 million in

1950) and there were 3 million workers over 65

in both 1950 and 1983. These increases in num -

hers have occurred despite drops in participation

rates.

Several factors are said to account for the decline in proportions of older workers. Some companies relieve the excess in their labor forces by

offering incentives to older workers to retire

early. Poor health has also been a limiting factor

in work participation, as discussed later in this

chapter. In addition, some legislation has supplied

incentives to leave the labor force by age 65 or

before. The availability of Social Security and private pensions often makes it financially feasible

for workers to retire before 65.

Though the labor force participation rates of

older men are expected to continue declining, current and proposed legislation that influences the

choice to retire or remain employed does not encourage early retirement. Recent amendments to

the Social Security Act raised the start-up age for

collecting full retirement benefits from 65 to 67,

which will be phased in between 2000 and 2022.

The 1978 amendments to the Age Discrimination

in Employment Act (ADEA) raised the age at

which employees can be forcibly retired from 65

to 70. Recommendations to streamline the Medicare system have proposed raising the age of

eligibility from 65 to 67 to encourage people to

continue working in order to be covered by insurance plans.

INDUSTRY TRENDS

Since 1900, changing technology, coupled with

shifts in consumer demand, has redistributed the

concentration of jobs among industries. In 1900,

36 percent of jobs were in manufacturing, 16 percent in trade, and 11 percent in services; today

only 20 percent of jobs are in manufacturing

while the trade and service industries each account for 22 percent. Between 1969 and 1979,

almost 90 percent of gains in total employment

occurred in the service-producing sector.

These sectors—manufacturing, service, and

trade—are those in which workers over 45 are

most likely to be employed. Men between 45 and

64 are most likely to be involved in manufactur-
338 ● Technology and Aging in America

Photo cradit Alonzo Zamorra

Some older workers are employed in trade or service

occupations that have not been affected

by technological change.

ing; men over 65 are most often employed in services; and women over 45 are most likely to have

jobs in the service sector.

OCCUPATIONAL TRENDS

Major economic shifts can be seen in growth

comparisons of white-collar, blue-collar, and service workers over time. In 1940) workers employed

in these occupations accounted for 31, 57, and

12 percent of the labor force respectively. By

1980, these percentages had shifted to 54 percent,

34 percent, and 12 percent (13). This increase in

both numbers and proportion of white-collar

workers indicates that jobs are becoming less

physically demanding and require more intellectual skills.

The potential effects of changing technology on

older workers are seen in comparisons of occupational trends by age. Among male workers 45 to

64, the greatest number (21 percent) are in crafts,

followed by managerial workers (19 percent), and

professional/technical occupations (17 percent).

The highest percentages of men over 65 are in

management (18 percent, or 2 percent of all management workers), the next highest in professional/technical (15 percent, or 2 percent of all professional/technical workers), and service (13

percent, or 2 percent of all service workers) occupations.

The pattern for female workers is again very

different. Employed women 45 to 64 are concentrated in clerical jobs; 40 percent of all working

women 45 to 64 are clerical workers. Lower proportions are involved in service (21 percent) or

professional/technical (19 percent) work. Women

over 65 are most often found in clerical (25 percent, or 2 percent of all clerical workers) or service (21 percent, or 2 percent of all service workers) occupations; 10 percent of all private household workers are women over 65.

Regardless of the number of older workers

across occupations, certain occupations, particularly farm, private household, and managerial occupations, have higher concentrations of older

workers. Half of all farmers and farm laborers

are men over 45 (14 percent are men over 65).

Thirty percent of managers and administrators

are men over 45. Among private household workers, 2 of every 5 are women over 45 (1 in 10 is

over 65) and 1 in 5 of those employed in a clerical

occupation is a woman over 45.

Large proportions of today’s older workers are

being affected by new technology as it rapidly

changes the ways in which work is done. But little is specifically known about the extent of the

influence of technology, or whether older or

younger workers are more influenced by it. It is
Ch. 10—Workplace Technology and the Employment of Older Adults ● 339

clear, however, that workers of all ages will need

to adapt to changing needs for skills.

Several examples illustrate this point. The nature of clerical jobs is undergoing significant

change. Many offices are switching from electric

typep-writers, which process one page at a time,

to computers and word processors that can edit,

store, and print lengthy documents in seconds or

minutes. The quality and speed of these document

printers has increased from a printwheel printtime of 2 minutes per page to laser printers that

produce typeset quality print in only 4 seconds

per page. Executives of the future can expect to

dictate directly into a sophisticated computer that

understands spoken language and can type the

document simultaneously as it is dictated. There

may thus be fewer clerical workers needed in the

future, and secretaries may need word processing, editing, and proofreading skills rather than

typing skills. .

Service jobs are also changing. For example, telephone operators’ jobs are changing as companies

install computerized switching equipment. Computers take incoming calls and distribute them

to available operators. In some locations, though

the human operator may take requests for specific phone numbers, the numbers are spoken to

the requester by a computer-synthesized voice

while the operator takes the next call.

Computers will make the jobs of some managers

easier and may, in some companies, eliminate

some middle-management positions. Computers

allow greater and faster corporate access to information and the ability to monitor the work being performed by staff. In addition, experts believe that computers can widen the span of

control of middle management so that fewer managers will be needed to supervise the same number of employees (5).

Computers may also simplify such professional/technical jobs as those of scientists. Quick access to data bases and the use of special software

packages that perform difficult and time-consuming calculations and create special graphics are

among some of the improvements. Architects can

now rely on computer-generated renderings for

some types of layouts, dramatically reducing the

time required to produce the final blueprints.

Eventually, the jobs of many private household

workers who are over 45 are likely to be directly

affected by robots that can perform housekeeping chores. Some high-cost robots now available

can be programmed to do such jobs as windowwashing, floor-mopping, and vacuuming. Human

workers may provide supervision and maintenance to these mechanical helpers.

Although technological change may reduce job

opportunities for some older workers as new

technologies continue to emerge, other older

workers will be able to compete with younger

workers for jobs that require new combinations

of skills.

JOB TRENDS

In specific industries or occupations technological advances will both change the way people do

their jobs and greatly reduce the number of jobs.

When jobs are eliminated, the workers who held

them are said to be displaced, i.e., unable to find

the same type of work again.

Despite the absence of comprehensive data, it

is clear that technology, as well as other factors,

has displaced some laborers, service station attendants, stenographers, and workers in printing, agriculture, longshoring, communications,

mining, and textiles (1,24,37,38,39,45). Several

hundred thousand metalworking positions and

thousands of white-collar jobs are estimated to

have been lost due to technological innovation

over an extended period of time (8). For example, the crafts occupations—which include printing and some metalworking occupations-employ

a large percentage of older workers. Because

roughly one-third of workers in white-collar jobs

are over 45, and the percentage of these jobs is

expected to decline slightly through 1995, older

workers in these occupations are also at risk of

losing employment.

A small degree of displacement among older

workers has been documented, but the data on

displacement do not distinguish between technological change and other causes of job loss. A

longitudinal survey begun in 1966 found that 7

percent of men over 45 in a national sample had

suffered an involuntary job loss over a lo-year

period. Occupation, age, and education had little
%0 . Technology and Aging in America

Photo credit: Alonzo Zamorra

Technological advances are displacing some

service station workers.

effect on the probability of older worker displacement. Displacement occurred more frequently in

the private than in the public sector and less frequently in companies with pension benefits. Displacement rates were, however, higher in the

manufacturing and trade industries, where older

workers are most heavily concentrated (31).

The impact of technological change on currently employed workers is unclear. Many labor

union officials contend that the use of robotics

and other technological innovations will displace

workers. Some industry officials estimate that

computer-integrated manufacturing systems reduce labor requirements by between 3 to 1 and

20 to 1 (48). Manufacturers and users of these

machines argue that any employment impacts will

be considerably reduced by attrition, retirement,

and retraining of existing workers (45,5 o). Observers in the automobile industry argue that although technological innovations such as robots

may cause immediate displacements, they will

ultimately create more jobs by making the United

States more competitive with foreign producers

(8). Technological advances are also expected to

create totally new areas of work.

Unemployment is a common consequence of

displacement. Although one-third to one-half of

those who lost jobs moved to new employment

almost immediately, an additional one-third were

unemployed up to 13 weeks, and the rest were

unemployed longer than 13 weeks. The period

of unemployment, however, was contingent on

the economic conditions at the time of displacement. As might be expected, those unemployed

in an unfavorable job market had longer periods

of idleness than did workers displaced during better economic times. The state of the economy is

thus likely to be very important to an older person’s ability to keep or get work.

A 1980 report found unemployment significantly related to the decision to retire early; that “older

male workers are being forced out of the work

force by a variety of factors such as age discrimination, and technological obsolescence . . . Retirement legitimizes withdrawal from the work force

in the face of difficulties finding suitable work”

(6). Even when such factors as health, socioeconomic status, available income, etc., were taken

into account, unemployment was associated with

early retirement. The study also found that for

white workers, 1 week of unemployment encouraged workers to retire to the same extent that

$1,000 in savings, stocks, and bonds would affect

this decision.

one of the most striking effects of displacement

and unemployment is the reported reduction in

wages upon reemployment. The Parries longitudinal study found that the major lasting effect of

displacement was lower wages; those who had

been displaced experienced average earnings that

were 22 percent below those workers who had

not been displaced (31). A study of the automobile

and steel industries found that when displaced

workers became reemployed, they did so at lower

earnings than they had previously enjoyed. The

authors estimate that displacement resulted in a
— —

Ch. 10—Workplace Technology and the Employment of Older Adults . 341

permanent earnings loss ranging from 7 to 15 percent of annual income (20). Another study of displaced workers found hourly wages averaged 33

percent lower at reemployment (46).

Job tenure, which is strongly associated with

age, also influences wages at reemployment. The

longer the tenure, the greater the relative loss in

earnings upon reemployment (20). The Congressional Budget Office estimated that displaced

workers with fewer than 10 years seniority were, . .

after 2 to 6 years, earning 91 percent of what they

would have earned had they not been displaced,

Workers with 10 to 20 or more years of service

had wages 81 and 75 percent, respectively, of

what they would otherwise have earned. Some

experts estimate that $50 for every year over age

25 is lost at reemployment after displacement (14).

.

Older workers also experience longer periods

of unemployment than do younger workers (in

1981 the mean duration of unemployment was

14.8 weeks for workers 25 to 54, 18.3 weeks for

workers 55 to 64, and 16.0 weeks for workers

over 65). This long period of unemployment may

result in discouragement, feelings of futility, and

eventual discontinuation of efforts to find new

employment. Data from the Bureau of Labor Statistics reveal the magnitude of the increase in

unemployment rates when discouraged workers

are included. The 1968-81 period showed an average increase from the adjustment of 0.5 percent

for men and 1.2 percent for women in the 25 to

54 group; 0.5 percent for men and 1.5 percent

for women in the 55 to 64 group; and 3.2 percent for men and 4.7 percent for women in the

over-65 group. As a result of their discouragement, some older adults who have been displaced

from their jobs may choose to retire.

Both displacement and unemployment can affect retirement income. If displacement occurs

before one is fully vested in a pension, pension

income can be completely lost. Furthermore, since

Social Security benefits are calculated on the basis

of earnings, lower wages at reemployment can

lead to lower Social Security income following

retirement.

The future

THE PROJECTIONS

Estimates of the size of the future labor force

and levels of industrial and occupational employ -

ment are based on varying sets of official govern -

ment projections. The most frequently used projections are those developed by the Department

of Labor’s Bureau of Labor Statistics (BLS). Industry, occupation, and labor force projections are

available to 1995, although they are generally acknowledged to be reasonably accurate for no

more than 5 or, at most, 10 years. High, middle,

and low projections reflect varying assumptions

about fertility, mortality, migration, and individual socioeconomic characteristics. occupations

that are likely to be affected by automation are

identified, but the BLS does not project the impact of automation on employment levels by occupation or determine the number of individuals

likely to be displaced by technology.

Though projections of future employment (including labor force, gross national product, employment by industry, and employment by occupation) are invaluable for public planning and

private decisionmaking, they depend on accurate

anticipation of changes in the economy. Since it

is impossible to correctly predict what may occur 10 years hence, three alternative sets of assumptions are developed in order to establish a

range of possible outcomes.

Because the art of projection is predicated on

the use of numerous assumptions, different combinations of assumptions can produce wide variations in outcomes. Four BLS projections of the

1980 labor force, made between 1965 and 1976,

were below actual totals. Much of this discrepancy was due to difficulties in predicting the activities of specific groups, For example, projections

of male participation rates were overestimated

while female participation rates were greatly

underestimated. The participation rate for women 25 to 34 in 1980 was a full 25 percent higher

than projected in 1965. For women 35 to 44, projection underestimation errors ranged from 15.2
342 . Technology and Aging in America

percent in 1965 to 7.2 percent in 1976. Another

problematic projection was for men 55 to 64; the

1965 projections overshot their actual participation rate by 12,3 percent. The 1976 projections

were off by only 1.1 percent.

Data Resources, Inc. (DRI), also forecasts civilian labor force participation. Although BLS projections were, on the whole, more accurate (mean

absolute deviation between actual and projected

figures was 2.0 for BLS v. 2.5 for DRI), the DRI

projections were closer to actual participation

rates for females, particularly those in the problematic age category of 25 to 34. DRI’s least accurate projections, those for women 35 to 44,

were still closer than those made by the BLS.

Though projections by both organizations can be

inaccurate, the BLS projections are used in this

report in order to be consistent with Federal

usage of these data for policymaking.

Projections of industry and occupation are

unavailable by age, largely because of the difficulty of predicting individual job choices, which

are based on numerous past experiences, future

expectations, and personal decisions. There are

thus no projections on which to base estimates

of the influence of future industrial and occupational shifts on labor force participation of older

workers. Yet certain possible effects can be anticipated, given what is already known about technological change and jobs held by current older

workers.

LABOR FORCE PROJECTIONS

Current BLS middle-growth projections indicate

that the size of the labor force will increase from

102 million in 1982 to 127 million in 1995. Most

of this increase is expected to occur between 1982

and 1990 as the U.S. economy recovers from the

recent recession. Between 1990 and 1995, employment is expected to climb, but at a slower rate

(34).

Three general trends are projected (12):

● Over the next several years labor force participation rates for women 20 to 44 are expected to continue their recent upward spiral, after which they will return to a slower

growth rate than that of the 1970s.

●

●

Labor force participation rates for men over

55 are expected to continue declining, although at a slower rate than during the

1970s.

Labor force participation rates for men 20

to 44 are expected to continue declining, also

at a slower pace than during the 1970s.

The projected labor force for 1995 shows a continuing high percentage of workers under 45 and

an increasingly smaller proportion of workers

over 55. The group between 45 and 54 in 1995,

which includes part of the baby boom cohort, is

expected to grow by 4 percentage points, or 10

million workers, from its 1982 total. Middlegrowth projections to 1995 suggest a slight

growth in numbers of older workers in some age

subgroups and a decline in others. In a total labor force of just over 131 million, workers over

45 would account for 30 percent of the labor

force (39 million). Of this group, 11 million (8 percent of the labor force) would be 55 to 64 and

3 million (just over 2 percent of the labor force)

would be over 65.

The growth in number and proportion of older

workers will mean an eventual maturing of the

labor force. The labor force reached its highest

median age, almost 41 years, about 1960. The recent influx of baby boom workers has sharply decreased the median age to a low of 35 years in

1982. The median age will continue at about this

level until 1995, when all the cohorts of baby

boom workers will be over 35, boosting the median age to well over 37 years. This maturing of

the labor force may enable industry to enjoy higher productivity and lower unemployment over

the next 12 years as the individuals who make

up the labor force become better educated, have

a wider range of needed skills, and gain additional

seniority (12).

The direction of future changes in labor force

participation of older workers differs markedly

by sex, but not by race. The labor force participation rates of men of all races over 45 are expected either to remain constant to 1995 or to

decline, in some cases substantially. For instance,

participation of white men 55 to 64 is expected

to drop from 70 percent in 1983 to 66 percent
Ch. 10—Workplace Technology and the Employment of Older Adults ● 343

in 1995; among those over 65 it is expected to

drop from 19 to 14 percent. Black men are expected to show similar patterns.

The proportion of women job holders over 45

in 1995 is expected to increase from 1983 levels.

Participation rates for both white and black

women 45 to 54 are expected to increase dramatically; a moderate increase is projected for women

of both races aged 55 to 64. The participation of

women over 65, however, is expected to decrease

slightly.

INDUSTRY PROJECTIONS

BLS projections assume that “smokestack industries” will not vanish, and attribute their recent

job losses to the economy. Yet manufacturing is

expected to grow slightly, accounting for only one

of every six new jobs between 1982 and 1995.

In key manufacturing industries such as automobiles and steel, previous employment peaks are

not expected to be regained. Increasing consumer

demand will boost production, but productivity

gains through advanced technology and management efficiencies are likely to limit employment

expansion (34).

Most of the new jobs—an estimated 75 percent

of those added through 1995—will be in the service sector. Within this broadly defined sector,

medical care, business services, hotels, personal

services, and nonprofit organizations are expected to account for one out of every three new

jobs.

Employment patterns in other industries are

also expected to change. The trade industry is expected to show large growth while both construction and finance/insurance/real estate are projected to grow moderately. The remaining industries should gain only slightly in employment, with

the exception of agriculture, which is expected

to decline slightly.

Assuming that the current industrial distribution of cohorts of workers now 45 to 54 and 55

to 64 remains the same in the future, and that

labor force growth follows BLS projections, these

workers are likely to be employed in industries

with high or moderate growth rates. Manufacturing, which has the greatest concentration of

workers over 45, is likely to grow moderately,

while services and trade are expected to grow

very quickly. This growth in demand for labor

could produce more job opportunities for older

workers, unless younger workers and mechanization limit these opportunities. Furthermore, since

service jobs engage a high proportion of other

than full-time workers, and older adults report

a desire to do part-time work, the high-growth

service sector may play an increasing role in the

employment of older workers.

The size of the employing firm has an important effect on the status of older workers. In 1979

about 72 percent of workers over 65 worked in

firms employing fewer than 100 people; 39 percent of those 55 to 64 did so. This is particularly

significant since about 78 percent of the employment growth in the private sector between 1978

and 1980 occurred in businesses with fewer than

100 employees (this figure does not represent the

volatility of these businesses, which often fail

within 3 years). The explosion of employment in

these small businesses may provide new jobs for

older employees who wish to continue working.

These firms may be more flexible as to work

structure, allowing alternative options to full-time

work for employees. older people are seeking and

finding employment in these small establishments.

Of those workers over 65 in wholesale and retail

trades and the finance/insurance/real estate sectors, the vast majority work in firms with 25 or

fewer employees.

OCCUPATION PROJECTIONS

Though demand for products is expected to

provide greater impetus for employment shifts

than labor-saving technology, automation is likely

to change the distribution of occupations. The

1995 forecast for specific occupations shows that

the largest redistributional effects will be among

professional/technical workers, who are expected

to gain just under 1 percent of jobs, and farmers/farm workers, who are expected to lose the

same proportion. Operative employment and laborers are also likely to show an overall loss, and

managers, craft, and service workers an overall

gain. Some specific occupations are likely to decline. By 1995, the proportion of white-collar

workers is expected to be 52 percent—close to

today’s level. Blue-collar workers are expected to
344 ● Technology and Aging in America

decline from 34 percent in 1980 to 29 percent in

1995 and service occupations to increase slightly

from 12 percent in 1980 to 16 percent in 1995

(42).

projections of the influence of high technology

on job growth depend on which BLS definition

is used. Under the broadest definition of “hightechnology” industries,2 technology-related employment could account for 17 percent of all new

jobs between 1982 and 1995; under the most limited definition it would account for only 3 percent of these jobs (for specific growth expectations see technical memorandum D) (42).

The percentage growth of specific occupations

within these fast-growing industries is particularly

high in occupations dealing directly with new

technologies. In middle-growth projections to

1995, most of the 20 fastest growing occupations

center around computer programming, servicing,

operating, and repair. Growth rates will also be

high for electrical and mechanical engineers,

physical and occupational therapists, and medical and banking clerks.

Growth in the number of jobs by 1995 affects

a different set of occupations. According to BLS

projections, only 40 of the existing 1,700 occupations will account for 50 percent of all employment growth. The greatest number of new jobs

will be available to building custodians, followed

closely by cashiers, secretaries, office and sales

clerks, nurses, and waiters and waitresses. Some

of these job categories are largely independent

of new technologies and they are unlikely to be

affected by technological change. A few, such as

office work and nursing, may be notably affected.

Most, however, are relatively low-wage manufacturing and service sector jobs,

‘The BLS provides three definitions of high technology, ranging

from very broad to very limited. They are, in order of magnitude

from broad to limited, the following: 1) Any industry that utilizes

technology-oriented workers accounting for a proportion of total

employment of at least 1?4 times the average for all industries. A

total of 48 industries are included in this category, threequarters

of them in manufacturing. 2) The proportion of technology ariented

workers relative to total employment in the industry is equal to or

greater than the average for all manufacturing industries and the

ratio of R&D expenditures to sales is close to or above the average

for all industries. This group includes 28 industries, and excludes

most nonmanufacturing industries. 3) The ratio of R&D expenditures to net sales is at least twice the average for all industries. This

definition includes only six industries, all in manufacturing.

A number of occupations are projected to

undergo rapid decline between 1982 and 1995,

as a result of expected demographic and economic

changes in the United States. Heading the list for

declines are jobs related to transportation, such

as railroad conductors and taxi drivers, probably

due to declining demand for these modes of transportation. Numbers of private household workers and servants, child-care workers, college and

university faculty, and graduate assistants are

likely to decline due to the lower numbers of

young people, Among the many occupations being threatened by technology are postal clerks,

postmasters and mail superintendents, stenographers, typesetters and compositors, and rotary

drill operators. If occupational employment patterns for current cohorts of workers 45 to 54 and

55 to 64 were to remain constant, future older

workers would be unlikely to benefit from the

projected new and additional jobs in high-technology fields. Most older adults are located in

slow-growing professional, managerial, or craft

occupations, and only small proportions of workers over 45 are currently employed in occupations such as scientists, computer programmers,

or computer technicians. They are consequently

less likely than younger workers to have the

unique education and training necessary to compete for or to keep these jobs.

Older workers may, however, benefit from

growth in the number of jobs in manufacturing

and service sectors, which contain large numbers

of older workers, and clerical or service occupations, where older workers are also concentrated.

other workers may see their job opportunities

decline. The kinds of occupations that are likely

to diminish in number are precisely those farm,

professional, and specific craft occupations in

which older workers tend to be employed.

Robotics are a major source of the controversy

surrounding displacement of future workers,

Some experts contend that industrial robots may

increase from today’s estimated 3,000 to as many

as 25,000 in the automobile industry alone by

1990, and these may eliminate a large number of

jobs (8,18). According to General Motors, a robot

displaces 1.7 workers in an assembly plant and

2.7 workers in a manufacturing plant (27). A recent study by the American Society of Manufac-
Ch. 10—Workplace Technology and the Employment of Older Adults Ž 345

Photo credit” The Coach Leatherware Co , Inc.

Job opportunities for skilled craft workers are expected

to decline in the future.

turing Engineers predicted that as many as 20

percent of existing jobs in the automobile industry could be performed by robots by 1985 (25).

The large numbers of older people who are automobile workers or who work in other manufacturing and craft occupations may thus be at great

risk of being displaced, although the need for robot maintenance and repair will create new jobs

for some of these individuals.

Robotics may threaten jobs in areas other than

automobile and steel manufacturing. Based on a

survey of users and manufacturers of robots, Robotics International predicts that 3 percent of current packers and wrappers, 5 percent of welders

and flamecutters, and 10 percent of production

painters would lose their jobs (35). Similarly, a

study of the Michigan auto industry finds that between 10,500 and 18,000 jobs, primarily welding

and production paint jobs, are destined to be eliminated over the next 10 years by technology. A

Carnegie-Mellon study has identified 4 million factory jobs that robots will perform, and an additional 3 million jobs that robots might assume by

the year 2000 (7).

The lack of specific information on older workers makes it difficult to determine which future

older employees will be at risk of job loss due to

technological change. Nonetheless, information

about displaced workers in the Parries longitudinal survey provides the basis for possible future

scenarios. In that study, displaced older workers

were most likely to be employed in the trade and

manufacturing industries. Because projections indicate that employment in both of these industries will grow, the future could provide many

employment opportunities for older workers,

either to remain in the labor force or to change

jobs. If many of these new jobs are technologically oriented, however, some older workers may

need training. For example, growth in manufacturing jobs is likely to be at either the high or low

end of the skill and wage continuum: either lowpaying occupations such as office clerks or custodians, or high-paying, high-skill occupations such

as computer technicians. Most older workers

need training to work in the higher end of the

skill and pay scales because they are less likely

to hold these kinds of jobs today. Without training, older workers may have an increasing number of jobs available to them but the jobs will be

at lower wages and at lower skill levels.

Yet current displacement rates in these industries are high. In 1982, 51 percent of all layoffs

and 28 percent of permanent job separations occurred in the manufacturing industry. Trade

ranked a close second in separations, followed by

services, If older workers continue to be displaced

in these industries, the growth in these industries

could result in net job losses for older workers.

Occupations with high concentrations of older

workers also had a high mean displacement rate

in the Parries study. Service, professional/managerial, and craft workers experienced involuntary job loss more often than other groups. Future

employment in these occupational groups is likely

to grow, although at varying rates. If technological change does not radically alter specific jobs
346 Ž Technology and Aging in America

within these groups and older workers remain

concentrated in the same industries, they may be

at low risk of future displacement.

There is as yet little agreement on the overall

number of workers who face displacement b y

technology. There is some consensus that technology will reduce the number of future jobs

available in some occupations, but its effects on

currently employed workers remain difficult to

predict.

NATURE OF WORK

Replacement of workers with machines or robots may also change the nature of work itself

by changing the number of hours people spend

at work, the type of work done, the skills needed,

and the sites at which work is performed.

At the turn of the century, workers often

worked 14 hours a day, 7 days a week, 52 weeks

a year. Today’s standard 40-hour, 5-day workweek can be partially attributed to the mechanization of industry that increased the productivity

of workers. Workweeks have been shortened

even further in companies that have raised the

number of hours worked per day while keeping

constant the number of hours worked per week

(40-hour, 4-day weeks with lo-hour days). Other

companies have reduced both total hours and

days worked per week (36-hour, 3-day weeks

with 12-hour days). The BLS forecasts that the

length of factory workweeks will be virtually unchanged in 1995 at 38.8 hours, compared with

38.9 hours today. For the private, nonfarm economy, average weekly hours are projected to fall

from 35.1 in 1982 to 33.1 in 1995.

Future technology will also change the type of

work and the skills needed in some jobs. For example, “paperless offices” of the future will hold

all records and files in a central computer, eliminating the need for an employee to move between

typewriter and copying machine. Conveyor belts

to move bulky material between offices may become commonplace. Clerical workers will need

word processing skills or skills in computer programming and operation.

Libraries are undergoing rapid change. Timeconsuming information searches that once sent

librarians to card catalogs and bookstacks can

now be done far more quickly and with minimal

movement from behind a desk-top computer

terminal.

Bank tellers may change from serving customers directly to servicing automatic tellers, with

machines taking over mathematical calculations

and recordkeeping while the human worker oversees their operation and replenishes supplies of

money and paper.

In broader terms, managers may do more of

their “managing” through computer monitoring

of employees’ work, increasing the number of

people and amount of information managed by

simplifying access to workers and their output.

Decisionmaking itself is now entering the realm

of the computer, which has already reduced the

number of middle managers in some companies

(23).

Technology can also change the nature of work

by changing the requirements that work be done

in specific locations. Typing or word processing

that used to require secretaries to be at the workplace during working hours can now be done at

home by using telephone-computer linkages. Hard

copy could always be taken home for editing, or

dictation typed directly into a computer and transmitted for print at an office work station. One

corporate official estimates that the numbers of

office workers who use some sort of electronic

office equipment will rise from today’s 5 million

to 35 million within 10 years (7).

Advancing computer technology also allows

work to be done while traveling, and communications technology, by the process known as “teleconferencing,” can “assemble” meetings of people in far-flung locations without their having to

leave home or office.

POSSIBLE IMPACT ON OLDER WORKERS

This evolution in job requirements maybe particularly beneficial to older workers by allowing

wider use of alternatives to full-time work. Results

of some surveys show that part-time work or

other alternatives to full-time employment are favored by many older workers. In 1979, about 26

percent of married and 21 percent of unmarried

adults aged 65 to 69 worked part-time. A 1981

Harris poll found that 57 percent of respondents
Ch. 10—Workplace Technology and the Employment of Older Adults . 347

A New Industry Machines That See

Machines that “see” may change the jobs of bins and place them into circuit boards with

some workers of the future. By combining a tele- greater speed and accuracy than humans.

vision camera and a computer (an “eye” and a

"brain”), robot machines can&? made to do my The computer micropchips that control these

tasks that humans now do. Robots can handle machines currently cost less than $10 each,

tedious or dangerous jobs repeatedly and stead- which inakes these robots and their capabilities

ily without fatigue. attractive to employers. The systems themselves,

however, are expensive-a complete vision sysFor example, a Westinghouse factory in Wins- tem with only limited capacity often costs beton-Salem, NC, plans to use sighted robots to tween $15,000 and $40,000.

forge turbine blades. These robots select pieces Expanded use of these systems is expected to of metal, place them in a furnace, then remove

the hot metal and place it in a machine that double or triple industry revenues from machine

shapes it into a blade. When the blade is finished, vision systems ($20 million in 1982) each year for

the next several years. a robotic “eye” inspects it to be sure it is perfectly

formed.

Other robots, which have arms, hands, and

fingers, can select electronic components from

Workerless Factories

Conventional “fixed automation systems’) in toolmaker factory in Florence, KY, which would

factories are slowly being replaced by “flexible need workers with a conventional manufacmanufacturing systems.” In a fixed system, ma- turing system, now employs three shifts of

chines are programmed to operate in a prede- day-shift workers, four controllers in an evening

fined sequence of steps to make a product; fiex- shift, and no workers at night.

ible systems alter their programs and hence their

products, depending on such factors as the avaii- Improved quality and lower capital equipment

ability of materials, the speed of other machines and operating costs are other benefits of flexi-

 Hughes Air . making needed components, and the demand. craft Co. to install than a conThis new technology can increase productivity ventional costs 87 percent less to

while employing fewer workers, For example, (: ,

a system installed in a GE locomotive factory now ),.

produces a 2,500-pound motor frame job that The orrkers

once took 16 days—in 16 hours. While some of this are unclear De.

workers were dislaced by the new system, vices for in the work force could be designed

others have been retrained to monitor and con- to simplify jobs for workers with vision deficits

trol the computerized machinery. The”fkm’ fore- or muscle. At the same time,

man is now the console operator. many manufacturin g

- large proportions of

Flexible manufacturing enables some factories older adults (21).

to operate with very few workers. A Japanese

38-800 0 - 85 - 12
——

348 . Technology and Aging in America

would consider part-time work after retirement

(17). A 1980 Traveler’s Insurance Co. survey reported that 85 percent of their employees wanted

paid work after retirement; over half preferred

part-time work (44). Although these surveys have

limited utility due to: 1) the gap between what

people report they would do and their actual behavior; and 2) the lack of information about the

specific circumstances in which people would accept a job offer, i.e., commuting time, wages, type

of work, and working hours, the data indicate

that some people would both prefer and use these

options, and that developing these alternatives in

the work force would be beneficial to them.

Although these alternative work options are as

yet rare, a study by the National Commission on

Employment Policy suggests that employers will

expand employment opportunities for older

workers as their numbers increase. Initial programs are likely to be developed because they

benefit both employer and employee (32,40).

Some employers have tailored a variety of employment options to the needs of middle-aged and

older employees, including active job recruitment

of older people, job-sharing, labor pools for parttime work, and phased retirement. older workers seldom take advantage of these options for

two reasons: managers do not adequately communicate their existence, and taking advantage

of these options may result in reduced salary and

benefits. Company use of such options depends

on such factors as: 1) the desire of the company

to project a positive image of older workers, 2)

the character of labor-management relations, 3)

the need to meet productivity and labor demand,

and 4) the condition of the economy. Fewer options are offered by companies in poor financial

positions (32,40).

Some employers consider work options as employee benefits. Employment opportunities and

new work options for older workers may be provided in order to attract older consumers, stabilize the younger work force with older role models, reduce absenteeism, gain experience in

working with a generally older work force in anticipation of demographic changes, hire workers

who will accept lower wages, encourage workers to stay at work to keep needed skills in their

work forces, and respond to government policy

(32,40).

Researchers who tapped the National Older

Worker Information System at The University of

Michigan (40) found data on 153 companies representing 309 programs and/or practices. These

programs included six types: hiring for full-time

employment (12 percent), hiring for part-time or

temporary employment (51 percent), job/worker

appraisal (5 percent), training (13 percent), job redesign (9 percent), and flexible scheduling (10 percent), On a national scale, few companies offer

such options, but they are expected to become

more plentiful as the number of older workers

increases.

An important conclusion of these studies is that

employers will provide options for older workers in the future, but only when it is to the firm’s

advantage to do so. As the older work force grows
Ch. 10—Workplace Technology and the Employment of Older Adults “ 349

and seeks these options from employers, their

range and number are likely to grow, particularly

as new technologies make it easier for empIoyers

to accommodate to shifts in workdays, hours, and

the daily work force.

older workers are especially likely to benefit

from the changing nature of work. People who

find it physically difficult or undesirable to leave

home, due to disability or poor health, may be

able to work at home doing clerical and office

tasks, for example, or computer programming,

writing, or research. Should bad weather, a long

commute, or inability to drive or difficulty in

using public transportation keep potential workers at home, such jobs could be ideal.

Some technological changes may enhance such

alternative work options as job-sharing. Workers

using computers could store their work for use

by a subsequent employee. By pairing an older

worker with a younger worker, flexible scheduling could be beneficial for both workers. An older

employee wanting to phase into retirement could

train an upcoming employee to take his place, retaining needed skills for the employer.

Additional benefits of alternative work options

include maintaining more people in the work

force than would be possible if each worker had

a full-time job, providing additional income tax

and Social Security tax revenues, delaying collection by retirees of Social Security or pension benefits, and providing a higher income for older

adults.

As these options become more common, competition for them is likely to increase between

older and younger workers, especially women,

who are currently seeking new work structures

in order to accommodate pressing financial and

family obligations.

Technology, retraining, and older adults

Retraining workers of every age is a matter for

serious consideration by both industry and government. Some employers are expressing concern

that the available pool of labor will not satisfy

their needs for skills. In the quest to keep worker

skills current, some older workers may need particular attention (33).

Information is meager about the extent of need

for retraining older workers. Among the important questions are: 1) how well do older workers’ skills match the skills needed in the labor market? 2) how quickly are older worker’s skills

becoming obsolete? 3) if older workers are retrained, how long will their skills be of value to

the employer? 4) how are older workers differentially affected by employer policies for retraining due to advancing technology? 5) what effect

does technology have on the working environment? and 6) will older workers, if retrained, be

able to compete successfully with younger workers for jobs?

The need to update workers’ skills will increase

in importance as technology continues to change.

As the labor force ages, fewer younger people

with recently learned skills will be available; in

turning to other sources for skills, employers will

need to focus on existing workers.

Jobs and the skills needed to do them are changing rapidly. Change may occur so quickly in the

future that, according to one expert, in order to

maintain their skills, workers may need to be retrained from five to eight times over the course

of their careers (7).

Employers and their unions are beginning to

recognize the growing need for new skills. In the

spring of 1982 the United Auto Workers Union

gained commitments from General Motors and

Ford Motor Co. for $20 million and $25 million,

respectively, to begin retraining programs for

their workers. Is the access of older workers to

these training programs comparable to that of

younger workers? Will large numbers of older

workers be retrained? Sources within the training industry indicate that older workers have

fewer opportunities than younger employees to

be retrained at employer expense. This unwrit-
350 . Technology and Aging in America

ten standard concerning retraining may stem

from a wide variety of causes—negative attitudes

about older age, age discrimination, the belief that

older workers will not want or be able to be retrained, or the belief that older workers will, by

retiring in a few years, be relatively more expensive to retrain than younger workers.

Some efforts are being made to retrain existing

workers. Employers are retraining both currently

employed and displaced or unemployed workers

to ensure their supply of skilled labor. Although

no figures are available on how much is spent specifically on retraining or which employees receive

it, the American Society for Training and Development estimates that employers spend about $30

billion a year for all types of employee retraining (9).

There is no comprehensive information available on the types of jobs targeted for retraining,

but a review of business and training publications

suggests much employer-sponsored retraining of

existing employees is for engineering and other

scientific positions, clerical workers, and specialized technicians. For example, machine mechanics are retrained to repair robots; engineers are

updated on computer applications and electronics; clerical workers learn to use word processing and other computer equipment; chemical

process engineers receive additional training in

biological processes; and copier-repair technicians

learn to service high-speed printers.

Though identifying workers displaced by technology is difficult, when displacement does occur, many workers become eligible either for jobs

requiring similar skills or for retraining. Robotics

International concluded that 50 percent of workers displaced by robots could be trained for new

jobs in the same plant and another 25 percent

could do other jobs in the plant without special

training (35). Some unemployed workers, such as

auto workers, are being retrained for jobs in robot repair and maintenance, electronics, and

microelectronics.

Many observers agree that the need for retraining will accelerate as technological change affects

larger segments of the work force (9,15). One corporate analyst predicts that by 1990, nearly all

manufacturing employees will spend 20 percent

of the workweek in training programs to keep

up with technology (15). A TRW Co. official states

that, “In this decade, virtually all of the Nation’s

workers, most of whom are now employed, will

need to be retrained or have their skills sharpened” (9). With the changing composition of the

work force, many of those needing retraining will

be both experienced and middle-aged.

Benefits from training and retraining

Employers report two major benefits from retraining: 1) more efficient use of human capital,

and 2) retention of useful employees who might

otherwise be hired by other companies. Other

benefits to employers include reduction in the

costs of recruitment and placement of new workers, decreased loss of productive employees

through attrition, maximum utilization of worker

skills, an upgrading of the quality of worklife of

the retrainers, and company perpetuation (36).

In discussing company perpetuation in this

context, one researcher says that “retraining

strengthens the economic life of a company and

increases its ability to compete effectively. Retraining is an organizational mechanism that permits a company to be more things to more people” (36).

For example, one company offered an introductory course in electronics to older engineers, with

course completion to be taken into consideration

in determining pay increases. Also, since a limited

number of engineers in each department could

attend the course, a certain degree of status was

associated with being selected. Maintenance technicians completing an electronics maintenance

and repair course were given pay increases and

higher status job titles. A company that retrained

welders upgraded their job titles, and the union

later won a salary increase for this group of crafts

workers (52).

Costs of training and retraining

Little information is available on the financial

costs of training, and nonfinancial costs or negative elements of training tend not to be addressed

in the training and retraining literature.
Ch. 10—Workplace Technology and the Employment of Older Adults ● 351

Managers often ask what training costs, and

whether the cost is justified, Answering these

questions requires itemization of program costs.

Usual budget categories include expenditures for

training-staff time, special materials equipment,

travel time for personnel to take special courses,

consultant fees, state-of-the-art expenses such as

conferences, and expenses for the training process itself, such as salary costs of the training. Once

an accounting of the specific cost is performed,

the organization can judge the program’s worth

(51).

Who pays for the costs of retraining and how

will they be borne by the company? Costs are

often associated with company size and industry

type. The larger the organization, the greater the

outlays. Major costs include wages and salaries

paid to workers being retrained, the time spent

by other employees on integrating trainees into

the work of the organization, wear and tear on

equipment, and higher accident or product rejection rates. In the context of adopting a philosophy about who should pay training costs, one

expert notes that “under competitive conditions,

all of the firm’s costs will be charged to the

worker if the training increases his future productivity in other firms as much as in the firm

in which he is training. Some fraction of costs will

not be charged to the worker if the training contains elements of specificity, that is if it increases

the worker’s future productivity in the firm more

than in other firms” (26).

Methods of training and retraining

The focus of methods of training older workers has shifted in recent years. As recently as the

late 1960s the older trainee was portrayed as one

with special learning problems associated with

age. Today, researchers and some employers consider older persons just as capable of learning new

skills as younger persons, if the training occurs

in a supportive environment. The work opportunities of older trainees, however, may be fewer.

Many methods for training are used by industry (see technical memorandum C). In deciding

on the most appropriate method or group of

methods for a given training program, management should consider: 1) what the trainee must

do to successfully complete the program; 2) the

extent to which trainees will be given an opportunity to discuss the training and measure their

own progress; 3) the extent to which the trainers

will be updated in their skills and given the chance

to evaluate the training process; 4) the degree to

which the training experience will approximate

the job experience; 5) how the training method

will adapt to differences in learning rates, availability of trainee time, and trainee attitudes; and

6) the cost of using the method(s) (51).

Concern about training the older worker first

appeared in the mid-1960s in European publications; much of the literature that continues to be

generated on this topic comes from Europe. In

1965, Belbin, the first expert to address the status

of the older trainee, outlined difficulties shown

by British workers in laboratory studies–problems associated with memory loss, rigidity in

learning new material, lack of practice, and inadequate self-confidence. By the early 1970s, the

literature posited that the older person does not

necessarily face major problems in learning new

skills, and that “in the past the problem has been

that teachers did not adapt [to the needs of adult

trainees] (3).” Learning success was described as

being only partly dependent on the teaching

method used with the older person. “The traditional methods of teaching based on exposition

and presentation of theory followed by later application may work well with younger people

. , . but it appears that these methods that are

refined slowly through school life do not survive

as natural and easy ways of learning once the individual has long left behind his schoolroom experience” (3).

An Aer Lingus (Irish Airlines) program is one

example of retraining efforts created to meet the

special needs of older workers. The airline

changed an outdated cargo warehouse that used

“shelves-and-forklifts” technology to a semiautomatic mechanism with electronically controlled storage and retrieval of freight and a computerized documentation system. Four elements

in the retraining process were found to be valuable in retraining the older worker: 1) group participation by the trainees in using the new technology; 2) management’s continuous communication with the workers on their progress and prob-
352 ● Technology and Aging in America

lems; 3) use of a “discovery method” of learning

where the trainees learned about the new technology on their own, in contrast to learning

through the lecture method; and 4) use of job-simulated experiences rather than abstract learning

materials (29).

Factors affecting participation of

older persons in retraining programs

The participation of older workers in retraining programs can be affected by requirements

and conditions imposed by the training provider

and by the attitudes and attributes of older workers themselves. Eligibility requirements and recruitment strategies often influence participation

and vary from provider to provider. Employers

consider job history or classification to be the

most common eligibility requirement.

Often, as can be seen in the following case study

examples, potential trainees must pass a screening test. When formal screening tests are not

used, some providers screen possible participants

to help ensure the success of training. Most providers claim they do not use age as a formal eligibility requirement. Years-of-service plays a minor role in determining eligibility; in some

instances, workers participate in training sessions

based on seniority. Income and employment status, e.g., being unemployed, are relevant in some

cases. Though these conditions might only apply

to the cases studied (see later section) they give

an indication of the way companies are conducting recruiting for retraining.

Some of these eligibility criteria might work to

the advantage of older workers while others

might work against older workers. Years-of-service requirements, for example, might favor older

workers, who often have longer tenure on the

job. The use of formal screening tests might work

against older workers whose education is less recent. Employers use a number of strategies to recruit and select participants for training. Some

of these include a formal notification process as

laid out in collective bargaining agreements, attendance at an initial information session, advertisement through company communication systems, and media or other third-party basis of

disseminating information.

Employers may use both explicit and implicit

incentives to encourage participation. Individuals

successfully completing training may receive a salary increase, new personnel may receive wages

while being trained, and classes may be offered

free of charge. Implicit incentives related to job

promotion possibilities and job security may also

be provided.

Providers may also use informal encouragement or discouragement to guide individuals into

or away from training opportunities, though

there is no indication that this is used more often

with older workers than with their younger counterparts.

Little research has been completed on factors

affecting an older worker’s participation in training and retraining. Twenty years ago, one study

of a small sample of men identified four factors

that tended to discourage workers from going to

training: 1) family influence, 2) fatigue from evening classes, 3) latent apprehension about ability,

and 4) nervous stress at the prospect of a more

complicated job (30). A more recent study of

printers (11) found that younger, healthier, and

better educated men were more interested in

learning new automated compositing techniques

than were most older printers who were within

2 or 3 years of retirement. Both younger and

older printers tended to base their interest in retraining on practical considerations—possibility

for promotion or the cost of retraining prior to

impending retirement.

Despite the paucity of factual data, the general

perception is that older workers hold negative attitudes toward retraining. Some evidence suggests

that older persons hold more negative attitudes

toward automation than do younger people. Opinion Research Corp. found that unwillingness to

accept increased automation in the workplace increased with age (15). Conversely, a General

Motors executive believes that some older employees “have less fear of change than the young people coming along. I don’t think acceptance of technology relates to age as much as it does to

motivation (15). ”

Providers often feel that attitudes related to retraining are likely to limit the participation of

middle-aged and older persons in training pro-
Ch. 10—Workplace Technology and the Employment of Older Adults ● 353

grams. Apprehension about operating new machinery skepticism about the outcomes of retrain-

.

ing, resistance to new technology, problems in

rethinking how a job is done, momentum of involvement in work tasks that limit free time, a nd

difficulty accepting young instructors were all

identified by those asked in the case studies as .

attitudinal factors that might limit the older person participation in training. Nevertheless, providers did not feel the attitudes of middle-ageci

and older workers were significantl y different

from those of younger workers or that they posed

major problems.

Dissatisfaction with a current job might influence the older individual’s decision to seek retraining, but voluntary withdrawal from the labor

force can be economically difficult for many

workers. The lack of wages or a stipend may be

a potential barrier to retraining the unemployed.

Although participants may be able to receive unemployment insurance in some States while attending the retraining program, this income may

be inadequate for middle-aged and older participants with numerous financial obligations.

Case study examples of retraining

Several types of programs are available to train

or retrain workers. Some are developed for use

within a certain company while others result

from cooperation among industry, government,

and educational facilities. Companies have thus

far initiated programs because the available labor pool does not have the needed skills or because it is advantageous to update or train workers in these skills. Most programs are not designed

specifically for mature workers or older unemployed individuals; in fact, because organizations

providing retraining seldom even collect detailed

trainee age data, little information is available on

the characteristics of retrainers.

For this report, two types of training were identified —pre-employment and post-employment

training. Each could be provided in-house or by

outside providers. Most of the representatives of

the training programs, despite the program’s

orientation, did not believe that older workers

needed different training than younger workers.

A number of retraining programs were examined. The case study examples cited here describe

current training and retraining programs, Some

cases were high-technology companies or companies dealing with new technologies; others

were not. Retraining was offered in order to u pdate workers’ skills. The electronic systems division of one large firm elected to retrain older

employees instead of hiring new staff because

retraining was believed to be less expensive. Fully

50 percent of the trainees were over age 40. The

company found retraining both saved money in . .

the long run by encouraging workers to continue

working and kept needed skills within the company. one reason for deciding to retrain was that

40 percent of the company’s work force woul d

Photo credit. Ted Horowitz

Retraining to update workers’ skills benefits

the company and the worker.
354 . Technology and Aging in America

be eligible to retire within 10 years; the retirement of this segment was projected to be very

costly. It was hoped that retraining would keep

some workers on the job longer and thus stagger retirement benefit expenditures.

Another company was founded with the express purpose of training older executives to operate personal computers. As a result, more than

60 percent of the workshop attendees have been

over 40.

Under the Investment in People Program, the

State of California matches union and automobile

manufacturers funds to retrain unemployed auto

workers at a trade and technical college. Entrylevel electronics, welding, and diesel automotive

are course topics.

Workers of all ages participated in those programs. Company officials found few failures, regardless of age, to complete the coursework;

younger and older workers did equally well in

the classes.

The future

The future of training and retraining for workers of all ages will depend largely on the availability of skills in the labor pool. To the extent that

older workers have the needed skills to do jobs,

they will not be candidates for retraining. However, the changing industrial and occupational

structure indicates that many workers will need

training to operate machines and production

processes that have never before existed. Methods of doing some jobs will change as technology

shifts, and workers will need to be trained to keep

up with these changes.

The need for retraining programs depends less

on the current balance of workers’ skills vis-a-vis

required skills than it does on the expected future

skill balance. If the work force cannot adapt itself

to changes in needed skills through educational

institutions, and new production technology does

not fully replace the need for human operators,

retraining programs will become an essential and

common practice (16).

If training programs become commonplace in

future years, the question then becomes whether

older workers will participate in these programs.

Though older adults may have gained considerable on-the-job experience over the years, they

are likely to need formal retraining to change jobs

or to compete for jobs with workers who have

more up-to-date skills.

Whether employers will target these workers

for skills upgrading is unknown. Employers may

choose to retrain older workers, as was seen in

some case study examples, if they believe it is to

their advantage to do so. They may also provide

retraining programs for all workers in which

large proportions of workers over 40 participate.

Older workers may not, however, be specifically

targeted for retraining, though they may need additional skills or retraining as job requirements

change.

Other evidence suggests that workers may have

decreasing opportunities for retraining as they

age. Some employers surveyed in the case studies

believed that it was more advantageous to retrain

younger rather than older workers because older

workers were more likely to retire. other employers would rather offer attractive retirement benefits to workers at or near retirement age than

offer to help update their skills (33).

There is substantial agreement that the need

for training and retraining for workers of all ages

will increase with the acceleration of technological innovation, but the approaches to meeting that

need remain under debate.

The success of future training endeavors appears likely to depend in large part on the willingness of government, business, labor, educational institutions, and other training providers

to collaborate, and for older workers to accept

and seek retraining opportunities. Some experts

believe no one sector has the resources or expertise to tackle the problem singlehandedly and that

traditional education and training approaches

have not succeeded for some population groups,

including certain types of older workers. Adaptation of training methods to respond to the learning needs of these subgroups could change this

pattern.
Ch. 10–Workplace Technology and the Employment of Older Adults ● 355

Technology, health, and physical capacity

Health and physical capacity are important aspects of an individual’s ability and desire to work.

Decline in either of these areas often leads to labor force withdrawal. Though its importance varies in different national surveys, poor health is

one of the most frequently cited reasons for the

decision to retire or otherwise withdraw from the

labor force.

many workers who retire for health reasons

leave the labor force as a result of chronic conditions (e.g., cancer, diabetes, arthritis, or heart

disease) (19), or because of physical impairments

(permanent defects, usually static in nature). Still

others leave work because of disability associated

with chronic conditions, accidents, or injuries that

limit their ability to work.

According to data from the National Center for

Health Statistics, chronic conditions are more

prevalent among those over 65 than among those

4.5 to 64. Women are more likely than men of the

same age to suffer from most chronic impairments. Physical impairments that limit the ability

to work include vision or hearing loss, absence

of extremities, paralysis, or deformities and impairments of the back, or upper or lower extremities—all conditions that are more prevalent

among those over 65.

The presence of chronic conditions may result

in impaired functional ability, ranging from minor disability or limitation in activity to severe

disability in which the individual is bedridden.

Results of surveys regarding extent of disability

in the population have varied over the years according to the ability of jobseekers to find employment at the time of the survey. They all agree,

houever, that a large majority of people 45 to 64

have no disabilities, and that more than half of

those over 65 have none. Moreover, only small

percentages of workers 45 to 64 and fewer than

1 in 5 people over 65 are unable to work due to

physical disability (see app. E, table E-39).

The Retirement History Survet, which examined the relationship between individual characteristics and work disability, found that workers

whose jobs were physically demanding were .

more likely to report disability than those whose

jobs were less so, and that the existence of work

limitations often led to withdrawal from the labor force (47). Disability rates also were higher

for workers with fewer years of schooling; because they are likely to have physically demanding jobs, they are more vulnerable to work disability with advancing age. Disability rates for those

over 50 were higher for women than for men.

Although physical limitations keep many from

working, others continue to work even though

they have minor illnesses. Days of activity restriction due to sickness averaged 31 days per year

for all workers over 45 in 1978-79, according to

the Health Interview Survey. This number rose

from about 23 days per year for those 45 to 54

to 46 days for those over 75. Yet the number of

days a worker actually stayed home from work

due to sickness decreased with age—from 5 days

per person per year for those 45 to 64 to 4 days

for those over 65. Though people who are older

and still working may be healthier than others

of their same age—because those in poor health

have left the labor force--older workers still miss

fewer days of work than their younger counterparts.

Although the role of technology in disability

rates and the general health and well-being of

workers remains ill-defined, modern production

and manufacturing processes, as well as the machines themselves, may contribute to many occupationally related deaths. The National Institutes of Health estimates that 5 to 10 percent of

cardiovascular deaths, 15 to 25 percent of cancer mortality, and 10 percent of deaths due to

pulmonary dysfunction may be attributable to the

types of jobs workers do (4). New production

methods that did not exist 50 years ago may induce or exacerbate health problems of workers

who have done the same job for many years.

Moreover, occupational exposure to hazardous

manufacturing processes is often not manifested

as disease for 15 to 25 years, and some conditions

may not be present until well after retirement.

As a result, many of the victims are older adults.

Yet most epidemiological studies of occupational
— — — —

356 ● Technology and Aging in America

health do not include workers over age 55 in their

samples (2).

Asbestos is a well-known example of a manufactured product that is correlated with occupational mortality. It is estimated that exposure to

asbestos in shipyards and other industrial settings

will be a factor in 2 million cancer deaths over

the next 30 to 35 years (10).

Disease and impairment also result from technology in the workplace. Recent surveys of workers producing or working directly with asbestos

found that 60 percent of older workers (mean age

of 47.5 years) had some degree of respiratory

limitation (4). Many chronic conditions in older

adults, including hearing impairment, arthritis,

respiratory problems, and dermatitis are either

caused or made worse by the work environment.

Another example of technology-related impairment was observed in a study of workers required to perform repetitive motions using the

wrist, such as might be experienced in assembly

line work. Repetitive pressure, overexertion, and

lifting, pulling, or throwing objects were found

to result in injuries. These injuries can be quite

costly; the mean cost per case for indemnity compensation was $1,026 and the mean cost per case

for medical payments was $618, Heading the list

for percent of wrist injury claims was the manufacturing industry (10,5 percent) followed by agriculture (5.4 percent). Since nearly one-third of

men and one-fifth of women employed in manufacturing are between 45 and 64, older workers

comprise a large at-risk group for such injuries.

Office automation may also disrupt physical

health. Considerable controversy about health effects surrounds the use of video display terminals

of minicomputers and word processing machines.

When working over extended periods, some operators report visual strain or loss, and headaches.

Back strain is also reported to result from inappropriate seating.

Work-related stress is another effect of technology. Computers are now capable of monitoring employee productivity, speed, and accuracy.

For instance, the Communications Workers of

America (CWA) notes that 150,000 of its members

at American Telephone & Telegraph (AT&T),

most of whom are operators using video display

terminals, are now monitored for speed and accuracy by computer. CWA estimates that by 1985

half of AT&T workers will be so monitored. In

addition, approximately 25 percent of the new

retail sales cash registers have monitoring capability. Employers use these systems to measure

the output of employees and determine production bottlenecks. Use of such equipment can increase productivity by as much as 20 to 100 percent (7).

Although this equipment means savings for employers, there are potential costs to the individual workers who use these systems. Monitoring

can increase the anxiety and fatigue of workers

and lead to depression. According to a 1980 Blue

Shield study, extreme monitoring can make employees “psychologically sick.” Researchers found

a higher incidence of anxiety, depression, irritability, fatigue, and anger among 250 monitored

employees when compared with 150 unmonitored workers. These symptoms have been associated with more serious problems such as coronary and gastrointestinal ailments (7). Signs of

stress at work include fatigue, nervousness, sleeping disorders, loss of appetite, dissatisfaction with

job or life, and use of tranquilizers, which may

increase in prevalence as the use of monitoring

increases.

Despite the fact that technologies in the workplace may contribute to deaths, injuries, and disabilities, a National Institute for Occupational

Safety and Health (NIOSH) study found that only

3 percent of occupational disease cases result in

worker’s compensation claims (28). Thus, many

workers may depend on private insurance to pay

for occupationally related health problems or, if

they have no insurance, pay their medical expenses out-of-pocket.

The future

Contrary to popular belief, there is growing evidence that the increasing proportions of people

now living to the oldest ages are not necessarily

healthier than their counterparts in the past (41).

Tomorrow’s older workers may thus be just as

likely to become physically disabled and unable

to work as today’s older workers. The Federal

Government is currently providing benefits to
—

Ch. 10—Workplace Technology and the Employment of Older Adults ● 357

both retirees and the disabled; outlays for these

benefits are likely to increase.

These patterns may, however, change for the

better. Just as some workplace technologies may

increase the risk of disability, others may reverse

these negative health trends. The health of workers may improve in the future through greater

understanding of physiological aging, medical

technologies, better health habits and health

maintenance technologies, and the careful implementation of workplace technologies. As current

medical research intensifies and finds answers to

some of the mechanisms of aging and disease,

these answers will be disseminated by doctors,

nurses, and other health care providers. Better

and more efficient medical technologies will be

developed to prevent or treat ailments more

quickly. As society becomes better able to control health problems, overall health status may

slowly improve. This will not, however, happen

in the short term; decades are apt to pass before

significant changes are seen.

Employers are becoming increasingly aware of

the importance of a healthy work force. Absenteeism due to sickness can cost industry millions

of dollars. In addition, the increasing costs of

health care benefits have prompted employers to

seek preventive measures to decrease these costs.

Many companies are developing and implement -

ing health promotion programs at the work site

to improve the physical and mental well-being of

their employees. Though good records are not

kept and the effects of these programs have not

been clearly documented, employers report many

positive outcomes. For instance, an elaborate program at Pepsico Corp. has resulted in what company officials believe to be greatly improved productivity and attitudes of workers who take

advantage of exercise facilities and employee

health screening (49).

If the trend for employers to provide health promotion and disease prevention programs for

workers continues, the workplace could become

a major site for education and promotion of proper health habits. Improved health of employees,

lower costs of health insurance, and additional

years of productive work could result from these

trends.

Workplace technologies can be a factor in improving worker health. The individual use of assistive devices can restore functional ability or

compensate for physical deficits. (Technical

memorandum A provides examples of currentlty

used workplace devices. )

Technology can also improve worker health

through the careful development, choice, and implementation of machines and production processes. Workplaces of the future could be designed

to greatly reduce both accidents that may cause

disability and exposure to noxious chemicals that

may cause disease. Robots will increasingly he

able to substitute for workers in dangerous jobs.

Though some workers might, in theory, be displaced by automation, evidence suggests that the

responsibilities of workers are usually shifted to

other areas or jobs, depending on the types of

occupations being examined (35). Moreover, retraining is not extensive in industry today, but

both government and the private sector are giving retraining increased attention, and many programs have recently been initiated to retrain

workers in new skills. Hence, controlled use of

technology may significantly reduce physical injury and illness in the work force.

Technology thus has the potential to improve

the health of all workers and safeguard the wellbeing of older adults. If the number of workers

who retire prematurely due to poor health were

to decline, individuals might still choose to retire

at a predetermined age, but for different reasons.

They could conceivably live their later years in

better health and enjoy a greater sense of well -

being. This positive effect could be important to

government in that fewer dollars might be spent

by Medicare and Medicaid for the care of the

elderly.

Priority areas for research

Accurate information is needed about many aspects of worklife at older ages, including:

●

●

specific, industry-by-industry effects of technological change on the older worker and the

workplace;

studies on attitudes and abilities that clearly

delineate age subgroups of the older worker

population;
358 ● Technology and Aging in America

●

●

●

●

whether older workers are displaced as technology changes;

precise epidemiological studies on the effects ●

of hazardous working conditions on older

workers ;

measurements of the capacities and abilities ●

of older workers relative to those of younger

workers ;

ways in which employer’s perceptions affect

.

employment and retraining opportunities for

older workers;

the physical and psychological effects of

unemployment, displacement, discrimination,

and retirement on the older worker; and

the effects of employer and employee incentives and disincentives to hire or retain older

workers .

Issues and options

ISSUE 1: Should Congress foster the use of

assistive workplace devices so that

older adults with physical limitations might remain in the wor k

force ?

Options:

1.1 :

1 .2:

1 .3:

1 .4:

1 .5:

Congress could maintain its present fevel o f

support for workplace devices, as in efforts by

the National Institute of Handicapped Research

(NIHR).

Congress could require AoA, NIA, NIOSH, or

another agency to provide a means for manufacturers of workplace and other devices to inform

employers and the public of the availability and

existence of these technologies. This agency could

be required to collect and assemble this information, assess the quality of these products, and disseminate the information to the public.

Congress could require coordination among

NIHR, the VA, and other rehabilitation centers to

promote and provide workplace technologies for

older workers.

Congress could require demonstration projects

(possibly using Older Americans Act Title V participants) to show effective use of workplace technologies. The components of this project could be:

● research on the effectiveness of the devices,

● targeting to regions of high unemployment for

older workers,

● targeting manufacturing and service industries

(due to the high concentration of older adults

working in these industries), and

● targeting to regions containing large proportions of older adults.

Congress could require NIA, AoA, DOL, NIOSH,

or another appropriate agency to develop coop1.6:

erative ventures with organizations for the handicapped. This effort would focus on information

collection and dissemination of material on workplace devices.

Congress could provide tax incentives to employers to use individual workplace devices, adapt

working environments, and increase the purchase of assistive devices for use by older

workers.

ISSUE 2: Should Congress devote resources

to retraining older workers for new

skills ?

Options:

2.1:

2.2:

2.3:

2.4:

Congress could maintain its present level of support for older worker retraining. Current effort

is concentrated in Title V of the Older Americans

Act and the Job Training partnership Act.

Congress could oversee the EEOC’s enforcement

of the Age Discrimination in Employment Act to

ensure that employers provide equivalent retraining opportunities to older and younger workers.

Congress could encourage cooperative arrangements among educational institutions, corporations, and company-sponsored foundations to

support research and demonstration projects to

undertake retraining of older workers. Congress

could provide financial assistance to educational

institutions that cooperate with the private sector in developing training programs for older

employees.

Congress could require AoA to fund retraining

demonstration projects using trainers who are

older, experienced, and highly specialized workers, such as members of the Senior Corps of Retired Executives.
Ch. 10–Workplace Technology and the Employment of Older Adults ● 359

2.5: Congress could provide financial, employment, 3.2:

and/or retraining assistance to older displaced

workers through the following mechanisms:

● Congress could finance more cooperative public/private training programs with special tar- 3.3:

geting to older employees. Onee important component would be a job- finding service upon

completion of the courses. 3.4:

. congress could provide tax incentives to

displaced workers to become retrained or take

job-related educational courses.

ISSUE 3: Should Congress foster the development of alternative work options ?

Options:

3.1: Congress could maintain its current level of support for alternative work options.

Congress could reduce some of the barriers employers experience (e.g., heavier taxes for parttime workers, costly fringe benefits, etc.) when

employing people other than full-tjme.

Congress could provide tax incentives for employers to develop more stable and permanent alternatives to full-time employment.

Congress could provide more low-interest loans,

through such mechanisms as Small Business Administration loan programs, to individuals desiring to become self-employed. Persons over age

60 could be added to the target groups for receiving these loans.

Technical memorandum A: workplace devicesl

This appendix contains examples of devices used by

older workers at some worksites. Though these are

more commonly used by handicapped individuals,

they can be adapted for use by workers of any age

who have some magnitude of physical or sensory

deficit.

Device: Optacon.

Description.- Compact portable reading system that

converts image of a printed letter or symbol into

a tactile form that can be felt with one finger.

Cost: S4,295. Additional lenses for CRT, calculator,

typewriters, and magnification, $195 to $1,195.

Job tasks enhanced: Reading for severely visually impaired.

Advantages: Users report it to be a good machine.

Allows blind persons to seek employment in wide

variety of fields formerly closed to them.

Disadvantages: Cost. Requires special week-long training. Reading very slow with use of machine, blind

may find it easier to have something read to them

or tape recorded.

Availab)e from: Telesensory Systems, Inc. (TSI).

Information sources: TSI. Fireman’s Fund.

Device: Talking Computers.

Description: Speech synthesizers either incorporated

in computer terminal circuitry or available as online adapters suitable for hookup to a variety of

1 Information from Birute Skurdenis, Western Gerontological Society (43)

computer lines; provide speech output of data on

monitor.

Cost: $4,500 to $5,000 (incorporated in terminal)

$4,900 to $5,900 (device adapting to any terminal).

Job tasks enhanced: Computer or word processing

activities by those with severe vision loss.

Advantages: Users report they generally work well.

Translation accuracy of speech synthesizers about

90 percent.

Disadvantages: Cost. Some equipment does not provide speech for cursors, character attributes, or

function codes. Speech quality varies.

Available from: Triformation Systems, Inc. Maryland

Computer Services, Inc. Automated Functions, Inc.

Information sources: Lawrence Livermore National

Laboratory. Telesensory Systems, Inc. BYTE.

Device: Digit-Cal Talking Caliper.

Description: Adaptation of Brown& Sharpe digital caliper; audioizes measurement functions from digital

readout.

Cost: $585.

Job tasks enhanced: Taking measurements for machinists, carpenters with total vision loss. Digital readout

without speech synthesizer useful for people with

minor or moderate visual impairment.

Advantages: Allows visually impaired persons to work

in machinists and carpenters trades.

Disadvantages: Only one tool model available, which

user found awkward. Nonvisually impaired machinists would only use it as a last resort. Talking box
360 ● Technology and Aging in America

breaks frequently and available working diagrams

are inadequate to allow machine shops to repair it

themselves.

Available from; American Foundation for the Blind.

Information sources: Lawrence Livermore National

Laboratory. American Foundation for the Blind.

Larsen.

Device: Talking Height Gauge.

Description: Adapted Brown & Sharpe tool hooked up

to speech synthesizer. Measures heights with great

deal of accuracy.

Cost: Unavailable.

Job tasks enhanced: Height measurements for machinists and carpenters.

Advantages: User reports it to be a very good tool.

Disadvantages: prototype, not yet available on the

market.

Available from: American Foundation for the Blind.

Information sources: American Foundation for the

Blind. Lawrence Livermore National Laboratory.

Larsen.

Device: Talking Cash Register.

Description: Digital display electronic cash register

with speech synthesizer incorporated into circuitry.

Cost: Approximately $5,000.

Job tasks enhanced: Blind cashiers, participants in Randolph-Sheppard Blind Vendors Program.

Available from: R. C0 Allen.

Information sources: American Foundation for the

Blind. American Council of the Blind.

Device: Talking Dial Indicator.

Description: Adaptation of Brown & Sharpe tool used

in lathe work. Plunger reads distance from perimeter to center of the object on lathe. Speech synthesizer produces speech output of measurements.

Cost: Unavailable.

Job tasks enhanced: Lathe work for visually impaired

machinists and carpenters.

Disadvantages: Cost. Market for speech output adaptors has not yet developed.

Available from: American Foundation for the Blind.

Information sources: American Foundation for the

Blind.

Device; Therm-Voice Talking Thermometer.

Description: Speech synthesizer provides speech out -

put of digital thermometer readout. Probes available for clinical or high temperature use.

Cost: Unavailable.

Job tasks enhanced: Measuring temperatures for visually impaired photo lab developers, X-ray technicians, chemists, bakers.

Advantages: Flexibility, first introduced clinically, new

uses discovered.

Available from: American Foundation for the Blind.

Information sources: American Foundation for the

Blind.

Device: Braille Output Printer.

Description: Converter unit provides braille output

translation for computer terminal operations.

Cost: Unavailable.

Job tasks enhanced: Computer access for blind persons trained in braille.

Disadvantages: Only 5 percent of those with visual impairments read braille.

Available from: Triformation Systems, Inc.

Information sources: Lawrence Livermore National

Laboratory.

Device: Tactile Braille Markings on Dials.

Description: Information on machine dials, e.g., lathes,

milling machines, surface grinders, translated and

etched in braille markings.

Cost: Minimal.

Job tasks enhanced: Machinists and carpenter work.

Advantages: Easy to use; nonvisually impaired users

of the machinery learn to use them rapidly.

Disadvantages: Not available; homemade. Time-consuming process and not feasible if dial is welded

on. Need to be familiar with machinery in order

to make accurate adaptation.

Information sources: Larsen.

Device: Talking Paper Money Identifier.

Description: Machine reads denomination of paper

money and hookup with speech synthesizer provides speech output of information.

Cost: Unavailable.

Job tasks enhanced: Cashiers with severe visual impairment.

Information sources: American Foundation for the

Blind.

Device: Versabraille.

Description: Portable information system that can receive, store, and reproduce notes in braille from

previously stored information such as ordinary

audio cassettes on which braille information has

been recorded or on computer and word processing terminals and printers.

Cost: Unavailable.

Disadvantages: Only 5 percent of people with visual

impairment read braille.

Available from: Telesensory Systems, Inc. (TSI).

Information sources: TSI.
 Ch. 10—Workplace Technology and the Employment of Older Adults ● 361

Device: Talking Numerical Control Drill Press.

Description: Allows computer programming of measurement specifications for drilling. Hookup with

speech synthesizer provides speech output of measurements.

Cost: Unavailable.

Job tasks enhanced: Allows metal and woodwork

machinists who have severe visual impairments to

remain at work.

Disadvantages: Cost of putting it together. Made onsite, not available commercially.

Information sources: Lawrence Livermore National

Laboratory.

Device: Closed Circuit TV (CCTV) Magnification

Systems.

Description: Closed circuit television receives signals

from camera transmitter held over copy to be magnified up to 60 times. Special lenses are available

for use with computer terminals, typewriters, and

microfilm.

Cost: $1)895 to $4,495.

Job tasks enhanced: Paper processing, computer use

for clerical or professional staff who have diminished visual ability.

Advantages: Users report it works well. Allows higher

degree of magnification than magnifying glasses.

CCTV technology widely used, including in surgical medicine and research.

Disadvatages: More machines are purchased by individuals, family, and through State rehabilitation

agencies than by businesses.

Available from; Apollo Electronic Visual Aids. Visualtek.

Information sources: Hughes. Sandia. Apollo. Visualtek.

Device: Large Print Computer.

Description: Microcomputer with display capable of

magnification from 2 to 16 times.

Cost: Unavailable.

Job tasks enhanced: Computer use by visually impaired persons.

Advantages: Switch enables use with or without magnification.

Available from: Visualtek.

Information sources: Visualtek.

Device: Magnifying Reading Glass with Illumination.

Description: Magnifying glass with small lamp attached

underneath to provide extra illumination to material being magnified.

cost.’ $15.

Job tasks enhanced: Reading.

Advantages: User response good. Extra illumination

Very useful for certain types of visual loss.

. .

Available from: Bausch & Lomb.

Information sources: Sandia National Laboratory.

Bausch & Lomb.

Device: Mounted Magnifying Glass.

Description: Six-inch diameter magnifying glass mounted

on desk; able to swivel in a variety of positions.

cost: $30 to $110.

Job tasks enhanced: Reading fine print or for partial

visual impairment. Also used in electronics circuit

board assembly. Can be used with computer readout and input.

Advantages: Users report it a good device.

Available from: Bausch & Lomb.

Information sources: Sandia National Laboratory.

Fireman’s Fund.

Device: Monoculars.

Description: Telescopic device with 8 x 20 magnification.

Cost: $50 to $60.

Job tasks enhanced: Person with partial visual loss can

search files.

Advantages: Good, simple device.

Disadvantages: Often easier to relegate the task of file

searching to another or to use a personally designed

filing system with large markings.

Information sources: Sandia National Laboratory.

Device: Viewscan.

Description: Eighteen pound portable reading device,

similar to CCTV, but screen is flat and small enough

to fit in briefcase.

cost.’ $3,500.

Advantages; User research found each feature was either very well liked or disliked by the users.

Disadvantages; Camera device that transmits information to viewer is sometimes difficult to use.

Availabel from: World Sensory Aids International.

Future: Video cassette books which will show print

on Viewscan at speed and size desired by reader.

Information sources: Smith-Kettleweil.

Device: Telecommunications Devices for the Deaf

(TDDs).

Description: A lightweight, portable printout or digital

display unit with keyboard that connects by handset hookup to the telephone; allows hearing impaired persons to type and receive messages over

the phone from other TDD users.

cost: $500 to $1,000.

Job tasks enhanced: Telephone communications for

severely or totally hearing impaired persons.

Advantages: Portability, many models can be packed

into a briefcase and carried from home to office.

Information available from local phone companies.
—.

362 ● Technology and Aging in America

A San Francisco Post Office mailing center installed

one to permit deaf employees to call in if sick or

late. This improved employee relations because difficulties formerly experienced by deaf employees

in contacting work had made them seem irresponsible.

Disadvanages: Most models in use can only communicate with other TDDs. TDDs tend to be available

in urban communities. Businesses are slow to adopt

their use because they cannot justify benefit for the

cost. If users have no prior experience with telephones because of deafness from birth or early

childhood, they must be trained in rudimentary use

of telephones (dial tones, busy signals, information

services).

Future: Communication through computer terminals.

Speech synthesization.

Available from: Local telephone companies.

Information sources: DCARA. Lawrence Livermore

National Laboratory. Pacific Telephone. AT&T.

Device: volume Control Telephone Handset (Receiver),

Description: A telephone handset with adjustable volume control for reception.

Cost: $0.56/month extra telephone charge (northern

California).

Job tasks enhanced: Telephone communication for

partially deaf persons.

Advantages: Inexpensive, most widely used of all devices for the hearing impaired.

Available from; Local telephone companies.

Information sources: DCARA. Hughes. AT&T.

Device: Amplified Speech Handset.

Description: Telephone handset with adjustable volume control for speech transmission.

Cost: Unavailable.

Job tasks enhanced: Communication for people who

can only speak in soft voices.

Disadvantages: Very limited use.

Available from: Local telephone companies.

Information sources: AT&T.

Device: 5C Electronic Larynx.

Description: Device held to throat vocalizes throat

sounds.

Cost: Unavailable.

Job tasks enhanced: Communication for people with

laryngectmies who have not learned to vocalize

or an assist for those who have.

Available from: Local telephone companies.

Information sources: AT&T.

Device: Canon Communicator Mark II.

Description: Portable communication aid for nonoral,

motor-impaired persons. Letters/symbols are selected on communicator’s keyboard and are printed

on paper tape display.

Cost: Unavailble.

Job tasks enhanced: Communication for people with

both oral and motor impairment due to cerebral

Palsy, stroke, etc.

Available from: Telesensory Systems Inc. (TSI).

Information sources: TSI.

Device: Tilt-top Work Table.

Description: 12” by 18” table top with adjustable height

and tilt. Load capacity of 40 pounds. Elastic straps

to hold material in place.

Cost: $28 to $37.

Job tasks enhanced: Electronic assembly, typing, and

reading; holds computer printout-size material.

Advantages: Flexible use for different needs.

Available from: Able/Table Weir Enterprises.

Information sources: Tektronix. Weir Enterprises.

Device: Splints and Finger Gloves.

Description: Splints for wrist and elbow support. Finger gloves to fit one finger and provide protection

when handling threads at high speeds.

Cost: Minimal.

Job tasks enhanced: Sewers and cutters in textile industry. Sewers and mechanics working with highspeed threads.

Advantages: Splints give support for repetitive actions.

Finger gloves provide protection from soft-tissue deterioration resulting from constant use in the same

pattern of action; can be easily constructed using

soft leather. Combining a glove or arm covering

with the device provides warmth for improved circulation.

Available from: Prepared by rehabilitation counselor.

Iforrnation sources: Rehabilitation in Industry.

Device: Foam Sponge Grip.

Description: Piece of foam with hole cut through center slips around objects such as pens and knives to

widen grip.

Cost: Minimal.

Advantages: Inexpensive. Can be constructed by

anyone.

Availble from: Prepared by rehabilitation counselor.

Information sources: Rehabilitation in Industry.

Device: Truck Cab Alarm System.

Description: Various systems to maintain driver alertness. Device mounted on vehicular equipment

measures normal seat or steering wheel movements. A change in these movements sounds alarm.

Device mounted on person registers alarms when

head tilts in certain way.

Cost: Unavailable.

Job tasks enhanced: Driving alertness.
Ch. 10—VVorkplace Technology and the Employment of Older Adu/ts 363

Advantages: Unobtrusive device that promotes safety

and saves lives.

Disadvantages: Products not reliable. Not proven cost

effective.

information sources: International Brotherhood of

Teamsters.

Device: Vibrating Truck Cab Seat.

Description: Driver’s seat provides gentle vibration to

keep blood from collecting in lower extremities.

Keeps driver alert and improves blood circulation,

Cost: Unavailble.

Job tasks enhanced: Driver alertness, especial]]}’ in

long-haul trucking

Disadvantages: Not proven cost effective or necessary.

Information sources: International Brotherhood of

Teamsters .

Technical memorandum B: industries in detail

Agriculture, forestry, fisheries

Mining:

metal and coal mining

oil and gas extraction

nonmetallic minerals except fuel

Construct ion:

general building, heavy construction, and special

trade contractors

Manufacturing:

Durable goods:

lumber and wood products

furniture and fixtures

stone, clay, and glass produrts

primary metals industries

fabricated metals

machinery except electrical

electric and electronic equipment

transportation equipment

instruments and related products

miscellaneous, i.e., jewelry, toyss, and wriiting

implements

Nondurable:

food and kindred products

tobacco

textile mill products

apparel

paper and allied products

printing and publishing

chemicals and allied products

petroleum and coal products

rubber and miscellaneous plastic products

leather and leather products

Transportation, communication, and

other public utilities:

railroads

local and interurban transport

trucking and warehousing

a i r transport

pipelines

transportation services

communication

electric, gas, and sanitary services

Wholesale and retail trade:

Wholesale trade

Retail trade:

general merchandise stores

food stores

apparel stores

furniture and home furnishings stores

eating and drinking places

Finance, insurance, and real estate:

banking

credit agencies

security, commodity brokers .

insurance carriers

real estate

Services:

personal services

business services

motion pictures

health services

hotels

Public adminstation:

Federal Government

State and local government
364 ● Technology and Aging in America

Technical memorandum C: training methodsl

Among the most widely used training methods in

industry are: I) lecture, 2) structured discussion, 3)

unstructured discussion, 4) on-the-job training, 5) vestibule training, 6) case study, 7) incident process, 8)

role-play, 9) in-basket exercise, 10) simulation, 11) management games, and 12) programmed instruction.

The first four techniques are self-explanatory; the

remaining methods require some description. Vestibule training is on-the-job training (OJT) in an area

where work is not being performed, freeing the

trainee of the pressures created by the OJT experience. In the case study method, the trainee learns

through analyzing and solving problems identified in

a documented description of a real job situation. incident process, a variation of the case study, requires

the trainee to add needed information and solutions

1

Informat ion from Paul and Coberly (33)

to a partially explained work incident. Role-play permits the trainee to play-act working at the new job,

as well as act out the roles of others at the work place.

In-basket exercise is an appropriate method for training persons who will be dealing with a large load of

documents. The trainee is presented with examples

of materials for review and is asked to respond to each

of them. Simulation is a version of OJT. Rather than

work in the job environment, however, the trainee

practices the tasks of the new job in a controlled work

situation. Management games use the model of a business situation. Trainees are asked to play out the roles

of managers in competing organizations. Lastly, programmed instruction involves the presentation of information to be learned in a series of short, sequential steps. The trainee continues to respond to the

questions in the series until the desired skill is

mastered (51).

Technical memorandum D: projected job

growth rates in high-technology industries

Projected job growth rates vary greatly among high- ly. Other rapid gainers are medical and dental instru -

technology industries. Computer and data processing ments (4.2 percent), office and computing machines

services, and research and development laboratories, (3.7’ percent), electronic components (3.2 percent), and

the only manufacturing industries in the high growth engines and turbines (3.1 percent). By contrast, chemgroup, are estimated to show some of the largest an- ical industries and petroleum refining are projected

nual rates of increase—5.2 and 3.9 percent respective- to have substantially lower growth rates because of

oil price effects. Employment in petroleum refining

is projected to decline by 1.6 percent per year between

1

lnformation from Perxmi(k (34) 1982 and 1995.
Ch. 10—Workplace Technology and the Employment of Older Adults ● 365

Chapter 10 references

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H. Sheppard (MI. ) (Cambridge} hlA: Schenkman

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7. Business 1 t ‘eeA’, “Retraining Displaced P1’orkers:

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8. Buss, D. D., “Retraining of lt’orkers for Automated

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10. F,pstein, S., 7’he Politics of” Cancer (New I’ork: Anchor Press/Doubleda~~, 1978).

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16. Hansen, J. A., hlartin, A., and hlax~~rell, J., ‘(R e -

training Displaced Adult Jt’orkers for Jobs in the

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19. Jack, S. S., “Current Estimates from the National

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20. Jacobson, L., and Leiry, R., “The Effect of Technical Change on Labor, ” The Public Research Institute of the Center for NaI~al Analysis, Jul~T 1982.

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22. Kinnucan, P., “Flexible Systems Ini’ade the Fac -

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23. Lasden, ~f., “Is the Nliddle Nlana,ger Fadin g

A~\ra}/’?” Computer Decisions 140-152, December

1983.

24. Leon, c. B., “occupational Winners and Losers:

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25. Leiritan, S,, and Johnson, C. hf., “The Nlodern Ser\-

26

27,

28,

29,

30.

ice Sector: Emerging Patterns of Output, Employment, Producti~’ity and Prices in L] .S. Ser~~ice Industries and Some Implications for Future Trends

and Policies ,“ in LJ .S, Congress Joint F.conomic

Committee, Special Studies on Economic Change:

t’olume 1 [11’ashington, DC: LT.S. Gotrernment

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Lusterman, S., Educafion in Industq7 (h’e~v }’ork:

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hlain, J., “J\lork Jt’on’t Be the Same Again ,“ Fortune 58-63, June 28, 1982.

Minkler, hf., and Fu]larton, J., ‘(Health Promotion,

Health Itlaintenance and Disease Pre\~ention for

the Elderly, ” contract submitted to the Office of

Health Information, Health Promotion, Ph~sical

Fitness and Sports Medicine, [1 .S. Department of

Health and Human Seriices, background paper

for the }trhite House Conference on Aging, 1981,

hlullan, C., and German, L., “Facilitating Adaptation to Change: A Case Study of Retraining Nliddle -

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Pacaud, S., “Sonw Concrete Examples of the Adfantages and Disad~~antages of Age Encountered

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366 c Technology and Aging in America

31

33.

34.

35.

36.

37.

38.

39.

40.

41.

42

43

Job Redesign and Occupational Training fix- Older

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Pau], C, E., and (;oberly, S,, “Retraining the Older

worker for (;hanging Technology: Programs and

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Personick, L’. A., “The Job Outlook Through 1995:

Industry output and Employment Projections, ”

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Pratt, D. T., “Robotics Boom Hinges on AI~ailability of People, ” National Business Employment

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Raitt, J., “Retrain to Retain: A Prescription for the

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1982.

Riche, R. TV., “Inlpact of New Electronic Technology,’) Month!v Labor Retriew’ 105(3):37-39, March

1982.

Rogers, T. F., and Friedman, N. S., Printers Face

Automation (Lexington, itlA: Lexington Books, D.C.

Heath & Co., 1980).

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Schneider, E. L., and Brody, J. A., “Aging, Natural

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\’ie\*’, ” Are~v England Journal of illedicine

309(1):854-856, 1983.

Sil\~estri, G. T., Lukasicwicz, J. M., and Einstein,

M. E., “Occupational Employment Projections

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1983.

Skurdenis, B,, Western Gerontological Society, “Sur44

45.

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Workers Over 40,” contract No. 333-451o.o, submitted to the Office of Technology Assessment,

May 1983.

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U.S. Comptroller General, General Accounting Office, Ad\~ances in Automation Prompt Con;ern

O\fer Increased U.S. Unemployment, GAO/AFMD82-44, Washington, DC, 1982.

46. [J.S. Congress, Congressional Budget Office, Dislocated Workers: Issues and Federal Options

(Washington, DC: U.S. Government Printing Office,

July 1982).

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1976.

48. U.S. House of Representatives, Committee on

Science and Technology, Subcommittee on Science, Research and Technology, “Technology and

Employ merit,” Report, June 7, 9, 10, 14, 15, 16, and

23, 1983.

49. University of Southern California, Andrus Gerontology Center, Seminar on Aging, Health and

work, May 1983.

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study prepared for the use of the Subcommittee

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1982).

51. Warren, M. W., Training for Results (Reading, MA:

Addison-Wesley Publishing Co., 1969).

52. Weinberg, E., Tannenbaum, A., and Grenholm, G.,

Industrial Training Programs for Technological

Change: A StudLv of the Performance of Older

t~~orkers, report prepared for the U.S. Department

of Labor (Washington, DC: U.S. Government Printing Office, 1963).
Appendixes
Appendix A

Morbidity and Mortality Data

Introduction

The “graying” of the population in the 20th century

is a well-documented phenomenon (see ch. 2). Scrutiny

of trends in the major causes of death (mortality) and

in the pre-valence1 of certain chronic illnesses (morbidity) that are known to increase with age may help

to better prepare our medical, research, and social

service resources to meet the health needs of the

growing elderly population.

Comparison of trends in morbidity and mortality for

specific conditions can often yield valuable clues to

their underlying forces. For example, while the death

rates from both heart disease and diabetes have gen -

erally fallen among the elderly in recent years, their

prevalence as chronic conditions has risen. The reason for this divergence is unclear, but probably involves better treatment of ongoing symptoms of the

chronic condition along with improved medical treatment for acute episodes. Better acute care keeps the

death rate down but also may add to chronic illness

through the after-effects of the acute episode. Since

chronic disease causes most disability and usurps a

large portion of our health care resources (see section

on “Morbidity”; also, ch. 8), such trends have important implications for government policy.

This appendix analyzes the age, gender, and race

differences in such trends among persons 65 and over.

Given the often striking heterogeneity among the

elderly in terms of health status and risk, health policy could be more effectively targeted towards certain

high-risk subgroups. Correlation of these trends in

morbidity and mortality with changes in behavioral

and environmental risk factors is attempted where

possible. Many risk factors are controllable and have

implications for public health promotion and education (see ch. 4).

Appendix B: Cell Biology of Aging presents theories

of biological aging as a chronological process distinct

from age-related disease, and outlines what is known

and not known about the aging process. A better

understanding of the mechanisms underlying aging,

and their possible involvement in the relatively high

prevalence of certain diseases in the elderly, may lead

to medical technologies that can delay the onset and

progression of both aging and age-related diseases (see

ch. 2). These advances could improve the general

Ilh-evalence is the estimated average frequency of an ei,ent or rcmdition

orcuring within a population during a specified permd of time, Which in th]s

report 1s usually 1 year

health and productivity of the growing proportion of’

people who reach old age.

First the limitations of the data are discussed, followed by sections on trends in mortality and morbidity

and ending with a brief summary of the conclusions

that may be drawn from this analysis.

Limitations of the data

This chapter is based largely on U.S. data collected

by the National Center for Health Statistics (NCHS). Because some States did not participate in the death registration program until 1933, most of the mortality

data used in this appendix is dated from 1940 onward.

Comparison of mortality and morbidity data from different -years is further limited by the numerous revisions of the International Classification of Diseases

(ICD) since 1900 (a total of nine, one every 7 to 10

years). Comparability ratios that account for these

classification changes are available for the rates of

most major causes of death to allow more accurate

trend analysis. No such ratios are available for data

on prevalence of chronic conditions, however, and

comparisons of morbidity data are thus generally limited to the period of the eighth ICD revision (196.8-78).

Analysis of morbidity trends is further complicated

by the tendency of the elderly to develop multiple disorders and to manifest symptoms different from those

of younger people. Diagnosis can thus be more difficult, with implications for both the accuracy of the

data and, most importantly, for health care delivery.

Moreover, as diagnostic practices and public alwareness of certain conditions improve, rates of both morbidity and mortality may be raised by increased detection of chronic cases and of principal (v. contributing)

causes of death, as is discussed further in the text.

Mortality

TRENDS IN GENERAL DEATH RATES

Death rates among the elderly have declined progressively since 1900; during some periods there have

been dramatic changes (figs. A-1 and A-2). From 1940

to 1978, the age-adjusted2 death rate for the elderly

fell by 38 percent (table A-l). Following a sharp drop

during the 1940-54 period, when the annual decline

average 1..5 percent, this rate leveled off between

z “Age-adjusted” means that age-specific rates are weighted according to

the age distribution of the population in a gi~wn reference }ear bee rh 2)

369
370 . Technology and Aging in America

Figure A-l.—Age-Adjusted Death Rates Among Persons Aged 65 and Over, by Sex: United States, 1940.78

.

1940 1945 1950 1955 1960 1965 1970 1975 1980

Year

NOTES: Age adjusted by the direct method to the population aged 65 and over in the United States as enumerated in 1940, using 5 age groups Death rates for the

group aged 85 and over in 1970 used in computation of rates are based on population estimates revised by the US Bureau of the Census to correct for overesti-.

mates of the group aged t 00 and over

SOURCE Adapted from US. DHHS, NCHS, 1982 (63).

Figure A.2.—Death Rates Among Persons Aged 65 and Over for All Causes, by Sex and Age: United States, 1950-80

Male Female

1950 1955 1960 1965 1970 1975 1960 1950 1955 1960 1965 1970 1975 1960

SOURCE: Adapted from U.S. DHHS, NCHS, 1983 (67).
App. A—Morbidity and Mortality Data . 371

Table A-l.—Age-Adjusted Death Rates for Males

and Females Aged 65 and Over: United States,

1940 and 1978

Age adjusted

Percent

Sex 1940 1978 change

Both sexes. . . . . . . . . . . . . . . . . . . 72.2 45.0 - 37.70/0

Male . . . . . . . . . . . . . . . . . . . . . . . . 79.5 60.0 -24.5

Female . . . . . . . . . . . . . . . . . . . . . . 65.3 34.8 -46,7

SOURCE U.S DHHS, NCHS, 1982 (63)

Table A“2.—Death Rates Among All Persons

United States,

1955 and 1967, then decreased sharply once again between 1968 and 1978 at an average rate of 2.0 percent a year (63), The percent change was similar for

all age-specific subgroups, ranging from – 35.4 percent for the 85 and over group to – 44.4 percent for

those 75 to 79 (table A-2).

GENDER DIFFERENCES IN DEATH RATES

The decline in death rates over the past century is

more pronounced for women than for men, as shown

Aged 65 and Over, by Selected Age Groups:

1940.78, 1980

65-69 70-74 75-79 80-84 85 years

Year years years years years and over

1940. , . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1941 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1942 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1943 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1944 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1945 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1946 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1947 ... , . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1948 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1949 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1950 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1951 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1952 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1953 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1954 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1955 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1956 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1957 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1958 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1959 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1960 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1961 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1962 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1963 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1964 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1965 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1966 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1967 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1968 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1969 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1970 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1971 . . . . . . . . . . . . . . . . . . . . . . ! . . . . . . . . . . . . . . . .

1972 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1973 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1974 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1975 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1976 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1977 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1978 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1980 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Percent change 1940-80 . . . . . . . . . . . . . . . . . . . . .

39.7

37.9

37.0

37.5

35.7

34.8

33.5

34.2

33.8

33.5

33.8

33.0

32.6

32.7

31.4

31.7

31.7

32.6

31.9

31.1

31.4

30.7

31.1

31.3

30.3

30.5

30.6

29.9

30.8

30.2

29.7

28.6

28.8

28.0

27.0

25.7

25.4

24.8

24.6

24.6

-39.3’%0

Deaths per 1,000 population

61.1 94.8 145.6

58.2 88.4 139.6

56.5 84.9 134.3

58.8 89.9 142.2

55.9 85.9 133.0

53.9 84.5 125.7

52.2 82.3 120.1

53.5 84.0 121.8

52.3 82.5 118.8

51.3 80.6 116.3

51.5 78.9 120.9

50.3 78.2 119.1

49.2 76.4 117.4

49.0 75.8 118.9

46.9 72.1 112.3

47.0 73.7 114.7

46.7 73.1 115.2

47.7 73.1 115.9

47.0 72.9 116.2

46.1 71.0 114.1

47.2 72.0 117.2

45.0 69.5 111.3

45.4 70.7 111.7

46.1 71.9 112.8

44.5 69.4 108.0

44.2 69.8 108.1

44.9 69.8 107.8

44.1 67.8 104.0

45.3 69.5 106.4

44.1 67.3 104.6

43.7 67.2 101.6

43.0 66.3 99.0

44.0 67.5 99.1

43.0 67.2 97.8

41.9 64.5 94.7

40.5 62.1 91.0

39.5 61.9 90.3

38.5 60.7 88.1

37.9 60.2 89.5

36.8 55.0 86.4

-39.8% -44.4% -40.7%

235.7

218.7

211.1

230.3

215.3

209.6

210.6

216.9

213.2

203.2

202.0

197.6

190.6

191.9

181.6

189.8

192.3

197.9

198.0

194.2

198.6

196.3

204.9

209.9

199.2

200.7

199.8

192.2

195.8

188.2

175.4

174.3

173.5

174.3

165.3

151.9

154.9

147.3

147.0

159.8

–35.4%

SOURCE:U.S. DHHS,NCHS, 1982(63) and 1983(67)
372 Technology and Aging in America

in figure A-1. The age-adjusted decline from 1940 to

1978 for elderly women was 47 percent, almost twice

the decline of 24 percent for elderly men in the same

period (table A-l). The percent change in the death

rate was less for women over 80 in this period (table

A-3). The percent decline for every age group of

elderly men was smaller than that for women (table

A-4). Correspondingly, the increase in life expectancy

at age 65 for women (+35 percent) from 1940 to 1978

was more than twice as great as that for men ( +16

percent) (63).

Furthermore, the ratio of death rates for elderly

men to those of elderly women has increased steadily

over the years but more slowly in the older age groups

(table A-5). The annual increase in the ratio for the

“younger” elderly subgroups dropped between 1968

and 1978 as a result of the accelerating decline in the

general death rate of elderly men under age 80 (63).

RACE DIFFERENCES IN DEATH RATES3

Death rates for elderly black women and elderly

whites of both sexes fell between 1950 and 1980 (table

A-6). The decline for whites was greater than that for

3’1’his report often distinguishes hetween white and Mack or white and ‘all

other rares ” depending on the ataifable statistics anci the signifiranre of’ the

difference between the subgroups Since the “all other’” populatmn is approximately $)5 percent hlack, these two categories are roughl} romparatie

Table A=3.–Death Rates Among Females Aged 65 and Over, by Selected Age Groups: United States, 1940-78,1980

65-69 70-74 75-79 80-84 85 years

Year years years years years and over

1940 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1941 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1942 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1943 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1944 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1945 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1946 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1947 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1948 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1949 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1950 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1951 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1952 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1953 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1954 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1955 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1956 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1957 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1958 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1959 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . , ., .

1960 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1961 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . , . . . . .

1962 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1963 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1964 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1965 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1966 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1967 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1968 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1969 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1970 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1971 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1972 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1973 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1974 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1975 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1976 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1977 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1978 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1980 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Percent change 1940-80 . . . . . . . . . . . . . . . . . . . . .

33.9

32.0

30.9

31.7

29.9

28.9

27.6

27.7

27.0

26.6

26.4

25.4

25.0

24.9

23.7

23.9

23.7

24.1

23.4

22.7

22.6

21.9

22.0

22.0

21.4

21.4

21.5

21.0

21.5

20.9

20.4

19.5

19.8

19.0

18.2

17.3

17.1

16.9

16.9

17.2

–49.3%

Deaths per 1,000 population

54.3 86.5 136.0

51.1 80.3 129.2

49.8 77.0 124.3

51.8 81.7 131.9

49.3 77.8 124.3

47.0 76.3 116.7

45.8 74.2 112.0

46.2 75.2 113.2

44.7 73.5 110.0

43.6 71.1 106.6

43.2 69.6 110.7

41.8 68.8 108.6

41.0 67.1 105.7

40.5 66.0 107.1

38.2 62.7 100.6

37.7 63.8 102.9

37.3 63.0 103.2

37.8 62.9 104.4

37.3 62.2 104.6

36.2 60.5 102.9

36.7 60.7 105.3

35.0 58.2 99.5

35.1 59.0 99.7

35.2 59.4 99.8

33.7 57.1 95.4

33.1 57.0 94.7

33.6 56.9 94.3

32.7 54.8 90.6

33.3 56.1 92.8

32.6 54.0 90.6

32.4 53.8 87.7

31.8 52.8 85.0

32.4 53.5 84.7

31.6 53.4 83.4

30.7 51.1 80.9

29.5 48.8 76.9

28.6 48.5 76.3

27.7 47.4 73.9

27.2 47.1 75.1

26.7 42.6 72.6

-50.8% -50.7% –46.6%

227.6

208.8

202.9

221.2

207.8

201.3

203.0

207.2

203.1

194.4

191.9

190.1

186.1

186.6

177.4

185.5

186.6

191.5

191.0

186.8

190.1

186.9

194.0

197.9

189.1

189.0

188.5

180.4

184.3

177.1

163.5

162.2

162.0

162.3

153.9

140,3

143.1

135.4

135.4

147.5

-35.2940

SOURCE: U.S. DHHS,NCHS, 1962 (63) and 1963(67)
App. A—Morbidity and Mortality Data . 373

Table A-4.–Death Rates Among Males Aged 65 and Over, by Selected Age Groups: United States, 1940.78,1980

65-69 70-74 75-79 80-84 85 years

Year years years years years and over

1940 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1941 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1942 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1943 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1944 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1945 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1946 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1947 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1948 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1949 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1950 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1951 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1952 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1953 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1954 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1955 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1956 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1957 . . . . . . . . . . . . . . . . . . . . . . . . ! . . . . . . . . . .!...

1958 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1959 . . . . . . . . . . . . . . . . . . .. .. .. .. ... ... ...$...

1960 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1961 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1962 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1963 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1964 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1965 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1966 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1967 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1968 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1969 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1970 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1971 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1972 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1973 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1974 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1975 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1976 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1977 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1978 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1980 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Percent change 1940-80 . . . . . . . . . . . . . . . . . . . . .

45.5

43.9

43.1

43.5

41.6

41.0

39.7

41.0

40.9

40.8

41.6

41.1

40.7

41.0

39.8

40.2

40.5

42.0

41.4

40.7

41.4

40.8

41.6

42.4

41.0

41.4

41.7

40.7

42.2

41.6

41.2

39.9

40.0

39.3

38.0

36.4

35.9

34.7

34.4

33.9

–25.50/o

Deaths per 1,000 population

68.0

65.5

63.3

66.0

62.9

61.0

59.0

61.3

60.4

59.6

60.6

59.7

58.3

58.5

56.7

57.5

57.5

59.0

58.2

57.6

59.5

56.9

57.8

59.6

58.0

58.3

59.4

59.1

61.3

59.6

58.9

58.2

59.8

58.7

57.2

55.6

54.3

53.2

52.4

50.8

-25.3%

103.7

97.2

93.7

99.0

94.8

93.7

91.4

93.9

92.7

91.3

89.6

89.1

87.3

87.1

83.3

85.4

85.3

85.6

85.9

84.0

86.2

83.9

85.6

88.1

85.6

87.0

87.4

85.8

88.4

86.4

86.8

86.2

88.4

88.1

85.1

82.5

82.6

81.5

80.7

74.8

-27.90/o

156.6

151.8

146.1

154.6

143.6

136.6

129.9

132.0

129.6

128.1

133.4

132.1

132.5

134.4

127.5

130.3

131.3

131.4

132.0

129.5

133.7

127.9

128.7

131.3

126.4

128.1

128.0

124.6

127.6

126.8

123.9

122.1

123.4

122.4

118.6

115.9

115.2

113.6

116.0

112.4

-28.2%

246.4

231.9

222.1

242.6

225.5

220.7

221.1

229.3

226.4

215.0

216.4

208.2

196.7

199.2

187.4

195.9

200.5

207.3

208.3

205.4

211.9

210.8

222.5

229.4

216.4

220.8

220.1

213.4

217.3

208.8

197.7

197.5

196.0

198.1

188.8

175.7

179.8

173.0

172.6

188.0

-23.7%

SOURCE:US. DHHS, NCHS,1982(63)and 1963(67).
374 ● Technology and Aging in America

Table A-5.—Mortality Sex Ratiosa Among Persons Aged 65 and Over, by Selected Age Groups: United States, 1940-78,1980

65 years 65-69 70-74 75-79 80-84 85 years

Year and overb

years years years years and over

1940 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1941 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1942 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1943 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1944 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1945 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1946 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1947 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1948 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1949 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1950 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1951 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1952 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1953 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1954 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1955 . . . . . . . . . . . . . . . . . . . . .?....... . . . . . . . . . .

1956 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1957 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1958 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1959 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1960 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1961 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1962 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1963 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1964 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1965 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1966 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1967 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1988 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1969 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1970 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1971 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1972 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1973 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1974 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1975 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1976 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1977 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ........0

1978 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1980 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1.22

1.24

1.24

1.24

1.24

1.26

1.25

1.28

1.30

1.32

1.34

1.35

1.35

1.37

1.39

1.39

1.41

1.42

1.43

1.44

1.47

1.49

1.50

1.53

1.54

1.57

1.57

1.59

1.61

1.62

1.64

1.66

1.66

1.68

1.69

1.72

1.72

1.73

1.73

—

1.34

1.37

1.39

1.37

1.39

1.42

1.44

1.48

1.51

1.53

1.58

1.62

1.63

1.65

1.68

1.68

1.71

1.74

1.77

1.79

1.83

1.86

1.89

1.93

1.92

1.93

1.94

1.94

1.96

1.99

2.02

2.05

2.02

2.07

2.09

2.10

2.10

2.05

2.04

1.97

Ratio

1.25

1.28

1.27

1.27

1.28

1.30

1.29

1.33

1.35

1.37

1.40

1.43

1.42

1.44

1.48

1.53

1.54

1.56

1.56

1.59

1.62

1.63

1.65

1.69

1.72

1.76

1.77

1.81

1.84

1.83

1.82

1.83

1.85

1.86

1.86

1.88

1.90

1.92

1.93

1.90

1.20

1.21

1.22

1.21

1.22

1.23

1.23

1.25

1.26

1.28

1.29

1.30

1.30

1.32

1.33

1.34

1.35

1.36

1.38

1.39

1.42

1.44

1.45

1.48

1.50

1.53

1.54

1.57

1.58

1.60

1.61

1.63

1.65

1.65

1.67

1.69

1.70

1.72

1.71

1.76

1.15

1.17

1.18

1.17

1.16

1.17

1.16

1.17

1.18

1.20

1.21

1.22

1.25

1.25

1.27

1.27

1.27

1.26

1.26

1.26

1.27

1.29

1.29

1.32

1.32

1.35

1.36

1.38

1.38

1.40

1.41

1.44

1.46

1.47

1.47

1.51

1.51

1.54

1.54

1.55

1.08

1.11

1.09

1.10

1.09

1.10

1.09

1.11

1.11

1.11

1.13

1.10

1.06

1.07

1.06

1.06

1.07

1.08

1.09

1.10

1.11

1.13

1.15

1.16

1.14

1.17

1.17

1.18

1.18

1.18

1.21

1.22

1.21

1.22

1.23

1.25

1.26

1.28

1.27

1.28

aRatioof “ale death rate to female death rate.

bAgeadjusted by the direct method to the population 65 years of age and over as enumerated in 1940 using 5 age groups

SOURCE:U.S. DHHS, NCHS, 1962(63)and 1963(67)
App. A—Morbidity and Mortality Data ● 375

I-olnom* m

c605u5aitia54

mlnmmm=tu- 1

. . . . . . .

. . . . . . .

. . . . . . : 6 :

. . . . . .

. . . . . . . 0 ) .

. . . . . . . c

. . . . . . ~ o

. =( g . . . . . . .

. . . . . . . 0 . -
376 Technology and Aging in America

blacks in all age groups. While the rate for black men

65 to 74 also fell during this period, the rate for those

over 75 actually rose after 1960.

Death rates were consistently lower for whites from

1960 to 1980 in the 65 to 74 age group but lower for

blacks in the over-85 group. In the 75 to 84 group,

however, the black death rate was lower for women

through 1970 and for men through 1975, after which

both rates rose to surpass the rates for whites. The

reasons for these race differences in death rates

among the elderly remain largely unknown. Suggestions include race differences in accuracy of age reporting and the possibility that very old black persons

are more likely than whites to be healthy (see ch. 2).

TRENDS IN MAJOR CAUSES OF DEATH

The trends in the major causes of death that underlie

the falling death rates since the turn of the century

are significant indicators of the efficacy of improvements in public health, health care practices, and medical technology. Such changes are also useful in predicting future trends in order to anticipate how the

Nation’s medical, social service, and health promotion

systems should prepare to meet changing needs.

Since the turn of the century, the major causes of

death among the elderly and in the general population have shifted from infectious diseases to cardiovascular diseases and cancer (tables A-7 through A9). Although mortality data before 1933 are incomplete, the available figures cite tuberculosis and “pneumonia and influenza” as the leading killers of people

of all ages until 1920 (NCHS, unpublished data). These

three diseases alone are estimated to have caused approximately 23 percent of all deaths in 1900 (table A7), The decline in infectious disease can be attributed

largely to improved public sanitation, the advent of

Table A“7.—Major Causes

vaccines, greater accessibility to health care for all subgroups of the population, and the development of antibiotic treatments. Pneumonia and influenza, however,

are still ranked fourth as cause of death among the

elderly and sixth in the general population.

The three current leading causes of death both in

the general population and among those over age 65

are diseases of the heart, malignant neoplasms (cancer), and cerebrovascular disease (stroke), in that order (tables A-8 and A-9). These three conditions accounted for three out of every four deaths among the

elderly both in 1950 and 1978 (63). Of the top 10 causes

of death among the elderly today, only cancer and

chronic obstructive lung disease are increasing.

Diseases of the Heart. -Heart disease has been the

leading cause of death in the general population as well

as among the elderly since the 1920s. The death rates

for heart disease increase progressively with age in

men and women, peaking in the 85 and over group

(fig. A-3, table A-10). Cardiovascular disease in general

affects 50 percent of those over 70, but only 11 percent of those under 40 (37).

Death rates for heart disease declined very rapidly

among the elderly in the 1968-78 period; annual decreases averaged 2 percent (63). The decline from 1950

to 1978 was consistently greater for elderly women

than men and generally less in the older age groups

(table A-10). The male-female ratio of death rates for

heart disease increased for all age groups over the period and is most pronounced in the 65 to 74 age group

(table A-1 1). The differences in both current rate and

decline between the sexes were smaller in the older

age groups, however.

There are also significant race differences in heart

disease mortality: elderly white men exhibit higher

rates than black men in most age groups; white womof Death: United States, 1900

Percent of

Rank order Number Ratea

all deaths

All causes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 343,217 1,719.1

1 Pneumonia (all forms) and influenza . . . . . . . . . . . . . . . . . . . . 107-109,33 40,362 202.2 11 .8%

2 Tuberculosis (all forms) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ....13-22 38,820 194.4 11 .3%0

3 Diarrhea, enteritis, and ulceration of the intestines. . ........119,120 28,491 142.7 8.30%

4 Diseases of the heart . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ....90-95 27,427 137.4 8.0 %

5 Intracranial lesions of vascular origin . . . . . . . . . . . . . . . . . . . . .. ....83 21,353 106.9 6.2 %

6 Nephritis (all forms). . . . . . . . . . . . . . . . . . . . . . ...............130-132 17,699 88.6 5.2%

7 All accidents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..169-195 14,429 72.3 4.2%

8 Cancer and other malignant tumors. . . . . . . . . . . . . . . . . . . . . .. ..45-55 12,769 64.0 3.70/~

9 Senility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..........162 10,015 50.2 2.9%

10 Diphtheria . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .......10 8,056 40.3 2.3%

aPer 100,000 people.

SOURCE: National Center for Health Statistics, unpublished data.
App. A—Morbidity and Mortality Data . 377

Table A-8.—Deaths and Death Ratesa for the 10 Leading Causes of Death: United States, 1980

Rank Percent of all

order Cause of deathb Number Rate deaths

All ages

. . . All causes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1,989,841 878.3 1000/0

1 Diseases of

heart . . . . . . . . . . . . . . 390-398, 402, 404-429 761,085 336.0 38.2

2 Malignant neoplasms, including

neoplasms of lymphatic and hematopoietic tissues . . . . . . . . . . . . . . . . . 140-208 416,509 183.9 20.9

3 Cerebrovascular diseases . .........430-438 170,225 75.1 8.5

4 Accidents and adverse

effects . . . . . . . . . . . . . . . . . . . . . . E800–E949 105,718 46.7 5.3

. . . Motor vehicle

accidents. . . . . . . . . . . . . . . . E810–E825 53,172 23.5 2.7

. . . All other accidents and adverse

effects . . . . . . . E800-E807, E826-E949 52,546 23.2 2.6

5 Chronic obstructive pulmonary diseases and

allied conditions . . . . . . . . . . . . . . . . 490–496 56,050 24.7 2.8

6 Pneumonia and influenza . . . . . . . . . . 480-487 54,619 24.1 2.7

7 Diabetes mellitus . . . . . . . . . . . . . . . . . . . . .250 34,851 15.4 1.7

8 Chronic liver disease and cirrhosis. . . . . . 571 30,583 13.5 1.5

9 Atherosclerosis. . . . . . . . . . . . . . . . . . . . . . . 440 29,449 13.0 1.5

10 Suicide . . . . . . . . . . . . . . . . . . . . . . . E950-E959 26,869 11.9 1.5

. . . All other causes . . . . . . . . . . . . . . . . . Residual 303,883 134.1 1.3

aRate~ per 100,000 populationIn specified 9roup.

bNinth Revlslon [international C(asslficatlon of Di~ea~es, 1975

SOURCE” National Center for Health Statistics, unpublished data

Table A“9.—Deaths and Death Ratesa Among Persons Aged 65 and Over for the 10 Leading Causes

of Death: United States, 1980

Rank Percent of total

order Cause of death Number Rate deaths

65 years and over

. . . All causes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1,341,848 5,252.0 100 ”/0

1 Diseases of

heart. . . . . . . . . . . . . . 390-398, 402, 404-429 595,406 2,330.4 44.4

2 Malignant neoplasms, including

neoplasms of lymphatic and hematopoietic tissues . . . . . . . . . . . . . . . 140-208 258,389 1,011.3 19.2

3

4

5

6

7

8

. . .

. . .

9

10

. . .

Cerebrovascular diseases . .........430-438

Pneumonia and influenza . .........480-487

Chronic obstructive pulmonary diseases

and allied conditions . . . . . . . . . . . . 490–496

Atherosclerosis. . . . . . . . . . . . . . . . . . . . . .. 440

Diabetes mellitus . . . . . . . . . . . . . . . . . . . . .250

Accidents and adverse

effects . . . . . . . . . . . . . . . . . . . . . . E800-E949

Motor vehicle

accidents. . . . . . . . . . . . . . . . E81O–E825

All other accidents and adverse

effects . . . . . . . E800-E807, E826-E949

Nephritis, nephrotic syndrome,

and nephrosis . . . . . . . . . . . . . . . . . . 580–589

Chronic liver disease and cirrhosis. . . . . . 571

All other causes . . . . . . . . . . . . . . . . . Residual

146,417

45,512

43,587

28,081

25,216

24,844

5,778

19,066

12,968

9,519

151,909

573.1

178.1

170.6

109.9

98.7

97.2

22.6

74.6

50.8

37.3

594.6

10.9

3.4

3.2

2.1

1.9

1.8

0.4

1.4

a Rate s per 100,000 population in specified 9rou P

bNinth Revision International Classification Of Diseases, 1975

SOURCE: National Center for Health Statistics, Division of Vital Statistics, Vital Statistics of the United Stafes, Vo/urne //, Mortallty (published and unpublished data).
378 “ Technology and Aging in America

Figure A.3.— Death Rates Among Persons Aged 65 and Over for Diseases of the Heart, by Sex and Age:

United States, 1950-78

85 years and over

I

I

Female 20,000 r

00- -

[

--\4--\ 75-84 years

+ e ~

\ . \

i m

- -

- - -

- \

- \ .

1 -

! 4 . 

1 “. “ . 1 1 1 I

restimaites

SOURCE: U.S. DHHS, NCHS, 1982 (63), -, .--, “-, “1, ” 
App. A—Morbidity and Mortality Data ● 379

Table A-lO.— Death Rates Among Persons Aged 65 and Over for Diseases of the Heart, by Sex and Age:

United States, 1950”78

Male Female

65-74 75-84 85 years 65-74 75-84 85 years

Year years years and over years years and over

Deaths per 100,000 population

1950 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1951 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1952 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1953 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1954 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1955 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1956 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1957 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1958 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1959 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1960 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1961 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1962 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1963 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1964 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1965 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1966 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1967 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1968 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1969 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1970 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1971 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1972 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1973 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1974 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1975 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1976 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1977 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1978 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Percent change, 1950-78 . . . . . . . . . . . . . . . . . . . . .

2,310.1

2,256.6

2,236.2

2,263.2

2,189.3

2,224.8

2,246.0

2,295.1

2,275.9

2,248.9

2,291.3

2,236.9

2,274.3

2,316,3

2,250.3

2,237.6

2,270.8

2,220.7

2,257.5

2,208.2

2,170.3

2,113.1

2,116.3

2,068.2

1,988.9

1,886.9

1,847.6

1,795.3

1,761.6

–23.70/o

4,825.0

4,811.1

4,733.5

4,760.6

4,562.6

4,713.5

4,745.7

4,735.6

4,741.3

4,633.1

4,742.4

4,617.7

4,701.3

4,807.5

4,620.4

4,695.5

4,676.8

4,554.9

4,652.6

4,584.0

4,534.8

4,490.7

4,531.8

4,519.5

4,305.2

4,156.1

4,136.1

4,082.4

4,064.1

-16.O%

9,654.4

9,375.4

8,817.9

9,008.7

8,637.2

9,044.7

9,288.4

9,596.4

9,683.4

9,540.6

9,788.9

9,816.4

10,414.7

10,686.2

10,086.8

10,312.1

10,244.5

9,968.3

10,078.0

9,829.2

9,346.0

9,407.2

9,203.8

9,308.6

8,897.1

8,171.0

8,274.9

8,053.3

7,990.6

-17.20/0

1,435.0

1,375.4

1,369.1

1,366.2

1,303.5

1,302.2

1,306.4

1,328.3

1,295.0

1,259.6

1,261.3

1,215.6

1,228.8

1,218.6

1,174.9

1,157.2

1,168.8

1,131.0

1,140.9

1,104.0

1,082.7

1,043.9

1,045.4

994.5

948.1

890.8

856.2

831.8

823.1

-42.60/o

3,873.0

3,796.1

2,760.9

3,762.2

3,570.8

3,686.4

3,688.6

3,694.3

3,663.6

3,561.5

3,582.7

3,438.0

3,489.6

3,480.4

3,356.7

3,347.2

3,334.1

3,207.3

3,259.2

3,170.4

3,120.8

3,070.8

3,082.1

3,036.4

2,903.5

2,742.4

2,731.1

2,662.5

2,665.6

-31.20/o

8,800.0

8,687.8

8,549.9

8,631.3

8,354,8

8,826.9

8,934.7

9,121.9

9,063.2

8,922.5

9,016.8

8,895.1

9,288.0

9,498.1

9,144.6

9,088.2

9,014.6

8,686.6

8,850.1

8,606.4

8.000.9

7,979.3

7,968.6

7,916.8

7,537.7

6,850.9

6,965.4

6,655.3

6,673.5

-24.20/o

SOURCE:U.S. DHHS, NCHS,1982(63)

38-800 0 - 85 - 1 3
380 ● Technology and Aging in America

Table A-11 .—Mortality Sex Ratiosa Among Persons Aged 65 and Over for Diseases of the Heart,

by Age: United States, 1950-78

85 years

Year 65-74 years 75-84 years and over

Ratio

1950 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1.61 1.25 1.10

1951 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1.64 1.27 1.08

1952 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1.63 1.26 1.03

1953 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1.66 1.27 1.04

1954 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1.68 1.28 1.03

1955 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1.71 1.28 1.02

1956 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1.72 1.29 1.04

1957 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1.73 1.28 1.05

1958 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1.76 1.29 1.07

1959 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1.79 1.30 1.07

1960 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1.82 1.32 1.09

1961 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1.84 1.34 1.10

1962 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1.85 1.35 1.12

1963 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1.90 1.38 1.13

1964 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1,92 1.38 1.10

1965 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1.93 1.40 1.13

1966 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1.94 1.40 1.14

1967 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1.96 1.42 1.15

1968 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1.98 1.43 1.14

1969 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.00 1.45 1.14

1970 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.00 1.45 1.17

1971 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.02 1.46 1.18

1972 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.02 1.47 1.16

1973 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.08 1.49 1.18

1974 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.10 1.48 1.18

1975 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.12 1.52 1.19

1976 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.16 1,51 1.19

1977 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.16 1.53 1.21

1978 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.14 1.52 1.20

aRatio of male death rate to female death rate; data derived from table 10

SOURCE:U.S. DHHS, NCHS,1962(63)

en,by contrast, exhibit consistently lower rates in the

65 to 74 age group and consistently higher rates in

the 85 and over group than black women. Thedecline

in death rates was generally similar in all sex-race

groups except for blacks 75 to 84, of both sexes, among

whom the death rate actually rose (table A-12).

Ischemic coronary heart disease is the major subcategory of heart disease mortality among the elderly;

it followed the same patterns of decline, with similar

sex and race differences, as heart disease in general

from 1968 to 1978 (68) Coronary heart disease mortality may be further subdivided into deaths from

chronic coronary disease and a cute myocardial infarction (occlusion of a coronary artery resulting in heart

attack). Chronic coronary heart disease exhibited a

higher death rate than myocardial infarction in all but

the 65 to 74 age group (68)

This general decrease in mortality from heart disease is due at least partially to improvements in preventive health practices of the general population that,

in combination with medical treatment, can significantly decrease risk factors for heart disease. The major risk factors forheart disease include hypertension,

cigarette smoking (24,43), high blood cholesterol, obesity (defined as 20 percent or more above the desirable

body weight for a given height, age, and sex), glucose

intolerance, lack of exercise (9) and stress (46).

Hypertension is the most powerful predictor of heart

disease (30) and the accompanying risk actually increases with age. Many of the other risk factors—

including blood cholesterol, smoking, and body

weight—become less significant in the elderly (8,39)

but are known to exacerbate hypertension (seech. 4).

The prevalence of chronic hypertension rose in the

1970s (see section on ’’Morbidity”) as the death rate

for cardiovascular diseases continued to fall. If these

prevalence figures are in fact accurate and not artifacts of improved diagnosis and/or statistical reporting, they probably indicate better medical treatment

and prevention of hypertension that reduces the associate drisk,The same may be true for diabetes, a condition whose prevalence amongthe elderly also seems
App. A—Morbidity and Mortality Data . 381

1111 1 1111 1 1111 1 1111 1

mlm h

l-e m

w

.

- m

:Z.>0
382 ● Technology and Aging in America

to be rising; it is not clear, however, that treatment

of diabetes reduces the associated risk of cardiovascular mortality.

A higher percentage of elderly men smoke cigarettes

than women, which may contribute to the gender difference in heart disease mortality. The percentage of

elderly women who smoke, however, has risen dramatically in recent years—a phenomenon that has not

yet been reflected in their cardiovascular death rates,

probably because the deleterious effects of smoking

on the cardiovascular system are only manifested over

a period of decades.

Downward trends have also been found in the consumption of cholesterol and saturated fats, high intakes of which have been associated with increased

risk of heart disease (15,19,47; see ch. 4). Per capita

consumption of foods high in these substances has decreased since the early 1960s, while the consumption

of foods high in unsaturated fats and fiber, like fish

and vegetables, has increased (70; table A-13). This

change in dietary habits may have contributed to the

decline in serum cholesterol levels in recent years (1).

Diets high in vegetables and low in saturated fats have

been shown to reduce blood pressure in normal subjects (41,42).

Cancer (Malignant Neoplasms).—Cancer is the

second most common cause of death for the general

population as well as for elderly people. The incidence4

4An incidence rate is the estimated number of new cases appearing within

a specified time period (which m this report is always 1 year), divided by

the total number of individula within a defined population group

Table A-13.–Change in Per Capita Consumption of

Various Products, 1963080a

Percent

Product Change

Cigarette tobacco. . . . . . . . . . . . . . . . . . . . . . . . . . . . -27.1%0

Fluid milk and cream . . . . . . . . . . . . . . . . . . . . . . . . -24.1

Butter . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . -33.3

Eggs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . -12.3

Animal fats and oils . . . . . . . . . . . . . . . . . . . . . . . . . – 38.8

Vegetable fats and oils . . . . . . . . . . . . . . . . . . . . . . . + 57.6

Fish . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . +22.6

a Figures for calculating percentage changes obtained from us. Department of

Agriculture,

SOURCE: Walker, 1963 (70).

and mortality from cancer generally rise with age (fig.

A-4)—51 percent of all malignant cancers are diagnosed at ages 65 and over (50,57). In 1980 cancer was

the second leading cause of death for persons 65 to

85 and the third (after stroke) for those 85 and over

(67). In 1978, cancer accounted for 26 percent of all

deaths among those 65 to 74, 18 percent among those

75 to 84, and 10 percent among those 85 and over (63).

Of the top three causes of death, cancer is the only

one for which death rates have continued to rise since

1950 (fig. A-5). This trend is due mostly to the dramatic

rise in death rates from cancers of the respiratory

tract (trachea, bronchus, and lung), among both the

elderly and the general population (fig. A-6). All three

of these cancers have been linked to cigarette smoking. The death rate due to respiratory cancer among

the elderly skyrocketed from 1950 to 1978—a jump

Figure A-4.— Death Rates Among Persons Aged 65 and Over for Malignant Neoplasms, by Sex and Age:

United States, 1950.78

!

E

tax

fm)

Female

3,000

2,000 –

85 years and over

o

NOTES Death rates for the group aged 85 and over in 1970 are based on Population estimates revised by the U.S. Bureau of the Census to correct for overestimates

of the group aged 100 and over ICD codes for 1950-67 are 140-205 and ICDA codes for 1968-78 are 140-209,

SOURCE: U.S. DHHS, NCHS, 1982 (83).
App. A—Morbidity and Mortality Data 383

Figure A-5.—Age.Adjusted Death Rates for Persons Aged 65 and over, by Leading Causes of Death:

United States, 1950.79

3,000

2,000

1,000

500

300

200

100

90

80

Year

NOTES” Causes of death are assigned according to the International List of Causes of Death. Because of the decennial revis!ons and changes in rules for cause-of.

death selection, there may be some lack of comparability from one revision to the next The beginning dates of the revis!ons are 1949, 1958, 1988. and 1979

SOURCE U S DHHS. NCHS, 1982 (65)
384 . Technology and Aging in America

Figure A-6.—Age.Adjusted Cancer Death Rates by Site: United States, 1930.78

1930 1935 1940 1945 1950 1955 1960 1965 1970 1975 1960

Year

NOTES: Rates for the population are standardized for age based on the 1970 U.S. population. Rates are for both sexes combined, except breast and uterus for female population only and prostate for male Population only.

SOURCE: American Cancer Society, 1983 (4).

manifested mostly among elderly men (fig. A-7). Cancer mortality is generally higher and has been rising

more rapidly in men than in women (fig. A-9, table

A-14). This male-female gap has widened over the

years, as illustrated by the increasing sex ratios of cancer death rates (table A-15).

Death rates among elderly men for three major

types of cancer—respiratory, genital, and colon—have

risen notably in the 1950-78 period and are consistently higher for men than for women (tables A-I6

through A-18). The incidence rates of respiratory and

genital cancer are likewise higher in men (4) (fig. A8). These cancers accounted for 43 percent of all new

cancers in both sexes in the 1970s (50). In 1978, lung

cancer was the leading cause of cancer deaths for men

65 to 84, while cancer of the genital organs (mostly

prostate) predominated in men over 85 (tables A-16

and A-17). Comparisons of data from two major surveys (49, so) indicate that the incidence of these three

cancers, and cancer in general, increased during the

1970s in men; the exact figures are probably not reliable, however, due to differences in sampling procedures and possible changes in diagnostic efficacy over

the period.

The overall cancer death rate among elderly women

actually fell slightly from 1950 to 1978 (table A-14).

Since the mid-1960s, however, the rate has risen for

all persons 65 to 84 (fig. A-4). The increase in female

cancer mortality is largely due to the sharp rise in respiratory cancer mortality among elderly women over

the period (table A-16). Deaths from cancers of the

genital organs, breast, and colon fell in most age

groups of elderly women (tables A-17 through A-19),

The incidence of all four cancers, especially respiratory, has risen during the 1970s (49)50). The simuhaneous decline in mortality may be partly due to improved early diagnosis and treatment of these cancers.

Breast cancer appears more frequently in women (fig.

A-8) but has a relatively low associated death rate.

Table A-20b presents the estimated proportions of

cancer deaths attributed to different factors. According to these estimates, tobacco and dietary factors

combined account for more than 60 percent of cancer deaths (14). Dietary factors have been implicated
App. A—Morbidity and Mortality Data ● 385

Figure A-7.—Age-Adjusted Cancer Death Ratesa — for Selected Sites, Males:

United States, 1930.78

80

70

80

50

40

30

20

10

0

1930 1940 1950 1980 1970 1980

Year

aAdjus@j to the age distribution of the 1970 U.S. Census population.

SOURCE: Cancer Stat/st/cs, 1984, American Cancer Society, 1964 (5).
386 ● Technology and Aging in America

Figure A-9.—Age-Adjusted Cancer Death Ratesa for Selected Sites, Females:

20

10

0

United States, 1930”78

80

70

60

50

40

30

1930 1940 1950 1960 1970 1980

Year

aAdjusted to the We distribution of the 1970 U.S. Census population.

SOURCE: Cancer Statitistics 1984, American Cancer Society, 1984 (5).
App. A—Morbidity and Mortality Data • 387

Table A.14.—Death Rates Among Persons Aged 65 and Over for Malignant Neoplasms,

by Sex and Age: United States, 1950-78

Male Female

65-74 75-84 85 years 65-74 75-84 85 years

Year years years and over years years and over

Deaths per 100,000 population

1950 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1951 . . . . . . . . ., . . . . . . . ., ., . . . . . . . . . . . . . . . . . .

1952 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1953 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1954 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1955 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1956 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1957 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1958 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1959 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1960 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1961 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1962 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1963 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1964 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1965 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1966 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1967 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1968 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1969 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1970 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1971 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1972 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1973 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1974 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1975 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1976 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1977 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1978 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Percent change, 1950-78 . . . . . . . . . . . . . . . . . . . . .

791.5

788.5

809.1

815.0

839.4

851.0

849.3

879.3

862.5

872.8

890.5

902.4

907.7

929.8

925.9

946.1

955.4

976.8

998.2

997.3

1,006.8

1,018.4

1,036.1

1,003.7

1,045.2

1,051.8

1,060.1

1,067.6

1,076.7

+36.00/o

1,332.6

1,307.3

1,349.2

1,358.9

1,371.6

1,373.9

1,416.6

1,384.5

1,358.6

1,356.4

1,389.4

1,394.8

1,387.2

1,405.2

1,416.6

1,451.6

1,477.9

1,505.2

1,520.1

1,541.1

1,588.3

1,614.7

1,651.7

1,665.7

1,715.1

1,728.4

1,782.1

1,809.4

1,849.4

+38.8°10

1,668.3

1,689.1

1,665.6

1,677.9

1,688.8

1,691.0

1,767.9

1,753.4

1,704.9

1,762.8

1,741.2

1,840.8

1,879.7

1,923.9

1,840.3

1,911.1

1,905.4

1,919.0

1,936.1

1,952.9

1,908.6

1,953.3

1,917.4

2,018.0

1,984.7

1,987.4

2,042.0

2,102.3

2,137.2

+28.10/o

612.3

592.1

594.8

594.6

589.4

585.7

578.2

573.2

571.2

560.5

560.2

557.9

555.0

551.0

542.6

549.4

551.0

557.3

553.1

552.6

557.9

557.1

571.5

563.7

566.4

563.1

576.0

581.3

588.7

-3.80/o

1,000.7

987.0

990.2

986.3

972.5

962.7

957.3

945.9

919.4

903.2

924.1

891.9

885.4

881.2

868.2

874.6

872.5

867.1

860.4

871.5

891.9

877.1

878.1

887.0

902.0

910.3

922.9

939.1

958.8

-4.20/o

1,299.7

1,284.2

1,304.7

1,296.5

1,275.3

1,303.3

1,286.0

1,309.7

1,268.6

1,241.1

1,263.9

1,273.5

1,264.3

1,280.7

1,238.9

1,234.9

1,252.9

1,215.0

1,223.6

1,202.5

1,155.8

1,173.2

1,174.0

1,142.7

1,133.9

1,128.2

1,159.0

1,143.5

1,139.3

12.3 %

SOURCE: U.S. DHHS,NCHS, 1982(63)

in many cancers of the gastrointestinal tract (see ch.

4) For example, some believe that a diet high in beef

and deficient in fiber may contribute to bowel cancer (4).

Smoking is most likely the major contributor to the

striking rise in respiratory cancer mortality, and cancermortality in general, among elderly men and women. Proportionally more elderly men than women

smoke, but this gaphas narrowed considerably in recent years; the percent of men over 65 who smoke

dropped between 1965 and 1980, while that for elderlY women rose by 75 percent (tableA-20a)The American Cancer Society estimates that cigarette smoking

is responsible for 83 percent of lung cancer among

men and 43 percent among women, more than 75percent combined (4). By its estimate, smoking accounts

for 25 percent of all cancers and has been linked to

conditions ranging from gastric ulcers to chronic bronchitis and emphysema to heart disease.

Industrial and other environmental exposures further compound the hazard: asbestos, for example, in

combination with cigarette smoking, increases the cancer risk nearly 60 times (4). This and similar synergistic

effects between behavioral and environmental risks

illustrate the need for public education about avoidable cancer risks as well as close regulation of carcinogenic hazards in the workplace and the environment in general.

Cerebrovascular Disease (Stroke).-In 1980

stroke was the third leading cause of death amongper-
388 ● Technology and Aging in America

Table A“15.—Mortality Sex RatiossAmong Persons Aged 65 and Over

for Malignant Neoplasms, by Age: United States, 1950-78

65-74 75-84 85 years

Year years years and over

1950 ........, . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1951 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1952 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1953 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1954 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1955 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1956 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1957 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1958 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1959 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1960 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1961 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1962 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1963 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1964 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1965 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1966 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1967 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1968 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1969 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1970 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1971 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1972 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1973 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1974 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1975 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1976 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1977 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1978 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1.29

1.33

1.36

1.37

1.42

1.45

1.47

1.53

1.51

1.56

1.59

1.62

1.64

1.69

1.71

1.72

1.73

1.75

1.80

1.80

1.80

1.83

1.81

1.83

1.85

1.87

1.84

1.84

1.83

Ratio

1.33

1.32

1.36

1.38

1.41

1.43

1.48

1.46

1.48

1.50

1.50

1.56

1.57

1.59

1.63

1.66

1.69

1.74

1.75

1.77

1.78

1.84

1.88

1.88

1.90

1.90

1.93

1.93

1.93

1.28

1.32

1.28

1.29

1.32

1.30

1.37

1.34

1.34

1.42

1.38

1.45

1.49

1.50

1.49

1.55

1.52

1.58

1.58

1.62

1.65

1.66

1.63

1.77

1.75

1.76

1.76

1.84

-— 1.88 .._-

a Ratio of male death rate to female death rate; data derived from tabl 14.

SOURCE: U.S. DHHS,NCHS, 1952(63)

sons 65to 84 and the second among those 85 and over

(67). The death rate from stroke increases markedly

withage, from 8 percent of all deaths among persons

65 to 74 to16 percent among those 85 and over (63).

The sex difference for stroke mortality is far smaller

than that for either heart disease or cancer, especially

in the older age groups. The gap has widened over

the years for those 65t064, with men in this agegroup

exhibiting consistently higher rates than women since

1950 (see table A-22). In the age group over 85) however, women have had consistently higherrates.Death

rates for stroke from blood clots or other occlusions

of cerebral arteries slightly lead those for hemorrhagic

(Bleeding) stroke in both 1970 and 1980(67,68)

Death rates for stroke among the elderly have decreased more rapidly during the past 30 years than

those for heart disease, especially since the mid-1970s

when stroke mortality began to fall most steeply (fig.

A-10). The decline in stroke mortality, as in heart disease, was generally greater among women than men.

The decline forboth sexes is smaller in the older age

groups (table A-21).

Risk factors for cerebrovascular diseaseare similar

to those for heart disease; again, most of these factors, except for hypertension, are less significant

among the elderly. As noted above, hypertension is

the most powerful risk factor for stroke (30). Therecent decline immortality due to stroke, and cardiovascular disease in general, is probably due largely to improved acute care, more reliable diagnosis, the

reduction of certain risk factors through changes in

the dietary habits of the public, and better medical

treatment of chronic conditions contributing to the

risk (as noted in the section on heart disease).

Other Major Causes of Death-The death rates of the

remaining seven major causes of death among the

elderly generally fell during the last four decades

(table A-23). Pneumonia and influenza death rates decreased by 55 to 70 percent among the elderly between 1940 and 1980 (less in older age groups) but
App. A—Morbidity and Mortality Data ● 389

Table A-16.—Death Rates Among Persons Aged 65 and Over for Cancer of Trachea, Bronchus, and Lung,

by Sex and Age: United States, 1950.78

Male Female

65-74 75-84 85 years 65-74 75-84 85 years

Year years years and over years years and over

1950 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1951 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1952 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1953 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1954 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1955 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1956 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1957 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1958 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1959 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1960 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1961 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1962 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1963 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1964 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1965 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1966 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1967 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1968 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1969 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1970 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1971 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1972 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1973 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1974 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1975 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1976 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1977 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1978 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Percent change, 1950-78 . . . . . . . . . . . . . . . . . . . . .

98.7

108.4

117.7

127.1

139.6

148.9

163.7

173.5

181.1

192.1

204.2

217.1

228.1

240.2

247.0

261.8

272.6

284.7

305.5

312.8

320.8

334.5

345.4

350.3

354.4

365.4

371.8

382.4

389.0

+291.4°10

Deaths per 100,000 population

82.6

85.3

95.6

106.2

110.5

126.9

133.3

138.8

143.2

152.2

167.1

176.2

191.4

205.9

218.6

231.7

254.2

278.1

292.9

303.3

330.8

357.1

373.3

381.5

407.2

417.9

443.0

467.8

478.6

+479.40/0

62.4

60.5

71.1

69.2

75.0

73.9

85.0

89.6

91.5

111.5

107.7

128.7

126.2

142.7

135.6

155.0

156.0

173.7

193.6

205.2

215.1

236.6

228.4

252.5

262.0

267.4

289.7

305.3

317.4

+508.60/o

23.3 32.9 28.2

22.1 33.6 30.6

24.5 33.8 28.9

23.4 32.8 29.4

22.9 34.5 31.8

23.9 34.1 30.3

24.1 33.9 31.1

24.2 34.3 34.6

24.6 36.0 36.4

24.2 34.4 30.9

24.4 32.8 38.8

25.6 35.8 39.4

25.6 35.6 40.1

27.3 35.0 43.2

27.7 38.2 38.7

30.4 36.6 43.7

31.7 40.9 50.7

34.2 41.9 43.8

39.1 49.7 55.3

42.1 47.5 51.3

43.1 52.4 52.7

48.6 55.0 58.7

53.0 56.4 57.4

55.0 60.5 58.4

60.2 64.2 63.2

64.5 66.8 65.7

71.7 74.9 69.3

76.7 78.6 70.1

84.9 87.1 70.0

+264.4% +164.7% –148.2%

SOURCE:US. DHHS, NCHS,1982(63)

remain the fourth leading killers among the elderly.

Tuberculosis, the second leading killer in the general

population in 1900, has declined by at least 80 percent among the eldery since 1940 and is no longer

a major cause of death in the United States. Vaccination, improved public sanitation, and improved acute

care account for most of the decline in such infectious

diseases.

The fifth and tenth leading causes of death among

the elderly, chronic obstructive pulmonary (lung)disease (including bronchitis, emphysema, and asthma)

and chronic liver disease (including cirrhosis) have

both increased in some age groups in recent years

(table A-23) Death rates were much higher forelderly

men than women for both diseases; they were four

to nighttimes higher for chronic obstructive lungdisease. This is due in part to the higher percentage of

men who smoke, a risk factor for both diseases (64),

and to the generalyhigher proportion of heavy drinkers among men, a risk factor for cirrhosis (65). The

death rate for obstructive pulmonary disease increases

with age and has risen more in the older age groups

since 1970 (more than twofold for those over 85; see

table A-23). Chronic liver disease mortality rose in both

the general population and among the population 65

to 74.

Mortality due to arteriosclerosis, currently the sixth

leading cause of death among the elderly, fell by at

least 60 percent between 1950 and 1980, with smaller

declines in older age groups. Mortality due to hypertension similarly fell by at least 67 percent during the

same period—elderly women exhibited lower rates

than men for both conditions (table A-23)

Death rates for diabetes mellitus (currently ranked

seventh among the elderly) have generally fallen since

1940 except in the 85 and over group, for which the
390 . Technology and Aging in America

Table A-17.—Death Rates Among Persons Aged 65 and Over for Cancer of Genital Organs,

by Sex and Age: United States, 1950.78

Male Female

65-74 75-84 85 years 65-74 75-84 85 years

Year years years and over years years and over

1950 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1951 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1952 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1953 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1954 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1955 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1956 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1957 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1958 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1959 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1960 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1961 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1962 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1963 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1964 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1965 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1966 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1967 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1968 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1969 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1970 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1971 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1972 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1973 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1974 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1975 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1976 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1977 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1978 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Percent change, 1950-78 . . . . . . . . . . . . . . . . . . . . .

103.9

100.6

103.5

105.7

106.1

106.4

105.3

103.4

104.3

102.0

102.1

101.3

102.3

104.6

103.0

100.4

101.3

102.4

105.8

102.9

103.7

103.2

106.1

105.5

106.9

105.4

106.4

105.4

107.1

+3.1%

Deaths per 100,000 population

281.4

286.5

290.2

296.9

305.5

296.2

309.1

299.8

286.9

278.5

285.9

286.1

284.8

282.4

282.4

286.6

283.6

286.4

285.1

288.5

299.4

297.9

300.8

309.3

310.5

312.4

321.4

322.1

331.6

+.13.8%

436.2

421.9

464.5

451.9

464.1

465.7

488.4

479.2

470.1

467.9

468.2

508.4

505.6

514.9

497.4

513.3

507.1

513.6

512.3

493.2

481.6

493.8

489.0

514.3

439.9

494.9

514.6

527.0

548.7

+25.8%

110.1

105.7

106.0

105.8

102.5

103.0

99.3

99.8

100.3

98.4

97.9

98.4

95.0

93.4

91.6

92.7

91.7

90.2

86.0

84.5

85.6

83.3

83.5

79.4

77.7

77.4

77.5

75.3

74.7

-32.2%

136.9

132.3

132.6

131.0

132.0

126.5

124.1

118.9

123.0

119.2

119.1

112.9

114.1

115.0

112.9

108.9

110.4

104.5

107.7

105.7

104.9

105.0

104.9

103.3

102.2

102.5

108.7

102.8

100.8

-26.4%

141.4

132.8

138.3

134,8

128,9

136.3

137.4

135.2

138.6

133.7

131.4

123.0

129.1

128.4

123.3

124.3

128.1

118.6

120.4

121.1

113.1

116.8

114.3

108.4

110.5

108.7

106.4

104.4

103.6

“ r –26.7%

SOURCE:US. DHHS, NCHS,1982(63)
App. A—Morbidity and Mortality Data ● 391

Table A“18.—Death Rates Among Persons Aged 65 and Over for Cancer of Colon,

by Sex and Age: United States, 1950-78

Male Female

65-74 75-84 85 years 65-74 75-84 85 years

Year years years and over years years and over

1950 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1951 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1952 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1953 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1954 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1955 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1956 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1957 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1958 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1959 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1960 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1961 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1962 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1963 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1964 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1965 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1966 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1967 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1968 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1969 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1970 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1971 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1972 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1973 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1974 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1975 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1976 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1977 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1978 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Percent change, 1950-78 . . . . . . . . . . . . . . . . . . . . .

84.9

85.6

87.1

85.0

84.2

85.9

87.5

89.4

87.4

87.5

86.7

89.6

88.3

90.5

88.7

93.2

93.8

94.0

95.2

95.6

95.7

97.0

95.8

96.0

100.8

99.1

102.6

104.5

104.9

+23.60/o

Deaths per 100,000 population

155.0 181.0 86.1 171.6

151.1 194.9 83.3 168.8

159.1 178.8 82.0 165.9

158.1 191.3 81.8 163.7

158.4 179.9 83.7 164.2

158.4 202.8 83.9 162.5

169.1 200.6 81.9 161.4

162.7 209.2 81.6 159.6

160.2 205.4 81.2 155.2

160.9 214.6 79.8 159.4

164.0 205.6 79.6 159.6

165.3 215.8 79.6 157.9

159.0 242.8 81.8 153.4

162.3 224.1 80.1 155.8

170.6 215.0 80.5 152.2

172.5 242.5 80.1 150.0

175.4 227.6 81.2 151.2

172.2 237.1 79.5 152.5

177.7 229.5 79.4 149.7

181.8 245.8 77.4 153.3

184.8 244.4 81.0 157.4

183.8 236.6 78.0 151.5

194.2 235.2 80.7 150.3

188.5 252.3 78.5 159.3

197.4 267.6 79.9 156.9

200.1 241.9 77.0 158.9

207.5 260.7 79.8 159.0

202.8 273.9 77.6 162.5

214.3 282.1 80.4 167.1

+38.20/o +55.8% -6.6% –2.60/o

240.0

230.8

231.0

241.0

240.9

245.9

227.4

243.5

250.2

231.1

232.6

235.8

233.9

242.6

230.0

227.0

244.0

223.3

235.3

229.8

224.8

224.1

229.7

214.2

224.9

211.6

229.6

221.8

228.5

–4.80/6

SOURCE:U.S. DHHS, NCHS, 1982(83)
392 ● Technology and Aging in America

Figure A-8.-Cancer Incidence and Deaths, by Site and by Sex: United States, 1983 (percent distribution)

Excluding non-melanoma sk cancer and carcinoma in situ

SOURCE” American Cancer Society, 1983 (4).

rate has almost doubled (table A-23). The reason for

this age-specific upturn is unclear, but the trend could

become increasingly important if, as projected, the

over-85 group grows proportionally larger in the

future.

Mortality due to accidents of all kinds is ranked

eighth among those over 65, but fell substantially from

1950 to 1980 with a smaller drop in the “motor vehicle accidents” category. Among older women, mortality from accidents was higher only in the 85 and over

group. Nephritis, the sixth leading cause of death

among the general population in 1900, now ranks

ninth among the elderly. The percent drop shown in

table A-23 is probably not reliable, however, because

the statistical description of the disease has changed.

Morbidity

TRENDS IN CHRONIC CONDITIONS

CAUSING DISABILITY

The prevalence of chronic disease is expected to increase as the population ages (18; see chs. 2 and 3).

Effective prevention and treatment of acute illness at

earlier ages have been key factors in helping people

to live longer. People who would once have died of

tuberculosis or other infectious diseases in their twen -

ties, for example, now live to develop chronic illnesses

whose risk and prevalence tend to rise with age. Advancing age also brings increased risk of certain acute

medical episodes (e.g., stroke, heart attack, and pneumonia) that may also add to the burden of morbidity

among the elderly through their deleterious aftereffects (e.g., dementia, paralysis, chronic heart disease,

and chronic obstructive lung disease).

Chronic disease is responsible for more than 80 percent of all disability (69) and usurps 80 percent of all

health care resources in the United States (13). An estimated 86 percent, or six of every seven, elderly people have one or more chronic conditions, compared

to less than 50 percent of the general population

(21,44,51). Most significantly, the proportion of those

with chronic conditions who suffer major disability

is much higher among the elderly: only 4 percent of

the general population afflicted with chronic illness

reported limitation in a major activity (i.e., working,

keeping house, or engaging in educational activities)

compared to 18 percent in the over-65 group. About

47 percent of community dwelling elderly exhibit

some degree of activity limitation due to chronic conditions (see ch. 2). All of the chronic conditions discussed in this appendix are relatively more prevalent

among the elderly and can cause significant functional
App. A—Morbidity and Mortality Data • 393

Table A“19.—Death Rates Among Females Aged 65 and Over for Cancer of Breast,

by Age: United States, 1950.78

85 years

Year 65-74 years 75-84 years and over

1950 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1951 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1952 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1953 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1954 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1955 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1956 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1957 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1958 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1959 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1960 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1961 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1962 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1963 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1964 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1965 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1966 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1967 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1968 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1969 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1970 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1971 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1972 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1973 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1974 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1975 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1976 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1977 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1978 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Percent chanGe, 1950-78 . . . . . . . . . . . . . . . . . . . . .

Deaths per 100,000 females

95.0 139.8 195.5

91.1 143.6 196.7

91.2 133.9 184.8

93.6 140.5 198.8

93.2 136.4 193.9

92.8 141.3 198.2

93.6 136.3 199.1

93.0 136.0 199.8

90.4 129.5 182.8

89.2 125.9 191.3

90.0 129.9 191.9

90.3 130.6 194.9

90.5 125.5 188.2

90.1 119.2 183.3

89.3 120.3 188.4

90.2 126.8 181.4

90.2 122.7 177.3

90.9 122.6 181.7

94.3 124.1 179.4

93.0 120.1 170.2

93.8 127.4 165.6

92.9 125.2 170.4

98.1 125.4 169.9

101.1 128.1 169.4

97.5 130.3 168.9

97.0 130.7 160.0

98.9 130.5 163.8

102.2 135.3 169.4

98.9 133.1 157.2

+4.1% –4.80/0 –19.60/o “ ,

SOURCE:US. DHHS, NCHS,1982(63)

Table A-20b.—Proportions of Cancer Deaths Attributed to Various Factors

Percentage of all

cancer deaths

Text Rangeof

section Best acceptable

number Factor or class of factors estimate estimates

5.1 Tobacco 30 25-40

5.2 Alcohol 2-4

5.3 Diet 35 10-70

5.4 Food additives <1

5.5 Reproductive and sexual behavior 7 1-13

5.6 Occupation 4 2-8

5.7 Pollution 2 <1- 5

5.8 Industrial products <1 <l– 2

5.9 Medicines and medical procedures 0.5-3

5.10 Geophysical factors : 2-4

5.11 Infection 107 l_?

5.12 Unknown 9 ?

a Allowing fora possibly protective effect of antioxidants and other Preservities

SOURCE: Doll and Peto,1961 (14)
394 ● Technology and Aging in America

Table A.20a.—Cigarette Smoking Status of Persons Aged 20 and Over, by Sex, Race, and Age:

United States, 1965, 1976, and 1980

Smoking status

Current smoker a Former smoker

Sex, race, and age 1965 1976 1980b

1965 1976 1980 b

MALE

Total C, d

All ages, 20 years and over . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

20-24 years. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

25-34 years.... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

35-44 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

45-64 years.... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

65 years and over . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

White:

All ages, 20 years and over . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

20-24 years.... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

25-34 years.... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

35-44 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

45-64 years.... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

65 years and over . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Black:

All ages, 20 years and over . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

20-24 years.... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

25-34 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

35-44 years. <... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

45-64 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

65 years and over . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

FEMALE

TotalC,d

All ages, 20 years and over . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

20-24 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

25-34 years.... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

35-44 years.... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

45-64 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

65 years and over . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

White:

All ages, 20 years And over.... . . . . . . . . . . . . . . . . . . . . . . . . . .

20-24 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

25-34 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

35-44 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

45-64 years.... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

65 years and over . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Black:

All ages, 20 years and over . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

20-24 years.... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

25-34 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

35-44 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

45-64 years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

65vears and over . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

52.4%

59.2

60.7

58.2

51.9

28.5

51.5

58.1

60.1

57.3

51.3

27.7

60.8

67.4

68.4

67.3

57.9

36.4

34.1

41.9

43.7

43.7

32.0

9.6

34.2

41.9

43.4

43.9

32.7

9.8

34.4

44.2

47.8

42.8

25.7

7.1

41.9%

45.9

48.5

47.6

41.3

23.0

41.2

45.3

47.7

46.8

40.6

22.8

50.5

52.8

59.4

58.8

49.7

26.4

32.0

34.2

37.5

38.2

34.8

12.8

31.8

34.4

37.1

38.1

34.7

13.2

35.1

34.9

42.5

41.3

38.1

9.2

Percent of persons

38.3%

39.7

43.1

42.6

40.8

17.9

37.4

39.0

42.0

42.4

40.0

16.6

45.6

45.5

52.0

44.2

48.8

27.9

29.4

32.7

31.6

34.9

30.8

16.8

29.5

33.3

31.6

35.6

30.6

17.4

30.8

32.3

34.2

36.5

34.3

20.5%

9.0

14.7

20.6

24.1

28.1

21.4

9.6

15.5

21.5

25.1

28.7

12.1

3.8

6.7

12.3

15.3

21.5

8.2

7.3

9.9

9.6

8.6

4.5

8.5

8.0

10.3

9.9

8.8

4.5

6.0

2.5

6.7

7.0

6.6

28.9%

12.2

18.3

27.3

37.1

44.4

30.0

13.3

18.9

28.9

38.1

45.6

19.3

4.1

11.8

13.8

28.6

33.0

13.8

10.4

12.9

15.8

15.9

11.7

14.4

11.4

13.7

17.0

16.4

11.5

9.9

5.0

8.9

9.6

11.9

13.3

29.3%

12.1

20.6

27.6

36.9

47.4

30.9

12.2

21.9

28.8

38.4

50.1

19.1

10.6

11.9

21.2

26.3

26.6

15.5

11.0

14.4

18.9

17.1

14.2

16.0

12.5

14.7

20.2

17.4

14.3

11.2

2.2

11.6

12.5

14.1

14.1

–, 9.4 4.5

a A current smoker is a person Who has Srlloked at least 100 cigarettes and who now smokes; Includes occasional smokers

bBasedon data for thelast6 months of 1980.

cBa~eof percent excludes persons with unknown smoking status.

dlncludesafl other races not shown St3PWitdY.

NOTE: Data are based on household interviews ofa sampleof the civilian noninstitutionalized population.

SOURCE:U.S. DHHS, NCHS,1982(65)
App. A—Morbidity and Mortality Data ● 395

Table A-22.—Mortality Sex Ratiosa Among Persons Aged 65 and Over

for Cerebrovascular Diseases, by Age: United States, 1950-78

85 years

Year 65-74 years 75-84 years and over

1950 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1951 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1952 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1953 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1954 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1955 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1956 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1957 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1958 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1959 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1960 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1961 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1962 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1963 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1964 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1965 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1966 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1967 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1968 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1969 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1970 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1971 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1972 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1973 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1974 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1975 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1976 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1977 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1978 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1.13

1.16

1.15

1.16

1.19

1.20

1.21

1.22

1.24

1.24

1.28

1.26

1.28

1.29

1.29

1.33

1.32

1.36

1.37

1.37

1.35

1.40

1.41

1.41

1.41

1.41

1.41

1.40

1.39

Ratio

1.06

1.04

1.07

1.06

1.07

1.07

1.07

1.08

1.07

1.07

1.08

1.09

1.10

1.10

1.12

1.12

1.13

1.15

1.14

1.15

1.15

1.18

1.17

1.15

1.15

1.16

1.14

1.16

1.14

1.03

0.96

0.95

0.93

0.91

0.95

0.94

0.95

0.93

0.96

0.98

0.98

0.98

0.99

0.99

0.99

0.98

1.00

0.99

0.98

0.99

0.99

0.99

0.97

0.99

1.00

0.99

0.99

0.98

a RatiO of male death rate to female death ‘ate

SOURCE:U.S. DHHS, NCHS, 1982(83)

disability (the types and degree of disability inflicted

by specific chronic conditions arediscussed inch.7)

The proportion of people with multiple diseases rises

rapidly with age. Surveys of the noninstitutionalized

elderly report an average of three chronic conditions

per person (51,71)0ther estimates areas high as five

per person, doubling for institutionalized elderly, and

rising to more than a dozen in the veryold (6). Table

A-24 lists the problems commonly coexisting in the

elderly.

This frequent multiplicity of disorders combines

With and exacerbates the tendency of diseases topre-

.

sent different symptoms in the elderly than in younger

people, rendering diagnosis difficult. The classic symptoms are often replaced by one or more nonspecific

problems that may be wrongly attributed to ’’aging”

in general (7; table A-25). This diagnostic difficulty has

implications for the accuracy of survey data and, most

importantly, for health care delivery. Improved detection, diagnosis, and statistical reporting of certain conditions has led to greater awareness of the multiplicity

of chronic diseases among the elderly.

Unfortunately, most of the trend analyses of prevalencein this appendix are limited to the period of the

eighth revision of the ICD (1968-78) since there are

no comparability ratios for chronic conditions. ln addition, NCHS data began to be collected annually only

in 1978, are not subdivided into age and sex groups

for the elderly, and represent only the civilian, noninstitutionalized population. Sporadic reports focusing on one of the six categories of conditions—circulatory, respiratory, digestive, skin and musculoskeletal,

other chronic conditions, and selected impairmentsare used where possible. Because the prevalence of

most of these conditions is higher among the institutionalized elderly, who are not represented here, and

since methodological studies show that chronic conditions are generally underreported in interview

surveys (especially those with stigma attached), the

given rates are very likely to be underestimates.
396 . Technology and Aging in America

Figure A-lO.— Death Rates Among Persons Aged 65 and Over for Cerebrovascular Diseases, by Sex and Age:

United States, 1950.78

NOTES: Death rates for the group aged 65 and over in 1970 are based on population estimates revised by the US. Bureau of the Censos to correct for overestimates

of the group aged 100 and over ICD codes for 1950-67 are 330-334, and ICDA codes for 1988-78 are 430438.

SOURCE: U S. DHHS, NCHS, 1982 (83)
App. A—Morbidity and Mortality Data ● 397

Table A-21 .—Death Rates Among Persons Aged 65 and Over for Cerebrovascular Diseases, by Sex and Age:

United States, 1950-78

Male Female

65-74 75-84 85 years 65-74 75-84 85 years

Year years years and over years years and over

Deaths per 100,000 population

1950 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1951 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1952 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1953 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1954 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1955 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1956 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1957 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1958 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1959 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1960 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1961 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1962 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1963 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1964 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1965 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1966 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1967 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1968 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1969 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1970 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1971 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1972 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1973 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1974 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1975 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1976 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1977 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1978 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Percent change. 1950-78 . . . . . . . . . . . . . . . . . . . . .

589.6

593.7

572.8

573.2

550.9

554.7

548.1

561.8

552.4

534.1

530.7

503.6

502.4

500.4

481.4

480.9

482.2

468.1

483.1

465.7

449.5

438.9

439.3

425.0

400.4

363.1

334.7

310.4

290.0

-50.80/o

1,543.6

1,546.0

1,559.1

1,552.7

1,514.9

1,553.1

1,547.5

1,594.1

1,601.0

1,566.7

1,555.9

1,495.9

1,493.2

1,497.1

1,448.8

1,439,0

1,445.1

1,398.4

1,418.2

1,373.9

1,361.6

1,358.9

1,356.2

1,338.5

1,277.2

1,176.7

1,098.9

1,060.0

984.5

-36.2%

3,048.6

2,925.8

2,965.9

2,918.3

2,887.2

3,185.5

3,257.8

3,474.5

3,529.1

3,558.0

3,643.1

3,659.2

3,771.4

3,803.2

3,638.5

3,693.7

3,663.8

3,548.6

3,591.6

3,396.1

3,211.2

3,167.5

3,188.6

3,133.8

2,969.5

2,650.9

2,574.4

2,402.4

2,244.2

-26.4%

522.1 1,462.2

511.1 1,490.8

499.9 1,451.7

493.1 1,461.6

461.2 1,414,6

462.1 1,452.8

452.4 1,443.6

460.5 1,470.9

444.4 1,490.7

429.7 1,462.9

415.7 1,441.1

400.0 1,375.9

393.3 1,359.6

389.3 1,365.2

372.5 1,295.5

362.6 1,284.3

364.3 1,281.7

343.7 1,219.0

351.6 1,248.8

339.8 1,190.1

333.3 1,183.1

313.5 1,151.1

312.1 1,162.3

301.3 1,167.6

283.7 1,114.0

256.9 1,014.5

238.1 962.1

221.0 916.5

207.9 865.5

–60.2% –40.8%

2,949.4

3,047.8

3,127.6

3,147.3

3,179.1

3,365.0

2,480.9

3,655.3

3,775.4

3,695.0

3,704.4

3,746.8

3,844.2

3,824.4

3,673.8

3,731.4

3,740.4

3,550.4

3,618.3

3,450.0

3,247.0

3,204.0

3,212.4

3,230.1

3,013.0

2,656.6

2,592.6

2,435.6

2,298.5

“ , -22.10/0

SOURCE:US. DHHS, NCHS,1982(63)
—

398 • Technology and Aging in America

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App. A—Morbidity and Mortality Data ● 399

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#00 . Technology and Aging in America

Table A-24.—Most Common Problems Coexisting

in Elderly Individuals

;:

3.

4.

5.

6.

7.

8.

9.

10.

11.

12.

13.

14.

15.

Congestive heart failure

Depression

Dementia syndrome

Chronic renal failure

Angina pectoris

Degenerative joint disease

Gait disturbance

Urinary dysfunction

Constipation

Vascular insufficiency in the legs

Diabetes mellitus

Chronic pain

Sleep disturbance

Multiple drug regimens

Anemia

SOURCE: Besdlne, et al., 1962 (6).

Table A-26 summarizes the general conclusions

drawn concerning which chronic conditions are rising or falling among the elderly, which exhibit gender or race differences in prevalence, and whether

these differences are pronounced.

Degenerative Mental Illness. --Older people represent about one-fifth of all first admissions to psychiatric hospitals and occupy almost one-fourth of all

psychiatric beds in the Nation (11). Physiological bases

for increasing numbers of mental disorders are emerging, bringing with them hope for treatment and prevention. About 50 to 60 percent of the institutionalized

elderly are thought to suffer from organic mental disorders (11). The distinction between organic (physiological) and inorganic (emotional) mental illness remains blurred, however. The interaction of mental

and physical disorders also warrants further study;

emotional problems and stress can precipitate physical illness and, conversely, chronic illness can cause

psychological problems such as depression (11,20).

Two major types of mental illness in the elderly are

depression and senile dementia. There are many other

illnesses that are significant: almost one out of every

three elderly people suffers from a sleep disorder, for

example (36). Although estimates for depression range

from 10 to 30 percent of those over 65, these figures

are suspected to be low because of difficulty in diagnosis (29). Isolation, chronic disease, and terminal illness can all contribute to depression.

Awareness of the prevalence and impact of dementia among our elderly population has only recently

taken root (25)38). Some even speculate that it is a major cause of death (26). Dementia, or the progressive

deterioration of cognitive function (usually accompanied by changes in emotions and personality), is a clinical syndrome whose underlying causes are varied and

Table A-25.—Disorders Likely to Present

Nonspecifically in Old Age

1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

Depression

Drug intoxication

Myxedema

Alcoholism

Myocardial infarction

Pulmonary embolism

Pneumonia

Cancer

Surgical abdomen

Thyrotoxicosis, masked or apathetic

SOURCE: Besdine, Levkoff, Wetle, 1963 (7)

ill-defined. The prevalence of severe dementia among

the elderly may be approximated at 1 to 6 percent,

with that of milder cases ranging from 3 to 15 percent (32). If an average prevalence of 4.1 percent for

severe dementia (32) is applied to the 1980 elderly

population, it amounts to over 1 million persons. These

figures represent a significant public health problem,

even when excluding the milder cases that are harder

to diagnose.

The prevalence of dementia increases markedly with

age, showing a four- to seven-fold increase between

persons aged 70-79 and those over 80; cumulative morbidity risk of severe dementia has been estimated to

be 20 percent by age 80 (32). Alzheimer disease is the

most prevalent form of dementia, accounting for an

estimated 50 to 75 percent of dementia cases (see ch.

3). The other types are due to arteriosclerotic brain disease and other specific organic brain disorders. The

age-specific prevalence for Alzheimer disease, which

is estimated to be 17 percent at age 80, rises almost

twofold to 30 percent by age 85 (45).

The prevalence of major mental disorders, particularly depression and senile dementia whose prevalence are known to rise with age, is likely to increase

as the very old segment of the U.S. population grows

(31). Much research is needed into the causes and risk

factors for these debilitating diseases.

Chronic Skin and Musculoskeletal Conditions.

—The most prevalent and debilitating among chronic

skin and musculoskeletal conditions is arthritis. Arthritis is a type of rheumatism in which the inflammation

and degeneration are confined to the joints, This category includes osteoarthritis in which the articular

(joint) cartilage degenerates. According to 1981 figures,

almost 50 percent of all persons over 65 are afflicted

with arthritis, The rate for women is more than 50

percent higher than that for men, and the rate for

blacks is higher than that for whites (table A-27). During the 1969-76 period, the prevalence of arthritis increased by 13 percent among the elderly.
App. A—Morbidity and Mortality Data . 401

Table A“26.—Differential Prevalence of Chronic Conditions Among Persons

Aged 65 and Over, by Race and Sex: United States, Recent Trends

Chronic conditions Race difference Sex difference

Rising prevalence:

Heart conditions: x

Coronary x

Disorders in heart rhythm x

Unspecified head trouble x x

Hypertensive disease

Poor circulation x

Chronic bronchitis x

Emphysema

Ulcers of stomach and duodenum x x

Hernia abdominal cavity x

Upper gastrointestinal tract disorders x

Arthritis

Bone disease x

ynovitis, bursitis, tenosynovitis x

Visual impairment x x

Hearing impairment : g

Thyroid problems x

Diabetes ~ ~

All anemias ~

Nephritis

Calculus of kidney

Sciatica

~

x

Falling prevalence:

Hypertensive heart disease

Stroke

x

x

Arteriosclerosis x

Varicose veins

Sinusitis

Frequent constipation x

Gallbladder conditions x

Enteritis and ulcerative colitis x

Gastritis and duodenitis

Rheumatism (non-articular) x x

Corns and callosities

Severe visual impairment x

Paralysis (complete or partial) x x

Iron deficiency anemia

Disorders of urinary system

Neuralgia and neuritis

Prostate disease

a A bold, underscored "X” indicates strong differences; other differences are less notable.

SOURCE Summarized from data in tables 27-32,

Nonarticular rheumatism (inflammation or degeneration of connective tissue in the body, including

muscles and tendons) was less common and, in contrast to arthritis, was more prevalent in elderly men

than in women. Rheumatism decreased for all subcategories from 1969 to 1976, although the drop was

much less for blacks than for whites (table A-27). Bursitis and other inflammatory diseases of the membranes and other tissues relating to the joints were

also fairly prevalent (more so in women) and increased

over the period.

Diseases of the bone, including osteomyelitis (inflammation), are generally more prevalent in elderly women than men. The percent increase in prevalence from

1969 to 1976 was more than three times higher in

women than in men. Although osteoporosis (loss of

bone density leading to brittleness and increased risk

of fracture) is supposed to be included in these figures,

it is likely that the disease is not well represented. Because osteoporosis is difficult to diagnose, there are

no definitive prevalence figures on this costly, debilitating disease (see ch. 3). One case study, however,

reported high prevalence of X-ray diagnosed osteoporosis increasing with age among elderly women: 74 percent of those aged 65 to 69, 84 percent of those aged

70 to 74, and 89 percent of those over 75 (23). Much

research is needed to develop tools for early diagnosis and to establish the true dimensions of the problem.
402 ● Technology and Aging in America

Table A.27a.—Prevalence of Chronic Skin and Musculoskeletal Conditions, by Age, Sex, and Race:

United States, 1969=76a (number per 1,000)

Total Male Female White Nonwhite

All All All All

Condition

All

ages 65+ ages 65+ ages 65+ ages 65+ ages 65+

1969:

Arthritis . . . . . . . . . . . . . . . . . . .

Rheumatism . . . . . . . . . . . . . . .

Bone diseases . . . . . . . . . . . . . .

Synovitis bursitis

tenosynovitis . . . . . . . . . . . . .

Corns and callosities . . . . . . . .

Skin neoplasmse . . . . . . . . . . . .

1976:

Arthritis . . . . . . . . . . . . . . . . . . .

Rheumatism . . . . . . . . . . . . . . .

Bone diseases . . . . . . . . . . . . . .

Synovitis bursitis

tenosynovitis . . . . . . . . . . . . .

Corns and callosities . . . . . . . .

Skin neoplasms . . . . . . . . . . . . .

Percent change in rate,

1969-76, age 65+:

Arthritis . . . . . . . . . . . . . . . . . . .

Rheumatism . . . . . . . . . . . . . . .

Bone diseases . . . . . . . . . . . . . .

Synovitis bursitis

tenosynovitis . . . . . . . . . . . . .

Corns and callosities . . . . . . . .

Skin neoplasmse . . . . . . . . . . . .

92.9

6.1

4.5

380.3

23.2

9.7

64.6

5.7

4.1

15.2

24.7

—

83.4

3.5

7.0

16.5

17.6

5.4

—

—

—

—

—

—

287.0

28.0

8.0

119.2

6.5

4.9

450.1

19.6

11.0

95.1 376.3

6.3 22.1

5.0 10.3

17.8 28.3

38.8 105.6

— —

431.9

: : ; 14.3

8.8 19.1

20.7 31.7

25.1 66.1

5.9 18.3

— + 14.8

— -35.3

— + 85.4

— + 12.0

— -37.4

— —

77.2 424.8

5.0 36.0

d

6.9 d

61.0 158.5

— —2.1

1 d 482.8

4.3 32.5

2.8 4.9 d

8.2 17.2

36.0 102.5

1.Od 3.0d

— + 13.6 — -9.7

— d

— d

— -41. 0

— —

16.5

41.5

—

27.7

109.9

—

25.0

65.5

—

17.7

57.1

—

29.6

143.1

—

116.7

4.0

8.0

436.6

16.0

17.8

337.9

18.2

10.7

147.7

4.4

8.9

505.5

14.5

22.7

31.6

86.0

14.8

19.0

26.5

5.2

30.3

69.5

16.8

28.3

45.7

19.6

21.4

34.8

5.0

+ 25.6

-31.0

+ 187.2

+ 17.7

-35.0

+ 33.8

+ 12.3

-26.0

+ 106.4

—

—

—

—

—

—

+ 9.4

-62.3

—

+ 13.2

-30.2

—

+ 6.8

-39.9

—

—

—

—

—

—

—

aBased on household interviews of the civilian, noninstitutionalized population

b Not elsewhere classified.

c Nonarticular unspecified,

d Not statistically reliable.

‘No data available.

SOURCE: U.S. DHHS, NCHS, 1974 (55) and 1978 (59)

Table A-27b.—Prevaience of Chronic Skin and Musculoskeietai Conditions, by Age

and Sex: United States, 1981a (number per 1,000)

Total Male Female

All All All

Condition ages 65+ ages ages

Arthritis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12.1 464.7 87.5 152.3

Rheumatism . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2,8 8.9 2.5 3.2

Bone diseases . . . . . . . . . . . . . . . . . . . . . . . . . . . 11.8 4.8

Synovitis, bursitis tenosynovitis. . . . . . . . . . . . 21.3 35.7 15.9 2:: :

Corns and callosities. . . . . . . . . . . . . . . . . . . . . . 19.1 5.9 12.6 25.1

Skin neoplasms . . . . . . . . . . . . . . . . . . . . . . . . . . 6.0 23.2 6.1 6.0

aBased on household interviews Of the civilian, noninstitutionalized population.

b Not elsewhere classified.

c Nonarticular unspecified.

SOURCE: National Center for Health Statistics, unpublished data.
App. A—Morbidity and Mortality Data ● 403

Although comparative data were not available for

skin neoplasms, it is worth noting that prevalence

among the elderly is more than five times that in the

general population and that the prevalence among

whites is many times that among blacks (table A-27)

due in large part to the relative lack of skin pigment

in whites (4). Corns and callosities (thickenings) of the

skin may seem relatively trivial but wararrant attention

due to their prevalence” and potential to limit mobility,

especially among the very old. These conditions are

more than twice as common in women than men.

Selected Impairments.—There are several gender

and race differences in the prevalence of visual, hearing, paralytic, and nonparalytic orthopedic impairments-all of which are important causes of disability.

Elderly women have higher rates than men for visual

impairments and orthopedic impairments of the back

and lower extremities. Hearing impairments and partial or complete paralysis, by contrast, are more common in elderly men (table A-28), Blacks over 65 exhibit

20 percent higher prevalence of visual impairments,

approaching double the rate among whites for severe

visual impairment s and for paralysis (table A-28).

Whites, however, have 26 to 34 percent higher rates

for hearing impairments than blacks. Hearing impairments and most orthopedic impairments become more

common with advancing age,

From 1971 to 1977 visual impairments in general

tended to rise in prevalence among all elderly groups

Whil0e sevrere visual impairments fell (table A-28). Since

the most common cause of visual impairment is cataracts, this rise may be due to the increased prevalence

of cataracts which, in turn, may be linked to a rise

in diabetes (see section on “Other Selected Chronic

Conditions”), a major risk factor for cataracts. Hearing impairments rose in prevalence in the 65 to 74 age

group but fell in the over-75 group. Paralytic impairments also rose, especially among whites and women.

Orthopedic impairments appeared to fall in most

groups (table A-28).

Chronic Circulatory Conditions.—The most common chronic circulatory conditions among the elderly

are heart conditions (mostly coronary heart disease—

CHD) and hypertensive disease. Striking gender and

race differences can be found in their prevalence:

prevalence of general hypertensive disease is almost

30 percent higher for blacks, whose prevalence of

hypertensive heart disease more than twice that of

whites (table A-29). Stroke prevalence is also 28 percent higher among blacks. Elderly whites, conversely,

have more than twice the prevalence of coronary

heart disease and varicose veins. As for gender differences, the prevalence of both general and cardiac

hypertensive disease are more than 70 percent higher

in elderly women than men (table A-29a). But the prevalence of coronary heart disease is 26 percent higher

in elderly men.

The comparatively higher prevalence of hypertensive disease in elderly women and blacks is surprising. Their death rates from heart disease are lower

for both as compared to men and whites, respectively,

and lower for stroke and hypertensive disease for

women (see previous section on “Mortality”). This

could mean that hypertension is better controlled, not

as severe, or generally not as strong a risk factor for

cardiovascular mortality in womnen and blacks. Also,

the high mortality associated with chronic coronary

heart disease may considerably raise the death rates

of whites and men.

Unfortunately, trends among these subgroups cannot be analyzed because the 1978 data are not subdivided by sex or race. Certain general observations can

be made about the 1972-78 period, however (table A29a): the prevalence of cerebrovascular disease, arteriosclerosis, and varicose veins all fell among the

elderly; the prevalence of all heart conditions except

hypertensive heart disease rose, particularly among

the elderly; coronary heart disease rose the least (1

percent). The available data indicate that the prevalence of general hypertensive disease also rose by

more than 26 percent among the elderly. G

These simultaneous increases in prevalence and decreases in mortality for heart conditions and hypertension among the elderly in the 1970s indicate that: 1)

incidence is increasing; 2) better ongoing treatment

of the chronic condition has reduced its associated

mortality risk; and/or 3) improved acute care is allowing increasing numbers of people to survive crises and

become chronic disease sufferers (see “Conclusion”).

Chronic Respiratory Conditions.–All three of

the chronic respiratory conditions discussed

here-chronic bronchitis, emphysema, and sinusitis–

are markedly more prevalent among the elderly. Emphysema, for example, is more than four times more

common among those over 65 than in the general population. The prevalence of all but sinusitis is higher

in elderly men, especially emphysema, for which the

rate is more than five times that of elderly women

(table A-30). This gender difference is partly due to

the greater number of current and former smokers

among men (table A-20a).

‘Sei er-e Ivsua] impairment is defined by A“CHS as no uspful sight or blindness in both eyes, or ]nabllity to read ordinary newspaper print }vith either

eye men white using correctiy P lenses

Wornparisons of data on both general and cardiac h~pertensi~e d]sease

are limited in accuracy because the diseases are frequentl~’ redefined for

data collection purposes, while the trends ma} be indwati~e, the specific fig.

ures are unreliable
404 . Technology and Aging in America

+

u

rj

u

z:

03

. . . .

. . . .

. . . .

. . . .

. . “ -

. .

. . : 3

. .

. .

. .

. .

. .

- .

. . .

. . -

. .

. . :%

. . .““E2 .
App. A—Morbidity and Mortality Data . 405

Table A“28b.—Prevalence of Selected Impairments, by Age and Sex:

United States, 1981a (number per 1,000)

Total Male Female

All All All

Condition ages 65+ ages ages

Visual impairment. . . . . . . . . . . . . . . . . . . . . . . 40.4 136.6 47.8 33.4

Severe b . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . —

Hearing impairment . . . . . . . . . . . . . . . . . . . . . 82.9 – – 283.6 91.1 75.3

Paralysis (complete/partial). . . . . . . . . . . . . . . 19.6 7.0 4.8

Orthopedic impairments or deformities . . . . 81.8 128.2 86.4 77.6

Back or spine . . . . . . . . . . . . . . . . . . . . , . . . 51.9 73.2 50.4 53.3

Upper extremities . . . . . . . . . . . . . . . . . . . . . 13.2 27.6 15.4 11.0

Lower extremities. . . . . . . . . . . . . . . . . . . . . 23.2 44.5 27.8 19.0

aBa~&j on h~uS*h@d inte~jews of the civilian, noninstitutlonalized population.

bNo data available.

SOURCE: National Center for Health Statistics, unpublished data.

The prevalence of sinusitis dropped slightly from

1970 to 1978, while that of the other two conditions

rose. Emphysema among the elderly jumped more

than 25 percent during this period. The reason for this

rising trend is not clear, but it may be linked to the

increase in mortality due to obstructive lung disease

in some older age groups since 1970 (see “Mortality”

section).

Chronic Digestive Conditions–There is a welldocumented age-related rise in the prevalence of many

digestive disorders (see ch. 4). The most common

chronic digestive condition reported by the elderly is

constipation, followed by abdominal hernias. The 1975

NCHS data reveal certain race and gender differences

(table A-31). Elderly whites exhibit much higher rates

than blacks for abdominal hernias, chronic enteritis,

and ulcerative colitis (inflammations of the intestine

and colon, respectively), and intestinal diverticula (outpocketings of the intestinal wall that are prone to infection). Elderly women report two to three times the

prevalence in men of frequent constipation, gallbladder conditions, intestinal diverticula, and chronic

enteritis and colitis. The rate of abdominal hernias,

however, is almost 30 percent higher among men.

In the period 1968-75, the prevalence rose for ulcers,

abdominal hernias, and particularly for functional and

symptomatic disorders of the upper gastrointestinal

tract (including the stomach). Prevalence fell for all

other conditions, most dramatically for enteritis and

colitis.

Other Selected Chronic Conditions.—This category includes chronic thyroid disorders, anemias, diabetes, neurological disorders, and disorders of the urinary tract. According to 1973 data, diabetes is the most

common ailment of this category among elderly women, while disease of the prostate is the most common

among men.

Both thyroid disorders and anemias are more than

three times more prevalent in elderly wornen than

men (table A-32), Women also report higher prevalence of diabetes (50 percent), urinary disorders (60

percent), and specific neurological disorders: sciatica

(pain along the course of the sciatic nerve from the

lower back into the legs), neuralgia (pain along the

course of one or more nerves), and neuritis (inflammation of a nerve). Calculus of the kidney, by contrast,

was almost twice as prevalent among men.

From 1973 to 1978 the prevalence of diabetes among

the elderly rose by 8 percent. The significance of this

rise, when paired with declining death rates for both

diabetes and heart disease, is discussed in the conclusion. The dramatic changes found in the prevalence

of other conditions—the rises in thyroid problems,

anemias, nephritis and calculus of the kidney, and

drops in iron-deficiency anemia, neuralgia and neuritis, and diseases of the prostate—may be generally

indicative of trends, but are probably exaggerated due

to improved diagnostic and reporting techniques.

Moreover, the figures on irond-eficiency anemia and

nephritis have been statistically unreliable (table A-32).

An important urinary disorder that is not covered

in these data is urinary incontinence, the inabilitv to

control excretion of urine. Incontinence is most common among the elderly and affects between 10 and

20 percent of community dwelling elderly to some degree and nearly 50 percent of those in nursing homes

(up to 700,000 persons) –about 50 percent of the latter also have episodes of fecal incontinence (16,34).

These figures are probably underestimates because

they reflect only those afflicted at the time and not

those with a history of incontinence (72). The medical and psychosocial impact of incontinence on the Nation’s growing elderly population is discussed in a case

study accompanying this report.
406 . Technology and Aging in America

Table A-29a.—Prevalence of Chronic Circulatory Conditions, by Age, Sex, and Race:

United States, 1972= 78a

(number per 1,000)

Total Male Female White Nonwhite

All All All

Condition

All All

ages 65+ ages 65+ ages 65+ ages a

65+ ages 65+

1972:

Heart conditions . . . . . . . . . . . . 50.4

Coronary . . . . . . . . . . . . . . . . . 16.2

Unspecified disorders:

Heart rhythm b 

. . . . . . . . . . 12.0

Heart trouble b . . . . . . . . . . 5.8

Hypertensive disease b . . . 10.5

Hypertensive disease d . . . . . . . 60.1

Cerebrovascular disease . . . . . 7.5

Arteriosclerosis d 

. . . . . . . . . . . .

Varicose veins d . . . . . . . . . . . . . 36.8

Poor circulation . . . . . . . . . . . . 4.6

1978:

Heart conditions . . . . . . . . . . . . 62.9

Coronary . . . . . . . . . . . . . . . . . 18.4

Unspecified disorders:

Heart rhythm b . . . . . . . . . . 14.7

Heart trouble b . . . . . . . . . . 8.5

Hypertensive disease b . . . 13.0

Hypertensive disease d . . . . . . . 87.8

Cerebrovascular disease . . . . . 80.0

Arteriosclerosis . . . . . . . . . . . .

Varicose veins d . . . . . . . . . . . . . 3 . 4

Poor circulation . . . . . . . . . . . . 5.3

Percentage change in

rate, 1972-78:

Heart conditions . . . . . . . . . . . . + 24.8

Coronary . . . . . . . . . . . . . . . . . + 13.6

Unspecified disorders:

Heart rhythm b . . . . . . . . . . + 22.5

Heart trouble b . . . . . . . . . . + 46.5

Hypertensive disease b . . . + 23.8

Hypertensive disease d . . . . . . . + 46.1

Cerebrovascular disease . . . . . + 6.7

Arteriosclerosis . . . . . . . . . . . . 0.0

Varicose veins d . . . . . . . . . . . . . -18.5

Poor circulation . . . . . . . . . . . . + 15.3

198.7

84.0

22.0

28.1

52.8

199.4

48.2

25.7

93.9

24.1

214.6

84.8

23.8

45.5

45.3

251.6

44.9

25.1

75.4

25.1

+ 8.4

+ 1.0

+ 8.2

+61 .9

-14.2

+ 26.2

-6.8

-2.3

-19.7

+ 4.2

48.0

19.0

10.0

6.9

7.4

46.4

7.6

3.5

14,5

3.4

60.8

20.9

12.6

10.5

10,4

72,1

9.4

3.4

12.4

4.6

+ 26.7

+ 10.0

+ 26.0

+ 52.2

+ 40.5

+ 55.4

+ 23.7

-2.9

-14.5

+ 35.3

199.3

95.7

21.0

36.0

36.6

141.2

54.0

30.0

52.2

19.8

—

—

—

—

—

—

—

—

—

—

—

—

—

—

—

—

—

—

—

—

52.7

13.6

13.7

4.8

13.3

72.9

7.4

57.6

5.7

64.7

16.0

16.6

6.6

15.4

102.4

6.7

3.4

46.4

6.0

+ 22.8

+ 17.6

+21 .2

+ 37.5

+ 15.8

+ 40.5

-9.5

0.0

-19.4

+ 5.3

198.3

75.7

22.7

22.3

64.4

240.9

44.0

22.7

123.8

27.2

—

—

—

—

—

—

—

—

—

—

—

—

—

—

—

—

—

—

—

—

51.7

17.8

12.4

5.7

9.6

58.3

; : ;

39.4

4.7

—

—

—

—

—

—

—

—

—

—

—

—

—

—

—

—

—

—

—

—

200.0

89.7

23.0

27.0

47.7

194.6

47.0

27.2

99.6

24.7

—

—

—

—

—

—

—

—

—

—

—

—

—

—

—

—

—

—

—

—

41.5

5.1

8.8

6.4

17.2

72.9

9.1

c

18.7

3.6

—

—

—

—

—

—

—

—

—

—

—

—

—

—

—

—

—

—

—

—

185.2

24.6

38.9

105.8

248.7

60.0

34.3

c

—

—

—

—

—

—

—

—

—

—

—

—

—

—

—

—

—

—

—

—

aBased on housebold interviews of the civilian, non institutionalized population.

bNot otherwise specified.

cNot statistically reliable.

d No t elsewhere classified.

SOURCE: U.S. DHHS, NCHS, 1974 (56) and unpublished data
App. A—Morbidity and Mortality Data ● 407

Table A-29 b.—Prevalence of Chronic Circulatory Conditions, by Age and Sex:

United States, 1981a (number per 1,000)

Total —Male Female—

All All All

Condition ages 65+ ages ages

Heart conditions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76.4

Coronary. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25.2

Unspecified disorders:

Heart rhythm b . . . . . . . . . . . . . . . . . . . . . . . . . . . 27.5

Heart trouble b . . . . . . . . . . . . . . . . . . . . . . . . . . . 11.5

Hypertensive disease b . . . . . . . . . . . . . . . . . . . . 0.7

Hypertensive disease c. . . . . . . . . . . . . . . . . . . . . . . . 113.4

Cerebrovascular disease . . . . . . . . . . . . . . . . . . . . . . 8.3

Arteriosclerosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15.1

Varicose veins C . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27.2

Poor circulation b. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3.1

277.0

117.7

80.7

29.1

81.6

21.6

60.2

63.5

3.1

378.6

45.4

97.0

83.2

18.1

20.9

10.2

0.3

100.4

8.7

15.8

10.4

2.5

33.7

12.7

1.0

125.5

8.0

14.5

43.0

3.7

a Based on household interviews of the civilian, noninstitutionalized Population.

b Not otherwise specified.

c Not elsewhere classified,

SOURCE National Center for Health Statistics, unpublished data

Table A.30a.— Prevalence of Chronic Respiratory Conditions, by Age, Sex, and Race:

United States, 1970-78a (number per 1,000)

Total Male Female White Nonwhite

All All All All All

Condition ages 65+ ages 65+ ages 65+ ages 65+ ages 65+

1970:

Chronic bronchitis . . . . . . . . . .

Emphysema . . . . . . . . . . . . . . . .

Sinusitis . . . . . . . . . . . . . . . . . . .

1978:

Chronic bronchitis . . . . . . . . . .

Emphysema . . . . . . . . . . . . . . . .

Sinusitis . . . . . . . . . . . . . . . . . . .

34.4

7.4

110.0

42.5 20.0 b

34.3 b b

141.1 53.2 79.2

32.7

6.6

103.0

41.2

31.7

136.1

31.2

10.3

92.6

47.3

58.8

121.5

34.0

3.1

112.6

36.6

11.6

147.1

33.0

9.7

105.4

47.4

39.8

129.9

29.0

14.4

96.3

36.8

5.2

114.0

—

—

—

—

—

—

—

—

—

— — —

— — —

— — —

Percentage change in

rate 1970–78:

Chronic bronchitis . . . . . . . . . .

Emphysema . . . . . . . . . . . . . . . .

Sinusitis . . . . . . . . . . . . . . . . . . .

+0.9

+47.0

+2.3

+15.0

+25.5

-4.5

+7.0

+39.8

+4.0

+8.2

+67.7

+1.2

—

—

—

—

—

—

—

—

—

— — —

— — —

— — —

aBased on household intemlews of the civilian, noninstitutionalized population

b No t statistically reliable.

SOURCE:US. DHHS, NCHS, 1973(53)

Table A-30b.—Prevalence of Chronic Respiratory Conditions, by Age and Sex:

United States, 1981 (number per l,000)a

Total Male Female

All All All

Condition ages 65+ ages ages

Chronic bronchitis . . . . . . . . . . . . . . . . . . . . . . 35.3 46.1 31.7 38.7

Emphysema . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9.3 42.9 14.3 4.6

Sinusitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 137.9 183.6 121.0 153.7

a BaSed on household interviews of the civilian, noninstitutionalized population.

SOURCE National Center for Health Statistics, unpublished data
408 ● Technology and Aging in America

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App. A—Morbidity and Mortality Data ● 409

Table A-31 b.—Prevalence of Chronic Digestive Conditions, by Age and Sex:

United States, 1981a (number per 1,000)

Total —Male Female—

All All All

Condition ages 65+ ages ages

Ulcer of stomach/duodenum . . . . . . . . . . . . . . . . . . . . ... , . . 17.5 28.8 17.7 17.2

Frequent constipation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16.0 52.2 8.5 23.0

Hernias of abdominal cavity . . . . . . . . . . . . . . . . . . . . . . . . . . 16.4 49.1 17.6 15.4

Functionallsymptomatic upper GI tract disorders . . . . . . . . 17.4 39.9 17.5 17.2

Gall bladder conditions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6.8 18.5 2.5 10.7

Gastritislduodenitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7.2 10.7 5.2 9.1

Diverticula of intestine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6.8 38.4 3.6 9.7

Chronic enteritis)colitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9.5 16.5 6.6 12.3

aBased on household interviews of the civilian, noninstitutionalized population.

SOURCE: National Center for Health Statistics, unpublished data.

Table A“32.—Prevaience of Other Selected Chronic Conditions, by Age, Sex, and Race:

United States, 1973”78a (number per 1,000)

Total Male Female White Nonwhite

All All All

Condition

All All

ages 65+ ages 65+ ages 65+ ages 65+ ages 65+

1973:

Thyroid . . . . . . . . . . . . . . . . . . . . . . . .

Diabetes. . . . . . . . . . . . . . . . . . . . . . .

All anemias . . . . . . . . . . . . . . . . . . . .

Iron deficiency . . . . . . . . . . . . . . .

Sciatica . . . . . . . . . . . . . . . . . . . . . . .

Neuralgia/neuritis. . . . . . . . . . . . . . .

Urinary system disease. . . . . . . . . .

Nephritis . . . . . . . . . . . . . . . . . . . .

Calculus kidney . . . . . . . . . . . . . .

Prostate disease. . . . . . . . . . . . . . . .

1978:

Thyroid . . . . . . . . . . . . . . . . . . . . . . . .

Diabetes. . . . . . . . . . . . . . . . . . . . . . .

All anemias . . . . . . . . . . . . . . . . . . . .

Iron deficiency . . . . . . . . . . . . . . .

Sciatica . . . . . . . . . . . . . . . . . . . . . . .

Neuralgia/neuritis. . . . . . . . . . . . . . .

Urinary system disease. . . . . . . . . .

Nephritis . . . . . . . . . . . . . . . . . . . .

Calculus kidney . . . . . . . . . . . . . .

Prostate disease. . . . . . . . . . . . . . . .

Percentage change in rate,

1973-78:

Thryoid . . . . . . . . . . . . . . . . . . . . . . . .

Diabetes. . . . . . . . . . . . . . . . . . . . . . .

Ail anemias . . . . . . . . . . . . . . . . . . . .

Iron deficiency . . . . . . . . . . . . . . .

Sciatica . . . . . . . . . . . . . . . . . . . . . . .

Neuralgia/neuritis. . . . . . . . . . . . . . .

Urinary system disease. . . . . . . . . .

Nephritis . . . . . . . . . . . . . . . . . . . .

Calculus kidney . . . . . . . . . . . . . .

Prostrate disease . . . . . . . . . . . . . . .

13.9

20.4

14.5

3.2

4.3

1.9

28.0

0.7

3.3

—

13.6

24.3

13.0

2.0

4,5

2.5

25.9

0.9

4.0

—

-2.2

+19.1

-10.3

-37.5

+23.2

-31.6

-7.5

+28.6

+21.2

—

19.7

78.5

20.9

2.6

11.9

9.0

60.7

1.0

7.0

—

25.6

84.8

27.0

l,5b

13.0

6.1

56.6

l,7b

11.0

—

+29.9

+8.0

+29.2

-42.3b

+9.2

-32.2

-6.8

3.7 7.3

16.3 60.3

4.6 8.0

1.0 b

3.4 9.8

1.1 6.7

14.1 44.8

0.5 b

3.9 9.9

13.1 66.8

2.2 –

20.1 –

4.8 —

O.lb –

2.5 –

1.5 –

14.6 —

1.1 –

4.7 –

13.2 28.7

-40.5 –

+23.3 —

+4.2 —

—b —

-26.5 –

-36.4 –

+3.5 —

+i’ O

b

+lzo.o —

+57.1 +20.5 —

— -0.8 -57.0

23.4

24.1

23.7

5.2

5.1

2.8

41.0

0.9

2.7

—

24.1

28.2

20.7

3.8

6.4

3.5

36.4

0.8

3.4

—

+3.0

+17.0

-12.7

-26.9

+25.5

-25.0

-11.2

-11.1

+25.9

—

28.4

91.3

30.2

3.9

13.4

10.7

72.0

1.5

5.0

—

—

—

—

—

—

—

—

—

—

—

—

—

—

—

—

—

—

—

—

—

14.9

19.9

13.7

3.1

4.9

2.1

28.3

0.7

3.4

3.6

—

—

—

—

—

—

—

—

—

—

—

—

—

—

—

—

—

—

.

—

20.2

75.9

22.3

2.9

12.7

9.5

59.1

1.1

6.4

68.3

—

—

—

—

—

—

—

—

—

—

—

—

—

—

—

—

—

—

—

—

7.1

23.9

20.4

3.5

b

b

26.4

b

2.5

b

—

—

—

—

—

—

—

—

—

—

—

—

—

—

—

—

—

—

—

—

b

104.5

b

b

b

b

77.7

b

b

51.6

—

—

—

—

—

—

—

—

—

—

—

—

—

—

—

—

—

—

—

—

aBased on household interviews of the civilian, noninstitutionalized population.

bNot statistica~y re~able.

SOURCE:U.S. DHHS, NCHS,1977(58)
410 ● Technology and Aging in America

Conclusions

Older Americans are very heterogeneous according to age, sex, and race-specific prevalence and

death rates for many conditions. Some general conclusions can be drawn from available data on the

health and functional status of the elderly, recent

trends in their mortality and morbidity, and the crossanalyses of these trends. These, in turn, yield further

implications for our health care system:

● Mortality:

— The overall death rate of elderly women Was

consistently lower than that of elderly men and

decreased almost twice as much from 1940 to

1978.

— Death rates for both heart disease and stroke

declined most rapidly among the elderly in the

1968-78 period and were generally lower for

women.

— Cancer and chronic obstructive pulmonary disease are the only major causes of death for

which rates have risen recently among the

elderly. The rise in cancer is mostly due to a

dramatic rise in lung cancer among men; rates

among women have also risen since the mid1960s, probably due to the increased proportion of women who smoke.

— Mortality from diabetes mellitus has fallen since

1940 except among those over 85; in this group

the rate almost doubled.

● Morbidity:

— The age-specific prevalence of Alzheimer disease is estimated to be 17 percent at age 80,

rising almost twofold to 30 percent by age 85.

— Almost 50 percent of all persons over 65 are

afflicted with arthritis. The rates for elderly

women are 50 percent higher than those for

elderly men.

— The prevalence of visual, hearing, and paralytic

impairments—all particularly debilitating conditions–rose in some elderly age groups.

— The prevalence of chronic hypertension, most

types of chronic heart disease, and diabetes—

all risk factors for cardiovascular mortality—

rose in the 1970s.

— Elderly blacks exhibit a much higher prevalence of hypertensive disease and stroke than

whites, although the latter exhibit twice the

prevalence of coronary heart disease.

— Elderly women have a 70 percent higher

prevalence of general hypertensive disease

than elderly men, but the latter have a 26 percent higher prevalence of coronary heart

disease.

— ‘[’here is a lack of accurate prevalence data for

dementia, cancer, and osteoporosis, and a gen -

erak lack of prelalence data subdivided age

groups above? age 65.

● Cross analyses:

— The prevalences of general hyperststione,

diabetes, and most chronic heart conditions—

all risk factors for cardiovascular disease-are

rising at the same time cardiovascular mortality is falling. This probably indicates better treatment of these chronic conditions, which reduces associated risk, and improved acute care,

which allows more people to survive crises, live

longer, and develop chronic illnesses.

— The paradox of higher prevalence of hypertension and declining heart disease mortality in

elderly blacks and women (also stroke and hypertension in the latter) suggests that hypertension is better controlled, less severe, or generally not as strong a risk factor in these groups.

— Both the prevalence and the death rate are rising for chronic lung disease, indicating that the

incidence is also rising. The rising incidence of

lung disease and of certain cancers—especially

cancer of the lung and gastrointestinal tract—

are probably linked to rises in controllable risk

factors such as smoking and dietary habits, that

could be addressed through health promotion

education.

— The prevalence and death rates for stroke (the

third leading killer among the elderly) are both

falling. This indicates that incidence is falling

and that risk factors like high blood cholesterol

have been behaviorally reduced and/or reduced through medical treatment,

In sum, death rates for most major causes of death

continue to fall, both among the elderly and in the general population. The prevalence of more than half of

the chronic conditions examined in this chapter, however, is rising. If these trends continue, they could result in a decrease in the general well-being of older

Americans—especially the very old—and a long-term

burden on our health care system-especially for conditions with high associated disability such as arthritis,

heart conditions, and visual and hearing impairrnents.

More intensive research into the causes and progression of chronic conditions that become more common

with age may lead to more effective prevention, better diagnostic techniques, and improved treatment to

reduce disability. More emphasis on preventive health

strategies and education of the public about controllable risk factors may help to delay onset or to eventually eliminate these conditions and their associated

disabilities.
App. A—Morbidity and Mortality Data ● 411

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(

The Epidemiology of Depression in the

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359, 1982.

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218, 1976.

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103-134.

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in the Elderly: A Random Sample Followed Up,” Comp.

psych. 1:26-35, 1970.

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(Englewood Cliffs, NJ: Prentice Hall, 1980).

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in the ElderlJ~, ” Amhi\’es of Internal Afedicine 140: 1155-

1161, 1980.

31. Kramer, J., “Some Consequences of the Increasing Prevalence of Mental Disorders, ” paper presented at the Annual Meeting of the American Association of the Advancement of Science, May 1983.

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1981).

33. Nielson, J., “Geronto-Psychiatric Period-Prevalence Investigation in a Geographically Delimited Population,” Acta.

PsJ/chiat. Scand. 38: 307-330, 1963.

34. Ouslander, J. G., et al., “Urinary Incontinence in Elderly

Nursing Home Patients, “ J. A. AI.A. 248: 1194-1198, 1982.

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36. Paroles, H., Opening Address, ‘(Practical Approaches for

Meeting the IMental Health Needs of the Elderly,)’ Project HOPE, Millwood, \’A, March 1983, pp. 23-24.

37. Perloff, D., Dokolo\r, M., and Cowan, R., “Prognostic

Va]ue of Ambu\atorV Blood Pressures, ” J.A .M.A. 249:

2792-2798, 1983. “

38. Plum, F., “Dementia: An Approaching Epidemic, ” ,Vature

279:372-373, 1979.

39. Pooling Project Research Group, “Relationship of Blood

Pressure, Serum Cholesterol, Smoking Habit, Relative

Weight, and EGG Abnormalities to Incidence of Major

Coronary Events: Final Report of the Pooling Project,”

J. Chron. Diseases 31:201-306, 1978.

40. Primrose, E, J. R., Ps.vchological Illness: A CommunitJ~

Stud-v (Springfield, IL: C. C. Thomas, 1962).

41. Puska, P., et al., “Controlled, Randomized Trial of the

Effect of Dietary Fat on Blood Pressure,” Lance? 1: 1-5,

1983.

42. Rouse, 1. L., et a]., “Blood-Pressure-Lowering Effect of

a Vegetarian Diet: Controlled Trial Normotensive Subjects,” Lancet 1:5-10, 1983.

38-800 0 - 85 - 14
412 ● Technology and Aging in America

43. Schuman, L. M., “Smoking as a Risk Factor in Longevity, ”

Aging: A Challenge to Science and Society, D. Damon,

N. W. Shock and LM. Marois (eds.) (New York: Oxford

University Press, 1981).

44. Shanas, E., and IMaddox, G. L., “Aging, Health and the

45

46

47.

48.

49.

50.

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and the Social Sciences, R. Binstock and E. Shanas (eds.)

(New york: \/an Nostrand Reinhold CO., 1976), pp.

592-618.

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Sparacino, J., “The Type A (Coronary-Prone) Behavior

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1979.

US. Department of Health and Human Services, National

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52. U.S. Department of Health and Human Services, National

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54.

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58

59

60.

61

62.

63.

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64. U.S. Department of Health and Human Services, National

65

66

67.

68,

69.

70.

71.

72.

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Appendix B

The Cell Biology of Aging

Introduction

The distinction between the effects of aging as a

chronological process and diseases whose prevalence

increase with advancing age remains blurred. Conditions once thought to be inevitable companions of old

age are now known to in fact be pathological in origin

and thus possibly treatable and preventable. One example is senile dementia, no longer the mysterious fate

of the very old, but often a clinical manifestation of

arteriosclerotic or biochemical brain disease.

Further research may elucidate the mechanisms

underlying aging and their possible connection to agerelated diseases, leading to the development of medical techniques that delay the onset and progression

of symptoms. While it may not lead to actual extension of the human life span, such knowledge could reduce the prevalence and impact of chronic conditions

that affect many elderly persons and drain our health

care resources, allowing marked improvement in the

general well-being and productivity of the growing

elderly segment of the population.

The cell is the physiological building block in all

higher organisms, including humans. Any investigation of mechanisms underlying the aging process must

therefore look at how different cell types are altered

over time to produce the structural and biochemical

changes normally associated with aging. Numerous

biological signs of aging have already been identified

in cells both within the human organism and grown

on artificial media. This section reviews the theories

and evidence concerning mechanisms underlying

biological aging.

Theories about cellular mechanisms

of aging

Theories about the cellular mechanisms underlying

the aging process can be divided into two broad categories: 1) those involving a “biological clock” that orchestrates degenerative processes and determines life

span; and 2) those involving accumulated damage, mutations, and waste products in certain cells.

BIOLOGICAL CLOCK THEORIES

The biological clock theory proposes that an organism is inherently programmed to begin aging at a certain rate according to its chronological age. Evidence

for this theory includes the observation that different

species of higher vertebrates have very specific life

spans that seem to be “programmed” into them according to species. Mechanisms underlying this programmed

aging could involve an intrinsic genetic component of

the tissues (24), and/or an extrinsic “neuroendocrine

pacemaker” (16,17).

The genetic version of the biological clock is bolstered by the observation that the survival time of

tissues grafted (or transferred) from an older animal

into a younger one of the same species seems to depend on the age of the donor and is not influenced

by the “younger” environment into which it has been

introduced (24). Similarly, when nuclei from younger

cells are transplanted into the cytoplasm of older cells,

the recipients then live longer and regain the ability

to replicate. These observations all suggest that a

“clock” controlling aging does exist and may be located

in the nucleus, possibly in the genetic material (24).

Genetic diseases that accelerate aging and abbreviate

life spans further support intrinsic genetic control of

aging, Werner’s syndrome, for example, is a rare

autosomal recessive disease (i.e., the gene for the disease is not carried on a sex chromosome and two

copies of it must be present for the disease to appear)

involving retarded growth, premature graying and

loss of hair, cataracts, teeth loss, osteoporosis, aduhonset diabetes, generalized atherosclerosis, and a median life span of 47’ years. Cultured fibroblasts from

people with Werner’s syndrome exhibit a markedly

abbreviated life span (23,53). Hutchinson-Gilford Progeria syndrome, another rare “age-accelerating” genetic

disease, has similar symptoms that appear by age 1

and a median life span of 12 years. More than 80 percent of the deaths are due to heart disease (23). Localization of the exact gene lesions and their role in

accelerating the aging process in these diseases could

reveal genetic mechanisms involved in normal aging.

The control of aging by a “neuroendocrine pacemaker” extrinsic to the tissues involved is supported

by evidence of progressive changes in neural and endocrine regulatory systems throughout adult life (17);

such changes would produce a “cascade” of alterations

in neural, endocrine, and tissue interactions, leading

to the dysfunction of cells in the ovary, liver, and other

target tissues (16). This neuroendocrine pacemaker

could produce both cellular and physiological changes

associated with aging. The mechanism driving these

regulatory changes may involve the cumulative impact

of specific hormones on the brain over time, After a

certain amount of exposure, negative feedback at the

hypothalamic level would cause changes in the homeostatic set points, causing ahered neuroendocrine out413
414 ● Tecttno/ogy and Aging in America

put and the observed functional and structural changes

associated with aging.

This neuroendocrine pacemaker could also produce

age-related disease by affecting genetic activity,

leading to disturbances in immune function, proliferation of arterial walls, malignant growths, and other

conditions that are associated with aging and limited

life span in mammals (17).

It is not known, however, whether observed agerelated changes in hormonal regulation and balance

are a cause or an effect of the aging process (30). Furthermore, the biological clock may have both an intrinsic genetic and an extrinsic neuroendocrine component. Much research remains to be done before any

conclusions may be drawn concerning programmed

aging.

ACCUMULATION OF DAMAGE: FREE RADICALS

AND OTHER HARMFUL AGENTS

The other major cellular theory of aging involves the

accumulation of physical and biochemical damage to

both genetic and nongenetic components of body cells

over time. Such cumulative damage would most affect cells that do not normally divide, like liver, heart

muscle, and nerve cells.

Free radicals are byproducts of cellular metabolism

that are capable of generating chemical reactions destructive to parts of the cell. As the cell continues to

metabolize over time, such damage may increase.

Some evidence suggests that free-radical damage may

be responsible for decomposition of certain cell parts

and the subsequent accumulation of lipofuscin (“age

pigments”) in various body tissues. Accumulation of

lipofuscin, and of partially digested materials that have

also been found in aging cells, may impair cell function and contribute to cell aging (3,4). Thus, the metabolic process itself may damage the cell over time and

contribute to aging.

Accumulated damage with age could also be manifested by genetic lesions produced by mutations or mechanical disruptions of the chromosomes (37,41,48).

Such damage could be exacerbated by a possible agerelated deficiency in genetic repair mechanisms (13,36)

and could result in the manufacture of faulty proteins

(e.g., enzymes, hormones, neurotransmitters) that cannot work properly (18).

Several of the genetic ‘(age-accelerating” diseases, including xeroderma pigmentosum and Cockayne’s syndrome, seem to involve defects in the cells’ genetic repair mechanisms (23)53). People afflicted with either

disease show increased frequencies of chromosomal

aberrations and their body cells are unusually sensitive

to the mutation-inducing properties of ultraviolet light.

The symptoms of both of these diseases include premature death and early onset of dementia and various

age-related degenerative neurological disorders.

Aberrant proteins could also accumulate both inside

and outside cells due to age-related defects in the

genetic material or in other protein-manufacturing

machinery in the cell. The chemicals and structures

responsible for “decoding” and implementing genetic

information could alter with age, resulting in structurally faulty proteins that would be unable to function normally (31).

Accumulated insults to the cell over time—whether

metabolic, environmental, or viral--could thus lead to

cellular degeneration, loss of function, cessation of

division, and cell death with a diminution of function

in various body organs. Such acquired lesions could

also lead to the formation of malignant cells and cancer. The damage could be exacerbated by the aging

immune system’s decreasing ability to detect and destroy aberrant cells and materials in the body.

Much research remains to be done, however, on the

accumulation of either genetic or nongenetic cellular

lesions as a function of age, and on the role of such

lesions in the aging process. Such knowledge could

lead to preventive or therapeutic techniques that prevent or correct this age-related damage along with any

associated debilitating symptoms.

Biological signs of aging

Certain systemic changes are generally acknowledged to characterize “normal” aging. Those body

functions that decline with age include: renal blood

flow (44), cardiac output (especially during exercise;

20), glucose tolerance (1), vital lung capacity (27), and

cellular immunity (2).

The great variation in the incidence and degree of

such age-related changes and diseases between people of the same age suggests that individual behavior

and physiology influence the aging process. Better understanding of causal factors underlying age-related

conditions could thus lead to better preventive and

therapeutic treatments.

This section briefly reviews what is known and not

known about the cellular basis of these and other

biological changes occurring with age, and what connections there might be between these changes and

age-related disease. The etiology and clinical impact

of many of these “signs” are not known.

CELL LOSS

Cell death in certain tissues could contribute to the

degeneration and death of the organism. In fact, while

it is not the sole cause, the loss of cells in certain re-
App. B—The Cc/l Biology of Aging ● 415

gions of the body is thought to contribute significantly

to the aging process. Such loss is particularly important in tissues whose cells are unable to renew themselves, such as nerve and heart muscle cells.

In certain regions of the brain, nerve cells appear

to be lost with advancing age (5), reaching 20 to 4 0

percent loss in some areas (10). Age-related loss of

neurons in the brain’s cerebral cortex (5,7), cerebellum

(21), and limbic system (45) could be involved in impairment of cognitive, motor, and learning/emotional

behavior, respectively, in the elderly. Alzheimer disease, a type of senile dementia found mostly in older

persons, is associated with substantial loss of cells from

specific brain regions, perhaps leading to clinical disruption of learning and memory.

The scattered loss of muscle fibers from the heart

and their replacement with noncellular fibrous strands

is observed in aging animals (29), along with a generally decreased proportion of muscle to connective

tissue and fat, both in the heart and skeletal muscles.

Alteration in the muscles controlling lung ventilation

and their responsiveness to neural stimulation, although not necessarily involving cell death, may contribute to acute and chronic difficulty in breathing.

In the kidney, a deterioration of excretory function

with age is accompanied by a steady decrease in the

number of the organ’s microscopic filtering units, or

nephrons. Losses of 40 to 50 percent of the maximum

number of nephrons can occur by age 70 (38). This

loss and other age-related cellular changes could be

related to functional decline of the kidney in the

elderly, including a decrease in glucose resorption,

water clearance, and total acid excretion. This reduces

an elderly person’s ability to maintain physiological

balance of blood components, and can lead to excess

circulating amounts of drugs if dosages are not adjusted to account for diminished kidney function.

Other organs undergoing appreciable atrophy with

age include the thymus, ovaries, uterus, and testes (29).

Hormonal changes in the elderly are suspected to contribute to these phenomena (see sections on cancer

and hormonal changes for details and implications).

CESSATION OF CELL DIVISION

The mechanisms that control cell proliferation and

limit the replicative life span of normal cells are unknown, but could be significant in the aging process

of the cell and the organism as a whole. Evidence

based on observations first made by Hayflick (25) suggests that some cells in the body can reproduce for

a limited number of generations; when grown in tissue

culture (i.e., in laboratory dishes with a special mixture of nutrients), they cannot divide indefinitely. In

fact, turnover of cells in areas where they are sloughed

off and renewed constantly (as in the skin or intestine)

may decrease with age and lead to a net loss of cells.

For example, there is a marked flattening and loss of

cells in both the inner and outer skin layers of the

elderly, along with impaired wound healing.

The relevance of a limited number of cell generations to the life span of the organism as a whole, however, has not been established. Study of cell lines that

continue to proliferate indefinitely, like cancer cells,

might yield clues to the mechanisms underlying the

limited replicative life spans of normal cells.

CHANGES IN CELL MORPHOLOGY

A decrease in the density of synapses (areas across

which nerve cells signal each other) has been reported

in certain regions of aging brains in humans (26,45)

and animals (4,19,22). Loss of dendrites (signal receptors) from certain nerve cells has been observed in

the cortex of elderly persons with senile dementia

(8,45) and in several brain regions of aging laboratory

animals (14,15)32,33)34,50). Degeneration of nerve cell

axons (signal receivers) is also seen in the brains of

old laboratory animals (l9,40). All of these changes

could reduce connectivity between nerve cells in the

brain and possibly cause impaired brain function in

the elderly. For more detail, see the OTA background

paper, Impacts of Neuroscience, published separately

as part of this assessment.

In addition, the nerve cell’s outer membrane often

exhibits a loss of transmitter receptors and increased

rigidity with age. Membrane rigidity reduces the active transport of ion exchange, thereby reducing transmitter efficiency. These changes may also inhibit cell

signaling by altering sensitivity to hormones, growth

factors, and neurotransmitters.

The increased rigidity observed in the surface membranes of cells other than neurons, including lymphocytes (immune cells) and liver cells, may be due

to a generalized increase in the cholesterol: phospholipid

ratio of the membrane, possibly leading to a decrease

in cell motility and function. The clinical effects of this

change are unknown.

The elastic properties of lung tissue also decline with

age and could contribute to the impeded ventilation

and reduced rate of metabolic gas exchange seen in

the elderly. Degeneration of the lung parenchymal

tissue and a reduction in its capillary bed has been

associated with emphysema. Further research is

needed into the effect of environmental pollutants, including tobacco smoke, on lung tissue. Chronic obstructive lung disease, including emphysema, is the

fifth leading cause of death among the elderly today,

has a rising mortality rate, and is increasing in prevalence as a debilitating chronic condition (see app. A).
416 ● Technology and Aging in America

CHANGES IN MATERIALS INSIDE THE CELL

The possible accumulation of damage to the cell’s

internal machinery underlies one of the major theories

of aging discussed earlier. Such a cumulative effect

is especially important in cells that do not normally

divide frequently (e.g., liver parenchymal cells) and

those incapable of dividing at all (e.g., nerve, muscle,

and egg cells). Such damage could be due to accidents,

disease, and/or the effects of normal metabolism over

time that may adversely affect such vital cell functions

as protein synthesis.

As cells metabolize they produce deleterious byproducts. Free radicals, for example, are extremely

reactive substances given off by the mitochondria (the

cell’s “energy generators”) during respiration that can

trigger chemical reactions destructive to cell structures. A major consequence of such oxidative damage

is lipid peroxidation, (39) which has been implicated

in the formation of lipofuscin, a yellow-brown “age pigment” found in some nerve, muscle, and liver cells of

old animals and humans (29,30), It is not known

whether lipofuscin interferes with cellular function,

but drugs that inhibit the formation of lipofuscin in

mice resulted in a mean extension of life span.

In old cells, damage to the intracellular sac that contains digestive enzymes may also occur, resulting in

a leakage of destructive enzymes out into the cytoplasm

that damages the cell (30). Other malfunctions could

result from the accumulation of partially degraded cell

parts that would normally be totally degraded into

reusable components after they have “worn out.”

Senescent nerve cells often collect abnormal filaments that progressively fill the cell body and dendrites, replacing the normal cellular “skeleton” thought

to be vital to many cell functions. This condition is

found in normal aging and, to a greater extent, in such

diseases as Down’s syndrome and senile dementia

(12,28). Similarly, massive quantities of filamentous

protein have been observed to accumulate in aging

cells in tissue culture. The effect of such changes in

cellular architecture is unknown, but they may interfere with some functions, including the internal

movement of cell components.

Another vital class of cellular proteins is the receptor proteins that are specifically adapted to receive

chemical signals from outside the cell in order to modify cell function. For example, cells in the adrenal gland

are instructed by chemicals from another gland via

such receptors to release stress hormones into the

blood. Certain kinds of receptors in the cell cytoplasm

(fluid interior) seem to undergo an age-related decrease in number that has been correlated with decreased responsiveness of the cell to certain hormones,

including sex hormones, disrupting their usual regulatory functioning (43). It is possible that the agerelated loss of hormonal function—implicated in disorders ranging from diabetes to immune deficiency

(see section on hormonal changes) -could stem from

a loss of available receptors, whether by a decrease

in their production, an increase in their breakdown,

or a “masking” of the receptors by a competing

protein.

CHANGES IN CELLULAR PROTEIN AND

EXTRACELLULAR MATERIALS

There is evidence of changes in cell protein with age,

both through changes in the amount and kind synthesized, and in their structural integrity over time

(30). In general, there seems to be an overall decrease

in rate of protein synthesis in most of the tissues of

older animals (46). Protein synthesis is vital to the

maintenance of cells, many parts of which “wear out”

with time and are replaced continuously. Malfunctioning of the synthetic process could lead to the general

disrepair and degeneration of a cell.

In several tissues, synthesis of structural proteins

ceases in the adult (e.g., cartilage), child (tooth dentine), or even before birth (eye lens proteins). During

aging, these proteins may be progressively altered,

leading to diminished function. Structural changes in

the lens proteins of the eye, for example, could “stiffen”

the lens, hindering the ability to focus and resulting

in the deterioration of near vision that is almost universal in the elderly. Cataracts, a clouding of the lens, may

also result from structural changes in lens proteins

(35).

One of the most well-known biological aging processes involves structural changes in certain extracellular proteins that are normally responsible for the

structural integrity of many tissues. For example,

cross-linking of collagens—proteins that lend strength

and stability to joints, tendons, and the skin—reaches

a constant level at maturation (49). The cross-links,

however, seem to be damaged with advancing age

(possibly by free radicals) to produce a stiffening of

connective tissue and thickening of basement membranes, both of which may impede cell function. This

may contribute to the loss of elasticity in the skin of

elderly persons.

Cross-linking of collagen in joint cartilage may contribute to osteoarthritis (age-related degradation of the

extracellular matrix that provides cartilage elasticity

has also been implicated in degenerative arthritis).

Cross-1inking may also contribute to the thickening of

the basement membrane of the kidney’s glomeruli

(minute structures responsible for initial filtration of

the blood). This could impede filtration and exacerbate the loss of excretory competence with age.
App. B—The Cell Biology of Aging ● 417

The protein mesh maintained on the surface of

almost all cells also seems to be biochemically altered

with age. The matrix is normally involved in cell attachment, shape, migration, and perhaps in cell

division–functions that could be affected by alteration of its constituent proteins.

Other extracellular components varying with age

contribute to the development of diseases more prevalent in the aged. Deposition of lipid-containing plaques

along the inner walls of arteries, or atherosclerosis,

occurs mostly in the elderly and underlies many forms

of cardiovascular disease. Deposition of amyloid (a

waxy substance consisting of proteins and sugars) in

blood vessels, characteristic of a variety of diseases,

is found consistently in the elderly and mainly in the

kidneys, heart, pancreas, adrenal gland, and central

nervous system (29). The clinical impact of such deposits is undetermined but could involve impaired

function of these organs.

Disorders involving decrease in bone mass (osteoporosis) or in the calcium content of the bone (osteomalacia) account for a large portion of chronic

disabilities in the elderly, including increased susceptibility to fracture due to a weakening and brittleness

of the bones (see ch. 3). Defects in vitamin D metabolism, hormone imbalances, and inactivity have all been

implicated in disturbing the complex balance between

the continual absorption and deposition of bone by

specialized cells.

ABNORMAL CELL PROLIFERATION AND CANCER

Hyperplasia, or the abnormal proliferation of cells

in certain body tissues, is often observed in the elderly.

Cancer, or malignant neoplasia, is second only to cardiovascular disease as a cause of death in the United

States (see app. A). The chances that a person will develop cancerous growths within a 5-year period rise

from 1 in 700 at age 25 to 1 in 14 at age 65. The overall incidence of cancer peaks between ages 40 and 80,

although certain forms of cancer (e.g., leukemia, lymphoma, and prostatic cancer) are more prevalent in

older age groups.

Hyperplasia is found in a variety of localized regions

in the elderly, including hyperplastic and malignant

growths in the endocrine glands and various types of

cancers in the skin, bladder, gastrointestinal (particularly the colon), urinary, and reproductive tracts. Some

formations, like “polyps” or small growths in the colon and bladder, may be a localized reaction to generalized cell loss and seem to presage local cancer formation (29). Cancers in the fatty and fibrous tissues

are also often found scattered throughout the aging

body. Malignant growths in the elderly also commonly

involve the breasts, lymphoreticular system, and lungs.

Although usually not malignant, age-related proliferation of smooth muscle cells in the arteries may contribute to atherosclerosis (47).

Cancerous growths seem to be largely triggered by

interactions between noxious agents (e.g., radiation,

chemical exposure, and viruses) and characteristics of

the host, including genetic factors, hormonal balances,

immunological responsiveness, and nutritional status—

all of which are more likely to be impaired in the

elderly (see ch. 4 and relevant sections of this appendix).

An inherited or acquired genetic component, including a possible age-related decrease in ability to repair mutated and otherwise damaged DNA, may predispose an individual to the birth and spreading of

malignant growths. Several “age-accelerating” genetic

disorders, like Werner’s syndrome, Bloom’s syndrome,

and xeroderma pigmentosa, involve increased incidence of certain cancers that are suspected to stem

from faulty DNA-repair mechanisms.

Altered hormone levels in the elderly have been

linked to some cancers: postmenopausal cancer of the

uterus has been associated with continued presence

of estrogen, both in its natural and ingested forms;

increased breast cancer with a rise in prolactin; and

increased prostate cancer with the drop in testosterone observed in elderly men.

Finally, the loss of immune function in the elderly

(discussed in the following section) may include a decreased ability to detect and kill aberrant or cancerous

cells after they have formed, thus facilitating the birth

and growth of cancers.

Although these genetic, endocrine, environmental,

viral, hormonal, and immunologic factors are all

suspect, the relationship between the aging process

and the markedly increased incidence of cancer in the

elderly compared to the general population remains

largely a mystery.

THE AGING IMMUNE SYSTEM

When the body is invaded by a potentially harmful

foreign substance, or “antigen,” including bacteria and

viruses, an immune reaction is triggered. The immune

reaction involves the binding and “deactivating” of the

antigen by one of two agents present in the blood and

body tissues: immune cells (T-lymphocytes or T-cells)

produced by the lymph tissue that directly attack the

antigen, or proteins in the blood known as antibodies

produced by specialized immune cells (B-lymphocytes

or B<ells) that are present in the spleen, lymph nodes,

and blood.

The T-cell is dependent on the thymus (a ductless

glandlike structure found in the neck or upper chest

of all vertebrates) and, in addition to its ability to
418 ● Technology and Aging in America

directly “neutralize” antigens, helps regulate the production of antibodies by B-ells. Antibody production

is aided by “helper” T-ells and hindered by “suppressor” T-ells. T-ells can also directly kill cancerous,

transplanted, or otherwise aberrant cells and are

thought to be responsible for cell-mediated or acquired

immunity (e.g., the resistance to a specific disease acquired after vaccination).

Aging is accompanied by a marked decrease in the

immune system’s ability to respond to invasion by

harmful substances, as well as an increase in autoimmune reactions (immune reactions to the body’s own

materials). The B-cells that produce antibodies decrease in number and activity with age. T-cell function exhibits the sharpest decline: direct T-cell attack

of antigens decreases with age along with helper Tcell activity, while activity of the suppressor T-cells

increases (46,52). As a result, the strength of immune

response to infectious agents and aberrant cells is reduced in the elderly.

The aging immune system is also less able to distinguish foreign invaders from native materials, leading

to injury of the patient’s own tissues by autoimmune

reactions (9,42). Age-related deposits of antibodyantigen complexes are often found in organs with extensive capillary beds like the kidneys, lungs, liver, and

the brain, and may contribute to localized tissue damage (29,52). There is speculation that rheumatoid arthritis may be due to some type of autoimmune reaction to tissues in the joints.

Age-related morphological changes in the immune

system have been associated with the above functional

abnormalities seen in the elderly. In particular, the

thymus undergoes a progressive decrease in size with

age, accompanied by a loss of function. Involution of

the thymus begins at puberty and leads to an approximate 85-percent decrease in mass by age so in humans (29). In addition, bone marrow is increasingly

replaced by fat and fibrous tissue in the elderly, with

a general reduction of both immune and red blood cell

production in peripheral tissues.

Such age-related decreases in immune function

could render the elderly more vulnerable to infectious

diseases, including pneumonia and influenza, which

remain fourth in leading killers among the elderly

today (see app. A), and could contribute to the agerelated increase in the prevalence of cancer.

AGE-RELATED CHANGES IN HORMONES

Endocrine glands (e.g., the thyroid, pancreas, pituitary, and testes) tend to shrink with age and exhibit

age-related declines in the secretion of some hormones. The sharp drop of estrogen secretion in women during menopause, for example, is well documented. The metabolism of many hormones also

declines with age, however, resulting in no net change

in the basal levels.

The age-related decrease in function of many hormones could be alternatively explained by an agerelated decrease in the effect of some hormones on

their target tissues or organs. Glucose intolerance, for

example, is more prevalent among the elderly and may

be due to a reduction in insulin sensitivity (and therefore reduced ability to metabolize glucose) in peripheral

tissues of older persons (11), coupled with an inherited

disposition towards the illness. Behavioral changes

associated with aging, including an increase in obesity

and decrease in exercise, may also contribute to these

changes.

This decreased effect of hormones on their target

tissues may also provide a basis for age-related changes

in presentation of illnesses, response to treatment, and

ability to respond to stress. For example, the heart of

an older person is generally less responsive to stimulation by catecholamine, a hormone that normally

causes the heart to pump harder and faster. As a

result, elderly people are less able to maintain adequate blood pressure in response to postural stress

or bleeding.

Conclusion

The aging process

teraction of several

probably involves a complex inmechanisms, possibly including

both a ‘(biological clock” and accumulated cellular le~

sions with age. Examination of aging on the cellular

level, however, is only part of the integrative approach

necessary to a full understanding of the process. Much

work remains to be done on the biochemical, cellular,

systemic, organismic, and even population levels

before a viable theory may be developed to explain

why and how people age. Such knowledge could, in

turn, lead to medical techniques that prevent or mitigate the symptoms of aging and age-related diseases

that afflict many elderly people and drain the Nation’s

medical and social service resources.

Appendix B references

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55(4):835-846, 1971.

2. Besdine, R., et al., Handbook of Geriatric Care, 1982.

3. Bjokerund, S.,“Studies of Lipofuscin Granules in Human

Cardiac Muscle, H. Chemical Analysis of Isolated Granules, ” Exp, MoZec. Path. 3:377-389, 1964.

4. Bondareff, W., and Geinisman, Y., “Loss of Synapses in

the Dentate Gyrus of the Senescent Rat, ” Nat. Amer. J.

Anat. 145:129-136, 1976.

5. Brody, H., and Vijayashankar, N., “Anatomical Changes
App. B—The Cell Biology of Aging ● 419

in the Nervous System, ” Handbook of the Biology of

Aging, C. E. Finch and L. Hay flick (eds.) (New York: Van

Nostrand Reinhold Co., 1977).

6. Brody, H., “Structural Changes in the Aging Nervous System,” Interdisciplinary Topics in Gerontology, vol. 7, H.

T. Blumenthal (cd.) (Munchen: Kayer, Basel, 1970).

7. Brody, H., “Organization of the Cerebral Cortex, HI: A

Study of Aging in the Human Cerebral Cortex,” J. Comp.

Neur. 102:511-5567, 1955.

8. Buell, S., and Coleman, P., “Dendritic Growth in the Aged

Human Brain and Failure of Growth in Senile Dementia,” Science 206:854-856, 1979.

9. Burnet, F. M., Immunological Surveillance Klxford,

England: Pergamon Press, 1970).

10. Curcio, C. A., Bue]l, S. J., and Coleman, P. D., “Morphology of the Aging Nervous System: Not All Downhill, ”

Aging Motor SGvstems, F. J. Pirozoli, and J. G. Malletas

(eds.) (New York: Praeger, 1983), pp. 7-35.

11. DeFronzo, R. A., “Glucose Intolerance With Age: Evidence

for Tissue Insensitivity to Insulin, ’’Diabetes 28:1095-1101,

1979.

12. DeJong, R. N,, and Pope, A., “Dementia,” The Nervous

S&vstem, D. B. Toner and T. N. Chase (eds.) (New York:

Raohn Press, 1975).

13. Esptein, J., et al., “Rate of DNA Repair in Progeric and

Normal Human Fibroblast, ” Biochem. Biophev’s Res. Com -

mun. 59:850-857, 1974.

14. Feldman, M. L., “Aging Changes in the ,Morphology of

Cortical Dendrites, ” Neurobiology of Aging, R. Teny and

S. Gershon (eds.) (New York: Raven Press, 1976), pp.

211-227.

15. Feldman, M. L., and Dowd, C., “Loss of Dendritic Spines

in Aging Cerebral Cortex ,“ Anat. Embry. 148:279-301,

1975.

16. Finch, C. E., “Emergent Issues in Neurogerontology, ”

Roche Seminars on Aging, No. 1, Section l/The Scientific Aspects, 1980.

17. Finch, C. E., “The Regulation of Physiological Changes

During Mammalian Aging,” Quart. Rev. Biol. 51:49-83,

1976.

18. Gallant, J., “The Error Catastrophe Theory of Cellular

Senescence,” Biological Mechanisms in Aging, R. T.

Schimke (cd.), 1981.

19. Geinisman, Y., “Loss of Axosomatic Synapses in the Dentate Gyrus of Senescent Rats, ” Soc. Areuro. Abstr. 5:5,

1979.

20. Gerstenblith, G., “Cardiovascular Aging, ” Biological

Markers of Aging, M. E. Reff and E. L. Schneider (eds.),

1982.

21. Hall, T. C., Miller, A. K. H., and Corsellis, J. A. N., “Variations in the Human Purkinje Cell Population According

to Age and Sex, ” hreuropatholo~ and Applied Neurology

1:267-292, 1975.

22. Hasan, M., and Glees P., ‘iUltrastructural Age Changes

in Hippocampal Neurons, Synapses and Neuroglia,” Exp.

Ger. 8:75-83, 1972.

23. Hay flick, L., “Genetic Disparities of Senescence, ” Biocultural Aspects of Disease, H. R. Rothschild (cd.) (New

York: Academic Press, 1981).

24. Hayflick, L., “The Cell Biolo&v of Aging,” N. Engl, J. A4ed,

(Dee.):1302-1308, 1976.

25. Hayflick, L., “The Limited Zn Vitro Lifetime of Human

Diploid Cell Strains,” Exp. Cell Res. 37:614-636, 1965.

26. Huttenlocher, P. R., “Synaptic Density in Human Frontal Cortex—Develop Mental Changes and Effects of

Aging,” Brain Res. 163:195-205, 1979.

27. Kannel, W, B., and Hubert, H., “Vital Capacity as a

Biomarker of Aging,” Biological Markers of Aging, M. E.

Reff and E. L. Schneider (eds.), 1982.

28. Katzman, R., et al. (eds.), “Alzheimer’s Disease: Senile

Dementia and Related Disorders,” Aging, vol. 7 (New

York: Raven Press, 1977).

29. King, D. W., et al., “Morbidity, and Mortality in the Aged,”

Hosp. Prac. (Feb):97-107, 1982.

30. Knook, D. L., “Aging of Cells: Accident or Programmed?”

Endeavour 6(4):162-167, 1982.

31. Linn, S., et al., “Decreased Fidelity of DNA Polymerase

Activity Isolated From Aging Human Fibroblasts,” Proc.

Nat. Acad. Sci. USA. 73:2878-2822, 1976.

32. Machado-Salas, and Scheibel, A. B., “Limbic System of

the Aged Mouse, ” Exp. Neur. 63:347.355, 1979.

33. Machado-Salas, et al., ‘(Morphologic Changes in the

Hypothalamus of the Old Mouse, ’’Exp. Neur. 57:102-11 1,

1977.

34. Machado-Salas, et al., “Neuronal Changes in the Aging

Mouse: Spinal Cord and Lower Brain Stem, ” Exp. Neur.

54:504-512, 1977.

35. Masters, P. M,, “Senile Cataracts: A Model for Studying

Post-Translational Changes in Structural Proteins, ” BioIo#”cal Markers of Aging, M. E. Reff and E. L. Schneider

(eds.), 1982.

36. Mattern, M. R., and Cerutti, P. A., “Age-Dependent Excision Repair of Damaged Thymine From Gamma-Irradiated DNA by Isolated Nuclei From Human Fibroblasts,”

~rature (Lend). 2.54:450-452, 1975.

37. Medvedev, Zh. A., “The Nucleic Aids in Development and

Aging, ” Advances in Gerontological Research, vol. 1, B.

L. Strehler (cd.) (New York: Academic Press, 1964), p.

181-206.

38. National Research on Aging Planning Panel, A Nationa/

P/an for Research on Aging, Nat. publication No. 82-2453,

September 1982.

39. Nohl, H,, and Hegner, D., ‘(Do Mitochondria Produce Oxygen Radicals In \’ivo?’’Em. J. Biochem. 82:563-567, 1978.

40. Nuranjo, N., and Green, E., “Use of Reduced Silverstain

to Show Loss of Connections in Aged Rat Brain, ” Brain

Res. Bull. 2:71-74, 1977.

41. Orgel, L. E., “The Maintenance of Accuracy of Protein

Synthesis and Its Relevance to Aging)” Biochem. 49:517-

521, 1963.

42. Phillips, S. M., and Wegman, T. G., “Active Suppression

as a Possible Mechanism of Tolerance in Tetra Parental

Mice, ” J. Exp. Med. 137:291-300, 1973.

43. Roth, G. S., “Age-Related Changes in Hormone Action:

The Role of Receptors, ” Biological Mechanisms in Aging,

R. T. Schimke (cd.), 1981.

44. Rowe, J. W., “Renal Function and Aging,” Bio/ogiaf

Markers of Aging, M. E. Reff and E. L. Schneider (eds.),

1982.

45. Scheibel, M. E., et al., “Progressive Dendritic Changes

in the Aging Human Limbic System, ” Exp. Neur. 53(2):

4 20-43 0) November 1976 .
#ZO . Technology and Aging in America

46. Schimke, R. T., and Agniel, M., “Biologic Mechanisms in

Aging: Summary of Conference Proceedings,” J. Amer.

Ger. Soc. 31:40-44, Jan. 1983.

47. Stemerman, M. B., and Maciag, T., “Age-Related Aberrations in Proliferative Homeostasis,” Biolo#”cal Mechanisms in Aging, R, T. Schimke (cd.), 1981.

48. Szilard, L., “On the Nature of the Aging Process, ” Proc.

Nat]. Acad Sci. USA 45:30-45, 1959.

49. Tanzer, M. L., “Collagen Cross-Linking: Relationship to

Theories of Aging,” Bio~ogical Mechanisms in Aging, R.

T. Schimke (cd.), 1981.

50. Vaughan, D. W., “Age-Related Deterioration of Pyramidal

Cell Basal Dendrites in Rat Auditory Cortex,” J. Comp.

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51. Weksler, M., “Age-Associated Changes in the Immune Response, ” J. Amer. Ger. SOC. 30(11):718-723, 1982.

52. Weksler, M., “The Senescence of the Immune System,”

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Appendix C

Nutrition Information

Introduction

Available nutritional surveys of the elderly, although

limited and flawed, reveal a low to moderate prevalence and/or increased risk of nutrient deficiencies

among both institutionalized and noninstitutionalized

groups. Inadequate nutrition may exacerbate many

aging processes, including progressive changes in body

composition and decline in function of various organ

systems. It may also increase the incidence of certain

age-related diseases. Evidence is surfacing on the prevalence and effects of long-term “subclinical” deficiencies that produce no immediate symptoms but could

induce progressive and subtle changes. Moreover,

many elderly exhibit changes with age that can affect

their dietary requirements, including altered eating

behavior, decreased physical activity, and reduced

ability to digest, absorb, and metabolize many nutrients.

Despite increasing amounts of evidence of the importance of adequate nutrition to the physical and

mental well-being of the elderly, specific dietary needs

of this growing segment of the population remain illdefined. This has important implications for the Title

111 Nutrition Program for the Elderly—and especially

for the meal and education services.

This appendix reviews the extent and reliability of

current information on the nutritional requirements

and status of the elderly. Evaluations of the title HI

programs are also reviewed in order to examine both

the efficacy of the programs and the accuracy of the

evaluations themselves.

Recommended Dietary Allowances

The Committee on Dietary Allowances (CDA) of the

Food and Nutrition Board, part of the National Academy of Sciences, has published a set of Recommended

Dietary Allowances (RDAs) every 4 to 6 years since

1943. Their latest estimates were published in 1980.

These RDAs specify the minimum levels of intake of

essential nutrients needed to maintain normal body

function in healthy population groups. The Committee, which consists of 8 to 10 scientists who are chosen as experts in nutrition-related fields, draws on the

international scientific literature, including epidemiological and metabolic studies, to determine RDAs.

According to the Committee, intakes below the recommended levels are not necessarily inadequate for

all individuals, but they increase the risk of deficiency.

For proteins, vitamins, and minerals, the allowances

are targeted to meet the needs of 95 percent of individuals within a defined population group (12). Average requirements for these nutrients are first estimated, along with their variability, within the group.

These figures are then increased once to meet the

needs of almost all of the group members, and once

more to compensate for inefficient utilization of consumed nutrients due to, for example, poor digestion

or absorption. The energy allowance is meant to be

adequate to maintain desirable weight while ensuring adequate nutrition.

RDAs are subdivided by age, sex, height, and weight,

and are adjusted to account for special nutritional

needs during periods of rapid growth, pregnancy, and

lactation. Unfortunately, the elderly are lumped into

a 51-and-over age group whose needs are not homogeneous and whose RDAs are essentially extrapolated

from survey and research information gathered from

younger adults. Except for the vitamins thiamine, riboflavin, and niacin, which are adjusted for males, the

recommended nutrient levels are the same for those

over 50 as they are for those 23 to 50. The recommended caloric intake is lowered for those over 50

and again for those over 75.

It is generally agreed that changes in metabolism,

physical activity, efficacy of organ systems, and body

composition that occur in the elderly, along with agerelated disabilities and chronic disease, can significantly alter the intake, absorption, and utilization of

various nutrients (see following section), RDAs extracted from direct study of the elderly, reflecting

what is known about relevant age-related changes, are

therefore sorely needed.

Although cost, time factors, and ethical constraints

have been barriers to thorough studies of the nutritional requirements and status of the elderly (12), the

National Academy of Sciences is planning to launch

a study of nutrition and the elderly with an emphasis

on what further research is needed to establish accurate age-adjusted RDAs.

Current survey estimates of energy, nutrient intake,

and dietary adequacy among the elderly are often

flawed by unstandardized methods, errors in estimates of consumption, food table analytical values, and

assumptions about absorption of nutrients in the gastrointestinal tract, When short observation periods (1

to 3 days) of food intake are used, the proportions of

individuals at both extremes of the distribution are

greatly exaggerated because of the large day-today

variation in intake of many nutrients. Moreover, nu421
—.

422 . Technology and Aging in America

tritional surveys of the elderly in the United States

have been of very limited scope, lack standards from

which to derive comparative frequencies of nutrient

deficiencies, and have seldom included individuals

over 75.

Ideally, nutritional assessment surveys of dietary

adequacy in any population group would be conducted

in a three-pronged fashion: quantification of food intake over several days to derive an average daily consumption of energy and major nutrients; measurement

of biochemical indices for many nutrients (or their

metabolizes) in the blood or urine in order to estimate

tissue levels; and physical examination of the subjects

for clinical evidence of any nutrient deficiencies and

for illnesses that may affect nutritional state.

Recent technological advances in assessing nutritional needs include more sensitive and specific biochemical assays (i.e., tests to measure the quantity or

activity of a substance) for nutrients in the blood and

body tissues, tests of physiological functions related

to nutritional status, the development of functional

assays for the activity of enzyme systems for which

certain vitamins are cofactors, and the analysis of

more vital foods for their nutrient content and for how

that content may be affected by food processing or

preparation.

Without valid standards of adequacy for nutrient intake and tissue levels in the elderly, however, results

of even an ideal survey could not be calibrated and

would be of limited value. In addition, very little is

known about how specific deficiencies, especially longterm subclinical deficiencies for which symptoms may

not be immediately apparent, contribute to the aging

process,

Age-related physiological and

sociological changes affecting

nutrition

Age-related factors that affect food intake, digestion,

absorption, and/or metabolism include: physiological

and biochemical changes accompanied by decline of

certain body functions with age; age-related disabilities

and disease; drug-nutrient interactions (discussed in

ch. 5 of this report); and psychosocial circumstances—

including isolation, depression, senile dementia, and

lower levels of physical activity.

The human body is known to undergo general

changes in composition with age, including a loss of

lean body mass (10,13) and an increase in fatty tissue

mass (39). The decrease in metabolically active tissue

and in physical activity indicates that caloric intake

should be cut back. This may increase the risk of nutrient deficiencies, however, which reinforces the

need for careful diet management by the elderly. The

age-related decline in acuity of taste and smell dulls

the pleasure of eating and may further reduce food

intake.

The most outwardly apparent age-related changes

that affect food intake occur in the mouth. In 1971,

about 45 percent of Americans over 65 who were surveyed had no natural teeth (43). Ninety percent of extractions are due to tooth decay or periodontitis. The

elderly are particularly susceptible to decay of the

roots of the teeth because the gums recede with age,

leading to greater exposure of the base of the teeth

(an area more susceptible to acid erosion). An added

risk factor is age-related decrease in the flow or

changes in the composition of the saliva (22).

Intake of starches and simple sugars (e.g., sucrose

or table sugar) aggravates decay and increases the risk

of loss of teeth (4). Carbohydrates are fermented by

oral bacteria to acid that erodes the dental enamel.

Impairment of biting and chewing due to lack of teeth

or ill-fitting dentures could have a significant influence

on the food choices of the elderly. Clinical observations that suggest a high prevalence of vitamin C and

B-complex deficiencies in older persons without teeth

(17,32) need to be updated and explored further.

Age-related physiological changes in the gastrointestinal (GI) tract may affect food intake, digestion, and

absorption. Minor abnormalities in esophageal tract

motility (movement in the tube connecting the mouth

and stomach) commonly seen in the elderly include

disordered contractions and more frequent spontaneous regurgitation of food. In the stomach, age-related

changes include decreased hydrochloric acid secretion, decreased intrinsic factor secretion, and decreased pepsinogen secretion (6)—all of which are important to digestion. The absorption of iron and folic

acid is known to be acid-sensitive. Diminished hydrochloric acid may also allow overgrowth of bacteria in

the small intestine and interfere with absorption.

In the elderly, the villi, or tiny absorptive protrusions in the intestine, are often blunted, and the

mucosal surface area of the GI tract lining is reduced.

The effects of these histological changes on digestion

are as yet unknown.

The elderly often exhibit a decrease in activity of

the enzyme lactase, which breaks down the milk sugar

lactose in the small intestine. When the absorption of

lactose is thus hindered, it moves down the GI tract

to the large bowel to be metabolized by bacteria into

short-chained fatty acids and various gases. The resulting abdominal discomfort, bloating, and diarrhea

may deter the elderly from consuming milk products,

contributing to the documented decrease of milkproduct intake and difficulty in maintaining adequate

calcium in later life. Enzyme additives available over
App. C—Nutrition Information ● 423

the counter can be used to aid digestion of liquids containing lactose. More research is needed into dairy

products in which the lactose has been predigested.

Little is yet known about age-related changes in the

absorption of vitamins and minerals, although it appears that the intestine is less able to compensate for

low calcium intake in the elderly. More study is also

needed on changes in the gut blood vessel circulation

that might affect absorption. GI hormone secretion

may change with age, affecting the utilization of nutrients and possibly influencing appetite. The constipation that is prevalent among the elderly may also limit

food intake.

A progressive reduction in renal function is often

observed in the elderly (40) and may affect the homeostatic level of various body substances normally regulated in part by the kidneys. Potentially harmful accumulations of nitrogenous waste from proteins and

phosphate due to kidney malfunction are often observed

in the elderly and may be treatable by dietary therapy (45).

The incidence of adultanset noninsulindependent

diabetes mellitus increases with age. According to one

study (46), half the population over 70 would be

diagnosed as having diabetes if the criteria used for

glucose tolerance in younger people were used. The

cause of this age-related decrease in glucose tolerance

is unknown, but it obviously has some impact on the

recommended diet, including restriction of concentrated simple sugars.

Finally, the psychosocial changes associated with

aging may also influence food intake and metabolism.

Dementia, isolation, depression, and other emotional

stresses can act as appetite suppressants. Social isolation, including living alone, has been shown to correlate positively with poor nutritional status (18,41).

Forced or voluntary reduction in physical activity may

also limit food intake by reducing appetite and even

exacerbate loss of bone mass in the elderly, One study

showed that nursing home residents aged 65 to 95 experienced a significant 4.2-percent increase in forearm

bone mass after exercising for 30 minutes three times

weekly for 3 years, while a control group exhibited

a 2.5-percent loss over the same time period (21).

The nutritional status of the elderly

The largest nutrition survey to date was taken in

the National Health and Nutrition Examination Survey

(HANES, 1971-74). This survey, however, excluded individuals over 74 and presented no authoritative biochemical evidence to correlate with low nutrient intakes or with the presence of clinical symptoms

associated with specific deficiencies.

Very few published nutrition surveys recorded the

use of vitamin, mineral, or other nutritional supplements. Although their use varies considerably among

ethnic groups, such dietary supplements are used by

an estimated 40 to 60 percent of the total older population in the United States (14,15,19) and can substantially affect reported nutrient intakes and biochemical

indices.

In general, serious or extreme nutritional deficiencies manifesting clinical symptoms are rarely seen

among the elderly in the United States. Unfortunately,

little information is available on the prevalence of

subclinical deficiencies and their possible long-term

effects.

Possible connections between nutritional imbalances

and aging or age-related diseases are discussed in

chapter 4. Many of these connections are tentative as

yet, More research is needed to yield conclusive

evidence as a basis for diagnosis and treatment of deficiencies.

Food programs for the elderly

In 1980, the rate of deaths due to nutritional deficiencies in the general population was 1 per 100,000

(42). The rates among those over 65 were several times

higher (table C-l): 2.4 in the 65 to 74 group, 9.4 in the

75 to 84 group, and 42.9 in the over 85 group. Although reliable figures are not yet available, far

greater numbers of elderly may suffer from chronic,

though not fatal, malnutrition; the long-term effects

on physiological and cognitive functions are only beginning to be understood (see ch. 4).

In 1965, the Federal Government assumed an active

role in fighting nutritional deficiencies in the poor with

Table C“l.— Mortality Among the Elderly Due to Nutritional Deficiencies, 1980

Total number of deaths Rate (per 100,000 in) Percent total death s

Age grou p in age grou p specified grou p in age grou p

65 and over. . . . . 2,060 8.0 0.15

65-75 . . . . . . . . . . 372 2.4 0.08

75-84 . . . . . . . . . . 728 9.4 0.14

85 and over. . . . . 960 42.9 0.27

SOURCE: National Center for Health Statistics, Advance Report of Final Mortality Statistics, 1980 (42).
424 ● Technology and Aging in America

the enactment of the Food Stamp Act, then a smallscale program designed to meet what was thought to

be a limited need for financial assistance in purchasing food. The Food Stamp Program is now the largest

of all food and nutrition programs affecting the noninstitutionalized elderly. In fiscal year 1981, for example, an average of 22,4 million people received food

stamps each month.

The Administration on Aging (AoA) first sponsored

congregate meals for people 60 and over (and their

spouses) in 1968 as a research and demonstration project under Title IV of the older Americans Act Amendment (public Law 92-258). Nutritional surveys Conducted in the early 1970s by the Department of Health,

Education, and Welfare (now the Department of

Health and Human Services) revealed a substantial

prevalence of malnutrition among the poor and the

inadequacy of the small-scale Food Stamp Program (l).

In response, Congress expanded the existing food

assistance programs and established the Nutrition Program for the Elderly in 1972 in an amendment to the

Older Americans Act under Title VII. This congregate

meal program was designed to meet the nutritional

needs of elderly people who were either unable to buy

nutritious food or prepare nutritionally adequate

meals, and for these who were isolated and lacked the

incentive to prepare meals at home. Another major

goal was to attract isolated elderly people to the program centers in order to promote social interaction

and facilitate delivery of other services,

Congregate meals under this program are available

at least once a day and usually 5 days a week. The

meal sites are meant to be strategically located to best

provide other supportive services such as outreach,

escort and transportation services, health services, information and referral, health and welfare counseling, and nutrition and consumer education.

In 1978, the Older Americans Act was amended

(Public Law 95-478) to consolidate the title VII nutrition services and the title V multipurpose senior

centers with the social service programs provided

under title HI. Separate funding was made available

to the congregate meal programs to provide homedelivered meals for individuals homebound due to illness, disability, or transportation problems. State agencies distribute funds to area agencies that provide nutritional services within the State. Local providers

contract with these area agencies. Federal guidelines

suggest that each area agency have a board of directors consisting of local volunteers and senior citizens.

An estimated 1.9 to 2.0 million elderly persons are

currently enrolled in the congregate and home-delivered meal programs (36,37).

The Federal Government now sponsors 13 major

programs designed to increase the amount and quality

of food available to “high risk” segments of the population, including the elderly (table C-2). In fiscal year

1980, $475 million was authorized for the National Nutrition Program for the Elderly ($375 million for congregate meals and $100 million for home-delivered

meals). Only $225 million was appropriated. Recent

figures show that these funds provided more than 168

million total meals at an average cost of $2.27 per meal

(1). These included almost 132 million home-delivered

meals for 3,083,454 people over 60.

A total of $676,7 million was appropriated for Older

Americans Act programs for fiscal year 1984, including $386,1 million for title 111 nutrition programs (a

$5 million increase over the previous year). Funding

levels for State agencies, senior centers, and other supportive services-as well as for title IV research, training, and demonstrations—remained the same (35).

EVALUATION OF FOOD ASSISTANCE PROGRAMS

FOR THE ELDERLY

Most evaluations of food assistance programs for the

elderly have concentrated on the social and psychological benefits of the meals. The nutritional adequacy

of the programs has been evaluated in seven recent

surveys: one major national survey contracted by AoA

in 1983 (36,37), two area surveys in central Missouri

(26,29,30,31) and Maryland (9), and four local evaluations of single meal sites in Nebraska, Colorado, New

York, and Illinois (8,16,20,23).

There is considerable variability in the conclusions

drawn by these surveys due to differences in how and

what kind of information was collected, and how the

Table C.2.—Federal Food Assistance Programs

Department of Agriculture:

Food Stampsa

Food Distributiona

National School Lunch Program

School Breakfast Program

Child Care Food Program

Special Milk Program

Summer Food Service Program for Children

Special Supplemental Food Program for Women, Infants,

and Children (WIC)

Department of Health and Human Services:

Head start

Nutrition Program for the Elderlya

Aid to Families with Dependent Children

Supplemental Security Incomea

Community Services Administration:

Community Food and Nutrition Programa

a Most likely to include elderly people.

SOURCE: Aging Health Policy Center, University of California at San Francisco,

1983 (1),
App. C—Nutrition Information ● 425

data were analyzed. Certain generalizations about the

efficacy of the programs can be made, however.

The surveys generally agreed that the programs

were very effective in improving intake of protein.

There was disagreement as to whether intake of iron,

niacin, thiamine, and vitamins A and C was improved

as dramatically. The consensus was that energy and

calcium intake were less improved than other nutrients by program meals. Yet intake of almost all of the

nutrients surveyed was found to be better overall in

participants as compared with both nonparticipants

and former participants.

The meals seemed to be reaching varying percentages of the designated target groups. The low-income

group was best represented, followed by those over

75. Other target groups, especially minorities and the

socially isolated, were less well represented among

participants. These underrepresented needy groups

may either be ill-informed about the meal programs

and nutrition in general or find access to the program

difficult.

Problems were also found in the sanitary conditions

at program meal sites, especially at those serving

catered meals, although conditions varied widely

among sites. In addition, the nutrition education mandated by title 111 was found to be generally insufficient

and infrequent at most sites. Furthermore, the nutrition education lectures were often too long—a short

(10-minute) talk accompanied by take-home reference

pamphlets may be more effective. A general dearth

of personnel trained in nutrition and management

at the meal sites may contribute to many of these

problems.

The above findings and other points raised by the

surveys are discussed in greater detail in the following sections. The parameters and limitations of each

of the five program surveys are presented in tables

C-3 and c-4. Flaws in the surveys that limit their accuracy and comparability are outlined below, including sample selection procedures, method of assessing dietary intake, and data analysis procedures.

Sample Selection. -Only three of the studies—the

national, Missouri, and Maryland surveys—appeared

to have used randomly and purposively selected

samples that were representative of the meal program

participants (9,26,29,30,31,36,37). Unfortunately, both

the Missouri and New York surveys, though random,

were racially homogeneous and did not record income

levels (table C-4). Both of these factors are important

in characterizing target populations in order to determine whether those in need are actually being reached

by the meal programs.

Two of the single-site surveys used volunteers for

subjects (16,23). Since volunteers may be more nutritionally aware and generally more involved in the program, this sample selection criterion may further bias

the results. Generalizations about the efficacy of food

programs cannot be made from nonrepresentative

samples; the data they contain are, at best, illustrative.

They can provide background data for surveys with

appropriate samples.

Assessment of Nutritional Intake and Status–Only

the central Missouri area survey and the single-site

evaluations in Colorado and Nebraska (16)20,26,31) attempted to use objective measures of health status,

such as biochemical measurements of nutrients in

blood and anthropometric measurements (i.e., measurement of height/weight proportions and skin-fold

thickness) for detecting problems with weight status.

The Missouri survey also used some clinical tests (table

C-3). These assessments take into account not only dietary intake but possible problems in the absorption

and metabolism of various nutrients that may change

with age and with certain age-related diseases.

The subjective measures of dietary intake used by

the other surveys, such as 24-hour recall, food diaries

(the individual records types and quantities of food

consumed over a specified period), and dietary histories (based on recall of the frequency with which certain foods are habitually consumed), are limited in accuracy and usefulness.

Accurate recall of the kinds and amounts of food

eaten over a 24-hour period, for example, is difficult

for anybody and may be especially difficult for the

elderly due to possible memory problems (34). Food

diaries are usually more accurate and can be useful

if those who review them are trained in food value

and nutrition. Often, however, only one day’s intake

is measured, in which case a large sample size must

be used to get a representative estimate for the designated population. Dietary histories can give an estimate of food intake over a longer period of time.

Even such subjective assessments, however, can reveal general trends in the effects of the congregate

meal program on nutrient intake, the proportion of

the RDA for particular nutrients, and the total day’s

intake contributed by the meal program (8,9,16,20,

23,26,29,30)31,36,37). These are also economical in

terms of the relatively small amount of time and effort needed to obtain the information.

Data Analysis-comparisons of data from different

food program evaluations can be further complicated

by differing procedures for analyzing data, especially

dietary intake data. For example, the national evalua -
-.

426 ● Technology and Aging in America

Table C-3.—Description of Surveys for Evaluating Title Ill Congregate Meal Programs

Funded by the Older Americans Act

Parameters Limitations

Survey Sample selection Sample size N measured of survey

National Participants Participants— Dietary intake- 1. Use of 24-hour

(1976, 1981) Purposive Ate a meal . . . . . . . . . 800 24 hour recall recall

Did not eat a meal . . 920 2. No biochemical

measures

Non-participants Non-participants— 3. No health

Purposive Neighbors . ........1,039 status measures

4. No anthropometric measurements

Missouri Participants

(1975, 1976, Random sample of

1979) lists of

participants

Nonparticipants

Subjects most

likely to participate in fact did

participate 1

year later.

Participants Dietary intake— 1. Area sample

Ate a meal. . . . . . . . . 154 Food record (1 day) 2. Only white

Did not eat a meal . . 213 Dietary histories participants

Non-participants . . . 99 Biochemical measures-Hct, Hb,

serum, iron, vitamins Bl

, A and C,

albumin, cholesterol

Clinical–Height,

weight, triceps

skinfold thickness,

blood Pressure

Nebraska Participants Participants— Dietary intake— 1.

(1980) Volunteers Volunteers. . . . . . . . . 30 24 hour recall

2.

3.

4.

5.

Biochemical—

Hct, Hb, vitamins

B6

, B12, A and C,

serum albumin

Anthropometric—

Height, weight,

triceps skinfold

thickness, arm

Use of 24-hour

recall

Small sample

size

No comparison

group

Local site only

Sample selection bias

girth, waist girth

Colorado Participants Participants. . . . . . . . 59 Dietary intake— 1.

(1979) Not stated Food record (1 day) 2.

3.

Non-participants Nonparticipants . . . 32 Biochemical- 4.

Not stated Hct, Hb, serum protein and albumin,

serum vitamins A

and C, serum iron,

total iron binding

capacity

New York Participants Participants. . . . . . . . 73 Dietary intake—

(1979) Random selection Food record (1 day) ; :

from list of

participants 3.

Local site only

No anthropometric measures

Sample selection bias

Cross-sectional

survey

Local site only

No biochemical

measures

No anthropometric measures

No comparison

group

4.
App. C—Nutrition Information . 427

Table C.3.—Description of Surveys for Evaluating Title Ill Congregate Meal Programs

Funded by the Older Americans Act

Parameters Limitations

Survey Sample selection Sample size N measured of survey

Maryland Participants Participants. . . . . . . . 169 Dietary intake— 1. County sample

(1980) Random selection Food record (3 days) 2. No biochemical

from 11 site lists measures

3. No anthropometric measures

4. No comparison

group

Illinois Participants Participants. . . . . . . . 8 Dietary intake— 1.

(1981) Volunteers 24 hour recall 2.

Non-participants . . . 32

Non-participants— 3.

Volunteers

4.

5.

Local sample

Sample size and

selection

Limited number

of nutrients

reported

No biochemical

measures

No anthropometric measures

SOURCES: Opinion Research Corp. and Kirschner Associates (1963) (37); Kohrs, O’HanIon, and Eklund (1978) (29); Kohrs, et al. (1979); Kohrs (1979) (26); Kohrs, et al.

(1960) (31); Grandjean, et al. (1961) (16); Harrill, et al, (1981) (20); Caliendo (1960) (8); Caliendo and Smith (1961) (9); Kim, et al. (1964) (23).

Table C-4.—Description of Subjects and Advantages of Each Nutrition Evaluation Survey

Survey Race Income Advantage

National

<$6,000-1981

Participants Participants 1. National sample and sample size

190/0 minority 520/o 2. Minorities represented

Non-participants Non-participants 3. Longitudinal

19% minority 460/o

Missouri 97% White NA (State guide- 1.

lines did not

permit) 2.

3.

4.

5.

6.

7.

Representative sample of area

participants

Longitudinal

Dietary methodology

Biochemical evaluation

Clinical evaluation

Analysis of dietary data provided in meaningful ways

Sample size

Nebraska NSa NS 1. Biochemical measures

2. Anthropometric measurements

Colorado NS NS 1. Dietary methodology

2. Biochemical measures

New York White NS 1. Analysis of dietary data provided in meaningful ways

Maryland 670/0 White NS 1. Minorities represented

300/o Black 2. Sample size

30/ 0 other 3. Dietary methodology

Illinois Korean NS 1. Minority evaluation

a Not stated.

SOURCES: Opinion Research Corp. and Kirschner Associates (1963); Kohr% O’HanIon. and Eklund (1978): Kohrs, et al. (1979); Kohrs (1979); Kohrs, et al. (1980); Grandjean, et al. (1981); Harrill, et al. (1981); Caliendo (1960); Caliendo and Smith (1981); Kim, et al. (1964).
428 ● Technology and Aging in America

tion presents figures for proportions of people meeting

certain dietary intake criteria, while others give mean

values for nutrient intake.

Yet both the national and Missouri evaluations offer longitudinal data that are extremely useful in

evaluating progress in participants’ nutritional status

over time.

Conclusions on the Effectiveness of the Food Pro

grams.—Dietary Intake and Nutritional Status of Participants: Guidelines for the Federal programs state

that a minimum of one-third of the RDAs for specified nutrients should be provided in any meal served

to an elderly program participant. The national evaluation reported that those elderly who ate a program

meal were more likely to achieve this goal between

11 a.m. and 4 p.m. than those who did not participate

(36,37; table C-5). The specified hours are those during which all of the surveyed programs, and a majority

of programs in general, serve their meals. Participants

were also more likely to meet at least two-thirds of

the RDAs over the entire day for the specified nutrients (table C-6). The results for both congregate and

homedelivered meals indicated that program meals

were most successful at improving dietary intake of

protein, B vitamins (riboflavin, niacin, thiamine) and

iron (table C-7), This evaluation documented a consistent tie between the program meal and a generally improved diet during the entire 1976 to 1981 evaluation

period.

Although the national survey also found that the program meals were less successful at improving intake

of other nutrients—such as calcium and vitamins A

and C—it could not be determined whether this reflects the nutritional content of the meals served or

the food preferences of the participants.

The national evaluation of food service delivery systems used in the title HI programs also studied the nutrient content of program meals. Table C-8 compares

the results of this evaluation for percentage of RDAs

provided by the menus to two other evaluations (25).

This study found that for most of the nutrients analyzed, the meals contributed more than one-third of

the RDA for participants over 50.

A notable exception was the trace element zinc, of

which the menus provided less than one-third of the

RDA. The national report failed to note this exception

in its discussion. Deficient zinc intake seems to impair

immune system function (44) and may be especially

detrimental to the elderly, since ability to ward off infection and harmful-micro-organisms often declines

with age.

This report also compared the estimated values for

nutrient content of the meals to values obtained from

chemical analyses of the food after cooking (25; table

C-9). Chemical analyses are particularly important for

nutrients that, like vitamin C, may be destroyed by

overcooking and for nutrients about which there is

little information available regarding the amount presTable C.5.—Percentage of Elderly Who Consumed 1/3 of Recommended Dietary Allowance

During the 11 a.m. -4 p.m. Period

Did not eat

Ate a program meal a program meal

Congre- Congregate Home- gate Homedining delivered dining delivered Non- Former

partic- meal partic- meal partic- particNutrient a

i pants recipients i pants recipients i pants i pants

(N = 800)

Calcium . . . . . . . . . . . . . . . . . . . . . . . 510/~

Vitamin A . . . . . . . . . . . . . . . . . . . . . . 55

Vitamin C . . . . . . . . . . . . . . . . . . . . . . 59

Thiamine. . . . . . . . . . . . . . . . . . . . . . . 70

Niacin . . . . . . . . . . . . . . . . . . . . . . . . . 73

Iron . . . . . . . . . . . . . . . . . . . . . . . . . . . 75

Riboflavin . . . . . . . . . . . . . . . . . . . . . . 78

Protein . . . . . . . . . . . . . . . . . . . . . . . . 87

Calories. . . . . . . . . . . . . . . . . . . . . . . . 53

(N = 340)

50%

50

52

67

66

67

75

83

48

(N = 920)

26%

28

36

52

46

57

64

35

(N = 63)

30%

32

44

49

46

51

54

63

30

(N = 1,039)

250/0

26

34

52

49

44

56

60

32

(N = 249)

25%

36

54

46

40

55

58

31

aElderly persons who ate a program meal were significantly more likely to meet 1\3 RDA for each nutrient (all 1df, 90.0 all P’s 0.01) (36)

SOURCES: Opinion Research Corporation and Kirschner Associates (1983).
App. C—Nutrition Information ● 429

Table C-6.—Percentage of Elderly Meeting at Least 2/3 of Recommended Dietary Allowance (RDA) for Key

Nutrients During Wave i and Wave ii

Wave II (Wave I in Parentheses)a

Congregate dining Home-delivered

participants meal recipients

Did not

Did not Ate a eat a NonAte a eat a program program partici - Former

site meal site meal meal meal pating partici -

Nutrientb yesterday yesterday yesterday yesterday neighbors pants

N = 800 N = 920 N = 340 = 63 N = 1,039 N = 249

(N = 765) (N = 1 ,049) (N = O) = o ) (N = 1,788) (N = O)

Calcium 640/0 460/0 580/0 41% 47%0 49%

(67%) (490/0) (470/0)

Vitamin A 64 46 51

(69) (56) (53)

Vitamin C 73 75 67

(81) (73) (70)

Thiamine c

90 83 89

(79) (74) (71)

Niacin c81 68 79

(81) (75) (72)

Iron 79 63 78

(86) (77) (76)

Riboflavin 94 83 90

(89) (79) (79)

Protein 95 90 92

(96) (91) (90)

Calories 64 48 63

(73) (68) (63)

aDletarY intake Was not assessed for home-dell vered meal recipients and former PartlClpants during WaVe 1.

bDiscriminant ana~sis revealed that fl~viflg eat~n a cong~egat~ or florne-dellvered meal wss significantly relatw tO better Overall diet Scores (Univariate F fOr COflgregate

meal participants, df = 1 and 741, = 27.7, p <0,01; univariate F for home-dellvered meal recipients, df = 1 and 123, = 11.8, p <0.01).

cThe Wave . to.wave increases in intake of these nutrients may be strongly related to 25 to 50 percent increases in food nutrient enrichment levels that took effect for

these nutrients since Wave I while RDAs for these nutrients have changed little.

SOURCES: Opinion Research Corp. and Kirschner Associates (1983) (38).

Table C-7.—Percent of Total Day’s Nutrient Intake Supplied by Title ill Meal

Meal Program

Missouri a Coloradob New Yorkc

Both

Nutrient Men Women Men Women sexes Range

Energy . . . . . . . . . . . . . . ... . . . . . . . 46.4V0• 52.4V0• 41 +3% 48 + 2% 45+3% 29–72%

Protein . . . . . . . . . . . . . . . . . ... . . . . 47.5* 55.1 ‘ 54* 3 59* 2 51 + 2 22-86

Calcium . . . . . . . . . . . . . . . . . . . . . . . . . . 42.4 45,2 48 + 4* 61 + 3’ 44* 3 12-91

iron . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41.6* 46.7* 46 + 3 52 + 2 48 + 3 12-79

Vitamin A . . . . . . . . . . . . . . . . . . . . . . . . . . 50.5 52.6 49* 5 59+ 3 57* 4 19-70

Thiamine . . . . . . . . . . . . . . . . . . . . ., . . . . 38.8 42.2 39* 3 42 + 2 48+ 3 18-90

Riboflavin . . . . . . . . . . . . . . . . . . . . . . . . 41.4 44,4 50* 3 56 + 2 47* 2 12-94

Niacin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45.6’ 53.0” 53* 4 54* 2 52 + 2 2-94

Vitamin C . . . . . . . . . . . . . . . . . . . . . . . . . . 48.4 46.3 36 + 5 44* 4 48+ 4 10-95

a Based on 54 men and 100 women

b Based on 14 men and 45 women c Based on 53 subjects Of both sexes

.Differences between men and women are statistically significant for the survey (p < 0 05)

SOURCES: Kohrs, O’HanIon, and Eklund (1978) (29); Kohrs, et al. (1980) (31); Harrill, et al. (1981) (20); Caliendo (1980) (8).
.

430 ● Technology and Aging in America

Table C-8.—Mean Percentages of Recommended Dietary Allowances (RDAs) Provided by Meals Served at

Congregate Meal Sites (mean + standard error)

Area served by meals

National a Missouri b Coloradoc

Nutrient Men Women Men Women Men Women

Protein . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66+ 1% 84* 2% 75* 3% 91* 4% 81 + 12% 99* 14%

Calcium . . . . . . . . . . . . . . . . . . . . . . . . . . . 61 + 2 61&2 65 + 3 65* 3 60* 3 60* 3

Iron . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51* 1 51* 1 5 3 3 53* 3 62+7 62 +7

Vitamin A. . . . . . . . . . . . . . . . . . . . . . . . . . 106 +0 133 +2 70* 12 87 +15 72& 28 90* 35

Thiamine . . . . . . . . . . . . . . . . . . . . . . . . . . 34+1 48 +1 41* 4 4 9 + 36 +1 43* 2

Riboflavin . . . . . . . . . . . . . . . . . . . . . . . . . . 6 4 + 71* 3 63 +3 86&3 61 +4 8 3 +

Niacin. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49+1 57* 2 40* 3 54& 3 65 +10 86& 13

Vitamin C. . . . . . . . . . . . . . . . . . . . . . . . . . 73&3 73&3 83+ 3 83+ 3 5 2 + 5 2 +

Zinc . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 4 + 2 4 + — — — —

aBased on 117 meals froms representative of each region and the United States.

b Based 20 menus served during survey days 5 sites.

c Based on 5 meals served at site during survey.

NOTE: CAUTION NEEDS TO BE EXERTED IN USING SUCH VALUES BECAUSE NUTRIENTS MAYHAVE BEEN LOST OR DESTROYED DURING COOKING PROCESS.

THESE RESULTS ARE ALSO BASED ON THE ASSUMPTION THAT THERE INADEQUATE PORTION CONTROL.

SOURCES: Opibuib Research Corporation and Kirschner Associates (1983) (37); Kohrs, O’HanIon, and Eklund (1978) (29); Harrill, et al. (1981) (20).

Table C-9.–Comparison of Analyzed and Calcuiated Percentage of Recommended Dietary Allowance (RDA)

Values in Meals Served to the Elderly (+ standard error)

Analyzed Calculated

Nutrient Men Women Men Women

Protein . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70 2% 90* 2%0 65 + 2% 83+2%

Calcium . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53 + 2 53* 2 59& 2 59* 2

Vitamin A . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62 + 6 78 + 8 112 +20 140 +24

Thiamine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ... , . . . . . . . . . . . . 40* 4 56& 6 34+ 1 48 + 2

Riboflavin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51 + 2 60 + 6 64 + 5 75 + 6

Vitamin C . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20* 2 19+2a 67+6 67+6

Zinc . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29+2a 29&2a 24+1a 24+10a

a Less than One-third of the RDA

SOURCES: Opinion Research Corporation and Kirschner Associates (1983)(37)

ent in certain foods (e.g. folic acid or zinc) (3,7,44).

More such chemical analyses would enhance the accuracy of these kinds of evaluations.

In the Missouri evaluation, the total day’s dietary intake of nutrients reflected the nutritional content of

the program meal (26,29; see fig. C-l). The nutrients

provided in the greatest amount by the program

menu—protein and vitamins A and C—were also consumed in the greatest amount. Nutrients that were

provided in smaller proportions of the RDA in the

meals-energy and niacin for men and thiamine for

both sexes—were those for which the totaldaily consumption was less than 100 percent of the RDA (fig.

C-l). These results from food records were reinforced

by data from dietary histories and blood sample analyses (27)28,31).

People who participated regularly in the Missouri

program reducedtheir risk for clinical deficiencies of

vitamins A and C. These results were strengthened

by longitudinal data; fewer incidences of low serum

values forthese vitamins were recorded after l year

in the program, and none were found after 4 years

of participation (27)28; table C-10). In contrast, no improvement was seen in risks for anemia, especially

iron-deficiency anemia, in terms of dietary intake or

serum hemoglobin and iron (26,27,28)31).

There is a risk of increasing intake of foods high in

saturated fats and cholesterol (like red meat) when

providing meals high in energy, protein, and calcium.

The Missouri evaluation, however, found no evidence

of either elevated intake of these substances or of

obesity (another risk factor for cardiovascular disease)

among regular participants who ate program meals

two to five times a week (27)31).

Percent of Total Day’s Intake Provided by Meal: The

proportion of the total day’s nutrient intake provided

by the program meal was evaluated by the Missouri

and the single-site surveys in Colorado and New York.

All three evaluations (8,20)29) indicated that a substantial proportion of the total day’s intake was consumed
App. C—Nutrition Information • 431

Figure C-1 .—One-Day Intake of Nutrients by Participants Eating at the Meal Program, Expressed as Percentage

of Recommended Dietary-Allowance

200

180

160

1

M—Males

F—Females

140

120

M—

—

—

M

F

—

, .

,

100

t

F

M

80

60

40 -

20 -

— — — —

Calories Protein Calcium Iron Vitamin A Thiamine Riboflavin Niacin Vitamin C

Total day’s intake Supplied by meal program

SOURCE: Kohrs, O’HanIon, and Eklund (1978), (29).

Table C-l O.—Percentages of Participants at One

Site Who Had Low Concentrations for Serum

Vitamins A and C,a According to Year Blood

Samples Were Taken

during the program meal. All indicated that an average of 40 percent or more of the total daily nutrient

intake (not the RDA) for each individual was consumed

during the meal (table C-7). The results of the other

two surveys are similar to those from Missouri (fig.

C-2). In some cases, an average of 60 percent of the

total day’s nutrient intake was provided by the program meal (table C-7). In Missouri, the program meal

supplied a larger average proportion of the total day’s

intake of energy, protein, iron, and thiamine to women

than to men.

Serum Serum

Year vitamin A vitamin C

1975 . . . . . . . . . . . . . . . . . . . . . . . 430/0 70/0

1976 . . . . . . . . . . . . . . . . . . . . . . . 13 2

1979 . . . . . . . . ............. . . . 0 0

a Low concentations for vitamins A and CWere gllO() rlll and < 1).z rTl@loo

ml, respectively.

SOURCE: Kohrs (1982), (27)
. —

432 ● Technology and Aging in America

Figure C-2.—Percent of Total Day’s Intake of Nutrients Furnished by the Meal Program, for Males and Females

* *

Calories Protein

Males

c 1

Females

● Significantly different (p< 0..05)

SOURCE: Kohrs (1982), (27).

Calcium Iron

These results suggest that a large number of participants in the three programs depend on the program meal for much of their daily food intake. Ironically, those participants whose major nutritional

source is the program meal are probably more at risk

for deficiencies since, even if the meal provides its

mandated 33 percent of the RDA for most nutrients,

their total daily intake would be well below the RDA.

The values for the New York evaluation reflect the

great variability underlying these data (table C-7). For

some participants in the New York program, the meal

provided more than 75 percent of their day’s intake

of protein, iron, calcium, riboflavin, niacin, thiamine,

and vitamin C. If the meal in fact provided only 33

percent of the RDA for these nutrients, these participants could be consuming less than half of the RDA

per day. Yet some received 12 percent or less of their

daily intake for many of these nutrients in the meal

and thus would be more likely to meet the RDA by

supplementing their diet outside of the program.

Participants v. Nonparticipants: The national, Missouri,

and Colorado surveys all compared the nutrient intake of participants with that of nonparticipants. All

three found that intake of vitamins and minerals was

significantly increased by participation in the title III

congregate meal program (20,29,36)37). The national

survey used 24-hour recall; the other two surveys used

food records.

Vitamin A Thiamine Riboflavin Niacin Vitamin C

These three surveys and another evaluation of elderly

Koreans participating in the meal program (23) all

found that the program significantly increased calcium

intake, one of the major nutrients frequently lacking

in the diets of older women and implicated in hypertension and osteoporosis.

The Missouri survey revealed that intakes of energy

and protein were greater for the participants who ate

the program meal than for both nonparticipants and

participants who did not eat a program meal on the

day of the food record (fig. C-3). The national survey

demonstrated that the energy intake for women under

age 76 who ate the program meal was proportionally

greater than that of women who did not participate.

Moreover, the energy and protein intake of those

participants not involved on a particular day was still

higher than that of the control group (nonparticipants)

in Missouri. This finding suggests that other services

such as transportation, shopping assistance, and nutrition education contribute to improved intake for

participants even when not eating at the program, and

that partial savings by eating program meals may be

used to buy more and better food.

In Colorado, the survey found that intake of several

other nutrients, including fat and some of the B vitamins (thiamine, riboflavin, and niacin), was greater

for participants than for nonparticipants. Biochemical

evidence of iron-deficiency anemia, found in a small
App. C—Nutrition /formation ● 4 3 3

Figure C-3.—InfIuence of Meal Program Participation Status on Percentage of Recommended Dietary

Allowance Consumede

— 100

I

a — b

Calories Protein Calcium Iron

Participants—meal program day

n

Participants- nonmeal program day

a Bars with different letters (a,b,c) are significantly different (P KO.05)

SOURCE: Kohrs, O’HanIon, and Eklund (1978), (29).

number of participants and nonparticipants in Colorado (220), was more common among the nonparticipants.

The national evaluation further reported that overall intake of energy and eight nutrients was greater

for participants in comparison with nonparticipants,

former participants, and those who did not eat the

meal that day (table C-6). The report suggests that improvement in dietary intake is a function of actually

consuming the program meal rather than simply being enrolled in either congregate or home-delivery

services (36,37).

Correlation of Nutritional Status With Sex, Age,

Race, and Income: The Nutrition Program for Older

Americans is mandated to help meet the needs of those

who are poor, socially isolated, over 75, members of

an ethnic minority, limited in ability to speak English,

and/or have a mobility impairment. A profile of participants in both the congregate and homedelivered

meal programs, as well as former participants and

nonparticipating neighbors, is given in table C-II. The

low-income and over-75 target groups appear to have

higher proportions who are program participants,

Control —nonparticipants

with those who suffer mobility impairment predictably composing most of the homedelivered meal recipients. Other groups, however, comprise markedly

lower proportions of all participants-including minorities, those who are socially isolated, and especially

those whose English is limited (table C-II). This could

be due to lack of awareness or inaccessibility of the

program among these groups.

Other demographic variables of interest are presented in table C-12. Recipients of homedelivered

meals were generally older, poorer (65 percent had

incomes below $6,000 in 1981), and in poorer health

than the congregate meal recipients. The national

evaluation concluded that congregate-meal participants qualifying as “priority” recipients due to advanced age, low income, minority status, isolation,

mobility impairment, or lack of fluency in English aggregately constitute three-quarters of all congregate

participants (36)37).

On average, participants are getting older-ne-third

of participants were over 75 in 1978 compared with

41 percent of congregate participants and two-thirds

of homedelivered meal recipients in 1982. Interest-
434 . Technology and Aging in America

Table C-11 .—Percentage of Survey Respondents With Specific Priority Traits

Priority traits

Limited

Social Mobility ability

Low Minority isola- impair- to speak Advanced

incomea

status tion ment English ageb

Home-delivered meal recipients

(N=415) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 650/0 15% 190/0 720/0 20% 670/0

Former participants

(N=249) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61 14 17 22 —c 59

Congregate participants

(N=1,735) . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52 19 17 11 2 41

Non-participating neighbors

(N=1,039) . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46 18 15 17 1 40

a Below $6,000 anual 1981 income.

b 75 years of age or older. c Denotes less than 1 Percent.

SOURCES: Opinion Research Corporation and Kirschner Associates (1983), (36).

Table C-12.—Selected Characteristics of Congregate

Meal Participants and Home-Delivered Meal

Recipients

Congregate Home-delivered

Characteristic participants meal recipients

,. , . ---- ,. # . . -.

Average age (in years) . . . .

Live alone . . . . . . . . . . . . . .

1981 family income below

$6,000 . . . . . . . . . . . . . . .

Income takes care of

needs only “poorly” . . .

Household receives food

stamps . . . . . . . . . . . . . .

Receives Medicaid

benefits. . . . . . . . . . . . . .

Get out of house nearly

every day . . . . . . . . . . . .

Able to clean and

maintain home by

themselves . . . . . . . . . . .

Fair or poor current

health . . . . . . . . . . . . . . .

Health worse than last

year . . . . . . . . . . . . . . . . .

Spent time in hospital/

nursing home in past

year . . . . . . . . . . . . . . . . .

Rarely or never attend

religious services. . . . . .

Never invite others to eat

at their homes . . . . . . . .

(N= 1,(3!3)

73

550/0

52

16

13

18

81

89

25

16

23

24

23

(N= 415)

78

61%

65

24

19

30

24a

41a

59a

38

44a

63a

66a

a Discriminnant function analysis revealed that these variables maximally

discriminate between the two groups. All univariate F values >650, all p’s 0,01

(df = 1 and 1,208)

SOURCES: Opinion Research Corp. and Kirschner Associates (1983), (36).

ingly, the average annual income of participants is also

rising and is more evenly distributed in the $9,999 and

under group with fewer participants earning less than

$4,000 a year (table C-13).

Results of both the national and Missouri evaluations

for dietary intake indicated that at least some of the

program’s target groups benefited (30)36,37). The

Missouri evaluation found that participants over 75

consumed a larger proportion of their total daily intake of calories and vitamin A than did younger participants.

The national evaluation found income to be significantly related to dietary intake among congregate and

home-delivered meal participants as well as nonparticipants (36,37). Among persons receiving less than

$6,000 annually, a greater proportion of those who

ate a program meal consumed the minimum recommended amounts of calcium, vitamin A, and calories

than those who did not participate (table C-14). Eating

a program meal significantly reduced income-related

intake differences for calcium and calories.

Although the Missouri evaluation did not indicate

income, it did conclude that the meal program ameliorated the differences in nutrient intake found to be

related to level of education and pre-retirement occupation (26,30; fig. C-4 and C-5). In fact, education,

pre-retirement occupation, and marital status were

not shown to be related to the RDA-proportion of nutrients consumed by those who ate the program meal

on the day of the food record. In contrast, such socioeconomic factors were significantly related to intakes
App. C—Nutrition Information ● 435

Table C.13.—lncome Distribution of Respondents During Wave I and Wave 11, 1975 and 1981

Wave II (Wave I in parentheses)

Home- NonParticipants delivered particiLonger Recent meal pating

Annual family incomea Total term entrants recipients neighbors

N = 1,735 N = 878 N = 857 N = 415 N = 1,037

(N= 2,803) (N= 972) (N= 1,831) (N =0) (N= 1,797)

Less than $2,000 . . . . . . . . . . .

$2,000-$ 3,999 . . . . . . . . . . . . . .

$4,000-$ 5,999 . . . . . . . . . . . . . .

$6,000-$9,999 . . . . . . . . . . . . . .

$10,000-$ 13,999 . . . . . . . . . . . .

($10,000 or more)b

$14,000-$ 17,999 . . . . . . . . . . . .

$18,000 -$21,999 . . . . . . . . . . . .

$22,000 or more . . . . . . . . . . . .

Refused/no response . . . . . . .

Total . . . . . . . . . . . . . . . . . . . .

3%

(19%)

(23)

(17)

(11)

10

(5)

6

2

3

(1)

100

3%

(220/0)

(50)

(14)

(10)

10

(3)

5

2

2

(1)

100

4%

(1 7%)

(45)

(19)

(12)

10

(6)

7

2

3

(1)

100

7%

(N .A.)d

(N3A)

(N.A)

(N.A)

(N.A.)

(N.A.)

(N.A)

(N.A.)

(N.A)

100

3%

(15%)

(40)

(19)

(14)

(11)

6

3

6

(1)

100

(loo) (loo) (loo) (N. A.) (loo)

aWave I data reflect self-reported or estimated annual family Income for 1975 Wave II data reflect self-reported or estimated annual family Income for 1981

b 00 or more,, was the highest income category used during wave 1

cDenotes less than 1 PerCent

‘Not assessed

SOURCES: Opinion Research Corp. and Kirschner Associates (1963), (36).

Table C-14.—Relationship Among Daily Dietary Intake of Low Intake Nutrients, Nutrition Program Participation,

and 1981 Family Income

Ate a program meal Did not eat a program meala

Met or exceeded two-thirds RDAb Below $6,000 $6,000 or more Below $6,000 $6,000 or more

(N = 678) (N = 409) (N = 1,107) (N = 1 ,077)

Calcium. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 1 % 630/0 420/0 51%

Vitamin A . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65 74 46 54

Calories. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73 78 62 73

 Includes all respondents who did not eat a program meal (I e partlclpants, home-delivered meal recipients, nonparticipants and former participants)

Among those who did not eat a program meal, Income was signiflcantly related to higher intake for each nutrient (all x 2. 1 df, >54, all p’s 0.01)

Among those who consumed a program meal, Income was significantly related to higher intake of vitiam A (X

2

. 1 df = 79, p › O 01), but not for calcium or

calories (all x 2, 1 df, 29, all p’s >0 05)

SOURCES: Opinion Research Corp. and Kirschner Associates (1963), (36).

of calories and seven nutrients among the participants

who did not eat the meal program that day and also

to the intake of six nutrients among nonparticipants

(figs. c-4 and c-s).

In general, using dietary intake as a measurement

for meeting the nutritional goals of the title III program, the national and Missouri evaluations found that

people with lower socioeconomic status benefited the

most by eating the program meal.

Nutrition Education: The title III program is mandated to provide nutritional education as one of the

services associated with the meal program. The national evaluation reported that at most sites nutrition

education classes were generally offered less than

once a month (36)37). Site managers reported that

benefits of nutrition education could be augmented

by increasing the frequency of the classes and by improving the qualifications of the teaching personnel.
436 ● Technology and Aging in America

Figure C-4.—influence of Group, on Percentage of Recommended Dietary Allowance for Protein,a

120

100

80

60

40

20

a—

—

.

.

a

b

.-

by Sex and Education

b

a

a 7

s eth

grade

9-12th

grade

> 12th

grade

s eth

grade

a

9-12th

grade

Males Females —

I I Participants —meal program day

Participants-nonmeal program day

Cent rot—nonparticipants

a—

a

> 12th

grade

aBar.g with different letters (a,b,c) are significantly different (p z 0.05) within each education 9r0uP.

SOURCES: Kohrs, et al. (1979), (30).

Nutrition instruction is useful in that it helps individuals to shop and prepare nutritious foods in an

economical way. The cost effectiveness of providing

nutrition education by registered dietitians and trained

nutritionists in terms of health costs averted and fewer

dependents on the meal program has not yet been

evaluated.

A pilot program in Missouri found not only that

older people were interested in participating in nutrition education classes, but that those who attended

a program regularly for 5 out of 10 classes increased

their knowledge of good nutrition (27,28). The effect

on dietary intake, however, was not evaluated.

In general, the nutrition classes tend to be too long.

A 10-minute lecture accompanied by take-home nutritional guides may be more effective.

Participants'Perception of Program Benefits: The national evaluation and an evaluation in Boston both

studied the participants’ perceptions of the meal

program.

The national evaluation found that people enrolled

in the program reported that participation may help
App. C—Nutrition Information ● 437

Figure C-5.—influence of Meal Program Participation Status on Percentage of Recommended

12(

10(

80

60

40

20

for Calories and Protein, by Occupationa

.

.

.

a

l a

L Professional

managerial

a

ab

a a —

a

1 a

Dietary Allowance

a a

Skilled

clerical

Unskilled

manua l

Professional

managerial

Skilled

clerical

Unskilled

manua l

Calories Protein

I 1

I IParticipants–meal program day

I !

Participants-nonmeal program day

Control—nonparticipants

a B With different letters (a,b,c) are significantly different within each Occupation.

SOURCE: Kohrs, et al. (1979), (30).

to keep them mobile. Those who remained active in by enhancing social activity and maintenance of posithe program from the beginning of the survey in 1975 tive self-perceptions of health status (36,37).

reported more mobility than did respondents who ei- The Boston evaluation attempted to determine the

ther left the program or never enrolled. The national participants’ perceptions in terms of their personal

evaluation also reported that when age, minority goals and the programs’ value to them (38). The parstatus, sex, and self-reported health were controlled, ticipants most valued the setting for the congregate

program benefits were not apparent in terms of in- meal, the recreational and social activities, and the

creased longevity. Even so, the evaluation asserted, financial relief. Most of the participants (81 percent)

participation itself may help sustain the quality of life indicated that the program was achieving all of the
438 ● Technology and Aging in America

following goals: provision of the meal, increased opportunities for socialization, and better health through

improved nutrition.

The greatest impact of the Boston program was

found to be in the financial, social, and recreational

areas. Even though the participants felt that the program was meeting the goal of improved health through

nutrition, fewer than 5 percent reported that the program affected their diet or health. The Boston study

concluded that those with more frequent patterns of

participation and those with greater need for financial assistance reported significantly greater effects on

monetary savings, food preparation practices, food

consumption, and food purchasing behavior (38).

Nutrition, Cost, Sanitation, and Acceptance of Different Food DeZivery Systems: By 1982, the number

of congregate meal sites was about 13)500, more than

twice the total of 6,700 in 1976. The number of meals

served per day also doubled during that period, rising to approximately 800,000 congregate and homedelivered meals in 1982. Although the prevalence of

homedelivered meals did not change from 1976 to

1982 (most programs offer them), the average number of homedelivered meals served daily per site doubled, and the proportion of homedelivered meals relative to all meals being served tripled. Currently, about

175,000 title III meals are being home-delivered daily

within the contiguous States, constituting about 22

percent of all title III meals (36,37).

Nutrition: The clearest comparison of the nutritional

effectiveness of congregate v. home-delivered meals

is presented in the national evaluation (table C-5). Intake of all nutrients measured was consistently lower

for home-delivered meal recipients. The national

evaluation attributes this, at least partly, to the home

recipients’ poorer health status and greater difficulty

in chewing (36,37). The greater isolation and related

depression to which the homebound are especially vulnerable may also inhibit intake.

The congregate and home-delivered meals were

identical in 80 percent of the sites—any differences

were attributable to transportation constraints or to

the different dietary needs of the homebound recipients who are more likely to need low-salt, low-sugar,

or low-fat meals. The national survey also concluded

that the recipients of home-delivered meals benefited

more than congregate participants, since the former

showed lower intakes for most nutrients on non-meal

program days (36,37).

Cost: A study of food delivery systems in the title

III programs for the elderly looked at four factors that

could theoretically influence cost of the meals: meal

preparation systems (i.e., catered v. onsite preparation), project size, urban v. rural setting, and region.

Project size was the only factor found to be related

to cost (25). The slightly lower costs per meal achieved

by larger projects were not a result of lower food and

food service costs but of lower cost for support activities like administration, outreach, and nutrition education. Statistical analysis of the relationship between

the cost and the quality of the meals found that the

two were unrelated.

The average cost per meal was calculated to be $4.08

by a later national study. Although figures were not

provided, a major problem with home-delivery service is that funding is inadequate to meet demand.

According to area directors, only 52 percent of the

elderly people who need home-delivered meals in the

United States are receiving them. Home-delivered

meals are usually prepared at or distributed through

the congregate meal sites (36,37). Additional cost may

be incurred, however, in providing delivery equipment and personnel.

Sanitation: A local evaluation in Ohio (24) studied the

sanitary conditions and acceptance of onsite-prepared

v. catered meals in the title III program. Analyses of

the meals for microbial contamination indicated that

onsite preparation was generally more sanitary than

catering.

Meal safety was also assessed in the 1981 national

study (25) through sanitary inspections of meal sites

and microbiological analyses of the meals themselves,

Results varied widely among sites, some of which were

found to be deficient in their sanitary practices. Although this study did not evaluate the administrative

personnel of the meal programs, it suggested that food

programs would benefit by utilizing registered dietitians to improve sanitation and food management in

general. Such dietitians are trained not only to regu.

late the nutritional content and sanitary conditions of

the meals but to ensure optimum preservation of nutrients in food preparation and cost-effective food

management.

In a nationwide study of food delivery systems and

technologies commissioned by the AoA with the American Dietetic Association, a major finding was that service regulations failed to designate qualified personnel

to plan, manage, and evaluate nutrition services (33).

other problems identified included a lack of detailed

food specifications on food products, equipment,

packaging, and delivery practices for both congregate

and home-delivered meals. Also cited as concerns

were: maintenance of food temperature during transportation; a reliance on untrained volunteers to deliver meals and services; variable food portion control;

limited space for food preparation and delivery; safety

and sanitation hazards; and a limited number of certified management personnel.
App. C—Nutrition Information ● 439

Many of the staff and food management problems

cited in the above studies could be addressed by instituting standard regulations for food programs mandating the employment of registered dietitians at meal

program sites. The national evaluation did not analyze

whether or how registered dietitians are used. One

of the most frequent complaints of State and area program directors reported in this study, however, concerned the low quality of the staff. Most of the local

directors (71 percent) said that additional training in

fiscal, personnel, and food management, as well as

gerontology, would improve nutrition program operations (36,37).

The national evaluation reviewed the educational

levels of certain management personnel, including

those called “nutritionists/dietitians.” It is probable that

many people so designated are not registered dietitians, since 7 percent did not finish college; this figure

jumps to 11 percent for area agency directors, 39 percent for “nutrition directors, ” and 83 percent for “site

managers” (36)37). Registered dietitians must have a

college degree with additional on-the-job experience

and must have been accepted into the American Dietetic Association. A nutritionist is required to have still

more training and usually also holds an advanced

degree.

Acceptance: Expert tasting panels were used in the

local Ohio study to assess the taste and esthetic quality

of the meals. onsite-prepared meals were found to be

of superior quality and greater in quantity than catered meals (24). Ratings for acceptance and food

quality were low for both types of meal preparations;

however, only 36 out of 501 respondents indicated

that they enjoyed the food served at the meal sites.

This clearly indicates a need for revised content and

preparation of the meals.

FOOD STAMP PROGRAM PARTICIPATION

The Food Stamp Program is the largest of all food

and nutrition programs affecting the noninstitutionalized

elderly. The degree of participation and the factors

determining participation in the Food Stamp Program

(FSP) have been evaluated in two studies. One was

based on the National Food Consumption Surveys of

low-income households conducted in the periods 1977-

78 and 1979-80 (2), and the other was an evaluation

of a local food stamp cashout demonstration (5).

The national study found that about 50 percent of

eligible elderly households participated in 1979-80, as

opposed to less than 40 percent in the earlier period

(2). Participation increased at about the same rate

among whites and blacks. This increase in participation could be due largely to elimination of the purchase

requirement in January 1979. There has been recent

speculation, however, that the expanding FSP is still

not reaching the most needy (38). Correlation of demographic variables with participation can help reveal

factors affecting the decision to participate and thus

help generate policies or regulations that would encourage participation of the most needy population

groups.

Significant influence of several variables on FSP participation was found in both the 1977-78 and 1979-80

periods. Participation at every income level among

those eligible rose by 10 to 15 percent in the later

survey, although figures for the lower income groups

and younger age groups were consistently higher in

both time periods (2,5; figs. C-6 to C-9). The proportion of the poorest households (those below poverty

level) participating rose from about 33 percent in 1977-

78 to 60 percent in 1979-80 (2). Interestingly, estimates

of participation in elderly feeding programs (including

congregate and homedelivered meals) dropped, while

overlap between these and the FSP seemed to rise

(tables C-15 and C-16). Since there was no change in

sampling criteria to allow for tightening of eligibility

requirements in 1979, FSP participation among the

relatively smaller eligible group in 1979-80 may in fact

have been underestimated.

Owning a home, which negatively affected participation, did so more strongly among urban than rural

residents in both surveys (figs. C-10 to C-13). Receiving Supplemental Security Income dramatically increased participation for all age groups (2,5). Participation of urban elderly increased more than that of

rural elderly in the later survey and most markedly

at the lower income levels; the increase in the proportion of eligible rural elderly participating, however,

was relatively greater (2).

Households headed by women were significantly

more likely to participate both in the local demonstration (5) and nationally, in urban areas in 1977-78, and

rural areas in 1979-80. People who lived in larger

households were more likely to participate in the FSP.

Living alone had a statistically significant effect only in

rural areas in 1979-80. Unfortunately, this means that

the socially isolated population, one of the FSP target

groups, is not well represented among participants.

The local cashout demonstration also found that people with some high school education were less likely

to use food stamps, Other factors inhibiting participation included lack of awareness, stigma, and distance from FSP offices (5). Participation in the FSP was

shown to increase food expenditures among those

surveyed.

The cashout demonstration further evaluated the effects of the food stamps and cashout on dietary intake of nutrients. While the overall estimated effect

of the program was positive for intake of all nutrients
440 . Technology and Aging in America

Figure C-6.-1977-78 Low-Income NFCS Urban Sample, Food Stamp Program Participation

.

INCOME $2,000 $4,000 $6,000 $8,000 $10,000 $12,000

LEGEND: AGE 55-64 65-74 75+

SOURCE: Akin, Guilkey, and Popkin (unpublished data), (2).

Figure C.7.– 1977.78 Low-Income NFCS Rural Sample, Food Stamp Program Participation

INCOME $2,000 $4,000 $6,000 $8,000 $10,000 $12,000

LEGEND: AGE 55-64 65-74 75+

SOURCE: Akin, Guilkey, and Popkln (unpublished data), (2).
App. C—Nutrition Information ● 441

Figure C“8.— 1979-80 Low-Income Followup Urban Sample, Food Stamp Program Participation

. -

100

80

60 -

40 -

20 “

0

1 n

INCOM E $2,000 $4,000 $6,000 $8,000 $10,000 $12,000

LEGEND: AGE ❑ 55-64 65-74 75+

SOURCE: Akin, Guilkey, and Popkin (unpublished data), (2).

Figure C-9.— 1979-80 Low-Income Followup Rural Sample, Food Stamp Program Participation

100

80

E

 6 0

0

c4 0

20

0

.

INCOM E $2,000 $4,000 $6,000 $8,000 $10,000 $12,000

LEGEND: AGE 55-64 ❑65-74 75+

SOURCE: Akin, Guilkey, and Popkin (unpublished data), (2).
442 ● Technology and Aging in America

Table C-15.—1977-78 Low-Income Population: Participation in Elderly Food and Feeding Programs,

Participation Status for Persons Aged 65 and Older (in percent)

In only

In only elderly

In neither food stamp feeding In both

Income as a percentage of poverty program program’ program a

programs Total

< 100% . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66.7% 29.5% 3.0% 0.8% 100%0

>1 00% and < 1250/o. . . . . . . . . . . . . . . . . . . . . . 58.7 36.0 3.4 1.9 100

125% and <175%0, . . . . 75.0 20.9 2.6 1.4 100

175% . . . . , . . , . . . . . . . . . . . . . . . . . . . . . . . . 73.1 24.9 1.6 0.4 100

Race:

White . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68.8 26.8 2.9 1.5 100

Non-white . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60.8 34.7 3.0 1.5 100

Residence:

Urban . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61.7 33.2 3.1 2.0 100

Rural . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68.7 27.5 2.8 1.0 100

Note: Sample size 2,501 households a lncludes congrate feeding, meals on wheels, and other home-dellvery programs. Because eligibility criteria for these Programs exclude most of the 55 to 64 age

group, statistics are presented only for those aged 65 and older

SOURCE: Akin, Gullkey, and Popkln(unpubilshed data~ (2)

Table C-16.—l979-8O Low-Income Population: Participation in Elderly Food and Feeding Programs,

Participation Status for Persons Aged 65 and Older (in percent)

In only

In only elderly

In neither food stamp feeding In both

Income as a percentage of poverty program program program a

programs Total

<100%0 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41.0% 51.8% l.2% 6.0% 100%

>100% and <1250/o. . . . . . . . . . . . . . . . . . . . . . 41.7 52.0 2.8 3.5 100

125% <175%. . . . . . 56. 3 41. 9 1 . 4 0.4 100

175% . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63.5 33.2 1.7 1.7 100

Race:

White . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53.2 42.8 2.4 1.7 100

Non-white . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45.2 50.1 1.7 3.0 100

Residence:

Urban . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48.5 46.5 2.4 2.6 100

Rural . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50.1 46.0 1.8 2.0 100

Note: Sample size is 1,588 households,

a lncludes congregate feeding meals on wheels, and other home-delivery programs Because ellglbllity Criteria for these Programs exclude most of the 55 to 64 age

group, statistics are presented only for those aged 65 and older

SOURCE: Akin, Guilkey, and Popkin(unpublLshed data), (2)

surveyed, the improvement was significant only for

calcium (5).Therewere no significant differences for

the intake of nine nutrients between food stamp participants and nonparticipants. Those who received

cash instead of stamps, however, had a higher intake

of four out of the nine nutrients: protein, calcium,

vitamin C, and thiamine.

OTHER FOOD ASSISTANCE PROGRAMS

Food For Seniors, or the Elderly Feeding Pilot Project, was initiated by Congress in September of 1982

to analyze the cost effectiveness of distributing food

commodity supplements to prevent chronic malnutrition among the elderly. The project was authorized

to continue through fiscal year 1984 at three Commodity Supplemental Food Program sites (Public Law

97-98 and Public Law 97-103). These sites are located

in Detroit, Des Moines, and New Orleans, with participation at each limited to 1,900 elderly persons.

The commodities are commercially produced for the

U.S. Department of Agriculture through competitive

bids and include milk, canned meats, vegetables, fruits,

dried egg mix, peanut butter, instant potatoes, and

cheese (11). The monthly supplements, worth more

than $25 at retail, are meant to satisfy 100 percent

of the requirements for protein and other key vitamins

and minerals at a cost of about $11, which includes

the food and local administration.

An initial progress report from the Detroit site

reports that the supplement is satisfying more than

100 percent of the monthly RDA of protein, vitamin
App. C—Nutrition Information ● 443

Figure C-lO.– 1977-78 Low=lncome NFCS Urban Sample, Food Stamp Program

Ownership and Receipt of Supplemental Security income

100 -

80 -

E

$ 60 -

g

o.

c.-

=

al 2 40

2

20 -

0-

GROU P NO HOME OWNS HOM E NO SS1

SOURCE: Akin, Guilkey, and Popkin (unpublished data), (2).

LEGEND: A G E 55-64 65-74 “ ‘ 75+ ❑

Figure C-n .—1977-78 Low-income NFCS Rural Sample, Food Stamp Program

100

80

E

 6 0

0

c

E

 4 0

20

0

Ownership and Receipt of Supplementai Security income

I 1

Participation,

(SSI) -

by Housing

YES SSI

Participation, by Housing

(SSI)

GROUP NO HOME OWNS HOME NO SSI YES SSI

LEGEND: AGE ❑55-64 65-74 75+

SOURCE: Akin, Guilkey, and Popkln (unpublished data), (2).

38-800 0 - 85 - 1 5
—

444 “ Technology and Aging in America

Figure C.12.–1979.80 Low-income Foiiowup Urban Sampie, Food Stamp Program Participation, by Housing

Ownership and Receipt of Supplementai Security income (SSI)

—

—

GROUP NO HOME OWNS HOME NO SSI

—

—

YES SSI

LEGEND: AGE “~;’:: 55-64 ❑ 65-74 75+

SOURCE: Akin, Gulikey, end Popkln (unpublished deta), (2).

Figure C“13.- 1979.80 Low=income Followup Rural Sample, Food Stamp Program Participation, by Housing

100-

80< -

E

E 60 - m

Q

Q

c.—

E

a)

g 40 -

c?

20 -

0

Ownership and Receipt of Supplemental Security income (SSI)

GROUP NO HOME OWNS HOME

—

—

NO SSI YES SSI

LEGEND: AGE ❑55-6 4

c 1

65-74 75+ ‘.

SOURCE: Akin, Guilkey, and Popkin (unpublished data), (2).
App. C—Nutrition Information . 445

D, calcium, iron, riboflavin, vitamin B-12, and phosphorus. of the participants surveyed (20 percent), all

who responded said that the program had helped

them and that they enjoyed the food. A majority of

the participants were female, widowed, and black (11).

Conclusion

Overall, the title III congregate meal programs appear to be meeting many of the guidelines for nutrient intake. The evaluations, however, are flawed in

both the gathering and the analysis of the data. Menus

and meals have never been analyzed for some of the

lesser known nutrients such as zinc, folic acid, and

vitamin B6. Recent surveys involving biochemical

assessments of the nutrition of the elderly suggest that

a significant proportion of this age group may be deficient in these nutrients (3,7,16,27,28,44).

The sanitary and esthetic quality of program meals,

the program staff, and nutritional education for participants were all found lacking in some surveys, suggesting the need for more regulatory policy and further evaluations.

Finally, further study is needed to determine if either the meal programs or the rapidly growing Food

Stamp Program are really reaching the most needy

people. Analysis of the participant profile in both programs reveals that some of the target groups, especially the socially isolated, are not well represented

among participants. This suggests that some needy

groups are either ill-informed about the programs and

nutrition in general or that the programs are not

readily accessible to them.

Appendix C references

1. Aging Health Policy Center University of California at

San Francisco, “Nutrition Policy and the Elderly,” M. Nestle, P. Lee, and J. Fullarton (eds.), policy paper No. 2,

1983.

2. Akin, J. S., Guilkey, D. K., and Popkin, B. M., “Changes

in Elderly Household Participation in the Food Stamp Program,” University of North Carolina, Chapel Hill, unpublished manuscript, 1983.

3. Bailey, L. B., et al., “Folacin and Iron Status and Hematological Findings in Predominately Black Persons From

Urban Low-Income Households,” Am. J. Chn. AWr.

32:2346-2353, 1979.

4. Bierman, E. L., “Carbohydrates, Sucrose, and Human Disease,” Am. J. C]in. Nutr. 32:2712-2722, 1979.

5. Blanchard, L., et al., “Food Stamp SSI/Elderly Cashout

Demonstration Evaluation,” final report, Food and Nutrition Service, U.S. Department of Agriculture, June

1982.

6. Bowman, B. B., and Rosenberg, 1. H., “Digestive Function and Aging,” Human Nutrition: Clinical Nutritjon

37C:75-89, 1983.

7. Brennan, R., Kohrs, M. B., Nordstrom, J., and Shank, R.

E., “Composition of Diets of Low-Income Women: Comparison of Analyzed With Calculated Values,” J. Am. Diet.

Assoc., November 1983.

8. Caliendo, M. E., “Factors Influencing the Dietary Status

of Participants in the National Nutrition Program for the

Elderly, I: Population Characteristics and Nutritional Intakes,” J. Nutr. Elderly 1:23-40, 1980.

9. Caliendo, M. E., and Smith, J., “Preliminary Observations

on the Dietary Status of Participants in the Title 11142 Meal

Program,” J. Nutr. for the Elderly 3-4:21-39, 1981.

10. Cohn, S. H, Vaswani, A. N., Vartsky, D., et al., “Vivo Quantification of Body Nitrogen for Nutritional Assessment,”

Am. J. Clin. Nutr. 35:1186-1191, 1982.

11. Focus: HOPE, Food for Sem”or Citizens-Progm?ss Report,

September 1982—February 1983, Detroit, MI.

12. Food and Nutrition Board, National Research Council,

Recommended Dietary Allowances, 9th rev. ed. (Washington, DC: National Academy of Sciences, 1980).

13. Forbes, G. B., and Reina, J. C., “Adult Lean Body Mass

Declines With Age: Some Longitudinal observations,”

Metabolism 19:653-663, 1970.

14. Garry, P. J., Goodwin, J. S., Hunt, W. C., et al., “Nutritional Status in a Healthy, Elderly Population: Dietary and

Supplemental Intakes,” Am. J. Clin. Nutr. 36:319-331,

1982.

15. Garry, P. J., Goodwin, J. S., Hunt, W. C., and Gilbert, B.

A., ‘(Nutritional Status in a Healthy Elderly Population:

Vitamin C,” Am. J. Clin. Nutr. 332-339, 1982.

16. Grandjean, A. C., North, L. L., Kara, G. C., et al., “Nutritional Status of Elderly Participants in a Congregate Meal

Program,” J. Am. Diet. Assoc. 78:324-329, 1981.

17. Green, H. F., Dreizen, S., and Spies, T. D., “A Clinical

Survey of the Incidence of Impaired Masticator Function in Patients of a Nutrition Clinic, ” J. Am. Dent. Assoc.

39:561-571, 1949,

18. Grotkowski, M. L., and Sims, L. S., “Nutritional Knowledge, Attitudes, and Dietary Practices of the Elderly, ”

J. Am. Diet. Assoc. 72:499, 1978.

19. Hale, W. E., Stewart, R. B., Cerda, J. J., et al., “Use of

Nutritional Supplements in an Ambulatory Elderly

Population,” J. Amer. Ger. Soc. 30:401-403, 1982.

20. Harrill, I., Bowski, M., Kylen, A., and Wemple, R. R., “The

Nutritional Status of Congregate Meal Recipients,” Agihg

36:311-312, 1981.

21. Heaney, R. P., Gallagher, J. C., Johnson, C. C., et al.,

“Calcium Nutrition and Bone Health in the Elderly,” Am.

J. Clin. Nutr. 30:431-440, 1977.

22. Katz, S., “The Use of Fluoride and Chlorhexidine for the

Prevention of Radiation Caries,” J. Am. Dent. Assoc.

104:164-170, 1982.

23. Kim, K., Kohrs, M. B., Twork, R., and Grier, M. R., “Dietary Calcium Intakes of Elderly Korean Americans,” J.

Am. Diet. Assoc. 84:164-169, 1984.

24. Kincaid, J. W., “Acceptance of Onsite Prepared Versus
446 ● Technology and Aging in America

25.

26.

Catered Meals in Title VII Programs,” J. Nutr. Elderly

1:27-38, 1981.

Kirschner Associates, Nutrition Serw”ces ll”tle III, Part C:

Analyses of Food Service Delivery Systems Used in Pron“ding Nuti”tion Servi”ces to the Elderly (Washington, DC:

Administration on Aging, U.S. Department of Health and

Human Services, 1981).

Kohrs, M. B., “The Nutrition Program for Older Americans: Evaluation and Recommendations,” J. Am. Diet.

&WX!. 75:543-546, 1979.

27. Kohrs, M. B., “Evaluation of Nutrition Programs for the

Elderly,” Am. J. Clin. Nutr. 36 (Suppl. 4):812-818, 1982.

28. Kohrs, M. B., “A Rational Diet for the Elderly,” Am. J.

Clin. Nutr. 36 (Suppl. 4):796-812, 1982.

29. Kohrs, M. B., O’Hanlon, P., and Eldund, D., “Title VHNutrition Program for the Elderly, I: Contribution to One

Day’s Dietary Intake,’)J. Am. Diet. Assoc. 72:4547, 1978.

30. Kohrs, M. B., O’HanIon, P., Krause, G,, and Nordstrom,

J., “Title VII-Nutrition Program for the Elderly, II: Relationships of Socioeconomic Factors to One Day’s Nutrient Intake,” J. Am. Diet. Assoc. 75:537-542, 1979.

31. Kohrs, M. B., Nordstrom, J., and Plowman, E. L., et al.,

“Association of Participation in a Nutritional Program for

Elderly With Nutritional Status,” Am. J. Clin. Nutr.

33:2643-2656, 1980.

32. Mann, A. W., Mann, J. M., and Spies, T. D., “A Clinical

33.

34,

35.

36.

Study of Malnourished Edentulous- Patients,” J. Am. Dent.

/kXWC. 32:1357-1368, 1945.

McCOO1, A. C., and Posner, B. M., “Nutrition Services for

Older Americans: Food Service Systems and Technologies,” Administrative Guidelines (Chicago: American

Dietetic Association, 1982), pp. 1-5.

O’Hanlon, P., and Kohrs, M. B., “Dietary Studies of Older

Americans,” Am. J. C/in. Nutr. 31:1257-1269, 1978.

Older American Reports, “Appropriations Panel Approves OAA Funding Levels,” VII(37), September 1983.

Opinion Research Corp. and Kirschner Associates, “Volume II: Analytic Report,” An Evaluation of the Nutrition

Services for the Elderly (Washington, DC: Administration on Aging, Department of Health and Human Services, May 1983).

37. Opinion Research Corp. and Kirschner Associates, “Volume III: Descriptive Report,” An Evaluation of the Nutrition Serw”ces for the Elderly (Washington, DC: Administration on Aging, Department of Health and Human

Services, May 1983.

38. Posner, B, N., Nutrition and the Elderly (Lexington, MA:

Lexington Books, 1979), pp. 85-146.

39. Rossman, I., “Anatomic and Body Composition Changes

With Aging,” Handbook of the Biology of Agl”ng, C, E.

Finch and L. Hayflick (eds.) (New York: Van Nostrand

Reinhold, 1977), ch. 8.

40. Rowe, J. W., Andres, R., and Tobin, J. D., et al., “The

Effect of Age on Creatinine Clearance of Men: A CrossSectiOnal and Longitudinal Study,’)

J. GemxoL 31(2) 1976,

pp. 155-163.

41. Sherwood, S., “Sociology of Food and Eating: Implications

42.

43.

44.

45.

46.

for Action for the Elderly,” Am. J. Clin. fiutr.-26:l108,

1973.

U.S. Department of Health and Human Services, National

Center for Health Statistics, “Advance Report of Final

Mortality Statistics, 1980,” MontMy Vita] Statistics

Reports, vol. 32, No. 4 supplement, 1983.

US. Department of Health and Human Services, National

Center for Health Statistics, “Edentulous Persons in the

U. S., 1971,” NCHS Series 10(89), 1974.

Wagner, P. A., Bailey, L. B., and Jernigan, J. A., “Zinc

Status and Cellular Immunity in the Aged,” Fed. Proc.

(abstract) 42:579, 1983.

Walser, M., “Nutritional Support in Renal Failure: Future

Directions,” Lancet 1:340-342, 1983.

Williams, T. F., “Diabetes Mellitus,” Clin, Endo. Metab.

10:179-194, 1981,
Appendix D

Biotechnology

Introduction

Recent advances in recombinant DNA (rDNA) technology, cell fusion technology (monoclinal antibodies),

and bioprocessing technology (biological production)

promise to make earlier diagnosis possible and improve disease prevention and treatment. The ability

to develop more definitive diagnostic technologies and

predictive tools, as well as more cost-effective therapeutics, gives biotechnology the potential to reduce

the severity and burden of chronic disease among the

elderly.

New methods of biotechnology may improve pharmaceutical development and production in a variety

of ways, perhaps most importantly by increasing the

supply, variety, and quality of products now being

marketed by making them more effective, convenient,

safe, or economical.

Monoclinal antibody and rDNA technologies can

complement each other. For example, monoclinal antibodies (MAbs) can be used to identify and purify new

compounds, and rDNA technology can be used to

biologically produce them. Yet without advances in

bioprocess technology, the production process b y

which genetically manipulated micro-organisms are

adapted for large-scale industrial use, rDNA-based

pharmaceutical development is not possible.

Cell fusion—monoclinal antibodies

Cell fusion, the artificial joining of cells, combines

the desirable characteristics of different types of ceils

into one cell. Through cell fusion, the traits for immortality and rapid proliferation (derived from certain cancer cells), and the traits for production of specific antibodies (derived from specialized cells of the

immune system) are combined in the new cell line

(hybridoma) that results from the fusion. These hy -

bridomas produce large amounts of monoclinal antibodies—antibodies that are specific to only one kind

of antigen. Because of their specificity and their ability

to “home in” on specific kinds of cells, MAbs can be

used for a variety of pharmaceutical applications,

ranging from diagnostic assays, passive vaccines, and

drug delivery (i.e., chemotherapy) to body imaging and

purification.

HOW ANTIBODIES WORK

Production of antibodies is one aspect of a complex

of biological reactions known as the immune response.

Antibodies are produced by specialized cells (B lymphocyte cells) found in the spleen, lymph nodes, and

blood. Bzells recognize substances foreign to the body

(antigens) and respond by producing antibodies that

specifically recognize and bind to the antigens. Antigens can be almost any substance recognized by the

body as foreign—bacteria, viruses, or even chemicals.

The binding of the antibody to the antigen results in

breakdown of the antigen, thereby removing the antigenic response in the body.

Structurally, all antibodies have the same basic Yshape—two “heavy” chains and two “light” chains (see

fig. D-l). Each heavy and light chain has a “variable”

and a “constant” region. The variable region contains

the site that recognizes and binds to a specific antigen

in much the same manner as a lock to a key. This site

varies greatly from antibody to antibody, allowing for

a wide range of antigens to be recognized by the large

number of different antibodies that are naturally produced by the body. The constant region of the antibody is associated with effecter functions, such as

the secretion of antibodies from the B-cells, and “signaling” to the immune system after the antibody binds

with the target antigen. Thus, if the antigen is a complex macromolecule (e.g., a protein) with many anFigure D-l .—Structure of an Antibody Molecule

SOURCE: Office of Technology Assessment

447
448 . Technology and Aging in America

tigenic determinants, a large number of different Bcells, and a variety of antibodies specific to those determinants will be produced. By virtue of a very complex genetic scheme, millions of potential antibodies

are possible, but each Bwell is committed to only one

antibody. When the appropriate antibody-producing

B-cell contacts and “recognizes” its antigen, it clones

a set of identical cells, all of which produce the genetically programmed antibody for the life of the cells.

THE MAKING OF ANTIBODIES

Antibodies have long been important tools for clinicians and researchers who use an antibody’s specificity

to identify particular molecules or cells and to separate them from mixtures. The conventional production method by which antibodies are made for diagnostic, therapeutic, and investigational purposes is to

inject an antigen into a laboratory animal and, after

an immune response is triggered, to collect antiserum

(blood serum containing antibodies) from the animal.

This method of antibody production results in production of many antibodies of several classes and various

specificities. Moreover, the limited life span of the animal prohibits large-scale production of reproducible

antibodies.

Cell fusion technology and the hybridoma-producing

MAbs that result allow for the production of an homogeneous and therefore reproducible reagent in almost

unlimited quantities. Figure D-2 illustrates the method

used to prepare MAbs. As in vitro diagnostic tools,

murine MAbs (MAbs derived from mice) are very valuable, but as clinical tools for in vivo diagnosis and

treatment of human disease, their use is limited by

the fact that mouse protein is antigenic in humans and

eventually would be rejected by

Figure D-2.—Preparation of Monoclinal Antibodies

Mouse is

immunized with

a foreign

substance

or “antigen. ”

the body as a foreign

removed and

producing

ceils (B lymphocytes.)

Mouse myeloma

(tumor) cells

are removed

and placed in

tissue culture

Cells divide in

liquid medium

The products of this

fusion are grown in a

selective medium. Only

those fusion products

Myeloma cells which are both “immorare mixed and tal” and contain genes

fused with from the antibody pro6 lymphocytes ducing cells survive.

These are called

“hybridomas.”

Hybridomas are cloned

and the resulting cells

are screened for antibody production.

Those few cells that

1

produce the antibodies

being sought are grown

I

in large quantities for

production of

monoclinal antibodies.

SOURCE: Office of Technology Assessment, adapted from Y. Baakin, “In Search of the Magic Bullet,” Technology Review, October 1982, pp. 19-23.
App. D—Biotechnology 449

substance. Thus, for in vivo application, MAbs must

be produced from a human myeloma/human spleen

cell fusion. Several investigators and many new biotechnology firms have reported development of human myelomas that are suitable for hybridoma preparation, and successful fusions apparently result from

using these cell lines (17).

DIAGNOSIS AND DETECTION USING MAbs

The ability of MAbs to ‘(zero in” or target very specific antigens could theoretically give rise to as many

detection tests as there are antigens. Clinical trials for

MAb-based diagnostics are under way in medical

centers all around the country and the Food and Drug

Administration (FDA) has already approved some 30

MAb-based diagnostic kits. Although the greatest potential diagnostic application of MAbs may be for cancer, MAbs are being used most successfully in diagnostic kits to test for viral and bacterial infection and

other factors. MAbs are also expected to find expanded application in detecting, purifying, and/or

measuring such things as enzymes, hormones, plasma

proteins, drugs, and micro-organisms, leading to better prevention and treatment of chronic disease.

Viral and Bacteria] Infections.-A major problem in

clinical microbiology is the inability to rapidly identify the particular agent responsible for clinical disease. In many instances, infectious organisms require

from 3 days to 3 weeks for culturing. As a result, physicians often prescribe a broad-spectrum drug rather

than wait for laboratory data. MAb technology and

probe technology (discussed later in this section) offer the potential for rapid and highly specific tests to

replace current culture techniques for direct detection of infectious organisms.

Infectious diseases are a major cause of hospitalization in the United States, accounting for one-quarter

of all hospital admissions (11). While hospitalized, patients with weakened or deteriorated immune function (e.g., elderly patients or patients undergoing

chemotherapy) are often plagued by “opportunistic”

infections that may jeopardize recuperation. Several

days may pass before the infection can be diagnosed

and treatment initiated. Many U.S. companies are developing MAb-based diagnostic products for both viral and bacterial infections—including two major

pathogens, Websiella and Pseudomonas. These very

accurate diagnostics can be read rapidly (often within

hours).

Use of MAbs in virology has made it possible to identify new substrains of many viruses and to make distinctions between isolates from different parts of the

world (11). The ability to identify and differentiate

among the substrains is expected to help in the preparation of more effective influenza vaccines, Vaccines

against such viruses will be especially useful among

the elderly population, in whom influenza can be fatal.

Cancer. -Cancer cells have characteristic proteins

called tumor-associated antigens as cell surface markers

or as internal cellular markers that may be shed into

the blood or other body fluids. Although no antigen

that occurs exclusively in cancer cells has been identified, tumor-associated antigens that are relatively restricted to cancer cells, or to certain kinds of cancers

(as opposed to normal cells), have been identified. Additionally, certain types of malignancies, such as B-celI

tumors, possess quite distinctive markers which allow

useful characterization. At this time MAbs have been

generated to recognize antigens associated with almost

all human malignancies and have been made and used

in clinical trials for a number of different cancers.

MAbs are also being made against carcinoembryonic

antigen, a proposed marker for colon cancer, as well

as antigens such as alpha-fetoprotein, a protein that

can be used to diagnose early stages of liver cancer

(14). TWO MAb-based diagnostic kits have already been

approved by the FDA for carcinoembryonic antigen,

as have other kits for prostatic acid prosphatase and

human chorionic gonadotropin, hormones used as indicators for prostatic or testicular cancer. In other

cases, MAb reagents are being used to identify tumor

cells by staining tissue specimens.

The currently available range of human MAbs is

likely to be greatly extended in the next few years as

more and more labs make use of hybridoma techniques. New MAbs are likely to prove useful in diagnosis and subtyping of carcinomas, sarcomas, and

other related neoplasms (16). Moreover, a greater

number of MAbs will be available to monitor the level

of antigens in the body, thereby determining the effectiveness of treatment and extent of diseases.

Radioimmunoimaging.–The process of locating

tumors in the body, large or small, early or late, can

be facilitated by injecting radiolabeled MAbs specific

to tumor markers into the body. The MAbs can then

be read with ordinary imaging equipment and the

location of the tumor identified. Radiolabeled MAbs

can also be used to track metastasis of cancers. One

of the attractions of radioimmunoimaging is that it has

the potential not only to provide information about

the size and location(s) of tumors, but to determine

whether the cancer has metastasized. For example,

MAbs can be developed that distinguish malignant

from normal cells in the peripheral blood and bone

marrow of patients with acute lymphocytic leukemia

(15).

Imaging can also help physicians to determine which

type of therapy may be appropriate. For example,

knowing where the MAb has distributed throughout
—

450 . Technology and Aging in America

the body will tell the clinician whether it would be

appropriate to attach a therapeutic agent to that same

antibody. If there is sufficient localization, and if the

antibody is not localizing at some other crucial tissue

that would be irreparably damaged by the therapy,

immunotherapy might be the treatment of choice.

In addition to their application in locating tumors,

radiolabeled MAbs specific to fibrinogen are also being developed to locate and characterize blood clots.

Heart Attack. -Myocardial infarction, a blood clotgenerated heart attack, causes death of heart tissue

cells. When heart tissue dies, cardiac myosin (contractile muscle fiber) is released into the bloodstream. MAb

diagnostics, based on MAb affinity for myosin, are being developed to signal the beginning of myocardial

infarction (13) and to assess the extent of permanent

myocardial damage shortly after a heart attack occurs

(5). A radiolabeled MAb could be used to identify the

damaged part of the heart muscle and to quantify the

percentage of muscle damaged. Such a test would

enable doctors to decide whether a patient is still at

risk from infarction and to prescribe appropriate

treatment much earlier.

Brain Disorders.-The main biochemical abnormalities that occur in aging and in dementing disorders, especially senile dementia, appear to involve defects in neurotransmitter synthesis. MAbs have recently been used to isolate specific proteins that are present only on a small subset of neurons in the brain.

MAbs can thus be used to detect and quantify minute

amounts of neurotransmitters present in different regions of the brain. They are expected to gain increased

use in isolating many of the small peptides that appear to function as neurotransmitters. The ability to

quantify the level of these neurotransmitters would

be useful in studying normal functioning under different circumstances and in examining the transmitter imbalances associated with a variety of neurological disorders like dementia of the Alzheimer type.

Detection of distinctive abnormal cellular components,

such as the “paired helical filaments” of Alzheimer disease, may also provide earlier and more certain

diagnosis.’

Development of MAbs promises to make the identilcation and tracing of cell components more precise.

Using MAbs, scientists can locate and study cells and

cell types in the nervous system that share a common

function by identifying particular molecules in the

midst of complex nerve tissue. Transmitter receptor

makeup is being investigated by this technique with

potential benefits for diagnosing or treating diseases.

It is expected that MAbs will soon help answer fundamental questions about neurobiology, such as how

%X ch. 3 for a discussion of the aging brain and dementia.

nerve terminals recognize and interact with correct

target cells, perhaps resulting in a wider understanding of brain disorders.

PURIFICATION

Because of their unique properties of homogeneity,

specificity, and affinity, MAbs can be used effectively

to purify molecules, especially proteins. Various important proteins, including leukocyte interferon, are

already being purified using MAbs (17). Many others,

including a number of protein “growth factors,” have

been isolated and are being characterized, with the

possibility that they may soon be candidates for production by rDNA technology. Furthermore, large-scale

production of very pure active vaccines, using MAbs

to bind and isolate the antigens, is now possible.

PREVENTION AND TREATMENT USING MAbs

Applications of MAbs to prevent or treat diseases

are being pursued on two fronts: 1) administration of

MAbs as passive vaccines to protect against specific

diseases; and 2) coupling cytotoxic agents (e.g., diptheria toxin, ricin—a plant-derived toxin-or cobra

venom) to MAbs that direct the agents to diseased cells

(i.e., for drug delivery) (3).

Vaccines.-The technology being used to develop

MAbs for diagnosing bacterial and viral infections is

also being used to develop MAbs for passive vaccines

and treatment of these infections. Very few viruses

can be treated with drugs. Because viruses are parasites that live and reproduce inside human cells, it is

nearly impossible to develop a drug that can search

out and selectively kill the virus without harming the

patient.

All viral infections and some bacterial infections are

resistant to antibiotics. Worldwide medical research

is focused on finding ways to manufacture MAbs for

hundreds of known viruses. Human MAbs are currently being developed for the treatment of problematic bacterial infections that are often resistant to

conventional antibiotics and commonly occur in hospitalized patients with long-term illnesses (e.g.,E. coli,

Klebsiella, and staphylococcus).

Immunotoxins.—With the advent of MAbs, the

promise of a “magic bullet” approach to cancer therapy has been revived, In this case, the magic bullet is

a tumor-specific antibody to which a toxic substance

(immunotoxin) has been chemically linked (2). MAbs

produced against unique antigens on the surface of,

for example, leukemia cells can be linked to plant or

bacterial toxins. Such immunotoxins may then be used

for the selective and specific elimination of cells bearing the target antigen on their surface (9). Unlike conventional forms of cancer treatment, which kill both
App. D—Biotechnology 451

healthy and cancerous cells and often create serious

side effects, it maybe possible to design MAbs tagged

with a chemotherapeutic agent that will bind only to

proteins on the surface of cancer cells. Several research groups have reported success in using antibodydirected cytotoxic agents (14), marking the first

time that tumor cells have been targeted for treatment

while leaving normal cells unaffected.2 The success of

these experiments gives credence to the belief that

antibody drug, antibody-hormone, antibody-enzyme,

or antibody-toxin conjugates may prove therapeutically useful in a variety of disease conditions.

Plasmapheresis. -The specific binding properties of

MAbs give rise to potential applications in treating

some of the autoimmune diseases-conditions in

which the body mistakenly identifies some of its own

substances as foreign and manufactures antibodies

against them. In myasthenia gravis, for example, antibodies are generated against the acetylcholine receptors in the neuromuscular junction, resulting in progressive weakening of the skeletal muscles. In a process

akin to kidney dialysis, MAbs could potentially be used

to purify the blood and remove these antibodies, thus

improving the condition of the patient. Similarly, MAbs

may prove useful in extracting factors implicated in

arthritis.

Recombinant DNA

DNA (deoxyribonucleic acid), a universal genetic

code, carries all of the information necessary to direct each and every function of every living organism;

it contains the complete plan for life itself. Recombi.

nant DNA, which includes gene cloning (reproduction),

is a technique used to join DNA from different organisms for a specified purpose (e.g., production of a protein). It allows direct manipulation and alteration of

the information coded in the genes so that the productive capabilities of the cell can be directed. Genes,

composed of different arrangements of DNA, contain

the information necessary for the creation and production of specific cellular proteins-compounds that

perform most of the necessary functions of the cell.

Gene expression is the mechanism whereby the genetic information of a cell is decoded and processed

in order to manufacture a product, usually a protein.3

‘An investigator at Scripps Clinic recently succeeded in linking cobra-venom

factor (CVF) which is itself nontoxic, but is found in cobra venom, to MAbs

directed against a specific surface antigen found on a human melanoma cell

line. These CVF-conjugated MAbs were subsequently able to specifically kill

the melanoma cells. In clinical trials at Johns Hopkins University and Hospital, radioactive iodine has been tagged to MAbs specific to liver tumor cells.

Many of the patients have experienced remissions and shrunken tumors; one

has been in remission for 3% years (8).

3Different proteins perform different functions Many are expected to be

useful in the prevention and treatment of chronic conditions among the

elderly. Enzymes, for example, are proteins that catalyze biological reactions.

Through rDNA, genes from a human cell that are

responsible for the production of a desired protein can

be inserted in a micro-organism where the protein is

expressed (i.e., produced) in large quantities as the

micro-organism reproduces (see table D-l). The ability

to develop micro-organisms that produce either new

pharmaceuticals (e.g., vaccines against cancer) or large

quantities of otherwise scarce pharmaceutical compounds (e.g., hormones that regulate immune response or calcium deposition) could revolutionize existing health care. Finally, the availability of pure

substances (e.g., proteins) may enable researchers to

answer more questions concerning cell biology and

medicine.

DIAGNOSIS AND PREVENTION USING rDNA

DNA Probes. -Probes are powerful tools that can be

used to recognize and bind to the inherent property

of any cell—its DNA. The genetic information encoded

by the DNA of each species is unique and, as such,

can be used to identify that species. DNA is a doublestranded, helical molecule composed in part of four

nucleotide bases—adenine (A), cytosine (C), guanine

(G), and thymine (T) (see fig. D-3). When these bases

pair up to form the rung-like structures of the DNA

molecule, they do it exactly the same way every time—

A always pairs with T and C always pairs with G. The

pairing is accurate, but not very strong. Thus, when

the DNA “unzips,” leaving a series of unpaired bases

on each strand, a strand with the corresponding sequence of nucleotide bases must be found before

another double helix can be formed.

DNA probe technology is based on the fact that DNA

is composed of two parallel, complementary strands

which are uniquely matched and held together by

chemical bonds. If separated, the two complementary

strands can find each other and rejoin (known as

hybridization), even in the presence of a large number of noncomplementary molecules.

To make a probe, a specific segment of DNA is

removed from a biological sample, or a segment of

DNA is synthesized to match a segment of DNA thought

to exist in the patient. This piece of DNA is then labeled

with a substance that allows researchers or clinicians

to follow it as it searches for a complementary strand

of DNA that has been obtained from the patient and

treated so that the double-stranded DNA is separated.

If the probe “pairs up” with the complementary strand

Examples include thrombolytic and fibrinolydc enzymes that dissolve blood

clots. Hormones, some of which are also proteins, control regulatory functions (e.g., insulin is a protein hormone that regulates sugar metabolism and

other functions; and interferon, an immune regulator’, regulates the response

of cells to viral infections), Other proteins have other spdalized functions

(growth factors, for example, regulate the growth of a variety of different

body cells such as nerves and bones).
452 ● Technology and Aging in America

Table D=I.—Some Proteins With Possible Pharmaceutical Applications Being Developed

With Recombinant DNA Technology

Size

(number

of amino

Class/substance acids) Function R&D status Project sponsors Applications

Human growth regulators:

Growth hormone (GH) . 191-198

Somatostatin . . . . . . 14

Somotomedins . . . . . . . 44-59

Growth hormone releasing

factor (GRF) . . . . . 44

Promotes growth Cloned, expressed, Genentech (U.S.)/ Growth promotion; heal1979 Kabigen AB (Sweden) ing burns, fractures;

UCSF/Eli Lilly (U. S.) cachexia

Inhibits GH secretion Cloned, expressed, UCSF/Genentech Adjunct to insulin

1977

Mediates action of GH Cloned, expressed, Chiron (U. S.) Growth promotion,

1982 regulation

Increases pituitary GH release Isolated, sequenced, Salk Institute (U. S.) Growth promotion

synthesized, 1982

Cacium regulators:

Calmoduiin . . . . . . . . . . . . . . . 148 Mediated calcium’s effects Determined to be None Numerous applications in

unprofitable basic research;

hypertension

Caicitonin . . . . . . . . . . . . . . . . 32 Inhibits bone resorption rDNA production Genentech, Amgen (U. S.) Bone disease therapy

Parathyroid hormone (PTH) 84 Mobilizes calcium; prevents calcitonin Cloned, but no Massachusetts General Osteoporosis therapy;

excretion production Hospital calcium metabolism

Reproductive hormones:

Luteinizing hormone (LH) Beta Females: induces ovulation

chain;

115b

Males: stimulates androgen

Folicle-stimulating

hormone (FSH). . . . . . . . Beta induces ovarian growth

chain;

115

Human chorionic gonadotrophin

(HCG) . . . . . . . . . . . . Beta Like LH; more potent

chain;

147

Cloning in progress Integrated Genetics Antifertility

(glycoprotein) (U. S.)/Serono Labs

(Itaiy)

secretion

Cloning in progress integrated Genetics/ Reproductive services

(glycoprotein) Serono Labs

Cloning in progress integrated Genetics/ Pregnancy testing

(glycoprotein) Serono Labs

Relaxin ., . . . . . . . . . . . . 52 Dilation of birth canal; relaxation of uterus Cloning in progress Genentech Soften bone connective

(non-glycoprotein) tissue of reproductive

tract; antiarthritic (?)

Neuroactive peptidex

E

-Endorphin . . . . . . . . . . . . . 31 Analgesia Cloned, expressed Amgen, others Analgesia

nkephalins . . . . . . . . . . . . . . 5 Analgesia Cloning in progress Agen, others Analgesia

Pancreatic endorphin. . ., . N.A.CUndetermined Cloning in progress Endorphin, Inc. Analgesia, particularly in

childbirth

Lym t

lnterleukin-2 133 Promotes T-cell growth, activity Cloned, expressed

Thymosin (fraction 5) . . . . 10-150 Promotes maturation of bone marrow Purified, sequenced

cells, T-ceil differentiation

Thymosin (alpha 1) . . . . . . . 28 Promotes T-helper and T-amplifier Purified, sequenced

functions cloned, 1979

Thymic hormone factor (THF) 9 Promotes T-helper and T-amplifier N.A.

functions

Thymic factor (TFX) ,.. ,.. . 40 Restores delayed-type hypersensitivity N.A.

Thymopoietins . . . . . . . . . . . . 49 Inhibits B-ceil differentiation N.A.

Ajinomoto Co. (Japan)

Japanese Cancer

Institute

Immunex (U. S.)

Cetus (U. S.)

Chiron

Genex (U. S.)

Biogen (U. S.)

Genetics Institute (U. S.)

Interferon Sciences (U. S.)

Quidel (U. S.)

George Washington

University

Hoffmann-La Roche

(Switz,)

Genentech

N.A.

N.A.

Ortho Pharms. (U. S.)

Maintain T-cell cultures;

immunotherapy

Immunodeficiency

diseases

Systemic lupus

erythmatosis; other

immune disorders

Antiviral protection in

immunosuppressed

patients

Cancer treatment

Reversing

immunodeficiencies
App. D—Biotechnology ● 453

Table D-l. -Some Proteins With Possible Pharmaceutical Applications Being Developed

With Recombinant DNA Technology—continued

Size

(number

of amino

Class/substance acids) Function R&D status Project sponsors Applications

Microphage inhibitory factor

(MIF) ., . . . N.A. Inhibits microphage migration Cell fusion Denki Kagaku (Japan) Immunotherapy

Respiratory system:

Alpha-l -antitrypsi n 45,000 Prevents destruction of alveolar walls by rDNA in yeast Zymos Corp. (U.S.)/ Emphysema treatment

molecular elastase Cooper Laboratories

weight (Us.)

aArrnOr pharm.aC.u~@al CO, lh~ SoUrce of ~lmon Calcltonln in the lJtlit8d states, does not believe that rDNA technology offers significant advantages over chemi~l synthesis for the production of ‘Imon

calcitonin at the present time A New Drug Application is pending for human calcifomn, but this product is 20 times less than salmon calcitonin for the same effects Hence, the economics of human

bcalcitonin production are less advantageous than those of salmon calcitonin production

Most reproductive hormones thus studied are glycoproteins consisting of two polypeptide chains All share a common (89 amino acids long) alpha chain. Biological activity is manifested in the beta

chain, and most cloning efforts focus on producing the biologically active component

C N A = Information not available

SOURCE Office of Technology Assessment

of DNA from the patient (i.e., if it finds a sequence ●

in the DNA that matches its own), the existence of the

organism or gene is confirmed (see fig. D-4). Thus,

based on the hybridization property, probes can provide new methods for not only diagnosing infectious

diseases but also

isolating minute

for predicting genetic disorders and

quantities of chemicals.

Viral and bacterial infections. The greatest commercial use of probes appears to be in detecting,

within hours or even minutes, viral and bacterial

infections. For instance, a probe obtained from

a pathogenic organism (e.g., cytomegalovirus

(CMV)) can be used to identify the presence of that

virus within human ceils, thus allowing specific

Figure D-3.-The Structure of DNA

Base pairs

gar-phosphate

ckbone

A schematic diagram of the DNA double helix. A three-dimensional representation of the DNA double helix.

The DNA molecule is a double helix composed of two chains. The sugar-phosphate backbones twist around the outside, with the paired bases on the inside serving to hold the chains together.

SOURCE” Office of Technology Assessment.
454 . Technology and Aging in America

Figure D-4.—DNA Probe Filter Assay

Sample Deposit organisms

on a matrix

Break open organisms Treat the DNA with chemicals

and Isolate the DNA to separate the strands and

bind them to the matrix

Add labeled DNA probas DNA probes hybridize Wash away extra probes

to complementary and add signal moleoules

DNA in the sample to identify

SOURCE: A. Klausner and T. Wilson, “Gene Detection Technology Opens Doors for Many Industries,” Biotechnology, August 1983; Ron Carboni, N. Y., NY., artist.

diagnosis based on whether or not the probe

“pairs up” with the DNA in the cell. Currently,

probes are being designed to detect a variety of

viruses, including CMV, hepatitis B, rotavirus, and

herpes.

● Genetic disorders. More than 3,000 human disorders result from defects in the basic genetic

makeup of individuals (18). DNA probes are being designed to detect the genes that can cause

some of the diseases. By screening individuals for

genetic disorders (e.g., Huntington’s disease),

probes can serve as an early warning system for

some diseases. If, in the future, more genes that

are responsible for predisposing people to disease

(e.g., cancer, mental disorders, heart attack) can

be identified, doctors may use probes to identify

those at risk. Harvard scientists have recently uncovered a rare inherited genetic defect that predisposes cholesterol buildup in tissues, which

leads to heart attacks (7). The defective gene responsible for the disease was identified with a

probe. In the future, scientists expect to identify

genes that predispose individuals to common

pathologies like cardiovascular disease, cancer,

and mental disorders. Doctors could then use

probes to identify persons who are at risk (4).

● Characterization and isolation of proteins. Aside

from their use in screening for disposition to disease, probes are also being used to characterize

and isolate many small peptides that act as neurotransmitters or regulators of the release of hormones from the pituitary gland. For example,

probes are being used to unravel the mechanics

of the brain’s control of blood circulation and

pressure.

The brain controls blood pressure in two ways:

by controlling the release of peptides and hormones that adjust blood circulation in response

to emotion and behavior, and by controlling the

nerve cells that innervate the blood vessels and

the heart. By using DNA probes, researchers are

attempting to trace the networks and the dynamics of the interacting transmitters and peptide hormones involved in the brain’s control of circulation with the hope of one day being able to control

blood pressure. Probes might also ultimately be
App. D—Biotechnology ● 455

used to indicate changes in cellular DNA that accompany aging.

● Cancer. Recent discoveries indicating that some

human tumor cells have identifiable oncogenes

have spurred research and development efforts

in this area (4). Earlier this year, the National Cancer Institute announced a 3-year, $1.8 million

grants program to develop genetic techniques for

cancer diagnosis, including DNA probes for oncogenes.

Vaccines. -At present, most vaccines are made from

the organisms that cause the particular disease they

are intended to prevent. These organisms (pathogens)

are killed or otherwise treated (“attenuated”) to make

them nonvirulent. They are then injected as a vaccine.

The body responds to the injection by producing antibodies against antigens on the surface of the attenuated organism. These antibodies then circulate in

the system, protecting the body from an invasion by

a live organism of the same kind. Thus, the immunity

is conferred.

Limitations associated with current vaccines include:

contracting the disease from incompletely attenuated

viruses, incomplete immunization due to changes in

the strains of the pathogen, and inefficient immune

response to nonliving organisms.

Recombinant DNA is being applied to the production of vaccines that do not use the genetic material

responsible for the pathogen’s virulence. Instead, the

gene for a surface protein of the pathogen is isolated

and cloned, and the surface protein is used as the vaccine. Instead of the whole organism, only the surface

protein responsible for eliciting the antibody response

is used. This permits greater quantities of purer antigens to be used.

Among the elderly, influenza can often lead to death

due to respiratory complications. Viral vaccines are

being developed through rDNA for influenza types A

and B. More effective vaccines such as these could prevent or minimize the effects of viral infections among

the elderly,

Several research institutes have begun animal trials

to test the efficacy of new vaccines targeted against

melanoma and other cancers of the lung, breast, colon, and rectum. The vaccine, a short segment of DNA

specific to the hormone human chorionic gonadotropin

(hCG), is designed to simulate patients’ immune systems to attack the hormone, which plays a role in tumor development. Many tumors, but not all, produce

hCG. For instance, about 86 percent of all lung cancers

produce hCG, and 50 to 60 percent of all breast

cancers produce hCG, which not only helps ensure the

survival of the tumor by fending off the body’s immune system, but also works as a growth hormone

to spur its development. Thus, if a vaccine could be

delivered so that the immune system would fight hCG,

further development of the tumor might be halted.

More practically, the vaccine could be delivered after

the tumor is removed to ensure complete eradication

of the tumor cells.

TREATMENT USING rDNA

Therapeutic proteins normally present in human

blood (e.g., clotting factors, antibodies, enzymes, certain hormones) are available only in limited supply;

the only possible sources are animal or human blood,

tissues, or urine. Recombinant DNA promises to provide an alternative route to the production of proteins

for therapeutic purposes.

Thrombosis. -Thrombosis, the blockage of blood

vessels by blood clots, is a major cause of disabling

diseases and death (12). Blood clots, which are made

of fibrin, platelets, a mixture of blood cells, red cells,

and leukocytes, can cause heart attacks when lodged

in the heart. When lodged in the brain, clots can cause

strokes; in the lungs they can cause pulmonary embolisms.

Use of rDNA to make new and safer anticoagulants

could reduce the incidence and severity of diseases

induced by thrombosis by restoring blood flow to the

affected heart muscle, thereby preventing or limiting

permanent damage. Tissue plasminogen activator

(TPA) and kidney plasminogen activator, for example,

are two naturally occurring enzymes currently being

produced via rDNA, They are being used to treat a

wide variety of severe cardiovascular disorders, including heart attacks and arterial blockages. Both enzymes are specific for fibrin, the protein of which clots

are made, and both are being developed for injection

to dissolve potentially fatal blood clots. Two patients

at Washington University in St. Louis, MO, and five

at the University of Leuven in Belgium have received

TPA treatment. When the TPA reached the heart, it

caused dissolution of the clots that were causing the

myocardial infarction. If TPA proves effective in further studies, it could be used in emergency rooms and

ambulances to treat heart attack victims.

TPA has certain advantages over the two enzymes

(urokinase and streptokinase) in current use. First, neither urokinase nor streptokinase are specific for blood

clots (i.e., fibrin) (12). Both destroy other blood proteins. In order to avoid hemorrhaging, cardiac catheterization and coronary angiography are necessary

to administer the enzymes directly to the site of the

clot. Furthermore, streptokinase, because it does not

occur naturally in humans, often elicits an allergic reaction that makes repeated treatments impractical.
456 . Technology and Aging in America

Heart Attacks.—Renal renin, an enzyme produced

by the kidneys, governs the release of angiotensin,

which constricts blood vessels and raises blood pressure. Because the kidneys secrete only small amounts

of renin that vanish quickly, the amount produced is

insufficient to allow amino acid sequencing. With

rDNA it should be possible to express human renin

in host organisms and to accumulate enough for structural studies (6). Once renin’s threedimensional structure is determined, an analog can be developed that

would bind to the renin receptor site, thereby inhibiting renin’s effect. Renin analogs are being developed through rDNA with the hope that high blood

pressure may soon be better controlled.

Emphysema. —Emphysema is caused in part by the

gradual attack of lung tissue by natural enzymes (10).

This lung deterioration can be accelerated by environmental factors such as air pollutants, bacteria, or cigarette smoke, or it can be caused by a congenital deficiency of alpha-l antitrypsin (AAT)—a protein which

counteracts degradative enzymes produced by the

body to destroy foreign particles in the lungs. Without AAT, surplus enzymes attack lung tissue itself,

causing emphysema. The availability of AAT could potentially be used to correct the condition in patients

with the deficiency, as well as to prevent further deterioration in those with emphysema.

Necrologic Disorders. -Recent attention has focused

on the variety of peptides found in the brain and other

parts of the body that are assumed to function as

neurotransmitters or neuromodulators. Included in

this group are chemicals important in modifying pain,

emotional response, and muscle tone; peptides implicated in seizure and postseizure events; and others

active in controlling brain mechanisms of cardiovascular regulation and food intake. With the use of MAbs

and DNA probes to isolate and characterize these peptides, coupled with rDNA to produce sufficient quantities for research (instead of purifying extracts made

from large quantities of brain tissue), doctors may one

day be in charge of a revolutionary arsenal of new

compounds able to treat conditions (e.g., dementia)

arising from necrologic disorders.

Cholecystokinin, for example, a peptide found in the

gastrointestinal tract, was also recently found in the

brain (I). Studies of genetically obese mice, which are

obese because of excessive food intake, show the

brains of these mice to contain three to four times less

cholecystokinin than the brains of normal mice. Adding the peptide to the systems of the obese mice reduced their voracious eating. Information derived

from such experiments may in the future serve to

treat the problem of human obesity.

Immune Regulation and Modification (lymphokines

and thymic hormones) .—Lympokines, such as

interleukin-2 and interferon, are immune mediators

and are produced by white blood cells (lymphocytes)

when these cells are exposed to foreign bodies or alien

cells. They regulate the response of the cells to microbial

infections and cancer proliferation. Their presence (or

absence) is thus crucial to the body’s immune system.

The importance of lymphokines in preventing disease and understanding cellular function is fostering

widespread research on these compounds. It is hoped

that research efforts may lead to the use of lymphokines to stimulate the patient’s own immune system to combat disease. For example, patients who are

undergoing chemotherapy or radiation therapy may

die from an unrelated infection such as pneumonia

because their immune systems have been severely

damaged. Interleukin-2, a lymphokine now being produced through rDNA, has been shown to restore immune balance in mice undergoing chemotherapy. The

same results are now being sought for human applications.

Interferon, a class of immune regulators being produced through rDNA, is being considered for various

pharmaceutical applications, including treatment for

viral infections and cancer. In some clinical trials, interferon has inhibited tumor cell growth, although its

effects on inhibiting tumor metastasis are better established than its ability to cause regression of primary

tumors (17).

Thyrnic Hormones: The thymus appears to be an endocrine organ with the capacity to synthesize many

different hormone-like products. These individual hormones probably act to regulate selective aspects of Tcell differentiation (into killer, helper, and suppressor

T-cells). The rationale for employing thymic hormones

therapeutically in adults is based on the observation

that circulating thymic hormone levels decrease dramatically with age as the thymus involutes, decreasing the efficiency of immune function. It has been suggested that the increased incidence of autoimmune

diseases and cancers in the elderly population might

reflect the loss of homeostatic control governed by the

thymus (16).

Clinical trials using thymic peptides suggest that

thymic hormones exert immunorestorative effects

when administered to patients with T-cell immunity.

Randomized trials in cancer patients have indicated

4T-cells are Iymphoc.ytes produced by the thymus Some T-ells recognize

antigens and send messages to B<ells, which start making antibodies. Some

T- cells assist B-cells in making antibodies; others suppress the same process; still others are themsel~fes capable of seeking out antibody-bearing cells

and killing them
App. D—Biotechnology ● 457

that thymosin fraction 5 (which contains a number of

active peptides) may be efficacious when administered

as an adjunct to conventional chemotherapy or radiation therapy by reducing the immunosuppressive side

effects of radiation and chemotherapy and helping the

patient to mount a response to the disease. Other

thymic factors (i.e., thymic humoral factor and thymic

factor X) have shown promise in treating a variety of

infectious diseases caused by adenoviruses. Potential

therapeutic applications are also being investigated for

autoimmune diseases. It is thought that some thymic

hormones may help normalize the aberrant immuno -

regulatory cell activity that is characteristic of these

diseases.

Conclusion

Many future pharmaceuticals, which cannot yet be

identified, are likely to emerge during this decade

from the basic work in biotechnology now under way.

Their development would provide new therapies for

many of the conditions that impair the functional

ability of many of today’s elderly. The advances arising from current basic research are expected to generate both new products and greater understanding

of the aging process. This understanding should lead

to significant reductions in the severity of chronic illness among the elderly and in the cost of health care

for this growing segment of the U.S. population.

Appendix D references

1. Adelman, G., “Cutting Edge Research and Development

Topics in Neuroscience, ” contract prepared for the Office of Technology Assessment, May 1983.

2. Baskin, Y., “In Search of the Magic Bullet,” Technology

Review, October 1982, pp. 19-22.

3. Berstein, L. D., “Monoclinal Antibodies: Prospects for

Cancer Treatment,” Immunological .4pproaches to Cancer Therapeutics (New York: John Wiley & Sons, 1982).

4. Bio/Wchnologv, “Gene Detection Technolo~v Opens Door

for Many Industries, ” August 1983, pp. 476-478.

5. Biotechnology IVewswatch, “Centocor Monoclinal To

Treat Infection, Test Infarction, ” Nov. 7, 1983, p. 8.

6. Biotechno@v Newswatch, “Computer Graphics Modeling Billion -Do]]ar Blood Pressure Drug, ” Sept. 5, 1983,

p. 2.

7. Biship, J., “New Gene Probes May Permit Early Predictions of Disease,” Wa]] Street Journal, Dec. 12, 1983.

8. I.Xscover, “Monoclonals: The Super Antibodies,” 14(6):72,

June 1983.

9. Genetic Engl”neering News, “Automated Cell Culture Control System May Help To Optimize Hybridoma Growth, ”

May/June 1983, p. 11.

10. Genetic Engineering News, “Zymos Researchers Clone

Gene for Liver Protein Thought to Aid Emphysema Victims,” November/December 1983.

11. Genetic Systems Corp., Seattle, WA, 1983 Annual Report.

12, Klausner, A., “Activating the Body’s Blood Clot Dissolvers:

Biotech’s New Role, ” Bio~echnologv, June 1983.

13. Maranto, G., ‘(Monoclinal What?” Johns Hopkins Magazine, August 1981, p. 30.

14. Noonan, N., “Monoclinal Antibodies,” contract prepared

for the Office of Technology Assessment, June 30, 1982.

15. Scharff, M. D., Roberts, S., and Thammana, P., “Hybridomas As a Source of Antibodies, ” Hosp. Prac., January

16.

17.

18.

1981, p. 61.

Schulof, R., and Goldstein, A., ‘

( Clinica] Applications of

Thymosin and Other Thymic Hormones,” Recent Advances in Clinical Immunology, R. Thompson and N. Role

(eds.) (Edinburgh, London, New York: Churchill Livingston Press, 1983).

U.S. Congress, Office of Technology Assessment, Commercial Biotechnology: An International Anal-vsis, OTA -

BA-218 (Washington, DC: U.S. Government Printing Office, 1984).

Wall Street Journal, “Altering Heredity: Scientists Hope

To Put New Genes in Victims of Two Genetic Diseases, ”

Jan. 26, 1984, p. 1.
Appendix E

workplace Technology

and the Employment of Older Adults

Figure E-l.– Percent Men Aged 58 to 63 Not in the

Labor Force, by Type of Longest Held Job and

Presence or Absence of Work Limitations

Without

limitations

50/0 Professional

\

1%0 Farmer

7“/0 Manager

80/0 Clerical

3% Sales

5% Craftsmen

60/0 Operative

4% Service

2% Farm

laborer

Nonfarm

laborer

SOURCE: Retirement History Survey (1969)
App. E—Workplace Technology and the Employment of Older Adults ● 459

Figure E-2.–Work Disability Rates for Men, by Selected Age Groups, 1970-80

(in percent)

25.2

25

2(

15

10

5

0

24.9

21.9 —

—

71 7.7

18.9

16.9

15.0 —

—

12.7

11.9

8.4 —

—

5.3

- - n

55-59

Age

1980

60-64 65-69

❑1970 1975

SOURCE: National Health Interview Survey, National Center for Health Statistics in Feldman (1963).

Figure E-3.—Work Disability Rates for Men and Women, by Selected Age Groups,

1976 (in percent)

04 7

20 -

15 -

10 -

5 -

0

20.9

L1. 1

18.3

15.1

14.0

12.7

11.6 10.5

9.7

8.2

50-52 53-55 56-58

Age

Men Wome n

59-61 62-64

SOURCE: 1976 Survey of Income and Education, Bureau of the Census in Feldman (1963).
460 . Technology and Aging in America

Figure E-4.—Work Disability Rates for Men, by Selected Age Groups and Years

of Education, 1976 (in percent)

50-52 53-55 56-58 59-61 62-64 65-67 68-70

Age

SOURCE: National Health Interview Survey, National Center for Health Statistics. In Feldman, 1983,
App. E—Workplace Technology and the Employment of Older Adults ● 461

Table E-1.–Labor Force Participation Rates and Number of Workers 45+ by Sex and Age, Selected Years, 1947-83

Number (in millions) LFPRa (in percent)

Year Total Men Women Men Women

Age 45-54:

1947. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10.6 7.9 2.7 95.50/0 32.70/o

1950. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11.5 8.2 3.3 95.8 38.0

1960. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14.9 9.6 5.3 95.8 49.8

1970. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17.0 10.5 6.5 94.3 54.4

1980. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16.9 9.9 7.0 91.2 59.9

1983. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16.9 9.7 7.2 90.8 62.3

Age55-64:

1947. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7.2 5.6 1.5 89.6 24.3

1950. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7.6 5.8 86.9 27.0

1960. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9.4 6.4 ; : : 86.3 37.2

1970. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11.3 7.1 4.2 83.0 43.0

1980. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11.8 7.2 4.6 72.3 44.5

1983. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12.1 7.2 4.9 69.7 42.1

Age65+:

1947. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.8 2.4 0.4 47.8 8.1

1950. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3.0 2.5 0.6 45.8 9.7

1960. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3.2 2.3 0.9 33.1 10.8

1970. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3.2 2.2 1.1 26.8 9.7

1980. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3.0 1.9 1.1 19.1 8.1

1983. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3.0 1.8 1.2 16.5 7.9

aLabor Force Partlclpation Rat e

SOURCES 1980 Handbookof Labor Statistics, Bureauof Labor Statistics, 19B3data from Emloyment and Earnings, Bureau of Labor Statistics, January 1984

Table E.2.—Employment by Age, Selected Years, 1950-95 (numbers in millions)

1950 1960 1970 1982 1995

Age Number Percent Number Percent Number Percent Number Percent Number Percent

16-44 . . . . . . . . . . . . 41.7 65% 44.6 62% 54.3 63% 78.2 71% 92.4 70%

45-54 . . . . . . . . . . . . 11.5 18 14.9 62 17.0 20 16.9 15 25.0 19

55-64 . . . . . . . . . . . . 7.6 12 9.4 13 11.3 13 12.0 11 11.0 8

65+ . . . . . . . . . . . . . 3.0 5 3.2 4.5 4.5 3.7 3.0 2.7 3.1 2.3

Median age(years). . 38.6 40.5 39.0 34.8 37.3

SOURCE: Table 2, Handbook of Labor Statistics 1980, Bureau of Labor Statistics,
—

462 . Technology and Aging in America

Table E“3.—Civilian Labor Force, by Sex, Age, and Race, 1955-83 (numbers in millions, LFPR in percent)

1955 1970 1983

Number LFPRa Number LFPR Number LFPR

Men:

45-54 . . . . . . . . . . . . . . . . . . . . . . . . . 8.9

55-64 . . . . . . . . . . . . . . . . . . . . . . . . . 6.6

65+ . . . . . . . . . . . . . . . . . . . . . . . . . . 2.5

65-69 . . . . . . . . . . . . . . . . . . . . . . . –

70+ . . . . . . . . . . . . . . . . . . . . . . . . —

White:

45-54 . . . . . . . . . . . . . . . . . . . . . . . . . 8.0

55-64 . . . . . . . . . . . . . . . . . . . . . . . . . 5.7

65+ . . . . . . . . . . . . . . . . . . . . . . . . . . 2.3

65-69 . . . . . . . . . . . . . . . . . . . . . . . –

70+ . . . . . . . . . . . . . . . . . . . . . . . . —

Black and other races:

45-54 . . . . . . . . . . . . . . . . . . . . . . . . . 0.8

55-64 . . . . . . . . . . . . . . . . . . . . . . . . . 0.5

65+ . . . . . . . . . . . . . . . . . . . . . . . . . . 0.2

65-69 . . . . . . . . . . . . . . . . . . . . . . . –

70+ . . . . . . . . . . . . . . . . . . . . . . . . —

Women:

45-54 . . . . . . . . . . . . . . . . . . . . . . . . . 4.2

55-64 . . . . . . . . . . . . . . . . . . . . . . . . . 2.4

65+ . . . . . . . . . . . . . . . . . . . . . . . . . . 0.8

65-69 . . . . . . . . . . . . . . . . . . . . . . . —

70+ . . . . . . . . . . . . . . . . . . . . . . . . —

White:

45-54 . . . . . . . . . . . . . . . . . . . . . . . . . 3.7

55-64 . . . . . . . . . . . . . . . . . . . . . . . . . 2.2

65+ . . . . . . . . . . . . . . . . . . . . . . . . . . 0.7

65-69 . . . . . . . . . . . . . . . . . . . . . . . –

70+ . . . . . . . . . . . . . . . . . . . . . . . . —

Black and other races:

45-54 . . . . . . . . . . . . . . . . . . . . . . . . . 0.5

55-64 . . . . . . . . . . . . . . . . . . . . . . . . . 0.2

65+ . . . . . . . . . . . . . . . . . . . . . . . . . . 0.06

65-69 . . . . . . . . . . . . . . . . . . . . . . . –

70+ . . . . . . . . . . . . . . . . . . . . . . . . —

96.50/0

87.9

9.6 —

10.4

7.1

2.2

—

94.30/0

83.0

26.8

.

9.7

7,2

1.8

1.0

0.8

90.8%

69.7

16.5

24.6 — — 11.8

96.7

88.4

39.5

—

9.5

6.5

2.0 —

94.9

76.5

26.7

—

8.6

6.5

1.6

0.9

0.7

91.5

70.8

16.9

25.0 — — — 12.0

94.2

83.1

40.0

9.3

6.1

0.2

88.2

79.2

27.4

0.8

0.5

0.1

0.06

0.05

84.5

58.6

12.7

18.9

9.2

43.8

32.5

10.6

6.5

4.1

1.1

54.4

43.0

9.7

7.2

4.9

1.2

0.7

0.5

62.3

42.1

7.9

15.0 — 4.5

42.7

31.8

10.5

5.8

3.7

1.0

53.7

42.6

9.5

—

6.2

4.3

1.1

0.7

0.4

62.4

41.6

7.9

15.1

4.5

— —

— — —

54.8

40.7

12.2

—

0.8

0.4

0.1

—

60.2

47.1

12.2

—

0.8

0.5

0.1

0.06

0.04

61.9

45.1

7.5

14.3 — — 4.2

a Labor force participation rate.

SOURCE 1980 Handbook of Labor Statistics, Bureauof Labor Statistics; 1983 data from Employment and Earnings, Bureau of Labor Statistics, January 1984,
App. E—Workplace Technology and the Employment of Older Adults ● 463

. . . . . . . .

. . . . . . . .

. . . . . . . .

. . . . . . . .

. . . . . . . .

. . . . . . . .

. . . . . . . .

. . . . . . . . .

. . . . . . . . E =
464 . Technology and Aging in America

Table E“5.—lndustry Distribution of Empioyed Men and Women Aged 45+, 1980 (percent)

Men Women

Industry 45-54 55-59 60-64 65+ 45-54 55-59 60-64 65+

Mining . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1% 1% 1% 1% 0.30/0 0.20/0 — —

Construction . . . . . . . . . . . . . . . . . . . . . . . 10 9 8 6 1 1 1% —

Manufacturing. . . . . . . . . . . . . . . . . . . . . . 29 29 28 12 19 18 17 90/0

Durable . . . . . . . . . . . . . . . . . . . . . . . . . 20 19 18 7 9 9 8 3

Nondurable . . . . . . . . . . . . . . . . . . . . . . 9 10 10 5 10 9 9 6

Transportation . . . . . . . . . . . . . . . . . . . . . . 10 10 8 3 3 3

Trade . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 15 16 2 20 19 21 26

Wholesale . . . . . . . . . . . . . . . . . . . . . . . 5 5 5 5 2 2 2 2

Retail . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 10 11 16 18 17 19 24

Finance/insurance/real estate . . . . . . . . . 5 5 5 7 8 7 6 6

Services . . . . . . . . . . . . . . . . . . . . . . . . . . . 18 18 20 30 40 40 41 42

Public administration.. . . . . . . . . . . . . . . 8 7 6 5 5 6 4 3

Agriculture . . . . . . . . . . . . . . . . . . . . . . . . . 4 5 7 14 1 2 2

Private household . . . . . . . . . . . . . . . . . . . — — — — 4 5 11

SOURCE: National Policy Center on Employment and Retirement, University of Southern California, unpublished data from the 1980 Currerrt Population Survey.

Table E-6.—Distribution of Workers Aged 55-64 and 65+, by Firm Size, 1979 (percent)

Workers age55-64 Workers age65+

Firm size 25- 100- 500- 25- 100- 500-

(number of employees) <25 99 499 999 1000+ <25 99 499 999 1000+

Mining . . . . . . . . . . . . . . . . . . . . . . . . . . 20/o — 13% — 85% — — — — —

Construction . . . . . . . . . . . . . . . . . . . . 43 23% 17 2% 15 47% 25% 15% 5% 7%

Manufacturing . . . . . . . . . . . . . . . . . . . 7 13 13 4 32 24 6 6

Transportation\Ailities. . . . . . . . . . . . . 13 8 10 5 : : : ; 3 – – 34

Wholesale trade . . . . . . . . . . . . . . . . . . 31 28 21 1 19 61 25 7 — 7

Retail trade . . . . . . . . . . . . . . . . . . . . . . 52 15 8 3 21 59 21 9 – 10

Finance/insurance/real estate . . . . . . . 30 18 8 7 37 78 2 12 3 5

Services . . . . . . . . . . . . . . . . . . . . . . . . 30 13 17 10 51 18 11 4 15

Public administration . . . . . . . . . . . . . 11 11 8 2 : 31 27 14 – 28

NOTE: The sample size on which the percentages are calculated is the populatlorl for which afirm size is identified; uncertain responses we not included.

SOURCE: National Policy Center on Employment and Retirement, University of Southern California, unpublished data from a special supplement to the May 1979 Current Population Survey.

Table E-7.—Unempioyment by Reason for Unemployment, by Sex and Age, 1968-81 Averages (percent)

Job losers

On Other Job

Characteristics Total Total layoff job losers leavers Reentrant

Men:

25-54 . . . . . . . . . . . . . . . . . . . . . . . . 3.70/0 2.70/o 0.90/0 1.80/0 0.4% 0.5%

55-64 . . . . . . . . . . . . . . . . . . . . . . . . 3.0 2.3 0.7 1.5 0.2 0.5

65 and over . . . . . . . . . . . . . . . . . . 3.6 1.8 0.5 1.3 0.2 0.6

Women:

25-54 . . . . . . . . . . . . . . . . . . . . . . . . 5.5 2.4 0.9 1.5 0.8 2.1

55-64 . . . . . . . . . . . . . . . . . . . . . . . . 3.4 2.0 0.8 1.3 0.4 0.9

65 and over . . . . . . . . . . . . . . . . . . 3.6 1.9 0.7 1.2 0.3 1.4

SOURCE: P. L. Rones, “The Labor Market Problems of Older Workers,” Monthly Labor Review, May 1983.
App. E—Workplace Technology and the Employment of Older Adults ● 465

Table E-8.—Median Weeks of Unemployment for aii Persons With Unemployment

Experience, Seiected Years, by Sex and Seiected Age Groups

Characteristic 1973 1975 1978 1981

Men:

25-54 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8.9 14.2 11.6 13.7

55-64 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11.3 17.1 13.7 13.6

65 and over. . . . . . . . . . . . . . . . . . . . . . . . . . . 14.9 19.1 18.3 16.2

Women:

25-54 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6.9 11.3 9.1 11.3

55-64 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10.8 16.6 11.7 11.2

65 and over. . . . . . . . . . . . . . . . . . . . . . . . . . . 8.6 19.1 14.3 13.3

SOURCE:P. L. Rones, ’’The Labor Market Problems of Older Workers;’ Monthly Labor Review, May 1983.

Table E-9.—Percentage increase in Unemployment

Rates for Job Seekers When including Discouraged

Workers, by Sex and Selected Age Groups

(average of 1968.81)

Age25 Age55

Sex to5 4 to6 4 Age65+

Men . . . . . . . . . . . . . . . 0.20/0 0.570 3.20/o

Women . . . . . . . . . . . . 1.2 1.5 4.7

SOURCE: P. L. Rones, ’’The Labor Market Problems of Older Workers/’ Monthly

Labor Review, May 1983.

Table E”10.—Percentage of Total Money income by Source, Ail Persons Aged 65+

Private Asset Government

Income (1979) Earnings SSA pensions income assistance

<$5,000 . . . . . . . . . . . . . . . . . . . . . . ~ . . . 30/0 760/o 3% 60/0 12%

$5,000-9,999 .......................................................................................... 10 59 12 15 4

$10,000-14,999 . . . . . . . . . . . . . . . . . . . . 18 43 17 19 3

$15,000-24,999 . . . . . . . . . . . . . . . . . . . . 34 26 16 22 2

$25,000+ . . . . . . . . . . . . . . . . . . . . . . . . . 48 11 13 27 1

SOURCE: Retirement Income Opportunities an Aging America: home Levels and Adequacy, Employment Benenefit Research Institute, 1982, Table 1-20, page 30. Tabulations from 1980 Census.
466 ● Technology and Aging in America

Table E= Il.–Total Income for Families and Unrelated Individuals, by Age, 1982

Under 65 65+

Income Class Percent Number Percent Number

Families:

<$7,499 . . . . . . . . . . . . . . . . . . . . 11 ”/0 5,697,560 14%

$7,500-12,499 . . . . . . . . . . . . . . .

1,343,580

10 5,179,600 22 2,111,340

$12,500-17,499 . . . . . . . . . . . . . . 11 5,697,560 18 1,727,460

$17,500-24,499 . . . . . . . . . . . . . . 18 9,323,280 19 1,823,430

$25,000+ . . . . . . . . . . . . . . . . . . . 50 25,898,000 26 2,501,000

Mean income . . . . . . . . . . . . . . . $28,585 $20,990

Total number . . . . . . . . . . . . . . . 51,796,000 9.597,000

Unrelated individuals:

<$5,000 . . . . . . . . . . . . . . . . . . . .

$5,000-5,999 . . . . . . . . . . . . . . . .

$6,000-6,999 . . . . . . . . . . . . . . . .

$7,000 -9,999 . . . . . . . . . . . . . . . .

$10,000 -17,499 . . . . . . . . . . . . . .

$17,500+ . . . . . . . . . . . . . . . . . . .

Mean income . . . . . . . . . . . . . . .

Total number . . . . . . . . . . . . . . .

21 4,095,420

6 1,170,120

3 585,060

11 2,145,220

28 5,460,560

31 6,045,620

$14,602

19,502,000

32 2,689,920

14 1,176,840

9 797,000

17 1,400,000

17 1,408,000

11 936,000

$9,366

8,406,000

SOURCE” Derived from Current Populatfon Reports, Series P-60, No. 140, “Money Income and Poverty Status of Famines and Persons in the United States

1982, ” U S Bureau of the Census, table 6, p, 12.

Table E-12.—Work Status of Adults Aged 65+, 1979 (percent)

Couples Singles

Work status 65-69 70-72 73+ 65-69 70-72 73+

Full-time . . . . . . . . . . . . 14 ”/0 60/0 30/0 7% 4% 1%

Part-time . . . . . . . . . . . . 26 23 12 21 13 6

No work. . . . . . . . . . . . . 60 71 85 72 83 93

SOURCE: T. Borzilleri, Income and Expenditures of the Ederly, Contract No. 333-8050, submitted to the Office of Technology

Assessment, October 1983.

Table E“13.-Estimated Mean Income of Elderly Persons, by Source of Income,

Sex, and Selected Age Groups (1980 Dollars)

Earnings Social Security Pensions

Age group (1980) (1982) (1982)

Men:

62-64 . . . . . . . . . . . . . . . . . . . . $3,949 $2,334

65-71 . . . . . . . . . . . . . . . . . . . . $8,369 —

65-67 . . . . . . . . . . . . . . . . . . . .

—

— 5,084 1,876

68-71 . . . . . . . . . . . . . . . . . . . . — 4,972 1,736

72+ . . . . . . . . . . . . . . . . . . . . . . 7,454 4,138

Women:

601

62-64 . . . . . . . . . . . . . . . . . . . . — 2,637 1,141

65-71 . . . . . . . . . . . . . . . . . . . . 7,297

65-67 . . . . . . . . . . . . . . . . . . . . — 3,115 8 4 6

68-71 . . . . . . . . . . . . . . . . . . . . 3,219 771

72+ . . . . . . . . . . . . . . . . . . . . . . 6555 3,271 259

SOURCES: Earnings—The Elderly and the Future Economy, Lawrence Olson, et al., 1981, table $9, p. 52; Social Security and

Pensions-S. R. Zadlewski, Microsimulation of the Private Pension System: Four Projections to the Year 2020, Urban

Institute, January 1983, table 5, p. 25.
App. E—Workplace Technology and the Employment of Older Adults ● 467

Table E-14.—0istribution of Persons Aged 58=63 by Self-Reported Health Status, by Marital Status and

Selected Age Groups, 1969

Men, spouse present Men, no spouse Women, no spouse

Health status Total Total 58-59 60-61 62-63 Total 58-59 60-61 62-63 Total 58-59 60-61 62-6 3

Number (millions):

Total . . . . . . . . . . . . . 6.8 4.2 1.5 1.4 1.3 0.7 0.3 0.2 0.2 2 0.6 0.6 0.7

Percent of above:

Better than peers. . . . 43°/0 35°/0 34% 350/0 360/o 280/o 250/o 30% 30% 35% 350/0 350/0 34%

Same as peers. . . . . . 41 42 44 42 41 41 43 40 38 39 41 38 39

Worse than peers. . . . 20 19 18 21 19 27 29 25 28 20 20 21 20

Don’t know. . . . . . . . . . 4 3 3 2 4 4 3 5 4 5 4 5 6

SOURCE: Retirement History Survey, 1969.

Table E-15.—Distribution of Persons Aged 58-63 With Work Limitations, by Extent of Limitation, Sex, Marital

Status, and Selected Age Groups, 1969

Men, spouse present Men, no spouse Women, no spouse

Extent of limitation Total Total 58-59 60-61 62-63 Total 58-59 60-61 62-63 Total 58-59 60-61 62-63

Number (millions):

Total . . . . . . . . . . . . . 6.8 4.1 1.5 1.4 1.3 0.7 0.2 0.3 0.2 2.0 0.6 0.6 0.7

Percent of above:

No limitation. . . . . . . . 61 0

/0 63°/0 670/o 620/o 580/o 530/0 590/0 54% 47% 61 0/0 650/o 600/0 580/o

Mobility only. . . . . . . . 4 4 4 4 4 2 2 2 3 3 3 4 3

Work limitation. . . . . . 35 33 29 34 38 44 40 44 50 36 32 36 39

SOURCE: Retirement History Survey, 1969.

Table E.16.—Work Limitations by Longest Held

occupation, Persons Aged 58-63, 1969

Number Percent

reporting with work

Longest held occupation (in millions) Iimitations

Total . . . . . . . . . . . . . . . . .

Professional . . . . . . . . . .

Farmer. . . . . . . . . . . . . . .

Manager. . . . . . . . . . . . . .

Clerical . . . . . . . . . . . . . .

Sales . . . . . . . . . . . . . . . .

Craftsman . . . . . . . . . . . .

Operative. . . . . . . . . . . . .

Service. . . . . . . . . . . . . . .

Farm laborer. . . . . . . . . .

Nonfarm laborer. . . . . . .

4.8

0.4

0.4

0.8

0.2

0.2

1.1

1.0

0.3

0.1

0.3

35%

21

45

28

30

31

33

39

38

49

43

SOURCE: Retirements History Survey, 1989

38-800 0 - 85 - 1 6
468 . Technology and Aging in America

Table E=17.—Labor Force Participation Rates, United States, 1900=83 (percent in labor force)

Sex/age 1900 1920 1940 1944 1950 1955 1960 1970 1976 1983

Both sexes: . . . . . .

Men:

14+ . . . . . . . . . . . . .

14-17 . . . . . . . . . . . .

18-19 . . . . . . . . . . . .

20-24. . . . . . . . . . . .

25-34. . . . . . . . . . . .

35-44. . . . . . . . . . . .

45-54. . . . . . . . . . . .

55-64. . . . . . . . . . . .

65+ . . . . . . . . . . . . .

Women:

14+ . . . . . . . . . . . . .

14-17. . . . . . . . . . . .

18-19. . . . . . . . . . . .

20-24. . . . . . . . . . . .

25-34. . . . . . . . . . . .

35-44. . . . . . . . . . . .

45-54. . . . . . . . . . . .

55-64. . . . . . . . . . . .

65+ . . . . . . . . . . . . .

55.0%

87.7 —

63.6

91.7 —

96.3 —

93.3

68.3

20.4 —

26.8

32.1 —

18.1

14.1 —

9.1

55.80/o

85.9 —

52.6

91.0

98.1

97.2

95.5

93.8

60.1

24.1 —

28.4

38.1

35.2

22.4

17.1

18.7

8.0

55.9%

83.9 —

44.2

96.1

99.0

98.5

97.1

87.2

45.0

28.2 —

23.3

49.5

39.0

28.8

24.3

25.4

7.4

63.10/o

89.8

—

70.0

98.5

: : :

95.8

92.1

52.2

36.8

—

42.0

55.0

34.0

40.5

35.8

27.0

9.8

58.30/o

84.4 —

53.2

89.0

97.7

97.6

96.4

87.0

45.8

33.1 —

31.5

46.1

34.9

39.1

38.0

32.5

9.7

58.7%

83.6

34.4

49.5

90.8

96.4

98.4

94.3

88.3

40.6

34.8

20.8

29.9

46.0

35.8

41.6

43.8

36.7

10.6

57.4%

79,7

46.7

73.1

88.9

92.9

96.4

92.9

85.2

32.2

36.1

34.6

51.0

46.1

44.8

43.1

49.3

42.5

10.5

60.30/o

79.2

48.4

68.8

85.1

94.2

95.7

90.6

81.5

25.8

42.8

40.6

53.4

57.5

56.9

50.9

54.0

40.7

9.2

61.2%

76.9

—

72.1

85.2

94.2

94.6

90.8

73.5

19.4

46.8

58.9

65.0

69.7

57.6

54.6

42.1

7.8

63.80/o

—

—

65.4

82.9 —

95.4 —

69.7

16.5

—

—

58.4

69.0

69.6%

62.3 —

7.9

SOURCES: Adapted from Aging and. Volume 1:An Inventory ofResearch Findings, by M.W. Riley and A. Foner Russell Sage Foundation, 1968. Data for 1970,

1976, and 1963 are from Employment and Eamings, Bureau of Labor Statistics, January 1964.

Table E-18.–Average Monthly Retired Worker Benefits With and Without

Reduction for Early Retirement, 1961-80

Without reduction for With reduction for

Aten d

early retirement early retirement

of year Men Women Men Women

1961 . . . . . . . . . . . . . . . . . . . . . . . .

1962 . . . . . . . . . . . . . . . . . . . . . . . .

1963 . . . . . . . . . . . . . . . . . . . . . . . .

1964 . . . . . . . . . . . . . . . . . . . . . . . .

1965 . . . . . . . . . . . . . . . . . . . . . . . .

1966 . . . . . . . . . . . . . . . . . . . . . . . .

1967 . . . . . . . . . . . . . . . . . . . . . . . .

1968 . . . . . . . . . . . . . . . . . . . . . . . .

1969 . . . . . . . . . . . . . . . . . . . . . . . .

1970 . . . . . . . . . . . . . . . . . . . . . . . .

1971 . . . . . . . . . . . . . . . . . . . . . . . .

1972 . . . . . . . . . . . . . . . . . . . . . . . .

1973 . . . . . . . . . . . . . . . . . . . . . . . .

1974 . . . . . . . . . . . . . . . . . . . . . . . .

1975 . . . . . . . . . . . . . . . . . . . . . . . .

1976 . . . . . . . . . . . . . . . . . . . . . . . .

1977 . . . . . . . . . . . . . . . . . . . . . . . .

1978 . . . . . . . . . . . . . . . . . . . . . . . .

1980 . . . . . . . . . . . . . . . . . . . . . . . .

$84

85

87

88

96

97

99

115

118

139

156

192

197

224

247

270

293

320

380

$65

66

67

69

75

76

82

95

112

126

156

164

186

206

224

242

264

288

$69

71

72

73

79

80

82

95

97

115

130

161

164

187

207

226

246

268

349

$57

58

58

59

64

65

66

78

79

94

105

130

135

154

169

183

198

214

275

SOURCES: Adapted from Bixby,1976, p. 6, and Social Securty Bulletin September1979,p .62. From Foner and Schwab, 1961,

p. 48.1960: Social Security Bulletin, Annual Statistical Supplement, 1962.
App. E—Workplace Technology and the Employment of Older Adults ● 469

Table E-19.—Retirees’ Answers to Hypothetical

Job Offers, by Year of Retirement (percent)

1976 retirees 1978 retirees

1976 1978 1978

Definitely accept. . . . . . . 30/0 60/0 5%

Maybe accept. . . . . . . . . . 14 11 20

No, health problems. . . . 40 40 33

No, other reasons. . . . . . 43 43 42

SOURCE: T. Borzilleri, Income and Expenditures of the Elder/y, Contract No.

333-8050, submitted to the Office of Technology Assessment, October

1983.

Table E.20.– Retirees’ Attitudesa Towards Their Retirement, 1980.83

Average

Reponse to question 1980-83 1980 1981 1982 1983

Glad I retired. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 620/o 600/0 61 0/0 640/o 630/o

Rather still be working. . . . . . . . . . . . . . . . . . . . . . . . 32 30 33 32 33

Undecided . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 10 6 4 4

a Note: Response is to question: “Are you glad you retired or would you rather Still be working?”

SOURCE: Derived from AARP Annual Survey of the Opinions of Older Americans, AARP, Washington DC, 1980, 1981, 1982, 1983.

Table E-21.— Retirement Satisfaction, by Income, 1983

Income class <$4,000 $4,000-$6,999 $8,000-17,999 $18,000+

Glad retired. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 350/0 520/o 690/o 81 0/0

Rather still be working. . . . . . . . . . . . . . . . . . . . . . . . 65 46 27 14

SOURCE: AARP 4th Annual Survey of the Opirrions of Older Americans, AARP, Washington, DC, July 1983,

Table E.22.—- Reported Reason’ for Not Working, 1980-83 (percent)

Average

1980-83 1980 1981 1982 1983

Don’t want or need to. ... , . . . . . . . . . . . . . 31 .3% 320/o 270/o 34% 320/o

TOO old . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21.8 17 19 24 27

Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25.8 24 33 23 23

No work available. . . . . . . . . . . . . . . . . . . . . . 4.0 2 4 5 5

Rules (retirement test). . . . . . . . . . . . . . . . . . 2.3 2 3 2 2

Don’t know/other. . . . . . . . . . . . . . . . . . . . . . . 13.8 23 14 12 6

a Note: Response is to question: “Is there any particular reason why YOU are not Currently working?”

SOURCE” AARP 4th Annual Survey of Opinions of Older Americans, AARP, Washington, DC, July 1983.
.———

470 ● Technology and Aging in America

Table E-23.–Number and Rate of Labor Force Participation, by Age, Sex and Race, 1990 and 1995

(numbers in millions)

1990 1995

LFPR* LFPR

Number (in percent) Number (in percent)

Both sexes and races:

45-54 . . . . . . . . . . . . . . . . . . . . . . . . . . . 19.9 78.80/o 24.9 80.00/0

55-64 . . . . . . . . . . . . . . . . . . . . . . . . . . . 11.0 52.7 10.9 9.5

65+ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3.2 10.5 3.1 9.5

Men:

White:

45-54 . . . . . . . . . . . . . . . . . . . . . . . . . 9.9 92.3 12.2 92.1

55-64 . . . . . . . . . . . . . . . . . . . . . . . . . 5.8 66.3 5.7 65.5

65+ . . . . . . . . . . . . . . . . . . . . . . . . . . . 1.7 15.3 1.6 13.7

Black and other races:

45-54 . . . . . . . . . . . . . . . . . . . . . . . . . 1.2 84.1 1.6 84.2

55-64 . . . . . . . . . . . . . . . . . . . . . . . . . 0.6 58.9 0.7 57.4

65+ . . . . . . . . . . . . . . . . . . . . . . . . . . . 0.1 12.0 0.1 9.9

Women:

White:

45-54 . . . . . . . . . . . . . . . . . . . . . . . . . 7.5 67.1 9.5 69.7

55-64 . . . . . . . . . . . . . . . . . . . . . . . . . 4.0 41.2 4.0 42.2

65+ . . . . . . . . . . . . . . . . . . . . . . . . . . . 1.2 7.4 1.1 6.9

Black and other races:

45-54 . . . . . . . . . . . . . . . . . . . . . . . . . 1.2 66.6 1.6 68.4

55-64 . . . . . . . . . . . . . . . . . . . . . . . . . 0.6 43.6 0.7 43.7

65+ . . . . . . . . . . . . . . . . . . . . . . . . . . . 0.2 8.2 0.2 7.7

a Labor force participation rate

SOURCE: Bureau of Labor Statistics, unpublished data.

Table E.24.—Number and Rate of Labor Force Participation, by Age, Race and Sex, 1995:

Middle-Growth Trend Projections

Labor force participation

Number (in millions) Rate (in percent)

Black Black

White and other White and other

Men:

16-24 . . . . . . . . . . . . . . . . . . . . . . . . . .

25-34, . . . . . . . . . . . . . . . . . . . . . . . . .

35-44 . . . . . . . . . . . . . . . . . . . . . . . . . .

45-54 . . . . . . . . . . . . . . . . . . . . . . . . . .

55-64 . . . . . . . . . . . . . . . . . . . . . . . . . .

65+ . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Women:

16-24 . . . . . . . . . . . . . . . . . . . . . . . . . .

25-34, . . . . . . . . . . . . . . . . . . . . . . . . .

35-44 . . . . . . . . . . . . . . . . . . . . . . . . . .

45-54 . . . . . . . . . . . . . . . . . . . . . . . . . .

55-64 . . . . . . . . . . . . . . . . . . . . . . . . . .

65+ . . . . . . . . . . . . . . . . . . . . . . . . . . . .

9.3

15.3

16.7

12.2

5.7

1.6

9.0

13.4

14.5

9.5

4.0

1.2

1.3

2.8

2.7

16.2

0.6

0.1

1.5

2.9

2.9

1.6

0.7

0.2

79.1%

94.6

96.2

92.1

65.5

13.7

75.4

81.8

82.7

69.7

42.2

6.9

52.7%

86.0

90.5

84.2

57.4

9.9

55.3

81.1

83.1

68.4

43.7

7.7

SOURCE: Bureau of Labor Statistics, unpublished data.
App. E—Workplace Technology and the Employment of Older Adults . 471

Table E-25.–Labor Force Participation Rates by

Age, Race and Sex, 1995

1995

Both:

65+ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

65-69 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

70-74 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

75+ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Men:

White:

65+ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

65-69 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

70-74 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

75+ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Black and other races:

65+ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

65-69 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

70-74 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

75+ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Women:

White:

65+ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

65-69 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

70-74 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

75+ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Black and other races:

65+ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

65-69 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

70-74 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

75+ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

9.5%

17.9

10.3

3.6

13.7

21.8

14.1

6.6

9.9

15.6

11.0

4.0

6.9

14.7

7.3

2.1

7.7

18.8

4.9

1.6

SOURCE: Bureau of Labor Statistics, unpublished data

TabIe E-26.–Labor Force Participation Rates, by

Selected Age Groups, 1995 and2020 (in percent)

1995 2020

16-24 . . . . . . . . . . 16°A 16%

25-34 . . . . . . . . . . 26 24

35-44 . . . . . . . . . . 28 23

45-54 . . . . . . . . . . 19 20

55-64 . . . . . . . . . . 8 29.3 14.3 37.5

65+ . . . . . . . . . . . . 2.3 3.2

SOURCE: Bureau of Labor Statistics, unpublished data.
472 ● Technology and Aging in America

Table E-27.—Actual and Projected Employment by Industry, Selected Years,

1982=95 (numbers in millions)

1982 1990 1995

Industry (actual) (projected) (projected)

Agriculture . . . . . . . . . . . . . . . . . . . . . . . 2.8 2.7 2.6

Mining . . . . . . . . . . . . . . . . . . . . . . . . . . . 0.7 0.8 0.9

Construction . . . . . . . . . . . . . . . . . . . . . 5.5 7.0 7.9

Manufacturing . . . . . . . . . . . . . . . . . . . . 11.3 13.6 14.5

Durable goods, . . . . . . . . . . . . . . . . . 7.9 8.7 9.0

Transportation. . . . . . . . . . . . . . . . . . . . 3.1 3.5 3.6

Communications . . . . . . . . . . . . . . . . . . 1.4 1.7 2.0

Public utilities . . . . . . . . . . . . . . . . . . . . 1.0 1.1

Trade . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22.5 26.3 28.5

Finance/insurance/real estate . . . . . . . 5.9 7.1

Services . . . . . . . . . . . . . . . . . . . . . . . . . . 24.3 29.3 32.6

Government . . . . . . . . . . . . . . . . . . . . . . 1.5 1.6 1.7

SOURCE: V. A. Personick, “The Job OutlookThrough 1995: lndustry Outputand Employment Projection:’Monf/)lyLabOrl?eview,

November19S3.

Table E-28.–Projected Employment Changes for Selected industries, 1982-95

Average annual rate of change

Industry 1982-95 1982-89 1990-95

Fastest growhg:

Medical and dental instruments. . . . . . . . . .

Business services . . . . . . . . . . . . . . . . . . . . . .

Iron and ores mining . . . . . . . . . . . . . . . . . . . .

Computers and peripheral equipment . . . . .

Audio and T.V. broadcasting . . . . . . . . . . . . .

Other medical services . . . . . . . . . . . . . . . . . .

Plastics products . . . . . . . . . . . . . . . . . . . . . . .

Scientific and control instruments . . . . . . . .

Electronic components . . . . . . . . . . . . . . . . . .

New construction . . . . . . . . . . . . . . . . . . . . . .

Most rapidly declining:

Leather tanning and industry . . . . . . . . . . . . .

Dairy products . . . . . . . . . . . . . . . . . . . . . . . . .

Wooden containers . . . . . . . . . . . . . . . . . . . . .

Leather products . . . . . . . . . . . . . . . . . . . . . . .

Tobacco manufacturers . . . . . . . . . . . . . . . . .

Bakery products . . . . . . . . . . . . . . . . . . . . . . . .

Rail transport . . . . . . . . . . . . . . . . . . . . . . . . . .

Cotton . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Private households . . . . . . . . . . . . . . . . . . . . .

Dairy and poultry. . . . . . . . . . . . . . .

4.3%

3.9

3.9

3.8

3.8

3.8

3.5

3.4

3.2

3.1

-3. 3

-2.3

-2.3

-2.2

-2.1

-2. 0

-1.6

-1. 5

-1. 5

-1.3

3.2%

4.1

5.7

4.0

4.2

3.6

4.1

3.2

3.6

3.3

-2. 3

-2.1

-2. 3

-2.4

-1. 2

-1.0

-1. 8

-1. 5

-1. 8

-1.4

6.l%

3.6

1.1

3.4

4.0

4.0

2.4

3.7

2.7

2.8

-4. 9

-2. 6

-2. 2

-1. 9

-3.4

-3.7

-1.2

-1. 5

–0.8

-1.3

SOURCE: V. A. Peraonick,’’The Job OutlookThrough 1995: lndustry Output and Employment Projections:’ MonthlyLaborRev@w,

November 1983.
App. E—Workplace Technology and the Employment of Older Adults ● 473

Tabie E+9.-Projections of the Twenty Fastest

Growing Occupations, Percent Increase: 1982-95

Percent growth

Occupation in employment

Computer service technicians . . . . . . . . . . . . 96.80/0

Legal assistants . . . . . . . . . . . . . . . . . . . . . . . . 94.3

Computer systems analysts . . . . . . . . . . . . . . 85.3

Computer programmers . . . . . . . . . . . . . . . . . 76.9

Computer operators. . . . . . . . . . . . . . . . . . . . . 75.8

Office machine repairers. . . . . . . . . . . . . . . . . 71.7

Physical therapy assistants . . . . . . . . . . . . . . 67.8

Electrical engineers . . . . . . . . . . . . . . . . . . . . . 65.3

Civil engineering technicians . . . . . . . . . . . . . 63.9

Peripheral EDP equipment operators . . . . . . . 63.5

Insurance clerks, medical . . . . . . . . . . . . . . . . 62.2

Electrical and electronic technicians. . . . . . . 60.7

Occupational therapists . . . . . . . . . . . . . . . . . 59.8

Surveyor helpers . . . . . . . . . . . . . . . . . . . . . . . 58.6

Credit clerks, banking and insurance . . . . . . 54.1

Physical therapists. . . . . . . . . . . . . . . . . . . . . . 53.6

Employment interviewers . . . . . . . . . . . . . . . . 52.5

Mechanical engineers . . . . . . . . . . . . . . . . . . . 51.5

Mechanical engineering technicians . . . . . . . 51.6

Compression and injection molding

machine operators . . . . . . . . . . . . . . . . . . . . 50.3

SOURCE: G. T. Silvestri, J. M. Lukaslcwicz, and E. M. Einstein, “Occupational

Employment Projections Through 1995,” Monthly Labor Review,

November 1983,
474 . Technology and Aging in America

Table E-30.-Projections of the Forty Occupations With Largest Growth, 1982-95

Percent of

Change in total growth in Percent increase

Occupation employment (thousands) total employment in occupation

Building custodians. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 779 3.0% 27.50/o

Cashiers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 744 2.9 47.4

Secretaries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 719 2.8 29.5

General clerks, office . . . . . . . . . . . . . . . . . . . . . . . . . . . . 696 2.7 29.6

Salesclerks . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 685 2.7 23.5

Nurses, professional . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 642 2.5 48.9

Waiters and waitresses . . . . . . . . . . . . . . . . . . . . . . . . . . . 562 2.2 33.8

Teachers, kindergarten and elem . . . . . . . . . . . . . . . . . . . 511 2.0 37.4

Truckdrivers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 425 1.7 26.5

Nursing aides and orderlies . . . . . . . . . . . . . . . . . . . . . . . 423 1.7 34.8

Sales representatives, technical . . . . . . . . . . . . . . . . . . . . 386 1.5 29.3

Accountants and auditors . . . . . . . . . . . . . . . . . . . . . . . . . 344 1.3 40.2

Auto mechanics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 324 1.3 38.3

Supervisors of blue-collar workers . . . . . . . . . . . . . . . . . . 319 1.2 26.6

Kitchen helpers. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 305 1.2 35.9

Guards and doorkeepers. . . . . . . . . . . . . . . . . . . . . . . . . . 300 1.2 47.3

Food prep and fast food workers . . . . . . . . . . . . . . . . . . . 1.2

Managers, store . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1.1

Carpenters . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 247 1.0 28.6

Electrical and electronic engineers . . . . . . . . . . . . . . . . . 222 0.9 60.7

Licensed practical nurses . . . . . . . . . . . . . . . . . . . . . . . . . 220 0.9 37.1

Computer systems analysts . . . . . . . . . . . . . . . . . . . . . . . 217 0.8 85.3

Electrical engineers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 209 0.8 65.3

Computer programmers . . . . . . . . . . . . . . . . . . . . . . . . . . 205 0.8 76.9

Maintenance repairers, utility . . . . . . . . . . . . . . . . . . . . . . 193 0.8 27.8

Helpers, trade... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 190 0.7 31.2

Receptionists . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 189 0.7 48.8

Electricians . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 173 0.7 31.8

Physicians . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 163 34.0

Clerical supervisors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 162 0.7 34.6

Computer operators. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 160 0.6 75.8

Sales reps, nontechnical . . . . . . . . . . . . . . . . . . . . . . . . . . 160 27.4

Lawyers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 159 0.6 34.3

Stock clerks . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 156 18.8

Typists . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 155 0.6 15.7

Delivery and route workers . . . . . . . . . . . . . . . . . . . . . . . . 153 0.6 19.2

Bookeepers, hand . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 152 0.6 15.9

Cooks, restaurants ....,. . . . . . . . . . . . . . . . . . . . . . . . . . 149 42.3

Bank tellers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 142 : :; 30.0

Cooks, fast food . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 141 0.6 32.2

SOURCE: G. T. Silvestri, J.M. Lukasicwicz, and M. E. Einstein, ’’Occupational Employment Projections Through 1995:’ Monthly Labor Review, November 1983.
App. E—Workplace Technology and the Employment of Older Adults ● 475

Table E-31 .–Projections of the Twenty Most Rapidly

Declining Occupations, 1982.95

Percent

decline in

Occupation employment

Railroad conductors . . . . . . . . . . . . . . . . . . . . . . .

Aircraft structure assemblers. . . . . . . . . . . . . . . .

Central telephone operators. . . . . . . . . . . . . . . . .

Taxi drivers. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Postal clerks . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Private household workers . . . . . . . . . . . . . . . . . .

Child care workers . . . . . . . . . . . . . . . . . . . . . . . .

Maids and servants . . . . . . . . . . . . . . . . . . . . . . .

Farm laborers . . . . . . . . . . . . . . . . . . . . . . . . . . . .

College and university faculty . . . . . . . . . . . . . . .

Roustabouts . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Postmasters and mail superintendents . . . . . . .

Rotary drill operators and helpers. . . . . . . . . . . .

Graduate assistants . . . . . . . . . . . . . . . . . . . . . . .

Data entry operators . . . . . . . . . . . . . . . . . . . . . . .

Stenographers . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Farm owners and tenants . . . . . . . . . . . . . . . . . .

Typesetters and compositors . . . . . . . . . . . . . . . .

Butchers and meat cutters . . . . . . . . . . . . . . . . .

Farm supervisors . . . . . . . . . . . . . . . . . . . . . . . . .

32.00/o

21.0

20.0

18.9

17.9

16.9

16.9

16.7

15.9

15.0

14.4

13.8

11.6

11.2

10.6

7.4

7.3

7.3

6.3

3.7

SOURCE: G. T, Silvestri, J. M. Lukasicwicz, and M. E. Einstein, “Occupational

Employment Projections Through 1995,” Monthly Labor Review,

November 1963.

Table E-32.—Distribution of Employment by

Occupational Group, 1982 and Projected 1995 (percent)

Occupational group 1982 1995

Professional, technical, and related . . . . . .

Managers, officials and proprietors . . . . . .

Salesworkers . . . . . . . . . . . . . . . . . . . . . . . .

Clerical workers. . . . . . . . . . . . . . . . . . . . . .

Craft and related workers . . . . . . . . . . . . . .

Operatives . . . . . . . . . . . . . . . . . . . . . . . . . .

Service workers . . . . . . . . . . . . . . . . . . . . . .

Laborers except farm . . . . . . . . . . . . . . . . .

Farmers and farmworkers . . . . . . . . . . . . . .

16.30/o

9.4

6.9

18.8

11.4

12.8

16.0

5.8

2.7

17.1 0/0

9.6

6.9

18.9

11.6

12.1

16.3

5.5

1.9

SOURCE: G. T. Silvestri, J. M. Lukasicwicz, and M. E. Etnstein, “Occupational

Employment Projections Through 1995,” Monthly Labor Review,

November 1983.
476 . Technology and Aging in America

Table E-33.-Estimated and Projected Mean Income, Selected Years: 1980-2050

Age group 1980 1990 2050

Men:

65-71 . . . . . . . . . . . . . . . . . . . . . . . .

72+ . . . . . . . . . . . . . . . . . . . . . . . . .

AIl 65+ . . . . . . . . . . . . . . . . . . . . . .

Women:

65-71 . . . . . . . . . . . . . . . . . . . . . . . .

72+ . . . . . . . . . . . . . . . . . . . . . . . . .

AIl 65+ . . . . . . . . . . . . . . . . . . . . . .

Families:

65-71 . . . . . . . . . . . . . . . . . . . . . . . .

72+ . . . . . . . . . . . . . . . . . . . . . . . . .

AIl 65+ . . . . . . . . . . . . . . . . . . . . . .

$8,369

7,454

7,850

7,297

6,255

6,658

18,019

14,984

16,608

$9,078

8,101

8,537

7,989

6,885

7,303

19,925

16,675

18,452

$10,094

9,042

9,517

8,998

8,528

8,703

22,270

18,874

20,746

SOURCE: L. Olsen, C. Caton, and M. Duffy, The Eldery and the Future Economy, 1981, table 3-9, p.52.

Table E.34.—Current and Projected Distribution

of Elderly With Incomes Below Adequate Budget

Levels, by Selected Age Groups, 1979.2005

1979 1990 2005

Individuals:

Men:

65-71 . . . . . . . . . . . . . 45% 42% 360/o

72+ . . . . . . . . . . . . . . 50 47 39

Women:

65-71 . . . . . . . . . . . . . 50 46 39

72+ . . . . . . . . . . . . . . 59 52 38

All individuals: . . . . . . 54 49 38

Families:

Head 65-71 . . . . . . . . 29 24 19

Head 72+ . . . . . . . . . 41 36 28

All famlies: . . . . . . . . . 34 29 23

SOURCE: L.Olsen,C.Caton, and M. Duffy, The Elderlyand the Future Economy,

1981, table, p. 52.

Table E-35.-Projected Mean income (1980 dollars) by Source, Sex, and Selected Age Groups, 1982.2020

Social Security Private pensions

1982 2000 2020 1982 2000 2020

Men:

62-64. . . . . . . . . . . . . . . . . . . . . . . $3,949 $5,791 $8,061 $2,334 $3,703 $4,974

65-67. . . . . . . . . . . . . . . . . . . . . . . 5,084 5,573 7,865 1,876 3,509 4,521

68-71 . . . . . . . . . . . . . . . . . . . . . . . 4,972 5,526 7,831 1,736 2,834 4,518

72+ . . . . . . . . . . . . . . . . . . . . . . . . 4,138 4,589 6,571 601 1,419 2,586

Women:

62-64. . . . . . . . . . . . . . . . . . . . . . . 2,637 3,233 4,674 1,141 1,603 1,865

65-67. . . . . . . . . . . . . . . . . . . . . . . 3,115 3,452 4,804 846 1,584 1,897

68-71 . . . . . . . . . . . . . . . . . . . . . . . 3,219 3,362 4,992 771 1,103 1,776

72+ . . . . . . . . . . . . . . . . . . . . . . . . 3,271 3,558 4,594 259 586 1,047

SOURCE: S. R, Zedlewski Microsimulation of the Private Pension System: Four Projections to the Year 2020,1Jrban institute, January 1983, table 5, p.25,
App. E—Workplace Technology and the Employment of Older Adults “ 477

Table E-36.—Distribution of Elderly Persons With Private Pensions, 1982 Estimates,

and Projections for 2000 and 2020, by Sex

Men Women

1982 2000 2020 1982 2000 2020

62-64 . . . . . . . . . . . . . . 250/o 53 ”/0 620/o 90/0 230/o 390/0

65-67 . . . . . . . . . . . . . . 31 54 65 11 24 41

68-71 . . . . . . . . . . . . . . 34 55 66 12 23 42

72+ . . . . . . . . . . . . . . . . 25 43 63 9 16 31

SOURCE: S. R. Zedlewski, Microsinwdation of the Private Pension System: Four Projections to the Year 2020, Urban Institute,

January 1983, table 6 p. 27.

Table E-37.-Projected Future Annual Family Income

at Age 65 (1982 Dollars)

Age in Year of Married

1979 retirement couples Non-marrieds

25-34 . . . . . . . . . . 2013-2023 $34,088 $15,697

35-44 . . . . . . . . . . 2003-2013 29,709 14,921

45-54 . . . . . . . . . . 1993-2003 22,469 9,846

55-64 . . . . . . . . . . 1983-1993 17,347 7,127

SOURCE: S. J. Schieber, Social Security: Perspectives on Saving the System,

Employee Benefit Research Institute, 1982, table 111-17, p. 100.

Table E“38.—Percent of Workers Not in the Labor

Force, by Years of Education, 1969

Number reporting Percent not in

Years of education (in thousands) the labor force

Total . . . . . . . . . . . . . 4,82 3 17“/0

0-8 . . . . . . . . . . . . . 2,10 6 21

9-11 . . . . . . . . . . . . 891 1 7

12 . . . . . . . . . . . . . . 1,031 11

13 or more. . . . . . 7 9 5 1 2

SOURCE Retirerment History Survey, 1969

Table E.39.–Comparison of Surveys on Work Force Disability, 1969-80

Percent without Percent with work Percent unable Percent limited in

disability Iimitations to work activity

45- 55- 45- 55- 45- 55- 45- 55-

Survey 54 64 65+ 54 64 65+ 54 64 65+ 54 64 65+

RHS, 1969a . . . . . . . . . . . 61 ‘/o – — 35% — —

13% — — — 22 ”/0 —

Lando, et al., 1978b . . . . 76 63 – 6 6 – 11 25 – 7 6 —

NCHS, 1978-79C . . . . . . . 81 71 55 – — — 9 17 10 15 22

NCHS, 1978-80d . . . . . . . 77 – 56 – – – – – 18 38

a Retirement History Survey, 1969 (ages 58-63 only)

b Lando Cutler, and Gambler, 1978

c National Center for Health Statitics 1978-79

d National Center for Health Statistics, 1978-80 (whites only)

SOURCE OTA adapted from sources noted above
478 ● Technology and Aging in America

Table E-40.-Proportion of Older Workers Within

Occupations, by Selected Age Group, 1982 (in percent)

45+ 55+ 65+

Professional. . . . . . . . . . . . . . . . . . . 280/o 1 1 % 20/0

Managerial . . . . . . . . . . . . . . . . . . . . 39 17 3

Sales . . . . . . . . . . . . . . . . . . . . . . . . 32 17 5

Clerical . . . . . . . . . . . . . . . . . . . . . . . 27 11 2

Craft, . . . . . . . . . . . . . . . . . . . . . . . . 35 13 2

Operatives . . . . . . . . . . . . . . . . . . . . 30 12 1

Transportation . . . . . . . . . . . . . . . . . 29 13 2

Nonfarm laborer . . . . . . . . . . . . . . . 21 9 2

Private household . . . . . . . . . . . . . . 41 27 11

Service . . . . . . . . . . . . . . . . . . . . . . . 28 15 4

Farm . . . . . . . . . . . . . . . . . . . . . . . . . 56 37 14

SOURCE. Bureau of Labor Statistics, unpublished data.

Table E.41.—Distribution of Older Workers by

Occupation, by Sex and Selected Age Groups, 1982

(in Percent)

Men Women

45-64 65+ 45-64 65+

Professional . . . . . . . . . . 17% 15% 15% 12%

Managerial . . . . . . . . . . . 19 18 9 9

Sales . . . . . . . . . . . . . . . . 16 10 7 12

Clerical . . . . . . . . . . . . . . 6 6 33 25

Crafts . . . . . . . . . . . . . . . 21 12 2 1

Operatives . . . . . . . . . . . 8 5 11 7

Transportation . . . . . . . . 5 3 <1 <1

Nonfarm laborers . . . . . . 5 6 <1 1

Private household . . . . . cl <1 3 10

Service . . . . . . . . . . . . . . 8 13 17 21

Farm . . . . . . . . . . . . . . . . 3 12 <1 1

SOURCE Bureau of Labor Statistics, unpublished data
Appendix F

Glossary of Terms and Acronyms

Glossary of Terms

Accessory apartment: A separate apartment created

within a single-family residence that results in little or no change in the house’s external appearance.

Activities of daily living (ADL): Basic self-care activities, including eating, bathing, dressing, transferring from bed to chair, bowel and bladder control,

and independent ambulation, which are widely

used as a basis for assessing individual functional

status.

Acute care Medical care designed to treat or cure disease or injury, usually within in a limited time

period. Acute care usually refers to physician and/

or hospital services whose duration is less than 3

months.

Acute condition: An illness or disorder which is

characterized by a sudden onset, sharp rise, and

short course.

Adult day cam Social and health services provided for

physically or mentally impaired individuals in a

nonresidential, day-care setting.

Age-adjusted rate: An indicator of the actual change

in demographic rates over time that controls for

the effects of age-structure differences in the population by weighting the age-specific rates according to the age distribution of the population in a

given, earlier, reference year.

Age-specific rate The rate of occurrence of an event

(e.g., death, marriage, birth, illness) for a specified

age group in a population.

Aged: Persons aged 65 and over.

Aging: The gradual changes in the structure of any

organism that occur with the passage of time, that

do not result from disease or other gross accidents,

and that eventually lead to the increased probability of death as the individual grows older. This process is associated with genetic and biological factors,

environmental influences, and, for humans, socioeconomic status.

Aging of the population The increasing proportion in

the total population of older (65 and over) relative

to younger (less than 65) persons. It is generally

measured in percentage distribution by age group,

but also measured in median age, the age at which

50 percent of the population is older and 50 percent is younger.

Alzheimer disease The most common form of dementia, an organic brain disease leading to progressive

loss of brain function and eventual death. The cause

is unknown and there is no effective standard medical treatment.

Appropriate technology Technology that is developed

or adapted in response to the needs, desires, and

capabilities of impaired people.

Arteriosclerosis A group of diseases characterized by

the thickening and loss of elasticity in the arterial

walls of either the brain or the heart.

Arthritis Inflammation of the joints due to infectious,

metabolic, or constitutional causes.

Assessment technology Testing instruments or procedures to measure and evaluate the physical, mental, and social functioning of individuals.

Assistive device A tool, prosthesis, or gadget that

helps the individual to compensate for certain functional impairments, such as hearing or vision loss,

or difficulty walking or eating.

Atherosclerosis: An extremely common form of

arteriosclerosis in which deposits of yellowish

plaques containing cholesterol and lipoid materials

are formed within the walls of large and mediumsized arteries.

Board and care homes: Nonmedical facilities that provide room and board and some degree of protective supervision on a 24-hour basis. Examples include adult foster homes, group homes, larger

residential care facilities, and retirement homes.

Cancer A malignant tumor of potentially unlimited

growth that expands locally by invasion and systematically by metastasis (transfer from one site to

another).

Cavitation: A uniform payment or fee for service.

Cardiovascular disease Heart disease; resulting from

debilitation of the heart and blood vessels.

Cerebrovascular disease Stroke; resulting from debilitation of the blood vessels of the cerebrum, or

brain.

Channeling demonstration program: The National

Long-Term Care Demonstration Program, funded

by the U.S. Department of Health and Human Services (DHHS) and the Administration on Aging (AoA),

designed to test the efficacy of case management

in controlling costs and improving access to appropriate long-term care.

479
480 Technology and Aging in America

Chronic conditiom A physical or mental illness or disorder characterized by a long duration (usually

more than three months) or frequent recurrence.

Cohort A population group that shares a common

property, characteristic, or event, such as a year

of birth or year of marriage. The most common cohort is the birth cohort, a group of individuals born

within a defined time period, usually a calendar

year or a 5-year interval.

Cohort component method: A system which separately projects age- and sex-specific fertility, mortality,

and net migration rates for each l-year or 5-year

birth cohort, using a base population derived from

the most recent census. Projections often include

three alternative levels of each demographic component.

Cohort data: Information relevant to particular population groups that are defined by birth or other historical events or dates and which are used to indicate change over time.

Cohort effect The consequences of the particular set

of historical events that a cohort experiences over

time.

Congregate housing A group-living environment that

provides an onsite meal program and may provide

other social, medical, and recreational services.

Residents have private apartments within the housing facility.

Crude rate The number of “events” (e.g., births,

deaths) occurring within a total population, often

expressed as number per 1,000 population.

Deafness: A degree of hearing impairment that renders hearing nonfunctional for ordinary purposes.

Dementitc The loss of intellectual mental function, due

to many different acute and chronic diseases, including Alzheimer disease, which may affect the

white matter and blood supply of the cerebrum.

Diabetes mellitus A familial constitutional disorder of

carbohydrate metabolism that is characterized by

inadequate secretion or utilization of insulin, by excessive amounts of sugar in the blood and urine,

and by thirst, hunger, and loss of weight.

Diagnosis-related groups (DRGs): A classification system that groups patients according to diagnosis,

type of treatment, age, and other relevant criteria.

In October 1983, Medicare instituted a prospective

reimbursement system based on 467 DRGs. Under

this system, hospitals are paid a set fee for treating

patients in a single DRG category, regardless of the

actual cost of care for the individual.

Disability: The inability to perfom an activity in the

manner or in the range considered normal because

of physical or mental impairment.

Diuretics Agents (e.g., drugs) that tend to increase the

secretion and flow of urine,

Echo (elder cottage housing opportunity) housing uniti

A compact, efficiently designed, temporary structure that are erected in backyards of family homes

and designed for use by elderly relatives. Also referred to as granny flat.

Elderly household Any household that is maintained

(or “headed”) by a person aged 65 or older.

Elderly population All persons aged 65 and over. In

designated cases in this report the age identifier can

be as low as 40 years (e.g., “older worker” in the

ADEA) or as high as 85 years (the very old).

Electronic cottage A computer-based office at home

that may provide opportunities for older workers

who want to work on a part-time or flex-time basis

and/or avoid travel to work.

Environmental fit (environmental congruence): The

extent to which the physical, social, and psychological milieu responds to the needs of the individual.

In many cases, environmental “demands” can be

alleviated by changes in one or more elements of

the environment, thereby providing improved environmental fit or congruence.

Fertility: The number of live births occurring to

women of child-bearing age (usually expressed as

“the annual number of births per 1,001) women

aged 15 to 44”).

Functional dependence The inability to attend to one’s

own needs, including the basic activities of daily living. Dependence may result from the changes that

accompany natural aging, or from a disease or

related pathological condition,

Functional impairment Inability to perform basic selfcare functions such as eating, dressing, and bathing, or instrumental home management activities

such as cooking, shopping, or cleaning because of

a physical, mental, or emotional condition.

Geriatric assessment cente~ An agency that provides

multidisciplinary evaluations of physical, mental,

emotional, and social problems of elderly patients

and recommends appropriate action.

Handicap: A disadvantage resulting from a physical or

mental impairment or disability that limits or prevents the fulfillment of a role that is normal (for

that individual) in a given environment,

Hard technology: Tangible products of research and

development efforts, such as machines, robots, appliances, drugs, and physical aids.

Hearing impairment: A deficit in hearing acuity, including both partial and total hearing loss.

High technology: Complex products of research and

development efforts, including items such as sophis-
App. F—Glossary of Terms and Acronyms for Technology and Aging in America 481

ticated new medical instruments, surgical procedures, or computerized robotic manufacturing

systems.

Home cam Medical, social, and supportive services

provided in the home, usually intended to maintain

independent functioning and avoid institutionalization.

Hospice A method of care that provides supportive

medical and social services for terminally ill individuals and their families. Hospice services can be

provided in a hospital, nursing home, congregate

center, or the patient’s home.

Household: A social unit comprised of those living together in the same dwelling, whether they are related to each other or not (sometimes distinguished

as single-person households or family and nonfamily households).

Housing tenure House ownership or rental status.

Hypertension In the elderly, defined as blood pressure greater than 140/90 mmHg, or isolated systolic

blood pressure greater than 160 with normal diastolic blood pressure.

Impairment: A physical or mental abnormality that

can be readily identified or diagnosed.

Incidence The estimated number of new cases of a

given illness or condition appearing within a specified time period (which in this report is generally

one year), within a defined population group.

Information technology The application of computers and telecommunication systems to the creation,

storage, manipulation, and dissemination of information.

Instrumental activities of daily living (IADL): Home

management and independent living activities, such

as cooking, cleaning, using a telephone, shopping,

doing laundry, and managing money.

Joint debridement Removal of unwanted tissue from

the joint space.

Life cardcontinuing care communtie~ Communities

that provide a continuum of services for elderly

residents, including homes or apartments for independent living, home care services, infirmary, and,

sometimes, nursing home services. Payment of an

initial membership or entrance fee and a monthly

fee guarantees the individual most types of longterm care services for the rest of his life.

Life expectancy: A measure of the average remaining

years of life at specified ages for different subgroups (e.g., by sex and race) of a population.

Life spare The biological upper age limit that a human

can potentially reach, currently considered to be

about 115 years.

Long-term care A variety of health and social services

provided for individuals who need assistance because of physical or mental disability. Services can

be provided in an institution, the home, or the community, and include informal services provided by

family or friends as well as formal services provided

by professionals or agencies.

Low technology: Simple products of research and development efforts, such as in-home assistive devices

and gadgets.

Medicaid A Federal/State program, authorized by Title

XIX of the Social Security Act, to provide medical

care for low income individuals. Federal regulations

specify mandated services, but States can determine

optional services and eligibility standards. The Federal Government’s share of costs ranges from 50

to 78 percent and is based on per capita income

in the State.

Medical technologies Drugs, devices, and medical and

surgical procedures used in medical care, and the

organizational and support systems within which

they are produced and provided.

Medicare A federally funded health insurance program authorized by Title XVIII of the Social Security Act to pay for medical care for eligible elderly

and disabled beneficiaries. Medicare reimburses

part of the costs for acute care and some types of

long-term care. Beneficiaries pay an annual deductible and co-payments for most covered services.

The program is divided into two sections: Part A,

which covers hospital and inpatient physicians’

services, and an optional Part B, which covers some

outpatient physicians’ services.

Medigap insurance Insurance policies offered by private companies designed to cover part of the cost

of the Medicare deductibles, co-payments, and some

medical services that are not reimbursable by

Medicare.

Morbidity The relative incidence or prevalence of disease, generally expressed in rates for specific populations in a specified period of time.

Mortality: The number or proportion of deaths in a

given population within a specified period of time.

Myocardial infarction A heart attack that is generated

by a blood clot.

Neoplasm: See cancer.

Nursing home A long-term care facility that provides

24-hour care, skilled nursing care, and personal

care on an inpatient basis.

Nutritiom The sum of processes by which an organism

takes in, breaks down, and utilizes food substances.

Obesity: Body weight that exceeds by 20 percent or

more the amounts specified in standardized tables

according to sex, age, and height.

Old old Persons aged 75 to 84.

osteoarthritis A degenerative joint disease occurring
482 ● Technology and Aging in America

chiefly in older persons, accompanied by pain and

stiffness. Also known as “osteoarthrosis” and “hypertrophic arthritis.”

Osteoporosis Porous bone; a condition in which total

bone mass is decreased while bone volume is unchanged, therefore decreasing the overall density

of the bone. Osteoporosis is estimated to cause twothirds of hip fractures in older people.

Osteotomy A surgical reshaping of the bone to reduce

stress, or to provide a more favorable anatomic

orientation of the joint.

Period data Information about variables or events that

characterize a population during a specified short

period of time, usually 1 year.

Pharmacokinetics: The study of the bodily absorption,

distribution, metabolism, and excretion of drugs.

Population pyramid: A graphic representation of the

sex and age composition of a population, using either 1- or 5-year age intervals for each sex to age

85 and over. The pyramid is expressed in numbers

or proportions of persons in each subgroup.

Postmarketing surveillance Monitoring of actual drug

use to help identify unknown, adverse reactions,

in order to establish drug safety and efficacy.

Presbycusis: Age-associated hearing loss caused by

changes in the inner ear.

Premarket testing: Experimentation to determine the

safety, toxicity, dosage range, and efficacy of drugs

prior to marketing.

Prevalence The estimated or enumerated number of

events (e.g., deaths or persons with a disease) existing in a defined population during a specified period of time (in this report, generally 1 year).

Prevention and preventive strategies: Application of

a technology or modification of a behavior pattern

that is intended to avert or delay the occurrence

of an unwanted or disabling condition.

Prospective payment system A hospital payment

method in which rates are set prior to the period

during which they apply and in which the hospital

incurs at least some financial risk; rates are based

on diagnosis-related groups (DRGs).

Randomized clinical trial A study of different clinical treatments in which individuals are randomly

assigned to test or to control groups.

Recommended Dietary Allowance (RDA): Estimates of

the minimum levels of specific nutrients needed to

maintain normal function; they may be specified

for subpopulations defined by age, sex, height, and

weight.

Rehabilitation Social or medical care designed to restore patients to their former capacity or to a condition of health or independent activity.

Respite care Physical care and supervision provided

for an ill or disabled individual in order to temporarily relieve the primary caregiver from such responsibility.

Risk factors Characteristics, behaviors, substances, or

environmental and other factors that are statistically associated with an increased likelihood of developing a given condition.

Social/health maintenance organization (S/HMO): A

provider of a wide range of health and social services for a prepaid annual premium.

Soft technology: A process or organizational system,

such as research and the development of new

knowledge, which can lead to the development of

hard technology.

Supplemental Security Income (SSI): A Federal program enacted in 1972 to provide monthly cash payments to aged, disabled, and blind individuals who

have incomes below the minimum levels established

for these subpopulations.

Technology: The development of knowledge and/or

its application to solving practical tasks and problems. Technology can refer to such factors as biomedical research into the causes of arthritic conditions as well as wheelchairs used by persons

suffering from severe arthritis. Technology can be

described as “soft” [research and knowledge), or

“hard” (products of research), and “high” (complex)

or “low” (simple).

Terminal illness A life-threatening illness or advanced

stage of a serious condition for which there is no

hope of survival.

Third-party payers A method of financing health care,

in which an individual purchases insurance from

a private (nongovernmental) third party, which in

turn will reimburse the individual’s health care provider, usually on a per-service basis,

Title III of the Older Americans Act: Federal legislation

that provides funding to States for development and

coordination of services for the elderly. The Administration on Aging allocates Title 111 funds to States

primarily on the basis of the proportion of each

State’s population aged 60 and over.

Title XX of the Social Security Act: Federal legislation

that provides funding to States for social services

for individuals of all ages. Title XX was restructured

as a block grant in 1981 and Federal requirements

for eligibility and services were eliminated.

Urinary incontinence: Inability to control urinary

function.

Very old: Persons aged 85 and over.

Vitality Ability to remain functionally independent,

or to be minimally dependent on various types of

assistance.

Young old: Persons aged 65 to 74.
App. F—Glossary of Terms and Acronyms for Technology and Aging in America 483

Glossary of Acronyms

AAA – Area Agency on Aging

AARP — American Association of Retired

Persons

AAT — alpha-1 antitrypsin

ACS — American Cancer Society

ADA — American Dietetic Association

ADAMHA – Alcohol, Drug Abuse, and Mental

ADEA

ADL

AHA

AHS

AMA

ANDs

AoA

AT&T

BLS

BSE

CAT

CBO

CDA

CDBG

CHD

CPI

CPR

CRS

CWA

DHHS

DNA

DOL

DRGs

DRI

EEOC

FDA

FmHA

FSP

FTC

GAO

GI

GNP

HANES

HCFA

Health Administration

– Age Discrimination in Employment

Act

— activities of daily living (functional

status scale)

— American Heart Association

– American Housing Survey (formerly,

Annual Housing Survey)

— American Medical Association

— Administratively Necessary Days

– Administration on Aging (USDHHS)

— American Telephone and Telegraph

co.

— Bureau of Labor Statistics

— breast self examination

— computerized axial tomography

— Congressional Budget Office

— Committee on Dietary Allowances of

the Food and Nutrition Board

— Community Development Block Grants

— coronary heart disease

— Consumer Price Index

– Current Population Reports (U.S.

Bureau of the Census)

— Congressional Research Service

— Communications Workers of America

— U.S. Department of Health and

Human Services

– deoxyribonucleic acid

— Department of Labor

– diagnosis-related groups

— Data Resources Inc.

— Equal Employment Opportunity

Commission

— Food and Drug Administration

— Farmers Home Administration

— Food Stamp Program

— Federal Trade Commission

— U.S. General Accounting Office

– gastrointestinal

– gross national product

— National Health and Nutrition

Examination Survey

— Health Care Financing Administration

(USDHHS)

hCG — human chorionic gonadotropin

HDL — high density lipoproteins

HHA/HRA – health hazardlhealth risk appraisal

HMO

HUD

IADL

ICD

IND

IOM

IPP

JCAH

JTPA

LDL

LTC

MAb

MVSR

NAS

NASA

NCHS

NCPIE

NHAS

NHIS

NHLBI

NIA

NIADDK

NIH

NIMH

NINCDS

NIOSH

NNHS

OARS

OMAR

OTA

OTC

PBS

PHS

PMS

PRO

RDA

rDNA

SES

– health maintenance organization

– Housing and Urban Development (U.S.

Department of)

— instrumental activities of daily living

— International Classification of Diseases

— investigational new drug

— Institute of Medicine (National

Academy of Sciences)

— Investment in People Program

— Joint Commission on Accreditation of

Hospitals

– Joint Training Partnership Act

– low density lipoproteins

– long-term care

— monoclinal antibody

–Monthly Vital Statistics Report (NCHS)

— National Academy of Sciences

– National Aeronautics and Space

Administration

— National Center for Health Statistics

– National Council for Patient

Information and Education

— National Hearing Aid Society

— National Health Interview Survey

– National Heart, Lung, and Blood

Institute

— National Institute on Aging

— National Institute of Arthritis,

Diabetes, and Digestive Kidney

Diseases

– National Institutes of Health

– National Institute of Mental Health

– National Institute of Neurological and

Communicative Diseases and Stroke

— National Institute of Occupational

Safety and Health

— National Nursing Home Survey

— Older Americans Resources and

Services (assessment instrument)

— Office for Medical Applications

Research

— Office of Technology Assessment

— over-the-counter (drugs)

— Public Broadcasting System

— U.S. Public Health Service

– post-marketing surveillance (generally

used for drug testing)

– professional review organization

— Recommended Dietary Allowance

— recombinant deoxyribonucleic acid

— socioeconomic status
484 . Technology and Aging in America

SMMO — social (services) and health TEFRA — Tax Equity Financing Reform Act

maintenance organization TPA — tissue plasminogen activator

SNF — skilled nursing facility USDHHS — U.S. Department of Health and

SSA — Social Security Administration Human Services

SS1 — Supplemental Security Income VA — Veterans Administration

TDD — telecommunication device for the deaf
Appendix G

List of Contractors

Carole B. Allan

Consultant on Technology and Aging

Chevy Chase, MD

George Baker and Associates

Center on Aging

University of Maryland

College Park, MD

Gay Becker

Aging Health Policy Center

University of California at San Francisco

San Francisco, CA

Thomas C, Borzilleri

Consultant on Economics and Aging

Bethesda, NID

W. Ted Brown

Department of Human Genetics

New York State Institute for Basic Research in

Developmental Disabilities

Staten Island, NY

Judith Backfield Cohen and Elsbeth Logan

Western Gerontological Society

San Francisco, CA

Robert B. Hudson

Social Policy

Fordham University

New York, NY

Mary Bess Kohrs

Department of Nutrition and Dietetics

University of Illinois Medical Center

Chicago, IL

Elizabeth A. Kutza

School of Social Service Administration

University of Chicago

Chicago, IL

William J, Lessard, Jr.

Consultant on International Aspects of Aging

Washington, DC

Robert McGandy

Human Nutrition Research Center on Aging

Tufts University

Medford, MA

Theodore Marmor

Center for Health

Yale IJniversity

New Haven, CT

Studies

Joseph Ouslander and Associates

The Rand Corp.

Santa Monica, CA

Carolyn paul and Sally Coberly

Andrus Gerontology Center

University of Southern California

Los Angeles, CA

Randall Reed

Department of Genetics

Harvard Medical School

Boston, MA

Mitchell Reff

Smith, Kline, & French Labs

King of Prussia, PA

Jacob S. Siegel

Center for Population Research

Georgetown University

Washington, DC

Birute Skurdenis

Western Gerontological Society

San Francisco, CA

Paul S. Taylor

Consultant on Technology and Aging

Bethesda, MD

American Speech-Language-Hearing Association

Rockville, MD

485
Index
Index

Abbott Northwestern/Sister Kenny Institute,

165-166

ABLEDATA data base, 213

Acetylcholine, 145n

Activities of daily living (ADL) scale, 290-293

Administration on Aging, 314

Adult day care services, 202-203, 205, 238, 239

Aer Lingus retraining program, 351-352

Age Discrimination in Employment Act (ADEA) of

1978, 36, 336n, 337

Agitation, 224

Alarm systems, 85, 170, 171, 317-318

Alzheimer disease, 62, 63-66, 67-69

behavior problems, 223, 224

NIA research role, 102

prevalence, 193

Alzheimer Disease and Related Disorders

Association, 110

American Association of Medical Systems and

Informatics, 165

American Association of Retired Persons (AARP),

147, 214

American Cancer Society (ACS)

dietary recommendations, 126

Reach for Recovery Program, 163

American Diabetes Association, 124

American Heart Association, 163

American Medical Association, 147

American Telephone & Telegraph Co. (AT&T),

166, 171, 356

Annual Housing Survey (AHS), 282-285, 292

Anti-cholinergic drugs, 145

Antidiabetic drugs, 148

Anti-inflammatory drugs, 93, 148

Anti-psychotic drugs, 145

Apartments, accessory, 306-307

Apple computer, 165

Appliances, self-monitoring, 317

Appropriate technology, 174n

Architectural Barriers Act, 288

Area Agency on Aging (AAA), 227

Arthritis, 90, 166. See also Osteoarthritis

Arthritis Foundation, 89, 92, 94, 110

Arthritis institute at NIH (proposed), 108-109

Artificial sphincters, 75

Asbestos, 356

Aspirin, 92, 146

Assessment measures, 208-210, 235

Assessment technologies, 207-212

Assistive devices

examples, 212-214, 359-363

funding, 214-215, 218, 220, 236

information sources, 213-214, 218, 220, 359-363

negative attitudes toward, 216

supply problems, 218-219

workplace use, 357, 358, 359-363

Audiologists, 86

Audio loop systems, 84

Audiometric testing, 78, 80

Back pain, 166

Baltimore Longitudinal Study on Aging, 100

Bathroom design, 320-323

Bathtub design, 322, 323

Bedpads, 74

Bedroom design, 320

Beth Israel Hospital, 168

Biomedical research

congressional support, 101-103

costs, 101-102

determinants of success, 106-107

Federal Government role, 100-109

funding, 103

issues and options, 110-111

justifications, 103-105

resource allocation, 105-109

Biotechnology, 105

Birth cohorts, 36-38

Blacks. See Race differences

Board and care facilities, 199-200, 314

Bone cells, 96-97

Bone mass loss. See Osteoporosis

Braille devices, 360

Brain, 64

Breast self-examination, 126

Building design and hearing impairment, 86

Bureau of the Census, 38

Bureau of Labor Statistics, 341-344

Calcium intake, 99-1oo

Canon Communicator Mark II, 362

Cancer

as cause of death, 48

risk factors, 125-126

screening for, 126

Cavitation concept, 263

Caregivers

burnout, 291

families as, 194-195, 293

support groups for, 225

technologies to assist, 195, 220-224

Carpeting, 316

Cartilage tissue, 90-91

Case management, 227

Catheters, 74

489
4ql . Technology and Aging in America

Cellular aging, 50

Cerebrovascular disease. See Stroke

Chair lifts, 222-223, 316

Cholesterol level, 125

Chronic conditions, 7-10

age at onset, 50, 51

community dwelling elderly, 54, 291-293

computer-assisted home health care, 169-171

control of, 50-51

institutionalization and, 52-53

policy implications, 51

prevalence and severity, 54-55, 61, 169, 291-293

research on. See Biomedical research

sel-*are, 163-164

work disability and, 355-356

See also specific conditions, e.g., Dementia;

Hearing impairment

Closed Circuit TV (CCTV) magnification systems,

361

Cochlear implant, 82

Cohort component method, 38

Cohort data, 36-38

Colorectal cancer, 126

Commodore 64 computer, 172

Community Development Block Grants (CDBG),

299-300

Community dwelling elderly

chronic conditions, 54-55

home ownership, 282-283, 301

urinary incontinence, 70

Community service coordination, 227

Comprehensive Assessment and Referral

Evaluation (CARE), 210

CompuServe, 170

Computerized axial tomography (CAT) scanning,

97

Computers

access to, 171-173

health programs, 165-169, 176-178

input and output devices, 162, 172-173, 359-362

prices, 171-172

talking, 359

use by elderly, 160-173, 318-319

workplace use, 339, 346

Congregate housing facilities

as type of long-term care, 204

cost, 206

design, 312-314

funding, 239

privately developed, 310-311

publicly sponsored, 309-310

See also Board and care facilities; Nursing homes

Congress

biomedical research support role, 101-103,

107-109

Congressional Budget Office, 253

Congressional issues and options

biomedical research, 110-111

drug testing, education, and labeling, 150-153

health care services, 270

housing, 325-327

information technology, 175-178

long-term care services, 235-237

risk factor amelioration, 130-132

workplace technology, 358-359

Coronary heart disease (CHD)

as cause of death, 47-48

risk factors, 122-125

Data Resources, Inc. (DRI), 342

Deafness. See Hearing impairment

Death causes

cancer, 48, 121

coronary heart disease, 47-48, 121

stroke, 48, 121

Death rates. See Mortality

Degenerative joint disease. See Osteoarthritis

Dementia, 8, 62

causes, 63-64, 66, 68

clinical changes, 64, 67

diagnosis, 65, 67-68

drug-induced, 145

family impact of, 64, 68

Federal concern, 65-66

genetic basis, 65, 68

life expectancy effect, 64

prevalence, 64, 67

research on, 65, 69

Dental care, 256-257

Dental disease, 13, 128

Department of Housing and Urban Development

(HUD)

Annual Housing Survey, 282-285

housing programs, 295-300

Design Research Center, University of WisconsinStout, 321-322

Diabetes, 124

Diagnosis-related group (DRG)

approach, 260, 261-262

Diet. See Nutrition

Disability and impairment, 288-289, 355-356

See also Functional impairment

Disease prevention. See Health promotion/disease

prevention

Doors

handles, 323

thresholds, 316

Dressing aids, 320

Drugs

as cause of dementia, 63, 66, 145
Index . 491

as cause of hearing impairment, 83

as cause of urinary incontinence, 71

clinical trials, 14-15, 148-149, 152-153

containers, 144-145

cost of, 138-140

development costs, 149

effects and metabolism, 140

for treatment of dementia, 65-66

for treatment of incontinence, 73-74, 75

for treatment of osteoarthritis, 92-93

issues and options, 15, 150-153

over-the-counter, 146

patient compliance with prescriptions, 143-145

patient education, 14, 146-147, 151

side effects and interactions, 141-142

testing and surveillance, 14-15, 148-149

use by the elderly, 13-15, 137-147

Dysacusis, 78

Ear, 80

Earnings, 340-341

Elder cottages, 307-309

Elderly households, 23-24, 40, 277-278

characteristics, 283-285

homeownership, 282

housing expenditures, 285-286

Elderly population

aging of, 41-43

definition, 3, 35-36

demographic projections, 3, 38-41

Electrical stimulation, 75

Emergency response alarm systems, 85, 170, 171,

317-318

Employment opportunities

displacement of workers, 339-341, 344-346

industry trends, 337-338, 343

nature of work, 346, 348-349

occupational trends, 338-339, 343-346

part-time work, 346-349

projections, 341-342

technology-related, 344-364

See also Labor force; Workplace technology

Environmental fit, 209-210

Environmental press, 289

Estrogen therapy, 98-99

Executive Order 12291, 147

Exercise

as risk factor, 10-11, 122-123

bone health and, 99

osteoarthritis and, 91, 92

Falls, 127, 315-317

Families as caregivers, 194-195, 293

Farmers Home Administration (FmHA) housing

programs, 295, 297, 298

Federal Government role

biomedical research, 100-109

dementia, 65-66

health programs, 264-266

hearing impairment, 88-89

housing policy, 294-300

urinary incontinence, 76-77

See also Congressional issues and options

Federal Trade Commission (FTC), 87

Fertility rates, 4, 38

Fire safety, 317

Floor surfaces, 316, 321

FM amplification devices, 84

Food and Drug Administration (FDA), 75

drug approval process, 141, 148-149

health instructional software regulation, 177-178

hearing aid sale regulation, 87

Task Group on Computers and Associated

Software as Medical Devices, 177

Food assistance programs, 129, 131-132

Forgetfulness, 223-224

Fractures, 12-13, 95, 97-98, 126-127

Functional dependence

age-specific prevalence, 190-192

definition, 120

measurement scales, 290-293

Functional impairment

causes, 191-194

chronic disease and, 190

denial of, 258

housing and, 288-293

long-term care funding, 235

medical diagnosis and, 189-190

mental condition and, 193-194

prevalence, 186, 190-191, 290-293

technologies for caregivers, 222-224

work disability and, 355-356

Functional independence, 120-121, 133

Gender differences

hearing impairment, 79-80

labor force participation, 337, 342

life expectancy, 43-47, 279-280

living arrangements, 55, 280-281

marital status, 278-280

occupational trends, 338

osteoporosis, 95, 100

retirement income, 55

General Accounting Office (GAO), 178, 194

Geriatric Assessment Units, 259

Glucose tolerance as risk factor, 124

Grab bars, 320, 321

Granny flats, 307-309

Grip devices, 362
492 . Technology and Aging in America

Handles, 323

Handrails, 316

Health and Nutrition Examination Survey (HANES),

259

Health care

appropriate for older persons, 257-259

computer-assisted, 167-171

self-care, 163-164

Health care costs, 21-23, 101-102, 104-105, 249-257,

268-270

age-specific, 251-252

containment strategies, 259-263

funding of, 251-252

growth of, 253-256

Health Care Financing Administration (HCFA), 65,

177, 263

Health care industry, 105

Health care providers

appropriate, 259

education on drugs, 145-146, 151-152

house calls, 169, 170

rehabilitation services, 217-218

S Upply of, 1 6 9

Health care services

coordination, 263-266, 270-271

quality assurance, 270

research priorities, 269

utilization, 254-256, 260-261

See also Health care providers

Health hazard/health risk appraisals (HHA/HRA),

166-167

Health instruction, 164-167, 175-178

Health Interview Survey, 355

Health maintenance organizations (HMOS), 263

Health promotion/disease prevention, 10-13,

119-133

nutritional deficiencies, 128-129

research programs, 109

risk factor amelioration, 121-28

types of prevention, 120

workplace technologies, 356-357

Hearing aid dealers, 86-87

Hearing aids, 83-84

dealers, 86-87

regulation of sale, 87

Hearing impairment, 9, 62, 78-89

age at onset, 81-82

causes, 81

denial of, 82

funding for treatment, 87-88

impact, 82

prevalence, 78-80

prevention, 82-83

service delivery system, 86-87

technologies to compensate for, 83-86

treatment, 82-86

types of, 80-81

Heart disease. See Coronary heart disease

Hip fractures, 95

Hip replacement, 93-94, 97-98

Hip surface replacement, 94

Home care

growth in, 256

information technology and, 169-171

Home care services, 200-202

costs, 205

funding, 237, 238, 239

Home loan programs, 298-299

Homesharing for seniors, 303

Hormone treatments for osteoporosis, 98-99

Hospice care, 203-204, 238, 239

“Hospital on the wrist,” 167-168

Hospitals

cost-containment, 261-262

long-term care services, 231

utilization, 264-266, 271

Households, 277-278

nonfamily, 281

See also Elderly households

House Select Committee on Aging, 137

Housing, 23-27

conversions, 304-307

deficiencies, 283-285, 287

demographic influences, 277-281

design and technologies, 315-324

excess space, 302

expenditures, 285-287

functional impairment and, 288-294

issues and options, 325-327

maintenance, 301

modular cottages, 307-309

ownership, 282-283, 301

research priorities, 325

shared, 302-303

See also Board and care facilities; Congregate

housing facilities; Nursing homes

Housing Act of 1937, 294, 295

Housing Act of 1954, 297

Housing Act of 1956, 294

Housing Act of 1959, 296, 297

Housing Act of 1964, 299

Housing and Community Development Act of 1974,

288, 295, 296, 298

Housing and Urban-Rural Recovery Act of 1983,

297

Housing policy, 294-300

Housing legislation

impact on elderly, 300-301

summary, 295-300
Index ● 4 9 3

HUD. See Department of Housing and Urban

Development

Hypertension as risk factor, 10, 122

Hypertropic arthritis. See osteoarthritis

Immigration rates, 40

Impairment. See Functional impairment

Incontinence. See Urinary incontinence

Information technology, 15-18

ability to use, 160-162

access to, 171-173

definition, 159n

drug use monitoring, 142-143

Federal Government role, 173-174, 175-178

health care use, 167-171

health instruction use, 164-167, 175-178

health program coordination use, 266

policy formulation, 174-178

research needs, 174

self-care use, 163-164

Infrared amplification devices, 84

Institute of Medicine (IOM) NIH organization study,

109

Institutionalization

functional disability and, 290

patterns of, 52-53, 281

Insurance coverage for health care, 266-268

International Workshop on Colorectal Cancer, 126

Investment in People Program, California, 354

Japan, 50

Job opportunities. See Employment opportunities

Joint Commission on the Accreditation of Hospitals

(JCAH), 178

Joint debridement, 94

Joint replacement, 93-94

Kellogg Foundation, 165, 168

Kitchen design, 319-320

Labor force

displacement, 339-341, 344-346

industry trends, 337-339

participation rates, 337-342

projections, 341-343

Laser cash registers, 348

Life-care communities, 230, 310-311

Lifechec health risk appraisal instrument, 167

Life expectancy, 3, 36, 41, 51

sex- and race-specific, 42, 43-47, 279-280

“Lifeline” system, 170, 171, 317

Life span, 4, 48-51

Lifting of patients, 222-223

Light pens, 162

Living arrangements

by age and sex, 280-281

socioeconomic characteristics and, 55-56

Longitudinal studies

bone mass loss, 100

displaced workers, 340, 345

Long-term care, 18-21

coordination of services, 226-231

costs, 205-206, 262

definition, 185

delivery systems, 225-232, 237

Federal Government role, 186-187, 235-237

functional impairment and, 189-194

funding, 186-189, 235-237, 237-240, 265-266

need for, 185-186

planning by individuals, 231-232

research priorities, 234

service-related issues, 204-207

technologies, 187-188, 207-225

types of services, 194-204

Magnification devices, 361

Malignant neoplasms. See Cancer

Marital status, 278-280

Median age of population, 4, 36, 41

Medical Device Amendments of 1976, 178

Medical monitoring, 170

Medical technology, 167-171

health care cost impact, 253-254

Medicare/Medicaid system, 41

disbursements, 101

funding for health devices, 172 (computers)

funding for hearing services and devices, 87-88

funding for incontinence products, 77

long-term care funding, 188-189, 237-239,

264-266

prospective payment system, 261-262

reimbursement structure, 129-130, 131, 173,

220-221

See also Health care costs

Medicaid 2176 Waiver Program, 238-239, 262

Medication. See Drugs

Med-Tymer, 144

Men. See Gender differences

Meniere’s disease, 81, 83

Mental functioning measurement, 209

Mental health programs, 168-169

Mental impairment. See Functional impairment

Meridian Health Care, 230-231

Morbidity, 121

Mortality

age-adjusted, 4n, 6, 43

age-specific, 38

disease-specific, 121
.

494 . Technology and Aging in America

infant, 4, 5

prediction of, 38

Mortgage insurance programs, 297

National Aeronautics and Space Administration

(NASA), 74-75

National Cancer Institute (NCI), 102-103, 107n

National Center for Health Statistics, 355

National Channeling Demonstration Programs, 262

National Commission on Employment Policy, 348

National Council for Patient Information and

Education (NCPIE), 146

National Health and Nutrition Examination Survey,

89

National Health Interview Survey, 290

National Hearing Aid Society (NHAS), 86-87

National Heart, Lung, and Blood Institute (NHLBI)

cholesterol study, 125

funding, 102-103, 107n

National Homecaring Council, 169

National Housing Act of 1949, 294

National Industrial Recovery Act, 294

National Institute of Arthritis, Diabetes, and

Digestive and Kidney Diseases (NIADDK), 103

National Institute of Handicapped Research (NIHR),

214, 219

National Institute of Mental Health (NIMH), 65

National Institute of Neurological and

Communicative Diseases and Stroke

(NINCDS), 65

National Institute on Aging (NIA), 65, 77

Alzheimer disease research, 102

biomedical research role, 101-102

establishment of, 105

funding, 102

information system development, 173

teaching nursing home program, 199

National Institutes of Health (NIH), 93, 98

biomedical research role, 101-103

Consensus Conference on osteoporosis, 98, 99,

100

funding, 101

organization, 108-109

worker health study, 355

National Long-Term Care Channeling

Demonstration Program, 208, 228

National Nursing Home Survey, 196, 290

National older Worker Information System,

University of Michigan, 348

National Plan for Research on Aging, 102

Networking, 160

Nursing homes

care systems, 198-199, 220-222

cost of care, 205

design, 312-314

drug use in, 145

entry age, 52

funding of care, 188-189, 196, 197, 237, 238,

265-266

mortgage insurance, 298

population projections, 52-53, 311

predictors of residency, 53, 290

residents, 196-198, 290-291, 311-312

Nutrition

as risk factor, 12, 124, 125, 126, 128-129

drug efficacy and, 142

osteoporosis and, 99-100

obesity as risk factor, 124, 126

Occupational trends, 338-339, 343-346

ohio State University, 167

older Americans Act, 36, 169, 227

Title 111, 239

older Americans Resources and Services (OARS),

121, 133, 210

older persons

biological characteristics, 140

drug testing and, 148-149, 150

‘(old-old, ” 36

On Lok agency, 229

Operation Match, 302

Optacon, 359

Organizational Structure of the National Institutes

of Health, 109

osteoarthritis, 9, 62-63, 89-95

assistive devices, 92

biology and anatomy, 90-91

definition, 90

diagnosis, 91-92

prevalence, 89-90

risk factors, 91

social factors, 94-95

treatment, 92-94

Osteoarthrosis. See osteoarthritis

Osteoporosis, 9, 63, 95-100

as risk factor, 127

biology and physiology, 96-97

diagnosis, 97

prevalence, 95

prevention, 99-100

treatment, 97-99

Osteotomy, 94

Otolaryngologists, 86

Ototoxic drugs, 83

Paging devices, tactile, 85

Parries longitudinal study, 340, 345

Patient Appraisal and Care Evaluation (PACE), 210
Index . 495

Period data, 36-37

Pharmaceuticals. See Drugs

Photon absorptiometry

Physical functioning measurement, 208-209

Physical impairment. See Functional impairment

Physicians

cost of services, 263

See also Health care providers

Picturephone device, 85

Population aging, 36, 40-43

Population pyramids, 45-47

Presbycusis, 81

Prescription records, 168, 319

Preventive measures. See Health promotion/disease

prevention

Project Match, 303

Public Health Service

Office of Disease Prevention and Health

Promotion, 165, 173

Public housing, 295

Quackery in arthritis treatment, 94

Race differences

hearing impairment, 80

housing deficiencies, 284-285

labor force participation, 342-343

osteoarthritis, 89

Reading devices, 359, 361

Recommended Dietary Allowances (RDAs), 128,

132

Rehabilitation Act of 1973, 84, 217

1978 amendments, 288

Rehabilitation after stroke, 125

Rehabilitation, Comprehensive Services, and

Developmental Disabilities Amendment of

1978, 218, 220

Rehabilitation Research and Training Centers in

Aging, 214, 219

Rehabilitation services

aural, 85-86

dissemination initiatives, 219-220

Federal Government role, 214-215, 236

funding, 236

problems limiting use of, 215-218

Rehabilitation technologies. See Assistive devices;

Rehabilitation services

Rental subsidies, 295-297

Research. See Biomedical research

Residential care complexes, 230, 310-311

Respite care, 204

Retirement History Survey, 355

Retirement income, 341

Rhode Island Department of Health, 167

Risk factors, 121-122, 129-130

cancer, 125-126

coronary heart disease, 122-125

dental disease, 128

fractures, 126-127

issues and options, 130-132

sensory loss, 127-128

stroke, 122-125

Robert Wood Johnson Foundation teaching

nursing home program, 199

Robotics International, 345

Robots

home use, 324, 339

worker displacement by, 340, 344-345, 347

Safety features, 315-324

Section 8 program, 295-296, 305, 309

Section 202 program, 296-297, 300, 309, 310

Section 236 program, 296

Section 221(d)(3) program, 297

Section 231 program, 297, 305

Section 232 program, 298

Section 312 program, 299

Section 502 program, 298

Section 504 program, 298

Section 515 program, 298

Self-care education, 163-164

Self-help groups, 163-164

Senate Special Committee on Aging, 137

Sensaphone, 318

Sensory loss as risk factor, 127-128

Sex-based differences. See Gender differences

Sickness Impact Profile (SIP), 210

Signaling systems, 85, 170, 171, 317-318

Sleeping pills, 141

Small Business Innovation Development Act, 173

Smoking as risk factor, 10, 122, 125

Social changes, 23-27

Social functioning measurement, 209-210

Social/Health Maintenance Organizations (S/HMOs),

229, 263

Social Security Act, 169

Title XVIII, 237-238

Title XIX, 238-239

Title XX, 239

Social Security Administration (SSA) population

projections, 38

Sodium fluoride, 98

Speech amplifiers, 362

Speech recognition systems, 85

Splints, 362

Stairs, 292, 316

Stress as risk factor, 11, 123-124
496 . Technology and Aging in America

Stroke

as cause of death, 48

rehabilitation, 125

risk factors, 122-125

Suburban elderly, 301-302

Supplemental Security Income (SSI), 239

Surgery for incontinence, 73, 75

Survival curves, 49

Talking machines, 359-360, 361

Tax Equity Financing Reform Act (TEFRA), 256

Technology

applications, 34

definition, 7, 137n

forms of, 33

See also Appropriate technology; Assessment

technologies; Biotechnology; Housing, design

and technologies; Workplace technology

Telecommunications devices, 318-319

Telecommunications devices for the deaf (TDDs),

361-362

Telecommunications for the Disabled Act of 1982,

85

Telephone use, 84-85, 362

Teletex system, 85

Teletypewriters (TTYs), 85

Tinnitus, 81

Tissue sensitivity, 141

Toilet design, 320-321, 322

Touch-sensitive terminals, 162

Training procedures for incontinence, 74, 75-76

Training programs. See Worker training and

retraining programs

Truck devices, 362-363

Tub chairs, 320

Undergarments, 74

Unemployment, 340-341

United Auto Workers Union, 349

Urinary incontinence, 8, 62, 66, 70, 77-78

causes, 70-71

costs of, 76-78

definition, 70

devices to control, 73, 74-75

prevalence, 70

treatment, 72-76

types, 71-72

Versabraille, 360

Vertebral fractures, 95

“very old, ” 36

Veterans Administration (VA)

listening device program, 89

long-term care services, 229, 240

rehabilitation services, 214-215, 219

Viewdata system, 85

Viewscan, 361

Vistaphone device, 85

Vitamin D, 98

Voice-activated systems, 162

Walkers, 316

Wandering, 224

White House Conference on Aging, 185, 300

Whites. See Race differences

Women. See Gender differences

Worker training and retraining programs

attitudes toward, 352-353

benefits, 350, 354

costs, 350-351

examples, 353-354

methods, 351-352, 364

older worker participation, 349-350, 352-353

Workplace technology

employment opportunities and, 335-349

health and, 355-357

issues and options, 358-359

research needed, 357-358

Work-related changes, 27-29

World Health Organization, 120

Wrist fractures, 95

Wrist injuries, 356

“young-old,” 36

zinc deficiency, 99

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