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Solutions to Care for an Aging Population

March 17, 2023
March 17, 2023

More than 10,000 U.S. adults are turning 65 each day. As the population ages, they generate a number of critical issues and trials for an industry that is already dealing with financial problems, severe staffing shortages, and provider burnout. The following are some of the unique challenges to be prepared for as a large proportion of our population ages over the next decade.

A Silver Tsunami is Coming 

"By 2030, all 73 million baby boomers will have turned 65, bringing about what is being called a “silver tsunami” that is expected to impact every aspect of our economy and society."

Wince-Smith, 2022


At more than $700 billion a year, or about 3% of GDP, people aged 65 and older currently account for more than one-third (35%) of U.S. healthcare spending. As the boomer population ages, Medicare costs are expected to more than double (Wince-Smith, 2022). Absorbing these costs and caring for an increasingly older population will be tough challenges for the U.S. over the next several decades.


Mental Health Needs are Increasing Among Older Adults

It is estimated that 20% of people aged 55 years or older experience some type of mental health concern. The most common conditions include anxiety, severe cognitive impairment, and mood disorders (such as depression or bipolar disorder). Mental health issues are often implicated as a factor in cases of suicide. Older men have the highest suicide rate of any age group. Men aged 85 years or older have a suicide rate of 45.23 per 100,000, compared to an overall rate of 11.01 per 100,000 for all ages (CDC, 2023).

One outcome of the COVID-19 pandemic among older adults in America has been a mental health crisis due to a lack of access to Medicare providers and needed services. A shortage of mental health providers persists while the COVID-19 pandemic has resulted in significant increases in anxiety and depressive disorders among older adults. Between 25-30% (20 million) older adults have reported these mental health disorders since April 2020. Physical distancing and quarantine have led many older adults and caregivers to feel isolated, lonely, agitated and withdrawn (National Council on Aging, 2022).

The ongoing opioid crisis has further impacted this trend and it is estimated that 5.7 million adults over the age of 50 required treatment for a substance use disorder in 2022. New research shows that not only are Medicare beneficiaries at a high risk for opioid misuse and addiction, but they are also not receiving adequate treatment and, as a result, overdose and end up hospitalized (National Council on Aging, 2022).

It will be critically important to expand Medicare’s provider network to include mental health counselors, marriage and family therapists, peer recovery support specialists, and other licensed behavioral health specialists. Currently, Medicare does not reimburse for services provided by mental health counselors or marriage and family therapists. These two professions make up approximately 40% of the licensed behavioral health workforce in the United States. They are covered by all other insurance providers, both public and private, aside from Medicare. With these two professions shut out of the largest insurer in the country, Medicare beneficiaries do not have sufficient access to mental health treatment (National Council on Aging, 2022).

Access to mental health treatment for Medicare beneficiaries in rural areas is especially lacking. As of 2022, over 150 million people in the United States live in Mental Health Professional Shortage Areas, according to the Health Resources and Services Administration. Fifty percent of rural counties in America have no practicing psychiatrists, psychologists or social workers (National Council on Aging, 2022).

There is also a strong incentive to support the integration of behavioral health and primary care for aging Americans and to support interdisciplinary care coordination and treatment teams.

A strong body of evidence shows that integrated care models like Collaborative Care, which integrates depression care into general medical settings, can improve behavioral health treatment delivery and outcomes for older adults (National Council on Aging, 2022).

Another compounding factor among seniors is their stigma towards mental health and mental healthcare.

According to therapist.com, “Many Boomers place a high priority on being self-sufficient. Therefore, seeking treatment for mental illness is often viewed as a personal or moral failure instead of a health problem.” Some families in the 20th century viewed mental illness as shameful for both the individual sufferer as well as their family. Baby Boomers may remember their families attempting to hide the fact that a family member had received some type of mental healthcare.

Therapist.com, 2022


Feyza Marouf, M.D., a psychiatrist at Massachusetts General Hospital’s (MGH) Department of Psychiatry, agrees that a stigma exists among older adults when it comes to seeking help for mental health issues. He acknowledges that this is a barrier clinicians are working to overcome. “There is a background of stoicism and a general reluctance to take medications, with older adults feeling they should muscle through the depression and anxiety,” Dr. Marouf says. “There’s a sense that, ‘I’m supposed to be strong and asking for help is weakness,’ with mental health that we don’t see with physical symptoms” (NCECE, 2019).

Experts suggest at least three steps that providers can take to improve seniors’ access to mental healthcare. One is to screen patients for common mental health issues as part of a primary care visit. “Older adults experience physical symptoms more intensely when they’re depressed,” explains Alexis Freedberg, M.D., Psychiatrist-in-Charge of the Cognitive Neuropsychiatry Unit at McLean Hospital. “When you have someone with a lot of pain that isn’t medically explained, and the experience of pain is taking over their lives, that may be a symptom of geriatric depression. Depression screening is therefore vitally important to take action before the patient’s health and outcomes get worse” (NCECE, 2019).

Another step is to take action when mental health care issues are suspected with a patient. 

"I would encourage all clinicians who suspect depression in their older adult patients to take action on it,” says David Mischoulon, M.D., Director of MGH’s Depression Clinical and Research Program.

NCECE, 2019


“We’ve done studies that depression may be picked up in the PCP setting, but PCPs may not take action because they’re not sure or they’re inadequately trained. My advice is the clinician should make a referral to a psychiatrist. Otherwise, a patient can go on without treatment and if depression isn’t treated early, the outcome is worse.”

Finally, it is important to start slowly with medication for mental health issues among older patients. Older patients can be more susceptible to the side effects of some medications and will often quit taking the prescription if the dosage is too high. Conversely, patients may not see any benefit if the dosage is too weak (NCECE, 2019).


Technology is Expanding Access to Senior Care

Growth in home healthcare is projected at an explosive rate from 2021 to 2031. According to the U.S. Bureau of Labor Statistics, employment in the sector will grow by 21%, adding 711,700 jobs each year on average over the decade. This is compared to the average industry employment growth projected at 7% (AMN Healthcare, 2022).

The primary reason for this growth is the aging of America. According to projections from the U.S. Census Bureau, the number of people over 65 will grow from 43 million in 2012 to 84 million by 2050, rising from 14% of the population to 21%. Additional factors fueling this growth include greater cost efficiency, better outcomes, and the preference of healthcare consumers to be treated at home (AMN Healthcare, 2022). This explosive growth will continue to fuel labor shortages across the care continuum, but new technology in the healthcare industry can help resolve them. These new technologies can help lower operational costs, improve care quality, and create a more sustainable business model for senior care (Meola, 2022).

One of the most potentially impactful technologies is telehealth in assisted living and home care. Technology has already begun to work its way into aging adult care, from laptops and smartphones with large buttons and displays designed for easier senior use to personal emergency response service (PERS) tools (think the infamous “I’ve fallen, and I can’t get up” commercials) (Meola, 2022).

A recent article in Harvard Business Review showcased efforts by four primary care organizations to help their senior populations become more agile with telehealth technology (Ilkram et al., 2020). These four organizations tackled four challenges posed by telehealth visits with physicians:

  • Patients lacked access to the internet or appropriate devices
    Two of the four primary care clinics deliver tablets to patients who lack them. Another mails custom-formatted tablets to its highest-risk patients and health coaches remotely instruct the patients on how to use the technology. The fourth clinic repurposed its fleet of pickup vans, previously utilized to drive patients to and from a clinician’s appointment, to provide delivery service and drop off the tablets at patients’ homes.
  • Patients had medical conditions that impeded their use of telehealth 
    One organization engages non-clinician caregivers (predominately patients’ family members) in telehealth visits to facilitate communication between the patient and the clinician.
  • Patients had the appropriate technology but limited digital literacy 
    The organizations introduced “practice visits,” in which administrative staff conducts a mock video visit with patients 1 to 2 days prior to the first video visit with the clinician.
  • Highest-risk patients needed regular monitoring of their vital signs 
    Providers dropped off monitoring devices, such as blood pressure cuffs, pulse oximeters, and weight scales for their highest-risk patients. They remotely coached the patients and their caregivers on how to measure vital signs so they could identify irregularities and, when needed, get urgent care.

Smart wearable technologies are increasingly being used by older individuals to help them live healthier, happier lives. Wearable technology can also bring peace of mind to family members and caregivers. Some wearables built exclusively for older adults incorporate capabilities like fall detection and emergency monitoring, giving them the freedom and flexibility to do anything they want while also providing an extra layer of security in the event of an emergency. Additional features that are being included in wearables designed for seniors include:

  • Medical alert wearables built specifically for older adults that feature wristwatches that not only track nutrition, heart rate, and activity goals but also features emergency monitoring. In the case of an emergency, users may communicate with emergency personnel by pressing a single button on the smartwatch’s built-in microphone and speaker.
  • Advanced location monitoring and automated alarms help handle day-to-day duties, so older adults don’t miss a doctor’s visit or forget to take medicine. For older adults with weak vision, these monitors have huge, high-resolution touchscreen and large icons.
  • In addition to monitoring steps, some wearables include automated sleep monitoring so that older adults may analyze their sleep habits and learn how to obtain more rest. These devices have a long battery life, a big backlit display, and access to common applications that older adults will appreciate, such as weather and calendar.
  • Other wearables offer daily fitness tracking, such as calories burnt, stairs climbed, and steps walked. In addition, they record heart rate variability, which is used to compute and show stress levels. Some even have built-in guided breathing techniques for relaxation and stress alleviation, making it easier for older adults to feel at peace and at ease in their everyday life. (Discovery Commons, 2023)

Certain assisted living and home care facilities are turning into smart homes to aid the aging population. Voice assistants such as the Amazon Echo (aka Alexa) and Google Home are helping seniors remember their daily schedules, such as when to eat, take medicine, or visit their doctors. Smart pillboxes help with dosage control and timing of medication. Even some smart clothing is already helping doctors monitor their patients’ movements to check for irregular gaits, or to alert the care team if a fall occurs. Beyond that, motion detectors, smart mattresses, and even personal robots can help make the assisted living experience more palatable (Meola, 2022).

The next step in the digital transformation of senior care comes from artificial intelligence, which will eventually be able to predict patterns in seniors’ behavior and prevent falls and other emergencies before they take place.


Hospital Facilities are Evolving to Accommodate Older Patients

The aging of the nation’s population will continue to complicate how hospitals deliver care. But hospitals are responding with a host of improvements in facility design, technology, and health care delivery in an effort to improve care for older patients (Regis College, 2022). 

Hospitals are implementing design changes — including some that are very simple — to better serve them. For example, hospitals are:

  • Modifying their lighting to help older patients maintain their normal sleep patterns
  • Using large-print clocks and calendars
  • Stocking extra reading glasses and hearing amplifiers
  • Installing larger and better signage to guide older patients through large facilities
  • Providing clear facility maps to older patients
  • Using lower and wider exam tables to reduce older patients’ fears of falling
  • Installing automatic doors at both entrances and exits
  • Using taller chairs with arms so older patients can stand up more easily

Hospitals also are leveraging technology to improve care for older patients. One of the best examples of this is the use of wireless smart beds. Smart beds can monitor patients’ vital signs, like their heart rate or respiratory rate, and alert hospital staff when intervention is needed. Smart beds also can enable nurses to communicate with patients remotely and detect incontinence, allowing nurses to assist patients in a more discrete manner (Regis College, 2022).

Along with smart beds, hospitals are installing specialized smart televisions designed specifically for health care settings. These devices can:

  • Allow patients to have video calls with family members
  • Offer tailored content that can, for example, help patients with Alzheimer’s disease stay calm while taking medicine or reduce their level of frustration
  • Support the use of pillow speakers that improve patients’ ability to hear the television

Hospitals also are harnessing the power of artificial intelligence (AI) to improve older patients’ health care. For example, there is the use of diagnostic tools based on AI that can identify older patients who are at increased risk of conditions such as urinary tract infections or pneumonia.

"With AI, hospitals can reduce fall rates by using predictive analytics that rely on real-time data of patients’ vital signs and medication intake. Additionally, wearable devices can monitor older patients’ hydration, grip strength, and muscle mass to identify those who are at risk of falls."

Regis College, 2022


Prescription Drug Problems are Being Addressed Across the Continuum

Drug-related problems are common in older adults and include drug ineffectiveness, adverse drug effects, overdosage, underdosage, inappropriate treatment, inadequate monitoring, nonadherence, and drug interactions.

"Drugs may be ineffective in older adults because clinicians under-dose (e.g., because of increased concern about adverse effects) or because adherence is poor (e.g., because of financial or cognitive limitations)"

Ruscin & Linnebur, 2023


Adverse drug effects are effects that are unwanted, uncomfortable, or dangerous. Common examples are oversedation, confusion, hallucinations, falls and bleeding. Among ambulatory people 65 or older, adverse drug effects occur at a rate of about 50 events per 1000 person-years. Hospitalization rates due to adverse drug effects are 4 times higher in older patients (about 17%) than in younger patients (4%). And 66% of these hospitalizations in older patients are due to 4 drugs or drug classes—warfarin, insulin, oral antiplatelet drugs, and oral hypoglycemic drugs (Ruscin & Linnebur, 2023).

Adverse effects are thought to be preventable in at least 25% of cases in older adults. Many drug-related problems could be prevented if greater attention were given to medication reconciliation when patients are admitted or discharged from the hospital or at other care transitions (transfer from nursing home to hospital or skilled nursing facility to home) (Ruscin & Linnebur, 2023).


Older Adult Program at Duke Recognizes Unique Challenges

Frailty occurs as a result of many diseases and medical conditions. Evidence suggests that frailty may be related to lost muscle mass that starts during midlife. Frailty means vulnerability, especially for those also facing acute illness, injury, or other stressor. In people over age 65, about 10% have physical frailty, with women and those over age 80 even more likely to be frail (Han, 2015). 

Research has shown that frail individuals are high resource users— office visits, hospitalization, long-term care. They fall more often, need more assistance, have more complications related to surgery and chronic disease, and are more likely to die compared to similar people without frailty (Han, 2015).

An interprofessional team from the Duke Schools of Medicine and Nursing, Duke Health System, and Duke Health Technology Solutions collaborated to create 30 online continuing education modules to assist health care professionals in the care of the frail elder population. The modules are geared to care for older adults who have higher rates of multiple medical conditions, limited physical and cognitive abilities, and limited resources.

The modules address five critical concept areas including: delirium, care transitions, medication management, malnutrition, and shared decision making. Each module contains customized content addressing the learning needs of the diverse health care workforce responsible for the care of frail elders through specific case material and role specific content (Duke University School of Nursing, 2019).

"Optimizing care for older adults truly takes a team that spans the care continuum,” says Loretta Matters, MSN, RN-BC, associate director of the Center for Geriatric Nursing Excellence and project director."


“The training modules were developed collaboratively by interprofessional faculty and clinicians from across Duke and focus not only on geriatric clinical issues but also care coordination and communication among team members, including the patient and family, to optimize care” (Duke University School of Nursing, 2019).


Addressing Healthcare Discrimination Against the “Elderly”

"Aging is a gradual process, not a disease. The term elderly evokes stereotypes and biases that are improper in the profession of medicine. Like imbecile and idiot, it has lost its original meaning and has become derogatory, demeaning, and offensive. Its use must be avoided; simply mentioning a patient’s age is more informative."

Javad Hekmat-panah MD, Department of Neurological Surgery, University of Chicago Medicine


Healthcare professionals feel comfortable to start treatments in younger patients with malignant diseases, despite median survival rates of less than 1 or 2 years, yet there is hesitancy to treat an older patient with benign diseases who might have a much longer life expectancy. Furthermore, without ill intentions, some investigators arbitrarily lump those over 65 years of age into one group, as though treatment should be the same for everyone in that group, rather than for each patient as an individual (Hekmat-panah, 2019).

As medicine became scientific during the last century, life expectancy increased everywhere. In the United States, for example, this rose from 47.3 years at birth in 1900 to 77.3 years in 2020 (for both sexes and all races). 

"Of the 18.2 million individuals who incur the highest healthcare costs in the United States, only 11% are in their last year of life; end-of-life cost is often exaggerated and unwarrantedly linked to the elderly, while in fact it applies to every age."

Hekmat-panah, 2019


Conclusion

Care for aging adults is changing dramatically. Healthcare leaders need to be aware of these trends and issues and adjust their organizations as needed to ensure the best outcomes for this very important segment of the population. At HealthStream, we remain committed to helping solve the most challenging issues healthcare faces. Not only have we partnered with recognized experts in older adult care, but we also work with organizations across the continuum of care to ensure their people have the support needed to provide quality care to each patient, regardless of age.





Robin L. Rose, MBA
Thought Leadership Consultant, HealthStream
February 2023


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References
AMN Healthcare. Why is home healthcare growing so fast? Update November 22, 2022.
Centers for Disease Control (CDC) and Prevention and National Association of Chronic Disease Directors. The state of mental health and aging in American Issue Brief 1: What do the data tell us? Atlanta, GA: National Association of Chronic Disease Directors; 2008.
Interprofessional team aims to enhance care of frail elder population across the care continuum. Duke University School of Nursing. July 17, 2019.
Han, L. Frailty and the elderly: So what does frail mean, anyway? Insight Therapeutics. November 23, 2015.  publications/insights/2015/11/frailty-in-the-elderly-so-what-does-frail-mean-anyway/
Hekmat-panah, J. The “elderly” in medicine: Ethical issues surrounding this outdated and discriminatory term. Inquiry. January-December 2019; 56.
Ikram U, Gallani S, Figueroa JF, Feeley, TW. 4 strategies to make telehealth work for elderly patients. Harvard Business Review. November 24, 2020.
Meola A. Future demand for elderly care services like assisted living and in-home care are rife for digital disruption. Insider Intelligence. April 15, 2022.
Miller J. How to improve access to mental health and substance use care for older adults. National Council on Aging (NCOA). May 18, 2022.
National Center for Equitable Care for Elders (NCECE). Overcoming the stigma of seeking help. Harvard University. October 17, 2019.
Regis College. How hospitals are improving care for elderly patients. August 29, 2022.
Ruscin JM, Linnebur SA. Drug-related problems in older adults. In: Merck Manual Professional Version. Rahway, NJ: Merck & Co, Inc. Accessed January 2023. https://www.merckmanuals.com/professional/geriatrics/drug-therapy-in-older-adults/drug-
Therapist.com. Baby boomers and mental health. Reviewed by Warns D. Updated October 10, 2022. Accessed October 10, 2022.
Wince-Smith D. Bracing for the silver tsunami. Forbes. February 25, 2022.