Responses of the Health Professions to the Demographic Revolution: A Multidisciplinary Perspective

RESPONSES OF THE HEALTH PROFESSIONS TO THE DEMOGRAPHIC REVOLUTION: A MULTIDISCIPLINARY PERSPECTIVE DAVID HAMERMAN* and ANDREA FOXt The view that we are in the midst of a "demographic revolution" [1] reflects the unprecedented growth in this country of the population over age 65. At the turn of the century those over 65 constituted about 4 percent of the population; now at 12 percent, the population over age 65 will approach 20 percent within three decades after the year 2000 [2—5]. The critical issue, however, is the "revolution within a revolution," whereby those age 85 and over constitute the fastest growing segment of the over-65 population [6]. Those age 85 and over have come to be designated variously as the "old-old" or "extreme aged/elderly" [6-8]. From 1960 to 1980, the 85-and-over group rose from under 1 million to 2.24 million, an increase of 141 percent. Projections to the year 2000 anticipate a further increase of 117 percent to 4.9 million; this group is expected to exceed 13 million by 2040 [6]. Vogt [9] expressed concern that "the implications of the growing aged population on our way of life have been only slowly recognized, and efforts to deal with this phenomenon have been woefully inadequate." This article discusses some of these implications and proposes ways the health professions can respond to the challenges of the demographic revolution. Work supported in part by an award from the National Institute on Aging (David Hamerman AG 00359). *Resnick Gerontology Center, Albert Einstein College of Medicine, and Division of Geriatrics, Department of Medicine, Montefiore Medical Center, 111 East 210th Street, Bronx, New York 10467. !Division of Geriatrics, Department of Medicine, University of Pittsburgh, School of Medicine, Pittsburgh, Pennsylvania 15213.© 1992 by The University of Chicago. AU rights reserved. 003 1-5982/92/3504-0792$01 .00 Perspectives in Biology andMedicine, 35, 4 ¦ Summer 1992 | 583 Age-Associated Chronic Conditions Advancing age imposes a risk of physical limitations and cognitive impairment. Heart disease and rheumatic disorders account for over half of the causes of disability [10]; dementias, osteoporosis with associated hip and vertebral fractures, and atherosclerotic changes affecting the cerebral, coronary, and peripheral arterial circulation exact a further age-associated toll. In one study, only about one-third of white persons age 80 or older and dwelling in the community were physically active [11]. Other reports indicate that advanced age is accompanied by limitations in the performance of personal and household activities [12—14]; cumulative disabilities requiring more home services may lead to institutionalization [15, 16]. Although not necessarily representative of the many very old individuals residing in the community, the homebound frail elderly have more global needs due to a lack of social interchange , home health providers, and medical care. In particular, they suffer from a reservoir of what Williamson et al. called "unreported needs" [17]. These include visual and hearing defects, genitourinary symptoms, pressure sores, malnutrition, and other conditions that are frequently accepted by very elderly community dwellers as an inevitable consequence of "old age." In the United States many older persons with unreported needs dwell in substandard conditions, particularly within inner-city housing [18, 19]. Those who are unwilling to leave home, or are incapable of doing so, fail to obtain medical services for months or years, and superimposed social isolation is often part of profound disabilities which, until recently, generally have not been recognized. One of the authors, accompanied by a nurse practitioner, observed 300 subjects residing at home who were homebound; 85 percent were over 75 years, and 48 percent were over 85 [20]. We found the presence of some form of mental disorder in half of the subjects. Other researchers also have reported dementing illness and dysphoric conditions in isolated home dwellers [21-23]. Psychiatrists , frequently as part of crisis intervention teams, generally have been more aware than internists of this burden of mental and behavioral disorders in the homebound frail elderly. The homebound elderly are a group whose numbers are likely to grow with the proportion of the very old. They generally do not come to medical attention until either minimal home services become unavailable, or, as a result of a...