Vol. 68, No. 2
131
Meeting the Needs of the Older Persons HILDRUS A. POINDEXTER, M.D., Ph.D., Professor of Community Health Practice, Howard University College of Medicine, Washington, D. C.
THE LIFE expectancy in the U.S.A. in 1900 was 49 years. In 1971 it was 71 years. There have been gains each year. In 1973, a more specific breakdown of life expectancies for four groups was: Negro male Negro female White male White female
61. 1 years 67.4 years 67.6 years 74.7 years
The gain continues and the available 1975 estimates of life expectancies for whites are: Male Female
68. 1 years 75.8 years
By U.S.A. standards and the large establishment practices, anyone over 65 years of age is a senior citizen must retire and is "old". Some kind and generous people call them "elderly" or older persons. This group makes up over 10% of our 215 million citizens, more women than men. At age 85 years, the percentage of women to men is about 2 to 1, and the percentage is rising. The factors in this percentage increase of those over 65 years are several, including practical advances in preventive medicine, primarily in the early years of life; general improvement in housing and environmental sanitation; improvement in our health infrastructure; and some improvement in the general social, economic and academic levels of the masses. The fact of the matter is that we have about 22 million older persons on our hands at a period in our cultural development when we do not know what to do about them or with them. By 1980 it is estimated that there will be 25 million over 65 years of age. The generation just under 65 years is striving for its own place in the sun and does not have the time nor desire to slow its pace of economic and social progress to be bothered by these older persons who because of the
aging processes are becoming mentally and physically slower in movement and social repartee. The aged will frequently accept with equanimity the physical features of aging and will use them as conversation subjects with their peers and contemporaries, even joke about them. Not so with their mental and emotional conflicts, also accelerated by aging. ORATION
I am qualified by age (I am a septuagenarian and show evidence of the sixth age as expressed by that immortal bard, William Shakespeare, in As You LIKE IT, Act II, Scene VII in his "seven ages of man" as spoken by Jacques); experience; and interest to write about older persons. During the last decade I have had free and easy communication and association with the elderly, by chronological definition, as peers and contemporaries. We have talked about needs and wishes of the elderly. I therefore speak subjectively of the rising cost of living, the need for more money, better housing and better care of physical and emotional ailments. We support legislation and appropriations to those ends. Here is a brief list of the needs expressed to me between tea and toast (not necessarily the real needs): 1. Older persons want to be a part of the family,
home/community and social order. 2. They do not want to be abandoned, nor socially isolated or insulated in some old folks nursing home or some attic of the house. 3. They need and want empathy. When the elderly is separated from his family, he becomes "an emotional ORPHAN". If in a home for the aged, the "home" is thought of as "God's Waiting Room" and he is there waiting to be called to heaven. 4. They want to be secure in their homes. Currently, many are afraid to go alone on the streets. They fear for bodily harm or loss of money.
132
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION
5. They want to be loved, needed, wanted and useful to their family above all else. When a person feels that he no longer falls into one or more of these categories he may well withdraw from family and society, lose his bounce for life and become progressively introspective and depressed.
I do not think that the elderly want to live forever or return to youth. They are still lucid enough to realize that physical man is mortal. If you live long enough you will get old and eventually die, but as physicians, we should endeavor to slow the aging process by good primary medical care health methods. While aging is inevitable, if you live long enough, many of the accelerators to the aging process are preventable. This is especially true for blacks who age faster. Here is a tabulation of the leading causes of disability and death among the elderly blacks: Heart Disease Cardio-vascular disease in which hypertension with or without arteriosclerosis as its major feature Malignancies of the genitoruinary tract and gastrointestinal tracts, the principle areas of preference. There is a major increase now in lung cancer. Accidents often associated with falls or other muscular coordination disturbances Acute upper respiratory infections: pneumonia, influenza, etc. Suicide often related to depression Diabetes Mellitus Cirrhosis of the liver Nephritis or Nephrosis Chronic upper respiratory condition; bronchitis, emphysema, tuberculosis, asthma Hernias
Here is a list of the more common, less fatal or non-fatal disabilities (morbidity) among the elderly of all races in U.S. A.: Arthritis and rheumatism. Osteoporosis (more often reflects in loss of teeth) Visual disturbances (more commonly in cataract and/ or glaucoma). About 8% of those over 65 years of age have some degree of cataract. This percentage is increased in diabetes. There are 1.2 million senior citizens in the USA with visual impairments. Cataract is the leading cause of blindness in the U.S.A. Glaucoma is second and diabetic retinopathy is third. They may overlap or occur concurrently. Decreases in hearing acuity Memory alteration Fixation of emotional conflicts (a cantankerous
MARCH, 1976
young adult now becomes an obstreperous old person). Intolerance and inflexibility become the hallmark of the elderly even his biases become fixed. He may become antisocial, or at least less sociable. Self-pity reflected in depression and loneliness may contribute to in house alcoholism, drug dependence and suicides. Constipation, musculoskeletal deterioration with disturbed coordination with gait changes, posture changes, penmanship changes, etc. Renal and rectal incontinence is frequent. A variety of other genitourinary tract and gastrointestinal tract pathologies may become known as one ages, such as hiatus hernias, hemorrhoids, and gall stones. Low back pain, disturbed sleep and headaches. With the elderly there is often a lowering of resistance to certain relatively non-invasive organisms as noted by Poindexter. 1
A large percentage of the conditions listed here are preventable by health education and personal efforts. The health education should be adapted to the target group and should use the several types of audio-visual media along with face to face communication. We senior citizens do not wish to be mandatorily retired when we are still physically and mentally willing and able to work and want to work. In general, the black-white differences in incidences and prevalence of the pathological conditions here given are not genetically related but they correlate very highly with environmental, social, economic, cultural practice and occupational factors. The solutions to these differences are social, political and economic. Both heredity and environment affect longevity of the individual. Environment includes the physical, mental and social environments. The effect of these facets on the aging process may be reflected in the individual cells, tissues or organs of the body, disturbing functions and affecting longevity. One may retard the aging process by diet, housing, clothing and recreation. Here are some of the social realities of the aged: About one fourth of the elderly in USA are living below the poverty level. About 86% of blacks live in housing with environmental sanitation defects. The percentages are higher among rural dwellers than urban dwellers.2.3 About 70% are existing on a deficient diet and show
Vol. 68, No. 2
Needs of the Elderly
significant anemia. This anemic state is associated with immuno-incompetence and greater susceptibility to a variety of nosocomial infections. This is due to many factors including economics, decreased appetitie, living along, personal depression. About 86% have one or more serious chronic diseases and a higher percentage of non-life threatening physical and emotional ailments.
The U.S. Goverriment and several national agencies and conferences including the 1959 and 1961 White House Conferences on Aging, have called and continued to call attention to remedial needs and wishes of the elderly. A 1963 publication4 by the Department of Health, Education and Welfare (HEW) gives a detailed bibliography of recent publications dealing with aging. For further references on the Declaration of Aging Rights and Legislations in this area, you are referred to the Gerontology Society," recent brochures,6 and releases by the National Caucus on the Black Aged.7 The youth and physical beauty cult of our western culture tends to do deference to the young and beautiful or at least those with great physical performance skills. This is not essentially the case in many Oriental cultures in which I have lived and worked. Many Oriental groups associate wisdom, knowledge and mature understanding of life and its significance with chronological aging. As one Vietnamese doctor, who was showing deference to me stated, "You are as my father, my brother is my brother. The father is given the preferred seat and sleeping quarters. " Gerontophobia is part of our western culture because we associate growing old with poverty, loneliness and relegation to a thirdclass citizenship. If you read the records and talk with those working daily with the elderly, you will find that most of them can cope with their physical infirmities with some professional medical support better than they can cope with mental and emotional conflicts and deteriorations. It should be clear that the public health efforts toward the elderly should be not merely to prolong a life but to prolong the
133
usefulness of life and reduce the preventable infirmities of old age. The marantologist can play a part here by helping older people accept nonpreventable infirmities and death in a peaceful manner and in reasonable comfort. "It is appointed unto all men, once to die" The Holy Book. The physician who concentrates his practice among the elderly (geriatrics) will soon find that time and attention to the individual are more rewarding than chemotherapy. There may be those who may accept the aging process with equanimity as many Orientals do, there are those who want perpetual youth or rejuvenation and there are those who want unusual therapy peculiar to their culture, as the herbs and bee pollens. A little time and attention in most of these is fundamental to effective management of their nonlife threatening ailments. Those serving the needs of the elderly should organize and use volunteers from churches, clubs and youth groups and get them to give some time to the elderly in the area of communication, companionship,, transportation, escort, home visits, reassuring telephone calls, shopping assistance, etc. Man knows that he must die and as he becomes older he really does not dread death. He would like to die peacefully without pain and in the presence of relatives or friends. It is in this area that gerontologist can make a great contribution by giving his time and attention.
There will be those among your clientele who want to be reminded by someone they trust of their physical limitations and their inevitable fate-physically these reminders may and often do help to moderate, for the better, certain appetites and actions. Church affiliation does contribute to life fulfillment and happiness of many elderly persons: in such cases, promote it and encourage it.8'9 Another source of valuable information on programs for the aging is Dr. Jack Kleh10 of the Medical Society of D. C. Practically every "old" person has his or her receipe for a contented or tranquil old age. Here is mine:
134
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION
Try to make preparations to have your own home so that you can remain with the family if possible and not be ostracized in an institution for the elderly. Try to keep your mate as long as possible since widow-widowerhood can be a lonely time of life. Depression is a major feature in the old because children may be absorbed in adventure and movement and grandchildren have other priorities above personal attention to grandparents. Economics helps but it is no substitute for a man-wife togetherness. This man-wife togetherness in later life may even make dying of the mate less disturbing. Special concentration is directed toward the 93% of the elderly in their own homes or who are living alone. The 7% how residing in approved "Homes" for the aged are getting considerable professional health care. Keep as physically fit by a balanced and proper diet, limited physical exercise and personal hygiene, as old age infirmities will permit. Keep as mentally alert as eye and ears and their aids permit by interpersonal social relations, reading and debate. The senility of old age, not accelerated by external factors, is not insanity. The mandatory retirement age should not be a signal to loaf, but to leisurely do something else-hobby or second career. He may even be more productive after 65 since the 9-5 job requirement may be removed. His current free time may permit the free spirit to soar. This may at last be an opportunity for further formal education and reflection on this quotation from Cicero that "large affairs are not performed by muscle or speed, nimbleness, but by reflection, character, judgment, etc." These qualities are not diminished by age. They may be augmented. Give the elderly some type of challenge within their capacity and they will continue active longer. Try to retain the ability to laugh and "joke" in spite of your "dotage" described by Shakespeare. A word
MARCH, 1976
of caution to the elderly: let your children or grandchildren take care of contracts and negotiations of new projects and programs and be available for counsel of wisdom before signing if called upon. Try to practice a philosophy of life that the body of man is mortal but the spirit and soul of man is immortal. Greed, lust and malice, if they ever existed, should not continue into old age. LITERATURE CITED
1. POINDEXTER, H. A. Microbial Opportunism J.N.M.A., 66:284,1974. 2. Older Americans Facts-Housing, U.S. Department of Housing and Urban Development Bulletin of 1973, page 23. 3. The American Journal of Public Health and the Nation's Health, Supplement 54 1, 1964. 4. KENT, D. P. Aging in the Modern World, an Annotated Bibliography OA 216, U.S. DHEW Administrator, Office of Aging, 1963. 5. The Gerontological Society, Dupont Circle, Washington, D.C. 20036. 6. The Minneapolis Age and Opportunity (MAO) Center Brochure, 1975. 7. The National Caucus on the Black Aged (NCBA) News, several issues, 1730 M Street, N.W., Suite 811, Washington, D.C. 20036. 8. STOUGH, A. B. The Role of the Church in Relation to the Aging Population, DHEW: Address for Ministers and Laymen of Central Michigan, Lansing, Michigan, May 7, 1963. 9. MC GRAY, R. and D. 0. Mobery. The Church and the Older Persons, Published by William Ecddmans of Grand Rapids, Michigan, 1962. 10. KLEH, J. Report of the Committee on Aging of the Medical Society of the District of Columbia, 1974-75. 2007 Eye Street, N.W. Washington, D.C. 20006.
131
Meeting the Needs of the Older Persons HILDRUS A. POINDEXTER, M.D., Ph.D., Professor of Community Health Practice, Howard University College of Medicine, Washington, D. C.
THE LIFE expectancy in the U.S.A. in 1900 was 49 years. In 1971 it was 71 years. There have been gains each year. In 1973, a more specific breakdown of life expectancies for four groups was: Negro male Negro female White male White female
61. 1 years 67.4 years 67.6 years 74.7 years
The gain continues and the available 1975 estimates of life expectancies for whites are: Male Female
68. 1 years 75.8 years
By U.S.A. standards and the large establishment practices, anyone over 65 years of age is a senior citizen must retire and is "old". Some kind and generous people call them "elderly" or older persons. This group makes up over 10% of our 215 million citizens, more women than men. At age 85 years, the percentage of women to men is about 2 to 1, and the percentage is rising. The factors in this percentage increase of those over 65 years are several, including practical advances in preventive medicine, primarily in the early years of life; general improvement in housing and environmental sanitation; improvement in our health infrastructure; and some improvement in the general social, economic and academic levels of the masses. The fact of the matter is that we have about 22 million older persons on our hands at a period in our cultural development when we do not know what to do about them or with them. By 1980 it is estimated that there will be 25 million over 65 years of age. The generation just under 65 years is striving for its own place in the sun and does not have the time nor desire to slow its pace of economic and social progress to be bothered by these older persons who because of the
aging processes are becoming mentally and physically slower in movement and social repartee. The aged will frequently accept with equanimity the physical features of aging and will use them as conversation subjects with their peers and contemporaries, even joke about them. Not so with their mental and emotional conflicts, also accelerated by aging. ORATION
I am qualified by age (I am a septuagenarian and show evidence of the sixth age as expressed by that immortal bard, William Shakespeare, in As You LIKE IT, Act II, Scene VII in his "seven ages of man" as spoken by Jacques); experience; and interest to write about older persons. During the last decade I have had free and easy communication and association with the elderly, by chronological definition, as peers and contemporaries. We have talked about needs and wishes of the elderly. I therefore speak subjectively of the rising cost of living, the need for more money, better housing and better care of physical and emotional ailments. We support legislation and appropriations to those ends. Here is a brief list of the needs expressed to me between tea and toast (not necessarily the real needs): 1. Older persons want to be a part of the family,
home/community and social order. 2. They do not want to be abandoned, nor socially isolated or insulated in some old folks nursing home or some attic of the house. 3. They need and want empathy. When the elderly is separated from his family, he becomes "an emotional ORPHAN". If in a home for the aged, the "home" is thought of as "God's Waiting Room" and he is there waiting to be called to heaven. 4. They want to be secure in their homes. Currently, many are afraid to go alone on the streets. They fear for bodily harm or loss of money.
132
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION
5. They want to be loved, needed, wanted and useful to their family above all else. When a person feels that he no longer falls into one or more of these categories he may well withdraw from family and society, lose his bounce for life and become progressively introspective and depressed.
I do not think that the elderly want to live forever or return to youth. They are still lucid enough to realize that physical man is mortal. If you live long enough you will get old and eventually die, but as physicians, we should endeavor to slow the aging process by good primary medical care health methods. While aging is inevitable, if you live long enough, many of the accelerators to the aging process are preventable. This is especially true for blacks who age faster. Here is a tabulation of the leading causes of disability and death among the elderly blacks: Heart Disease Cardio-vascular disease in which hypertension with or without arteriosclerosis as its major feature Malignancies of the genitoruinary tract and gastrointestinal tracts, the principle areas of preference. There is a major increase now in lung cancer. Accidents often associated with falls or other muscular coordination disturbances Acute upper respiratory infections: pneumonia, influenza, etc. Suicide often related to depression Diabetes Mellitus Cirrhosis of the liver Nephritis or Nephrosis Chronic upper respiratory condition; bronchitis, emphysema, tuberculosis, asthma Hernias
Here is a list of the more common, less fatal or non-fatal disabilities (morbidity) among the elderly of all races in U.S. A.: Arthritis and rheumatism. Osteoporosis (more often reflects in loss of teeth) Visual disturbances (more commonly in cataract and/ or glaucoma). About 8% of those over 65 years of age have some degree of cataract. This percentage is increased in diabetes. There are 1.2 million senior citizens in the USA with visual impairments. Cataract is the leading cause of blindness in the U.S.A. Glaucoma is second and diabetic retinopathy is third. They may overlap or occur concurrently. Decreases in hearing acuity Memory alteration Fixation of emotional conflicts (a cantankerous
MARCH, 1976
young adult now becomes an obstreperous old person). Intolerance and inflexibility become the hallmark of the elderly even his biases become fixed. He may become antisocial, or at least less sociable. Self-pity reflected in depression and loneliness may contribute to in house alcoholism, drug dependence and suicides. Constipation, musculoskeletal deterioration with disturbed coordination with gait changes, posture changes, penmanship changes, etc. Renal and rectal incontinence is frequent. A variety of other genitourinary tract and gastrointestinal tract pathologies may become known as one ages, such as hiatus hernias, hemorrhoids, and gall stones. Low back pain, disturbed sleep and headaches. With the elderly there is often a lowering of resistance to certain relatively non-invasive organisms as noted by Poindexter. 1
A large percentage of the conditions listed here are preventable by health education and personal efforts. The health education should be adapted to the target group and should use the several types of audio-visual media along with face to face communication. We senior citizens do not wish to be mandatorily retired when we are still physically and mentally willing and able to work and want to work. In general, the black-white differences in incidences and prevalence of the pathological conditions here given are not genetically related but they correlate very highly with environmental, social, economic, cultural practice and occupational factors. The solutions to these differences are social, political and economic. Both heredity and environment affect longevity of the individual. Environment includes the physical, mental and social environments. The effect of these facets on the aging process may be reflected in the individual cells, tissues or organs of the body, disturbing functions and affecting longevity. One may retard the aging process by diet, housing, clothing and recreation. Here are some of the social realities of the aged: About one fourth of the elderly in USA are living below the poverty level. About 86% of blacks live in housing with environmental sanitation defects. The percentages are higher among rural dwellers than urban dwellers.2.3 About 70% are existing on a deficient diet and show
Vol. 68, No. 2
Needs of the Elderly
significant anemia. This anemic state is associated with immuno-incompetence and greater susceptibility to a variety of nosocomial infections. This is due to many factors including economics, decreased appetitie, living along, personal depression. About 86% have one or more serious chronic diseases and a higher percentage of non-life threatening physical and emotional ailments.
The U.S. Goverriment and several national agencies and conferences including the 1959 and 1961 White House Conferences on Aging, have called and continued to call attention to remedial needs and wishes of the elderly. A 1963 publication4 by the Department of Health, Education and Welfare (HEW) gives a detailed bibliography of recent publications dealing with aging. For further references on the Declaration of Aging Rights and Legislations in this area, you are referred to the Gerontology Society," recent brochures,6 and releases by the National Caucus on the Black Aged.7 The youth and physical beauty cult of our western culture tends to do deference to the young and beautiful or at least those with great physical performance skills. This is not essentially the case in many Oriental cultures in which I have lived and worked. Many Oriental groups associate wisdom, knowledge and mature understanding of life and its significance with chronological aging. As one Vietnamese doctor, who was showing deference to me stated, "You are as my father, my brother is my brother. The father is given the preferred seat and sleeping quarters. " Gerontophobia is part of our western culture because we associate growing old with poverty, loneliness and relegation to a thirdclass citizenship. If you read the records and talk with those working daily with the elderly, you will find that most of them can cope with their physical infirmities with some professional medical support better than they can cope with mental and emotional conflicts and deteriorations. It should be clear that the public health efforts toward the elderly should be not merely to prolong a life but to prolong the
133
usefulness of life and reduce the preventable infirmities of old age. The marantologist can play a part here by helping older people accept nonpreventable infirmities and death in a peaceful manner and in reasonable comfort. "It is appointed unto all men, once to die" The Holy Book. The physician who concentrates his practice among the elderly (geriatrics) will soon find that time and attention to the individual are more rewarding than chemotherapy. There may be those who may accept the aging process with equanimity as many Orientals do, there are those who want perpetual youth or rejuvenation and there are those who want unusual therapy peculiar to their culture, as the herbs and bee pollens. A little time and attention in most of these is fundamental to effective management of their nonlife threatening ailments. Those serving the needs of the elderly should organize and use volunteers from churches, clubs and youth groups and get them to give some time to the elderly in the area of communication, companionship,, transportation, escort, home visits, reassuring telephone calls, shopping assistance, etc. Man knows that he must die and as he becomes older he really does not dread death. He would like to die peacefully without pain and in the presence of relatives or friends. It is in this area that gerontologist can make a great contribution by giving his time and attention.
There will be those among your clientele who want to be reminded by someone they trust of their physical limitations and their inevitable fate-physically these reminders may and often do help to moderate, for the better, certain appetites and actions. Church affiliation does contribute to life fulfillment and happiness of many elderly persons: in such cases, promote it and encourage it.8'9 Another source of valuable information on programs for the aging is Dr. Jack Kleh10 of the Medical Society of D. C. Practically every "old" person has his or her receipe for a contented or tranquil old age. Here is mine:
134
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION
Try to make preparations to have your own home so that you can remain with the family if possible and not be ostracized in an institution for the elderly. Try to keep your mate as long as possible since widow-widowerhood can be a lonely time of life. Depression is a major feature in the old because children may be absorbed in adventure and movement and grandchildren have other priorities above personal attention to grandparents. Economics helps but it is no substitute for a man-wife togetherness. This man-wife togetherness in later life may even make dying of the mate less disturbing. Special concentration is directed toward the 93% of the elderly in their own homes or who are living alone. The 7% how residing in approved "Homes" for the aged are getting considerable professional health care. Keep as physically fit by a balanced and proper diet, limited physical exercise and personal hygiene, as old age infirmities will permit. Keep as mentally alert as eye and ears and their aids permit by interpersonal social relations, reading and debate. The senility of old age, not accelerated by external factors, is not insanity. The mandatory retirement age should not be a signal to loaf, but to leisurely do something else-hobby or second career. He may even be more productive after 65 since the 9-5 job requirement may be removed. His current free time may permit the free spirit to soar. This may at last be an opportunity for further formal education and reflection on this quotation from Cicero that "large affairs are not performed by muscle or speed, nimbleness, but by reflection, character, judgment, etc." These qualities are not diminished by age. They may be augmented. Give the elderly some type of challenge within their capacity and they will continue active longer. Try to retain the ability to laugh and "joke" in spite of your "dotage" described by Shakespeare. A word
MARCH, 1976
of caution to the elderly: let your children or grandchildren take care of contracts and negotiations of new projects and programs and be available for counsel of wisdom before signing if called upon. Try to practice a philosophy of life that the body of man is mortal but the spirit and soul of man is immortal. Greed, lust and malice, if they ever existed, should not continue into old age. LITERATURE CITED
1. POINDEXTER, H. A. Microbial Opportunism J.N.M.A., 66:284,1974. 2. Older Americans Facts-Housing, U.S. Department of Housing and Urban Development Bulletin of 1973, page 23. 3. The American Journal of Public Health and the Nation's Health, Supplement 54 1, 1964. 4. KENT, D. P. Aging in the Modern World, an Annotated Bibliography OA 216, U.S. DHEW Administrator, Office of Aging, 1963. 5. The Gerontological Society, Dupont Circle, Washington, D.C. 20036. 6. The Minneapolis Age and Opportunity (MAO) Center Brochure, 1975. 7. The National Caucus on the Black Aged (NCBA) News, several issues, 1730 M Street, N.W., Suite 811, Washington, D.C. 20036. 8. STOUGH, A. B. The Role of the Church in Relation to the Aging Population, DHEW: Address for Ministers and Laymen of Central Michigan, Lansing, Michigan, May 7, 1963. 9. MC GRAY, R. and D. 0. Mobery. The Church and the Older Persons, Published by William Ecddmans of Grand Rapids, Michigan, 1962. 10. KLEH, J. Report of the Committee on Aging of the Medical Society of the District of Columbia, 1974-75. 2007 Eye Street, N.W. Washington, D.C. 20006.
