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Aging is a Health Disparity Maria Torroella Carney, MD, FACP Commissioner Nassau County Department of Health April 28, 2010 2 nd Annual Best Practices.

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Presentation on theme: "Aging is a Health Disparity Maria Torroella Carney, MD, FACP Commissioner Nassau County Department of Health April 28, 2010 2 nd Annual Best Practices."— Presentation transcript:

1 Aging is a Health Disparity Maria Torroella Carney, MD, FACP Commissioner Nassau County Department of Health April 28, nd Annual Best Practices Conference The Institute for Healthcare Hofstra University

2 Aging in America in the Twenty-first Century “It is our contention that official government forecasts of survival, life expectancy and aging for the US population may have been significantly underestimated.” Aging in America in the Twenty-first Century: Demographic Forecasts from the MacArthur Foundation Research Network on an Aging Society; The Milbank Quarterly, Vol 87, No 4, 2009 (pp )

3 U.S. Population Distribution U.S. Population Distribution U.S. Population Distribution U.S. Population Distribution

4 Projection of US Population 65+ is to Double 2000 to 2030 (in millions) Source: U.S. Census Bureau, Aug. 2008

5 US Population by Age 18 – % Over % >18 Yrs. 25.7% 18 – 64 Yrs. 61.9% % 1 out of 8 US Residents currently is 65 +

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7 Nassau County

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9 15% of Nassau Residents 65 +

10 1,334,544 Residents: 10.1% Black & 10% Hispanic Nassau County Population by Race/Ethnicity

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12 Message  Nassau County is undergoing a rapid demographic shift  Population is aging & significantly older than 10 years ago  Population continues to be more ethnically, racially and economically diverse  Data indicates these trends will continue

13 Poverty Distribution in Nassau County 5.2% of Nassau County Residents are in Poverty 68,631 Residents

14 White 3.9% Black 10.7% Asian Pacific 4.0% Hispanic 12.4% Nassau County Poverty Levels by Race/Ethnicity

15 Nassau County Population 65+ by Race & Poverty Level 92.6% of Pop % in Poverty 2.1% of Pop % in Poverty 1.9% of Pop % in Poverty 3.0.% of Pop. 9.8% in Poverty

16 County Health Ranking Health Outcomes – 6th Health Outcomes – 6th Mortality – 1st Mortality – 1st Morbidity – 17 th Morbidity – 17 th Health Factors – 1st Health Factors – 1st Healthy Behaviors – 7 th (tobacco, diet, exercise, alcohol use, high risk sexual behavior) Healthy Behaviors – 7 th (tobacco, diet, exercise, alcohol use, high risk sexual behavior) Clinical Care – 3rd Clinical Care – 3rd Social and Economic Factors – 2nd Social and Economic Factors – 2nd Physical Environment – 32 nd Physical Environment – 32 nd Environmental Quality Environmental Quality Built Environment Built Environment Source: Robert Wood Johnson Foundation in partnership with University of Wisconsin Population Health Institute County Healthy Rankings 2010

17 Access to Health Care in Nassau 12 Hospitals 12 Hospitals 34 Nursing Home/Rehabilitation Centers 34 Nursing Home/Rehabilitation Centers 6 Hospices 6 Hospices 21 Home Health Care Agencies 21 Home Health Care Agencies 12 Long Term Care Agencies 12 Long Term Care Agencies 8 Prenatal Care Assistance Programs 8 Prenatal Care Assistance Programs 4 Community Health Centers 4 Community Health Centers 12 HIV Testing Sites 12 HIV Testing Sites Urgent Care Centers expanding Urgent Care Centers expanding

18 Nassau Health Care Providers  Over 8,000 Physicians  2666 Primary care  5368 Specialists  1057 Physician Assistants  1,218 Nurse Practitioners  2,019 Dentists

19 US Life Expectancy Source: CDC Website. Life expectancy at birth in 2000 by race and sex and Health, United States 2008, table 26 American Journal of Public Health Publications, Vol. 96, No.9, September 2006.Health, United States 2008, table 26

20 US & New York State Life Expectancy

21 US Life Expectancy at Birth by Race and Sex Source: CDC Website. National Vital Statistics Reports, Vol. 58, No.1, August 19, 2009

22 Comparison of Life Expectancy for Males & Females Between Most & Least Socioeconomic Deprivation Groups Source: International Journal of Epidemiology 2006; 35: US Life Expectancy: Singh & Siahpush Significant increasing gap in Most Deprived SEG– Males Life Expectancy

23 58.5% Residents 65+ are Overweight

24 Obesity Trends* Among U.S. Adults BRFSS, 1985 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14%

25 Obesity Trends* Among U.S. Adults BRFSS, 1990 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14%

26 Obesity Trends* Among U.S. Adults BRFSS, 1997 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19% ≥20%

27 Obesity Trends* Among U.S. Adults BRFSS, 2000 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19% ≥20%

28 Obesity Trends* Among U.S. Adults BRFSS, 2005 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%

29 Obesity Trends* Among U.S. Adults BRFSS, 2007 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%

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31 As we age, we are more likely to live with chronic disease. As we age, we are more likely to live with chronic disease. Incidence & Incidence & severity may vary …

32 Nassau County Diabetes Hospitalization Rate by Community

33 Cancer Incidence Rate by Race/Ethnicity

34 Cancer Mortality Rate by Race/Ethnicity Prostate cancer mortality rate is 3 times higher in black males. Breast cancer mortality rate is greater in black females.

35 Aging is a Disparity

36 Why are there disparities?  Poor Nutrition  Early Detection & Prevention  Insured/Underinsured Access to Care & Available Treatment over lifespan  Education Healthy choices & Healthy behaviors  Genetic Predisposition

37 Access to Health Care Built Environment Community Economic Development Health Literacy Health Marketing Natural Environment Public Policy Public Well Being Social Capital Individual & Family Community

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39 Percent Immunized in US By Age, Race & Ethnicity

40 Dementia Disparity  African-Americans are about two times more likely & Hispanics are about one and one-half times more likely than their white counterparts to have Alzheimer's and other dementias.  Although whites make up the vast majority of the more than five million people with Alzheimer's and other dementias, African-Americans and Hispanics are at higher risk for developing the disease. Alzheimer's Association's® 2010 Alzheimer's Disease Facts and Figures

41 Health Insurance for the Aging Medicare Medicare By 2030, it is projected that 300,000 people will live to age 100+ Some families have 3 generations enrolled in Medicare Medicaid Medicaid Nassau County Dept. of Social Services has identified 57,000 eligible and mostly enrolled Many physicians do not accept Medicaid patients. Patients rely on hospital emergency departments for primary care. Many enrollees do not understand how to navigate within their Medicaid Managed Care organization. Privately Insured Privately Insured

42 Predictors for Placement in Nursing Home Age Age Caucasian Caucasian Living alone Living alone Female Female Daily Living Activities’ Dependence: toileting, feeding, bathing, dressing Daily Living Activities’ Dependence: toileting, feeding, bathing, dressing Cognitive impairment Cognitive impairment Socio-demographic Socio-demographic Lack of potential sources of support Lack of potential sources of support Hospitalization or prior Nursing Home admission Hospitalization or prior Nursing Home admission Disease risks: Diabetes, HTN, Cancer, Stroke, Fall Disease risks: Diabetes, HTN, Cancer, Stroke, Fall Characteristics Predicting Nursing Home Admission in the Program of All-Inclusive Care for Elderly People, Friedman SM et al. The Gerontologist vol 45;2: Predicting Nursing Home Admission in the US: A Meta-analysis. JE Gaugler et al. BMC Geriatr 2007;7:13.

43 “We Don’t Carry That” Only 25 percent of pharmacies in predominantly non-white Neighborhoods had opioid supplies that were sufficient to treat patients in severe pain, as compared with 72 percent of Pharmacies in predominantly white neighborhoods. RS Morrison et al. “We Don’t Carry That” – Failure of Pharmacies in Predominantly Nonwhite Neighborhoods To Stock Opioid Analgesics. N Engl J Med 2000;342:1023-6

44 Barriers  Physical & Mental Disabilities: Mobility; vision, hearing, speech & memory loss  Geographic: Transportation resources; shortage of accessible physicians  Cultural  Socioeconomic  Organizational: Lack of interpreters; wheelchair accessibility; lack of universal design  Psycho-social: Stigma; denial, fear, lack of advocacy

45 Physician-Patient Communication Barriers  Speech or language articulation  Foreign language  Time constraints  Inability of physician or patient to meet face to face  Illness  Altered Mental Status  Medication Effects  Psycho-social factors  Gender differences  Racial or cultural differences JAOA Vol 105, No 1, Jan 2005, pp13-18

46 Elder Abuse Physical Physical Emotional Emotional Financial Financial Sexual Sexual Neglect Neglect Self-Neglect Self-Neglect Kleinschmidt KC. Elder Abuse: A Review; Ann Emer Med 1997 Oct; 30 (4):463-72

47 Elder Abuse Risk Factors A Major precipitating factor: Family Distress A Major precipitating factor: Family Distress Hypotheses include: Hypotheses include: Domestic Violence Grown Old Domestic Violence Grown Old Cycle of Family Violence Cycle of Family Violence Lack of Financial Resources Lack of Financial Resources Psychopathology in Abuser Psychopathology in Abuser Lack of Community Support Lack of Community Support Caregiver Stress Caregiver Stress National Center of Elder Abuse; US Administration on Aging 8/21/2007

48 Elder Abuse and Minority Risk Ethnic and/or Minority Elders – multiple jeopardy Ethnic and/or Minority Elders – multiple jeopardy Language barriers Language barriers Unfamiliar with American institutions Unfamiliar with American institutions Lack of transportation Lack of transportation Financial difficulties Financial difficulties Stigma/shame in asking for help Stigma/shame in asking for help Importance of Keeping Individual Problems from Outsiders Importance of Keeping Individual Problems from Outsiders Mistrust of Mainstream Services Mistrust of Mainstream Services Falicov CJ. The Latino Family Life Cycle. Sanchez YM. "Elder mistreatment in Mexican American communities: The Nevada and Michigan experiences.” So DW, Gilbert S, Romero S. "Help-seeking attitudes among African American college students."

49 Cultural Norms and Values about Family and Elderly African Americans – kinship, extended family networks African Americans – kinship, extended family networks Asian-hierarchical by age and gender, family networks - Respect Asian-hierarchical by age and gender, family networks - Respect Hispanic/Latinos-respect to elders Hispanic/Latinos-respect to elders Native Americans –elderly repository of wisdom, collectivism Native Americans –elderly repository of wisdom, collectivismwww.netce.com/coursecontent.php

50 Cultural Diversity at End of Life Emphasis on Individualism versus Collectivism Emphasis on Individualism versus Collectivism Definition of Family Definition of Family Common views of gender roles, child-rearing practices, care of older adults Common views of gender roles, child-rearing practices, care of older adults Views of Marriage and relationships Views of Marriage and relationships Communication patterns Communication patterns Religious and spiritual-belief systems Religious and spiritual-belief systems Views of physicians Views of physicians Views of suffering Views of suffering Views of afterlife Views of afterlife Cultural Diversity at the End of life: Issues and Guidelines for Family Physicians. HR Searight. Am Fam Physician 2005 Feb 1;71(3):

51 Advance Directives Health Care Proxy Health Care Proxy Living Will Living Will Do Not Resuscitate Do Not Resuscitate At Home Do Not Resuscitate At Home Do Not Resuscitate MOLST: MOLST: Medical Orders for Life–SustainingTreatments 40% Elderly white compared to 16% of Elderly blacks have advance directives Cultural Diversity at the End of life: Issues and Guidelines for Family Physicians. HR Searight. Am Fam Physician 2005 Feb 1;71(3):

52 A’s of Aging  Awareness  Alert to a problem  Access Care  Advocacy

53 NOW Life expectancy is shorter in Blacks & Hispanics Life expectancy is shorter in Blacks & Hispanics Lifespan has improved over time; however, at a slower rate for more deprived populations Lifespan has improved over time; however, at a slower rate for more deprived populations Aging in itself poses challenges. These challenges are exacerbated in minority and socioeconomically deprived populations Aging in itself poses challenges. These challenges are exacerbated in minority and socioeconomically deprived populations Screening & disease disparities exist Screening & disease disparities exist

54 Future More Research on Health Disparities in Aging is needed More Research on Health Disparities in Aging is needed Additional medical Geriatric; health education and training Additional medical Geriatric; health education and training Enhance Screening at earlier ages for at risk populations Enhance Screening at earlier ages for at risk populations Increase Education and Awareness Programs Increase Education and Awareness Programs Utilize Medical Reserve Corps for Outreach Utilize Medical Reserve Corps for Outreach Educate Health professionals, insurance companies, hospitals on the importance of Health Literacy Education Educate Health professionals, insurance companies, hospitals on the importance of Health Literacy Education Expansion of Medicare – Ideal Expansion of Medicare – Ideal Health Care Reform to come


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