SURGEON GENERAL'S WORKSHOP Health Promotion and Aging Backgmund Papers Edited by: DEP SG Faye G. Abdellah SR PHARM Steven K. Moore DEPARTMENT OF HEALTH & HUMAN SERVICES -. Public Health Service The Surgeon General of the Public Health Service Rockville MD 20857 November 23. 1987 Dear Workshop Participant, Change often offers opportunity! As our society changes and we have an older population, age has traditionally been equated with diminished capacity and ability. This does not necessarily have to be the expected outcome. The combined expertise of the scientific community, the interest of the aging network, and the will of older individuals to modify their way of living to accommodate healthful lifestyles, can allow later life to be both meaningful and active. At my request, individuals ;Jho have expertise in various aspects of health pro.notion and aging have compiled a series of papers that seek to document what we know about health promotion research and activities. These papers are thus provided to you in preparation for the deliberation of the Workshop participants on Health Promotion and Aging. Though they may not offer answers, the papers will hopefully provide an overview of what is knoun and provoke thought on the topic areas prior to the meeting. In the same manner, the papers do not seek to provide answers, for in many instances we do not necessarily have these answers yet. We do have indicators and Mith the proper emphasis and encouragement, we hope to move forrrard into the arena of preventive activities and healthful lifestyles. Please consider these papers as starting points for your further thought and deliberation, and more importantly, for our joint action in the application of health promotion to our aging society. Surgeon General Surgeon General's Workshop Health Promotion and Aging Background Papers TABLE OF CONTENTS -- _---- topic area - -- Alcohol Dental Health Exercise Injury Prevention Medications Mental Health Nutrition Preventive Health Services Smoking Cessation cage A-l B-l c - 1 D- 1 E-l F- 1 G - 1 H -1 I - 1 Health Promotion and Aging "Alcohol" Erma Polly Williams, M-R-E. Continuing Education Faculty, Rutgers Center of Alcohol Studies Consultant to the New Jersey State Division on Aging Consultant to the New Jersey State Division on Alcoholism Alcohol is here to stay. Older people probably have a better sense of the meaning of that statement than younger people since anyone over the age of 55 lived part of their life under Prohibition. Anyone over the age of 65 probably remembers at least fragments of the "roaring twenties", and anyone over seventy probably recalls Temperance slogans, speeches and rallies. Older people are also here to stay. With people over 65 representing approximately 12% of the population, they are the fastest growing segment of the society, and include many more people of increasingly advanced age. As the quality of life for these older people is strongly tied to the maintenance of health, it is appropriate that there should be a consideration of the relationship of age and alcohol from a health perspective. Interest and concern about the incidence of alcohol use and abuse by the older portion of the population have increased dramatically over the last 20 years. This increase is evident in the core of alcohol literature, as well as in the publications of many disciplines, reflecting the multidisciplinary dimensions of the phenomenon. It is being addressed in professional journals, giving evidence that the problem is being encountered by the many systems and agencies that provide services to older people. Y?t despite this tide of attention, the area of study and the level of response to the need do not seem to gain much headway. In view of all the needs of older people in our society, problems related to alcohol are relegated to a low place on the priority list. And in the alcohol field, the aged do not appear to generate the excitement and involvement of other population groups. The society is becoming increasingly sensitive to the presence of elderly people. By sheer weight of numbers, it is becoming more imperative that issues related to their health and well-being be addressed. The pervasiveness of the use of alcohol as a societal practice, and the types of impact that this use can have on the indjviduals and the resources of the society, require that it be one of the areas addressed in relation to the older segment of the society- BAZTC DEMOGRAPHIC AND POPULATION DATA Extent of drinking ~-~ In considering the data available that indicates the nature and the extent of the problem, it should be noted that the designaticns of the older we and the designations rzlaterl to alcohol use and abuse arit specific to the individual study, and become relative terms when used to discuss several studies that may not have the same specific criteria. Cross sectional studies of the use of alcohol have provided information that, when compared to younger age groups, the rates of abstainers increase and the A-l percentage of drinkers decrease in the older age groups. Cahalan et al. (19691, using national household survey data, reported the percentage abstainers by age group: age 40-49, 29%; age 50-59, 40%; and age 60+, 47%. The proporticn of heavy drinkers for the same age groups were 15%, 10% and 6%, respectively. For men, Cahalan reported that more than half of the men o;`er 65 were not regular drinkers (54% being either abstinent or infrequent drinkers) and the lowest percentage of heavy drinkers were found in this age group. In the age group of 60-64, 20% were classified as heavy drinkers, representing 35% of those that drank. At age 65, this figure dropped to 7%, cr 11% of those that drank. In the same study, for women, there was similar decline but evidenced at age 50. Two thirds of women aged 50 to 64 did not drink at all or infrequently . After age fifty, the percentage of heavy drinkers among women became inconsequential. Similar tendencies were reported by Barnes (19791 from a general population survey in western New York state, by Christcpherson et al. (1984) from a survey in rural Arizona, and by Meyers et al. (1981) from a household survey in Boston. Barnes noted that while the regional rates of heavy drinking are significantly higher than the national rates, the trends holds. Rates cf abstinence increased from 13% for those age 50-59, to 31% for age 60-96. In addition, Barnes refined the age group of 60+ and reported that 24% 3f males age 60-69 were hEaiTy drinkers; for those age 70-96, 6% were in that category. Among females, heavy drinkers accounted for none of those age 60-69, but ;I% of those age 70-30. The reasons for the decrease in the proportion of drinkers from the younger to the older age categories has been considered by sereral researchers _ Items were included in several studies that inquired about previous drinking patterns or problems. Responses frequently mentioned concerns for health or health problems that were experienced as a reason to temper the quantity and/or the frequency of drinking _ Other responses rsng,,d from eccnomic reasons, changing social opportunities, and changing response to the substance. Gnmberg (1982) has summarized possible explanations for the decrease in social drinking as economic (decrease in drinking may result from lower income). physiolcgy (change in obtained blood alcohol levels with physical aging), effects of alcohol (resulting impacts and behaviors are no longer worth th:: cost:, life cycle differences (decrease a natural occurrence 3s cohorts ages), unique historical aspects (drinking habits of current generation influenced by Prohibition, Depression), and medical problems (health status, with increased medical problems, cause older pecple to limit or eliminate drinking! _ J Two additional items shculd be kept in. :ilind when considering this data. The cohorts of older people that are repcrted in each of these studies are products af the social and historical influences of their time: xhich are then intertwined with an array of unique individual experiences. Subsequent generations of older pccple will, in inany r2spects, b;. very different from the ,:1der people of these studies. Specifically, it should bt remembered that cross sectional studies present data that evidence a lower percentage of abstainers and an increase in the level of drinking in the younger age groups. There is also evidence in surveys that drinking practices remain consistent overtime with some people. Christophorson (1984) has presented data that there is a tendency for people to carry drinking patterns into old age as long as circumstan::Fs and health permit. Data frsrr, th2 Normative Drinking Study confirms this (Glynn et 31. 1984) - ?l?ri, originally surveyed in their IO's and 50's, ten years later reported consistent drinking habits. It would aPpear that future generations Of older people would present a larger proportion of drinkers and a potential of more people who continue to drink at higher levels into old age. Problems w$.JJ drinking Evidence of problems related to alcohol use among older people comes from several types of sources with a range of criteria for the designation of a problem. Cahalan (1970) utilized the self reporting of eleven typzs of problems, including quantity/frequency and pattern of drinking, elements of physical and psychological dependency, and interpersonal, social, health, economic and legal problems. He reported that 12% of men age 60-69 had a current problem score of 7+. For age 70+, it was 1%. For women age 60-69, 1% had a current problem score of 7+; age 70+, less than one-half percent. These figures do represent a tapering off of drinking problems fcr men after age 50 but continuing until age 70. Further analysis involved the development of a social-psychological risk score which included attitude toward drinking, environmental support for heavy drinking, alienation and maladjustment, impnlsivity and ncn-conformity, looseness of social controls, and unfavorable expectations. Data indicates that men 60t of highest risk sccre show almost the same problem score as those of younger age groups. A second community sur:Iey source of infcrmation on problems related to drinking is the Epidemiologic Catchment Area Study which utilizes the WIMH Diagnostic Interview Schedule. This schedule provides for assessment of alcohol abuse and dependence based on the American Psychiatric Association's Diagnostic and Statistical Manual, DSM-III (Ameri'can Psychiatric Association 1980). Three sites of the five in the study have presented information related to alcohol abuse and dependence. The lowest rates of alcohol abuse and alcchol dependency were among those 65+, ranging from 4% to 8% at sometime in their life. In terms of the recent occurrence of problems (within the last 6 months!, 3% of males reported a problem, 1% of females. Similar rates were found for blacks and whites, and social class did not appear to have a large effect (Robins, 1994). Warheit and Auth (19841, investigating concurrent alcohol and mental health problems, found similar rates for alcohol problems within the older population. In looking at the correlation between mental health concerns and alcohol use, an alcohol risk score was developed and the sample divided into high and lcw alcohol risk groups. Items included were drinking in general, intoxication, problems related to drinking (personal, social the frequency of and family), self- perceptionS regarding the appropriateness of alcohol use, and the use of alcohol to face daily problems. For the older segment of the sample, age 50t, the high risk group generally gave more indications of poor mental and physical health than the low alcohol risk group of the same age _ Advancing ag? bras highly associated the increasing feelings of helplessness among the high risk group. Self perception of pcor health was more common in the alcohol high risk grcup. In reporting their present mental health, 39% of the high risk group responded fair or poor; among the low alcohol risk group, only 22.1% reported fair or poor mental health. Almost half (46.3%) of the high risk alcohol group reported at least one hospital stay in the last three years, 14.6% had three or m?re inpatient stays. This is contrasted with the low risk group that reported 28.7% had one or two stays, 4.7% had three or more. Generally, Warhei t and Auth concluded that alcchol use rather than age alone seemed to a better predictor of the kinds of health problems that necessitate hospitalization. A-3 Studies that report on the older population within institutions and medical settings provide additional information. McCusker et al. (1971) conducted a prevalence study of newly admitted patients to the medical wards of a Nen York City hospital serving a high proportion of blacks and Hispanics. Questionnaires were utilized to gather information to rate alcohol related problems over the past year. The moderate level of the scale, identified as the threshold for the diagnosis of alcoholic, identifed frequent intcxication up to cne or two times per week and/or significant impairment in social, family, or occupational functioning, or evidence of physical impairment related to alcohol. In the age group 50-69, 63% of the males and 35% of the females met this criteria. A study of 113 consecutive male admissions to acute medical wards was made by Schuckit and Miller (1976) in a Veterans Administration Hospital. Interviews established the patient's psychiatric diagnosis, organicity tests determined the presence of organic impairments, chart reviews provided basic demographic information, past and present physical and mental status, medication and drug and alcohol history. A resource person validated the patient information. Of these admissions, 18% (20) were diagnosed as alcoholic, with 55% (11) of these considered inactive, or having had no alcohol related problem in the 6 months prior to hospitalization, although 3 of the I1 still drank. Data from psychiatric services provides other evidence: of 534 first admissions of patients age 60+, 28% had serious drinking problems (Simon et al. 1968); in an outpatient psychiatric program in Harlem Hospital, 12% of the elderly were noted as having a drinking problem (Zimberg 1369); in a county psychiatric screening ward, among 100 consecutive admissions of persons 60+, 44% were alcoholic (Gaitz and Baer 1971); and in a medical home care program, 13% of the elderly patients requiring psychiatric consultation were diagnosed as alcoholic (Zimberg 19711. Although it is not possible to determine the actual prevalence, the fact remains that a sizable proportion of the elderly do evident? alcoholism and problem drinking. While recognizing that older people do drink less, an estimate of the prevalence of alcoholism among those whc do drink approximates that cf ether adults, nearly 8% (Nate 1984). Estimated rates in clinical practice with older people ranges from 10 to 20% with a higher proportion among the elderly who are hospitalized and institutionalized (Schuckit and pastor 1379, Zimberg 1982). Ufferent types of presentation - As early as 1968, there were attempts to dr:ielop a classification system of older alcoholics. It was recognized that there are sub-groups who presented similar histories and symptoms. Simon et al. (1968) reported that among a uroup of first admission psychiatric patients with serious drinking problems, age 60 and older, about l/3 had become alcoholic after age 60, while about 2/3 had been a?coholic before age 60 and had a long history of alcohol abuse. He also noted that a little over l/3 had chronic brain syndrome, but this diagnosis was not excl?;sive to either group. The proportion of :I! late life and 2/3 long standing was confirmed by Rosin and Glat t (1971) from studies of psychiatric home consultations and admissions :0 alcoholism units and hospital geriatric units. Schuckit and Miller (1976) also made a distinction betrreen early-onset and late on-set, using age 40 as the demarcation. Among the Ferscns ages 65t being admitted to a medical ward, using this designation, the groups was almcst equally A - 4 divided- Carruth et al. (1973) noted three distinct types: individuals with no history of problem drinking until one developed in response to age related stress, a second group that had at times experienced problems but only developed severe and persistent problematic drinking in old age, and a third group who had a long history of alcoholism and continued to drink into old age. Gomberg (1982) also recognized three groups, the survivors: alcoholic persons who have grown older; those with intermittent histories of heavy drinking in response to severe stress; and the reactive problem drinkers who are responding to the stresses and losses of aging by drinking heavily. The generally accepted division is that of early-onset and late-onset without a specific age of onset. The distribution of 2/3 early-onset vs. l/3 late onset is generally confirmed by personnel in the field. Different terms are at times used. Geriatric alcoholics (early-onset) are the stereotypic chronic alcohol abusers who have continued to drink while aging, and geriatric problem drinkers (late-onset) include those who had no history of a problem and those who occasionally experienced problems, all of whom develop abusive patterns in response to the stresses of aging (Dupree and Zimberg, 1984). Recognizing this general classification facilitates the process of identification and treatment. General characteristics of the early-onset individual include a medical history that indicates extended severe drinking, mental pathologies and personality characteristics related to chronic alcohol use, a social history that indicates the impact of alcohol, such as a poor work history, a disrupted or stressed social and family history, poor relationship skills, and fewer economic resources. Late-onset characteristics generally include alcohol related medical problems that may be acute but of.shorter duration, better problem solving and relationship skills, and more stable job, family and social histories. Problems in these areas are usually of recent origin and of shorter duration. Psychological problems are generally more focused upon issues related to age, such as loneliness, depression, grief, boredom and pain. The hidden older Foblem drinker Observations have been made by several researchers that older problem drinkers are a hidden population. The high percentage of alcoholics among the older populations in acute medical and psychiatric institutions is probably more reflective of the debilitating and/or long term impact of alcohol on an older person than it is of the sensitivity of the intervention mechanisms that exist. Perceptions of service providers indicate that the older person is underrepresented in the alcohol treatment network. Many reasons are given for the inadequate level of identification. There is a more subtle presentation of symptoms of problem drinking and alcoholism in older people. Presenting symptoms are inaccurately identified as -being related solely to medical or psychological problems associated with the aging process. Care providers, including medical personnel, are reluctant to become involved in the identific3tion/intervention process. The elderly themselves may have a lack of awareness about the effects of alcohol and are reluctant to self discbose. Denial and enabling may exist within family units. Due to the life stage, there is a lack of social and occupational identifiers- Finally, significant others and care providers may have the inaccurate perception that the drinking is a rational choice of A - 5 behavior, and further, may believe that it is logical given the age of the person. ALCOHOL, ALCOHOL USE AND HEALTH The impact of alcohol and alcohol use on the health and well being of any one older person has many dimensions. Of primary importance is the quantity and the frequency of the drinking experiences. How much alcohol is taken into the system and how frequently these occasions occur generally provide information that allows for the description of light, moderate or heavy drinker. A second consideration is the pattern and the duration of the drinking history. Movement along the continuum of type of drinker at different periods in the life span provides a variable to the current impact. Cultural and social norms that influence the designation of appropriate drinking occasions, such as with meals, or at drinking oriented events, may ameliorate or exacerbate the effect of the alcohol on any one occasion, and cumulatively, the effect of the use of alcohol on the entire system. General physical condition, and all the elements that support that condition, such as genetic factors, nutrition, the balance of rest and physical activity, are important. The presence of chronic and acute medical conditions plays a role, as does the existence of drug regimens, whether monitored by a physician or self-prescribed. Generally, the more intense and prolonged the use of alcoholic beverages, the greater the impact the substance ethanol will have upon the health of the individual. The general process of aging brings its own contribution to health implications for alcohol use. Response to the aging process is highly individual, in terms of persons and all of the components of each person. But there are general principles that apply. Advancing age witnesses a gradual lowering of the level of the homeostatic state. This is accompanied by a lessening of the physical reserve of the entire system and each of its parts. All body systems and organs tend to decrease in efficiency of operation and to loose resiliency. Stress, whether physical, emotional or environmental, has a greater impact upon the system and each of its parts. Returning to the pre-stress state or finding a new level of balance is more gradual, taking a longer period of time than when younger. Vulnerability to disease states increases with age and is compounded by stress _ Disease states also increase the vulnerability of older people to the impact of alcohol. It is `particularly important to remember that, as an individual ages, there are greater mutual effects that operate between the physical, social and emotional health of an individual. The older age stage of life brings unique developmental tasks, stresses and age related life crises. In responding to these tasks, stresses and crises, the totality of the person is affected. Of specific importance to. the use of alcohol and other chemical substances are general physiological changes. with age there is a decrease in the lean body mass and an increase in fat storing tissue. Alcohol, being water soluble, is distributed through less lean tissue, resulting in higher concentrations within organs _ Generally, when compared to younger people of equal weight and drinking the same amount, older people may be espected to evidence a higher blood alcohol level _ Time and rate are also affected. Age has a tendency to slow both the process of metabolism and of elimination. The blood alcohol level may be held for a longer period of time. In addition, the elimination process may be A-6 particularly affected by the presence of medications. The liver, being the principal organ involved, may be operating at a less efficient level and may be required to process multiple substances at the same time. All of these have impact upon the tolerance level, which is generally characterized as decreasing with age (Schuckit 1980, 1982, and Bosmann 1984). There are medical and health and safety areas that need particular emphasis in the concern of health and alcohol use as related to older people. It must be emphasized that, although there is a wealth of material that addresses the relationships that exist between specific areas and alcohol, the particular emphasis upon the older person frequently has been inferred from other studies or has been inconclusively explored to date. It should also be noted that biomedical research has not thoroughly explored health problems in the older age group, or among segments witbin that group. The cardiovascular system The implications of alcohol use for cardiovascular disease are particularly important in relation to older people as hypertension and heart conditions account for two of the four most common chronic conditions of non- institutionalized elderly. Although the exact relationship between alcohol consumption and the development of cardiovascular diseases has not been determined, there are areas that are important to consider. Generally, alcohol can have a direct effect on the heart muscle leading to an increase in the cardiac rate and output. In older people this may produce stress on the organ itself and on the rest of the cardiovascular system because of a reduced level of physiological reserve. In individuals with impaired cardiac functioning, this may have the ultimate effect of decreased cardiac output and diminished efficiency of the system. Alcohol can directly affect the heart as a cardiac toxin and the cardiovascular system by increasing blood pressure. Excessive amounts of alcohol have been strongly linked with the development of hypertension, stroke, myocardial degeneration, arrhythmia, and cardiac failure. Alcohol can also mask the symptoms of a disease state, such as angina pectoris. Individuals frequently do not feel the associated pain in the chest while drinking but the medical indications are that the affected tissue continues to suffer from the lack of blood flow. Continued or increased activity may increase the stress level although no pain is felt. (Gambert et al. 1984, Hermos et al. 1984, Kannel 1986, Schuckit 1982.) J There is, however, evidence of lower rates of congestive heart disease in association with moderate alcohol intake. Regular use of alcohol appears to have the effect of increasing high density lipoprotein cholesterol which may retard the development of coronary artery disease (Barboriak et al. 1983, Kannel 1986). Non-drinkers had higher mortality rates than those who drank lightly (in reference to the Normative Aging Study) and non-drinkers had higher blood pressures than those who drank in small amounts (in reference to the Framingham Study) (Gordon 1984.) The central nervous system The relationship of the health of the central nervous system in the maintenance of autonomy and independence makes it a particularly sensitive area to consider A-7 in relation to alcohol use and aging. There are changes that do take place with age that result in variations in functioning compared to the time when the individual was younger. But for healthy older people these changes do not necessarily have to exert a deleterious effect on the ability tc manage their life or to cope with their environment. Age frequently brings an increase in reaction time and in the time needed to retrieve something from memory. With age, there is also an increased tendency to exhibit confusion when under physical, emotional or social stress. Cognitive processes may be slowed but seldom become impossible tasks for healthy older people. Educational gerontology has contributed much to the affirmation of the ability of older people to perform learning tasks provided that the information is well organized, presented in a way that compensates for sensory changes, that the stress of the learning situation is reduced, and the risks associated with performing incorrectly are minimized- Ethanol affects the central nervous system. It may have the short-term effect of acting as a stimulant. However, the long-term effects are as a depressant. This may result in respiratory depression, sedative-hypnotic effect, ataxia, pronounced disinhibition, impaired motor skills, neuropathy, and unconsciousness. Age related metabolic changes are generally accompanied by an apparent increase in the sensitivity of the brain to all central nervous system depressing drugs, including alcohol. Very small amounts of alcohol can produce symptoms that are commonly identified as age-related mental decrements, or may exacerbate age related phenomenon. The mis-reading of the presentation of an older person is frequently responsible for non-identification of alcohol problems (Bosmann 1984, Schuckit 1982). Much research has been conducted on the effect of alcohol upon the central nervous system. A prominent theme' in that research is the question of accelerated or premature aging as an effect of alcohol use. Functional changes that are related to aging and functional changes that are the result of alcohol use are frequently very similar in their presentation. The processes of aging and of alcohol intoxication have much in common in the way that they affect memory, learning, recognition and organizational processes. In a "worst scenario" of the aging process or from long and intense use of alcohol, similar organic changes may take place in the brain and disease states occur. Current research outcomes do not seem to support the theory of premature aging. Although chronic alcoholic drinking appears to increase the behavior defects that accomp'any aging, as yet, a common pathology,has not been identified. Alcohol use is responsible for some brain dysfunction, but the effects seem to be independent of and parallel to the effects of normal aging. Studies do suggest that people who use alcohol to excess appear to run an additional risk of neuropsychological impairment beyond what might be expected from the aging process. Further, since some of the deficits related to alcohol use are at least partially reversible, continued research may illicit some value in terms of therapies for age related problems. (Blusewicz 1982, Bosman 1984, Lowe 1985, Parsons and Leber 1982, Russell 1984.) Medications and over-the-counter drugs The use of alcohol combined with a regimen of overTthe-counter or prescribed medications is a common but potentially lethal occurrence. As one grows older, the number of drugs one takes usually increase. A figure commonly cited is that A - 8 older people who are 12% of the population are using approximately 25% of the prescribed medications. Further, it has been estimated that over-the-counter preparati0nS account for approximately 90% of all drugs taken by the elderly (Baker 1985). The problem of drug use and misuse has many dimensions and is compounded when drugs are used with alcohol. Alcohol interacts adversely with many drugs, a situation that is particularly significant with other central nervous system depressants. Polypharmacy is not uncommon among older people. Frequently, the medical regimens are being prescribed by more than one physician, and older people often have difficulty in correctly self-administering the medications. The potential for drug interactions and adverse drug reactions is great under such circumstances, particularly in view of the changing physiology with age. ~11 of these situations are intensified with the use of alcohol. Adverse drug and alcohol interactions can be potentially life threatening to older people because of the decrease in reserve in vital organs. Many older people have poor or incorrect conceptualizations of how their bodies handle substances and need education in order to practice healthful habits. Further, many professionals and para-professionals who work with older people are unaware of the seriousness or the extent of the problem. (Atkinson 1984, Glantz 1983, Schuckit 1980.) Nutrition Healthful nutritional practices among older people have been a concern of many who work and have contact with the elderly. Nutritional practices are affected by the totality of the life circumstances of older people. Social, psychological, economic and physical factors are important to consider, Changing circumstances within the family unit, such as the loss of a spouse, may affect the pattern of food preparation and may precipitate all but minimal attention to the activity- Depression, social isolation and physical incapacity can- intensify and make insurmountable the problems related to the maintenance of a good diet. Life-long dietary practices, which may not have seemed problematic at a youn$er age, now become detrimental and debilitating. Physical changes that are age related, coupled with the use of medications, may require modification of these practices. The ability to make such changes may be limited by a lack of information, minimal economic resources or lack of access to appropriate facilities for shopping, storage or preparation of food. Malnutrition has been long recognized as being caused by chronic alcohol use. The impact of the use of alcohol on nutrition is seen as a result of a change in ability to function as well as affecting the appetite, absorption, metabolism and excretion of nutrients. When compounded with physiological aging, with the reduction of functional reserves ,' the effect may be particularly detrimental. It is widely recognized that the elderly user is much more susceptible to the nutritional consequences of alcoholism. It is not as widely recognized that there may be nutritional consequences for the more social user, particularly if there are acute or chronic diseases present and medical drugs are being taken. There are many specific nutrition-alcohol interrelationships that should be kept in mind both in the maintenance of healthful practices and in the treatment of alcoholism in elderly people. One will illustrate the weight of the area of consideration. The cwurse of normal aging brings a reduction in bone mass as well as reduction of the capacity of the gastrointesinal tract to absorb calcium. A-9 The presence of metabolic acidosis, a common result of consuming alcoholic beverages, may further aggravate a negative calcium balance. The development of osteoporosis, a frequently identified condition in older people, particularly women, may be aggravated by alcohol use. Adequate calcium levels are also required to maintain the transmission of nerve impulses at appropriate levels. These processes are also negatively affected by age and by the presence of ethanol, and may be subjected to a compounded effect. (Gambert 1984, Mishara and Kastenbaum 1980, Russell 1985.) Carcinoma The question of the carcinogenic effects of alcohol use have been of concern for several years. It does appear that there is a tendency for the chronic alcoholic to develop squamous cell carcinoma in the region of the pharynx. Carcinoma of the esophagus is frequently detected in those who are diagnosed as alcoholic, representing over half of all cases of esophageal cancer. There is some evidence that alcohol abuse may also be associated in the development of carcinoma in the mouth. However, there are methodological problems in the research in this area. It becomes extremely difficult to distinguish between the effects of alcohol and other factors that are frequently present, such as smoking, exposure to pollutants and malnutrition. It has been estimated that approximately 90% of alcoholics are also smokers, and the role of smoking to the development of some kinds of carcinoma has been well documented. Research has also indicated that there may be carcinogenic implications related to the way cells respond to ethanol. It does not appear, however, that alcohol has an equal role in the development of all types of cancer, and where there does appear to be a relationship, additional research is still desired. (Bosmann 1984, Bambert 1984, Mishara and Kastenbaum 1980.) Safety Problems related to safety and alcohol use are many, from pedestrian accidents to the interference of an alcohol-induced state in performing simple chores in the kitchen. Stress for older people who are injured in accidents has the same ripple effect on their health and mental outlook as disease states. Older people seem paPticularly susceptible to falls. Hingson and Howland (1987) report figures from the Center for Disease Control, indicating that each year 200,000 older Americans experience hip fractures associated with falls. Older people are also disproportionately represented in deaths from falls, over one-half of fatal falls involve persons over 75 years of age. There is a strong link between the use of alcohol and falls. In fact, one of the items frequently included in a list of clues of a drinking problem is the experience of falling. Although there is substantial evidence that alcohol increases the risk of falls, studies have not yet provided information that is specific to the elderly. However, from a perspective of maintaining safe practices, the potential effect of the use of alcohol on the incidence of falls among older people should not be neglected (Hingson and Howland 1987). In discussing burns of older persons, Anous and Heimback (1986) noted that frequently burns tend to be deeper because of delayed reaction times, impaired A - 10 senses and the fact that many older burn patients live alone. The reduced capacity of the older physical system has special import in dealing with the stress related to the burn experience as well as affecting the process and time of healing. It was also noted that older cases with documented alcohol problems tended to be loners and to have a higher percent TBSA (Total Body Surface Area) burn. (Anous and Heimbach 1986.) Benefits from alcohol use The beneficial use of alcohol with older persons has been a recurring theme in the literature that relates to aging and alcohol. Stories of the prescribing of spiritus frumenti have been documented in many case histories and in studies of practices within care facilities for older people. Common conditions that are addressed in this manner are loss of appetite, as an aid to digestion, as a nutritional supplement, as a relaxant, sedative and a sleeping aid. Most studies of the use of alcohol generally conclude that there is a therapeutic value to the serving of alcoholic beverages in institutional settings. Some note that, under such conditions, the medication levels may be reduced. In many of the studies, there was an effort to provide a varied or special setting for the events of drinking, as well as there being additional staff and others present who were involved in exchanges with the .residents of the facility. These factors make it difficult to identify the exact source of the benefits observed (Mishara and Kastenbaum, 1980). In reporting on their own research, Mishara et al. (1975) stated that the amount of alcohol that was consumed was small and that there was an effect of the social setting that supported drinking. There was evidence of psychological benefits in terms of morale, improved sleep and a general sense of improved well-being. It was particularly noted that the participation in the study was voluntary and that a physician's approval had been obtained for each participant. Other studies have been conducted with non-institutionalized older people. In his study, Kastenbaum reported on the effects of the use of one or two 3 ounce servings of wine on self-sufficient older people living in the community. It was noted that the changes, both those that were subjective and self-reported, and those that were determined by psychological assessment procedures, were generally in the positive direction. On the subjective items, participants reported improved subjective status in terms of morale, improved sleeping patterns, reduced chronic fatigue, anxiety and depression. In objective tests, there was a tendency for those with relatively better functioning to show improvement in behaviors dnd performances that have strong cognitive components. (Mishara and Kastenbaum 1980.1 Health issues in treatment ___- _____ For the older person, entry into the treatment syst,em is frequently through a health care agency, usually the acute care hospital. Compared to younger people the older person often presents in a more debilitated condition. Because of the number of pathological conditions that may develop as a ;esulP of long term alcohol use, it is not infrequent that the older persons enter the system for treatment of other diagnosed conditions, and then in the process of medical treatment, are encouraged to confront the reality of the relationship that alcohol use has to the current condition and to the prognosis for recovery. A - 11 While recognizing that all systems of the body are affected by the use of alcohol and have the potential of reacting adversely, there are certain medical conditions that are indicative of long term use. Cirrhosis of the liver, gastritis, chronic or acute pancreatitis, with accompanying abdominal pain, weight loss and diabetes are significant risks of long term use. Other conditions frequently associated are atrophy and weakness of the muscles, polyneuropathy, the inability of the body to fend off infections or to support healing, malnutrition and dehydration. Pneumonia and pulmonary tuberculosis also occur more frequently among alcoholics. In advanced cases, sever neurological damage may be seen as Korsakoff's psychosis and Wernicke's disease (Mishara and Kastenbaum, 1980). Generally, the late-onset individual presents with fewer and less severe medical complications, although Schuckit and Miller (1386) do point out that this type drinking is during the medically vulnerable years and may cause disproportionate medical problems. Because of the greater likelihood of the older person entering treatment for related health conditions before entering alcoholism rehabilitation programs, the role of the health care professional in identification and intervention must be recognized. Most older people trust medical personnel and hold them in high regard. Being able to accurately access the situation, to interpret the presenting symptoms correctly and to use the medical record to facilitate breaking through the denial make the health professional a vital link in the network of treatment. The value that many older people place on their health often facilitates and provides motivation for engaging in the process. (Mishara and Kastenbaum 1980, Schuckit 1982, Sherouse 1983.) There are many medical and health issues that need to be considered in the course of treatment, There is no agreement on the use of medications in the process of treatment, with particular concern focusing on minor tranquilizers and sedatives (Gomberg, 1982). Monitoring the physical conditions and the medication regimen is an ongoing process. In the course of treatment, with medical care, good nutrition including vitamin therapy, and appropriate rest, there is frequently an improvement in the physical well-being of the older person, and specific medical conditions may abate in their severity- However, a parallel situation may also develop. Conditions whose presence and pain are masked by the anesthetic quality of the alcohol become evident. After the alcohol is out cf the system, dental problems, urinary tract infections, venereal disease and other conditions may be identified in the course of rehabilitation. Because of `poor physical condition and lack of reserve, older people may require more direct nursing care and help with meals, bathing and personal care. The daily schedule of the treatment program may tax their strength and endurance, and the requirements may have to be modified to allow for more rest. Attendence to medical needs, perhaps even readmittance to an acute care facility, may interrupt the treatment schedule and necessitat? decisions.or adjustments in administrative policies. The need for a wheel chair, crutches, or assistance in movement affects the participation of the client and requires additional concern on the part of the staff. Attention to hearing aids, teeth, eye glasses, and similar devices, facilitates the recovery process in terms of participation, self-image, and the development of good health habits (Williams 1985). Other relevant treatment issues -__- A - 12 The issue Of the responsibility of providing treatment services for the older alcoholic generally focuses on the questions of which service system, age or alcohol treatment, should carry primary responsibility, and whether there should be specialized programs within existing systems. Little has been done to evaluate the effectiveness of different systems or different treatment modalities with older People. Treating within the alcohol service system has been the general approach, with the recommendation that there be some adaptations and a specialized outreach program to reach the older person (Janik and Dunham 1983)- Emphasis upon social supports and peer groups appears to increase positive outcomes (Kofoed et al. 1987, Zimberg 1982). Payment for treatment requires that there be an appropriate mesh between the treatment needs of the individual, the types of alcoholism services that are available and acceptable to that person, and the regulations that govern the resources that may be tapped, whether Medicare, Medicaid, private third party, veterans benefits or others. Uorking with an older person in need of treatment often requires unusual orchestration abilities on the part of the service provider in order that access to all phases of treatment becomes financially available. Prevention opportunities for prevention programs do exist. Two excellent possibilities exist through the development of self-help groups for older people and the preretirement and retirement planning groups that are often a part of personnel services in industry and business, labor and professional groups and organizations (Gomberg, 1982). Such programs would be of primary benefit to individuals who.may at be at risk for the development of late-onset problems. Self-help groups could be developed in the community under the sponsorship of senior centers, community mental health programs, voluntary organization and others. These groups would have the advantage of being holistic in their approach, providing life-coping skills and support systems. BY including substance use within their concerns, but avoiding the label, these groups would be more appealing to older people who frequently feel stigmatized by the words problem drinker or alcoholic. Secondary prevention services could be provided by the development of programs that would-sensitize and .provide skills .to service providers of older people, whether in medical or social services. Intervention at the earliest possible stage precludes the further exacerbation of medical, psychological and social problems, optimizing the possibilities of successful treatment within the context of continuing support systems. Tertiary prevention is an integral part of treatment, targeted to the successful completion of treatment and the prevention of future problems. This approach must also include the development of life skills to help the older alcoholic successfully adjust to the realities of his/her life stage. There are many programs that have been developed to address prevention issues on all levels. Only a few examples will be sited. The Senior Alcohol Services of Vancouver, Washington, provides community training and information as well as treatment that includes aftercare, couples' counseling and family groups- The Kassachusetts Housing Finance Agency through its Tenant Assistant Program (TAP) A - 13 provides education, information and referral services in a program that concentrates'on outreach to improve the quality of life of the tenants. Elements of the program address all three levels of prevention. The Michigan Office of Substance Abuse Services and the Michigan Office of Services to the Aging sponsored the development of a three volume guide, Older Adult Substance Abuse, designed to foster a team approach to prevention. The three volumes are A Resource Manual, Prevention Program Development, and Medications Information. (Resch and Christensen, 1983.) The Wisconsin Department of Health and Social Services issued a planning guide, Examination of Problems and Solutions Related to the Chronic "Revolvinq Door" Alcohol Abuser _ The final report contains 26 -- recommendations to break the cycle and to provide for meaningful alternatives. (Wisconsin Department of Health and Social Services 1981) The AAA Foundation for Traffic Safety of Falls Church, VA, has developed a film with guide, Senior ____ Adults, Traffic Safety and Alcohol, which provides information for older people about the substance and the effects of alcohol and problems that it may generate. A SAMPLE OF NATIONAL EFFORTS There have been efforts by several agencies and groups to address the concern of aging and alcohol use on a national level. The four that are mentioned are by no means the only efforts, but do illustrate the variety of the efforts that have been made, representing a public policy effort, research, and a treatment related project _ Blue Ribbon Study Commission on Alcoholism and Aging -- - The Blue Ribbon Study Commission on Alcoholism and Aging, sponsored by the National Council on Alcoholism, was convened in the fall of 1979 with the Honorable Wilbur D. Mills as chairperson. The Commission was composed of a broad range of representatives from government, academia, voluntary organizations and the health and social service sectors. The stated goals of the Commission were: 1. to gather and evaluate present knowledge concerning alcoholism and aging: 2. to identify and analyze the information needed for thorough understanding of the problem through defining specific issues; 3. to identify and evaluate the options open as to what can be done to resolve these issues successfully; and 4. to disseminate the information gathered to the American public and to groups and individuals directly involved in the policy and implementation process. (News release! of the National Council on Alcoholism, February 22, 1980.) The outcomes of the Commission are three. 1. The Commission sponsored a two day tract, The Aging and Alcohol Abuse, at the 1980 National Alcoholism Forum of the National Council on Alcoholism. 2. It organized and sponsored a Mini-Conference on Aging and Alcoholism, held at Wingspread, Racine, WI, in conjunction with the 1981 White House Conference on Aging. 3. It prepared a report, with recommendations, to be included in the proceedings of the 1981 White House Conference on Aging. Six categories of recommendations were included: research and development, education and training, increasing the utilization of services, ensuring and improving the effectiveness of treatment, increasing the availability and access of services and protection of patients' rights. A - 14 Research center on aging and alcohol established In December 1982, the National Institute on Alcohol Abuse and Alcoholism funded the Alcohol Research Center at the University on Gainesville, one of nine national research centers. This center is specifically designated to conduct research into the causes and the consequences of alcohol use and abuse by the elderly - As a interdisciplinary center, the research agenda includes a multi- faceted approach to the subject. An extensive educational program for a broad spectrum of health professionals is a major component of the activities. kesearch conference In November, 1983, a national research conference was convened on The Nature and Extent of Alcohol Problems Among the Elderly. The conference was sponsored by the National Institute on Alcohol Abuse and Alcoholism in collaboration with the National Institute of Mental Health and the National Institute on Aging. The conference produced a monograph by the same title, edited by George Maddox, Ph.D., Lee N.,Robins, Ph.D., and Nathan Rosenberg, Ph.D.. In the preface it is stated that "the workshop at Washington University was intended as a beginning point in a systematic NIAAA effort to stimulate research interest and activity in the alcohol-aging area." (p. v-1 The keynote address of the conference by Robert Straus (pp.7-28) focused on factors of change as related to both aging and alcohol, the need to develop a biomedical perspective in relation to the topic, and stated that both alcohol studies and gerontology were entering a biobehavioral era of scientific thought and activity. The conference was organized to present key issues and current evidence of mental health and social correlates of alcohol use, presented from research of the Alcohol Research Center of the University of Gainesville, FL, longitudinal data of alcohol problems among the aged from studies in St. Louis and from the Normative Aging Project of the Veterans Administration, and research data from the Epidemiological Catchment Area Studies. Future research needs were addressed by most participant in the course of their papers, emphasizing the need for more current and more extensive research that is specific to the older population. & demonstration project related to treatment The Health Care Financing Administration Alcoholism Project was a three year demonstration project targeted to evaluate the cost effectiveness of reimbursement under Medicare of treatment in non-hospital settings. Of the six states involved in the project, most also included the provision of reimbursement under the state funded medical assistance program or Medicaid. Because of the source of the reimbursement funds, in most agencies, there was the added benefit of stimulating the entry of the elderly into treatment. In addition to collecting data related to the reimbursement effect, agencies who participated increased and expanded their experiences with the elderly, and developed and adapted treatment modalities `to meet the need of this population. A report on this additional benefit of the project was prepared by the Rutgers University Center of Alcohol Studies, New Brunswick, New Jersey. The evaluation of the data related to the reimbursement study has not yet been completed. A - 15 The identification of "what needs to be done" frequently has the quality of confused time sequence. Research of the problem area should precede the development of policy which would in turn give impetus to program development. But it is impossible to begin again. The reality is that movement on all fronts is needed and must proceed as best possible. The relationship of research in the field of aging and alcohol to the development of public policy has been addressed by Stall (1987). Stall proposes a particular value of long-term perspective research as an integrative and interpretive tool for reassessing the data from both retrospective and cross sectional studies. Such research would make it possible to test and evaluate the hypotheses that have been advanced to explain the data, and would provide direction for the development of public policy. Ruben (1986) points out that elements of incongruence are present between public policy and what we do know about the nature and the scope of the problem, Future development of policy would benefit from consideration of these observations. In relation to health and aging, there are many avenues of research that have been opened but not fully addressed. Enumeration of specific areas is repetitive and more adequately done by those whose expertise is within the specific areas of study. However, in reviewing studies, it becomes very evident that much of what we understand is based on studies that are not we and/or alcohol specific. Whereas, there is justification for applying the results of such research to the aged or to alcohol problems, additional studies that are focused on the problem area would provide a firmer foundation for the development of policy and the implementation of programs of prevention and treatment. Programs, and ultimately people, who are coping with the problems of aging and alcohol abuse, are impacted by policies in the fields of aging, alcohol treatment, health, social services, housing, transportation, and innumerable other areas of governmental responsibility. How these policies intermesh is a prime concern for the issue of aging and alcohol. The perspective from the field frequently is that policies interact in ways that are more prohibitive than facilitating. In considering what policies should be enacted, this concern should be addressed. For example, these questions might be discussed: Whaf weight should be given to current epidemiological projections in the consideration of policies related to the development of programs of prevention and treatment? What effect do current health care policies, such as the DRG's, have upon the provision of the level and the extent of medical care needed by the older person who may have multiple and extensive needs related to alcohol abuse? What policies would facilitate the development of primary prevention programs in the arenas that are most utilized by those at high risk? What incentives might be offered to encourage the private sector to be involved in the provision of prevention programs related to late-onset alcoholism? In what areas should policies be developed to address the high cost of providing institutional care for those severely disabled by alcohol? Are A - 16 other options possible tnat would allow for a more optimal quality of life? What policy provisions are possible that would encourage and support linkages between alcoholism treatment and age services to actualize the concept of continuity of care? Based on evaluative research of treatment modalities, what policy decisions should be considered to support specialized components to provide treatment for older persons? Are federally sponsored programs for volunteer service appropriate avenues for involving older people in the process of addressing the need for education and prevention in relation to alcohol use and health? The range of exploration is limitless. And the time is now. REFERENCES Anous, M-M., and Heimbach, D.M. Causes of death and predictors in burned patients more than 60 years of age. J Trauma 26: 135-139, 1986. Atkinson, R.M. Alcohol and Drug Abuse in Old As. -__ Washington, D.C.: American Psychiatric Press, Inc., 1984. Baker, W-W. Psychopharmacology of aging: Use, misuse and abuse of psychotropic drugs. In Gottheil, E. et al., ed. The Combined Problems of Alcoholism, w -- Addiction and Aging. Pp.150-163. Springfield, IL: Charles C Thomas, 1985, Barboriak, J-J.; Anderson, A-J.; Rimm, A.A. et al. Alcohol and coronary arteries. Clin Exp Research 3: 29-31, 1979. Barnes, G.M. Alcohol use among older persons: Findings from a western New York state general population survey- J Am Ger Sot 27: 244-250, 1979. Barnes, G.M.; Abel, E-L-; and Ernst, C.A.S. Alcoholism and the Elderly: A __ __ Comprehensive Bibliography. Westport, CT: Greenwood Press, 1980. Blusewicz, M-J.; Cannon, W-G.; and Dustman, R.E. Alcoholism and aging: Similarities and differences in neuropsychological performances. In Wood, W-G., and Elias, M-F.. ed. Alcoholism and.Aginp: Advances in Research. - Pp. 47-60. Boca Raton, FL: CRC Press, Inc.: 1982. Bosmann, H.B. Pharmacology of alcoholism and aging. In Hartford, J-T., and Samorajski, T., ed. Alcoholism_ in w Elderly: Social and Biomedical Issues. II___ Pp. 161-174. New York: Raven Press, 1984- Cahalan, D. Problem Drinkers. San Francisco: Jossey-Bass Inc., 1970. Cahalan, D.; Cisin, I.H. ; and Crossley, H.M. American Drinking Practices. New Brunswick, NJ: Rutgers Center of Alcohol Studies, 1969. Carruth, B.; Williams, E-P.; Boudreaux, L. et al. Alcoholism and Problem Drinking Among Older Persons. U.S. Department of Health, Education and Welfare, A - 17 Administration on Aging, Grant No. PHS-SRS-93-P-75146/2-02. New Brunswick, NJ: Rutgers Center of Alcohol Studies, Rutgers University, 1973; and Springfield, VA: NTIS, 1973. Christopherson, V-A.; Escher, M.C.; and Bainton, B-R. Reasons for drinking among the elderly in rural Arizona. J Stud Alcohol 45: 417-423, 1984. Gaitz, C-M., and Baer, P.E. Characteristics of elderly patients with alcoholism. Arch Gen Psychiatry 24: 372-378, 1971. Gambert, S-R.; Newton, M.; and Duthie, E.H. Medical issues in alcoholism in the elderly. Elderly: 1984. Glantz, M.D.; Research In Hartford, J-T., and Samorajski, T., ed. Alcoholism in the -__ Social and Biomedical Issues. Pp. 175-191. New York: Raven Press, ~ - Petersen, D-H.; and Whittington, P.J. Drugs and the Elderly Adult. ~ __ Issues 32. Rockville, MD: National Institute on Drug Abuse, 1983. Glynn, R-J.; Bouchard, G-R.; LoCastro, J-S,; and Hermos, J.A. Changes in alcohol consumption among men in the Normative Aging Study. In Maddox, G. et al., ed. Nature and Extent of Alcohol Problems Among the Elderly. Research Monograph No.14. Pp. 101-116. Rockville, MD: National Institute on Alcohol Abuse and Alcoholism, 1984. Gomberg, E-S-L. Alcohol use and alcohol problems among the elderly. In Special Population Issue. Alcohol and Health Monograph No.4. Pp. 263-290. Rockville, MD: National Institute on Alcohol Abuse and Alcoholism, 1982. Gordon, T. Discussion: Session I. In Maddox, G. et al., ed. Nature and Extent of ~-~_ Alcohol Problems Among the Elderly. Research Monograph No.14. Pp. 134-138. Rockville, MD: National Institute on Alcohol Abuse and Alcoholism, 1984. Gottheil, E.; Druley, K-A.; Skoloda, T.E.; and Waxman, H-M. The Combined Problems of Alcoholism, 1385. Drug Addiction and Aging. Springfield, IL: Charles C Thomas, Hermos, J.A.; LoCastro, J-S.; Bouchard, G-R.; and Glynn, R.J. Influence of cardiovascular disease on alcohol consumption among men in the Normative Aging Study, In Maddox, G. et al., ed. Nature and Extent of Alcohol Problems ~-___- Among the Elderly. Research Monograph No.14. Pp.117-132. Rockville, MD: National Institute on Alcohol Abuse and Alcoholism, 1984. Hingson, R., and Howland, J. Alcohol as a risk factor for injury or death resulting from accidental falls: A review of the literature- J Stud Alcohol, -- 48(3): 212-219, 1987. Janik, S-W., and Dunham, R.G. A nationwide examination of the need for specific alcoholism treatment programs for the elderly, J Stud Alcohol 44: 307-317, -- 1983. Kannel, W.B. Nutritional contributors to cardiovascular disease in the elderly. J Am Ger Sot 34:27-36, 1986, --- Kofoed, L-L.; Tolson, R-L.; Atkinson, R-M. et al. Treatment compliance of older A - 18 alcoholics: An elder-specific approach is superior to "mainstreaming". J @ Alcohol 48: 47-51, 1987. Lowe, G. Alcohol and memory processes: Implications for the elderly alcoholic. Proceedings of Dependence. Pp. 34th International Congress on Alcoholism gx& Drug 27-28. Alberta, Canada: Alberta Alcohol and Drug Abuse Commission, 1985. Naddox, G.; Robins, L-N.; and Rosenberg, N., editors. Nature and Extent of ---- Alcohol Problems Among the Elderly. Research Monograph No.14, Rockville, MD: National Institute on Alcohol Abuse and Alcoholism, 1984. McCusker, J.; Cherubin, C-F.; and Zimberg, S. Prevalence of alcoholism in a general municipal hospital population. Ny State J Med 71: 751-754, 1971. Meyers, A-R.: Goldman, E.; Hingson, R.; and Scotch, N. Evidence for cohort or generational differences in the drinking behavior of older adults. Int'l J Aging Human Dev 14: 31-44, 1981. Mishara, B-L., and Kastenbaum, R.: Alcohol and Old As. New York: Grune and Stratton, Inc., 1980. Mishara, B-L.; Kastenbaum, R.; Baker, F, et al .: Alcohol benefits in old age: An experimental investigation. Sot Sci Med 9:535-547, 1975. Nate, E.P. Epidemiology of alcoholism and prospects for treatment. Ann Rev Med I_ __ __ 35: 293-309, 1984. Parsons, O-A., and Leber, W.R. Premature aging, alcoholism and recovery. In Wood, W-G., and Elias, M-F., ed. Alcoholism and Aging: Advances in Research. Pp. - 79-92. Boca Raton, FL: CRC Press, 1982. Resch, J-E., and Christensen, J-M.: Older Adult Substance Abuse, Volumes I_, II and III - -- Lansing, MI: Michigan Office of Substance Abuse Services and Michigan Office of Services to the Aging, 1983. Robins, L-N. Introduction to the ECA Project as a source of epidemiological data on alcohol problems. In Maddox, G. et al., ed. Nature and Extent of Alcohol ___-___- Problems Among the Elderly. Research Monograph No.14, Pp. 201-216. Rocll'ville, MD: National Institute on Alcohol Abuse and Alcoholism, 1984. Rosin, A-J., and Glatt, M.M. Alcohol excess in the elderly. Q J Stud Alcohol -___ 32:53-59, 1971. Ruben, D.H. The elderly alcoholic: Some current dimensions. Adv Alcohol Substance Abuse 5: 59-70, 1986. Russell, J-F. et al. Veterans Administration supports research on alcohol and the elderly. Alcohol Health Res World 8(3): 16-23, 1984. ~-- Russell, R.M. A discussion of ethanol-nutriant interactions in the elderly. Drug-Nutrient Interactions 4: 165-170, 1985. Schuckit, M.A. Clinical review of alcohol, alcoholism, and the elderly patient. J A - 19 Clin Psychiatry 43(10): 396-399, 1982. Schuckit, H.A. Phenomenology and treatment of alcoholism in the elderly. In Farm, W-E.; Karacan. I.; Pokorny, A.D. et al., ed. Phenomenology and Treatment of - Alcoholism. Pp. 167-179. New York: Medical and Scientific Books, 1980. Schuckit, M.A., and Miller, P.L. Alcoholism in elderly men: A survey of a general medical ward. Ann NY Acad Sci 273: 558-571, 1976. Schuckit, M-A., and Pastor, P.A. Alcohol-related psychopathology in the aged. In Eaplaa, O-J., ed. Psychopathology of Aging. Pp. 211-227. New York: Academic Press, 1979. Sherouse, D.L. Professional's Handbook on Geriatric Alcoholism. - Springfield, IL: Charles C Thomas, 1983. Simon, A.; Epstein, L-Y.; and Reynolds, L. Alcoholism in the geriatric mentally ill. Geriatrics 23(10): 125-131, 1968. Stall, R .: Research issues concerning alcohol consumption among aging populations. Drug and Alcohol Depend 19: 195-213, 1987. Warheit, G-J., and Auth, J.B. The mental health and social correlates of alcohol use among differing life cycle groups. In Maddox, G. et al., ed. Nature and Extent of Alcohol Problems Among the Elderly. Research Monograph No.14, Pp. 29-82. Rockville, MD: National Institute on Alcohol Abuse and Alcoholism, 1984. Williams, E-P.: Older Alcoholics in Treatment. New Jersey Department of Health, Division of Alcoholism. New Jersey Health Service Contract No. 85-274-ALC. New Brunswick, NJ: Rutgers Center of Alcohol Studies, Rutgers University, 1985. Wisconsin Department of Health and Social Services. Examination of Problems and - Solutions Related to the Chronic "Revolving Door" Alcohol Abuser. -__ Planning Guideline #l. Madison, HI: Department of Health and Social Services, 1981. Wood, W-G., and Elias, M.F., Editors. Alcoholism and Aging: Advances in Research. - Ijoca Raton, FL: CRC Press. Inc., 1982. Zimberg, S. Outpatient geriatric psychiatry in an urban ghetto with non- professional workers. & J Psychiatry 125: 1697-1702, 1969. Zimberg, S. Psychosocial treatment of elderly alcoholics. In Zimberg, S.; Wallace, J.; and Blume, S-B., ed. Practical Approaches to Alcoholism Psychotherapy. Pp. 347-363. New York: Plenum Press, 1985. Zimberg, S. The psychiatrist and medical home care: Geriatric psychiatry in the Harlem community. Am J Psychiatry 127: 1062-1066, 1971. -- A - 20 Health Promotion and Aging "Oral Health" Helen C. Gift, Ph.D. Epidemiology and Oral Disease Prevention Program National Lnstitute of Dental Research National Institutes of Health 1. BACKGROUND There is a growing interest in the oral health needs of older persons, particularly as the size of the population age 65 and older increases and as the composition of th increase in population is occurring in the oldest-old-age 85 and over B t age group changes. The largest -a group for which little is known regarding oral health. Historically, older adults have had fewer financial and social resources than have other age groups, but evidence suggests that the picture is changing. For example, in 1984, 91 percent of older adults received Social Security benefits; 24 9 ercent received income from private pensions, and 68 percent received income from private assets. These represent considerable improvements over the past two decades. Furthermore, it is projected that improvements in the socioeconomic status of older individuals will continue over the next several decades. This does not mean, however, that all older Americans will be financially able to secure the necessary benefits from health care. Even considering these improvements, general health and medical expenditures are sizable. While older Americans represent nearly 12 percent of the population, they account 2fy 27 percent of all health expenditures and purchase 25 percent of all medications sold in this country. In the most comprehensive, published data-the National Medical Care Expenditure Study (NMCES)-it was reported that three percent of the per capita health expenditure for those 65 and older went for dental care in 1977. Modest increases were observed in mean dental expenditure per older person between 1970 and 1977-from $31 to $40 (1977 dollars)5 Traditionally, dental care for older persons has been an out-of-pocket expense. In 1981, nineteen percent of tkose ages 65-74 had some dental insurance, while 10 percent of those age 75 and older had some coverage. @elf-reported dental insurance is often at a high- er level for this age group.) In spite of major successes in dental research, treatment and prevention over the past several decades, oral diseases of all kinds remain among the most costly health prob ms prevalent in the United States, adding up to a national bill of $22.7 billion for dental services in 1986. 3p Older Americans traditionally have accounted for large proportions of less advantaged categories and are more likely to be without major support systems, judged by sociodemographic and access measures. For example, there are high proportions who 1) live alone and are widowed, 2) have few ye r are below the poverty level, 4) are not in the labor force, or 5) live in non-urban areas. f 8 g\eiJy~ytion, 3) > Improvements in oral health status and dentally-related. behaviors of the older age group have been observed over the past several decades. Continued improvements in oral health status, oral hygiene practices and dental service utilizatipy ~5 e projected as upcoming cohorts continue to become better ~~e~s~sdrPlo~!l e ffluent and dentate, yet, the older individual will continue to be at risk for oral There is no research evidence to suggest that tooth loss or specific oral diseases are a necessary concomitant of the aging process, nor do al in terms of oral health or dentally-related behaviors. {persons over age 65 fall into one descriptive group Rather, it appears that there is a great deal of heterogeneity in the older population.15 k&a ise, there is no evidence that older persons are, by definition, in poor general or oral health. The combination of genetic predisposition, lifestyle and socioeconomic environment, exposure to fluorides, oral hygiene at home and dental-visit behaviors lifetime, contribute to the state of oral health, or lack thereof, in later Maintaining quality of life through retention of the dentition requires the prevention and/or treatment of oral diseases beginning at younger ages and continuing throughout the lifetime. Preventive activities for B -1 all ages include professional and self-care. Professional preventive activities include examination of the dentition, supporting structures and muscosal tissue for decay, attrition, abrasion, periodontitis, recession, oral cancers and evidence of oral symptoms of systemic diseases, as well as oral hygiene education and regimens such as prophylaxis and fluoride applications. Appropriate restorative tBatment of observed conditions is accepted as preventing further destruction of oral structures. The prescription for maintaining optimal oral health through self-care is the same for the older person as it is for the younger one: daily toothbrushing with a fluoride toothpaste, use of a fluoride and/or antimicrobial rinses, interdental cleaning, dental visits at least once a year and observation of a balanced diet and food intake pattern. Some oral conditions may be prevented or retarded by a change in behaviors including stopping ~"4" of tobacco, improving toothbrushing technique or abandoning inappropriate chewing behaviors. Other oral conditions and appropriate treatments may be controlled through careful monitoring of systemic conditions and medications. The overall quality of life of any individ articularly an older one, can be enhanced through oral diseases prevention and health promotion. Y'b'a~ The health of the oral cavity--teeth, oral soft tissues, underlying bone, neural apparatus, immune system and glandular mechanisms-is critical to chewing, tast- ing, swallowing and speech, as well as adaptation to dentures if they are worn. Health of the oral cavity also contributes to nutrition, facial esthetics and protection from systemic infection and injury. Most older Americans are relatively healthy and functionally independent. They can be expected to cont- inue to follow habitual patterns of oral hygiene behavior and use of dental services. Still, an estimated 40 percent of older Americans are 4s ejected to constitute a special-needs category based on complex health problems and functional status. These include: emotional and physical stresses associated with the aging process; physical an mental disabilities resulting from chronic diseases and physical and financial barriers to access to care. 86 IL ORAL HEALTH STATUS-OUTCOMES OF ORAL HEALTH PROMOTION A. Data Sources Descriptions of the oral health and related behaviors of older Americans are available from a number of national and local sources. National data are the most readily available, but rziany of these studies placed an upper limit on age in the sample. Furthermore, those studies which do include older individuals typically have not focused on this age group, thus the ability to analyze the data may be iimited by the number of older individuals in the subsample. The weakness in all surveys conducted to date is the near absence of a comprehensive data set on older individuals--including attitudes, knowledge, behaviors, environmental/structural conditions, as well as clinically-determined oral health status. The major surveys which include both interview and clinical examination data on older Americans are the National Health and Nutrition Examination Survey (NHANES I), Hispanic Health and Nutrition Examination Survey (HHANES), and A St d with depaid Dental Care: 1981 # sff Dental Health Related and Process Outcomes Associated (HRSA). A National Institute of Dental Research (NIDR) study- National Suivey of Oral Health in U.S. Employed Adults and Seniors: 1985~86-contains complete clin' al but minimal self-reported data on a sample of 5686 older Americans who attended 208 Senior Centers. 8 Most other national studies do not include clinical examination and are based on data collected by interview, including information on dentally-related behaviors, attitudes and knowledge. An example is the National Health Interview Survey (NHIS) conducted by the National Center for Health Statistics. Dental health questions have not been a routine part of the core questionnaire since 1981, but issues related to dental health have been included regularly in supplements. Other examples are the 1980 NCHS Personal and Preventive Practices Survey; NHANES I Epidemiologic Followup Study; the National Medical Care Expenditure Survey, 1977; the National Medical Care Utilization and Expenditure Survey (NMCUES), 1980; and Center for Health Administration Studies and National Opinion Medical Expenditures and Use of Health Services: 1953,1958,1963,1964,1970. p$?e$bch Center Surveys of Descriptions provided in this manuscript are based on reported correlations between selected measures of predisposing and enabling factors, perceived r,eed and oral health variables which, most often, have not B-2 been analyzed in combination as part of any predictive model. Emphasis has been placed on national probability samples and verified data over convenience samples or self-reported data. In some cases, reports may appear inconsistent, as recent analyses are providing more in-depth understanding of issues than was available when earlier research was published; for example, separation of the dentate and edentulous groups in the analysis of dental expenditures, visits and oral hygiene behaviors. B. Oral Health Status 1. Fdentulousness (Absence of Teeth) Traditionally, the primary measure of oral health status of older populations has been the extent of eden- tulousness. It appears now that each succeeding gener t'o li more individuals are retaining their teeth as they age. fghas improved compared to older cohorts and Based on NHIS data, in 1958, 67 percent of persons over age 74 reported being edentulous. The proportion of edentulous persons in this age category has decreased over the years to 60 percent in 1971 and 45 percent in 1983. Decreases also have been seen in populations as they reach the age group 65-74, with 55 percent being edent 98 us in 1958, 45 percent in 1971 and 34 percent in 1983. Declines were seen among both females and males. Edentulousness is rn$&e prevalent among older persons below the poverty level and among those with fewer years of education. One fourth (27%) of those ages 65 and older who attended senior centers in 1985-86 had 20 teeth or more, while 17 percent had 1-12 teeth. The average number of teeth decrea average being 18.1 at age 65 and 15.1 for the age category age 80 and over. j%d steadily with age, with the Presence of teeth appears to be related to socioeconomic status and race. Among the Baltimore Longitudinal Study panel members, a primarily healthy, middle-socioeconomic, well-educated, volunteer, older, study group-the averag?plder person has 70 percent of natural dentition (20 of 28 teeth&and only 4 percent wear full dentures. Data from a North Carolina study, encompassing 15 yeas? indicate a decrease in mean number of missing teeth in succeeding cohorts of whites, but not in blacks. The functional adequacy of dentition is further reflected in the measured treatment needs for prosthetic services: in the 65 and older age group in 1981, 8 percent needed bridge unit(s); 19 percent needed partial denture(s); 9 percent needed full denture(sL6 Based on self-report in 1983, approximately one-fourth of ~~~on~~~,s~~~~~~~~~~eeded new dentures. This proportion increased to over one-third among those 2. Caries Caries in older adults is exhibited mostly as recurrent caries surrounding failing restorations, cervical caries associated with plaque accumulation at the gingival margin, root caries Y-f? ciated with gingival recession or as a side effect of medical conditions or pharmaceutical challenges. Research in$jcates that a small portion of individuals account for most of the restorative treatment needs for caries. In 1985-86, older adults attending Senior Centers had an a faces. About 92 percent of these surfaces being increase in the prevalence of root s Yaf r aces caries. ii YP rage of 20 decayed or filled coronal tooth sur- 1 . 35 Additionally, as individuals age, there is an Well over one-half (63%) of the indivi Ill uals over age 65 have root surface caries. Only about one-half (54%) of these root surfaces are filled. Prevention of root caries is particularly important, since there is insufficient knowledge of optimal ther- apeutic approaches for root caries, making restoration difficult. While fluoride traditionally has been associated with prevention of decay in children, a recent study in Canada showed that the occurrence of root decay in adults with lifelong histories o 1493 tjoridated water consumption was approximately 60 percent less than it was in nonfluoridated areas. 3. Periodontal Diseases Periodontal disease is a frequent self-reported chronic condition in persons ag hypertension, hearing loss, heart conditions, vision impairments and diabetes. B-3 older persons including gingivitis, periodontitis, gingival recession and 1985-86, over one half (53%) of older adults attending Senior Centers had or more, 23 percent had supragingival calculus and 66 percent had subgingival and supragingival calculus-prevalence rates greater than younger adults. Appl$ximately 22 percent of older individuals have loss of attachment of 4 mm or greater at one or more site. The prevalence of periodontal diseases appears to increase with age." l3 36 The higher prevalence and, severity of periodontal diseases among older persons may not rather, may reflect the accumulation of disease over time. 5E suit from enhanced susceptibility, but If periodontitis is defined as mild pocketing, there may not be greater proportions of older adults with disease. With the increasing numbers of adults in this age group, however, this remains a considerable disease issue. The number of teeth lost due to periodontal diseases is not f~ 1y , o n but the number of teeth which need to be extracted from periodontal disease increases with age. Whether periodontal diseases are episodic or steadily progressive is still undecided, but evidence suggests that those persons who have retained their teeth to old age have a type of periodontitis that, at any given site, usually progresses slowly. 4. Oral Cancer The prevalence of oral cancer is greater among men tha ch women and increases with age, with the great majority of cases occurring in people over t ln 1987, 29,800 new cases of oral cancer were discovered and 9400 deaths were estimated. $5 age of 40. In a series of screenings conducted between 1957 and 1972 among older white adults in Minnesota, IO percent had at least one oral lesion unusual e recorded. Leukoplakia had a prevalence of 29.1/1000 and oral cancer a prevalence of .9/1000. YY$Jap~ gressive impact of smoking, drinking and use of smokeless tobacco on the condition of teeth and develop- ment of soft tissues lesions-specifically oral cancer-is more apparent in older individuals. Use of roducts and alcohol, both individually and in combination, is associated with denture-rel ed Also, lower educational levels and infrequent dental visits are associated with oral lesions. $3 5. Other oral conditions Other oral conditions are reported more often in older than younger adults. These include oral motor function and sensori-motor problems, such as difficulties in chewing, tasting or swallowing, oral effects of systemic diseases, acute and chronic pain, among others. No real evidence exists that a generalized deterioration in oral motor function or performance occurs with aging, but selected oral conditions-alteration of lip posture, masticatory muscle function, increasing dysfunction of the tongue and suspensory musculature-appear to be related to aging. Functional problems which might result from these conditions include labial spill of saliva, inability to prepare food for swallowing, altered speech, dysphagia, traumatic bite injury, increased mouth breathing. Very serious dysftf ctions in oral motor function can lead to fatal choking, laryngeal food &netrat-lon and regurgitation. Certain diseases of the salivary glatis are more common in older adults, specifically local inflammatory diseases and Sjogren's syndrome. Acute suppurative sialadenitis, as well as chronic recurrent sialadenitis, is more common in elderly, seriously ill, debilitated patients. The prevalence of Sjogren's syndrome-lymphoepithelial lesions-is second only to rheumatoid arthritis among the connective tissue diseases and a typical onset is age 40-60. In addition, there i& some indication that submandibular saliva and possibly minor gland secretions may be affected by aging. Evidence suggests that there is a decline in bone mass so that by age 70, the total is only about 60 percent of the peak. These changes can be observed in the oral cavity, can be exacerbate disease processes and can contribute to functional problems, such as poorly fitting dentures. If ?"qEertain Some oral conditions have become stereotypic of agingaiminution of stimulated parotid fluid output, structural changes in epithelium, atrophic change in oral mucosa, and generalized decreases in taste acuity and perception--but research has led increasingly to a lack of consensuc on these conditions. Evidence suggests that other factors, such as polypharmacy, inadequate nutrition, or systemic diseases, B-4 may be the precursors of these conditions and not age, per se. l4 41 42 43 Other age-reIated change- `1 taste and oral sensation, e.g. touch, temperature, and pressure sensibility, have been observ,d b,t :. I well described or documented. 111. AREAS OF PARTICULAR CONCERN A. Concomitant Medical Conditions, Pharmacological Challenges and Oral Conditions 1. Nature of Problem There are approximately 120 physical or mental diseases which manifest symptoms in the oral cavity or affect ab `ty to perform dentally-related behaviors. with age." The prevalence of most of these conditions increase For example: o Slower movements, less agility, impaired vision and hearing, urinary dysfunction, vascular insufficiency, among other things, may affect the ability to follow recomm and may make it impossible for an older individual to visit a dental office; zidations for self-care o The oral symptoms which result from hypofunctional or nonfunctional salivary glands are unpleasant and painful and affect vital functions such as speech, taste, chewing and swallowing. Xerostomia is highly associated with prescribed radiation or medications. It ma~~~e~n~i~r~~~~~~~~~ibility infections-both oral and systemic-and have an impact on nutrition to caries and periodontal diseases; o Cancer in the head, neck and oral cavity increases with age; o Aging diabetic patients are vulnerable to oral i nfi ections and impaired healing which may lead to periodontal diseases and related oral problems; o Psychoses, affective disorders and sleep disturbances may affect the patient's willingness or ability to perform appropriate r health, speaking or swallowing?' 1 hygiene or seeking of dental services, thus affecting oral o Neurological problems, including stroke and Parkinson's disease, can adversely affect oral functions. Dementing conditions such as Alzheimer's disease increase with age. Traditional education, training or compliance methods might be 5tf effective in changing any inappropriate dental health beliefs or behaviors for such patients. o Chronic and acute pain can adversely affect oral functions and the provision of dental care. Oral health Status also can affect general health status. Examples include the impact of missing teeth, inadequate restorations or poorly fitting dentures on food intake which ultimately might affect nutrition. Mso, .untreated o# infections can result in serious systemic complications, especially in immunocompromised patients. Medications for age-related systemic conditions--e.g. congestive heart failure, diabetes, depression, sleep disturbances, chronic pain--influence the oral conditions observed, cpytribute to the cause of some oral conditions, and affect the kinds of treatment which can be provided. More than 75 percent of a rural Iowa population age 65 and older took medications that could affect oral health or dental treatment. About one-half of the older individuals in the Iowa study took drugs which may cause xerostomia, e.g. antihypertensives, antihistamines, decongestants, diuretics, pain killers and tranquilizers. Other commonly used drugs affect blood clotting and cause oral ulcerations or sloughing of soft tissue. About one-fourth of these older adults took muscle relaxants and medications for anxiety, which can interact adversely with drugs commonly used in dental surgery for sedation and pain relief. Drugs used commonly for cardiac conditions by older persons can interact adversely with local anesthetics containing epinephrine. Broad spectrum antibiotics, medications for diabetes, systemic corticosteroids, phenytojn for convulsions, nifedipine used for cardiovascular disease, medications for angina and congestive heart B-5 failure and antipsychotic medications each may be associated with abnormal healing, predisposition to infection, overgrowth o &' mgival tissue, inability to tolerate long, stressful appointments and/or abnormal oral-facial movements. Also, dental visits create anxiety for many older individuals, a condition which may be heightened by some drugs. 2. Mechanisms and Interventions Established To Deal With Problem Health education and promotion efforts have been used to increase the awareness of older adults or care- takers regarding systemic conditions and medications which relate to oral health. Examples include:, Radiation, Chemotherapy, and Dental Health, Detection and Prevention of Periodontal Disease in; Diabetes and NIDR Fact Sheet: Dry Mouth (Xerostomia). Health care providers can play an active role in early diagnosis of systemic and oral conditions, assisting the patient and each other in limiting the progressio dentist, pharmacist and physician is very important. ivYi diseases. Emphasis on the interaction among the Education for dentists, physicians, nurses and pharmacists, both in basic training and continuing education, should provide increased attention to medical conditions and pharmacologica challenges exhibiting symptoms in the oral cavity. Increased emphasis should be given to recording, routine monitor- ing and clinical application of medical histories, particularly those specific to changes since the most recent visit. Review of related medical conditions involves recording medications whichthe individual is taking. This is particularly important for patients who are taking multiple medications." Dentists should be knowledgeable regarding alternate treatment approaches for compromised patients. For example, the removal of oral infection and employment of antibiotic therapy is especially critical for patients undergoing cardiac or joint-replacement surgery. Where discontinuing medication with negative oral side effects or substituting less harmful agents is not possible, a protective regimen for the oral environment can be instituted. This could include sugar-free chewing gum or candy, artificial saliva, con- trolled-release devices and specific plaque control programs to reduce bacterial burden. The National Foundation of Dentistry for the Handicapped and the American Society for Geriatric Dentistry encourage programs which address the needs of older individuals. They encourage dentists to consider the style of furniture, positioning of the patient, office lighting, staff assistance and other aspects of practice to improve the ease and comfort of the delivery of services to the older patient. Hearing and sight limitations have been acknow!edged in some dental disease prevention programs for the impaired older adult. The American Denal Association (ADA) is developing hospital protocols for twelve medical/surgical con- ditions, including head and neck radiation therapy, cardiovascular disorders, cancer chemotherapy and end-stage renal diseases. These protocols, will assist physicians and hospital-based dentists in understanding oral complications of diseases, why they are important and what to do about them. The Veterans Administration (VA) has established guidelines for the oral health of medically compromised patients in long-term care facilities to assist the health care team. The American Society of Hospital Pharmacists sponsors a project through affiliated state c&ptefs which distributes materials to educate older consumers on appropriate drug use and compliance. Similarly, the American Pharmaceutical Association, in collaboration with state pharmacy associations, has encour- aged the use of Medication and Self-Medication Awareness Tests and Health Check Test to de onstrate to older consumers the importance of having information about medicines and how to use them. i% "Share the Health", a National Pharmaceutical Council project provides education and T-8 istance for older adults regarding medication identification and purpose through "Operation Brown Bag". 3. Apparent Deficiencies More basic research and health professional education is needed to clarify the linkages among systemic conditions, medications and oral problems seen in o!der individuals. More health services research is needed to develop, evaluate and demonstrate ways to improve: 1) interaction among the dentist, B-6 physician, pharmacist and patient regarding health care, * 2) clinical applications of information on medical histories in the practices of dental and medical professionals; and 3) the routine updating of medical his- tories in the practices of health care providers; 4) oral health care of medically compromised patients in long-term care facilities. B. Orientation toward Oral Health and Oral Hygiene 1. Nature of Problem The importance attached to oral health is a key factor dete IF ining actual oral health status and the behaviors which influence its attainment among older adults. A range of attitudinal, behavioral and socioeconomic factors over a lifetime interact to form that orientation. In turn, these factors affect an individual's performance of oral hygiene practices, dental visit behaviors, and compliance with recommended regimens. Attitudes, knowledge and beliefs appear to have the dentally-related behaviors among older adults as they do among younger adults. gjrne correlations with As current middle- aged adults become older, it is assumed that they will keep appropriate levels of knowledge and attitudes thus creating a more informed older sector in the future. Perceived oral health status, as measured by the self-reported presence of conditions, has be investigated in several research projects and is often a key explanatory variable for visiting a dentist. 22 In a study of older rural Minnesota residents regarding perceived overall health status and presence of common health problems, dental (or denture) problems were frequently mentioned conditions along with vision problems, arthritis, hypertension and obesity. There were no differences in self-reported dental problems when the age group 60-74 was compared to that 75 and older. Other stu ws have shown that dental problems receive less mention than other chronic conditions of older persons. 4; ln a 1981 national survey, only 18 percent of dentate individuals age 65 and older--compared to 28 percent of younger adults-reported two or more oral problems (e.g. broken tooth, bleeding gums, sensitive to hot and cold, canker6sores, toothache, sensitive to sweets), while only 10 percent reported problems with chewing and biting. In a study of older Massachusetts health care panel study members, perceived need for care was best explained by perceived oral health status, dentate status and previous dental utilization. Age*ger se, was not significantly related to perceived need and socioeconomic indicators were not predictive. Perceived oral health status is not always a reflection of actual clinical conditions.45 47 48 For example, in a recent study of older patients scheduled for periodontal treatment `4'1p nly 18 percent were aware before arriving at the dental school that they had periodontal disease. In another study, it was estimated that 70 percent of older adults need treat "48 nt, 25-40 percent of older adults perceive that need, and 20-35 percent of older adults seek treatment. Lack af perceived need has been a primary reason for not seeking dental care. 8 24 53 55 62 63 64 Addi- tionally, a low re Al tive priority usually is assigned to dental care in comparison to other health and func- tional activities. Survey research indicates that the combination of perceived need and attitudes toward oral healqk gp d e is y as considerable predictive power in explaining the use of dental services by older adults. 6Q gi & 6l$ For example, in a sample of older individuals in senior centers in the Seattle area, those who attributed greater importance to oral health, believed they needed dental had more teeth, and had more positive dentally-related beliefs, were more likely to seek dental care. we7 Older Americans seem to be resigned to accepting their oral health status, yet express positive attitudes regarding oral health. Fifty seven percent of adults ages 65 to 74 believe nothing can be done to change oral health, while 70 percent of those age 75 and older believe this. Only 32 percent of older adults strongly agree that some people have good teeth and other have bad teeth no matter what they do, while 9 percent strongly agree that people lose their teeth anyway. The majority of dentate older individuals never expect to lose all of their teeth. It appears that if individuals reaches age 65 and if they have not lost their teeth already, they do not expect to. fied with the way their teeth look.6 Interestingly, 80 percent of dentate older adults are satis- As expected, most older individuals believe t a care is often too high; but, most indicate that cost of care is not a barrier for them, 8 i @e cost of dental B-7 Information regarding appropriate dentally-related behaviors may never have been learned or may change over time. Today's older people are more likely not to have been exposed to a preventive orientation early in life and/or may remember outdated information. Their early exposure to dentistry may have predated the acceptance of self-efficacy measures for oral health status. Older adults today have received a large amount of conflicting health information over a lifetime. Misinforma&n and confusion often discourages older persons from changing behaviors or seeking preventive services. The cognitive skills of older individuals as reflected by attention and recall may be somewhat diminished compared to younger individuals. This may require special attention to methods of communication, including message structuring, repetition and reinforcement, shorter limitations, active participation and multiple modes of presentation. ?f ssion length, information Research projects are demonstrating that established attitudes and beliefs can be altered or used to the advantage of oral health. For example, the generalized belief that people can take responsibility for their own health has been shown to be associated with reduction in plaque levels. Conversely, older persons who look to others for control and believe that dental prophylaxis &, important are more likely to avail themselves of diagnostic, preventive and therapeutic dental care. Orientation toward oral health is evident also in attitudes, knowledge and behaviors known to affect oral health status. Approximately three-fourths of older adults believe smoking increases risk of cancers in the throat-a lower proportion than in younger adults. Slightly over a third of older adults believe&avy drinking increases risks of mouth arid throat cancers, a higher percentage than adults of other ages. Health professionals may hold inappropriate beliefs which compound the problems faced by the older indi- vidual. For example, beliefs that older persons cannot learn, will forget quickly what il@.tEhtl that it is too late for them anyway may interfere with effective practitioner-patient interaction. Smce phys- icians have more contact with older adults than dentists, their attitudes toward oral health issues are important to monitor and change as appropriate. Social and psychological risks are not easily quantified, yet need serious consideration in understanding the promotion of oral health. Significant improvements in oral health may be achieved only when the gap need and perceived need-as reflected in numerous attitudinal variables--is 2. Mechanisms and Interventions Established to Deal With Problem Not only should dental practitioners understand normal and pathological aging, they also should have excellent interpersonal skills. Dental practice provides an opportunity to educate and change the attitudes of the patient through examination and communication. For example, when the dentist or dental hygienist cleans teeth, self-care can be discussed. Additionally, when dentists and other health 0";;; ,","Pl,`gai screen for oral cancer, they can educate patients on the relation of tobacco, alcohol and Precancerous lesions and conditions'predisposing to cancer that can be detected and treated early result in less mutilation and increased survival rates. Cognitive behavioral methods that emphasize a strategy of changing an individual's inaccurate beliefs are believed to be effective in oral health promotion. Educational and oral health promotion sessions can be conducted in private practice, but probably can reach more people, at lower cost, if provided in other settings, especially where older persons gather. It has been demonstrated that some preventive dental and educational sessions, in which motivation to %% hieve oral health is significantly enhanced with regular feedback, can be conducted by paraprofessionals. Oral health promotion to improve attitudes and change behaviors can relate to and build on the current lifestyle of the older individual. For example, research demonstrates that older people watch more telev- ie5;on~;;l~;~~~; ;;ews~~~rs regularly. In addition, their use of other media can be targeted and used Non-dental organizations that already have access to older adults can facili- tate changes in oral health attitudes and behaviors. The American Association of Retired Persons (AARP) and the American Red Cross work together to keep members informed regarding health B-8 ::.toy;; topics through -resource manuals, slide/tape programs and articles in publications. activities. &, these organizations have established demonstration projects to encourage health promotion Educational materiaIs to improve orientation toward oral conditions and appropriate self-care and professionally-provided services are available from several sources. Some of these are specific to older adults-emphasizing problems which are more prevalent in later years or prepared with the older person in mind, e.g. the use of large print. Others addressing general adult problems also are useful to older persons. The Federal gover ment , state public health departments, professional associations, and universities are active in producing oral health education audiovisual and print materials to be used with individuals or in community or institutional settings. Examples include `Keeping Your Smile in Later Years" (ADA brochure), radio spots on special care for older persons and "Prescription for Periodontal Health" (NIDR film). m May, 1987, as part of the Congressionally proclaimed "Older American Month", the ADA established a National Senior Smile Week. The theme was "A Healthy Smile Can Last a Lifetime" and the purpose of the campaign was to heighten awareness on the part of the general public of the importance of dental care and the availability of dental services for the older adult. The kit, provided to state and local dental societies, included a planning guide, program ideas, a slide and script for television, a cassette for radio and sample advertising copy, as well as posters and other visual aids. The effort was designed to encourage media, special community activities and dental practice programs. Communities were encouraged to work with pharmacists, hospitals, health fairs and nutritional counseling services. The pro- gram also encouraged the involvement of more dentists in the provision of appropriate care for older aduIts. This program will continue on an annual basis. The American Dents1 Hygienists Association (ADHA) has developed a national campaign-"A Beautiful Smile is AgelesstL-to increase older adults' access to oral health information and services. The nationai organization developed a `program &ifr for use in promoting oral health care that has been adopted by 349 local chapters of the organization. 3. Apparent Deficiencies The 1980s have shown an increase in efforts to improve attitudes and knowledge of oral health for older adults, yet the efforts have not been widespread, sustained or evaluated. Many have been demonstration projects at the local level. More directed efforts are needed to encourage: 1) positive attitudes regarding the oral health of older persons on the part of both the health practitioners and the public; 2) educational materials for older dentate individuals; 3) education on lifestyle including the oral implications of tobacco use, alcohol consumption and polypharmacy. C, Oral Hygiene Behaviors 1. Nature of Problem Appropriate toothbrushing with fluoride toothpaste, interdental cleaning and rinsing with fluorides or antimicrobial products are useful methods to keep the oral cavity clean to prevent caries and periodontal diseases. In addition to preventing further oral disease, appropriate oral hygiene behaviors can result in improved physiological and psychological wellbeing. Plaque retention is a major problem in older adults, exacerbated by existing restorations, rough root surface topology, and inability to brush correctly. Diminished manual dexterity, in addition to more severe functional limitations associated with serious conditions frequently seen in older persons--such abilities to use a toothbrush and interdental devices. 2f s stroke, arthritis, Parkinson's disease-decrease Also, the motivation to prevent diseases and learn ~g$yIi?l ques may be less than for a younger adult, and for some people, self-care may not be physically . Most (70%) dentate older Americans believe that brushing is the most iv ortant preventive measure for dental problems. This is reflected in their dentally-related behaviors. The great majority (88%) of B-V deptate older adults report brushing at least once a day-front and back of teeth and over one fourth (27%) of older dentate individuals report flossing at least four lmes a week. Frequent snacking h reported by less than one third (30%) of adults, age 65 and older. 8' Wh'l over two-thirds of dentate older adults report using a fluoride dentifrice. 620 less than for younger adults, 2. Mechanisms and interventions Established to Deal With Problem Availability of appropriate oral hygiene aids, instruction on how to use them and continuation of lifetime oral hygiene activities address this issue. These may be accomplished through maintenance of activities from younger ages or established through special training sessions. Physical limitations of certain older adults may require oral hygiene measures such as fluoride and antimicrobial rinses. Also, toothbrushes and other oral hygiene aids are being developed with better`grips and other specifications to improve ability to clean the entire oral cavity. The VA has developed an oral hygiene in-service manual which has been used since 1985. It is provided to nursing unit administrators and is designed for periodic updating. Additionally, hands-on in-service training is offered. Researchers at the University of Washington have demonstrated, using several different groups of older individuals, that oral hygie 31 e can be improved and maintained through behavior management based on contingency reinforcement. Research suggests that older persons benefit most from a combin program of regular oral examinations by a dentist and interactive educational sessions for home care. 59 An interactive educational approach with a self-management focus can improve oral health by increasing the individual's personal responsibility for health, perception of general health and self-esteem. A focus on 1) prevention of further disease, 2) control of iatrogenic disease, 3) prescribed regimens for medical conditions, 4) maximizatio3p f oral functions, such as mastication and speech, has been successful in these educational sessions. Trained paraprofessionals and peers have been used to instruct older individuals using such behavioral techniques. A combination of traditional educational booklets, videotapes, modeling, one-on-one interaction with the instructor, self-monitoring, reporting and refining of home-care behaviors and repetitive interventions have resulted in better plaque scores over time as well as improvements in25dental behaviors, perceived overall health, morale and beliefs about the importance of oral health. Demonstration projects with older persons are in place in several major communities, for example, an `Elders Take Charge' program in Denver. Such programs need to be identified and oral health education and training should be incorporated into these general health efforts. Commercial manufacturing can encourage oral hygiene behaviors through advertising of products. 3. $pparent Deficiencies The importance of oral hygiene for all ages needs to be emphasized more by dental and medical personnel and the media. Other forums which have ready access to older people, e.g., retirement homes, consumer advocacy groups, Visiting Nurses Association, could be encouraged to promote oral hygiene. For those people for whom self-care is not possible, caretakers who provide necessary oral health regimens are essential. The lack of acceptance by caretakers of this responsibility is a glaring deficiency. D. Professionally-Provided Dental Care 1. Nature of Problem Use of dental services has increased over the past two decades among older adults.50 51 The percent of lder visiting a dentist during the past year increased from 21 percent in 1964 The 1983 data show that older people have an average of 1.5 visits to the B - 10 dentist during the past yef[, in contrast to 2.0 visits for those age 45-64. never been to the dentist and Less than one percent ha85 38 percent have received no dental services in the past five years. Only 31 percent of older adults, 75 years of age and older, have been to the dentist during the past year. Older white individuals ar about twice as likely to have gone to a dentist during the past year than black individuals (40% VS. 19%) f0 As i sd he case among younger adults, having a dental visit during the past year js directly related to income. It appears that the dental visit pattern of the dentate older person is very $T#aq;tg2the younger adult, while it is the edentulous older adult who is less likely to visit the dentist. Over one-half of dentate older Americans reported visiting the dentis\Sdurmg- the past 12 months in 1983, compared to approximately IO percent of edentulous older adults. Slmrlar data af& reported from the 1986 NIDR National Survey of Oral Health in the U.S. Employed Adults and Seniors. At the other extreme, in 1986 two-thirds of edentulous older adults reported that it had been three years or longer since they we t to a dentist, while only 19-20 percent of the younger adults or dentate older adults had this visit 32 pattern. Reasons for visiting a dentist are similar for younger adults and dentate o de 6 16 !!!I ults, with `prevention and checkup' being the primary reason followed by `something being wrong'. Edentulous oldfb el#g cite `something wrong' or `prosthodontic care' as the reason for their most recent dental visit. Some evidence suggests that level of education influences the reason for visit more than does the number of visits e-r er se. As with younger adults, older a$u@ are more likely to give no need (dentate) or no teeth (edentulous as reasons for not visiting a dentist. Most older individuals report having reasonable access to a dentist, yet, access to care is not easy for some older adults, particularly frail and medically compromised individuals. Access problems may include actual availability of dentists, perceived barriers to medical care, immobility, i % at ion, problems with meeting expenses, functional impairments or the need for assistance in daily living. The evidence of the extent to which finances and isolation are problems is inconsistent. For example, the best predictors of the use of dental services in a study of older individuals in Massachusetts were presence of teeth and perceived need for care. Once these people reached age 75, dentate status a perceived need outweighed education and liquid assets in differentiating a dental user from nonuser. `4i! Income and other socioeconomic variables appear to be associated with the priority and relative value attached to oral health. These priorities and preferences (relative values) develop from many sociocultural influences which occur over a lifetime and are not overcome by provision of money, per se. Expenditures for dental services as well as utilization of dental services and oral hygiene behaviors among older persons traditionally are reported to be less than for younger adults. Absence of visits and lower levels of oral hygiene behaviors have been shown to be related to social and economic factors--such as lower level of education, rural residence, and inability to pay-which are characteristics common among older ad&s. Some research has demonstrated that Medicaid, reduced-fee and free care have not increased use of dental services in a t ay; yet little was done in analysis to differentiate dentate and edentulous older persons. lY6TiF!P&% n g-oT;, g&get6 `itB t dental visits and expenditures among dentate older adults are similar to . Historically, the large percent of older adults who were edentulous appears to be associated with the lower expenditure and visit level. With an increasing number of dentate older adults, the issue of finances may need special consideration. With the need for complex restorations and the lack of insurance, the influence of cost of care among the older person may be considerable. Having a regular source of care is highly correlated with the use of preventive health services. In fact, having a regular source of care may predict the use of preventive dental serv'c 6 74 far better than do perceived need, enabling or predisposing characteristics of older individuals. While preventive services are generally less expensive than are restorative services, the absence of insurance or prepayment for most older individuals or the failure of may4 reimbursement systems to acknowledge pre- ventive services may create a barrier for their regular use. B - 11 2. Mechanisms and Interventions Established to Deal With Problem Improvements in financial capabilities, such as availability of dental insurance and reduced-fee program5 address this problem for older adults. The ADA is working actively to encourage the coverage of dental care in Medicare and is encouraging corporations and insurance companies to extend dental benefits to retired and older Americans. National and local efforts established to improve access for older adults who have financial, disability, 01 geographical barriers to dental care address this issue. For example, during the late 1970's, the ADA and its constituent and component societies began a directed effort to improve the use of appropriate dental services by addressing the issues of convenience and available r E ources in Prevention and Control of Dental Disease Through Improved Access to Comprehensive Care. Through this program, over 119 state and local dental societies provide a toll-free number for referrals to local dentists. Seventy percent of the programs offer a full range of dental services, nine percent denture services only. Over 70 percent of- the programs are directed toward older adults and over 80 percent are reduced fee py5grams. Transport- ation or portable equipment are available through 10 percent of the access programs. In 1988, the ADA plans to encourage the component and constituent societies to re-emphasize the access programs, Additionally, the ADA contributes funds to help sustain the activities of the National Foundation of Dentistry for the Handicapped and endorses the dental degree program--Disabled Dental Services- promoted by the Association of Geriatric Dentistry. Through the ADHAs nationwide geriatric outreach project--"A Beautiful Smile is Ageless"--nygienists- work on a voluntary basis in oral health care programs. The programs provide dental screening and on- site visits to long-term care facilities, senior group settings and individual homes. Improving access to residents of nursing homes has been an objective of other projects. As part of their teaching programs, some dental schools work with nursing homes. Many provide slide/tape materials tom assist nurses in looking for oral health problems in patients, health education materials for patients and preventive treatment prescriptions along with a recall program for residents. Some dentists throughout the United States have begun to provide care to homebound an& institutionalized older Americans. Using vans furnished with portable dental equipment, dentists carr screen a large number of older individuals and provide appropriate care to those who need it. These dentists, working with nursing home administrations, coopera t ingl s ith caretakers and attending to records, are making the provision of services in institutions a reality. 3. Apparent Deficiencies Except for the VA, most of the programs mentioned above have been developed on a local and voluntary basis, resulting in inconsistent availability of care for many older adults. More directed efforts are neede,d to assure adequate oral health care for indigent, institutionalized and homebound older adults. Few programs exist in combination with non-dental organizations, e.g. Visiting Nursing Association. Con- tinued effotts are needed to encourage payment assistance, e.g. dental insurance or Medicare for retired adults, as well as reduced-fee programs or improved medicaid for dental services for those unable to pay. Much of the dental care system, as it exists today, is passive-individuals must seek out care. Some efforts have been made to accommodate the service delivery system to the needs of the older adults, but- more consistent attention needs to be given to reaching out and meeting needs where they exist- community, senior centers, nursing homes or individual residences. E. Oral Health of the Edentulous 1. Nature of the Problem Edentulousness, while decreasing in the overall older population, is highly associated with level of education. Beyond this, its prevalence among older people reflects a predominant form of dental practice and patient expectation that existed when these people were younger. To continue the decrease in- B - 12 edentuloUnesS, individuals must perceive the value of retaining their teeth. Also, dentists, as well as other health care prOfeSSiOnalS, must encourage and reinforce the value of retention of teeth. Appropriate oral health care changes after an individual receives dentUres.6 24 Self-care usually involves cleaning dentures to prevent bad breath and oral infections as well as to preserve healthy tissues for denture Support- Regular visits to the dentist are important for instruction on appropriate home care, detection of soft tissue lesions, refityfg of dentures to accommodate changing bone structure and repairing ill-fitting or broken dentures. Although approximately 3 million denture wearers experience denture retention problems because of alveolar ridge deterioration, dental visits after receipt 0f6c&tures are low, on average. Most denture wearers believe that they need never again g0 to the dentist. 2, Mechanisms and Interventions Established to Deal with Problem Professionally-developed educational tools as well as mass media have been used to encourage denture wearers to maintain adequate oral hygiene and to visit the dentist regularly. The ADA Access Program encourages denture wearers to visit the dentist regularly at reduced fees. 3. Apparent Deficiencies Even with a decreasing proportion of edentulousness in the older population, the number of denture wearers will remain substantial and increased efForts to improve the oral health of these individuals are needed. Efforts to educate denture wearers must counter a strongly held traditional belief that routine dental care is not needed. F. Professional Training for Research, Teaching and Patient Care 1. Nature of Problem Evidence suggests that dental, medical, pharmacy, and gerontology professionals have ac