June 2018

Vol. 45   No. 6

 Cover Story



The Many Shades of Boomer Healthhttps://www.providermagazine.com/Issues/2018/June/Pages/The-Many-Shades-of-Boomer-Health.aspxThe Many Shades of Boomer Health<div>​​</div><div>Baby boomers have often been defined by the social changes they have launched, including political engagement and protests. The generation—usually defined as those born in the United States between 1946 and 1964—also is often associated with greater sexual expression, experimentation with drugs, and environmental concerns.</div><div> <br>Now, this generation that once chanted, “Don’t trust anyone over 30,” is turning 60 … and 70, and as they age, they are bringing clinical care needs, strong opinions, <a href="/Issues/2018/June/Pages/Financial-Frets-and-Boomer-Bank-Accounts.aspx" target="_blank" title="Financial Frets and Boomer Back Accounts">financial issues,​</a> and family dynamics that will pose challenges for facilities.</div><div> <br>Understanding what it means to be an aging boomer is essential for long term and post-acute care (LT/PAC) providers to position themselves to care and advocate for this population.</div><h2 class="ms-rteElement-H2">Boomers and Health</h2><div>As boomers age, providers will see many of the same illnesses and conditions they currently manage. For instance, Mike Wasserman, MD, CMD, geriatrician, and chief executive officer of Rockport Healthcare Services in Los Angeles, says, “Because of the societal increase in diabetes, this will continue to be an important issue.”</div><div> <br> <img src="/Issues/2018/June/PublishingImages/Brubaker.jpg" alt="J. Kenneth Brubaker" class="ms-rtePosition-1" style="margin:5px 15px;" />A related concern, says J. Kenneth Brubaker, MD, CMD, medical director of Masonic Villages in Elizabethtown, Pa., is obesity. “We are seeing more obese patients. And in addition to diabetes, they often have heart disease, strokes, early-onset dementia, and vascular problems.” These problems include peripheral vascular disease, diseases of the blood vessels outside the heart and brain, and vascular dementia, a common form of dementia caused by an impaired supply of blood to the brain.</div><div> <br>“We also will continue to see an increase in Alzheimer’s disease and dementia,” Wasserman says. “In fact, this may be the single-most important disease state in relation to its impact on society as the boomers age.”</div><h2 class="ms-rteElement-H2">The Alzheimer’s Issue</h2><div>Alan Horowitz, RN, a health care attorney with Arnall Golden Gregory, agrees. “By mid-century—according to the Alzheimer’s Association—someone in the U.S. is expected to develop Alzheimer’s disease every 33 seconds. Therefore, one of the biggest challenges for the industry will be caring for the increasing number of people with dementia,” he says.</div><div> <br>A related concern to the growing rate of Alzheimer’s, says Horowitz, is sexuality in the context of cognitive impairment. “Some people with Alzheimer’s disease or other forms of dementia become hypersexual, and many boomers who lived through the summer of love had more relaxed attitudes about sex,” he says. “Hardly a week goes by where someone from a skilled nursing facility doesn’t ask me about sexuality and dementia.”</div><div> <br>It is important for providers to recognize that merely because a resident has Alzheimer’s disease or another form of dementia, that doesn’t necessarily mean that he or she lacks the decision-making capacity to be sexually active, Horowitz says. “Consequently, the growing challenge for providers is to strike the appropriate balance between respecting resident rights and protecting and promoting resident safety.”</div><div> <br>An interesting trend, according to a recent study in the Journal of Gerontology, is that people seem to be developing dementia later and living with the illness for a shorter period of time. The authors suggest a possible connection between the later development of dementia and better prevention and care of stroke, a major risk factor for dementia. At any rate, this will be a trend worth watching as boomers age.</div><h2 class="ms-rteElement-H2">Patients with HIV/AIDS</h2><div>The human immunodeficiency virus (HIV) is off of most people’s radar screens, says David Nace, MD, MPH, director of long term care and influenza programs in the Division of Geriatric Medicine at the University of Pittsburgh, but it is a real issue and a concern as boomers age.</div><div> <br>“Patients with HIV and AIDS [acquired immune deficiency syndrome] are living longer, and we will start to see more of these patients in post-acute and long term care,” he says. “This illness will pose significant challenges because of the cost and complexity of its care.”</div><div> <br>At the least, he says, facilities should connect with practitioners—such as attending physicians, nurse practitioners, and pharmacists—who have full knowledge of HIV/AIDS medications. Access to an HIV/AIDS specialist would be ideal.</div><div> <br> <img src="/Issues/2018/June/PublishingImages/Nace.jpg" alt="David Nace, MD" class="ms-rtePosition-2" style="margin:5px 10px;" />“People today are more comfortable talking about HIV/AIDS, and society’s perceptions about the disease are changing,” says Nace. However, he suggests that facilities plan for how they will accommodate HIV/AIDS patients. “This can be a struggle,” he says. “There are about 700 nursing homes in Pennsylvania, but not every one will be comfortable managing patients with HIV/AIDS. This is no longer a primary care disease, and not every practitioner or caregiver will have the skills necessary to care for these patients.”</div><div> <br>HIV/AIDS patients present two challenges, Nace says. One is management of the disease itself, which requires specific medical competencies. The second is cultural, which requires facilitywide knowledge (versus lingering myths and misunderstandings) and acceptance. He urges facilities to make use of community resources, where they are available. </div><div> <br>Facilities in more rural or suburban areas may have less access to support. However, Nace suggests some creative solutions. For instance, perhaps they can “share” an HIV/AIDS specialist in the region with other facilities or connect with clinical experts via telemedicine. <br></div><h2 class="ms-rteElement-H2">The HCV Factor</h2><div>According to the Centers for Disease Control & Prevention (CDC), baby boomers are five times more likely to have <a href="/Issues/2018/June/Pages/A-Conversation-with-an-HCV-Specialist.aspx" target="_blank" title="A Conversation with an HCV Specialist">hepatitis C virus</a> (HCV) than other adults. Most boomers, CDC says, likely became infected in the 1960s through 1980s when HCV transmission was highest. Many people with this disease, which can lead to liver damage, cirrhosis, and possibly liver cancer, don’t even know they are infected. This is possible because people with HCV may have the disease for many years without experiencing any symptoms. </div><div> <br>There is no clear reason why HCV is more prevalent in baby boomers. According to CDC, this population may have been infected by medical equipment or procedures from before the time of universal precautions and infection control procedures. </div><div> <br>Others may have been infected by contaminated blood and blood products or sharing needles or equipment used to inject drugs. Whatever the reasons, the disease—and its management—should be a concern of LT/PAC providers and practitioners. </div><div> <br>John Poterucha, MD, a gastroenterologist and professor of medicine at the Mayo Clinic, echoes this urgency. “Liver disease is the ninth-most common cause of death, and liver cancer is on the rise,” he says. </div><div> <br>“One reason for this is that there are more patients with chronic liver disease and cirrhosis. Most of the time, HCV doesn’t cause symptoms until the patient gets cirrhosis and symptoms related to that. At that point, it may be too late to do anything.” </div><div>When symptoms do appear, they include:</div><ul><li>Bleeding and/or bruising easily; </li><li>Fatigue; </li><li>Poor appetite; </li><li>Yellow discoloration of the skin and eyes (jaundice); </li><li>Dark-colored urine; </li><li>Itchy skin; </li><li>Fluid buildup in the abdomen (ascites); </li><li>Swelling in the legs; </li><li>Weight loss; </li><li>Confusion, drowsiness, and slurred speech; and </li><li>Spider-like blood vessels on the skin.</li></ul><div>Chronic HCV starts with an acute phase. However, this often goes undiagnosed because it rarely causes symptoms. When it does, these may include jaundice, fatigue, nausea, fever, and muscle aches. Acute symptoms appear one to three months after someone is exposed to the virus and may last up to three months.</div><div> <br>The good news is that some people clear the virus from their bodies after the acute phase and don’t develop chronic HCV. Up to 50 percent of people with acute HCV may clear the virus, and most respond well to antiviral therapy.</div><h2 class="ms-rteElement-H2">How to Proceed</h2><div>CDC recommends that baby boomers get tested for HCV. Specifically, a blood test called the HCV antibody test can determine if a person has ever been infected with the HCV virus. There are two possible antibody test results:</div><ul><li>Nonreactive, or negative. This means the person doesn’t have HCV. However, if someone has been recently exposed to the HCV virus, he or she will need to be tested again. </li><li>Reactive, or positive. This means that HCV antibodies were found in the blood and the person has been infected with the HCV virus at some point. A reactive test doesn’t necessarily mean the person has HCV. Even if he or she has cleared the HCV virus, the individual’s blood will always have the antibodies.</li></ul><div>If a test is reactive, additional blood tests will be necessary to measure the quantity of the HCV in the blood, or the viral load, and identify the genotype of the virus. The most common genotype in North America and Europe is called Type 1. While the illness follows a similar course regardless of the genotype, this determination will impact treatment recommendations. </div><div> <br> </div><div>If a patient is diagnosed with chronic HCV, the practitioner likely will want to assess liver damage. This involves one or more tests, including:</div><ul><li>Magnetic resonance elastography (MRE), a noninvasive alternative to a liver biopsy; </li><li>Transient elastography, a type of ultrasound; or </li><li>Liver biopsy, typically done using ultrasound guidance and inserting a thin needle through the abdominal wall to get a liver tissue sample.</li></ul><h2 class="ms-rteElement-H2">Treatment Options</h2><div>HCV is treated with antiviral medications designed to clear the virus from the body. Researchers have made significant advances in HCV treatment over the years, and newer drug therapies enable better outcomes, fewer side effects, and shorter treatment times (some as little as eight weeks).</div><div> <br> <img src="/Issues/2018/June/PublishingImages/Poterucha.jpg" alt="John Poterucha, MD" class="ms-rtePosition-1" style="margin:5px 15px;" />These newer medications have been proven highly effective, says Poterucha, with a clearance rate of up to 99 percent. While effective and generally well tolerated, they also may come with a hefty price tag, which can be an issue for some patients. </div><div> <br>In instances where there are serious complications from chronic HCV, liver transplantation might be an option, although this is unlikely to be a viable intervention for older patients. The physician will work with each person (and family members, as appropriate) to choose the best, most cost-effective treatment plan.</div><div>Unfortunately, liver disease isn’t limited to HCV, and illnesses such as alcoholic liver disease and non-alcoholic fatty liver disease are harder to treat. “In the general population, 25 to 30 percent of people have fat in the liver, and a subset of these will develop cirrhosis,” says Poterucha. Risk factors include obesity, high triglycerides/lipids in the blood, and diabetes. However, he says, “Because we’re better at treating all of these conditions, we’re seeing people with liver disease living longer.”</div><div> <br>As more boomers enter LT/PAC centers, it will be beneficial to determine if they have a diagnosis of or are at risk for HCV or other liver disease. Poterucha suggests taking a symptom inventory and finding out if they have had HCV testing and, if so, what the results were. If the patient has symptoms of liver disease, testing may be advisable.</div><div> <br>Any diagnosis of HCV or other liver disease should be addressed in the care plan. “For the most part, there is not much we can do if a patient has advanced disease, and expensive treatments wouldn’t be advisable,” Poterucha says. However, symptom management and comfort care, including addressing fluid retention, are viable goals for these patients, he says.</div><div> <br> </div><h2 class="ms-rteElement-H2">Alternative Therapy Aficionados </h2><div>Baby boomers grew up in an era of experimentation, health food stores, and holistic treatments, so it’s only natural that many will want access to some of these in LT/PAC. One of the greatest challenges this represents for care centers is a demand for medical marijuana.</div><div> <br>“To date, 46 states, the District of Columbia, Puerto Rico, and Guam have legalized medical marijuana, and facilities are struggling with the question of how to address residents’ desire to access this unorthodox form of therapy, while not running afoul of federal laws,” says Horowitz.</div><div> <br>While medical marijuana is legal in most states, it remains illegal under the federal Controlled Substances Act, so facilities face a dilemma regarding a host of issues. As more boomers enter this care setting, says Horowitz, “Facilities would be wise to have policies and procedures so that staff fully understand what is and is not permitted regarding medical marijuana.”</div><div> <br>Geriatricians tend to be more holistic to begin with, says Wasserman. “We’re attuned to ways we can help patients beyond traditional medicine.” For instance, he says, “If I can get people to start exercising regularly, I can usually stop at least one medication.” He is seeing positive lifestyle trends in boomers. </div><div> <br>“They see the value of exercise, healthy diets, and lifestyle changes such as drinking less and not smoking,” he says. At the same time, they are utilizing massage, acupuncture, meditation, and chiropractic care as part of their health care regimens.</div><div><h2 class="ms-rteElement-H2">The Geriatrics Approach to Care </h2></div><div>Even as the population has aged, most medical research still hasn’t involved elders. As a result, says Wasserman, “We’re still operating without a net. We have physicians using new and expensive treatments on a patient population they haven’t been tested on—older adults. When you use procedures, tests, and devices on a 90-year-old that were tested on 50-year-olds, we shouldn’t be surprised when they don’t have the same outcomes,” he says. “We need to go back to the geriatrics approach.” </div><div> <br>For instance, he says he had an 88-year-old patient who was being aggressively treated for prostate cancer. The patient was weak and hospitalized. </div><div> <br>“I know that patients over 80 rarely die from prostate cancer, so I took him off the cancer treatment and put him on testosterone. He was able to get out of the hospital and feel better,” Wasserman says. “This year, my two-year-old grandson, Bailey, and I joined that patient to celebrate his 100th birthday.</div><div> <br>“If we want to do a better job for baby boomers, we need to talk more about the geriatrics approach to care and teach it to our students.” </div><div> <br>This requires a change from “a society where there is a push to use every treatment, medication, and intervention possible, even when there is no basis for them or when they don’t consider the patient’s goals,” he says. “This could be one reason we are seeing the average life expectancy stagnating.”</div><div> <br>Advance care planning will be hugely important with boomers, says Wasserman, and this comes back to how physicians are trained to care for older patients. “Most don’t know how to have these discussions,” he says. Wasserman says he asks his older patients: “What do you think of this statement: No aggressive treatment if poor quality of life is expected?” Ninety percent of the time they will agree, he says. </div><div> <br>While there are many forms and tools patients and families can use to help support and document end-of-life planning conversations, Wasserman says that those tools are no substitute for one-on-one conversations with the clinician. “For advance directives to have meaning, it is critical for the clinician to be able to have person-centered care discussions with his or her patients.”</div><h2 class="ms-rteElement-H2">The Boomer Niche</h2><div>While baby boomers are still a few years away from descending on long term care en masse, seniors housing organizations are already appealing to them. </div><div> <br>For example, Latitude Margaritaville, inspired by singer-songwriter Jimmy Buffett, is advertising planned communities featuring recreation, dining, and live entertainment aimed at boomers. As boomers age and have illnesses that require short- or long-stay care, LT/PAC providers may consider offering services that appeal to them.</div><div> <br>“There is a benefit to specializing in boomer care,” Horowitz says. In addition to memory care and other specialized units, boomer-oriented facilities may want to consider providing access to alternative therapies and holistic medicine, as well as various emerging technologies. </div><div> <br>“Even older boomers are very computer-savvy, counting on email, social media, Skyping, and other technology to stay in touch with family and friends,” Horowitz says. “They have laptops, tablets, and cell phones. At the very least, they will demand easy access to Wi-Fi.” At the same time, he notes, boomers and their families increasingly will be attracted by settings that offer cutting-edge technology that will enable <a href="/Issues/2018/June/Pages/Becoming-Like-Dad-and-Mom-Another-Perspective.aspx" target="_blank" title="Becoming Like Dad and Mom">mom or dad</a> to stay safe and remain as high-functioning for as long as possible. This might include wearable remote monitoring devices and sensors, GPS and other devices to prevent wandering, telemedicine capabilities, and interactive TV computers.</div><div> <br>Facilities need to consider what services boomers might want and address these services on admission. </div><div>For instance, Horowitz says, “If a person likes and has responded well to aromatherapy or acupuncture, which may not covered, you should discuss on admission if they want to continue such services and how they will pay for them. Admission conversations about what is and isn’t covered should be expanded to address some of the services that boomers are most likely to want.” </div><div> <br>Therefore, it is important to provide the family with a written list of covered services, as is generally required. </div><div> <br>“It’s an emotional time, and people may not retain everything they’re told on admission, so putting it in writing is a practical and easy way to itemize what the facility offers and what costs, if any, a resident or the family may have to bear.”</div><h2 class="ms-rteElement-H2">When it’s Time for Skilled Care</h2><div>Providers can help boomers and their families understand the benefits of skilled nursing centers and why or when they might be the right choice.</div><div> <br> <img src="/Issues/2018/June/PublishingImages/Wasserman.jpg" alt="Wasserman" class="ms-rtePosition-2" style="margin:10px 15px;" />“Across the country, the mood is toward keeping people out of nursing homes. People want to stay in their homes, and their families want that as well—partly because nursing home care is expensive and they think that community-based care will be more cost-effective,” says Brubaker. “We need to engage families and help them understand why it may not be safe for mom or dad to stay in their home.” </div><div> <br>Wasserman adds, “There seems to be this idea circulating that we don’t need nursing homes and that everything should happen at home. The reality is that many nursing home residents enjoy increased socialization, more structure, and the ability to get their needs met by qualified professionals who care deeply about their well-being. They actually are quite happy.”</div><div> <br>With boomers aging and becoming the new LT/PAC patients, he says, “This is the perfect moment to focus on this care setting and what it should be as we move into this new era.” </div><div> </div><div> <em>Joanne Kaldy is a freelance writer and communications consultant based in Harrisburg, Pa.</em></div> ​Baby boomers—usually defined as those born in the United States between 1946 and 1964—are often associated with greater sexual expression, experimentation with drugs, and environmental concerns.2018-06-01T04:00:00Z<img alt="" src="/Issues/2018/June/PublishingImages/coverstory_t.jpg" style="BORDER:0px solid;" />Caregiving;Management

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