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When it comes to public health, seniors really are different

September 1, 2007
by Paul R. Willging, PhD
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Public health can be broadly defined, and many of its facets are of equal importance to the entire population. But when dealing with the health of seniors, it is risky to assume that one can always extrapolate from younger populations. Indeed, one can plausibly argue that many of the needs of older adults in the public health arena are unique. Consequently, there is a real disconnect between the special needs of seniors and existing public health guidelines, which often do not speak to those needs.

Geriatric issues differ from the challenges facing other population groups. Geriatric issues include frailty, incontinence, the peculiar needs of homebound and cognitively impaired older adults, polypharmacy and adherence to medication, and care plans for those with multiple comorbid conditions (with or without cognitive impairment). And even geriatric approaches to issues relevant to younger age groups (e.g., physical activity for those with health problems or disability, screening for chronic disease) must be modified when substantial subclinical disease or risk (such as in a disaster) exist. More about that later.

Several aspects of aging make seniors more susceptible to the same illnesses and hazards that threaten all of us. Aging is characterized by “a gradual deterioration in function and the capacity of the body's homeostatic systems to respond to environmental stresses” (Vander, Sherman, and Luciano, Human Physiology: The Mechanisms of Body Function, 1990). It is reflected in the diminution of an individual's physical, psychological, and/or social reserves.

This diminution of reserves poses special risks for seniors, regardless of where they call home. Certainly, long-term care is as uniquely cognizant of the different needs of seniors as is any cohort of healthcare professionals. But even we need to recognize that what traditionally seems to work for one subset of seniors (much less the population as a whole) might not work for all.

Any reputable public health system will establish screening and prevention programs to protect residents from contagious diseases. But even here, that system cannot—when it comes to seniors—simply mimic what works for other population cohorts. Rather, it needs to be oriented toward chronic conditions rather than acute care episodes. And it needs to be oriented as much toward quality of life as quality of care.

Even the relative importance of primary, secondary, and tertiary prevention differentiates seniors from younger population groups, with a considerably greater emphasis on the secondary and tertiary aspects than on the primary. Seniors are different. But seniors themselves present a heterogeneous group. A part of that heterogeneity lies in the fact that all seniors can be found somewhere on a frailty curve, one that ranges from extremely robust to extremely dependent. Movement along that curve will be manifested in differing levels of disability, frailty, and cognitive impairment. In other words, while seniors as a group present their own particular spectrum of public health needs, they also represent an incredible variety of need within the group.

So, why am I giving this primer to those who work with seniors, day in and day out, in a healthcare environment? Because so many of our communities are housed in urban environments where the needs of seniors have been all but ignored. And you can't ignore your environment. It will come back to haunt you. Yes, we know that seniors are different. In that regard, we are uniquely positioned to address their peculiar needs. But when it comes to the cities in which we operate and the public health systems they employ, the elderly are seen simply as 40-year-olds with wrinkles.

We do not have public health guidelines that speak to the particular needs of seniors. The majority of public health guidelines that do exist are primarily focused on increasing positive health behaviors, such as physical activity, in those who are still reasonably healthy.

Now, couple the unique needs of seniors and their increasing numbers (the so-called “silver tsunami”) and their convergence with an equally powerful social phenomenon—increasing urbanization. And bear in mind how little planning, of any type, has been devoted to their intersection. Clearly, we need a focus on geriatric public health issues and guidelines, particularly within the urban environment. We need a “blueprint” on relevant standards of practice for seniors. And we need a blueprint that lends itself to timely implementation.

Let's apply this concept to an issue of increasing interest, at least to me: seniors and crisis management. (And, following Hurricanes Katrina and Rita, that issue should be of equal interest to you, as well.) When environmental catastrophe strikes, the typical urban public health infrastructure is unprepared to deal with the general population—forget seniors. And for that reason, seniors suffer disproportionately from the effects of such disasters. One can look to countless examples other than Katrina, many from equally recent history. Look, for example, at the devastating heat waves that struck Chicago in 1995 and Paris in 2003.

A disproportionate number of Chicago's senior residents died or suffered significant health problems during the 1995 heat wave, primarily because they didn't have the respiratory or circulatory ability to fight off the heat (nor a public health system designed to help them through the crisis).