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October 2001
Volume 65 |
Number 10
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| The
‘Age Wave’: America’s Tsunami of the Future? |
Robert
W. Vaughan, M.D
The major trend of U.S. health care has already happened. It
is “silver,” driven by the dramatic, dominant demographic
trend in American society toward a gerontocracy.1
Moreover, in modernized countries, longevity is occurring with
its resultant socioeconomic consequences. For example, the average
life expectancy in Japan has vaulted to one of the highest in
the world: 83 years for women and 76 for men. 1
In addition, while citizens are living longer, fertility rates
in the United States, Europe, Japan and other modernized nations
are dropping. Most have fallen below minimum replacement levels.
As citizens of a country become more educated and financially
secure, increasing numbers of women pursue nondomestic careers,
and the fertility rate plummets. An exception exists: Because
of a more open immigration policy, the United States is unique
among developed countries in maintaining a replacement fertility
rate.
Nevertheless, we too are growing older as a nation and are poised
on the cusp of a senior boom within a decade. Therefore, it seems
prudent for anesthesiology leaders in community and academic practice
to identify the implications of the major trend of the American
age wave and help create new systems of care delivery (i.e., eldercare).
Definition and Perspective
This paper will define what we mean by the “age wave,”
provide a historical perspective of the political journey from
elderly poverty to more economic security for older citizens today
and reflect on how an aging population might transform anesthesia
practice and the medical specialty of anesthesiology. In addition,
data will be presented on the accelerating shift from inpatient
to outpatient anesthesia, the internal shift in ambulatory surgery
toward office-based procedures, and it will conclude with why
a new eighth subspecialty of geriatric anesthesia is right on
target for the future.
There is good news: We have some time to adjust and help reinvent
the U.S. health care system to accommodate the special needs of
the growing senior population. First, let us define the term,
“age wave.” The U.S. age wave results from the convergence
of three separate and unprecedented demographic phenomena that
never have occurred before in world history [Figure
1]. First, the senior boom of longevity produced by lifestyle
changes and applied medical technology is joined by a second trend,
reduced fertility rate. Consequently, our greater population of
elders is not offset or diluted by a high birth rate as would
have occurred in the past. The above two trends are further supercharged
by a third factor, the aging of the post-World War II baby boom
cohort. 2
ASA, like representatives of all specialties of medicine, has
the lead-time to begin to actively address the most pervasive
“tsunami” in American society — the age wave. The
oldest members of the baby boomers (the cohort of 78 million born
between 1946-64) will not turn 65 until 2011. Although the American
population is graying, presently it is aging quite slowly. With
this dominant and unstoppable demographic trend over the next
two to three decades, however, U.S. health care faces, for the
first time in human history, an unusual crises of success: longevity
[Figure
2].
Why is this trend so unusual? Because during 99 percent of the
time that human beings have spent on earth, the average life expectancy
was 18 years. 1 Populations did not age because
of early deaths from accidents, trauma, infectious disease, polluted
water, poor sanitation, violence and natural disasters. Old age,
with the quite rare exception, was uncommon. Certainly there was
no need for Social Security or Medicare. It was not until the
early 20th century that American voters felt that elderly poverty
was becoming a major social problem for a majority of families
during the Great Depression (1920s-30s). Social Security was enacted
in 1935 as a safety net to provide a monthly income to rescue
persons 65 years of age from poverty. Subsequently during World
War II, pension plans by employers were made tax deductible to
serve as incentives to save and provide a necessary supplement
to a worker’s Social Security. Finally, as health care costs
consumed more disposable family resources of fixed-income elderly,
Congress enacted Medicare and Medicaid in 1965, radically improving
finances for the elderly and the poor. These U.S. social safety
nets reduced elderly poverty from 95 percent in 1935 to 10 percent
today.
To reiterate, what we see today are 32 million Americans greater
than 65 years of age. Of that cohort, those greater than 85 are
the second fastest growing segment of our aging society. These
trends are historically unprecedented. The American age wave as
previously noted will be supercharged by a cohort of baby boomers
born following World War II; the oldest of this aging cohort will
become 65 in 2011 [Figure
2]. New solutions and a new design for health care delivery
will be required. Tinkering around the edges of our previously
appropriate acute, episodic U.S. health care system for youth
will not work for older Americans.
Implications
True or False? Aging today means infirmity, disability and warehousing
in nursing homes. NOT TRUE! Over the last couple of decades, levels
of chronic disability among older Americans actually declined.
3 This reversal was most pronounced among those
older than 85 years! In the United States, improved medical care,
diet, exercise and public health advances made in only the last
decade all have contributed to the opportunity for a more vigorous
and healthy old age. 4
For example in 1982, 6.2 percent of the nation’s elderly
were in nursing homes. In 1999, the percentage had dropped to
3.4 percent. 3 Similar results also have occurred
in other developed countries (Japan, United Kingdom, Norway and
Sweden). In each instance, improved health status and vitality
correlate best with education levels and financial well-being.
Especially through lifestyle changes (exercise, nutrition, weight
control, avoiding smoking and excess use of alcohol), older adults
have learned how to stay younger longer with improved mental and
physical health. Although statistically persons greater than 65
consume more health care services (especially hospital and anesthesia/surgical
care), they are aging healthier.4 Even so, 60 percent of the older
cohort: have two or more chronic diseases (hypertension, cardiac
disease, diabetes, arthritis, Parkinson’s, etc.); account
for 60 percent of U.S. health care spending; consume 50 percent
of hospital inpatient days/year; and account for 40 percent of
surgical procedures.1 These data give us added
perspective and reinforce the need to reinvent health care systems
to accommodate older Americans.
Anesthesiology, with its focus on patient comfort and safety
for periprocedural medical science, has an enormous opportunity
and responsibility to lead that aspect of the transformation process.
Seniors today are more informed and sophisticated in health care
and are demanding more information about surgery and anesthesia.
We can and should supply the knowledge about safe anesthesia care.
In addition, the emerging, aging baby boomers are healthier, wealthier
and more politically astute than previous cohorts. For example,
the American Association of Retired Persons (AARP) remains a powerful
political force with 34 million members. That organization has
become the second largest nonprofit organization in the world;
only the Catholic Church is larger. Why is AARP so politically
powerful? There exists an almost perfect correlation between age
and voting percentage in America. That behavior accentuates the
political power of 65-year-olds, who remain politically alert
and engaged during the average 19 more years of longevity. 5
This fact is not lost on politicians. Seniors will demand a different
health care system that is more responsive to their needs for
ambulatory, supportive and follow-up care. In addition, seniors
value their homes as the best site for recuperation and healing.
Presently, what is missing is a new integrated and information-oriented
infrastructure to support that option.
Eldercare
Quite soon, a totally new eldercare system, not a disjointed one,
will become a major political issue in elections. Such a new system
must include a focus on assisted living, support for independent
living and higher standards with audits before paying for “home
care.” In addition, adult daycare will be an expected benefit
to relieve especially working women who are often the health care-givers
in American families. A new model for long-term care will be developed
beyond just “warehousing.”
Anesthesiology, with its major societal role in pain management,
will be expected to be a leader in the emerging dialogue for design
and implementation of any new eldercare system. As the older surgical
patient moves from home to hospital-based care, ambulatory day
surgery or office-based procedures, anesthesiologists must be
more cognizant of the special socioeconomic needs of older patients
as they return safely home. 6
Surgical Procedures
Contrary to the projected decrease in surgical procedures by managed
care, total procedures have continued to increase, from 26 million
in 1990 to 42 million in 2000. Projections forecast more of the
same (to 50 million by 2006) even before the baby boom cohort
joins the age wave. The driving force for the increase in procedures
has not been a result of manipulation of payment mechanisms (i.e.,
managed “premiums”) but rather patient demand for new
technology, a booming, high-tier “cash-and-carry market”
and the attempt to stop or modify aging with surgical interventions.
Another dramatic shift in health care delivery particularly pertinent
to anesthesia planning has been the enormous shift to ambulatory
rather than inpatient surgery. What is especially impressive from
1980 to 2000 is the eight-fold increase in ambulatory procedures
in the United States (from 4 million to 32 million). Despite the
dramatic shift away from the hospital inpatient setting, another
shift has occurred with the site of ambulatory surgery shifting
toward freestanding facilities and physician offices [Figure
3]. Thankfully, responsible ASA leadership has responded appropriately
with guidelines, standards and practice parameters for ambulatory
and office-based anesthesia. Such a courageous, proactive response
has not been without controversy and lawsuits by those who are
focused more on control and money than patient safety. 7
Continuous quality improvement, measured quality and anesthesia
standards remain the model of the future for any new health care
delivery systems.
Conclusion
Despite unabating controversy, anesthesiology remains on the right
course for the future and for the right reasons. Safety and comfort
of patients remain our goals. Forming the eighth subspecialty
of anesthesiology through the Society for the Advancement of Geriatric
Anesthesia (SAGA) augments this process of proactive planning
toward new ideas and enhanced learning. Initially, that group’s
curriculum focused on the knowledge base of classic pathophysiology
(physiology, pharmacokinetics, pharmacodynamics and disease pathology)
of aging patients. Other topics covered include preoperative risk
and evaluation, postoperative delirium, critical care and trauma,
palliative care and ethical considerations when caring for an
elderly patient. 8 However, the complexities
of social and economic issues related to the emerging age wave
must be included for completeness in the political arena. We do
not have the luxury of isolating our specialty from political
progress. Active involvement in problem solving at the community,
state and national level will broaden our efforts outside of just
the comfortable opinions inside the medical specialty of anesthesiology.
Other health care colleagues and elected representatives will
look to us for expertise and guidance. Political action has never
been more important for our members and the elderly patients we
serve. Just remember, if we do not plan and implement the future
of anesthesiology, someone less qualified surely will do it for
us and our patients. Society will be the lesser without the combined
efforts of all ASA members.
In summary, we should redefine longevity as a crisis of success,
the true wealth of nations.9 Indeed, prolonging productive and
fulfilling life for Americans should be celebrated as a unique
historical achievement. All of us in health care can be proud.
To paraphrase social philosopher Theodore Roszak, we are beginning
to see the first-ever generation of senior dominance — “hungry
minds, gifted with wit and experience, political savvy, sheer
weight of numbers and keen perceptions and perseverance learned
in a full life.” 9
Our goal remains to be engaged as leaders in the reinvention
process. We must lead in developing the new and emerging eldercare
systems. This is our challenge and responsibility. Remember, it
is in our own self interest to do so. The elderly is not “them”
— they are “us” a few decades into the future.1
References:
1. Dychtwald K, ed. Age Power: How the 21st Century
Will Be Ruled by the New Old. New York: Jeremy R. Tarcher/Putnam;
1999:1-29, 77-86.
2. Dychtwald K, Flower J, eds. Age Wave: How the
Most Important Trend of Our Time Will Change Your Future. New
York: Bantam Books; 1990: 4-6.
3. Manton KG, Gu X. Changes in the prevalence
of chronic disability in the U.S. black and nonblack population
above age 65 from 1982-99. Proc Natl Acad Sci. 2001; (10):1073.
4. Erwin SL. Fourteen forecasts for an aging society.
The Futurist. 2000; 34(6):24-28.
5. Carter J, ed. The Virtues of Aging. New York:
Ballantine Publishing Group. 1998:22-32.
6. Vaughan RW, Vaughan MS, Aluise J. Safely home:
1990s’ challenge for anesthesiology. Anesthesia Airways (suppl).
1990; 2(2):1-12.
7. Twersky RS. Update on office-based anesthesia:
Caveats on the professional finger pointing. ASA Newsl. 2001;
65(8):17-18.
8. Rooke GA. New opportunities in geriatric anesthesia.
ASA Newsl. 2000; 64(5):6-7.
9. Roszak T, ed. America the Wise: The Longevity
Revolution and the True Wealth of Nations. Boston: Houghton Mifflin;
1998:12-23.
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Robert W. Vaughan,
M.D., is Clinical Professor in the Department of Anesthesiology,
University of North Carolina, Chapel Hill, North Carolina. |
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