Recent studies of the attitudes of elders toward their lives and toward the medical system suggest that the majority are well satisfied with their lives but that they may not be as satisfied with the kind of medical care they receive.

The Genesis ElderCare Poll, carried out by Lieberman Research, Inc., and sponsored by Genesis ElderCare, a leading provider of residential and community-based services to elders and their caregivers, surveyed close to 800 people aged 65 and over who live independently in their communities. The purpose of the study was to better understand the aging process from the perspective of those who are living through it; to see if there are attitudinal differences based on age, income, living situation and other factors; and, finally, to document what kind of support well elders living in the community are getting or think they need.

The Genesis ElderCare Poll, in which the authors played a significant role in research design, showed a high degree of attitudinal consistency between the four age groups studied: 65­69, 70­74, 75­79 and 80+.

Positive Attitudes about Aging

The percentage of elders who report high satisfaction with their lives, a desire to learn new things, looking forward to each new day, enjoying meeting new people and keeping up with what is happening in the world remains at a high level regardless of age. Elders in all four age groups say they are trusting (90 percent) and more fortunate than most (85 percent). And they say they feel that as they age they increase in wisdom and are treated with respect by those around them. The number who worry about feeling depressed or bored is low (high teens to low twenties) and is consistent across the four age groups. The study reveals that few elders worry about being robbed or mugged, even those living in urban settings. These elders also have almost no preoccupation with their own mortality or the issue of dying. The top worry is not about a personal concern, but about the country's problems.

Concerns with functional mobility, on the other hand, do increase significantly among those 80 and older. And concerns with physical appearance also jump significantly with this segment.

The two factors that do have a major impact on certain key areas of life satisfaction were found to be income and living status. Those who are unmarried but live with someone had response patterns very similar to those who are married, but not as strong. Companionship, then, has a positive impact on attitude but does not generate as high a level of positive attitude as does being married.

Compared to those who are married, people living alone (40 percent of the elder population) feel less attractive, have more negative feelings about themselves and report higher levels of depression and boredom. These negative feelings correlate not only with living alone but also with economic factors. Many of those living alone are widows with incomes close to or below the poverty level.

Almost two-thirds (61 percent) of elders report receiving help from family members, primarily in the form of emotional support. The next most frequent type of help cited was in fixing things around the house. Help that compensates for functional decline (shopping, transportation and the like) was more common for those elders 80 and older.

Slightly more than half of those surveyed reported that they regularly took walks or exercised. Other frequently reported activities include listening to the radio (55 percent), cleaning or fixing up the house (58 percent), cooking (64 percent), spending time with family or friends (74 percent), reading (77 percent), chatting on the phone (77 percent), just relaxing (80 percent) and watching television (93 percent).

Elders living in rural areas are more worried about being able to get around and more often report feeling bored. Elders in suburban areas are less satisfied with their lives than their urban or rural counterparts. Those in urban areas report the highest levels of life satisfaction and are more likely to categorize their health status as good or excellent. Urban elders also have the highest average level of liquid assets, which may account for their higher level of satisfaction.

In order to correlate the study's findings with some of those coming out of the MacArthur Field Study of Successful Aging, elders were asked to self-report on their health status. Health status that is reported to be fair or poor lowers overall life satisfaction and interferes with the enjoyment of a wide range of activities, including learning about new things, reading, walking and hobbies. Those who report low health status worry more and feel less useful, are more bored and helpless and more frequently report feeling depressed.

Yet, when queried about the activities in which they actually engaged during the previous day, those who reported low health status said they had taken walks, exercised, played a sport, cooked, done laundry and gone shopping as frequently as did those who reported their health status as excellent or good.

The possibility exists that mobility among those reporting low health status is not in fact depressed as much as this group perceives it to be depressed. If this speculation is true, then psychosocial interventions may be more meaningful than interventions aimed at functional restoration.

Attitudes about the Healthcare Delivery System

The Genesis ElderCare Poll also looked at attitudes concerning encounters with the healthcare system and personal care physicians. We found extremely high levels of satisfaction with physicians, the quality of care provided and the physician's understanding of the issues of aging. Elders reported almost no hesitation in asking their physicians questions and were satisfied with the responses they got.

We did, however, find less positive reactions to the issues of choice and healthcare decision-making. Only half of the respondents reported being offered choices by their physicians. Less than half said they take an active role in making decisions about their own healthcare. Thirty-one percent said they leave such decisions entirely in the hands of their physicians.

This reported high level of satisfaction with physician interactions is interesting in light of other data reported in a 1996 study by the Advisory Board Company and published as Medicare Strategy: Reenvisioning Health Care for America's Seniors, which indicate that only 27 percent of elderly patients agree with their physicians concerning the main goals of an office visit and only 17 percent agree that psychosocial issues were addressed in encounters with their physicians. Because psychosocial issues often influence functional independence and healthcare utilization, it is unfortunate that physicians are not better trained to deal with them.

With only 36 percent of patients and physicians expressing agreement as to what the primary medical problems are, and with a 17-minute average office visit for patients over 75, perhaps it is not surprising that, among the elderly population, an estimated 78 percent of alcoholism remains undiagnosed, as does 75 percent of depression and 25 percent of severe cognitive impairment. These three conditions alone contribute heavily to utilization of medical services. Yet with the average office visit so short, physicians have little time to identify and help manage such issues.

We suggest that such data indicate that the current system for providing care to elders is not able to deal effectively with many of the conditions that trigger healthcare utilization and, in the end, accelerates loss of independence and decreased functional self-sufficiency. We believe that a new model of eldercare is needed.

As long as our culture persist in seeing old age as a disease state, we will be tempted to construct a healthcare delivery system that reacts extremely well to crisis and illness but flounders in the areas of prevention, wellness and fostering independence.

The current system collects snapshots of elders, mostly in their roles as victims of various disease states and illnesses. The sense of the whole person necessarily remains discontinuous because the system is looking at only a small part of the life of each elder.

Hence the current delivery model has extreme difficulty in identifying underlying causes even as it continues its excellence in treating symptoms. We can, for example, easily repair an elder's broken hip. But we have a great deal of difficulty tracing the fall to poor depth perception caused by an outdated bifocal prescription.

The current delivery system was not designed for the needs of elders with chronic conditions and for whom psychosocial issues play as important a role in illness as do viral agents and bacteria.

As we have seen in the results from the Genesis ElderCare Poll, one's attitudes do not change because of age. Yet it would seem that the attitude of the healthcare system toward those who receive care does change as patients age. Less time is spent with those who are older. And insufficient time is spent on trying to identify such root causes of healthcare utilization as alcoholism, depression and cognitive impairment. Further, there is little investment in support services for caregivers, despite growing documentation that the family is the primary care provider for most Americans as they age.

A Holistic Approach to Healthcare

We are not suggesting that the fault lies with the delivery system or with physicians; instead, we believe it springs from our lack of understanding of aging. We are just beginning to understand that much of what we had believed to be indigenous to aging is actually the cumulative effect of prior lifestyle choices and social factors that can be managed. As Robert N. Butler of the Mount Sinai Medical Center in New York City, chair of the Genesis ElderCare Advisory Board, recently commented to one of the authors, "We falsely attribute to the aging process much that is due to disease, social adversity and lifestyle. This is also a message of hope. We can do a great deal about these factors even when we cannot alter aging itself."

Whether it is a greater understanding of the role mild exercise can play in reducing osteoporosis or more appreciation of the level of instrumental support elders receive from their families, our growing understanding of the processes of aging should lead to a reassessment of how we support our elders as, in increasing numbers, they live through their 80s, 90s or past the century mark, often with great vigor of mind, body and spirit.

As we begin to understand aging as an on-going life process rather than a series of disease states, we will begin to reach consensus on how to create effective support services for elders and their families.

Given the needs expressed by elders and their families when seeking to navigate the medical and life-management issues presented by aging, we believe that an effective model of healthcare delivery for older adults should address certain core issues:

• It should allow us to understand the whole person, not just the body in crisis or the disease state.
  
  
• It must provide for a full life by focusing on the management of aging processes through education, wellness, prevention and imparting of specific skills to caregivers.
  
  
• It must be goal oriented, offering choices as to the types and levels of support elders want in order to maintain their independence, dignity and sense of control.
• At its core it must have a care coordination approach.
  
  
• It must contain a system for sharing information among practitioners.
  
  
• It must be willing to abide public scrutiny of its outcome measurements, including cost effectiveness.

Finally, this model must be funded so that prevention is rewarded. This last point is crucial. Medicare injects almost $200 billion annually into the healthcare system. Yet, all along the continuum, what is being reimbursed are services related to the treatment of diagnostic-related groups (DRGs). Symptoms, not causes. Treatment, not prevention.

What would the outcomes have been--in terms of utilization, cost and quality of life--if 20­30 percent of the $1.8 trillion spent by Medicare during its first 30 years had gone to wellness programs, prevention, education and community-based programs?

Under the current model, we are very good at repairing Mrs. Jones's fractured hip; we are not so good at figuring out why she fell in the first place.

A life-management model for eldercare seems to us to be an imperative, given the combination of the ruinous costs of the current medical model and its concomitant inability to adequately address the health and psychosocial needs of elders and their caregivers, many of whom are under extraordinary stress from their caregiving work.

As we listen to the voices of our elders, we hear them telling us that elderhood is not a qualitatively different stage of life. We can move beyond the current set of myths about aging and recognize our true responsibility--to change the way healthcare for older adults is delivered in the United States.

Only then will we be able to claim that we are making progress toward increasing not just our life expectancy but also our health expectancy.

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