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SPEAKER: Our topic today, "Who needs long-term care?", certainly has to be divided up in those three parts. Who are they, what are the needs, and what do we mean by long-term care? As to who they are, I'm sure you've heard a lot in the last day.

When we think back on the extent to which there were TB sanitaria in the United States, I would remind us that they, too, have begun to disappear as a consequence of the brilliant and contributing character of medical science, which unraveled the causation of tuberculosis, and then found a means, namely an antibiotic, to help arrest and cure a disease that, as you know, at the turn of the century and up through the 1930s was called consumption and brought to end the lives of many people of all ages.

So in that sense, the scientific progress certainly has a lot to do with the "who," that is, who the older persons in America are, what the needs are, and what the character of long-term care is all about. Now, at any one moment in the United States-- and it does vary from state to state, jurisdiction to jurisdiction-- something like 5% to 7% of individuals reside in some type of an institution. It may be a state mental hospital. It may be a nursing home. It may be a home for the aging.

That's at any one moment in time. But that does mean-- and we must always have a balanced picture, a balanced portrait of older persons in the United States. And that means that something like 93% to 95% of older persons are not in any kind of an institution.

Now, for those who worry, and many do, that the end of their lives may be spent in institutions, let me say another positive. 80% of individuals who survive past 65 will never, never have any kind of a nursing home or long-term institutional experience. 20% will. And that's a very important group of frail, older persons that we must be sensitive to and learn a good deal about.

But nonetheless, it's that 80% that we must remember never have to have any type of a nursing home experience. Our task, as I see it, is to increase that percentage, maybe one year to move up to 82%, then 84%, and before long we will decline the number of persons in institutions.

Now, because we've had this dramatic increase in the numbers of persons in their 80s and beyond, that does increase the likelihood of institutionalization because it is after 75 and 80 and beyond that we begin to have more and more diseases, multiple pathology. In fact, it's been estimated in some studies that, say, an individual 75 to 80 may have as many as five or six diseases.

You may think that's extraordinary. But when you think about it a minute, maybe a little arthritis, some cystitis, a little heart disease, maybe some hypertension, and you add it all up, and pretty soon you have five or six conditions, which also means that frequently the individuals are on more than one medication, which in itself can create special problems. So we do have the increasing prospect of the "who," that is, the persons who need long-term care.

Now, there are three major antecedents for institutionalization, which we should be conscious of. Instability and falls. That may account, from some surveys, for 8% of the admissions to nursing homes.

Second is various forms of dementia. That is senility or compromises in intellectual functioning, which makes it difficult for a person to be able to remain in their own home. They may not remember to take their medications. They may not eat properly. They may leave the stove on because they become confused. They may be found wandering in the street.

And the third common antecedent or cause for admission in institutions is incontinence-- incontinence of urine or feces-- which is obviously a most unhappy, undignified way for persons to have to spend the last days of their lives. And those three topics are critical priorities of the National Institute on Aging. They must be because they're all extraordinarily costly, and we must find ways to contain costs. They're extraordinarily distressing and painful to older persons and to their families, and so we want to find important solutions to them.

Now, the second word in the title was the word "need." And the need does need some very special consideration. Again, I'm speaking nationally, not about Minnesota, but 50% of persons in nursing homes in the United States, 500,000 of the 1 million persons over 65 who reside in some 19,000 institutions, do not have any families. Do not have any families.

So that when the press, as it sometimes does in its journalistic fervor, attack the American family for abandoning its older persons, I think it's been often an unfair indictment because many of the persons in nursing homes simply have no family. They have no one to whom to turn. 80% of the persons in homes for the aging, in nursing homes in the United States are women because women outlive men.

And this differential-- life expectancy, again, is a topic that must be addressed by research. We've all known that women are tougher than men, but we better find out why. Is it the immune system? Is it the hormonal system? What is it that makes it so possible for them to outlive the weaker half?

And they do so now by an average of four years from the age 65. And from birth, women outlive men now by nearly eight years. And this differential is actually increasing. As more and more women enter the workforce, in contrast to what some had anticipated, more and more women are living longer than men.

A generation of women born between 1905 and 1910, who would now be between, say, 76 and 82, had their main childbearing years during the economic depression in the United States in the 1930s. And 20% simply had no children.

Another 22% had but one. And they may have lost that child through a variety of means so that perhaps 30% of the women in that generation have no children. So we're talking about a very needful group of women without children, often without husbands, who require some type of long-term care.

Now, I've emphasized the vulnerable and the frail up to now. But I don't want to lose sight of the point I made earlier about balance. We must be conscious of those who are not frail, who remain vigorous and active, and we must do everything to help maintain their health through new notions of health promotion and disease prevention, proper nutrition, adequate exercise, control of blood pressure, which can make an enormous difference since systolic, which is the upper-level blood pressure, continues to be a significant risk factor for stroke.

So if we can reduce stroke through adequate control of blood pressure, we are reducing the admission to nursing homes. In short, we must find ways of reducing vulnerability.

The third part of that title, exactly what long-term care is, I have, I admit, up to now stressed institutions because in many parts of the country, and I understand from my discussions this morning with people in Minnesota that here too long-term care tends to mean, in most people's minds, institutional care. But we are trying to rethink exactly what long-term care means, to broaden its definition, and to have it include a range of facilities and services that provide intermittent or continuing care over a long period of time, but not exclusively meaning in institutions. There may be services in the home, there may be services in senior centers, there may be health promotion clinics, day care centers and the like.

Now, I submit that we should all begin to prepare for our futures, that we need really a nationwide set of study programs. We need our high schools, our public schools, our universities and colleges, our churches, our unions, our corporations to be much more sensitive to the profound change in the age structure of our society. I mentioned the average life expectancy in 1900. Then, there were only 4% of our population over 65. Now it's 11%

But by the time the post-World War II baby boom grows gray, 20% of the population will be over 65, one of every five Americans. Surely we have to be preparing for this? We have to have more study programs. We have to read. We have to participate in decision making. We have to have an intergenerational approach.

Some of this is happening in various parts of the world. In France, there's a program called The Third Age, or Troisieme Age, in various universities, in which individuals who may never have had the opportunities for education have returned to school and enjoyed a variety of courses. In this country, we have the elderhostel movement.

Lifecycle education to help acquaint us with what should be and can be expected at different stages of life would make the kind of contribution which I'm referring. This I cite in distinction from continuing education. That is the kind of retraining that all of us need so that we don't become bored out-- burned out or bored, so that we as doctors, for example, have continuing medical education and are up to date with the newest diagnostic techniques, so we that are in the world of agriculture know the latest know-how, so whatever walk of life, whatever occupation we have, we have opportunities to continually grow and learn.

We certainly have to overcome, in doing this, many of the stereotypes, including the stereotype that older persons are a burden or that older persons are simply dependent. I think I've already made plain that 95% of older persons at any one moment are going concerns, and there's no reason for us to carry on with some of the stereotypes of older persons as though they were not able to take care of themselves.

On the other hand, we could do a lot to help provide better support for older persons and their families, not only in terms of money, although money is certainly not an unimportant topic. In Japan, for example, which now has the longest living population in the world, that is, the longest living people-- the Japanese woman, for example, is the longest living individual anywhere in the whole world. And in Japan, to help the family, which already has a major dedication to its older family members, tax incentives and tax payments are made available to assist the family.

After all, in this country, for example, with increasing number of women in the workforce, the traditional availability of the woman in taking care of the older persons in various parts of the United States is not as available. So we could provide respite and provide that respite through a practical means of cash payments.

The second way that we can help support the family is through helping families learn more about aging. Again, I go back to the study group concept. There are isolated instances of this happening. At Stanford University, for example, families receive training in helping them to take care of someone that has emphysema, which is a serious breathing disorder that can occur, not uncommonly, in fact, quite frequently, in older people. So we can, through education and training, help families to better take care of their family members.

We must broaden the choices enormously. In the state of New York, there are now nursing homes without walls. A Republican Senator of the state of New York, not a US senator, but a state senator, Tarky Lombardi, evolved a technique by which a nursing home could become a center of a variety of types of services, not including necessarily institutionalization. And this type of panoply of services makes the term "nursing home without walls" a very creditable one.

We need to have more effective emergency response systems to help maintain older persons at home. Day care centers. The development of support groups by families. Minnesota has some reason to be proud, through the contributions of one of Minnesota's citizens in Minneapolis, to the development of the Alzheimer's Disease Grassroots Family Movement in the United States. There are now some 50 chapters in 50 cities, and they provide a means to help families to deal with the distress of trying to properly take care of a family member who suffers from this most common form of senility called Alzheimer's disease.

We need to evolve still further home health agencies. In many rural areas of the United States, for example, in the sister state of North Dakota-- I guess my voice has been failing, or the microphone has-- the availability of home health services or the proximity of older persons to home health services has been very small. In fact, nationally, only one out of seven persons over 65 have immediately available various types of home health services.

I suspect that the ratio is much, much better in the state of Minnesota, but you certainly are likely to need to expand such home health services. I don't know if the state of Minnesota has made application for Section 2176, which is the Home and Community Care Waivers, made available through the Reconciliation Act in Congress last summer. But if not, it's something that the state should look into, or if it already has, should take quite seriously, because it provides still further opportunity for helping to maintain older persons in their own home.

And of course, the Veterans Administration is becoming increasingly concerned about older citizens since the average age now of World War II veterans is getting very close to the age 60. And it won't be many years before some 9 to 12 million veterans in the United States will be potentially available for services under the Veterans Administration. So the VA, too, is gearing up to make practical contributions to long-term care.

I think we're going to have to undertake a rather major revolution insofar as American hospitals are concerned. They are so accustomed to acute care and are not as sensitive to chronic care. Just as we need to develop, even to a greater perfection, pre-admission screening programs for nursing homes, we're going to have to have pre-hospitalization programs to help keep people from ever even getting on the track, which may lead them eventually into the nursing home. And that type of pre-hospitalization evaluation should at the very start, at the moment of admission of an older person into a hospital, include the planning for discharge.

What so often happens in American hospitals is the patient is admitted, treatment is undertaken for the acute illness, and only after the acute episode is over does any kind of thoughtful planning about the future get started. And by the time that happens, then there are an increasing number of hospital days and an escalation of hospital costs. And we obviously have to be a good deal more conservative fiscally than we presently are. We must cut costs, and we must cut hospital days.

But to do this properly, we're going to have to learn a lot more about techniques of assessment. We have very unsophisticated level of development. There are a number of assessment techniques that are being used. Some of them are extraordinarily long, and people become disheartened and don't use them. Some of them, on the other hand, suffer by being very brief and basically shortchanging the proper evaluation of an older person.

Now, we do need brief techniques and inexpensive techniques. On the other hand, no self-respecting cardiologist would think of making decisions that are going to affect the possibility of, say, a coronary bypass operation without there having been an extremely comprehensive evaluation of the individual as a whole and of that individual's cardiac status.

And yet people will interview in a brief amount of time and go through a very cursory examination of an older person and come to all sorts of decisions, which may be extremely early curtailing of that older person's life and restrict the likelihood of their being able to continue to remain in the community. So we must develop much more sophisticated techniques that go the range from medical evaluation to psychological assessment to an assessment of the support systems, the social circumstances of the older person.

We're going to have to influence the private insurance industry to begin to undertake demonstration programs for private insurance in the long-term care area. We don't yet have enough epidemiological information to provide the database for risk assessment to make it possible for insurance companies to feel they can take the financial risk of supporting insurance programs for long-term care. So on a national basis, we're going to have to find means to obtain that kind of information.

And we're going to have to see how willing the middle aged are going to be to purchase insurance for long-term care. But just as it took some centuries for people to become sensitized to life insurance, to annuity insurance, to a variety of types of social community protections through the mechanism of private insurance, so, too, we're going to have to encourage people to begin to think in terms of insuring themselves for their long-term care and needs in old age.

There are very many ways in which we're going to have to protect older persons in the community who do become vulnerable. They might not have full capacity, intellectual capacity. They may have memory problems. And as a consequence, there may be some very real problems of protection.

I'm not at all sure that this is a problem in Minnesota, but in many urban areas of the United States, there is the violence, the crime to which older people are tragically subjected. There's white collar crime in which older persons may be sold land under water in Florida, may be cheated insofar as a hearing aid is concerned. So there are these necessary steps of protection of older persons.

Once an individual is in an institution, we need to devise much more effective ways to monitor nursing homes. We cannot expect to depend upon local government, state government, or the federal government. We must really take that responsibility in our own hands. In New York city, for example, there's an organization called Friends and Relatives of Institutionalized Older Persons. FRIA is its acronym. Friends and Relatives of Institutionalized Aged.

More and more around the country, we should have organizations of family members, and potentially of older persons who might eventually be at risk insofar as nursing home admission. That type of program does not cost money. It's like a PTA for older persons and their protection.

Families must visit older persons. So frequently, once a person is in an institution, the family becomes uneasy about visiting. They don't know what to say when they come in. They need to have visits. It's a way also of protecting the person. Human nature is such that the squeaking axle gets the grease. So the nurse in the nursing home knows that Mr. and Mrs. Jones do visit their mother or do not.

And I don't mean by that that there aren't very fine nurses that work very hard to see that there's good care in homes for the aging and nursing homes. I'm just speaking about the realities of careful monitoring and the fact that there are, of course, always, unfortunately, some rotten apples, some rotten apple nursing homes that do not provide decent care.

We must have much more available information and the right to inspect and look at the records of homes for the aging and nursing homes. Since 2/3 of the monies that go into these homes come from public dollars, we have a right as citizens to know what type of care is being provided for older persons. The National Coalition of Nursing Home Reform, which has its central office in Washington, DC, would certainly be available, I'm sure, for those who might think of wanting to develop small organizations or groups to help more effectively to protect older persons, both in the community and in institutions.

Well, you won't be surprised, since I direct a research institute, if I turn my attention now for a few minutes to the importance of research. I've already spoken about the obliteration of polio and the end of tuberculosis. There's a good deal of hope now insofar as senile dementia or Alzheimer's disease is concerned. There are new findings of marked reductions in a significant enzyme in the memory portion of the brains of those persons who do develop Alzheimer's disease.

So we now face the possibility of being able to intervene and define means of remedying the deficiency, replacing this deficient enzyme, or replacing the chemical messenger which is created by that enzyme. There is new hope, too, in the condition which particularly affects older women called osteoporosis, or bone thinning, which accounts for so many hip fractures. And these hip fractures lead not only to institutionalization, but perhaps to ending the days of mobility and freedom and capacity to go to church and visit relatives and to do things which mean so much to older persons.

All of this research, as well as all of the other avenues of approach, which I've mentioned, will help contain the tremendous costs which are associated with the later years and which I know you receive some briefing in the keynote remarks of Dr. Newcomer. One way that which we can begin to reduce the number of individuals in nursing homes and to reduce the costs is through reducing the number of institutions which are built. And that, in a sense, forces the system to provide better outpatient care approaches.

Second, we must have better trained people, better trained nurses, better trained nursing aides that work so often in homes for the aging, better trained doctors. The development of geriatrics in the United States is long overdue. Some states, like the state of Ohio, has provided funds directly for medical schools to help those medical schools get off the ground in developing systematic teaching with regard to aging. We must have a leadership group of individuals who will become the educators, the researchers who will come up with new techniques of diagnosis and treatment for older people.

But for us to have that type of doctor, the geriatrician, we have to have training centers. As far as I know, the medical school at Mayo has not yet made that type of move. The University of Minnesota does have the beginnings of a program under Dr. Patrick Irvine, who I think is here perhaps today.

And I think we're going to have to have our 126 medical schools in the United States begin to meet the realities of the increasing numbers of older persons by much more systematic, sophisticated training in the field. This does not mean that we need to have a brand new field of practitioners called geriatricians, but we do have to have the individuals who will teach the gynecologist, the internist, the family doctor, the psychiatrist to be properly trained in delivering this type of care.

We can't just, of course, depend upon the medical schools either. We must turn to continuing medical education, which is a way in which we can reach those doctors who are already in practice. I know how frequently older people experience the occasion in which they see an older-- see a doctor about a complaint, and the doctor says, well, now, Fred, what can you-- what do you expect at your age? Or some other really very unhelpful comment.

And the truth, of course, is that everyone, regardless of age, deserves a comprehensive diagnosis and treatment approach. And there are many things, increasingly many things which we can do to bring comfort to persons as they grow older, from arthritis, from hip problems, from breathing problems, from a variety of conditions.

I would like to say a word about costs as associated with age. I've emphasized them because we must. And we do have to be thinking about how to save money and to use precious dollars carefully. But we must not continue to present the costs, the health costs of older persons as though it was the fault of older people.

The reason health costs are now associated with older persons is because they are no longer associated with younger persons as a result of the fact that we have deferred or postponed costs. Children no longer are sick and die at the rates in which they used to from a variety of diseases, particularly infectious diseases. Women no longer suffer as much or die giving birth to children.

150 years ago, only one out of every three babies ever could be expected to live through their 60s. Now, over 80% of newborn babies can expect to live into their 60s. 80% of all death occurs after 60. So the reason health costs are related to older persons is a reflection of the triumph of longevity, which I referred to earlier.

So we should stop simply referring to health costs and age as though older people have brought us some kind of problem. Furthermore, as a doctor, I think I have to and other doctors have to take some responsibility. We haven't lost money since Medicare and Medicaid. In fact, we doctors have probably gained enormously, maybe even more than older persons have, as a consequence of reimbursement.

And we tend to reimburse doctors on the basis of organs, on the basis of procedures. We divide people up. We don't see them as a whole person. We see them as a kidney, or we see them as a liver, or as a heart, or we see them in terms of the procedures about which and through which we make money as physicians. I frankly predict we're going to have a reimbursement revolution in not too many years from now. Doctors are not going to be able to continue to profit as much as they presently profit from the way in which they are paid under Medicare, Medicaid, and through private pension and private insurers.

Another reason is the development of technology. That technology has been largely to the good. New techniques to improve diagnosis and treatment. But very frequently too hospitals have profited from excessive use of laboratory tests and excessive use of technology, all to the expense of older people and to our state, local, and federal government.

Finally, many of the costs, particularly in institutions, that are credited to health costs are really a function of residence. When you're living in an institution, you're also paying your rent for staying there. So we need to do a much more effective cost accounting. Business people would never allow this kind of poorly thought through cost accounting to occur if they were running a farm or running a factory. And we can't run our health care system on such an inadequate and fiscally irresponsible way.

Let me conclude by saying that there's a lot of thinking going on in Washington. Secretary Schweiker has been deeply interested in long-term care. And Dr. Edward Brandt, the Assistant Secretary of Health, and Surgeon General C. Everett Koop have been developing plans to try to think through promising and effective contributions to enhance the quality of care and the costliness of long-term care.

There's a lot of talk these days about the safety net, and we're trying to carefully find exactly where that point is, where people are truly vulnerable, truly frail, if elderly, and therefore must receive our ministrations, either through the private sector, through charities and church or community, or through government at all levels, municipal, state, or federal. The task of finding that thin line, that tightrope insofar as the safety net is concerned, will probably preoccupy this country for the next decade or so.

But I'd like to conclude by returning to one of my first points. That group, the baby boomers, some of you are in the audience. You were born between 1946 and 1964. There were 76 million of you then. There are 70 million of you now. There will be 55 million of you in the years roughly between 2010 and 2030.

I urge you to begin to prepare now. Be more sensitive to the elders of our society, to your parents, and to those who may not have the advantage of being parents. Be sensitive if for no other reason than your own enlightened self-interest, because one of the glories of human existence is the potential now to grow old and to enjoy the richness and the rich possibilities of an extended and happy later years. Thank you for your attention.

[APPLAUSE]