Make Our Lives a Blessing

Kaiser Health News ran an article this week about “the secret happiness as you age.” It features the story of a 76 year old man who, despite severe heart disease, diabetes, glaucoma, and osteoarthritis, describes himself as a “happy guy.” He can’t see well, he can’t drive, and he has to rest after walking short distances—really short, like 10 yards. So how does he manage to be happy?

His secret is that he focuses on those things in life that do bring him joy—listening to music and audiobooks, and writing. He also derives pleasure from helping others in small ways. The article concludes with a quote from a geriatrician who says that “the real key to happiness at every age and stage—particularly old age—is not material things, but gratitude for life’s simple blessings, like laughter among friends or watching a sunset with a loved one.”

The message that frailty doesn’t have to spell misery is a refreshing one. Readers of this blog know that I spend a great deal of time discussing frailty: defining it, advocating screening for it, and promoting an “intermediate” approach to care for people who have it. I lament the disproportionate time and energy spent on addressing robust old age and dying, two important states but not where most older people spend most of their time. The Kaiser Health article is an important reminder that we don’t need to hide frail people from view as though they carry an unbearable, unmentionable stigma. But what is missing from the piece is the recognition that while individuals who are frail can take steps to make their lives rewarding, the larger society has an important supportive role to play. 

Creating and disseminating the technological aids that can make life enjoyable are crucial: without his audiobooks and his virtual assistant (in the example given, Amazon’s Alexa), achieving satisfaction might have been impossible. We need to make age-friendly environments, like those promoted by the World Health Organization’s “Age-Friendly Cities and Communities Program.” This means building walkable communities, providing appropriate transportation, and linking service providers to individuals. It means developing accessible housing and means for civic participation, along with access to medical care. It means joining the AARP Network of Age-Friendly Communities or local organizations, such as the Massachusetts Healthy Aging Collaborative. Only then will happiness among frail elders be the norm rather than the exception.

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Beyond Doctoring

I’ve long been amazed by the legerdemain that went into deciding what Medicare will cover and what it won’t. I’m not talking about decisions made in the past decade about what procedures to pay for, by and large rational decisions that have been based on a careful analysis of the evidence supporting their efficacy. I’m talking about some of the most basic aspects of Medicare, such as its exclusion of long term care. Now I recognize that the main concern of those who crafted the 1965 legislation was to provide some kind of health insurance for older people without busting the budget. To achieve this end, they decided to distinguish between things that are medical (which Medicare would ostensibly cover) and things that are not (which it wouldn’t). What that distinction has meant is that housing, transportation, diet, and all kinds of other nominally social goods are off limits for Medicare coverage. A new study by Elizabeth Bradley and her colleagues at Yale shows just how arbitrary—and often counterproductive—such a conceptual divide actually is.

Following up on their groundbreaking work in which they showed that countries with higher social service spending relative to health care spending had better health outcomes, the study team compared the performance of the 50 states (and the District of Columbia) over a 10-year period, from 2000-2009. They defined the extent of each state’s investment in social services by calculating the ratio of social service plus public health spending (on education, income support, nutritional assistance, housing, transportation, and the environment) to the state’s total government health care spending (Medicare plus Medicaid). Then they examined the relationship between this ratio and eight health outcomes (including the percent of the population that is obese, has asthma, or has functional limitations, and mortality rates for heart attack, lung cancer, and diabetes). What they found is that states with higher ratios of social to health spending had significantly better health outcomes (in 7 of the 8 domains).

It's striking that the variability in spending on health care (as a percentage of GDP) across the states is considerable, ranging from less than 4 percent in Colorado, Utah, and Wyoming to nearly 10 percent in Maine, West Virginia, and Missouri. Likewise, the variability in spending on social services and public health is dramatic, going from about 12 percent to over 20 percent. The net effect is that the allocation of resources between social services and health care differs substantially from one part of the country to the next.

It’s a complicated study and I’m sure that methodology mavens will have a field day with it. But the attempt to assess the contribution of social supports to outcomes is so reasonable and the results are so striking that we have to take very seriously the idea that social factors are a major determinant of health and well-being. I’m convinced this is particularly true in older people, whose quality of life is at least as affected by where they live and their ability to find meaning in life as it is by their physical ailments. I suspect that this study is as important as work by Michael Marmot showing that health worsens as people descend the social ladder—not just because of income inequality, but also because of discrepancies in social status. If we want to foster good health, which the World Health Organization defines as “a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity,” we need to focus on relationships and housing as well as on drugs and devices. And for older people, that may mean user-friendly computers and better assisted living facilities rather than a left ventricular assist device or a new monoclonal antibody.

What Did You Say?

We have a Model 88 radio on our kitchen table that we must have had for 20 years. It’s one of those devices where you adjust the volume by pressing the “up” button or the “down” button. My mother, who turned 90 last month, customarily set the volume to 50 and I set it to 35. I don’t know how those numbers translate into decibels, but 50 is louder than 35. Considerably louder. I took this quantitative observation as definitive evidence that my mother’s hearing was impaired, as is true for just about everyone who’s made it to their tenth decade, but she wasn’t persuaded. After a year of nagging—I confess, I nagged—my mother responded to an offer of “free hearing screenings” at the local senior center. When the screening was cancelled because of a blizzard, I figured that was it—I’d lost my chance. But the audiologist was persistent and he managed to reschedule the test.

My mother didn’t pass the exam. She was frankly quite surprised and assured me that all her friends complained that their children “mumbled” and were hard to understand, but they—octogenarians all—had no problem hearing each other. I suggested that was because they were all hard of hearing so when they got together they sat around yelling. She didn’t appreciate my comment, but she humored me and actually got fitted for hearing aids. She disappointed the fellow who did the initial screening and found a different audiologist, a lovely woman whose office is nearby and who treated my mother with both patience and respect. Nearly two years after I started nagging, and a year after the blizzard of 2015, my mother has two remarkable, virtually unnoticeable, in-the-ear hearing aids—and a $6000 hole in her bank account.

I can’t say that the hearing aids have transformed her life. But we don’t have nearly as many of those awkward dinner conversations in which I say something and a minute later, my mother says the same thing because she didn’t hear what I’d just said. The television in her room no longer blasts away in the evenings. The hearing aids haven’t solved all her problems, but they help. Just because it may not be possible to cure disease or restore function, doesn't mean there's no point improving a few crucial domains such as hearing and balance. Those modest adjustments can make all the difference.

My mother is not unique in her skepticism about hearing aids. Although 80 percent of people over age 80 have hearing loss, only 20 percent use hearing aids. For people with mild hearing loss, the rate is dramatically lower—more like 2 to 3 percent. A recent report by the President’s Council of Advisors on Science and Technology (PCAST), whose findings in the realm of hearing were summarized by Christine Cassel of the National Quality Forum and colleagues in a recent issue of the Journal of the American Medical Association makes some important policy suggestions that could radically change the status quo. 

PCAST identifies two critical barriers to change: primary care doctors, who tend to ignore hearing loss, feeding into their patients’ denial; and Medicare regulations, that exclude insurance coverage for audiology assessments and for hearing aids. The report doesn’t have much to say about how to modify physician behavior other than to assert forcefully that “it is time for the health care system to make hearing a priority.” It does have some concrete suggestions about paying for hearing aids, pointing out that the Veterans Administration does cover this technology and negotiates prices from major manufacturers, with the resulting cost averaging $400 rather than $2400 per device. Other western countries such as England, Denmark, and Switzerland include hearing aids as part of basic health care coverage. After all, the rationale for excluding them from the original Medicare legislation in 1965 wasn’t that they failed to meet the "reasonable and necessary" standard, but rather that they were presumed to be low cost, something consumers should pay for themselves. PCAST also suggests that the FDA could allow certain types of hearing aids to be sold over the counter, much as some reading glasses are available over the counter. The hope is that by making the process of getting hearing aids more “user friendly,” usage would increase.

Hearing loss has major consequences: it is associated with a marked increase in the risk of both falls and dementia. It leads to social isolation, poor quality of life, and greater dependence. And we can actually do something about it. The cost of making a difference is far less than the cost of treating all the hip fractures that older people will have because they don’t hear a warning or the services they need because they have become frail and dependent. Why can’t Congress (which would have to amend the Medicare legislation to pay for hearing aid technology and to amend the FDA’s rules for device regulation) see that this is a win-win situation?