- Email: [email protected]
Adults With Disabilities Are Aging
FEATURE ARTICLE
Adults With Disabilities Are Aging H. Barry Waldman, DDS, MPH, PhD, Steven P. Perlman, DDS, MScD, and Ramiz A. Chaudhry, DDS H. Barry Waldman
Steven P. Perlman
H. Barry Waldman Dr. H. Barry Waldman is a Distinguished Teaching Professor of the State University of New York. He was the first faculty member of the School of Dental Medicine at Stony Brook where he has served for more than 38 years in numerous roles, including Department Chair and Assistant Dean, and he has also participated in teaching programs throughout the Health Sciences Center and the undergraduate college. He has published more than 850 monographs and articles in international, national, and regional publications evaluating health delivery and social issues, including manpower, health economics, delivery modalities, and quality assessment, with particular emphasis on the issues facing the delivery of health services to both younger and older patients with special health care needs. Together with Dr. Perlman, he initiated changes in the accreditation process that now require all schools of dentistry and dental hygiene to provide training for students in the care of patients with special needs. Steven P. Perlman Dr. Steven Perlman is Associate Clinical Professor of Pediatric Dentistry at Boston University Goldman School of Dental Medicine. He devotes his practice and teaching to the treatment of children and adults with disabilities. He was the first dentist in Massachusetts to receive the Excellent Physician Award, and the only graduate of the Dental School to be recognized as Distinguished Alumni of Boston University. He received the Harold Berk Award from the Academy of Dentistry for Persons with Disabilities, and the Manny Album Award from the American Academy of Pediatric Dentistry. He was president of the Academy of Dentistry for Persons with Disabilities and Massachusetts Academy of Pediatric Dentistry. He founded Special Olympics Special Smiles, for which he serves as the Global Clinical Director. The
B
etween 2001 and 2005, almost one-third of the noninstitutionalized adult U.S. population had limitations and disabilities in a vast array of physical, emotional, cognitive, work, and self-care areas. These limitations increase dramatically in the older adult population—an age cohort that will escalate dramatically during the next decades. Nevertheless, dental and medical education programs and practitioners indicated that the care of patients with disabilities was not a high priority. As a result, limited didactic and clinical training is provided in the care of patients with disabilities, inadequate numbers of new health profession school graduates are pursuing careers in geriatrics, and limited numbers of dental practitioners provide care to patients with special health care needs. The necessity for improvements is couched in terms of concern that decisions for change could be made by forces other than the health professions. We are an aging population. Within 2 decades, one in five U.S. residents (about 70 million individuals) will be 65 years of age and older (in six states—Florida, Maine, Montana, New Mexico, North Dakota, and Wyoming—one in four will be 65 years of age or older).1 Social Security and Medicare funds could be exhausted— will benefits have to be reduced? Health care costs for the elderly could reach unbelievable proportions of the gross domestic product; we already are the highest in world. Media headlines repeatedly highlight retirement communities in the ‘‘better locales,’’ but just as often the media neglect to emphasize the potential consequences of the ‘‘baby boomer’’ and ‘‘X’’ generations filling the assisted living facilities, nursing homes, hospitals and, yes, our homes. In addition, they have
not really discovered the fact that, presently, almost two-thirds (63%) of the 65 years of age and older population have one or more disabilities. Further, 37% of the current 45- to 64-year-old population has one or more disabilities.1 These proportions may well increase as growing numbers of seniors reach their eighties, nineties, and beyond. As a consequence of deinstitutionalization and the Supreme Court Olmstead ruling that individuals with disabilities were entitled to live in their communities, private dental practitioners will be called upon to provide care for this burgeoning population. ‘‘Disability’’ is a multidimensional and dynamic concept that involves both individuals and their environment. The complex set of physical, emotional, or mental difficulties may well affect general issues of
ADULTS WITH DISABILITIES ARE AGING
American Academy of Pediatric Dentistry Foundation named him Dentist of the Year. He serves as Vice President of the American Academy of Developmental
Ramiz A. Chaudhry Medicine and Dentistry. Ramiz A. Chaudhry Dr. Chaudhry is a resident in the Department of Periodontics and Implantology at Stony Brook University School of Dental Medicine. He is a graduate of Stony Brook University School of Dental Medicine. He is the past president of his class and the Minorities Student Dental Association (MSDA). His research interests include diabetes and periodontal disease and periodontal health and chairside economical restoration of esthetic ceramic (CEREC) restorations.
health services, social participation, educational opportunities, and prospects for employment, as well as a seemingly infinite array of specific daily activities and lifetime prospects. The National Center for Health Statistics’ (NCHS) 2008 report on Disability and Health in the United States (using National Health Interview Survey data) reviews many of these issues it its latest report on the healthrelated differences between noninstitutionalized adults with and without disabilities.2 Previous writings in the Alpha Omegan reviewed the issues faced by children and young adults with disabilities.3,4 The current presentation will continue this effort with a review of adults with disabilities in their middle and older years—keeping in mind the fact that: (1) a broader awareness of the general health and activities of individuals with disabilities could facilitate the delivery of services by community-based dental practitioners, and (2) there are wide variations in the abilities and needs of each individual with a disability. DEFINITIONS
The NCHS survey report dichotomizes disabilities into two broad categories: basic action difficulties and complex activity limitations. Basic Action Difficulties Movement
Walking, standing, bending, kneeling, reaching overhead, and using hands and fingers. Sensory
The ability of a person to see and hear what is going on around him or her. Selected elements of emotional functioning
Feelings that interfere with accomplishing daily activities.
24
Cognitive functioning
Difficulties with remembering or experiencing confusion. Complex Activity Limitations Leisure activity limitations
Difficulties attending movies, sporting events, visiting friends, and pursuing hobbies. Ability to work
Difficulties in terms of type and duration. Maintaining independence
Including self-care and the ability to maintain a household, such as shopping, cooking, et cetera. NUMBERS AND PROPORTIONS
On average, between 2001 to 2005, approximately 62 million people (almost 30% of the noninstitutionalized adult U.S. population) had basic actions difficulties, increasing from 35% for the 45- to 64-yearold age group to 61% for the 65 years of age and over population. During the same period, 14% of the adult population (30 million people) had complex activity limitations, increasing from 17% to 32% for the middle age and older population groups. More than one-fifth of the adult population reported difficulties with walking, bending, reaching overhead, or using their fingers to grasp something; 13% reported vision or hearing difficulties; 12% reported work limitations; More than half of adults (52%) with self-care problems were 65 years of age and older; A greater proportion of females than males had disability limitations. This increased rate takes on added significance when considered in terms of the fact that a greater percent of females than males live into their eighties, nineties, and beyond (Table).
Alpha Omegan Volume 102 Number 1
ADULTS WITH DISABILITIES ARE AGING Table. Prevalence estimates of disabilities among adults 18 years of age and over by age, gender, and type of limitation: United States, 2001-2005*
Total Any limitation Basic actions difficulty 18–44 years of age 45–64 years of age 65 years of age Male Female Emotional difficulty Seeing or hearing difficulty Cognitive difficulty Complex activity limitation 18–44 years of age 45–64 years of age 65 years of age Male Female Social limitation Work limitation Self-care limitation
Population
Percent
211,133 66,317 62,338 18,296 23,422 20,620 26,152 36,186 6,487 27,655 5,876 30,097 7,418 11,751 10,928 12,891 17,205 14,599 24,548 8,738
— 31.4% 29.5% 16.7% 34.7% 60.7% 25.8% 33.0% 3.1% 13.1% 2.8% 14.3% 6.8% 17.4% 32.2% 12.7% 15.7% 6.9% 11.6% 4.1%
*Data taken from Altman and Bernstein.2
DEMOGRAPHIC CHARACTERISTICS OF THE POPULATION WITH DISABILITIES Age
The aging of the population takes on further meaning when viewed in terms of the increasing rates of obesity, with its attendant consequences of diabetes, arthritis, and other obesity-related conditions. According to Altman and Bernstein,2 ‘‘as a result, disability prevalence could increase to a greater extent than would be expected because of the change in the age distribution.’’ In addition, there is the concern that approximately two-thirds of individuals with difficulties associated with basic actions and complex activity limitations are less than 65 years of age; and they have not reached their older years when multiple factors add to and exacerbate existing conditions. Gender
While nondisabled adults were divided almost equally between
men and women, 60% of adults with both basic activity difficulties and complex activity limitations were women. Women were also overrepresented in the population with emotional difficulties (64%).
are less likely to have completed their high school education. People without disabilities were more likely to have a college degree (double or more the rate) than people with disabilities.
Race and Ethnicity
Employment
Compared to individuals in their respective populations without disabilities, (1) a greater proportion of individuals with disabilities were white; (2) a greater proportion of individuals with complex activity limitations were black; and (3) a smaller proportion of individuals with disabilities were Asians and Hispanics.
Almost 70% of individuals with complex activity limitations and 51% of those with basic actions difficulties had no job with the past year.
Education
The age of onset of a disability can affect the level of education that a person attains. However, the majority of individuals with a disability acquire that disability after they have completed their education. Adults with disabilities, compared to adults without disabilities,
Alpha Omegan Volume 102 Number 1
Family Income
One-half of adults with complex activity limitation and also 40% of those with basic actions difficulty reported family income below 200% of the federal poverty threshold. Health Status
One-third to one-half of adults with disabilities (compared to 3% of adults without disabilities) reported that their overall health was fair or poor. Compared to adults
25
ADULTS WITH DISABILITIES ARE AGING without disabilities, adults with disabilities are: Less likely to have a healthy weight and are more likely to be obese; More likely to be current smokers; Less likely to be alcohol drinkers; Less likely to be involved in regular exercise. Regular leisure-time activity decreases with age regardless of disability status, but the rate of decline is greater for adults with disabilities.
SUMMARY
The population is aging! Older individuals are faced with an increased burden of an array of disabilities. The escalating number of adults with disabilities (in addition to growing numbers of youngsters with developmental disabilities who are now surviving into adulthood) will require resources, trained personnel, housing, and a system of support that may well be beyond the imagination of any of today’s forecasters and planners.
Access to Health Care
Adults 18 to 44 years of age were reported less likely to have a usual source of medical care than adults in older age groups, regardless of disability status. Almost all (>95%) of individuals 65 years of age and older (with and without disabilities) had a usual source of medical care (the source of dental care was not reviewed in the NCHS study). Individuals with emotional difficulties were more likely than those with types of disabilities to report a clinic or health center as their source of care. Insurance Coverage
Adults (18-64 years of age) with disabilities are much more likely than those without disabilities to be covered by public program, primarily Medicare and Medicaid. One-quarter of adults under 65 years of age with a complex activity limitation had Medicaid coverage, as did 14% of those with basic actions difficulties. People with emotional difficulties most often reported being uninsured. Medicaid is a particularly important source of medical insurance for the more seriously disabled portion of the population that may not have been able to earn enough credits to receive Social Security Disability benefits.
26
What Do All These Numbers and Proportion Mean?
The certainty is that the health and social systems of our nation (and let’s not to forget the personal issues that will be faced by individual families) will need to come to terms with two separate but interrelated complex issues (‘‘geriatrics’’ and ‘‘disabilities’’); essentially, a comorbidity of factors. (In the past, ‘‘comorbid’’ indicated a medical condition existing simultaneously but independently with another condition in a patient. A more recent usage indicates a medical condition in a patient that causes, is caused by, or is otherwise related to another condition in the same patient.5) The relationship between geriatrics and disabilities would seem to fit under the umbrella of both definitions. The United States is not alone in these evolving issues. In many of the industrial nations, from Europe to Japan, there is increasing concern regarding the issues discussed below.
Geriatrics The combination of decreasing birth rates and an aging population will result in a shrinking work force to support the economic needs of the elderly.
The availability of interested and trained professionals to provide needed services. The need to develop living arrangements (from assisted living to nursing homes and other longterm facilities). Traditional living arrangements have been altered by the absence of family caregivers as a result of the increasing necessity for two income earners. Balancing expensive health services and quality of life decisions. Societal decisions regarding the allocation of scarce resources between younger and older populations.
Disabilities Increased ability to maintain and prolong the lives of individuals with disabilities. Deinstitutionalization of individuals with development/intellectual disabilities. Mainstreaming individuals with disabilities resulting in dependence upon local communities and providers for a wide range of services, including education, health care, employment, recreation, and residential needs. The availability of interested and trained professionals to provide needed services. Supervision and assistance as family members become unavailable because of other demands and/or death. Balancing expensive services and quality of life decisions.
The reality is that these issues raise questions regarding the very fabric of our society—the value of life, the teachings of religions, willingness to forego certain desires so as to benefit those in need, and (maybe) the need to raise questions regarding responsibilities.
Alpha Omegan Volume 102 Number 1
ADULTS WITH DISABILITIES ARE AGING Dental Issues
Most dental school curricula only recently have come to terms with the need to provide programs in the care of the elderly. Many of the difficulties faced in dental education and the general delivery of oral health services for the elderly and the disabled are not that dissimilar from those faced in the general field of medicine: limited interest in advanced training in geriatrics and services for the disabled. A 2003 report to the U.S. Congress concluded that, ‘‘The medical problems of older people often are viewed as unexciting and irreversible. Geriatricians will likely have lower income relative to procedurally oriented specialties, further dampening physicians’ interest in this career.’’6 A 2007 study carried out by the Academy of Developmental Medicine and Dentistry found that: (1) a majority of deans of medical and dental schools reported care of patients with disabilities was not a high priority; and (2) a majority of dental residencies reported limited didactic and clinical training in the care of patients with disabilities.7
Specifically, changes have been introduced in the accrediting process of schools of dentistry and dental hygiene to ensure the preparation of new graduates are capable of carrying out the care of individuals with special needs. Since 2006, the Commission of Dental Accreditation instituted a new standard which requires that ‘‘Graduates must be competent in assessing the treatment needs of patients with special needs.’’8 But this is only a start,
and it will require many years before adequate numbers of trained practitioners are available to provide needed services for a burgeoning adult population with disabilities. Is it possible that decisions regarding directions to be taken for improving the care for this population could be made by forces other than the dental professions? In the past, when dentists were unwilling to provide needed denture services for underserved populations in the state of Oregon, three-quarters of the voting citizens of that state approved the legalization of denturists.9 More recently, the Alaska Dental Society and the American Dental Association filed a lawsuit to prevent the training of dental therapists to provide care for patients in underserved areas. The dental organizations dropped the suit after a state court judge issued a ruling critical of the dentists. The American Dental Association continues to oppose allowing therapists to operate anywhere in the lower 49 states. Currently, therapists are allowed to practice only in Alaska, and only on Alaska Natives. According to the New York Times, ‘‘The dental groups object not because of any evidence that the clinic provides substandard care, but because it is run by an individual who is not a dentist. After two years of training in a program unique to Alaska.[a dental therapist] performs basic dental work like drilling and filling cavities.’’10 The need is to provide necessary care for the burgeoning population of older adults with disabilities. Will dental therapists be able to replace trained practitioners in care of these patients with special needs?
Alpha Omegan Volume 102 Number 1
Probably not—but are we willing to wait around until government agencies, the electorate, and/or private entrepreneurs come up with their solutions? References 1. U.S. Census Bureau website. U.S. Interim population projection by age, sex, race, and Hispanic origin. 2005. Web site: http://www.census.gov/population/ www/projections/usinterimproj/ Accessed November 15, 2007. 2. Altman B, Bernstein A. Disability and health in the United States, 2001-2005. Hyattsville, MD, National Center for Health Statistics, 2008. 3. Waldman HB, Perlman SP. Children with special health care needs. Alpha Omegan 2004;97:12–5. 4. Waldman HB, Perlman SP. Young adults with disabilities and uninsured for health care. Alpha Omegan (in press). 5. The Free Dictionary. Comorbidity. Website: http://encyclopedia.thefree dictionary.com/comorbidity Accessed August 2, 2009. 6. Medicare Payment Advisory Commission website. Report to the Congress. Impact of the resident caps on the supply of geriatricians. Website: http://www.medpac. gov/publications/congressional_reports/ nov2003_Gtricians.pdf Accessed August 4, 2008. 7. Holder M, Waldman HB, Hood H, et al. Preparing health profession program graduates to provide care to individuals with disabilities. Disability and Health Journal (in review). 8. Commission on Dental Accreditation. Accreditation standards for dental education. Chicago, American Dental Association, 2004. 9. Bureau of Economic and Behavior Research. The Oregon lesson: results of postulation research. J Am Dent Assoc 1979;95:749–54. 10. Berenson A. Dental clinic, meeting a need with no dentist. New York Times, April 28, 2008. Web site http://www. nytimes.com/2008/04/28/business/28 teeth.html?_r¼1&oref¼slogin Accessed August 3, 2008.
27
Adults With Disabilities Are Aging H. Barry Waldman, DDS, MPH, PhD, Steven P. Perlman, DDS, MScD, and Ramiz A. Chaudhry, DDS H. Barry Waldman
Steven P. Perlman
H. Barry Waldman Dr. H. Barry Waldman is a Distinguished Teaching Professor of the State University of New York. He was the first faculty member of the School of Dental Medicine at Stony Brook where he has served for more than 38 years in numerous roles, including Department Chair and Assistant Dean, and he has also participated in teaching programs throughout the Health Sciences Center and the undergraduate college. He has published more than 850 monographs and articles in international, national, and regional publications evaluating health delivery and social issues, including manpower, health economics, delivery modalities, and quality assessment, with particular emphasis on the issues facing the delivery of health services to both younger and older patients with special health care needs. Together with Dr. Perlman, he initiated changes in the accreditation process that now require all schools of dentistry and dental hygiene to provide training for students in the care of patients with special needs. Steven P. Perlman Dr. Steven Perlman is Associate Clinical Professor of Pediatric Dentistry at Boston University Goldman School of Dental Medicine. He devotes his practice and teaching to the treatment of children and adults with disabilities. He was the first dentist in Massachusetts to receive the Excellent Physician Award, and the only graduate of the Dental School to be recognized as Distinguished Alumni of Boston University. He received the Harold Berk Award from the Academy of Dentistry for Persons with Disabilities, and the Manny Album Award from the American Academy of Pediatric Dentistry. He was president of the Academy of Dentistry for Persons with Disabilities and Massachusetts Academy of Pediatric Dentistry. He founded Special Olympics Special Smiles, for which he serves as the Global Clinical Director. The
B
etween 2001 and 2005, almost one-third of the noninstitutionalized adult U.S. population had limitations and disabilities in a vast array of physical, emotional, cognitive, work, and self-care areas. These limitations increase dramatically in the older adult population—an age cohort that will escalate dramatically during the next decades. Nevertheless, dental and medical education programs and practitioners indicated that the care of patients with disabilities was not a high priority. As a result, limited didactic and clinical training is provided in the care of patients with disabilities, inadequate numbers of new health profession school graduates are pursuing careers in geriatrics, and limited numbers of dental practitioners provide care to patients with special health care needs. The necessity for improvements is couched in terms of concern that decisions for change could be made by forces other than the health professions. We are an aging population. Within 2 decades, one in five U.S. residents (about 70 million individuals) will be 65 years of age and older (in six states—Florida, Maine, Montana, New Mexico, North Dakota, and Wyoming—one in four will be 65 years of age or older).1 Social Security and Medicare funds could be exhausted— will benefits have to be reduced? Health care costs for the elderly could reach unbelievable proportions of the gross domestic product; we already are the highest in world. Media headlines repeatedly highlight retirement communities in the ‘‘better locales,’’ but just as often the media neglect to emphasize the potential consequences of the ‘‘baby boomer’’ and ‘‘X’’ generations filling the assisted living facilities, nursing homes, hospitals and, yes, our homes. In addition, they have
not really discovered the fact that, presently, almost two-thirds (63%) of the 65 years of age and older population have one or more disabilities. Further, 37% of the current 45- to 64-year-old population has one or more disabilities.1 These proportions may well increase as growing numbers of seniors reach their eighties, nineties, and beyond. As a consequence of deinstitutionalization and the Supreme Court Olmstead ruling that individuals with disabilities were entitled to live in their communities, private dental practitioners will be called upon to provide care for this burgeoning population. ‘‘Disability’’ is a multidimensional and dynamic concept that involves both individuals and their environment. The complex set of physical, emotional, or mental difficulties may well affect general issues of
ADULTS WITH DISABILITIES ARE AGING
American Academy of Pediatric Dentistry Foundation named him Dentist of the Year. He serves as Vice President of the American Academy of Developmental
Ramiz A. Chaudhry Medicine and Dentistry. Ramiz A. Chaudhry Dr. Chaudhry is a resident in the Department of Periodontics and Implantology at Stony Brook University School of Dental Medicine. He is a graduate of Stony Brook University School of Dental Medicine. He is the past president of his class and the Minorities Student Dental Association (MSDA). His research interests include diabetes and periodontal disease and periodontal health and chairside economical restoration of esthetic ceramic (CEREC) restorations.
health services, social participation, educational opportunities, and prospects for employment, as well as a seemingly infinite array of specific daily activities and lifetime prospects. The National Center for Health Statistics’ (NCHS) 2008 report on Disability and Health in the United States (using National Health Interview Survey data) reviews many of these issues it its latest report on the healthrelated differences between noninstitutionalized adults with and without disabilities.2 Previous writings in the Alpha Omegan reviewed the issues faced by children and young adults with disabilities.3,4 The current presentation will continue this effort with a review of adults with disabilities in their middle and older years—keeping in mind the fact that: (1) a broader awareness of the general health and activities of individuals with disabilities could facilitate the delivery of services by community-based dental practitioners, and (2) there are wide variations in the abilities and needs of each individual with a disability. DEFINITIONS
The NCHS survey report dichotomizes disabilities into two broad categories: basic action difficulties and complex activity limitations. Basic Action Difficulties Movement
Walking, standing, bending, kneeling, reaching overhead, and using hands and fingers. Sensory
The ability of a person to see and hear what is going on around him or her. Selected elements of emotional functioning
Feelings that interfere with accomplishing daily activities.
24
Cognitive functioning
Difficulties with remembering or experiencing confusion. Complex Activity Limitations Leisure activity limitations
Difficulties attending movies, sporting events, visiting friends, and pursuing hobbies. Ability to work
Difficulties in terms of type and duration. Maintaining independence
Including self-care and the ability to maintain a household, such as shopping, cooking, et cetera. NUMBERS AND PROPORTIONS
On average, between 2001 to 2005, approximately 62 million people (almost 30% of the noninstitutionalized adult U.S. population) had basic actions difficulties, increasing from 35% for the 45- to 64-yearold age group to 61% for the 65 years of age and over population. During the same period, 14% of the adult population (30 million people) had complex activity limitations, increasing from 17% to 32% for the middle age and older population groups. More than one-fifth of the adult population reported difficulties with walking, bending, reaching overhead, or using their fingers to grasp something; 13% reported vision or hearing difficulties; 12% reported work limitations; More than half of adults (52%) with self-care problems were 65 years of age and older; A greater proportion of females than males had disability limitations. This increased rate takes on added significance when considered in terms of the fact that a greater percent of females than males live into their eighties, nineties, and beyond (Table).
Alpha Omegan Volume 102 Number 1
ADULTS WITH DISABILITIES ARE AGING Table. Prevalence estimates of disabilities among adults 18 years of age and over by age, gender, and type of limitation: United States, 2001-2005*
Total Any limitation Basic actions difficulty 18–44 years of age 45–64 years of age 65 years of age Male Female Emotional difficulty Seeing or hearing difficulty Cognitive difficulty Complex activity limitation 18–44 years of age 45–64 years of age 65 years of age Male Female Social limitation Work limitation Self-care limitation
Population
Percent
211,133 66,317 62,338 18,296 23,422 20,620 26,152 36,186 6,487 27,655 5,876 30,097 7,418 11,751 10,928 12,891 17,205 14,599 24,548 8,738
— 31.4% 29.5% 16.7% 34.7% 60.7% 25.8% 33.0% 3.1% 13.1% 2.8% 14.3% 6.8% 17.4% 32.2% 12.7% 15.7% 6.9% 11.6% 4.1%
*Data taken from Altman and Bernstein.2
DEMOGRAPHIC CHARACTERISTICS OF THE POPULATION WITH DISABILITIES Age
The aging of the population takes on further meaning when viewed in terms of the increasing rates of obesity, with its attendant consequences of diabetes, arthritis, and other obesity-related conditions. According to Altman and Bernstein,2 ‘‘as a result, disability prevalence could increase to a greater extent than would be expected because of the change in the age distribution.’’ In addition, there is the concern that approximately two-thirds of individuals with difficulties associated with basic actions and complex activity limitations are less than 65 years of age; and they have not reached their older years when multiple factors add to and exacerbate existing conditions. Gender
While nondisabled adults were divided almost equally between
men and women, 60% of adults with both basic activity difficulties and complex activity limitations were women. Women were also overrepresented in the population with emotional difficulties (64%).
are less likely to have completed their high school education. People without disabilities were more likely to have a college degree (double or more the rate) than people with disabilities.
Race and Ethnicity
Employment
Compared to individuals in their respective populations without disabilities, (1) a greater proportion of individuals with disabilities were white; (2) a greater proportion of individuals with complex activity limitations were black; and (3) a smaller proportion of individuals with disabilities were Asians and Hispanics.
Almost 70% of individuals with complex activity limitations and 51% of those with basic actions difficulties had no job with the past year.
Education
The age of onset of a disability can affect the level of education that a person attains. However, the majority of individuals with a disability acquire that disability after they have completed their education. Adults with disabilities, compared to adults without disabilities,
Alpha Omegan Volume 102 Number 1
Family Income
One-half of adults with complex activity limitation and also 40% of those with basic actions difficulty reported family income below 200% of the federal poverty threshold. Health Status
One-third to one-half of adults with disabilities (compared to 3% of adults without disabilities) reported that their overall health was fair or poor. Compared to adults
25
ADULTS WITH DISABILITIES ARE AGING without disabilities, adults with disabilities are: Less likely to have a healthy weight and are more likely to be obese; More likely to be current smokers; Less likely to be alcohol drinkers; Less likely to be involved in regular exercise. Regular leisure-time activity decreases with age regardless of disability status, but the rate of decline is greater for adults with disabilities.
SUMMARY
The population is aging! Older individuals are faced with an increased burden of an array of disabilities. The escalating number of adults with disabilities (in addition to growing numbers of youngsters with developmental disabilities who are now surviving into adulthood) will require resources, trained personnel, housing, and a system of support that may well be beyond the imagination of any of today’s forecasters and planners.
Access to Health Care
Adults 18 to 44 years of age were reported less likely to have a usual source of medical care than adults in older age groups, regardless of disability status. Almost all (>95%) of individuals 65 years of age and older (with and without disabilities) had a usual source of medical care (the source of dental care was not reviewed in the NCHS study). Individuals with emotional difficulties were more likely than those with types of disabilities to report a clinic or health center as their source of care. Insurance Coverage
Adults (18-64 years of age) with disabilities are much more likely than those without disabilities to be covered by public program, primarily Medicare and Medicaid. One-quarter of adults under 65 years of age with a complex activity limitation had Medicaid coverage, as did 14% of those with basic actions difficulties. People with emotional difficulties most often reported being uninsured. Medicaid is a particularly important source of medical insurance for the more seriously disabled portion of the population that may not have been able to earn enough credits to receive Social Security Disability benefits.
26
What Do All These Numbers and Proportion Mean?
The certainty is that the health and social systems of our nation (and let’s not to forget the personal issues that will be faced by individual families) will need to come to terms with two separate but interrelated complex issues (‘‘geriatrics’’ and ‘‘disabilities’’); essentially, a comorbidity of factors. (In the past, ‘‘comorbid’’ indicated a medical condition existing simultaneously but independently with another condition in a patient. A more recent usage indicates a medical condition in a patient that causes, is caused by, or is otherwise related to another condition in the same patient.5) The relationship between geriatrics and disabilities would seem to fit under the umbrella of both definitions. The United States is not alone in these evolving issues. In many of the industrial nations, from Europe to Japan, there is increasing concern regarding the issues discussed below.
Geriatrics The combination of decreasing birth rates and an aging population will result in a shrinking work force to support the economic needs of the elderly.
The availability of interested and trained professionals to provide needed services. The need to develop living arrangements (from assisted living to nursing homes and other longterm facilities). Traditional living arrangements have been altered by the absence of family caregivers as a result of the increasing necessity for two income earners. Balancing expensive health services and quality of life decisions. Societal decisions regarding the allocation of scarce resources between younger and older populations.
Disabilities Increased ability to maintain and prolong the lives of individuals with disabilities. Deinstitutionalization of individuals with development/intellectual disabilities. Mainstreaming individuals with disabilities resulting in dependence upon local communities and providers for a wide range of services, including education, health care, employment, recreation, and residential needs. The availability of interested and trained professionals to provide needed services. Supervision and assistance as family members become unavailable because of other demands and/or death. Balancing expensive services and quality of life decisions.
The reality is that these issues raise questions regarding the very fabric of our society—the value of life, the teachings of religions, willingness to forego certain desires so as to benefit those in need, and (maybe) the need to raise questions regarding responsibilities.
Alpha Omegan Volume 102 Number 1
ADULTS WITH DISABILITIES ARE AGING Dental Issues
Most dental school curricula only recently have come to terms with the need to provide programs in the care of the elderly. Many of the difficulties faced in dental education and the general delivery of oral health services for the elderly and the disabled are not that dissimilar from those faced in the general field of medicine: limited interest in advanced training in geriatrics and services for the disabled. A 2003 report to the U.S. Congress concluded that, ‘‘The medical problems of older people often are viewed as unexciting and irreversible. Geriatricians will likely have lower income relative to procedurally oriented specialties, further dampening physicians’ interest in this career.’’6 A 2007 study carried out by the Academy of Developmental Medicine and Dentistry found that: (1) a majority of deans of medical and dental schools reported care of patients with disabilities was not a high priority; and (2) a majority of dental residencies reported limited didactic and clinical training in the care of patients with disabilities.7
Specifically, changes have been introduced in the accrediting process of schools of dentistry and dental hygiene to ensure the preparation of new graduates are capable of carrying out the care of individuals with special needs. Since 2006, the Commission of Dental Accreditation instituted a new standard which requires that ‘‘Graduates must be competent in assessing the treatment needs of patients with special needs.’’8 But this is only a start,
and it will require many years before adequate numbers of trained practitioners are available to provide needed services for a burgeoning adult population with disabilities. Is it possible that decisions regarding directions to be taken for improving the care for this population could be made by forces other than the dental professions? In the past, when dentists were unwilling to provide needed denture services for underserved populations in the state of Oregon, three-quarters of the voting citizens of that state approved the legalization of denturists.9 More recently, the Alaska Dental Society and the American Dental Association filed a lawsuit to prevent the training of dental therapists to provide care for patients in underserved areas. The dental organizations dropped the suit after a state court judge issued a ruling critical of the dentists. The American Dental Association continues to oppose allowing therapists to operate anywhere in the lower 49 states. Currently, therapists are allowed to practice only in Alaska, and only on Alaska Natives. According to the New York Times, ‘‘The dental groups object not because of any evidence that the clinic provides substandard care, but because it is run by an individual who is not a dentist. After two years of training in a program unique to Alaska.[a dental therapist] performs basic dental work like drilling and filling cavities.’’10 The need is to provide necessary care for the burgeoning population of older adults with disabilities. Will dental therapists be able to replace trained practitioners in care of these patients with special needs?
Alpha Omegan Volume 102 Number 1
Probably not—but are we willing to wait around until government agencies, the electorate, and/or private entrepreneurs come up with their solutions? References 1. U.S. Census Bureau website. U.S. Interim population projection by age, sex, race, and Hispanic origin. 2005. Web site: http://www.census.gov/population/ www/projections/usinterimproj/ Accessed November 15, 2007. 2. Altman B, Bernstein A. Disability and health in the United States, 2001-2005. Hyattsville, MD, National Center for Health Statistics, 2008. 3. Waldman HB, Perlman SP. Children with special health care needs. Alpha Omegan 2004;97:12–5. 4. Waldman HB, Perlman SP. Young adults with disabilities and uninsured for health care. Alpha Omegan (in press). 5. The Free Dictionary. Comorbidity. Website: http://encyclopedia.thefree dictionary.com/comorbidity Accessed August 2, 2009. 6. Medicare Payment Advisory Commission website. Report to the Congress. Impact of the resident caps on the supply of geriatricians. Website: http://www.medpac. gov/publications/congressional_reports/ nov2003_Gtricians.pdf Accessed August 4, 2008. 7. Holder M, Waldman HB, Hood H, et al. Preparing health profession program graduates to provide care to individuals with disabilities. Disability and Health Journal (in review). 8. Commission on Dental Accreditation. Accreditation standards for dental education. Chicago, American Dental Association, 2004. 9. Bureau of Economic and Behavior Research. The Oregon lesson: results of postulation research. J Am Dent Assoc 1979;95:749–54. 10. Berenson A. Dental clinic, meeting a need with no dentist. New York Times, April 28, 2008. Web site http://www. nytimes.com/2008/04/28/business/28 teeth.html?_r¼1&oref¼slogin Accessed August 3, 2008.
27