imageWhat accounts for one-third of all healthcare spending, more than 40 percent of all doctor visits and one-third of all prescription drug sales?

People aged 65 years and older.

The same Baby Boom generation that popularized the Hula-hoop and the quote, “Never trust anyone over thirty,” is entering its fifth decade. Wherever this disproportionately large group moves on the timeline of history, it makes an impact. This time, the significant increase in the number of people over the age of 50 is placing new and unique demands on our healthcare system.

In keeping with that trend, geriatrics, the medical specialty that focuses on caring for elderly patients, is in high demand. Demographers predict that by the Year 2003, geriatric patients will account for one-third of the U.S. population. On the bright side, Baby Boomers, who take care of their health and are genetically lucky, can expect to live a long and active life. On the other hand, those who neglect their health or have been dealt a poor hand in the genetic lottery, may find themselves facing one or several diseases that strike the elderly with regularity.

The patient education web page of The American Geriatrics Society lists several health-related topics that concern the elderly: osteoporosis, depression, falls and balance problems, end of life care, Alzheimer’s, safe driving for seniors, chronic pain, dementia, stroke awareness and prevention, urinary incontinence and memory loss.

In this month’s Disease Management section our writers look into a few health-related solutions for the elderly. From prostate cancer and pain management to finding comfortable furniture that’s also easy to get in and out of, there are more medical options and healthcare information to keep up with than in past years.

It ain’t what it used to be — pain management for the elderly
Doctors today can do more about pain than ever before. In fact, pain management has progressed from one of the many tools inside the black satchel of any good internist to a separate, subspecialty similar to diagnostic or allergy medicine. Moreover, modern pain management goes well beyond the use of drugs and now consists of a broad-based approach that employs a variety of methods to maximize patient comfort and functionality. Despite these advances, only about 25 percent of people, including the elderly, ever see a pain specialist. That means that nearly three quarters of those suffering from moderate to severe and disabling pain, the majority of whom are elderly, may be suffering unnecessarily.

“Most pain in the elderly is joint pain. Patients are at risk of a vicious cycle in which joint pain leads to inactivity and inactivity leads to diminished function and then again to joint pain,” said Russell Portenoy, M.D., Chairman of the Pain Management and Palliative Care Department at Beth Israel Hospital in New York.

For many elderly folks, the scenario goes like this: They develop severe joint and low back pain and consequently they find themselves less and less able to do things. So, they go to an internist who recommends an anti-inflammatory drug. But the pain does not get better. They go back to the internist who recommends another anti-inflammatory. The second drug does not work, and they go back again, or perhaps they go to another internist.

“The first step”, said Portenoy, “is to establish whether or not there are treatable etiologies for the pain. The best example of that in the non-cancer world is joint replacement for retractable arthritis.” This also demonstrates the importance of a thorough assessment. “If the underlying cause of a patient’s pain is treatable and a risk- benefit assessment suggests treatment is in the patient’s best interest then that treatment should be pursued, along with other analgesic approaches,” Portenoy explained.

Pain Management — The Basics
After completing a thorough assessment, a pain specialist develops a customized pain management program for each patient. Of course, many drugs are available for pain ranging from over-the-counter to prescription narcotics. Some antidepressants are useful for treating particular forms of neuralgia and neuropathy. Drug therapy for pain includes nerve blocks in which an anesthetic is injected in close proximity to the nerve involved as a means of impeding its conductivity.

A similar but non-chemical approach is transcutaneous electrical nerve stimulation or TENS. TENS patients wear a small battery-powered stimulator that sends impulses through the skin that are similar to nerve impulses but different enough to prevent the transmission of pain to the brain. Rehabilitation also is a common component of pain management. Techniques range from physical therapy to keep joints flexible to the use of splints to prevent nerve or tissue injury. Surgery is used to treat pain in several ways, but one of the most common procedures for pain in the elderly is hip replacement.

Complementary and alternative approaches such as massage therapy and acupuncture are now commonly used in the pain management armamentarium. Finally, it may be necessary for a patient who is experiencing chronic pain to make lifestyle changes to both reduce current pain and help prevent future pain. Weight loss and increased activity are common lifefstyle adjustments.

Pain Problems of the Elderly
Older patients should keep in mind that not every pain specialist understands the problems of their age group. One such problem is the difficulty in assessing pain. Many older patients do not report pain because they want to be thought of as “good patients.” Then there’s the higher likelihood that older patients have more than one medical condition contributing to their pain. “About 70 percent of the pain specialists in the United States are anesthesiologists, and they may not have a lot of experience with the management of conditions such as diabetes, heart disease, or chronic obstructive pulmonary disease. Consequently, they may not have a lot of first-hand experience handling the co-morbidities that elderly patients with chronic pain present with,” Portenoy said.

    An additional challenge for elderly patients is today’s mix-and-match world of healthcare. “Trying to piece together good pain care in the current system — Medicare, Medicaid, and managed care — is very complicated. It is extremely commonplace for us to be able to offer patients only part of what they need,” Portenoy said. Patients may not receive all the treatment a pain specialist recommends due to lack of coverage, denial of coverage, their HMO doesn’t have the prescribed drug in its formulary or because the patient doesn’t have outpatient drug coverage. Finally, there is the issue of the family’s role. Family members should address their elder’s pain problem within the context of their family, particularly if the elder does not have a spouse and caregiving is being provided in whole or in part by children. “It’s an enormous challenge for everyone involved, “ Portenoy concluded.

— Jonathan Briggs

Matching PSA/fPSA
The clinical value of the free PSA (fPSA) assay has been validated by many recent studies. But because there are so many brands of PSA and fPSA assays available, it has become increasingly important for laboratorians to be aware that these tests should not be used interchangeably.

Clinical studies have shown that using different brands of PSA and fPSA assays to aid in the detection and monitoring of prostate cancer can produce inaccurate test results. These inaccurate results can, in turn, lead to misdiagnosis.

There are several factors to consider when choosing PSA and fPSA assays. These include:

1. Only use FDA-approved assays. To obtain FDA approval as an aid in the detection of prostate cancer, PSA assays must undergo rigorous, controlled clinical studies to establish cutoffs and positive predictive values that provide specific and accurate performance data on sensitivity and specificity.

There are about nine total PSA tests currently available in the United States, but only a few have FDA approval to aid in the prostate cancer detection. Only one fPSA assay currently has FDA approval. It is used in conjunction with total PSA to enhance the specificity of prostate cancer detection (Hybritech free PSA test by Beckman Coulter).

While some labs create “home brew” tests for fPSA, these assays are not FDA approved. Other labs use Investigational-Use-Only (IUO) fPSA tests, which are meant to be used in clinical trials. Generally, IUO tests should not be used for reporting “chartable” patient results. Both home brew and IUO tests may not be calibrated to FDA-approved total PSA assays and could give misleading results when differentiating prostate cancer from benign diseases, especially when not matched to the manufacturers’ total PSA test.

2. Use equimolar assays. Total PSA measurements are made up of both “free” and “bound” forms of PSA. There are two types of PSA assays that measure these: equimolar and skewed.

Equimolar tests are preferred because they detect free and bound PSA equally and provide the most accurate reflection of total PSA.

Skewed assays detect free and bound PSA unevenly. Studies have shown these assays can overestimate or underestimate total PSA levels. It is important to understand the effects of equimolarity when using a fPSA assay with a skewed total PSA assay.

3. How was assay cutoff established? The first test to be FDA-approved for monitoring prostrate cancer (in 1985) and for detection of it in conjunction with a digital rectal exam (in 1994) was the Hybritech total PSA test. In clinical studies, 4.0 ng/mL was established as the upper limit of normal, a cutoff that appears in most of the literature on the use of total PSA.

Other PSA assays use the 4.0 ng/mL cutoff, but they may not be supported by clinical trials to confirm this range. These tests may not be calibrated to the Hybritech total PSA, which means the results are not accurate.

Additionally, fPSA assays must be correctly calibrated for use with total PSA tests to produce accurate results. The only FDA-cleared fPSA assay has a 25 percent cutoff rate. This cutoff was determined in clinical studies to be 95 percent accurate in distinguishing prostate cancer from benign conditions. fPSA assays not approved by the FDA may not have the same cutpoint and may not work accurately with other total PSA tests.

4. Only use matching brands of PSA assays. Clinical studies show that different commercial PSA and fPSA tests give different results, even in the same sample. Using different combinations of brand names of total PSA and fPSA assays can produce significantly different results in cutoffs, sensitivity and specificity, all of which can produce inaccurate test results.

Jack Montgomery is the technical specialist in chemistry and special chemistry at Rogue Valley Medical Center in Medford, Ore.

dm02.jpg (7512 bytes)Small design changes make LifeSpan furniture ideal for elderly
Some of the new chairs designed by LifeSpan Furnishings were on display at a California senior center last fall when one patron decided that she was definitely not interested in the innovative seating options.

Robert T. Jeffery, a partner in the Emeryville, Calif., company that is a pioneer in manufacturing furniture that meets the comfort needs of the sick or elderly yet doesn’t look like it belongs in a hospital room, recalls that the older woman was firm in her opinion.

She was not swayed by the chair’s sleek lines, or its patterned, textured upholstery. Nope, it simply wasn’t to her taste.

Then she sat down.

“It was a 180-degree change,” he said, with a laugh. “She ended up saying, “Oh, this is really comfortable. It feels good.”

Jeffery and LifeSpan president and senior designer Brian Donnelly, are starting to get used to their products selling themselves.

With a growing line of chairs and tables, LifeSpan is finding itself with a fast-expanding client list of individuals, senior centers and assisted living facilities. It no longer has a “typical” customer as everyone from octogenarians to expectant moms can appreciate furniture that looks as good as it feels.

LifeSpan’s purpose, according to Jeffery, is to manufacture stylish, well-crafted furniture that has been slightly modified to provide safe and comfortable seating for people who might have difficulty with a so-called “normal chair.”

The changes are surprisingly subtle, he said, and thanks to Donnelly’s artistic eye, the result is aesthetically pleasing furniture that easily blends with the decor of people’s living rooms, dining rooms and patios.

“You move a pivot point back, or make the arms higher and it’s surprising what a difference can be made,” Jeffery said. “We want to make people feel as comfortable as possible in furniture that looks good. If you didn’t know, you would think our chair was just a usual arm chair.”

Although subtle, Jeffery said that the changes make a big difference when someone with limited strength or mobility has to lower themselves into a chair, or find the leverage to get from a sitting to standing position.

“Our line of furnishings is for people of any age,” he said, “whether it be someone who is elderly, or a third-trimester mom, or someone who has sore knees due to tendonitis.”

Although LifeSpan was formed in 1998, Donnelly has been designing furniture for comfortable living since 1990. His patented work has earned numerous awards including the 1999 Design Journal’s Award for Design Excellence. In 1996 he received an award from Products for Independent Living.

Donnelly’s specialized design work started 10 years ago when he found himself looking for comfortable furniture for his aging father. An industrial designer and associate professor at San Francisco State University at the time, Donnelly was dismayed by the lack of attractive options.

“What was out there — and what’s still out there — is mostly very medical looking and very ugly,” Jeffery said. “We find that aesthetics are very important. People do not want to think of themselves as sick or aging.”

What started as a labor of love for Donnelly has resulted in a line of attractive furniture and a burgeoning company. As the company’s web site ( shows, the expanding product list includes chairs that range in style from contemporary to a traditional wing chair.

Modifications such as more stabilized legs and extended arms on the chairs make it easier for people with limited strength or mobility to sit down. Some of the chairs also feature gently swayed backs and curved footrests that neatly slip beneath the chair when not in use.

The tables are designed at a comfortable height that compliments the chairs, and also take into consideration the need to have medication and other objects handy. A recessed area provides a secure spot for beverages or pill bottles, and optional side storage allows for larger items such as magazines or books.

As is the practice at LifeSpan, Jeffery said that the features of the furniture evolve after a lot of research and practical observation. For example, the table designs reflect recent studies indicating that many elderly people like to ‘cocoon’ their favorite sitting area. “They like to have all the things that they need handy,” Jeffery said. “The remote control for the television, their eyeglasses, boxes of tissues, and medications and such. We rely on a lot of input from geriatric specialists.”

Despite the specialty of the designs, LifeSpan has not scrimped on aesthetics. Buying one of their pieces affords the same options that people are used to at furniture stores.

There are choices of woods and metals, and fabric swatches to display a variety of upholstery choices. The chairs range in price from approximately $250 to about $700. Many of the products are sold on the Internet, Jeffery said.

As the company continues to show its wares at design fairs and also make visits to senior centers, Jeffery said it is clear that there is a large market niche for user-friendly furniture that does not look like it came from a medical supply store. And one of LifeSpan’s biggest challenges in coming months, he said, will be to keep up with the growing demand.

“In a way, we bit off more than we can chew,” he said, describing the increasing demand for the products plus the attempt to continually add new items to the LifeSpan line. “We’re trying to keep it all together,” Jeffery said. “We’ve made a conscious decision to offer something of great social value: Furniture that is attractive, functional and affordable.”

— Barbara Rice