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Age-Old Questions

Diseases associated with aging may not be the most glamorous part of public health, but they are increasingly important. RSPH faculty are spanning the disciplines to answer pressing questions surrounding the financial and quality-of-life costs of growing old.




By Rhonda Mullen

The day Joe Brown’s aged mother fell asleep with a cigarette smoldering in her hand marked the beginning of a traumatic turn in her own life as well as the lives of her family members. While she recovered in a hospital burn unit, the progression of her husband’s dementia became painfully obvious. Brown, a computer specialist, had to take his father’s car away and find him an assisted-living facility, all while grappling with the approach of Y2K at work. The family resources dwindled quickly. Brown enrolled his mother in Medicaid when she was finally released from the hospital. Then came the daunting task of finding a nursing home with a bed available for a Medicaid patient.

Brown was overwhelmed, tired, and depressed by the time he met clinical psychologist Nancy Thompson, who was leading a caregivers’ support group. Unfortunately, says Thompson, an associate professor in behavioral sciences and health education, situations like Brown’s grow more common every day. They are part and parcel of one of the biggest public health challenges of the millennium: a demographic shift fueled by aging baby boomers and longer life expectancies.

In the United States, the number of people 65 and older will double by the year 2030, making up 20% of the nation’s population. Those 85 and older are the fastest-growing segment, and by 2050, estimates predict they will number 19.4 million.

To compound the problem, while Medicare rolls are swelling, there are fewer people in the younger generation to refill the coffers. The implications of what is being called the “demographic imperative” are staggering. Many experts predict the country will be unable to afford care of an increasingly older, frailer population within the next generation without significant changes in current systems.

The Rollins School of Public Health (RSPH) is collaborating with the schools of Medicine and Nursing to take on this demographic imperative. Faculty are engaged in studies that range from health economics to health education. At Emory’s new Center for Health in Aging, they are leading research efforts and integrating public health approaches—those that emphasize prevention and cost-effective quality care for all our nation’s elderly—with medical approaches.

Directed by renowned Emory geriatrician Joseph Ouslander, the center is based on Emory’s 72-acre Wesley Woods campus, alongside an acute-care geriatric hospital, two nursing homes, an outpatient clinic, residential apartments for the elderly, and clinical, research, and administrative offices. The center is a learning laboratory, a clearinghouse for researchers with diverse interests related to aging—including genetics, physiology, psychology, sociology, finance, and spirituality. Its mission is to develop interdisciplinary research and training programs in geriatrics to help people age in healthy, affordable, ethical, and enjoyable ways.

Spending smarter

Providing long-term solutions that are “feasible and fundable” is the objective of Victoria Phillips, an associate director of the new center and associate professor of health policy and management at RSPH.


With an economist’s eye, Victoria Phillips examines health policies affecting the elderly. In many of her studies, she finds that “more expensive” does not always mean “better.”
The research questions she examines are complex: What is the most cost-effective treatment for geriatric depression? What role do behavior problems in those with dementia play in nursing home placement? How can we improve quality of life for those with chronic illnesses and disabilities as we extend life expectancy?

A health economist, Phillips looks beyond cost evaluations. “Economists examine many issues related to the health care system, like insurance benefits and provider reimbursement,” she says. “I’m particularly interested in the costs and outcomes of interventions to improve health care delivery and in finding better ways to organize and finance health care.”

Her work on a study of geriatric depression, for example, compares the costs and effectiveness of anti-depressants and electroconvulsive therapy (ECT) in elderly patients for whom conventional therapy has been unsuccessful. The five-year study of about 200 severely depressed patients at Wesley Woods, led by Emory psychiatrist William McDonald, is now in its fourth year. According to Phillips, data from a pilot study suggests that those receiving ECT as a maintenance therapy relapsed less often than those treated solely with medication. Although ECT adds to the cost of therapy initially, researchers observed no comparative cost difference between the two groups because hospital costs for relapsed patients added up quickly.

In a second study, Phillips and a colleague at Georgia State University are searching for ways to support dementia sufferers in the community rather than in nursing homes. With a sample of 500 elderly Medicaid beneficiaries from four regions in Georgia, the researchers have documented that problem behaviors often associated with dementia, other than the memory loss itself, are important risk factors for early nursing home placement.

“Our findings suggest that if resources were redirected toward intervention and treatment of dementia-related problem behaviors, we might be able to keep those with behavior problems in community-based settings safely for longer periods, possibly saving Medicaid money,” says Phillips. Guided by the study results, Phillips and colleagues are formulating care plans for case workers that address dementia-related problem behaviors.
Research at the new Center for Health in Aging at Emory will integrate quality of life into studies regarding elder care on both societal and individual levels.

In a third study that is just beginning, Phillips is gathering data to design interventions that lower the incidence rates for secondary conditions like depression or muscle spasms for people with a primary disabling condition, such as stroke. The study is funded by the CDC as part of the Healthy People 2010 initiative.

In April, Phillips began recruiting the study’s goal of 1,100 participants who recently suffered stroke or spinal cord injury. She is collaborating with researchers at the Shepherd Center in Atlanta and the Jim Thorpe Rehabilitation Center in Oklahoma. Participants will be drawn from the centers, both located in the nation’s “stroke belt.” Each month, researchers will ask participants about health care utilization and their general physical and mental condition, including pain and depression.

“While a number of studies to prevent secondary conditions like depression are under way, we really don’t know when and how many secondary conditions develop,” says Phillips. “We critically need data to guide the design of new interventions, and we need baseline data to judge if they have been effective.

There’s no place like home

Keeping the elderly healthier, independent, and free from secondary injuries are goals to which Allan Goldman aspires as director of Preventive Health Programs for the Georgia Division of Aging Services. Goldman, 76MPH, laments that Medicaid and Medicare reimburse acute care but fail to emphasize prevention or cover assistive devices or home modifications. “Our health care delivery is biased toward institutional care in hospitals or nursing homes as opposed to keeping people in their own homes and communities,” says Goldman.

“Those who choose to remain in their communities cost one-quarter the amount it takes to support someone in a nursing home. We also see an improved quality of life, where people have more control over what happens to them.” —Allan Goldman, 76MPH, Georgia Division of Aging Services

Adjunct faculty member and alum Allan Goldman works to keep the elderly healthier, independent, and free from injuries as director of Preventive Health Programs for the Georgia Division of Aging Services.

Georgia—which boasts the fourth fastest-growing group of elderly people in the country—may soon be overwhelmed by health care costs unless that changes. Goldman hopes this statistic will urge legislators to use tax dollars more strategically.

He says preventive health services can keep people healthier with simple, low-cost, low-tech approaches. Falls, for example, can be prevented through fitness training or by improving lighting and reducing clutter in the home. Medicare reforms to cover foot care would help people remain mobile. Home modifications such as grab bars in bathrooms or levers to replace doorknobs for arthritic hands allow older people to function in their homes and avoid injuries like hip fractures that could send them to a nursing home.

The preventive model is proving itself in Georgia, where people eligible for nursing home placement were given an option under a Medicaid waiver program to stay in their home and receive a package of services including home nurse visits and help with cleaning, shopping, and transportation. “Those who choose to remain in their communities cost one-quarter the amount it takes to support someone in a nursing home,” Goldman says. “And the benefit is not just the money. We see an improved quality of life, where people have more control over what happens to them. In a nursing home, they have to eat and sleep at a prescribed time. They lose control and become dependent.”

Living well

Helping patients live well when near death is a focus of Nancy Thompson’s research. Too often, as the end draws near, quality of life is not a high priority, she says.

“We must have objective research to understand how best to use limited resources.”
  —Nancy Thompson, RSPH

Thompson and colleagues at Emory are examining the health care environments where Georgians spend their last days. Through a pilot survey, funded by the Georgia Collaborative to Improve End of Life Care, the researchers examined common practice patterns for patients at the end of life. Of the hospitals surveyed, 95% reported that patients have an advance directive to inform life-support decisions upon admission. Some 45% had pain-management policies in place. Those surveyed split on whether issues of addiction and physical dependence on pain medication were discussed with patients nearing the end of life.

“These results begin to give us ideas where the biggest issues lie,” Thompson says. How hospital culture affects dying patients is one issue of critical importance.


The mission of the Emory Center for Health in Aging is to develop interdisciplinary research and training programs to help people age in healthy, affordable, ethical, and enjoyable ways. Assisted living facilities, two nursing homes, and an acute-care geriatric hospital on the 72-acre Wesley Woods campus provide a learning laboratory for researchers across many disciplines.
“For example, medical staff who are trained to respond aggressively to emergencies develop a second nature to try to save a life,” Thompson says. “How do we retrain them to consider another course of action, for example, to respond less aggressively?”

In a study led by Emory transplant coordinator Jennie Perryman and sponsored by the Health Resources and Services Administration, Thompson is trying to affect donation rates for transplants as well as improve quality of life for those near death. In the pilot for this study, for which Thompson was an evaluator, Emory Hospital successfully made internal policy changes, such as giving patients color-coded bracelets indicating resuscitation wishes. These reduced emergency measures performed on patients who chose not to be kept alive by artificial means. This practice, in turn, boosted organ donation rates.

Researchers are now planning a series of forums at hospitals statewide to share these ideas with other hospitals. Again, Thompson will evaluate the project to judge its success or failure.

Projects like these are vital to developing good solutions to the questions of aging that public health is called to answer. “We must have objective research to understand how best to use limited resources,” says Thompson.

Although she sees the need for neutrality in her evaluator’s role, Thompson is a sympathetic supporter in her work with families of patients near death. “I’m concerned with all of the people affected by the dying process, the patient and their whole social network,” she says. “Sometimes, families need to talk to someone who is familiar with these issues. The Joe Browns need to know that it is okay to admit they are tired, overwhelmed, and ready to give up. They need to hear that they are not alone and that a whole country is being affected by these questions of old age.”

Rhonda Mullen is an Atlanta freelance writer and the former editor of this magazine.


Autumn 2001 Issue | Dean's Message | In Brief | La Mano de Obra: The Hand of the Worker
Forgotten Disease of Forgotten People | Eric Ottesen Interview | Alumni News | WHSC | RSPH
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