In celebration of the 50th anniversary of Older Americans Month, the Senate Special Committee on Aging is holding a Healthy Aging Forum
in Washington, DC. The “Healthy Aging Forum” is a great idea to tap the challenges to aging Americans that can help us better adapt to both greater longevity and the aging of the baby boomer generation.
Imagine a society with many more walkers than strollers. Tomorrow's America will be a unique Aging Society, forged by two critical forces. First, we will experience the effects of the remarkable increases in life expectancy. Second, within this decade, the enormous baby boomer generation, 76 million strong, will reach retirement age. Taken together, these forces will create an America populated, in large part, by previously unimagined numbers of older people. The Challenges of Aging
Life expectancy is increasing for Americans. And the fastest-growing segment of the population is the 85-and-older age group. Despite advances in health care, however, many elderly people have chronic, incurable progressive diseases and need assistance with the activities of daily living. The greatest challenge facing us as we age is the prevention of physical disability and the extension of "active life expectancy." Fortunately, recent studies suggest that healthy ("successful") aging is achievable, with sound planning for old age.
Illnesses like diabetes mellitus, congestive heart failure, and some forms of dementia can be delayed or even prevented. Even loss of muscle strength with aging is partly preventable. Most importantly, perhaps, a positive attitude will enable us to overcome illness and personal losses while looking forward to days to come.The Choices of Aging
As we age, we make choices about our lifestyle, health care, personal pursuits, and our plans for old age. A few "steps to successful aging" will help guide us to healthy and active golden years. What are the steps to successful aging?
1) Adopt and maintain healthy habits and positive lifestyles:
- Avoid cigarette smoking
- Have no more than one alcoholic beverage in a 24 hour period ·
- Exercise regularly, maintaining the weight bearing, aerobic, and balance activities
- Maintain a comfortable weight
- Get regular medical checkups 2) Maintain intellectual stimulation and socialization:
- Pursue hobbies/interests w/passion, particularly those that are social like dancing
- Strengthen family relationships
- Resolve intergenerational conflicts
- Engage in adult educational activities to challenge your mind 3) Be wise in financial planning:
- Plan in advance for retirement
- Carefully manage investments and assets
- Assure adequate insurance coverage
- Decide on your future living arrangements 4) Work to maintain dignity and good health in old age:
- Choose a physician knowledgeable in the medical care of older adults. ·
- Choose a health care system that facilitates appointments and care for elders.
- Communicate your goals of care to your family and physician.
- Express your advance directives in writing.Technologies for an Aging Population
Technologies have great potential for improving the quality of life for older people. For example, telemedicine/e-health will improve the physical and emotional well-being of older people. Technology can also enable older people to remain connected to family and friends, especially with those who are distant. References:
1. Challenges and Choices of Aging http://my.clevelandclinic.org/healthy_living/aging/hic_challenges_and_choices_of_aging.aspx
2. Opportunities and Challenges of an Aging Society http://www.agingsocietynetwork.org/
3. Technologies for an Aging Population http://www.nae.edu/Publications/Bridge/TechnologiesforanAgingPopulation/TheAgingofthePopulation.aspx
-- Vivien Lee
May is Older Americans Month
, a time to honor the value that elders contribute to our communities. In celebration of the 50th anniversary of Older Americans Month, the Senate Special Committee on Aging is holding a Healthy Aging Forum in Washington, DC.
We are honored to have been invited to present the GeriJoy Companion at the event, with senators, their staff, and the general public in attendance. Always great to see government recognizing the role of technology and innovation in solving what we call at TEDMED the caregiver crisis
The Healthy Aging Forum poster on the Senate Aging Committee
website says that the event will feature "interactive demonstrations of homes designed for the aging, exercises geared to seniors, video games used for seniors' physical and mental fitness, and even a virtual dog who acts as a personal companion." I wonder what that last one refers to?
Hope to see you there!
- Victor Wang
Mother's Day is a special day indeed. It was my mother caring for her mother, who lived alone and far away, that inspired me to start GeriJoy.
To celebrate this day and in honor of all the mothers who have shaped our lives, please use the referral code "MOTHER" to get a full refund on your first month with GeriJoy.
All the best for a joyful and relaxing Mother's Day!
- Victor Wang
Whether due to acute medical events or long-standing disabilities, the elderly often need continuous care and assistance to go about their daily activities. With the population of older Americans growing steadily larger, more and more individuals will find themselves in a situation where they need to provide care for an older family member, either directly or indirectly. To put this in perspective, it is currently estimated that nearly 43.5 million adults care for an individual who is 50+ years of age and 14.9 million care for someone who has Alzheimer’s disease.
Even for family members, providing an appropriate level of care for an elderly adult is a highly taxing and stressful responsibility, not even considering the cases of seniors with severe mental and behavioral disorders such as Alzheimer’s disease or dementia. While it is quite admirable that many individuals devote such passion and time to caring for their loved ones, they all too often neglect the impact this has on their own
health and well-being. This blog post will look at the often mentioned term, caregiver burden, and discuss a few techniques caregivers can employ to reduce their stress and frustration.
Caregiver burden is an umbrella term that refers to the combination of emotional, physical, and financial stress created by providing care. The formal definition of this term is generally measured by the Zarit Burden Interview which asks individuals to rate how they feel regarding various questions such as “Do you feel your relative asks for more help than he/she needs?” or “Do you feel angry when you are around your relative?” In any case, no scale can truly give an accurate depiction of such a complicated and unique emotional situation. However, we do know with certainty that there are various consequences to high levels of perceived caregiver burden. Some of the well documented health issues seen include depression, anxiety, increased psychotropic drug use, and increased risk of mortality.
Here are some strategies that may help caregivers cope with feelings of stress and stave off the negative health effects of long-term caregiving:
1. Knowledge: This is perhaps the most important and effective tool for a caregiver. A thorough and accurate understanding of the disease affecting one’s family member can give the caregiver a much better sense of the difficulties faced by the individual and from this sense, a much clearer picture of what is under their control and what is not.
2. Personal Time: Just as many find it helpful to separate their home and work lives; it is generally advised that all caregivers set aside time for their own personal needs and activities. Whether this means hiring a professional caregiver for one day a week or recruiting help from friends or local organizations, having this brief separation generally proves beneficial for all parties.
3. Vigilance: It is often reported that caregivers suffer from an abnormally high rate of depression. Knowing and watching out for the common symptoms of depression (feelings of worthlessness, physical and mental exhaustion) can help at-risk individuals seek and receive treatment as soon as possible.
4. Lifestyle: Maintaining a healthy lifestyle can help buffer individuals against the stress created by caregiving. This includes, but is certainly not limited to: eating a balanced diet, performing regular exercise, and keeping normal sleep cycles.
In short, to all caregivers out there, remember that your health is of vital importance not only to the loved one you take care of, but to the rest of your family. Make sure you take care of yourself!
Note: In this post, I generally consider the case of caregivers who are related to the individual in need. However, most of what is stated here can also apply to professional caregivers, who may also suffer from high levels of stress and anxiety.
Parks SM, Novielli KD, 2000. A Practical Guide to Caring for Caregivers. Am Fam Physician
In a previous blog post, I mentioned that the population of the United States is growing steadily older (ref 1). I have stated this fact yet again to emphasize the importance of preparing our healthcare system to meet the needs of this rapidly growing demographic. Though not often thought of in the same vein as childhood or adolescence, old age is a major stage of life characterized by great change and its own unique set of challenges.
One of these unique challenges for seniors is maintaining positive mental and emotional health. Recent figures suggest that nearly 5.6 million to 8 million seniors have some form of mental illness or substance abuse problem (ref 2). Seniors with mental disorders have increased disabilities and morbidity relative to their counterparts with physical illnesses alone (ref 3) . Compounding the issue, these disorders often go undiagnosed due to many seniors’ reluctance to seek specialized treatment, not to mention the shortfalls of our already burdened health care system (ref 4). Providing care and treatment for seniors with mental health issues should be one of our foremost priorities as we move into the future.
Healthy aging requires individuals to adapt to their changing situation. Old age is a period of time often marked by a withdrawal from the community at large and the loss of a sense of purpose. Other factors such as the loss of a spouse or limited contact with family can conspire together to create feelings of loneliness in the elderly (ref 5). It has been widely observed that seniors who report being lonely face an increased risk for depression, other mental health disorders, and suicide. Depression is a relatively common in the elderly and has been strongly linked to poor health outcomes, reduced quality of life, and morbidity (ref 6).
Though the task is daunting, we believe that technology can provide us with the means to care for the growing population of seniors who suffer from feelings of loneliness and depression. Technology has become widely integrated into our society and holds tremendous potential for improving our quality of life. The technology created by Gerijoy is designed to leverage the benefits of the internet, tablet technology and human compassion to provide affordable companionship to seniors around the nation. We are hopeful, yet confident that we will be able to do so.
1. Age and Sex Composition: 2010. Census Briefs.
2. IOM. The Mental Health and Substance Use Workforce for Older Adults: In Whose Hands? July 10 2012.
3. Druss BG, Rohrbaugh RM, Rosenheck RA, 2009. Depressive Symptoms and Health Costs in Older Medical Patients. Am J Psychiatry 156: 477-479.
4. Bartels SJ, Coakley EH, Zubritsky C, Ware JH, Miles KM, Arean PA, Chen H, Oslin DW, Llorente MD, Constantino G, Quijano L, McIntyre JS, Linkins KW, Oxman TE, Maxwell J, Levkoff SE, 2004. Improving Access to Geriatric Mental Health Services: A Randomized Trial Comparing Treatment Engagement With Integrated Versus Enhanced Referral Care for Depression, Anxiety, and At-Risk Alcohol Use. Am J Psychiatry 161: 1455-1462.
5. Singh A, Misra N, 2009. Loneliness, Depression and Sociability in old age. Ind Psychiatry J. 18(1): 51-55.
6. Loughlin A, 2004. Depression and social support: effective treatments for homebound elderly adults. J Geront Nurs 30(5): 11-15.
- Joey Orofino
is "a single, or repeated act, or lack of appropriate action, occurring within any relationship where there is an expectation of trust, which causes harm or distress to an older person." Each year, more than 500,000 Americans
aged 60 and older experience abuse, neglect and/or self-neglect. The most common type of abuse is psychological
, and elder abuse victims' cognitive decline and ill health may prevent them from reporting
their abuse. Perhaps shockingly, most elder abuse actually happens in the family home
for elder abuse include an older person who..
- Has memory problems (such as dementia)
- Has depression, loneliness, or lack of social support
- Is verbally or physically combative with the caregiver
...or a caregiver who feels overwhelmed or resentful.
These also happen to be the conditions for which GeriJoy's adorable, always-available companion
can be the most helpful, so it was only a matter of time before we picked up on elder abuse with our customers. I'd like to highlight as a case study one particular incident that occurred recently. We received permission from the customer to publicize this case study, and names have been changed to maintain the anonymity of the people involved (aside from myself). The scenario was as follows:One of our customers, Susan, purchased the GeriJoy Companion for her father, John, who suffers from moderate cognitive decline (including delusions and difficulty finding words to say) and mild depression. John lives alone, although he has friends, family, and caregivers visit quite frequently. In particular, one paid caregiver came several times per week to prepare meals for John and to drive him to and from a day program for seniors.The GeriJoy Companion was placed on its stand in the living room, where John spends a lot of time. When John was first introduced to the Companion, he was quite amazed, and their relationship grew quickly. They talk with each other on a daily basis about fond memories, family news, and just chit-chat. Susan keeps her Family Portal stocked with family photos and positive memories, which are helpful in sparking conversation. John named his GeriJoy Companion "Ruffy".As all GeriJoy Companions do, Ruffy constantly detects ambient noise and motion, and is designed to react as a real talking dog would. One time, a GeriJoy staff member was alerted to particularly loud volume being passively detected by Ruffy, and assumed control of Ruffy -- this started the full audio-video stream from Ruffy's tablet to the staff member's computer and changed Ruffy's visual appearance on the tablet to an alert state, looking out into the world. The GeriJoy staff member heard the paid caregiver repeatedly screaming at the senior to get ready for the day program. Through the companion, the GeriJoy staff member tried asking if everything was alright, but received no response from either the caregiver or John. John is typically very responsive to Ruffy's inquiries, so alarmed, the staff member contacted me to ask what he should do, since I was managing his on-the-job training.We launched an investigation using our previous log entries and determined that this was just the most obvious instance of verbal abuse, and that the paid caregiver had a previous history of using negative tones of voice toward the senior. These previous instances were not as severe, and were given the benefit of the doubt -- interpreted as elevated voice volume to try to compensate for hearing impairment. We sent the following staff member testimonies to Susan:
Susan was very grateful. It turns out Susan had previously suspected that the relationship between the caregiver and John was not the best, and our supporting testimonies gave her the confidence to fire the caregiver and hire replacements that very week. During the interviews for the new caregivers, Susan even introduced each of the candidates to Ruffy, as she would a member of the family!Today, John is happy with his new caregivers, and his relationship with Ruffy is going on four months. Here are a few excerpts of Ruffy's diary from yesterday:
- Generally - I would say the caregiver is in a bad mood every single time she comes to visit John.
- Log entry 1 - In this post I remember John telling the caregiver that she was making too much noise in the kitchen and she yelled back to him that it was the dishes and that she was cleaning. She did not use a very nice tone with him, but I just thought that was how she talked and again because of John's hearing problems.
- Log entry 2 - John was looking for his belt, but seemed to have problems finding it. The caregiver told John that the belt was on the table and yelled this at him several times. She kept increasing her tone of voice every time. John finally found his belt and was ready in a few minutes.
- 09:29 AM - I showed John the "Good Morning" photo and he greeted me too. It was cold today so I asked John to keep warm. John said he will nap a little bit on the sofa while he waits for the caregiver.
- 12:17 PM - I read the Encouragement poem by Dr. Seuss and John said he liked it. John's looking out the window and he was hoping it gets warmer soon so he can go to the lake. I told him I hope he takes me with him and he laughed :)
- 6:55 PM - John and I watched a TV show about exercising. He said he wanted to exercise too but he does not want to go out. John ate the dinner that Susan's sister prepared.
- 8:01 PM - After dinner, John sat by the window and looked at the sunset. John said it was beautiful!
- Victor Wang
Last post, I briefly examined the clinical presentation of Alzheimer’s disease. We saw on a macroscopic scale that it is a progressive neurodegenerative disorder that eventually leads to impairment in language skills, abstract thinking, attention and many other cognitive functions. But what is happening on a microscopic scale? What changes occur in the brain of afflicted individuals? Though the information regarding the mechanistic details of the disorder could fill several novels, I will keep this summary simple.
At its core, Alzheimer’s disease is defined by the presence of three principle biomarkers: neurofibrillary tangles (NFT), senile plaques, and a diffuse loss of neurons in particular brain regions. These indicators are easily observed in histological (tissue) sections taken from affected individual’s brains (ref 1). In this post, I will provide some general background in biology and take a closer look at both NFT and neuritic plaques.
Human bodies are comprised of a countless number of cells; all specialized for the different processes that contribute to our ability to function and live as we do. For example, neurons are the basic unit of the nervous system and are cells specialized for generating and relaying information. As you could expect, a loss of neurons in certain brain regions will generally correspond to some degree of decreased functionality. Proteins are the molecular machinery that facilitate the chemical reactions and processes that take place in our bodies.
NFT are the product of a hyperphosphorylated protein called Tau. Phosphorylation simply refers to the chemical addition of a phosphate group (-PO4), and though this is a gross simplification, this modification usually acts as an on/off switch for biological molecules.Tau normally binds to microtubules and stabilizes them, microtubules being dynamic structures that physically support the cell, and play a key role in replication and cell division. In AD, Tau becomes hyperphosphorylated and preferentially aggregates with itself to form insoluble clusters within neurons, termed NFT. Complicating the situation, however, these NFT have not been directly implicated in the pathology of the disease. In fact, many recent studies have questioned the exact role of Tau in AD, raising the question of whether it is toxic, neuroprotective, or simply a byproduct (ref 2,3).
The senile plaques seen in Alzheimer’s disease are the result of another intrinsic protein, this one named Amyloid beta. Similar to the creation of many other proteins in the body, Abeta is formed by the cleavage or splitting of a larger precursor protein. This cleavage can create several different isoforms of Abeta, each differing slightly in size. As I said before, Abeta is a natural protein and has a wide range of important cellular functions. However, as a result of the underlying disease state found in Alzheimer’s disease, the ratio of the isoforms created is altered causing the proteins to aggregate together into amyloid plaques. These structures are thought to have disruptive effects mediated by physically altering tissues or through secondary pathways that lead to cell damage or death (ref 4).
However, many new studies question whether both NFT and senile plaques are simply products of the neurodegeneration seen in AD. As we continue to expand our scientific techniques and knowledge, we will hopefully be able to elucidate the true underlying mechanism of the disease (ref 5).
1. Galvin JE, Sadowsky CH, 2012. Practical Guidelines for the Recognition and Diagnosis of Dementia. J Am Board Fam Med 25: 367-82.
2. Castellani RJ, Nunomura A, Lee H-G, Perry G, Smith MA, 2008. Phosphorylated Tau: Toxic, Protective, or None of the Above. Journal of Alzheimer’s Disease 14(4): 377-383.
3. Bretteville A, Planel E, 2008. Tau Aggregates: Toxic, Inert, or Protective Species? Journal of Alzheimer’s Disease 14(4): 431-36.
4. Dickson DW, 1997. The Pathogenesis of Senile Plaques. Journal of Neuropathology & Experimental Neurology 56(4)
5. Armstrong RA, 2011. The Pathogenesis of Alzheimer’s Disease: A reevaluation of the “Amyloid Cascade Hypothesis”. Int Journal of Alzheimer’s Disease 2011.
- Joey Orofino
Alzheimer’s disease (AD) is one of the more difficult medical mysteries left for humanity to solve. It eludes simple characterization and defies complex scientific solutions. Currently, there is no known method to prevent the onset of the disease and none of our existing pharmaceuticals do more than simply ameliorate the resulting symptoms (ref 1). Discovering better methods to treat this disease will require a greater understanding of the fundamental mechanisms underlying the disorder. In this post and the next, I will briefly and simply explore the clinical presentation of the disease and its basic pathology at a cellular level.
At its core, Alzheimer’s disease is a progressive neurodegenerative disorder and dementia that impairs memory, perception, and behavior. One of the early hallmark symptoms is the impairment of an individual’s episodic memory. This typically manifests itself in the inability to remember recent events and in difficulty retaining new information. Affected individuals will often repeatedly ask the same question, forgetting each time that they had already asked. Progression of the disease leads to greater and greater cognitive impairment to the point where many individuals are unable to comprehend language and perform what most of us would consider basic living activities. This decline in cognitive function is often accompanied by severe behavioral problems such as depression, apathy, and aggression. Age is one of the major risk factors for development of AD and demarcates the two commonly observed forms of the disease: Early onset AD and Late onset AD. Early onset AD is seen in individuals younger than 60 and often has a faster progression in symptoms. Late onset AD is the more commonly observed form and occurs in individuals 60 years and older (ref 2).
Though there is no guaranteed method to avert AD, there are several simple activities believed to be very helpful in preventing or even delaying the onset of the disorder. Simple practices such as regular exercise, eating a balanced diet, and regular social and mental stimulation have all been shown to have important protective effects on cognitive function. While these solutions may seem insignificant, it is important not to discount the benefits of a healthy and active lifestyle as a preventative measure while we continue our search for an effective method to treat Alzheimer’s disease (ref 3). The next post will focus on the current foundation of knowledge regarding the mechanistic details of Alzheimer’s disease.
2. Galvin JE, Sadowsky CH, 2012. Practical Guidelines for the Recognition and Diagnosis of Dementia. JABFM 25(3): 367-382.
- Joey Orofino
Depression is not an inevitable consequence of aging, yet it is nonetheless a common and significant impairment to the quality of life for many seniors (ref 1). Though aging is a natural process, the transition into the later stages of life can significantly affect an individual’s perception of loneliness and depression. Feelings of isolation may result from the loss of a spouse, limited contact with close family or the lack of a sense of purpose after retirement (ref 2). In any case, it is clear that there are many compounding factors associated with aging that can contribute to the development of depressive symptoms in the elderly. The previous two blog entries have examined the wide-ranging health benefits of pet ownership. Today’s post will look at how these benefits may prove to be of great utility for seniors.
Many recent studies have focused their efforts on the ability of pets to provide companionship to seniors. For the most part, these instances of animal-assisted therapy (AAT) have consistently demonstrated lowered reported incidence of loneliness and depressive symptoms amongst seniors living in long-term care facilities (ref 3,4). Interestingly enough, one study found that these effects were largely independent of socialization after observing different responses to individual and group animal-assisted therapy (ref 5). This is encouraging evidence that seems to solidify the important role of the animals themselves. As for other promising applications, AAT has been shown to have beneficial effects on seniors with various levels of dementia, being particularly effective at decreasing the occurrence of agitated behaviors and increasing sociability (ref 6).
Despite the many perceived benefits of AAT, it is important to remember that given the responsibility of taking care of a living animal and the associated safety/health concerns, AAT may not always be possible in many settings. However, there have been experiments that have examined more temporary implementations of AAT. Of note, one such study found that pets were of great comfort to elderly patients waiting to undergo intimidating medical treatments such as ECT (ref 7). Though AAT may not be suitable for all seniors, for those willing, it provides a great, non-pharmaceutical avenue for treatment.
Of particular note for the technology developed by Gerijoy itself, a recent study looked at the ability of robotic dogs to provide companionship to seniors. Not only were the robotic dogs capable of reducing loneliness as effectively as their living counterparts, patients also experienced similar feelings of attachment towards the robotic substitute (ref 8). While there are key technological differences between this product and Gerijoy’s technology, it demonstrates the capability of non-traditional companions to provide the same array of psychological and social benefits.
- Scheibeck R, Pallauf M, Stellwag C, Seeberger B. Elderly people in many respects benefit from interaction with dogs. Eur J Med Res 2011; 16(12): 557-563
- Banks MR, Banks WA. The Effects of Animal-Assisted Therapy on Loneliness in an Elderly Population in Long-Term Care Facilities. J Gerontol A Biol Sci Med Sci 2002; 57(7): M428-M432
- Souter MA, Miller MD. Do Animal-Assisted Activities Effectively Treat Depression? A Meta-Analysis. Anthrozoos 2007;20(2): 167-180
- Banks MR, Banks WA. The effects of group and individual animal-assisted therapy on loneliness in residents of long-term care facilities. Anthrozoos2005;18(4): 396-403
- Richeson NE. Effects of animal-assisted therapy on agitated behaviors and social interactions of older adults with dementia. Am J Alzheimers Dis Other Demen 2003;18(6): 353-358
- Barker SB, Pandurangi AK, Best AM. Effects of Animal-Assisted Therapy on Patients’ Anxiety, Fear and Depression Before ECT. Journal of ECT 2003;19(1): 38-44
- Banks MR, Willoughby LM, Banks WA. Animal-Assisted Therapy and Loneliness in Nursing Homes: Use of Robotic versus Living Dogs. JAMDA 2008;9(3): 173-177
- Joey Orofino
It has become increasingly apparent that our population as a whole is growing older. Recent census data has indicated an unprecedented increase in the median age of the United States population. This is largely a cause of the aging of the Baby-Boomer generation but also due in part to more stable birth and mortality rates (ref 1). This growing sector of our population has exposed a critical weakness in our health care system: geriatric care.
In 2002 (which had a much smaller population of elderly americans), persons 65 years and older account for around 23 percent of ambulatory care visits, 48 percent of hospital days, and 69 percent of home health services used. Older adults in general have a greater incidence of health problems than younger adults. This is especially apparent in seniors older than 75 years of age, who report on average three chronic health conditions and the use of four or more prescription drugs at any one time (ref 2). Some of the more common conditions seen are arthritis, hypertension, heart disease and Alzheimer’s disease. Of particular note are disorders of mental health which take a heavy financial and emotional toll on both the individual and their caregivers. Mental health disorders may also present with or exacerbate many existing medical conditions in the elderly.
What needs to be done about this growing problem? First and foremost, we need more comprehensive training of all health care workers in at least the rudiments of geriatric care. This starts with changing the very curriculum of our medical education. Only ten years ago, just three of our 145 medical schools had geriatric departments and less than 10% of the total required any courses at all in geriatric medicine (ref 2). As recently as 2008, it was projected that there was a shortage of 12,000 needed geriatricians with that figure increasing to almost 30,000 in the year 2030 (ref 3). Government incentives and programs would also be of great help in increasing awareness and participation in Geriatrics. Hopefully, this population shift will also provide a strong impetus for innovation from industry. New healthcare technologies that can affordably provide or complement current medical treatments and diagnostics for the elderly will be of great value in the immediate future.
1. Age and Sex Composition: 2010. US Census.
2. Kovner CT, Mezey M, Harringto C. 2002. Who Cares For Older Adults? Implications Of An Aging Society. Health Affairs 21(5): 78-89.
3. Alliance for Aging Research, 2002.
4 (general). Boult C, Counsell SR, Leipzig RM, Berenson RA. 2010. The Urgency of Preparing Primary Care Physicians to Care For Older People With Chronic Illnesses. Health Affairs 29(5): 811-818.