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Senior Hunger Older Americans Act HELP Testimony

Senior Hunger Older Americans Act HELP Testimony

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Published by Patricia Dillon
1514 Koren 06212011 FINAL
1514 Koren 06212011 FINAL

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Published by: Patricia Dillon on Jul 08, 2011
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Mary Jane Koren, M.D., M.P.H.Vice PresidentThe Commonwealth FundOne East 75th Street New York, NY 10021mjk@cmwf.org www.commonwealthfund.org Invited Testimony before theU.S. Senate Committee on Health, Education, Labor, and PensionsSubcommittee on Primary Health and AgingHearing entitled “Senior Hunger and The Older Americans Act”
June 21, 2011
The views presented here are those of the author and not necessarily those of The CommonwealthFund or its directors, officers, or staff. To learn more about new Fund publications when they become available, visit the Fund’s Web site and register to receive e-mail alerts. CommonwealthFund pub. no. 1514.
Thank you, Mr. Chairman, for inviting me to testify today. I am Dr. Mary JaneKoren and a geriatrician by training. Most of my career has been devoted to serving theelderly, particularly those with serious chronic conditions. I have taken care of residentsliving in nursing homes, made home visits to patients living throughout the Bronx as theassistant medical director of the Montefiore Home Health Agency, and later wasappointed to be the director of New York State’s Bureau of Long-Term Care Services.Currently, I am a vice president at The Commonwealth Fund, an independent, privatefoundation located in New York City that is working toward a high-performing healthsystem. The grantmaking program I manage is aimed at improving long-term servicesand supports, particularly for people covered by both Medicare and Medicaid—alsoknown as “dual eligibiles”—and for those transitioning from one level of care to another. No matter which hat I’m wearing—geriatrician, policymaker, or grantmaker—mygoal is to help frail older adults maintain their independence and well-being. The programI speak of today, Title III–C of the Older Americans Act, Nutrition Services, is one of thesimplest, yet most effective programs to help low-income seniors stay in their homes andout of hospitals and nursing homes. You have heard today from both federal and state policymakers and from program administrators. I will therefore try to give you a different perspective. Based on my professional background and frontline experience caring for elderly patients, I’ll briefly cover four areas. First, I will discuss exactly why hunger, or undernutrition, is so common in this population; second, talk about the consequences of undernutrition both for patients and for rising health care expenditures; third, describehow home-delivered and congregate meals can help low-income seniors, their families,health care providers, and policymakers, especially in a time of constrained resources;and last, make several recommendations to strengthen these programs.First, some information about aging: because of the way our bodies age, older  people have a heightened risk of “hunger.” The aging process itself predisposes a personto undernutrition—physiologically, it’s a stacked deck. These physiologic changes makeit extremely difficult for even healthy older adults to stay well nourished. Here are someexamples. There is what’s termed the “anorexia of aging,” a natural phenomenon inwhich the desire for even adequate quantities of food declines commensurate with thedecline in physical activity seen in the very old. This means that seniors don’t feel ashungry as you or I do at meal times and so tend to only eat a little bit or even skip a meal.Compounding that, stomachs “shrink,” or become less compliant, as people age so theyfeel full faster. This sensation of satiation is further mediated by the release of suchhormones as cholecystokinin, leptin, and dynorphin that act both on the brain and on the
 gut. The senses of smell and taste likewise diminish with age—food loses its savor,making meals less interesting and enjoyable so people tend to eat less. Oral problems,such as poor dentition, ill-fitting dentures, or decreased saliva production are common inold age, which can make eating a misery. It has been estimated that dental problemsalone may decrease food intake by up to 100 kcal per day. Not a lot, perhaps, for one day but cumulatively over weeks and months, enough to cause an insidious and inexorableloss of weight.
Swallowing problems, or dysphagia, can make meal times a source of stress, not enjoyment. People who’ve experienced difficulty swallowing may be reluctantto eat very much or be very selective about what they eat because of their fear of choking.In addition, older adults don’t get as thirsty as young people, which, especially in hotweather or for people with congestive heart failure on diuretics, can cause dehydrationwith serious complications, including dizziness, delirium, and falls.
In a word, the aging process itself sets the stage for inanition or energy–protein malnourishment.On top of this, there are a whole host of medical problems and social issuescommon to low-income older adults that further compromise an elder’s ability tomaintain optimum nutrition. Far and away the most common cause of undernutrition isdepression. Research has shown that depressive symptoms are associated withinsufficient food intake and nutritional deficiencies, especially in poor elderly peopleliving at home because of loss of appetite, diminished enjoyment of food, difficulty withfood preparation, and consumption of a less varied diet.
A vicious circle gets startedwhere depression leads to poor intake, which worsens depressive feelings, and so on. Itcan be a hard circle to break, especially in the homebound elderly who tend to becomelonely, withdrawn, and apathetic. One study, for example, found that depressivesymptoms, which were more common among women in the study, were linked withdiminished mobility and social interaction.
In addition, social isolation is one of the
“Nutrition,” chapter 2, page 9,
Merck Manual of Geriatrics, Second Edition
(Whitehouse Station, N.J.: Merck & Co., Inc. 1995).
Up to 2 percent of falls in elderly patients result in hip fractures and up to another 5 percent result inother fractures. These types of injuries account for about 5 percent of hospitalizations for patients over 65years old. About 5 percent of elderly hip-fracture patients die while hospitalized, while overall 12-monthmortality ranges from 12 percent to 67 percent. See N. Alexander, “Falls,”
Merck Manual of Geriatrics,Third Edition
(Whitehouse Station, N.J.: Merck & Co., Inc. 2000).
L. German, C. Kahana, V. Rosenfeld et al., “Depressive Symptoms Are Associated with FoodInsufficiency and Nutritional Deficiencies in Poor Community-Dwelling Elderly People,”
 Journal of  Nutrition, Health & Aging,
2011 15(1):3–8, cited in J. E. Morley, “Undernutrition: A Major Problem in Nursing Homes,”
 Journal of the American Medical Directors Association,
May 2011 12(4):243–46.
J. R. Sharkey, L. G. Branch, N. Zohoori et al., “Inadequate Nutrient Intakes Among HomeboundElderly and Their Correlation with Individual Characteristics and Health-Related Factors,”
 American Journal of Clinical Nutrition,
Dec. 2002 76(6):1435–45.
B. W. Penninx, S. Leveille, L. Ferrucci et al., “Exploring the Effect of Depression on PhysicalDisability: Longitudinal Evidence from the Established Populations for Epidemiologic Studies of theElderly,”
 American Journal of Public Health,
Sept. 1999 89(9):1346–52, cited in Sharkey, Branch, Zohooriet al. “Inadequate Nutrient Intakes,” 2002.

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