16-05-2025
Take Care
Former Health Secretary and geriatrician David Scrase discusses New Mexico's aging population. (Photo provided by the New Mexico Health Care Authority)
David Scrase has worked as a geriatrician in New Mexico for nearly 30 years, and served several stints as the secretary of the Health and Human Services Departments. He is on the frontlines when it comes to treating older residents and their caregivers.
'This is a growing, giant issue,' Scrase told Source NM. 'I always tell people…I never go into a room where at least 80% of the people aren't trying to figure out what to do with an older person in their family who's going through something like this. It might not be their immediate family, but…everyone is on the verge of, or in the middle of, or just past having to make these kinds of decisions about how to provide care.'
Scrase started his practice in Michigan in 1981, relocated in 1998 to New Mexico and, he says, started concentrating on patients 75 and older in 2015. He also works as a clinical professor with the University of New Mexico Health Sciences Center.
Source NM spoke with Scrase recently about his concerns over aging health care and caregiving. The following interview has been edited for clarity and concision.
Source NM: What concerns do you have about the state of care for seniors in New Mexico?
David Scrase: New Mexico in the year 2000, we were ranked number 39th in the country in terms of the percent of people we had in our population that were 65 and older. And in 2030, according to some really reliable projections, we'll rank fourth.
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Seniors, in general, use about three times as many resources as people under 65, and so you've got this more than doubling of the senior population combined with three times the use rate. So there's going to be a dramatic growth of seniors and need for care for seniors.
There's also the fact that we have the number one poverty rate among people 65 and older, so we have the highest poverty rate for seniors. And poverty creates illness and complexity.
In the United States, over 6 million people are living with Alzheimer's disease. That's projected to more than double in the next 15 to 20 years. And over 11 million people are caregiving for dementia patients and they're providing 15 billion hours of free care. And in addition to having to really grow our healthcare facilities to manage all the growth in the population and their use of resources, we're going to have an issue with caregivers.
What are you seeing in your own practice?
Typically, we see people with dementia either coming in with their spouse, who probably is about the same age as them, and they're in their 80s and they're getting progressively less able to perform normal activities or daily living. So the natural history of Alzheimer's disease is a gradual decline and, therefore, how much caregiving they need is a gradual increase. As we have more Alzheimer's disease patients and they have this decline, more burden is placed on the families. And so it's extremely rare for me to see someone in their 80s not get completely worn out if they're the sole caregiver for a spouse or partner.
The most common group of people outside the home that become caregivers are, of course, daughters, which is about 50%, and then followed by daughters-in-law, which is estimated to be 40 to 45%, and so then the men get involved, unfortunately in the last 5 to 10%. And these caregivers, they're quitting their jobs. If they're from a big family, they set up some sort of elaborate rotation, but it's really, really hard to provide care at home for people who may be at the nursing home-level of care needed.
That is an economic consequence to their family, to the country, et cetera, et cetera, because Medicare doesn't pay a daughter to take care of her dad. They don't provide any help when Dad moves in with the family.
As a geriatrician, I'll have residents rotate with me, and I'll always say at the beginning of the session, because half of my patients maybe have dementia, I'll say, 'I want you to pay attention to, one, how advanced this patient's dementia is and, two, how much time do I spend talking to the patient versus how much time I spend talking to the caregiver.' And as people's dementia advances, I spend a lot more time making sure the caregiver's OK, that they have strategies to take care of themselves, that they can cope, because Alzheimer's disease, we don't have a lot of great treatments that really improve it. And if the caregiver collapses, then the whole system collapses. And so typically, the worse the dementia, the more time I spend with the caregivers.
What concerns have you heard from other New Mexico practitioners?
People are living longer and older people are becoming increasingly complex. I've seen a huge change from 1990. And so it's harder for some primary care doctors to manage the growing complexity of an 80-year-old's medical problems. If someone raises the question and someone has a memory issue, that's like a half hour of time that you have to figure out how to squeeze into a 20- or 30-minute appointment. And often it doesn't come up until halfway through and so doctors are scheduling people to come back for those assessments. But we're going to see more and more of it.
What advice do you give to family caregivers?
The number one thing is you need to take care of yourself first. And it's like you have this bucket of what you can scoop out every day of help to give to your loved one. And if your bucket's not full, it's not a long-term strategy. That's probably the biggest issue is getting people to accept the fact that to be an effective caregiver, the first thing they need to do is take care of themselves.
We have these things called the Six Activities of Daily Living: bathing, dressing, feeding, moving around, transferring, continence and going to the bathroom, and when people need help with two of those six, they qualify at the basic level for nursing home care, and there's families who're trying to provide three, four, five, sometimes six things at home. And so if it's clear that the family members are just not able to survive this, then I'll recommend that they improve the quality of time they spend with their loved one by putting them in a place where trained professionals can provide all this day-to-day medical care and support care and they can go and have quality time with their relative.
And then there's a middle one where they're not as bad as they need to be in a nursing home, but it's clear that we're on this downhill course. And I'll say, 'you need to have a plan B. I suggest you go out and look at some assisted living places or some graduated level of care places where you could be in assisted living and then go to a memory care unit maybe and then a nursing home.'
Most people focus on the question of whether or not they want to go to a nursing home, yes or no. And I don't think that—particularly as people get sicker and sicker— is a helpful question to ask. I think the question is, 'Do I want to go to a nursing home and accept the pros and cons of that choice, or do I want to keep mom at home and accept the pros and cons of that choice?' Because there are consequences whichever decision, and that's why I think I try to work with families to say, 'hey, this isn't something you need to decide to feel guilty about. You could really focus on the quality of the time you're spending with your loved one.'
This article was written with the support of a journalism fellowship from The Gerontological Society of America, The Journalists Network on Generations and The NIHCM Foundation.
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