Population norms, but not individual norms, can be established for any physiologic parameter and its laboratory measurement. Yet, variability is the hallmark of aging, and physiologic change is no exception; as a result, extrapolating from norms to individuals is done with less confidence in the elderly. Many normal elderly persons show little or no physiologic decline in organ function, while many others show significant decline. One of the most useful techniques to establish the presence of disease is to compare current laboratory values with results obtained when disease was not present. Of course, this type of comparison is likely to be possible only for routinely performed tests.
Age-associated declines in cardiac, pulmonary, renal, and metabolic function correlate with changes in normal laboratory values (see TABLE 113-2). For example, systolic blood pressure increases, and maximal cardiac output decreases whether measured invasively or noninva-sively. Vital capacity, forced expiratory volume at 1 sec, and maximal breathing capacity decrease progressively with age

Deviations in results (which, in many cases, were more likely the result of disease than of normal aging) were noted in 5% to 10% of the population for the following: women > 80 yr, a low hematocrit; women 65 to 80 yr, elevated calcium levels; both sexes of both age groups, reduced serum phosphate concentrations and elevated lactic dehydrogenase (LDH) and alkaline phosphatase levels.
Serum electrolyte values are not abnormal because of age alone. Alkaline phosphatase values approaching 140 u./L may be found in up to 5% of persons of all ages (normal = 35 to 120 u./L), but elevations may be caused by some drugs (eg, narcotics), eating a fatty meal, and bone abnormalities (including tumors, hyperparathyroidism, Paget’s disease, a healing bone fracture, osteomalacia, and renal osteodystrophy). However, the positive predictive value of an elevated alkaline phosphatase level is very low in patients with no prior diagnosis of liver disease, malignancy, or bone disease.
In patients with osteoporosis, levels of serum calcium, phosphate, and alkaline phosphatase and the electrophoretic protein pattern are usually normal. In patients with metastatic cancer and almost always in those with osteomalacia, alkaline phosphatase is increased. Transient increases that do not usually exceed normal limits are noted in osteoporotic women after hip fractures.
A low serum albumin level in a healthy person is usually dietary in origin and unrelated to aging. However, serum albumin tends to fall when older persons develop serious disease, especially when accompanied by undernutrition. Vitamin deficiency, except for B12, is rare in healthy ambulatory persons; studies have reported vitamin B12 deficiency in 12% of hospitalized elderly patients who have no evidence of general malnutrition.
Serum ferritin increases with age, and serum iron decreases minimally. Although fasting blood glucose increases with age, values remain within the normal range. Glucose tolerance decreases gradually with age. However, lack of exercise, obesity, and the use of some medications may be more important influences on glucose tolerance than age alone. Glucose levels are highest in the nonfasting state after a carbohydrate challenge or during a cortisone-glucose tolerance test. HDL cholesterol level tends to rise with age, as does LDL cholesterol, but this is based on values in survivors and, therefore, may not be a general aging trend.

Prostate-specific antigen (PSA) levels rise with age; the levels are typically about 2.5 ng/mL in men 40 to 49 yr of age, increasing to about 6.5 ng/mL by age 70 to 79. PSA levels may increase as a result of conditions other than cancer, such as benign prostatic hyperplasia or a prostatic infection, or briefly as a result of prostatic manipulation.
Age per se has no influence on the erythrocyte sedimentation rate (ESR). The sensitivity of an ESR > 20 mm/h in identifying the presence of a clinical disorder is 0.55; however, the specificity is 0.96, and the positive predictive value of an elevated ESR being associated with a clinical disorder is 0.93. Monoclonal gammopathy or elevated fibrinogen level, as well as more common chronic inflammatory diseases, can be a cause of elevated ESR in patients having no other obvious cause. The influence of plasma fibrinogen, total protein, serum globulins, and immunoglobulins on the ESR in older persons is similar to that in younger adults. Therefore, any age-related changes in ESR are best explained by disease rather than by aging itself. Severe anemia or hypo-albuminemia limits the test’s usefulness.
A study using agarose gel electrophoresis and immunofixation demonstrated a 10% incidence of monoclonal gammopathy in apparently healthy persons ranging in age from 62 to 95 yr. The incidence is 6% in persons < 80 yr and 14% to 19% in those > 90 yr. An unexplained ESR elevation in the elderly warrants investigation for a monoclonal gammopathy, which occurs in about 35% of such persons. These gammopa-thies may indicate a dysregulation of the immune system occurring with age (ie, impaired T-cell or B-cell function).
Serum levels of the major subsets of immunoglobulins (IgG, IgM, and IgA) do not show clinically significant changes with age. A decline in several T-cell functions is the most consistent age-related change in the immune system.

EFFECTS OF HORMONAL CHANGES
Testosterone
An age-dependent decrease in morning and mean 24-h plasma levels of testosterone occurs; free testosterone levels are less affected. A marked decrease occurs only after the seventh decade. Diet does not seem to influence levels significantly at any age. Smokers have higher testosterone levels than nonsmokers in all age groups, but this difference is not significant in the elderly. In response to stress, serum testosterone levels show greater increases in younger than in older men.
Estrogen
Urinary estrogen increases in elderly men, resulting in an increased estrogen:testosterone ratio. The source of this estrogen appears to be androstenedione, which is metabolized to estrogen by peripheral tissues. Estrogen levels in women decrease after the menopause, the consequences of which are discussed in Ch. 83.
Pituitary and Adrenal Hormones
In general, both pituitary and adrenal function decrease slightly. Decreased pituitary function leads to increased levels of gonadotropins secondary to lower levels of gonadal hormones. Growth hormone levels decrease with aging. Decreased adrenal function may lead to lower circulating levels of Cortisol, although the diurnal pattern is usually preserved.
Serum renin and aldosterone levels fall with age, causing the so-called hyporeninemic hypoaldosteronism state. Together, these changes make hyperkalemia more likely, especially when potassium supplements or potassium-sparing diuretics are administered. Serum vasopressin levels tend to rise with age.
Kndorphin levels increase with age. This may explain the suggestion that elderly persons have a decreased awareness of pain to such events as cardiac ischemia.
Serum concentrations of immunoreactive and bioactive parathyroid hormone increase with age in order to maintain normal serum calcium levels.

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Most patients with diseases that can be detected by biochemical profiles present with clinical symptoms and signs of such significance that laboratory tests usually have little screening value. For example, an increase in lactate dehydrogenase (LDH) levels without symptoms is only weakly predictive of underlying disease.

The sensitivity of a test or the rate of detection is probably more sig­nificant. For example, the total serum protein level is not very sensitive for detecting any of the conditions that may alter it; on the other hand, elevated serum cholesterol or blood glucose levels are virtually always detected in a patient with familial hypercholesterolemia or diabetes, re­spectively. Because measuring fasting blood glucose is useful and rela­tively inexpensive, it is a worthwhile screening test for asymptomatic patients with a family history of diabetes or obesity. Also, determining serum cholesterol level is worth the cost, considering the risk for ath­erosclerosis associated with elevated cholesterol and the evidence that lowering the level may reduce cardiovascular morbidity and mortality (see also Ch. 81). The frequency at which these tests should be repeated has not been determined. Some recommend rechecking cholesterol levels in the elderly every 5 yr if the initial cholesterol level is normal, but others advocate remeasuring cholesterol only if the levels are ele­vated or borderline.

Persons who decline coverage but later change their minds must pay a surcharge based on how long they delayed enrollment. Participants may discontinue coverage at any time but must pay a surcharge on the premium if they re-enroll.
Part B covers physician services and physician-prescribed services, such as hospital outpatient services, including emergency department care and day surgery; physical, occupational, and speech therapy; diagnostic tests including portable x-ray services in the home; and durable medical equipment for home use. If surgery is recommended for a patient, Part B covers part of the cost of a second and even a third opinion.
In addition, Part B covers medically necessary ambulance services, certain services and supplies (colostomy bags, prostheses) not covered by Part A, drugs and biologicals that cannot be administered by the patient, spinal manipulation by a licensed chiropractor for subluxation demonstrated on x-ray, dental services deemed necessary to medical treatment, optometry services related to providing lenses for cataracts, and the services of physician assistants, nurse practitioners, clinical psychologists, and clinical social workers. Outpatient mental health care, with certain limitations, is covered. A complete description of Part B services and other provisions is available in The Medicare Handbook, updated annually.
Under Part B coverage, Medicare determines the allowable charge for each service and pays 80% of the allowable charge, aftei the annual deductible is paid. If the billed charge equals the allowable charge, the patient pays the remaining 20%. If the billed charge exceeds the allow-
able Medicare charge, the patient pays 20% of the allowable charge and the amount above the allowable charge, up to a maximum percentage of the allowable charge; in 1993, the maximum was 115%. Physicians, whether they participate in Medicare Part B or not, whose charges exceed the maximum Medicare fees are subject to fines.
Physicians may or may not participate in Part B of the Medicare program. A participating physician takes assignment on all Medicare patients. (Assignment means that beneficiaries assign their right to receive payment from Medicare to the physician and that the physician receives payment—80% of allowable charges—directly from the program.) A nonparticipating physician either does not take assignments or takes them selectively. If a physician does not take an assignment, Part B pays the 80% to the patient, who is then responsible for all payments to the physician. Whether participating or not, the physician must send the claim to Medicare and must bill the patient for the Part B deductible ($100 in 1993).
A physician who does not take assignment for elective surgery must give the patient a written estimate in advance if the total charge is more than $500. If the physician does not provide an estimate, the patient can later claim a refund from the physician for any amount paid over the allowable charge.
The Medicare payments to physicians have been criticized for being inadequate compensation for the time involved in giving physical and mental status examinations and obtaining the patient history from family members. A Medicare fee schedule based on a resource-based relative value scale (RBRVS) for physician services became effective in January 1992 to address this concern. The effects of the Medicare fee schedule on patient care and on the practice of geriatric medicine remain to be seen.
The services covered by Parts A and B can be provided through a health maintenance organization (HMO). Medicare pays the HMO a lump sum per enrollee (capitation) based on the average expenditures for Medicare beneficiaries in the geographic area. If the income from Medicare is greater than the expenses, the HMO must share part of the excess with its Medicare members by providing services not covered by Medicare (eg, preventive medical services) or by eliminating cost sharing.

Part A of Medicare is supported by a payroll tax collected during a person’s working years. Part A represents paid-up hospital insurance for Medicare-qualified retirees, who pay no premiums during retire­ment. Generally, only people who are eligible to receive Social Security monthly payments are eligible for Medicare. Persons who never worked or who did not accumulate enough Social Security work quarters are not eligible for Medicare.

In general, a Medicare beneficiary is entitled to inpatient hospital care for a maximum number of days (60 days in 1993) during a benefit pe­riod. The beneficiary pays a deductible ($690 in 1994), which is estab­lished annually by the government. A benefit period begins when the person is admitted to the hospital and ends when the person has been out of the hospital or skilled nursing facility for a given number of con­secutive days (60 days in 1993). A readmission in a new benefit period requires that another deductible be paid. If the patient’s hospival stay exceeds the maximum number of days in one benefit period, Medicare pays a large part of the recognized costs for days 61 to 90, and the bene­ficiary pays a daily copayment equal to one fourth of the deductible. This extension is limited to 30 hospital days. In addition, Medicare pro­vides partial coverage for 60 hospital reserve days during a benefi­ciary’s lifetime; after these days are used, they cannot be replaced. The beneficiary pays one half of the deductible for reserve days. Part A provides some coverage for psychiatric hospital stays.

Medicare Part A covers virtually all hospital services, including dis­charge planning and medical social services. It covers the cost of a semiprivate room or, if medically necessary, a private room, but not such amenities as television and telephone.

The amount Medicare pays for hospitalization is predetermined by the diagnosis related group (DRG) that covers the beneficiary’s principal diagnosis. Some adjustment is made for age and comorbidity. The hos­pital may make or lose money, depending on how soon the patient is discharged and how many diagnostic and therapeutic services are used. Under this arrangement, the financial pressure for earlier discharge and <!– /* Style Definitions */ p.MsoNormal, li.MsoNormal, div.MsoNormal {mso-style-parent:”"; margin:0cm; margin-bottom:.0001pt; mso-pagination:none; mso-layout-grid-align:none; text-autospace:none; font-size:10.0pt; font-family:”Times New Roman”; mso-fareast-font-family:”Times New Roman”;} @page Section1 {size:612.0pt 792.0pt; margin:70.85pt 70.85pt 70.85pt 70.85pt; mso-header-margin:35.4pt; mso-footer-margin:35.4pt; mso-paper-source:0;} div.Section1 {page:Section1;} –>

limited intervention may conflict with medical judgment. When a pa­tient cannot be discharged home safely or to a nursing home because no bed is available, Medicare pays a relatively low per diem for an alter­nate level of care.

Part A covers posthospital convalescent care and rehabilitative care in a nursing home. However, because Medicare does not pay for custo­dial or long-term care, coverage ends when the patient is stabilized and skilled professional care is no longer needed.

Hospice care is covered by Part A under certain conditions (see HOS-PICE CARE in Ch. 25). The beneficiary pays no deductible or copayment except for part of the costs of outpatient drugs and of respite care, a provision to support family members caring for the patient at home (see Respite Care in Ch. 25).

Individually, Medicare, Medicaid, Medigap, and private long-term care insurance have shortcomings in providing comprehensive geriatric care, which includes the medical, nursing, and supportive needs of the elderly patient. Medicare excludes long-term custodial care and many preventive services; Medicaid belatedly intervenes after the patient is impoverished; Medigap, like Medicare, excludes long-term care and outpatient prescribed drugs; and private insurance is unaffordable by most elders, leaves them vulnerable to financial catastrophe, and sup­ports only fragments of long-term care. Collectively, these programs rarely promote integrated acute and long-term care or coordination of

ealth and social services. However, several model projects have dem­onstrated that with organized delivery of services using combinations of public funding and private insurance, comprehensive geriatric care can be adequately financed.

Social and health maintenance organizations (SHMOs) are demonstra­tion programs conducted by Medicare. They use Medicare, Medicaid, and private patient payments to cover a complete range of care benefits managed by nurses, social workers, and physicians. Patients not eligi­ble for Medicaid benefits use private payments to cover a limited amount of long-term care, principally in the home. Like an HMO, an SHMO is at financial risk for the cost of services and has a stake in frugality.

The Program of All-inclusive Care of the Elderly (PACE) is a federally supported, multisite program of comprehensive care. Its primary ob­jective is to keep patients in the community as long as medically, so­cially, and financially possible. A professional multidisciplinary team assesses patient needs, develops a care plan, integrates primary care and other services, and arranges for the implementation of services. The project is sponsored by one or more facilities and community groups; the project sponsor receives a preset amount of Medicare, Medicaid, and private funds and guarantees the provision of benefits at a capitated rate. If the costs of benefits exceed the pooled funds, the project covers the loss.

In San Francisco’s Chinatown, On Lok, the forerunner of PACE, pro­vides prepaid comprehensive care for elderly persons who have a level of impairment that usually requires admission to a nursing home. On Lok provides adult day care and coordinated, comprehensive services, including custodial or personal care, drug treatment, dentistry, and housekeeping services in a community housing project. Fewer than 6% of On Lok participants (who enroll for life) have needed nursing home placement, and hospital admissions and lengths of stay are half those for comparable elders.

The life-care community or continuing care retirement community is a model for combining housing, health care, and other services under packaged financing and management. These communities may have a clinic, an infirmary, or even a nursing home on the site, and housing is designed to accommodate disabled persons. The most extensive of these communities serve wealthy retirees willing to sign long-term con­tracts for their housing and care. Some life-care communities have failed when inflation and an aging population caused costs for services to exceed income. Some communities keep costs down by providing housing and minimal services with options to purchase additional ser­vices (see also Life-Care Communities in Ch. 24).

In 1990, the US Bipartisan Commission on Comprehensive Health Care (the Pepper Commission) developed a model approach to long-term care financing that resembles Social Security. Throughout their working lives, Americans would contribute a portion of earnings to a long-term care fund, with services administered by state government and community organizations. This fund would provide custodial care <!– /* Style Definitions */ p.MsoNormal, li.MsoNormal, div.MsoNormal {mso-style-parent:”"; margin:0cm; margin-bottom:.0001pt; mso-pagination:none; mso-layout-grid-align:none; text-autospace:none; font-size:10.0pt; font-family:”Times New Roman”; mso-fareast-font-family:”Times New Roman”;} @page Section1 {size:841.7pt 595.45pt; mso-page-orientation:landscape; margin:43.9pt 73.5pt 18.0pt 72.0pt; mso-header-margin:35.4pt; mso-footer-margin:35.4pt; mso-columns:2 not-even 315.35pt 66.0pt 314.85pt; mso-paper-source:0;} div.Section1 {page:Section1;} –>

for as long as a person needed it at home and for 3 mo in a nursing home I he panel also proposed a liberalized Medicaid program for persons who need longer nursing home stays. In consideration of national health reform in the early 1990s, some proposals omitted long-term care on the grounds that the nation could not afford it.

According to one study, long-term care costs will rise substantially if no major changes are made; the $54.7 billion spent on nursing home care and the $20.7 billion spent on home care in 1993 will increase to * 126.2 billion and $40 billion, respectively, in 2018. The study also con­cluded that private insurance was unlikely to have a major effect on individual and Medicaid spending for long-term care and that social insurance was central to the financing and delivery of long-term care (home and community-based care plus 3 mo in a nursing home) with supplementation by private insurance and liberalized Medicaid

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