HOW AN AGEING POPULATION WILL CHANGE THE WORLD - BBC NEWS
How the Aging Population Is Changing the Healthcare System
By 2030, one in five Americans will be over age 65, and the healthcare system is just beginning to feel the burden.
By Susan E. Matthews
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New York City is made for walking, which Bronx-bred Joseph Siegel knows well. After living in Brooklyn and Manhattan, Siegel, who had a successful career in insurance and brokerage, retired to the Upper West Side. Now, he likes to travel with his wife Esther — last year they went to Southeast Asia.
But recently, Siegel has had a difficult time walking, so he decided to get a knee replacement he’s been considering. “Traveling means you have to be able to get around,” Siegel says. While this makes sense, what’s not clear is how many years Siegel will have to use his new knee.
Siegel is 84 years old. About a week after his operation, he woke in the middle of a Saturday night to unbelievable pain, saying he “felt like his stomach was going to explode.” He had to have emergency surgery for a stomach ulcer, which he hadn’t known he had prior to the knee surgery. The painkillers he was taking for his knee replacement may have been a contributing factor, he says, though his doctor says it also may have been a pre-existing condition.
Siegel spent three weeks in the ICU, and during much of that time he couldn’t breathe or eat on his own. But he was able to move back to his own apartment, and has managed his recovery with the help of a nurse from the Visiting Nurse Service of New York (VNSNY), who comes to his home three days a week. Of his recovery, Siegel said he’s realized how much longer his body takes to heal, compared to when he was younger, but he adds that he’s lucky to have his nurse, a physical therapist for his knee, and the care of Esther, his wife of 60 years. While he’s finding it more difficult to sleep through the night because of the pain, he says he’s also lucky that his insurance and Medicare will be covering the costs, though he noted he “can’t imagine what the bill is.”
At 84, Siegel is still full of vigor and curiosity, which is why he got the surgery in the first place. He seems young at heart — he even has an iPhone 5 — and he's part of a growing number of older Americans who expect to live healthy lives well into their seventies, eighties, and nineties. These older Americans are becoming a bigger part of the population, and they will need a different sort of healthcare as they age — care that the nation’s healthcare system may not be prepared to provide.
More People, Living Longer
Thanks to the baby boomers, who began turning 65 in 2011, the population of older Americans is expanding. By 2030, one in five Americans will be a senior citizen, nearly double the 12 percent in 2000, according to “The State of Aging and Health in America,” a 2013 special report from the U.S. Centers for Disease Control and Prevention (CDC).
Not only are there more seniors, they’re also living longer. In the past century, life expectancy has increased by nearly 30 years. Men born in 1900 could expect to live until age 48, but by 2000, men's life expectancy had jumped to 74. In 1900, women could expect to live 51 years, but as of 2000, their life expectancy had also jumped to 74 years, and by 2050, the average woman may make it to age 86 (men can expect to live to age 80).
This massive shift in the country’s demographics will put new pressures and demands on the healthcare system — even Google knows it. The search engine giant has ventured into new territory with Calico, a company it launched in September 2013 to address the "challenge of aging and associated diseases." Doctors will have to rethink every aspect of care for the older population, even rethinking how we die. In addition to the big picture, the country will also have to figure out how to pay for this extra care and how to support an older population. “It’s a vulnerable segment with the largest care needs,” says Thomas Gill, MD, a geriatrician and director of the Yale Program on Aging. “This will be a very important issue to address from a policy standpoint. We’re probably going to need to be a little more creative with how we finance and provide care to that segment of the population.”
Everyday Health's series, “From Boomers to Seniors: A Special Report on Aging and Health in America,” will take a close look at these issues — from the cost of senior care, to the science of aging, to the trials of being a geriatrician in an era when there's a shortage of doctors who specialize in elder care.
How We Die – Then and Now
As the number of people living into their seventies and eighties has increased, so have incidences of the diseases that cause their deaths. In 1900, infectious disease was the leading cause of death in America, with influenza, pneumonia, tuberculosis, and gastrointestinal infections accounting for almost half of all deaths, not to mention being a relatively quick way to go. Today, however, only pneumonia and influenza even crack the list of leading causes of death, and while this is for the entire population, the shift also applies to the elderly, says David Jones, MD, PhD, professor of global health and social medicine at Harvard University. Instead, chronic conditions — heart disease, cancer, non-infectious airway diseases (such as fibrosis) have taken over the top spots. In 2010, the CDC reported that accidents and Alzheimer’s disease were the fifth and sixth leading causes of death, showing how modern medicine has conquered certain diseases, causing a shift in how we die.
Eventually, a whole other slew of diseases might do us in, suggests an analysis published by Jones and his colleagues in the 200th anniversary edition of the New England Journal of Medicine in December 2012.
“By the time antibiotics and vaccines began combating infectious diseases, mortality had shifted toward heart disease, cancer, and stroke,” they wrote. “Great progress has been made to meet these challenges, but the burden of disease will surely shift again. We already face an increasing burden of neuropsychiatric disease for which satisfying treatments do not yet exist.”
Jones says he believes that in the near future, heart disease may fall below cancer, which will take over as the leading cause of death. “One thing we’re sure of is that the human body, left to its own devices, will deteriorate over time,” he says. Doctors may be very successful at prolonging life by preserving the physical body, but the brain will decline, as will essential functions like hearing and eyesight. For example, Jones’ grandmother lived until she was 102, he says, but by the time she was a centenarian, she suffered from failing vision and hearing, which caused her to be cognitively isolated. “It’s very easy to imagine a world where people will have limited quality of life because of vision or hearing or bone structure,” Jones says.
Rethinking the Healthcare System
While we may not yet know what the leading causes of death will be in 2050, there may be a limited number of people available to help treat these conditions. The American Geriatrics Society estimates that at minimum, 30 percent of older Americans today need a geriatrician to help them face the aging process. The means that the need for geriatricians will grow to nearly 30,000 by 2030, though there are currently only around 7,500 certified geriatricians in the United States today.
“Geriatrics is not one of the higher paying specialties,” says Sarah McGee, MD, MPH, a geriatrician at the University of Massachusetts Medical School, adding that it’s “maybe not as glamorous, since it’s not as procedure oriented.” Despite these deterrents, Dr. McGee says she’s enormously satisfied with her career, and Gill says geriatricians often rank at the top when it comes to career satisfaction. Treating the baby boomer generation could be particularly interesting because this patient population been more engaged with healthcare and involved in decision-making throughout their lives, McGee says. The baby boomers “are not going to do whatever the doctor said,” according to McGee.
Two-thirds of all people over age 65 experience multiple chronic conditions, making specialized geriatric care even more critical. In fact, according to the CDC, 95 percent of older Americans’ healthcare costs are for managing their many chronic conditions. Facing several chronic conditions at once is called multi-morbidity, and having geriatricians who are trained to handle these scenarios is critical, says Gill. Otherwise, an older adult could end up receiving medications for each condition — possibly as many as 15 or more daily medications — which geriatricians work to avoid. Geriatricians help to not “miss the forest for the trees,” according to Dr. Gill. “Geriatricians keep the forest in mind in trying to address things in a broader approach rather in this disease-oriented approach,” Gill says.
Sometimes, the decisions behind treatment are made even more complicated by the cognitive decline that often accompanies aging — one in every eight adults over age 60 has cchanges in thinking, including confusion and memory loss, the CDC reported. Nearly 5 million Americans currently suffer from Alzheimer’s disease. This often requires caregivers to fundamentally rethink the relationship between quality of life and length of life. The field of palliative care has come about during McGee’s time as a practitioner, which she says is promising. Palliative care focuses treatment on reducing the amount of pain a patient is experiencing, rather than traditionally trying to treat the diseases the patient may have.
Jones notes that physician-assisted suicide is consistently a controversial topic, and was voted down in his home state of Massachusetts. He supports the idea, however, particularly considering his grandmother’s last two years of life, when she was blind and deaf. “Every night she went to bed thinking she hoped she died in her sleep,” he says. He also cites research that showed that in states where it is legal, most people who take advantage of doctor-assisted suicide are doctors themselves. “We could all get to a point where our quality of life is miserable because of neurodegenerative diseases,” says Jones. “We should all be able to say enough is enough — ‘I want to die with dignity.’”
The Yale Program on Aging helps to educate physicians on how to address the elderly’s unique needs, and even more, to encourage them to conduct more research on older adults’ health needs, using older adults as subjects. “This is a population that often isn’t included in clinical trials,” Gill says, but if more research is conducted now, treatment may improve down the road. For example, some older adults are retaining much of their cognitive function, and later in our package you can read about what researchers have found is different in these super-agers’ brains.
Caregivers on the Decline, Too
In addition to needing more medical care, the elderly often rely on an informal network of friends and family to help them with their daily needs. Unfortunately, the number of unofficial caregivers is also expected to decline, an AARP report pointed out in August. In 2010, researchers from the AARP’s Public Policy Institute estimated that there were seven potential caregivers for every elderly adult over age 80. This ratio will drop to four to one by 2030 and eventually fall to three to one by 2050, because baby boomers are aging away from being caretakers to becoming the ones who need caretaking. This becomes even more problematic in light of the fact that 68 percent of Americans think they will be able to rely on their children and other family members when it comes to long-term care.
If family members are not available, the elderly may have to rely on a visiting nurse or go into an assisted living center, which may only add to the already mounting medical bills that seniors acquire. Medical care for one person over age 65 is between three to five times more costly than care for one person under age 65, the CDC reported, and sometimes the costs and the responsibilities fall on the next generation. Already, the cost of dementia care is equal to 0 billion annually worldwide — or 1 percent of global GDP. By 2050, 227 million adults globally are expected to require a caregiver to help them through the aging process.
Jones says that we often have a “very romanticized vision of the past,” assuming that multigenerational households took excellent care of the elderly. But he says that in reality, it was often the whole community who looked after the elderly, and that could be a model that could still be effective today. “I suspect the best solution isn’t going to be to medicalize aging, but to rethink society,” he says. This means having a different view toward aging more naturally and accepting death. “This isn’t necessarily a problem that should be handled by the healthcare system,” says Jones, adding that already, there is “a lot of cynicism or fatigue in the healthcare system towards patients who are very old and very ill who are pursuing therapies without definite hope of getting better.” Instead, if the elderly were more prepared for the aging process and more prepared to say no to treatment that won’t help quality of life, the healthcare system wouldn’t face so much of the burden. Luckily, that’s just what some seniors are starting to do.
Trying Not to Be a Burden
While many people may rely on their family as they age, 84-year-old Alma Alspach says that her number one hope is “not to become dependent on her children.” Alspach, who lives in Chicago, may be luckier than most when it comes to achieving this goal. Eight years ago, she began participating in a research study conducted at Northwestern University that aims to study healthy aging brains in order to better understand Alzheimer’s disease. Alspach originally volunteered for the study because she saw a flyer for it while visiting a friend in the hospital and wanted to give back, but she was surprised when the researchers told her last year she was a “super ager,” meaning that her brain has stayed remarkably young even as she ages.
“I thought they were kidding because of my age,” she says of first hearing the term. Alspach, who chooses to live alone in downtown Chicago rather than with one of her two sons, hasn’t had any serious health problems since she had a small surgery on her thyroid in 2002, and a fall in a train station a few years ago.
The only explanation Alspach can give for her good fortune with aging is that she stays active and tries to give back, particularly by volunteering in her apartment complex. “That’s why God has me hang around for so long — because I’m so helpful,” she says, joking that she’s “certainly not one who practices healthy eating.” Living in the city keeps her busy running errands and up on her feet, she says.
Longevity doesn’t even run in her family, she adds, noting that her mother died at age 75 and her sister at age 72. Both of her parents died quickly of heart problems, she notes, remembering that she had talked to her father at noon one day, and two hours later he was gone. “They didn’t suffer and that’s the best thing you can ask for,” she says.
Siegel, who is still recovering from his knee replacement and ulcer, agrees. He says he is hoping to improve enough so he can get in another “good 10 years.” Then, if he could just “drop dead, it would be perfect.” Going fast is the dream, he says, referring to a friend he knows in his nineties who “spends his life in doctors’ offices." “He has all kinds of problems, and it’s costing a fortune … it’s really no kind of life,” Siegel says.
Gill notes that in his practice, when asked, older patients constantly rank maintaining independence as their No. 1 priority, even above longevity. Both Siegel and Alspach are living proof of older adults who are planning for medical emergencies and decisions with exactly that in mind. If more of the growing generation of older adults does the same, the crises facing our healthcare system may not be so problematic.
In our series “From Boomers to Seniors: A Special Report on Aging and Health in America,” we’ll look at how doctors will mitigate the impending rise in the older population, what we can learn from the elderly, and what anyone who may find themselves caring for a senior should know.
Additional reporting contributed by Jennifer Brown.
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