Winning In The Last Inning: How to Grow Old, Stay Independent and Financially Solvent

By Robert Preston

A helpful book for anyone involved in caregiving for the elderly or disabled. Long term care is an approaching tsunami which the country and most families/individuals can't afford. Disruption in the approaches and methodology of long term care will occur - understanding these changes and adapting to the new procedures will make the care of a loved one manageable and easier.

• Language: English
• Publisher: BookBaby
• Release date: Apr 4, 2012
• ISBN: 9781620954775

Book preview

life

Preface

How does one grow old in the United States and remain independent and financially solvent? How can we obtain help when needed without sacrificing dignity or financial independence? By being an innovator - applying nontraditional methods and approaches to long term care.

Visit any Nursing Home (NH) for an hour or more and you can’t escape the feeling of despair that permeates the halls – maybe that’s why many residents receiving any form of institutional care get so few visitors.

There is an assortment of things one can do to remain independent well into old age – things over which you have control. This book focuses on six key areas: 1) staying healthy (which includes use of the latest technology for treatment outside of institutions), 2) facing death and illness realistically, 3) relying on yourself financially (as much as possible) to avoid the rationed care down the road as governments become insolvent, 4) using global resources for treatment and care when they make the most sense, either by traveling abroad or through immigrant help domestically 5) using the latest technology and innovative thinking to remain at home when illness or frailty due to advancing years sets in and 6) being smart about your money so you remain in control of your destiny.

For years, my attitude towards long-term care (LTC) and its corresponding insurance products mirrored the traditional. Institutional care seemed appropriate when family/friends could no longer handle a patient. LTC insurance offered protection against financial insolvency in old age when expensive, institutional care might be needed. Looking back, I was naïve!

My outlook on LTC took a 180 degree turn with an experience my father (a high level financial executive) had in the early 1980’s. He suffered a severe stroke with serious aftereffects which impaired his physical mobility. While his mental acuity was never affected, his ability to walk, transfer and care for himself was severely altered after the attack.

Rehabilitation helped some, but not enough for him to live independently ever again. As his wife had died years before, he needed daily help to function. We tried home health care agencies, assisted living facilities, and several (supposedly) five star nursing homes (NH) – (five star in costs anyway), in the Northeast and Florida. The care was never very good, or often, even adequate; frequently it was just plain inept. I got a firsthand view of what it’s like to be dependent on low paid strangers, the labor pool we draw from, in this nation, for custodial help. We were always a private pay client, so, supposedly, were eligible for the best services available for someone in his condition. There were times, when we had a private room in a NH supplemented by private help, costs averaged $10,000/month (back in 1999).

My office was in Connecticut while Dad resided in Florida. One weekend I made an unannounced trip to his assisted living facility (ALF), where we also employed extra private help to, supposedly, make his life better. I arrived midmorning to find him sitting in the middle of the room, undressed, unbathed, and needing many areas of support services. He indicated no one had been in the room yet that day to help him get washed, dressed, or to have breakfast. I was, obviously, upset about this situation. Having had many discussions in the past with the institution about poor service, I realized the time for talk was over and a different road lay ahead. Since we had experimented with several institutions and types of care, the days of thinking a better option was around the corner were over. I was frustrated after years of poor service, exorbitant charges and a poor attitude on the part of many staff, no matter what level of care we tried. I’d come to realize non familial personnel will never care as much about a loved one as direct relatives, an oxymoron in retrospect.

I got on the plane that weekend to return to Connecticut, realizing it was time to think outside the box. Radical problems merit radical solutions. I began to accept the fact it would be impossible to get my father the care he needed, wanted, or deserved, at any price, going down traditional paths. I looked at maps of the world, talked to friends who traveled a lot, and began to think the answer lay outside our shores. And it did. At that point current technology and recent medical advances, enabling people to receive more care at home, were unavailable.

Using the Internet to chat with people in other countries, it slowly dawned on me that many third world countries had exactly what we needed for far less cost than what was available within our domestic shores. They offered cheap labor, a good attitude (people desperately need work in these other countries), clean, well-managed facilities and an attractive climate. I was close to setting up shop in Mexico where all details had been arranged over the Internet, when an option in Costa Rica (CR) was discovered that seemed too good to be true. A well staffed NH, (one to one ratio of staff to patients), nice setting, excellent references, for $1700/month, was available, excluding drugs and medicines. Health care was rated highly in CR (many doctors trained in the US or Britain and are board certified) and costs were substantially less.

I discussed the opportunity with Dad and after so many years of high costs, poor service and overall disappointment, he opted to try it ASAP. We did, and never looked back.

The care was excellent. Healthy food, lots of TLC from the staff, good medical care delivered more efficiently than in the States and costs that offered real value for dollars expended. We had turned the corner on finding good care for reasonable costs. We hired a private chauffeur and bilingual woman to supervise his care, all for about one-third (total monthly costs) what we’d been paying in the US. I visited Dad once a month to perform ongoing quality control over the details of his care. Eventually we transferred him to a smaller facility in the country, away from San Jose, which offered more personal care for about the same costs. He never wanted to come back to this country and passed away peacefully in CR after several years of excellent care.

Since the demand for LTC is about to soar as the supply of seniors multiplies, it behooves us to find the most efficient methods possible to care for this demographic certainty. Don’t look to the government for the answers or funding. As David Walker, Comptroller General of the US noted in a 2007 60 Minutes episode, I would argue that the most serious threat to the US is not someone hiding in a cave in Afghanistan or Pakistan but our own fiscal responsibility, referring to the huge unfunded liabilities of Social Security, Medicare and Medicaid. Since the government won’t be able to bail us out of the expensive demands to be made on society, how will the private sector care for the millions of seniors needing custodial help?

The answer lies in an about face of priorities. To date, the concern has been on paying for elders’ care, assuming costs will continue to escalate from current levels. The emphasis has been on the income side of the equation (larger entitlement programs, private LTC insurance, increased savings). The real answers to burgeoning elder care lie in drastically reducing the costs of said care. This will be accomplished through a radical transformation of how we care for ailing seniors. Four areas will converge to transform the cost structure of custodial care: 1) foreign help, available either through relocation to a third world country, or importing the necessary manpower assistance through revised immigration policies 2) medical and home surveillance technology that will enable seniors to remain home when incapacity strikes 3) a rationed approach to reimbursement by government as the precarious state of our national finances becomes apparent to our global partners and the populace and 4) an expansion of local, community based services, funded through a combination of private and municipal resources.

In addition to the personal experience with my father, my professional actuarial and tax practice (for 25 years) reinforced the concepts presented in this book. Constant dealing with client’s financial assets, along with a professional analysis of the three major entitlement programs seniors depend on (Medicare, Medicaid and Social Security) convinced me many families are ill-prepared for large LTC expenses and will be disappointed if relying on government help. I saw firsthand how a parent or spouse needing LTC can destroy the long range financial plans of a family. Accordingly, it seemed appropriate to share the insight, conclusions and predictions noted to spare many the rapid financial destruction that can occur through exhaustive LTC needs.

Part I of The Book examines the road that brought us to this precipice. Part II looks at the status quo families must deal with, today, if someone is afflicted with a chronic medical problem which requires extensive access to the health care system along with LTC needs. Part III offers alternatives to the traditional options using technology, global opportunities and enhanced local community services. With a more cost effective, compassionate and efficient approach to care elders can remain at home with deteriorating conditions, while those needing intensive care might consider foreign help here or abroad.

The discussion, besides offering alternatives to traditional options, will allow the reader to realize his/her experience is shared by many, and there is a way out of the frustration many find overwhelming.

CHAPTER OUTLINE

Part I:  Universal Problems

1.    Aging – Brief synopsis of the recent phenomena of aging; causes, antidotes and how, live long enough, you’ll probably be a candidate for some sort of LTC.

2.    Attitudes – Death, illness and suffering; how Western Civilization’s denial of death and emphasis on quantity rather than quality of life (particularly in contemporary America) induces an inflated and insatiable demand for LTC services; why a shift in priorities is overdue.

3.    Entitlements – America’s reliance on entitlement programs for the elderly has many assuming LTC is a societal problem requiring governmental solutions; reality is the government’s financial situation precludes involvement in the burgeoning LTC industry, thus mandating individuals assume responsibility for these services, or face a doomsday scenario of limited care in poverty stricken conditions.

4.    Caregivers – Finding qualified people, domestically, to care for the mushrooming elderly population, using the generally accepted channels, will be neigh impossible; no matter how many innovative types of institutions to care for the aging spring up with attractive infrastructure, staffing these organizations with qualified help will be a constant problem.

Part II:  Dealing with the Current LTC Environment

5.    Health Care – a lack of health, severe enough, induces demand for LTC; consequently, a brief critique of the health care system (strengths and weaknesses), along with a cursory look at some of the imminent changes we’re about to experience in delivery methods and options of care; individual responsibility for a healthy lifestyle can assist seniors in stacking the odds towards an independent future.

6.    Nursing Homes – Analyzing the status quo and why this form of institutional care has a limited future.

7.    Other Alternatives – When the focused care of a NH isn’t required, there are assorted options for those who can no longer live independently.

8.    CCRC’s – The Mercedes of aging in place; why perception is not always reality.

9.    Home Care – Where most seniors needing LTC prefer to be; why implementing the concept, affordably, in the current environment, is so difficult.

10.  Paying for LTC (public and private) – traditional methods of paying for LTC (Medicare, Medicaid and private insurance) are not sustainable, necessitating a new approach to the costs and delivery of custodial services.

Part III:  Solutions for the Future

11.  Global help and how to get it – why extending the net for LTC labor outside our borders makes sense, and how to do it.

12.  Technology and Home Health Care – future trends and innovations will make home health care available (and affordable) for many; how technology through sensors, cameras, Internet services and advanced medical techniques and breakthroughs will enable seniors to remain at home until the end.

13.  Government Cooperation – easy, low cost policies the government can adapt to facilitate and encourage affordable home health care.

14.  Some final thoughts and a twelve step program for implementing accessible home health care.

15.  The ideal scenario of caring for elders in a perfect world…

16.  Potpourri of survival tips for the elderly addresses the retention and disposition of assets, as well as retaining control over one’s financial destiny as long as possible. Without financial means, any sort of independent living at home is problematic.

Introduction

Three unsustainable trends are about to intersect to permanently change the lifestyle of our elderly. First, the three primary entitlement programs seniors rely on (Medicare, Medicaid and Social Security) have trillions of dollars in unfunded liabilities (What’s a trillion dollars? If you laid one dollar bills end to end, you could make a chain that stretches from earth to the moon and back again 200 times before you ran out of dollar bills.) ¹ with no existing coherent plan to fund them. Second, the institutional treatment (warehousing) of millions of infirm elderly is tragic and unacceptable, yet getting quality, affordable help for home care is difficult, if not impossible, for many. Third, medical care for all, especially the elderly will move from institutional care at the provider’s point of service to emphasis on home diagnosis, treatment and maintenance. This final trend will occur along with government rationing as a national panic to control health care costs will soon permeate all medical treatment.

The residence and care options for those growing old and needing help appear bleak today; demographic projections suggest horrific conditions for many.

If you have acted as a caregiver for a loved one, you have an inkling of what I’m speaking about. If someone you know has required institutional care, you may have experienced some of the frustration in haphazard services. Paying thousands of dollars a month for an institutional closet providing minimal services is frustrating. Monitoring home care for a loved one can be equally foreboding and painful.

As an increasing portion of our population is approaching old and elderly it behooves us to reexamine the programs and methodology in caring for this segment of society. How we treat the elderly and the programs we adopt will eventually affect the rest of us. As goes the care for your parents, spouse and friends, so follows the care for you – at some point. We’re all in the lineup for possible chronic health problems before death which may require outside help.

The oncoming wave of baby boomers will not be as accepting and stoic of the sterile, impersonal quality of LTC rendered to their parents and previous generations. They will demand more privacy and control over these services, more options, and more efficient pricing. Ways of caring for the disabled elderly will change radically, and one of the core elements will be the proliferation of procedures and services, spearheaded by technology, that allow individuals to remain in their homes. For those too ill to remain home with assistance, foreign residence may offer a viable option when compared to domestic opportunities.

There are three stages to the average person’s life. The normal, high quality days of living – the years when we’re independent, feel well and function accordingly. The final stage of life encompasses death and dying and can last anywhere from a few hours to a few years. Often, between these two extremes, many enter a no man’s land where loss and deterioration, both physical and mental, accelerates and living as one has in the past is not possible. As in all situations in life, there’s a spectrum exhibiting mild limitations to total disability. Should one get old enough, the probability of entering the frightening zone of incapacity with extreme handicaps increases.

Eventually, as the field of biotechnology evolves, we may be able to compress the infirm period of life into shorter and shorter periods, until the transition from a fully functioning body to death takes, ideally, a matter of hours or days (more in chapter 12). At that ideal point there will be less need for dealing with the chronic, incapacitating illnesses that afflict many elderly Americans before death.

There has been an increased interest, the past few decades, in death and what happens upon passage to the other side. Books such as Life on the Other Side by Sylvia Browne, Life After Life by Raymond Moody and The Five People you meet in Heaven by Mitch Albom all attest to an increased interest in the death experience. A plethora of self-help books to live life to the fullest during one’s prime years, have poured forth the past half century. It’s the period between the zenith of life and the end of the parade, i.e., the years of decline that have been denied best seller status. This book attempts to fill the void by offering help and counsel to those concerned with or traversing the dark cavern in-between.

How might all this affect you?

As the morning ritual of shaving or putting on a face attests, none of us are immune to aging. Birthdays, funerals and periodic visits to the doctor all vouch for mortality. Aging parents and spouses are inevitable. Caring for them when ill or incapacitated is a reality many of us eventually, or currently, face. When the responsibility strikes it can be overwhelming. One of the unpleasant realities (particularly for time pressed individuals) is how difficult it is to effectively delegate many of the tasks that accompany care for an incapacitated person. In some ways it’s like fighting a war – the battle take money, time and high energy – sometimes the fight can be so exhausting a caregiver’s health will suffer.

Finding, and affording, the appropriate mix of help can be daunting and at times impossible. The options available within the domestic US can be discouraging. Exorbitant costs, help that provides substandard care, intensely regulated institutions that offer inconsistent service, too often accompanied by a lack of empathy are common. Staffing is a perpetual problem.

Care for the elderly is frustrating whether it involves doctors, labs, transportation or therapy. There are no bargains, package deals or sale days – at times the cash rushes out in a torrent with little reimbursement; many custodial and recuperative costs for the aging are not insured. It’s safe to figure a high percentage of direct medical costs will be covered by Medicare for those 65 and older (approximately 54 per cent); expenses not covered may or may not be reimbursed by supplemental insurance programs. The high costs of aging will eventually affect us all, whether insured through entitlement programs or paid for out-of-pocket.

Financing these costs is tricky. Medicaid (state assistance) covers the indigent. Medicaid planning may be an option to stave off bankruptcy for the middle class, but there’s a growing consensus it’s an immoral approach for salvaging financial assets for heirs. Additionally, what if you plan for Medicaid eligibility and it’s not around because of state cutbacks or public financial shortfalls when you need it (2011 saw many states with severe budget deficits and Medicaid is an obvious target)? And LTC insurance, while widely marketed and touted as a solution to custodial care costs, can have gaps in coverage, may not provide the level of assistance many want or are accustomed to through prior living standards, and assumes the companies taking your premiums will be able to pay out the benefits promised several decades away (in 2011 many prominent carriers, such as the Metropolitan, are raising premiums significantly – some are getting out of the business altogether). Additionally, unless it’s purchased at a young entry age, costs can be prohibitive and are not guaranteed, as will be further explained in chapter 10.

As the population ages, with more demands on an already stressed system, the status quo (part II) will deteriorate, eventually becoming unacceptable.

So we’re faced with the enigma that current spending levels and institutional models won’t solve the LTC problems facing the aged, but less costly alternatives might. The future consists of reallocating dollars to more efficient options, along with changing attitudes about aging, life expectancy and death. These solutions can be put into place with a little ingenuity, common sense and a greater reliance on the technology that’s about to explode in this area. Time will show the real solutions to our aging problem won’t come from government legislation but innovation from the private sector. We’ve got to squeeze more treatment and care from far less dollars.

Part I – The Dilemma

Chapter 1 – Aging

To me, old age is fifteen years older than I am – Bernard Baruch

Old age is the most unexpected of all the things that happen to a man. – Leon Trotsky

The age factor means nothing to me. I’m old enough to know my limitations, and I’m young enough to exceed them. – Marv Levy, 80, named General Manager of the NFL Buffalo Bills in 2005

Myth – Old age inevitably leads to deterioration and dependence. Institutional care will be necessary for a growing part of our elderly, with reimbursement from increased government funding and long term care insurance.

A nurse, Phyllis McCormack, at Sunnyside Royal Hospital, Hillside, Montrose, Scotland summed up the process of aging in this simple, succinct verse entitled Look closer, nurse.

"What do you see, nurses? What do you see?

What are you thinking when you’re looking at me?

A crabby old woman, not very wise, uncertain of habit, with faraway eyes?

Who dribbles her food and makes no reply

When you say in a loud voice, I do wish you’d try!

Who seems not to notice the things that you do,

And forever is losing a stocking or shoe….

Who, resisting or not, lets you do as you will,

With bathing and feeding, the long day to fill….

Is that what you’re thinking? Is that what you see?

Then open your eyes, nurse, you’re not looking at me.

I’ll tell you who I am as I sit here so still,

As I do your bidding, as I eat at your will.

I’m a small child of ten… with a father and mother,

Brothers and sisters, who love one another.

A young girl of sixteen with wings on her feet

Dreaming that soon now a lover she’ll meet.

A bride soon at twenty, my heart gives a leap,

Remembering the vows that I promised to keep.

At twenty-five now, I have young of my own,

Who need me to guide and a secure happy home.

A woman of thirty, my young now grown fast,

Bound to each other with ties that should last.

At forty, my young sons have grown and are gone,

But my man’s beside me to see I don’t mourn.

At fifty once more, babies play round my knee,

Again we know children, my loved one and me.

Dark days are upon me, my husband is dead;

I look at the future, I shudder with dread.

For my young are all rearing young of their own,

And I think of the years and the love that I’ve known.

I’m now an old woman…and nature is cruel;

‘Tis jest to make old age look like a fool.

The body, it crumbles, grace and vigor depart,

There is now a stone where I once had a heart.

But inside this old carcass a young girl still dwells,

And now and again, my battered heart swells.

I remember the joys, I remember the pain,

And I’m loving and living life over again.

I think of the years…all too few, gone too fast,

And accept the stark fact that nothing can last.

So open your eyes, people, open and see

Not a crabby old woman; look closer. See ME!!"

And growing old we are. During the past 100 years in America, the percentage of the population over 65 has tripled, while the actual number has increased eleven fold. The over 65 group is headed towards 20 percent of the population by 2030 – 70 million people (more than twice the number it is today, and ten times what it was 100 years ago).² The over 85 part of our citizenry is the fastest growing segment of society (it’s predicted to be 8.5 million by 2030); by 2000 it had increased 28 times from what it was at the beginning of the last century. Singles comprise almost 50 percent of this category, which bodes ill for those that become incapacitated (the majority of singles living alone are women). The bulk of the rapid growth in seniors is just ahead, projected to occur between 2010 and 2030 – because of the boomers. As a precursor to demands on caregivers, it’s estimated about half of the 85 and older persons need some sort of assistance with daily living (bathing, eating, toileting, etc). And those over 85 absorb more than 20 times the NH costs as those 65-69.³

In over 20 states the over 65 population makes up more than 12 percent of the total population, and in Pennsylvania, West Virginia and Florida more than 15 percent. Some counties in Florida and other states, such as North Dakota, have an over 65 density rate of approximately 30 percent. We’ve got over 35 million seniors (65 and older) in the nation today, with projections of 87 million by 2050. As demographics is destiny this trend will alter the landscape in services, tax rates, real estate values and the cost of social programs. Just as the boomers have monopolized every national trend since entering kindergarten, they won’t disappoint with old age.

In 1900 one in 25 Americans was over 65 (4 percent). In 1900 the average American lived to be 49 years old.⁴ Before the middle of this century, 20-25 percent of the populace will be over 65, with the majority (hopefully) supported through our entitlement network (Social Security, Medicare, Medicaid) – a huge responsibility for the working population. The Social Security Administration notes that the life expectancy for a male aged 65 in 1940 was 12.7 years; that’s expected to increase to approximately 18.6 years by 2040 – add another three years for females. The ratio of people of working age to those age 65 and above (the dependency ratio) may shrink from 4.7 today to 2.6 by 2040. ⁵ Although the problems of an aging society are gaining attention, until a situation attains crisis mode, solutions are not aggressively sought (when is a red light installed at an intersection? – after several accidents).

Quick fixes to our dilemma will involve unimaginable pain to society. The antidote to major economic dislocations is intelligent advance planning (rare in Washington); in fairness to all segments of society, action sooner than later is relevant. And regardless of what our leaders in Washington do over the next decade to address these issues, you, as an individual, can (and should) prepare for the eventual changes sure to come.

In the recent millennium census 12.4 percent of our populace was over age 65, while 21 percent was under age 15. Compare that to a country like Costa Rica where 34 percent of the population is under 15 and only 5 percent is over age 65. In many third world countries the population is exploding, causing other problems associated with the burden of too many people (of all ages). In chapter 11 we’ll discuss how the merging of these opposing trends could mitigate problems for both groups.

Is modern medicine responsible for the increased longevity? Yes and no. People born in the recent past have a life expectancy, today, of around 77 years, 29 more years than those born at the turn of the 20th century. In 1900 75 percent of the population died before age 65; today 70 percent die after that number. Up to a few centuries ago, most of the world was young by today’s standards. For 99 percent of humanity’s life on this planet life expectancy was age 18.⁶ In the last century life expectancy increased by over 50 percent. Contrary to customary opinion, most of the increase in the averages occurred because of reduced mortality for the very young and young adults (thanks to vaccines and antibiotics eliminating infectious diseases which affect the young), and not high-tech medicine associated with old age. About six of those increased years are due to other factors such as better infrastructure – water, sewers, improved nutrition and more comfortable housing. Modern medicine can take credit for keeping us alive for short (2-3 years) periods as we approach death, but not for overall increased longevity. Society’s attitude towards longevity also plays a role which includes our acceptance or rejection of death.

A large portion of total medical costs goes to people over 65 – about 40 percent of the pie; on top of that, Medicare spends 25 percent of its budget on individuals in the last year of life.⁷ The increase in medical expenses is not linear throughout life – it’s geometric as we age. As noted, we spend twenty times more on custodial funds for the frail over age 85 as compared to the younger elderly (65-69).⁸ Money well spent? A difficult question that will be debated and analyzed increasingly during the upcoming decades and where emotion, ethics and finance interact. Interestingly, all this money being spent on health care does not give Americans the longest average life expectancy – there are many countries ahead of us in the life expectancy game, including Canada, Japan (the longest) and Italy.

Aging is not a disease – it’s a natural by-product of living long enough. Although our society is averse to natural aging (as evidenced by the cosmetic industry, both in personal beauty products and plastic surgery medicine), it’s a natural state of affairs. Live long enough, and the body’s resistance to deterioration and disease will eventually succumb – it’s a certainty. And if perchance one doesn’t succumb to one of the gotchas of old age (heart disease, cancer, stroke) then a gradual weakening will occur (entropy) which will eventually lead to an inability to function independently and a preponderance of time in bed.

The study of why the body ages (bio-gerontology), and the conditions of aging (geriatric medicine), are two separate areas of science. The focus has been on the latter, although inroads are beginning to be made on the former. As the payback is not as direct or rapid on the why of aging, most funding has been and is directed to the conditions and problems of aging, along with haphazard attempts to forestall the negative effects of longevity.

Once an organism has achieved sexual maturity and passed the prime reproductive period, the process of natural selection and genetic programming has the average organism deteriorating and eventually removed from the natural order. It’s contrary to the normal cycle of life to prevent or fight aging – and it’s an uphill battle, as possibly it should be. Most species, not captivated or tamed by humanity, don’t age. Death normally occurs by accident, disease, a sudden ending through the efforts of a predator, or starvation. Aging, as humans experience it today, is a relatively recent phenomena.

Biological aging (contrasted to chronological aging) is termed senescence. This is the scientific label for an organism’s deterioration based on the passage of time. It warrants a separate definitive category as it is distinct from other body processes in four ways: 1) its characteristics must be universal; 2) the changes which constitute it come from within the individual; 3) the processes associated with senescence occur gradually; and 4) the changes which appear in senescence have a deleterious effect on the individual.⁹

What if we could cure aging? Stop the process and double or triple life span. While individually that may be desirable, on an aggregate basis it would create another set of problems that, potentially, could be worse for the individual than aging as we now experience it.

The world’s population has increased from about 5 million individuals in 8000 B.C., to over 6.7 billion today, with projections of possibly 9 billion within a few decades. As we ward off old age and encourage longevity, we’re entering a new environment with hazards not yet considered. While not the focus of this book, the dilemma of how many people the globe can support while continuing to renew itself, is a relevant question, and one directly related to future longevity and the percentage of aged persons in society. Global birth rates are a topic needing attention before calamity besets our globe and the environment. Possibly the real reason behind NASA’s manned flight explorations is to establish colonies in outer space to prevent the extinction of the human species.

Recent studies infer the globe is being overtaxed by human demands. Mathis Wackernagel noted on the web site of the Proceedings of the National Academy of Sciences that mankind’s ecological footprint now outstrips what the biosphere can produce on an ongoing basis – i.e., we’re exhausting Mother Earth’s capital. Increased longevity has many ramifications and is a double edged sword. As a minister succinctly sermonized everyone wants to get into heaven, but no one wants to die to get there.

As we age, the system breaks down. Old age is not an illness. It is a continuation of life with decreasing capacities for adaptation.¹⁰ While we can forestall some infirmities (cancer, heart disease), inevitably as time progresses, the molecular and cell behavior of our core becomes more unstable, leading to eventual infirmity. Even if we find cures for cancer and heart disease, the life expectancy added will probably be no more than in the vicinity of 15-20 years (the majority of this increase would be caused by solving cardiovascular problems – curing cancer would only add about 3 years to the over 65 group). The big, easy increases of life expectancy may be behind us. In the ‘90’s, death rates from cancer and circulatory problems evidenced modest decreases, with the decrease in atherosclerosis the most noticeable – it is no longer a major cause of death in this country.¹¹

As we become more successful in deterring the effects of cancer, cardiovascular problems and strokes, more individuals will reach the fragile years attributable to advanced aging. Modern medicine can’t be relied upon to maintain a high quality of life indefinitely, even if some major breakthroughs in current maladies affecting the elderly are resolved. Eventually, the normal frailties and hazards of old age will win out, and living independently becomes impossible for most. Once we’ve attained age 85 or beyond the odds of incipient decline, resulting in a dependence on others to perform the normal daily activities, increases progressively. This is the group most likely to require intense custodial care, and possibly NH assistance. As noted previously, the over age 85 group is the fastest growing part of our population (when compared to all age groups below it – certain sub-groups older than 85 are increasing even faster); ominous demographics certain to compound the problems of LTC.

Although Americans are living longer and the percentage of us reaching old age is increasing annually, there are 24 countries ahead of us in life expectancy.

Sampling of countries with highest life expectancy – 2001*

*Courtesy – CDC, 2005 (note the approximate six year spread between males and females, independent of country)

The average age at death is much higher than 100 years ago. At the beginning of the 20th century, around 40 percent of the citizenry reached age 65 – now, over 75 percent do, with the percentage higher in both cases for women. As the population ages, the causes of death change – bouts with bacteria (e.g., tuberculosis) and influenza that used to result in early death have been replaced with chronic problems such as heart, cancer, renal disease and stroke; pneumonia, however, is still a principal contributor to the demise of many older elderly.

The quality of overall health has increased considerably over the past century. During the Civil War era people suffered for decades with major problems, but continued with their life’s duties. Surgery was not advanced and problems such as hernias were simply endured, with little hope of resolving the discomfort. Over 80 percent of the population had some form of heart disease by age 60 (that’s been reduced to less than 50 percent today). With each advancing wave of medical technology, certain problems were eliminated, but replaced with others associated with longer life spans, such as Alzheimer’s, diabetes, failing eyesight and loss of balance.

Mortality tables are being analyzed and reworked for the very old, i.e., those 85 and up, in many countries – Canada, US, India, Japan. As these tables are reworked and perfected, it will be possible to more accurately predict the number and condition of the elderly in each society, and plan accordingly. In all developed societies (an exception being Russia) the number of the very old (85 and up) seems to be increasing consistently with each census taken – thus, more elderly ailments will become the norm. In the US the fastest growing (percentage) part of the population is the centenarian, those over 100 (there are now almost 95,000 centenarians in the US). With the very old ages, typical mortality trends break down, and the curve is seen to level off with a diminishing slope, evidencing a type of mortality deceleration.

Over the next 10-20 years the attainment of 100 may become commonplace in the US. Shripad Tuljapurkar, a Stanford University biologist, believes state-of-the-art, anti-aging technologies could…radically start altering global demographics, extending people’s life spans by 20 years.¹²

As we continue to treat the senior ailments (heart disease, stroke, cancer) more successfully, and defy death of its traditional accomplices, the problems of the very old will become more common. In addition to the aging ailments noted are incontinence, cognitive impairment (Alzheimer’s), renal disease, diabetes and problems related to chronic lung obstruction. Unfortunately, adding quantity of years because of medical advancements doesn’t necessarily equate with more quality years; this is a point on which we must begin a national debate weighing the pros and cons. Keeping people alive for more years through sophisticated medical technology does not guarantee the projection of a prior satisfactory lifestyle and at some point that realization may alter our research priorities. Studying the results of aging is not the same as critiquing the causes of aging.

The trend of more dependent elders has not been relegated to the