Update on Aging


With apologies to Charles Dickens for the title, today let’s look at some aspects of long term care.

The specter of “The nursing home” is raised when one has reached that point where one is alone to the extent that family cannot provide in-home care. This is a complicated area that most people do not plan for and either can afford it or cannot. If you can afford it, it just reduces the legacy you leave to your relatives. If you really cannot afford it, e.g., you have nearly nothing but your modest home, then government programs pay for it. If you fall in the middle, it looks to be an expensive activity.

Approximately 70 percent of Americans turning 65 today will need long term care at some point in their lives. This figure comes from both Leading Age (http://leadingage.org), a Washington-based lobbying group that represents nursing and retirement homes and the National Clearinghouse for Long-Term Care Information (http://www.longtermcare.gov).

Who pays now. “On an aggregate basis, the biggest share, 49 percent, is paid for by Medicaid.  On an individual basis, however, ‘who pays for long-term care’ can look very different. This is because people with their own personal financial resources do not qualify for Medicaid unless they use up their resources first paying for care, so-called ‘spending down.’  If you have reasonable income and assets, most likely you will be paying for care on your own” (http://www.longtermcare.gov/LTC/Main_Site/Paying_LTC/Costs_Of_Care/Costs_Of_Care.aspx#National).

I could not find information on this question: How many people who do not qualify for Medicaid need long term care but don’t do it and instead struggle along on their own until their health is so deteriorated that they only need the 90 days provided by Medicare? This seems to be an area worth exploring and one no doubt filled with sad stories.

Private insurers have found it difficult to sign up enough customers for long term care insurance to make the business profitable. A new twist is to pair long term care insurance with whole life insurance (http://www.bloomberg.com/news/2011-05-18/insurers-pair-long-term-care-with-life-to-entice-older-buyers.html). On the other hand, MetLife will stop selling new policies in December (http://www.bloomberg.com/news/2010-11-11/metlife-halts-sale-of-long-term-care-insurance-after-review.html).

Speaking about private long term care insurance Catherine Theroux, a Limra spokeswoman, said, “This is a market that is
challenged even in the best of times. It’s an expensive product and it’s not something people want to talk about.”

The Federal government has taken a small step to fill the gap. This recent legislation is explained in a Bloomberg article, “The health-care law President Barack Obama signed in March 2010 created a program that will pay a daily cash benefit that averages $50 or more to those who can no longer care for themselves, for workers who enroll in and contribute to the program. Details of the plan, called the Class Act, such as the cost of premiums for workers who enroll, haven’t been released, said Lauren Shaham, spokeswoman for Leading Age.” Currently the median cost of a private room in a nursing home is about $213 a day, so the government program really is a small help.

Senator Lindsey Graham, a Republican from South Carolina, said, “The Class Act is a Ponzi scheme that would make Bernie Madoff blush. It’s billed as an insurance program for long-term care, but really it’s just a huge and very costly government accounting trick”  (http://www.bloomberg.com/news/2011-05-18/insurers-pair-long-term-care-with-life-to-entice-older-buyers.html).  Republican viewpoints being what they are we might take this opinion with a grain of salt but it does highlight the fact that few workable solutions are available, that a real analysis of the issues and potentials has not yet been done, and that there is no consensus as to policy.

So, where do health care providers fit in? How can you advise and help your clients/patients? It’s tricky, but given the trials and the options of becoming a participant in the long term care community perhaps the real solution lies in prevention, staying healthy and strong. I sort of hate to say it but perhaps we really do need to follow Former President G. W. Bush’s advice on health care, “Don’t get sick.”

 

Last week I closed with this statement, “As the huge bolus of Baby Boomers moves thru the population people who move slower, are less agile, susceptible to cold and heat, and weaker but generally affluent will become a majority force in America.”

Upon further reflection I wondered if that was completely true. The majority part, well, make that major part. The Baby Boomer bulge is quite influential now and is going to stay so for a long time to come. How about this, “Baby Boomers, defined as adults born between 1946 and 1964, include over 79 million Americans. This demographic group represents more than half the nation’s wealth, with an estimated $2.3 trillion in annual buying power” (Source: U.S. Census Bureau 2009, Met Life Mature Market Institute 2009 Demographic Profile).

So what about the other part of that earlier blog, will rural areas, now only 16% of the population, experience any growth in the near future?

There appear to be two distinct population segments that are moving to rural areas. The first are young Hispanic families coming to work in the food processing industry and other factory-type jobs (Dalla) and the second are Baby Boomers coming for a variety of reasons, but mainly retirement (Cromartie & Nelson).

These two groups do not overlap very much as to demographics either. The make up of the boomers is: “17% are minorities. 12% are Black. 4% are Asian. Less than 1% are American Indian and Alaska Natives. People of Hispanic origin (who may be of any race) comprise 11% of Baby Boomers” (Source: Met Life Mature Market Institute 2009 Demographic Profile). Boomers who move to the country are usually empty-nesters seeking a scenic place to retire or a cheaper home (Cromartie & Nelson). The advance of Internet services has allowed boomers to continue to work at white-collar jobs as distance employees or consultants.

And one just wonders, if after a life of chasing the American dream, the boomers did not recall their hippy days of yearning for a rural commune, and now finally are seeking out that vision. I know that where I live the old hippy is not a vanishing breed.

Hispanics who move to rural areas for factory jobs are initially young men, with their families following along later. Thus, this group is younger with children and perhaps a few elders tagging along as well.

Approximately 6 million boomers live in Texas and more will move here. We even have a state program to promote retirement in Texas, the GO TEXAN Certified Retirement Community Program (http://www.retireintexas.org). To date a significant number of rural East Texas communities are already participating. This migration will have a significant effect on Texas and will generate health care and wellness concerns as a result.

These two groups will have different drivers for the communities they live in. Younger families, with limited incomes, will need schools and social services geared to the issues of the young. The boomers will demand and be able to pay for health services and social infrastructure to aid mobility and access. Thus, many a sleepy rural community, struggling along on dwindling farming and ranching activities and with moribund retail services, may soon find itself with new and demanding residents who will bring both consumer benefits and social liabilities.

References:

Cromartie, John and Nelson, Peter. Baby Boom Migration and Its Impact on Rural America. United States Department of Agriculture, Economic Research Service, Economic Research Report Number 79, August 2009.
http://www.ers.usda.gov/publications/err79/err79.pdf

Dalla, Rochelle. Examining Strengths and Challenges of Rapid Rural Immigration. Great Plains Studies: A Journal of Natural and Social Sciences, 2004.
http://digitalcommons.unl.edu/cgi/viewcontent.cgi?article=1714&context=greatplainsresearch&sei-redir=1#search=%22rural%20immegration%22

A few weeks ago I wrote about a nostalgic trip back to rural roots as told in the film, The Trip to Bountiful. That imaginary rural community was almost deserted as people had moved on to new things. Most of us have moved on it seems. A recent article in the Austin American Statesman cited that just 16% of Americans live in rural areas. In 1910, the year my father was born, it was 72%.

For a country that has this farming/cowboy image, the reality may be difficult. What lies in the future seems to be the megalopolis. What is this? It is the urban conglomeration one gets when all the space between cities gets filled in with more city. It’s sort of like how Jack London described people with drinking issues by saying (paraphrased), “They only drink between drinks.”

Yen says of megalopolises, “… analysts point to a merger of areas between Austin and San Antonio, Tampa and Orlando in Florida and possibly Phoenix and Tucson, with the Washington-Baltimore region extending southward to Richmond, Va.”

Los Angles is a megalopolis. Coming out of the empty desert, one hits the urban sprawl at Thousand Palms and does not leave it until, hours later, one scoots thru Santa Clarita. And, here’s the good part, it’s all built for the young. “Cities and suburbs were designed for younger people, full of stairs and cars, [Andrew Scharlach] explained. As they become increasingly difficult to navigate, older people gradually retreat” (Neergaard, 2011).

This expanding urban world relies on cars (still!) and has few accommodations for people who move slower, are less agile, susceptible to cold and heat, and weaker (and in that category are more than just the elderly). A recent article at MSNBC.com explores what urban places are doing to make the megalopolis more user friendly. A wide range of clever and useful things are being implemented. Chairs in stores. Access to toilets. Air conditioning. Accessible and convenient bus transportation. Etcetera. Some old buildings are being developed to be community gathering places and cities are changing building codes to encourage greater access. Good steps, all. Tiny steps in a big problem, but still a beginning.

Rural areas (where we live, that shrinking 16%) already had problems of access, no public transportation, no accessible buildings, and often new development brings design aimed only at the most frequent and affluent customers able to drive and navigate a huge, hot, cold, wet, slippery parking lot. The solution to access is to become the most frequent and affluent customer. Neergaard says, “By 2050, 1 in 5 Americans will be seniors. Worldwide, almost 2 billion people will be 60 or older, 400 million of them over 80.

I say, they who buy are catered to. As the huge bolus of Baby Boomers moves thru the population people who move slower, are less agile, susceptible to cold and heat, and weaker but generally affluent will become a majority force in America. Who said getting old was all bad?

References:

London, Jack. A Goboto Night in Son of the Sun, Doubleday, 1912. http://london.sonoma.edu/Writings/SonofSun/goboto.html

Neergaard, Lauran. Aging baby boomers strain cities built for the young, MSNBC.com, July 10, 2011. http://www.msnbc.msn.com/id/43696689/ns/us_news-life/t/aging-baby-boomers-strain-cities-built-young

Yen, Hope. Rural U.S. population share hits low. Austin American Statesman, July 27, 2011. http://www.statesman.com/news/nation/rural-u-s-population-share-hits-low-1663240.html

 

An opinion

We have labels for every stage in life: baby, child, adolescent, teen, young adult, middle aged, mature adult, elderly. I don’t like labels. I did not like being called “kid” when I was 9, and now, as I’m on the down slope to “three score and ten,” I don’t care much for “elderly” either.

But we are concerned with aging and as such is not our population of interest the elderly? I think not.

Being elderly is a label, a judgment, a condition, a state… what? Let’s say it is at least a label.

Now, how about aging? Aging is not a label. It is a process. My aged cheese is six months old, not sixty years old. But aged cheese is akin to aging in people. An aged cheese has changed over time. Its chemical and structural make up has evolved. So to with us. As soon as we are born, we have cells that are maturing and dying to be quickly replaced by new cells. Thus, we begin to age from birth.

So, aging is not a label and it affects all of us. I like that.

Now, what about the term geriatrics, as in East Texas Geriatric Education Center-Consortium?  The American Geriatrics Society Foundation for Health in Aging defines it as, “Geriatrics is the branch of medicine that focuses on health promotion and the prevention and treatment of disease and disability in later life”  (http://www.healthinaging.org/public_education/what_is_geriatrics.php).

They sort of dodge the bullet by saying “later life,” but as one looks over web sites dealing with geriatrics the focus is always on older people, and rarely on the processes of aging which actually occur across the life span.

This is my conclusion. Aging deals with the changes in organisms over time and thus our audience, the audience of the ETGEC, is everyone. For example, the number of elderly people who have gum disease and oral cancers is somewhat dependent on the extent to which young children get good preventive oral care.

I expect that most of our educational programs will focus on wellness and disease processes in older adults with a number of activities focused on the frail elderly and hospice care. Areas of life where we cannot escape the label of elderly. I just want to keep in mind that we are actually involved with a process, from birth to grave, a process of change and evolution.

Somewhere in here we might consider the value of the label elder as opposed to elderly. I still do not like labels but maybe being an elder of the tribe has utility and might be considered.

Is remembering the past an important activity of life? I don’t mean dwelling in the past or hoping the past could have been better, but the value of recalling past events and fitting them into the framework of our lives.

Perhaps we can develop new behaviors from the mindful use of our past. Herman Woulk, in the forward to his anti-war novel War and Remembrance, writes, “The beginning of the end of war lies in remembrance.”

Perhaps the past is just memories that tug at our hearts and either cause us to smile or remind us to cry.

Regardless, I think there is value in remembering our past. Some call this process Reminiscence and Life Review when working with older adults (See http://www.reminiscenceandlifereview.org for more about this area).

There is real value in using a film to stimulate our thinking. When thinking about a good film to use with older adults in East Texas my thoughts turn to Horton Foote‘s play and  subsequent film, The Trip to Bountiful. This story, see summary below, is set in a fictional Texas town and was based on a real place, written by a real son of the soil, and connects with true Texas experiences. Foote was raised in Wharton and many of his plays are “rooted in the tales, the troubles, the heartbreak, and the hopes of all he heard and saw there.” (From comments by President Bill Clinton cited at http://hortonfootesociety.org/node/4)

So, should you wish to wander down your own corridor of time a quick trip to Bountiful might just prime the pump.

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The Trip to Bountiful

The film, set in the 1940s, tells the story of an elderly woman, Carrie Watts, who wants to return home to the small town where she grew up, but is frequently stopped from leaving Houston by her daughter-in-law and an overprotective son who won’t let her travel alone.

Mrs. Watts is determined to outwit her son and bossy daughter-in-law, and sets out to catch a train, only to find that trains don’t go to Bountiful anymore. She eventually boards a bus to a town near her childhood home. On the journey, she befriends a girl traveling alone and reminisces about her younger years and grieves for her lost relatives. Her son and daughter-in-law eventually track her down, with the help of the local police force. However, Mrs. Watts is determined. The local sheriff, moved by her yearning to visit her girlhood home, offers to drive her out to what remains of Bountiful. The village is deserted, and the few remaining houses are derelict. Mrs. Watts is moved to tears as she surveys her father’s land and the remains of the family home. Her son eventually turns up, and drives her back to Houston. (From: http://en.wikipedia.org/wiki/The_Trip_to_Bountiful and copied here based on http://creativecommons.org/licenses/by-sa/3.0)

Links

to images:
http://www.imdb.com/media/rm2712965632/tt0090203
http://en.wikipedia.org/wiki/File:Trip_to_bountiful.jpg

Is Aging a Disease? 

By Rodger Marion

We are born and after awhile we die. We all die. All that varies is the time span between birth and death. No one actually dies from old age. We die from various accidents or pathologies. Then, what are the benefits of increasing the lifespan?

David Gems, in the referenced article below, defines some useful terms to begin our discussion. If we do not die from old age, what do we call it. Gems says, “… biologists use the term ‘senescence’ for the increasing frailty and risk of disease and death that come with aging.” And he calls increasing the lifespan “decelerated aging” and he’s all for it. So am I, in general, but the deeper questions might be: is senescence a disease and why is living longer a good thing?

On the disease question, Gems says, “Consequently, populations accumulate mutations that exert harmful effects in late life, and the sum of these effects is aging. Here evolutionary biology delivers a grim message about the human condition: Aging is essentially a multifactor genetic disease. It differs from other genetic diseases only in that we all inherit it. This universality does not mean that aging is not a disease. Instead, it is a special sort of disease.

Well all that sounds like dancing around the issue but it appears that as we get older things change and our odds go up that we develop something terminal.

OK, so what about the prospect of putting off the inevitable for awhile? Gems says, “It is possible to slow aging in laboratory animals. In fact, it is easy.” He goes on to explain how the life span of nematode worms can be extended tenfold through a simple gene alteration. This logic probably extends to humans as well, but Gems says, “One theory attributes [aging] to an accumulation of molecular damage. Another points to excess biosynthesis … Yet the truth remains unclear.”

So there is a genetic solution in there someplace. Further, Gems encourages a holistic approach to wellness and treatment. He says, “One scientist studies heart disease, another Alzheimer’s disease, another macular degeneration and so on. Yet such ailments are symptoms of a larger underlying syndrome: aging. It is for this reason that there is a law of diminishing returns when it comes to treating diseases of aging. The battle with aging is akin to that between Heracles, the hero of Greek mythology, and the multiheaded Hydra. Each time Heracles hacked off a head, two more would sprout in its place.”

He concludes, “Yet in the long run a more powerful way to protect against age-related disease would be to intervene in the aging process itself. This would provide protection against the full spectrum of age-related illnesses. Returning to our classical illustration, to really defeat the  diseases of late life we need to strike at the heart of the Hydra of senescence: the aging process itself.”

Back to why live longer? Gems ponders the issue but I concluded he was inconclusive. I want to leave the question open for you all to explore. So, here is your assignment: What’s your take on the value of decelerated aging?

Reference:

Gems, David. Aging: To Treat, or Not to Treat? American Scientist, July-August 2011. http://www.americanscientist.org/issues/pub/2011/4/aging-to-treat-or-not-to-treat

Image from American Scientist: http://tinyurl.com/3v9gudt

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