Death by Numbers

What if we eliminated the top diseases of older adults? Goodbye Cancer, Diabetes, Cardiovascular Disease, Stroke, Influenza and Pneumonia, and chronic obstructive lung disease. Will we then live forever, as some have suggested?

The surprising answer is that curing all of these diseases will result in very little change in additional life. Of course, we can only do this statistically.

Kenneth Manton and his colleagues from Duke University eliminated one disease at a time in their statistical modeling. What they found is that if we eliminate all of these killer diseases overall we expect to see those over 87 years of age to live an addition 5.7 years for males (estimated for 1987) and 6.5 years for females. This is about the same improvement in life expectancy at 65 in the last 100 years in the USA (5.7 years.) If you are 65 years old today, you have a 50/50 chance of living an additional 5.7 years than if you were living in the 1900s. In the last hundred years, the great improvement in life expectancy is not amongst older adults, but among newborns and infants and have very little to do with clinical care at later ages.

However, this is not the end of the story.

Most older adults suffer from not just one, but multiple health conditions. So if we assume that we can cure one disease, say cancer, we will still be faced—sooner rather than later—with another disabling disease that might kill us slower. And this is what happens.

Douglas G. Manuel with the Institute for Clinical Evaluative Sciences, Toronto, Canada, and his colleagues calculated what happens when they eliminated specific killer diseases from their data. They reported that by eliminating cancer they predicted that one fifth of the years of life gained would be spent in poor health—and increased cost. On the other hand, eliminating musculoskeletal conditions, would result in a year of good health for women and under half a year for men. And that is what we are finding across the world.

As life expectancy has increased, the number of healthy years lost to disability has also increased in most countries. Joshua Salomon from the Harvard School of Public Health and his colleagues found that although most countries have made substantial progress in reducing mortality over the past two decades, non-fatal disease and injury have not improved to the same degree.

Our progress in health outcomes is also slowing down in the US, especially diseases that we can control and especially for women. Nearly 20 years ago, the United States was closer to the middle of other industrialized countries, but countries like Ireland and South Korea improved sharply, leaving the United States behind.

In addition, across all industrialized countries, because we are living longer and living with diseases, the occurrence of chronic diseases has increased. Finding a cure should be matched with finding care. Our reliance on medical breakthroughs at the cost of statistical outcomes ignores the immediate need that we face. We need to think about finding care as much as finding a cure. 

 © USA Copyrighted 2014 Mario D. Garrett

Dating in Older Age

When most people think of their parents and grandparents, they do not see them as sexual beings. It is the same way that we do not like thinking of our children and grandchildren as sexual beings either. Our mutual relationships are based on nurturing non-sexual behaviors. But with the worldwide discrepancy between male and female life expectancy, it is likely that one of us will become widowed or—in industrialized countries—divorced. We will become single again.

Single older adults are a unique phenomenon because there are so many. In the United States there are whole communities and cities built exclusively around older adults. And it is not surprising to learn that older adults are the fastest growing demographic of online daters.

Sheyna Sears-Roberts Alterovitz and her colleagues from the University of California, Berkley analyzed Internet personal ads. They found that across all ages, men sought physical attractiveness and offered status-related information more than women. On the other side, women were more selective than men and sought status more than men. With older age, men desired women increasingly younger than themselves, whereas women desired older men until ages 75 and over, when they sought men younger than themselves. Which is not surprising since at age 75 years and older, most male peers are dead.

Women are pickier than men in online dating. Their preferences for age and ethnicity are stricter than men’s, and they initiate contact and reply to fewer adverts. Most academic papers talk about evolutionary theory that predicts that men have a stronger preference for attractive mates and that women value good earning potential and education more than men do, as well as women's preference for taller men. But with older adults, there is no evolution to worry about. Post-menopausal women are not after a strong partner to secure the future of their offspring.

Women are likely to have experienced caregiving of their deceased partner. They are likely to have endured caregiving of their children, their parents, their spouse’s parents, family members, neighbors and friends. Their priorities are different from men’s. They want someone who is independent, solvent, healthy and mobile. They do not want to spend their time caretaking--again. This is not evolutionary theory, but pragmatism.

Men on the other hand ensure that they do not end up caregiving by wanting someone younger, someone who can liven up their sex life, drive, cook, and look after them. In online dating men and women construct different profiles. Women focus on their looks and sociability while men focus on their financial and occupational successes. With a changing environment, it is more important for older adults to meet someone that fits their needs. There is some urgency and older adults are willing to lie. Studies with younger online daters (under the age of 50) have reported that men are more likely to lie about their wealth while women are more likely to lie about their age. Men tended to overestimate their height and women tended to underestimate their weight. There is a collusion of lies. Giving women and men what they are both looking for.

 © USA Copyrighted 2014 Mario D. Garrett

Our Subconscious Internal Reality

We live in automatic mode most of the time.

Our brain is the most complex structure. Throughout our lifespan--culminating in our mature years--our brain develops a working model of our reality. We live in our mind much more than in reality. The mind becomes so good at this that we live in an unconscious mode. Even if we think that we are making conscious decisions, they are not conscious in the way we understand it.

As we grow older we become more sophisticated at internalizing the world and learning to predict and anticipate changes. We get so good at this that we do this automatically all the time. It is not that we are not aware of what we are doing, it is that we become aware and respond after our unconscious mind has already determined it. John Bargh from Yale University has written extensively on the unconscious. He pushes for the concept of the unconscious determining decision-making. People often do not give much conscious thought to how they vote, what they buy, what they eat or the way they negotiate their daily life. Consciousness is an afterthought.

The world has always been very complex and we cannot deal with this complexity without shortcuts that our internal model of reality can create. We live in an subconscious world. Our brain is complex enough to allow an internal representation of the world, and we live vicariously through this model. Chun Siong Soon and other scientists from Germany and Belgium have studied this phenomenon and measured in minute details when consciousness is brought into play within our internal world. They reported that there is a network of high-level control areas in the brain that initiate an upcoming decision long before it enters awareness. Our awareness seems to be an illusion of control, an after thought.

Writing more than three decades ago, Felicia Pratto discussed how we are constantly engaged in evaluating our immediate environments without being aware of the process, the outcome of the process, nor even of the stimuli we are faced with. Furthermore, she perceptively argues that it may be that we cannot control automatic evaluations, but they can influence our conscious experiences, including judgments, emotions, and attitudes.

Older adults are experts of this unconscious reality. Our brain has been designing these simulations of our immediate environment for many decades and it has become so good at it that we interact in our life in automatic most of the time. Most psychologists put this reliance on our internal world as a result of some diminished or compromised cognitive or recall ability.  A reliance on “gist” memory is just older adults reliance on their very complex internal representation rather than the unique details of the immediate environment. This works well until we have a trauma. Then we wake up. We switch the automatic pilot off (or it is switched off) and we have to figure how to engage in our immediate environment consciously. That is when we face problems.

© USA Copyrighted 2014 Mario D. Garrett

Kafkaesque Government Guidelines on Dementia

In 2011 the National Institute on Aging published a series of guidelines on dementia. They argued for biological determinism, where an organic disease causes dementia.  The new insight—they argue—is that we can see the early changes before there are any signs of the disease. There might even come a time when you have the disease but not suffer from dementia itself.  Which brings us another Kafkaesque moment from the government. The guidelines are an oversimplification and simply wrong.

Dementia is not one disease, and it might not even be a disease as much as a set of symptoms—perhaps a syndrome. What is interesting about these guidelines is how they were skewed in order to leave out the psychology of the disease.

The guidelines proposed an early, preclinical stage with no symptoms, followed by a middle stage of mild cognitive impairment and a final stage of Alzheimer’s disease dementia. The fear mongering might be implicit but not completely unpredictable. Associating mild cognitive impairment with dementia, where more than a quarter of older adults report some issues with memory, is an unconscionable bad science (correlation is not causation) and shows unscrupulously lack of moral or ethical standards.

In real science there are other such prodromes—early symptoms—for dementia, only one of which is memory lapses. An early symptom is depression. In the guidelines depression was completely left out. There is no mention of depression.

In 2010—before the guidelines were published—Meryl Butters and her colleagues from the University of Pittsburgh and the University of Toronto, Canada, reviewed 23 studies that followed around 50,000 adults in their 50s for five years. They found that depressed patients were more than twice as likely to develop vascular dementia and 65 percent more likely to develop Alzheimer’s disease than those who were not depressed. More recently, Deborah Barnes with the University of California, San Francisco similarly looked at 13,535 members of a health maintenance organization Kaiser Permanente—and  found that older adults who suffered depression earlier on in their middle age, were three times more likely to develop vascular dementia.

We find these early symptoms with other brain diseases as well. The fact that we find similar early symptoms of depression for Parkinson’s Disease is a significant indicator that depression is a serious early symptom. In a review of 14 studies encompassing 1500 patients, AM Gotham from the University of London estimated that just under half of people with Parkinson’s had earlier symptom of depression.

In the guidelines there is also no mention of the role that white matter has in dementia and how cognitive training is the only effective intervention reported so far. Daniel George (Penn State) and Peter Whitehouse (Case Western Reserve University, Ohio) both champions of the psychology of dementia, argue for a more social and intergenerational approach to addressing dementia. This is an exciting agenda. Instead the guidelines represent a dying proposition of biological determinism that exclude social and environmental factors as reflected in the emerging science of epigenetics and neuroplasticity.

© USA Copyrighted 2014 Mario D. Garrett

Garrett MD & Valle RJ (2014).A Methodological Critique of The National Institute of Aging and Alzheimer’s Association Guidelines for Alzheimer’s disease, Dementia and Mild Cognitive Impairment. Dementia: The International Journal of Social Research and Practice. DOI: 10.1177/1471301214525166