Highway Brain and the Earthquake Dementia

Our brain changes as we grow older. Changes dictated by the slow shrinking of the brain, creating a widening of the pockets inside the brain. And there are also changes in parts of the brain used for certain tasks.

We are learning more about these changes because of a new technique of seeing into the brain called functional Magnetic Resonance Imaging. The functional part is that we can have people perform an activity while we watch their brain’s activity.

On the whole we witness variable results when we compare older and younger adults. Sometimes there is less activation among older adults, sometimes more activation, and invariable older and younger adults differ in which parts of the brain they use while undergoing the same activity (eg reading.)

The brain is a wonderfully clever but lazy organ. It works as hard as it has to and nothing more. Which is why sometimes it is hard to learn, because we have to persuade it that it has to. Like any precocious teenager, they will do enough to get by. The brain is like that teen.

David Snowdon studies 678 nuns—Catholic members of the School Sisters of Notre Dame—who are 75 to 106 years of age. The nuns undergo extensive testing and when they die, his team examines their brain. It was Snowdon who first reported a very strange anomaly. He found that a third of the nuns who for all intents and purposes acted normally throughout their life, when they performed the autopsy, they found that their brain had the disease of Alzheimer’s. This finding has since been found in other populations, notably in Sweden where otherwise healthy and competent older adults were found to have diseased brains.

The quick answer to this finding is that some people have “cognitive reserve”. Basically they have more brains and so they can afford to loose some to the disease.  But this does not explain why certain occupations—academic, research, engineering and art, occupations that develop your brain—do not protect you from dementia. It seems that the reserve is not just in size but that the reserve need to be in quality—how you develop and grow your brain.

Like a precocious teen, the brain knows of ways of escaping from its many duties. Doing things that we take for granted—like reading for example—the brain develops an interstate of neural pathways that makes it easy for it to accomplish that repetitive task.  What seems to work is when we trick our brain in developing new pathways.

In a 21-year study of older adults, 75 years and older, Robert Katzman and Joe Verghese, found that mental activities like reading books, writing for pleasure, doing crossword puzzles, playing cards as well as playing golf, swimming, bicycling, dancing, walking for exercise and doing housework did not offer any protection against dementia with some important exceptions:  frequent dancing, playing an instrument and playing board games.

Creating new pathways is what works. When disease interferes with the flow of traffic, then having alternate pathways helps divert traffic. This is what seems to be happening and why it is not just the size of the brain but the networks that we develop that protect us from dementia.

Mario Garrett, Ph.D., is a professor of gerontology at San Diego State University and can be reached at mariusgarrett@yahoo.com

Elder Abuse and Dementia

Elder abuse is on the rise and the main predictor is the increasing number of older adults.  With the global population of older people (aged 60 and above) predicted to triple from 672 million in 2005 to almost 1.9 billion in 2050, it is expected that there will be a similar increase in incidence of abuse.

Cultural differences in attitudes towards older people and what people consider abuse make international comparisons problematic. With this caveat, international estimates of elder abuse in community settings from Canada, Finland, the Netherlands, the United Kingdom and the United States range from 4–6%. Globally we are anticipating that by 2050 there will be over 114 million older adults to have been abused.

As of 2010, there are an estimated 35.6 million people with dementia worldwide. This number will nearly double every 20 years, to an estimated 65.7 million in 2030, and 115.4 million in 2050.  Both elder abuse and dementia will form a part of our landscape.

There are many aspects of elder abuse. The landscape covers; prevention and legal prosecution; family dynamics and career con artists; health and economics; loneliness and vulnerability. Above all of these concerns—and an issue that cuts across all these issues—is the complication that dementia brings to elder abuse.

Dementia is a disease that slowly kills the brain. The term describes symptoms of memory and thinking that interferes with day-to-day activities. We still do not know the cause/s of dementia, and to this day, do not have any prevention or cure.

Dementia changes the dynamics of caregiving and care receiving. Although more than half of older adults with dementia live in the community, two out of three nursing home patients have dementia. Patients with dementia are more likely to end up in a nursing home or assisted living facility.

According to family members, one in four nursing home residents are likely to be abused. In some cases the patients themselves are the abusers—both resident-to-resident aggression as well aggression directed towards their caregivers.

For those that are still living in the community, caregiving becomes an added hardship. As the disease progresses, 15 to 75 percent of patients develop psychotic behaviors.  In addition, a third of patients will have delusion, in some cases resulting in aggressive behavior. Studies show that one in three caregivers reported that their patient become aggressive with them and as a result they were likely to physically retaliated.

The fact of having dementia increases the likelihood of abuse. But in some cases there is no abuse and the patient becomes uncertain of the facts. Did they misplace their wallet or did someone steal it? Distinguishing the facts is difficult especially when there is no one else involved in the caregiving. Even if there is obvious cause for concern—when there is physical abuse that is uncontestable—it is difficult to have the testimony of a person with dementia hold in a court of law.

We have very little information about the lives of people living with dementia who have also been abused—a testament of how weary district attorneys are to have their client evaluated especially since the defendant in the court case can subpoenas that information. Being judged as mentally incompetent diminishes their testimony in court.

But we cannot continue to deflect the issue that dementia affects everyone, and not just the patient. The only viable solution is more openness, education, and better information. In 2050 when we are projected to have over 114 million people who are abused and 115 million suffering from dementia, will we approach the problem as we are approaching it today?

Mario Garrett, Ph.D., is a professor of gerontology at San Diego State University and can be reached at mariusgarrett@yahoo.com

Aging and Pandemics

Populations change.  Not only do people change--people die and babies are born each day--but the structure of a population changes.  These sequential changes that every population goes through, predicts that we are entering a scary stage.

The theory goes something like this. A hundred and more years ago women gave birth to a lot of children only to see most of them die of infections and famine. Then we saw improved access to clean water, better sanitation and a better diet, which led to fewer diseases and a decline in deaths from infections and famine.  Women started having fewer children and most survived through adulthood. With fewer children being born and increasing survival, we reach a stage in our population where we are today in most developed countries--a very low incidence of infectious diseases and women continue having smaller families. In most developed countries today, women are having so few children that, without immigration, our populations will start to decline.

As a result we have entered the age of gerontology, were we have an aging population and a shrinking younger population.

With an aging population come a wave of chronic diseases--stroke, cancer, diabetes, heart disease, and neurological diseases such as Alzheimer's disease. Medicine,  in the face of such chronic diseases, starts focussing more on monitoring and maintaining health rather than battling infectious diseases. Because of this stability, from now on, populations fluctuate only as a result of wars and epidemics. We cannot predict wars, but we can predict pandemics.

We are at present going through one of the most lethal pandemics in our history. HIV/AIDS has now already claimed over 22 million people. More than 42 million are currently living with the disease and even if a vaccine for HIV were discovered today, over 40 million people would still die prematurely as a result of AIDS.

Despite this threat,  the two pandemics that clinicians seem more worried about--because of their unpredictability--are influenza and antibiotic resistant infections.

After five main pandemics of influenza, history has taught us that there will be emerging influenza pandemics every thirty to fifty years. Studies are showing how dangerous the last avian flu could have been if it became airborne. This type of airborne influenza--or its 144 variants--can devastate populations as the Spanish Flu did at the turn of the century with over 50 million people killed.

The second emerging concern is drug resistant infections. The spread of bacteria, virus or cancer cells that is resistance to drugs is man-made. Although Joshua and Esther Lederberg while at the University of Wisconsin-Madison showed that resistant bacteria has always been present, their increase is brought about by inappropriate and ineffective use of antibiotics. We are carelessly engineering super bacteria. The World Health Organization reports that, as an example, there are 50 million people with multi-drug-resistant tuberculosis, which exist in 49 countries, including the United States.

Although we have entered a tranquil and stable stage in our population--with an aging population where we are mainly dealing with long-term diseases--we do have the threat of pandemics that will dramatically affect this equilibrium. The question is not how, but when.


Mario Garrett, Ph.D., is a professor of gerontology at San Diego State University and can be reached at mariusgarrett@yahoo.com

How Physicians Die

Sherwin Nuland wrote a beautiful book about How We Die.  Similar to other physicians, Nuland got to observe a multitude of deaths. So he knows intuitively as well as scientifically about the dying process. From this vantage point, physicians have a unique perspective about their own morbidity and ultimate mortality which the rest of us non-clinical lay persons do not have.

Ken Murray, a retired family medicine physician and Clinical Assistant Professor at the University of Southern California, has written extensively on this and one of the conclusions that he makes is that physicians would want better quality of their remaining life rather than quantity.

Such assertions have been supported by convincing anecdotal evidence, but only recently did we obtain some proof to substantiate this.

In 2008, Marsha Wittink from the University of Rochester Medical Center, with her colleagues published a study that reported that physicians who initially wanted the most aggressive treatment for their disease, changed their mind three years later. However, although some changed their mind, there were some (41%) who still wanted the most aggressive treatment. It is therefore not clear-cut.

For some people, including physicians, they change their mind when they are dying. Some want a hasty natural ending, others hold on to life at all costs. How true is this if you know you are dying anyway?

The answer came in a study published in 2011 by Hans-Peter Brunner-La Rocca, and his colleagues from the University Hospital Basel in Switzerland. These Swiss researchers talked to 555 heart failure elderly patients about their end-of-life preferences. They repeated the interview again in twelve months and then again in another six months. What they found is that seven out of ten patients initially said they would rather live two years in their current state then live only one year in excellent health. After a year elapsed, this proportion grew to eight in ten and remained the same after eighteen months.

Some people have interpreted this finding as indicating that most people want to live at all costs which becomes more acute the closer you are to death.  However, surprisingly, when the researchers asked patients whether they wanted CPR in a crisis, about a third said no. While another third said they did want CPR—even among patients with "do not resuscitate" orders in their medical files.

In all this uncertainty, the correct interpretation is that most people opt to live despite the physical discomfort. But when the time comes, a third of patients want the natural process to take its course. What this tells us is that we are dealing with a lot of variables and that one policy does not fit all.

The statistics from the Oregon Death With Dignity Act (DWDA) tell us that for the 70 or so patients who go through with DWDA a year, they are exclusively White, are more likely to be better educated (four out of ten have a degree), tend to have cancer (eight out of ten) and have informed their family about their wishes. This is a very privileged and small minority but an important one.

The lesson to take is that each case is unique and there can be no one policy for everyone.We should respect all individual options when it comes to death.

Mario Garrett, Ph.D., is a professor of gerontology at San Diego State University and can be reached at mariusgarrett@yahoo.com

Dying Priorities

The most divisive issue in America is not the economy, politics, war on drugs, racism, health care or our ongoing military wars across the world. The most recent Gallup's annual Values and Beliefs survey of 2010 reported that doctor-assisted suicide is the most controversial of the issues tested. Equally 46% reported that it is moral unacceptability and morally acceptable.

In contrast, Americans are fairly unified in their opposition to another life-ending choice--suicide--with 77% calling this morally wrong. Taking subordinate position in dividing the nation is gay and lesbian relations, abortion and having a baby outside marriage. 

All these issue drive to the heart of the American ideal of personal freedom.  And yet Americans remain fixated on an issue of doctor-assisted suicide—better known as Dying With Dignity Act (DWDA)—where nationally, in 2011, only 71 people died using this option. In contrast to the 2.5 million Americans that die each year, those that die with DWDA are a very very small minority. They are nearly exclusively White, primarily women, educated, and exclusively people with life threatening disease (mainly cancer.)  

While many people are blessed to be released from life from a final act of covert over-medication, such action is necessarily too late. And while most Americans think a good death consists of dying at home, surrounded by family, and free from pain and suffering—regardless of one’s age, gender, ethnicity, or religious background—one in five people die in an Intensive Care Unit. Death for most Americans is a medical failure rather than a dignified release.

Except for physicians, who tend to shy away from aggressive medical treatment when the prognosis is negative, most Americans tend to undergo a lot of unnecessary, expensive and invasive treatment.

But three of every four Americans do not fear death as much as they fear being in pain at the time of death.  Despite these clearly stated and seemingly universal preferences, too many of the 2.5 million Americans who die in health care settings each year suffer needlessly in pain at the end of life.

And this should be the national issue. Nearly eight out of every ten hospital deaths occurred without a palliative care /formal pain management. More than four out of every five older adults in long-term care facility experienced untreated or under-treated pain at the time of death. While 70 percent of all Medicare decedents, regardless of their age or where they died, received an inadequate amount of pain management.

Sara Imhof and Brian Kaskie predicted in 2008 that "we can only conclude that public policies will fall even further behind the advancement of evidence-based pain-policy guidelines, and the number of Americans who continue to suffer needlessly in pain at the time of death will only increase."

It does not have to be this way. Dying in pain is a national travesty. We need to honor the body’s capacity to let go. In studies that looked at voluntary refusal of food and fluids, nurses report that patients die more serenely then with DWDA. The body knows how to shut itself down. We need to incorporate a dignified exit in our health care system where Americans can at least be protected from a painful death.

Mario Garrett, Ph.D., is a professor of gerontology at San Diego State University and can be reached at mariusgarrett@yahoo.com

Being Happy Changes You

Why do happy people live longer?

The idea that an optimistic attitude causes people to live longer has been repeatedly observed. Although we identify our longevity to having “good” genes, only recently have we began to understand how our genes are affected by how happy we are.

The best way to study the effect of genetics on longevity is to look at twins. Monozygotic twins, those that split from one egg, have nearly similar genetic makeup. Twins that have a different egg (dizygotic) only share the same level of genotype as with any other siblings.

More than three decades ago, Cook and his associates published a study in 1981 looking at the onset of dementia among monozygotic twins who were both affected by Alzheimer's dementia. In one case study, dementia began in her late 60s, while in the other twin the onset of dementia was at age 83.

Subsequent studies confirm that although monozygotic twins might both have the disease, how they express them and when they express the disease might differ. The difference used to be attributed to the environment. But recent studies blurred the difference between genetics and the environment. 

Twelve years ago, in 2000, Randy Jirtle and Robert Waterlanda from Duke University modified the expression of an agouti gene that which made mice fat, yellow and prone to cancer and diabetes.  These mice did not live very long. The researchers produced young mice that were slender brown and without displaying their parents' susceptibility to cancer and diabetes and lived to an active old age. The effects of the agouti gene had been virtually erased.  

Remarkably, the researchers modified the expression of this gene not by altering the mouse's DNA, but by changing the moms' diet.  Feeding the mother a diet rich in onions, garlic, beets, and in the food supplements often given to pregnant women the researchers provided a chemical switch that reduced the agouti gene's harmful effects. 

These foods--known as methyl donors--enhance or diminish gene activation and gave birth to a whole new science of epigenetics. But can epigenetic changes influence longevity?

In 2012, Jordana Bell of King's College London and colleagues looked at the DNA of 86 sets of twin sisters aged 32 to 80, and repeated with another 44 sets of younger twins aged 22 to 61, and discovered that 490 genes linked with ageing showed signs of epigenetic change. In particular, among these malleable gene expression were four genes that relate to cholesterol, lung function and maternal longevity.

What is phenomenally interesting is that these changes are not just brought about by diet and methyl rich donors, but also by such lifestyle factors such as smoking, environmental pollution, stresses, and attitude.  So we might say that optimistic attitude allows your good genes to shine through while diminishing the effect of  your bad genes. And the effect jumps across generations. If you are long lived, thank your grandparents for being optimistic.

Mario Garrett, Ph.D., is a professor of gerontology at San Diego State University and can be reached at mariusgarrett@yahoo.com

New Insights in Aging

http://www.amazon.com/dp/B008031ZB2

Why America’s Aging Population is not the reason for the Legacy of Debt

Mario D. Garrett – February 20, 2011

AMERICANS HAVE a looming obligated deficit of $63.6 trillion—a figure which is more than what the Gross Domestic Product (GDP) of the entire world produces ($61.1 trillion), and about four times the GDP of the United States ($14.6 trillion.) This is the largest single debt in the world’s history.

Some blame all or part of this deficit on an aging population, arguing that increasing cost in health care spending, Medicare and Social Security are the main culprits for this obligated debt. Others point to the growing deficits that we build annually into our federal budget, driven by our military spending and pork barrel earmarks. In 2011, we have added an additional $1.6 trillion to the national deficit. If, as some economists predict, our current ailing economy will continue to suffer, then it is imperative to question the legacy that we are leaving our children and grandchildren, and to examine the real reason why we have a deficit and whether an aging population is to blame. This article goes beyond the clichés and the sound bites to expose the  underlying dynamics of how aging in America came about and how the obligated deficit has been created. The aging of America exposes a radical and political game changer.

The reality of an aging population is that it has been driven by social factors rather than by people living longer. In the last century (1900-2000) in the United States, life expectancy for 65 year olds has increased by only 5.7 years. This is less then present difference in life expectancy at birth between Whites and Blacks in America—which is 6.3 years. Instead, two of the most important contributing factors to the aging of populations are the decline in births and the decline in infant mortality. These two phenomena go hand-in-hand.

While the decline in infant mortality was orchestrated by improved sanitation, clean water, improved diet and the introduction of immunization—a decline in the birth rate came about as a result of women becoming better educated. Better-educated women have fewer children—because they are either studying/working, they have reduced incentive and opportunity to bear many children—and they tend to have children later in life, with greater lag in-between bearing children. With better education come better personal health practices, more nurturing of infants and consequently better survival through infancy.

Women’s educational attainment in the United States (both high school and college) shot up in the fifties partly due to the GI Bill and increased federal funding for higher education. Beginning after WWII, the nation’s share of female workers rose from less than 25 percent to 38 percent (1970) to 47 percent (2009). The ripple effect from this simple yet dynamic social change is far reaching. The crude birth rate (number of births per 1,000 people) went up at the end of the Second World War peaking at 26 followed by a gradual decline to fewer than 15—which created the baby boom. Over the next six decades these baby boomers started to become older: while the decline in the birth rate continued. So much so that in developed countries, the fertility rate has dipped below replacement level and is still plummeting despite policies in Europe that are attempting to reverse it. This has serious implications as we shall see.

A decline in the number of children means that our labor market will shrink. This is important because we euphemistically refer to Social Security—which also applies to Medicare as well—as a “pay-as-you-go” system. This means that money that workers pay today goes to support the benefits of existing retirees. If we have fewer workers paying into the system, while at the same time experiencing a growing population of beneficiaries, then we have a problem of how to pay these entitlements. In the past we had a surplus with more workers than beneficiaries.

When there was a surplus, the government spent it. For this expenditure, the government prints out treasury special issues—known as trust fund bonds that are not real bonds since they cannot be sold or exchanged. Even the interest on these trust fund bonds are again paid in treasury special issues trust fund bonds. People mistake these bonds as real. Unlike other treasury bonds, these are printed on paper and are filed away in a four-drawer cabinet. However the 2009 Social Security Trustees Report was explicit in explaining that: "Neither the redemption of trust fund bonds, nor interest paid on those bonds, provides any new net income to the Treasury, which must finance redemptions and interest payments through some combination of increased taxation, reductions in other government spending, or additional borrowing from the public." This means that these are not funds or bonds, since to pay this money back the government itself admits that it will have to raise taxes, borrow more, or print additional monies to honor them. The government cannot sell these trust fund bonds on the market because they are worthless. The trust fund bonds are paper IOUs that are valueless unless the government can repay them.

Started by President Reagan—and followed by all other presidents—this newly establish Social Security surplus, was put into the general fund. As a result, each year’s surplus is spent every year. At different times, three members of Congress expressed public outrage at this practice; these were Senators Daniel Patrick Moynihan of NY, Harry Reid of NV, and Ernest Hollings of SC. What was needed was a law to separate these Social Security surpluses away from the budget so that they do not get spent and instead get invested for the benefit of future retirees. This is exactly the law that President Bush signed in 1990. The Budget Enforcement Act—Section 13301—made it illegal for Congress to use Social Security funds by excluding Social Security from all budgets including the congressional budget (taking it “off budget”). However to this day, this law is ignored. If that surplus remained in a fund, then the solvency of Social Security would not be jeopardized. If the fund still existed, Social Security would not have to rely solely on future cohorts. Congress robbed the cookie jar and is now blaming the very people that put the cookies in the jar in the first place.

Congress has not had the ability to stay within budget (apart from 1999 and 2000) and it is unlikely that they will save enough to be capable of honoring the obligation for Social Security which stands at $7.6 trillion, and the obligation for Medicare which stands at $38.1 trillion. More telling is that there is no such budget plan by Congress to ever do so. This year, 2011, our annual Social Security surpluses have disappeared. Not only do we have to contend with a deficit every year—with no surplus money coming from Social Security—but we also have to find money to start paying retirees from sources other than Social Security contributions. The sad part of this story is that we have known this will happen for at least three decades.

The 1982 Greenspan Commission was established to study and make recommendations to Congress on how to solve the Social Security obligations when the baby boomers mature. The recommendation was for a major payroll tax hike to generate Social Security surpluses for the next 30 years, in order to build up a large reserve in the trust fund that could be drawn when the boomers become retirees—now. In effect, the 1982 increases in contributions meant that the baby boomers funded for their eventual retirement as well as funding the benefits of the retirees at the time. This created a massive surplus. A surplus that was designed to fund the eventual retirement benefits of the baby boomers. However, as we have seen, these surpluses were never invested, they were spent.

The other part of this double jeopardy concerns Medicare. Medicare by far is the largest federal obligation, and will overshadow all other budget items within the federal government. By 2007, total spending on health care in the United States was $2.3 trillion or $7,600 per person. The percentage of GDP that is spent on national health is projected to continue to increase (from 5.2 percent in 1960 to 20 percent in 2016), which translates to $4.2 trillion. Rising health care costs are an emergent issue especially for the United States. By comparison, Switzerland, Germany and France allocated around 11 percent of their GDP to health. But despite this enormous outlay of resources on health services in the United States, these dollars do not translate to better health.

While health care costs in the United States are mushrooming—consuming a greater part of our GDP—there exist no comparable improved health outcomes, such as improved life expectancy. The United States continues to slide further behind other countries in health status. In 1997, the U.S. ranked 15th in mortality. Since then, Finland, Portugal, the United Kingdom and Ireland have reduced the rate of preventable deaths more rapidly than the United States. Similarly disappointing are results of child well-being, in which the U.S. ranked second to last when compared to twenty one countries similar to the United States in terms of their economies.

If U.S. health care costs are not contributing to improved health, where are resources going? The United States spends six times more per capita on the administration of the health care system than its peer Western European nations. Moreover, more U.S. health care costs are primarily expended on the dying. During the five-year period 2001–05, nearly a third of total Medicare spending—31.7 percent—went toward the care of moribund patients with severe chronic illness during their last two years of life. It seems that our health system has not learned how to deal with an aging population that naturally dies. And it will continue to ignore the moral, ethical and economic issues as long as other cohorts are footing the bill.

Both Social Security and Medicare surpluses—ostensibly different and separate programs—are comingled in one big trough from which both Democrats and Republicans feed. Some have referred to social security—and, by association, Medicare—as a ponzi scheme. Its viability depends on an intergenerational exchange. Those that contribute into the system today, pay for all benefits of today’s retirees. Implicit in this arrangement is that future contributors into social security would then pay for the current workers when they retire in the future. This intergenerational exchange is more demanding on future cohorts since the proportion of workers to retirees will decrease. Future cohorts will continue to bear a larger and larger responsibility for paying off previous debt.

But future cohorts are changing. The intergenerational exchange becomes an interethnic exchange. By 2050, minorities—those who identify themselves as Hispanic, black, Asian, American Indian, Native Hawaiian, Pacific Islander or mixed race—will account for 54 percent of the U.S. population (currently 34%), which is projected to total 439 million that year. Among the nation’s children, the trend is even more pronounced so that by 2050, this will jump to 62 percent (compared to 44 percent today).

Immigration is playing a leading role in both the growth and changing composition of the U.S. population, points out the Pew Research Center. It finds that immigrants and their descendants will account for 82 percent of the projected population increase from 2005 to 2050. Nearly 20 percent of Americans will be foreign born in 2050, compared with 12 percent in 2005, the center projects. On the other side of the Medicare/Social Security equation, one in five people will be 65 and older by 2050 and 59 percent will be White. While by 2050, there will be 19 million people age 85 and older and 67percent will be White.

So the weight of the Medicare/Social Security burden will be borne primarily by minorities—and immigrants—for the benefit of predominantly White retirees. By the time these younger largely minority cohorts, who have contributed towards the benefits of the emerging baby boomers, get to retire themselves, these benefits will be dramatically reduced since the solvency of Medicare/Social Security can only be achieved by an increase in contributions and/or a decrease in benefits.

This inequity is further exacerbated because of the diminished life expectancy of minorities compared to Whites. Minorities do not receive the same total level of benefits as Whites because they die earlier. Predictions indicated that life expectancy will decline and will primarily affect minorities. There is also a disproportionate level of contribution from minorities because Social Security contribution is capped at $106,800, minorities, on the whole, contribute at the full percentage, while the mainly White—and in smaller numbers, Asian—pay an increasingly smaller percentage the higher their income is above the cap.

The demographics that determine an uneven playing field are dictating that minorities will pay more into Medicare/Social Security—more minority younger cohorts with a  higher percentage contribution into Social Security—but they will benefit less due to shorter life expectancy, and smaller individual contributions. But the inequity is that minorities depend on social security to a greater degree than Whites. A much higher percentage of minorities relied on Social Security for all of their income; 33 percent of Blacks and 33 percent of Hispanics, compared with only 16 percent of Whites. The reality of an intergenerational and interethnic exchange becomes more apparent because we need to further promote it to be able to stay economically viable.

We are witnessing a chronically sick economy driven by a narcissistic political system that does not have any long term objectives and which is not held accountable for its excesses. We stand as a nation in a quandary and there are no real solutions come through the densely managed media. As with anyone facing a major health issues, the prognosis calls for radical change. We need to change how we do business, again.

How do we move forward to bring about change? A Bloomberg National Poll of December 2010 reported that three quarters of respondents saw unemployment, jobs, Federal deficit and spending most important issue facing the country right now. As with most terminal diagnosis the prognosis needs to be radical. There is a need for invasive and strategic change in how we are doing business. In order to bring about change we need to start a discussion on issues that elicit visceral reactions in most people. We need to put these on the table and to engage the public to understand these interventions: and then to implement change. Dissent is the voice of change.

• Medicare. We have to deal with health care costs if we are going to be serious about economic reform, and Medicare costs are prime for change. A third of all costs go toward the care of patients during their last two years of life. Although we do not know when some patients will die, we do know which patients prefer to not have invasive interventions. We need to honor people’s wish to die with dignity. Death among frail older adults is not a failure. Physician assisted suicide and voluntary refusal for food and fluids needs to be part of any geriatric program including Medicare.

• Eliminate administration. In business cutting overhead and administration and focusing on the product is what keeps the company competitive. The same needs to be true in our economy. Where there are large administrative bodies such as in education, health, government or military, the role of administration needs to be reexamined. One example is to replace layers of defunct bureaucracy with computer technology. For example, information technology can be used for health care surveillance and monitoring where individual prescriptions can be tracked digitally to reduce the possibility of drug to drug interaction.

• Education for all. The primary engine for the economy and health is education. Educational opportunities should be expanded to ensure that those who have a capacity to learn have the opportunity to do so, and for those with diminished capacity to offer remedial education for life. School needs to be de-centralized with more public education taken on at libraries, adult enrichment centers, community colleges, high schools and work settings. Re-employment funds that will sponsor workers in new jobs for up to a certain number of years, will replace unemployment benefit. This will provide an incentive for the employer to hire more workers, and provide an incentive for the worker to re-train in emerging industries. Being unemployed should never be an option.

• Eliminate insurance companies from Health Care. At least 24% of every healthcare dollar goes toward insurance firms’ administrative expenses and payment processes. The use of computerized technology–including innovative smart card technology, mHealth, telemedicine and other technology driven application to improve healthcare services–would make middlemen insurers unnecessary.

• Separate funds for Social Security and Medicare. Keep the surpluses off budget. Social Security and Medicare are the most successful programs in our history and they have contributed to a more equitable society. Remove the cap on contribution from Social Security (currently at $106,800). Ensure a generous sliding scale so that those who are less needy receive less benefit then those who depend completely on these programs. Allow survivors benefits to only one ex-spouse. Include all workers into the program. Currently some workers can opt out. Make it a national program without any “opting out” options.

• Promote Immigration. Over the long run, a net inflow of immigrants equal to 1% of employment increases income per worker by 0.6% to 0.9%. This implies that total immigration to the United States from 1990 to 2007 was associated with a 6.6% to 9.9% increase in real income per worker. That equals to an increase of about $5,100 in the yearly income of the average U.S. worker in constant 2005 dollars. Such a gain equals 20% to 25% of the total real increase in average yearly income per worker registered in the United States between 1990 and 2007.

As with any terminal diagnosis the remedy might be repugnant, but these interventions are necessary in order to truly change the way we are doing business in America. By definition, changing how we do business needs to be radical in order to be effective, and bring about change. It is a legacy that we need to promote. As with the social factors that brought about the aging of America, we need to change social structure in order to effectively accommodate these changes. By becoming more equitable, we would regain our legacy and we can ensure that we have successfully passed the baton to our more diverse children.

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Mario Garrett is a psychologist and professor at San Diego State University. He has worked at the United Nations International Institute on Aging, and universities in London, Bristol, Bath, Malta, Texas and New Mexico.

Conceptual Solution to Elder Abuse

Nothing makes it faster into the newspapers then a sensational story of physical or sexual abuse of a vulnerable person. We find such atrocities repugnant. Each incident diminishes our expectations of ourselves as civilized—we become less human. 

What distinguishes elder abuse from any other type of abuse is that—sadly—it is all too predictable. We can predict with some level of accurately who is prone to elder abuse in terms of both becoming a victim, and becoming abusive. Unlike any other type of abuse, elder abuse is predictable.

The few statistics that we have show that those who become abused are more likely to be isolated female with some form of vulnerability, whether that is physical or mental. Also, an abused older adult suffering from dementia makes it less easy to prosecute. By the time the case makes it through the ponderous legal system there is a likely chance that cognitive impairment has become more pronounced. People who experience violence tend to suffer dementia earlier, faster.

On the other hand, those who abuse are more likely to be male family members, most often the victim’s adult child or spouse. The familial relationship makes it that much harder to report. Research has shown that the abusers in many instances are financially dependent on the elder’s resources and have alcohol and drugs problems. A study by Arnold S. Brown from Northern Arizona University, showed that a large number of people who commit elder abuse have themselves been abused as children. Abuse is a learned behavior.  

How we deal with abuse as a society is unfortunately outdated. The response grew from treating elder abuse like child abuse.  The current system of prosecuting cases in court is untenable. There is also a dark side of how law is used. In terms of financial abuse, there is growing anecdotal evidence suggesting that older adults are being denied access to their bank funds because of concerns that they are withdrawing too much money. There is a fine line between protecting the older adults and treating them as children. 

Even if there is financial abuse and the case—as an exception—makes it to court, in virtually all cases little of the stolen money is recovered.  In cases of physical abuse the ponderous slowness of the legal profession that does not protect the victim from escalation and in some cases fatality. But the overwhelming concern is the demographic revolution that will overwhelm the system purely on the number of frail older adults that are emerging.

The solution is therefore to prevent abuse from happening. Being predictable helps us to prevent it. Canadians are ahead of us here. They developed an effective “buddy system” where volunteers befriend vulnerable older adults. In order to not loose our humanity we need to be more social. Perhaps the reason we feel less civilized is because we have become less civilized, we have lost our social capital.  An excellent summary of such a program is to be found at the University of California at Irvine website, www.centeronelderabuse.org.

Mario Garrett, Ph.D., is a professor of gerontology at San Diego State University and can be reached at mariusgarrett@yahoo.com

The Age of Psychology

Human populations across the world are changing. They are becoming older, both in terms of the number of older adults and in terms of how many older adults there are to the younger population. Such changes have an effect on numerous issues such as funding and provision of housing, transportation, income and health.

Health is perhaps that most important of these changes because it affects us personally, is usually irreversible, and affects all the other issues directly. With an aging population, pattern of diseases have changed.  Throughout our life, most have experienced a death of a close acquaintance due to an infection or an accident. We all remember some great epidemics that have hit the Unites States.  Killing 500,000 people, the 1918 outbreak of Spanish influenza was the worst single U.S. epidemic. This was followed in 1949 by the polio epidemic when 42,173 cases were reported with 2,720 deaths.  More recently, another polio epidemic three years later in 1952 that killed 3,300 with 57,628 cases reported.

We are going through another epidemic now. An epidemic that was discovered in 1981 with AIDS, with a total estimated 988,376 U.S. AIDS cases with 550,394 deaths. The most recent epidemic was the 2009 H1N1 epidemic known as Swine Flu, affected more than 70 countries with 22 million Americans contracting the virus, and when about 3,900 Americans died.

Such seemingly catastrophic and unnecessary deaths pail in comparison to deaths from chronic diseases which are becoming more and more common because of an aging population. Chronic diseases--such as heart disease, stroke, cancer, diabetes, and arthritis--are among the most common, costly, and preventable of all health problems in the U.S.  Seven out of 10 deaths among Americans each year are from chronic diseases. Heart disease, cancer and stroke account for more than 50% of all deaths each year.

And chronic diseases not only cause death they diminish the quality of life. In 2005, 133 million Americans--almost half of all adults--had at least one chronic illness.  Arthritis is the most common cause of disability, with nearly 19 million Americans reporting activity limitations. Diabetes continues to be the leading cause of kidney failure, non-accident lower-extremity amputations, and blindness among adults.

Out of this changing situation, the fastest growing cause of death in America is however due to dementia. Unlike heart disease and cancer death rates--which are continuing to decline--deaths from Alzheimer’s disease are on the rise. Alzheimer’s disease is the 5th leading cause of death for adults aged 65 years and older. Driven by the sheer numbers of older adults, an estimated 5.4 million Americans have Alzheimer’s disease. This number has doubled since 1980, and is expected to be as high as 16 million by 2050. Julie Bynum, from the Dartmouth Institute Center for Health Policy Research estimated that Medicare and Medicaid spending for individuals with Alzheimer’s disease in 2011 is $130 billion.

While clinical intervention have proved inconsequential in reversing this trend, psychology, and the science of neurology will become more significant disciplines in addressing this new age.

Mario Garrett, Ph.D., is a professor of gerontology at San Diego State University and can be reached at mariusgarrett@yahoo.com

Older Adults in Films: The Invisible Older Woman

According to the Nielsen Company’s market research, Americans increased their television viewing in 2010 to an astounding average of 34 hours per person per week. In addition, that same year, more than three out of four Americans went to the movies at least once. Latinos, followed by Blacks, went more often than Whites.

But how much does our fascination with media shape our views of reality?  The content of the tv shows and films we love provides a distorted representation of our society. The impression we receive is that older adults are the exception. Although prime time television portrays many young adults (20–34 years old), significantly fewer older adults appear on screen. Older adults make up about 3% of television characters, but comprise almost 15% of the total population. This finding is consistent throughout the short history of television.  The same pattern emerges when we examine television advertising, game shows and cartoons. Fewer than one in 20 of all characters is aged 55 years and older. Even in soap operas—typically replete with older-looking actors—older adults are still under-represented, although appearances go up to 8%. The same is true for magazine advertisements, where older adults comprise only about 6% of the images. It seems that the pictorial media is shunning older adults.

And women fair much worse than men. Older men appear as much as ten times as frequently as older women, with a similar pattern among characters in children’s television cartoons. Approximately 77% of older characters on those shows are male. As for ethnicity, a 2002 study that examined 835 television characters found only four African American characters over the age of 60, and other ethnic groups were almost totally absent from the 60+ age group. They are have become invisible in television and film.

In America, advertising that portrays older adults overwhelmingly associates them with health-related products. Interestingly, seniors appear even if these products are for ailments that are not particularly age-related (e.g., allergy medications). In advertisements related to Alzheimer’s disease, long-term institutionalization, and loss of bladder control, older adults are invariably shown as being happy, smiling and generally being amiable.

Television and film executives argue that older adults do not comprise their primary target audiences. They argue that older clients stick with the same products. But do not tell that to Lexus. By providing an excellent quality product and customer support, older people did switch brands. Perhaps older adults are waiting for the right quality product. Moreover, one look at television will tell you that perhaps that product is not out yet. Nevertheless, perhaps there is a possibility with film.

The Coming of Age film festival—which première’s its second year on January 12, 2012 at Balboa Park’s Museum of Photographic Arts (MOPA)—will highlight how some films can represent older adults realistically. The champion of older adults, Florida Senator Claude Pepper once lamented: “Are the elderly the lepers of television, ostracized from public view?” 

Not yet.  The Coming of Age festival is addressing that imbalance, one film at a time. To book free seats, call MOPA at  619-238-7559 or visit their website at www.mopa.org.

Mario Garrett, Ph.D., is a professor of gerontology at San Diego State University and is currently on sabbatical at the University of Melbourne, Australia. He can be reached at mariusgarrett@yahoo.com

Seeing through Ages

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One of our greatest fears is becoming dependent. Blindness and vision impairment—which increase with age—directly contribute to dependency, presenting challenges to families and caregivers.

National studies indicate that vision loss is associated with diabetes, heart disease, stroke, death, falls and injuries, depression, and social isolation. It also compromises our quality of life because it diminishes our ability to read, drive, walk, watch entertainment and participate actively in visual art. Eventually vision loss and blindness isolates us from others.

Vision impairment comprises an important public health issue for older adults, affecting one out of six older Americans.  Vision impairments double in persons aged 80 years compared with persons ten years younger. Although more than half of those with impaired vision could improve their eyesight by using prescription lexes, others experience underlying diseases that can result in blindness.

Because eyes are such refined organs in the body, they are prone to damage through increase in blood pressure. Anything that contributes to blood pressure can therefore directly cause blindness—smoking, high cholesterol, being overweight and diabetes. These serious diseases include diabetic retinopathy, cataract, glaucoma, and macular degeneration. Vision problems might start slowly, but they have serious consequences that can lead to blindness. In many cases, blindness can be prevented through early detection and treatment.

Cataracts, the most common eye disease, afflict nearly one in three older adults. A cataract is a clouding of the eye’s lens. More than 15 million Americans aged 65 years or older have a cataract in one or both eyes. By 2020, the estimated number of people aged 40 or older with cataracts is expected to rise to more than 30 million.

Afflicting one in ten older adults, glaucoma and age-related macular degeneration (AMD) are the second most common type of eye diseases among older adults.

Glaucoma is caused by fluid pressure which damages the eye’s optic nerve. Both slow- and fast-developing (painful) glaucoma characterize this disease which is more prevalent among Blacks and Latinos. The number of glaucoma cases specifically among Latinos aged 65 years or older who have diabetes is expected to increase 12-fold by 2050.

On the other hand, AMD affects the central part of the retina (macula), occurring in both wet and dry forms. Wet AMD occurs when blood vessels start leaking under the macula, impairing the senses. While dry AMD—the most common in about 90% of cases—is where the macula thins over time.  AMD is more likely to affect Whites and accounts for half of all blindness among White Americans.  AMD cases are expected to double by 2050, increasing to 17.8 million.

Among older adults who reported moderate or extreme vision loss, one out of four reported that cost prevented them from seeking eye care. In some cases a balanced nutritional supplement can save your eyesight. Older adults should know that Medicare pays for glaucoma screening, cataract removal, and treatment of macular degeneration in some cases. Although Medicare does not pay for routine eye examinations or glasses, numerous agencies offer free or reduced-rate examinations. Your local adult enrichment center should have more details. Eye Care America (http://www.eyecareamerica.org/), run by volunteer ophthalmologists, offers no cost screenings to those who qualify.

Aristotle and Cool Old Age

Science does not have to look to ancient Greece for ideas. Even so, some of the assumptions that we have about aging are ancient. Ask anyone what they think about getting older and you will notice that we have not progressed very much recently—the central theme that emerges about aging involves attrition and running out of juice.

The idea of attrition started with Aristotle (384-322 BC) and was later adopted by the Romans, Muslim and Western European medical establishments.  It became the basis for our early understanding of how the human body works.  Essentially, Aristotle held that the human body was filled with four humors: black bile, yellow bile, phlegm, and blood. Any imbalance in these four humors resulted in diseases and disabilities. Aging is caused by the drying out and cooling of these humors. This idea had a wide following, and involved numerous hot baths and saunas in order to maintian our wetness and innate heat. 

Surprisingly, older adults do have slightly lower temperatures. The 98.6° F benchmark for body temperature comes from Carl Wunderlich—a 19th-century German physician.  In 2005,  Irving Gomolin from Winthrop University Hospital in New York, found that older people have lower temperatures than this average. In a study of 150 older people with an average age of 80-plus, they found the average temperature to be 97.7°. What is fascinating is that the older you are, the lower your body temperature.

This finding does not by itself dispute Aristotle’s. Since older people are more likely to die, then a decline in temperature would seem to indicate that their “innate heat” is ebbing.  But recent 2006 research, led by Italian researcher Bruno Conti at the Scripps Research Institute, has shown that a decline in body temperature is beneficial. The study found that mice who had lower core body temperatures lived 12% (male) to 20% (female) longer than mice with higher core body temperatures. The difference in temperatures between "cold" and "normal" mice was 0.5-0.9 F (0.3-0.5 C), which is the same difference between the average person and older adults.

The science behind this anomaly is just now becoming clear to us. One of the known ways to increase longevity is to restrict our calories. Caloric restriction increases life- and healthspan in all sorts of animals.  Several studies have reported that animals on reduced calorie diets also had a lowering of core body temperature.

It could be that lowering of the body core temperature is one way of slowing the aging process. Thus the reason older adults may have lower body temperature is not because they are dying, but because it is nature’s strategy for keeping them alive longer. In the Baltimore Longitudinal Study of Aging, men with a core body temperature below the average (median) lived significantly longer than men with body temperature above the average. Being cool is, well, cool.

Cicero and the Attitude of Aging

With all the scientific interest in anti-aging products, and all the money spent on procedures to make us look younger, healthier and more vibrant, a single reality still stands at the end of the day:  Aging is inevitable.  Being conscious of this will save you a lot of heartache (and money.)

Researchers and authors continue to discuss how best to describe ideal aging.  From Successful Aging, to Healthy Aging, to what we now call Conscious Aging, the central theme is to accept our limitations but to not let them determine who we are.

In contrast to philosophers who came before him, Cicero (106-40BC) was the first person to acknowledge aging as a period of diminished abilities but concluded that this—by itself—was not negative. Cicero had in fact articulated our current concept of psychological aging—of being conscious of the aging process and adapting accordingly.

While everyone around him searched for the holy grail of anti-aging, Cicero advocated acceptance. Reflecting his training as a diplomat, he argued that old age was a time of transition, not despair. Even though we might withdraw from active pursuits, he argued, older adults can still fulfill advisory functions. Cicero championed the belief that old age was not a disease—that we should accept our limitations and actively engage in those activities which we can still perform. It’s all about attitude. Make sure that your cup is half full.

In 2002, in a now classic study by two Yale professors, Becca Levy and Martin Slade, supported Cicero’s ideas. The researchers surveyed 660 individuals aged 50 and older on their perceptions about aging. Twenty three years later, they found that older individuals with more positive self-perceptions of aging—recorded 23 years earlier—lived 7.5 years longer than those with less positive self-perceptions of aging. This advantage remained after age, gender, income, loneliness, and functional health were included as possible factors. The findings suggest that self-perceptions influence longevity.

This year a new test is set to hit the market in Britain that measures a person’s telomeres. Telomeres are structures found on the tips of chromosomes that correlate with how fast a person is aging biologically. Predicted by Leonard Hayflick—before their discovery—telomeres tell us how many times our cells have already divided (and because the number of times is finite, we can tell how many times they can continue to replicate until they die).  Will such a test change how you behave?

It is likley that it will in a posive way. In 2005 Chris O’Brien surveyed over 3500 individuals in Britain, on how long they expected to live. On average—compared to local statistics—they under-estimated. Males estimated that thy will die 4.62 years earlier and women 5.95 years earlier than they are likely to die.  In this case, undertaking the blood test would improve our expectation of living longer. Attitude determines not just our longevity but it makes living more than just an expresssion of our telomeres.

Taoist Orgasms and Older Adults

Sometimes we joke about how other civilization, or other ages, looked upon old age. Since we have “medical-ized” aging and death, we have shielded ourselves from experiencing other ways of understanding aging. For many of us, aging refers just to the physical and mental breakdown of the body. But before modern science, the only way to learn about aging was through philosophy and religion.

Chinese philosophers probably thought about longevity and aging before anyone else. Early Taoist thinking—some 2000 BC—contended that there is an energy substance contained in the human body known as Jing—and that once your Jing has been expended, you will die. This comprised a simple but compelling explanation. Jing could be lost from the body in a variety of ways—most notably through bodily fluids.

Taoists embraced extensive practices to stimulate/increase and conserve their bodily fluids. The fluid that contained the most Jing was male semen.  Taoist men attempted to decrease the frequency of, or totally avoided ejaculation—in some cases redirecting the ejaculation—in order to conserve their life essence.  Others reportedly recycled and composted their own fecal matter as fertilizer for their crops—human manure. The Jing was the most precious of all substances because it was life personified.

With women surviving longer than men, later Taoist teachings needed to completely ignore females in order to make assertions about longevity hold. In addition to this major omission, recent studies also debunk the myth of a Jing. Studies published in the last few years show that sex, ejaculation and orgasms have the opposite effect of Taoist predictions.

In 2011 Howard Friedman correlated the “orgasm adequacy of wives” with longevity. Using data gathered from a group of 1,500 California students in the 1920’s—and following them throughout their lives—Friedman was able to correlate their sexual activities with longevity. The results were exciting. Women who had more orgasms during intercourse tended to live longer than their less responsive peers. 

For men, a 2009 British study interviewed nearly 918 men aged 45 to 59 about their sexual frequency. Ten years later, when all death records were forwarded to the researchers, they measured the subjects’ life spans. The findings were conclusive. Men who had two or more orgasms a week had died at a rate half that of the men who had orgasms less than once a month. Ejaculating more than 100 times a year increases life expectancy by 5-8 years.

The causes of longevity might include more than sexual climax. Although the climax by itself has positive neural and chemical effcts on the body, it may be that the pre-existing conditions for sex are equally or more important.  Conditions which allow for sex—and its fulfillment—to take place might be more important than the climax itself. These factors may include being healthy, gregarious, active, a certain level of hygiene and cognitive functioning, physical capacity, as well as certain level of social adaptness. All, by themselves, may comprise strong correlates of longevity, without the climax. However, these studies do debunk myths that conserving the Jing will promote living longer.