Smell and Dementia

The sense of smell is accomplished through our olfactory system, which is an old system in our biological development. It is also one of the most evocative.

Smell acts as a portal to our emotions. It transports us directly to another time, another place and the only other medium that does this so quickly is the auditory sense--through music. But unlike music-- which can be written down and transferred in what Karl Popper calls World 3--smell is ephemeral.

Smell is somewhat undefined. Good, bad, sweet, acrid, then we loose track of translating the subtle smells into language. Smell has its own language and it cannot comfortably be translated into words.

Smell has power, it is evocative and nuanced so that a particular smell can immediately transport us to our first kiss, or the fear of high school, or your first child being born. Visceral and strong emotions which are hidden in the recesses of your mind. Never lost but subdued until dementia starts to erase them.

The olfactory system has a direct path to the brain. With humans, this system starts with the nose and ends a short distance away at the base of our brain. Olfactory receptors, with very thin fibers,  run  from the roof of the nasal cavity through perforations in the skull ending in the olfactory bulbs, which are a pair of swellings underneath the frontal lobes. It is the only sense that has such a direct physical connection to the brain. It is is also the first to be affected with the onset of dementia or Alzheimer’s. When the brain is affected by dementia, the area that deteriorates first is the area that is responsible for smell.

There is currently a patent, by researchers from Columbia University lead by Davangere Devanand, for a test using scents that include cheese, clove, fruit punch, leather, lemon, lilac, lime, menthol, orange, pineapple, smoke and strawberry. Using this test, the clinicians can predict that an individual who cannot recognize three of the ten scents are five times more likely to develop Alzheimer’s. It has also been found to predict Parkinson’s disease as well as certain types of schizophrenia and brain tumors.

Many people who lose their sense of smell also complain that they lose their sense of taste. Smell enhances the information we get from the mouth; salty, sweet, sour, and bitter tastes. Loss of taste might explain why weight loss is also an indication of dementia. It is not the weight loss on its own, but rather the loss of smell, which brings about the loss of appetite and consequently to diminished appetite.

There are some sixty seven medical conditions identified as possibly causing loss of smell--dementia being one of them. Some of these causes are temporary, such as colds, and nasal allergies such as hay fever.  It may also occur due to some medications and localized nasal polyps and tumors. Such factors reduces the odds of making the patent smell test a very reliable indicator in predicting dementia. But for individuals, it is important to notice changes in how well we can smell. So if you are having trouble with smell, check with your physician first to make sure that this is not a temporary condition.

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

Super Brains and Dementia

We have a lot of evidence showing that the older you get the more problems we start having with our brains. In healthy adults they tend to shrink, and then they become prone to diseases, not excluding our nemesis of Alzheimer’s disease. We always assumed that these changes are fixed.  But then how do we explain exceptional older adults.

Exceptional adults are examples of what is possible, and not what is statistically likely.

When Emily Rogalski from Northwestern University looked at two groups of Chicago-area older adults of 80 years and older with similar education--12 who had exceptional memory, and ten normal older adults--she was not ready for the findings.  Her study reported that the exceptional group not only had sharp memories--as sharp as people 20 to 30 years younger--but she also found that their brains appear younger.  When compared to 50 to 65 year olds, these exceptional older adults had a thicker outer layer of the brain important for memory, attention and other thinking abilities. While in another region deep in the brain, they had thicker anterior cingulate--which is responsible for attention. Not only was there no shrinkage, these exceptional older adults show youthful brains.

Henrikje van Andel-Schipper was the oldest woman in the world when she died at age 115 in 2005. After Gert Holstege, from Groningen University, undertook a post-mortem of her brain he found few signs of Alzheimer's or other diseases. It seems that these exceptional people have escaped the normal effects of aging.

Jessica Evert from Ohio State University and her colleagues support this view. When examining death from heart disease, nonskin cancer, and stroke, 87% of male and 83% of female centenarians that they studied delayed or escaped these diseases.

If we apply the concept of escapers to the brain, then we can say that exceptional older adults escape from damaging their brain.  As far-fetched as this might seem, researchers are now focusing on studying how we might be developing the brain in detrimental ways. Known as negative plasticity—by not exercising the brain, learning things the wrong way and responding to stress—could be  causing the brain to shrink and develop inefficiently. 

Although brain shrinkage is related to aging, we now know it is not fixed and invariable. If the brain shrinks because of trauma that we impose upon it, then we need to start taking better care of our brain. The brain likes to be challenged, to be happy, stress free, fed well and exercised--just like a precious teen.

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

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