Aging in America: Addressing the Complexities of Longer Lives and an Aging Population

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00:02 Speaker 1: No matter who you are, no matter where you live on the planet, and no matter how much you exercise or what you eat, we all share one thing in common about our health: We are all getting older. There's no way to stop it, and unless the mythical fountain of youth gets discovered soon, no way to reverse the aging process. By the time I finish this sentence you and I will have gotten older. By the year 2060, there will be nearly 100 million Americans aged 65 and over, that's about double the amount today. This tremendous growth poses serious challenges and public health researchers are working today to meet those challenges.

00:44 S1: Hello and welcome to Population Healthy, a podcast from the University of Michigan School of Public Health. Join us as we dig into important public health topics, stuff that affects the health of all of us at a population level, from the microscopic to the macroeconomic, the social to the environmental, from neighborhoods to cities, states, to countries and around the world.

01:17 S1: Today, we'll hear from four researchers who examine aging in different ways. We'll explore what it means for all of us here in the United States when people live longer and longer, and the financial costs of getting older. We'll talk about diseases that primarily affect the elderly and then finally, how a furry friend may benefit us as we age. We begin with what may seem counter-intuitive, the burdens that come with living healthier longer lives.

01:44 Neil Mehta: I am Neil Mehta, I'm an Assistant Professor in the Department of Health Management and Policy at the University of Michigan School of Public Health. So, demography is the scientific study of human populations and how they change, and what's really exciting about the field is that we study how big or macro population changes, for example, increasing life expectancy, changing birth rates, how they sort of affect our daily lives. Demography is a very data-driven field and what's nice about demography is that we're really open to ideas from other fields such as sociology, economics, and epidemiology, and a lot of demographers work in the area of population health. So we study how, for example, life expectancy, which is a key indicator of population health, how life expectancy changes over time and what the future life expectancy will be. These are critical fundamental questions to public health.

02:45 NM: So the main driving question for me is whether we as a society will continue to enjoy increasing health and longer lives. So for at least a half a century, life expectancy in the United States has been increasing, it sort of declined a little bit more recently, but the major trend is up, up, up. So a lot of people think that that's great, we're living longer, but are we living those lives healthier? And for the most part, yes, but the critical issue is, will those trends continue? So for example, will our children enjoy as much health and longevity, as we did? Today, a little bit more than one in 10 Americans are older than 65. By 2060, a quarter of us are gonna be older than 65. That's a major demographic shift that's going to affect almost every aspect of our institutions, and also our daily lives.

03:51 NM: For the most part, older Americans are living healthier than they have in the past. And what we do in demography and in other areas in public health is we look at not specific diseases. So for example, whether one has diabetes or one has high cholesterol or one has hypertension, but we look at overall functioning, so can an individual participate in work? Can they take care of their children? Can they prepare a meal? Having hypertension is important to your life, being able to go to the grocery store is also really important to your life. And by measuring the ability of people to do these daily tasks, we can get a really good insight on the underlying health of the population and when we do this, what we see is that over time, individuals are healthier than they were in the past, and they're able to function better than they were in the past.

04:52 NM: With that said, there are some really concerning trends that have cropped up very recently, so within the past five to 10 years, and what researchers have identified is that middle-aged Americans, so Americans in their 40s and 50s seemed to be not doing as well as middle-aged Americans only 10 or 15 years ago. These levels of functioning and disability that I spoke about are sort of plateauing, and in some instances, we have some evidence that they're increasing. Now we haven't seen that pattern in a long time, so that's very troubling because these individuals are gonna age and they're going to be part of our older population very soon. So what's going on there? We really don't know.

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05:41 NM: One big demographic transformation that has occurred over the past century is that families have what we call become more vertical. Because of increasing life expectancy, we spend more time with our parents than in the past. We also have less siblings to rely on to care for our aging parents. That affects many aspects of our lives. So you have a generation where they're caring for their children as we have throughout human history, but we're also diverting resources, diverting attention to our aging parents, and we have to balance that. What sorts of policies whether they be public policies or whether they'd occur for employers or private companies, what sorts of policies should we and do we need to support working adults in caring for both their parents and their children? And it's a direct result of increasing life expectancy at older ages and having parents that live a long time. Which is good news, right? We want our parents to live a long time, but we have to deal with these issues, and that's an area that a lot of us think about in our research.

07:00 NM: Population aging will affect all aspects of our lives, our politics, our institutions. We've heard a lot about the solvency of the social security system. Will it be there for Americans tomorrow? Will we be able to afford to give social security benefits to Americans tomorrow? A major reason that this is a big issue is because of population aging. If we were not aging as fast as we are as a society, we would not have concerns about whether we could afford social security for the next 50 years. One thing I do wanna raise is the issue of vulnerability where we see a lot of older Americans not having the resources or the wealth or the income that they may have once had. We see very high levels of poverty among older Americans. We see particularly among older Americans who are racial or ethnic minorities, we see very high levels of poverty. We see a lot of housing insecurity among older Americans. So I've emphasized good health and increasing longevity, and yes, that's true, but there are long-term concerns about the economic and social well-being of older Americans that we should engage with as public health practitioners.

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08:28 S1: Aging is expensive both for older adults and their families but also for our country as we struggle to fund social security, Medicare, and other social safety nets. Economists and public health experts are trying to find lasting solutions to alleviate the financial burden of an aging population.

08:48 Edward Norton: My name is Edward Norton, I'm a professor of Economics in the School of Public Health and in the Department of Economics, and I've been at the University of Michigan for 11 years. A lot of my research is on elderly and their care in nursing homes, home healthcare and care after they leave the hospital, what's called post-acute care, and in particular how much they spend and the quality of care they get. Though in general terms, we are spending almost $1 in $5 on healthcare in the United States, about 18%, and because our population is gradually getting older, that fraction that we spend on healthcare is likely to go up even more. The Baby Boom Generation, those born in the 20 years after World War II, are now starting to retire and go on Medicare, and generally older people spend more on healthcare so the amount we spend on healthcare is just gradually going up and up.

09:47 EN: And also the fraction of non-elderly adults is shrinking, so there are fewer working-age adults to support elderly and help pay for their healthcare, and this will continue to be a problem for the next 50 years or so. Social security is a pension system that people pay into during their working years, and then they receive pension from the government after they retire. That is currently fully funded, but eventually unless additional funds are put in, we will run out of money for that. Medicare is the federal health insurance for all people above age 65 as well as some people who have disabilities below age 65, and that again is largely financed through taxes on working-age adults although some of it comes through general revenues. What we're concerned about is growth in healthcare spending that outpaces the rest of the economy. Thirty years ago, we were only spending just over $1 in $10 on healthcare, and that has gone up to almost $1 in $5.

11:00 EN: Medicaid is the state-run health insurance program. It's partly funded by the federal government, it's an enormous part of every state budget, partly funded by state taxes, partly by federal taxes. But again, because healthcare is expensive, because our population is gradually getting older and health expenditures increase with age, this is a real concern going forward, whether we'll have enough money to pay for healthcare.

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11:32 EN: If you go to the store and you buy something and it doesn't work, you would take it back to the store, either get your money back or exchange it for a product that works better. With healthcare, if you go to the hospital and say, you get surgery, you're discharged home, things don't go well, you have to be readmitted, Medicare pays again, and instead of getting a refund or something, Medicare pays a lot more when things go wrong. So gradually people realized that this was a system that was not putting enough emphasis on improving quality of care and was leading to very high expenditures. So what Medicare has gradually been doing is trying to find ways to encourage consumers to choose higher quality providers and for providers to have high quality care. So partly they publish information about quality of hospitals and nursing homes and home health agencies hoping that patients will choose higher quality providers, and also they collect measures of quality of care and now financially reward hospitals that provide better quality. It really is a holistic approach.

12:49 EN: If you think about patients who are discharged from a hospital, I would say a few years ago, the attitude of the hospital was, "Okay, time for discharge, time to go home. Good luck. Hopefully, we won't see you, but if you come back, we'll get paid. So it's okay." Now there's much more of an attitude of, "Oh, we are gonna be evaluated not only on the quality of care we provided in the hospital, but if you're readmitted or if you spend a lot in the next 30 days or if you die in the next few months, we're actually gonna be penalized even though you're not actually in our hospital. Therefore, we need to work better with nursing homes, with home healthcare agencies, with the patient and their family to make sure they have all the right information to recover quickly and have the best possible outcome."

13:40 EN: And so hospitals now are spending a lot more time and effort trying to educate the patients and their families about how to have a better recovery and are working more with nursing homes and home health agencies trying to get patients to go to providers that will provide the best care. And so, it really is more holistic that way. Some hospitals are finding ways to contract or work directly with nursing homes, in some cases even building their own nursing home to have more control over that. Through these incentives, the hospitals are really thinking about post-acute care in a more holistic way.

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14:25 S1: As our nation's population ages, more and more people are living with Alzheimer's disease. Public health researchers are working to better understand this form of dementia in order to work toward treatment and prevention options.

14:38 DuBois Bowman: My name is DuBois Bowman, I serve as the Dean of the University of Michigan School of Public Health, and I'm also a faculty member in the Department of Biostatistics. My research over the past decade or so has really centered on brain imaging and using brain imaging as a tool to try to understand disruptions to the brain whether psychiatric disorders or neurological disorders, and also to understand how those changes alter over time, and also how they respond to treatments. So Alzheimer's disease primarily is a disease that affects elderly population. In fact over 96% of the cases exist in people 65 years of age and older, and we're undergoing large demographic shifts in the United States where we have people living longer lives in a higher proportion of society at older ages.

15:35 DB: So, correspondingly, what we are anticipating is a growth and the prevalence of disorders like Alzheimer's that affect an aging population. Just to give you a sense of how this plays out for Alzheimer's disease, there are roughly 5.8 million in the United States currently. By the year 2050, that number is expected to look something more like 14 million. We are bracing ourselves, and I think it's a clear public health challenge to prepare ourselves to deal with this increasing burden of Alzheimer's disease.

16:10 DB: We're still learning a lot about how Alzheimer's disease works. There have been great strides in recent years, but as with many brain disorders and some other human conditions, the picture is incredibly complex. There are 100 billion neurons in the brain that support all of the functions that we know as humans, and this is observed by just an incredibly sophisticated and complex network of signaling and interaction between neurons. What happens in Alzheimer's disease is, there's some dysregulation of that normal functioning, and what we noticed is that there is an accumulation of a protein called tau that happens inside of neurons, and then in addition, an accumulation of beta-amyloid, they begin to form plaques between neurons. Ultimately, this dysfunction and dysregulation ends up causing neurodegeneration and cell death, and then that cell death becomes excessive and ultimately leads to some of the symptoms that we see in Alzheimer's disease like loss of memory.

17:26 DB: There are currently no treatments that stop or halt the progression of Alzheimer's disease, there are no treatments that prevent neurodegeneration. So the landscape for developing new neuroprotective treatments is an open one, and I think a challenge for the scientific and pharmaceutical industries. Right now, there are some treatments that are available, but the treatments that are available are intended largely to help to mitigate some of the symptoms of Alzheimer's disease rather than more systemically stopping the progression.

18:02 DB: From a public health perspective, prevention of Alzheimer's disease is certainly the ultimate goal, and as we encounter an aging population, we will have to put more focus and efforts on preventing Alzheimer's disease and other forms of cognitive decline. Currently, there is no irrefutable evidence about prevention strategies. However, it has been a topic of recent discussion, and so the National Academy has in fact published a report where they address this topic specifically and really try to evaluate the evidence for prevention.

18:42 DB: The good news is that they came out with some clear suggestions. The bad news is that the recommended strategies had encouraging but inconclusive evidence. And just to give you an idea of some of the recommendations, things like increased neural stimulation or cognitive training, and these can be very simple tasks in daily lives, like trying a new crossword puzzle, learning a novel task that will push your brain to do things in new ways. A second recommendation, it concerns physical activity. Suggestions are to just increase from what you do currently in a moderate way, and as you build capacity, to perhaps increase the challenge. But it doesn't necessarily need to be incredibly vigorous forms of physical activity to deem benefits. The last recommendation from the National Academy's report deals with blood pressure management. One of the suspected risk factors for Alzheimer's disease targets kind of a change in neurovasculature which can be impacted by chronic hypertension, and so if an individual has hypertension, to take appropriate measures to alter diet, to increase exercise, and if necessary, to introduce medications to properly manage.

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20:10 DB: My research really has the long-term goal of finding markers for Alzheimer's disease that may manifest before symptoms. The symptoms that present in Alzheimer's disease, the changes in memory, the decline in cognitive function are believed to occur decades possibly after some of the underlying neurodegeneration. So as we think about early intervention, longer term even prevention there's a clear need to identify early markers or biomarkers of disease. As a short-term goal, what we've done in our research is try to mine large-scale data to tease out patterns that change over time, that are distinct between individuals with Alzheimer's disease and healthy controls. Some of the findings in my work that we're excited about and excited to continue exploring really focus on some brain structures that are believed to occur very early in the disease process. So for example, the hippocampus, which is known to play a critical role in memory, we've noticed changes in hippocampus and not only specific to the hippocampus but in how the hippocampus relates to other brain regions.

21:34 DB: We're very excited because given the theory that this is one of the early aspects of neuropathology that occurs if we identify individuals who have signs of Alzheimer's that are detectable in their brain scans but it's before they begin to exhibit symptoms, it will give us an opportunity to begin to develop and test treatments as a broader scientific community in including the pharmaceutical industry. I'm optimistic for the future that we will have insights and breakthroughs in the near future that will help some patients today but even longer term help family members of some patients who may have increased risk or future individuals to hopefully ultimately bend the incidents and prevalence of Alzheimer's disease.

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22:33 S1: There has never been a better time to study aging. There are new opportunities to think creatively about living longer, healthier lives. Our next researcher has found some noteworthy connections between older adults and their pets.

22:46 Cathleen Connell: Hello, my name is Cathleen Connell. I'm a faculty member at the University of Michigan School of Public Health. My work focuses on chronic illness self-management among older adults. Well, pets are hugely popular and they're naturally occurring source of support and they can contribute to physical health, social, emotional, cognitive health. In addition to that, many people benefit from being able to care for others. And there are always plenty of pets that need a good home so in this way there's this wonderful set of opportunities and synergy between pets and older people. The national poll on healthy aging is being conducted at the Institute of Healthcare Policy and Innovation with two partners, AARP and Michigan Medicine, which is the medical school at the University of Michigan. The poll is a nationally representative survey of adults aged 50 and above, it addresses a whole range of health topics. My close colleague and friend, Mary Janevic, and I were invited to help create a module on pets and over 2000 adults completed the module on pets using an online format.

23:51 CC: We learned a lot from our poll results about how pets can contribute to the overall health of their owners. First, we learned that companionship was the primary reason why people reported getting a pet in the first place and then we had people respond to a set of potential benefits and the vast majority of pet owners responded that their pets help them enjoy life, it made them feel loved and treasured, it helped reduce their stress, their pets gave them a sense of purpose, their pets helped them stick to a daily routine and their pets helped them cope with physical or emotional symptoms. This was the majority of pet owners so we weren't shocked that they so strongly endorsed these benefits but they really are very meaningful. And then there were some extra benefits for dog owners. The majority of dog owners in our poll reported that their pets helped them to feel protected, feel connected with others and helped them be physically active. And that's not hard to imagine because for many owners and their dogs they end up taking a walk sometimes daily and that gets people out, greeting other people, all of those were extra benefits reported by dog owners.

25:00 CC: So these benefits provide examples of how pets can contribute to both physical and emotional and mental health as well as add happiness and improved quality of life. In addition to benefits of pets, it's important to be balanced and consider some of the concerns that people reported to us about their pets or about owning a pet. 55% of the people who responded to our poll reported owning a pet, so that meant 45% didn't. The non-owners reported not wanting to be tied down and not having time to care for a pet, those are legitimate issues and concerns and so pets may not be a right fit for all people at all times. And then there's also some challenges that pet owners reported including pets making it difficult to travel or enjoy activities away from home, pets sometimes put a strain on people's budget because pet care can be very expensive and falls due to a pet were reported by 6% of our respondents. Now that's a low percentage but any fall particularly among an older adult is a serious concern.

26:03 CC: Another thing to consider is that the majority of older adults have one or more chronic conditions that they manage and the symptoms or the complications of those conditions might impact an older adult's mobility or their strength and thus their ability to provide care. And the loss of a pet might be particularly challenging for older adults especially those that live alone because their day-to-day routine might have been so intertwined with that pet's daily routine that their loss is just so significant. If older adults are considering pet ownership there's some things that they might wanna think about, the first is choosing the right pet, be it a cat or a dog but there's also rabbits, fish, birds, reptiles, there's so many different options. Obviously, they take different levels of care and some might fit someone's budget a little bit better than others so those are some of the things to think about. But if adoption is the right fit, a senior pet might be an especially good choice for an older adult because potentially they might require less exercise for example, in the case of a dog and often older pets will stay longer at shelters because puppies and kittens and younger pets are so popular and so appealing so for an older adult a senior pet might be a wonderful adoption and give that older pet just the right fit.

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27:28 S1: Thank you for listening to this episode of Population Healthy from the University of Michigan School of Public Health. We're glad you decided to join us and hope you learned something that will help you improve your own health or make the world a healthier place. If you enjoyed the show, please subscribe or follow this podcast on iTunes, Apple Podcast, Google Play, Stitcher, Spotify or wherever you listen to podcasts. Be sure to follow us at UMICHSPH on Twitter, Instagram and Facebook so you can share your perspectives on issues we discuss, learn more from Michigan Public Health experts and share episodes of the podcast with your friends on social media. You can also check out the show notes at our website, population-healthy.com for more resources on the topics discussed in this episode. We hope you join us for next week's episode where we'll dig further into public health topics that affect all of us at a population level.