You’re Looking Very Well

by Lewis Wolpert

  Symptoms such as frailty, wandering, agitation, falls, and lack of motivation and appetite, create a huge burden for both patient and carers. A businessman, Gerry Robinson, used two BBC TV programmes to explore care homes for old patients with dementia. The results were distressing. Inmates can spend hours without any contact with anyone. A woman cried out for help for half an hour before anyone came; in another case an alarm cord was out of reach. Staff morale was very low. Robinson argued that engagement was essential for the inmates and the system needed to be reorganised. Person-centred care is essential, care which is tailored to meet the needs of the individual rather than those of the group or the staff.

  Dementia sufferers are being ‘drugged and robbed’ by a system where they have to pay five times their pension for poor-quality care, according to the Alzheimer’s Society. More than 100,000 sufferers are being given the wrong drugs, which actually makes their condition worse, at a cost of over £60 million a year. Only about one fifth of nurses working with people with dementia receive any or enough dementia training, and almost all nurses said they found working with people with dementia very or quite challenging. A typical negative story describes staff leaving a sign next to the bed of a patient with dementia telling her: ‘You are not well, you need to stay in hospital. Just sit there, rest, relax and don’t bang the table.’ She did not understand and could not remember anything for longer than a few seconds. Dementia patients occupy a quarter of all hospital beds and are staying far longer in hospital than may be necessary. Not only does this cost the NHS hundreds of millions of pounds, but the majority of people with dementia leave hospital worse than when they arrive, and a third enter a care home, unable to return home.

  The family of an Alzheimer’s sufferer have won a legal battle to reclaim more than £100,000 in care-home fees that the local NHS trust had refused to pay because it claimed that her condition was not health-related. Health authorities had ruled that the patient, who died aged 74, did not qualify for NHS funding because her condition was deemed to be a social, rather than a health, problem. As a result, she was forced to sell the home that she had lived in for 30 years for £170,000 to pay for her £600-a-week nursing home fees.

  The practice of over-prescribing medication is based on the assumption that it is the natural process of ageing for the quality of health to decrease, and therefore there is no point in attempting to prevent the inevitable decline of old age. Such differential medical treatment of elderly people can have significant effects on their health outcomes. However, free influenza immunisation is being offered to everyone aged 65 and over, and routine breast cancer screening is being extended to women up to and including the age of 70.

  A study in Newcastle of 85-year-olds gave a positive set of results for medical care by the NHS. Almost one third of the sample had attended outpatient clinics in the three months before the study. In the previous year, 20 per cent had had at least one overnight stay in hospital, spending, on average, seven days in total over the stays. Almost all of the sample had seen their general practitioner within the past year. Perhaps the most striking findings were the low levels of disability of people living in institutional care, and positive self-rated health despite high levels of disease and impairment. Although women were more likely to survive to age 85, they were more likely to be living in institutional care, to have a higher total disease count and higher prevalence of many diseases.

  A three-month undercover investigation at Brighton’s Royal Sussex County Hospital by the BBC’s Panorama showed how hospital care can fail the elderly. In one scene a patient is left to die on her own; another patient is left waiting hours to go to the toilet; another was left screaming with pain as she had not been give her medication for hours. Margaret Haywood, a nurse with more than 20 years’ experience, agreed to go undercover for the Panorama programme, wearing a hidden camera while working as a nurse to fill a short-staffed ward at the hospital for 28 shifts on an acute medical ward. She found that none of the patients had a care plan. She was then struck off from working as a nurse, but this was later reduced to a one-year caution.

  An environmental factor, cold, has been responsible for the deaths of many old people in their homes. The average energy bill has increased by 80 per cent since January 2003‚ and an energy bill of £1‚027 would absorb 16 per cent of the income of a single pensioner. In the winter of 2004/5‚ more than 30,000 people over 65 died from cold-related illnesses in England and Wales, and there were some 16,000 excess winter deaths among the over-75s. Because nearly half of pensioners will cut heating in winter for financial reasons, some 5 million over 60 will get cold shock. The UK has a higher number of winter deaths than in colder European countries, despite the government’s winter fuel payments.

  It is very unusual for the cold to kill people directly, and in the main these deaths are from respiratory or cardiovascular ailments. Deaths may also result from heart attacks‚ strokes‚ and bronchial and other conditions‚ and may often occur several days after exposure to the cold. The elderly are more vulnerable because of various illnesses and of course, the failure to warm their homes. Age Concern estimated that 250‚000 older households have been pushed into fuel poverty by price hikes. Many pensioners have to choose between eating or heating.

  Paul Cann‚ from the new united charity Age UK, says:

  To deliver consistent and decent quality healthcare for older people‚ dignity must be at the heart of the NHS Reform Bill. On every occasion and in every health setting‚ older people should be alleviated from discomfort and pain‚ given help to make choices and treated as individuals not numbers.

  13. Adapting

  ‘The tragedy of old age is not that one is old, but that one is young’

  — Oscar Wilde

  Men and women in the developed world typically live longer now than they did throughout history, an increase from about 25 years 2,000 years ago to around 80 at the beginning of the twenty-first century. The increase has been mainly due to the advances in medicine and biology which have given us vaccines and antibiotics, and the development of sanitation systems, as well as better lifestyles and better nutrition. All of these have been successful in preventing infectious and parasitic diseases causing premature deaths. But we now need to understand the implications of the increase in age of the population.

  At present just 11 per cent of the world’s population are over 60, but in developed countries they will be one third of the population by 2050. In rich countries one in three individuals will be pensioners and one in 10 over 80. In some countries in the West the over 65s are the fastest growing age group. Those over 80 in the world are expected to increase to 4 per cent by 2050, four times more than now. Current estimates are that 700,000 of those in the UK at present around 25 years old will live to be a hundred. Moreover, half of babies being born now will reach a hundred thanks to higher living standards. But our bodies are still wearing out. Children will be outnumbered by those over 75 in what some call the Zimmer-frame society. How will society adapt?

  A majority view is that an increase in numbers of older people would make no difference to safety, security, standards of living, health or access to jobs and education. But one third of the public think life would be worsened by an increase in the older population because it would have negative economic effects. It is worth noting that by 2050 it is estimated that more than one third of voters in the UK will be over 65, and since the old vote more than the young, they could wield much power and vote for much costly support in their old age.

  David Willetts, the current science and education minister, has argued that the baby boom of 1945–65 produced the biggest, richest generation that Britain has ever known. Today, at the peak of their power and wealth, baby boomers, he claims, run our country; by virtue of their sheer demographic power, they have fashioned the world around them in a way that meets all of their housing, healthcare and financial needs at the expense of their children. Social, cultural and economic provision has been made for
this reigning section of society, whilst the needs of the next generation have taken a back seat. But it is the old who will have the greatest impact.

  Some analyses suggest that improvements in health and longevity have resulted in enormous gains in economic welfare. One estimate of the economic impact of post-1970 gains in life expectancy suggested that they might have added as much as 50 per cent to the GDP of the US. Even so, there are profound economic problems to be tackled.

  The Economist has called the economic effect of an ageing population a slow-burning fuse. It claims that age-related spending by a country like the UK will in the future be more serious than the recent recession. The elderly require money for pensions, health and care. The age-related spending by the government in the UK is already about £7 billion, less than 1 per cent of GDP, but it clearly needs to rise. Already there are billions of pounds of benefits for the old which are not claimed. The last years of life can cost tens of thousands of pounds and this increases with advanced age. In many cases the cost of the last year of life is more than all that has been spent in earlier years. Forcing older workers to retire cost the UK in 2009 an estimated £3.5 billion in lost economic output. Pension plans, social security schemes and notions of the length of working lives will need to undergo major reformulation.

  The small increases over time in average life expectancy that lead to very large increases in the size of a population are prompting many arguments. Reproductive practices might have to change in order to keep the population from becoming too large. In regard to the escalating costs of looking after the old, one group in the US has suggested there should be cuts to protect the young. It has been argued that any technological advances in life extension must be equitably distributed and not restricted to a privileged few. There are suggestions that the UK will become a giant residential home, with the young looking after the old. With family ties weakened by increased mobility and rising divorce, in the future the elderly will be less likely to be married or co-habiting, and more will live alone; and since they do not want to leave their homes it will hard for the young to find one to buy.

  Such concerns were presented by Jeremy Lawrence, writing in the Independent, who described the ageing population as the greatest threat to human society: ‘No invading army, volcanic eruption or yet undreamt of plague can rival ageing in the breadth or depth of its impact on society… The impact of this transformation will be felt in every area of life, including economic growth, labour markets, taxation, the transfer of property, health, family composition, housing and migration. And the “demographic agequake” is already under way.’

  The countries with the oldest populations—that is with the highest percentage over 65—are Monaco, then Italy and then Japan. The median age of the world population will, in the next 40 years, go from 28 to 38. The United States is on the brink of a longevity revolution. The elderly comprise 12 per cent of the US population, and their number is projected to almost double between 2005 and 2030, from 37 million to 70 million. By 2030, the proportion of the US population aged 65 and older will double to about 71 million older adults, or one in every five Americans. The far-reaching implications of the increasing number of older Americans and their growing diversity will include unprecedented demands on public health, ageing services and the nation’s healthcare. Although there may be unjustifiably pessimistic views of what is before us, an ageing population does present severe problems. But there are also great advantages.

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  An analysis of the consequences of increasing life expectancy must include the economic implications of changed population age structures, especially changes in the ratio of those in the labour force to those outside it, mainly children and elderly, which is known as the support ratio. In the early stages in which life expectancies rise, the proportion of the population within the labour force age range rises significantly, providing a substantial boost to economic growth. However, as people live longer those extra years will have to be financed, and there are only a limited number of ways to do this. These include working longer, increasing social security or other taxes, increasing immigration, and reducing consumption.

  In order to reap the economic benefits of longer lives, some of the extra years of life will probably have to be spent working productively. In the UK one in five over the age of 55 can expect to work till they are 70 and even older. This is because of their limited finance. At 55 many still have a mortgage and less than £2,000 in savings. There is considerable variation in the EU about attitudes to the extension of working life—9 out of 10 in the Netherlands, Denmark, and Finland are positive, but in Greece, Portugal, Spain and Hungary they are not at all keen. It may be sensible to compensate younger people for working when they are older by allowing them to work fewer hours per week over the whole course of their lives.

  The number of people supporting pensioners is decreasing, and it will go from four workers for each pensioner at present to two workers for every pensioner in 2050. A major problem of the ageing of societies is that people are having fewer children. The current global average is 2.6 children per woman, while in rich countries it is 1.6. One reason is that women are having babies later in life. This means that in some rich countries the population is beginning to decrease. In ageing countries, the economy can shrink as more retire and there are fewer young to take their place, and the older workers may be less productive. Japan has a very low ratio of workers to pensioners, just three to one, and by 2050 the number will probably halve. Such changes can reduce economic growth significantly. In some countries immigration is filling this labour gap; another solution is to encourage people to have more children, as has been done in France and Japan. There is also the problem of finding enough young adults for the armed forces.

  Pensions raise serious economic issues. The official retirement age for most developed countries has remained the same even though the population is ageing. Many have even retired before the official retirement age. Retirement pensions are the largest component of age-related spending, and the cost of state pensions in rich countries will probably double by 2050 and reach more than 15 per cent of GDP. Payments to the pensions of retired civil servants in the UK which are based on final salary are very expensive—the pensions can be as large as two thirds of final salary. Each one-year increase in longevity increases costs £1.3 billion a year.

  Part of the problem is that men can now look forward to between 14 and 24 years in retirement, much more than anticipated. Older workers also want a less onerous workload. The UK government’s decision to abolish the compulsory retirement age, currently 65, wll increase the number of the workforce. Retiring later will help financially, but will not the young then be deprived of senior appointments? It is estimated that unless urgent action is taken there will be a £6 billion hole in the funding of social care within 20 years. Free care at home could cost the state more than £1 billion. A very big financial hole is being opened up.

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  The Big Question: ‘Is the world’s population the wrong age?’ In some countries there are too many old people, while in others the population is very young. While the developed world is facing up to the challenges of an increasing number of elderly citizens, some developing countries are facing the strain of populations in which a third of the people are under the age of 15. Neither situation is ideal, but the challenge is to find ways of adapting to cope with the economic demands of differing population ages.

  According to a UK survey, most individuals approaching old age had not yet thought about how they would be cared for. I myself am guilty of this. At least 13 million, according to the government, are not saving enough to retire on a decent income. Some 70,000 people have to sell their homes each year to cover the cost of long term care. When asked about the supposed worries they would have when 75, about half those aged 45 to 75 were rightly worried about money for long-term care. At 65, the government says, a woman can expect to face average care costs of £40,400 and a man, who will not live a
s long, £22,300. Those with severe health problems such as disability and Alzheimer’s disease and and other forms of dementia are by law entitled to free NHS care, but ageing illnesses makes self-support increasingly difficult. Plans for nearly half a million needy elderly to remain in their own homes would cost £670 million a year, and in current economic circumstances such figures are vulnerable.

  The health of the elderly remains a major issue. Health spending on the elderly in the EU is about one third of the total health budget. In the UK more than 40 per cent of the NHS budget is currently spent on people aged over 65. The estimated number of people in the UK living with the effects of stroke, which mostly strikes people over the age of 60, will rise significantly, and the number of people with dementia will increase to around a million in 2025 imposing a major burden on social services and families. The cost of looking after them has been predicted to increase to £35 billion. The number living with coronary heart disease, osteoporosis, osteoarthritis and age-related macular degeneration of their sight will all increase dramatically. Treatment of all these illnesses is, to put it mildly, expensive. Currently those over 65 consume one third of all drugs but are only 14 per cent of the population. The NHS will face increasing demand for its services to the old. To go further and increase the quality of services will require an additional 3 or 4 per cent increase each year.