Map of life expectancy at birth from Global Education Project.

Monday, April 02, 2007

The Soul Thief

That's Alzheimer's disease and other forms of serious dementia. We have many looming challenges, ever more grave and gathering during the past six years of misrule, but this is in fact one of the most serious. Global climate change is obviously up there near the top, along with the inevitable decline in global petroleum production. (These are complexly linked, in ways that could redound to benefit or harm.) The prospects for major war -- also closely associated with the question of petroleum -- are deeply worrying, but war can be avoided.

The fiscal disaster facing the United States has been greatly exacerbated by six years of irresponsible tax cutting and military profligacy, but the demographic problem facing the U.S. (and other developed countries) is real enough. Naturally, the current administration focused on the wrong problem. Social Security wil not be terribly difficult to sustain as the population ages, in fact it can be made very nearly solvent simply by eliminating the cap on income subject to the FISA tax. However, the solvency of Medicare, and also the Medicaid burden for long-term care for the indigent elderly, does present a very difficult challenge.

Actually Medicare spending is projected to rise from about 3% of GDP now to 8.8% by 2030, which is a lot but ought to be manageable in an increasingly wealthy society. (About half of that increase comes from the growing population of people over age 65, and half from increasing cost per beneficiary.) Nevertheless the transfers represented by Social Security and Medicare in 2030 are projected to be 50% of federal tax revenues.

But dementia doesn't have a whole lot to do with Medicare spending -- the burden ultimately falls on Medicaid. That's because there is little that can be done medically about dementia, but people with dementia ultimately require long-term, largely custodial care, and only Medicaid will pay for that once people exhaust their savings -- as most will. Medicaid spending is projected to grow faster than Medicare spending in coming years. Right now Medicare costs about $420 billion/year, while combined state and federal spending on Medicaid is $322 billion, or 76% as much. By 2015, Medicare spending is projected to be $792 billion, while Medicaid will cost $669 billion, or 85% as much. Presumably Medicaid spending will surpass Medicare spending by 2030.

While most of us want to live a long time, there is some really bad news connected with that: 3% of people age 65-74 are diagnosed with Alzheimer's disease, but after age 85, the prevalence goes up to nearly 50%. And, since there are other prevalent forms of dementia -- not counting mild cognitive impairment, which is almost ubiquitous in people over 85, we're talking prevalence at least half that of Alzheimer's -- a large majority of people over age 85 suffer from dementia. It's difficult to say how many of them will require institutional care before they die -- that's a race between the ability of medicine to extend life and the processes of dementia -- but obviously, if we keep living longer and longer, we're going to have more and more people living in dementia wards of nursing homes, and maintained there at public expense. Before they land there, they will spend months or years in custodial care, destroying their families' fortunes.

We are talking about a phenomenon that will require a massive shift in resources. It's already happening -- adult day programs, custodial care facilities, and nursing facilities for people with advanced dementia are springing up all over the country. It's difficult to keep them staffed.

I'm not going to sugarcoat it -- these assisted living facilities and nursing homes are very depressing places to visit. Even the nicest ones can't do anything to compensate for the destruction of the social capacities of their residents. The people cannot even make friends with each other, because they cannot form new memories and they have very limited ability to communicate. They mostly just sit in silence. Some may respond in a limited way to focused stimulation by staff, and to visitors, but the spark merely flickers and then dies out again. There is no dinner conversation, no deconstruction of the afternoon movie, no repartee over the desultory game of bingo that the most functional can still manage to play, or pretend to play. Five or six thousand dollars a month is keeping the people clean, dressed during the day, and fed. That's it. Nursing homes, costing twice as much, are even worse.

Unless we can achieve real breakthroughs in preventing, or at least greatly delaying, the common forms of dementia, we face what I believe can legitimately be called a disaster for society. This is in fact a philosophical and ethical challenge as well as fiscal challenge, and it is a deeply personal challenge for each of us. We need to talk about it a lot more.

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