Dementia: The Good, The Bad, The Ugly And A Proposal
By: Elizabeth Bauer
Elder Law Associates Newsletter dated May 31, 2019
First, a reminder: retirement policy isn't simply about getting people over the "finish line" of retirement age with a sufficient nest egg or projected future income. It's just as important to pay attention to the well-being in retirement of the current and future elderly. That being said, one of the key old-age policy issues we will be facing in the future will be that of dementia, and the anticipated future "dementia epidemic."
So here's some good news: the risk of dementia has actually been decreasing. A 2017 study using 2012 data found that, based on a study of a representative sample, among individuals aged 65 - 74 years old, 14% had signs of cognitive impairment that was not severe enough to be labeled dementia (CIND, or Cognitive Impairment - No Dementia), and 3.2% met the full definition of dementia. For those 75 - 84 years old, the prevalence rates increase to 22.6% and 9.9% respectively, and for those 85 and over, the prevalence of CIND and full dementia are 29.9% and 29.3%.
Those numbers aren't great. But in each category, they have dropped from the last time this study was conducted, in 2000. For the total study group, all participants 65 and over, the incidence of dementia dropped from 11.6% to 8.8% from 2000 to 2012. With an age-and-sex standardization, the drop is even slightly better, from 11.6% to 8.6%.
Is this a fluke? The researchers speculate that a part of the cause may be the increasing education levels of the American population, since early and lifelong education is believed to reduce dementia risks. In addition, late-in-life obesity is actually counterintuitively associated with lower rates of dementia, and while the incidence of known dementia risk factors of diabetes and heart disease has increased, these diseases are both more likely to be controlled with medication than in the past, as also demonstrated by reductions in diabetes complications during this time period.
In addition, a 2016 article in Alzforum.org reports that an accumulation of studies over time, and in particular an analysis of three decades of data from the Framingham Heart Study, demonstrate a near-halving of dementia rates over time. The average age at diagnosis has also increased from 80 to 85 years. The Framingham study also found that (as summarized at Alzforum):
For example, the risk of dementia after a stroke dropped by three-fourths from the beginning to end of the test period, suggesting better disease management.
While much more research is needed, and commenter Lon S. Schneider of the University of Southern California observes that there may be some cohort effects as successive generations experience greater prosperity, Schneider continues by observing that the level of decrease is so substantial that the preventive measures which appear to be effective should be celebrated ever bit as much as a new medication of similar effectiveness, and promoted more heavily for the next generation.
The challenge, of course, is this: the preventative actions are long-term. In the same manner as retirement planning requires being able to think in the very long-term, so too does the instruction to live a healthy lifestyle to avoid dementia in old age. On the other hand, given that, let's face it, many of us fear mental infirmity more than financial shortfalls, this might be more attainable.
But here's some bad news: there is still a "Dementia Epidemic" in the wings. In the U.S., the lowered risk of dementia at any given age is balanced out by the greater proportion of the U.S. population forecast to reach older, high-risk ages, both due to increased longevity and the declining fertility rate; as a Census Bureau graphic says, we're moving from an age pyramid to a pillar. In the developing world, the increasing number of elderly will also drive the numbers higher, with the latest (2015) predictions that of a doubling in numbers globally every 20 years, from 47 million in 2015 to 74.7 million in 2030 and 131.5 million in 2050. To be sure, I'm a bit miffed that we're left to assume that this is not a mere matter of overall population growth and that the proportion of the population with dementia will also increase, but this increase would occur at any rate merely due to the increasing aging of the global population. And in particular with respect to middle- and low-income countries, there are serious worries that unless they become much more prosperous in a hurry, neither the health systems nor the traditional family caregiver networks will be able to handle the increased need.
What's more, the anticipated growing number of elder orphans will intensify the problem. An "elder orphans," as defined by the AARP, is "someone who is aging alone with no family available to address their caregiving needs." While that organization advises those at risk of being in such a situation to develop a social network, and others push back on this idea as a concern in the first place because they see it as a criticism of those who have not married, it is plain to see that, for all the strategies such individuals might employ to plan for old age -- seeking out community groups, researching available assistance, planning ahead for single-level housing with shopping and doctors available in case of driving restrictions, and saving ahead to pay for aides -- it's not as easy to "plan ahead" for someone to take charge in case of dementia, or even to advocate for a screening test in the first place.
Despite intensive research, we're still far from a prevention strategy, treatment or cure.
Even as recently as a month ago, news outlets reported that yet another pharmaceutical clinic trial was being discontinued for lack of effectiveness. The NIH is spending aggressively, with $1.46 billion budgeted for research this year, compared to $562 million in 2014, but, as CNBC reports,
From 1998 to 2017 there have been about 146 unsuccessful attempts at developing drugs for Alzheimer’s disease, according to the Pharmaceutical Research and Manufacturers of America, or PhRMA, the industry’s main trade group. That means for every research project that succeeded to yield a new medicine, about 37 failed.
Major drug companies such as Pfizer, Johnson & Johnson, Eli Lilly and Merck have ended their attempts to treat Alzheimer’s by targeting beta amyloid after failing to produce good results. In January, Swiss drugmaker Roche announced that it was ending two-late stage trials for Alzheimer’s that also targeted beta amyloid. It’s still testing another amyloid drug at a higher dose.
What's more, Science magazine reports that a stated congressional goal to have an effective treatment for Alzheimer's (the most prevalent but not the only type of dementia) by 2025, while matched with a further boost in spending up to $2.3 billion, appears to be far too optimistic, having been set when hopes were high that a particular type of treatment which seemed promising at the time, would be effective, yet hasn't panned out.
But here's a proposal for a set of actions that I don't believe exists at the moment:
Retirement policy experts would do well to think about the sort of "systems hardening" that might be appropriate for the elderly who are living with dementia, especially those without (local) caregivers or even without a diagnosis.
Many of us are by now receiving reminders from our health insurance provider: "get your cholesterol levels checked!" "Time for your flu shot!" "Get a mammogram!" Our over-65 elders aren't generally covered by employer-sponsored insurance, but a third of them now participate in Medicare Advantage plans which are designed to go beyond processing payments and to coordinate care as well.
Here's a further step those plans could take: rather than simply nagging the participants about preventive health care, each participant could be invited to place on file the contact information for a designated third-party, such as a spouse, child, or even neighbor or friend, who could then be alerted in the case of changes in behavior that might signal undiagnosed dementia, such as a failure to keep to regularly-scheduled doctors' appointments, pick up prescriptions, respond to correspondence or return phone calls, or the like.
Finance-wise, caregivers are already aided by the combination of autopay for bills and direct deposit for income that ensures that the ill-effects of an individual becoming impaired are not as harsh as otherwise, and the caregiving burden lightened. But, taken a step further, IRA providers, banks, or other financial institutions might encourage participants, while still of sound mind, not merely to designate beneficiaries but to permit them to identify actions (or lack thereof) that might suggest weakening cognitive ability, and contact third parties in case these flags are triggered. Has someone who previously regularly accessed an account online, ceased to do so? Have regular IRA distributions stopped? Is a bank account becoming overdrawn in a way that wasn't the case before, or, to the contrary, has spending stopped? To the degree to which credit cards are not already set up on autopay, the issuers might serve the community, at an admitted cost in terms of lost late-fee profit, by alerting a designated third-party of changes in behavior such as late payments by previously on-time customers.
Would this make a difference?
Readers, this is not a personal blog, but I do blog at "Jane the Actuary" at the Patheos website, and have written a bit there about recent family experiences. It is those personal experiences which lead me to believe that some sort of "institutional" early-warning notifications could be very helpful indeed, especially in the case of a senior who is not an "elder orphan" strictly speaking, but whose family lives some distance away and may not be able to notice the decline sufficiently soon enough.
Article Source: Forbes.com
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