Monday 5 March 2007
A report published last week by the UK Alzheimer’s Society, Dementia UK: a report into the prevalence and cost of dementia, confirmed what many people already knew: that dementia is one of the main causes of disability in later life. What was disappointing was the way the research was framed as another ‘ageing timebomb’.
Today, about one-in-five people over the age of 80 has a form of dementia. As a progressive disease, the impact on the individual ranges from mild to severe, so that only a small proportion lose most of their capacity for independent living. But for those worst affected it is extremely distressing for themselves and especially for their caring relatives.
The study could have been greeted simply as a rational contribution to helping society adjust its priorities to an ageing population. With demographic shifts, the types of illnesses that society should focus on change. With substantially reduced infant mortality and more people living to an old age compared to 100 and even 25 years ago, less medical research can be devoted to defeated or contained diseases such as polio, smallpox, tuberculosis, scarlet fever, measles or typhoid, and more can be devoted to heart disease, stroke, cancer and dementia. That’s rational social adaptation.
Unfortunately, a review of the media headlines illustrates a much more alarmist and miserabilist message: ‘Dementia timebomb warning’, ‘The country’s looming dementia crisis’, ‘Dementia timebomb will cost NHS millions’. Such a reaction to the underlying research in this report is not only unjustified but also counter-productive. The Alzheimer’s Society itself warns that such alarmist talk is misleading. It argues with reason that: ‘The use of phrases such as the demographic timebomb, or the view that older people are a burden on our society, does not encourage the view that a sustainable system can be developed.’ (2)
There is nothing new here. The threat of a ‘timebomb’ is frequently invoked in relation to ageing - just look at the debate about pensions. But this fear and anxiety is not a good way to plan transformation and progressive adaptation. Instead, fear-mongering today tends to reinforce a fatalist resignation to the future, epitomised by a naturalist view of ageing: we’re ageing, old age historically brings negative consequences, so we have to put up with it.
Knee-jerk responses in the face of an ‘emerging crisis’ make things worse, more often than not. (That’s also the story of the perverse, counter-productive impact of pension reforms over the past 20 years.) For example, the report draws attention to the ‘starkly different ordering of [research] priorities: cancer 23.5 per cent, cardiovascular disease 17.6 per cent, musculoskeletal disorders 6.9 per cent, stroke 3.1 per cent and dementia 1.4 per cent’. I’m sure it is not the authors’ intention but when legitimate calls for more specific research funding are made in the hyperbolic context of a perceived looming ‘cost crisis’, one can easily imagine the response will be ‘okay, let’s cut funding to these other areas and reallocate to dementia instead’. In the short term, this might seem to support the prospects for potential dementia sufferers, but overall could produce a worse future for old people if other age-related chronic disorders lose funding as a result.
These anxieties about the social and economic impact of ageing are unjustified. We need to challenge an intensifying paradox of our times: that even though we are living longer, healthier and more prosperous lives than ever in human history, we are also more negative about ageing and old age. In the past, old age had both positive and negative connotations – experience and wisdom, not just decrepitude. Today, we only seem to recognise the negative: a timebomb bringing about an intolerable economic and social strain based on millions more dependent people.
Firstly, society is getting wealthier all the time. Whatever the extra costs associated with an older population, the trend of rising productivity means that we will have even more resources in the future, so we can bear these costs easily.
History justifies that perspective. There is nothing new or unprecedented about ageing. Developed countries will age over the next half-century at much the same rate that they have for the last hundred years. In contrast to the warnings today that ‘ageing will slow down future economic growth’, this demographic shift hasn’t stopped us from getting more prosperous as a society and older people have benefited from this greater social wealth.
Secondly, a narrow ‘telescope’ view of the future tends to mislead when broader social consequences are drawn. Focusing on one particular feature of the future can fail to incorporate offsetting factors.
The most obvious example as it applies to ageing is that fewer young people necessarily offset more old people. Hence, more absolute spending on old age-related costs is offset by less on younger sections of the population - for example, on education and the specific health costs of the young.
Even in the narrow area of health within wider social spending there are inevitable offsets. Some forms of morbidity rise with age, so more old people mean more illness to be treated. But we are living not just longer lives but longer healthier lives. This trend counteracts the impact of increased health spending related to old age.
This is even more the case when the main influence on the ageing of society is no longer falling birth rates but longer life. For most of the twentieth century, ageing populations mostly represented a changed ratio between young and old people – falling fertility reduced the size of younger cohorts producing an automatic increase in the average age and in the proportion of old people in the population. More recently, since about the 1960s, greater longevity has become a bigger influence on the age structure. The fact that we are living longer is partly attributable to the defeat, or better treatment, of diseases that used to debilitate or kill off younger people. People, including those who are already old, are living to a greater age. Postponed death of this sort tends to go along with people being fitter and healthier during their lives because they are both reflections of social progress and higher living standards.
Most of us are getting through youth and middle age without requiring much medical support, and much less than our parents and grandparents needed. Lower health costs earlier in life means a healthier society, which is good, and which brings about an inevitable concentration of health resources on the older segment of the population because of the higher probability of disease and death with advancing age.
A related factor that is often downplayed in discussions of age-related health costs is that the cost of dying is more relevant than the cost of ageing. The highest costs arise in the final six-to-18 months prior to death, whatever the age of death. Focusing on the costs of people with dementia in their final years forgets that this means we are paying the cost of these final months for fewer younger people - and in the context of dementia, ‘younger’ means people below the age of 80.
In other words, just because there will be more people with dementia in an ageing population doesn’t tell us anything about total social expenditures in the future.
Thirdly, the future is one of transformation and adaptation, not extrapolation. This is the statistical distinction between ‘projections’ and ‘forecasts’, which invariably get mixed up in everyday discussion. This confusion is a boon to those who make fearful speculations about the future. A statistician can make a projection about the future based on certain present-day assumptions and extrapolating from them. But every serious professional statistician will add the warning that this is not a forecast of the future, because things will change - society progresses - and therefore the assumptions made for the projection will become invalid.
This misleading shorthand applies to the dementia study itself. It claims: ‘The total number of people with dementia in the UK is forecast to increase to 940,110 by 2021 and 1,735,087 by 2051, an increase of 38 per cent over the next 15 years and 154 per cent over the next 45 years.’ Hence the alarmist BBC News headline: ‘1.7m “will have dementia by 2051”’. (3) These figures are really projections, not forecasts, based on the researchers’ assumptions about the numbers of elderly people, the incidence of conditions such as high cholesterol and blood pressure, and levels of exercise. Many of these assumptions will not work out exactly.
More importantly, the prevalence of dementia could fall if some means of preventing or, in the shorter term, postponing dementia were discovered. This is the message of the report that should be heeded – more research can accelerate building upon the existing indications of scientific and medical progress in this area. But this gets a little lost in the hyperbole.
More broadly we can reasonably expect further improvements in standards of health in the future. The general trend is that in most countries a symptom of living longer healthier lives is that the age of onset of particular illnesses is postponed. The average 65-year-old today is much healthier than one in 1950 due to a combination of improvements in living standards and medical progress; healthy life expectancy is growing with increases in overall life expectancy.
The only uncertainties are the pace of improvements in healthy life expectancy and total life expectancy - and the relation between them. In general, morbidity is being postponed. There are indications for some illnesses, though not yet dementia, of tendencies to their compression as well as postponement. This means that some chronic disorders might be concentrated into a smaller proportion, and even a shorter absolute period, at the end of a person’s life. That’s because the older you are when you become ill, the quicker you may finally succumb to that illness.
This report on dementia is one more example of the unjustified negativity with which an ageing population is perceived these days, alongside the ongoing fears and panics about the cost of pensions and other age-related phenomena such as the cost of long-term care. All this pessimism about the human success story of people living longer older tells us more about society’s collective sense of uncertainty and anxieties about where we are heading, than it does about a rational understanding of any of these age-related issues.
(1) Dementia UK: a report into the prevalence and cost of dementia, Alzheimer’s Society
(2) Policy positions: demography, Alzheimer’s Society
(3) 1.7m ‘will have dementia by 2051’, BBC News, 27 February 2007
reprinted from: http://www.spiked-online.com/site/article/2915/