What We Believe

Kudos to the Huffington Post for running an article about the new report from the FrameWorks Institute, “Gauging Aging: Mapping the Gaps Between Expert and Public Understandings of Aging in America.” And shame on the NY Times, the  Washington Post, the Wall Street Journal, and the other major newspapers in America for ignoring it. That’s not entirely surprising since the report is all about the disconnect between public perception and reality, and the media are to a large extent responsible for shaping popular understanding.

The new study does not report the results of an opinion poll. It is not based on trendy focus group analysis. It seeks to understand what both geriatric experts and the lay public believe about aging and the “assumptions and thought processes” that underlie their opinions. The authors, supported by funding from AARP and a variety of foundations including the John A Hartford Foundation and the Retirement Research Foundation, use a “cultural-cognitive approach” to their work. That means they probe, they explore, they question. They do not rely on “big data.”

So what did they find? They learned a great deal about the gaps between the scientific understanding of aging (by which I mean physiologic, medical, psychological, and sociologic) and the public’s view. They learned so much that I will just touch on some of the highlights here.

Attitudes toward aging: the experts see aging as presenting challenges, but also an opportunity for growth and the possibility of continued contributions to society. The public sees aging as the enemy, to be combatted rather than embraced or supported. In particular, aging is thought to bring with it decay and disability; in fact, older people are very heterogeneous.

Root cause of aging: Americans tend to believe that what happens to them is entirely within their control. If they eat right, exercise, and lead a virtuous life, they can avoid the aging process entirely. The truth is more nuanced, with both genetic and external factors playing a significant role. In a similar vein, the public tends to believe that if older people do become disabled or demented and cannot take care of themselves, then their family rather than the government has an obligation towards them.

What we need in order to age well: The experts see a need to create structures to facilitate older engagement—whether opportunities for part time work, better transportation, or more volunteer positions. A related theme is the need, recognized by experts, for new public policy initiatives to modify today’s reality. The public, by contrast, takes the status quo for granted and assumes it’s up to older people to avail themselves of existing options.

There’s more. Maybe I will write more about this subject next week. Better yet, just read the study. And I look forward to future work from the FrameWorks Institute addressing how to change popular perceptions. Maybe they will shed some light on how to modify the public view of climate change and evolution, too.

Doing the Right Thing

For the third time in a 50 years, it’s hip to talk about dying (except, perhaps, if you are in the middle of dying yourself). Interest seems to come in waves. First there was Elisabeth Kubler-Ross, whose book On Death and Dying, published in 1969, opened the curtains on life’s final act. Then came Sherwin Nuland in 1994, with How We Die: Reflections on Life’s Final Chapter. And now we have Atul Gawande with Being Mortal: What Matters in the End, along with several other important books, ranging from the Institute of Medicine report, Dying in America and, most recently, Angelo Volandes’ The Conversation, with its overstated subtitle, A Revolutionary Plan for End-of-Life Care. It’s good that we are talking about care near the end of life, and maybe this time the interest won’t sputter out before we actually do something to assure that all patients die with a minimum of pain and distress, in their homes if that’s where they want to be, and without unwanted medical technology. But what of the months and sometimes years before death, when so many people are neither robust nor dying, but somewhere in between?

Patients and doctors alike seem to want a black and white world, where you either focus exclusively on prolonging life or you focus exclusively on being comfortable. It’s either the ICU or hospice. Even Susan Jacoby, in her trenchant book Never Say Die, advocates that doctors “do everything possible only if there is a realistic hope that I can emerge as a functioning, mostly competent human being. Then stop and let me die.” She moves the bar demarcating intensive medicine and comfort care—she thinks comfort care should begin before dying starts rather than after it has begun—but her world is still black and white. What I am interested in, by contrast, and why I write about people who are frail and people in the early and middle stages of dementia, is the gray zone.

In the gray zone, people are not dying in any conventional sense. They are still living and may continue to live for some time—in the case of people with Alzheimer’s disease, perhaps even 5 years—but they have begun the final phase of their lives. They are beginning their final descent, as airline pilots so helpfully tell you a good half hour before you reach your destination, but won’t actually land for some time, and even then it will be a while before you arrive at the gate and can take off your seatbelt.

Who is in the gray zone? Principally people with either physical frailty or cognitive frailty (dementia). People who have a serious, ultimately fatal illness such as congestive heart failure or kidney failure or a progressive neurologic disease such as Parkinson’s or amyotrophic lateral sclerosis (Lou Gehrig’s disease). People who have a bad disease that will inevitably get worse and who have embarked on the spiral of relentless decline that will culminate in their death.

What approach to medical care makes sense for people in the gray zone? Not everybody wants the same thing, but it is my belief based on clinical experience, scientific evidence, and common sense that most people who are physically or cognitively frail favor what I call intermediate care. This is care that is focused on maintaining whatever functions the person still has—activities such as walking, talking, seeing, hearing, and thinking. Preserving functioning is the primary goal of care. It may not be the only goal of care: people in the gray zone will often wish to live longer, but only if the treatments intended to achieve this end do not further impair their functioning. People in the gray zone usually want to be comfortable (doesn’t everyone?), but they are willing to undergo some discomfort in exchange for the strong possibility of holding on to the functions they have.

What does intermediate care look like? We tend to talk more about what it excludes than what it includes. It excludes attempted CPR—because people who are frail almost never survive attempted CPR and if they do, it is likely to be in a state of far poorer functioning than before the cardiac arrest. It excludes treatments such as risky chemotherapy and treatment in the ICU for the same reason: these medical therapies are seldom effective in prolonging life in patients who are frail and if they succeed, the price is usually a decline in function. What intermediate care includes is treatments that are intended to maintain function, things such as cataract surgery or hip fracture repair. It includes life-prolonging treatments such as antibiotics for pneumonia or transfusions for gastrointestinal bleeding if they can be accomplished with only a small risk of deterioration in the person’s ability to function. That means it may well include hospital treatment, up to a point. The distinguishing features of intermediate care are both the benefits it is likely to confer (better functioning, possibly longer life) and the burdens it is likely to avoid (decline in precisely those areas that the patient values most, whether mobility or cognition or some other domain of daily functioning). Intermediate care can be high tech or low tech: the issue is not the complexity or the cost of the treatment, but its effects.

We need to let patients know they have entered the gray zone—if they mistakenly believe they will get better or they fail to realize they are dying, they will be unable to make wise choices about the kind of medical care that is right for them. We need to tell patients that there is such a thing as intermediate care and help them understand what it means in practice. 

A Matter of Opinion

In an op-ed in the New York Times this week, my fellow Harvard physicians Pamela Hartzband and Jerome Groopman argue that it’s pernicious to reward physicians for meeting quality standards. These measures of performance, they say, are “population-based and generic, and do not take into account the individual characteristics and preferences of the patient or differing expert opinions on optimal practice.” Really? Are there no practices that physicians should routinely follow if they are to practice good medicine?

The answer revolves around the concept of “preference sensitive care,” articulated by Jack Wennberg and Elliott Fisher of the Dartmouth Center for the Evaluative Clinical Sciences. Preference-sensitive care involves treatments that involve significant tradeoffs affecting the quality and or length of life. It is contrasted with effective care, which involves essentially uncontroversial treatments that are unambiguously optimal, or for which there are no viable alternatives. What Hartzband and Groopman are arguing is that essentially all care is preference-sensitive and there is no such thing as effective care. Therefore, they conclude, there is no way that we can legitimately grade treatment as inherently good or bad—it either reflects patients’ wishes—or physicians’ recommendations—or it doesn’t.

The view that there are no medical practices that constitute “effective care” and that all medical care is preference-sensitive strikes me as profoundly misguided. In 2003, RAND evaluated the quality of medical care in the US and found that only 55% of adult patients surveyed by telephone had received recommended medical treatment. These treatments included counseling on smoking cessation to patients who had had heart attacks and long-acting inhalers for people with chronic asthma. Did the 45% of patients who did not get standard treatment actually receive care that, while not consistent with expert recommendations, conformed well to their preferences? Could 45% of physicians have deliberately and thoughtfully chosen a course that deviated from expert recommendations because they had unique insight about what was best for their patients? Is there a plausible reason why physicians should not advise cardiac patients to stop smoking or patients with at least moderately severe asthma to use inhalers? I doubt it.

What about older people? Perhaps this is one population where most treatment is preference-sensitive. After all, as I have often argued in this blog, what makes sense for people who are frail, dying, or have dementia depends heavily on their goals of care. Even a seemingly clear-cut decision such as whether to have surgery for a broken hip might have a values component. A patient who is dying, for example, and whose only goal of care is his comfort, might choose to have bed rest and pain medication rather than the rigors of surgery. So are there quality indicators, those “metrics” that Hartzband and Groopman vilify, that apply to the geriatric population?

I looked at the most recent HEDIS (Healthcare Effectiveness Data and Information Set) measures, the set of indicators used by health insurance companies throughout the US to evaluate physician performance. These were designed by the NCQA (National Committee for Quality Assurance), a non-profit, non-governmental, independent body that relies on expert judgment and public feedback to determine quality indicators. It turns out that there are 5 HEDIS measures for older adults, addressing physical activity, pneumococcal vaccination, osteoporosis testing, medication management, and fall risk management.

The 5 domains were chosen for good reason. Physical activity plays a role in maintaining physical function as well as in staving off depression, cardiovascular disease, and other chronic illnesses common in old age.

Pneumonia is very common in the elderly and it’s a killer. When it doesn’t kill, it causes shortness of breath and confusion, often resulting in hospitalization, and may trigger other conditions such as a heart attack. Osteoporosis is responsible for tremendous suffering, mainly in the form of pain and impaired mobility, and predisposes to fractures. Falls, like osteoporosis, are the cause of an enormous amount of misery in old age. Nobody, and I mean nobody, wants to fall, just as nobody wants to have osteoporosis. Medications are commonly used by older people—on average, they take about 5 prescription drugs—and the more medications a person takes, the greater the likelihood of side effects.

If the targets are reasonable, are the specific quality indicators themselves? In general, the answer is yes. The pneumonia metric, for example, looks at the percentage of adults 65 and older who report ever having received a pneumococcal vaccination. The only people for whom getting a pneumonia shot doesn’t make much sense are those who are dying. And even patients who are dying presumably weren’t dying a year or two years ago, at which point they should have gotten immunized against pneumonia. Since the measure asks if a person has ever been vaccinated, the only older patients for whom this is inappropriate are those who develop a lethal illness at age 65 or those who regard life as worse than death (usually also people with a fatal illness) and who hope they will get pneumonia. There will always be people who refuse the shot out of a misguided belief that it will cause them harm. Some people will have religious objections—though I have yet to find an established religion that forbids vaccination (the exception is Christian Scientists but they aren’t likely to go to doctors in the first place). So physicians will rarely achieve a score of 100% on the vaccination metric. But the question is not whether vaccination can always be achieved; it’s whether vaccinating against pneumonia constitutes good medical practice.

It would be nice to have separate measures for patients  who are near the end of life, for those who meet the criteria for enrollment in hospice (whether they have chosen to enroll or not). At the very least, for patients with a limited life expectancy, the physician should be able to indicate that the quality indicators are “not applicable.” But apart from this concern, the quality measures strike me, on balance, as entirely reasonable.

According to a report just released by the NCQA, 54% of the US population (171 million people) now have health insurance from a plan that uses HEDIS measures. Over the last 3-5 years alone, 46% of the HEDIS measures have shown consistent, statistically significant performance gains. Surely this is progress. Some treatment decisions are preference-sensitive and for these cases, we should find a way to determine if physicians are eliciting their patients’ preferences and treating them accordingly. For those treatments that constitute “effective care,” the quality indicators make good sense.

The Five Percent

It’s a dirty little secret that nobody other than professional geriatricians and palliative care doctors seems to know. But inside those circles, most everyone is aware that palliative care is an up and coming field that has tripled in size since 2000, while geriatrics is floundering, with fellowship training slots going unfilled in recent years and the number of board certified geriatricians declining. So an editorial in the Journal of the American Geriatrics Society advocating that the two disciplines work together to promote a joint agenda set me to thinking: why the difference? 

A slew of factors have contributed to the success of palliative care. As Dr. Diane Meier points out in her editorial, the decision to push the field by “making the business case” to hospital CEOs rather than by focusing on getting NIH research funding was crucial. The creation of CAPC, the Center to Advance Palliative Care, which focused on leadership training and skills development, was a brilliant innovation. But I couldn’t help wondering whether the different trajectories of palliative care and geriatrics, which both address the needs of the 5% of the population who are the sickest—and who use half of all health care resources—could be traced in part to different attitudes toward the old and toward the dying. An article by geriatrician Dr. Louise Aronson in a new series of groundbreaking articles on aging in the Lancet suggests attitudes matter. 

Dr. Aronson quotes the comments of Dr. Robert Butler, in many ways the founder of contemporary geriatrics, that “aging is the neglected stepchild of the human life cycle.” Writing 40 years ago, Butler made the case that “ageism” allows people to distinguish themselves from older people, to see themselves as safe from the debility and decline that afflict many in the final phase of life. Aronson tells several anecdotes to emphasize that the disdain for old people persists in medical circles today: a surgeon who laughs at a student who says she wants to go into geriatrics and jokes that the “disease” the student will specialize in is “constipation;” a senior physician joking that the best way to avoid the adverse consequences of hospitalization in the elderly is “never to build nursing homes within 100 miles of hospitals.”

I remember that my decision to do a fellowship in geriatrics was met with the same mix of derision and incredulity 30 years ago. Another young doctor in my medical residency program gave me an extremely backhanded compliment: “But you’re very smart,” she said, “so why would you go into geriatrics?” Could it be that palliative care is thriving because we are ready to face dying but geriatrics is struggling because we are unwilling to face what comes before the end?

Aging is one of the greatest challenges faced in the world today. Throughout the world, people are living longer. Falling fertility rates and rising life expectancy have led to an aging population in the developed world, but the same phenomena are striking the developing world with a vengeance: in the US, it took took 68 years for the proportion of the population over age 65 to double and in France it took 116 years—but in China, it will happen over a period of 26 years and in Brazil in a mere 21 years.  The demographic shift has been accompanied by a shift in the “global burden of disease:” in 2010, 23% of the total disease burden in the world was attributable to disorders in people over age 60. The most burdensome disorders afflicting our aging world include heart disease, stroke, chronic lung disease and diabetes, as well as lung cancer, falls, visual impairment, and dementia. The good news is that we already know a great deal about what we need to do to increase the “lifespan,” as one of the commentaries in the Lancet series calls the length of time that an individual is able to maintain good health. 

We need to use a conceptual framework that focuses on functioning rather than on disease. We need to build and support an appropriately trained workforce—both formal and informal (ie family) caregivers. A comprehensive public health strategy must taken into consideration the physical and the social environment. It needs to be grounded into an approach that begins with comprehensive assessment, elicits patient preferences, and implements a treatment plan that is continuous, coordinated, and multidisciplinary. So if we know what to do, why don’t we do it?

The barriers to a global strategy for aging are many. They include a health care system that focuses on treatment of single diseases in isolation—even though most older people have “multimorbidity” and following guidelines for single diseases leads to over-treatment and excess costs. They include social factors, such as inadequate income protection and lack of caregivers. They include lack of knowledge—as the incidence of heart disease falls and treatment of cancer improves, a larger and larger percentage of older people will die of dementia, a disease with no known treatment. Currently, 44 million people have dementia world-wide, and that number is projected to rise to 136 million by 2050. But perhaps the greatest barrier is ageism, the belief that poor health is inevitable, that all interventions are ineffective, and that better outcomes, even if they can be achieved, are not inherently valuable. 

We need to tackle the global challenge of aging. The World Health Organization has taken an important first step: at the World Assembly last May, it agreed to prioritize work on aging, to develop a “World Report on Ageing and Health,” and then to generate a Global Strategy and Action Plan.

But it cannot just be the WHO who cares about aging. We all need to care.

Farewell to All That

In his 1905 farewell speech to the faculty of Johns Hopkins University Medical School, Dr. William Osler commented that the school was wise to hire someone young and energetic in his stead (he was very distinguished—and 55 years old). In passing, he mentioned Anthony Trollope’s satirical novel from 1882, “The Fixed Period,” in which all 67-years olds are to be sent to a special sanctuary, a kind of cross between a high-end resort and a liberal arts college, and given one year to put their affairs in order. At the end of the year, the plan is to chloroform them. The idea was to make sure that everyone quit while he was ahead, without waiting for the decline thought to inevitably accompany aging. Osler’s speech sparked a huge outcry in the media, which inveighed against his alleged endorsement of universal, mandatory euthanasia. Osler, who was well known as a joker and prankster, had endorsed no such thing. His remarks about the “comparative uselessness of men over 40 years of age” and his recommendation for compulsory retirement at age 60 were said tongue-in-cheek.

A similar media frenzy ensued nearly 80 years later when then governor of Colorado, Richard Lamm, was quoted as saying that elderly, terminally ill patients "have a duty to die.” Lamm hastened to assure the public that he didn’t actually mean that seriously ill patients should commit suicide, assisted or otherwise. What he meant, or so he insisted, was that it made no sense from a societal perspective to expend enormous resources on medical care for the dying. His choice of words was unfortunate, as was his failure to acknowledge that another reason for limiting care near the end of life was precisely that it aggressive treatment did little, if any good, not merely that it cost a lot.

Now enter Ezekiel Emanuel, an ethicist, physician, and health policy guru, with his loud proclamation that once he reaches the age of 75, he wants treatments devoted only to his comfort, not to prolonging his life. Emanuel, unlike Trollope and Lamm, is dead serious, as his article in the Atlantic, "Why I Want to Die at 75," attests.

At its core, his argument shares the legitimate concern of his intellectual predecessor, philosopher Daniel Callahan, that failure to accept our inevitable mortality is leading us to make foolish decisions about medical care. As patients we choose, as a society we pay for, and as researchers we pursue treatments that offer a vanishingly small possibility of prolonging life, treatments that come with tremendous physical and emotional suffering and enormous cost. To the extent that Emanuel is arguing that this approach is wrong, I agree with him entirely. To the extent that Emanuel is arguing that we as individuals need to revise our goals of medical care as we age, I agree with him entirely. But to the extent that he is arguing that life is worthless after age 75 and that it would be better to forgo all medical care except that focused on comfort after one's 75th birthday, I think he is fundamentally misguided. 

Of course if Dr. Emanuel wishes to decline medical treatment in the future, that is his prerogative. Contemporary biomedical ethics teaches respect for individual autonomy, which means every individual is free to refuse any (or all) proffered medical treatments. So why should anyone apart from his friends and family, and perhaps his physician, care about the personal decisions that Emanuel makes about his medical care? The reason that people care—and that there has been a strong and negative reaction to Emanuel’s announced plans—is that they rest on various assumptions which, if true, would suggest that everyone else ought to consider the same approach. So it is essential to examine critically Emanuel’s views of what matters in life and his implicit belief that the only possible goals of medical care are either maximization of comfort or prolongation of life.

As a quick way to get a sense of what Ezekiel Emanuel considers important, take a look at PubMed, which lists all published scientific publications. Emanuel published 19 articles in 2013, almost all of them in leading journals including the New England Journal of Medicine, JAMA, and the Lancet. And that doesn’t include all his New York Times op-ed pieces (he is a “contributing opinion writer” for the Times), which arguably are far more influential. Now move on to Emanuel’s bio. He is Chair of the Department of Medical Ethics and Health Policy and Vice Provost for Global Initiatives at the University of Pennsylvania. As to what he does in his spare time, apparently he climbs mountains—the Atlantic article features a photo of him and his two nephews, with whom he recently climbed Mt. Kilimanjaro. Dr. Emanuel (he is also an oncologist) continues, at age 57, to function at a level that many would place somewhere off in the stratosphere.

So Emanuel is something of a superman and he’s concluded that when he stops being able to keep up his current pace, he can’t imagine that life will be worth living. Not that he plans to commit suicide or to ask anyone else to end his life. He will simply forgo all potentially life-prolonging therapy and die at the earliest opportunity. Now here is the first place where Emanuel is sadly misguided. He fails to understand or at least acknowledge the importance of any dimension of life other than what he has thus far experienced—success measured by the publication count and the prestigious positions, the mountains scaled, literally and metaphorically. It’s not just that proclaiming that life must be lived at a fevered pitch or not at all seems to categorize most of the rest of us as not-living-a-worthwhile-life; after all, Emanuel doesn’t claim to be imposing his standards on everyone else. It’s that Emanuel’s relentless desire for a narrowly defined kind of accomplishment gives short shrift to precisely those activities that many cultures deem of greatest value. The Jewish tradition, for example, calls upon every individual to participate in acts of loving kindness (gemilut chasadim) and in efforts to repair the world tikkun olam), however small those efforts.  Every stage of life comes with its challenges and its possibilities and it’s up to us to try to do our best in whatever condition we find ourselves.

But while I feel sad that such a talented and (otherwise) insightful person as Dr. Emanuel fails to see any merit to a life other than the one he is currently leading, that is not my main criticism of his stance. Nor is my main criticism that he is naïve if he believes that forgoing life-prolonging therapies such as pacemakers and antibiotics will necessarily shorten his life, when many people live for years without such treatments. Moreover, excluding a treatment from consideration merely because it might lengthen life may well have several presumably unintended consequences: refusing a flu shot (in the hope that you might contract the flu, develop complications, and die, a relatively unlikely outcome) has public health consequences as you may transmit the flu to others who do not share your death wish; and declining a pacemaker (in the hope that a slow heart rate might be lethal) may result in falls, broken bones, and dizzy spells all of which impair your quality of life without killing you. The primary difficulty I have with Emanuel’s perspective is that he completely misses the possibility that someone might have any other goal aside from maximizing comfort, on the one hand, or prolonging life, on the other. My view is that this is in-between position that Emanuel ignores is precisely what most people find themselves endorsing as they age.

We are both mortal and at high risk of experiencing increasing disability in the last couple of years of life (though not, as Emanuel seems to think, starting at age 75). The implication of these realities is that when death appears on the horizon (if, for instance, you develop a fatal illness) or when frailty rears its head (if, for example, you develop one or more impairments in your basic daily activities), it is a signal to reconsider the goals of medical care. Most people, I have suggested elsewhere in this blog as well as in my book, The Denial of Aging: Perpetual Youth, Eternal Life, and Other Dangerous Fantasies, choose comfort as their primary goal if death is imminent and choose maintaining their daily functioning, that is maximizing their quality of life, if they are becoming frail. Most people make this switch even though they continue to wish for a longer life; they are simply saying that if the price they have to pay for longer life is pain and suffering (in the first case), or poor quality of life (in the second), they are not interested. Dr. Emanuel, in his black-and-white, all-or-nothing view of the world, fails both to recognize that there is a middle ground where people choose treatments that promote quality of life, and that decisions to forgo treatment are predicated on the need to make trade-offs, not on the wish to die.

I hope that in all the furor over Dr. Emanuel’s article in the Atlantic—and he has certainly triggered a storm of protest—we will be able to get beyond the arrogant implication that only a life of intense and continuous activity is worth living, and accept the more modest reminder that is at the heart of his article: that we are all mortal. And as we approach the end of our lives, we may wish to modify our hopes and expectations in accordance with the reality of our situation and seek medical treatments that correspond to our new goals of care.

To Cover or Not to Cover

A chest CT scan showing what is almost certainly lung cancer: the Centers for Medicare and Medicaid Services will decide soon whether to cover screening for lung cancer with CT scans. The debate heats up as the decision nears. My thoughts coming next weekend.

The Coming Cataclysm

Some time in the next 6 years the world will experience an unprecedented cataclysm. Not a tsunami or an epidemic or a large scale war, although those are possible, too. This seismic shift will go undetected by the majority of the world’s population and yet it will change our lives. Between 2015 and 2020, for the first time in world history, the population of people over 65 will be greater than the population of children under 4.

It’s all nicely laid out in a report issued a few months ago that didn’t get very much attention. I didn’t notice it at all. It was the US Census Bureau’s Report “65+ in the United States” and it consists of nothing but statistics. Most of the observations and the predictions are nothing new: the population of older people has grown (it reached 40.3 million in 2010); the median age is increasing (up from 22.9 in 1900 to 37.2 in 2010); life expectancy has shot up (going from 47.3 at birth in 1900 to 78.7 at birth in 2010 and going from 11.9 years at age 65 in 1900 to 19.2 years in 2010); more women than men make it to old age (in the over 90 set, there are only 38 men for every 100 women); the population is becoming more diverse: 84.8% of the population self-identify as white in 2010 compared to 86.9% in 2000).

But buried amid the welter of interesting but not novel data about the US are some striking statistics about the entire world. First and foremost is the unprecedented demographic shift that will take place between 2015 and 2020: the total number of people over age 65 will exceed the number who are 4 or younger. This is because both fertility and mortality rates have been falling. As a result, people over 60 went from 8% to 11% of the population between 1950 and 2011, but by 2050 they will make up 22% of the world's population--2 billion people. Looked at a little differently, the global population is projected to increase by a factor of 3.7 between 1950 and 2050, but during that same century, people who are 60+ will go up by a factor of 10 and people who are 80+ by a factor of 26. 

Today, the countries with the highest proportion of people over 60 are Japan (31%), Italy (27%), and Germany (26%) with 7 other European countries not far behind. But the countries that are aging most rapidly include 4 in the Middle East (UAE, Iran, and Oman) and 4 in Asia (Singapore, Korea, Viet Nam, and China).

Accompanying the shifting age distribution will be an ever more dramatic dependency ratio: the number of people over 65 for every 100 people aged 20-64. This means that fewer and fewer young people will have to sustain more and more old people. And it will be in the low and middle income countries that all this transformation will be occurring most rapidly.

The reason all this matters is that it will put an enormous strain—economic, medical, and social—on everyone, but especially on the poorest countries in the world. It will affect demand—for goods (more walkers than tricycles) and for labor (more personal care attendants than elementary school teachers). The net effect may be as destabilizing as nuclear weapons. As a position paper published by the State Department and the National Institute on Aging put it, global aging represents a “triumph of medical, social, and economic advances over disease”—but it also represents an enormous and most governments have not even begun to plan for the long term.

So we have one more thing to worry about, along with climate change and religious fundamentalism and infectious diseases. What can we do about it? We do not need to accept the doomsday scenario of massive workforce shortages, asset market meltdowns, economic growth slowdowns, financial collapse of pension and healthcare systems, and mass loneliness and insecurity. But we do need to take steps now.

There are lots of interventions that can make a difference. 

One is to raise the normal legal retirement age. Another is to use international migration. A third is to reform health care systems, incorporating new models of long term care. A fourth is to encourage businesses to employ older workers, enabling them to work part time and facilitating their continuing productivity through environmental modifications that address mobility, vision, hearing, and other deficits. Economists, sociologists, demographers, historians and physicians at places including the World Bank and the Stanford University Center on Longevity have come up with a menu of strategies.

It’s up to all of us to pressure both the private and public sectors to act. Contact your senators and representatives. Write letters to the editor to major newspapers. The time to act is now.