More People Living to 90 and Beyond: How do we care for them all?


So many people are expected to become nonagenarians (90 or older) in the coming decades that some experts suggest changing the definition of "oldest old" age from 85 to 90 years old, according to a recent government survey.

The report, released by the National Institute on Aging and the U.S. Census Bureau, projects that, by the time the year 2050 rolls around, almost 9 million people will be at least 90 years old. To put this number in perspective, there are an estimated 2 million people aged 90 and older currently living in America.

Longer life expectancies may seem like something to celebrate. But, the real question is, what will the quality of life be for these 9 million people and the countless number of caregivers they will have to rely on?

A whopping 84.7% of people 90-plus indicated that they have a disability of some sort. Almost 70% have trouble running errands solo, or find walking and climbing stairs to be extremely arduous.

Even more troubling, 40% of the respondents reported having some kind of cognitive difficulty.

How much have medical advances impacted life expectancy? To put it in perspective, in 1921, when today's nonagenarians were born, life expectancy was 54 years old.

The financial outlook for upcoming seniors does not look particularly rosy either. People in the 90-plus set rely heavily on Social Security and Medicare to help them pay their bills. According to the survey, half of the nonagenarians' income comes from Social Security and 98.8 percent receive benefits from Medicare.

While these government aid programs are available to the elderly today, there is some doubt regarding their future solvency. If these percentages remain consistent, many future caregivers will find themselves facing longer and more costly periods of caregiving.

According to, experts have estimated that Social Security will run out of money as early as 2036, a full 14 years before the 90-plus population reaches its peak. Medicare is not expected to do much better. This could mean that the financial burdens of caring for upcoming seniors will fall more heavily on the shoulders of their caregivers.

So while medical advances continue to increase life expectancy, the question remains: who will care for the oldest old and how will they fair financially?

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As a daughter from family of nonagenarians, this issue is of great interest to me.My post is going to be long but what it leads to, I think, is important….

What I think we are going to see – this is going to really, REALLY, affect us (age group of 40 – 70) – is the change of the medical classification of dementia to a terminal disease. This is going to be more important than your Medicare eligibility age raised or getting worked up about the Medicaid look back period or MERP.

Right now dementia’s tend to be treated for the “presenting symptom”.
Example: dad isn’t eating = feeding tube & Megace;
mom has pneumonia = hospitalization, respiratory tx & antibiotics.
US Health System now does things based on curative therapy to treat dementia’s and illnesses that happen to a person with dementia no matter where they are on the level or stages of dementia. This costs $$ and resources the person still has the underlying terminal disease of dementia.

In 2000, the AMA’s Diagnosis, Management and Treatment of Dementia: A Practical Guide for Primary Care Physicians states: “Many physicians are used to thinking of cancer, congestive heart failure, and chronic obstructive pulmonary disease as conditions for which palliative care and hospice referral may be appropriate; most do not think about dementia in the same way….Alzheimer’s disease and other progressive dementias are life-altering and eventually fatal conditions for which curative therapy is not available. Thinking of dementia as a terminal illness from which people are dying over years instead of months allows one to focus explicitly and aggressively on a palliative care plan.” This is a BIG deal & HUGE change. After the AMA guide came out in 2000, we started to see more hospice created in anticipation of the increased #’s of terminal diagnosis for dementia. And more doc’s suggesting hospice which Medicare pays for.

Then in 2009, the Mitchell study came out. It’s a very detailed study on dementia, especially advanced dementia. Mitchell concludes dementia is a terminal illness best served via palliative care in advanced stages.

IMHO what the Mitchell study (and others too, but Mitchell is significant) is going to do is to enable change of what happens with dementia patients based on data. In turn, this will limit what is done TO and paid FOR with advanced dementia patients. Dementia, as a terminal disease, will all be about palliative care. Example: dad isn’t eating = comfort care, no feeding tubes;
mom has pneumonia = comfort care, no hospitalization.

This change is already happening. On April 19, 2011 NIH released new clinical diagnostic criteria for Alz. The emphasis is now on biomarkers, scan/neuroimaging and cognitive testing to evaluate and diagnosis dementia into 3 stages. The last diagnostic guidelines on dementia was back in disco days of 1984.

The Mitchell study and NIH guidelines will guide what changes are made for advanced dementia care (stage 3). It will be radically different from what most of us expect from health care – which is all about “cure” and doing whatever might bring about a “cure”. It will be about palliative care only in a hospice based setting (either at their home, NH or free-standing hospice) for advanced dementia.

Once dementia is viewed as terminal and a person has reached a certain level of advanced dementia, the only thing the insurers, Medicare and Medicaid will pay for will be hospice and the limited comfort care within hospice guidelines. So if you wanted to “cure” your parent or your spouse of Alz, and they have advanced dementia, you will have to do it via private pay as the insurer & others will not.

I think the numbers are 4.5M + people with dementia in the US now and it is expected to triple in 40 years, then hospice based care (with its focused path of palliative care) is the only financially feasible way for families, Medicare, Medicaid and the insurers to deal with advanced dementia and have the resources for health care for the rest of the population. It’s not pretty but reality often isn’t.
I know this is politically incorrect to say, but will say it anyways. The impact of people living longer or I should say "existing" longer is more than some people may realize. I'm 52 and the financial burden between taking care of elderly parents and kids still going to college is great. The emotional and mental stress that it causes continues to the point that it can break up families because there's not enough time or money to go around. Hiring help is an option, but not the end of story. I'm all for living long when a person is not suffering, but when every day life is such a struggle, I really have a hard time with it. anyone else agree?
While in my supposely good mental health at this time, if the time comes, should I unfortunately get dementia, I say don't fix my heart if my head isn"t right!!