The elderly are the fastest growing segment of our population. The U.S. Census Bureau estimates that those over age 65 will approach 20% of the population by 2030, while that segment of the population over 75 will quadruple in the next 50 years. The reasons are multiple – the maturing of the “baby boom” generation, improved health care for chronic debilitating diseases, and a national commitment through the Medicare program to care for the elderly. In fact, mortality from cardiovascular disease, the leading killer of men and women in America and much of the developed world (and increasingly in the entire world), has declined steadily over the past two decades due largely to improved treatment for and survival from myocardial infarction (heart attack). Ironically, these medical advances have increased the burden of medical care. People who formerly would have succumbed to a major heart attack, may well survive. Unfortunately, many now suffer from chronic congestive heart failure, which currently afflicts five million Americans and represents the greatest single Medicare expenditure. As medical therapies improve, and mortality rates decline, people are able to live longer, but, in many cases, with complex medical conditions.

 

These new medical realities bring with them new and perhaps previously unanticipated challenges. Care of the elderly tends to be very resource-intense. Although currently only representing 13% of the population, those over 65 currently consume 36% of the U.S. health care dollar. And the effectiveness of that health care dollar has recently come into question. The United States spends more than twice any other developed nation on health care, yet ranks well below tenth in estimates of infant mortality, avoidable death and other vital parameters. At the same time, health expenses continue to increase at a rate that exceeds the growth in GNP, a frustrating trend that erased advances in wages and income even in the most prosperous of years. As a nation, we are now facing serious if not economically crippling issues of runaway national debt, forcing for the first time in our history the devaluation of our bonds, once felt to be amongst the most secure in the world. Medicare/Medicaid represent nearly a quarter (23%) of the federal budget. Any reasonable plan for debt reduction will either need to curtail expenditure in this area, or drastically reduce expenses in other major areas such as Social Security (20%) and national defense (19%). In fact, drastic reductions in Social Security would in and of themselves likely adversely affect the ability of the elderly population to maintain or access medical care, as less of a fixed income would be available for copayments, medications and other incompletely covered services. Certainly there are no simple solutions. Philosophically, the nation is severely divided and political will seems to be more focused on reelection than problem solving.

 

There are certain disturbing and medically pertinent facts, however, that should not be lost in the debate. Smoking is the cause of one in five deaths each year, more than one-tenth from second-hand exposure. Despite overwhelming public awareness campaigns, 20% of the adult population continues to smoke. "For people who do not smoke, excess weight and lack of sufficient physical activity may be among the most important risk factors for cancer," John Seffrin, the Cancer Society’s chief executive officer, recently noted. That’s for cancer – the number two killer in the country. For cardiovascular disease, the number one killer, obesity and physical inactivity, and the attendant risk of diabetes, currently threaten to reverse the remarkable gains achieved over the past two decades in the improved awareness and control of blood pressure and hyperlipidemia.

 

As I personally approach the august ages about which we speak, what occurs to me is that perhaps as a nation, we cannot afford to carry the burden of disease that we have come to accept. Yes, we can successfully perform complex surgery on increasingly elderly people; yes, we can manage increasingly complex mixtures of chronic diseases; yes, we can save lives through intensive care that was only imaginable a few short decades ago. But will we be able to afford to do so? Perhaps the wiser question revolves around what we must do to promote and preserve our health. Certainly the “silver bullets” of advanced medical care will continue to emerge from our research efforts, but while the two big ticket items have considerable room for prevention, the adage of “a stitch in time” seems to be the most appropriate word to the aging wise.