The first thing one would notice about Lulu is her smile. “Hello, dear, when is your party?” Lucille “Lulu” Weinstein beams at me. “I need to decide what to wear. What are you going to wear to the party? A blue dress or a pink one?”
Lulu’s effervescent and undeniably sweet personality easily charms. She’s the kind of lady who wants to have a nice time and look good doing it. The 87 year old who likes to put on lipstick and pull back her hair into a neat twist suffers from Alzheimer’s. It’s a chronic disease marked by bouts of confusion and a rather frightening sense of losing one’s identity.
Alzheimer’s leads Lulu to jump from asking about the weather to discussing a party she’s made up in her head. Lulu, a patient at Carmel Board and Care, California, is lucky. She’s cheerful and gentle, and has been placed by her loving family in a top nursing facility whose employees care for all of her basic needs as well as her emotional ones. She has a constant stream of visitors and is generally happy.
Many Americans, those who cannot afford first-rate private care, are not so lucky.
Americans 65 years or older were numbered at 39.6 million in 2009, making up 12.9 percent of the U.S. population or about one in every eight Americans. That number will increase, according to the U.S. Department of Health and Human Services. It is estimated that about 72.1 million older persons will make up the 65 plus age bracket by 2030. With a rising aging population comes a growing demand for special care facilities. Living longer means that diseases become long-term and chronic, and services are more expensive as people spend more time in facilities. Not everyone will be able to afford private care and will eventually come to rely on social welfare—but can governmental services, city and federal alike, cope with demands?
Unless one has had to navigate tricky geriatrics services for an elderly loved one, they don’t usually consider the ramifications of getting older. Los Angeles, after all, is often perceived as the land of perpetual youth, both by California residents and tourists. The Sunset Strip is filled with aspiring models and actors, some beyond their prime, perfectly coiffed, with sprayed on tans and a disconcerting, overabundance of face-lifts. There is an understandable sense of trepidation people feel about aging, so it's hardly surprising so many of us try to delay it as long as possible. But there is no way to ignore, however, that the Baby Boomers have begun to collect benefits while taking advantage of already economically strained health and social services.
"There seems to be a sort of fear, if you will, of aging," said Valentine Villa, a California State Los Angeles Social Work professor and the director of the Applied Gerontology Institute. "In aggregate we are doing better in terms of health, in terms of socioeconomic status. We've been living longer."
The issues that surround aging are complicated. For example, there are shortcomings as certain demographics have a higher likelihood of age-related problems evident in Los Angeles.
“We see disparities, racial disparities, among African-American women in particular and among African-American and Latino children,” said Karen Lincoln, associate director of the USC Roybal Institute.
The ailments are both genetic and linked to culture or socioeconomic situations, such as food culture and the realities of poverty. They can lead to higher instances of problems ranging from diabetes to obesity—ailments that are more prevalent among ethnic communities in Los Angeles. As people live longer, many more are now becoming old enough to suffer from chronic illnesses like Alzheimer's.
“Latinos, African Americans, some Asian and Native Americans don't do as well as non-Hispanic whites,” said Villa.
Beyond demographic concerns exists challenges that health care providers will face as aging populations experience more long-term, debilitating illnesses that will require around-the-clock care.
“A lot of those people who would have died of heart attacks are now [suffering from] Alzheimer's that they would never have got because they would have died early,” said Kelvin Davies, professor at the USC Davis School of Gerontology and an expert in Alzheimer's. “We used to have more coronary care units... that was the shining star of hospitals twenty years ago.”
Davies’ research looks at why people age, focusing on Alzheimer’s and other age-related ailments. His latest study published in August in the Journals of Gerontology found that Lon protease, an enzyme, or a substance that increases the rate of a reaction is mobilized less frequently as a cell ages.
When Lon protease isn't called on as frequently, cells are less protected from oxidative damage, such as peroxides and free radicals, which cause damage to a cell.
Davies and his research team exposed cells to various oxidative stresses, such as ozone, hydrogen peroxide, pesticides and herbicides and other toxins. In experiments, some of which used human lung cells, Lon production increased to fight oxidation. The process can be likened to rusting or food spoiling.
“You find that if you give cells the right opportunity, cells adapt,” said Kelvin Davies, professor at the USC Davis School of Gerontology. “They adapt by changing their gene expression which means that they start making more of some proteins and less of others.”
Scientists believe Lon protease protects mitochondria, organelles that transform oxygen to energy. With the decrease of Lon production, mitochondria function starts to deteriorate. Older cells don’t have that same ability to adapt to environments that cause damage, however, so they ultimately die.
“What we think is going on is that this is part of a normal, adaptive response that all cells have,” explained Davies.
Davies’ research shows that as people age they are less able to cope with stresses ranging from physical, such as chronic illness, to psychological, such as Alzheimer’s.
In Alzheimer’s the process of Lon protease can be compared to soldiers in a war. Oxidants are warded off or endured because of the mobilized Lon. Older cells, however, take longer to produce Lon in experiments. The longer it takes cells to mobilize Lon, the more a cell has to cope with oxidation which eventually kills it.
“If you disable Lon protease, if you genetically modify [Lon protease] or if you decrease the rate of a cells’ production of Lon protease, the cells are particularly sensitive to oxidation stress and typically die,” said Davies.
Davies’ findings can help scientists to better understand the aging process and in the future could direct medicine to new diets and drugs that improve the quality of life. Researchers could potentially find treatments that would increase the productivity and function of Lon protease. No current treatment, including much-advertised, over-the-counter supplements that contain enzymes, is capable of increasing Lon productivity, according to Davies.
He is also cautious about exaggerating the research.
“We understand very little about the aging process,” said Davies. Scientists first need to understand better what changes in aging and what contributes to the aging process, and understand that current research is not going to provide an immediate remedy for chronic, age-related diseases.
Davies says current treatments aren't promising and notes that the future for Alzheimer’s patients looks bleak.
“Unless somebody comes up with something for Alzheimer's then we're going to need an awful lot of care facilities because people are just not able to cope in their own homes all the way through the disease,” said Davies.
Health care dollars will go to these new facilities for chronic care where a patient may sometimes spend years. And, for those who rely on programs like Medicaid, care and equipment winds up being an expensive taxpayer burden.
“It's not their fault, but we need to do something about coping with that,” argued Davies.
Organizations like the Department of Aging are concerned about rising numbers of chronic illnesses, especially in light of the U.S. Census Bureau’s newly released numbers which show a record 46.2 million Americans—1 out of every 6 people—are living in poverty today. “The only word for it is grim,” said Robert Greenstein, president of the Center on Budget and Policy Priorities, in a September report.
Los Angeles’ Department of Aging is particularly focused on “low income, socially isolated” senior citizens who require more assistance, according to Laura Trejo, general manager of the Los Angeles Department of Aging.
“We are keeping a watchful eye so people are not falling through the cracks,” said Trejo. The organization provides support to senior citizens and disabled individuals that include transportation, especially for disabled citizens, and a daily nutritious meal for senior citizens who are disadvantaged.
As more people find themselves out of work and facing poverty, the City of Los Angeles could see an increase in residents who seek public services of which plenty have been cut due to budget woes. Los Angeles’ Department of Recreation and Parks which provides senior citizens with centers has lost two sites, said Carolyn James, principal recreation supervisor. Park services for the elderly keep individuals, especially more independent seniors, engaged. They give seniors a place to gather and hold events—to socialize. In Los Angeles and throughout the state, budget cuts have threatened public programs such as these.
The Department of Aging has fared better, but they, too, “have been impacted in loss of city resources,” according to Trejo. The organization's budget is made up of federal and state grant funding from the Older Americans Act, the Older Californians Act, and the Medi-Cal program.
It could also have larger implications as people move back in with their parents or grandparents suddenly find themselves contributing to their children and grandchildren's households. According to experts these seniors often contribute their social security and pensions to their children and grandchildren.
With city services already stretched to the limit, the private sector sometimes offers a better alternative in terms of quality.
“The private sector has managed to help,” said Phoebe Liebig, associate professor of Gerontology at the USC Davis School of Gerontology. Liebig notes private services, financed and run by businesses or religious groups, which include care facilities and programs for senior citizens.
MCL Medical, a company that supplies several for-profit facilities with adult diapers and nutrition formulas for elderly patients, has had to navigate governmental bureaucracy that pervades the Medi-Cal program.
“Not only does Medi-Cal not pay providers but they do not provide patients with adequate services,” said Ofer Elkayam, president of MCL Medical. “They use subpar adult diapers, for example, which often lead to bed sores when they aren’t changed frequently enough.”
Elkayam has worked with senior citizens in some capacity for more than two decades.
“You cannot ever forget that you are dealing with people,” he said. “It could be our parents, it could be us there.”
At Carmel Board and Care Elkayam’s wife, Edva, oversees eight privately run health facilities in the San Fernando Valley, each house boasting three full-time caregivers for every six patients.
“Families of our patients want peace of mind and we give it to them,” said Edva Elkayam. “Always you let your patients feel that you understand them.”
The nursing facilities under the Carmel umbrella offer a private trainer specialized for the elderly, gourmet-style meals and regular activities designed to keep patients engaged. Unlike most facilities, Carmel doesn’t keep to a visiting hours schedule but instead implements an open-door policy so family members can visit loved ones at any reasonable hour.
Patients like Lulu are happy here and are loved by the staff.
“Did you meet my Lulu?” Florence Ormilla, a house manager for one of Carmel’s homes in Woodland Hills, asked me.
Ormilla is responsible for everything from administering medication to making sure patients, who she likens to her grandparents, aren’t bored.
“I left the Philippines…but found my inner peace and contentment that I’m doing my part,” said Ormilla. “I am their granddaughter now, I take care of them.”
Health care facilities are filled with many well-intentioned individuals, but many lack these same resources. Whereas Lulu has constant engagement, those individuals living in poorer quality facilities—including some public nursing centers—face poorer care and less one-on-one interaction.
Although it is impossible to know how bad it is, several reports document that at least one in ten patients have reportedly been abused in nursing institutions. Most crimes go undetected, according to the national Center on Elder Abuse.
Mistreatment of elders can range from physical and sexual abuse to psychological harm and abandonment.
In 2008 a five star rating system was adopted by President George W. Bush to help evaluate cost of treatment as well as to bring scrutiny to failing facilities.
But not everyone has saved for retirement or is able to afford best treatment. And many who have paid into individual retirement arrangements have also lost funds with the recent market downturn.
Some experts say current programs, like Social Security and MediCare, will have to play a big part in the solution even though they may need some reform.
“Yes, there will be shortfalls,” said Villa, “but we can do things to change this.”
Others are less optimistic about the future of social security. When social security was introduced by FDR there were 163 people working for every one person receiving it. By 1950 there were about 15.3 people working for every recipient. Within the next 15 years there will be two people working for every recipient. In 1940, when the average life expectancy was 60 years of age, the retirement age was set at 65. Today the average life expectancy is about 82 and the retirement age is still 65. The current system is not sustainable (But see).
“There’s a larger population that is going to have to rely on social security with fewer people paying into that system,” said Lincoln. “You’re going to have this huge population of people who are receiving the benefits and fewer people paying into it,” said Lincoln. “That’s just a recipe for disaster. I’m not sure how we can sustain this system.”
It isn’t just the poor who rely on social security because people from all segments of society collect their benefits—but with a limited pool the funds are not indefinite.
“I’m not sure what we can do for those who are retiring now, but certainly we need to begin to think about how to prepare people for retirement,” explained Lincoln.
One method could combine social security with other types of funds, while at the same time educating people about retirement. Experts agree social security just won’t be enough, especially with more people taking advantage of the program.
Given a choice most people—understandably—prefer to age in their own homes. Eventually, however, the best intentioned of families may need to place a mother, father or grandparent in care. It isn’t an easy decision either emotionally or financially. The care, after all, is costly—in excess of $3,500 a month at the best of facilities. Insurance typically only covers a portion of that. It’s unclear how our society will cope with changing aging demographics, especially in light of current economic turmoil the nation faces. What is clear is that conversations about aging need to take place so that people are aware of the limitations of social security and city services. Reports indicate that Americans save less and spend more—ultimately it will be this that will create a perfect storm as people live even longer and find that they need to rely on flawed, untenable programs.
Images by author.