Society

The New Old Age

Longevity is now our reality. Are we ready for it?

BY

Illustration by Mügluck


I am five years older than my mother was when she died of breast cancer, in 1982. She was sixty-five, which now seems ­merely middle aged. I don’t know what expectations she had about aging; I doubt she had any, especially after her diagnosis, but I know what mine are. A while ago, I consulted an online life-expectancy calculator, which predicted that I am going to live until I am ninety-eight. Yikes. If I cut down on wine and up my aerobics and strength training, I may become a centenarian—the fastest growing demographic in Canadian society.

Longevity is the new reality and I am in the vanguard of an emerging demographic trend. Life expectancy soared from seventy-two for men and seventy-nine for women in 1982—the year my mother died—to eighty for men and eighty-four for women in 2015. I’m not afraid of dying. The legalization of medically assisted dying means that death is losing its sting, at least for the terminally ill. What terrifies me is old age. What’s the point of longevity if I run out of money or become socially isolated because I am deaf and immobile and have outlived all my friends? Or, far worse, if I am plagued with myriad conditions that rob me of cognition and autonomy and force me to linger like last week’s leftovers because I will no longer be competent enough to request an assisted death? That boomers like me aren’t leaving this mortal coil any time soon also has costly implications for younger generations, which will have to support us in our dotage either as caregivers or with their taxes, or both.

Three years ago, we hit a tipping point: for the first time, there were more Canadians over the age of sixty-five than under fifteen—16 percent of the population, or almost 6 million people. And that massive older segment was growing four times faster than the population at large. If that trend continues, demographers predict that by 2031, the year the earliest boomers turn eighty-five, nearly one-quarter of Canadians will be sixty-five or older. Will we as a society have the medical, social, and financial resources to cope?

My blustering, swaggering cohort of more than 8 million children born between 1946 and 1965 has elbowed and barged its way through every stage of life. Lifestyle changes—less smoking, more exercise—and advances in medicine, technology, and science mean that cancer and cardiovascular illnesses, the acute killers of my mother’s generation, will become chronic diseases for many baby boomers. The downside is that we are likely to live long enough to develop diseases of the mind and brain. In 2016, there were an estimated 564,000 Canadians living with dementia; so far, there is no cure and no effective treatment. That number is expected to reach 937,000 by 2031.

But there is another scenario. Many eighty-five-year-olds are doing just fine as they hobble into their nineties and beyond. These are the lucky ones: the people who have won the genetic, geographical, and socio-economic lotteries. Besides good fortune, some of us—nobody knows how many—are learning the secrets of successful aging, either intuitively or by diligent application.

Forget bridge, crosswords, and cruises: the best and most consistent advice for a secure and healthy old age involves long-term financial planning, a capacity for independence, cardiovascular exercise, minimal consumption of sugar and alcohol, restful and brain-cleansing sleep, and stimulating activities to build up our cognitive reserves.

How much fun is that? That’s not the right question. Instead, ask yourself: Why should old age be easy? Achieving success in every other life stage—from toilet training to earning a livelihood to raising a family—requires grit, practice, stress, and flexibility. That’s why nobody wants to be young again. It was hard enough the first time. As boomers embark on old age, we need to remake the image of Freedom 55 and all the other nonsense that has been spewed about the “golden years” and learn how to forge more expansive ideas about retirement, independence, housing, and ways of living.

Retirement is a relatively new concept. German chancellor Otto von Bismarck is credited with inventing public pensions for the elderly in the 1880s. Before then, people worked till they died or until a younger generation offered them a rocking chair by the fire in the family home. The new-fangled pension was not a risky initiative, because the plan provided for ordinary citizens over the age of seventy at a time when life expectancy was around forty. Fifty years later, in the middle of the Great Depression, American president Franklin Delano Roosevelt signed the Social Security Act. It was geared to a retirement age of sixty-five; life expectancy for men was sixty. Historically, we worked until we dropped.

In Canada, the Old Age Pensions Act, providing a means-tested pension for those seventy years and older, was introduced in 1927. Life expectancy at the time was sixty-six for men and seventy-one for women. The Canadian Pension Plan was enacted in 1965. The CPP, which requires all working people aged eighteen to sixty-five to contribute a portion of their earnings to a government-administered fund, has been modified over the decades, especially after a crisis in the late 1990s when pension experts predicted that the demographic bulge represented by aging boomers could bankrupt the system for future generations. Besides the increased life expectancy and sheer number of boomers heading for retirement, the birth rate had been dropping for generations. In my mother’s era, women had an average of 3.6 children. Those days are long gone. The last time Canadian women produced an average of 2.1 children—the number needed for the population to replace itself—was 1971. Today, the fertility rate is only 1.6.

Those figures mean that the ratio of what we traditionally call retired folks to working stiffs has nearly doubled over the past forty years; economic think tank the C. D. Howe Institute estimates it will go up by an equal amount over the next forty years. That demographic imbalance, according to C. D. Howe, “puts pressure on living standards, dampens the growth of government revenue and presents challenges” to public pensions and health care—the benefits that aging boomers like me will be gobbling up with gusto.

The obvious solution is to increase immigration, because our policies favour people who are young and hard working and inclined to have children. But immigration alone is not enough, according to William Robson of C. D. Howe. He argues that we also need to work longer, by raising the normal retirement age, and balance life expectancy against immediate financial needs. (Somebody who retires at sixty-five can claim a maximum of $1,134 in CPP a month; that sum is nearly 50 percent higher for a person who retires at seventy.)

Lots of workplace pensions, where they do exist, are not as secure as they should be. The financial crisis of 2008, historically low interest rates, and overly generous extensions from regulators mean that many defined-benefits pensions are underfunded, according to a 2017 study prepared by the Canadian Centre for Policy Alternatives. It found that thirty-nine of the sixty companies listed on the S&P/TSX maintained defined-benefit pensions plans, but only nine of them were fully funded. At the same time, many of these companies have been increasing shareholder payouts substantially. “In 2016,” the authors state, “Canada’s largest companies paid out four times more to shareholders than it would have cost to fully fund their pension plans.” Without stronger regulation, these companies are gambling with the retirement savings of their employees.

Illustration by Mügluck

And that’s only if you’re lucky enough to have a pension: many of my younger friends, and those in the arts and cultural communities, never accrued a company pension plan or set aside the maximum annual contributions in a registered retirement savings plan. Those are the people I worry about—including my own grown children. My son and daughter are in their thirties. They both have jobs with benefits and are in long-term relationships, but their partners are self-employed, which means they have to choose between investing in their companies, having children, or setting aside money every month in retirement savings plans.

The good news is that the CPP is solvent: right now, it pays out 100 cents per promised dollar, says Robson. The worst prognosis is that in another twenty-five years, it might be ninety cents on the dollar, but “it won’t be zero.” And yet Wanda Morris, vice-president of advocacy for the Canadian Association of Retired Persons, warns that nobody should assume that the CPP alone will guarantee a comfortable retirement: even for those who can claim the maximum amount, it probably won’t be enough to live on. The key is planning for the future—a long one.

If you’re fortunate enough to have a stable relationship, that can also help—if only because having a spouse means you can keep an eye on each other’s decline, share expenses, split income for tax purposes, and (eventually) claim survivor benefits. After nearly fifty years, I am still married to the father of my now grown children. Blame it on a lack of imagination if you will, but the fact that my husband and I are still a couple means that we haven’t had to divide our assets or sell the family home and split the proceeds. Even so, everything depends on the volatility of the stock market, our longevity, and our cognitive and physical health. If one, or both, of us needs full-time care for a decade or so, we may outlive our money—a spectre that haunts me in the middle of the night.

Life-insurance companies and public-policy analysts keep coming up with longevity-insurance plans to mitigate our fear of being destitute in extreme old age. One proposal, called Living Income for the Elderly (its acronym is LIFE)—a voluntary, government-led, pooled risk fund—is inciting chatter on the investment pages. The scheme, devised by Bonnie-Jeanne MacDonald, the senior research fellow at Ryerson University’s National Institute on Ageing, calls for amended legislation to allow people to invest in a deferred annuity at sixty-five that would start paying out at age eighty-five. But (like the old notion of a tontine) the longevity jackpot depends on outliving the other investors: if you die before eighty-five, your contribution would be used to pay out benefits to those who live longer. And, for many people, that is the rub. So far, there isn’t a large appetite for deferred annuities, maybe because “people don’t want to look like chumps if they die and never collect anything,” notes Robson. “But what difference does it make, because they’ll be dead.”

There are worse things than being dead, as many suffering patients told me as I was researching medical assistance in dying for my book A Good Death. Being physically maintained long after their cognitive powers had been exhausted was high on their worse-than-dead list, an attitude I share. Like many of them, I aspire to membership in the Elect, not in that old religious meaning, as in chosen for salvation, but in the secular sense of a superager, people over eighty whose memories are as sharp and retentive as those of a much younger cohort.

Research on superagers is in its infancy, but Lisa Barrett, a psychology professor at Northeastern University, says that joining that exclusive group is about more than inheriting good genes or enjoying financial security: based on the available scientific evidence, a lot of it has to do with social interactions and persistent mental and physical exercise. (Doctors suggest, for example, that a cardio workout three times a week is essential if I want to guard against dementia. That’s my idea of torture.)

Lots of scientific studies, Barrett has found, show that when people engage in any kind of task that requires effort, such as solving a hard problem or remembering names of people they have just met, they experience an “unpleasant feeling.” Normally what people do, especially as they get older, is “divest themselves” of activities that make them feel that way. They stop doing the hard stuff. But “feeling bad is good for you,” Barrett tells me—not all the time but occasionally. Using exercise as an example, she says that “feeling like crap isn’t necessarily a clue that what you are doing is bad for you or that you should stop.” Rather, that’s the point when determination and tenacity come in. “On top of sleep and nutrition and exercise,” Barrett says, “we need to stay engaged socially and to keep challenging ourselves” because the tendency to disengage when it gets tough “could add to the burden of cognitive decline in an aging population.”

That doesn’t mean we can’t still have fun, but it might be a good idea to change our expectations about what we want to do in retirement—or whether to retire at all. In 2013, the Vanier Institute of the Family reported that 37 percent of Canadians who planned to work past age sixty-five said they would do so because they wanted to, not because they needed the money. That desire to stay involved is one of the reasons, along with poor financial planning and traumatic bad luck scenarios, that labour market participation of seniors has more than doubled in recent years, from 6 to 7 percent in 2000 to 14 percent in 2017.

For those who do retire, staying cognitively fit can be a challenge—and that requires learning to cultivate independence: even those of us who are in couples can’t just rely on our partners for mental engagement. Figuring out new dynamics is especially tricky in a long and compatible relationship. You already know how to finish each other’s sentences, how much spice to put in the curry, and what subjects are guaranteed to end in an argument. Once the children are grown and off the payroll, and the tyranny of dinner is nothing more than a bad memory that gets restaged at family celebrations, it is easy to cuddle up with your partner and nestle together like a couple of ancient tabbies eating takeout while bingeing on Netflix.

In the same way that we learned we can’t delay child-bearing forever, we must learn we can’t put off preparing for old age. We need to train for it, and that means learning to live in a new, interconnected way by expanding our circles to include people of different ages, interests, and backgrounds. When my mother-in-law, who lived on the other side of the country, was widowed at ninety, she adamantly refused to move into a retirement home. “Too full of old people,” she complained. Instead, she hired students from the local university as companions to visit with her two evenings a week, and she started using the services of the elder centre she had helped found two decades earlier.

About twenty years ago, a woman I know, in expressing condolences about a mutual friend, said to me, “At least I was widowed at fifty. I had time to learn how to live alone.” I took that message to heart and began paying better attention to my female friends. I joined a Sunday morning walking group of women with whom I was loosely connected through work or other relationships. None of us are BFFs, but over the years, we have shown the strength of weak ties, in the words of sociologist Mark Granovetter, as our network of walkers has experienced disease, death, divorce, and the joyous burden of grandchildren.

Last year, four of us signed up to walk a portion of the Camino de Santiago, a network of pilgrimage routes in the Iberian Peninsula—from Ponte de Lima, Portugal, to Santiago de Compostela in Galicia, Spain, some 160 kilometres in twelve days. I had no fancy transformational goals in mind other than the obvious: learning whether I had the stamina to make it to the end. And if I didn’t do it now, when would I ever attempt such a trek again? Several pilgrims in our sixteen-member group were on the shady side of seventy, which was encouraging. There was only one couple. The rest were women: a few divorcees, at least one widow, and plenty of women like me whose husbands had responded to the notion of walking the Camino with some variation of “are you kidding?”

I shouldn’t have been surprised by the paucity of men. The tour organizer, Ann Kirkland of Classical Pursuits, told me later that men have never numbered more than a third of the participants on any of the trips she has organized. She directed me to an article in Forbes magazine that reported that “women ranging in age between twenty and seventy comprise three-quarters of those taking nature, adventure, or cultural trips,” according to the Travel Industry Association of America. That’s a small but telling example of why women seem better prepared for old age than men: we are willing to take on new experiences.

Divorce has greyed or silvered along with the aging population. According to a 2014 Statistics Canada report, in 2011, “twelve percent of the population aged 65 and over was divorced or separated—three times the proportion in 1981.” Among people aged fifty-five to sixty-four, the figure jumped from 6 percent to 20 percent. “Women largely instigate grey divorce, and men are surprised,” says Nora Spinks, CEO of the Vanier Institute, contrasting it with “year five of marriage, when men tend to instigate and women are surprised.”

Many of the women who want out of marriage, says Spinks, “are turning sixty, and they have been with the same person for thirty years, and they are saying to themselves, ‘I’ve got another twenty years to go, and I don’t want to do this anymore.’” Many of them have looked after their kids and then their parents, and they see another wave of caregiving waiting for them on the other side of the bed. In the past, women would just “suck it up,” but baby boom women are different. “A lot of them have their own wealth, their own pensions, and their independence,” explains Spinks.

Even for women who appear to be financially secure, divorce or separation can have a “dramatic impact on family finances,” Spinks says. For women, this can be “the quickest way to poverty,” especially as they age, because they traditionally have lower pensions: they have been paid less than men, interrupted careers to raise children, or opted for part-time or lower-paying work to care for older family members. Among women aged seventy-eight to eighty, divorce or separation results in a 17 percent drop in family income compared to the levels they were enjoying when they were fifty-four to fifty-six, according to a 2012 Vanier Institute report. The study ends with the warning that “this trend will likely take on a deeper hue over time.”

Canada’s population is not the only thing that is aging. Our vaunted universal health care system was born in Saskatchewan in 1947, when Premier Tommy Douglas introduced a comprehensive, province-wide public insurance plan for hospital services—the first such program in North America. After decades of protest, political will, and public-policy innovations, the plan was passed into federal law in 1966.

Medicare suits acute illnesses in a relatively young and healthy population, but it cannot meet the escalating needs of an aging cohort. The plan does not cover prescription drugs dispensed by pharmacies, dental care (other than surgical procedures in hospital), psychotherapy and physiotherapy by non-physicians, or home and community care for those who can no longer manage on their own. The bulk of these services is either paid for by private- or company-insurance schemes, out of pocket—or declined by impoverished patients who can’t afford them.

The second-largest component of health care spending in Canada, according to a major report called Pharmacare 2020: The Future of Drug Coverage in Canada, is on drugs—a cost that is particularly telling when you consider that many Canadians don’t have any drug coverage. We filled more than 500 million prescriptions at retail pharmacies in 2015, at a cost of about $30 billion, according to that report. That means that Canadians “pay out of pocket for $6 billion in prescriptions, or 22 percent of all prescription drug costs.” A 2015 Angus Reid study found that 23 percent of respondents reported that they, or another member of their household, had not taken prescribed drugs because of the cost. And seniors are “estimated to account for roughly 40% of all spending on prescribed drugs,” according to the Canadian Institute for Health Information.

Canada is the only developed country with a universal health plan that does not include prescription drugs. Critics, politicians, practitioners, and patients have been calling for them to be included in medicare since the 1960s. The Pharmacare 2020 report, which has been endorsed by more than 100 academics and clinical experts in Canada, argued that drug coverage in Canada is “an incomplete and uncoordinated patchwork of public and private drug plans” that leaves many patients with little or no coverage. Instead of provincial and territorial health services working together on bulk purchasing, Canadians buy drugs piecemeal. That’s one of the main reasons we pay about 41 percent more for prescription drugs than the median expenditure in the Organization for Economic Co-operation and Development.

A national pharmacare program would enable more than 2 million Canadians to fill prescriptions that they otherwise would not be able to afford, the Pharmacare 2020 report says, and save the private sector up to $10 billion while costing the government about $1 billion to administer. The beneficiaries would include more than 500,000 older Canadians, who “despite having some public drug coverage, face much higher prescription costs than older people in comparable countries.”

In her book, Better Now: Six Big Ideas to Improve Health Care for All Canadians, Danielle Martin (no relation), a family doctor and a vice-president at Women’s College Hospital in Toronto, says seniors face a double problem of being unable to afford their medication and being overmedicated in “huge numbers.” Instead of just numbly accepting a prescription, she suggests we ask pertinent questions such as: Do the side effects outweigh the benefits? An estimated one in six hospitalizations in Canada could be prevented, according to research done for Pharmacare 2020, if prescription drugs were used more appropriately. “If you look at the way our system is set up,” says Martin, “it is deeply hospital-centric—all roads lead to the emergency department.” In countries where pharmacare is done well, she says, safeguards protect people from being harmed by inappropriate or unnecessary prescribing.

Public demand for a national pharmacare program is high. In a May 2017 Environics poll, 91 percent of respondents said they strongly or somewhat strongly supported the implementation of a national pharmacare program. After nearly sixty years of Royal Commissions, the federal government announced in its 2018 budget that it is setting up an advisory council to assess the possibility of implementing a national pharmacare plan. Eric Hoskins, the medical doctor and former Ontario health minister who oversaw the introduction of a pharmacare plan in his home province for people over sixty-five and under twenty-five—a plan that has already been scaled back by Ontario’s new PC government—will be in charge. No money has been promised, so it may well go the way of so many other good intentions in the past.

Grandparents, according to the Vanier Institute, have grown healthier over the past thirty years. We are living longer, and there are more of us; 41 percent of us were seniors in 1985, up to 53 percent in 2011. If we are healthy, we are in a good position to spend a couple of decades interacting with our grandchildren and helping them (and their parents) cope with the stresses of daily life. I want to see my grandchildren grow up and to engage with them as adults who share the same imperfect but fascinating world. And when my children thank me for giving them some respite from the “fearsome threesome,” I point out (probably more often that necessary) that “my turn will come.”

I know if—and more likely when—it does, they will be there for me. The Health Council of Canada reported in 2012 that family members provide between 70 and 75 percent of all home care received by seniors. And many seniors don’t even have that option.

Being dependent on my family is not the way I want to end my days. Like most people, I want to live in the place I call home, surrounded by the treasures I have accumulated, and with easy access to my familiar neighbourhood haunts, but I know if I wait too long to rationalize my living arrangements, I could end up with other people making choices for me. And those choices may be in total opposition to the way I want to live. “We want autonomy for ourselves and safety for those we love,” the American assisted-living guru Keren Brown Wilson says, as recounted in Atul Gawande’s book Being Mortal: Medicine and What Matters in the End. Exactly. It reminds me of a feisty, energetic auntie of mine, who was moved into a retirement home in her nineties. She was well cared for, but she was bored to distraction, and the home itself was in an awkward location for drop-in visits by friends and family.

More than three-quarters of Canadians have a disability by the time they are eighty-five, a proportion that rises steadily with each birthday. Telemedicine as well as regular home visits by nurse practitioners and social workers could help us manage in our own homes perhaps until the end, if we had a comprehensive, coordinated system of supporting seniors in place as they age. Alas, home care, another glaring omission from medicare, is a hodgepodge of inadequate and costly programs, none of which are universal, accessible, or portable from one province to another; these programs often kick in only after diagnosis with a terminal disease.

Frequently, the elderly are admitted to hospital not because they are desperately ill but because there aren’t enough medical and social supports to care for them at home or available spots for them in long-term care residences. Through no fault of their own, these patients—designated ALC (for alternate level of care) and often dismissively referred to as “bed blockers”—are contributing to wait times for patients requiring urgent care.

The emergency department can also be the next-to-last stop on an end-of-life journey. Danielle Martin describes a familiar scenario in which you take an elderly loved one to the ER, they are admitted for three days to “get tuned up” and are sent home, and three weeks later, they are back in the ER and on the ward. “It is expensive, and it is a horrible way to live. As soon as they get into hospital,” she continues, “they fall and break their hip or they get an infection and they become frail and they are never able to go home, so they end up in long-term care.”

As of April 2016, ALC patients were taking up 14 percent of hospital beds in Ontario. (A 2010 analysis found similar rates across the country.) Median wait times to move into long-term care in Ontario in 2014/15 was sixty-eight days for hospital patients and ninety-four days for those living at home, according to the Canadian Medical Association. Calculate the price of keeping somebody in hospital who would be better cared for in the community, either at home or in a long-term residence, and you can see why health care expenditures are soaring. It costs approximately $842 per day for a hospital bed compared to $126 for a long-term bed and $42 for care at home, the CMA has found.

There are approximately 255,000 long-term care beds in Canada. That isn’t nearly enough to meet the demographic surge of elderly Canadians who will require care. The Conference Board of Canada estimates that we will need an average of 10,500 new beds per year—a total of 199,000 new beds by 2035, at a cost of $63.7 billion.

These care gaps, along with excessive wait times for non-emergency treatment and a clunky arrangement whereby most physicians are independent contractors rather than an integral component of health care delivery, have downgraded our system internationally. Our position is now ninth—ahead only of France and the United States—on the Commonwealth Fund’s analysis of eleven health care systems in the developed world. Despite our dismal placement, the report noted that Canada spent the equivalent of 10 percent of its gross domestic product on health care in 2014, which was more than higher-ranked countries Norway, Australia, and the United Kingdom.

As a country, Martin says, we need a national vision that takes an older patient’s spiritual, social, emotional, and mental well-being into account. Our system must become more integrated, because so much of what provides quality of life for older people is not in the “cure and fix” area but the “manage and maximize quality of life” category.

Hers is not a solitary voice. Both the Canadian Medical Association and the Canadian Association of Retired Persons are calling on the government to develop a national seniors’ strategy that would include housing, social programs, and caregiver supports. The demand for residential care will increase significantly over the next several years, the CMA says, citing an analysis that residential-care capacity will need to double in the next two decades. This demand will require a transformation in the spectrum of care available to seniors.

That’s why CARP “is advocating for greater financial support, particularly for low-income caregivers and recipients, significant investments in respite care, and home care to help alleviate the burden on caregivers,” Wanda Morris says. It is significantly cheaper for people with moderate needs to be cared for at home rather than in a long-term care facility or hospital. Those savings help our health care dollars go further, but, says Morris, “much of the burden is taken up by family members and informal caregivers, and it is simply not acceptable that caregivers should sacrifice their mental and physical health because they don’t receive appropriate support.” Caregivers save the Canadian health care system $26 billion every year, and “these contributions are taking a significant toll on our caregivers both physically and mentally.”

The federal government committed in its 2017 budget to spending $11 billion over ten years on home care, palliative care, and mental health care. Figuring out how to use that money to enable us to live as independently as possible—without wearing out our loved ones—is the challenge.

Being warehoused in sterile institutions, as many of our elders now are, is not going to suffice for baby boomers, possibly the largest, most demanding, and politically active cohort ever. As a generation, we fought for reproductive rights; sexual equality; protections against racial, gender, and religious discrimination; and the right to die. Our hair may be grey and our skin wrinkled, but we can still be a force for change, especially at the ballot box.

Boomers have grabbed so much of life’s riches and adventures. Now it is time for us to give back: not only for ourselves but for the sakes of our children and the generations yet to come. Fixing pharmacare and home care could be our final and most significant campaign—if we are up for one last struggle.

Sandra Martin is a contributor to the Globe and Mail. Her most recent book is A Good Death: Making the Most of Our Final Choices.

Mügluck is an award-winning illustrator who lives in Montreal. Her work has appeared in the New York Times and Air France Magazine.




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