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Extraordinary longevity: Individual and societal issues*
by Donald B. Louria, MD
(December 2005)

The science relating to understanding and/or modifying the aging process is moving at breakneck speed. There are multiple technologies that are being investigated, including: caloric restriction-mimicking drugs (caloric restriction in multiple species increases life spans by 30 to 300 percent); peptide hormones (derived from gene studies) that prolong life in mice; chemical agents that stimulate genes called sirtuitins that are critical in promoting increased life spans (the most promising is resveratrol, found in red wine and grape skin); genetic manipulation either promoting or interfering with specific genes; telomerase-like drugs (that can keep the ends of chromosomes long and prevent cell death); stem cells that can be used to rejuvenate or replace old tissues; and nanotechnology.

Although the experimental studies are mind boggling in their scope and accomplishments, the potential for human application, is for the future. There is, at present, no drug, herb, alternative medicine, vitamin, mineral that modifies the aging process in humans and thereby increases life spans. There are, of course, a variety of medications and other substances that treat or prevent certain diseases, but that is different from modifying the aging process itself.

Preventing and curing specific chronic diseases such as heart disease, cancer, and stroke, plus vigorous health promotion and disease prevention can increase life spans by perhaps 10 to 15 years. In contrast, understanding and preventing the aging process can potentially allow people to live 110 to 120, or more, years. There are no guarantees that extraordinary longevity can be achieved in humans, but I do guarantee that, given the amazing developments in the science of anti-aging, we will, at some time in the relatively near future, employ one or more technologies or pharmacologic agents in an attempt to interfere with the aging process. Furthermore, I believe the question increasingly is not whether life expectancy in the United States at birth will increase from the current 77 years to 100 or even 120 years, but when.

Striking increases in individual and population longevity will have profound effects. Each 10-year prolongation of life expectancy world wide will increase the eventual population of Planet Earth at stability by an estimated 1.3 billion persons. If world longevity follows the patterns that will be achieved first in the more developed countries and reaches 95 years, three decades longer then the current worldwide longevity, that would mean a further population increase of 4 billion persons. Instead of the current estimated final population at stability of about 10 billion persons, there would be 14 billion, a huge difference. Given the damage to the planet being inflicted by 6 billion people, the potential for another 8 billion people raises the issue of sustainability. Can one generation meet its needs and wants without depleting the earth’s resources to such a degree that future generations are unable to satisfy their needs and thrive? The derivative question is, when does the human crush make life miserable for most people and impossible for many other species? A marked world population increase has, potentially, a variety of undesirable effects that could far outweigh any potential benefits. These include: more huge urban centers, most with festering, unhygienic slums that promote emerging infection epidemics that can rapidly spread world wide; increased poverty and malnutrition; resource depletion that, together with ethnic, religious, and tribal animosities, leads to ferocious conflicts; population-related global warming that, in turn, could create hundreds of millions of refugees and political instability that would lead to more strife.

In the United States, there will be daunting issues as the number of old and very old people increases dramatically. Currently, there are 37 million people over age 65, and 4.5 million over age 85. By 2050, those figures will increase to 80 million over age 65 and 20 million over age 85 - and that does not include additional numbers that could result from interfering with the aging process.

The critical issue as we create large numbers of very old people relates to quality of life. Will very old people be vigorous and healthy, living full lives with many exciting activities, or will their lives be filled with boredom, inactivity, and depression? Will the body be rejuvenated, but the mind suffer deterioration? Will the mind remain clear and active even as parts of the body deteriorate? We are racing towards profound life extension with no answers to these critical questions. Then there are the intertwined issues of retirement duration, social security, pensions, health care costs and return to the labor market. At present, individuals can anticipate that 25 to 29 percent of adult life will be spent in retirement (if one retires at age 65). When life expectancy is 95 years, that percentage will rise to about 40; if average life expectancy increases further to 110 to 120 years, at least one-half an adult’s life could be spent in “retirement”. It is hard to conceive that, with that duration in retirement, businesses could afford significant pensions (which are already under siege). Similarly, it is hard to see how the social security system could survive into the next century. By 2050, there will be only two active workers for every retiree, a ratio that will get smaller with each succeeding decade and will threaten the viability of the social security system - and that is without consideration of the compounding effects of marked longevity increase.

Older people consume more health care dollars; those over age 85 use more than double the annual health care dollars used by 65 year olds. At present, 13 percent of the population is over age 65; they use more than 30 percent of health care dollars. When those over age 65 increase to 30 percent of the population, will they use 75 percent of health care dollars? That would be an impossible situation. Additionally, the older people are, the greater the likelihood they will outlive their financial resources; poverty, and near poverty rates double for those age 85 years and older compared to those ages 65 to 69. That, of course, is another quality of life issue. The retirement age will almost certainly have to be delayed until at least age 70, but many old, and even very old, people will wish to return to the labor market because of financial necessity, or for other reasons. If average life spans were to be increased to 110 to 120 years, that could result in four generations competing for the same jobs and lead to some serious inter-generational antagonisms. The inter-generational problems could well be exacerbated by the strong possibility that younger generations, in addition to their own family and personal obligations, will have to assume some financial and other responsibilities for retired parents, grandparents, and even great-grandparents.

Some suggest that there has been a decline in illness and disability among older people and they argue we will have many more older people, but they will be healthier. I believe this is largely a mirage. There has been a significant drop in disability in older people, but it is, for the most part, in the category of mild disability (called IADLs - instrumental activities of daily living, such as doing the shopping, food preparation, and housekeeping). There has been only small change in the percentage suffering from moderate to severe disability (called ADLs - activities of daily living that include ability to bathe, dress, and feed oneself, ambulate and care for self at toilet). Even if reductions in overall disability rates occur, there will be, nevertheless, many more disabled persons because of the anticipated marked growth in the over age 65 population. Thus, the numbers of older people who are frail will increase, they will utilize a large percentage of the health care dollars and will often have an unsatisfactory quality of life. If health care costs resulting from extraordinary longevity are not to become astronomical, we must make inroads on this persistent proportion of frail, disabled, and unhealthy older persons. That will be impossible unless we intervene early in the three intertwined American epidemics of overweight and obesity, diabetes, and physical inactivity. If we do not control those nagging epidemics, our efforts to reduce disability in old and very old people will hit the proverbial stone wall; hordes of fat, diabetic, sedentary people will join the ranks of the old and very old, making significant reduction in moderate to severe disability impossible. The evidence now indicates that overweight and obesity will not have much impact on deaths for those over age 65, but will result in a doubling of the percentage of persons with disabilities and reduce by half the likelihood of recovery from the disability once it has occurred. The most effective approach to these health issues, in my judgment, is regular comprehensive prevention examinations throughout adulthood with a focus on healthy behavioral change. That is not being done in the United States. Obviously, there are no guarantees that the comprehensive prevention examinations for all adults will reduce overweight and physical inactivity, and rigorous evaluation will have to be built in, but involving the health professionals is a good place to start and there is a reasonable potential for at least some success.

What then can we do to avoid what could be a societal disaster if life span increases dramatically?

A broad systems approach in thinking must be used and leverage points identified indicating where the system can be beneficially changed. We must think like futurists and draw up alternative scenarios for future decades and centuries. Combined with systems thinking, this allows for movement toward the most attractive scenario, at the same time, it is hoped, avoiding or mitigating the pitfalls and obstacles. The basics of the most attractive scenario are not difficult to imagine – old and very old people who are reasonably healthy; have sufficient and stable financial resources; have a reasonably good quality of life; and are active, involved, and productive, contributing to society.

We must debate the issues and then start making the necessary adjustments, predicating the debate both on the realization that moderate life extension (to at least average life expectancy of 90 years) will occur and on the assumption that marked life extension (to 100 to 120 years) is a distinct possibility.

There are specific actions we should either take now or consider carefully for future decades, among which are the following:

Clearly, we must create a strengthened social security system with some sort of virtually mandatory savings during working years or devise some other alternative to provide adequate financial resources for an ever-growing number of old and very old people. Whatever system is created, we will have to prepare for the time when even a strengthened social security system will have to be replaced. One imaginative idea is to provide each newborn in the United States with $2,000 a year for 18 years, a total of $36,000. Saved in a retirement account, this supposedly could provide one million dollars at retirement. If this is fully phased in and Social Security replaced, it would not only be more effective, but also less expensive. Intriguing proposals such as this deserve careful consideration. Additionally, we will have to figure out how to keep a significant percentage of old and very old people in the labor force by utilizing our communication and other technologies so that many, probably most, of them can work at home. We will also need to consider further delays in the retirement age (beyond age 70) as average life expectancy increases.

If we start to plan and act now, we have a reasonably good chance of successfully coping with our aging society. We need to have committees and commissions at national, state, and municipal levels, as well as academic institutions, focusing on the issues and on potential solutions for specific problems. If we delay and dawdle, especially with the accelerating pace of scientific advances, the likelihood of successfully coping will be markedly reduced. Achieving or at least moving reasonably effectively towards the optimal scenario will not be easy. The obstacles and pitfalls are daunting, but it can be done, at least in part, if we act vigorously and intelligently. If we do not take this path, we are likely to be dragged, willy nilly, to our demographic destiny - and, almost certainly, we will find some very unpleasant surprises when we get there.

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*Adapted from my article in the Journal of the American Geriatric Association, Volume 53, number 9 (supplement), pages S317-319. 2005.