Aging in America: Survive or Thrive

ANNOUNCER: America is aging.

Is the nation ready for this growing older population?

PAUL: The growth of homelessness with older adults is staggering.

DR. BUTLER: Doctors don't get paid for keeping you healthy.

DR. CASSEL: Our nation does spend a lot of money on medical care for older people, but we don't spend it on the right things.

AMY: Caregivers are really the unsung hero of the dementia journey.

BRENDA: I will always love him, but he won't be the man that I married DANIEL: The nursing home system in five to 10 years from now is completely unsustainable.

ANNOUNCER: What will this new longevity bring?

KEN: Is it a challenge or an opportunity?

ANNOUNCER: Aging in America, Survive or Thrive.

MARTIN: For much of human history, life has been short.

Our early ancestors lived barely long enough to reproduce themselves.

The invention of tools and the development of agriculture increased the prospects for survival.

Yet 2,000 years ago, at the height of Imperial Rome, most Romans didn't live past age 25.

Life continued to be brief and fragile through the Middle Ages.

The Industrial Revolution that began at the middle of the 18th century increased wealth and longevity for a majority of people.

At the same time, a revolution in medical science, the germ theory of disease, new surgical practices and life-saving pharmaceuticals began to transform medical care.

Subsequent improvements in public health also lengthened life.

Still at the beginning of the 20th century, average life expectancy in the U.S. was just over 47 years.

Today, the average person in the United States can expect to live to the age of 77, a greater gain in life expectancy in the last 100 years than in the preceding 5,000 years.

While this new longevity is to be celebrated, the question remains, are America's institutions and social policies prepared for the rapidly increasing older population?

He was a visionary, a pioneer, and the leader of a movement.

Dr. Robert N. Butler did more to change our perception and understanding of older adults than any other American.

DR. HODES: I think what made Dr. Butler unique was the combination of vision and the ability to communicate and act upon that vision.

DR. CASSEL: Bob Butler has a really important legacy in this country and globally.

MARTIN: A psychiatrist, a philosopher and activist, Dr. Butler established an entirely new field of medicine creating the nation's first department of geriatrics at a medical school.

DANIEL: Bob was erudite.

He was brilliant.

He was compassionate, and he was scientific.

FERNANDO: He helped to make aging, gerontology, geriatrics trendy, and if I can dare say, sexy.

MARTIN: Perhaps no one before him nor since, has grasped the challenges as well as the promise of an aging population.

KEN: He was a big thinker and he thought about things before anybody else saw them.

DR. BUTLER: We have to keep in mind that today's children will one day be older people, and today's older people were once children.

There's a unity and a continuity to life, which we must bear in mind.

And when we are negative towards old age, we're slashing our own tires.

This is really our own future we're talking about.

MARTIN: Half a century ago, Dr. Butler wrote a Pulitzer Prize-winning book, "Why Survive?

Being Old in America."

This landmark work was a call to action to address the issues of older Americans.

50 years later, how far has our nation progressed in its treatment of our longest lived citizens?

When Dr. Butler wrote, "Why Survive?"

there were less than 23 million Americans over the age of 65.

Today, there are over 55 million, and yet the issues he identified, including our attitudes towards aging itself still persist.

DR. BUTLER: A number of years ago in 1967, 68, I began to use the term, "ageism" in America.

By ageism, I meant age discrimination.

And I adopted it as analogous to other terms that related to prejudice in America, racism and sexism.

So it seemed valuable to me to introduce a new term, which is now widely used.

KEN: So Bob coined this notion of ageism, which has gotten popular, a lot of people are talking about it today, but it was Bob Butler that put it on the map, put it out in the world, saying that it was a kind of a prejudice that may be kind of baked into people's thinking and their feelings and their language and the way they viewed the value of people.

MARIE: You know, there's this thing called, age, and it sucks.

(laughs) (people singing "Happy birthday") (people cheering) FERNANDO: We can still be 80 years of age and do things that maybe we thought we could only do when we were 60 years of age.

But inevitably, health issues, chronic conditions, mobility limitations, these things are part of the natural evolution.

How do we keep from stereotyping persons that happen to be older, have a walker, they're in a wheelchair, they're using assistive devices.

How can we get the public at large not to fear growing older with a limitation?

MARTIN: One of the most prevalent and pernicious forms of ageism can be found in the commercials and advertisements that flood our screens.

WOMAN: I'm already on Medicare.

Where's my additional benefits?

MARTIN: Wacky, older adults have been an easy way to get a cheap laugh.

Day, me say day, me say day, me say day-o I'm 85 and I wanna go home MARTIN: Another common message found in current commercials is that looking older must be avoided at all costs.

ELLEN: Hey, wrinkle face.

That's what people could say, if you're still using a liquid foundation that can settle into your lines and wrinkles and make you look older like an apricot or a prune.

And I like both.

I just don't wanna look like one.

(elevator dings) MARTIN: One of the most significant forms of ageism occurs in the workplace.

DR. CASSEL: Whenever I'm asked by a search firm to make a suggestion for somebody for a major leadership role, or to serve on a board, the first thing, we want a young dynamic person.

And those two words go together, young and dynamic.

They never say, we want an older, more experienced, dynamic person.

And why those three words don't go together, that's ageism.

JO ANN: You know, I think the damage of ageism is certainly losing the value and the wisdom that older people bring into the workplace.

The experience of just their work history and working alongside younger generations who are skilled in the use of technology, I think is a great thing.

WOMAN: I was working and casting on a show that I absolutely loved, and I was let go.

So here I was 56 and I was experiencing ageism in the industry.

I didn't know if I'd ever work again.

KEN: In some ways, the worst form of ageism is we assume that because you're 65 or 70, you have nothing left to give, you're done.

WOMAN: Now I'm a casting producer in digital ad agency.

Dan, I want you to do that line again.

This is the first time I feel like I'm actually valued for all of my experience.

FERNANDO: One of the great benefits of extended lifespan, and I'm 75 years of age, I'm really starting to understand at this ripe old age, is that we can have new roles, new roles, to speak loudly for those things that are over the horizon.

Just as Robert Butler was doing 50 years ago when he looked over the horizon and realized that ageism was keeping us from being the best that we could be.

DR. BUTLER: When I first began to speak and write about the problems of older people, I would often be asked, "How did I ever get interested in aging?"

This question would be expressed in tones of some concern, like was there something wrong with me?

And that concern clearly derived from my childhood.

(people talking indistinctively) CHRISTINE: So this is Daddy when he was in elementary school.

CYNTHIA: Isn't it funny how we all call him Daddy?

CHRISTINE: Yeah.

DR. BUTLER: I was raised from my infancy by my grandparents, this was because my father and mother separated.

My father essentially deserted me.

My mother, she was part of the theater and struggled, when I was 11 months old, she asked her parents to take care of me.

ALEXANDRA: His grandfather died.

CHRISTINE: The loss.

ALEXANDRA: When he's six years old.

CYNTHIA: His mother's gone.

ALEXANDRA: Who his mom is working in the city.

His grandfather dies.

No one tells him that he died.

DR. BUTLER: My grandfather had been with me, but he was gone.

I was not to see him again, he was dead.

Supposing someone had been able to prolong the life of my grandfather, couldn't there have been better medicine?

I decided that I would grow up to be a doctor.

CHRISTINE: Dad's affinity was due to three important people in his childhood.

His grandfather, who he suddenly lost and was traumatized by the loss, his grandmother, who saw him through all the crazy tragic events during the depression in his childhood.

And Dr. Rose, who was the community physician who helped him when he was sick with Scarlet Fever, and he was really, really sick.

DR. BUTLER: We lived in rooming- type houses, my grandmother and I, and eventually moved into a hotel, which was burned out in the middle of the night to the ground.

CHRISTINE: And when their welfare hotel burned down, she just kept on trucking.

It was the two of them against the world.

ALEXANDRA: Yeah.

CYNTHIA: For a while, he lived on the porch of a neighbor, he and his grandmother.

So, you know, the poverty, you know, it impacted his whole life in terms of his sensitivity to poverty.

I wish somebody Would place a dollar in my hand DR. BUTLER: I saw something certainly of what poverty and housing problems, illness and loneliness can be for older people.

What I found too, the capacity for triumph in my grandmother who reared me, who survived despite odds, that were almost overwhelming.

JASMINE: It's interesting how one's access to financial resources can affect their lifespan.

We look at New York, for example, what we see is between downtown Manhattan and East Harlem, which is about a 20-minute sub ride.

The life expectancy in downtown Manhattan is 85 years old, down in East Harlem, 76 years old, a nine-year difference, which equates to six months difference in life expectancy between each one minute of that subway ride.

Why is there such a difference in life expectancy?

And it's a different resource that these locations have.

So if we look at East Harlem, there's no coffee shops, there's no parks, there's nothing.

But if I were to go downtown Manhattan, there's walkable neighborhoods.

Additional things that are important with regards to one's ability to live well and age well, include pharmacies to be able to access medications, to be able to access health information.

MARTIN: More than 17 million Americans age 65 or older are economically insecure.

PAUL: The growth of homelessness with older adults is staggering.

I've been doing this 30 years, and each year, we are seeing more and more older adults becoming homeless.

Something bad happens.

The loss of a job, an illness, fixed income, rent goes up.

MARTIN: For the economically insecure older person, misfortune or unexpected adversity can dramatically alter their lives.

(engine rumbles) CONNIE: So in this time that people were really amazed about how my resilience and bounce back, but it's like no one ever asked my story from the start.

My mother was brutally murdered when I was eight years old.

My mother was killed by my father.

Everything happened really fast.

The home I knew as home is no more.

I'm sent away to strangers, no contact from my mother or dad's side of family.

So I had to con- figure everything out as a child on my own.

So I went and got education in nursing.

So life is good, everything's going well, have a good savings, but this thing called cancer comes and takes it all.

There's no such thing as personal savings when you're a cancer patient, because it leaves you depleted with nothing, emotionally, financially, physically drained.

And my attitude is just keep pushing, keep pushing, keep pushing.

And I know I need a secure place over my head, but it wasn't working out.

I'm not gonna be out here with them.

I'm not one of them.

People are gonna help me.

People are gonna come through.

It didn't happen.

So I rented the U-Haul.

I was good, I was okay.

And it turned out my living in this van 11 months, but it was pretty dangerous because of vulnerability of a woman being on the street.

I consider this part of the journey, the van, as a healing.

A healing and recovery for the broken little girl, being at my lowest, being beat down.

What am I gonna do?

I applied for every kind of service.

But then there's this agency called, Serving Seniors.

They came in like a knight in shining armor.

And through their help, I landed a permanent place in under two months.

That sense of stability, the privacy, the security is everything.

I'm grateful.

I'm grateful for clean running water.

Hell, I have a lot of health issues.

So me going to the bathroom, having a private bathroom is everything.

Why is it a fight to give people their basic humanitarian needs?

PAUL: If there had been an intervention of somebody paying a couple months worth of rent, her homelessness would've been prevented in the first place.

MARTIN: Serving Seniors is a nonprofit organization that addresses this challenge on a local level.

Based in San Diego, their mission is helping older adults in poverty.

Meals are their core service and they provide one and a half million meals annually at their senior centers and by home delivery.

PAUL: Dignity is really the heart of what we do.

And so we provide an array of services.

Our approach is really holistic.

We're looking at the whole person.

What does he or she need to live a healthy and fulfilling life?

What we need to do for older adults that are financially insecure is one of two things.

We either need to get them more income, or we need to reduce their costs, their expenses.

As a society, we have to step in or face the real possibility of more and more older adults ending up on the street.

And if you are someone who looks at it just from a dollars and cents standpoint, much cheaper to intervene at the front end with a small subsidy than the cost of somebody being on the street.

When you factor in the police, fire, paramedics, emergency room, hospitals, criminal justice, all of the other supports that go into it, it's about $35,000 a year.

Or you can subsidize somebody for $500 a month on their rent, keep them housed for about $6,000.

So the question is, where do you wanna spend your money?

And the added bonuses, you do something that's good from a human perspective because you keep people off the street and they avoid all the trauma that goes from you know, sleeping on the sidewalk.

(sirens wailing) DR. BUTLER: Let's be frank, doctors don't get paid for keeping you healthy.

Hospitals don't get paid for keeping you healthy.

The disincentives are powerful.

It's really when you're sick that you make money as a doctor and as a hospital.

MARTIN: The problem for older people is that America's healthcare system was designed for the acute care needs of the young, rather than the often more complex chronic diseases of older adults.

DR. CASSEL: Back in the '70s, there was no specialty of geriatric medicine.

One of the main influences for me was reading Robert Butler's book, "Why Survive?"

It was one of the few places that really pulled together, kind of what I was seeing as a young physician and did it in a very compelling way.

MARTIN: In 1982, Dr. Butler founded the first department of Geriatrics in a U.S. medical school at Mount Sinai in New York City.

DR. CASSEL: Sadly, the field of geriatrics has never really taken off the way Bob Butler envisioned that it would and many of us hoped that it would.

DR. WALTER: There's less than 7,000 geriatricians in the U.S. right now.

I mean, contrast that with over 60,000 pediatricians, you know, it doesn't match up with the whole population aging.

Our health systems have not prepared for an aging population and the issues that come along.

MARTIN: The division of geriatrics at the University of California at San Francisco has developed innovative approaches to address these challenges.

DR. WALTER: We currently do not have enough geriatricians to take care of all the older people in this country, right?

So we absolutely have to train other disciplines and specialties the basic principles of geriatrics.

DR. CASSEL: What's really needed is an interdisciplinary team, we need nursing, we need social work, we need pharmacy, we need occupational and physical therapy.

And together, that can really form a much more effective and cost-effective team.

MARTIN: One of UCSF's innovations is an emergency department that is expressly designed to serve older patients.

DR. WALTER: So in terms of the geriatrics emergency department, we actually call it, our age-friendly emergency department.

And how it works is, well again, it was because people would come in, especially folks who have dementia or have other complex medical illnesses, and they were not getting the care they needed in the emergency department.

DR. DEGESYS: An age-friendly emergency department is a state of mind, not a place.

If you think about coming to an emergency department, nobody likes being there, nobody wants to be there.

It's really somebody's worst day.

You need help getting him on the bed.

And it's even harder for older adults who have impairments with hearing or vision, or they don't have their caregiver with them.

We'll help you, we'll help you.

What makes age-friendly emergency departments different is that they have distinct protocols and policies to care for these vulnerable patients in a completely different way.

So I'm gonna have Anna, our nurse practitioner, come talk to you.

Okay?

MR. WILLIAMS: Okay.

(machine beeping) MARY-ANNE: I'm Mary-Anne, one of the social workers with the AFED team here at UCSF.

ANNA: Hi Mr. Williams.

My name's Anna, I'm a nurse practitioner with the age-friendly team here.

Do you live with anyone at home?

MR. WILLIAMS: Temporarily.

Not.

ANNA: Okay.

Any depression?

MR. WILLIAMS: Just recently since.

MARY-ANNE: Are you up for a quick cognitive screen?

All right, so I'm gonna give you three words.

Okay, and I'll ask you to remember them and then I'll ask you them back in a couple of minutes.

So the three words are banana, sunrise, and chair.

And then can you go ahead and put the numbers of the clock here the way you feel they should be.

All right, and now can you set the hands of the clock to 11:10.

Thank you.

And are you able to recall any of the three words I gave you a couple of minutes ago?

MR. WILLIAMS: Banana, sunrise, I think it was chair.

ANNA: Yep, that's right.

Thank you.

CLAIRE: Hi, Mr. Williams.

My name is Claire, and I'm the pharmacist with the age-friendly emergency department service.

I'm here to talk to you today about the medications that you were taking prior to coming here.

Is this a okay time to do so?

MR. WILLIAMS: Yes.

CLAIRE: Okay.

DR. DEGESYS: We are a unique age-friendly emergency department because we have a full-time pharmacist, a full-time social worker, and a full-time nurse practitioner, or an advanced practice provider that work as a team to assess our geriatric patients.

MARY-ANNE: He seems pretty isolated living home alone, and he does have some memory concerns.

So although his overall mini-cog was within the normal limits, I think it would be good to get some more neurocognitive evaluation.

CLAIRE: During the interview also, I learned that he sometimes will self-medicate with an extra quarter of a tab.

It sounds like maybe, his doctor's not aware of that.

So I think that's another important thing we can kind of talk to him about.

DR. DEGESYS: So our approach in our age-friendly emergency department is really holistic so that we're not just taking care of the medical issues, but we're taking care of the patient as a whole.

I hope that other emergency departments will follow suit and we'll have more and more emergency departments improving the care that older adults, especially those with cognitive impairment get in emergency departments.

DR. WALTER: So age-friendly health systems, really a great way to say what geriatrics is and what we do and how we help people.

So it has the four Ms.

It's about what matters.

So what matters is one of the Ms.

Medications.

Mentation, which is helping people think better, right?

Not to give medications that cause confusion.

And mobility.

So our house calls program is our flagship program.

It's our oldest program here at UCSF.

Seeing people in their home, I think you can address a lot more issues than you can if they're just coming in for a 15-minute appointment to the outpatient clinic, it's really hard for them to get in.

So they end up using the emergency department for their care instead of primary care.

Care at home is also more cost-effective.

They've shown that one emergency department visit is the same cost as 10 house calls.

You'll get a lot more stuff done in those 10 house calls than you will for that one emergency department visit.

DR. BAILEY: I think I picked geriatrics as my specialty because I really enjoy the connection I make with my patients and their loved ones.

I find that for older patients, meaning matters more than just their diagnoses.

And that's why I went into medicine, particularly working in the house calls.

That was the point where I was like, "Oh yeah, this is what I was meant to do."

(footsteps) Hi Sha'Nice.

SHA'NICE: How you doing?

DR. BAILEY: Oh good.

Oh, good to see you.

SHA'NICE: Good to see you too.

Come on in.

DR. BAILEY: How you doing this morning?

MABEL: Good.

DR. BAILEY: Yeah, you look beautiful.

MABEL: As always, you know.

(both laughing) DR. BAILEY: I was looking at the chart and I read about the wound.

How's that going?

How's it healing up?

MABEL: I don't know.

It bothers me, but like I told the doctor, I'm not cutting no more.

Ain't not going cut on me no more.

Just I'll die with whatever I have.

I'm just going to die with it because I can't go through that no more.

I'm too old to go through that again.

DR. BAILEY: So being in the patient's home, I do feel like I have a better understanding of who they are.

Is it frustrating taking this many medications or are you okay with it?

MABEL: Oh, it's okay.

DR. BAILEY: I have to say the biggest thing is seeing their loved ones.

That element, I think is the one that I take home with me.

What that day-to-day, minute-to-minute, hour-to-hour caretaking actually looks like.

MABEL: My eyesight's going, my hearing is going.

It just... DR. BAILEY: Yeah, Mabel, we've talked about this, that you've outlived a lot of your friends and family.

MABEL: I know.

All my friends are gone, you know just... but God's keeping me here for a reason.

DR. BAILEY: And I think Sha'Nice is probably a part of the reason you're still here.

MABEL: I don't know what I would do without her, I don't know what I would do without my granddaughter.

SHA'NICE: She's taking care of, you know, all my life so it's only right that I be here and I take care of her.

DR. BAILEY: That's right.

Oh, you crying?

Oh, Mabel, let me rub your hand.

You're so sweet.

So Mabel, it's been such a privilege to be able to come see you at home.

MABEL: I know, thank you, thank you, thank you, thank you.

DR. BAILEY: I do believe that the connection is a part of the therapy.

The pharmaceuticals, the devices, those of course are important, but really, it's the human connection, I think that takes it from curing to healing.

That's why I was called to do this work.

SHA'NICE: Bye Dr. Batley, it was good seeing you.

DR. BAILEY: I'll see you guys before the holidays.

DR. WALTER: I do think healthcare is a much broader concept than medical care.

Healthcare is about bringing not just the medical issues that people have, but also addressing the social issues, whether that's caregiver support, helping people take medications.

I mean, there's so many support... helping people with loneliness, social isolation.

So bringing the medical and the social together is, I think what is good healthcare.

DR. CASSEL: Our government and our nation as a whole does spend a lot of money on medical care for older people, but we don't spend it on the right things.

I think with the money that we spend, we could actually get a lot more value for the money we spend, if we spend it differently.

(children playing) (school bell rings) (children playing) DR. BUTLER: Alzheimer's disease, painful, devastating disease.

It accounts for half of the people in nursing homes.

If we made a major commitment of research, we could bring that to an end.

We used to think that senility was the natural outcome of aging.

Now, we know that's not so.

DR. CASSEL: Bob Butler, made... one of his many major contributions was in getting rid of the term senility, saying, cognitive impairment with aging is a medical condition, it needs more research.

That's big part of why they created the National Institute on Aging.

MARTIN: In 1974, Dr. Butler became the founding director of the NIA.

50 years later, this government agency with an annual budget of more than $4 billion is currently the hub for cutting-edge research on Alzheimer's disease.

DR. HODES: When Bob Butler began his tenure as director of the newly established National Institute on Aging, Alzheimer's disease was a clinical diagnosis based on impression.

People at older age who had decreased memory, decreased executive ability, the ability to do mental manipulations, if you will, but important to note, the diagnosis could be made, at that point was made only after death by looking at the brain's individuals affected.

So when he very insightfully made this a priority of the institute, it was on the basis of very little understanding of the underlying biology, but a profound understanding of the importance of uncovering it.

MARTIN: The NIA Center for Alzheimer's and Related Dementias or CARD enables scientists from different disciplines to collaborate on research to prevent and improve treatments for these diseases.

DR. HODES: One important aspect of understanding Alzheimer's disease is the genetics of disease.

And the way this works is that scientists are able now to look at the genome, the whole structure of all of our DNA, and compare the DNA of people who do have Alzheimer's disease with those who don't.

KIMBERLEY: The main aim is that, you know, we've done a huge amount so far of understanding the genetics, but there's still lots to learn, especially, you know, identifying new mutations and new genes.

So we're hoping that we can identify these mutations and that could lead to the development of new therapeutic targets and eventually, drugs.

DAN: Most academic labs worldwide tend to study a single gene at a time, maybe a handful of genes, but most labs just don't have the resources that we do that actually allow us to massively scale up our research.

And we are actually able to study dozens and even hundreds of disease-causing gene mutations at the same time.

We want to know at the earliest stages of disease what is going on in the cell so that we can nip it in the bud and just try and fix it as early as possible.

DR. HODES: The reason for optimism is the pace at which this discovery occurs.

Genetics, stem cells, differentiation, all of this is so rapid that the explosion is bound to be translated into meaningful clinical outcomes in the years to come.

DR. CASSEL: Because of what Bob Butler started, there is now a huge emphasis on finding a treatment, understanding the underlying causes of Alzheimer's disease, and this is really important and needs to continue to be supported.

But sometimes in the process of all the attention and the funding that goes towards finding the cure, we forget about the process of caring for the millions of people who are experiencing this illness.

So what I'd like to see is an equal amount of attention to shaping the healthcare system for better care for the people who have Alzheimer's disease and their caregivers.

(car engine rumbling) AMY: So in Southeastern Wyoming where I work, I am the only dementia care specialist providing comprehensive dementia care to patients and families in the entire state.

This is a real problem.

There are so many patients, an estimated 10,000 families in Wyoming with dementia, and we don't have the type of support or access that families need.

I started working with Brenda and Michael about a year and a half ago.

They enrolled in our dementia care program.

BRENDA: So we are from Midlothian, which is right about here in Texas.

I first noticed that something wasn't right when we first moved up here to Wyoming from Texas.

Up here in Wyoming, he was in a totally new environment and couldn't pull back or rely on his memory.

Another sign that I saw, and I didn't recognize it at first, is he was somewhat irritable and Michael's not that kind of a person or has never been that kind of a person.

He's always been really happy and pleasant, I really didn't know what was going on with him at all and that was painful because it wasn't him and I didn't understand why it was happening.

MICHAEL: In my mind's eye, I don't think there's anything wrong with me.

I really don't, except for the lack of a trend of thought.

And I am forgetful and that's real aggravating.

'Cause I'm sure whatever I was saying was profound.

(laughs) BRENDA: Being his caregiver does take a toll on me, it takes a toll on me mentally because I have to remember everything for me and for him as well.

It takes a toll on me physically because there are things that he can't do that I've taken over physically.

It takes a toll on me emotionally because sometimes he'll say something hurtful and I know he doesn't mean it to be mean, but it still hurts.

MICHAEL: Within the last year, I've been real angry and depressed.

Okay, it's all right.

It's all right.

Okay, come on.

BRENDA: The way I feel about it is I have sadness because I will always love him and I made the promise to take care of him in sickness and in health, but he won't be the man that I married.

And so sometimes that's hard.

Sometimes I just have to walk out of the house and go visit with the animals or something because I've gotta just take a step away.

I'm scared for him because I want him to be safe.

And with the Alzheimer's and his memory loss, I don't know that he'll always be safe, especially out here where we are and in a new environment like we are having moved up here.

(sighs) Yeah.

INTERVIEWER: When you think about the future, what do you think about?

MICHAEL: Peoples taking care of me, being a burden.

I don't wanna be burden.

AMY: You're so brave.

You're so brave.

MICHAEL: Thank you.

BRENDA: I worry that if something happened to me, what would happen to him and it is on my mind all the time.

I don't know if this is egotistical on my part, but I don't think anybody can take care of him the way I do.

AMY: Caregivers are really the unsung hero of the dementia journey, and we really need to improve our support to caregivers so that they can maintain their own sense of wellbeing and purpose in life.

NEWSCASTER 1: More than 3,600 deaths from COVID-19 in this country are believed to be linked with nursing homes.

NEWSCASTER 2: The coronavirus killing senior citizens at an alarming rate NEWSCASTER 3: In Massachusetts, coronavirus killed 47 veterans.

NEWSCASTER 4: After 17 bodies were found at a small makeshift morgue built for just four people.

NEWS COMMENTATOR: It's easy right now to just blame the nursing homes and the assisted living facilities.

I also think we have to point the finger at how we pay for these services and how we regulate these services.

KATHLEEN: In the wake of COVID-19, there has been significant study and work around the issues that the pandemic uncovered, and they include huge areas such as staffing and understanding appropriate staffing and looking at what the wages for staff, different levels of staff are in nursing homes.

JASMINE: Last year, I spent some time in a number of nursing homes just visiting to go speak to the residents on a number of different issues.

And it was beyond me with regards to the stark differences in the homes that I went into.

I would go into a home and I would immediately be caught by smells of urine.

I would see residents in their beds unkempt, their sheets soiled, the residents in their beds the entire day as opposed to being out in the communities.

And then I would go into nursing homes where I would see residents who were out in the halls, in their wheelchairs or walking around, saying hello, lively, who had pictures outside of their doorway indicating that that was their room.

BELLA: What's your name?

NURSING HOME WORKER: This is Quita.

BELLA: Oh, and I'm Bella, I'm Bella.

NURSING HOME WORKER: Oh, Quita, did you say hi to Bella?

JASMINE: So there's differences in nursing homes based off of their ownership.

And what we've seen in the literature is nursing homes who are for-profit, they are more likely to have fewer staff and more likely to deliver poor quality of care to their residents when compared to not-for-profit nursing homes.

DANIEL: Let me start by saying that not every for- profit nursing home is terrible and not every nonprofit home is superlative.

However, most of the time that is the case.

And the reason is that if somebody is running a nursing home to make money, then there is an inherent conflict of interest between the amount of money that they're going to put into providing high-quality care and the amount of money that they're gonna put into their pocket.

MARTIN: The ultimate challenge for nursing homes is how to provide comprehensive care for those who have highly complex medical illnesses, serious cognitive and functional impairment, and who need support for the basic activities of daily living.

KATHLEEN: One thing that's hard to escape from when we're talking about nursing homes is that people don't wanna be there by and large.

So when you ask people where they want to be, where they want to receive care, nursing homes are often seen as a last resort.

And that is because of a fear, which is sometimes and all too often a reality that people feel isolated away from the community in nursing homes.

And that's still true.

DANIEL: The nursing home system in five to 10 years from now is completely unsustainable, both because of the massive number of older adults reaching not the age of 65, but the age of 75, 80 and 85 is growing exponentially.

The dollars that are going into the long- term care system can't possibly provide for all of the people that are gonna need long-term care.

MARTIN: One alternative that gives many the support to stay in their homes is called PACE - Program for All-Inclusive Care of the Elderly.

With more than 300 centers in 33 states across the country, PACE offers a different model of delivering healthcare and social services to older adults.

KATHLEEN: PACE combines Medicare and Medicaid funding to provide comprehensive care to people who have long- term care needs, to people who are nursing home eligible.

PACE pulls the medical and the social aspects together centered around an adult day model.

So the adult day center is your home base, and people live in their homes, often receive some services in their homes, but also receive transportation, support and supportive services in the PACE site as well.

PACE PARTICIPANT: It is really amazing how great the place is really.

KATHLEEN: Oh, I'm so glad to hear that.

PACE PARTICIPANT: Till this come along, I was kind of in the house by myself and this way I get to meet people, talk to 'em, aggravate 'em.

KATHLEEN: Yeah, yeah.

PACE PARTICIPANT: And they aggravate back.

KATHLEEN: Yeah, no, that's what it sounds like.

I can hear that either.

KATIE: Day center services, the primary focus is socialization, activities, there's meals, there's all of those things that come with that, but in addition to that, there's also a full- service medical clinic here at the center.

Laundry, I think is another example of a service that we all take for granted.

So the ability for our participants to bring dirty clothes in when they come in for the day, and then when we take 'em home in the afternoon, you know, taking those clean clothes home with them, it's one less thing they have to worry about at home.

That's important to maintain that independence.

PACE WORKER: Any falls since I've seen you last?

PACE PARTICIPANT: Get to ten.

PACE WORKER: You got this.

PACE PARTICIPANT: Can I stop now?

PACE WORKER: No, you can't stop.

You've only done two minutes.

(laughs) PACE PARTICIPANT: I got it.

PACE WORKER: Nice try.

KATIE: The concept of being proactive as a PACE program as opposed to reactive is both better healthcare, but also it's very cost effective.

We can address, you know, if somebody is seeing a slight decline in their mobility, we can address that before there's a catastrophic fall.

PACE DOCTOR: You just walk, they'll get outta your way, we're just doing our normal thing, right?

WOMAN: Yep.

DANIEL: We spend a fortune of money in long-term care and we are absolutely spending it in the wrong place.

The amount of dollars that go to nursing homes to take care of people who are below the poverty line on Medicaid could be much more beneficially used if they were reallocated to allow people to stay at home longer, to convert other kinds of buildings into affordable housing with services and to make the essential nursing home industry obsolete.

KATHLEEN: What I wish for in our long-term care system is that we could start over, that we could create a long-term care system that absolutely includes institutional care for people who need 24 hour, hands-on supportive care, as well as, a very robust home and community-based services sector that is accessible anywhere you live in this country.

DR. BUTLER: There's no doubt that we all wanna remain in our own home for as long as possible.

And I think that older people having created the infrastructure for us, having created the society that helped finance much that we enjoy.

We have a certain intergenerational compact, which we owe to them.

Every effort we can make to make it possible to stay where you wanna stay.

MARTIN: Despite the many challenges posed by America's aging population, our new longevity promises opportunities only dreamed of by previous generations.

KEN: All of history, we've been young and now we're learning to be old and we don't quite know what to make of it.

Is it a challenge or an opportunity?

JO ANN: Today, we're living totally different lives than our parents or grandparents.

It used to be that you would grow up, go to college, get married, work perhaps at one place of employment and then retire.

KEN: I think what's awakening now are two things.

One is the realization that you might have new purpose at 50.

You might have 30 years of life after your main career is over.

And so people are doing a lot of scratching their heads thinking, "Who can I be next?"

MAN IN COMMERCIAL: School isn't gonna be easy.

WOMAN IN COMMERCIAL: I know.

But I think you're gonna do great Dad.

KEN: Some people are going back to school and learning some new tricks.

They're learning some new crafts.

Some of the most successful entrepreneurs in the world right now are over the age of 60 because they've been through life and they've got experience.

So romance and relationships are blooming.

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JO ANN: We want to make sure that you're living your post-65-plus-year life in the best possible way that you can.

Having that mission or purposeful meaning in your life, I think is key to happiness.

MICHAEL: Looking back, I see my life through a different lens now, and what that means is, I can create a new identity for myself.

I was in banking for 41 years and work that I did was pretty high-pressured and stressful so I could not see myself continuing with my career.

In my 60s, when I was working, there was always a parallel side of trying to identify my cultural heritage.

So good morning, everyone.

Welcome to Little Tokyo.

I am Mike Okamura and I am going to be leading the tour this morning of 140-year-old historic Little Tokyo.

I'm currently the president of the Little Tokyo Historical Society and the mission of LTHS is to preserve, share, and educate the history of Little Tokyo.

It's important to not only understand the history, but to share the history and to bring everyone current as to what's happening with Little Tokyo now as we encounter gentrification, eviction, displacement.

So we're very proud of all this that still remains.

It was under threat of demolition.

City Hall is just a block and a half west of here, and it always looms as a threat to our small neighborhood.

Being retired, I'm given the opportunity to pursue so many endless adventures, be on different paths, and I'm taking advantage of that now.

A case in point is working at a restaurant part-time.

Hi, welcome to Azay.

How many in your party?

WOMAN: Just two.

MICHAEL: By working at the restaurant, which is in the heart of Little Tokyo, it continues to enhance my experiences in the neighborhood and stay connected, a different way of giving a tour of Little Tokyo in retirement.

It gives me so much more freedom.

When I think about this stage in my life, the purpose that I'm always considering now is what the legacy I will leave behind.

And for me is my passion in doing community work and my Japanese- American heritage.

This is a way for me to extend this knowledge and the ability to just find new joys and pursue new interest and new journeys.

MARTIN: The Pulitzer Prize-winning author, Dr. Robert N. Butler died on July 4th, 2010.

His New York Times obituary hailed him as a prophetic visionary who established an entirely new field of medicine.

ALEXANDRA: I think that he was able to look at something that most people still can't bear to look at.

Our inability to deal or look at the bloody real parts of life and our sort of neglecting the most vulnerable people in our societies.

CYNTHIA: It's sad for me to think that he worked on this and identified these problems so many years ago and we're not anywhere near where we should be.

CHRISTINE: I think it was disappointing to him that politicians and other people who were, you know, leaders in our society often just couldn't come to grips with the realities of what aging meant in our society.

JO ANN: Clearly, I think over the last 50 years, we've seen some improvements in the perceptions, particularly here in the U.S. of how people think about older people, but we have a long way to go.

FERNANDO: I do believe we need a new social movement on behalf of aging and the lifespan.

Not on behalf of older persons per se, but on behalf of what can we do to have a better quality of life as we live longer.

MARTIN: We are the beneficiaries of the greatest possible gift - time.

Time to spend with family and loved ones, time to learn and grow, and time to even reinvent ourselves.

The challenge is to create an age-friendly society where everyone can enjoy and find purpose in those extra cherished years.

KEN: We spent the last a hundred thousand years trying to make old people and now we're doing a pretty good job.

We call it a problem.

Maybe we ought to be thinking more as Bob Butler would and did about what are the potentials, what are the contributions, what are the opportunities that will surface as we have more and more long-lived men and women?

MARTIN: Imagining a more and equitable world for older adults is not just for those who have currently reached the age of maturity, but for the future generations who will succeed them.

ANNOUNCER: Aging in America: Survive or Thrive is available with PBS Passport and on Amazon Prime Video.