Try a simple experiment. You will need the stopwatch on your smart phone. Close your eyes and start the stopwatch. Count seconds until you get to 120. Stop the clock. How accurate you were in timing two minutes will depend on your age. All groups tend to underestimate the time. In a survey of different age groups the 15–29-year-olds averaged 115 sec. The 30-49 age group 96 sec and the over 50 group 86 sec. Time moved faster for the older group.

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We have many senses in our body. We can see, hear, touch, smell and taste. But we have other subconscious senses that allow us to know where our limbs are in space. Senses to allow us to balance and many others. What we don’t have is a sense of time. We do have a clock that conditions our circadian rhythms and allows us to know the pattern of our day.(See Newsletter #286 "Social Jetlag") We don’t have a stopwatch. Time is subjective and an assessment. It is also subject to our emotions.

Time and Emotions.

How accurate are we when asked to reproduce a length of time? Typically, in these studies we are shown an image on a screen for a fixed period of time. The screen goes blank but then the image reappears. We are asked to push a button when the same amount of time has elapsed. It turns out that most people are pretty good at this game.

To make it more difficult the task is changed. Instead of reproducing the time we are asked to halve it or to double it. The results are not so good. The average respondent will underestimate the doubling. They will stop the clock short of the time needed to double the interval. People will overestimate half the time. We seem to converge on the original time.

Most of these studies use some neutral or abstract image to look at. Emotions, however, have been manipulated using the image. A picture of a person is used. In a recent study there were three pictures of the same person. A third of the sample got a neutral face. A third a sad face and a third an angry face. The emotions influenced the time perception, and the change varied by age and task.

The emotion had no impact on the simplest task of reproducing a time. The complicated tasks of dividing or doubling time caused young participants to overestimate time in both cases. They no longer underestimate the doubling time. Researchers suggest that this may simply be due to cognitive load. Processing the emotion as well as the time takes more effort. More effort means more time.

Older respondents react to emotions in a different way. They will overestimate time intervals with the neutral face but underestimate time with a sad or angry face. The researchers suggest that this is due to the well known effect. Older people favour pleasant over unpleasant experiences. ( See Newsletter #033 "Always Look on the Bright Side of Life") . They spend more time looking at the neutral face. They don’t want to feel sad or angry. In the young and the old it seems that our perception of time is influenced by how we feel.

Decades not Seconds and Minutes.

In a recent study people were asked to reflect on their lives. They were asked how quickly time seemed to pass as they aged. Anyone over 40 agreed that time seemed to pass more slowly when they were “growing up”. Older people felt that recent time seemed to literally fly by. Psychologists suggest that this kind of time is assessed based on new memories created.

When we are “growing up” almost everything is new. We are laying down memories every day. As we age, more of what we experience is already familiar. A common test is to ask: “What did you do last Wednesday?”. For many older people this is a difficult question. Especially retirees. We are happy to live in a familiar routine. A Wednesday is the same as any other day. Holidays can have the same effect on everyone. We lose track of the days of the week when the familiar clues disappear. A weekend is the same as any other day. Without the “punctuation marks” of new and novel events time does fly.

Want to Slow Time Down?

Be more aware of what is going on around you. Look to capture the novel and the different. Change you routine. Do different things. Stimulate the brain and the memory.

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What however does an average mean in this context? There are huge variations depending on the demographics of the respondent. For all those who have planned their retirement the gap is 2.5 years. For those who have not made any plans it is 7.3 years. For households with an income of over £100,000, who have planned their retirement, the expectation gap is less than a year.

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The Department of Work and Pensions (DWP) conducts a survey every two years. It is called the “Planning and Preparing for Later Life” survey. Their latest report is from 2024. The sample is 4000 people between the age of 40 and 75. It is weighted to be representative of the UK population. It looks at whether people expect to have the standard of living that they want when they retire. It presents results on the kind of planning people do. When they expect to retire and the kind of information they use. It includes many other apparently useful data.

There is the same problem. The results are published as averages. They are assuming that this group is homogeneous. Clearly, they cannot be. Some will have already retired. Others will only now be starting to think about retirement. Some will have private pensions and some not. The group needs to be segmented to be understood.

Understanding the Different Segments.

The DWP and their suppliers have tried to create different segments. They have clustered people together in groups. Each group is more like itself than the rest of the population. In the end they have found five such segments. Two that are not confident that they will get the standard of living that they want. They represent about 40% of the population:

The Unprepared and Financially Vulnerable (16% of the Population)

Their income is less than £12,500 a year and they have few financial resources. They are predominantly renters. They are not saving for retirement (they cannot afford to). There are more women than men in the group. 54% have a long-term illness. Only 22% have a private pension. Most expect to be dependent on their State Pension.

What is perhaps surprising about this group is that 84% have not retired yet. 60% are between 50 and 55. They have not planned their retirement, but have little to plan. They are not confident that they can achieve the standard of living that they desire in retirement.

Informed but Insecure (24% of the Population)

They have planned their income and expenditure. The started saving for their retirement in their 20’s and 30’s. They have medium to high levels of financial literacy. They expect their expenditures to go up in retirement. They own their own properties but generally have lower levels of savings. They admit that their understanding of pensions is “patchy”. They are not confident to make decisions about pensions. They are not confident that they can achieve the standard of living that they desire in retirement.

The other three segments are confident of reaching the required standard of living.

The Secure & Confident Group (14% of the Population)

They depend mostly on their private pension. 11% are still working and often self-employed. They are an older group with many already retired. The are very unlikely to be renting and are actively engaged in retirement planning.

Equipped and Unengaged (27% of Population)

They are moderately financially secure with an income up to £53,000. They have a private pension to supplement their State Pension. A third of them are already retired. However, they are not doing any financial planning for their retirement.

Financially Stable and Planning (20% of the Population)

They are very like the “Equipped and Unengaged”. Except they are actively engaged in planning their retirement.

These groups of people are very different. The help that they need is very different. Combining averaging results will not generate useful policies. Is it part of ageism to assume that all retirees are the same?

The Bigger Problem

The working age population is declining. Countries need to maintain a workforce to support the costs of ageing. Some at least of these groups will need to continue working past retirement age. Others may work to stay active and because they want to. The DWP survey suggested that on average people wanted to stop work at 60. They expected to work until 66. They too show a five year expectancy gap.

The gap may not be as surprising as it appears. In 1994 the most likely age to retire was 59. There was a smaller peak at state retirement age of 65. Today that “retire at 59” peak has almost disappeared. The most likely age is 66. People have not kept up with the changes since their parents retired.

Both the ideal and the expected age needs to increase to maintain the number of workers. Segmenting the population offers a better chance of finding the best approach to achieve this. Simply providing more information and advice may not be enough. Some like the “Unprepared and Financially Vulnerable” may have to work. Hopefully work can be restructured to make all groups want to stay employed. Other groups may need that education and help to plan a successful retirement. Structuring jobs, at all levels, to allow for caring responsibilities would remove some barriers. Many people planning retirement are still caring for their parents. Certainly, ageism will have to be tackled for all groups.

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The Case for More People.

The article is based on a new book by Joe Studwell. In “How Africa Works” he discusses the impact of population density. He argues that it will take until 2030 for Africa to have a population density the same as Asia in 1960. Today the population of Africa is 1.5Bn which is roughly the same as that of India. However, Africa has a land mass nine times larger. In 2000 the population density was the same as in England in 1066.

Why does population density matter? Economists argue for “agglomeration economies”. These are the benefits of bringing people together in towns and cities. There are different types of benefits. The first is the ability to share. To share expensive infrastructure such roads, electricity grids, schools and hospitals. For firms they can also share specialist suppliers and lowers transport and utility costs.

The second benefit is that agglomeration creates bigger and denser talent pools. Firms can find it easier to find employees with the right skills mix. Individuals can find it easier to find the right job. This is the argument made for the success of Silicon Valley. Agglomeration also creates large accessible local markets. Proximity promotes the sharing of ideas and promotes innovation. See also Newsletter #32 "The Power of the Cities"

If agglomeration is a driver of increased GDP per head, then Africa does not have enough people to create the necessary towns and cities.

The Case for Reducing Fertility Quickly.

The article produced a lot of reaction including a “Letter to the Editor”. The simplest argument was that there are already large cities within Africa, Cairo has a population of 24m people. It has 15,300 people per square kilometre. Lagos has 17m people and Johannesburg up to 7m depending on how you measure it. Despite this the African GDP per head has been static for half a century. The cities are surrounded by shanty towns. The population density of Manhattan is over 26,000 people per square kilometre. This is compared to 25,000 for Kinshasa and 45,000 for Giza. Clearly GDP per head has not followed density.

Countries need to invest in their human capital. That means education and investment in skills of all kinds. A booming population puts strains on any educational system.

The more serious argument is based on the “demographic dividend” demonstrated across parts of Asia. As fertility drops it generates a generational “sweet spot”. The last large generations enter the workforce before the number of dependent older people increases. Resources are freed up to increase prosperity. For this to happen fertility must fall. The agglomeration argument instead would argue for fertility to stay high.

The Policy Problem

The problem is that Government policy has a major role to play in the success of any “prosperity engine”. Obviously, there are issues of corruption and the dark side of development. Even the well meaning cannot always get it right.

The unemployment rate of graduates in India is 29.1%. “Under 26” unemployment in general is nearly 10%. High GDP growth has not been translated into proportional formal employment. 43% of the workforce is engaged in agriculture. This has come down from 66% forty years ago. Only 14.5% of workers are employed in firms with more than 20 employees. Estimates suggest that 80-85% of workers operate in the informal sector. They have no written contracts and no social security.

India has huge towns and cities. Mumbai has a population density of 83,000 people per square kilometre. Kolkata has 78,000. They are generating agglomeration benefits. The fertility rate has fallen from nearly 6 in 1964 to 1.98 today. The simplistic models are not deterministic. When faced with reality they show how difficult managing economic growth can be.

Arguments about Models do not matter

Intellectually it might be fun to argue about fertility and urbanization. Unfortunately, the populations of Africa are not waiting for the answer. Fertility rates are dropping everywhere. In the Democratic Republic of Congo, they have fallen from 7 in 1985 to 6 today. In Ethiopia the have fallen from 7.36 to under 4 in the same period. Egypt has gone from 7.09 in 1950 to 2.75 today. The overall population growth rate has plateaued at around 2.5%. Unlike many parts of the world Africa is still growing. However the growth rate is slowing.

In 1950 there were only 33m Africans living in cities, there were 195m in the countryside. Urban dwellers have grown to 720m and rural to 830. The City dwellers will soon be larger than those in the country. No matter what government wants people are attracted to towns and cities.

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The Ageing Senses

For some of us age brings with it decline in our senses. The most common problems are with sight and hearing. By the age of 55, 94% of Americans need glasses. The vast majority need them to be able to read. Presbyopia is the technical term. The lenses of our eyes grow throughout our lives. The lenses thicken every year as protein is deposited on the surface. The result is that the lens becomes less flexible. At the same time the muscles in the sack that holds the lens weakens. The result is that we cannot squeeze the lens to focus on text close to our eyes.

The alternative problem is myopia. The inability to see in the distance. The shape of our eyeballs change. There is a bigger distance between the front of the eye and the back. As a result, the image fails to focus on the retina in our eye. There is a growing number of cases especially amongst children. It is suggested that this is caused by increasing hours spent viewing smart phones. Their small screens means they are held too close to the eye.. The problem seems to be made worse by the reduced time spent outside looking at the distant horizons.

Around the year 1300 the first glasses were invented by glassblowers in Venice. These did not have arms but balanced on the end of the nose. Before that, people used polished balls of glass. These could be placed on to the surface of the document to magnify the text.

Loss of hearing is predominantly due to the loss of the sensitive hairs within the inner ear. There is clearly an age effect since hearing loss is more prevalent with age. However, this may not be a strictly age driven effect. It is known that noise, especially at high levels, can damage those sensitive hairs. This is a cumulative effect and older people have had a greater exposure. The incidence of hearing loss in men is nearly twice that of women. Much of the difference has been put down to noise exposure. The damage is not even. We lose higher frequencies first.

When does Sensory Loss start?

The ageing of the eyes starts when we are young. In the US 35-48% of 12–17-year-olds wear glasses. By 35-54 that rises to close to 75%. By 65 well over 90% of people would benefit from wearing glasses. Most do and many treat them as a fashion accessory. We can buy glasses from most of the major fashion brands such as Cartier or Versace. There are multiple brands dedicated to glasses alone. We are so accustomed to glasses that we not blame ageing for them.

By the age of 55 only 14% of Americans have hearing loss issues. This rises to 33% in the 65-74 age group. Over 75 it can rise to 50%. The situation with hearing aids is very different to glasses. Up to the age of 69 only 16% of people who have a clinically significant hearing loss are using a hearing aid. Even though they are known to help. By 75 the number rises to 20%. By 85, 35% of potential users have adopted them.

Social Stigma

The difference between hearing aids and glasses seems to be social stigma. Over 50% of people who should wear hearing aids say they do not do so because of the social stigma. It is strange kind of stigma. Walking down the average street you are surrounded by people wearing earphones. Having a small white piece of plastic sticking out of your ears is acceptable. More than that it is social plus. Indeed, Apple now have authorization to sell airpods as a hearing aid. The results seem to be mixed. The airpods can amplify sounds at different frequencies to fit an audiogram. They do not have directional capability common in modern hearing aids but work for moderate hearing loss. Unfortunately battery life is only 10 hours.

In Scandinavia a few smaller fashion houses have tried to glamorize hearing aids. They have tried to make them look like earrings for women. Perhaps they should be dressed up as airpods?

Hearing Loss is hard work.

As any sense declines the brain must work harder to fill in the gaps. Hearing loss is the same and can make sufferers tired. Hearing loss is an important risk factor for the development of dementia, in particular Alzheimer’s disease. Mid-life hearing loss increases the risk of developing dementia by double any other single factor. The mechanisms are unclear but hearing loss reduces social interactions in most sufferers. This in turn can reduce the stimulation given to the brain.

During a recent interview Sir Paul McCartney drop one of his hearing aids. (Years of live concerts had done the damage). He happily put it back without embarrassment. Do we need a personality led campaign to change the image of hearing aids?

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I recently notice an interesting innovation. Amongst the players in some orchestras were soundproof Perspex screens. It was clear that they were designed to protect the rest of the orchestra from the brass section. There have now been several legal cases. Musicians have sued the orchestra for the loss of their hearing. All because of their proximity to the trombones!

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What is Noise?

When does music become noise? As individuals, it is when the music interferes with other activities. Perhaps when we cannot have a conversation. Restaurants have increasingly been criticized for their noise levels. That noise can be everything from music to multiple guest conversations. From the sound of the back-office systems to staff.

A survey measured the noise level at peak time in some two thousand three hundred bars and restaurants in New York. They used sound meters. In just thirty percent of restaurants were noise levels suitable for a conversation. A further forty percent had levels between seventy and seventy-five decibels. This would make conversation possible but difficult. It would mean shouting. The remaining thirty percent were operating at noise levels that made conversations impossible. Bars were much worse. Ninety percent have noise levels unsuitable for conversation even with shouting.

The Regulator’s View of Noise.

There are regulations to protect employees from hearing damage. There are two dimensions to this: the level of the noise and the duration of the exposure. This effectively defines the amount of sound energy exposure. How much an individual gets during their working day. There is an emerging benchmark adopted by many countries. It is eighty decibels for eight hours.

What happens when the noise levels are higher? Employees can wear ear protectors or reduce their exposure time. Eight hours at eighty decibels is the same “sound dose” as only forty-five minutes at ninety-five decibels. It is only fifteen minutes at one hundred decibels. It does not matter whether this is the noise of a power drill or just a noisy bar. (If that looks odd remember that decibels are measured on a logarithmic scale).

The regulations have been extended to protect people working in pubs and clubs. In the E.U. the rules are set at the same level as factory workers. There is a peak exposure of one hundred and thirty decibels (or the sound of a jet engine). Those bars in New York average just above the eighty-decibel limit for a typical week. Sixty percent of them have noise levels above it during the peak hours. Add live music to the mix and the average rises to ninety-five decibels. A dance floor will take it to one hundred and five decibels.

The noise level of a live band in a small venue is equivalent to having a trombonist stand in front of you and blast at you for five minutes. If you work as a musician, you may get a much bigger exposure! In bars and clubs, everyone working there should wear ear protectors. Alternatively they can manage their time of exposure.

Restaurants, bars, and clubs do not operate for their staff but to serve customers. Standing next to the bar staff, the waiters, the D.J.’s and dancing on the dance floor are the consumers. They are as exposed to the sound energy. It is doing just as much harm to their ears. The noise level on a full dance floor is equivalent to standing in a noisy metal working workshop. Those same consumers may indeed have come from work. Where they spent their working hours at the recommended limits in just such a workshop. Unfortunately, it is the total average exposure that matters. There is no distinction between work and play, day or night.

Hearing, Noise and Ageing.

Most of hearing loss comes from the cumulative effect of noise. It destroys the sensitive hairs in the ear and reduces their sensitivity. It appears that even without such damage hearing sensitivity can decline with age. Researchers suggest that noise levels should be reduced by up to ten decibels for older people. Age influences the “signal to noise” ratio. We need a higher sound level relative to the background noise to be able to hear something. This is particularly the case with high frequency noises. Applying such a restriction would make most New York restaurants and bars “no-go” areas for older people.

Modern restaurant design does not help. Gone are the carpets. Gone are the curtains, soft furnishings and ceiling that used to absorb sound. Hard floors, no table clothes and vaulted ceilings increase reverberation. The separate noisy bar is now incorporated into the dining room. Kitchens have become open plan. It may look beautiful but it sounds dreadful.

Turning the noise down to help older consumers can have positive side effects. It turns out that noise can destroy the taste of the food. The classic example of noise and food is air travel. Eighty-five decibels is typical for a large aircraft in mid-flight. Coping with the noise takes intellectual energy away from the senses. What a restaurant loses through noise on the quality of the food it may gain in drink sales. Alcohol consumption is higher in a loud versus quiet bar. Above eighty decibels we lose the ability to tell how strong our drink is.

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We know from that study that literacy and numeracy are related to individual earnings. The skills profile of a country has also been related to national growth rates. Economists are concerned about the ageing of the population. It could affect productivity and growth rates. If cognitive ability, literacy and numeracy decline with age so will the economic wellbeing of the country as the proportion of older people increases.

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Cross-sectional analysis of the PIAAC data suggests that both literacy and numeracy start to decline in the late 20’s or early thirties. In previous Newsletters I have shown that such analysis is flawed ( Newsletter #178 A Picture of Healthy Ageing). Different cohorts or generations have improving levels of cognitive ability. Because of this a cross-sectional approach will overstate any decline.

The German Longitudinal PIAAC Data.

To unpick the cohort effect, we need longitudinal data. Data on the same individuals over time. Uniquely Germany converted the original OECD respondents into a panel. They could retest them three years later. They could separate out the cohort effect and look at the aggregate underlying trends. The results were published last year.

Age Related declines in Literacy and Numeracy.

The actual declines start much later than the cross-sectional data would suggest. Average literacy continues to increase until the age of 45. Numeracy up until the age of 40. After that skill changes turn negative. The decline is stronger for numeracy than literacy. The scale of the declines by 65 can be assessed by comparing with performance at younger ages. By the age of 65 literacy fell to the level of a 35-year-old. Numeracy was back to the level of a 25-year-old.

Use It or Lose It

The situation is better than even the longitudinal data shows. The results above are averages. Within the PIAAC questionnaire were other measures. In particular, there were questions about the use of numeracy and literacy. Other studies have tried to use surrogates to assess skills usage. They have used such things as occupation. In this case the questionnaire asked directly about skills usage at work or in the home. Questions included:

“Reading emails, memos or correspondence” and

“Calculating costs or profits and budgets”.

They were able to calculate for each person an index of their use of their literacy and numerical skills.

They broke down the average, they looked at the trajectory of both skills with and without usage. Those individuals who were using their skills continued to increase them until the age of 65. (The sample was of working age people. The data does not go beyond 65). There is a peak at about 55 but after that the rate of increase merely slows. For the individuals not using their skill the decline starts at the age of 30. Usage allows individuals to continue to grow their skills at least until the age of 65. It really is a case of use it or lose it.

Cognitive Ability

Cognitive Ability is measured at many different levels. It stretches from things close to the functioning of the brain. For example, researchers measure cognitive speed or the ability to focus attention. At a higher level comes things like literacy and numeracy. Finally, researchers also look at decision making ability. The further from brain function, the more older individuals can use their wisdom to mitigate any decline. They are all related but very different.

Literacy and Numeracy and GDP.

Does the ageing of the population imply a decline in productivity and growth? This data suggests that the problem may be smaller than originally feared. Decline starts later than cross sectional analysis would suggest. In no case does the level drop below the standard of a 20-year-old. The ageist narrative of decline starts at too young an age. The data also suggests that individuals who need to use literacy and numeracy continue to grow them until the age of 65.

More people will work beyond 65. Unfortunately, this data does not help. Other studies suggest individuals can maintain these abilities until the age of 80. Only then do they drop below the average 30 year old.

To quote the authors:

“Behavioural choices can overcome biological changes”.

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The Eden Model

I have been reading a book by Dr William Thomas. He has spent his whole professional life trying to change the US model of nursing homes. He has been promoting innovative models including his first – the Eden Alternative. His focus is on wellbeing rather than medicine.

His approach has been to unpick wellbeing. To try to define it in very actionable terms. Nursing homes sit in an awkward place. They are not “watered down” hospitals but are medical. They are also the homes of the patients. His approach and models however can fit all older people who need care, no matter where they live.

His arrival in the sector captures his mind-set. In 1991 he was working in accident and emergency at a local hospital. He was introduced to the local nursing home. It was institutionalized and, as he put it, a place full of people “cruising down life’s off ramp”. Despite this he was inspired and joined as the resident doctor.

He argued that no matter where we are on life’s journey we still need to care for something or someone. It is why so many retired people volunteer. We may be receiving care, but we also want to give it. On his first day he bought a parakeet for a patient and told them to take care of it. This motivated them, stimulated them and got them visiting other residents. The care home subsequently had eighty parakeets, ten finches, two love birds, plus a couple of dogs and cats. Over 90% of rooms had a birdcage, each placed so the resident could see the bird and talk to it.

Loneliness, Helplessness and Boredom

According to him, these are the three threats to wellbeing for the elderly. We can be lonely even when surrounded by other people. Even when we are regularly invited to social events every Tuesday! We do not belong.(See Newsletter #95 Loneliness.)

However hard professionals try to avoid it. Care homes of all kinds are institutions. They can so easily take control away.( See Newsletter #114 Taking Control of Life.) If meals are provided and delivered at a set time, they can destroy the joy that used to come from feeding people. From eating together. The result is what is called learned helplessness.

The human brain is designed to be stimulated. If life is totally predictable then the brain has nothing to do. It shuts down.

Efficiency versus Effectiveness

All services trade off costs against effectiveness. Individualized care costs money, it introduces uncertainty into the operation. The temptation is to think of a home resident as a set of medical symptoms. It is cheaper to “treat” people than to “care” for them. Once they have been diagnosed, they are defined by their diagnosis and treatment. They become a patient not a person. The progression from home to care home to nursing home and hospital reduces a person’s identity. It is stripped away, leaving them unknown and vulnerable.

Well-Being

What if the objective of care is not a healthy body? What if instead the objective is well-being? The Eden Alternative identifies seven dimensions of wellbeing. What if the institution is rebuilt around these seven?

If identity is to be preserved, then the individual needs autonomy and a special kind of security.(See Newsletter #271 To Old to Work and Too Young to Die. ) Autonomy means the absence of the arbitrary exercise of authority and loss of freedom. Experiments have shown that something as simple as allowing people to have breakfast when they want it, reduces learned helplessness. Instead of a “7.00am communal meal”. Choosing when your visitors can come has the same impact. Security means freedom from doubt and anxiety. That must be achieved whilst preserving privacy, dignity and respect. Some risk must remain.

Giving meaning and growth to a resident improves their wellbeing. The pets in that first nursing home gave the residents purpose. This reduces helplessness. This was followed with houseplants for residents. “The Maintenance Department” suggested using plastic plants! The residents wanted to see their impact on something that was living. Our need to develop, to grow and to learn lasts until the very end of our lives. Just because we move into a home does not mean that the urge disappears.

Leaving “home” breaks something. It breaks the connections with the community and the sense of being part of something bigger. That has to be rebuilt in a new home. The sense of belonging must be recreated.

The last part of their model is joy. That spontaneous happiness that lifts the spirits.

Making it Happen.

We cannot measure well-being. We cannot put it on a chart at the end of a resident’s bed. We cannot diagnose a decline and prescribe an extra dose of autonomy. We certainly cannot write a procedures manual in some central team. Thomas and his team insist that the only way is to imbue the ideas into the front-line carers. To let them understand the people they are caring for and then let them solve the problem themselves. This is the same strategy used by personalized services of all kinds.

Does it Work?

The Eden Alternative is still being rolled out around the world even after all this time. There are limited number of studies that have tried to evaluate the impact. Obviously, it is difficult. What do we make the comparison against? Researchers have chosen matched “traditional” nursing homes. The results however are positive. The Eden homes scored high in attacking loneliness, helplessness and boredom. Satisfaction was higher.

The original homes were funded by the New York State Department of Health. Their study showed a 50% reduction in infections, a 71% drop in daily prescription drug costs and a 26% reduction in staff turnover. The wrong metrics but the correct answer! You can have effectiveness and efficiency. Thomas went on to develop “Green Houses”. These are small nursing homes built around a family concept. Very similar to the Dementia Homes described in Newsletter #118 Hill Top Villages.

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At almost the same time pioneering UK surgeons learnt how to replace hips, knees and cataracted eyes. With current success rates above 95% these operations have become routine. They may not convey superpowers, but they have extended healthy ageing.

The first hip replacement took place in 1962, in the UK. The first modern lens replacement took place in 1967. This came with with the invention of phaco-emulsification. This was followed in 1968 by the first knee replacement. These were all invented by a single generation of surgeons.

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Returning Sight

The lenses of the eye are organic. The protein within them can degenerate and become cloudy. This creates blurred or foggy vision. The eyes become more sensitive to glare. Colours may fade. The first lens replacement was done by Sir Harold Ridley in the UK in 1948. He was able to remove the lens and replace it with a synthetic one. This involved a large incision in the eye. In 1967 an American surgeon invented a way of liquifying the old lens and removing it with suction. This enabled the incision to be reduced to a few millimetres. Modern cataract surgery took off.

650,000 cataract operations are performed annually by the UK National Health Service. The numbers are growing annually by 14%. The operation is now a “day surgery” taking less than half an hour. Success rates, as measured by patient outcomes, are over 95%. Globally it is estimated that there are between 20m and 28m operations a year. This is up from only 3.5m in 2000. Each operation represents the return of sight to an individual. Industry estimates suggest that within a year the operation to replace the 1 billionth lens will take place somewhere in the world. Cataracts are a disease of ageing. The average age at the time of surgery is 76. 1Bn older people have gained increased healthspan.

The Curse of Osteoarthritis

Osteoarthritis occurs when the smooth cartilage in the joints wears down. It thins out. That makes the movement of bone on bone rough. The result is pain, stiffness and restrictive movement. When the joints are in the hips and knees this can dramatically affect mobility. This is more important than one expects. It represents independence for people. It represents sociability. Those having trouble “keeping up” will often not engage in social activities. The result is often isolation and loneliness.

Hip and Knee Osteoarthritis is the 11th highest contribution to global disability. There is still a huge variation in the incidence of repair operations. The OECD average is 191.5 per 100,000 people but Germany has 310. The ageing population is driving some of this but clearly there are other factors at work. Mexico has only 8.6 operations per 100,000 population.

Hip and Knee Replacement.

These operations are driven by osteoarthritis. It represents the primary cause of 93% of all hip replacements. The most likely age of the operation is now 75-79 with a 60% bias towards women. There is a 95% success rate as defined by patients’ own assessment. They see measurable improvements in health and pain. Remarkably, the time in hospital is now below 3 days in the UK. The new hips are expected to last longer than the patients receiving them. The number of hip replacements per year in the UK is now over 100,000. Each represents a “permanent” improvement in mobility and health.

Six years later, in 1968, the first knee replacement took place. Again, in the UK. Success rates are as high. 95% of patients report a large improvements. Last year there were between 100,000 and 110,000 knee replacements in the UK.

The Bionic Future

Can bionic trainers save the day? Exoskeletons have been developed for the military. These full body suits enable solders to outperform normal definitions of strength and stamina. There is now an emerging industry offering partial exoskeletons as a consumer product. They are designed to augment existing movements. The promoters suggest that they would be worn everyday. They are “an e-bike for walking”.

The Dephy company is promoting "Sidekick".“ It consists of an adapted pair of trainers. These connect to a pack that straps to each calf muscle. This has batteries and sophisticated electronics. Its software can learn your gait in about 25 steps. It then provides powered help to make walking easier. (see link).

Not a Super Hero

These operations do not produce super heroes. They can however extend the enjoyment of life. The current generation are living longer than our parents. We have more years where health is important. That same generation has produced three medical breakthroughs. Each extends the enjoyment of life.

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Teenagers account for about 20% of the women of reproductive age in the US. Even steep declines have a marginal effect on overall fertility. Preganacies did fall by 71% considerably higher than any other group. The 30-34 year olds only declined by 1%. Those over 35 increased preganacies by 9%. Many factors are known to influence fertility. A recent, often quoted, paper gives one explanation for the teens. It suggests an incremental effect of smartphones particularly on the youngest cohort.

International Comparisons

The US data shows an interesting trend. Teenage pregnancies were relatively stable in the five years before 2007. In 2007 the trend line has a kink and the decline accelerates. The paper looks at 168 different countries around the world. It finds a similar acceleration in the decline in teenage pregnancies. Particularly in the more affluent countries. The pattern is the same but the kink appears in different years. The team then corrected for the roll out of broadband and 3G/4G infrastructure. They looked at the penetration of smart phones. The patterns then overlapped exactly. For the 19 most affluent countries the pattern was very close to the USA.

They point out that:

“The near universal timing of the break across countries with fundamentally different healthcare, welfare, economic and cultural environment point to a common global technological shock”

Hudson & Boedo 2026

Detailed Analysis of the USA

The USA is divided into 3135 different counties. For each county they were able to assemble data on teen birth rate and abortion rates. To this they added broadband infrastructure, mobile data coverage and smartphone ownership. They added many other factors known to explain fertility declines. This included things like religion. All between 2003 and 2020. The rollout of Web infrastructure was highly variable. It depended on the economic and physical characteristics of each county. They could therefore track changes in pregnancies as smartphones rolled out.

In this case they could look at the kink in the trend line correcting for other possible factors. They showed that young people were not just delaying pregnancies. The financial crisis and the opioid epidemic had no effect. There was something else going on.

Why did the trend have a kink?

Their argument is an interesting one. Teenagers especially want to be where everybody else “hangs out”. Before the tipping point “unstructured social time” was spent face to face. When more people were on line than off there is a break point. Everybody then migrates online. They can show that the tipping point occurs when more than half of teenagers are on line and using social media.

There is evidence from time use surveys to support their case. In 2004 45% of US teens owned a cell phone. By 2006 that reached 63%. In person socializing fell from 68 minutes per day to 38 minutes. “Computer leisure” including social media, texting and games rose from 22 minutes per day to 96 minutes. ( interestingly television viewing fell from 152 minutes to 72 minutes.)

It is “unstructured time” that the smart phone soaked up. Time spent in structured team sports remained constant. ”Meeting friends in person” fell from 50.3% to 34.9%. Even driving licenses for 16 year olds fell. The loss of that face-to-face time seems to have caused sexual activity to decline. The share of teenagers that had intercourse fell from 47.8% to 38.4%. There is 0.97% correlation between teen birth rate and in-person socializing.

What Does It Mean?

The greater decline in teen pregnancies is universal. This suggests that this is an additional factor to the general fertility decline. The detailed county analysis in the US suggests a causal effect. Declines follow the growth of smartphones and social media usage. The kink comes when a tipping point is reached. A replication in the 294 local authorities in the UK showed the same results. The results are so similar that the two curves completely overlap.

In other Newsletters I have suggested that one explanation for general fertility decline is the absence of “coupling”. People are not teaming up with a partner as much. There is no study yet to test whether the behaviours learned as a teen carry over into later life. US teen abortion rates were as high as 30%. The smartphone may have helped reduce the numbers. Researchers are however looking at other negative effects. For example, they are exploring smartphone roll outs and the impact on teenage suicides. This may be more related to the online content than is the case with preganancies.

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It was only in April 2023 that India became the largest country in the World. It passed China when when its population reached 1,425,775,850. Now three years later it too has low fertility. In 1950 India had a population of 360m. The average woman had 6 children. That number is now 1.9.

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Today, 71% of the worlds population lives in countries that have a fertility below replacement level. In 1950 the global average fertility was 4.85 children. Today it is just above replacement level at 2.2. Only Africa has a fertility rate above replacement (3.85). Europe by comparison has fallen to 1.41.

Declining Population

The Indian population has not yet started to decline. There are enough young people of child bearing age to maintain the growth momentum for a while. 65% of the population are under 35. Forecasts vary for when the population will actually peak. The range is between ten and twenty years from now. Some forecasts are much sooner. They suggest a peak within the next ten years. They cite the 1m Indians a year that leave the country as migrants.

The Variability Problem

India is an excellent example of the problems faced by all countries with declining populations. There is a huge variations in demographic dynamics within individual countries. Two Indian states are already in population decline. The North Eastern state of Sikka has a fertility level today of 1.1. Across the country states are scambling to undo policies designed to restrict population growth. For many years there was a real fear of a “population explosion”. In Andhra Pradesh there was a policy that you could not stand for public office if you had more than two children. That law was recently repealed. The fertility level in Andhra Pradesh is now 1.5 compared to 1.46 in the EU. It has a population half way between Italy and Spain.

Population decline brings with it a decline in working age population. That in turn reduces tax revenues and puts pressure on public services. Child and adult mortality in India can still be too high by international standards. Kerala has a child mortality rate comparable to the US. It is still higher than much of Europe. In rural areas child mortality average 28 per 1000 child born. In urban areas it is only 19. It has been driven down by investment in health infrastructure including public health.

The huge variablity is not unique to India. It has a North South split. Fertility in the South is much lower. In the USA the split is between the Great Plains, Midwest and South which all have higher fertility compared to the rest of the USA. The North East has the lowest fertility. North Dakota has the highest birthrate in the USA. “Leveling Up” is a major problem everywhere. This is politically sensitive. At the same time initiatives to improve fertility are at the state level.

Getting Rich before you get Old.

10% of the Indian population are over 65. The forecasts are for that to double by 2050. It is fortunate that today there is a huge working age population. In fact the working age population of India represents 20% of the global total. India should be able to collect a “demographic dividend”. The number of children to be educated will go down. The number of older people in need of care is only growing slowly. However that dividend requires 7.85m new jobs every year. Currently youth unemployment is 16%. Graduate unemployment has been quoted as high as 40%. India produces 5m graduates a year.

The economy is creating jobs. The problem is like everywhere else in the World. Whether they are in the correct geography and sector. Agricultural jobs are growing. Manufacturing growth is proving harder. The movement of Apple assembly from China to India is helping. New assembly factories have hired 125,000 people this year. 80% are women entering the workforce for the first time.

An Inverted Logic.

A recent study in the Nordics highlights the imporance of employment to fertility. Historically the better educated and more affluent couples were less keen to have children. Workers with lower incomes had the children. The situation has now reversed. The insecurity of the job market means that lower income couples are less likely to have children. More affluent couples are doing it instead. Jobs are yet another factor in the decline in fertlity.

Looking at states or regions within a country shows one view of variability. In reality there is as much diversity down to the city level.(See Newsletter #121 "Ageing is a Universal Issue)

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