The Young-, The Middle-, and the Old-Old
Here, as promised and before someone else takes off with my idea, I am going to talk about three stages of aging. I think of it in decades: 65-75 year olds representing the young-old and 75-85s representing the middle-old and 85s-beyond representing the old-old. Of course, this is a tidily packaged approach.
Others have made a case for a different definition of aging, as Dr. Charles Flexner recently did in his Medicine Grand Rounds Lecture at Johns Hopkins. He stated that the aging process was driven by a series of inflammatory and thrombotic events which finally culminate in death. Doctors term it "physiologic age" when someone seems either younger or older than their years. This is articulated in our culture by coined phrases like "50 is the new 40" or "you're only as old as you think you are", widely used to make us feel better and not give up at least trying to defeat the aging process. Attitude can make a difference. I try to comfort those who are deeply affected by their age on their 30th birthday (and succeeding decades). I am inspired by those who are still working in their 80's and even early 90's. Where do they find the strength?
Aging, whichever way you cut the cake, is a biological destiny. Unless something as drastic as death intervenes, aging will happen. Americans don't like it. It fundamentally violates American ideals of freedom and prosperity. It flies in the face of the culture of beauty and dispels the notion that life will be ever-better. Further, it defies equality. Some will age with grace, and others face one difficulty after another. How well one ages is often socially determined, the poor aging more rapidly and facing premature death due to cardiovascular and other causes.
THE YOUNG OLD
Between age 65 and 75, many Americans are travelling the world and doting on grandchildren. Some are still working, and others are pouring into volunteer activity. My mom retired early and travelled with my stepdad, but recently had to curtail the travel schedule a bit since she is tutoring a middle-schooler and meeting one-on-one with immigrant women to teach them English. She has also taken advantage of more free time to exercise and lose weight and attend Aspen Music Festival concerts. She reads a lot and spends time with family. She has been able to find more balance in the four quadrants of physical, mental, social and spiritual health.
The key health strategy in this decade should be to modify risk: quit smoking, keep chronic diseases well-controlled, strengthen the muscles, exercise for heart health, eat healthfully (Mediterranean Diet or DASH for most people), and keep the mind active to prevent memory loss. Basically, this decade involves preparation for the next.
People aged 65 to 75 can experience serious disruptions. Some will suffer from stroke or heart attack; though, exercising and being on statin therapy and having well-controlled blood pressure greatly decreases the risk of these events. Some will be diagnosed with cancer, and mammography and colonoscopy are particularly important in finding cancer early in this age group. Women need to have their bone density checked with a DEXA scan, as treating osteoporosis reduces risk of fractures. Some will have to take care of a disabled spouse or an elderly parent and feel the subtraction of "the golden years". Others will lose a spouse or a close friend. It is key, when facing these losses, to build a community of support among family and friends. Work or volunteer activity provide the opportunity to be among others.
THE MIDDLE OLD
Many of those who are 75 to 85 years old are still quite active: physically, socially, intellectually, and spiritually. My grandmother travelled to Egypt, Turkey and China in this decade. A number of my patients work full time. Still others are ushering at theaters and concert halls, or attending events there.
In this decade, strategy should include daily walks which prevent falls and a careful look at the medication list. If experiencing falls, balance training and muscle strengthening with a physical therapist can help prevent the next. This is important, because hip fractures are one of the main causes of loss of independence. Wearing an alert button can also be a source of comfort to family members, because if one falls and is not able to get up, then family members are alerted before emergency personnel. De-cluttering the home environment is also timely. Some may want to consider moving from a house to a building with an elevator, in order to decrease the work of living. Medications should be evaluated with the help of a health professional. Some medications that are safe for younger people increase the risk of falls, confusion, and other major problems in older adults.
In this age group, some are held back by joint pain. Aching knees can limit outside activity and lead to isolation. Here, I pause to comment that research shows that normalizing weight in middle age adds years of able-bodied living. Obesity and sedentary lifestyle are risk factors for arthritis as well. If otherwise in reasonable health, knee or hip replacements can serve to reduce pain and increase mobility. Mobility is directly connected to longevity. For those in too much pain to exercise on land, the pool is a great place to walk or aqua-jog or to do aqua-aerobics. There are pool exercise classes geared toward those with arthritis. Pain can be hard to treat, because strong pain medications are not well-tolerated. Other modalities should be considered: topical medications, topical herbals like arnica, acupuncture, massage therapy, heat, ice, stretching, physical therapy, and cognitive behavioral therapy. We find that depression also co-mingles with chronic pain, partly owing to isolation and partly due to loss of ability to do usual activities like cooking and housework.
Inability to cope, or lack of resilience, and depression are risk factors for memory loss. I believe those who age the best are those who apply creativity to coping with the new normal. Having a sense of humor is helpful. Being realistic is also of the essence, as planning in advance can prevent major crises. For example, it is better to down-size before disability worsens further.
Restoring joy is also of the essence. It is a fact that older people face a series of losses, of not only loved ones but also of normal functions they once took for granted. This may lead to an ongoing grieving process which, if unacknowledged or unprocessed, leads to embitterment. Those of us who are younger need to make space for our elders to grieve their losses, to sound them out and cry out at times. At the same time, some of our elders need to work with a mental health professional who can help with stress management and adjustment to life's changes.
THE OLD-OLD
There is a saying, "The longer you stay, the longer you stay." This applies to some of my nonagenarians who wonder why God still has them here. None of them have heard God speak from a burning bush. I do try to remind them, "He isn't finished with you yet." Most are easily reminded that they do want to meet their great-grandchild or live until the college graduation. Most are still able to experience some pleasure even though eyes and ears aren't what they used to be. Many of those surviving to the ninth decade still have their faculties, so it is important to include them in conversation and treat them as adults. They will complain to me that their children are trying to tell them what to do. Others raise concern that they are a burden to their children. Letting go of control is not easy, but being old-old means becoming increasingly part of a village. True: "it takes a village."
Family-members, caregivers and friends are key teammates. Too often, the entire care of an older adult falls on one of the children even in a larger family. This may be for a variety of reasons, but sometimes it is necessary for the main caregiver to assign other family members to a schedule to provide relief. Many other caregiving tips are available. Caregiver stress can contribute to health problems, so it important to address it. In the case of dementia, when an elder is unable to be left alone, hiring an aide to come in for several hours a day can help a great deal. The environment should be uncluttered, and loud noise should be avoided. Having the grandkids visit, once a blessing, may cause an older adult to become agitated or confused. A wonderful resource for caregivers of those with dementia is Dr. Peter Rabins' book _The 36 Hour Day_.
The goal for this age group may be to stay out of the way of successful aging, where it is evident. Mostly it is to anticipate problems before they happen. It is all about the little things. Either the little things add up to improve the quality of life or the little things add up to unravel it altogether. Usually it is a combination of both. It may be three steps forward, one step back. Sometimes it is one small step forward, and a giant fall back. The end of life may be heralded by a series of transitions across the healthcare system: from home to hospital to rehab to home to primary care to hospital to specialist to primary care to hospice. The last years of life may be characterized by these intersections, so it is key to have a primary care strategy that includes coordination of care.
A long-term relationship with a primary care provider or geriatrician and his/her staff becomes more and more important toward the end of life. The science of medicine becomes more and more mixed with the art of medicine, as events unfold. It has been said that we become more and more different from one another as we age; in other words, ninety year-olds are much more different from one another than nine year-olds. That may explain why it is hard to find much evidence-based medicine for this age group. Frailty is not a disease but rather a condition resulting from passage of time, a series of physiologic events, and other contributors. Taking care of our frail elders has been likened to plugging up holes in a leaky glove. It is multi-dimensional and may become multi-directional. Care decisions are dynamic, and the presence and guidance of a primary care provider serves to minimize chaos.
SUMMARY
Aging is an unavoidable fact of life. There are three stages of aging, corresponding to the decades. Lifestyle, the presence or absence of chronic diseases, sudden health crises, life circumstances, and resilience account for much of the variability in physiologic age. The family, caregivers and others play an increasing role as aging progresses; loss of control, while inevitable, poses a major adjustment for older individuals. It is key to include competent elders in their own decision-making but also to help them recognize the need for a team-approach. Finally, it is key to have the coordination of care by a committed primary care provider who tracks transitions through the healthcare system and is able to translate circumstances and have key conversations with elders and their families toward the end of life.
