Aging Well

My mother will turn 88 in a few weeks. According to the definition of successful aging put forward by Rowe and Kahn nearly 16 years ago, she is aging quite well. Her kidneys, lungs, and heart work fine. She is still very active—she teaches a French class once a week at the local senior center, she tutors English to foreigners, she plays scrabble with friends, and she drives daily to visit my father at the nursing home where he lives. My mother does have her share of medical problems: she has painful arthritis affecting her knees and her back and she is very weak, finding it difficult to turn a door knob or to lift a container of milk. Until about a year ago, she walked at least a mile every day, but now she can only take short walks and has to sit down frequently. Her memory isn’t what it once was, though it’s still pretty good. My mother will say that “old age is no picnic” and that “people live too long” today. When her physician told her she was aging gracefully, she told him he was full of it. Her doctor has one perspective on successful aging; she has another one. How are we to put the two views together? Are we using the right definition of “successful aging?”

A new study in The Gerontologist tries to answer this question. The authors carried out in-depth interviews with 56 elders who have significant disabilities and are enrolled in the On Lok program, the original PACE program (Program of All Inclusive Care for the Elderly) in San Francisco. Members of PACE all have enough disabilities to qualify for entry into a nursing home and for Medicaid enrollment, so they are both frail and poor. In fact, the group studied had an average age of 78; 64% were women; the average number of ADL dependencies (problems in areas such as bathing or dressing) was 2.2 and the average number of IADL dependencies (areas such as food shopping or cooking) was 6.6. It was a diverse group, with 23% African American, 32% Asian American, 20% white, and 20% Latino. 

By and large, the group held the view that aging is an unavoidable process that entails disability. The key to successful aging, they said, was to accept your limitations and to adapt. If you have trouble walking, use a walker. If a walker isn’t enough, use a wheelchair. They also tended to focus on relative disability rather than absolute disability—as long as there were others who were worse off, then they felt they were doing well. The minority who said they hadn’t aged successfully commented that they had not found ways to adapt to their disabilities and they felt were a burden to their families.

So the PACE elders and my mother don’t have quite the same perspective. My mother would agree that it’s critical to accept your limitations and to adapt, and she’s done that. She doesn’t want to be a burden on anyone, and she isn’t. But I doubt she would say she is “aging well.” She is aging better than my father, who has dementia and Parkinson’s and lives in a nursing home because he needs help with just about everything, but she wouldn’t call herself a phenomenal success.

Perhaps the whole idea of “successful aging” or “aging well” is the wrong way to think about this phase of life. For no other stage of development do we assign grades: we don’t say someone had a “successful childhood” or a “failed adolescence.” We might refer to their emotional state during a particular stage: someone might have a “happy childhood” or a “troubled adolescence.” We might use the label “successful” for a career or a marriage, but not for a part of the life cycle. So why do we insist on evaluating aging in this way? 

Instead of grading aging, government and professionals should do work to assure that people are satisfied with their lives and are contributors to their community. After all, this is arguably the goal for the entire population, regardless of age. Our challenge is to figure out how to achieve this for people who are old and frail, whether because of physical impairments, cognitive impairments, or both. 

Just as we cannot eradicate inequality among people—they have different genetic endowments, they are born into different families and different cultures—but we can aspire to provide equal opportunity, perhaps our goal for older people should similarly be to promote equality of opportunity. We cannot eliminate differences in disease burden or disability, but we can seek to assure that everyone has a fair chance to make the most of themselves, whatever their situation. It’s time to switch from talking about “successful aging” to coming up with a successful aging policy.

Dr. Muriel Gillick, who will qualify for Medicare in three years, is a geriatrician and palliative care physician, and a professor in the Department of Population Medicine at Harvard Medical School. She has written four books for a general audience discussing ethical, medical, and other issues arising in old age, most recently “The Denial of Aging: Perpetual Youth, Eternal Life, and Other Dangerous Fantasies” (Cambridge, MA: Harvard University Press, 2006). She blogs at Life in the End Zone, where this post was initially published.

One Response to “Aging Well”

  1. Carol Eblen

    I agree that the PACE program is a good solution to the compassionate care of the elderly who generally accept that disability of some kind is an inevitable aspect of aging that is only avoidable by dying suddenly and prematurely while one is young.

    WE can learn from the courage of the young who are disabled who also, like the elderly, need the protection of law and policy to protect their rights to achieve their full potential to live a quality of life that is acceptable to them.

    Protecting Self determination and the autonomy of the elderly and the disabled should be the first priority of the Hastings Center and all of the bioethicists but it hasn’t been —has it?

    The bioethicists have failed the patients in their effort to protect the physicians autonomy to over treat patients for profit and/or compassion under guises like “therapeutic privilege” and articles written for each other like “Uncertainty and Futility: A Case Study, by Thomas P. Duffy, a founding member of the Hastings Center. .

    As life expectancy increases because of medical technology and as medical technology contributes to the better quality of living of the elderly who are provided with new hips and new knees and surgeries for better vision, etc.. there appears to be a move to target the elderly and the disabled with a “hurry up and die policy” when they become “terminal” and are over treated and under treated in the out patient setting at the end of their lives for profit and/or compassion? .

    Are you aware, Dr. Gillick, that the MBAs in Medicare and their private senior partners, big insurance, do not reimburse hospitals/physicians for the expensive hospitalizations precipitated by futile outpatient and inpatient treatment as determined by the MBAs in Insurance and not by medical professionals (except, of course, many physician heads of hospitals also have MBA degrees.)

    It appears that the bioethicists have enabled cruel over treatment of the elderly in the outpatient setting and the inpatient setting for many years since the 1991 PSDA was passed and they weren’t placed under its provisions. The hastening of the death of the elderly/disabled without their informed consent is a reality because the bioethicists have not been able to define “medical futility” since the Patient Self Determination Act became law in 1991.

    Medicare and Big Insurance didn’t wait for the bioethicists to define “medical futility” They define what is medically futile and fiscally futile and now the individual physicians are losing their autonomy as more and more physicians’ practices are bought up by the hospitals and the physicians become employees of the hospitals.

    Can a successful aging policy include an epidemic of unilateral covert and overt (default) DNR Code Status that is extrapolated into the medical charts of the elderly and the disabled to limit further treatment that is NOT deemed medically futile under some due process procedure but that nevertheless will not be reimbursed by Medicare/Medicaid and their partners, Big Insurance?