Aging Well

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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

    Thank you, Dr. Gillick, for this interesting article and for sharing your Mother’s experience and her view of her old age with us. I agree with your Mom that it is hard to age, but she has aged “well” and “successfully” in comparison to others of her age who have chronic disease and/or disabilities that make finding joy in their lives more difficult or almost impossible.

    I am 86 and believe that I have aged “well” and “successfully” because I can still do all of the daily activities of living and am still driving. I have no chronic diseases but a little pain with my right hip and now and then a little trouble with my equilibrium. I play bridge for three or four hours at a time three times a week and work on the puzzles in the paper, read and watch TV and socialize with my children, who live close by, and now and then go out to dinner with friends.

    I know I will never run or dance again and that most of life is behind me and the next biggest challenge I will have in life is to die a good death —but I’m not ready yet. While I am sometimes depressed, I am sometimes happy and joyful, as has been my lot for all of my life.

    You ask “Are we using the right definition of ‘successful aging?'” and you believe we should have a “successful aging policy” that assures that everyone has a “fair chance to make the most of themselves.”

    I agree with you! But to do this, we cannot take the right of “self determination” away from the elderly and disabled because they are the most logical patients upon which to save dollars for Medicare and private insurance on end-of-life costs. —Can we?

    You must know that The Patient Self Determination Act of 1991 passed by the US Congress at the request of Medicare has been circumvented to date both as to the elderly/disabled patients “right to die” and the “right to live” for reasons of fiscal expediency —for profit!

    The noise in the Congress and the new laws passed in the past few years in some of the states, like New York, indicates that the states have not implemented the provisions of the PSDA in a manner that protects the autonomy of the elderly/disabled to decide for themselves when they “are better off dead.” —-unless, of course, “medical futility” is invoked by the hospitals/physicians under some “due process” procedure.

    As a consequence of the failure of the states to implement the goals of the 1991 PSDA, i.e. (1) to prevent over treatment of the elderly for the profit moti8ve and (2) to save money for Medicare and the private insurers when elderly/disabled patients would CHOOSE/ELECT to refuse expensive life-extending/life-saving treatments in order to shorten their suffering unto a certain death, Under the 1991 PSDA, the life-extending/life-saving treatment that the elderly/disabled person refuses in an advanced directive does NOT have to be deemed medically futile by the hospitals/physician.

    The Medicare Hospice Entitlement together with the PSDA has not been as successful as was anticipated in reducing end-of-life expenses for our growing older population. Self-rationing by elderly patients was not encouraged when treating physicians chose not to seek informed consent from the elderly/disabled for curative care as opposed to palliative care/transition to hospice. Over treatment for profit of the elderly/disabled on Medicare has been a terrible problem for Medicare and the private insurers. Several years ago, CMS started to introduce reimbursement protocols that punish physicians/hospitals for non beneficial over treatment, errors, mistakes, omissions, and the complications thereof. The elderly Medicare patients are unaware that they are Charity patients for the hospital and in a very hostile situation. They don’t have to be informed under current law.

    The Hastings Center says it believes in “self determination” but unless the bioethicists recognize and expose that fiscal futility and medical futility often exist in the same patient and that over treatment and errors, etc.. are not always reimbursed to the hospitals/physicians by CMS and the private insurers, the concept of “self determination” is destroyed,