How the 'Old Old' Can Have Best Lives

Soaring numbers of people aged 85 and up will face challenges of coping with frailty.

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Americans 65 and older are projected to grow from 13 percent to 20 percent of the nation's population by 2050, when one in four older people will be 85 years of age or older. That's 5 percent of the entire country -- one in 20 people. That's the Age Wave getting ready to wash over us. Yet surprisingly little attention is being focused on the "old old." How are we going to take care of them? The ranks of geriatric medicine have been thinning, not growing. How are our communities going to accommodate and treat them? And, most important to older people, what does a high quality of life look like at that age and how can they attain it?

[See Growing Older, Getting Mellower, Feeling Good.] The period of life that precedes death for most people is characterized by several years of increasing frailty. Viewed as a separate and predictable late stage of life, are there ways frailty can be a positive life experience? In an academic-journal paper, "The Frailty Identity Crisis," Mount Sinai Medical Center professors Howard Fillit and Robert N. Butler say that psychological factors and attitudes toward frailty are some of the biggest current challenges, and potential opportunities, to improving this period of people's lives. "Most of us, if we don't die suddenly from something, will have this period of our lives," Filliet says in an interview. "It's called frailty and it lasts around four years on average."

Frailty is defined in different ways but generally reflects a pronounced decline in physical stamina and strength that often includes unintentional weight loss. Frail people usually have multiple medical problems that restrict their physical activities, the authors say. And they begin to feel like "old people," a process associated with a range of psychological problems, the loss of invaluable social networks and a struggle to find continued purpose in life. "Associated with the physical realities of growing old is an inability to project oneself into the future, an atrophy as real as any physical change," their article says, "In contrast to earlier developmental life passages, this transition is associated with a limited future and the perception of declining opportunities, followed by the realization of one’s impending death." Dr. Fillit is also executive director of the Alzheimer's Discovery Drug Foundation, and Dr. Butler is a long-time leader on aging issues who heads the International Longevity Center.

The frailty identity crisis, they suggest, can be addressed by recognizing frailty as a natural stage of life, developing a healthy psychological outlook to adapting to it, and then getting appropriate support from caregivers and, if available, family and friends. The goal is to build and maintain a lifestyle that adapts to the frail person's physical realities. But in continuing to seek social and other experiences, evidence shows that frailty itself can be reversed for some people. Developing realistic and attainable goals helps frail people rekindle a sense of purpose in their lives. Such goals need to be scaled to the frail person's specific circumstances, and the goals should change along with the person's physical capabilities.

[See Eat Less Food and Play More Bridge.]

External perceptions of frailty also can shape how well a person responds to frailty and whether they feel their remaining years can be worthwhile. "There is much more that societies could do to help frail patients, such as easier means of transportation and more effective senior services in communities that enhance independent living," the paper says. "Perhaps of most importance, the perception of frailty needs to be changed. Realistic, positive role models of frail older adults should be developed and promoted, recognizing their abiding value and dispelling stereotypes that proclaim that the only life worth living in old age is one of robust physical health."

Fillit says the medical profession, in particular, needs to do a better job of listening to older patients and interacting with them as people, not appointments. "People need doctors who recognize frailty for what it is and try to help people live with frailty, rather than ignore it or deny it," he says. Fillit says he often spends an hour with a patient while noting that the average doctor visit in the U.S. is eight minutes. And he stresses that much of the work he does involves listening and not dispensing medications. "This isn't rocket science, but someone has to ask the questions."

"The major problem of the older person is, what are you going to do with the rest of your life?" Fillet says. "And when you ask them, 90 percent of the time people have no answer. And it's not their fault. Society has not provided them with the tools" to answer that question. "And when I ask them that, they often say to me, 'Doctor, no one has every asked me that question before.'"

As an example, he recalls a recent patient. "I just saw a patient the other day who came in complaining of memory problems. I tested her and she didn't have any problems. It turns out that she was alone by herself all day. So, I told her to have at least one social meal a day with someone else, and she thought that was a great idea. She also said that she couldn't read any more because of failing eyesight. I knew this woman had financial means, so I suggested that she find a young person to come in and read to her, and she said she had been thinking about that for a long time but didn't know how to do it. It wasn't the reading I was trying to encourage, it was the social interaction," Fillet says.

"These people are just being put aside" by prevailing medical and societal attitudes, Fillit feels. "The goal of geriatric medicine is not to cure people. The old saw is that we are adding life to years, not adding years to life. It's all about the quality of life."