The Very, Very Old: The Challenges of Increased Longevity

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A new entry for our forthcoming book on the MediCaring model for care for frail elders. 

Living to be very, very old–advanced old age, the oldest of the old–is not just middle age with gray hair.  It is not. And yet even though we know what is ahead,  very old age will come as a shock to most of us. We have been lulled into thinking that we will all age well–that we will be 90 and still dancing with the stars, or jumping from airplanes. Or we think that we will die with a golf club or a steering wheel in our hands,  a lover in our arms. We expect to go on forever as we always have done, making our own choices, providing for ourselves and our families, and living out our triumphs and despairs surrounded by kith and kin.  We are sustained by complex social and cultural arrangements that influence each of us,and that we influence.  For most of our lives, that framework is almost unnoticed and is enough to meet our needs.  When living with serious limitations in old age, we find that we urgently need assistance for daily needs.

The realities of living with multiple chronic conditions (MCC) and in a challenging economy have changed the experience of retirement. Millions of Boomers will age with  MCCs, such as hypertension, diabetes, glaucoma, arthritis, and even cancer, that will require increasing levels of clinical management to get by. And, at some point, those who survive to  advanced age, will find that at the usual  supports and arrangements no longer match our needs, either for medical care or social services. As we have grown better at preventing or treating diseases like cancer and heart disease,  millions of us will manage to live  into our ninth and tenth decades, developing serious chronic medical problems, and eventually becoming quite old and very frail. Indeed, the fastest growing demographic in America is the 85 and older crowd.

This demographic reality is forcing us to consider another reality:  the challenges often associated with living  into “older” old age, when long-term disability and the confluence of multiple chronic medical problems and diminishing social and financial resources makes a new and unfamiliar set of life challenges. This is truly the new old age: the predictable, but often unexpected, result of better health care and improved public health.

Quite simply, most Americans now face a long slow decline, rather than a short course to death.  For the most part, we will endure this period because life, even when we live with significant health problems, is sweet. But in our current medical and social services environment, enduring will be a real challenge, one that will require significant levels of direct personal help, medical care, and financial resources . We will find that thriving in advanced older age requires  major rearrangements of assumptions about relationships, meaningfulness, and life in general. And many of us will find the task made even more difficult by our collective failure to address what lies  ahead.

Such simple things will throw us off course: One bad fall, and we often cannot live alone in the family home again.  A little more loss of sight, and we cannot drive to get food or to visit friends.  The margin between living as we wish and being in serious trouble becomes quite thin.  Physiologically, people in their eighties and   beyond have very little reserve in most organ systems, so a challenge to the heart, or lungs, or kidneys, or any other organ system leads to evident and serious illness. Unlike younger people, what was once  a minor setback that is behind us within a few days can now lead to death.

The rate of cognitive failure increases dramatically with age: those who make it to age 85 have a 50-50 chance of having serious memory loss as a major part of their life course (1).  Many will have Alzheimer’s type dementia, but some will have strokes, dementia associated with Parkinson’s disease, or another etiology. And those who evade chronic failures of the mind are still at risk of distorted thinking from delirium with a fever, a change in medication, or even dehydration.  The rate of disability for self-care — often called functional disability, or dependency in activities of daily living — also increases dramatically with age.  Most older adults eventually have some problems  walking and moving about.  Many have challenges with communication, incontinence, tooth loss, arthritis, and other troublesome body malfunctions.   These problems continue, and generally worsen, for several (sometimes many) years, through to the end of life.

To live well in late old age, we really have to depend on one another more than we do at any other time in life, except, perhaps, for infancy and early childhood  Sometimes, devices, medications, or simplifying one’s daily routine helps a great deal.  But even then, another person usually must be “on call” in case something goes wrong.  For most of us, there comes a time when we depend on other adults to help us with the most routine acts of daily life, from getting out of bed to getting to the bathroom, from surviving from dawn to dusk.

And yet we do not now have the structures in place that will support our survival. MediCaring offers a new, better, and more affordable model for providing medical care and social services to frail elders and their families. Building it will require ingenuity, trial-and-error, and investment. Whether we build it or not, the very old will come. Build it now, and the future might be easier on us all.

key words: Dr. Joanne Lynn, Medicaring, frail elders

(1) Alzheimer’s Foundation of America. Alzheimer’s Statistics. http://www.alzfdn.org/AboutAlzheimers/statistics.html. Accessed April 21, 2014.

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