PREPARING FOR OLD AGE

As the days go by, none of us gets any younger; the call of ageing is that which we all must answer.

If we're going to add life to years—and not just years to life—a few things need to change. Here are some suggestions.

Changing Attitudes

1. Scaffolding

Society hasn’t provided any structural “scaffolding” for aging. There are all sorts of guides for the first part of the lifespan, but nothing for the person who says, “I’m 75, now what?” If we’re going to create a better old age, we need to find ways to help older people lead meaningful lives. Meaning can come from any number of directions. One is volunteering—older adults volunteer more hours than any other age group. Another way to foster meaning is reminiscence therapy, which helps older people make sense of their lives and let go of certain things. One of the biggest issues for older adults is forgiveness, often in the context of family.

2. A Lifespan Approach

To prevent difficulties in old age, you need a lifespan perspective. A primary care provider needs to work across the age range. So does any specialist. I’m not saying there shouldn’t be people who know a lot about gerontology or midlife issues, but it’s impractical to have separate gerontology units in health systems, except perhaps in very large systems like Michigan’s. Nor am I sure that, theoretically speaking, it’s appropriate. If a health practitioner who’s seeing an older patient needs expert advice or consultation, then he or she should have it—but do we really want to set up a system where there are gerontology nurses, case managers, diagnosticians, and so on? Children are different—their diseases manifest differently—so I believe we need pediatrics specialists. But when it comes to adult medicine, a lifespan approach is the way to do it. And so far, our system is not set up for that.

If we want to improve people’s health in old age, we must make sure their health at any given point in time is good. And we must work to minimize the rate of decline to a point where they can stay as healthy as possible as long as possible. This is quite consistent with the kind of life-course perspective on health that is widely advocated by both the U.S. Centers for Disease Control and Prevention and the World Health Organization. A life-course approach means that if people want to age healthily, they need to begin practicing health-promoting behaviors when they are young—don’t smoke, use alcohol moderately, exercise, watch your diet, and so forth. That’s very straightforward.

In early 2013, the Institute of Medicine issued a report on the health of people in the U.S. as compared to 17 peer countries. The report underscores the need to adopt a life-course perspective on health: if we want to improve the experience of aging, we have to start prenatally. The report also highlights the fact that social determinants of health are shaping future cohorts of the elderly. So much of our narrative around optimal aging is still focused on individual responsibility for your health, as opposed to changing society in ways that support healthy practices—things like health-care financing, walkable cities, access to healthy foods, the elimination of poverty. The list is long. It’s much easier to tell someone you should eat this or do this than to say, “We need to overhaul the entire system.”

3. Retire from Driving

Studies show that older drivers have higher crash rates per mile driven than most other segments of the population. Older drivers are also frailer and therefore more vulnerable to injury. This suggests we should all plan to “retire” from driving when we get older, much as we retire from other things. But few people plan for that. Many people are downright naïve and in retirement move to a mountaintop, which means they’re dependent on driving.

Better public transportation would help. Livable cities, where you can get your needs met without having to drive, would also be good. In the meantime, the best idea I’ve heard about is a group of older people in Maine who got together and decided to share ownership of a car and to share a driver. It’s still a private car, but it’s not the senior shuttle, and it’s not a van for the disabled. It seems to me this is a plan many of us could adopt.

4. Rethink Dementia

We’ve invested a lot of energy and resources into the effort to find new drugs and means of earlier detection of Alzheimer’s and dementia, instead of looking for more holistic ways to care for those who already have the disease. The British psychologist Thomas Kitwood wrote at length about the importance of working with the existing capacities of people with Alzheimer’s. Kitwood’s aim was to understand, as far as possible, what care is like from the point of view of the person with dementia, and he identified a number of psychological and social factors that must be met in order for people with dementia to maintain well-being—chief among them comfort, attachment, inclusion, occupation, and identity. Closer to home, Anne Basting of the University of Wisconsin, Milwaukee, offers a cultural critique of dementia care in her book Forget Memory (2009). Basting stresses the importance of engaging persons with Alzheimer’s and other dementias in activities that focus on the present, and she includes examples of innovative programs that stimulate growth, humor, and emotional connection. In The Moral Challenge of Alzheimer Disease (2000), Stephen Post of Stony Brook University takes an ethical look at the way we treat people with Alzheimer’s and dementia and criticizes our “hypercognitive society” for placing inordinate emphasis on people’s powers of rational thinking and memory.

Changing Environments

5. Social Life

Social engagement is a critical component of healthy aging, so in thinking about aging, and in designing both clinical and policy interventions, we need to pay attention to the social life of older adults. When we design residential facilities and care programs, we need to recognize that the social component of those facilities and programs is an important—and positive—attribute. When we’re creating an intervention to promote mobility and exercise, we should think about including an obvious social component that encourages and facilitates social connections. Walking groups in malls or parks or neighborhoods, for example, give people the opportunity to connect with one another while exercising.

6. Age-Friendly Cities

Populations worldwide are aging rapidly, and it’s incumbent on cities and communities to strive to meet the needs of this growing demographic. Through its Global Network of Age-Friendly Cities and Communities, the World Health Organization is identifying those cities around the world that are actively trying to better meet the needs of residents over 60 by integrating an aging perspective into urban planning and creating age-friendly urban environments. Cities and communities in the network are of varying sizes and involve a range of cultural and socioeconomic contexts, but they are linked by a common commitment to reducing or eliminating barriers and expanding services in such key areas as housing, transportation, communication, health care, and outdoor spaces and buildings.

7. Better Nursing Homes

Without common quality measures and agreement on definitions, it’s hard to assess what’s happening in nursing homes across the U. S.—let alone across the world. What constitutes diabetes? How do you define incontinence? What do we mean by a nursing-home “bed”? For the past two decades, my research group has been working to establish standard measures for nursing-home assessments.

We’ve developed international standards and at least 20 measurement instruments that are being used by nursing homes around the world. We’ve developed clinical assessment protocols, or CAPS, that help identify major problem areas and offer guidelines on how to address those problems. Our work now extends far beyond nursing homes and is being applied in the areas of mental health, pediatrics, intellectual disability, palliative care, and prison populations.

Brant Fries, Professor, Health Management and Policy; Research Professor, U-M Institute of Gerontology

In the broader world of long-term care and nursing homes, there’s much discussion of the need to move away from what Dr. Bill Thomas, founder of the Green House Project, describes as “a factory, assembly-line approach to care” and toward a more diffuse, community-oriented approach that “enriches all of our lives, caregiver, family member, and elder alike.” As Thomas argues, “We do damage to people of all ages when we fail to honor and care for the frailest and chronic, most chronically ill among us.” Thomas is convinced the baby boom generation will force a change. When baby boomers were kids, he says, there were just three flavors of ice cream. Now there are thousands. Today there are “just a few flavors of long-term care for the elderly.” But when the boomers work their way through the system, “there will be a thousand flavors. And that’s the way it should be.”

We need to examine—and find ways to reduce—the use of antipsychotic drugs in nursing-home patients. Between 60 and 70 percent of nursing-home residents have dementia—often in combination with depression—and as recently as four years ago, one in four of them was on antipsychotics. There is substantial literature on how to treat the behavioral symptoms of dementia without resorting to psychotropic drugs. Nursing staff members need to be trained and encouraged to do that.

A promising trend is the recent emergence of nursing home physician-specialists—sometimes referred to as SNFists, or Skilled Nursing Facility specialists. Similar to hospitalists, SNFists exclusively manage patients in skilled-nursing facilities and also follow patients from the hospital into post-acute care in nursing homes. Patients benefit from the consistency in care, and there are signs that SNFists help reduce hospital readmission rates.

8. Home Care

Increasingly, we’re trying to help move people out of nursing homes or not put them in nursing homes in the first place. My research group is working with several states to develop algorithms and instruments to determine who needs to go into a nursing home, who’s eligible for care, and who can be cared for outside of a nursing home. States are looking for ways to reduce Medicaid expenditures, and one way to do that is to identify those individuals who could be cared for equally well in a different setting, or with fewer resources. Globally, whole nations are adopting these same instruments.

Home care is clearly a growing trend. Many countries are asking how they can provide a continuum of services to let people age healthily at home rather than in institutions. In England, there’s talk of substituting home care for costly skilled care in nursing homes. The Scottish National Health System is working to develop a telephone triage system to help keep seniors from overusing emergency-room services—an important factor in making it easier for older adults to live at home. But since both home care and assisted living are much less regulated than nursing-home care, we need to examine the quality of care people receive in home settings and identify problem areas.

Changing Systems

9. Experience Corps

A promising idea to promote social engagement among older adults is a program called Experience Corps, launched by Columbia University epidemiologist Linda Fried and her colleagues. A community-based volunteer program that pairs older adults with school kids, Experience Corps is designed to bolster the academic success of children while promoting the health and well-being of seniors. This kind of intergenerational program is precisely the sort of intervention we need to be developing.

10. Long-term Care

If there’s one best-practice idea we should adopt in the U.S., it’s social insurance for long-term care. Japan has had it since 2000 or 2001, Germany since 1995, and the Netherlands for even longer. South Korea started a mandatory long-term care insurance program a couple of years ago, and Taiwan is considering doing the same.

Clearly the U.S. is not ready to take on another major new initiative like long-term care, but we should be thinking about it. On average, older Americans can expect to spend three years in need of assistance for functional disability. According to the most recent figures, the average cost of full-scale nursing care in the U.S. is $82,000 a year. You can easily become destitute. High-income Americans can presumably afford the high cost of care, and low-income Americans have Medicaid, so it’s primarily the middle class who will suffer.

11. Multiple Chronic Conditions                      

Because of the specialization that defines our medical care system, our overall system is set up to deal with chronic conditions one by one by one—but it’s not uncommon to find older adults who have ten or more chronic conditions. To make real progress on dealing with the challenges of multiple chronic conditions, or MCCs, three things must happen: 1) We need to improve our data-sharing systems and induce health care providers to share information among different specialty groups. 2) We need to adopt a community-based approach to chronic-disease management—which we can do in part by training, certifying, and supervising community health workers to work across conditions and be part of a clinical care team that isn’t specialty-oriented. 3) We need to find creative ways to close the gap between what happens to a person in the clinic and what happens in day-to-day life. Health care providers can work with local supermarkets, for example, to provide educational sessions and healthy-food coupons to people with chronic conditions, and with park and recreation facilities to lower admission fees and even donate services.

In 2010, the U.S. Department of Health and Human Services issued a framework for addressing multiple chronic conditions, and that effort has inspired a great deal of research, much of it focused on the need to develop clinical practice guidelines for people with co-morbidities. Often, what doctors prescribe for managing one disease will contradict or counteract the regimen prescribed for another condition. Patients can easily feel overwhelmed and depressed. In fact, depression is higher in patients with MCCs, and with depression comes a host of problems—including lack of motivation for self-care. We need to address that..

12. No More Fee-for-Service

If we’re going to control both Medicare and private spending for senior health care, we need to move away from a strong fee-for-service orientation and toward a system that gives both hospitals and physicians greater incentives for thinking about efficiency. The Affordable Care Act has created some momentum for this, and there’s some acknowledgement on the provider side that the old system is going away, but this may not be enough to move the needle.

13. Telemedicine

Telemedicine can connect older adults with health care providers regardless of location, time, and geography. The most significant recent development is “telehome care”—or in-home monitoring of chronic illness—which can range from a simple alert system for people who find themselves in an emergency situation, to ongoing monitoring of conditions like diabetes and congestive heart failure, to the design of unobtrusive environments for detecting and measuring health issues like food or liquid intake.

Chronic illness is on the rise, and more people are living to older age, so this technology is likely to become more common. And in-home devices are becoming less expensive.

14. National Health ID

Some countries, like Belgium, have adopted a national health I.D. system that uses electronic records, so that providers can, with permission, access a patient’s personal health history. So if an older person shows up at a hospital in a confused state, a provider can find out whether that person has dementia or some other condition that might explain his or her confusion. This can be critical to saving lives and determining treatment. It’s a system Nigeria  should adopt.

15. Advanced Directives That Work

In general, our system in Africa. is not equipped to help people efficiently and expeditiously draft advanced care directives for end-of-life treatment, including Do Not Resuscitate orders, or DNRs. As I discovered when I set out to draft an airtight advanced directive for myself, each individual state has its own requirements, and few have any language to deal with the issue of intellectual disability. We need a more accessible and systematic way of helping people set up advanced directives for end-of-life care.