Saturday, January 2, 2010

Overlooking the Frail Years


Paula Span raises a number of interesting issues in this post on the NY Times New Old Age Blog. She presents the story of an active 70 something man who was very comfortable discussing the possibility of his death, but seemingly unable to discuss the possibility of being frail and needing help caring for himself.


As the post notes, most people will have a period (often quite long) of frailty at the end of their lives in which they will need the help of another person for some tasks of daily living. I think the popular media and many in the medical profession sometimes try to suggest otherwise, suggesting that frailty is avoidable if you just do the right things. The evidence overwhelmingly suggests otherwise. It is certainly right to encourage good health habits, including good nutrition and exercise. But it is more likely that healthy living will delay frailty--not avoid it.


I think even in Geriatrics, we sometimes oversell our ability to prevent functional decline and frailty. In our enthusiasm, we point to some intervention studies that have reduced the risk of disability. These intervention can clearly enhance the well being of older persons, and it is a shame they are not more widely implemented. But if one looks closely at these studies, the effect sizes tend to be modest, and they slow down trajectories of decline rather than stop these trajectories.


Is there any harm in overselling the ability to prevent frailty and functional decline? I think there may be. Ms. Span deals with one of these harms--it may inhibit people from advance care planning that considers what elders want to happen if they can no longer live independently.


But, I think there is another harm as well. I think it may inhibit research and policy planning that could improve the quality of life of frail persons. It may also cause the public to to undervalue the frail elderly.


There is sometimes a tendency to think of functional dependence as almost akin to a terminal outcome. We need to think much more about how frail dependent elders can maintain good quality of life. I think many of us can certainly point to very frail patients who continue to be socially engaged and seem to maintain an excellent quality of life. These elders are not included in most definitions of successful aging, but they certainly are successful agers, and we need to learn much more about how we can facilitate this type of success.

6 comments:

Christopher Langston said...

Thanks Ken - One reason people don't like to think about the probability of a period of frailty in the years before the end of life is the fear we have of dependence. I don't think there are any socially acceptable cultural models of being profoundly dependent upon others after childhood.

I also agree that this inability to face the probability of frailty and dependency has consequences. I think it is one reason that we don't work very seriously as a society to improve the quality of life and care in nursing homes. People think that it won't happen to them or that they won't let it. The Times' blog is full of people who say that they would rather be dead than in a nursing home.

To those who say that they'd rather die than go to a nursing home, I reply that you get to go to a nursing home and get to die.

Chrissy Kistler said...

I think we all understand that we will die some day; we just want to be perfectly healthy right up until the end. Pretty much everyone I know is terrified of Alzheimer's or the other dementias' slow inexorable mental and physical decline. Yet even when we're talking about non-cognitive impairment, i.e. physical impairment and infirmity, these are huge issues that threaten our sense of self. I agree that many people don't want to think about: what will happen when I can't cook for myself, can't bath myself, can't clean my house/apartment...

My 83 yo grandmother has been having difficulties getting herself around, and trying to discuss giving up the car, hiring someone to chauffeur her around, help with the household chores, it's really, really hard on her. I can't imagine how difficult it would be to discuss worsening frailty and dependence. As a physician it's hard, as a family member, doubly so.

Alex Smith said...

Can I compare to cancer? In cancer, historically, there has been so much focus on "cure" rather than "care" and doesn't leave enough room for those who will not be "cured." Doesn't leave room for patients, their family caregivers, health providers, or researchers.

Similarly with frail elders, the focus has been so exclusively on prevention and restoration of function, it leaves little room for the overwhelming majority of elders who develop progressive functional dependence.

ken covinsky said...

Thanks for the thoughtful comments. A few additional thoughts:

Chris--It is interesting to think about how we balance the natural fear of dependence with efforts to improve societal attitudes towards the frail, who are often marginalized.

We all would prefer to be robust rather than frail. At the same time, most moral traditions put great value on respect for the elderly. This should translate into efforts to improve the quality of life of the elderly, whether that be the robust elder sage, or the frail elder with dementia. Maybe we need to do more to frame both the socio-medical and moral arguments for better care of the frail elderly.

Chrissy--I think your story again illustrates the point Span was making: It is almost easier to contemplate death than being dependent. On the other hand, the implication of never being frail is sudden death. Despite what people say about "not wanting to be a burden" it seems this pathway is actually much harder families emotionally.

Alex--the analogy to cancer is interesting. In both cases, the failure to complement, "curative" treatment with "carative" treatment can lead to poor care.

What is interesting about frailty and functional decline in the elderly is that it is not commonly thought of as a palliative care condition. But in actual practice, much of what we do to help patients is palliative, and the palliative care model has a lot to teach us about the management of frailty. Perhaps a factor that has inhibited the application of this approach is that palliative needs of frailty are much less driven by prognosis and much more dictated by clinical need.

Melanie Haiken said...

Hi Ken,
This a great post and helpfully amplifies on the topic as introduced by the NYT. I continued the discussion on our blog at Caring.com and linked to your post; thought you might want to see it. Link: http://www.caring.com/blogs/caring-currents/facing-up-to-the-reality-of-frailty-and-decline-in-a-family-members-last-years

Andrew Dudley said...

Hey guys,

I feel that more should be done to counter the age related loss of skeletal muscle (sarcopenia) and ensuing frailty by encouraging strength / resistance training.

It has been shown in countless studies that it is never to late to start. If the patient can pick up a weight, no matter how small, their skeletal muscle will instantly respond.

Therefore, any patient facing the uncertainty of frailty, has the ability to take preventative action by rebuilding and maintaining their strength and physical function, thus delaying and even evading entry into a sedentary lifestyle, frailty and the disability zone...

Andrew Dudley
Editor
Sarcopenia.com