Aging With DignityAging With Dignity

Muriel R. Muriel R. GillickGillick, M.D., M.D.Department of Population MedicineDepartment of Population Medicine

Harvard Medical SchoolHarvard Medical School

Is this aging?Is this aging?

Or this?Or this?

Or this?Or this?

View of Aging TodayView of Aging Today

Healthy agingHealthy aging

Successful agingSuccessful aging

Active agingActive aging

Healthy AgingHealthy Aging

Successful AgingSuccessful Aging

Successful AgingSuccessful Aging

Rowe and Kahn,1997

WHO on AgingWHO on Aging

Active ageing:The process of optimizing opportunitiesfor health, participation and security in order to enhance quality of lifeas people age.

Good and Bad Old AgeGood and Bad Old Age

Historically 2 poles of old ageHistorically 2 poles of old age–– Positive pole: vigor, valorPositive pole: vigor, valor–– Negative pole: decline, deathNegative pole: decline, death

Dualism continues todayDualism continues today

Perfidious consequences of divisionPerfidious consequences of division–– Implies frail, demented, dying are failuresImplies frail, demented, dying are failures

Argument for TodayArgument for Today

Important to promote prevention to Important to promote prevention to foster robust agingfoster robust aging

Need to accept that many will develop Need to accept that many will develop frailty or dementia and all will diefrailty or dementia and all will die

Critical to find way to enable all to Critical to find way to enable all to retain dignity, whether robust, retain dignity, whether robust, demented, frail, or dyingdemented, frail, or dying

Argument for TodayArgument for Today

Describe historical dualismDescribe historical dualism

Define what I mean by people who are frail, Define what I mean by people who are frail, demented, or dyingdemented, or dying

Explain why attending to needs of these Explain why attending to needs of these groups is importantgroups is important

Capture what it is like to be in these groups:Capture what it is like to be in these groups:–– Describe physical needsDescribe physical needs–– Demonstrate psychosocial/existential concernsDemonstrate psychosocial/existential concerns–– Show what allows for aging with dignityShow what allows for aging with dignity

Aging in US HistoryAging in US History

PrePre--1800: dialectical view1800: dialectical view–– A time of loss, declineA time of loss, decline–– An opportunity for hope, redemptionAn opportunity for hope, redemption

18501850--1900: Victorian morality1900: Victorian morality–– Pole of sin, decay, dependencePole of sin, decay, dependence–– Pole of selfPole of self--reliance, virtue, healthreliance, virtue, health

Cole, The Journey of Life: 1992Cole, The Journey of Life: 1992

Aging in US HistoryAging in US History

19001900--1950: scientific management1950: scientific management–– Old are sick, poor, dependentOld are sick, poor, dependent–– Scientific knowledge as key to salvationScientific knowledge as key to salvation

19801980——present: healthy agingpresent: healthy aging–– Old have potential for vigor, healthOld have potential for vigor, health–– Good old age comes from exercise, diet, attitudeGood old age comes from exercise, diet, attitude

Cole, The Journey of Life, 1992Cole, The Journey of Life, 1992

Frailty: Failed Aging?Frailty: Failed Aging?

Defining FrailtyDefining Frailty

Chronic disease Disability

Vulnerability

Frailty

Why Frailty MattersWhy Frailty Matters

65+ in the US, 2005

Frailty Will Not Go AwayFrailty Will Not Go Away

An AgingWorld:2008

Dementia: Failed Aging?Dementia: Failed Aging?

Why Dementia MattersWhy Dementia Matters

Why Dementia MattersWhy Dementia Matters

Alzheimer’s DiseaseInternational, 2009

Dementia Rx LimitedDementia Rx Limited

Cholinesterase inhibitors Cholinesterase inhibitors ““lead to lead to modest benefit in a substantial modest benefit in a substantial minority of patients.minority of patients.””

APA Practice Guideline, 2007APA Practice Guideline, 2007

Dementia is Not Dementia is Not PreventablePreventable

““There is currently no evidence There is currently no evidence considered to be of even moderate considered to be of even moderate scientific quality supporting the scientific quality supporting the association of any modifiable association of any modifiable factorfactor……with reduced risk of with reduced risk of AlzheimerAlzheimer’’s disease.s disease.””

–– NIH State of the Science Conference, 2010NIH State of the Science Conference, 2010

Dying: Failed Aging?Dying: Failed Aging?

Death is Part of AgingDeath is Part of Aging

An Aging World:2008

End of Life TrajectoriesEnd of Life Trajectories

Lynn, AdamsonRand: 2003

Aging with DignityAging with Dignity

Challenge is to invoke prevention to Challenge is to invoke prevention to promote robust agingpromote robust aging

Simultaneously avoid neglecting frail, Simultaneously avoid neglecting frail, demented, and dyingdemented, and dying

Stories of real patients provide the keyStories of real patients provide the key

A Man with FrailtyA Man with Frailty

Sam: 83 year old widowerSam: 83 year old widower

Hospitalized with chest painHospitalized with chest pain

Underwent cardiac catheterizationUnderwent cardiac catheterization

Refused surgeryRefused surgery

Went home with intermediate careWent home with intermediate care

What Mattered to Sam?What Mattered to Sam?

Physical domainPhysical domain–– Functioning in his apartmentFunctioning in his apartment–– Control of shortness of breath, painControl of shortness of breath, pain

Psychosocial/existential domainPsychosocial/existential domain–– Playing/listening to musicPlaying/listening to music–– Helping othersHelping others

What Made Dignified What Made Dignified Aging Possible?Aging Possible?

Palliative approach to carePalliative approach to care–– Focus on symptom relief, not lifeFocus on symptom relief, not life--

prolongationprolongation

Technological innovationsTechnological innovations–– To maintain independenceTo maintain independence

What is Palliative Care?What is Palliative Care?

Comprehensive, interdisciplinaryComprehensive, interdisciplinary

Approach to pain and symptom controlApproach to pain and symptom control

With attention to psychosocial issuesWith attention to psychosocial issues

And a focus on advance planning forAnd a focus on advance planning for

Patients with lifePatients with life--limiting illnesslimiting illness

Role of Palliative Care Role of Palliative Care

Lynn, AdamsonRand: 2003

Technology for Frail ElderTechnology for Frail Elder

A Woman with DementiaA Woman with Dementia

78 year old woman in nursing home78 year old woman in nursing home

Hospitalized with hip fractureHospitalized with hip fracture

Confused, agitated in hospitalConfused, agitated in hospital

Decision to focus on comfort and Decision to focus on comfort and simple lifesimple life--prolonging measuresprolonging measures

What Mattered to Alice?What Mattered to Alice?

Physical domainPhysical domain–– Comfort; lifeComfort; life--prolongation if compatible prolongation if compatible

with comfortwith comfort

Psychosocial/existential domainPsychosocial/existential domain–– Human interactionHuman interaction–– Continuity of selfContinuity of self–– MusicMusic

What Made Dignified What Made Dignified Aging Possible?Aging Possible?

Medical focus on comfort Medical focus on comfort

Appropriate living environmentAppropriate living environment

WellWell--trained caregiverstrained caregivers

RelationshipsRelationships

Older Dependency RatiosOlder Dependency Ratios

An Aging World:2008

A Dying ManA Dying Man

66 year old engineer with brain tumor66 year old engineer with brain tumor

Biopsy showed malignant Biopsy showed malignant gliomaglioma

Oncologist advised surgery and chemoOncologist advised surgery and chemo

Mental status markedly declinedMental status markedly declined

Family opted for home careFamily opted for home care

What Mattered to Jay?What Mattered to Jay?

Physical domainPhysical domain–– Control of seizuresControl of seizures–– Management of incontinenceManagement of incontinence

Psychosocial/existential domainPsychosocial/existential domain–– Interaction with familyInteraction with family–– Establishment of legacyEstablishment of legacy

What Made Dignified What Made Dignified Dying Possible?Dying Possible?

HospiceHospice–– Interdisciplinary teamInterdisciplinary team–– Expertise in symptom management, Expertise in symptom management,

access to access to opioidsopioids

Dignity therapyDignity therapy–– LegacyLegacy–– AutonomyAutonomy–– Continuity of selfContinuity of self

Meaning at the End of LifeMeaning at the End of Life

Nicholas Nixon,Photography

ConclusionConclusion

Prevention useful to promote robustPrevention useful to promote robust

Focus on successful aging ignores Focus on successful aging ignores vulnerable eldersvulnerable elders

Separation of aging into positive and Separation of aging into positive and negative poles historically perilousnegative poles historically perilous

Need to focus on dignity/qualify of life Need to focus on dignity/qualify of life for all eldersfor all elders

No Magic BulletNo Magic Bullet