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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