Overlooking the Frail Years

Paula Span raises a number of interesting issues in this poston 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.