By BILL THOMAS, MD
When most people think about independence in the context of aging, they connect it to issues related to medical diagnoses and treatment. In fact, the experience of independence in later life is defined primarily by and through function. The relationship between function and independence was first explored by Dr. Sidney Katz and his team at Cleveland's Benjamin Rose Hospital more than half a century ago. His team analyzed data on treatments, clinical progression, and patient outcomes gathered from older people under their care. Although they began their work with the expectation that clinical diagnoses would be the best predictor of outcomes, they found that it was seemingly ordinary abilities like bathing, eating, mobility and hygiene that tracked most closely with the ability to live independently.
This insight has never been more important than it is today. A 2009 report on Medicare beneficiaries showed that 25 percent self-reported difficulty with at least one ADL. Although overall chronic disability among older age groups has decreased in the last few decades, management of disability and maintenance of functional independence among elders has never been more important. According to a review performed by the Brookings Institute, a person's functional status continues to be a significant predictor of "admission to a nursing home; use of paid home care; use of hospital services; living arrangements; use of physician services; insurance coverage; and mortality."
During my decades in clinical practice it became clear to me that while our health care system's ability to diagnose and treat acute conditions is unparalleled, the tools we need to help elders safeguard and extend their function and independence are too often missing or unavailable. This is disheartening because practical determinants of function are exceptionally simple. People, especially people who are older and unwell, need to move, eat, sleep and heal. We can see the truth of this simple assertion in Dr. Harlan Krumholz's analysis of what he termed "post-hospitalization" syndrome. In an editorial, published in the NEJM he wrote, "During hospitalization, patients are commonly deprived of sleep, experience disruption of normal circadian rhythms, are nourished poorly, have pain and discomfort, confront a baffling array of mentally challenging situations, receive medications that can alter cognition and physical function, and become de-conditioned by bed rest or inactivity."
Whether they are in the hospital or at home, elders benefit greatly when we enable them to do the simplest and most vital things. We should help elders 1) MOVE by emphasizing physical activity and strength maintenance or improvement, 2) EAT by promoting good nutrition while addressing nutritional deficiencies, 3) SLEEP to enhance the body's ability to rest and recover while minimizing pain and stress so they can 4) HEAL. We are truly healed only when are able to move forward and find our new normal. Doing so would radically transform the experience of hospitalization and, as Dr. Krumholz concludes, "Shorter lengths of stay put an even greater premium on preparing patients for a successful convalescence from the first day."
Combatting "post-hospital" syndrome is important but what about the vast majority of older people who are not in the hospital or receiving care of any kind? A survey of offerings currently available to elders living at home are skewed toward "care" and essentially assist elders with closing the barn door after the "horse" of independence is already gone. What older people and their families need and too often cannot gain access to are specific strategies, tools and techniques that can help them master the art of moving, eating, sleeping and healing in their own homes and on their own terms. Older Americans, despite their many differences, are united on this point. They treasure the ability to live in the place and manner of their own choosing and want to do so for as long as possible. Who can blame them?
There can be no doubt that the health care system will continue to contribute vitally to the well-being of older Americans. In the not too distant future, however, doctors and nurses will be joined in this effort by new and deliberately non-clinical technologies, strategies and enterprises dedicated to helping millions of older Americans get the simplest things (move, eat, sleep and heal) right. These innovations should be welcomed by the health care professionals who are dedicated to safeguarding the health and well-being of their older patients. The ability to help elders improve their strength and well-being will do much to disrupt the conventional narrative of aging and craft a new story based on strength, purpose and belonging. We all deserve a new--and better -- old age.
