I.Learning from the Oldest-Old Return to the Beginning
Too often we think of older age as simply the loss of functioning rather than a time to enjoy the fruits of a long life. Many elders themselves believe that older age brings mainly unhappiness and poor health. More than half of the elders in one survey associated old age with depression, dependency, reduction in sexual ability, aches and pains, trouble sleeping, less energy, and unattractiveness (Sarkisian, Hays, & Mangione, 2002). No wonder anti-aging creams sell so well! However, later life may also mean more leisure time and having the wisdom to focus on what is truly important. Of course, enjoying these benefits of aging depends on having good health and independence.
Fortunately, we have begun to learn why some people seem to be contented and healthy into their 90s and 100s, while others die in late middle age. Some scientists believe that humans of the future, perhaps even the near future, will live hundreds of years (Wright, 2003). Others believe that the average lifespan will never go much above what it is now. As of now, however, it appears that your older patients are probably divided into two groups. Most people can make it into their late-80s in good health if they take care of themselves. Good habits can generally add about eight years of life to the average lifespan. Those in another smaller group have a natural tendency to long life that opens the possibility of living to 100 or more. These people also frequently, but not always, have a healthy lifestyle (Perls & Terry, 2003). Looking at the long-lived in both these groups tells us many things you need to know to take the best care possible of your patients.
So, what do those who live healthfully to very old age have that everyone else does not?
A. Better Health Overall
Studies of the “oldest-old, that lucky 100+ group, ” show that they do not have the same number of illnesses as other elders. Many only reach great frailty at the very end of their lives. A group of Georgia centenarians had about the same number of medications and ill health as younger elders (Purdy, 1995). Centenarians from the New England Centenarian Study had a mean of only four chronic diseases, 3.4 medications and 6 hospitalizations per year (Hitt, Young-Xu, Silver, & Perls, 1999). One of five had no serious diseases even at age 100 (Friedrich, 2002). Nine out of ten of centenarians lived independently in their homes to an average age of 92 (Perls, undated).
Those who live longest also tend to avoid dementia longer that others. Among New England study centenarians, about a third had no dementia (Friedrich, 2002). The Georgia study found that centenarians functioned as well cognitively as those in their 60s or 80s if they used their life experience for problem-solving. Still, their overall cognitive level was less than for younger people (Georgia Centenarian Study, undated).
Clearly, those who live to be 100 or more not only have longer lives, but healthier lives as well.
B. Healthy Habits
So, what makes for so many decades of good health? The good news, for those who eat right and exercise, is that those who live to very old ages frequently practice basic healthy habits. The bad news, if you are one of those whose idea of a great lunch is a hot fudge sundae topped off with a cigarette, is that those who live to very old ages frequently practice basic healthy habits. While this is not surprising, it does underscore the very real benefits of healthy habits.
1. Good Nutrition and Exercise
Three studies found that those who maintained a healthy weight tended to live longest (Georgia Centenarian Study, undated; Vaillant, 2002; Perls, undated). In addition, the Georgia centenarians ate more vitamin A and carotenoids, though similar numbers of calories and fats as younger people. They also had breakfast regularly (Purdy, 1995, Georgia Centenarian Study, undated). They did, however, drink whole milk rather than lower fat alternatives (Georgia Centenarian Study, undated). A diet high in folic acid may also help keep away Alzheimer’s disease (Snowden, 2001).
The Georgia study found that the centenarians tended to be active (Georgia Cententarian Study, undated), while a study by Harvard also found an association between moderate exercise and longer life (Vaillant, 2002).
These healthy habits are also important for those who may not live to 100, but who wish to have the longest, healthiest life possible. The Agency for Healthcare Research and Quality says that 14% of deaths in 1993 were the result of poor nutrition and lack of exercise (Agency for Healthcare Research and Quality, 2002). A variety of other studies may have found some of the reasons why activity is so important to long life:
older women who are active have almost 6 years of “active life expectancy” more than women who are inactive women who exercised had 58% fewer falls exercise helps sleep one study found strength training as effective as medication for depression exercise may help reduce rate of cognitive decline
(Centers for Disease Control, 2003)
2. Don’t Smoke Or Drink Much If You Want to Live Longer
You probably will not be surprised to learn that centenarians tend not to smoke or do not have a long history of smoking. This was true of the Georgia centenarians, the New England Centenarian Study, and Harvard’s study (Georgia Centenarian Study, undated; Vaillant, 2002; Perls, undated). A study of nuns also underlined the importance of not smoking. While the death rate from smoking-related illnesses in the U.S. was rising along with the number of those who smoke, the non-smoking nuns rarely died from these conditions (Butler & Snowden, 1996).
Your patients who use alcohol only moderately are also more likely to be longer-lived (Georgia Centenarian Study, undated; Vaillant, 2002). This is especially important given that 9% of those 55 and older do “binge drinking” (Substance Abuse and Mental Health Services Administration, 2001) while 17% of elders have some form of alcohol or medication management problem (Substance Abuse and Mental Health Services Administration, 1998). Medication mismanagement can include becoming addicted to medications, intentionally or unintentionally not taking them as prescribed, or having adverse interactions between medications.
Substance abuse can be especially dangerous to older adults beyond those affecting substance abusers of all ages. Even elders who don’t “binge” may find that they tolerate the effects of alcohol and medications less well than when they were younger (Substance Abuse and Mental Health Services Administration, 1998). Also, both alcohol or medication abuse may be misdiagnosed as dementia and other ailments associated with later life (Blow, 1998). Finally, alcohol can interact with many prescription medications. The more medications an elder takes, the more likely they are to have an adverse reaction that could endanger their life and health.
3. Still, Maybe Your Patients Will Be Able to Get Away with Bad Habits
While good health habits abound among those who live to be 100 or more, not all centenarians practice them. “In fact, “a small number of people, particularly guys, do everything short of throwing an atomic bomb at their bodies and still live to be 100” (Wright, 2003). Clearly other factors affect length of life and health. What are some of these?
C. Mental Well-Being
Older adults who are free from mental illness and have a go-get-‘em attitude to life may tend to live longer.
1. Let a Smile Be Your Umbrella
The Georgia Centenarians said that they were very happy with their lives (Purdy, 1995) despite their limitations. Further, people who are cheerful later in life were generally the same earlier, so that happiness is life-long for centenarians (National Institute on Aging, undated). In addition, among the general population, those with the most severe depression do tend to die younger than those who are not depressed or who have milder depression (Unutzer, Patrick, Marmon, Simon, & Katon, 2002).
Why does mental health affect physical well being? First, good mental health supports healthy habits. Patients who are self-motivated are more likely to walk and experience the benefits of exercise (Friis, Nomura, Ma, & Swan, 2003). On the other hand, how well the Georgia centenarians ate was more the result of whether they were happy or sad that anything else (Purdy, 1995).
Second, severe mental illness may interfere with basic self-care. A study of middle-aged and older schizophrenic women found that they were more likely to be obese, smoke, and not have mammograms (Dickerson, Pater, & Origoni, 2002)
It may also be that physiological changes associated with mental health may also affect physical health. For example, one reason why depression may be associated with dementia is that both are related to a shrunken hippocampus (Snowden, 2001). Also, late life chronic depression may be associated with vascular changes in the brain. It often occurs at the same time as heart disease, stroke, cancer, and Parkinson’s disease. (National Institute of Mental Health, 2003).
2. What’s the Best Personality to Have for Long Life?
The effects of personality are less clear. Those who lived longest and healthiest had:
The ability to cope well with the challenges life threw them (Vaillant, 2002) Forgiveness, gratitude and joy (Vaillant, 2002) A personality that was “dominant, suspicious, practical and relaxed” …more likely to acknowledge problems … less likely to seek social support as a coping strategy” (Georgia Centenarian Study, undated, p. 2). Remember the value of “dominant” and “suspicious” characteristics the next time you have a feisty patient who is creating problems for you or your staff. More ability to handle stress (Perls, undated) Optimism from an early age, according to the “nun study” (Snowden, 2001). However, the Georgia study found that just as many pessimists as optimists made it to age 100 (Purdy, 1995).
3. Keeping Your Wits About You
Being mentally active seems to help stave off the dementia that robs so many of your elder patients of their independence. The “nun study” found that “idea density” and “grammatical complexity” in early writings predicted dementia in later life. The effect was not related to education (Snowden, 2001). In addition, the nuns who did mentally-stimulating activities such as reading and doing crossword puzzles had less dementia (National Institute on Aging, 2002).
D. The Social Circle
Those who have a happy homelife and many friends are more likely to be healthy and long-lived. The Aging in Manitoba study found that those who participated in everyday activities with others had a longer life, as well as a happier one with less disability (Menec, 2003). “Talking on the phone, having someone to help, and having a caregiver” all contributed to greater survival among the George centenarians (Georgia Centenarian Study, undated, p. 3).
1. Family Is Most Important
Marriage is perhaps the most important relationship most people have. In fact, a healthy marriage was the best prescription for successful aging in the Harvard study (Vaillant, 2002). Older people in general are less likely to die early if they are married (Cooper, Harris, & McGready, 2002).
For some elders, knowing their social role within the family is the key to well being. Hispanic elders in one study believed their health was good when they were happy with their family relationships and poor when they were not, no matter how healthy they actually were (Beyene, Becker, & Mayen, 2002)
Family and friends can ensure that elders have the basic food, shelter, and care they need to survive a medical crisis. One reason why fewer elders are in nursing homes may be that more men are living long enough to take care of their ill wives at home (Redfoot & Pandya, 2002). This may also be a reason why elders who are married tend to live longer – they receive better care from spouses than they might if they lived alone.
Also, those who are spouses or parents tend to take fewer life-threatening risks (Bosworth & Schaie, 1997). Your elder patients may be especially concerned that they not become a burden to their adult children and so be motivated to take better care of themselves.
2. Friends Are Key for a Good, Long Life
In addition, those with more friends may be healthier because they exercise more. Many health promotion programs, including walking clubs and group fitness classes, encourage seniors to exercise by offering an opportunity to be with friends. Among reasons elders cite for exercising are to have fun, to socialize, to improve appearance, personal satisfaction, and health benefits (RoperASW, 2002).
Social groups that revolve around a common interest can also serve as informal support groups for those who are uncomfortable going to a bereavement or disease-related group. Pool or card rooms, sewing groups, book clubs, and other activities provide a place for older people to get together and talk about what is bothering them with their peers who understand their feelings.
Social isolation may itself be a result of poor health. Those with vision, hearing, or mobility problems may not be able to get out to visit with family or friends or go to activities they enjoy. They may be embarrassed to talk with others because they are afraid they will not be able to hear and respond inappropriately. They may not be able to join in conversations if they are not able to hear what is being said. In these cases, what begins as one health problem can become more.
3. The Special Case of Care Giving and Receiving
Having family can also be bad for health, however. Caregivers for frail elderly relatives may neglect their own health, for example. Caregivers experience greater fluctuations in weight, exercise less, and sleep less than others (Gallant & Connell, 1997). Another study found that, though 80% of caregivers surveyed had had a mammogram in the past year, how burdensome their care giving was affected whether they had had a self-exam or provider exam (Chang, Sarna, & Carter, 2001).
Care giving also strongly affects the emotional health of the caregiver. Caregivers may be stressed when their own activities and social lives are restricted, when they are not being able to meet the needs of employers or other family members, and when they must face the distrust or resentment of their relative. The burden is especially strong when their loved one has dementia and may not be able to thank, or even recognize, them. Not surprisingly, up to about half of all caregivers are clinically depressed (American Association for Geriatric Psychiatry, 2002).
The care giving burden can be lightened, however, by a social support system (Chappell & Reid, 2002). In addition, caregivers participating in a home-based four-times-a-week exercise program also had significantly better blood pressure and sleep (National Institute on Aging, 2001). Formal services like respite care can also help by giving caregivers the time to meet their own needs.
About half of those who receive care are unhappy about it (Newsom & Schulz, 1998). They may feel distress at being suddenly dependent, resentment when an a caregiver stops them from driving or doing other activities, embarrassment at getting assistance with personal care, and concern that they are a burden to their caregiver.
Care giving and receiving can also be a positive experience, however. It may be the first time in decades that adult children and parents or spouses can spend real time together. Care giving is more likely to be happy if the person receiving care had once provided help to their caregiver (Keefe & Fancey, 2002).
4. Elder Abuse
Elder abuse is the most harmful form of poor family relations. An estimated 500,000 (National Center on Elder Abuse, 1998) elders are abused each year. Elder abuse includes not only physical abuse, which ranges from hitting and pushing to homicide, but also humiliation and other forms of mental abuse, sexual assault, and financial exploitation. Other elders are neglected by caregivers who fail to meet their basic needs. Elders who are abused die earlier than their peers even when their deaths had no relationship to their abuse (Lachs, Williams, O’Brien, Pillemer, & Charlson, 1998).
While some abusers are overstressed caregivers, more often the abuse is the result of the abuser’s already-existing substance abuse or mental problems. In fact, many abusers are actually financially dependent on their victims (Brandl & Cook-Daniels, 2002a). You may also be surprised to learn that about one in three caregivers is abused by the elder they care for (Brandl & Cook-Daniels, 2002a). What type of abuse occurs seems to be associated to the relationship of the abuser to the victim. It may be that spouses are more often physically violent while adult children tend financially exploit their elder parents (Brandl & Cook-Daniels, 2002b).
