Not Dead Yet: A Manifesto for Old Age. Julia Neuberger
an audience, but being on my own makes the prospect of being really ill and frail alarming. When I broke my wrist, there was Gavin to drive me to hospital and fasten my bra … Losing your husband has two separate aspects: there’s missing the actual man, your lover; his quirks, his kindness, his thinking. But marriage is also the water in which you swim, the land you live in: the habits, the assumptions you share about the future, about what’s funny or deplorable, about the way the house is run, or should be; what Anthony Burgess called a whole civilization, a culture, ‘a shared language of grunt and touch’. You don’t ‘get over’ the man, though you do after a year or two get over the death; but you have to learn to live in another country, in which you’re an unwilling refugee.17
Bowling and Dieppe cite the theoretical definitions of successful ageing as life expectancy, life satisfaction and well-being (including happiness and contentment), mental and psychological health and cognitive function, personal growth, learning new things, physical health and functioning, independent functioning, psychological characteristics and resources, including perceived autonomy, control, independence, adaptability, coping, self-esteem, positive outlook, goals, sense of self, social community, leisure activities, integration and participation, social networks, support, participation and activity. But they point out that there are a whole range of extra lay definitions, including accomplishments, enjoyment of diet, financial security, neighbourhood, physical appearance, productivity and contribution to life, sense of humour, sense of purpose and spirituality – none of which are mentioned in the ‘professional’ literature at all. When you look at the categories that lay people added, they are the things that make anyone tick at any time of life: food and drink, sense of humour, a sense of purpose and, of course – much misunderstood by professionals – a sense of spirituality.
Even without those additions to the literature, much of the research shows that many of the areas of successful ageing are interrelated. Having a large number of social interactions and activities and lots of relationships is associated strongly with greater satisfaction with life and with generally better health and functioning better. Despite considerable class differences in survival and different attitudes according to the numbers of stressful events in life – such as loss of a partner or even a child – there are ways to make it easier for people to age well on their own terms, and according to their own values. Personal values, individual experience and a nonprofessional perspective are all key to defining what successful old age is for individuals. But a large part of that is about the nature of life, relationships, love and the ability to act.
So you have to give three cheers to Ann Bowling and Paul Dieppe’s conclusion: ‘Health professionals need to respect the values and attitudes of each elderly person who asks for help, rather than imposing our medical model on to their lives.’
The tyranny of a definition
Dr Muriel Gillick, a Professor of Ambulatory Care at Harvard Medical School, wrote one of the best reflections I have ever read on the subject of centenarians:18
Centenarians have something important to teach. Often they have wisdom arising from their accumulated experiences which they enjoy sharing, and which they are able to share because they aren’t burdened by multiple maladies, each with its own demanding regimen of pills, monitoring tests, and physician visits. Their world is the antithesis of the elderly community in Florida, which has developed a culture that revolves around their health. The average elderly Floridian sees multiple specialists, often making more than one physician visit each week. Gathered around the table while eating an ‘early bird special,’ they exchange doctor stories. When one member of the group reports that he has seen a new specialist – perhaps a rheumatologist has joined the ranks of his cardiologist, urologist, and general internist – the others eagerly add the new doctor to their own list of ‘providers.’ In parts of Florida, the state with the largest elderly contingent in the United States, Medicare spends more than twice as much per capita for health care as it does anywhere else. What its citizens get in exchange for this largesse is more hospital days, more tests, more ICU admissions, and more subspecialty consultations in the last six months of life, with no evidence that the additional attention improves the quality of care.
But Professor Gillick says there is another lesson which is even more relevant to the question of definition:
The usual claim is that centenarians remain robust until a catastrophic event occurs, at which time, like the ‘one-hoss shay’ of Oliver Wendell Holmes, they collapse completely. Centenarians are different from other people in that the ageing process has been postponed – at age 95, their organs are like those of a typical 75-year-old. But there is no reason to believe that their organs are programmed to fail simultaneously. The reason the centenarian dies from his pneumonia or his heart attack is that doctors do not aggressively treat their 100-plus-year-old patients – they do not routinely admit them to the intensive care unit, place them on a breathing machine, start dialysis, or initiate any of the other interventions that are commonplace in octogenarians. Centenarians die quickly because we let them, and the 85-year-olds die slowly because we don’t.
There are other ways in which our mechanistic definitions of old age undermine the health of older people. Far too many drugs are given to older people, quite inappropriately, wrote Dr Mark Copperfield, in his column in The Times, arguing that sensible older people refuse to take most of them, restricting themselves to ‘the pink ones that stop their joints from aching’.19
But, he says, the trouble starts when they go into a care home, and matron insists on giving them the lot, promptly at 7 p. m., ‘with predictable consequences’. Meanwhile, others who have been there longer are falling like ninepins, going to the hospital, having too many of all sorts of analgesics, sedating drugs, antidepressants and whatever.
Sir Richard Doll, who discovered the link between smoking and lung cancer, died at 92 and worked long past retirement, told pensioners not to expect NHS time and money to be spent on research into prolonging life, and advised them to ‘live dangerously’. The alternative is that you will be defined according to a mechanistic definition of your age and treated accordingly.
Where we go wrong
So good health, and promoting independence, are key to any definition of being healthy for an older person him or herself. This sense of being in control, having the care we need and not being subject to other people’s ideas of what would be just right for us, is critical for a sense of autonomy and well-being. You might have thought this fitted quite well with the ethos of the times, given all the mantras we hear about a patient-led NHS. Yet neither doctors nor patients are quite sure.
The patient-led NHS, with its huge emphasis on patient choice – which has to be a good thing in most circumstances – seems to have forgotten about continuity of care, about a personal relationship with the GP, about the small things that matter more than being able to choose where to have some particular procedure in middle age. Older people may need any number of procedures. What they don’t usually need – or indeed want – is to have an isolated procedure done somewhere they have apparently ‘chosen’, apparently only on the basis of convenience or speed of access, but a long way from the care they get the rest of the time for their growing number of chronic conditions.
Diana Jelley, a GP in North Shields, puts this very well. There was a patient she had been looking after for some fourteen years, popping in to see her when she needed, a retired nurse who had had a heart attack aged 76 and whose condition gradually worsened over the years.20