And when I’m 84?

Clinicians, researchers, and Beatles fans take note: Older people’s needs are diverse and constantly changing, Dr. Eric B. Larson writes.

by Eric B. Larson, MD, MPH, Kaiser Permanente Washington Health Research Institute (KPWHRI) executive director, and Kaiser Foundation Health Plan of Washington vice president for research and health care innovation

Who doesn’t know that quirky Beatles tune, “When I’m 64”? Written by Paul McCartney at age 16, it was released when I was an undergrad. Many in my generation thought that once we hit a certain threshold, we’d all become part of one monolithic class called “old.”

But now that age 64 is in my rear-view mirror, I know that’s not true. Today — as always — there’s a great diversity of hardiness among people in their 60s, 70s, and beyond. While some are slowing down, others seem as vibrant as ever. In many ways, we’re like adolescents — each going through changes at our own pace. My older patients often ask “What’s normal?” and there’s rarely a simple answer. Whether we’re talking heart health, bone health, cancer risk, vision, hearing, or wrinkles — my answer often begins, “That depends.” I find it curious that so many still seem to view all people over age 65 as one uniform group. Physician and author Louise Aronson recently described this phenomenon in a New York Times editorial, “Stop treating 70- and 90-year-olds the same.”

The problem, she explains, is reflected in clinical guidelines that tend to divide all people into two basic groups: children or adults. The medical establishment recognizes that children are different from grown-ups and constantly changing, so they’re given special consideration. But we also don’t understand the range of changes that come with aging, so older people’s needs are too often ignored. Whether for drug treatment, vaccinations, surgery, or other interventions, recommendations often fail to take into account that aging is a time of increased variance and we’re not all changing at the same rate.

Consider ‘slow care’

Such lack of discernment can cause a host of problems for older people. Modern medicine aims for speed and accepts invasiveness. Intensive treatments or quick changes to drug regimes may work well for older people who are retaining their resilience; well bodies may still adapt to new prescriptions or recover quickly from surgery. But for those who are frail, sudden changes can be quite draining — emotionally and physically.

For this reason, many clinicians increasingly recognize the need for what Dartmouth geriatrician Dr. Dennis McCullough called “slow medicine.” Such care aims to help frail older people avoid extreme and sudden changes. Keeping people out of hospitals should be a goal. The fast pace of hospitals — along with their unfamiliarity and disruptions in daily routine — can be a source of great stress for frail, older people. Our research found an association between hospitalization and increased risk for dementia. Also, hospitalization almost always puts older people at risk for overtreatment.

The key, of course, is to avoid cookie-cutter medicine. People of all ages need care that’s based on their own individual needs and desires. And older people — whether in their 70s, 80s, or beyond — especially need such care because they are increasingly faced with complicated decisions that affect their longevity and quality of life.

Research to address individual needs of older people

At KPWHRI, we are continually working on research that addresses the diverse needs of aging populations. We seek ways to make care safer and more effective for older people — of all ages. And we’re helping to develop ways to ensure that care is aligned to meet their individual values. Here are just a few examples:

• Drug safety
  By exploring the relationship between commonly used drugs, side effects, and chronic health problems that affect many older people, our findings can help clinicians make safer treatment recommendations.
• Shared decision-making
  Working with clinicians throughout Kaiser Permanente, we’re learning how shared decision-making aids can help patients make choices based on their own personal needs and values about issues such as joint-replacement surgery, cancer treatment, and late-in-life care.
• Dementia risk
  We have discovered practical ways to prevent or delay Alzheimer’s disease and other dementias. We’ve also helped develop interventions to improve quality of life for people with these conditions. And soon we’ll be working with researchers from the Global Brain Health Institute at the University of California, San Francisco to develop and test a unique, personalized multiple risk-factor strategy for reducing the risk of dementia.
• Vaccines
  We’re conducting clinical trials to test the safety and side-effects of, and immune response to new vaccines for two common illnesses that are especially risky for older people. One is respiratory syncytial virus, a common cause of cold-like illness that can be dangerous for those with chronic heart or lung disease or weakened immune systems. The other is norovirus, often referred to as food poisoning or stomach flu, which causes gastroenteritis and is also especially dangerous for older people with chronic illness or weakened immunity.

Listening now to McCartney’s lyrics, I still appreciate his sentiment: We all want to be well cared for, no matter what our age. But after more than 40 years of medical research, clinical practice, and life experience, I’m glad to take a more nuanced view of what it means to be 64, 74, 84, and more. And I’m glad to be working on ways to make aging ever more enriched and satisfying.

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