A Fitting Conclusion to a Life Well Led
The fast-changing demographics of the population pose a special challenge to contemporary America. Those who are 85 and older are the fastest-growing segment of society. These older individuals are spending a longer part of their lives in retirement, and their needs will test their communities. Families, congregations, and other organizations must focus as never before on an urgent goal: helping older citizens attain a meaningful and fulfilling late life.
The probability that a 50-year-old will reach the age of 90 has tripled in the past 50 years (today, 16.4 percent of men, 28.2 percent of women). These added years, however, can be fraught with complications. During the last year of life for those 85 and older, up to 45 percent spend some time in a nursing home, 60-70 percent have difficulty with walking, dressing, or toileting, 40-50 percent have cognitive impairment. Of those who are cognitively impaired, 25 percent don’t recognize their own family and 20 percent have dementia-related behavioral problems.1 Indeed, the prevalence of dementia doubles with every five-year period after age 60. This condition affects 12 percent of those aged 80-85, 25 percent of those aged 85-90, and more than half of those who are 90 and older.2 Although older Americans are more physically independent than they were 20 years ago, 50 percent of individuals aged 85 and older need some help with daily activities.3
True Quality of Life
The task facing society is to help older citizens attain a high quality of life without diverting substantial social resources from other needs. These challenges cannot be met until families and communities have a full understanding of the priorities valued by older individuals. What gives them satisfaction? What can make their lives meaningful and fulfilling?
Perhaps surprisingly, good health is not the holy grail of life satisfaction for older individuals. One study of patients with cancer, chronic lung disease, and heart failure, all of whom met the hospice criteria for terminal illness, found that 40 percent reported that the quality of their life was “good,” while an additional 17 percent stated that “it couldn’t be better.” In another study, 37 percent of chronically ill patients requiring frequent hospitalizations and physician visits reported that the quality of life was “about as good as it could be.”
If “good health” does not necessarily define quality of life, then what does? Older individuals identify other factors that are more important to life satisfaction than health – frequent contacts with friends, the ability to continue to plan for the future, the sense of a role in life, relationships with their family, and a feeling of control over their lives. They also enjoy their role as a link between generations. Individuals with a poor quality of life are characterized by low self-esteem, exhaustion from their experiences of grief or other setbacks, a loss of interest in life, and lack of any sense of control over their lives.
More than anything else, older persons want to retain their identity in their last years. They want to be able to carry on the rhythm they have had throughout their lives. The pace and beat may vary, but they want to sustain a familiar rhythm to their particular personality. Preserving that identity depends on staying focused on what is most important to them, understanding who they are, and keeping a strong perception of their own worth, value, and fulfillment.
This can be difficult. Older persons’ identities are challenged by changes in their bodies, transitions in their way of life or residence, and loss of individuals important to them.
But there are a numbers of steps that older persons can take to maintain their identity. These include:
- Stay connected. It’s important to continue making an effort to be active in family life and community. It requires staying in touch with the people and institutions that are vital to the older person. Older persons must make sure they are not separated from friends and families by moves. They will need a network of family and friends more and more as they age.
- Maintain a personal role. We all fear the thought of feeling superfluous, of having little value to others, and of becoming a burden. Everyone wants to feel needed. In later life roles should be adapted to new or declining levels of function. Older people still have a major role to play, even if they can no longer provide physical support to their families. They serve as advocates and mentors. They approve the direction of the lives of their children and grandchildren. They stand as a living symbol of family tradition.They embody an intergenerational link that keeps those traditions alive.
- Adapt to altered capabilities. Older individuals must constantly adjust to changing circumstances and accordingly adjust feasible goals and expectations. They should emphasize competencies they possess in abundance – their specific skills and knowledge – and place less emphasis on abilities they are less likely to possess, such as physical endurance. To maintain a sense of value and self-esteem, they must minimize the discrepancy between expectations and achievements as much as possible.
- Adjust to medical problems and choose interventions wisely. This ability in late life is essential to life satisfaction. Medical problems come with the territory, can take over one’s life, dominate conversations, and affect interactions with others. This is no way to spend the last years. Older people need to learn to roll with the punches, get treatment, and then get on with their lives. They should avoid feeling sorry for themselves and focus instead on calming the concerns of family members. An older person’s last years need not be filled with worry. They should not sit around and wait for “the other shoe to drop.” They should focus on the quality of each day, not on apprehensions about the future. Because late life brings a new role, that of a patient, older individuals need to decide what they want from health care. Do they want to extend their lives at all costs? Alternatively, do they want to maintain the particular flow of their lives, their connections to those most important to them, and an ability to do as much for themselves as possible?
- Maintain independence. Staying independent is important to continuing to be “who you are” in late life. Older people need to consider, for example, whether they want to stay on medications that might extend their lives a bit but prevent them from performing daily activities. They should determine whether a major medical intervention might incapacitate them further and reduce their contact with those most important to them. These are daunting issues, but on another front the news is good: older Americans are substantially more physically capable than they were 20 years ago. Data from the National Long Term Care Survey demonstrates that 73.5 percent of individuals 65 and older had no chronic disabilities in 1982; that number increased to 81 percent by 2004. For those aged 85 and older, the percentage of people who are fully independent has gone up from 37.9 percent to 50.3 percent.4 If an older person is having difficulty with daily activities, an evaluation by a physician and therapist can be very helpful. The clinician needs to identify the “rate limiting factor” to independence and intervene appropriately.
- Learn to cope with disabilities. Physical and cognitive disabilities often accompany late life. Coping with these limitations is essential to satisfaction in the last years. Older individuals can learn a good deal from others who have managed with disabilities. They’ll discover that many disabled people learn to maintain a sense of control over their lives, find a positive aspect of their illness experience, keep perspective by staying mindful of those who are more disabled than they are, and use problem-solving coping strategies throughout. They understand their restrictions and introduce order and predictability into their lives.
- Leave a legacy. Older individuals want to leave a legacy. They should thus think about how they want to be remembered and what they wish to leave behind. Most older individuals are unlikely to bequeath great works of arts, monuments, or edifices. They leave behind how they lived their lives. They need to consider how they will pass on their values and beliefs and preserve themselves in the memory of those who follow them. We are all products of those who come before us. We have been given values, traditions, beliefs, and approaches to life. We take that cultural heritage and hone these concepts and values in the context of our own life and times. Acting as a link between generations is an important role in late life. To live on in the lives of others, however, we must stay connected with who we are even as we face life’s challenges in our last years.
Families, communities, and religious organizations should use all of these priorities as a litmus test when devising plans to help their older members and evaluating proposed interventions. The question to keep in mind: will these efforts help these older individuals maintain “who they are” to the very end?
Families and communities can help older persons stay connected by providing transportation to religious services and public gatherings, physician’s visits, and other necessary appointments. Transportation is a major problem for older Americans, given the limits of public transportation and the driving problems that often come with age.
Loved ones should make sure that older relatives still have a major role in the family. Community and religious organizations should make use of the special expertise of their older members. Ensure that they participate in the decisions and direction of the larger group. The institutional memories of these senior members can add greatly to these deliberations.
Public buildings and facilities should accommodate the cognitive and physical limitations of older residents. Signs and instructions should be clear, succinct, and easy to read. Seating in lobbies, waiting rooms, and auditoriums should be high enough to allow for easy transfers, and should be stable and with comfortable arms. Low couches and cushioned “easy chairs” should be kept to a minimum. Most importantly, toilets should have raised seats, with available “grab bars,” and be large enough to accommodate wheelchairs and walkers.
Older persons should be allowed to maintain control of their lives to the very end. Their most important decisions in these last years are where they will live and what medical interventions they will undergo.
When making decisions about living sites, the criterion should be the satisfaction of the older person. An older person should never be placed in an environment that he or she dislikes simply to provide “peace of mind” to the children. Concerns about older individuals’ “safety” should not adversely affect the quality of their lives.
As long as they are able, older persons should make their own healthcare decisions. If they cannot, family members need to honor the elders’ wishes that were articulated while still fully competent. Families should resist the urge to push older relatives into medical interventions they do not want. Older persons should be comfortable with the impact and consequences of any intervention they undertake.
For centuries, one of the most important roles of elder citizens was to pass on the essential knowledge, skills, and communal cultural heritage to the next generation. They were given the responsibility of ensuring that this heritage be protected and transmitted. Though this information may now be entrusted to written and electronic media, the communal role of elder members should carry on.
In an enlightened and accomplished society, elder members should not be moved to the periphery. They should expect to continue to have robust and close relationships, a sense of control of their lives, the ability to continue to grow and develop, and the opportunity to leave a legacy to those who follow. Humane societies should ensure that the last years of their older citizens are fitting conclusions to lives well led.
Dr. Leo Cooney, Jr., M.D., Humana Professor of Medicine (Geriatrics), established the program in geriatrics at Yale in 1976. He was the first director of the Continuing Care Unit, now known as the Yale Acute Care for the Elderly Unit. At Yale his focus includes assisting elderly individuals to attain the highest level of independence possible, and preparing medical residents and students to care for the multiple problems of the frail elderly. He has won numerous teaching awards and is a past president of the American Geriatrics Society.
1 Y. Liao, D.L. McGee, G. Cao, et al., “Quality of the Last Year of Life of Older Adults: 1986 vs 1993,” JAMA, vol. 283 (4), (2000), pp. 512-518. See also H.R. Lentzner, E.R. Pamuk, E.P. Rhodenhiser, et al. “The Quality of Life in the Year before Death,” American Journal of Public Health, vol. 82 (August 1992), pp. 1093-1098.
2 C.P. Ferri, M. Prince, C. Brayne, et. al., “Global Prevalence of Dementia: A Delphi Consensus Study,” Lancet, vol. 366 (2005), pp. 2112-2117.
3 K. Manton, et al., “Change in Chronic Disability from 1982 to 2004/2005 as Measured by Long-term Changes in Function and Health in the U.S. Elderly Population,” Proceedings of the National Academy of Sciences, vol. 103, no. 48 (2006), pp. 18374-18379.
4 Manton, et al.