For Immediate Release
Date: Sep 12th, 2016
Contact: W. Michael Mansfield, D.M.D.
Aging and Frailty Basics
Seeing a friend, relative, patient or acquaintance age through the years and/or who is at the end of life is an experience most everyone has faced. As the percentage of the population over the age of 65 continues to increase in the United States, an increasing percentage of the patients many dentists see will be over 65. According to the Pew Research Center (http://www.pewresearch.org/daily-number/baby-boomers-retire/ Accessed 7-19-16), 10,000 people turn 65 every day. In the “State of Aging Report 2013” by the Center for Disease Control and Prevention (http://www.cdc.gov/aging/pdf/state-aging-health-in-america-2013.pdf Accessed 7-19-16), it is estimated that approximately 20% of the U.S. population will be over 65 by the year 2030. Having a working knowledge of key components of Aging and Frailty will allow all of us to better understand, help and communicate with those people over 65, their caregivers and other healthcare professionals.
At this point in time (2016), who are these people who make up the over 65 demographic? The over 65 demographic (often called older adults or senior adults) consists of three generations. Those three generations are the GI or Greatest Generation, the Traditional or Silent Generation, and the Baby Boom or Boomer Generation. People who are members of a particular generation often have similarities and shared values due in part to shared experiences/events which help define them.
The Greatest Generation
We are seeing the members of the Greatest or GI Generation rapidly leave us. According to many experts, this generation consists of people born roughly between the years of 1900 and 1925. There are events which are shared by members of a particular generation which help define them. For the Greatest Generation, three of those events would be: WWI, the Great Depression and WWII. Dr. Jill Novak writes in a post titled, “The Six Living Generations in America”, (http://www.marketingteacher.com/the-six-living-generations-in-america/ Accessed 7-16-16)
the characteristics members of the GI Generation often share include:
• Assertive and energetic doers.
• Excellent team players, community-minded, and strongly loyal to jobs, groups, schools, etc.
• Strongly interested in personal morality and near-absolute standards of right and wrong.
• Believing that you work until your die or can’t work anymore.
• Avoiding debt, saving and buying with cash.
• Able to remember life without airplanes, radio/TV, refrigerators, electricity and air conditioning.
The Traditional Generation
People born between 1925 and 1946 make up the Traditional or Silent Generation. Shared events for this generation include: the Great Depression, WWII, the Post-WW II Economic Boom, the Korean War, Assassinations of John Kennedy, Bobby Kennedy and Martin Luther King, the Vietnam War, the Civil Rights Movement and Watergate.
Common characteristics/beliefs of members of the Traditional Generation according to Dr. Novak include;
(http://www.marketingteacher.com/the-six-living-generations-in-america/ Accessed 7-16-16)
• Have a strong sense of trans-generational common values and near-absolute truths.
• Are disciplined, self-sacrificing, cautious.
• Most women have stayed home, generally to raise children and if they have worked, it is/was only at certain jobs like teacher, nurse or secretary.
• Men are loyal to the corporation and generally believe that once you get a job, you keep it for life.
• The richest, most free-spending retirees in history.
• Believe that marriage is for life and that divorce and having children out of wedlock are not acceptable.
• Are avid readers.
Note: Like most members of the Greatest Generation, they are punctual.
Baby Boom Generation
People born between 1946 and 1964 comprise the Baby Boom Generation (Boomers). Defining events for the Baby Boom Generation include: Assassinations of John Kennedy, Bobby Kennedy and Martin Luther King, the Vietnam War, Man Stepping on the Moon, Woodstock, Watergate and the Internet.
Common characteristics/beliefs of members of the Baby Boom Generation according to Dr. Novak include;
(http://www.marketingteacher.com/the-six-living-generations-in-america/ Accessed 7-16-16)
• Optimistic, driven, team-oriented.
• Envision technology and innovation as requiring a learning process.
• Tend to be positive about authority, hierarchal structure and tradition.
• Sometimes called the “me” generation and are often considered self-righteous and self-centered.
• Have strong desires to reset or change the common values for the good of all.
• Women of this generation began working outside the home in record numbers.
• The first generation to have their own children raised in a two-income household where mom was not omnipresent.
• The first TV generation and divorce generation, where divorce is/was beginning to be accepted as a tolerable reality.
• The first generation to use the word “retirement” to mean being able to enjoy life after the children have left home. Instead of sitting in a rocking chair, they go skydiving, exercise and take up hobbies, which increases their longevity.
Activities of Daily Living
Understanding characteristics common to each of these generations can lead to better communications and an understanding of factors which may be associated with specific behaviors by members of a particular generation. Good communications with other healthcare professionals can also be facilitated by members of the dental profession having an understanding of common measures/assessments of aging. For example, the Activities of Daily Living (ADL) are a list of activities which may be assessed to help determine a person’s functional status. These activities include 17 Functions which are evaluated as being able to be done independently, with help, dependent on/requiring someone else to do or does not do. Note that oral care is one of the items on the list of Daily Living Functions commonly assessed that is provided below. A checklist of the Activities of Daily Living (ADL) may be found at:
(http://www-tc.pbs.org/wgbh/caringforyourparents/caregiver/pdf/cfyp_adl_checklist.pdf Accessed 7-15-16)
-Using the Phone
Instrumental Activities of Daily Living
Instrumental Activities of Daily Living (IADL) are activities which are more complex than the Activities of Daily Living (ADL). According to the American Psychological Association, (http://www.apa.org/pi/about/publications/caregivers/practice-settings/assessment/tools/daily-activities.aspx Accessed 7-16-16) an IADL Scale was developed to assess people living and functioning in community settings and not long term care facilities, such as nursing homes. The IADL scale consists of 22 activities such as shopping, cooking and managing finances. The capacity to handle these complex functions normally is lost before the more basic activities of daily living (e.g., eating and oral care/tooth brushing), which are measured by ADL scales. Dental care professionals may be one of the first healthcare professionals to notice people who are starting to experience a decline in their ability to take care of themselves by observing a decline in oral health status.
What is Successful Aging?
Models which contain various elements key to a person being able to age successfully have been proposed. One popular model recognizes the importance of spirituality to a person’s ability to optimally age. In 2002, Crowther, Parker and others proposed adding the additional component of “Maximizing Positive Spirituality” to the widely recognized Rowe and Kahn Model of Successful Aging. The article titled, “Rowe and Kahn’s Model of Successful Aging: Revisited: Positive Spirituality-The Forgotten Factor” appears in Volume 42, No.5 of The Gerontologist. Rowe and Kahn’s Model had originally consisted of three components, however, the Revised Rowe and Kahn Model of Successful Aging consists of the following four components:
· Minimizing Risk and Disability/Disease
· Engaging in Life Actively (Social Engagement)
· Maximizing Physical and Mental Activities (Cognitive Function)
· Maximizing Positive Spirituality
According to the World Health Organization, (http://www.who.int/mediacentre/factsheets/fs404/en/ Accessed 7-16-16), at the biological level, aging results from the impact of the accumulation of a wide variety of molecular/cellular damage over time, which leads to a gradual decrease in physical and mental capacity, a growing risk of disease, and ultimately death. These changes are only loosely associated with a person’s age in years. While some older adults at a particular age may have extremely good health and functioning, other older adults at that same age are frail and require significant help from others. Although some of the variations in older people’s health are genetic, much is due to people’s physical and social environments – including their homes, neighborhoods, and communities, as well as their personal characteristics – such as their sex, ethnicity, or socioeconomic status.
There appears to be a range from Excellent/Good to Poor/Failing in describing the health status of adults as they age, which illustrates the diversity in the physical and mental status of older adults. As we age, people may acquire more chronic conditions and a decreased ability to handle acute conditions. According to the U.S. Center for Disease Control, (http://www.cdc.gov/nchs/health_policy/adult_chronic_conditions.htm Accessed 7-18-16) in 2008, 85% of people over 65 have one or more chronic condition; 56% have two or more chronic conditions; and 23% have three or more chronic conditions. The Appalachian Region has a high frequency of multiple chronic conditions and because Kentucky is in the heart of the Appalachian Region, dental professionals will likely see patients with numerous chronic conditions.
What is Frailty?
The term Frail is often used to describe older adults who are at the Poor/Failing end of the Health Status Continuum. What is Frailty? According to an article titled, “Frailty in elderly people” by Clegg, A Young, J Iliffe, S and others that appeared in the Journal The Lancet (March 2, 2013, Volume 381 pp 752-762), Frailty is a state of vulnerability to poor resolution of homoeostasis after a stressor event and is strongly associated with adverse outcomes. It is a consequence of cumulative decline in many physiological systems during a lifetime. This cumulative decline depletes homoeostatic reserves until minor stressor events trigger disproportionate changes in health status. Failure to detect frailty potentially exposes patients to interventions from which they might not benefit and indeed could be harmed.
Fried LP., Tangen CM, Walston J, and others in a 2001 article which appeared in The Journal of Gerontology: Medical Sciences Vol. 56A, No.3 M146-M156 titled, “Frailty in Older Adults: Evidence for a Phenotype” attempted to provide a standard definition for Frailty. Figure I of the article provides a diagram which summarizes many key components (clinical signs and symptoms) which contribute to the “Cycle of Frailty”. Key components include:
· Chronic Under-nutrition
· Sarcopenia (Loss of Muscle Mass) Note: This also results in decreased strength and power, decreased walking speed and decreased Activity
· Decreased Metabolic Rate
· Decreased Total Energy Expenditure
On a personal note, my father experienced Frailty and more specifically, a minor event that triggered other significant events. The photo of my father, below, was taken approximately one year before he died in 2012. Characteristic of many in the Greatest Generation, Dad believed one should work until they had to quit or died. He worked until he was almost 84-years -old. The stressor event that led to his having to retire, becoming frail and ultimately his death, just before he was 87-years-old, was breaking his ankle. Dad had incurred a decline in numerous physiological systems during his lifetime, however, this event initiated a series of other serious health events, which ultimately led to his being hospitalized and then placed in a long term care facility where he died a few months later. After his retirement and broken ankle he became more inactive, physically. This inactivity led to increased muscle weakness (Sarcopenia), which led to numerous falls and instability.
The results of my father’s inactivity as he approached the end of his life, show the importance of older adults staying active and how important it is to “keep moving”. Many people think that as one ages there should be a decrease in physical activity, however, this is not true in most cases. According to the Department of Health and Human Services’ Office of Disease Prevention and Health Promotion Physical Guidelines for Older Adults, for adults aged 65 and older who are fit and have no limiting chronic conditions, the guidelines are the same as for all adults. However, the HPDP office does have some specific Guidelines Just for Older Adults which contain some provisions. (http://health.gov/paguidelines/guidelines/older-adults.aspx Accessed 7-18-16). These include recommending that when older adults are limited because of chronic conditions, they should be as physically active as their abilities and conditions allow and they should do exercises to maintain and improve balance to decrease the risk of falling.
A person’s walking speed is a great indicator of their overall health status. A study of 35,000 people by S. Studenski and others at the University of Pittsburg which appeared in the January, 2011 issue of the Journal of the American Medical Association, JAMA. (2011; 305(1):50-58.) showed that in every segment of the population studied (regardless of sex and age), there was a strong correlation between walking speed and longevity. Specifically, the greater the walking speed in our older years, the greater the longevity, generally speaking. This is probably not exactly news that everyone would like to know. However, it is a great way to get a glimpse of a person’s (i.e. patients) overall health. The bottom line for all of us could be to “keep moving”, even as we age. An interesting Interview with Dr. Studenski may be found online at (https://www.youtube.com/watch?v=ziLSckxVprc Accessed July 15, 2016).
In Conclusion, understanding basic aspects of aging and frailty will help members of the dental profession effectively communicate with older adult patients, caregivers and other healthcare professionals when treating older adult patients.