Is there such a thing as finding peace as we age?

Ask Dr. Bob (Robert Lahita MD, PhD)

People are aging, acquiring diseases, and progressing with conditions like dementia.  Sooner or later, this hits home with a relative who is ill or a former president of the United States like Jimmy Carter who brings the question of end-of-life care into real perspective.

Geriatrics is a medical specialty and is growing by the day.  Geriatricians often refer to the gradual narrowing of an elderly person’s life. It is not easy to define the specific age group.  In other words, is a 65-year-old a geriatric patient, or is a person who is 90 an accurate old patient? 

According to the United States Social Security Administration, anyone over 65 is considered elderly.  But not everyone agrees. A 2014 research review found limited guidance on what defines “elderly.” Describing an older adult as elderly should be based on physical health and medications rather than chronological age.  Defining the word elderly may be a feeling and not a number.  In my practice, I have patients who are in their 50s and who look frail and in poor health. This is fun to debate and could take up this entire column.  But it's relevant today because of politics and the selection of our next president, who may be considered aged.

Let's first look at a group who we fondly refer to as “superagers”. Even at an advanced age, superagers have the memory of people who are 20 to 30 years younger than them.  In superagers, the shrinkage of some regions of the brain, called age-related atrophy of the grey matter (especially in areas responsible for memory), develops much slower than in the normal aged person. The question is whether such patients resist memory loss or develop coping mechanisms to offset normal aging.

There were studies of large numbers of patients in Europe (Leibnitz Institute on Aging, Jena, Germany). The overall conclusion was that superagers indicated that they were more active than control subjects in their middle years.  Going for a daily walk or taking the stairs instead of the elevator was a significant way to be a superager.  Such patients also suffered less from depression or anxiety disorders.

One interesting finding was that superagers exhibited lower concentrations of biomarkers for neurodegenerative diseases than the control groups.  This means that the superagers were not likely to get Alzheimer’s or other forms of dementia.  Genetics enters the analysis of superagers. The presence of the APOEe4 allele, which predicts Alzheimer’s disease and is thought to be a promising biomarker for dementia, was present in both the control regular-aged patients and the superagers and seemed to have no predictive effect for the superagers. The research teams say that genetics certainly plays a significant role in who gets demented with age and not simply lifestyle.

Neurodegenerative diseases are largely genetically driven.  Some do not depend on aging and occur relatively young, and others are given once the patient goes into the late 80s or 90s. Diseases like frontotemporal dementia, vascular dementia, Alzheimer’s, and others generally run in families. There are many markers for these diseases, like specific proteins in the spinal fluid or the APOEe4 gene that have been found in people with these diseases.

What is palliative care?

Prevention and the relief of suffering in advanced illness is the basis for palliative care. It is an interdisciplinary specialty of medicine that focuses on improving the quality of life for people with increased disease and their families.  It is not hospice. Palliative care is called for someone who has suffered a significant stroke, a failing heart, someone with new-onset cancer, how to manage during chemotherapy, or caring for someone with dementia. Patients go on and off palliative care.  It is not usually “end-of-life” care, but it can be.  Families are usually intimately involved in palliative care.

Doctor-patient communication and communication with family members is the cornerstone of palliative care.  There are four stages in the temporal progression towards death: 1) advanced care planning, 2) communicating bad news, 3) negotiating the goals of care (for example, whether there is a living will or should the patient go into hospice) and 4) whether care should continue or be withdrawn.  The spiritual realms and the psychosocial issues are dealt with in palliative care as well.

What is Hospice?

Hospice is a subset of palliative care. Those in hospice get palliative care, but not all palliative care is receiving hospice. Generally, patients in hospice require four levels of care, often dictated by Medicare Hospice benefits. There are four levels of care:  inpatient care (hospitalized patients), needs for continuous care, home care, and respite (rest or relief from something difficult).  The doctor must certify a six-month or less prognosis of the disease process. However, the patient might continue beyond the certified time.  The patient in hospice is always under the direct care of a doctor.  Patients can be continually recertified in hospice. Ninety percent of hospice care occurs in the home setting, either a private residence or a nursing home.

Psychosocial and spiritual care is part of both palliation and hospice.  The latter is because suffering may not be physical.  I think of Jimmy Carter, the 39th president who lost his wife at the age of 99. No doubt, while at the hospice, his loss of Roselyn Carter was more than physical pain. Nevertheless, his condition required palliative care, respite, and all the psychosocial and spiritual needs.

These are essential topics to discuss in this brief but important column.  All of us will someday require palliative care and maybe even hospice.  And whether you have 20 people in your family who will comfort you in your time of need or no one.  It should provide peace to know that these vehicles exist to quiet pain and suffering at any time in life when personal chaos exceeds one’s ability to cope.  The end of life for each of us is unique, and peace should be a final goal.