Never had it so good?BMJ 2008; 336 doi: https://doi.org/10.1136/bmj.39532.671319.94 (Published 24 April 2008) Cite this as: BMJ 2008;336:950
What does it mean to be old? What is the relationship between ageing and illness? How does the subjective experience of multiple and compounding illnesses relate to the medical model and the taxonomy of disease? These questions become more pressing as an ever greater proportion of the population survives into extreme old age, and as the postwar baby boomers—those who “never had it so good,” as Harold Macmillan put it—begin to draw their pensions.
Globally the proportion of people aged ≥60 years is growing very fast. It is expected that by 2025 a total of about 1.2 billion people will be in this age group. By 2050 this number will have risen to two billion, 80% of them in developing countries. The older population itself is also ageing. Currently 69 million people are aged over 80, and although this age group now accounts for only 1% of the world’s population (and 3% in developed countries), it is the fastest growing segment of the population.1
The World Health Organization and many national governments are promoting the concept of “active ageing,” which portrays ageing as a positive experience and promotes continuing participation in social, economic, cultural, and civic activities. The concept is based on rights rather than on need and seeks to move away from a view of elderly people as frail and dependent. All this is to be applauded, but it may conceal a worrying reluctance to acknowledge the inevitable reality of death and dying. All bodies must die and find ways of doing so.
Age is a fundamental cause of disease, working through a multiplicity of causal pathways to generate multiple risk factors and multiple disease outcomes.2 All clinicians are familiar with this process, by which treating one disease in a frail, older person often means that symptoms reappear through another pathway. As the treatment of disease slowly becomes more effective, an ever greater proportion of the population survives with multiple compounding chronic diseases. The commonest of these are cardiovascular disease, stroke, diabetes, cancer, chronic obstructive pulmonary disease, musculoskeletal conditions, and mental illness (including dementia), occurring in many different combinations. The orthodox medical view is that these are distinct and definable conditions each of which carries a different prognosis and requires different treatment. However, people who live with multiple diseases, physical and mental, experience them simultaneously and inseparably. The patient with diabetes and depression and congestive cardiac failure does not have these conditions in separate compartments of her life. She has all three inseparably and, if she is also lonely and frightened, all of this is a single condition.
The problem is that in health care the specialist medical view predominates. And, as a direct result, multiple diagnoses lead almost inevitably to polypharmacy as each condition is treated in perverse isolation from the others. Research findings are extrapolated from younger age groups and interpreted overoptimistically in the context of what inevitably are limited life expectancies. As a direct result, older people are taking an ever increasing number of prescribed drugs, but because of diminished physiological reserve they are also more susceptible to adverse drug reactions and interactions. Nevertheless, the all too easy accusation of age discrimination means that the limited time available for older people to derive clinical benefit is not seen as a legitimate reason for “underprescribing.”3 Systems of “quality improvement” that involve payment for performance, such as the UK Quality and Outcomes Framework (QOF), apply standards with no allowance for age and systematically encourage overtreatment of hypertension and type 2 diabetes, to the detriment of patients.4 Many preventive treatments in old age may simply change the cause of death and not its date. The energetic treatment of cardiovascular risk factors is effective in reducing cardiovascular mortality but does not prolong life and increases the likelihood of a diagnosis of cancer or dementia.5
Old people themselves have different priorities and can find the epidemiological perspectives of healthcare professionals to be intrusive and inappropriate.6 Most elderly people are very aware of death and know that it must be faced and negotiated: “The big event of old age—the thing which replaces love and creativity as a source of drama—is death.”7
Many frail older people have a rapidly diminishing appetite for technological health care and a proportionately increased need for sensitive, gentle, hands-on physical care: a need that is easily compromised by the very real fear of becoming a burden. At present, medicine seems to have limited means of marking this transition, but such means are urgently needed, because the continuing emphasis on individual diseases leads, usually inadvertently, to undertreatment, overtreatment, or mistreatment—and often all three.8
Tragically, the global trends of commodification, privatisation, and fragmentation in health care mean that the dimensions of care most needed by frail elderly people become less and less accessible. Yet multiple illnesses can be coherently managed only by a personal generalist physician who is able to provide continuity of care for the patient’s whole experience of illness,9 while at the same time remaining alert to those diagnostic possibilities that are readily remediable. But how, within a market system, can unprofitable need for time intensive and hands-on personal care from a known other ever be given commensurate priority?
Competing interests: None declared.
Provenance and peer review: Commissioned; not externally reviewed.