1248
THE NEW ENGLAND JOURNAL OF MEDICINE
-
SOUNDING BOARD
THE SPECTER OF DECREPITUDE MOST people, including most physicians, see aging as a process of unrelenting impairment of all body functions. True, individual functions deteriorate at varying rates - one man learns that the act of urination can absorb most of his time and attention and another finds that tending his garden has become a cruel ordeal because of arthritic pain in his thumbs but sooner or later everyone becomes subject to the all-too-familiar ravages of old age. Although this perception of a more or less smooth and continuous progression into old age may hold for physical infirmities, to assume an analogous gradual decline in intellectual and emotional capabilities may be a serious mistake. Quite often, mental function continues unhampered except for an annoying increase in forgetfulness until "something happens" and, over a period of weeks, or even days ("he's failing rapidly"), a clear-cut, often striking change in personality occurs. It seems to me that the "same person in an older body" undergoes a metamorphosis into a specific state for which I shall pre-empt the term "decrepitude. " We have all. encountered the spritely alert oldster with a sparkling eye who has suddenly shriveled into an ancient who is slow of gait, suspicious, querulous and whining, demanding unremitting attention and full of acrimony for what is seen as a dearth of present rewards for past favors. Such people have become decrepit, and the more attractive the original personality, the more obvious the change. They see themselves centered in a sour universe. Although one or more of the components of this state of decrepitude, the depression, the paranoia or the hostility, may dominate the clinical picture, all patients share one key characteristic - namely, the loss of all interests outside themselves. Decrepitude of recent onset may be reversible, but once well established, it becomes a permanent state relieved only by death. Admittedly, I speak here only from personal observation, limited by lack of broad experience or expertise - that is, as a generalist. Moreover, if pressed, I would be hard put to distinguish in all cases between decrepitude and other afflictions of the aging mind. The distinction is nonetheless important because I hold the conviction that decrepitude is precipitated not only by physical changes but also by a withdrawal of social and emotional support by family and friends. Common examples include the death of a spouse or other close relative, physical separation by removal to a hospital or, worse, to a nursing home, which, far too often, is a depressing melange of deadening routine and implacably jolly attendants. The separation may be emotional rather than physical, as when care at home is turned over to impersonal "practical" nurses. I recall an experience in which a
Nov. 30, 1978
well paid attendant assigned to night duty complained bitterly because I refused to sedate the patient to her satisfaction; the patient was disturbing her rest! Finally, this withdrawal of support need not be real; it need only be perceived by the patient as real. The advent of urinary incontinence, for instance, may be devastating. The patient sees himself as a "dirty old man" and, despite the repeated reassurances of an affectionate family, concludes that he could not possibly be loved any longer. The urge to burst into print in an unfamiliar area of geriatrics could have been contained easily if I had not become aware that there is an additional, often unrecognized and readily preventable cause of decrepitude. I refer to the effect of social deprivation. Indeed, strong-minded aging people who feel threatened will intuitively go to unusual lengths to conserve what they see as their emotional fitness. I can illustrate this process with two anecdotes. My father-in-law, an 88-year-old retired Montana homesteader, is one of those spare, quiet, open, undemanding, modest and ready-humored men, well schooled in the rigors and rewards of self-reliance. Many years ago, in young adulthood, he acquired a rhinophyma, which one very soon forgot to be aware of but which I thought gave an amusing Cyrano cast to his appearance. Well, unlike many of his peers, my father-in-law has ready access to sophisticated medical care, and at the age of 85, opted to have a rhinoplasty. We found this behavior somewhat puzzling but did not inquire deeply into his reasons. He said simply that he had always been self-conscious about the appearance of his nose and would prefer not to have the growth on the end of it. Then, about 18 months ago, he underwent a cataract removal with the insertion of a prosthetic lens. His care was less than optimal in that his attendants apparently were not aware that elderly folk often become confused after taking anesthetics and analgesics. The patient, left unattended during the night, arose from bed and pawed at his painful left orbit, pulled off his dressings and damaged the recent operative site. The net result is a milky, opacified cornea in an eye that barely perceives light. Several months ago he was evaluated by an experienced ophthalmologist, who thought that there was nothing to be done, particularly since the remaining eye was functioning well, but suggested that he should be fitted with a cosmetic shield matching his good eye so that the unsightly cornea would be covered. This procedure was done. It proved to be expensive and time-consuming, requiring considerable artistry on the part of an ocularist who matched the hand-drawn iris to the other, functioning eye. I wondered whether all of this was worthwhile, especially since it required extra exertion on my part, but my father-in-law remained quietly insistent. Finally, it became clear that what seemed to be a sudden burgeoning of vanity in an old man was not that at all. Light dawned when he remarked with obvious
The New England Journal of Medicine Downloaded from nejm.org at PENN STATE UNIVERSITY on November 17, 2015. For personal use only. No other uses without permission. From the NEJM Archive. Copyright © 2010 Massachusetts Medical Society. All rights reserved.
Vol. 299 No. 22
MASSACHUSETTS DEPARTMENT OF PUBLIC HEALTH
satisfaction, "Now I don't have to worry about frightening little children anymore." His was not a striving to regain a lost youth; rather, he was greatly concerned lest he become repellent to other human beings. Another example. There is the lady with treated hypothyroidism and pernicious anemia, now 79, who, after raising four children, embarked on several additional careers to become not only an accomplished poet but also a well recognized authority on ethnic dancing. Her usual tolerant graciousness gave way to an imperious presence when she encountered serious obstacles. The progressive osteoarthritis of both knees led to obvious bowing and made dancing increasingly painful and difficult. I told her with earnest good humor that she was "not as young as she used to be" and that aspirin along with a judicious reduction in physical activity was in order. Her response was explosive, instructive and humbling. Today, she remains as active as ever, on straight legs and prosthetic knees, teaching among other things, belly dancing. I recognize that these two people are unusual in having ready access to excellent medical care and in their determination to get the care they were convinced they needed. Yet other instances abound, and I suspect most readers could supply their own examples of failure as well as success in the battle against decrepitude. Once one accepts the conviction that physical and emotional health of the elderly is contingent upon, among other factors, physical acceptability to others, therapeutic goals become clear. First of all, the word must be spread. It must be understood that there is a very strong need among the old (as among the middleaged and young) to participate regularly in social intercourse. Social deprivation, no less than sensory deprivation, leads to a progressive narrowing of emotional horizons to the point where the elderly person rather abruptly will become decrepit and will languish and die. Secondly, relatively simple cosmetic or prosthetic measures may prevent the onset of decrepitude and must not be overlooked. The cost of decrepitude is high. Nursing homes, supported massively by Medicare funds, have become the way stations for the decrepit in the last stage of their journey. The prosthetic approach to repair the infirmities of age would not only prevent or delay the onset of decrepitude but also help to ensure that old people remain acceptable to their families and remain in them. Although geriatric research should continue to address the overarching problems of the aging process, it should not neglect a multifaceted attack on the concomitants of aging that make the old less acceptable to themselves, to each other and to the rest of us. In the long run such an approach would prove relatively inexpensive and cost effective. Consider the effect on caring relatives if they could be assured, for instance, that incontinence of urine or feces would never be a problem. Grandma's
1249
deafness and Grandpa's blindness might be seen more often as endearing nuisances rather than as unacceptable deficits, and Mom and Dad might be far more reluctant to relegate them to a nursing home. The development of a prosthesis effectively to replace sphincters would provide release from one of the most repugnant of all afflictions and would go a long way toward banishing the isolation of the old and the guilt of the young. A renewed emphasis on advances in prosthetics for the old may not prolong life, but it may well shorten that time of great misery, the time between decrepitude and death. Some of the good time saved could be spent at home with the family pondering answers to the hopeful question, "Will the Circle be Unbroken in the Sky, Lord, in the Sky?" Rush-Presbyterian-St. Luke's Medical Center Chicago, IL 60612
OF
44,
M4
l
THE NEW ENGLAND JOURNAL OF MEDICINE
-
SOUNDING BOARD
THE SPECTER OF DECREPITUDE MOST people, including most physicians, see aging as a process of unrelenting impairment of all body functions. True, individual functions deteriorate at varying rates - one man learns that the act of urination can absorb most of his time and attention and another finds that tending his garden has become a cruel ordeal because of arthritic pain in his thumbs but sooner or later everyone becomes subject to the all-too-familiar ravages of old age. Although this perception of a more or less smooth and continuous progression into old age may hold for physical infirmities, to assume an analogous gradual decline in intellectual and emotional capabilities may be a serious mistake. Quite often, mental function continues unhampered except for an annoying increase in forgetfulness until "something happens" and, over a period of weeks, or even days ("he's failing rapidly"), a clear-cut, often striking change in personality occurs. It seems to me that the "same person in an older body" undergoes a metamorphosis into a specific state for which I shall pre-empt the term "decrepitude. " We have all. encountered the spritely alert oldster with a sparkling eye who has suddenly shriveled into an ancient who is slow of gait, suspicious, querulous and whining, demanding unremitting attention and full of acrimony for what is seen as a dearth of present rewards for past favors. Such people have become decrepit, and the more attractive the original personality, the more obvious the change. They see themselves centered in a sour universe. Although one or more of the components of this state of decrepitude, the depression, the paranoia or the hostility, may dominate the clinical picture, all patients share one key characteristic - namely, the loss of all interests outside themselves. Decrepitude of recent onset may be reversible, but once well established, it becomes a permanent state relieved only by death. Admittedly, I speak here only from personal observation, limited by lack of broad experience or expertise - that is, as a generalist. Moreover, if pressed, I would be hard put to distinguish in all cases between decrepitude and other afflictions of the aging mind. The distinction is nonetheless important because I hold the conviction that decrepitude is precipitated not only by physical changes but also by a withdrawal of social and emotional support by family and friends. Common examples include the death of a spouse or other close relative, physical separation by removal to a hospital or, worse, to a nursing home, which, far too often, is a depressing melange of deadening routine and implacably jolly attendants. The separation may be emotional rather than physical, as when care at home is turned over to impersonal "practical" nurses. I recall an experience in which a
Nov. 30, 1978
well paid attendant assigned to night duty complained bitterly because I refused to sedate the patient to her satisfaction; the patient was disturbing her rest! Finally, this withdrawal of support need not be real; it need only be perceived by the patient as real. The advent of urinary incontinence, for instance, may be devastating. The patient sees himself as a "dirty old man" and, despite the repeated reassurances of an affectionate family, concludes that he could not possibly be loved any longer. The urge to burst into print in an unfamiliar area of geriatrics could have been contained easily if I had not become aware that there is an additional, often unrecognized and readily preventable cause of decrepitude. I refer to the effect of social deprivation. Indeed, strong-minded aging people who feel threatened will intuitively go to unusual lengths to conserve what they see as their emotional fitness. I can illustrate this process with two anecdotes. My father-in-law, an 88-year-old retired Montana homesteader, is one of those spare, quiet, open, undemanding, modest and ready-humored men, well schooled in the rigors and rewards of self-reliance. Many years ago, in young adulthood, he acquired a rhinophyma, which one very soon forgot to be aware of but which I thought gave an amusing Cyrano cast to his appearance. Well, unlike many of his peers, my father-in-law has ready access to sophisticated medical care, and at the age of 85, opted to have a rhinoplasty. We found this behavior somewhat puzzling but did not inquire deeply into his reasons. He said simply that he had always been self-conscious about the appearance of his nose and would prefer not to have the growth on the end of it. Then, about 18 months ago, he underwent a cataract removal with the insertion of a prosthetic lens. His care was less than optimal in that his attendants apparently were not aware that elderly folk often become confused after taking anesthetics and analgesics. The patient, left unattended during the night, arose from bed and pawed at his painful left orbit, pulled off his dressings and damaged the recent operative site. The net result is a milky, opacified cornea in an eye that barely perceives light. Several months ago he was evaluated by an experienced ophthalmologist, who thought that there was nothing to be done, particularly since the remaining eye was functioning well, but suggested that he should be fitted with a cosmetic shield matching his good eye so that the unsightly cornea would be covered. This procedure was done. It proved to be expensive and time-consuming, requiring considerable artistry on the part of an ocularist who matched the hand-drawn iris to the other, functioning eye. I wondered whether all of this was worthwhile, especially since it required extra exertion on my part, but my father-in-law remained quietly insistent. Finally, it became clear that what seemed to be a sudden burgeoning of vanity in an old man was not that at all. Light dawned when he remarked with obvious
The New England Journal of Medicine Downloaded from nejm.org at PENN STATE UNIVERSITY on November 17, 2015. For personal use only. No other uses without permission. From the NEJM Archive. Copyright © 2010 Massachusetts Medical Society. All rights reserved.
Vol. 299 No. 22
MASSACHUSETTS DEPARTMENT OF PUBLIC HEALTH
satisfaction, "Now I don't have to worry about frightening little children anymore." His was not a striving to regain a lost youth; rather, he was greatly concerned lest he become repellent to other human beings. Another example. There is the lady with treated hypothyroidism and pernicious anemia, now 79, who, after raising four children, embarked on several additional careers to become not only an accomplished poet but also a well recognized authority on ethnic dancing. Her usual tolerant graciousness gave way to an imperious presence when she encountered serious obstacles. The progressive osteoarthritis of both knees led to obvious bowing and made dancing increasingly painful and difficult. I told her with earnest good humor that she was "not as young as she used to be" and that aspirin along with a judicious reduction in physical activity was in order. Her response was explosive, instructive and humbling. Today, she remains as active as ever, on straight legs and prosthetic knees, teaching among other things, belly dancing. I recognize that these two people are unusual in having ready access to excellent medical care and in their determination to get the care they were convinced they needed. Yet other instances abound, and I suspect most readers could supply their own examples of failure as well as success in the battle against decrepitude. Once one accepts the conviction that physical and emotional health of the elderly is contingent upon, among other factors, physical acceptability to others, therapeutic goals become clear. First of all, the word must be spread. It must be understood that there is a very strong need among the old (as among the middleaged and young) to participate regularly in social intercourse. Social deprivation, no less than sensory deprivation, leads to a progressive narrowing of emotional horizons to the point where the elderly person rather abruptly will become decrepit and will languish and die. Secondly, relatively simple cosmetic or prosthetic measures may prevent the onset of decrepitude and must not be overlooked. The cost of decrepitude is high. Nursing homes, supported massively by Medicare funds, have become the way stations for the decrepit in the last stage of their journey. The prosthetic approach to repair the infirmities of age would not only prevent or delay the onset of decrepitude but also help to ensure that old people remain acceptable to their families and remain in them. Although geriatric research should continue to address the overarching problems of the aging process, it should not neglect a multifaceted attack on the concomitants of aging that make the old less acceptable to themselves, to each other and to the rest of us. In the long run such an approach would prove relatively inexpensive and cost effective. Consider the effect on caring relatives if they could be assured, for instance, that incontinence of urine or feces would never be a problem. Grandma's
1249
deafness and Grandpa's blindness might be seen more often as endearing nuisances rather than as unacceptable deficits, and Mom and Dad might be far more reluctant to relegate them to a nursing home. The development of a prosthesis effectively to replace sphincters would provide release from one of the most repugnant of all afflictions and would go a long way toward banishing the isolation of the old and the guilt of the young. A renewed emphasis on advances in prosthetics for the old may not prolong life, but it may well shorten that time of great misery, the time between decrepitude and death. Some of the good time saved could be spent at home with the family pondering answers to the hopeful question, "Will the Circle be Unbroken in the Sky, Lord, in the Sky?" Rush-Presbyterian-St. Luke's Medical Center Chicago, IL 60612
OF
44,
M4
l
