Themes of Aging

Abstract

THE AGING OF THE WORLD’S POPULATION, WITH ADULTS older than 60 years projected to increase from its current 10% to 20% by 2050, will challenge countries, communities, and health care to adapt and embrace care for and support of aging adults. The call for papers for the 2010 Aging issue, the third JAMA theme issue on this topic in 15 years, stated that the central and still unmet priority is for medicine to adapt to the shifting demographics and changing requirements of caring for an aging population. In this theme issue, several rigorous research reports, an in-depth review, and scholarly commentaries provide new insights and define challenges in addressing this priority. Effective treatment of Alzheimer disease, the sixth leading cause of death in the United States, continues to elude researchers. In this issue, Quinn et al found no effect of docosahexaenoic acid on cognitive decline or functional ability, and, as Yaffe suggests in an accompanying editorial, effective treatment will likely need to target the disease before memory impairment and functional ability become clinically manifest. Mitchell et al found that survival with advanced dementia is extremely difficult to predict, making hospice referral challenging and exacerbating the heartbreak (in addition to expense) of families who watch their loved ones dwindle away for months to years to a shell of the person they remember so well. In a compassionate rethinking of the surrogate decision-making model, Sulmasy and Snyder propose a new model in which clinicians can help family members recall the real goals and authentic values of loved ones to help navigate through the difficult decisions that must be made when the patient can no longer participate. Although changing the course of Alzheimer disease continues to elude the research community, functional ability, which is essential for elders to remain independent in the community, has a dynamic course with improvement as well as decline and is influenced by many factors including hospitalization and restricted activity. Gill et al provide insights into the association of hospitalization and restricted activity with the course of functional ability. Frailty, defined as time longer than 10 seconds on the 10-foot rapid gait test, increased the risk of functional decline after hospitalization or restricted activity likely by reducing patients’ functional reserve. Furthermore, exploring the conditions associated with the greatest decline, Gill et al found that fall-related injury was the most likely condition to be followed by new or worsened disability. Thus, fall prevention and mitigating the adverse effects of falls remain another crucial area of research. In a randomized controlled trial of a hospital-based intervention, Dykes et al found that individualized fall prevention strategies targeting hospital staff, patients, and families reduced risk of falls by 1 fall per 1000 patient-days, with a larger effect among those older than 65 years. No effect was seen for reducing fall-related injuries, although a much larger study would be required to test that effect. However, fall-related morbidity is not limited to injury, and prevention is an essential step in preserving and improving functional ability among hospitalized elders. Although minimizing risk during hospitalization is an important component of effective geriatric care, even more important is preventing hospitalization whenever possible and helping patients preserve function and maintain independent living. However, health care focused on (and reimbursed for) individual diseases at discrete points in time by individual physicians and other health care professionals does not treat the complex interplay of conditions and environment that Gill et al demonstrate lead to functional disability. Boult and Wieland review the pilot programs under way in the United States that are designed to organize health care around patient needs, rather than vice versa. Integrated, coordinated care—in which all members of the health care team, including primary care and specialist physicians, nurses, physical and occupational therapists, social workers, and other health care professionals, coordinate care of elders to maximize their health and resources to maintain and restore independence—has the potential to foster the changes in health care needed to adapt to the aging population. Although more research is needed to determine which components are most important to maintaining independence of elders, the coordinated care model, possibly centered around the medical home, holds promise for elders seemingly caught between, rather than supported by, current health care provisions. To realize that promise in the