1. EMGO Institute for Health and Care Research Geriatric Ethics Prof. Cees M Hertogh, MD,PhD Frailty and the future of old age

2. Topics Analysis of the concept of ‘frailty’ Against the theoretical background of ‘healthy ageing’ and its presuppositions

3. Seneca on old age Ad Lucilium epistolae morales

4. Seneca on old age I shall not abandon old age, if old age preserves me intact for myself, and intact as regards the better part of myself; but if old age begins to shatter my mind, and to pull its various faculties to pieces, if it leaves me, not like, but only the breath of life, I shall rush out of a house that is crumbling and tottering Ad Lucilium epistolae morales

5. The transformation of health and illness Three era’s since 1900: –Infectious disease –Chronic disease –‘Senescence-process’

6. Compression of morbidity paradigm: “A new syllogism for aging” 1. natural life span is relatively fixed 2. the age of first appearance of aging manifestations and and chronic symptoms can increase more rapidly than life expectancy 3. therefore the duration of morbidity and disability will decrease (James F. Fries, 1980)

7. Explanations and policy implications Early detection and ‘medicalization’ of chronic disease Patient education and life style approaches Investment in ‘plasticity’ of ageing (Function-enhancing medical interventions) (improvements in built environment)

8. ‘rectangularization’ of the survival curve

9. Grimley Evans on healthy old age: By delaying the onset of disabling diseases to later ages when intrinsic aging has raised fatality by reducing adaptability, the average duration of disability before death will be shortened. In brief: we shall spend a longer time living and a shorter time dying

10. Grimley Evans on healthy old age: By delaying the onset of disabling diseases to later ages when intrinsic aging has raised fatality by reducing adaptability, the average duration of disability before death will be shortened. In brief: we shall spend a longer time living and a shorter time dying

11. Intrinsic ageing ‘homoeostenosis’ : The progressive narrowing of the capacity to adapt through loss of reserve power ‘natural death’ : quality of host resistance > nature of insult to equilibrium

12. The future of old age from the point of view of compression theory

13. Frailty: a controversial concept Multiple conceptualizations! Dictionary and daily life: Health care:

14. Frailty: a controversial concept Multiple conceptualizations! Dictionary and daily life: –Liability to break or to be broken, weakness –Moral weakness, instability of mind –(susceptibility to be wounded) Health care:

15. Frailty: a controversial concept Multiple conceptualizations! Dictionary and daily life: Health care: –Transition from service-directed concept (70’s) –To ‘interventionist’ concept (90’s) ‘narrow’ biomedical concept (Fried) ‘broad’ epidemiological concept (Deeg, SCP, TFI)

16. Federal council on aging (USA): Persons, usually but not always over the age of 75, who because of an accumulation of various continuing problems often require one or several supportive services in order to cope with daily life (FCA, 1978) Frailty = Chronic disease = Disability

17. ‘Frailty’ as a clinical syndrome: A biologic syndrome of decreased reserves in multiple systems that result from dysregulation that can occur with aging, disease, and/or lack of activity or inadequate nutritional intake Primary and secondary frailty Progressive or temporary frailty (Fried et al, 2001)

18. The cycle of frailty (Dayhoff et al, 1998):

19. Phenotype of frailty Weight loss Low grip strength Low levels of physical activity Subjective exhaustion Slow walking speed (Fried et al, 2001)

20. Frailty according to the SCP: A heuristic term to identify risk groups A process involving the accumulation of physical, psychological and/or social deficits in functioning which increase the risk of adverse health outcomes (functional impairments, admision to an institution, death)

21. SCP, februari 2011: 2010: –700.000 frail persons (> 65 jr) –550.000 living independently –150.000 in care home or nursing home 2010 – 2030: –> 1.000.000 frail persons –= 300.000 increase, but 100.000 fewer than expected

22. Recommendations and policy implications Early, preventive interventions Monitoring older persons with measurement instruments (self administered) Responsibility for older person herself, as well as for GP, home care and municipal officer Focus of interventions on life style approaches, care network and resilience Fits in with present accent on self management and personal responsibility for functional autonomy and participation

23. Comments No evidence Antonym of ‘successful’ ageing Denies the patient perspective Potentially stigmatizing Unilateral focus on prevention denies the meaning of frailty as a transitional state

24. Recent news from gerontology… The good news: the third age (young old) Increase in life expectancy: more people live longer Substantial latent potential for better fittness in old age Succesive cohorts show gains in physical and mental fitness Evidence of cognitive-emotional reserves of the aging mind More and more people age succesfully High levels of emotional and personal well-being (self- plasticity) Effective strategies to master the gains and losses of late life

25. Recent news from gerontology… The not-so-good or bad news: the fourth age (oldest old) Sizeable losses in cognitive potential and ability to learn Increase in chronic stress syndrome Sizeable prevalence of dementia (about 50% in 90-year- olds) High levels of frailty, dysfunctionality and multimorbidity Dying at older ages: with human dignity?  prospects for the 21st century: the era of chronic incompleteness of mind and body? (Baltes & Smith, BASE)