A new view of old age

Old age and aging, the autonomy and dignity of older people, (particularly those coping with illness), and end-of-life care are the subjects that have accompanied Prof. Dr. Adelheid Kuhlmey throughout her career in research and teaching.  As the Director of the Institute of Medical Sociology and Rehabilitation Science, she constantly reminds young physicians that gerontology will form part of all of their future professional lives – with pediatricians the only exception. In her role as a member of the German Ethics Council, she is calling for sound and responsible medical care in what is an increasingly technology-based society.

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Prof. Kuhlmey, what is it that fascinates you about old age and aging?

I'd have to say that everything about it fascinates me, including the processes involved in biological aging. Gerontology is an interdisciplinary field of study, and I have always tried to stay abreast of new findings which might explain why human beings and animals get old. Is the aging process more of a result of coincidence, of changes in the molecular structure, which occur as a result of either internal or external factors? Or is aging something that is controlled by our genes, theoretically making it possible for us to look at an individual's genetic makeup and know exactly what their aging process will look like based on their genetic code? I am of course also interested in aging as a social phenomenon. Old age and aging are fascinating subjects from a social point of view: as each of us passes through the various stages of aging, we are also surrounded by people from all the different stages living in coexistence. I have also always been interested in the psychological aspects of aging, which produce interesting phenomena, such as the fact that, psychologically speaking, we do not age at the same rate as our bodies. During our middle years, for instance, our inner selves – the way we think and feel – remain unchanged for a period of many years. As a result of this, we usually feel 10 years younger than we really are. This can result in odd experiences in our day-to-day lives, such as when we bump into someone we haven't seen for many years: we are surprised by how much they have aged, but at the same time, we remain unaware of the fact that we have aged as well.

Over the years, however, you have developed a new focus in your work...

Correct. One of my main areas of interest is the connection between what we refer to as normal aging and the development of age-related illnesses. If, for instance, our current average life expectancy were only 60 years, we would not even be discussing certain conditions, such as dementia. Certain diseases only get the chance to develop because of our extended life expectancy. There is one question I have been particularly interested in during more than 35 years in medicine: what is normal aging and what constitutes pathological aging? I am fascinated by the fact that we have this opportunity to live until old age, but how can we ensure that we remain healthy; and what is the purpose behind living a long life, of living to extreme old age?

What is the purpose?

Biologically speaking, and in terms of securing the succession of generations, old age probably does not have much of a purpose. There is a cultural and societal purpose attached to the fact that people can grow old, that we, as a society, can safeguard the experience and expertise of older people. For economists, for instance, each year of a human life has an economic value attached to it. When a person dies prematurely at age 45, for instance, they are unable to realize their full potential; the result is that society misses out on the benefits associated with their skills and expertise. There is a loss attached to a premature death, including in economic terms. Although I must admit that I object to the economization of this issue. The true value of a long life is its cultural capital. The coexistence of the many adult generations we see today represents a major benefit; the different generations draw inspiration from one another and contribute their generation-specific experiences. This makes for a colorful society.

At what point does a person enter old age or extreme old age, to use the proper gerontological terms?

That is a very interesting question: at what point does a person become 'old'? In biological terms, we consider a person to be 'old' when 50% of their birth cohort is no longer alive, which means that 60- and 70 year olds no longer qualify as old in today's world. Based on this definition, and given today's life expectancies, we consider a person to be old once they are aged over 80. In gerontology, we differentiate between the Third and Fourth Ages, which represent the 60- to 80-year-olds whom we consider as the 'young old', and the over-85s who we consider the 'oldest old'. This is not set in stone, of course, as we are working with an open-ended scale in terms of our maximum possible life expectancy.

Does this mean we need to redefine our view of old age and aging; and if so, how?

Our view of old age is changing very slowly indeed. We are currently moving towards a society in which age will be irrelevant. A great deal continues to be linked to our physical age, of course, including within the legal context. However, many people now do things in the later stages of life that we might previously have associated with different and quite specific stages of life. They do so either because it is possible in biological terms, or because we are making it possible through medical advances. It wasn’t that long ago that we witnessed one classic example of this at Charité: when our midwives helped a sexagenarian mother give birth to quadruplets. I received a number of inquiries following this event, asking for my opinion as a gerontologist. My response was that, personally speaking, I am not sure if it is really necessary for someone who is aged over 60 years, and who already has children, to have more children. As a gerontologist, however, I have to say: why not? Old age is changing. It is now medically possible for a woman of that age to bear children. Demographically speaking, she can expect to live for another 30 years. It is therefore perfectly possible for her to raise children. As for likely developments over the next 100 to 200 years, I would not discount the possibility of this sort of thing becoming an integral part of people's life plans. Upon reaching the age of 20 or 25, women might seriously ask themselves how they can fit children into their life plans. They might even consider biobanking tissues, an option that would allow them to postpone their decision; and at age 50, they might say: now is the right time for a baby. Medically speaking, none of this is a problem. However, there are certain legal restrictions that apply in Germany. I do think that the past few decades have shown a stepwise move towards an 'age-irrelevant' society, so, in 500 years' time, all of this might be completely normal.

Would you say public debate lags behind developments?

Absolutely, yes. In many cases, we are still attached to this view of life being divided into three distinct phases: the first comprising childhood, adolescence, and the time we spend in education and training, followed by an active working life and, finally, a post-working life. This division of life into three phases is no longer valid or appropriate; it suggests most of us would completely withdraw into our private spheres for a duration of some 20, 30, or even 40 years. It would also make old age the longest phase of our lives. We need new images and ideas of what old age is, of what we might want to do with the extra years we have gained. It would be useful if we did not simply continue to do more of the same, but used structured solutions; if we did not simply continue to extend our working lives, but showed a bit of imagination. Let's take senior professorships as an example: how can we organize the activities and responsibilities of people who are still capable of performing at 100%. We have barely started to define such new roles. Our research shows that the competencies of older people are not lost because they cease to exist, but because we fail to utilize and develop them. That is simply not acceptable. We must therefore succeed in identifying areas of activity and responsibility that will create new roles for older people, which allow them to utilize their skills and realize their potential. Participation and training are preventive measures that help keep people healthy.

What projects are you and your colleagues at the Institute currently involved in?

Motivation instead of frustration; tablet-based games offering varying degrees of difficulty adapt to users with dementia. Photo: Antonia Richter, Charité.

We are currently having a lot of success with a tablet-based project. And while the project involves introducing people with dementia to working with tablet computers, we have encountered only minor reservations. It is a collaborative project with colleagues from Technische Universität, who have developed different apps, including games, which we believe to be capable of enhancing cognitive performance. We are hoping to use these to monitor the health status of participants over time. We are also hoping that this will allow us to use our interventions in a highly targeted manner, and that this will result in better and more adequate care. This project shows us that, if we want to help vulnerable patients, we need to be far more imaginative in the manner in which we are using everyday technologies. This project also shows us that it is possible to improve these people's day-to-day lives over the long-term, and that they can enjoy a better quality of life.

Estimates for Berlin suggest that, in 2030, one in four citizens will be over 65 years of age. Are we sufficiently prepared for this, including in terms of medical care provision?

No, absolutely not. We have, of course, been aware of current demographic changes for some time. We have also realized that these changes have started to affect our health care realities, in terms of both medical and nursing care. However, we are not merely seeing a major shift in the age profile of our population. We are also witnessing unforeseen and unforeseeable advances in medical technology. Medically speaking, so much is possible. We developed our modern health care system in order to be able to respond quickly to acute illnesses and events. Now, the field of medicine is facing an entirely new set of challenges as a result of current demographic changes. We must respond to the emerging chronic disease burden. We must accept that treating an acute episode will no longer result in the patient being discharged, but that they may have to remain in our care for years or even decades to come. We have made some progress already, for instance in the treatment of diabetes. However, our system of delivering medical and nursing care has not yet adapted to the realities of long-term care needs, including those of seriously-ill patients, people with multiple illnesses, people with conditions that combine both physical and psychological disorders. I think that the process of adapting to these new realities will take some time. Never before have we seen such a massive shift in the age structure, with large proportions of a particular birth cohort going on to live to extreme old age. That is a historical first.

Can you see potential solutions to these issues, and how would these stack up in terms of financial feasibility?

We can only find solutions if we change the way we think. First of all, we have to try to prevent the expected sharp increase in resource use. We have to ensure that we meet the challenges of an aging population by increasing preventive measures and improving health. Secondly, we have to think about the degree to which technology can assist us in the task of providing day-to-day care to older patients, or patients in general.  For instance, we need to ask ourselves whether technological solutions might be able to take over the monitoring of certain health parameters in the not-too-distant future. Then there is the concept of health literacy. How can we achieve a situation where people of increasingly advancing years are provided with opportunities to further their knowledge of health-related issues, making them capable of adequately assessing their own health status? We will also have to ask some very tough questions; such as, is it really necessary for us to do all of the things we are capable of doing today? We will also have to be stricter in measuring our actions against the benchmark of whether what we do actually enhances the quality of life of those in our care. It is no longer appropriate for us to leave these types of decisions to the professional health care system. We need to ask ourselves the same questions – in the same way we do when we draft a patient's living will.

Autonomy, the increasingly technological nature of medicine, and patient quality of life – all of these are issues currently being discussed by the German Ethics Council. In what way are you hoping to contribute to this debate?

I am particularly interested in the question of how the increased use of medical technology affects the way we care for vulnerable patients; how we can ensure this care remains appropriate and justifiable from a medical ethics point of view – such as when patients with care needs are treated using autonomously-controlled devices. These are all questions of modern medical ethics, which we cannot simply ignore. Another interest of mine is the question of how we are going to deal with the issue of compulsory treatment, i.e. treatment that is considered 'in the best interest of the patient' but imposed without consent. Physical restraints, for instance, belong in this category. Restraints do stop patients with dementia from wandering and getting lost, and may even protect them from potential illness or even death from exposure. But aren’t there any alternatives we might consider? This is something I am particularly concerned about, and it is certainly an issue that requires our attention, particularly in view of the increasing numbers of patients who are accessing our medical services, and who come to us with acute problems in addition to their ongoing care needs and severe dementia.

What would your recommendations be, particularly in regard to compulsory measures being deemed 'in the best interest of the patient'?

Often, such measures are developed in order to safeguard patient safety. We conducted a study in which we compared dementia care provided in an apartment setting with that provided in conventional care homes. We were able to show that simple differences in the way care was structured resulted in fewer compulsory measures, such as physical restraints, force-feeding and sedation. This was because staff were able to change the way they interacted with patients, a change which led to a reduction in instances of aggression and wandering, patients showing more self-control when interacting with other patients, and an environment that did not place undue emphasis on wandering. This is only one example, and we will need to be much more imaginative in how we approach care systems and structures. We need to think about how we can avoid perpetuating old structures by simply doing more of the same; rather, we need to look at a new, modern approach to care provision.

Is this something you are keen to pass on to the new generation of clinicians?

It certainly is, yes. The current generation of young physicians who are still in training will be particularly affected by these issues. 70% of young women from this generation are expected to live to 100 years of age. However, this generation is not merely characterized by the fact that most of its members will live to extreme old age. In Germany, we are currently training the generations of physicians who will be treating the baby boomers as they get older. These physicians will be under particular pressure from increasing numbers of health care users, people who are tech-savvy and relatively well educated, and who have never experienced war or deprivation. They are likely to be quite demanding. They are also likely to demand to be kept well-informed, and strive to keep themselves well-informed. This is something I keep trying to communicate to our young physicians: you need to be prepared for a situation in which anyone who is not a pediatrician will have to work as a geriatrician, at least to some degree, or will at least require some degree of specialist geriatric knowledge.

How do you personally feel about living to 80, 90, 100 - or even beyond?

My medical family tree would suggest that my chances of living a long life aren't bad at all. However, after more than 35 years in gerontology, I would echo something that one of my teachers in gerontology, the famous life span psychologist Paul Baltes, used to say. He described extreme old age as 'hope with a black ribbon'; I am inclined to agree with this statement. If there is one thing I have learned during my many years in gerontology, it is that people want to live. However, when I look at the lives of the many extremely elderly people who take part in our studies, I also see that this stage of life is hard work and that, sometimes, it does invoke this 'black ribbon' coined by Paul Baltes. Thinking about my own situation, I think I would prefer to leave things to fate.