Woody Allen and ageing

"In my next life I want to live my life backwards. You start out dead and get that out of the way. Then you wake up in an old people's home feeling better every day. You get kicked out for being too healthy, go collect your pension, and then when you start work, you get a gold watch and a party on your first day. You work for 40 years until you're young enough to enjoy your retirement. You party, drink alcohol, and are generally promiscuous, then you are ready for high school. You then go to primary school, you become a kid, you play. You have no responsibilities, you become a baby until you are born. And then you spend your last 9 months floating in luxurious spa-like conditions with central heating and room service on tap, larger quarters every day and then.. Voila! You finish off as an orgasm! I rest my case."

This quote is from Woody Allen and was sent to me by one of the participants to our meeting. It is very timely as at my work I was joking earlier this week about the possibility of deageing. Especially deageing after reproduction seems a real option to me, meaning that when the kids grow older, you have more energy again. I must admit that I am a bit obsessed with growing older, approaching 50, and want to do everything to stop the process. And to find out that I have a bit more energy again, because my kids can pee, eat and move on their own gives a feeling of, well, comfort (and living in Geneva for most of the week also helps in this respect, although I miss them a lot at the same time).

But on a more serious side, it is also something we should deal with at WHO. In our discussions on how to structure the meeting, we are struggling with finding an alternative for the old models where you relate age and disease to various forms of care. If you have chronic diseases, find some disease management programme, If you are frail, you need to have home or institutional care, and if you are dying, the palliative care guys are waiting for you. As I said already in my earlier blog, it is all a bit sad and focused on the average patient.

What we really want is to find the right mix of support, assistive devices and care for you to remain longer independent. If your functions decline, and that is going to happen to all of us, how can we compensate for that as much as possible? I am not going to tell you what is our new model (will be released soon), but it is going to radically alter the lives of older people worldwide (ok, this may be an exaggeration).

However, I am convinced that you can start already now in trying to shift the age where you become dependent and frail. By taking care of the FIELDS of ageing (Food, Intake, Exercise, Liquids, Drugs and Stress, see earlier blog) it must be possible to stay in better shape and to be better able to cope with getting older. Just like people who are in good shape often recover faster after an operation, fitter people will probably face serious decline much later in life.

A word on dependency, as we struggle with that as well. What is it after all? There is much written about this in the literature. Dependent is often explained in terms of dependency on other people with performing activities of daily living. But can you be dependent on assistive devices as well? Are more resilient people with similar declined functions less dependent? And how to define the border line? Does frailty implies that you are also dependent? And is the wording (dependent) not a terrible way to speak about people?

Enough questions and I am not qualified enough to answer them. But we will address them during our meeting in April.

For now I wish everybody a happy Easter. After all, Easter always represents a new beginning, and the start of spring. In fact Easter is THE feast of deageing. Or as Woody Allen says "I don't want to achieve immortality through my work... I want to achieve it through not dying."

Old people, joy is coming

This week I went to a small art cinema in Eaux Vives, the area I live in Geneva, to see the movie "No" by Pablo Lorrain. The film is about the referendum that the dictator Pinochet in Chile was forced to organise under international pressure, asking the people for a mandate to continue another 8 years. The people in the No camp, a diverse group ranging from communists, dissidents and Christian democrats, had little time to design a campaign, but were allowed to broadcast 15 minutes each day on national television. They first made short movies about the misery of the Pinochet regime, the people that disappeared and with as concluding message that this should never happen again and that you should vote no. A young marketing professional joins the group and tells them it will not work. People will not want to jeopardize their increase in welfare, will be afraid to vote or will think that change will not happen anyway. The only chance for change is to look at the future and come with a message of hope and humor. After a lot of opposition from within the party (it is not easy to be joyful when your relatives were killed) and from outside (secret police) they do a campaign with the slogan 'Chile joy is coming'. They win, Pinochet has to leave and the rest is history.

Ok, nice story, but what has this to do with ageing and care you might ask? I will come to that in a moment. The first step to explain this is to have a look at the new health policy of the Dutch government.

Essential element of the newest health reforms in the Netherlands is a transition from looking at systems to looking at people. There are not only big differences in health status between people, but also in their social environment and the degree to which they have control over their own life. Despite the fact that different people need different care, we often still give them equal treatments.

The Dutch health ministry wants to solve that by integrating the existing systems for curative care, long term care and social support and to have a much more local and people centred approach in care.

I brought up this policy in an interesting discussion I had in Geneva with a close colleague. As I wrote before, we are organising a meeting with the title "building systems to address functional decline and dependence in ageing populations". For this meeting we write few papers, one of which on functional decline when people get older. The paper summarises the various definitions of frailty, functional decline and disability and how they relate to the different forms of care. There are already nice chronological schemes in the literature connecting different phases in your life to for example chronic diseases management, long term care and palliative care. In other words, your degree of dependency determines what care you need.

In our discussion we had the feeling that this does not reflect the recent developments, for example in the Netherlands, to a more patient centred and integrated care approach. It may be a better way to start not only from health status but also from the social environment and personal characteristics of people to get the full picture. You may then better understand what they need and together decide on the mix of care that will give best results. The mix of care must be such that it will contribute to the overall aim of maximising independence of people over their life course. After all, it is about people's ability to adapt to ageing.

During the meeting we may ask participants to reflect on these issues. But even if we come up with a different format, for me it is interesting to see that there are many similarities to the new health policy back home. We could even radically change the title of the meeting. Not building systems to address decline in people, but building people to address their decline.

But what is the link to the film I started with? Well, you need an optimistic message to change systems. Saying that you will decline later in life, that you are not able to perform functions anymore, that you therefore need care and at the very end maybe even palliative care is not really a hopeful message. Doesn't it sound so much better that it is wonderful to grow older and that our health care and support systems will contribute via a personalized approach to you being as long as possible independent and joyful later in life. As in the film, the dictator/top down approach should make place for the benefit of democracy/ the power of people to have more control over their own lifes. That would be a real revolution! Old people of the world, joy is coming!

Stress in old age

This week we had a visiting professor from Israel specialised in ageing and stress. To some extent this is rocket science in this country, as part of the research focuses on the anxiety of people when faced with rocket attacks. But they also use American research from people exposed to hurricanes.

The key question is whether older people are better able to cope with this kind of stress than young people. Is resilience getting stronger with age? And what dimensions of stress may change with age? You would expect that old people have more experience and know what to do in stressful situations. On the other hand, they may be a bit less flexible.

The theory of coping with stress goes back to the flight or fight response. There are many videos on Youtube explaining this. I like the one with the guy jumping away when a car suddenly drives into the pavement. It is then explained how you react in an emergency situation like that, what will happen to your muscles and to your hormone production.

http://www.youtube.com/watch?v=m2GywoS77qc

But going back to the question whether older people react differently. The evidence is mixed. For both hurricanes and rockets it was found that older groups experience less post traumatic symptoms than younger people, especially the middle aged groups. That is not completely surprising, as people in middle age have to cope with jobs and families. There is a difference if you just have to get the newspaper in the morning when there is a hurricane raging outside or you have to bring the kids to the nursery school and be in time for work. The professor herself experienced it when having to go for lectures to the university when there was an imminent rocket threat. Still old people seem to deal a bit better with psychological aspects and accompanying negative emotions. They report stress less often when they experience it (instead, they complain about the weather).

On the other hand, in old age stress is more often experienced through somatic symptoms, like slipping away and falling down more often. Existing health problems in old people like high blood pressure,cardiovascular disease, osteoporosis and digestive problems are intensified by stress. Stress hormones are released and absorbed slower and have a longer impact. Both ageing and stress hormones will impact immune functions. Old adults experiencing stress are vulnerable to infections and viruses like flu even when they are vaccinated.

So we are not sure about the relationship between old age and stress. But we know that over time stress can even be passed on to next generations. The classic example is post traumatic symptoms in a second or third generation holocaust survivors. Remarkable enough it can be shown that this is also the case for any positive effects. Resilience is also often higher in third generation holocaust survivors. The big question is how to pass the good things and block the bad.

Finally, is it possible to be happy and stressed at the same time? Yes, according to the professor. That is good news for me, as the coming weeks will be busy. I will be a happy, stressed and little bit old man.

Overmedicalisation

"Fred, you suffer from Self talking syndrome type 2". I turn around, a bit surprised, to my room mate, a doctor from Singapore. He is also a philosopher by nature and I wait for the daily question or theory that he wants me to react on. He continues "You are talking to your computer and that is maybe treatable". And then he starts to explain that this is an example of overmedicalisation, more a joke by him and that we have to find a balance in life. We divert the discussion to long term care - as we are both dealing with that - and conclude that there may even exist something like oversocialisation in some countries. And in other countries undersocialisation (not enough attention for social care) in the aim to come to universal coverage for medical care.

After our discussion, I thank him for finding the topic for my next flight blog (I usually write these blogs in the airplane back home on late Friday afternoons). Last week I already wrote about the danger of using too many medicines, especially when getting older, but the problem of overmedicalization is broader. The overtreatment of the attention deficit hyperactivity disorder (adhd) in kids may be the most well known example, but examples can also be found in fields like depression, sleeping disorders and, hm ok, talking to yourself.

How to define overmedicalisation exactly? Or rather medicalisation because this is how the term was first devised by sociologists in the 1970s. They viewed medicalisation as a form of social control in which medical authority expanded into domains of everyday existence. Doctors were seen as agents of social control. Ivan Illich, a philosopher, in his book "Limits to medicine: medical nemesis", elaborated on this. He stated that the medical profession harms people through iatrogenesis, a process in which illness and social problems increase due to medical intervention. He saw it on 3 levels: the clinical, involving serious side effects worse than the original condition; the social, whereby the public is made docile and reliant on the medical profession to cope with life in society; and the structural; whereby the idea of aging and dying as medical illnesses effectively "medicalized" human life and left individuals and society less able to deal with these "natural" processes (source: wikipedia).

Nowadays and after the roaring sixties and seventies, the criticism has become less sharp and a far cry from the earlier calls for a revolution against the biomedical establishment. Even scholars who critique the societal implications of brandname drugs remain open to these drugs' curative effects. That is probably why we now call it "overmedicalisation" rather than just "medicalisation". But recently the trend is to become more critical again. With the information revolution, more and more people want hard evidence for effective treatments and more and more is known about adverse effects of medicines. Our trust that big companies in banking, food industry and pharmaceuticals are acting in the interest of their customers is under fire with all this new information.

But before turning a revolutionary myself, let me turn back to overmedicalisation and ageing. As Illich already said, ageing should not be seen as an illness in itself. We too often use the words "frail" and "elderly" in one sentence, just because old people react a bit slower and tend to forget things more easy. Of course, they may have more diseases than when they were younger, but ageing itself is not (yet) curable. To make the distinction more clear, I propose that professional care workers who assist old people with activities of daily living (for example washing) are not allowed to wear white or green nursing uniforms. Pink, red or yellow, it does not matter, as long as it is colorfull, showing that ageing is not a disease.

Finally, should I worry about my talking to machines? Probably not as I am just ahead of my time. Computers and mobile devices are already able to deal with spoken comments and that will only increase in future. Whether it is desirable that computers in WHO will learn all types of Dutch dirty words is another matter. After I have left, they will probably need some treatment....