Helping the elderly live well in their season of life

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from Luke’s Journal 2020 | Ageing Gracefully | Vol.25 No.3

Front-page headlines of the Australian Newspaper on the 17th of July 2020 read: “Age not an issue: Hospitals ordered to treat elderly”. 

In the midst of COVID-19, the fact that our elderly members are still loved and admired has been a refreshing reminder. This contrasts with the discrimination of ageism, which I believe has grown in our youth-obsessed and happiness-chasing culture. 

This article is a reflection on these ideas in the context of combating frailty in ageing. It is about helping the elderly live well in their season of life.

The Biblical view on ageing

Seniority and old age are viewed very positively in the Bible. They are often considered to be part of a good life. Indeed, “long life” is a common blessing in the Jewish community. Many if not all of us are aware of the commandment to honour our parents as the commandment that comes with a promise. 

“Honour your father and your mother, so that you may live long in the land that the Lord your God is giving you”. (Exodus 20:12) 

The Bible additionally regards older people as wise and to be respected. The ageing community members in our society are vulnerable. The experience of losing independence, being taken advantage of and often disregarded is not uncommon. In this context, the Bible exhorts us to honour God by caring for the vulnerable and needy. 

“He who oppresses the poor shows contempt for their Maker, but whoever
is kind to the needy honours God”. Proverbs 14:31

Meanwhile, “I’m getting old!” is a common reflection from individuals whose bodies are failing, whether it is osteoarthritis or lack of capacity. It highlights the negative view our society has on ageing, suggesting a despondent, defeatist attitude and a sense of worthlessness.

“The Bible exhorts us to honour God by caring for the vulnerable and needy.”

“Too old?”: An introduction to Pam’s story 

As we consider this topic, meet Pam, aged 76 years. Her parents lived into their 90’s. She has been widowed 7 years after enjoying a great marriage, Pam has also recovered from breast cancer treatment where she lost almost 10% of her lean muscle mass. An avid swimmer all her life, Pam participates in swim meets three times per week before having coffee with her squad. She also loves gardening. 

In her post-cancer treatment Pam fell and tore her rotator cuff tendon in her shoulder. There was no improvement with non-operative treatment. She was advised by some doctors not to have surgery, as she is “too old”. Her pain, movement restriction and weakness left her unable to swim and limited in her gardening. Let’s keep her in mind as we look at frailty and ageing. 

Defining frailty and ageing

The term “older” carries different connotations around the world. In developing countries it is associated with the inability to live independently and obtain gainful employment. The World Health Organisation (WHO) defines “older” as “age > 50 years”, while the United Nations uses “> 60 years”. In Western countries “older” is considered to be “> 65 years”, which comprises 15% of the Australian population. Our older community is then sub-categorised into “young-old” (65-75 years), “old” (75-85 years) and “very old” (>85 years).¹

The process of ageing is often associated with the syndrome of frailty. According to the British Geriatrics Society (BGS), ‘Frailty describes a condition in which multiple body systems lose their built-in reserves.’² In general, people suffer from three or more out of five symptoms that co-exist. These include: 

1. Unintentional weight loss

2. Muscle loss and weakness

3. A feeling of fatigue

4. Slow walking speed 

5. Low levels of physical activity. 

These symptoms will be expanded on, as we consider the physiological changes occurring with ageing.

The prevalence of frailty is 15-26% in those over 75 years, increasing with age.

The physiological changes and frailty symptoms in ageing

The physiological changes of ageing are well understood as affecting all systems of the human body. Understanding these changes allows us to tailor our interventions more effectively, in particular regarding physical activity.

a) Cardio-respiratory changes
From the age of 50, there is a 5-10% decline in VO2max (cardio-respiratory capacity) per decade. A VO₂max of 15-20ml/kg is required for independent community living. The sedentary (inactive) elderly often reach this around age 80-85.³ 

b) Musculoskeletal changes
The process of sarcopenia – loss of muscle mass, strength and endurance – commences at age 25. This becomes significant after 65 years when at least 25% of peak youth strength is lost. At 80 years, there is 50% loss of skeletal muscle due to muscle atrophy. Degenerative changes within most tissues occur, in particular the development of tendinopathy and articular cartilage degeneration. 

c) Neurological changes 
Proprioceptive, sensory and cognitive changes occur. The proprioceptive and sensory changes increase the risk of falls and therefore hospital admission for trauma care. The outcome from such admissions generally leaves older patients in a declining health state. Cognitive changes, such as short-term memory loss, may affect compliance with exercise and also the ability to learn new movements.

d) Other factors
Sleep, hormonal changes, fatigue and adjusting to the changing seasons of life all have to be taken into account when considering the prescription of exercise. Relationally, many elderly people experience bouts of severe loneliness following the loss of a loved one, a “shrinking friendship circle” and social isolation from the community. In addition to the existing physical deficiencies, there are frequently deep social, emotional and spiritual needs.

“The health benefits of exercise for the elderly are profound.”

Assessing frailty

There are many tools available to assess for frailty. As a minimum the BGS include gait speed, a timed up and go test and the PRISMA 7 questionnaire. As the majority of frail patients have sarcopenia the “SARC-F” questionnaire is a helpful scoring tool. This tool combines capacity (e.g rising from a chair) with at-risk events (e.g. falls). It is also a predictor for falls and frailty.⁴

It is incumbent on all healthcare providers to be on the lookout for frailty in elderly people. Do approach this holistically considering physical, psycho-social and spiritual needs.

How to combat frailty in ageing

I must underpin all I say by endorsing the need for excellent General Practitioners (GPs) in this setting. A great GP stands out as gold.

A holistic approach is required, which is both highly satisfying and time consuming. Within formal geriatric care services there will be multi-disciplinary teams available to the patient. This is ideal but not always possible. In the setting of a general practice, where the patient may have good family and social support, gains can be made to conquer frailty and improve the health and wellbeing of the elderly. 

Once any acute illness is excluded such as infection or metabolic disorder, the foundations of exercise prescription, dietary review and social support work together. Supervision to enhance compliance is needed more than that required in younger patients. To combat frailty the interventions include increased physical activity, dietary review and support to aid compliance. 

a) The principles of prescribing exercise in the elderly
The health benefits of exercise for the elderly are profound.^5,6 The ability to improve aerobic performance, strength and balance still exists despite the ageing process. The results are impressive with even the most sedentary individuals. 

Patients should be active and exercise for at least thirty minutes every day, i.e. > 150 minutes per week. Variety and safety is key with good supervision and support through family or health care professionals such as nurses, personal trainers, physiotherapists or exercise physiologists. 

It should be noted that certain patients are fundamentally lazy and indeed may be proud of their inactivity. In a respectful way they need to be led to see that by choosing to be inactive and idle they will become a burden to loved ones and the community. Remember the sluggard in Proverbs 24:30-34. (Note: I am excluding those unmotivated due to mental illness.)

As a guideline, exercise prescription for the elderly⁷ is similar to younger patients with the following adjustments: 

i) Longer recovery, warm up and cool down periods required

ii) More variety and less repetition in training and activities

iii) Aerobic training: Moderate intensity for 150 minutes a week. Vigorous intensity for 60 minutes a week

iv) Resistance training twice weekly 

v) Careful balance (proprioceptive) and flexibility training 

vi) Consider group activities such as aqua-aerobics, chair based exercises and slow movement classes.

b) Nutritional review
Patients’ weight, protein and caloric intake all need careful assessment. Supplements may be required. In patients who are motivated and otherwise well, the use of testosterone and other anabolic agents have been studied. 

c) Care in other areas
Psychosocial and spiritual care is essential. I have found that the reality of being frail and needy usually makes older patients consider their life purpose and the trajectory of their life journeys. 

This is very similar to what I have observed caring for elite athletes with career-ending/ threatening injuries. I frequently take the opportunity to ask: “I know things are tough for you at the moment. How do you feel looking ahead?” I frequently offer to pray for them, noting that this has never been rejected and even may lead to gospel conversations. These experiences are a reminder of the command in 1 Peter 3:15-16 to “be ready and speak with gentleness and respect.”

“Old, but not frail”: Pam’s story continues

Remember Pam, the swimmer and gardener? She did not improve with non-operative treatment and underwent arthroscopic rotator cuff repair surgery, rehabilitation and reconditioning. She returned to her friends swimming at 80% of her pre-injury levels. Gardening is fine and makes her happy. In her gratitude she became an effective swimming instructor for children with disabilities.

Summary

Combating frailty in ageing is satisfying, important and time consuming. A multi-disciplinary approach is best where the patient knows that the practitioner is a great support and offers hope. 

Heroics are not expected, as most patients understand their season of life. From a platform of great care and trust it is an opportunity for the Christian healthcare worker to share the gospel hope of an eternal future where there is no more pain and suffering. 

“There will be no more death or mourning or crying or pain, for the old order of things has passed away”. Revelation 21:4b

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References:

1. National Ageing Research Institute http://www.nari.net.au/
2. Turner, G et al. Best practice guidelines for the management of frailty: a British Geriatrics Society, Age UK and Royal college of General Practitioners Report. Age and Ageing 2014; 43:744-747. DOI: 10.1093/AGEING/AFU 138
3. Cruz-Jentoft, AJ, et al. Sarcopenia: revised European Consensus on definition and diagnosis. Age and Ageing 2018, 0 :1-16. DOI: 10.1093/ageing/afy 169
4. Malstrom K.M, eta al. SARC-F: A Simple questionnaire to rapidly diagnose sarcopenia. JAMDA 14(2013) 531-532. http://www.jamda.com
5. Exercise in the Age of Evidence Based Medicine: A Clinical Update. Dr Stephen Blair et al http://www.medscape.org/viewarticle/549398 
6. Concannon et al. Exercise in the Older Adult: From the Sedentary Elderly to the Masters Athlete. American Academy of Physical Medicine and Rehabilitation, Vol. 4,833-839, November 2012.
7. https://orthosports.com.au/pdf-download/Exercise-Prescription-(Part-2).pdf