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Prescribing Senior Citizens the American Dream

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My Grandparents

Happy birthday, Grandma

With her oxygen tank in tote, her husband at her side, and her great-grandchildren joining by phone, my grandma celebrated her 93rd birthday, extinguishing her candles to an affectionate but tone-deaf recital of “Happy Birthday.” Between the two, my grandparents have lived for 188 years, a testament to advances in modern medicine. Their challenge, like that of other nonagenarians, is simple — to live long and prosper — and we can help.

Consider yourself lucky: A look at the past

Old age is a relatively modern phenomenon. Over the last 150 years, U.S. life expectancy has nearly doubled, increasing from 38.3–44.0 years (between 1850–1880) to 78.8 years (in 2014). Undoubtedly, this progress has been underpinned by healthcare advances — a notion reflected in mortality data, which depicts a shift away from infectious causes.

In 1900, the three most common causes of American demise were communicable diseases: pneumonia/influenza in first, tuberculosis, and third, diarrhea/enteritis. With sanitary and antibiotic advances, the paradigm has shifted. Of the top 10 most common causes of U.S. deaths, only one etiology is infectious (pneumonia/influenza, which has fallen to 8th). Additionally, diseases like diphtheria, once the 10th leading cause of death in the US in 1900, have been rendered nearly obsolete through vaccination. Just think, in 1921, diphtheria killed 15,000 Americans. By comparison, only two cases of the disease were reported to the CDC between 2004 and 2014.

Medical innovation has mollified transmittable scourges, with maladies of ‘old age’ including heart disease, cancer, and chronic respiratory disease supplanting infection as the leading causes of death, according to 2015 CDC data.

The American Dream

With life expectancy set at nearly 80 years, not only can we live the American Dream, we can live it longer: after all, 80 is quite literally the new 40.

My grandparents serve as a readily available case-in-point. They immigrated to the U.S. in 1960, navigating their way through Ellis Island, balancing 3 crotchety children and a fleet of over-packed suitcases. Here, for nearly 60 years, they have lived the American dream, defying actuarial tables in the process (my grandfather is 39 years beyond his predicted lifespan, my grandmother 33 years). At their desk, they have mapped out their future, with birthdays, pregnancy due dates, and family vacation schedules dotting their calendar. For them and many nonagenarians, the battle is not for quantity of life (they’ve excelled here), but quality of life.

Sometimes less is more — The medication paradox

Quality of life does not necessitate a complete absence of discomfort. After all, some wear and tear is expected after a 90-year fight with gravity. The propensity to treat each new symptom with a new medication (including the symptoms caused by the prior “salve”) is counterproductive, often precipitating an iatrogenically-induced downward spiral of polypharmacy.

Unfortunately, this practice of “over prescribing” is not uncommon in the elderly. According to a 2015 review article appearing in JAMA Internal Medicine, approximately 1 in 5 drugs commonly used in older people (age 65 and older) may be inappropriate, with this number increasing to 1 in 3 among those in aged care facilities. As such, the relevant patient question might not be “What medicine should I start taking?” but rather, “What medicine(s) can I stop taking?”

This concept, coined “deprescribing” has demonstrated real-world efficacy. A 2008 review published in Drugs Aging, comprising 31 separate drug-withdrawal trials, demonstrated a reduction in falls and improvement in cognition in elderly patients in whom psychotropic medications were safely withdrawn (a finding which has been recapitulated in subsequent reviews). In the case of my grandparents, I have rebuffed physician attempts to prescribe psychoactive sleep aids. They already have three artificial hips; another fall is not in the cards.

While medication decisions are best done in concert with clinicians, resources outlining potentially inappropriate medications are available online along with algorithms for deprescribing. In the case of the elderly, Beers Criteria have been established to identify possibly harmful medications. When in doubt, talk to your doctor.

Sometimes more is more — Socialization

Admittedly, talking to one’s doctor is not everyone’s cup of tea. However, there may be benefit in talking to one’s peer group. My grandparents, while tethered by canes and walkers, do their best to socialize, with trips to farmer’s markets, enrollment in life-long learning classes, and participation in gardening clubs. These communal activities, it turns out, may be good for elderly wellness, according to a 2015 publication in the Journal of Epidemiology & Community Health. In this Japan-based study, “community salons” were established for senior citizens with a range of activities, including arts and crafts, bingo, and recreational engagement with preschool children. Over the course of five years, 2,421 physically and cognitively independent senior citizens were surveyed. The result — “salon participants” were ~50% less likely to become functionally disabled than their non-participating counterparts. Similar results were noted in a 2003 study published in the Journal of Gerontology, which followed 3,218 elderly patients over the course of six years. The authors concluded that social and productive activities were positively related to greater happiness, better overall function, and reduced mortality. Solitary activities, in contrast, were positively related only to happiness. Distilling these results down, the conclusion is simple — elderly populations benefit from socialization.

The beauty of perspective

I’ll close with my grandmother’s social highlight of the year — her birthday soiree. As the party was winding down, the dishes drying in the sink and the guests well satiated, my grandfather pulled me aside, a ritual signifying the beginning of “a talk.” Every visit, my grandfather and I share a one-on-one conversation, reflecting on stories of the past, atrocities endured during WWII, his adventures with the World Bank.

Our discussion traced a similar narrative, though with a break from tradition. “Westy” my grandfather said, our conversation reaching its denouement, “have I ever told you what I do each morning?” he asked, motioning me forward. I shook my head, moving my chair closer to his. He curled his fingers, placing the back of his palm on my chest, as if to check my temperature. “I feel her,” he continued, his gaze turning towards my grandmother, who was engaged with my wife in the kitchen. “To make sure she is warm, that she is breathing.” There was a silent pause, as he turned back to face me. He smiled. “Thank you for coming, Westy.”

We are the prescription

As we descended the driveway, my grandparents appeared on the porch, side-by-side, arm-in-arm, standing proudly like two silver-haired lions watching over their pride. I tapped the horn gently as my wife waved, their happy silhouette faded into the horizon. This is the American Dream.

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