Weird berries. Capsules of unpronounceable supplements. Yoga or tai chi. Crossword puzzles. Such amulets, we’re told, may ward off disability — which is the real fear that accompanies aging, isn’t it? Not the sheer number of years that will have passed, but the things we’ll no longer be able to do.
But our efforts to dodge disability appear to be falling short. Gerontologists once hoped for a “compression of morbidity”; the idea was that we could remain healthy and active until our bodies fail at advanced ages, and we swiftly died. But new research shows that this has not materialized for most of the elderly. The price we’re paying for extended life spans is a high rate of late-life disability.
The latest evidence comes from researchers at the University of California, San Francisco, who combed through 15 years of data from the national Health and Retirement Study to determine disability rates in the final two years of people’s lives.
“Despite massive investment in geriatric medicine, we can sometimes delay or slow down disability, but we can’t prevent it,” said Dr. Alex Smith, a palliative care specialist and lead author of the study, published on Monday in JAMA Internal Medicine. “A vast majority of people who live to older ages live with disability or a mobility problem in the last years of life, and for women it’s even more likely.”
The numbers, based on interviews with more than 8,200 adults over age 50 who died from 1995 to 2010:
– Two years before their deaths, 28 percent of people were disabled, defined as needing help with an activity of daily living like bathing or dressing or using a toilet. Of those, 12 percent reported “severe” disability, meaning they needed help with three such activities or more.
– The disability rate rose markedly with age. Of those who died at ages 50 to 69, only 15 percent had been disabled two years earlier. Of those who died after reaching age 90, half had been disabled.
– Mobility problems occurred even more often. Two years before they died, 69 percent of the older adults had trouble walking more than a few blocks, 45 percent found it difficult to walk one block, and more than half struggled to climb a single flight of stairs.
– Women fared worse. Their longer lives mean they survive to ages at which disability becomes more common, but that’s not the whole story. “A woman who dies at 80 has a longer period of disability than a man who dies at 80,” said Dr. Ken Covinsky, a geriatrician and senior author of the study.
Why? Women are more prone to disabling disorders like depression, arthritis or osteoporosis. They have lower household wealth, also associated with disability. And they’re more apt to live alone. “Husbands who are disabled have their wives taking care of them,” Dr. Smith said. “But women with disabilities don’t have their husbands anymore to take care of them.”
The researchers also noted that this study looked only at physical disability, not cognitive problems, which also affect the ability to function independently.
What keeps this picture from being unremittingly grim is the fact — hard for younger and able-bodied people to grasp, sometimes — that disability in itself doesn’t have to mean a lousy life.
In fact, U.C.S.F. researchers have also studied old people with significant disabilities — a small but diverse group of 62 residents of San Francisco — and their quality of life. Their dependence made them eligible for nursing homes, but instead they lived in their communities with support from the Program of All-Inclusive Care for the Elderly, or PACE. A great majority rated their quality of life as fair to very good, the middle of the spectrum.
“They were doing O.K.,” said Dr. Smith, senior author of that study. “Younger people underestimate our ability to adapt to adverse circumstances.”
Partway through our conversation, both doctors recalled a couple sitting in the front row the day before at grand rounds at their medical school, an event open to the public. The husband was 95, his wife perhaps a bit younger, and both used walkers. After the event, it took several people to help them exit, get into a taxi and go home. Yet they’d enjoyed the discussion and had asked several questions.
This couple might well have qualified as disabled, using the study’s criteria. “Do we mourn the fact that this man needs a walker?” Dr. Covinsky mused. “Or celebrate that he uses it to get around and stay very intellectually engaged?”
To point out that disabled people can live satisfying lives doesn’t absolve us from doing our best to remain healthy. “The emphasis on trying to do the right things — not smoking, keeping a reasonable body weight, exercising — that’s important,” Dr. Covinsky said. “There’s good evidence it helps you live longer.”
But, he added, “we shouldn’t deny demographic reality. If you live to be 90, the majority of people will have a period of disability.” Even those who eat plenty of kale.
Knowing this should help us plan for what’s coming — we’ll need better transportation options and senior housing, better insurance programs, better lots of stuff — both as individuals and as members of an aging nation. Personally, I like blueberries, yoga and crossword puzzles (kale, I’m still grappling with), and I tend toward optimism. But we can’t rely on any of those to keep us functional later in life.
Paula Span is the author of “When the Time Comes: Families With Aging Parents Share Their Struggles and Solutions.”
This post has been revised to reflect the following correction:
Correction: July 8, 2013
Because of editing error, an earlier version of this post misstated the journal in which the new study on disability rates was published. It is JAMA Internal Medicine, not JAMA.