Monday, 5 March 2018

Capacity, environment and diversity: changing the vision of aging

Marco Inzitari

Judging by appearances, one might think that health professionals build their fortune on the misfortune of others. Traditionally, in fact, we deal with risk, diseases and their negative impact, more or less catastrophically. And, in the face of an aging population, we focus on multi morbidity, chronic disease, geriatric syndromes, disability and the end of life.

The recent report of the World Health Organization (WHO), entitled "World Report on Aging and Health" (September 2015), is committed to a change of focus. The report, which is positioned as a reference of health policies on aging, is long and complex, and addresses many dimensions of aging, from prevention to manifestations and consequences, to the need for long-term care (not in the mere sense of resource, if not of necessity continued in time, no matter how it’s provided).

As one of  the main novelties, the report, focusing on a principle of healthy aging (defined as the "development and maintenance of functional capacity that allows well-being, in old age"), turns our vision of health and aging, and adopts a simple paradigm, which is based on three elements:
  • Functionality
  • Intrinsic capacity
  • Environment

Functionality isn’t a new concept, especially in geriatrics and gerontology, since the possibility of performing the tasks and functions that for an individual are valuable should be the guide of all therapeutic actions. It’s rather the other two concepts that, in semantic terms, can be "revolutionary". The first, the "intrinsic capacity", is the residual potential, in physical and cognitive terms of the person.  It also not completely surprising, but I would highlight the concept of "capacity" as opposed to what we usually consider, “disability". How much the operationalization of this new concept will be different from “frailty”, we will see in the future. However, it gives the idea of something to take care and preserve through the all lifespan, from childhood to older life.  The second, the "environment", is also paramount to maintaining functionality, which ends up being the result of the interaction between intrinsic capacity and environment. But too often it’s a forgotten element, both in the clinic (in our consultations we rarely ask ourselves more than if the patient has architectural barriers, for example), or in research (it’s hard to find studies collecting data on the context, except for minimal questions related to social support).

Figure 1. Components of healthy aging according to the "World Report on Aging and Health"

I had the pleasure of inviting Susanne Iwarsson, now a professor at the Department of Medicine, University of Lund, Sweden, and an occupational therapist, to my hospital. Her first two slides, part of an old series of images, spoke of capacity and environment, and they suggested that we can learn a lot from the other professions. In fact, in the Nordic countries, occupational therapists play a fundamental role in the care of the elderly and, often by their experience in the practical solving of problems in the organization, they acquire a coordinating role. These teachings remind me that I have also been learning a lot from social workers, to broaden my vision of the person's autonomy, not only as a lack of "dependence", but as a decision-making capacity in relation to the person's own wishes.

Figure 2. Investment and return on investment in aging populations according to the "World Report on Aging and Health".

The positive spirit towards enhancing the intrinsic capacity of the older person exists through the entire WHO report: from the need for prevention (which refers to the importance of detecting frailty  in order to intervene with pillars such as physical exercise and nutrition), to the rehabilitative tension, which should be present during all long-term care, up to the imperative to exploit the potential of older people to the full, as a resource in terms of production and social added value. I have already mentioned it in an old post.

A final aspect of the document, which I consider key, is that of "diversity". Aging is too broad a concept: as it’s well underlined, people of 60 can have the psycho-physical potential of one of 30, and others of 50 years of one of 80. In other words, chronological aging does not correspond to the biological age, hence the need to refine and customize, to maximize the residual capacity, breaking false myths, although still resistant, on aging. Sports, like art, are full of examples of healthy aging, I would even say or “successful" aging, and if it were necessary to provide tangible evidence of the arguments of the report that I have commented, I will be happy to explain highlighted cases in the next post.

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