Staying independent in our later years
There are many ways to keep on the move and living on your own in older age.
We all hope to stay active and independent for the rest of our lives. And most of us want to stay in the familiar surroundings of our own homes and neighborhoods, rather than move to an assisted living or continuing care community, or — worse — a nursing home, a prospect so devastating that, according to a study published in the medical journal BMJ, many older women who suffer hip fractures say they would rather die than face it.
Fortunately, there are ways to help ensure that you never have to make such a dire choice. Addressing a handful of health risks at midlife can profoundly affect your ability to continue living independently. Meanwhile, new concepts and technologies are helping to make staying in our own homes and communities an attainable goal for increasing numbers of us. Below are some steps you can take — and recommend to friends and aging parents.
Safeguarding your health
A 20-year nationwide survey of people ages 45 to 74 identified five health problems that substantially boost the risk of admission to a nursing home: smoking, inactivity, obesity, diabetes, and high blood pressure (Archives of Internal Medicine, May 8, 2006). These problems contribute to many chronic illnesses that can cause disability and death as we age, including heart disease, stroke, osteoporosis, and certain cancers. Among those ages 45 to 64, diabetes more than doubled the risk of eventually entering a nursing home. Obesity in the 65-to-74 age group increased the risk by 31% (although it had no significant impact at a younger age). For those ages 45 to 64, physical inactivity boosted the risk of entering a nursing home by 40% (although it had no significant impact at older ages).
Smoking increased the likelihood of a nursing home admission by 56% in the younger group and by 32% in the older group. High blood pressure also increased the risk, by 35% in the 45 to 64 group and by 29% in the older group.
The effect was even greater when risk categories were combined. For example, diabetic smokers in the younger group were five times more likely to enter a nursing home than people the same age with no risk factors.
What to do. Taking steps to address these five factors could reduce not only the risk of a future nursing home admission but also the chance of premature death. Fortunately, most are within our control.
Here are several things you can do to preserve your independence throughout life. Keep in mind that these changes interact and reinforce one another; the more you adopt, the greater the potential payoff:
If you smoke, talk to your doctor about options for quitting. We all know that smoking is bad for health, but here's a quick reminder of how bad: it's harmful from before birth to the end of life, raising the risk of cardiovascular disease, cancer, respiratory disease, osteoporosis, macular degeneration, and cataracts.
Become more active. Just 30 minutes of brisk walking five days per week reduces the risk of heart attack, stroke, and diabetes; lowers blood sugar levels; decreases depression; and helps activate genes that clear fat and sugar from the bloodstream. Upping your physical activity level to 60 to 90 minutes most days of the week can help you lose weight — and keep it off.
•Improve your diet through some simple changes. Add more servings of dark green, red, orange, or yellow vegetables or fruits to your daily intake, with a goal of reaching nine servings per day. And switch to healthier fats: skip trans fats, choose fewer saturated fats, and get more healthy fats (monounsaturated and polyunsaturated oils and omega-3 fatty acids). Plant oils, nuts, and fish are all good sources.
To get your blood pressure under control, exercise regularly, don't smoke, and consider adopting the classic DASH eating plan (www.nhlbi.nih.gov/health/public/heart/hbp/dash): a diet high in fruits, vegetables, and low-fat dairy products and low in red meats (and other sources of saturated fats), sweets, and sodium (salt). The OmniHeart trial, published in 2005, showed that you can lower blood pressure even more by eating fewer carbohydrates and more healthy fats and protein. If improved diet and increased exercise alone don't bring your blood pressure under control, prescription antihypertensive medications may help, as long as you take them consistently.
Talk to your primary care provider about bone mineral density (BMD) testing. All women ages 65 and over should have their BMD tested. If you're at high risk for osteoporosis, your clinician may recommend screening at an earlier age. Be sure to get adequate calcium (1,000 to 1,200 mg per day) and vitamin D (800 to 1,000 IU per day).
Depression is another risk factor for nursing home admission. A 2007 European study that analyzed information from 11 countries on adults ages 65 and over receiving home care services found that the more severely depressed a person was, the more likely she or he was to be admitted to a nursing home. There are several possible explanations. Depression can chip away at immune function, heart health, self-care, and the ability to stay active and connected with others. If you think you might be depressed, talk to your clinician about antidepressants and psychotherapy.
At almost every age, falls are the leading cause of injury in women. Among older people, men are more likely to die from a fall, but women are more than twice as likely to suffer a fracture — especially a hip fracture, which often results in long-term impairment and nursing home admission. In 2003, nearly three out of four patients hospitalized for hip fractures were women.
Simply being afraid of falling can affect mobility and independence. A study published in the April 2008 Journal of the American Geriatrics Society found that 60% of 673 older community-dwelling adults who said they were worried about falling avoided or restricted everyday activities, such as shopping, bathing, outdoor walking, and visits to relatives or friends. These self-imposed limits were associated with declining ability to handle the tasks of daily living over the following three years.
What to do. If you're concerned about falling, have your clinician assess your situation, prescribe a plan to put you on a safe track, and help set your mind at ease. She or he can evaluate your gait (how steadily you walk), the sensation in your feet, your medications, your vision, and your muscle power — for example, whether you have sufficient strength to rise from a chair or recover your balance easily. Your clinician may refer you to a physical therapist or other professional who can suggest anti-fall techniques and ways to improve the safety of your home.
To avoid falls, try some of these proven strategies:
Exercise. Weak muscles, poor balance, and limited flexibility due to arthritis often turn trips into falls. In one study, a fall prevention program comprising strength training and balance exercises reduced falls and fall-related injuries by 35% in people ages 80 and over. Yoga or tai chi is also helpful. For example, in a study of previously inactive women in their 70s at Harvard's Spaulding Rehabilitation Hospital in Boston, 12 weeks of tai chi was better than brisk walking for balance, leg strength, and flexibility. In a study reported in the Journal of the American Geriatrics Society, a 15-week program of tai chi reduced the rate of falls by nearly 50% in a group of elderly people.
Check your vision. Age-related vision changes also contribute to accidents and falls. Have regular eye exams, and keep your glasses or contacts up to date. One randomized trial found a reduction in falls among women over age 70 after cataract removal, although not all studies agree on the effects of that procedure.
Review your medications. The body's response to medication, prescription or over-the-counter, changes with age. Some medications — narcotic pain relievers, antihypertensives, and certain tranquilizers, for example — may cause drowsiness or dizziness or otherwise impair balance. These side effects (like all side effects) are more likely to occur if you are taking multiple medications. Regularly review your medications with your clinician, and discuss the possibility of dropping or changing those that may be causing troublesome side effects.
Remove home hazards. Many fixes are simple and inexpensive. Improve your home's lighting with higher wattage, fluorescent bulbs, or additional lamps. Night-lights or other nighttime lighting may also help. Coil loose electrical wires, and affix them safely along walls. Keep stairs and walkways uncluttered. Repair torn carpeting. Remove throw rugs or secure them with nonslip backing or double-sided tape. Rearrange kitchens and closets so that you can easily reach the items you use most often. Install handrails on stairways and landings, and put light switches at the top and bottom of stairways. Use nonslip strips or rubber mats in tubs or showers. Install grab bars in tubs or showers and near the toilet.
Getting the help you need
Download or request a free copy of "Exercise: A Guide from the National Institute on Aging," available at www.nia.nih.gov/HealthInformation/Publications/ExerciseGuide.
Aging at home assistance
Call your local Council on Aging and ask about "village-model" communities and services in your area. Senior centers may offer inexpensive or free transportation to grocery stores, social activities, and services such as home helpers, government assistance programs, and legal and financial advice.
Download the National Center for Injury Prevention and Control publication "Check for Safety: A Home Fall Prevention Checklist for Older Adults," available at www.cdc.gov/ncipc/pub-res/toolkit/CheckListForSafety.htm.
Home assessment guides are available through the Environmental Geriatrics program at the Weill Medical College of Cornell University Web site: www.environmentalgeriatrics.com/home_mod/patient_guides.html.
Visit the Harvard School of Public Health's Nutrition Source at www.hsph.harvard.edu/nutritionsource.
Aging at home
Age may slow our steps or impair our performance of everyday tasks, but that doesn't make an assisted living facility or nursing home inevitable. You have increasing opportunities to get the services you need in your own community.
One new development is the growth of nonprofit community-based organizations that offer varying amounts of assistance for a yearly membership fee. The services may include trips to the grocery, exercise classes, book groups, and visits to museums, concerts, and lectures. These groups may also direct members to prescreened vendors offering paid services — such as home repair, plumbing, in-home nursing care or companions, bill paying, or snow removal — as well as volunteers who are willing to help with household chores and other tasks.
Several such "village-model" organizations have sprung up in urban areas. Examples are Boston's Beacon Hill Village, which was started by residents and relies on private fees and foundation funding (annual membership: $580 per individual or $850 per household); Cambridge at Home, in Cambridge, Mass. (annual membership: $900 per individual or $1,200 for couples); and Capitol Hill Village, in Washington, D.C. (annual membership: $500 per individual or $750 per household). It remains to be seen whether this model can be adapted to suburban or rural areas — or to less wealthy communities.
A growing number of high-tech aids are also available to support independent living. With a personal emergency response system, such as Medical Alert System or Life Guardian Medical Alarm System, you can contact family or neighbors or summon an operator to link to emergency services. People are reminded to take their pills by beeping or vibrating watches and electronic pillboxes with voice, sound, or flashing-light alerts. Families separated by distance can regularly check in face-to-face via computer systems that provide two-way viewing and voice.
Another indispensable aid to independent living, this one decidedly low-tech, is emphasized by Dr. Anne Fabiny, chief of geriatrics at Cambridge Health Alliance and assistant professor of medicine at Harvard Medical School: "It's very difficult to stay in your own home without help from family or friends. Think about who in your social network is going to be willing and able to provide help." Start the conversation now, she suggests. It may seem early, and it may not be easy, but it can serve to articulate where we'd like our lives to go — and the help we need to get there.