- Email: [email protected]
When Blue Turns Gray: Postwarranty Performance
PERSONAL REFLECTIONS
When Blue Turns Gray: Postwarranty Performance Ben Eiseman, M.D., D.Sc.
Objective: The objective of this study was to review the lifestyle and expectations of a group of 86- to 87-year-old Yale College graduates at the time of their 65th reunion and to compare the results with equivalent data from the general public. Methods: A five-page questionnaire was sent to the 263 living survivors of the Yale College class of 1939 at the time of their 65th reunion. Results: One hundred fifty-one replies were received, some only partially completed. Median survival was 79 years. Among the more interesting results was a wide discrepancy (optimism) between the perceived quality of life and that which one would anticipate from the many physical disabilities of the study group. Conclusion: This is by nature a self-selected group of male octogenarians, but their lifestyle and medical disabilities fit with the general population; their attitude toward being elderly is remarkably positive, and their personal and civic performance continues beyond expectations. (Am J Geriatr Psychiatry 2006; 14:21– 26) Key Words: Geriatric lifestyle, performance at 87, questionnaire, 65th Yale reunion
T
his 65th reunion of our Yale College class of 1939 provides a unique opportunity to obtain a profile of 86- to 87-year-old Yale graduates. Because at our age, we are perforce interested in both our medical conditions and our quality of life, I sent a questionnaire to each of the 263 classmates listed as surviving (30% of our 860 graduating class). I used your 151 replies as the basis of my comments. Forty-three percent failed to respond, and I have to presume they were, as a group, sicker than those who replied. Based on the information furnished by the respondents, I review our current health status, compare it with expectations for our age-specific cohort in the general public, and, finally, see what can be learned from this exercise.
Who Are We? Let us start by identifying ourselves. We are the 263 survivors, comprising 30% of a class of 860 at the time of our Yale graduation, in 1939. Most of us were born in 1917 and are therefore now either 86 or 87. At birth, our life expectancy as male children was 50.1 years. We have, therefore, exceeded our initial warranty by 36 years. It should come as no surprise that we now require periodic overhauls and occasional parts replacement. The mean life expectancy of our great grandson, born this year, is 73.6 years.1 We have even outlived his warranty by 13 years. Not bad. The ladies in the audience can add approximately six years to their life expectancy at birth, but do not assume the lead is
Received July 7, 2005; accepted September 9, 2005. From the University of Colorado Hospital. Send correspondence and reprint requests to Ben Eiseman, M.D., D.Sc., Professor Emeritus, Surgery & Medicine, University of Colorado Hospital, Campus Box C308, 4200 East 9th Ave., Denver, CO 80262. e-mail: [email protected] © 2006 American Association for Geriatric Psychiatry
Am J Geriatr Psychiatry 14:1, January 2006
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Postwarranty Performance maintained. The gender gap narrows as ladies and men get older. When you girls reach 86, your expectancy varies little from ours. Sociologists and economists categorize us as the oldest old. Currently, there are 4.24 million persons over 85 in the United States, and the number is expected to reach 6.123 million by 2010.1 Although we constitute a small proportion of the population, we control a disproportionate percentage of the nation’s wealth. This might whet the appetite of aggressive salesmen; do not bet the farm on our gullibility. Your questionnaire answers confirm that we male octogenarians seldom buy consumer products. Few if any of us smoke; our average alcohol consumption is one, or occasionally two, drinks a day of wine or beer. Most of us have not purchased a suit for over five or 10 years. One classmate indicated he bought a suit five years ago for his first wife’s funeral, and another indicated he also splurged; that was 12 years ago, at the time of his second marriage. We do not even travel overseas much any more. Many of us had our fill during our active professional lives. We read a lot, but most of us only watch primetime TV for 1–2 hours of news a day. However, the 15%–20% of us who have mobility limitations rely heavily on TV for diversion and entertainment. Few of us go to a movie more than two to three times a year. Approximately half of us use cell phones, largely as emergency backup, but no more than 8% of us buy anything off the web and only half of us use e-mail. Life Expectancy Let us next turn to what Saddam might call the mother of all bottom lines: our life expectancy. At age 85, it is 5.7 years.1 Grasping at straws, one might question whether we might share the dramatic increase in life expectancy that occurred during the 20th century and get an equivalent boost. At age 85,
TABLE 1.
forget it! The scientific advances prolonging life in the 20th century resulted from public health measures that prevented death from infectious disease in infants and children, not as the result of managing illnesses that take the lives of octogenarians. Our life expectancy of 5.7 years differs little from the age 86 expectancy of our fathers or grandfathers. If they lived to this ripe old age, they had a further life expectancy of four years. Modern health care and health awareness delay death from conditions such as heart disease, cancer, stroke, or emphysema. Classmates interested in short-term capital gains, inheritance taxes, and gifts to grandchildren might want to know that, at age 86, we have a 13.9% mortality rate during the next 12 months and a 15.32% 12-month mortality rate when we are 87.1 This equates to 36 deaths per year and means that one of our classmates dies, on average, approximately every 10 days. Yale Graduate Expectancies The quoted statistics apply to the general public, of which we Yale graduates represent a biased sample. We were one of the last homogeneous classes at Yale. We were all male, all white, mostly second- or thirdgeneration Americans, mostly from families well above the poverty line, and most of us were reasonably intelligent and became well-educated. Of course, we are aware there are inevitably high-profile, glaring outliers, even at Yale. Such privilege results in proven advantages in prolonging life, delaying dependency, and better physical and mental performance that persists later in life. Affluence and intelligence, as reflected in years of education, allegedly provide a delay in physical and mental deterioration. To define the survival of Yale graduates, I asked the alumni office to identify the years in which half of our class and the classes of 1935–1949 were still
Median Survival of Yale Graduates Median Survival
Graduation Year 1937 1938 1939 1940 1941
22
Class Size
Percent
Number
Years After Graduation
Class Age
780 775 702 824 841
50 50 52 50 50
394 395 367 412 427
56 57 61 58 57
78 79 83 80 79
Am J Geriatr Psychiatry 14:1, January 2006
Eiseman alive. Assuming we were 22 when we graduated, Table 1 shows that 50% survival was reached at our 61st reunion in the year 2000, when we were age 79. In Yale classes between 1939 and 1949, 50% survival usually occurred between the 57th and 60th reunions, corresponding to age 78 – 80. Our class is an obvious longside outlier for reasons I cannot explain. This is well beyond the expectancy of the general public. Remember, however, that the study starts with a group of healthy 21- to 22-year-old graduates, not at birth. We were self-selected by surviving childhood, weekend trips to the Yale bowl, and winter midnight automobile rides back from Northampton, Poughkeepsie, and, for some of us, even from North Conway. You might be interested to know your chances of living to be 100. In the United States, there are 88,000 such centarions of whom only 17,000 are males. By 2017, when we would reach 100, there will be a total of 197,000 centarions, of whom a mere 43,000 will be men.1 I supposed approximately 10 of you will be among that number in 13 years. Quality-of-Life Expectancies Ten years ago, at age 76, we were scarcely beyond adolescence and at our 55th reunion. Duration of life was our primary concern. Now, at a mature 86, our primary concern is to maximize life’s quality. Such a philosophy alters our approach to the discovery and management of an existing or suspected disease. Unless we suffer a broken ankle, or an acute condition such as appendicitis, the best we can anticipate from medical care is palliation. It is foolish and unrewarding to anticipate even the best doctor is going to cure you of either complaints or of the disease, itself, despite all the promising TV advertisements. Quality of life (QOL) is clearly an individualized assessment. The only valid number—such as the one I suggested in the questionnaire between zero, as death, and 10 as perfect life—is the one that you assigned yourself. Perhaps, the most interesting questionnaire finding was the glaring difference between the number you ascribed to your QOL and objective evidence of crippling disease. Invariably, the self-assessed QOL was far better than I, as a physician, would have anticipated from the diseases and disabilities that you reported. At least 85% assessed the quality of their own life to be between
Am J Geriatr Psychiatry 14:1, January 2006
seven and nine. The mean QOL for all responders was 7.6, despite the presence of cancer, colostomy because of colon cancer, visual and hearing defects, or memory deficits. The comments that many of you appended to the questionnaire were often more valuable than the numbers themselves. One classmate indicated “My quality of life would be 10 if my wife were alive.” His self-assessed QOL was 8. Five classmates with reported serious mental disease listed the expected self-assessment of depression. I have no satisfactory explanation for the discrepancy between my objective and your subjective QOL assessments other than individual tolerance and perception. These factors become important in health decision-making in the elderly when life years like dollars, yen, or euros have variable value and purchasing power. Little did we anticipate in studying Fairchild, Furniss, and Buck in Economics 101, 65 years ago, that in just 65 more years, we would be dealing with discounted or enhanced years of remaining life in the supply-and-demand formula. Octogenarians and their physicians must use a unique rating system in plotting health management decisions. Relief or avoidance of pain and disability is first in outcome importance. Close on its heels, in priority, is physical independence and personal sense of dignity. A symbol of independence at age 86 is a driver’s license. As one observer noted, “At our age we can get another wife, but not a driver’s license.” Like our teenage grandchildren, we resent being “grounded” and at the mercy of even the most inept middle-aged members of our “support system.” I was surprised to learn that only five of the respondents had experienced an automobile accident while driving in the past two years. This was, of course, influenced by the gracious way many of us allow our wives to drive at night Quantifying independence is imprecise. Measurements of basic functions such as dressing or performance in the bathroom, which are cherished by geriatricians, are not exactly what either we at age 86 or the Founding Fathers of America meant by independence. These activities of daily living, or ADL as they are known colloquially, may be easy to quantify but they do not stand as enshrined Jeffersonian societal symbols to most of us in our mid-80s. Our questionnaire reflected the importance of a
23
Postwarranty Performance spouse in mitigating mobility limitations and in the self-assessments of ADL. A clever wife can make us believe we are independent long after the fact. Three classmates indicated a gender role reversal, whereby they provided important support to a wife with advanced Alzheimer disease. Healthcare Decisions for Octogenarians Most of you are familiar with techniques of decision analysis from your professional activities. The equivalent pattern should be used in the unique healthcare decision-making in old age. In the current spirit of transparency, I should admit my prior interest in this subject, but I promise not to flog the books I have written on the subject. Elderly gamblers should be conservative. At 86, our bodies, like plywood mobile homes parked in a tornado-prone trailer park, are friable dwellings. Our risks are greater and our objectives are limited; we need not take inordinate risks to achieve limited gains. We do not have many chips on the table, and, being in short supply, each is valuable. Be certain your bright young specialist consultant understands this philosophy. Rarely do we have the luxury of suffering from only the single disease to which he has dedicated his life. Most of the reported medical problems such as visual and hearing impairments or skin and prostate cancers were anticipated in a geriatric survey. Prostate cancer was reported by 25% of respondents. Two frequently mentioned problems were unsteady gait associated with frequent falls and muscle weakness. The latter is caused by apoptosis. For an explanation, see me after class, but I might add at that the second “p” in apoptosis is silent and its silence is a marker of those in the know. No one mentioned lung or pancreatic cancer; presumably those who had it were too sick to reply or have not survived. The relative infrequency of reported diabetes might in part be related to the rarity of obesity in us survivors. The average reported weight gain since graduation was only approximately 12 pounds. Only one classmate mentioned peptic ulcer, but gastroesophageal reflux disease (GERDS), which formerly was unrecognized but now has become a more prestigious (cool) diagnosis, was indicated by approximately 10% of respondents. When faced with a healthcare decision in this era
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of mass communication, we elders find ourselves being the frenzied focus of self-appointed advisers. Some are family members, who, until that moment, were not even suspected of having particular medical expertise. If our children do not consider themselves medical experts, certainly one of their investment club members or bridge partners qualifies. These people have two common skills: computer literacy and leisure time to surf the web. Treat the enthusiastic, well-meaning amateur health manager with the same suspicion you direct toward the investment adviser lacking training and experience. Find a well-trained, mature specialist who has the ability to listen, as well as to talk, and is able to devote more than the single 8-minute office visit allowed by his hyperefficient HMO. I was pleased to learn from the questionnaire that the average office visit for most of you lasted a full 15 minutes. Where We Live A surprising 69% of us live in our own homes. I sense many of us are uncertain whether the effort and cost of remaining in a big empty house is worth the extra bother over the simpler but, perhaps, less forgiving residence in a progressive care or nursing home. Cost may be a factor. The 31% of us not living at home reported living in apartments, condominiums, retirement communities, or progressive care facilities. Boundaries between these evolving types of institutions are ill-defined. Cost of Our Health Care It was foolish of me to hope you could cut the Gordian knot of the U.S. healthcare charges, billing, accounting, and collection system. I have admitted long ago that I could not discover how much was ever collected or disbursed to the many claimants for care blatantly displayed on numerous bills sent me following what is known in the trade as a “healthcare encounter.” Most of us deal with this absurdity in a most practical way by simply ignoring all bills sent us for at least three months, by which time many disappear for some magical reason. If after six months, a small residual amount is due our physician, we pay it and await our next healthcare encounter. As you know, we pay more per capita and a
Am J Geriatr Psychiatry 14:1, January 2006
Eiseman greater proportion of our gross domestic product for health care than any other nation in the world. As we all are very much aware, healthcare costs increase with increasing age. I estimate that we Yale ‘39 graduates pay approximately two or three times this amount when out-of-pocket expenses are added to our insurance payments. For this, we get a grossly inequitable system for basic health care that causes many low-income earners to not seek the care that they really need. This disgrace cannot last much longer. Some form of rationed health care is inevitable. For the elderly, much of our out-of-pocket healthcare expenses are for pharmaceuticals. If you look carefully, you will find that regardless of the nature of the pharmaceutical, it costs approximately $100 per month. This fact rang a distant bell in my conscience. It resembles the arbitrary price of currently $39 per barrel of oil as determined by OPEC in another unregulated industry. The questionnaire indicated we average six to eight different medications each day. Less than 5% of us report taking no routine medications. Three respondents indicated they consumed over 20 medications a day, and one poor fellow, listing his QOL as four, indicated he took 34 pills each day and visited a physician over 60 times a year. The benefits or hazard of such polypharmacy, each ordered by a different specialist, is uncertain, to say the least, and could easily be the theme of another sermon. Two Health Problems Worthy of Special Mention Memory Loss. Memory loss, along with depression, was grossly underrepresented by our respondents. As most of us know, memory loss is one of the earliest signs of approaching old age. The rate of progression varies. We are generally uncertain whether this represents Alzheimer disease or merely senile dementia. Only six respondents admitted to the diagnosis of Alzheimer disease. Less than 10% of respondents reported significant memory loss and less than 5% admitted to Alzheimer disease. Each of the latter has required institutional care. Memory deficit can be quantitated by asking the subject to recall as many words as possible from a list of 10 words read five minutes previously. The same recall is then requested 15 minutes thereafter. Recall
Am J Geriatr Psychiatry 14:1, January 2006
of four or fewer words equates with a moderate deficit and two or less to severe impairment. I leave it to your discretion whether you and your wife want to test each other with this little parlor game. I planned to test each of you during this reunion but I misplaced the list of words I had typed out for repetition, which I could have sworn I put in my jacket pocket. There is unfortunately not a damn thing anyone can do to slow down or reverse the process of memory loss, so I advise you to worry about our nation’s foreign policy or your golf handicap and get on with smelling the roses. Depression At 86, most of us are familiar with the frustrations of retirement and old age, yet the question concerning depression was almost universally ignored in your answers. The only exceptions came from five classmates under active treatment for depression. Yet, symptoms of depression were evident in a number of the commentaries some of you appended to the questionnaire. Some resembled the contents of Pandora’s box and could only be stored on Cassandra’s Palm Pilot. Frequent contributing factors to depression in the elderly include loss of a spouse; painful, incurable, or debilitating disease; and drugs, including alcohol. Many of the symptoms mentioned in the comments appended to the questionnaire are commonly observed in depression. They include: Memory loss and inability to perform simple cognitive challenges; Loss of spouse and loneliness; and Loss of self-confidence, self-respect, dignity, and societal worth. It is reasonable to question whether those who played a prominent leadership role in their professions might be particularly susceptible to depression when infirmities of old age and retirement deprive them of these capabilities.
CONCLUSIONS Let us see what we might have learned from this review. I hope you did not anticipate I would add another pharmaceutical to the mound of drugs you already are consuming to maintain your health. I
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Postwarranty Performance considered advising a harmless nostrum, but knowing how many of you spend much of the cold months in Florida, I thought you would be unable to afford such a medication because of distance from Miami, Florida, to Canada. Lacking such material evidence of help, what have we learned from this second State of the Body ‘39 report? Perhaps we have merely gathered solace by understanding that most of our own disabilities are shared by others. Perhaps the expectancy statistics, starting with our anticipated mean survival of 5.7 years,1 might be helpful in your future planning. The near universal optimism concerning our current QOL, even in the face of physical disabilities, will certainly be an inspiration to many. In closing I must mention a haunting question. It is whether it is appropriate to devote such a large proportion of our national resources to those of us who no longer can provide equivalent societal ben-
efit. The members of our class who have demonstrated an outstanding record of national and international leadership may be particularly prone to such doubt. We graduated at a moment in history when there was unparalleled opportunity for leadership. We enthusiastically accepted the challenge without bothering about the philosophical principle that from whom much is given, much is anticipated. We succeeded beyond historical expectations given in the long tradition of Yale. We are proud of this record, which we pass as our heritage to our successors. Our class motto for Yale 1939 should be “Duces Fuimus” (We were leaders.). To this we can add at our 65th reunion, “Nostra acta, spiritus et dignitas manent.” (All that remains is our record, our spirit, and our dignity.)2 This work was presented on May 26, 2004, at the 65th year reunion of the Yale University class of 1939.
References 1. Arias E. United States Life Tables. Vital Statistics Report, 2002, vol 53. Hyattsville, MD, National Center for Health Statistics, 2004 2. Federal Interagency Forum on Aging-Related Statistics. Older
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Americans 2000: Key Indicators of Well-Being. Federal Interagency Forum on Aging-Related Statistics, Washington, DC, U.S. Government Printing Office, August 2000.
Am J Geriatr Psychiatry 14:1, January 2006
When Blue Turns Gray: Postwarranty Performance Ben Eiseman, M.D., D.Sc.
Objective: The objective of this study was to review the lifestyle and expectations of a group of 86- to 87-year-old Yale College graduates at the time of their 65th reunion and to compare the results with equivalent data from the general public. Methods: A five-page questionnaire was sent to the 263 living survivors of the Yale College class of 1939 at the time of their 65th reunion. Results: One hundred fifty-one replies were received, some only partially completed. Median survival was 79 years. Among the more interesting results was a wide discrepancy (optimism) between the perceived quality of life and that which one would anticipate from the many physical disabilities of the study group. Conclusion: This is by nature a self-selected group of male octogenarians, but their lifestyle and medical disabilities fit with the general population; their attitude toward being elderly is remarkably positive, and their personal and civic performance continues beyond expectations. (Am J Geriatr Psychiatry 2006; 14:21– 26) Key Words: Geriatric lifestyle, performance at 87, questionnaire, 65th Yale reunion
T
his 65th reunion of our Yale College class of 1939 provides a unique opportunity to obtain a profile of 86- to 87-year-old Yale graduates. Because at our age, we are perforce interested in both our medical conditions and our quality of life, I sent a questionnaire to each of the 263 classmates listed as surviving (30% of our 860 graduating class). I used your 151 replies as the basis of my comments. Forty-three percent failed to respond, and I have to presume they were, as a group, sicker than those who replied. Based on the information furnished by the respondents, I review our current health status, compare it with expectations for our age-specific cohort in the general public, and, finally, see what can be learned from this exercise.
Who Are We? Let us start by identifying ourselves. We are the 263 survivors, comprising 30% of a class of 860 at the time of our Yale graduation, in 1939. Most of us were born in 1917 and are therefore now either 86 or 87. At birth, our life expectancy as male children was 50.1 years. We have, therefore, exceeded our initial warranty by 36 years. It should come as no surprise that we now require periodic overhauls and occasional parts replacement. The mean life expectancy of our great grandson, born this year, is 73.6 years.1 We have even outlived his warranty by 13 years. Not bad. The ladies in the audience can add approximately six years to their life expectancy at birth, but do not assume the lead is
Received July 7, 2005; accepted September 9, 2005. From the University of Colorado Hospital. Send correspondence and reprint requests to Ben Eiseman, M.D., D.Sc., Professor Emeritus, Surgery & Medicine, University of Colorado Hospital, Campus Box C308, 4200 East 9th Ave., Denver, CO 80262. e-mail: [email protected] © 2006 American Association for Geriatric Psychiatry
Am J Geriatr Psychiatry 14:1, January 2006
21
Postwarranty Performance maintained. The gender gap narrows as ladies and men get older. When you girls reach 86, your expectancy varies little from ours. Sociologists and economists categorize us as the oldest old. Currently, there are 4.24 million persons over 85 in the United States, and the number is expected to reach 6.123 million by 2010.1 Although we constitute a small proportion of the population, we control a disproportionate percentage of the nation’s wealth. This might whet the appetite of aggressive salesmen; do not bet the farm on our gullibility. Your questionnaire answers confirm that we male octogenarians seldom buy consumer products. Few if any of us smoke; our average alcohol consumption is one, or occasionally two, drinks a day of wine or beer. Most of us have not purchased a suit for over five or 10 years. One classmate indicated he bought a suit five years ago for his first wife’s funeral, and another indicated he also splurged; that was 12 years ago, at the time of his second marriage. We do not even travel overseas much any more. Many of us had our fill during our active professional lives. We read a lot, but most of us only watch primetime TV for 1–2 hours of news a day. However, the 15%–20% of us who have mobility limitations rely heavily on TV for diversion and entertainment. Few of us go to a movie more than two to three times a year. Approximately half of us use cell phones, largely as emergency backup, but no more than 8% of us buy anything off the web and only half of us use e-mail. Life Expectancy Let us next turn to what Saddam might call the mother of all bottom lines: our life expectancy. At age 85, it is 5.7 years.1 Grasping at straws, one might question whether we might share the dramatic increase in life expectancy that occurred during the 20th century and get an equivalent boost. At age 85,
TABLE 1.
forget it! The scientific advances prolonging life in the 20th century resulted from public health measures that prevented death from infectious disease in infants and children, not as the result of managing illnesses that take the lives of octogenarians. Our life expectancy of 5.7 years differs little from the age 86 expectancy of our fathers or grandfathers. If they lived to this ripe old age, they had a further life expectancy of four years. Modern health care and health awareness delay death from conditions such as heart disease, cancer, stroke, or emphysema. Classmates interested in short-term capital gains, inheritance taxes, and gifts to grandchildren might want to know that, at age 86, we have a 13.9% mortality rate during the next 12 months and a 15.32% 12-month mortality rate when we are 87.1 This equates to 36 deaths per year and means that one of our classmates dies, on average, approximately every 10 days. Yale Graduate Expectancies The quoted statistics apply to the general public, of which we Yale graduates represent a biased sample. We were one of the last homogeneous classes at Yale. We were all male, all white, mostly second- or thirdgeneration Americans, mostly from families well above the poverty line, and most of us were reasonably intelligent and became well-educated. Of course, we are aware there are inevitably high-profile, glaring outliers, even at Yale. Such privilege results in proven advantages in prolonging life, delaying dependency, and better physical and mental performance that persists later in life. Affluence and intelligence, as reflected in years of education, allegedly provide a delay in physical and mental deterioration. To define the survival of Yale graduates, I asked the alumni office to identify the years in which half of our class and the classes of 1935–1949 were still
Median Survival of Yale Graduates Median Survival
Graduation Year 1937 1938 1939 1940 1941
22
Class Size
Percent
Number
Years After Graduation
Class Age
780 775 702 824 841
50 50 52 50 50
394 395 367 412 427
56 57 61 58 57
78 79 83 80 79
Am J Geriatr Psychiatry 14:1, January 2006
Eiseman alive. Assuming we were 22 when we graduated, Table 1 shows that 50% survival was reached at our 61st reunion in the year 2000, when we were age 79. In Yale classes between 1939 and 1949, 50% survival usually occurred between the 57th and 60th reunions, corresponding to age 78 – 80. Our class is an obvious longside outlier for reasons I cannot explain. This is well beyond the expectancy of the general public. Remember, however, that the study starts with a group of healthy 21- to 22-year-old graduates, not at birth. We were self-selected by surviving childhood, weekend trips to the Yale bowl, and winter midnight automobile rides back from Northampton, Poughkeepsie, and, for some of us, even from North Conway. You might be interested to know your chances of living to be 100. In the United States, there are 88,000 such centarions of whom only 17,000 are males. By 2017, when we would reach 100, there will be a total of 197,000 centarions, of whom a mere 43,000 will be men.1 I supposed approximately 10 of you will be among that number in 13 years. Quality-of-Life Expectancies Ten years ago, at age 76, we were scarcely beyond adolescence and at our 55th reunion. Duration of life was our primary concern. Now, at a mature 86, our primary concern is to maximize life’s quality. Such a philosophy alters our approach to the discovery and management of an existing or suspected disease. Unless we suffer a broken ankle, or an acute condition such as appendicitis, the best we can anticipate from medical care is palliation. It is foolish and unrewarding to anticipate even the best doctor is going to cure you of either complaints or of the disease, itself, despite all the promising TV advertisements. Quality of life (QOL) is clearly an individualized assessment. The only valid number—such as the one I suggested in the questionnaire between zero, as death, and 10 as perfect life—is the one that you assigned yourself. Perhaps, the most interesting questionnaire finding was the glaring difference between the number you ascribed to your QOL and objective evidence of crippling disease. Invariably, the self-assessed QOL was far better than I, as a physician, would have anticipated from the diseases and disabilities that you reported. At least 85% assessed the quality of their own life to be between
Am J Geriatr Psychiatry 14:1, January 2006
seven and nine. The mean QOL for all responders was 7.6, despite the presence of cancer, colostomy because of colon cancer, visual and hearing defects, or memory deficits. The comments that many of you appended to the questionnaire were often more valuable than the numbers themselves. One classmate indicated “My quality of life would be 10 if my wife were alive.” His self-assessed QOL was 8. Five classmates with reported serious mental disease listed the expected self-assessment of depression. I have no satisfactory explanation for the discrepancy between my objective and your subjective QOL assessments other than individual tolerance and perception. These factors become important in health decision-making in the elderly when life years like dollars, yen, or euros have variable value and purchasing power. Little did we anticipate in studying Fairchild, Furniss, and Buck in Economics 101, 65 years ago, that in just 65 more years, we would be dealing with discounted or enhanced years of remaining life in the supply-and-demand formula. Octogenarians and their physicians must use a unique rating system in plotting health management decisions. Relief or avoidance of pain and disability is first in outcome importance. Close on its heels, in priority, is physical independence and personal sense of dignity. A symbol of independence at age 86 is a driver’s license. As one observer noted, “At our age we can get another wife, but not a driver’s license.” Like our teenage grandchildren, we resent being “grounded” and at the mercy of even the most inept middle-aged members of our “support system.” I was surprised to learn that only five of the respondents had experienced an automobile accident while driving in the past two years. This was, of course, influenced by the gracious way many of us allow our wives to drive at night Quantifying independence is imprecise. Measurements of basic functions such as dressing or performance in the bathroom, which are cherished by geriatricians, are not exactly what either we at age 86 or the Founding Fathers of America meant by independence. These activities of daily living, or ADL as they are known colloquially, may be easy to quantify but they do not stand as enshrined Jeffersonian societal symbols to most of us in our mid-80s. Our questionnaire reflected the importance of a
23
Postwarranty Performance spouse in mitigating mobility limitations and in the self-assessments of ADL. A clever wife can make us believe we are independent long after the fact. Three classmates indicated a gender role reversal, whereby they provided important support to a wife with advanced Alzheimer disease. Healthcare Decisions for Octogenarians Most of you are familiar with techniques of decision analysis from your professional activities. The equivalent pattern should be used in the unique healthcare decision-making in old age. In the current spirit of transparency, I should admit my prior interest in this subject, but I promise not to flog the books I have written on the subject. Elderly gamblers should be conservative. At 86, our bodies, like plywood mobile homes parked in a tornado-prone trailer park, are friable dwellings. Our risks are greater and our objectives are limited; we need not take inordinate risks to achieve limited gains. We do not have many chips on the table, and, being in short supply, each is valuable. Be certain your bright young specialist consultant understands this philosophy. Rarely do we have the luxury of suffering from only the single disease to which he has dedicated his life. Most of the reported medical problems such as visual and hearing impairments or skin and prostate cancers were anticipated in a geriatric survey. Prostate cancer was reported by 25% of respondents. Two frequently mentioned problems were unsteady gait associated with frequent falls and muscle weakness. The latter is caused by apoptosis. For an explanation, see me after class, but I might add at that the second “p” in apoptosis is silent and its silence is a marker of those in the know. No one mentioned lung or pancreatic cancer; presumably those who had it were too sick to reply or have not survived. The relative infrequency of reported diabetes might in part be related to the rarity of obesity in us survivors. The average reported weight gain since graduation was only approximately 12 pounds. Only one classmate mentioned peptic ulcer, but gastroesophageal reflux disease (GERDS), which formerly was unrecognized but now has become a more prestigious (cool) diagnosis, was indicated by approximately 10% of respondents. When faced with a healthcare decision in this era
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of mass communication, we elders find ourselves being the frenzied focus of self-appointed advisers. Some are family members, who, until that moment, were not even suspected of having particular medical expertise. If our children do not consider themselves medical experts, certainly one of their investment club members or bridge partners qualifies. These people have two common skills: computer literacy and leisure time to surf the web. Treat the enthusiastic, well-meaning amateur health manager with the same suspicion you direct toward the investment adviser lacking training and experience. Find a well-trained, mature specialist who has the ability to listen, as well as to talk, and is able to devote more than the single 8-minute office visit allowed by his hyperefficient HMO. I was pleased to learn from the questionnaire that the average office visit for most of you lasted a full 15 minutes. Where We Live A surprising 69% of us live in our own homes. I sense many of us are uncertain whether the effort and cost of remaining in a big empty house is worth the extra bother over the simpler but, perhaps, less forgiving residence in a progressive care or nursing home. Cost may be a factor. The 31% of us not living at home reported living in apartments, condominiums, retirement communities, or progressive care facilities. Boundaries between these evolving types of institutions are ill-defined. Cost of Our Health Care It was foolish of me to hope you could cut the Gordian knot of the U.S. healthcare charges, billing, accounting, and collection system. I have admitted long ago that I could not discover how much was ever collected or disbursed to the many claimants for care blatantly displayed on numerous bills sent me following what is known in the trade as a “healthcare encounter.” Most of us deal with this absurdity in a most practical way by simply ignoring all bills sent us for at least three months, by which time many disappear for some magical reason. If after six months, a small residual amount is due our physician, we pay it and await our next healthcare encounter. As you know, we pay more per capita and a
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Eiseman greater proportion of our gross domestic product for health care than any other nation in the world. As we all are very much aware, healthcare costs increase with increasing age. I estimate that we Yale ‘39 graduates pay approximately two or three times this amount when out-of-pocket expenses are added to our insurance payments. For this, we get a grossly inequitable system for basic health care that causes many low-income earners to not seek the care that they really need. This disgrace cannot last much longer. Some form of rationed health care is inevitable. For the elderly, much of our out-of-pocket healthcare expenses are for pharmaceuticals. If you look carefully, you will find that regardless of the nature of the pharmaceutical, it costs approximately $100 per month. This fact rang a distant bell in my conscience. It resembles the arbitrary price of currently $39 per barrel of oil as determined by OPEC in another unregulated industry. The questionnaire indicated we average six to eight different medications each day. Less than 5% of us report taking no routine medications. Three respondents indicated they consumed over 20 medications a day, and one poor fellow, listing his QOL as four, indicated he took 34 pills each day and visited a physician over 60 times a year. The benefits or hazard of such polypharmacy, each ordered by a different specialist, is uncertain, to say the least, and could easily be the theme of another sermon. Two Health Problems Worthy of Special Mention Memory Loss. Memory loss, along with depression, was grossly underrepresented by our respondents. As most of us know, memory loss is one of the earliest signs of approaching old age. The rate of progression varies. We are generally uncertain whether this represents Alzheimer disease or merely senile dementia. Only six respondents admitted to the diagnosis of Alzheimer disease. Less than 10% of respondents reported significant memory loss and less than 5% admitted to Alzheimer disease. Each of the latter has required institutional care. Memory deficit can be quantitated by asking the subject to recall as many words as possible from a list of 10 words read five minutes previously. The same recall is then requested 15 minutes thereafter. Recall
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of four or fewer words equates with a moderate deficit and two or less to severe impairment. I leave it to your discretion whether you and your wife want to test each other with this little parlor game. I planned to test each of you during this reunion but I misplaced the list of words I had typed out for repetition, which I could have sworn I put in my jacket pocket. There is unfortunately not a damn thing anyone can do to slow down or reverse the process of memory loss, so I advise you to worry about our nation’s foreign policy or your golf handicap and get on with smelling the roses. Depression At 86, most of us are familiar with the frustrations of retirement and old age, yet the question concerning depression was almost universally ignored in your answers. The only exceptions came from five classmates under active treatment for depression. Yet, symptoms of depression were evident in a number of the commentaries some of you appended to the questionnaire. Some resembled the contents of Pandora’s box and could only be stored on Cassandra’s Palm Pilot. Frequent contributing factors to depression in the elderly include loss of a spouse; painful, incurable, or debilitating disease; and drugs, including alcohol. Many of the symptoms mentioned in the comments appended to the questionnaire are commonly observed in depression. They include: Memory loss and inability to perform simple cognitive challenges; Loss of spouse and loneliness; and Loss of self-confidence, self-respect, dignity, and societal worth. It is reasonable to question whether those who played a prominent leadership role in their professions might be particularly susceptible to depression when infirmities of old age and retirement deprive them of these capabilities.
CONCLUSIONS Let us see what we might have learned from this review. I hope you did not anticipate I would add another pharmaceutical to the mound of drugs you already are consuming to maintain your health. I
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Postwarranty Performance considered advising a harmless nostrum, but knowing how many of you spend much of the cold months in Florida, I thought you would be unable to afford such a medication because of distance from Miami, Florida, to Canada. Lacking such material evidence of help, what have we learned from this second State of the Body ‘39 report? Perhaps we have merely gathered solace by understanding that most of our own disabilities are shared by others. Perhaps the expectancy statistics, starting with our anticipated mean survival of 5.7 years,1 might be helpful in your future planning. The near universal optimism concerning our current QOL, even in the face of physical disabilities, will certainly be an inspiration to many. In closing I must mention a haunting question. It is whether it is appropriate to devote such a large proportion of our national resources to those of us who no longer can provide equivalent societal ben-
efit. The members of our class who have demonstrated an outstanding record of national and international leadership may be particularly prone to such doubt. We graduated at a moment in history when there was unparalleled opportunity for leadership. We enthusiastically accepted the challenge without bothering about the philosophical principle that from whom much is given, much is anticipated. We succeeded beyond historical expectations given in the long tradition of Yale. We are proud of this record, which we pass as our heritage to our successors. Our class motto for Yale 1939 should be “Duces Fuimus” (We were leaders.). To this we can add at our 65th reunion, “Nostra acta, spiritus et dignitas manent.” (All that remains is our record, our spirit, and our dignity.)2 This work was presented on May 26, 2004, at the 65th year reunion of the Yale University class of 1939.
References 1. Arias E. United States Life Tables. Vital Statistics Report, 2002, vol 53. Hyattsville, MD, National Center for Health Statistics, 2004 2. Federal Interagency Forum on Aging-Related Statistics. Older
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Americans 2000: Key Indicators of Well-Being. Federal Interagency Forum on Aging-Related Statistics, Washington, DC, U.S. Government Printing Office, August 2000.
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