The bad thing about aging is that aging ends in death. Discussion of the end of life and how we die is conspicuously absent from AARP publications and other materials for seniors.
Several lists of the major causes of death for seniors can be found online, like this one. Heart disease and cancer are at the top for all senior populations. Beyond that, gender, ethnicity, and economic level correlate with slight percentage differences, but strokes, COPD, and Alzheimer’s are high on every list. For more information, check out Trends in Causes of Death Among the Elderly (PDF).
Of course, these lists skew the facts by limiting each death to one cause and by not considering “old age” as a cause, even though it’s often a better descriptor than the individual disease names. Most people who live long enough have multiple ailments, and it’s their combined depletion of life force that eventually results in death. For contrasting viewpoints, compare The Immediate Cause of Death with Do People Really Die of Old Age?
In How Many of You Expect to Die?, Jane Gross, quoting Dr. Joanne Lynn, condenses the causes of death to three: cancer, organ failure, and gradual overall decline/dementia. For better or worse, most of us don’t know which path will be ours until late in the process.
Cancer
Although many old people die of cancer, according to Dr. Lynn, statistically, cancer deaths peak at age 65. About 20% of Americans die this way. Many old people live with manageable, slowly progressing cancers and end up dying of organ failure or extreme frailty.
Cancer deaths are actually decreasing, as earlier detection and more successful treatments become available. In this area, as in so many others, we’re on the verge of epic changes in the way we understand illness and health, changes likely as huge as those brought about by computers and the internet. Using information about the genome and microbiome, remedial approaches will someday be individual, minimally invasive, and generally magical as compared to what we know and understand at present. But we’re not there yet. Today individuals diagnosed with cancer must decide for themselves how much treatment they’re willing to undergo and what kind of management plan to adopt.
The cancers that kill us often aren’t diagnosed until they’re in late stages. In these cases, despite aggressive treatment, the end generally comes after a relatively sudden, steep decline, even after a lifetime of health and fitness. There’s generally time to make final arrangements: designate a health representative, prepare a will, conclude your affairs.
Individuals differ greatly in how far they’re willing to go to “fight” cancer. Obviously, the younger you are and the more potential years of life you have left, the more it makes sense to undergo aggressive treatment. The older you are, speaking very generally, the more likely the effects of aggressive treatment will be as bad as the disease. The better part of wisdom may be to opt for palliative care at some point – that is, care aimed at alleviating symptoms rather than effecting a cure. Palliative care is fundamental to the philosophy of hospice.
Of course, it’s easy to think this in the abstract, and I have no idea what I’d actually do in this situation. Still, all the nurses I’ve talked to who’ve worked in hospice programs (admittedly a small sample) strongly recommend hospice as the best, easiest, most natural way to die. Hospice workers will understand your situation and work with you to safeguard your quality of life and ensure that your end-of-life wishes are honored.
While those who reject aggressive treatment may find that an early choice of hospice is in their best interests, those who want to do everything possible to stay alive may be interested in clinical trials. You can find online a searchable database of clinical trials currently being conducted around the country.
Organ Failure (Heart, Lungs, Kidneys)
According to Dr. Lynn, deaths from organ failure – heart, lungs, and kidneys are the most common – peak around age 75. About 25% of Americans die this way.
Failing organs tend to follow a gradual decline, with brief dips into crisis, one of which finally results in death. According to Dr. Lynn, individuals in this situation need “consistent disease management to head off crises, aggressive intervention at the first sign of trouble, and advance planning for the final crisis.”
Individuals who die from organ failure usually experience a prolonged period of crises. As their conditions advance, their lives become a series of medical interventions and trips to the hospital. Since each crisis and emergency room visit is disruptive in the best of circumstances, the best strategy might be finding a place where your care needs can be met holistically and compassionately.
Extreme Fragility
If you manage to escape death from cancer or organ failure, you may be condemned to a long period of decline. During this time, everything slowly becomes harder, until you reach the point where you can’t walk, get into or out of bed, or provide for any of your basic needs. According to Dr Lynn, about 40% of Americans will follow this path, described as “everyone’s worst nightmare, an interminable and humiliating series of losses …” (This is our reward for successfully delaying death.)
Here’s what Michael Wolff says in A Life Worth Ending, his moving description of the plight of his aging mother: “By promoting longevity and technologically inhibiting death, we have created a new biological status held by an ever-growing part of the nation, a no-exit state that persists longer and longer, one that is nearly as remote from life as death, but which, unlike death, requires vast service, indentured servitude really, and resources.” His article ends with an eloquent plea to find better ways of dealing with the unintended consequences of prolonging life.
Being an old frail person unable to manage is unendingly difficult, even with caring family caregivers. With little likelihood of technological fixes and no hope of reversal, it’s a sad and costly fate that will become even more common as the senior population grows. Sadly, our health care structures are ill-equipped to serve this population, and in many ways makes their lives harder. (This is further discussed in The Health Care Old People Need.)
Is there any solution? Compassionate euthanasia, perhaps? If you google “compassionate euthanasia, you’ll find a lot of information about cats, but Wikipedia provides terrific information about euthanasia for humans. Please share your thoughts and experiences.
Alzheimer’s
I’m indebted to Kelly Raach, Southern Arizona Regional Director of the American Alzheimer’s Association, for providing information and reviewing this summary.
Alzheimer’s differs from other diseases of old age in that it affects people’s mental as well as physical processes. When diagnosed prior to age 65, it’s considered to be “early onset Alzheimer’s,” which is generally associated with specific genetic markers. But as ages rise, the incidence of Alzheimer’s also rises, even without the genetic markers. Overall, one in eight older Americans struggles with Alzheimer’s. Among individuals over the age of 85, some studies suggest that 50% have Alzheimer’s to some degree.
Because of this, a lot of attention is being focused on understanding the causes of Alzheimer’s and there are regular reports of breakthroughs in the news. In fact, although much about Alzheimer’s remains unknown, our understanding of it has changed dramatically over the past decade.
Formerly considered secondary to a “true” cause of death, Alzheimer’s is now considered a cause of death in its own right; in fact, it’s the sixth most common cause of death among people over 65. The disease unfolds in a predictable way, whether early onset (diagnosed before age 65) or developed at any time later. The progression of the disease as well as the treatment plan are pretty much the same regardless of the age at which one is diagnosed. However, because the time of diagnosis varies greatly, there are considerable differences in how rapidly the disease seems to progress after diagnosis and how effective the treatment is. For more information: The seven stages of Alzheimer’s
Living Alone with Alzheimer’s
Studies show that people who have Alzheimer’s and live alone are more likely to end up in nursing homes at an earlier stage than those who live with others. It may be because people who live alone are more likely to fail to recognize their own decline, or to be in denial about it. Without input from others who know them well, they may fail to seek help until the disease is fairly far advanced. At that point, the drugs don’t work well and functional incapacity comes sooner. People with Alzheimer’s who live alone, estimated to be at least 800,000 today (and rising), often receive attention only when their neighbors or service people call the authorities, or they’re found wandering lost in the night. (Source: 2012 Alzheimer’s Facts and Figures (PDF))
There’s no cure for Alzheimer’s. There are drugs which can slow down its progress, especially if taken at the early stages of the disease, but anyone diagnosed with Alzheimer’s will ultimately be unable to manage any of the tasks of daily living and will need extensive care until the end.
The Alzheimer Society of Canada offers advice on living alone with Alzheimer’s, with tips for live independently for as long as possible.
What to do if you suspect you have Alzheimer’s
A diagnosis of Alzheimer’s is terrifying to anybody, but I’m sure it must be especially terrifying to people without family. The prospect of an extended period when others must make decisions about the most basic aspects of one’s life is hard for anyone to face. It’s easy to understand why people delay getting diagnosed. Yet, if you suspect you might have Alzheimer’s, you’re well advised to get checked as soon as possible. (Learn the Ten Signs of Alzheimer’s.) The earlier identified, the longer you’re likely to be able to remain independent, which translates into time to get your affairs in order.
If you suspect Alzheimer’s or are diagnosed with it, many will have a natural tendency to withdraw. However, developing a support network is essential to managing the disease in its early stages. Fortunately, excellent support is available. The Alzheimer’s Association, which began as an organization to support caregivers, is starting to pay attention to the needs of people with Alzheimer’s who live alone. Their 2012 Report (PDF) for the first time, includes a section on those living alone with Alzheimer’s and they’re slowly changing their materials to speak not only to caregivers but also to those in early stages of Alzheimer’s. They’ll be able to direct you to support services in your community, inform you of clinical trials, and be with you as you wind down your affairs.
Other Dementias
Old people are subject to dementia from other causes, but although symptoms may be similar to Alzheimer’s, they need to be treated differently. A common cause of dementia symptoms is drug interactions. Since many seniors end up taking multiple medications, it’s a good idea to have a pharmacist or care coordinator review your medications each time a new one is prescribed. Sometimes a change in prescriptions can result in symptoms completely disappearing.
Degenerative Nerve Diseases
Degenerative nerve diseases, like Parkinson’s and ALS,where an intact mind is increasingly locked into a non-functioning body, seem (from the outside) particularly difficult. Can readers contribute more information?