THE SLOW FIX

CAROLE LEWIS

Aging gracefully means taking charge of your health

When I was a bright-eyed graduate student studying rehabilitation medicine, I attended a captivating lecture on the history of medical progress that has become a major part of my philosophical approach to geriatric medicine. The gist of the lecture was that medical progress had a relatively slow growth phase until the last few centuries. Beginning in the 19th century, however, our understanding of microorganisms, sanitation, and disease processes helped to expand the science of medicine. In particular, the last 50 years have seen exponential growth in the science and understanding of disease and intervention opportunities.

Most recently, as antibiotics and other innovations continue to bring infectious disease under control to some degree, at least for the majority of Americans, medical focus has shifted to chronic illness.At the beginning of the 20th century, life expectancy was barely into the late fifties or early sixties. By the end of the 21st century, life expectancy is likely to be into the nineties. As the aging population contends with chronic conditions, it is critical that long-lived solutions be found. For example, as recently as 20 years ago, a knee arthroplasty in an older patient might need to last only 10 years. In the not-too-distant future, the same replacement surgery might need to last 40 years or more.

Because people are living longer, and because this aging population has clear expectations about the quality of life, it is essential that treatments and interventions be forward looking and geared for the long term. Here’s a quick look at some interesting statistics from the 2000 Census that illustrate the aging of America:

In the past century, the percent of the population 65 years and older has more than tripled, from 4.1 percent in 1900 to 13 percent in 2000.

Persons 65 years or older numbered 32.8 million in 1993, and 34.7 million in 2000.

And the older population is getting older. In 2000, the 65-74 age group numbered 18 million (8 times the number in 1900), the 75-84 age group numbered 10.8 million (14 times the number in 1900), and the 85+ age group numbered 3.4 million (27 times the number in 1900).

Additionally, because the aging population is highly dependent on pharmaceuticals, there is a great need to evaluate the long-term impact of undesirable side effects of these medications. Ideally, of course, treatments and medications improve our lives and our general ability to function in society. But it is now becoming clear that many of the disease processes we’re likely to see in the 21st century actually may be due to some of the interventions pursued in the 20th century. For example, recent medical attention is being paid to concerns that chronic use of various (often multiple) medications throughout a lifetime can predispose the elderly to Parkinson’s-like symptoms.

This strategy of over-medicating and undertaking surgeries at the drop of a hat could appropriately be called the Quick Fix. The Quick Fix approach often is characterized by a desire to get back to whatever it was you were doing before, with the least possible delay. A case in point: Ronnie Lott, a defensive back with the powerhouse San Francisco 49ers, crushed the tip of his little finger in a collision with an opponent in a lateseason football game. The prognosis: Miss the playoffs because of a pin inserted in the bone and a full hand cast. After consultation with experts and no alternative treatment ideas, Lott suggested a novel approach—clip off the damaged fingertip above the first joint. See you on Sunday. The 49ers went on to win the Super Bowl with Lott playing his usual pivotal role. In this case, after weighing all the costs and benefits, not just the medical ones, a reasonable decision was reached. Would this have been a prudent decision if the affected body part had been a damaged knee or neck? Probably not.

Every patient naturally wants a quick fix to his or her problem. Without pausing to reflect on the most prudent, long-term strategy, society’s need for instant gratification often results in regrettable decisions that may have serious ramifications later in life. For example, a hasty decision regarding back or foot surgery may lead to a lifetime of chronic pain, the need for additional surgery, and/or debilitation.

LOOKING BEYOND THE QUICK FIX

An alternative to this Quick Fix mentality is what I like to call the Slow Fix. This approach involves a high degree of informed decision-making, proper perspective on the available approaches, a good support structure with consultations and second opinions, and a willingness to avoid jumping to less-than optimal decisions. There are five main parameters to the Slow Fix solution:

1. Recognition of physical changes. As one nears the age of 80, the body undergoes various physiological changes. In my gerontology and geriatrics practice, I try to have patients believe that the longevity of vigor and good health can be extended indefinitely. Certainly, some 90-year-olds are in better shape than some 60-year-olds. It is equally as certain, however, that eventually certain body systems go into decline as senescence sets in. Certain controllable factors like diet and exercise, combined with random factors like good genetic stock, can forestall the inevitable, but the more realistic approach is to acknowledge that change is coming and to prepare appropriately.

Education and awareness about proper physical conditioning, nutrition, preventive medicine, and a host of other issues are the keys to developing a more astute aging populace. Education about anatomy, illness, and well-being should begin at an early age and should be taught to everyone, not just those who want to focus on the life sciences.While it may be unnecessary for all to be instructed in the intricacies of the Krebs Cycle or the tertiary structure and folding of proteins, having a rudimentary understanding of our bodies, what can go wrong with the parts, and how to prevent or fix the problems seems not only useful, but essential.

Imagine, for a moment, that you go to the doctor or some other medical practitioner and are told that you have developed a condition that will require medical intervention. The options laid out before you include surgery, amputation, exercise, or a life with pain. The uninformed patient has not a clue even what questions to ask, let alone any real understanding of the options, and the pros and cons of each alternative. Now, imagine a more informed patient who understands something about medicine, knows what to ask and whether to seek a second opinion, and hopefully was smart enough to undertake some precautionary measures a decade ago.Which patient would you rather be?

Making advanced health education, prevention, and wellness classes mandatory for the entire population may be impractical at this time, but certainly moving in that direction would seem a wise choice.Health education primers for elementary and middle-school children may facilitate an early comfort level with the scientific and medical disciplines that may help the general population feel better equipped to tackle complicated medical decisions later in life.Having this greater comfort level and, in general, a more informed population would be beneficial to practitioners, patients, and family members.

2. Feeling good about life. Guillaume Apollinaire, the great French surrealist poet, once said something to the effect that “in our constant pursuit of happiness we should pause and just be happy.” The things that cause us happiness, that make us feel good, are important to our well-being. The activities, relationships, or places that bring joy into our lives should be explored and understood, and the earlier in life, the better. Constant evaluation of this principle is important and can lead to a more positive and fulfilling outlook, which can lead to a lifetime of beneficial heart-felt improvements.

3. Nutrition. Eating right and getting the right level of supplements is important, but the landscape is constantly shifting, just like Americans’ waistlines. C a r o l e L ew i s COSMOS 2 0 0 2 - 2 0 0 3 4 6 Unfortunately, conflicting findings, incomplete research, and rampant nutrition “pseudo-science” have led to exploitation of the general population. Fad diets, unproven supplements, and other gimmicks are marketed with reckless abandon, making it virtually impossible to sort out legitimate programs and products from bogus ones. Certainly, more research is required, as are protective consumer programs to prevent exploitation and abuse.

It’s becoming clear that counting calories and fat grams are not keeping Americans trim, so the questions now turn to what types of foods we should be eating, in what proportions, and, perhaps, in what combinations with other foods. Recent focus on the amount of carbohydrates vs. proteins consumed and the size of portions has indicated that some current notions about eating behaviors and choices need to be rethought. Genetic science discoveries related to the “obesity gene” and the potential for gene therapy in the future hold some hope for the clinically obese, but for the rest of us, moderation and common sense are the prudent approaches. Suffice it to say that proper nutrition and eating habits are part of a healthy lifestyle, as is maintaining an appropriate weight for one’s age and height.

4. Sleep. The wealth of literature on sleep and its medicinal benefits is far less controversial, however. Sleep research has shown that every individual has a particular requirement for the ideal number of hours of sleep per day. It is best to figure out the amount of sleep that is best for you and to attempt to establish a sleep routine. Getting too much or not enough sleep over an extended period of time, or having an erratic sleep pattern, is not healthful and can lead to inefficiency, accidents, injuries, and other impediments to a healthy, productive, and energetic lifestyle. As the old proverb says, “Don’t burn the candle at both ends.” But as an equally astute, but clearly newer proverb advises, “Just do it.” Striking a happy medium between the extremes of slothfulness and hyperactivity is suggested for each individual, as the particular make-up of the individual dictates.

5. Exercise. An essential part of a healthy lifestyle, one that leads to longevity, is a good balance of cardiovascular and strengthening exercise. The literature very clearly supports the concept that exercise is beneficial and can provide a better prognosis for patients with a variety of conditions, from hypertension to Parkinson’s disease, and from osteoporosis to stroke. Even low levels of exercise like walking and gardening can do wonders for our bodies, as well as our self-outlook.

It is interesting to note that muscle conditioning (or lack thereof) is a good indicator of pain and dysfunction. For example, studies have shown that radiographic imaging (x-rays) is less indicative of functional decline than a dynamometry muscle test. When patients were asked to describe a functional pain or disability, there was a better correlation between that pain and a muscle strength test. Joint x-rays, in contrast,were less conclusive. Physicians should be routinely ordering these types of tests, but often overlook them.

Dynamometry check-ups should be part of any preventive regime, and should be administered once a year as part of a routine physical exam. Once the test establishes which muscle groups are weak, specific strengthening programs can be designed to prevent decline. What could be more eye-opening than to see test results that clearly demonstrate the patient has belowaverage strength for a muscle group, compared to the norm for his or her age group. Such a revelation would help provide the motivation to make the changes necessary to improve one’s ability to walk greater distances, or get up the stairs more easily. As progress (i.e., strengthening) is accomplished through a therapeutic or rehabilitative exercise regime, the patient can attach a concrete result (e.g., a higher strength reading) to the reduced joint pain. Improved muscle strength translates into an ability to resume everyday activities and to enjoy them...pain-free!

Along with strength, endurance, flexibility, and posture, other components of physical function can be improved through exercise. Improvements in any and all of these areas can make a dramatic difference in feelings of well-being. However, if we do not exercise and develop the musculature to encourage good posture, flexibility, and endurance, we’re far more likely to become bedbound or dependent on a wheelchair at an earlier age.

Exercise programs should be designed to incorporate all of the essential components of fitness (i.e., strength, flexibility, and cardiovascular endurance), but they also must be designed to meet the particular needs of the individual patient. Generic exercise standards can be used as the building blocks for addressing a particular problem, like low-back pain or a torn shoulder muscle, but the best program for a particular individual must be tailored to address the idiosyncrasies of his or her unique condition. For example, postural strengthening can require strengthening of one or more muscle groups, depending on the specific weakness of the individual patient. The specific program will be developed based on an initial evaluation with a physical therapist, modified based on follow-up evaluations, and fine-tuned over time until a maintenance set of exercises can be developed to keep the patient in a proper functioning capacity, after recovery to a norm has been established.

The solution, exercise, is relatively easy to administer, but it is not a pill. It is not a quick fix, but rather a timed, incremental, and long-term fix perfected through expertise and commitment. Practitioners must be committed to the long-term view and a disciplined, thoughtful approach. Patients, for their part, must commit to the exercise program and believe in the approach.

Just like exercise, the Slow Fix requires a long-term view of life and health. How do you get started on this life-long journey? Take the Slow Fix and start to make gradual changes in the way you live. Set goals in each of the five different areas that make up the Slow Fix. All of us need to look at where we are and set goals for the near term, as well as the more distant future. This type of planning should not be done just late in life, when someone reaches 70 or 80 years old, but as a young adult and even as early as the middle- and high-school years. Instead of lamenting the problems of aging, we should be working on our own long-term plans to keep body and mind fit and healthy. Challenge yourself to commit to the Slow Fix.

Carole Lewis (CC ’98) is a practicing physical therapist and adjunct professor at the George Washington University School of Medicine. She is the author of Aging: Health Care’s Challenge, and editor of Topics in Geriatric Rehabilitation.

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