Aging and adaptation

American writer Edith Wharton once wrote, “In spite of illness, in spite even of the arch-enemy sorrow, one CAN remain alive long past the usual date of disintegration if one is unafraid of change, insatiable in intellectual curiosity, interested in big things, and happy in small ways.”¹ I suspect that it is the last of these things that might make the most difference.

It was on the recent 1-year anniversary of my father-in-law’s death at the age of 91 years that I was reminded of Wharton’s wise words about successful aging. Although a significant part of the last 5 years of his life was blighted by COVID-19—robbing him in the first months of social connections and access to the pool where he would swim at least 3 times a week, and exacerbating some chronic health issues—my father-in-law never failed to adapt.

When he suddenly could no longer see family and friends in person, he rapidly switched to using Zoom on his computer and FaceTime on his smartphone. When he could no longer use the swimming pool, he ordered a recumbent bike and a portable step machine and started to exercise in the confines of his apartment. He continued to enjoy the small things in life that always gave him pleasure—such as exchanging puns and dad jokes by email with friends and family. But many older people struggle to adapt as they age, especially if they are affected by health problems that impair their mobility or cognitive abilities. My father-in-law was very fortunate to have agency and control, right until the very end of his life. Many people do not.

In his 2014 book Being Mortal: Medicine and What Matters in the End² American surgeon and writer Dr Atul Gawande brilliantly articulated a generational tension between aging baby boomers, their adult children, and their health care providers: as people age, the majority prefer to remain in their own homes, even if that carries significant risk. Most people also prefer to die in their own homes. This is the concept of “aging in place.”³ But adult children and health care professionals, like family physicians, often privilege safety over individual autonomy and its attendant risks.

This issue of Canadian Family Physician features 2 articles to help family physicians support patients and their families as they adapt to the changes that come with aging. The first is a Geriatric Gems article by Dr Chris Frank and colleagues entitled “Managing risks of aging at home. Considerations to support older adult patients” (page 639).⁴ The article presents an organized and comprehensive approach to in-home risk assessment leading to risk mitigation based on a patient and family’s values and comfort with risk. Frank et al’s approach is based on the concept of the dignity of risk, an approach to care that originated in the 1970s to redress the then-prevalent view that individuals with intellectual and developmental disabilities were incapable of making decisions for themselves or living independently. As always with this series, readers will find it both helpful and practical.

The second article is a commentary by Drs Ken Shulman and Sara Mitchell (page 613).⁵ They argue that in the future “… family physicians will need to learn how to navigate the intricate landscape of determining patient mental capacity in legal disputes. This is shaped by an unprecedented transfer of wealth from an older population with cognitive and mental health challenges to a younger generation with complex families under great economic strain.”⁵

Like the article by Frank et al, Shulman and Mitchell describe a comprehensive, situation-specific approach for assessing decision-making capacity in older adult patients that can help family physicians establish both patient safety and autonomy and ensure that assessments by family physicians are both medically sound and legally defensible.

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