How to address the “#1 health issue” in aging?

  1. healthy-aging-older-womenWhat is the #1 health issue that threatens quality of life as we age?
  2. And what is the #1 thing that can be done to prevent that health concern?

These are two questions I received by email recently, on behalf of a woman who is part of the “health and healthy lifestyles subcommittee” for a “village information network” that aims to support older adults in her community.

She also asked the following related questions:

  • Do you know of a best practice somewhere, that could serve as a model for that prevention of that health issue?
  • Do you know of a small town somewhere that is doing a great job with livability for older adults?
  • Do you know of any inter-generational healthy lifestyle programs that might work well in our college town?

I was invited to provide very short one sentence answers, presumably for my convenience but also perhaps to keep things simple for the committee, who surely doesn’t want to wade through long dissertations on barriers to better aging and better approaches.

But I found myself unable to promptly respond with short answers. To begin with, because I have a health services research background, my initial reflex is to want to check on the “evidence” rather than fire off a response related to my own hunches or personal experience.

But any evidence related to the first two questions will depend on which population is being studied. How old, and with what underlying health conditions? Urban, suburban, or rural? Socioeconomic status and ethnicity? Community-dwelling or in facilities?

And how to define “quality of life as we age”? Quality-adjusted life years? Or perhaps other metrics that take into account autonomy, purpose, and social connectedness? (See here and here for scholarly articles addressing this issue.)

As you see, it’s easy to fall down a rabbit hole when considering the “simple” question of what is the #1 threat to quality of life while aging.

Still, the questions are compelling, especially when considered in light of the practical needs at hand. A community group is trying to support the older adults living in a small college town. When it comes to health, what should they focus on?

Three top health issues that threaten quality of life as we age

I don’t have time to research this in depth right now, so, for now, I am going to go with my hunches and personal experience.

My initial hunch is to suggest these three issues, when it comes to threatening quality of life while aging:

  • Isolation
  • Functional limitations
  • Cognitive impairment and dementia

I chose these three because they affect a lot of older adults and/or because I feel they cause a disproportionate amount of heartache and frustration for older people and their families.

A runner-up would be insufficient exercise. Exercise is good for just about all aspects of health, it’s especially important for maintaining health while aging, and many seniors don’t get enough of it. But, promoting exercise is also a bit obvious. And, the real challenge is how to get people to exercise more if they are suffering from isolation, functional impairments, or dementia.

Another runner-up would be sub-optimal healthcare. Probably most people regardless of age are getting sub-optimal healthcare. (I explain what is optimal healthcare here.) Because they come into contact with the healthcare system more often and because most healthcare still isn’t grounded in the geriatrics knowledge base, older adults are especially likely to experience sub-optimal care. They are also more likely to be harmed by such care. But, most older adults don’t seem to be very concerned or aware of this. So I will leave it as a runner-up for now.

Let me now provide some more comments regarding my top three.


Particular health and aging problems associated with isolation include:

  • A high risk of loneliness, which has been associated with all kinds of poor health outcomes. Conversely, having a good social network is generally linked to better health outcomes in older adults.
  • Difficulty getting assistance with chronic health or life needs from others. This is sometimes due to the isolated senior’s discomfort with requesting assistance, but it’s also logistically more challenging for family and others to help seniors who live alone or in more isolated areas.
  • Difficulty summoning help in an emergency (e.g. after a fall)

Interestingly, indicators of isolation or social connectedness were not included in the recent Older Americans 2016 report on indicators of well-being; let’s hope this changes for future reports.

Reducing isolation

There are a number of approaches to take, and probably the best is to combine them. These include:

  • Encouraging older adults to participate in group activities/organizations for fitness, leisure, education/skills-building, and volunteering.
    • Focused outreach — perhaps by other older volunteers? — to older adults would help increase participation in these activities.
  • Friendship/help phone lines for older adults, such as the ones described here “Researchers confront an epidemic of loneliness.”
    • Home visits, either for social/volunteer purposes or to deliver another service, can also reduce isolation. A recent study found that seniors participating in Meals on Wheels reported less loneliness.
  • Encouraging older adults to live in pedestrianized urban areas or perhaps communities specially designed for seniors.
    • Living in closer proximity (i.e not transportation dependent) to other people and especially to activities would likely go a long way towards reducing isolation in older adults. It can also improve access to support services if they become needed.

We should also pay special attention to reaching out and accommodating seniors at high risk for isolation. As a clinician, I particularly worry about isolation in those who:

  • Live alone
  • Have lost their spouse or living companion
  • Have developed cognitive impairment
  • Have developed mobility limitations
  • Have otherwise lost the ability to drive

Functional limitations

Functional limitations mean having difficulty doing activities or tasks that adults can usually manage (the ADLs and IADLs). These can be caused by cognitive problems, physical health problems, or a combination.

Such difficulties are very common in older adults and are part of the vast majority of age-related challenges. Problems managing functional limitations is why people end up feeling they have to go to assisted-living, or sometimes are forced into nursing homes.

Functional limitations also often worsen isolation, since they make it harder for older adults to participate in social activities and other activities that help seniors thrive.

Here is a chart showing the prevalence of functional impairment in older adults; it’s from a Census Bureau report titled “65+ in the United States: 2010.”

Fig 2-14 from 65+ in the united states.600 pix

Reducing the impact of functional limitations

Functional limitations can be prevented or reduced via the right type of healthcare (and they are often exacerbated by sub-optimal healthcare). But really the bigger problem is that our communities are usually very bad at providing services and supports to help older adults, once they’ve developed any limitations in their ability to manage life tasks.

Some examples of such services and supports include:

  • Services to help seniors go places, if they’ve lost the ability to drive safely. E.g. paratransit, senior ride services, etc.
  • Services to help seniors obtain nutritious meals, if they are having difficulty with grocery shopping or meal preparation. E.g. Meals on Wheels
  • Ensuring that public spaces are accessible and welcoming to those with mobility limitations. Is the sidewalk usable by someone who needs a walker or wheelchair?

A more innovative example of this type of service is the “Community Aging in Place, Advancing Better Living for Elders” ( CAPABLE) program, which Howard Gleckman recently described in this blog post.

The service involved sending a care team — nurse, occupational therapist, and handyman — to the home of select older adults. The team identified home modifications and other strategies to help the seniors function better in their home. Crucially, the handyman implemented the modifications. Researchers found that after participating in the program, 75% of the seniors were better able to manage their Activities of Daily Living, and symptoms of depression improved.

Unfortunately, in most communities, older adults have a lot of difficulties accessing services and supports to help them compensate for any ADL or IADL difficulties. This is a huge threat to quality of life, and this needs to change.

In my better world for older people, we won’t have prevented all disability, because I think that’s impossible. Most people eventually develop some chronic impairments, and although better healthcare should be able to reduce that and push it to later in life, we are never going to be entirely rid of it.

Instead, we must create a world in which aging adults can thrive despite having developed chronic disabilities.

Cognitive impairment and dementia

Cognitive impairment could be lumped under functional limitations, but I think it deserves special considerations.

Problems with memory and thinking can cause a lot of health and quality of life issues for older adults. They also usually bring up problems and concerns related to autonomy and control over one’s life.

Per the Older Americans 2016 report released by the government this year, in 2011 dementia affected about 11-13% of people aged 75-84, and 24-30% of people aged 85 or older.

For many seniors, cognitive impairment initially affects the ability to manage IADLS (transportation, finances, shopping, home maintenance, medications and other self-healthcare). It can also cause stress and emotional challenges for seniors and for their families. Particular problems that I see seniors experiencing include:

  • Financial problems, either due to errors or due to financial exploitation by others.
  • Difficulty getting to one’s usual activities, due to problems driving or managing public transportation. This can exacerbate isolation.
  • Difficulty managing chronic diseases and medications
  • Safety concerns, such as
    • ability to summon help from home, esp in the event of a fall or injury
    • problems leaving the stove on or otherwise safely heating meals
    • keeping the house adequately heated or cooled
    • wandering
    • medication errors
  • Family caregiver strain and burnout (spousal caregivers are often older)
  • Family problems managing health, finances, and other affairs because the older person never completed power of attorney documents

Reducing the impact of cognitive impairment and dementia

To reduce the impact on quality of life, for seniors and for families, we need a multi-pronged approach:

  • Prevention and delay of cognitive impairment, by helping older adults optimize their brain health.
    • Many people know that exercise and managing cardiovascular risk factors are important. Far fewer people realize that avoiding certain types of medication and delirium prevention are also important. I have a short list of what people should do here.
  • Optimization of brain health in people who already have cognitive impairment or dementia. Just because most forms of dementia are “incurable” doesn’t mean that nothing can be done.
    • Most approaches shown to help prevent or delay dementia also help maintain the brains of people with dementia in best possible working order.
  • Services and supports for people with dementia and their family caregivers. This could include:
    • Making sure that those who provide services to seniors — including first responders — are trained and equipped to provide their services to people who may be cognitively impaired.
    • Assistance and support for spouses and other family caregivers.
    • Creating dementia-friendly communities, as described here.

Next steps for the health and healthy lifestyles committee

A good step for any community group interested in supporting aging residents would be to learn more about the current older residents. Questions I would be interested include:

  • How old are they?
  • What is their living situation like?
    • Alone or with others?
    • Home, apartment, independent living, assisted living?
  • What kinds of difficulties are they experiencing?
  • What kinds of functional limitations do they have?
  • How many chronic conditions do they have?
  • How much socializing do they do? What kinds of activities do they do?
  • What are they most concerned about? What are they most interested in? What do they think would be most helpful to make their community a better place to grow old?

It would also be good to assess what types of services and supports are already available in town, as well as what are the town leadership’s interests and concerns regarding its older residents.

Do YOU have answers or suggestions for this committee?

Here are the questions once again:

  1. What is the #1 health issue that threatens quality of life as we age?
  2. And what is the #1 thing that can be done to prevent that health concern?
  3. Do you know of a best practice somewhere, that could serve as a model for that prevention of that health issue?
  4. Do you know of a small town somewhere that is doing a great job with livability for older adults?
  5. Do you know of any inter-generational healthy lifestyle programs that might work well in our college town?

If you have suggestions or ideas, please post below in the comments! I would especially like to know of small towns (or big ones) that are particularly livable for older adults with functional limitations.


  1. e uprichard says:

    #1 problem is falling. It’s true for every elder person regardless of any other factors. The other factors you raise are largely unpreventable and a bit existential. Dementia and failing health are unavoidable. Many problems are solved by elder-oriented housing (whether assisted living facilities, usually expensive, or communities such as Del Webb).

    This is not to say that all the other suggestions are not fabulous… but I see just basic safety as the most important and secondly, a community of some sort.

  2. David Utzschneider MD PhD says:

    sort of a big question but one problem is finding the simplest, easiest, friendliest, most efficient, values based, high value way to navigate through the health care system for the patient and their family/caregivers. do I need this medicine? do I need this procedure ? etc.

    • Leslie Kernisan, MD MPH says:

      Agree that this is important. It is certainly part of addressing suboptimal healthcare, which I mention in the post as important and probably underrated by the general public.

  3. Leslie Kernisan, MD MPH says:

    Here’s a comment I received by email from a reader:

    “Thank you for your very thoughtful post.
    As a 15-year resident in a lifecare facility, I have witnessed daily the impact of aging and health issues. One that is seldom discussed is the loss of control in decision-making. At many points in our lives others make a judgement that control and decisions can be taken away, often denying the ‘personhood’ and individuality that is still present – children, health agents, facility administrators – There is a lack of empathy when they decide what is good for you.
    Because of the requirement for confidentiality in a facility such as mine, friends could not help with personal information. I got the facility to develop a legal document permitting each resident to designate a fellow resident as an advocate who is entitled to be given medical information and is enabled to at least have some input. This has been helpful, but not sufficient.
    Health personnel need more and continuous training in the perception of people, no matter the age or infirmity, as partners, rather than just people being taken care of.”

  4. Leslie Kernisan, MD MPH says:

    And another comment that came in by email:

    “Very interesting – hope somehow you are able to follow up with this group. Don’t think this is #1, but I’m very concerned with a lack of coordination among care providers. Our Clinic, where I see a number of specialists, seems to be trying through the use of computers. That gets a “hmmm” rating from me – so far, I’ve caught doctors looking at someone else’s screen and arguing with me about treatment for a condition I don’t have. Should they have the right screen, however, the information is scanned so quickly that I don’t think it registers. Fortunately, I can still argue with – especially – being prescribed a wrong- for-me medicine, but what will happen if I loose that ability? Would also that I could have my other specialists hop out of the computer, explain the problem, and then leave. Seriously, think a more group approach to treating the elderly – since we seem to have more multiple problems than younger folk – is necessary. Oh, and the ability of individual doctors to recognize that they are not experts on every subject. Hope my thoughts help.”

  5. Aging is not a guarantee for dementia but is definitely a risk factor for it. I am a physicIan and have noticed that many of my older patients really struggle with the fear of developing dementia. Everybody forgets things, but when an elder person forgets something they seem to focus on its significance much more.

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