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Ageing beyond frailty:
palliative care and the oldest old
Prof. Cees M Hertogh, MD,PhD
Elderly Care Medicine & Geriatric Ethics
EMGO Institute for Health and Care Research
Eos and Tithonos
• The ambivalent ideal of
aging
The transformation of health and illness
• Three era’s since 1900:
– Infectious disease
– Chronic disease
– ‘Senescence-process’
Compression of morbidity paradigm:
“A new syllogism for aging”
•1. natural life span is relatively fixed
•2. the age of first appearance of aging
manifestations and and chronic symptoms can
increase more rapidly than life expectancy
•3. therefore the duration of morbidity and disability
will decrease
• (James F. Fries, 1980, 2011)
Explanations and policy implications
• Early detection and ‘medicalization’ of chronic
disease
• Patient education and life style approaches
• Investment in ‘plasticity’ of ageing
• (Function-enhancing medical interventions)
• (improvements in built environment)
‘rectangularization’ of the survival curve
Grimley Evans on healthy old age:
• By delaying the onset of
disabling diseases to later
ages when intrinsic aging has
raised fatality by reducing
adaptability, the average
duration of disability before
death will be shortened.
• In brief: we shall spend a
longer time living and a
shorter time dying
Grimley Evans on healthy old age:
• By delaying the onset of
disabling diseases to later
ages when intrinsic aging
has raised fatality by
reducing adaptability, the
average duration of disability
before death will be
shortened.
• In brief: we shall spend a
longer time living and a
shorter time dying
Intrinsic ageing
• ‘homoeostenosis’ :
• The progressive narrowing
of the capacity to adapt
through loss of reserve
power
• ‘natural death’ :
• quality of host resistance >
nature of insult to
equilibrium
Frailty: a controversial concept
• Multiple conceptualizations!
Frailty: a controversial concept
• Multiple conceptualizations!
– Transition from service-directed concept (70’s)
– To ‘interventionist’ concept (90’s)
Federal council on aging (USA):
• Persons, usually but not always over the age of
75, who because of an accumulation of various
continuing problems often require one or several
supportive services in order to cope with daily life
• (FCA, 1978)
• Frailty = Chronic disease = Disability
Frailty: a controversial concept
• Multiple conceptualizations!
– Transition from service-directed concept (70’s)
– To ‘interventionist’ concept (90’s)
• ‘narrow’ biomedical concept
» Frailty phenotype (Fried)
» State variable (frailty index) (Rockwood)
• ‘broad’ epidemiological concept (Deeg, SCP, TFI)
Frailty according to the SCP:
• A heuristic term to identify risk groups
• A process involving the accumulation of physical,
psychological and/or social deficits in functioning
which increase the risk of adverse health
outcomes (functional impairments, admission to
an institution, death)
Frailty according to the SCP:
• A heuristic term to identify risk groups
• A process involving the accumulation of physical,
psychological and/or social deficits in functioning
which increase the risk of adverse health
outcomes (functional impairments, admission to
an institution, death)

• Frailty as a transitional state between the third
and the fourth age
The fourth age
• Laslett:
– a period of decline and decrepitude (> 85)
• Gilleard & Higgs:
– Ageing without agency
– the ‘black hole’ of old age
• Baltes & Smith:
– Person-based
– Population-based
Recent news from gerontology…
• The good news: the third age (young old)
• Increase in life expectancy: more people live longer
• Substantial latent potential for better fittness in old age
• Succesive cohorts show gains in physical and mental fitness
• Evidence of cognitive-emotional reserves of the aging mind
• More and more people age succesfully
• High levels of emotional and personal well-being (selfplasticity)
• Effective strategies to master the gains and losses of late life
Recent news from gerontology…
• The not-so-good or bad news: the fourth age (oldest
old)
• Sizeable losses in cognitive potential and ability to learn
• Increase in chronic stress syndrome
• Sizeable prevalence of dementia (about 50% in 90-yearolds)
• High levels of frailty, dysfunctionality and multimorbidity
• Dying at older ages: with human dignity?
•  prospects for the 21st century: the era of chronic
incompleteness of mind and body?
• (Baltes & Smith, BASE)
Geriatric palliative care
“Concentrating on diagnosing the disease
for which often little can be done will lead to
ignoring symptoms and disabilites for which often
much can be done”
(Tinetti)
Palliative medicine
Elderly care medicine
Two radical notions converge,
each expanding the scope
and invigorating the other
(Cassell)
Illness trajectories
Geriatric palliative care
• An approach that improves the quality of life of patients and their
families facing the problems associated with life-threatening illness
– (WHO, new)
• Integral multidisciplinary care for patients with incurable diseases,
aimed at reaching and maintaining optimal quality of life for both
patients and their relatives.
– (WHO, old)
• The medical care and management of older patients with healthrelated problems and progressive, advanced disease for which the
prognosis is limited and the focus of care is quality of life
– (EUGMS, 2007)
Domains relevant for GPC
• Pain and symptom management
• (Functional) autonomy and QoL
• Psycho-social needs and meaning
• Advance care planning and medical decisionmaking
• Supportive care for carers
Our research: dementia & stroke
• Pain and symptom management
– Dementia: pain and problem behaviour
– Dementia: pneumonia in the last stage of life
Our research
• (Functional) autonomy and QoL
– Care needs of elderly chronic stroke patients
(CASTILON)
– Dementia: (electronic) alternatives for restraint
use
Our research
• Psychosocial needs and meaning
– Spiritual end of life care in nursing homes
– ‘succesful’ old in deep old age: the patient’s
perspective
Our research
• Advance care planning and medical decision
making
– Role of advance directives (for euthanasia) in
dementia caregiving
– Early palliative care in dementia caregiving
– Advanced dementia: an aid to decision-making
– Thoughts on the future: the perspective of
dementia patients
– Palliative care following acute stroke: a guide to
decision making
Our research
• Supportive care for carers
– Advanced dementia: an aid to decision-making
– Care needs of chronic stroke patients
(CASTILON)
Do not go gentle into that
good night.
Old age should burn and
rave at close of day;
Rage, rage against the
dying of the light
Dylan Thomas