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Archive for February, 2015

A Sociological Look at Frailty and Aging [A Three-Part Series] Part I  

Introduction

I am initiating a three-part series on frailty and aging. Part I consist of: facts about frailty and aging and attitudes about older people. Part II will cover an overview of important research related to how to stay healthy longer with exercise. Part III will hone in on an important study published recently in 2013 in the Journal of Aging.

The Demographic Picture

In the industrialized countries, life expectancy and, thus, the old age population have increased consistently over the last several decades. In the United States the proportion of people aged 65 or older increased from 4% in 1900 to about 12% in 2000. In 1900 only about 3 million of the nation’s citizens were 65 or older (out of 76 million total American citizens). By 2000, the number of senior citizens had increased to about 35 million (of 280 million US citizens). Population experts estimate that more than 50 million Americans—about 17 percent of the population—will be 65 or older in 2020. By 2050, it is projected that at least 400,000 Americans will be 100 years of age or older. The number of old people is growing around the world chiefly because of the post-World War II baby boom and increases in the provision and standards of health care. By 2050, 33% of the developed world’s population and almost 20% of the less developed world’s population will be over 60 years old. The growing number of people living to their 80s and 90s in the developed world has strained public welfare systems and has also resulted in increased incidence of diseases like cancer and dementia that were rarely seen in pre modern times. When the United States Social Security program was created, persons older than 65 numbered only around 5% of the population and the average life expectancy of a 65-year-old in 1936 was approximately 5 years, while in 2011 it could often range from 10–20 years. Other issues that can arise from an increasing population are growing demands for health care and an increase in demand for different types of services. Of the roughly 150,000 people who die each day across the globe, about two thirds—100,000 per day—die of age-related causes. In industrialized nations the proportion is much higher, reaching 90%.

Attitudes toward Older Citizens

When I was young, I held respect for my parents and grandparents because I, and society, generally held them to be venerable. That was the 1950s and before. That notion of respect for the elderly appears to be an outdated idea in the 21st century. People are not entitled to veneration simply because of their longevity, but rather because of whom they are as a person (what Dr. Martin Luther King referred to as “the content of one’s character”) and their individual behavior. Our attitudes toward older persons back in the 50s were also based on a kind of myth that older people should be venerated. Or, in my view, if a person wants respect— they must first be respectable. Age by itself has nothing to do per se with respect. It is human conduct that matters, not longevity. That being pointed out, it is nevertheless really unfortunate, but society has never really had a very positive view of its older citizens. Even today some folks are antagonistic toward the elderly. And when people discriminate against older citizens—it is called ageism. And ageism certainly does exist in our society. Historical periods reveal a mixed picture of the “position and status” of old people, but there has never been a “golden age of aging.” Studies have disproved the popular belief that in the past old people were venerated by society and cared for by their families. Veneration for and antagonism toward the aged have coexisted in complex relationships throughout history. In ancient times, the very few people who lived beyond 35 physically and mentally healthy, especially those of social status and wealth were treated with “respect and awe.” In contrast, those who were frail were seen as a burden and ignored or, in extreme cases, killed. For example, there once was the Eskimo practice of putting their elders on an ice-berg and saying bye-bye grandma. People were defined as “old” because of their inability to perform useful tasks rather than their years. In any era businesses often fail to recognize the experiences and contributions of long-term employees. In Greek and Roman cultures, old age was denigrated as a time of “decline and decrepitude.” In the Classical period, “beauty and strength” were esteemed and old age was viewed as defiling and ugly. The Medieval and Renaissance periods depicted old age as “cruel or weak.” In the Modern period, the “cultural status” of old people has declined in many cultures. Research on age-related attitudes consistently finds that negative attitudes exceed positive attitudes toward old people because of their looks and behavior. In his study Aging and Old Age, Posner discovers “resentment and disdain of older people” in American society. Harvard University’s Implicit-association test measures implicit “attitudes and beliefs” about Young vis-a-vis Old. Blind Spot: Hidden Biases of Good People, a book about the test, reports that 80% of Americans have an “automatic preference for the young over old” and that attitude is true worldwide. The young are “consistent in their negative attitude” toward the old. Ageism documents that Americans generally have “little tolerance for older persons and very few reservations about harboring negative attitudes” about them. In spite of its prevalence, ageism is seldom the subject of public discourse. So what do we know about this less than venerated segment of the population?

The Four Dimensions of Aging

Old age comprises four dimensions: chronological, biological, psychological, and social. Chronological age may differ considerably from a person’s functional age. The distinguishing marks of old age normally occur in all five senses at different times and different rates for different persons. In addition to chronological age, people can be considered old because of the other three dimensions of old age. For example, people may be considered old when they become grandparents or when they begin to do less or different work in retirement. For many decades doctors used to describe older citizens as inevitably heading toward losing their strength, vitality, stamina, and general health, and attributed these phenomena to “the process of aging or getting older.” This old attitude probably made older people feel helpless, and relegated them to eventually accepting the notion that getting older meant becoming a crippling image of one’s prior self. This also has made many younger people feel that only bad health and eventual demise was all they had to look forward to in their older years. This “one size fits all” characterization of getting older was simplistic, and an inadequate medical explanation of the aging process. Do people eventually get sick and die? Of course they do. But our physical and mental condition during our older “golden years”, until our final days, does not necessarily have to be in a constant state of fragility and disability. Far from it! The lion’s share of older people does enjoy a robust, active, thriving lifestyle. The scientific evidence is clear. Having a healthy lifestyle includes healthy nutritious food, plenty of exercise, and quality health care. This will not only extend a person’s longevity, but a longevity that is also productive, and thriving. Older citizens can therefore enjoy all the satisfactions of being an older citizen like being comfortably retired, and having the freedom to pursue any interest. Is this a utopian view of old age? Well, maybe a little. Other negative factors can alter this positive outlook such as lack of money or other resources, and the absence of family and friends. Losing a spouse or loved one can put tremendous stress, loneliness, fear and anxiety on an older person. Surveys of happiness long ago showed that the happiest years of a person’s life is between 25 and 45 years of age. Not surprisingly that twenty year period (25-45) is the very years when people are raising a family, their careers are taking off, and life in the bedroom is exceptionally good. Quality of life in our older years does not have to suffer, provided one has the proper mindset. People need to possess a research and science-based perspective. So, from a research perspective one needs to ask this sort of question. What differentiates people who become frail in their older years from others who appear to be healthy, robust, thriving and happy? At one level this type of question is antiseptic and rather academic. At another level however, this type of research question has personal implications for how he/she ought to live their life during one’s older years. Everyone needs to look at this question intellectually, but simultaneously ask oneself— what implications do the question and its answer have for me? Connecting the applicability of research findings to oneself is, of course, up to you. I encourage all of you to think long and hard on this. Do you want to be frail, or healthy, robust and thriving as you age? There are no guarantees in life. But for the majority of people at any age you have decisions to make that certainly will determine whether you succumb to frailty, or spend your golden years in good health. So, let’s start by what we know about frailty and what we know about the construct of aging.      I used to think the worst things in life were either death or having a conservative Republican in the White House. Now I know death is the lesser of those two evils. My attitude toward conservative republicans hasn’t changed; however, death is not the worst outcome in life—its frailty. It must be pointed out that aging and frailty is not the same thing.

So what is Frailty?

Frailty is a common geriatric syndrome that embodies an elevated risk of catastrophic declines in health and function among older adults. Frailty is a condition associated with aging, and it has been recognized for centuries. As described by Shakespeare in As You like it, “the sixth age shifts into the lean and slipper’d pantaloon, with spectacles on nose and pouch on side, his youthful hose well sav’d, a world too wide, for his shrunk shank…” The shrunk shank is a result of loss of muscle with aging. It is also a marker of a more widespread syndrome of frailty, with associated weakness, slowing, decreased energy, lower activity, and when severe, unintended weight loss. As a population ages, a central focus of geriatricians and public health practitioners is to understand and then beneficially intervene on, the factors and processes that put elders at such risk, especially the increased vulnerability to stressors (e.g. extremes of heat and cold, infection, injury, or even changes in medication) that characterizes the situation many older adults find themselves experiencing. Frailty is a common geriatric syndrome. Estimates of frailty prevalence in older populations may vary according to a number of factors, including the setting in which the prevalence is being estimated – e.g., nursing home (higher prevalence) vs. community (lower prevalence), and the operational definition used for defining frailty. Using the widely used frailty phenotype framework proposed by Fried et al., (2001), prevalence estimates of 7-16% have been reported in non-institutionalized, community-dwelling older adults. The occurrence of frailty increases incrementally with advancing age, and is more common in older women than men, and among those of lower socio-economic status. Frail older adults are at high risk for major adverse health outcomes, including disability, falls, institutionalization, hospitalization, and mortality.

Prevalence of Frailty

Frailty is a common condition in later old age, but different definitions of frailty produce diverse assessments of prevalence. One study placed the incidence of frailty for ages 65+ at 10.7%. Another study placed the incidence of frailty in age 65+ population at 22% for women and 15% for men. A Canadian study illustrated how frailty increases with age and calculated the prevalence for 65+ as 22.4% and for 85+ as 43.7%. A worldwide study of “patterns of frailty” based on data from 20 nations found (a) a consistent correlation between frailty and age, (b) a higher frequency among women, and (c) more frailty in wealthier nations where greater support and medical care increases longevity. In Norway, a 20 year longitudinal study of 400 people found that bodily failure and greater dependence became prevalent in the 80+ years. The study calls these years the “fourth age” or “old age in the real meaning of the term.” Similarly, the “Berlin Aging Study” rated over-all functionality on four levels: good, medium, poor, and very poor. People in their 70s were mostly rated good. In the 80-90 year range, the four levels of functionality were divided equally. By the 90-100 year range, 60% would be considered frail because of very poor functionality and only 5% still possessed good functionality. In the United States, the 85+ age group is the fastest growing, a group that is almost sure to face the “inevitable decrepitude” of survivors. (frailty and decrepitude are synonyms.)

What are the Marks of Aging?

The distinguishing marks associated with old age comprise both physical and mental characteristics. The marks of old age are so unlike the marks of middle age that it has been suggested that, as an individual transitions into old age, he/she might well be thought of as different persons “time-sharing” the same identity. These marks do not occur at the same chronological age for everyone. Also, they occur at different rates and order for different people. Because each person is unique, marks of old age vary between people, even those of the same chronological age. A basic mark of old age that affects both body and mind is “slowness of behavior.” This “slowing down principle” finds a correlation between advancing age and slowness of reaction and task performance, both physical and mental.

Physical Marks of Old Age

Physical marks of old age include the following:

  • Bone and joint. Old bones are marked by “thinning and shrinkage.” This results in a loss of height (about two inches by age 80), a stooping posture in many people, and a greater susceptibility to bone and joint diseases such as osteoarthritis and osteoporosis.
  • Chronic diseases. Older persons have at least one chronic condition and many have multiple conditions. In 2007-2009, the most frequently occurring conditions among older persons in the United States were uncontrolled hypertension (34%), diagnosed arthritis (50%), and heart disease (32%).
  • Dental problems. Less saliva and less ability for oral hygiene in old age increase the chance of tooth decay and infection.
  • Digestive system. About 40% of the time, old age is marked by digestive disorders such as difficulty in swallowing, inability to eat enough and to absorb nutrition, constipation and bleeding.
  • Eyesight. Diminished eyesight makes it more difficult to read in low lighting and in smaller print. Speed with which an individual reads and the ability to locate objects may also be impaired.
  • Falls. Old age spells risk for injury from falls that might not cause injury to a younger person. Every year, about one-third of those 65 years old and over half of those 80 years old fall. Falls are the leading cause of injury and death for old people.
  • Hair usually becomes thinner and grayer.
  • Hearing. By age 75 and older, 48% of men and 37% of women encounter impairments in hearing. Of the 26.7 million people over age 50 with a hearing impairment, only one in seven uses a hearing aid.
  • Hearts are less efficient in old age with a resulting loss of stamina. In addition, atherosclerosis can constrict blood flow.
  • Immune function. Less efficient immune function (Immunosenescence) is a mark of old age.
  • Lungs expand less well; thus, they provide less oxygen.
  • Pain afflicts old people at least 25% of the time, increasing with age up to 80% for those in nursing homes. Most pains are rheumatological or malignant.
  • Sexual activity decreases significantly with age, especially after age 60, for both women and men. Sexual drive in both men and women decreases as they age.
  • Skin loses elasticity, becomes drier, and more lined and wrinkled.
  • Sleep trouble holds a chronic prevalence of over 50% in old age and results in daytime sleepiness. In a study of 9,000 persons with a mean age of 74, only 12% reported no sleep complaints. By age 65, deep sleep goes down to about 5%.
  • Taste buds diminish so that by age 80 taste buds are down to 50% of normal. Food becomes less appealing and nutrition can suffer.
  • Urinary incontinence is often found in old age.
  • Voice. In old age, vocal cords weaken and vibrate more slowly. This results in a weakened, breathy voice that is sometimes called an “old person’s voice.”

Mental Marks of Old Age

Mental marks of old age include the following.

  • Adaptable describes most people in their old age. In spite the stressfulness of old age; they are described as “agreeable” and “accepting.” However, old age dependence induces feelings of incompetence and worthlessness in a minority.
  • Caution marks old age. This antipathy toward “risk-taking” stems from the fact that old people have less to gain and more to lose than younger people by taking risks.
  • Depressed mood. According to Cox, Abramson, Devine, and Hollon (2012), old age is a risk factor for depression caused by prejudice (i.e., “DE prejudice”). When people are prejudiced against the elderly and then become old themselves, their anti-elderly prejudice turns inward, causing depression. “People with more negative age stereotypes will likely have higher rates of depression as they get older.” Old age depression results in the over-65 population having the highest suicide rate.
  • Fear of crime in old age, especially among the frail, sometimes weighs more heavily than concerns about finances or health, and restricts what they do. The fear persists in spite of the fact that old people are victims of crime less often than younger people.
  • Mental disorders afflict about 15% of people aged 60+ according to estimates by the World Health Organization. Another survey taken in 15 countries reported that mental disorders of adults interfered with their daily activities more than physical problems.
  • Reduced mental and cognitive ability afflicts old age. Memory loss is common in old age due to the decrease in speed of information being encoded, stored, and retrieved. It takes more time to learn new information. Dementia is a general term for memory loss and other intellectual abilities serious enough to interfere with daily life. Its prevalence increases in old age from about 10% at age 65 to about 50% over age 85. Alzheimer’s disease accounts for 50 to 80 percent of dementia cases. Demented behavior can include wandering, physical aggression, verbal outbursts, depression, and psychosis.
  • Set in one’s ways describes a mindset of old age. A study of over 400 distinguished men and women in old age found a “preference for the routine.” Explanations include old age’s toll on the “fluid intelligence” and the “more deeply entrenched” ways of the old.

Epidemiological Research on Frailty

Epidemiologic research to date have led to the identification of a number of risk factors for frailty, including: (a) chronic diseases, such as cardiovascular disease, diabetes, chronic kidney disease, depression, and cognitive impairment; (b) physiologic impairments, such as activation of inflammation and coagulation systems, anemia, atherosclerosis, autonomic dysfunction, hormonal abnormalities, obesity, hypovitaminosis D in men, and environment-related factors such as life space and neighborhood characteristics. Advances in knowledge about potentially modifiable risk factors for frailty now offer the basis for translational research effort aimed at prevention and treatment of frailty in older adults.

The Social Construct of Aging

While I personally tend to think of frailty as a medical condition in need of extensive modern day research and medical treatment, I also tend to think of aging as a social construct dependent upon social definitions and the influence of culture. Much of the interpretation of a social construct like aging often depends on the interaction between culture and individual social perceptions. Like stereotypes, not all individual social perceptions are necessarily wrong.

Variability of Social Definitions

Here following is why I see aging as a social construct. Why? Sociologically speaking, definitions of aging or being an older adult are so variable. The chronological age denoted as “old age” varies culturally and historically. Thus, old age is “a social construct” rather than just a definite “biological stage.” Old age consists of ages nearing or surpassing the life expectancy of human beings, and thus the end of the human life cycle. Euphemisms and terms for old people include old people (worldwide usage), seniors (American usage), senior citizens (British and American usage), older adults (in the social sciences), the elderly, and elders (in many cultures including the cultures of aboriginal people). Sometimes people speak of older people in derogatory terms such as “look at that old bastard,” or old geezer, old fuddy-duddy, old coot, old fogy, old fart, old poop. People can be really mean and insensitive without much justification or reason. Often, the only social crime an elderly person has committed is that—“they got older through no fault of their own.”

Senescence

Old people often have limited regenerative abilities and are more susceptible to disease, syndromes, and sickness than younger adults. The organic process of ageing is called senescence. The medical study of the aging process is gerontology, and the study of diseases that afflict the elderly is geriatrics. The elderly also face other social issues such as retirement, loneliness, and ageism, issues around money, opportunities, simultaneously experiencing mental and physical decline, and a serious impact on self-esteem; it’s somewhat of an identity crisis. You are no longer the person you were, both inside and out. This identity crisis is, unfortunately, what may be responsible for many older people committing suicide. Recent work on frailty has sought to characterize both the underlying changes in the body and the manifestations that make frailty recognizable. It is well-agreed upon that declines in physiologic reserves and resilience is the essence of being frail. Similarly, scientists agree that the risk of frailty increases with age and with the incidence of diseases. Beyond that, there is now strong evidence to support the theory that the development of frailty involves declines in energy production, energy utilization and repair systems in the body, resulting in declines in the function of many different physiological systems. This decline in multiple systems affects the normal complex adaptive behavior that is essential to health and eventually results in frailty typically manifesting as a syndrome of a constellation of weakness, slowness, reduced activity, low energy and unintended weight loss. When most severe, i.e. when 3 or more of these manifestations are present, the individual is at a high risk of death. The syndrome of geriatric frailty is hypothesized to reflect impairments in the regulation of multiple physiologic systems, embodying a lack of resilience to physiologic challenges and thus elevated risk for a range of deleterious endpoints. Generally speaking, the empirical assessment of geriatric frailty in individuals seeks ultimately to capture this or related features, though distinct approaches to such assessment have been developed in the literature (see de Vries et al., 2011 for a comprehensive review). Two key approaches are discussed below:

Linda Fried / Johns Hopkins Frailty Criteria

A popular approach to the assessment of geriatric frailty encompasses the assessment of five dimensions that are hypothesized to reflect systems whose impaired regulation underlies the syndrome. These five dimensions are: weight loss, exhaustion, weakness, slowness, and low levels of activity. Corresponding to these dimensions are five specific criteria indicating adverse functioning, which are implemented using a combination of self-reported and performance-based measures. Those who meet at least three of the criteria are defined as “frail”, while those not matching any of the five criteria are defined as “robust”. Additional work on the construct is done by Bandeen-Roche et al. (2006), though some of the exact criteria and measures differ. Other studies in the literature have also adopted the general approach of Linda P. Fried et al. (2001) though, again, the exact criteria and their particular measures may vary. This assessment approach was developed and refined by Fried and colleagues at the Johns Hopkins University’s Center on Aging and Health. This Center is home to Johns Hopkins Claude D. Pepper Older Americans Independence Center, which focuses on frailty research.

Misconceptions of Frail People

Johnson and Barer did a pioneering study of Life beyond 85 Years by interviews over a six year period. In talking with 85+ year olds, they found some popular conceptions about old age to be erroneous. Many studies of old age overlook the 85+ survivors so their conclusions do not apply. Such erroneous conceptions include (1) people in old age have a least one family member for support, (2) old age well-being requires social activity, and (3) “successful adaptation” to age-related changes demands a continuity of self-concept. In their interviews, Johnson and Barer found that 24% of the 85+ had no face-to-face family relationships; many have outlived their families. Second, that contrary to popular notions, the interviews revealed that the reduced activity and socializing of the over 85s does not harm their well-being; they “welcome increased detachment.” Third, rather than a continuity of self-concept, as the interviewees faced new situations they changed their “cognitive and emotional processes” and reconstituted their “self–representation.”

Old Age from an Old-Age Perspective

Early old age is a pleasant time: children are grown, retirement from work, time to pursue interests. In contrast, perceptions of old age by writers 80+ years old, “old age in the real meaning of the term,” tend to be negative. Lillian Rubin, active in her 80s as an author, sociologist, and psychotherapist, opens her book 60 on Up: The Truth about Aging in America with “getting old sucks. It always has, it always will.” Dr. Rubin contrasts the “real old age” with the “rosy pictures” painted by middle-age writers. Writing at the age of 87, Mary C. Morrison delineates the heroism required by old age: to live through the disintegration of one’s own body or that of someone you love. Morrison concludes, “old age is not for the fainthearted.” In the book Life beyond 85 Years, the 150 interviewees had to cope with physical and mental debilitation and with losses of loved ones. One interviewee described living in old age as “pure hell.” .Death and Frailty

     Old age, death, and frailty are linked because approximately half the deaths in old age are preceded by months or years of frailty.

     Older Adults’ Views on Death is based on interviews with 109 people in the 70-90 age range, with a mean age of 80.7. Almost 20% of the people wanted to use whatever treatment that might postpone death. About the same number said that given a terminal illness, they would choose assisted suicide. Roughly half chose doing nothing except live day by day until death comes naturally without medical or other intervention designed to prolong life. This choice was coupled with a desire to receive palliative care if needed. About half of older adults suffer multi-morbidity, that is, they have three or more chronic conditions. Medical advances have made it possible to “postpone death,” but in many cases this postponement adds “prolonged sickness, dependence, pain, and suffering,” a time that is costly in social, psychological, economic terms. The longitudinal interviews of 150 age 85+ people summarized in Life Beyond 85 Years found “progressive terminal decline” in the year prior to death: constant fatigue, much sleep, detachment from people, things, and activities, simplified lives. Most of the interviewees did not fear death; some would welcome it. One person said, “Living this long is pure hell.” However, nearly everyone feared a long process of dying. Some wanted to die in their sleep; others wanted to die “on their feet.” The study of Older Adults’ Views on Death found that the more frail people were, the more “pain, suffering, and struggles” they were enduring, the more likely they were to “accept and welcome” death as a release from their misery. Their fear about the process of dying was that it would prolong their distress. Besides being a release from misery, some saw death as a way to reunion with departed loved ones. Others saw death as a way to free their caretakers from the burden of their care. According to Erik Erikson’s “Eight Stages of Life” theory, the human personality is developed in a series of eight stages that take place from the time of birth and continue on throughout an individual’s complete life. He characterizes old age as a period of “Integrity vs. Despair”, during which a person focuses on reflecting back on his life. Those who are unsuccessful during this phase will feel that their life has been wasted and will experience many regrets. The individual will be left with feelings of bitterness and despair. Those who feel proud of their accomplishments will feel a sense of integrity. Successfully completing this phase means looking back with few regrets and a general feeling of satisfaction. These individuals will attain wisdom, even when confronting death. Coping is a very important skill needed in the aging process to move forward with life and not be ‘stuck’ in the past. The way a person adapts and copes, reflects his aging process on a psycho-social level. Newman & Newman proposed a ninth stage of life, Elderhood. Elderhood refers to those individuals who live past the life expectancy of their birth cohorts. There are two different types of people described in this stage of life. The “young old” are the healthy individuals who can function on their own without assistance and can complete their daily tasks independently. The “old old” are those who depend on specific services due to declining health or diseases. This period of life is characterized as a period of “immortality vs. extinction.” Immortality is the belief that your life will go on past death; some examples are an afterlife or living on through one’s family. Extinction refers to feeling as if life has no purpose. Comments

Theoretically speaking, we all have a lifetime to prepare for old age socially, monetarily, and in terms of long-term care. But the reality is that few of us, particularly when we are young, ever really begin to dwell or think about old age until we are on its doorstep. Many of us should begin to plan for our retirement in our 20s. But most workers don’t begin planning for retirement until their late 30s or early 40s. And for some it’s almost an afterthought. It’s understandable because most people live in the here and now. When younger people are up to their necks in debt, little thought is given to planning for retirement; they think very little what it means to be old. No one can predict what is going to happen in the future. It would be great if we could all plan for every contingency in life. But life has a way of kicking us in the shins when we least expect it (i.e., diagnosis of disease, accidents, loss of a job or loved ones, etc.). Or, as I once heard someone say, “Life’s a bitch—then you die.” Some people like to say, “What will be is what will be, and I can’t do anything about it.” Or, some people will say “I can’t stop myself from aging and have no control over it. If it’s inevitable, I can’t do anything about it.” These expressions project a fatalistic outlook on life. What underlies this type of attitude is an unwillingness to take responsibility, or can be a feeling of helplessness. These rationalizations or feelings are an attitude of resignation in the face of some future events which are thought to be inevitable. As said before, no one can exactly predict what is going to happen in the future. Nevertheless, that does not mean that one can’t take prudent steps to prepare for most of those contingencies (possibly frail health, not enough resources, diseases, etc.) That’s why the life insurance industry is always thriving. Insurance companies use probabilities to determine future outcomes based on group data. Where old age and the possibility of frailty is concerned one most definitely can plan. You know what I’m talking about. It’s about making important lifestyle changes at any time of life i.e., a healthy diet, plenty of exercise, and minimizing risk factors of all kinds (like smoking, drinking excessively, or driving too fast or too carelessly on the freeway). Space in this blog does not permit me the luxury to tackle every aspect of lifestyle changes. I’ve chosen to narrow the scope of Part II and Part III ahead to the impact of exercise on frailty and aging.

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