Arthur M. Sherwood, PE,
Scientific Director, Center of Excellence
Rehabilitation Research and Development Center
on Healthy Aging with Disabilities
VA Medical Center
In 1995, an estimated one of three people in the United States had chronic conditions characterized by persistent and recurring health consequences lasting for periods of years. Almost half of those people were limited in daily activities by their chronic conditions. Almost five percent of the population (12 million) is unable to live independently, and most of them are dependent on caregivers for additional help (1). It is projected that by the year 2030, more than 40 percent of all Americans will have a chronic condition, with 10 percent limited in their ability to got to school or work, or to live independently. The U.S. is currently spending $470 billion (in 1990 dollars) annually on the direct costs of medical services for persons with chronic conditions, including nursing homes and other institutional care. "The U.S. does not have a coherent approach to caring for people with disabling chronic conditions. As a result, increasing numbers of people live with deteriorated health; others find that the services they require do exist but are not accessible. Individuals suffer, and society at large pays a toll in lost productivity and avoidable health care expenditures"(1).
Research has shown that the previously assumed "natural decline associated with aging" is not inevitable; increased activity and other health-promoting behaviors may prevent and even reverse these effects (2). Inactivity may result from individual choices in lifestyles as much as from an underlying impairment. Prevailing clinical practice presumes the inevitable decline of these individuals. Recognized in Healthy People 2000 (3) as a special population at higher risk for problems as they age, the veteran with disabilities faces issues of aging earlier than the person without disabilities. It is time to discard the prejudices of ageism and disabilities (4).
It is essential to "distinguish between the true effects of aging and those processes, including disease, that also may appear or become more pronounced with time but are biologically irrelevant to the underlying mechanisms of human aging"(2). "Although the incidence of disease increases with age, aging and disease are not synonymous. Aging is a normal concomitant of the passage of time that takes place in everyone; disease occurs in only part of the population"(2). Data from the Baltimore Longitudinal Study of Aging (BLSA) led to the conclusion that there is no one uniform age course for all variables. "Analysis of BLSA longitudinal data indicates that a precipitous drop in any physiological or behavioral function is likely to be a manifestation of a pathological condition. A corollary is the hypothesis that, in variables that remain essentially stable over the adult life span, any significant change may be a manifestation of pathology" (2).
The fact that chronic debilitating conditions may be in part preventable, demands that rehabilitation specialists, and particularly rehabilitation researchers, focus their efforts on the restoration, maintenance, and promotion of a healthy lifestyle. Key elements may well be the efforts to maintain an active and involved life, particularly the promotion of exercise and good nutrition and elimination of harmful behaviors. However, individuals with disabilities, just as the rest of the population, do not always act in their own best interests; particularly when it involves a commitment of time and energy. Thus, in attempting to assist these individuals, it is essential to consider not just the physical well being, but all dimensions of the individual, as suggested by Covey (5) and others (6). In a medical context, emphasis may be placed primarily on physical needs, which take precedence, as suggested by Maslow's hierarchy of needs (7). However, other dimensions are often equally or more important, such as in cognitive dysfunction in the elderly. A holistic view of the individual demands consideration of social and spiritual dimensions as well, all of which can contribute to the healthy elder with a disability. Although less directly influenced by interventions of the rehabilitation practitioner, these dimensions are no less important to the individual and to maintenance of the desired healthy lifestyle.
The future of elderly persons with disabilities in the U.S. can be brightened. We do not have to accept functional decline and illness as a given for this population. To lessen the detrimental impact of conditions associated with disabilities, however, practices that restore and promote healthy and active lifestyles must be advanced through research, clinical care, and education. Notwithstanding the importance of care targeted to the primary injuries causing disabilities, our charge to comprehensively care for persons requiring rehabilitation services requires that we also emphasize the health practices contributing to treatment successes.
Arthur M. Sherwood, PE,PhD
This guest editorial is an invited opinion.
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