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The fourth age, frailty and transitions

Alisoun Milne

in Mental Health in Later Life: Taking a Life Course Approach

One of the implications of an ageing population is the growing number of people aged 85 years and over. This cohort is increasingly described as belonging to the fourth age: a life stage that ... More

One of the implications of an ageing population is the growing number of people aged 85 years and over. This cohort is increasingly described as belonging to the fourth age: a life stage that ‘demarcates experiences that occur at the intersection of advanced age and impairment’. The fourth age intersects with frailty: a biomedical status characterised by multiple impairment, decline and dependency.26 per cent of those aged 85 years and over are considered to be frail. The losses and challenges that accompany the fourth age, including becoming frail, can be conceptualised as transitions. Physical, psychological and experiential transitions tend to multiply in the fourth age and to co-occur. The fourth age, frailty and transitions intersect in a complex and mutually reinforcing way posing a profound challenge to mental health and psychological wellbeing. Autonomy, agency, dignity, independence, identity, choice and control are all threatened. Older people’s accounts draw attention to a need to accommodate both change and continuity and to preserving selfhood. A discourse dominated by a focus on ill health and frailty tends to obscure the influence of the lifecourse, including inequalities, on health outcomes. A policy and practice focus on ‘managing frailty’ is a key example.Less

Death and dying in older people

Caroline Nicholson and Jo Hockley

in Death, Dying, and Social Differences

This chapter first considers the challenges of end of life care in late old age. It then introduces the concept of ‘frailty’ in older people and the importance of acknowledging dying in old age as a ... More

This chapter first considers the challenges of end of life care in late old age. It then introduces the concept of ‘frailty’ in older people and the importance of acknowledging dying in old age as a more natural event than dying from cancer or other diseases earlier in the life course. It explores the concept of ‘natural dying’ in the Fourth Age as both an opportunity and a challenge: an opportunity to maximize and learn from the capacity of those living and dying in late old age; a challenge to the current professionalization of death and dying within the developed world, where the focus is on medicalized and ‘abnormal’ death in the very frail older people. Finally, the chapter looks at care homes as a place where older people live and die. It sets out the important role care homes now have in framing end of life care, the demands that beset them, and the aspiration that care homes could be significant in challenging society's taboo of death.Less

Empirical Evidence of Frailty

Darrell Duffie

in Measuring Corporate Default Risk

This chapter provides strong evidence of missing common or correlated default risk factors, some of which may not even have been contemporaneously available. Based on this idea, it provides estimates ... More

This chapter provides strong evidence of missing common or correlated default risk factors, some of which may not even have been contemporaneously available. Based on this idea, it provides estimates of a frailty-based model of joint default arrivals, in which default correlation can arise from variables that might have been available to the econometrician but were not included in the model, and also from additional unobservable sources of correlation. The results show substantial dependence of default intensities on common unobservable (or at least un-included) factors whose effects are condensed for modeling purposes into a single multiplicative dynamic factor, parameterized as an Ornstein–Uhlenbeck frailty process. The estimated parameters governing the mean reversion and volatility of this frailty process, as well as the posterior (filtered) probability distribution of the frailty process, indicate substantial persistence and time variation in hidden common default risk.Less

Non-cancer patients as an under-served group

Julia Addington-Hall and Katherine Hunt

in A Public Health Perspective on End of Life Care

This chapter argues that end-of-life and palliative care for those with non-malignant conditions is an area that requires innovation and future planning. With the demographic shift towards a more ... More

This chapter argues that end-of-life and palliative care for those with non-malignant conditions is an area that requires innovation and future planning. With the demographic shift towards a more aged population and the forecasted increases in long-term conditions, the numbers of people following frailty and dementia illness trajectories is growing rapidly. However, one of the hardest tasks in the management of chronic disease is to understand the transition from actively seeking remission of disease to positively accepting approaching death. Until there are considerable advancements in prognostication in other conditions, it will remain a public health challenge to be able to justify end-of-life care for individual non-cancer patients.Less

End-stage renal disease in the older person

Lina Johansoon and Edwina A Brown

in Supportive Care for the Renal Patient

This chapter discusses old people who have ESRD. It defines the term ‘old’ as a person who has lived a long time and is no longer young. The chapter states that before the 1970s, dialysis treatment ... More

This chapter discusses old people who have ESRD. It defines the term ‘old’ as a person who has lived a long time and is no longer young. The chapter states that before the 1970s, dialysis treatment was only available to patients who were no older than fifty, but due to the increase in the number of older people who needed dialysis, this treatment was soon made available to those people as well. It discusses a number of factors, such as nutrition, frailty, depression, and cognitive function.Less

Objectives and Scope

Darrell Duffie

in Measuring Corporate Default Risk

This chapter summarizes the scope and objectives of the book, and provides an historical background on the development of the related research corporate default risk literature.

Frailty‐Induced Correlation *

Darrell Duffie

in Measuring Corporate Default Risk

This chapter presents the foundations for frailty modeling of correlated default in a setting of stochastic intensities. The approach is to assume that default times are jointly doubly stochastic ... More

This chapter presents the foundations for frailty modeling of correlated default in a setting of stochastic intensities. The approach is to assume that default times are jointly doubly stochastic given extra information unavailable to the econometrician. This “hidden” information includes covariates that, although not directly observable, have conditional probability distributions that can be filtered from histories of default times and observable covariates. The dependence of default timing on unobservable covariates allows for sources of default correlation beyond those present in the observed covariates. The methodology relies on Markov Chain Monte Carlo (MCMC) techniques, provided in appendices, for evaluating likelihood functions and for filtering or smoothing hidden (frailty) state information.Less

A life course approach to biomarkers of ageing

Carmen Martin-Ruiz and Thomas von Zglinicki

in A Life Course Approach to Healthy Ageing

The challenge of devising a set of biomarkers capable of measuring the ageing rate in humans was articulated long ago. Despite major concerted efforts, progress so far has been limited. In recent ... More

The challenge of devising a set of biomarkers capable of measuring the ageing rate in humans was articulated long ago. Despite major concerted efforts, progress so far has been limited. In recent years, developments in the basic biology of ageing reveal the possibility of pharmacological or gene therapeutic extension of healthy lifespan in mammals, as well as the increasing importance of frailty as a clinically relevant syndrome. This approach enhances the need for sensitive and specific biomarkers of ageing that are validated in both experimental animals and, importantly, in humans over the whole age range. This chapter discusses challenges in biomarker validation over the human life course, and compares the validity of cellular and physiological measures.Less

Advance care planning for an ageing population

Martin J. Vernon

in Advance Care Planning in End of Life Care

Population ageing is driven by declining fertility and improved life expectancy. As people survive to later life with multiple long-term conditions, advance care planning ACP) is of increasing ... More

Population ageing is driven by declining fertility and improved life expectancy. As people survive to later life with multiple long-term conditions, advance care planning ACP) is of increasing importance to those wishing to retain control over their end-of-life care. Understanding disability trajectories for people can assist with advance care planning, mindful that older people living with frailty have increased risk of acute and unexpected health decline. Routine frailty identification by severity in older people can prompt care planning in anticipation of health decline and imminent lost capacity to make important decisions. Recognizing potential professional and organizational barriers to advance carer planning for older people could also improve its uptake. Guided serious illness conversations could assist this process over time for older people and those important to them. In care homes and among people with dementia ACP is also likely to be beneficial.Less

A great age

Bill Bytheway

in Unmasking age: The significance of age for social research

Often, the concept of being ‘very old’ is always linked to ‘frailty’. This association raises the issue of what constitutes the latter. All too often, the oldest generation are being looked after in ... More

Often, the concept of being ‘very old’ is always linked to ‘frailty’. This association raises the issue of what constitutes the latter. All too often, the oldest generation are being looked after in the security of care homes: out of sight and out of mind. In this chapter, two detailed case studies of people living to a great age are presented. The first case study is based on the published diaries and biography of the celebrated writer, Frances Partridge. It is then followed by a case study drawn from the TOG project, and a diary detailing the twelve months leading up to a 100th birthday.Less

Good Theories, Lucky Hunches

J.D. Trout

in Wondrous Truths: The Improbable Triumph of Modern Science

Some true explanations are too complicated for humans to cultivate understanding. This statement may seem unforgiving of human frailty and normal limitation, but it certainly isn’t unfamiliar. We ... More

Some true explanations are too complicated for humans to cultivate understanding. This statement may seem unforgiving of human frailty and normal limitation, but it certainly isn’t unfamiliar. We think nothing of making the same claim about “lesser” species. Bees can’t appreciate the true explanation for their nectar-locating abilities. Spiders can’t explain the strength of their own silk, and they can’t understand the true explanation even if you took the time to explain it. The limitations are utterly analogous in the case of humans. Only the most extreme species exceptionalist would invite someone to conclude that humans are without such limitations. A good explanation is an accurate one, whether there is ever a moment when we understand it. But by following its causal deliverances, we may push science along the right track, even without a sense of understanding.Less

Korea at the End of the Eighteenth Century

Don Baker and Franklin Rausch

in Catholics and Anti-Catholicism in Choson Korea

This chapter explains the traditional philosophical and religious tradition of Korea in order to elucidate what a radical challenge Christianity posed when it entered Korea at the end of the 18th ... More

This chapter explains the traditional philosophical and religious tradition of Korea in order to elucidate what a radical challenge Christianity posed when it entered Korea at the end of the 18th century. It also discusses the traditional social structure and legal system of Chosŏn Korea as well as the factionalism that was characteristic of its politics.Less

Towards an ‘active caring community’ in Brussels

An-Sofie Smetcoren, Liesbeth De Donder, Daan Duppen, Nico De Witte, Olivia Vanmechelen, and Dominique Verté

in Age-Friendly Cities and Communities: A Global Perspective

Chapter 6 addresses the question of how an age-friendly urban environment can support frail older people to ‘age in place’. To address this issue, the chapter presents findings from a study which ... More

Chapter 6 addresses the question of how an age-friendly urban environment can support frail older people to ‘age in place’. To address this issue, the chapter presents findings from a study which assessed the value of an ‘Active Caring Community’ project in supporting frail older adults living in disadvantaged neighbourhoods in Brussels, Belgium. The project was aimed at creating a community which supports the process of ageing in place; where residents of the community know and help each other; where meeting opportunities are developed; and where individuals and their informal caregivers receive care and support from motivated professionals. The authors highlight the importance of the social dimension of the environment, and discuss a range of related opportunities and constraints which may affect older people’s frailty.Less

Frailty

Paul Higgs and Chris Gilleard

in Personhood, Identity and Care in Advanced Old Age

Frailty or infirmity is seen as a central element in the construction of the social imaginary of the fourth age. While the term is widely employed as a bio-medical condition that is capable of being ... More

Frailty or infirmity is seen as a central element in the construction of the social imaginary of the fourth age. While the term is widely employed as a bio-medical condition that is capable of being defined and measured, this chapter argues that frailty serves as a marker – a signifier – of an almost intangible loss of capabilities, autonomy and status. The frail older person is represented as the older person who is at risk. While much research has been conducted to define that risk, little has emerged that demonstrates how such risks can be reliably reduced or eliminated. Whatever else frailty means, it serves to define the frail (or ‘frailed’) older person as ontologically at risk and thereby the object of other’s discourse – in short the inescapable subject of third person accounts.Less

Dementia, multimorbidity, and frailty

Karen Harrison Dening

in Psychosocial Issues in Palliative Care: A community based approach for life limiting illness

Increasing age is the strongest risk factor for developing dementia, frailty, and other co-morbid conditions. Dementia is not a disease in itself but a syndrome; a collection of symptoms: such as a ... More

Increasing age is the strongest risk factor for developing dementia, frailty, and other co-morbid conditions. Dementia is not a disease in itself but a syndrome; a collection of symptoms: such as a decline in memory, reasoning, and communication skills, and a gradual loss of skills needed to carry out daily living activities. Whereas frailty is a distinctive health state in which multiple body systems gradually lose their in-built reserves. However, often ‘layered’ on these two may also be several other conditions that coexist within an individual. There is a growing body of evidence to support the psychosocial care for people with dementia as the disease advances but little of the effect and outcomes where there is a combination of these conditions. This chapter explores some of the issues for families affected by these conditions and the care and support that may be of benefit through case management.Less

Model Risk, Mortality Heterogeneity, and Implications for Solvency and Tail Risk

Michael Sherris and Qiming Zhou

in Recreating Sustainable Retirement: Resilience, Solvency, and Tail Risk

Mortality models used to assess longevity risk and retirement funding have been extended to stochastic models with trends and systematic risk. Systematic risk cannot be readily diversified in an ... More

Mortality models used to assess longevity risk and retirement funding have been extended to stochastic models with trends and systematic risk. Systematic risk cannot be readily diversified in an insurance pool or pension fund. It is an important factor in assessing solvency and highlighting the tail risk in longevity insurance and pension products. Idiosyncratic risk can be diversified in typical pool sizes, although less effectively at older ages. Mortality heterogeneity is not usually taken into account in stochastic mortality models, though it reduces the effectiveness of idiosyncratic mortality risk pooling. Heterogeneity has been modeled with frailty models and more recently with Markov multiple-state ageing models. This chapter provides an overview of recent developments in models for mortality heterogeneity, using a model calibrated to both population mortality and health condition data to consider the impact of model risk and heterogeneity in assessing solvency and tail risk for longevity risk products.Less

Health and Financial Sustainability in Ageing Japan

Hideki Hashimoto

in Health in Japan: Social Epidemiology of Japan since the 1964 Tokyo Olympics

As a front runner of population ageing, Japan faces a future that the human species has never experienced. While we rejoice in longevity, it can bring financial and social challenges resulting from ... More

As a front runner of population ageing, Japan faces a future that the human species has never experienced. While we rejoice in longevity, it can bring financial and social challenges resulting from loss of independence. Frailty and dementia are important in this context. To meet those challenges, the Japanese government has been making efforts to reform public medical and social care systems, and to develop a trans-sectoral social policy programme for dementia. Culturally, the Japanese value seniority and family traditions of caregiving. Drastic demographic change, and the subsequent decrease in household capacity for informal caregiving, requires cultural and normative reform in society. An ongoing dialogue between social determinants of health and policy responses in Japan can provide valuable lessons for other countries with a growing ageing population, including the UK.Less