Treating the Growing Population of Centenarians
For about the past year, Priya Goel, MD, can be seen cruising around the island of Manhattan as she makes her way between visits to some of New York City’s most treasured residents: a small but essential group of patients born before the Empire State Building scraped the sky and the old Yankee Stadium had become the House That Ruth Built.
Goel, a family physician, works for Heal, a national home healthcare company that primarily serves people older than 65. Her practice has 10 patients older than 100 ― the oldest is a 108-year-old man ― whom she visits monthly.
The Gray Wave
Goel’s charges are among America’s latest baby boom ― babies born a century ago, that is.
Between 1980 and 2019, the share of American centenarians, those aged 100 and up, grewfaster than the total population. In 2019, 100,322 persons in the United States were at least 100 years old ― more than triple the 1980 figure of 32,194, according to the US Administration on Aging. By 2060, experts predict, the US centenarian population will reach nearly 600,000.
Although some of the ultra-aged live in nursing homes, many continue to live independently. They require both routine and acute medical care. So, what does it take to be a physician for a centenarian?
Goel, who is in her mid-30s and could well be the great-granddaughter of some of her patients ― urged her colleagues not to stereotype patients on the basis of age.
“You have to consider their functional and cognitive abilities, their ability to understand disease processes and make decisions for themselves,” Goel said. “Age is just one factor in the grand scheme of things.”
Visiting patients in their homes provides her with insights into how well they’re doing, including the safety of their environments and the depth of their social networks.
New York City has its peculiar demands.Heal provides Goel with a driver who chauffeurs her to her patient visits. She takes notes between stops.
“The idea is to have these patients remain in an environment where they’re comfortable, in surroundings where they’ve grown up or lived for many years,” she said. “A lot of them are in elevator buildings and they are wheelchair-bound or bed-bound and they physically can’t leave.”
She said she gets a far different view of the patient than does an office-based physician.
“When you go into their home, it’s very personal. You’re seeing what their daily environment is like, what their diet is like. You can see their food on the counter. You can see the level of hygiene,” Goel said. “You get to see their social support. Are their kids involved? Are they hoarding? Stuff that they wouldn’t just necessarily disclose but on a visit you get to see going into the home. It’s an extra layer of understanding that patient.”
Goel contrasted home care from care in a nursing home, where the patients are seen daily. On the basis of her observations, she decides whether to see her patients every month or every 3 months.
She applies this strategy to everyone from age 60 to over 100.
Tracking a Growing Group
Since 1995, geriatrician Thomas Perls, MD, has directed the New England Centenarian Study at Boston University. The study, largely funded by the National Institute on Aging, has enrolled 2599 centenarian persons and 700 of their offspring. At any given time in the study, about 10% of the centenarians are alive. The study has a high mortality rate.
Dr Thomas Perls
The people in Perls’ study range in age, but they top out at 119, the third oldest person ever in the world. Most centenarians are women.
“When we first began the study in 1995, the prevalence of centenarians in the United States was about 1 per 10,000 in the population,” Perls told Medscape Medical News. “And now, that prevalence has doubled to 1 per 5000.”
Even if no one has achieved the record of Methuselah, the Biblical patriarch who was purported to have lived to the age of 969, some people always have lived into their 90s and beyond. Perls attributed the increase in longevity to control at the turn of the 20th century of typhoid fever, diphtheria, and other infectious diseases with effective public health measures, including the availability of clean water and improvement in socioeconomic conditions.
“Infant mortality just plummeted. So, come around 1915, 1920, we were no longer losing a quarter of our population to these diseases. That meant a quarter more of the population could age into adulthood and middle age,” he said. “A certain component of that group was, therefore, able to continue to age to a very, very old age.”
Other advances, such as antibiotics and vaccinations in the 1960s;the availability in the 1970s of much better detection and effective treatment of high blood pressure; the recognition of the harms of smoking; and much more effective treatment of cardiovascular disease and cancer have allowed many people who would have otherwise died in their 70s and 80s to live much longer. “I think what this means is that there is a substantial proportion of the population that has the biology to get to 100,” Perls said.
Perls said the Latino population and Blacks have a better track record than Whites in reaching the 100-year milestone. “The average life expectancy might be lower in these populations because of socioeconomic factors, but if they are able to get to around their early 80s, compared to Whites,their ability to get to 100 is actually better,” he said.
Asians fare best when it comes to longevity. While around 1% of White women in the United States live to 100, 10% of Asian women in Hong Kong hit that mark.
“I think some of that is better environment and health habits in Hong Kong than in the United States,” Perls said. “I think another piece may be a genetic advantage in East Asians. We’re looking into that.”
Perls said he agreed with Goel that healthcare providers and the lay public should not make assumptions on the basis of age alone as to how a person is doing. “People can age so very differently from one another,” he said.
Up to about age 90, the vast majority of those differences are determined by our health behaviors, such as smoking, alcohol use, exercise, sleep, the effect of our diets on weight, and access to good healthcare, including regular screening for problems such as high blood pressure, diabetes, and cancer. “People who are able to do everything right generally add healthy years to their lives, while those who do not have shorter life expectancies and longer periods of chronic diseases,” Perls said.
Paying diligent attention to these behaviors over the long run can have a huge payoff.
Perls’ team has found that to live beyond age 90 and on into the early 100s, protective genes can play a strong role. These genes help slow aging and decrease one’s risk for aging-related diseases. Centenarians usually have a history of aging very slowly and greatly delaying aging-related diseases and disability toward the ends of their lives.
Centenarians are the antithesis of the misguided belief that the older you get, the sicker you get. Quite the opposite occurs. For Perls, “the older you get, the healthier you’ve been.”
MD Bias Against the Elderly?
Care of elderly patients is becoming essential in the practice of primary care physicians ― but not all of them enjoy the work.
To be effective, physicians who treat centenarians must get a better idea of the individual patient’s functional status and comorbidities. “You absolutely cannot make assumptions on age alone,” Perls said.
Dr Natalie Baker
The so-called “normal” temperature, 98.6° F, can spell trouble for centenarians and other very old patients, warned Natalie Baker, DNP, CRNP, an associate professor of nursing at the University of Alabama, Birmingham, and president of the 3000-member Gerontological Advanced Practice Nurses Association.
“We have to be very cognizant of what we call a typical presentation of disease or illness and that a very subtle change in an older adult can signal a serious infection or illness,” Baker said. “If your patient has a high fever, that is a potential problem.”
The average temperature of an older adult is lower than the accepted 98.6° F, and their body’s response to an infection is slow to exhibit an increase in temperature, Baker said. “When treating centenarians, clinicians must be cognizant of other subtle signs of infection, such as decreased appetite or change in mentation,” she cautioned.
A decline in appetite or insomnia may be a subtle sign that these patients need to be evaluated, she added.
COVID-19 and Centenarians
Three quarters of the one million US deaths from COVID-19 occurred in people aged 65 and older. However, Perls said centenarians may be a special subpopulation when it comes to COVID.
The Japanese Health Ministry, which follows the large centenarian population in that country, noted a marked jump in the number of centenarians during the pandemic ― although the reasons for the increase aren’t clear.
Centenarians may be a bit different. Perls said some evidence suggests that the over-100 crowd may have better immune systems than younger people. “Part of the trick of getting to 100 is having a pretty good immune system,” he said.
Don’t Mess With Success
“There is no need at that point for us to try to alter their diet to what we think it might be,” Baker said. “There’s no need to start with diabetic education. They may tell you their secret is a shot of vodka every day. Why should we stop it at that age? Accept their lifestyles, because they’ve done something right to get to that age.”
Opinions differ on how to approach screening for centenarians.
Goel said guidelines for routine screening, such as colonoscopies, mammograms, and PAP smears, drop off for patients starting at 75. Perls said this strategy stems from the belief that people will die from other things first, so screening is no longer needed. Perls said he disagrees with this approach.
“Again, we can’t base our screening and healthcare decisions on age alone. If I have an independently functioning and robust 95-year-old man in my office, you can be sure I am going to continue recommending regular screening for colon cancer and other screenings that are normal for people who are 30 years younger,” he said.
Justin Zaghi, MD, chief medical officer at Heal, said screening patients in their late 90s and 100s for cancer generally doesn’t make sense except in some rare circumstances in which the cancer would be unlikely to be a cause of death. “However, if we are talking about screening for fall risks, hearing difficulties, poor vision, pain, and malnutrition, those screenings still absolutely make sense for patients in their late 90s and 100s,” Zaghi said.
One high-functioning 104-year-old patient of Perls underwent a total hip replacement for a hip fractureand is faring well. “Obviously, if she had end-stage dementia, we’d do everything to keep the person comfortable, or if they had medical problems that made surgery too high risk, then you don’t do it,” he said. “But if they’re otherwise, I would proceed.”
Avoid the ED
Goel said doctors should avoid sending patients to the emergency department, an often chaotic place that is especially unfriendly to centenarians and the very old.”Sometimes I’ve seen older patients who are being rushed to the ER, and I ask, What are the goals of care?,” she said.
Clinicians caring for seniors should keep in mind that infections can cause seniors to appear confused ― and this may lead the clinician to think the patient has dementia. Or, Goel said, a patient with dementia may suddenly experience much worse dementia.
“In either case, you want to make sure you’re not dealing with any underlying infection, like urinary tract infection, or pneumonia brewing, or skin infections,” she said. “Their skin is so much frailer. You want to make sure there are no bedsores.”
She has had patients whose children report that their usually placid centenarian parents are suddenly acting out. “We’ll do a urinary test and it definitely shows a urinary tract infection. You want to make sure you’re not missing out on something else before you attribute it to dementia,” she said.
Environmental changes, such as moving a patient to a new room in a hospital setting, can trigger an acute mental status change, such as delirium, she added. Helping older patients feel in control as much as possible is important.
“You want to make sure you’re orienting them to the time of day. Make sure they get up at the same time, go to bed at the same time, have clocks and calendars present ― just making sure that they feel like they’re still in control of their body and their day,” she said.
Physicians should be aware of potential depression in these patients, whose experience of loss ― an unavoidable consequence of outliving family and friends ― can result in problems with sleep and diet, as well as a sense of social isolation.
Dr Neal Flomenbaum
Neal Flomenbaum, MD, professor ad emergency physician-in-chief emeritus, New York–Presbyterian/Weill Cornell Medical Center in New York City, said sometimes the best thing for these very elderly patients is to “get them in and out of ED as quickly as possible, and do what you can diagnostically.”
He noted that EDs have been making accommodations to serve the elderly, such as using LEDs that replicate outdoor lighting conditions, as well as providing seniors with separate rooms with glass doors to protect them from noise, separate air handlers to prevent infections, and adequate space for visitors.
These patients often are subject to trauma from falls.
“The bones don’t heal as well as in younger people, and treating their comorbidities is essential. Once they have trouble with one area and they’re lying in bed and can’t move much, they can get bedsores,” Flomenbaum said. “In the hospital, they are vulnerable to infections. So, you’re thinking of all of these things at the same time and how to treat them appropriately and then get them out of the hospital as soon as possible with whatever care that they need in their own homes if at all possible.”
“I always err on the side of less is more,” Goel said. “Obviously, if there is something ― if they have a cough, they need an x-ray. That’s very basic. We want to take care of that. Give them the antibiotic if they need that. But rushing them in and out of the hospital doesn’t add to their quality of life.”
Flomenbaum, a pioneer in geriatric emergency medicine, says physicians need to be aware that centenarians and other very old patients don’t present the same way as younger adults.
He began to notice more than 20 years ago that every night, patients would turn up in his ED who were in their late 90s into their 100s. Some would come in with what their children identified as sudden-onset dementia ― they didn’t know their own names and couldn’t identify their kids. They didn’t know the time or day. Flomenbaum said the children often asked whether their parents should enter a nursing home.
“And I’d say, ‘Not so fast. Well, let’s take a look at this.’ You don’t develop that kind of dementia overnight. It usually takes a while,” he said.
He said he ordered complete blood cell counts and oxygen saturation tests that frequently turned out to be abnormal. They didn’t have a fever, and infiltrates initially weren’t seen on chest x-rays.
With rehydration and supplemental oxygen, his symptoms started to improve, and it became obvious that they were not symptoms of dementia but of pneumonia and that he required antibiotics, Flomenbaum said.
Too often, on the basis of age, doctors assume patients have dementia or other cognitive impairments.
“What a shock and a surprise when doctors actually talk to folks and do a neurocognitive screen and find they’re just fine,” Perls said.
The decline in hearing and vision can lead to a misdiagnosis of cognitive impairment because the patients are not able to hear what you’re asking them. “It’s really important that the person can hear you ― whether you use an amplifying device or they have hearing aids, that’s critical,” he said. “You just have to be a good doctor.”
Often the physical toll of aging exacerbates social difficulties. Poor hearing, for example, can accelerate cognitive impairment and cause people to interact less often, and less meaningfully, with their environment. For some, wearing hearing aids seems demeaning ― until they hear what they’ve been missing.
“I get them to wear their hearing aids and, lo and behold, they’re a whole new person because they’re now able to take in their environment and interact with others,” Perls said.
Flomenbaum said alcohol abuse and drug reactions can cause delirium, which, unlike dementia, is potentially reversible. Yet many physicians cannot reliably differentiate between dementia and delirium, he added.
The geriatric specialists talk about the lessons they’ve learned and the gratification they get from caring for centenarians.
“I have come to realize the importance of family, of having a close circle, whether that’s through friends or neighbors,” Goel said. “This work is very rewarding because, if it wasn’t for homebound organizations, how would these people get care or get access to care?”
For Baker, a joy of the job is hearing centenarians share their life stories.
“I love to hear their stories about how they’ve overcome adversity, living through the depression and living through different wars,” she said. “I love talking to veterans, and I think that oftentimes, we do not value our older adults in our society as we should. Sometimes they are dismissed because they move slowly or are hard to communicate with due to hearing deficits. But they are, I think, a very important part of our lives.”
Most centenarians readily offer the secrets to their longevity. Aline Jacobsohn, of Boca Raton, Florida, is no different.
Jacobsohn, who will be 101 in October, thinks a diet of small portions of fish, vegetables, and fruit, which she has followed since her husband Leo died in 1982, has helped keep her healthy. She eats lots of salmon and herring and is a fan of spinach sautéed with olive oil. “The only thing I don’t eat is meat,” the trim and active Jacobsohn said in a recent interview over Zoom.
Her other secret: “Doctors. I like to stay away from them as much as possible.”
Dr Shari Rosenbaum
Shari Rosenbaum, MD, Jacobsohn’s internist, doesn’t dismiss that approach. She uses a version of it when managing her three centenarian patients, the oldest of whom is 103.
“Let them smoke! Let them drink! They’re happy. It’s not causing harm. Let them eat cake! They’ve already won,” said Rosenbaum, who is affiliated with Boca Raton–based MDVIP, a national membership-based network of 1100 primary care physicians serving 368,000 patients. Of those, nearly 50 are centenarians.
“You’re not preventing those problems in this population,” she said. “They’re here to enjoy every moment that they have, and they might as well.”
Rosenbaum sees a divergence in her patients ― those who will reach very old age, and those who won’t ― starting in their 60s.
“The centenarians don’t have medical problems,” she said. “They don’t get cancer. They don’t get diabetes. Some of them take good care of themselves. Some don’t take such good care of themselves. But they are all optimists. They all see the glass half full. They all participate in life. They all have excellent support systems. They have good genes, a positive attitude toward life, and a strong social network.”
Jacobsohn ― whose surname at the time was Bakst ― grew up in Frankfurt am Main, Germany, during the rise of the Nazi regime. The family fled to Columbia in 1938, where she met and eventually married her husband, Leo, who ran a business importing clocks and watches in Cali.
In 1989, the Jacobsohns and their three children moved to South Florida to escape the dangers of kidnappings and ransoms posed by the drug cartels.
Jacobsohn agreed that she appears to have longevity genes – “good stock,” she calls it. “My mother died 23 days before she was 100. My grandmother lived till 99, almost 100,” she said.
Two years ago, she donated her car to a charity and stopped driving in the interest of her own safety and that of other drivers and pedestrians.
Jacobsohn has a strong support system. Two of her children live nearby and visit her nearly every day. A live-in companion helps her with the activities of daily life, including preparing meals.
Jacobsohn plays bridge regularly, and well. “I’m sorry to say that I’m a very good bridge player,” she said, frankly. “How is it possible that I’ve played bridge so well and then I don’t remember what I had for lunch yesterday?”
She reads, mainly a diet of history but occasionally novels, too. “They have to be engaging,” she said.
The loss of loved ones is an inevitable part of very old age. Her husband of 47 years died from emphysema, and one of her sons died in his 70s from prostate cancer.
She knows well the fate that awaits us all and accepts it philosophically.
“It’s a very normal thing that people die. You don’t live forever. So, whenever it comes, it’s okay. Enough is enough. Dayenu,” she said, using the Hebrew word for, “It would have been enough” ― a favorite in the Passover Seder celebrating the ancient Jews’ liberation from slavery in Egypt.
Jacobsohn sang the song and then took a reporter on a Zoom tour of her tidy home and her large flower garden featuring Cattleya orchids from Colombia.
Howard Wolinsky is a Chicago-based medical journalist. You can read more of his stories about prostate cancer at TheActiveSurveillor.com.
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