Ageing: understanding the loss of autonomy

The author is a geriatrician, epidemiologist and researcher at the Center hospitalier de l’Université de Montréal. He is also one of the co-founders and the medical expert of the company Eugeria, whose mission is to improve the daily lives of people with Alzheimer’s disease.

When we think of aging, especially in the last years of life, the idea of ​​loss of autonomy quickly comes to mind. Although there are as many ways to age as there are seniors, the prevalence of loss of autonomy increases with age. According to data from the last Canadian census, 28% of seniors aged 85 and over live in collective settings where care and services are offered. When we question the elderly, we find that it is not so much age in itself that worries them, but much more to find themselves in Autonomy loss and thus become a burden on their loved ones or society.

Small confession before going further: geriatricians abhor the term “loss of autonomy”! There are at least three reasons for this. First, it is too general an expression that often serves as a catch-all. Then, the loss of autonomy is, in itself, only the consequence of a problem or a situation; the cause or the origin must be found. And, finally, the term portrays autonomy as something to be lost and paints it black, rather than presenting it as an evolving condition. Let’s examine each of these reasons to see more clearly.

What is “loss of autonomy”?

Autonomy can be defined as the ability to be autonomous, that is to say not to depend on others. When you think of all the little things a person has to do in a day — even the first one, getting out of bed! —, we quickly realize that we can depend on others for many simple things, like eating, or more complex things, like taking care of our finances.

The general term loss of autonomy often masks the degree of loss and the activities specifically affected. However, no longer being able to dress is not equivalent to requiring assistance to complete one’s tax return.

When health professionals seek to detail the loss (or capacity) of autonomy, they use precise and standardized tools that assess what are called activities of daily living (ADL) and activities of household living. (AVD). ADLs include everything that is essential to « basic » autonomy: taking care of personal hygiene, dressing, eating, going to the toilet, transferring (from bed to chair, for example) and move into his home. DSAs are the more complex activities necessary to stay at home for more than a few days: housework and laundry, shopping, cooking, taking medication, managing finances, getting around (including driving a vehicle) and communicate.

Autonomy is more of a continuum than a single category. Rather than saying that a loved one or a patient has a loss of autonomy, it is preferable to establish exactly which facets of autonomy are problematic in order to better find the origin of the situation and better deal with it.

The important thing is to understand the causes

Recognizing which aspects of autonomy are impaired is only the first step in a broader diagnostic assessment to seek out the causes of the problem, which are frequently multiple and interrelated. The possible factors can be grouped into four main categories: a new acute medical illness or its exacerbation, a cognitive disorder (dementia), impairment of mobility or impairment of the affective domains and social support. The speed of appearance and progression of the loss of autonomy is often revealing. For example, a new cerebrovascular accident (CVA) or a fracture following a fall will quickly cause a deterioration of « autonomy », while the consequences of depression or Alzheimer’s disease will will settle over several months or several years.

The assessment for “loss of autonomy” usually involves an interdisciplinary team to review each category. The doctor will review the medical assignments; the physiotherapist will focus on the musculoskeletal system; the occupational therapist will detail the accomplishment of each ADL and DDA; the social worker will report on the mood and, most importantly, the support network around the person. Most of the time, each of these areas will help explain the decline in autonomy. With aging, there is rarely just one cause.

The following fictional case illustrates what can happen: an elderly person with mild cognitive impairment and osteoarthritis contracts an infection, such as pneumonia. However, her spouse, who died recently, supported her during her occasional forgetfulness and helped her move around. Each of the elements taken in isolation is already enough to cause a loss of autonomy, but it is almost always in combination that they manifest themselves and lead to a greater decline. Geriatrics is always a team effort!

Dealing with Loss of Autonomy

The final reason geriatricians dislike the term “loss of autonomy” is its defeatist connotation. If we must not see everything in pink and pretend that any loss of autonomy is avoidable or reversible, we must not see everything in black and imagine that loss of autonomy is equivalent to institutionalization in a CHSLD.

First, some causes of loss of autonomy are reversible. For example, you can recover from a stroke or a fracture. Second, while a decline in autonomy is permanent, the World Health Organization’s disability model offers a broader view. Rather than considering that autonomy (and the ability to carry out one’s activities) is individual, the model assumes that, in addition to arising from disease, limitations to activities and participation in society are also related to environmental and personal factors. In other words, even if a person’s intrinsic capacity is reduced, the concrete consequences of this reduction will vary according to the accompaniment and support put in place.

A good example is home care. A senior with Alzheimer’s disease that makes it difficult to take medication or prepare meals can be assisted and stay at home. Another experiencing mobility issues may benefit from physiotherapy or visits from a homemaker for morning and bedtime routines. With the aging of the population, the needs for support for autonomy will grow. In this regard, neither the loss of autonomy nor the CHSLDs should be the end of the story.

A word on prevention

A quick word on prevention to finish. We all know the gestures that are part of a healthy lifestyle: eating well, doing physical activity, not smoking and enriching our social contacts. But let’s remember that adopting them will not only delay the onset of cardiovascular and cognitive diseases. These actions will also reduce the onset and progression of the loss of autonomy. The ideal time to put them into practice is in middle age, before old age. As the saying goes, prevention is better than cure, and declining independence is no exception!