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The road that can have a nursing home as its final stop begins with chronic disease, those illnesses of aging that begin insidiously, get progressively worse, and strike more and more of us as the years advance.

Most older people have at least one chronic illness. However, the medical diagnosis is not the only thing that counts. What is especially important is whether a person’s illness causes disability. Chronic diseases set us on the path to a nursing home only when they become severe enough to limit how we function – when they make it difficult to live independently. Although four out of every five people over sixty-five have at least one chronic condition, only about one in five is disabled by illness in even a minor way – an estimated 5.2 million people as of 1985. A much smaller number, 4 percent of women and 3 percent of men, are severely impaired – housebound or confined to bed by chronic disease.

Decade by decade an increasing proportion of people fall prey to severe disabilities. However, it is only by our mid-eighties that we run a real risk of being extremely incapacitated by chronic disease. And there is an interesting sex difference: older women are more at risk than older men. The reason is that men are more likely to suffer from chronic diseases that end in death (such as coronary heart disease); while women are more prone to develop conditions that do not kill but can limit independent living for years (such as osteoporosis).

How important is the distinction between disease and disability to health in the elderly? According to a 1984 report, very important. Among a group of frail older people, researchers found that their subjects’ ability to function – manual dexterity, grip strength, walking skill – predicted the chance of imminent nursing-home placement more accurately than traditional medical tests such as assessments of illness based on a physical examination. This study underlines the need to go beyond the standard illness-oriented approach in measuring health in older people. In addition to diagnosing “arthritis” or “heart disease” in an eighty-year-old, another important question should be: How does that diagnosis affect the person’s ability to negotiate life?

And understanding health in older people requires another mental shift – from worrying only about life-threatening chronic illnesses (cancer, heart disease, stroke), to viewing diseases that people do not die from as very important too. Though they lack the drama of being potentially fatal, osteoporosis, hearing and vision problems, and arthritis markedly affect the quality of life in our later years. For instance, of the top four disabling chronic diseases in the elderly heart disease, hypertensive disease, hearing deficits, and arthritis – only the first two pose any threat to life.

So, disability is the real old-age enemy, a foe that, while inextricably tied to chronic disease, is not the same thing as “illness” itself. Fighting disability requires a new approach. Doctors have to diagnose and treat “infirmity” as well as the underlying illness, they must widen their focus from life-threatening illnesses to diseases that do not kill but may be just as likely to take us down the path to a nursing home. How well is the medical profession doing at adopting this new approach?

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GENERAL HEALTH