[Dependency: possible risk or inevitable outcome?].

Abstract

This is the burning issue of the hour. In attempting to resolve it within the context of advanced age, it is important to clarify the meaning of the words involved: Independence and autonomy are far from being synonyms. Independence refers to the ability to perform physical activities of daily living (bathing, eating, preparing meals, shopping, money management), whereas the second word, autonomy, refers more to the ability to make decisions, to reason, to express an appropriate opinion in a given situation. Hazard and inevitability are totally at variance. Hazard implies the likelihood of occurrence of an event harmful to health, or to the length or quality of life. Hazard is more or less predictable, whereas inevitability is the expression of a supernatural power controlling all events. To find out whether "dependency is a hazard or an inevitability", it is necessary to conduct a historical review of the extension in human longevity and in particular of the current "weight" of aging both on individuals and on society at large. In Geneva, the proportion of the over 65-year-olds grew from 5.1 percent in 1880 to 13.4 percent in 1990. During that time, the gain in life expectancy was 52.4 percent for Geneva males of 80 years of age and 93 percent for Geneva females of the same age. This drastic change in age groups was coupled with a noteworthy change in household sizes. In 1860, the number of persons per household was 4.5. In 1990, it was down to 2.2. Conversely, the number of inmates in Geneva's medico-social institutions went up from 649 to 1168 between 1982 and 1992. In this socio-economic and cultural perspective, the concept of "globality of the individual" throughout his lifetime explains: age-related physiological changes; the long-term repercussion of physical, professional or leisure activities; the consequences of the accumulation of such varied risk factors as overweight or its opposite, malnutrition, tobacco or stress. Such frailty caused by aging is an ideal breeding ground for disease. For now, what matters most is the functional consequence of disease. Is the disease acute or chronic? Two out of three deaths result from a chronic disease, which caused loss of function by organs (impairment), loss of function by the subject himself (disability) or loss of function by the individual in society (social handicap or disadvantage). Raising the question "Dependency: a hazard or an inevitability?" boils down to asking oneself about the place of disease in our society and its determinants, and about all aspects of medicine and especially of prevention. When detected, a susceptibility brings into play primary prevention, aimed at averting the onset of the disease. After a disease has set in, measures to prevent recurrence, or secondary prevention, are required. Lastly, prevention of dependency and of loss of autonomy is part of tertiary prevention. Except for violent traumatic accidents, the formulation of the above concepts proves that dependency is essentially "a hazard". Therefore, let us anticipate!