July 14, 2013

The One-Hoss Shay

Oliver Sacks turned 80 last week. The noted neurologist and raconteur wrote an inspiring piece in the NY Times in honor of the occasion, in which he says he looks forward to being an octogenarian. He recognizes that he has a fresh perspective by virtue of his experience—he is what used to be called a “wise old man,” before such a phrase became politically incorrect. His hope is to have a few more years doing what he says matters most, loving and working, and then to die “in harness,” or “fully engaged” with life. In other words, he is hoping to be like the remarkable buggy that was constructed so well that it didn’t fall apart for 100 years, immortalized by Oliver Wendell Holmes (who like Sacks was a physician and a writer) in 1900:

      Have you heard of the wonderful one-hoss shay,
      That was built in such a logical way
      It ran a hundred years to a day,
      And then all of a sudden it—ah, but stay,
      I’ll tell you what happened without delay…

And many verses and decades later:

      There are traces of age in the one-hoss shay,
      A general flavor of mild decay,
      But nothing local, as one may say.

But then, after 100 years:

      What do you think the parson found,
      When he got up and stared around?
      The poor old chaise in a heap or mound,
      As if it had been to the mill and ground!
      You see, of course, if you’re not a dunce,
      How it went to pieces all at once,
      All at once, and nothing first,
      Just as bubbles do when they burst.

Of course, when the buggy fell apart, it did so in entirety—taking the deacon who was riding it down as well. Given no warning that the buggy was about to collapse, the deacon could not protect himself. But for people, living long and well and to the fullest, and then dying all at once, as Oliver Sacks hopes his fate will be, seems like the best alternative. The question is, how often does that wish come true?

Over 30 years ago, James Fries predicted that we would see the “compression of morbidity,” or a progressive shortening of the time between the development of age-related disability and death. In a recent review, Fries offered evidence that this is exactly what has happened, with modest increases in life expectancy between 1982 and the present along with a significant decline in rates of disability. Others disagree, arguing that people are living longer than they used to and are spending those added years frail and debilitated. 

The crucial issue is what we can anticipate today when we reach 80, not whether or by how much matters have improved. And the current reality, according to Medicare data, is that 54% of people over 85 have at least 4 chronic diseases and 25% have more than 6. Not only do the oldest individuals have many diseases, but these illnesses translate into problems walking and dressing and bathing: 56% of people over 80 report a severe disability. 

Chronic illness and disability are thus the norm for octogenarians, at least by the time they reach 85. Remaining vigorous and then dying quickly is simply not the reality for many older individuals. This does not mean that they cannot live life to the fullest, but it does mean that for the majority of octogenarians to stay engaged with life, we need to find ways to enable them to derive meaning from their existence. We have to take steps to assure that they can maintain and nourish relationships with others, whether by enhancing transportation to enable them to overcome difficulties with mobility or by teaching computer skills to allow them to communicate remotely. We have to facilitate their desire to contribute to society, whether through part time, flexible employment opportunities or by creating oral history projects in which they can participate. 

Designing medical interventions that allow us to remain robust into old age and then die of sudden death may be as flawed a quest as creating Holmes's perfect buggy. It may be as replete with unintended consequences as striving for immortality (more about the perils of aiming for immortality in a later post). Our challenge as a society is to find ways to support older people in their quest for meaning--even if they are not built like the one-hoss shay. 


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