May 21, 2021

Tiptoeing Towards the End Zone

On January 12, 2006, I launched this blog, which I first called “Perspectives on Aging” and, a number of years later, reincarnated as “Life in the End Zone.” Initially, the frequency of my posts was erratic but then, a year and a half after the blog’s inception, NY Times columnist Paula Span gave “Perspectives” a boost, recommending it along with just one other blog on aging in her weekly column, “The New Old Age.”  She sent me an email at the time, telling me that my readers would expect predictability and that I was now obligated to post weekly and on a fixed schedule. 

For years, I faithfully followed Paula Span’s advice, but more recently have been writing only sporadically. Every few years I contemplated retiring the blog, but then I would get an email out of the blue from a reader who told me how useful she found a particular post. Two months before his death in 2019, the distinguished ethicist Dan Callahan, who I was privileged to call a friend, commented in his last email to me that he “particularly appreciated” my piece on “dignity and the insensitive nurses”—a post I wrote about an episode at an area nursing home in which nurses and nursing assistants were cruel and callous to a resident they disliked. How could I stop writing when I received this kind of feedback?

After I published the 400th post I thought surely this was a good time to stop. But then came the pandemic, which disproportionately affected older people. There was a great deal to say, so on March 2, 2020, I began writing more regularly. I wrote about the devastating Covid outbreaks in nursing homes; I wrote about the role of telemedicine; I wrote about vaccines. And then, gradually, as the pandemic began to recede, as vaccination rates in older people soared, and as Covid disappeared from nursing homes, I again found I had less to say. So, when I saw Jane Brody’s column in the NY Times this week, “A Birthday Milestone: Turning 80,” I was inspired.  I would write about my own birthday milestone—last week I turned 70.


What Jane Brody says, in a nutshell, is that “the secret of a happy, vibrant old age” is to “strive to do what you love for as long as you can do it.” But she says more about what it takes to live a long and fulfilling life.” First, exercise. Without regular exercise, she opines, “you can expect to experience a loss of muscle strength and endurance, coordination and balance, flexibility and mobility, bone strength and cardiovascular and respiratory function.”  Translated into geriatric lingo, what she is saying is that to preserve function, the ability to walk, to do errands, even to dress and bathe without help, regular exercise is important. Next in importance, she says, is “quality fuel,” or a good diet. Here Brody is vague, but stresses avoiding “ultra-processed foods” and eating plenty of fruit and vegetables.  Finally, there are “attitude, motivation, and perspective” about which she does not further elaborate.


What Brody is talking about is “successful aging.” For years I have wanted to write about successful aging, as it was called by Rowe and Kahn in their landmark 1987 work of the same title. The idea of successful aging has been the subject of both intense criticism and passionate enthusiasm. One problem is that we all want to lead a “good life,” but we may have very different ideas of what that looks like. Sometimes, what we think we need for a good life turns out not to be what we need at all: people who have a life-altering medical condition, whether Parkinson’s or osteoarthritis or chronic obstructive pulmonary disease may wish they hadn’t developed that disorder but find that they are nonetheless able to lead rich, enjoyable lives. 


Since Rowe and Kahn’s original work appeared, the gerontologic literature has discussed “active aging” (to avoid the invidious comparison between success and its opposite, presumably failure). It has talked about “productive aging,” “healthy aging,” “aging well,” or “a good old age.”  But these alternative formulations all stigmatize in much the same way as does “successful aging.” The opposite of active is inactive, of productive is unproductive; the opposite of healthy aging is sick aging and the opposite of aging well is aging poorly. The opposite of a good old age is a bad old age. It seems to me that another way of looking at all this is to distinguish between the steps you should take when you are young and healthy to maximize the likelihood that you will retain certain capacities in old age, on the one hand, and the way you should deal with old age once it has arrived, on the other. 

What people may aspire to, in addition to simply living longer, includes the ability to take care of yourself (physical function), the ability to think and reason (cognitive function), and (emotional function). But as they begin to become old, whether denoted by reaching eligibility for Medicare or suffering physical or cognitive decline or becoming afflicted with chronic diseases, they need to figure out how to make the best of their existing condition. Whether they become short of breath on exertion due to years of cigarette smoking or due to environmental exposures or due to idiopathic pulmonary fibrosis (idiopathic implying that nobody has a clue what causes this progressive, debilitating condition), they have to make decisions about how best to live their lives, given their limitations. And those decisions reflect their personal preferences (what matters most to the individual), their circumstances (their financial, physical, and social situation), as well as what they aspire to for whatever time they have left.


In light of these distinct considerations—1) planning for the distant future, 2) planning for the near future, or 3) making the most of the current reality—I will offer my personal thoughts on turning 70. These are not prescriptions for other people; they are a description of my thought process, which may serve as an illustration of the kind of process others may wish to go through.


I start with the current reality. I am blessed with good health, which I attribute at least as much to genes and luck as to virtuous past behavior in the realms of exercise and nutrition. I am also fortunate to be financially comfortable enough that I do not need to work. At age 70, I find that I for the most part accept myself as I am, which doesn’t mean I cannot change (either for better or for worse) but rather that I feel I can focus on what I derive satisfaction from doing, not from what I feel I ought to do. That means spending time with my husband, who after 49 years of marriage remains my best friend. It means spending time with my 95-year-old mother and with my three sons, who have become fine and interesting adults. It involves trying to make sense of the world, which I often try to do by reading broadly about about health and medicine, incorporating what I learn from the realms of history, politics, science, sociology, and other disciplines to shed light on current problems. While I will engage in activities that I find meaningful, I will avoid activities that are stressful or create conflict. That has meant giving up seeing patients, which used to make me feel useful and even important, but which increasingly became burdensome as medicine became bureaucratic, patients became litigious, and disease remained as intractable as ever. I also want to devote more time to arguably purely selfish activities such as exploring the worlds of novels and of nature.


When I plan for the near future, say the next five to ten years, maybe longer if I’m lucky, I think of this as investing. Not in the stock market or the bond market, though insuring there will be sufficient retirement money to live comfortably is certainly important, but rather in my physical health and physical functioning. This is where exercise comes in, both aerobic exercise to guard against cardiovascular disease and strength training to remain nimble. Strength will be essential to enable me to continue to climb stairs and lift my new granddaughter and any other grandchildren who may come along. I also need to invest in building and deepening friendships, since I am persuaded that over the long run, the best bulwark against depression will be a strong social network. Finally, I want to continue to find ways to be engaged with the world, not just through friends and family. For me, that means remaining intellectually engaged. 


As to planning for the distant future—it’s too late for that. Truly long-range planning involves decisions about diet and exercise when you’re in your 20s and 30s; it entails deciding early on not to smoke; it means getting an education (education decreases but by no means eliminates the chance of developing dementia in later life).


As I enter a new phase of life—which feels more like a new stage because I recently became a grandmother, not because I had a birthday—I am going to make a conscious effort to develop new interests and new activities. Unlike Jane Brody, who advocates doing whatever you are passionate about as long as you can in large measure, I suspect, because she herself continues to be passionate about the same things she has always loved, I find that my enthusiasm for clinical medicine waned, as did my excitement about other aspects of geriatrics. I want to move more in the direction of reading, thinking, and ultimately writing about the history of medicine, and how that can help shape contemporary health policy. Recognizing that interests change over the life course, I gave up the practice of medicine. I’m not quite ready to let go of this blog, but I will write when there is a topic relevant to “life in the end zone” about which I feel strongly. I’m no longer going to peruse the New England Journal of Medicine and JAMA weekly for new developments that I might write about as I increasingly feel that what is published in medical journals no longer excites me the way it once did. I will still read Health Affairs and I’m expanding my horizons to include the Bulletin of the History of Medicine. I expect that my eagerness to blog will wax and wane. I hope you will bear with me as I begin to think about the end zone in a new and very personal way.