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 400^th 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. 

Never Say Old

As a brief follow up to her important 2011 book, Never Say Die: The Myth and Marketing of the New Old Age, the writer Susan Jacoby published an editorial in the NY Times this past week. 

Provocatively entitled,  “We’re Getting Old, but We’re Not Doing Anything About It,” she points out that the presence of 5 septuagenarian presidential candidates (Biden, Sanders, Warren, Bloomberg, and Trump) falsely encourages the population to think that 75 really is the new 50 and that aging doesn’t bring with it the risk of frailty, dementia, and disability. Jacoby, in her usual incisive way, argues this view is mistaken—and dangerous.

In fact, while many people do remain vigorous well into their seventies, and a smaller but not inconsequential percentage continue to be robust well into their eighties (and an even smaller percentage into their nineties), the risk of developing one or more medical conditions that get in the way of independence and well-being rises steadily with age. The much vaunted “compression of morbidity,” the dream that we will all remain totally intact until precipitously, preferably during sleep, we die, hasn’t quite materialized. Jacoby cites a study reporting that one in seven people who are 65 years old today can expect to experience 5 or more years of disability before they die. Dementia rates are falling—but since the size and proportion of older people is increasing, the absolute number of people with dementia is projected to rise steadily. According to the Alzheimer’s Association, there are 5.6 million people over 65 with dementia today, there will be 7.8 million in 2025—and 13.8 million in 2050. Frailty remains a major problem: a 2015 population study in the US found that while only 10.7 percent of people age 65-69 were frail, among the 75-79-year-olds the rate was 20.1 percent, and for those aged 85-89, it was 37.9 percent.

So, what are the implications of this reality? Jacoby offers three: provide more support for caregivers; encourage employers to allow vigorous older adults to continue working; and address various medical ethical issues such as physician assisted suicide. This is a good beginning—and about as much as one can reasonably put into a NY Times op-ed—but there are many others.

Here are a few additions: In the arena of housing, we need far more housing that is handicapped accessible. Doorways should be wide enough for wheelchairs, buildings should be on a single level or have elevators. In the domain of urban planning, communities need to be walkable with extensive and accessible public transportation. In terms of medical care, the overriding issue is not care of the dying, but how best to care for the living. We need far more attention to function: to maintaining and fostering basic abilities such as mobility and higher-level abilities such as cooking and shopping. To achieve this end, physicians need to assess function, they need to know how to diagnose frailty, and they need to know how to promote and support function. Physicians also need to determine the old person’s goals of care and to work with patients and family caregivers to develop an approach to treatment that is consistent with those goals.

The new year will begin in just two days. Among our resolutions for the coming year should be a commitment to making America a better place for us as we get old—and I agree with Jacoby that we should abandon the foolish euphemism “older people” and stick with plain “old.” This should be a resolution we actually follow.

Of Mice and Men

For middle-aged mice, these are the best of times. Scientists now understand genetic factors that lead to the development of disease, disability, and death—in mice. Most importantly, researchers have found ways to improve the “healthspan,” the period of disease- and disability-free life before death—in mice. The question is whether the approaches they are developing will be applicable to people, and the ethical implications if they are.

The basic ideas are spelled out in a trio of “viewpoint” articles published in JAMA last week. S. Jay Olshansky, writing from an epidemiologic perspective, observes that over the past century, dramatic gains in life expectancy have been accomplished by reducing in mortality of children and young adults. But once these gains have been made, the only remaining way to lengthen life expectancy is by extending the lives of people at the other end of the age spectrum. Medical science has therefore concentrated on tackling the diseases of old age, one by one. Unfortunately, as Barzilai et al comment in their essay, “efforts focused on preventing individual diseases will have limited net effect on population health because one disease will be exchanged for another.” We’re already seeing this phenomenon: as fewer people die of heart disease, they develop and die of Alzheimer’s instead. Far better would be to tackle the aging process itself. Targeting the underlying driver of all the chronic diseases at once could, in principle, prevent or at least delay those disorders.

So, what do we know about turning off biological aging? We know there’s a gene in mice with the euphonious name rps6kb1 and if it’s “knocked out” (molecular genetics speak for “inactivated”), female mice live longer, healthier lives. We know there’s another gene called Sirt6 (short for Sirtuin 6), which is present in multiple mammalian species including humans, and if it is “overexpressed” (genetics speak for “turned on”) in male mice, they live longer. We also know that all creatures including people have “senescent cells,” cells that, old cells that start releasing all kinds of chemicals. When an individual has more than some threshold number of such cells, it develops chronic diseases, frailty, and is at high risk of dying. When the senescent cells of a mouse are destroyed, the mouse lives longer and without a long period of deterioration before death.

And what progress has been made in identifying drugs that achieve these goals in mice? And what about in people? Reportedly, the Interventions Testing Program, funded by the National Institute on Aging, has examined 26 “candidate drugs” for their effects on mice. They have identified 6, including the anti-inflammatory drug, aspirin, the anti-diabetes drug, acarbose, the immunosuppressive drug, rapamycin, and the estrogen, 17a-estradiol, as effective in some mice. Intervening in mice of an age equivalent to 70 human years has “extended life by more than 20 years and increase[d] health span even more substantially.” Other studies have found that the drug dasatinib (related to the anti-cancer drug, Tarceva) has a powerful effect in destroying senescent cells. In mice that are the equivalent of 80 human years, treatment with dasatinib combined with quercetin (a plant chemical found in green tea, red wine, apples, and other foods) increases survival 36 percent without increasing disability before death.

We don’t know whether any of these chemicals work in humans. And we have no idea at all whether they will produce side effects, though we do know that earlier attempts to interfere with cell lifespan were associated with the development of cancer. This is not entirely surprising, as the essence of cancer is uncontrolled cell proliferation. So even the very upbeat article by Tchkonia and Kirkland, the third of the triad, ends on a cautionary note: “…Patients should be advised not to self-medicate with senolytic agents or other drugs that target fundamental aging processes in the expectation that conditions alleviated in mice will be alleviated in people.”

If, years from now, human studies indicate the drugs or others like them are effective, we will have to deal with the ethical implications of extending the “healthspan.” What will they cost? Will everyone have access to such medications? Will we create greater inequality within society? Between countries? Banning such research on the grounds that a ballooning of the elderly population is unsustainable is almost certainly going to be impossible—the lure of more disease-free life will be irresistible. But we can begin to think about the consequences of our brave new world.

Rescue and Reform

A new poll conducted by the Kaiser Family Foundation found that nearly 80 percent of Americans want Congress and the President to modify the Affordable Care Act to make it work. They don’t want repeal and replace. 
       The numbers are impressive: 95 percent of Democrats and 52 percent of Republicans favor a legislative fix to the current law. Even among Trump supporters, an absolute majority (51 percent) support such an approach. In fact only 17 percent of the public (although 40 percent of Republicans) believe the Trump administration should act to initiate the infamous “death spiral” by taking such steps as eliminating the universal mandate and withdrawing subsidies to poor people. Taking Medicare as a model of sweeping, comprehensive health care legislation, we can look at just how much the program was reformed by Congress in the first 15 years after the law went into effect.
       Passed by Congress in 1965, Medicare first became a reality on July 1, 1966. In 1972, Medicare eligibility was extended to people under age 65 with long-term disabilities as well as to those with end-stage renal disease. This was no minor tweaking of the program: today 9.1 million people out of the 55 million on Medicare are in the under-65-with-disabilities category. In the last year for which data are available, Medicare spent a whopping $30.9 billion on end-stage renal disease out of total expenditures of $646 billion. 
       In 1973, “Medicare HMOs” were introduced. The federal government established standards for what benefits had to be provided, but basically outsourced plan design, management and marketing to private insurance companies. The name of this program has evolved over time, from Medicare Choice + to the current Medicare Advantage plan, but the idea remains unchanged: instead of enrolling in Medicare Parts A, B, and now D with deductibles and co-pays, Medicare enrollees can opt for one-stop shopping. Today, a record 17 million people, or 31 percent of all Medicare beneficiaries, are enrolled in a Medicare Advantage plan.
       Jumping ahead to 1980, the decision was made to broaden coverage of Medicare home health services, allowing more people to stay out of hospitals and nursing homes because they received physical therapy and occupational therapy, as well as visiting nurse services at home. At the same time, supplementary Medicare insurance plans (“Medigap”) for those people not enrolled in an HMO, came under federal oversight to cut down on all too common abuses found at the time. 
       And then in 1983, in what was perhaps the most far-reaching reform of the Medicare program ever instituted, prospective payment was introduced for hospital care. What this meant was that instead of hospitals charging whatever they wanted—with Medicare dutifully paying soaring bills—Medicare set rates that were based on the expected length of stay for a given condition. The hospital got paid that fixed amount (adjusted for co-morbid conditions and geographic variation in the cost of living) regardless of how long a patient was in the hospital. In other words, patients with an unusually long length of stay cost the hospital money and patients who were discharged unexpectedly early generated revenue for the institution. The result of this innovation, in addition to controlling how much money Medicare spent on hospitalizations, was to shorten length of stay, moving much “post-acute” to the home or the skilled nursing facility.
       Reforming Medicare didn’t stop in the 1980s. But my point is not to present an extensive history of the Medicare program (though if your interest is piqued, you might like my forthcoming book, Old and Sick in America: the Journey through the Health Care System); rather, it is to emphasize the complex, innovative, health care legislation seldom bursts onto the scene fully and impeccably formed. It usually needs to be fixed. The ACA is no exception.

       After chanting “repeal and replace” for so many years, the Republican majority needs to save face. But the way to do t do that is not to sabotage what we have, a compromise bill designed to save private health insurance rather than jettisoning the industry in favor of single payer coverage. The Republican Party should appropriate the idea behind the ACA as its own, acknowledging its true founding father, the extremely conservative Heritage Foundation. Maybe what’s needed is a new mantra. How about “rescue and reform?”

-->

Now Hear This!

This week I'm posting a podcast I did for GeriPal about my forthcoming book, "Old and Sick in America: the Journey through the Health Care System."

To the Barricades!

On this weekend of the Women’s Marches—175,000 of us marched in Boston alone—it’s fitting to remember that aging is predominantly a women’s issue. Robert Butler, the founding father of contemporary geriatrics, made the point powerfully and persuasively in a short article in the New England Journal of Medicine in 1996, "On Behalf of Older Women—Another Reason to Protect Medicare and Medicaid." Sadly, the observations and concerns he raised 20 years ago are exactly the ones we face today as President Trump nominates Tom Price, foe of Medicare and Medicaid, to serve as head of the Department of Health and Human Services, and Paul Ryan, Speaker of the House, hopes to finally succeed in carrying out his long-standing goal of privatizing Medicare.

Butler begins by saying that old age is a territory populated largely by women.” Updating the data he presents: life-expectancy at age 65 is 17.9 years for men and 20.5 years for women, which means that women typically outlive men by at least 2.5 years. Since death rates are higher for men throughout much of the lifecycle, this means there are currently 25.1 million older women in the US, compared to only 19.6 older men. The ratio of men to women falls with age: in the 65-74 year old bracket, there are 86.9 men for every 100 women; among those over age 85, there are only 48.3 men for every 100 women.

Butler continues: “Proposals to curtail Medicare and Medicaid, if enacted, could leave beneficiaries, the majority of whom are women, paying more out of pocket for what may be less medical care.” He reminds us that the concern about Medicare and Medicaid have arisen “because political leaders want to balance the federal budget…while giving some Americans a tax cut,” not because of concern about quality of care. His words could have been written today instead of 20 years ago. And alas, older women are apt to live in poverty today, just as was the case when Butler wrote: the median income of older people in 2013 was $29,327 for men—but only $16,301 for women. Put differently, 6.6 percent of older men live below the poverty line, compared to 11 percent of women.

The theme of aging as a women’s issue was picked up by acerbic social commentator Susan Jacoby in her 2011 book, Never Say Die: the Myth and Marketing of Old Age. She points out that the household income of women is cut in half when their husbands die. Unequal pay for equal work has a cumulative effect: pensions are lower for women. Women who take time out of work to raise a family are rarely able to compensate for the loss of wages, seniority, and missed promotions. Because women typically live longer than men, they are more likely to become frail, to develop dementia, and to be widowed. As a result, fully two-thirds of nursing home residents are female. And the issues that affect older women in general affect older women of color in spades.

As we pressure the government to preserve reproductive health rights, to institute equal pay for equal work, and to enforce laws that prohibit discrimination based on sexual orientation, we should also pressure government to maintain and improve health care for older women. That means protecting Medicare and Medicaid, subsidizing supportive housing, and assisting family caregivers--at last report, there were 34.2 million Americans providing unpaid care for an adult over age 50 and two-thirds of these caregivers were themselves over 65. So to the barricades!

-->