Til Death Do Us Part

Why did this image go viral? In case you haven’t seen it before, it depicts a couple who were admitted to separate rooms in a Georgia hospital. Thanks to the wisdom of the nursing staff—and some bending of the rules—they were reunited. I think the photo struck a chord because it captures the important reality that what matters most as we get older—and perhaps at any age—is relationships.

We devote an inordinate amount of effort when we are younger to being “successful,” which we tend to define in terms of fame and fortune. And then, when we retire, we focus on living longer, on diet and exercise, on health and on experiences. But what so clearly mattered most to the couple in this photo is each other. Yes, the oxygen flowing through the plastic tubing is important. Yes, the intravenous catheter (not visible in the photo but I’m reasonably sure it was there) was useful for delivering potentially life-prolonging medication. But what makes life meaningful above all is our connections to others.

Lisa Berkman, a prominent social epidemiologist, has found compelling evidence that social networks—our links to our community—even affect our physical health. They influence whether we get a heart attack or stroke in the first place and how we fare if we get one. They affect our propensity to develop cognitive impairment and how well we cope if dementia strikes. But perhaps George Vaillant said it best when summarizing his book, Triumphs of Experience: the Men of the Harvard GrantStudy. This ambitious, longitudinal project followed 268 men who graduated from Harvard in the 1940s with a series of in-depth interviews over the course of their lives. Of course, generalizing rom these privileged Americans, all male and all born in one era, to the rest of us is risky. But despite their talents and their opportunities, these men had their share of alcoholism, of poverty, of suffering, and of disease. The inescapable conclusion that Vaillant reached  was, as he put it himself: “It was a history of warm, intimate relationships—and the ability to foster them in maturity—that predicted flourishing in all aspects of these men’s lives.” And that's the message conveyed by the photo of the two nonagenarians in their hospital johnnies, holding hands.

Aging Well

My mother will turn 88 in a few weeks. According to the definition of successful aging put forward by Rowe and Kahn nearly 16 years ago, she is aging quite well. Her kidneys, lungs, and heart work fine. She is still very active—she teaches a French class once a week at the local senior center, she tutors English to foreigners, she plays scrabble with friends, and she drives daily to visit my father at the nursing home where he lives. My mother does have her share of medical problems: she has painful arthritis affecting her knees and her back and she is very weak, finding it difficult to turn a door knob or to lift a container of milk. Until about a year ago, she walked at least a mile every day, but now she can only take short walks and has to sit down frequently. Her memory isn’t what it once was, though it’s still pretty good. My mother will say that “old age is no picnic” and that “people live too long” today. When her physician told her she was aging gracefully, she told him he was full of it. Her doctor has one perspective on successful aging; she has another one. How are we to put the two views together? Are we using the right definition of “successful aging?”

A new study in The Gerontologist tries to answer this question. The authors carried out in-depth interviews with 56 elders who have significant disabilities and are enrolled in the On Lok program, the original PACE program (Program of All Inclusive Care for the Elderly) in San Francisco. Members of PACE all have enough disabilities to qualify for entry into a nursing home and for Medicaid enrollment, so they are both frail and poor. In fact, the group studied had an average age of 78; 64% were women;  the average number of ADL dependencies (problems in areas such as bathing or dressing) was 2.2 and the average number of IADL dependencies (areas such as food shopping or cooking) was 6.6. It was a diverse group, with 23% African American, 32% Asian American, 20% white, and 20% Latino. 

By and large, the group held the view that aging is an unavoidable process that entails disability. The key to successful aging, they said, was to accept your limitations and to adapt. If you have trouble walking, use a walker. If a walker isn’t enough, use a wheelchair. They also tended to focus on relative disability rather than absolute disability—as long as there were others who were worse off, then they felt they were doing well. The minority who said they hadn’t aged successfully commented that they had not found ways to adapt to their disabilities and they felt were a burden to their families.

So the PACE elders and my mother don't have quite the same perspective. My mother would agree that it’s critical to accept your limitations and to adapt, and she's done that. She doesn’t want to be a burden on anyone, and she isn't. But I doubt she would say she is “aging well." She is aging better than my father, who has dementia and Parkinson's and lives in a nursing home because he needs help with just about everything, but she wouldn't call herself a phenomenal success.

Perhaps the whole idea of “successful aging” or “aging well” is the wrong way to think about this phase of life. For no other stage of development do we assign grades: we don’t say someone had a “successful childhood” or a “failed adolescence.” We might refer to their emotional state during a particular stage: someone might have a “happy childhood” or a “troubled adolescence.” We might use the label “successful” for a career or a marriage, but not for a part of the life cycle. So why do we insist on evaluating aging in this way? 

Instead of grading aging, government and professionals should do work to assure that people are satisfied with their lives and are contributors to their community. After all, this is arguably the goal for the entire population, regardless of age. Our challenge is to figure out how to achieve this for people who are old and frail, whether because of physical impairments, cognitive impairments, or both. 

Just as we cannot eradicate inequality among people—they have different genetic endowments, they are born into different families and different cultures—but we can aspire to provide equal opportunity, perhaps our goal for older people should similarly be to promote equality of opportunity. We cannot eliminate differences in disease burden or disability, but we can seek to assure that everyone has a fair chance to make the most of themselves, whatever their situation. It’s time to switch from talking about “successful aging” to coming up with a successful aging policy.

Playing Games

It’s not often that a “research letter,” a short, preliminary report about ongoing research, makes it into the national media. But this week, newspapers picked up on just this kind of article from Nature, a prominent science journal. The article tentatively concluded that people aged 60-85 who practiced a custom designed video game several hours a week got better at multi-tasking. Not only that, but the improvement persisted 6 months later and was manifest not just in better performance on the game but in other measures of attention and memory. So is it time for octogenarians to start playing video games with their grandchildren?

Even before the University of California San Francisco lab published its NeuroRacer results, online companies like Lumosity were doing a booming business. Calling itself a “brain training and neuroscience research company,” Lumosity creates computer-based games that ostensibly offer a “scientifically proven brain workout.” It reported a 150% increase in business between 2012 and 2013, with 35 million users worldwide by January of this year and as many as 100,000 new subscribers each day. Clearly, people want to believe that playing mind games will keep them sharp and perhaps even fend off dementia. 

To be fair, the authors of the study in Nature aren’t proposing anything of the kind. They offer their work as an illustration of the “plasticity” of the “prefrontal cortex,” or the ability of the brain to adapt with practice, even at older ages. But do mind exercises translate into useful improvements—as opposed to better scores on simple tests? And at least as important, if mind exercises are effective, what about singing in a chorus? Participating in a discussion group? Writing a letter-to-the-editor? The new study compared volunteers (hardly a random selection of the population) who played the video game to other volunteers who did not; it did not compare playing the video game to other activities. 

What’s wonderful about these other pastimes—playing music, arguing, writing—is that they are fulfilling in and of themselves, whatever their cognitive benefit. Social engagement helps prevent depression; it gives people a sense that they matter. Perhaps it’s harder to study the effects of making music than to measure the EEG (brain wave) correlates of playing video games; after all, playing Beethoven may be different from playing Mozart, trios may be more challenging than duets, and playing the piano may not be equivalent to playing the clarinet. It’s certainly a great deal easier to monetize a video game than a social network that helps older people find others with shared interests. 

Researchers should keep on studying highly standardized, precise activities. But for now, I’d take my chances with the real world, not the virtual world.

Why We Work

With Labor Day rapidly approaching, I began wondering about older people in the workforce. Just how many people over 65 work? What about over 75? How is this changing? And what does work mean for older individuals?

Of course 65 is an arbitrary way to define old age. Most people who turn 65 are not old in any meaningful sense—they are certainly nowhere near the end of life: they can expect to live another 19.1 years. For women, life-expectancy at age 65 is still greater, or 20.3 years. Even age 75 is no longer very old, with a life-expectancy of another 12.1 years.  Moreover, as I pointed out in my last blog posting, roughly half those years are “disability-free.” But Social Security kicks in at 65 and so does Medicare, so this continues to mark the conventional threshold between working and retirement.

It turns out that a substantial and rising proportion of the population continue to work after their 65th birthdays. US Census Bureau projections for 2014 are that just under one in five people over age 65 will be working, a 36% increase in just 5 years.  For the 65-74 year old group, it will be slightly over one in four, and for those over 75, it will be a little under 10%. Roughly half of those people who continue to work will do so pretty much full time; about one-third will work 15-34 hours a week, with the remainder working 14 hours or less. 

The US is not the only developed nation to see a marked increase in older workers. England has experienced a surge of older workers, with numbers topping a million this spring: in 2013, 57% of people who reached the official retirement age said they planned to continue working, compared to 40% a year earlier. 

Some of the change is a direct consequence of the recession. The value of retirement plans that were tied up in the stock market took a huge hit, and with it came the realization by many people that they didn’t have enough money saved up to retire at 65. They also stood to lose employee-sponsored health insurance—along with their main source of identity. 

What I found fascinating is that there’s a lot of advice available for prospective retirees about where to live, how to save for retirement, and how to make your money last after you do retire but not much, as a recent article in Time pointed out, about how to make the most of the post-65 period, with or without a job. The pundits encourage everyone to be eat well, remain active and to nurture close personal relationships before they turn 65 in the hope of remaining healthy but are silent about what to actually do with their lives if they succeed..

My personal advice—and I wrote about this in my book, The Denial of Aging: Perpetual Youth, Eternal Life and Other Dangerous Fantasies, in the chapter “Making the Most of the Retirement Years,” is to concentrate on finding meaning in life. If work gives you a sense of meaning and if you’re able to keep at it, then do it. If work doesn’t give you a sense of meaning or if you can no longer continue what you’ve been doing, then it’s best to find something else that gives you that all-important sense of being part of the human community and making a contribution to the world. And it’s the job of the rest of us to make sure there are ample opportunities to do just that.

News of a Life in Review

The father of modern geriatric medicine, Robert Butler, died last summer at the age of 83. His contributions to the study of aging and to the care of older people were prodigious: he was the founding director of the National Institute on Aging, the division of the National Institutes of Health devoted exclusively to the elderly; he persuaded Mount Sinai School of Medicine to establish the first ever Department of Geriatrics-and was promptly appointed its first chairman; his book, Why Survive: Being Old in America, published in 1975, made the case that America was "ageist" and argued forcefully that views of older people as feeble and "senile" reflected prejudice and ignorance, analogous to "racism."

Less well-known is Butler's endorsement of the idea of a "life review." Older individuals frequently look back on their lives, trying to create a coherent narrative that helps give meaning to their lives. Butler coined the term "life review" for this process and, far from mocking it as a sign of incipient dementia, as was the fashion in the 1950s, he encouraged the practice, suggesting it gave older people the opportunity to find what Erik Erikson called "ego integrity" in the final stage of life.

American medicine, by contrast, has focused on finding a quick fix to the problems of aging. Vitamin E, an anti-oxidant, was heralded as a miracle drug, until it turned out that instead of preventing heart disease and cancer, it had no effect in preventing either one and seemed to increase the risk of heart failure. Estrogen for women met a similar fate: touted as the fountain of youth and alleged to prevent such age-associated ailments as dementia and coronary artery disease, it was found to be useless in protecting against dementia and to increase the rate of heart disease. Vitamin D, the most recent candidate for anti-aging potion, just this month met the same fate. The Institute of Medicine concluded that vitamin D had not been shown to boost immunity, to prevent cancer, or to stave off diabetes.
The search for a magic bullet to prevent aging has led us to neglect the quality of life for those who are already old, and who may be frail or demented.

One strategy we already have for improving life satisfaction in old age is life review. A series of small studies this past year have confirmed the utility of life review for psychological well-being. One study of reminiscence therapy in Taiwan nursing homes found less loneliness, less depression, and greater psychological well-being in the experimental group. Similar results emerged from a randomized study conducted in ten Danish nursing homes. A Dutch randomized trial conducted in the community found that enrollment in a life review course called "Looking for Meaning" reduced depressive symptoms, a result that persisted at six months.

Unlike medications, life review has virtually no side effects. But unlike new drugs covered by patents, it will not enrich anybody and has no powerful corporate sponsors (Venlafaxine, an antidepressant, cost $70 for a one-month supply, according to Drugstore.com, and Quetiapine, an antipsychotic commonly used for symptoms such as agitation, costs $90 for a one-month supply).

I recently engaged in a limited form of life review with my parents, who are now 85 and 86. I interviewed them at length about their experiences during their first 25 years. Both were born Jewish in Germany, my mother in the port city of Stettin (now Szczecin, Poland) and my father in the small East Prussian town of Osterode (now Ostroda, also in Poland). In January, 1939, they both left Germany forever on a children's transport to Belgium. When Germany invaded Belgium in May, 1940, they escaped by train to the south of France as part of a group of 100 refugee children. There they remained, in a children's colony supported by the Swiss Red Cross, until they were threatened with deportation to Nazi death camps and fled, in 2 separate expeditions, over the border to Switzerland. My interviews focused on their early lives in Germany and their experiences as refugees, first in Belgium, then in France, and next in Switzerland. After the war, refused residency by the Swiss, they immigrated: my father to Brazil and from there to the U.S., and my mother directly to the U.S.

The process of telling their story, while sometimes painful, was clearly valuable to my parents. They found it helped them make sense of their lives to think about how their early experiences affected them as American citizens and as parents. They felt there were lessons to be learned-lessons about countries' responsibilities to refugees and about what it means to act humanely-which they were eager to communicate and hence were gratified to see their story made public in my recently released book, Once They Had a Country: Two Teenage Refugees in the Second World War.

So as we salute Robert Butler for his many invaluable contributions to geriatrics, let us not forget the humble life review.