The End of Old Age

Introduction

Old Is the Problem and Aging Is the Solution

MOST OF US envision living a very long life, and we wonder and scheme how to get there. Now imagine if I told you that I had discovered several potential secrets to achieve this, and I laid them before you on three covered silver trays. You uncover the first and discover a small glass bottle containing genuine water from the fabled Fountain of Youth. You uncover the second tray and discover a pill bottle with a brightly colored label touting a formula designed to add years to your life. Finally, you lift the cover off the third tray and discover, to your surprise, two cigarettes, a glass of red port wine, and several French chocolates.

Which would you choose? You might be bemused by the water and tempted to take a sip, but you realize, no doubt, that it is a gimmick and nothing more. The mysterious supplement in the pill bottle may be bolstered by fantastic claims on its label, but there is no solid proof of its power, and any potential benefit is only a guess. And then there is the strangest choice of all—the smokes, the drink, and the candy. If you choose to indulge in one or more of these treats, you may be guaranteed some brief pleasures—but long life? It seems unlikely. But there is, of course, a story behind this last choice.

Perhaps you have heard of a French woman by the name of Jeanne Louise Calment, the oldest person in recorded human history, who died in 1997 at the age of 122 years and 164 days. As a young girl, she watched the Eiffel Tower being built and later recalled the likes of a rather scruffy and unpleasant artist by the name of Vincent van Gogh who used to frequent her father’s fabric store. When she was ninety years old, an enterprising forty-seven-year-old lawyer made an agreement with Madame Calment to pay her a monthly stipend in exchange for her property upon her passing. Unbeknownst to poor Mr. Raffray, however, he would be making payments to this supercentenarian for the next thirty years, up until his own death, after which his widow continued their financial obligation for another two years. When asked about her secret to such a long life, Madame Calment pointed to her lifestyle: she loved regular servings of port wine and chocolate, was physically active but not an exercise fanatic, and smoked two cigarettes daily up to the age of 117. Her longevity strategy, planned or not, certainly seems both unreliable and idiosyncratic, but it is not unlike similarly strange secrets of other supercentenarians.

For example, there was the remarkable Dutch lady Hendrikje van Andel-Schipper. At the age of 112, Hendrikje underwent extensive cognitive testing and scored above average for someone forty years her junior. Her mental clarity remained extraordinary up until the day of her death four years later. An autopsy of her brain revealed few of the telltale pathological signs of similarly aged brains, such as narrowed, sclerotic blood vessels, or plaques containing the toxic amyloid protein associated with Alzheimer’s disease. Predictably, Hendrikje was neither teetotaler nor triathlete, and engaged in none of the popular antiaging strategies, such as a vegan diet, caloric restriction, vigorous exercise, or any other youth-restoring pill, potion, or plan. When asked about her secret to a long life, Hendrikje—much like our friend Madame Calment—revealed a simple and surprising routine: a daily dose of raw herring and a glass of orange juice. The oldest Japanese person ever—117-year-old Misao Okawa—attributed her longevity to sushi and sleep. The Italian 116-year-old Emma Morano cited raw eggs and brandy as her secret formula, whereas the American 116-year-old Susannah Mushatt Jones eschewed alcohol and cigarettes but included at least four strips of bacon in her daily diet.

Do any of these examples mean that we should trash the treadmill and fire up the eggs and bacon? Obviously not. It is clear that none of these supposed secrets to a long life is a reliable strategy, and that some other factors must be at play. Research into the lives of centenarians and the long-lived communities in which many of them reside (the so-called Blue Zones) have all revealed several shared elements of healthy lifestyles, including regular physical activity, close family, or community attachments, and Mediterranean-like diets laden with fish, fruits, vegetables, olive oil, and even a glass of wine. Endless books happily expand upon all these strategies, many plumped with a healthy dose of antiaging sentiment. In the end, however, we know of no surefire strategy or genetic endowment that brings certainty of joining the ranks of these superelders. And we must face a well-recognized truth: a long life doesn’t necessarily equal a good life, and in many circumstances, long in years brings letdowns, languishing, and lots and lots of struggles. Being old, in many ways for many people, seems more of a problem than a promise.

Maybe in our quest for a long life, then, we are missing the point. As a geriatric psychiatrist who has worked for most of my career in the epicenter of aging that is South Florida, I have a unique vantage point to witness the endpoints of these long lives. I get to see whether people actually reap what they sow. And studying aging in Miami is like embarking on a diver’s pilgrimage to the Great Blue Hole: a wondrous abyss teeming with old in every hue, form, and layer. I have seen the best and the worst of old age: moneyed and destitute, vibrant and withdrawn, sturdy and decrepit. Sometimes one of these attributes singly defines a person; more often they are all balled up together in a seemingly contradictory but functioning person. In my quest, I have read and researched the vast ocean of thinking, data, musings, and hucksterisms on old age, trying to apprehend and understand the great old white whale into whose mouth I am drawn closer every day. My advantage in writing about aging is not that I am that old myself, but that my life’s work has brought the whole beast into my hands. So, let me tell you what I’ve learned. This is not the old age of times gone by. It’s not even the old age that I saw when I began my career in geriatrics some twenty years ago. My average patients are now in their mid- to late eighties and early nineties and, despite lots of daunting medical and psychiatric issues, they are less concerned about living a long life and more focused on living a life full of purpose and meaning. We are so concerned about making our body and brain younger, but perhaps these aged individuals have something special to teach us about the actual strengths of aging that we only gain with time.

My former patient Leah, for example, was a well-known political activist in Miami who began life in a down-and-out Brooklyn borough and spent years thinking that her life was limited to only being a caregiver for her disabled daughter. Aging liberated her activist instincts, however, and in her later years she spent each election cycle fiercely stumping for her favorite candidates, leading get-out-the-vote campaigns in her community, and rallying against the opposing party in newspaper and television interviews. With age, Leah emerged as a more vibrant, opinionated, and dedicated individual whose interests and activism peaked in her nineties and continued unabated until her death at the age of 106. Another example is my patient Eduardo, who used to come for monthly psychotherapy sessions decked out in jeans and designer shirts. In his eighties he continued to grow and diversify the business he had started some fifty years earlier, and in his nineties he continued to mentor two generations of offspring on his work ethic and business acumen. You may argue that Leah and Ed are both exceptions and exceptional, but I am seeing more Leahs and Eduardos every day. Older? Yes. Sicker? In some ways, yes. But scratch the veneer of the typical “old person” that we perceive only through our limited, youthful goggles and a bursting, blooming culture appears of someone engaged in important artistic activities, business transactions, community events, intergenerational relationships, and spiritual endeavors that are rich, varied, life-sustaining, and sometimes jaw-dropping in their intensity and influence. Whether they know it or not, these individuals are plotting the end of old age, a veritable redefining and resculpting of the aging process whereby the narrow and negative paradigm of “old” that we believe in is simply no longer true.

If you want to see the end of this tired notion of old age, then, just open your eyes to the growing legions of relatively healthy and hearty aging individuals who are living, working, playing, and serving vital roles in every one of our communities. For myself, I live in the state of Florida, which has four of the top ten counties in the United States with the highest percentage of individuals older than the age of sixty-five. Here you will find burgeoning retirement communities draping the local interstates like the big fat pomelos hanging off trees in the surrounding citrus groves. You will also find the actual spring of water dubbed the “Fountain of Youth” in a small park in the city of Saint Augustine, where Ponce de León reportedly first set foot on these shores back in 1513. But neither magical waters nor the promise of youth are what these waves of seniors here and elsewhere seek. Their aim is not simply to rest their aching bones for a few happy years before dying—as life after retirement has traditionally been envisioned. Quite the contrary: they intend to live a good life that age itself has granted—in places where age is king and youth is simply in the way. Call it what you will—an age wave or silver tsunami—but it’s hitting big in every developed country, spreading fast and busting with tens of millions of individuals continually adding to its ranks. And many of us are either already there or soon to enter its realm. The strengths and promises of aging are upon us.

The Paradoxes and Paradigms of Old Age

If given the choice to live as long as Madame Calment or Hendrikje van Andel-Schipper, would you take it? When I pose this question to audiences around the country, I often get the same responses: a smattering of enthusiastic takers shoot their hands up right away, but most listeners are more reticent as they sit in contemplation of being so old, wavering their hands back and forth to say “maybe” but with a few hard conditions. “If I kept all my teeth I’d do it,” shouted out a middle-aged man at one such event, but then quickly backtracked and added that he would also want to retain the ability to recognize his wife and drive his car if he would ever crest beyond the age of one hundred. Others add similar conditions, such as an intact memory, strong legs, and regular bowel movements among their choices. Within these conditions, I perceive a resignation to the expected decrepitudes of old age and rarely a callout to anything good. My questioning reveals several clear paradoxes of old age: we all want to get there, but we live in fear of what it will entail. We want the best possible old age, but also want to feel and look younger. We rely on the past as the anchor of our identity, yet we must at times let go and break free from it so as to accept and accommodate change. Aging is an inevitable one-way journey and we fret along the way and plot all sorts of manners to stave off or cushion the bumps and blows.

And yet despite some tectonic and wholly positive developments in the life of the average aging person, we are still stuck between two tired and prevalent perspectives on old age: either we must submit gracefully to its rigors and ultimate tragedies, or fight it relentlessly with supposed antiaging strategies until we find a cure. Either way, we are mired in a paradigm that casts old age as our implacable enemy. Even in our designations of successful aging, we view any victories won in daily life as being wrestled away from our inevitably older self. My message here is quite different, however: aging is the solution and not the problem. As we all get older, we face inevitable points that pose struggles, losses, reconsiderations, or crises that throw us off balance and force life-altering responses. These age points are as predictable and critically important to our adult development as the milestones of childhood and adolescence. Instead of seeing them as harbingers of decline and old age, however, the seniors that surround me show timeless benefits to aging that emerge and sustain them during these age points, enabling them not simply to cope successfully but also to create new ways of living.

In my previous book on this subject, entitled How We Age: A Doctor’s Journey into the Heart of Growing Old, I wrote about how we need to place greater value on our elders and hope for a better old age, even in the throes of illness and dementia. My goal was to inspire readers to look at aging in a different and more hopeful vein. But I am not content to simply gaze at the holiness of old age. And neither are the legions of baby boomers and others who are aging by the day. They want to do something and they want to do it now. No more waiting to get old and ill and then die helplessly. No more endless searching for some miraculous antiaging pill that does not exist now and will not exist in the foreseeable future. No more putting hope in antiaging claims that are predictable, tiresome, and largely untrue. The point of this book is to survey the emerging strengths of aging individuals and distill them into a practical, meaningful action plan for a better aging process.

I realize that this mission may prompt some doubts. Whether we consider our own aging self or look to those much older, we see daunting decline and loss. In my geriatric psychiatry practice tending to some of the most ill and debilitated elders, I see the worst forces of old age every day. Despite our deepest yearnings and the billions of dollars spent on health care and antiaging products, no one has escaped aging and everyone will eventually die. As a result, many will argue that any such benefits we imagine in late life are mostly illusory and short-lived at best. There is even a moral argument that we should resist prolonging our life beyond its natural boundaries, so as to clear the brush, so to speak, for successive generations. If we have any independence at the end, let it wield a swift and painless blow and avoid the aching, mindless languishing that so many endure.

Such realism has many prominent voices who will extol aging only up until a certain point. “It’s great to be old,” says author Susan Jacoby, “as long as one does not manifest too many of the typical problems of advanced age.” Longer years may only bring more illness, poverty, and privation to the majority of elders in our youth-focused culture. She calls into question many of the supposed benefits of aging, including the sacrosanct notion of wisdom, and points out the risk in believing that any or all of our supposedly healthy habits will bring a better future. We hit a wall sooner or later when, as Jacoby asserts, “anyone who has outlived his or her passions has lived too long.”

Similarly, medical ethicist Ezekiel Emanuel argues that although death is a loss, “living too long is also a loss.” In his provocative article “Why I Hope to Die at 75,” Emanuel declares that he will engage in no lifesaving or regenerative therapies beyond the age of seventy-five, as he will have achieved his life goals and made his important contributions by then. He does not intend to shorten or end his life after that point, but he sees no tragedy in its demise, declaring that aging limits both our ambitions and expectations, leaving our “memories framed not by our vivacity but by our frailty.” Emanuel projects that his post-seventy-five self will be increasingly “feeble, ineffectual, even pathetic.”

Many common folk perspectives on aging adhere to this simple and stark paradigm, defined centrally by a future of decline and struggle. Indeed, most aging individuals face severe attenuation of their most cherished abilities. And many of us will not be fortunate enough to avoid the most common and compelling scourge of old age—dementia. One undeniable fact, then, must frame and perhaps even counter any discussion of the strengths and benefits of aging: over 50 percent of the population around the age of eighty-five suffers from Alzheimer’s disease or other forms of dementia (called neurocognitive disorders, in updated parlance), representing a growing epidemic of monstrous social and economic proportions. These cognitive disorders are game changers in late life, robbing us of independence, identity, and the ability to make the meaningful contributions that once defined us throughout our life span. Writer Kent Russell states quite bluntly in his article “We Are Entering the Age of Alzheimer’s” that this disease steals our very humanity, creating “mindless, selfless, unreasonable creatures, somehow still looking like human beings.… They might as well be headless bodies, up and shambling around.” He portrays old age as a zombie apocalypse—a veritable World War G, for geriatric.

These are strong arguments, but they are neither new nor novel. Jacoby and Emanuel are merely restating the words of Roman statesman and philosopher Cicero, who wrote in 44 BCE: “Old age is the final act of life, as of a drama, and we ought to leave when the play grows wearisome, especially if we have had our fill.” Remarkably, Russell is describing a diminished old age no different from that portrayed over four thousand years ago in writings by Ptah-Hotep, first minister to Pharaoh Isesi: “The end of life is at hand; old age descendeth [upon me]; feebleness cometh, and childishness is renewed. He [who is old] lieth down in misery every day. The eyes are small; the ears are deaf… and he remembereth not yesterday.… These things doeth old age for mankind, being evil in all things [emphasis added].” We know these things about the aging process, even as they characterize only the downside. At the same time, neither Jacoby nor Emanuel (nor Cicero, for that matter) would argue against the potential benefits of old age. They simply reject the platitudes about aging that lack empirical evidence or that deny or ignore the difficult and enduring struggles that most people face. This is the gauntlet laid down for any and every commentator on old age—myself included.

So, where does this leave us? What are we to do with our biological fate? British researcher and gerontologist Aubrey de Grey and other life extension proponents recoil from these struggles of aging, loudly proclaiming old age to be a horrible disease that must be cured. The main limitation to progress is not only the rudimentary science on aging, de Grey believes, but a fatalistic and defensive “pro-aging trance” that leads people to see aging as a natural and immutable part of being. In contrast, de Grey and a cadre of antiaging advocates argue that we can eventually solve the tragic mystery of old age by learning to re-engineer cellular aging in order to extend the life span indefinitely. Futurist Ray Kurzweil and his colleague Terry Grossman agree, and outline three successive bridges to this future; the first being present-day dietary and health strategies; the second, the impending biotechnology revolution, to rebuild our body; and the third, an anticipated nanotechnology–artificial intelligence revolution, to rebuild our brain. Many young aging people crowd onto this first bridge, enlisting various body and brain exercises and other remedies touted for extending the life span. There are significant merit and considerable science behind some of these existing approaches, but as I emphasized before, they cannot guarantee any individual positive outcome, and practical applications for more radical technological innovations are barely on the radar. This is the enduring uncertainty of aging with which we all live.

In the face of this seemingly inescapable predicament, we continue to frame old age in a narrow and simplistic manner. Such a prevailing model is based on a mechanistic series of steps that inexorably unravel our youth. Biologist and aging researcher Robert Arking casts this journey in corresponding scientific terms, defining aging as a “time-dependent series of cumulative, progressive, intrinsic, and deleterious functional and structural changes that usually begin to manifest themselves at reproductive maturity and eventually culminate in death.” This definition is accurate and it is echoed in much of our experience. Beginning around middle age, we take notice of accumulating physical changes, medical issues, and losses. Development gives way to decline, and gains slip away to losses. Dreams of youth seem less attainable. We begin to have more and more experiences in which our aspirations butt up against fading abilities and opportunities.

It is at this very juncture, however, when something remarkable may happen that can change the way we view and experience aging, affecting the very meaning of what it is to be old. Aging begins to unfold in a beautiful and yet maddening fashion wholly different from our typical cast of it, bringing not simply glory and destruction, joy and despair, but an incredibly complex weave of these experiences. The result is a powerfully enriching and contagious culture of aging representing an expression of our achieved humanity and an incubator for further growth.

I propose here a different paradigm of aging along with an action plan that identifies and engages the myriad pieces of our own aging self that can dispel negative stereotypes of being “old” and bring renewed hope in our future. This paradigm shows how one can actively live a creative age as opposed to falling headlong into an uncontrollable old. Age must neither define us nor serve as only a limiting, negative factor, but should become a powerful, life-changing tool that enables us to elevate, celebrate, and transcend being old in ways that have profound influences on our personal world and the greater world around us. We can begin to consider the keys to these lifelong explorations and achievements with an interesting thought experiment.

Imagine that you are young again. Some magical potion will transport you down a nostalgic rabbit hole to an age that seems to represent the peak of youth, vigor, and vitality. You can revisit and rewrite your life, making different choices, correcting mistakes, and seeking out the relationships or pursuits you still treasure and those you regret having ignored or left behind. You can make great changes to devise a new future, or attempt to follow the same course that has brought you everything that you value today. It’s an impossible but intriguing fantasy that we all engage in from time to time, perhaps increasingly as the years pass by and more of our life lies behind us than ahead.

And yet it is easy to miss an essential element in these musings. Pull back the curtain to reveal the true master behind these ruminations and you will find, unmistakably, your own well-aged self who is pushing the buttons and pulling the levers. It is all the knowledge, experience, maturity, perspective, balance, and wisdom bequeathed by age that enables you to look back with such keen vision on your life. Would you really trade your current persona for your twenty-one-year-old self to make decisions today? You would have youth, but too much else would be missing. We all think we know the formula to better aging because it is pounded into our eyes and ears and inboxes every day: exercise the body and brain; eat right; drink enough water and get enough sleep; don’t overdo the sauce or the spice. We believe that this formula will make our body and brain more like those of young people, but none of the extraordinary elders described in this book based his or her lifestyle on these factors. Exercise and other healthy actions may improve our body and enable a longer life, but they bring no guarantee of a better life. The true formula is age itself.