Presented to the medical residents and attendings at the Greenwich
Hospital Morning Conference March 9th, 2017
John S. Tamerin, Attending Psychiatrist
Traditionally, one’s 65th birthday was the first step into old age.
In 1900 the average life expectancy was 47. By 1950 it had become 65.
Now, the average life expectancy is 78 ... 76 for men and 80 for women. People 65 years of age and older are the fastest growing segment of the U.S. population.
The question I will try to address in this presentation is this: Can the generation of Americans over age 65 expect to achieve a satisfying, high quality of life as they enter into their 70’s, 80’s and 90’s? The answer is a resounding “yes”, provided they engage in healthy behaviors and patterns of thought starting in middle age.
While a number of different metaphors have been attached to the aging process, such as the machine metaphor (i.e., the body is an aging machine that over time begins to break down), it is clear that as we age our physiology changes. One question is whether these age-related changes are absolute or susceptible to the influence of various interventions, including efforts at prevention. The answer is that many of the age-related physiological changes respond quite well to intervention.
Let’s begin with Physical Activity ...and start with an extreme example of a man who had his picture in the New
York Times suggesting that Age may be no indicator of aging.
The NY Times on February 8th of this year showed a 105-yr.-old French cyclist and record holder. It was reported in the Journal of Applied Physiology that he set a one hour record in cycling in which he rode as many miles as he could around an indoor track in 60 minutes. He pedaled more than 14 miles. Subsequently tested in a laboratory setting, he was found to have the aerobic capacity of a healthy 50 year old. This is obviously an extreme example of a general principle.
There has been a vast amount of research in this area, so I will focus on just a few studies that I found particularly interesting.
In the area of heart health, studies have found that relative to a sedentary person, the older adult who has maintained an active lifestyle has a lower maximal heart rate and a significantly larger stroke volume. As such, the active older adult has the advantage of a larger maximal cardiac output. Obviously, your medical faculty can and probably have said a lot more about this.
Regarding the musculoskeletal system, utilizing an older group, ages 72 to 98, research demonstrated an astounding increase in muscle strength of 113% following only 10 weeks of resistance training. Additionally, the subjects exhibited increases in gait velocity and increases in stair-climbing power. These individuals were all residents of a nursing home, providing good evidence that even frail older adults can benefit from exercise and resistance training.
However, the approach for a healthy future should be proactive rather than reactive. For example, consider the role of exercise in the prevention of osteoporosis. While age-related change in bone health seems like a dire forecast, much like the muscular system, the skeletal systems responds well to regular physical activity. Not only does exercise improve bone health, it also increases muscle strength, coordination, and balance, and leads to better overall health.
The best exercise for bones is the weight-bearing kind, which forces the body to work against gravity. Some examples of weight-bearing exercises include lifting weights, walking, hiking, jogging, climbing stairs, tennis, and dancing.
In a study conducted by Sidney and Shephard, a group of 65-year-old men and woman were followed for one year. The participants carried out a program of aerobic exercise up to four times a week. At the end of the one-year period the group had successfully maintained whole body calcium content.
Fitness and exercise should begin long before we reach older age.
At the outset, the young adult whose life includes regular physical activity has a distinct advantage over the sedentary young adult in that regular participation in weight bearing and load-generating activities develops a higher bone mineral content. And while aging brings bone loss regardless of activity habits, at any given age the active young adult retains a distinct advantage over the sedentary young adult.
As such, according to Shephard it takes many more years for the active young adult to experience bone degradation to such a level as to increase the likelihood of pathological fractures. From these investigations it becomes apparent that if we expect to be successful at staving off the effects of aging and preserving good health, then we must begin a regular exercise routine before age has manifested itself in such a way that it compromises our capacity. Simply stated, the inclusion of regular physical activity into our daily lives is the greatest weapon that we have against the onset of age-related disease and disability.
Now let’s shift to
The significance of psychological factors on healthy aging
A survey of adults age 60 and older found, perhaps not surprisingly, that those with naturally optimistic attitudes were in better health than those more prone to worry, more fearful of change and having more regrets. The more positive-thinking survey participants indicated generally satisfactory acceptance of their lives and circumstances, and belief in their ability to maintain their health and daily activities throughout their remaining years.
One of the biggest emotional threats to healthy aging is loneliness. A study of 2,100 adults age 55 and older, conducted by the Center for Cognitive and Social Neuroscience at the University of Chicago, determined that older adults suffering from chronic loneliness have a 14% higher risk of premature death.
Also striking results from a study at Duke University Medical Center showed that single people are twice as likely to die prematurely as married people.
Studies indicate that 50-70% of all primary care medical visits are related to psychological factors such as anxiety, depression, and stress. Physical and mental health affect each other. For example, older adults with medical problems such as heart disease have higher rates of depression than those who are medically well. Conversely, untreated depression in an older person with heart disease negatively affects the outcome of the disease. Even mild depression lowers immunity and may compromise a person's ability to fight infections and cancers.
The good news for the Baby Boomers is that there is increasing evidence that their behavior at age 50 will impact how they feel at age 80.
A much publicized longitudinal study at Harvard demonstrated that good versus bad aging at age 70 to 80 could be predicted before age 50. This landmark 75 year study followed two cohorts of adolescent boys, including 237 college students (physically and mentally healthy sophomores at Harvard in the class which including JFK) and 332 inner city youths, and followed participants until their death or into their 90’s. For both groups the predictors of healthy aging included: having a positive, adaptive coping style, not abusing alcohol, maintaining a healthy weight, having a stable marriage, and engaging in exercise. Surprisingly, the variables that did not predict healthy aging were ancestral longevity, cholesterol level, childhood temperament (which suggests that we all can grow and change this aspect of ourselves), parental characteristics (i.e. you can have a healthy and successful life despite a negative parental experience), and ease in social relationships (so, if you are shy, it does not predict unhappiness). These findings are hopeful for Baby Boomers because they suggest that we have greater control over our health and happiness even after retirement than previously believed to be possible.
In his definition of healthy aging, Vaillant (the author of this study) in addition suggested that aging well also involves 1. the ability to forgive, 2. to feel grateful, and 3. to experience joy. Such behaviors and emotional states are also largely under our voluntary control.
Most health-conscious men know their blood pressure and cholesterol. But can you recite your Lubben Social Network score? The score reflects your level of “social engagement” or the richness of your social network—including close friends and family. Studies have demonstrated that how connected we are to other people can be as important to healthy aging as not smoking or maintaining a good weight.
Social engagement may also help to preserve one’s memory. Specifically regarding:
Emotional Health and Happiness in Later Life
Depressive illness is one example of a common psychiatric disorder in late life that is often underdiagnosed. So when you see older patients, be vigilant about considering this possibility. Depression in late life is a treatable condition and should not be viewed as an inevitable concomitant of old age.
In the Medical Outcomes Study, major depressive illness was found to be as debilitating as advanced coronary artery disease.
It is particularly important to stay connected with others. The happiest people are those who are the most socially involved.
In addition, authors in this area suggest the importance of finding a broader meaning to one’s life, either through religious involvement or other humanitarian- based efforts in order to have a buffer against the psychologically deleterious impact of stress and adversity.
Incorporating these suggestions into one's life patterns at the age of 50 can influence health in the older adult years.
A number of authors have addressed the theme of Creativity in later life
These authors suggest a new paradigm that articulates the idea of seeing older people for their potential rather than their problems and, as such, defines the emerging field of creative aging.
These authors indicate that Creativity enhances physical health, and enriches relationships. It also constitutes the greatest legacy people can leave to their children, grandchildren, and society as a whole since, historically, elders have functioned as keepers of the culture who pass on the history and values of a community to the next generation.
Recent research has shown that social and recreational activities (including artistic activities) can help older adults live longer, healthier lives. In his book The Mature Mind, Dr. Gene Cohen, director of the Center on Aging, Health & Humanities at George Washington University documents recent discoveries in neuroscience that radically challenge conventional assumptions about the aging brain. For example, though it is true that the brain loses neurons throughout life, studies have shown that it is not the number of neurons that determines intellectual capacity but rather the connections between neurons. These dendritic connections grow and develop when the brain is exposed to a rich, stimulating environment. Studies have shown that between one’s early 50’s and late 70’s, the number and length of dendrites can actually increase.
In 1975, Robert Butler, M.D., one of the pioneers in the field of gerontology, Pulitzer prize winning author and first Director of the National Institute on Aging in his landmark book Why Survive?: Being Old in America, linked psychoanalyst Erik Erikson’s theory of the lifecycle to the process of aging. Erikson had theorized that in the final stage of aging, which he called “Integrity vs. Despair,” the key developmental task was to examine one’s past, come to terms with one’s losses, and celebrate one’s successes, thereby achieving a sense of integrity. Butler connected this process with the presumed propensity among older adults to reminisce—something gerontologists had dismissed as unhealthy, even pathological. Butler, by contrast, saw reminiscence as central to integrating one’s life—working out unresolved issues from one’s past, present, and future—and challenged gerontologists to actively nurture this process. His conclusions strongly support the importance of talking with older patients about their lives and not about just their current illness or symptoms.
Now let’s shift to the area of Cognition As we all know, cognitive decline, especially memory deficits, are associated with
Is it true that as we age, despite levels of physical fitness and general health, we can expect memory and other cognition changes to occur?
Recent research findings are promising in regard to the possibility of modifying or forestalling the cognitive declines that typically occur with increasing age and preventing the risk of Alzheimer’s disease. There is a growing body of research that supports the notion of neural plasticity across the lifespan, suggesting that cognitive and physical stimulation helps to maintain perceptual and memory skills For example, in a study of 800 older men and women followed for 4.5 years, frequent participation in common cognitive activities was associated with reducing the risk of developing Alzheimer’s disease. On average, a person who was at the
In a film called Do Not Go Gently, Dr. Cohen, who founded the Creativity Discovery Corps, featured an architect who, at age 96, submitted a plan for redeveloping the World Trade Center site.
90th percentile for frequent cognitive activity at baseline was 47% less likely to develop Alzheimer’s disease compared to a person who engaged in infrequent cognitive activity.
Regular participation in intellectually stimulating activities and aerobic exercise throughout the lifespan appear to be modifying factors in forestalling and possibly reversing cognitive decline.
Gerontologists indicate that older adults benefit from activities such as working crossword puzzles, learning a foreign language, playing an instrument, learning new computer programs, and visiting museums because they involve information processing that may have a buffering effect against cognitive impairment in late life.
They conclude that any brain exercise is better than being a total mental couch potato. But the activities with the most impact are those that require you to work beyond what is easy and comfortable—just as in physical weight lifting. Playing endless rounds of solitaire and watching the latest documentary marathon on the History Channel may not be enough. “If it's too easy,” the chief of geriatrics at Cambridge Health Alliance and professor of medicine at Harvard Medical School, says “it's not helping you.”
To quote this prominent gerontologist, “Learning new things is really important, because you are using mental skills that you would not otherwise use.” When you are actually learning something, you are creating new neural pathways. That's hugely important.” This seems to be the current mantra.....that the more challenging tasks have the most impact. Taking on a challenge like acquiring new language skills can be very difficult, but the benefits are greater.
Finally, is there any connection between Religion and Physical and Mental Health
Religious practice and beliefs have been found to be a source of psychological help. I was rather amazed to find that religion predicts longevity. In a meta-analytic study analyzing twenty nine articles, researchers concluded that individuals who scored higher on measures of religious involvement were almost 30% less likely to have died during the period represented by the study than those scoring lower on religious involvement measures.
Religious participation also reduces the likelihood of some illnesses. For example, in a sample of 3,963 older adults, those who were religiously active tended to have lower blood pressures compared to those who were less active. However, I was amused to learn that this applied to attendance at religious services and private religious activities, but not to those watching religious shows on television. So there is no easy out.
Finally, I am going to conclude by reading you a letter I recently wrote and sent to my high school classmates. I graduated from a private (then only boys) day school in New York called Horace Mann in 1955 (long before most of you were born).
Almost a third of our class of ‘55 has died. Actually, as sad as that is, we are the fortunate ones – not only for having had such a special educational and social opportunity but to have already outlived the national average life expectancy for males which is 76.4. Statisticians also say that on average, if you have lived to be 65, the likelihood is that your life expectancy is now 84. Many of us will be 80 this year and on average we will live another 8 years.
Enough statistics! The question is now, as Abraham Lincoln famously said, “It’s not the years in your
life that count but the life in your years.”
I have read the obituaries of our classmates with an admixture of sadness and admiration. So many of our classmates have lived full, robust and contributive lives. Perhaps some of the credit goes to the years we all spent at Horace Mann.
The question I would like to pose, however, focuses not on the past but on our present and the future, and asks what are we going to do with the time we have left which, if we are lucky, will be another 8-10 years.
To make this a bit more personal, I continue to see patients as a psychiatrist; I teach medical students and residents; I still write and deliver papers at professional meetings and write op-eds for the Connecticut newspapers (four in the last year warning about the dangers of Donald Trump which clearly didn’t accomplish very much!); play jazz saxophone and do a lot of pro-bono work in the mental health field. Perhaps equally important is the fact that I do a great deal of exercise and still play pretty competitive singles tennis 4 times a week.
24 years ago I went to Israel to compete in the Maccabiah Games in the Masters Tennis division (55 and older). For those of you who are not familiar with this event, the Maccabiah Games were first held in 1932. They are an international Jewish multi-sport event now held every 4 years in Israel. It is the third-largest sporting event in the world with 9,000 athletes competing on behalf of 78 countries.
This year I will be returning to compete in the Grand Masters Tennis event (ages 80-85) since I will be 80 this year. Who I will be up against are most likely former tennis pros and a few ex college players who are still in very good shape. This competition keeps me both young physically and young at heart.
I am sure some of you who have had similar experiences with physical fitness, exercise and competition may be interested in the findings of an extensive longitudinal study of 900 men which explored many areas including their physical activity and included brain scans of each participant.
The brain scans (MRIs) showed that the top quartile of active individuals proved to have substantially more gray matter, compared with their peers, in those parts of the brain related to memory and higher-level thinking. In addition, those whose physical activity increased over a five-year period – though these cases were few – showed notable increases in gray-matter volume in those same parts of their brains. Perhaps most meaningful, people who had more gray matter correlated with physical activity also had 50 percent less risk five years later of having experienced memory decline or of having developed Alzheimer’s Disease.
Perhaps there are significant flaws in this study and we need to remember that these conclusions are based on pooled data so there are obviously notable exceptions. However, for obvious reasons, I personally liked the conclusions!
Finally, in contrast, I realized that “sometimes it’s time to hold and sometimes it’s time to fold” and decided that I would not ski again. My wife developed severe altitude sickness in Colorado and finds the winter weather in the mountains very unpleasant. I, on the other hand, have loved the mountains. I have enjoyed skiing over the years and have developed many very dear friends in the Vail Valley where for 10 years I served both on the Board of Directors and the Board of Scholars of the Vail Leadership Institute. So, I decided I would take one more trip to Mecca, stay with friends, do a few days of skiing and then donate all of my equipment and call it quits.
Attached below is a little video of my last run on the mountain. I thought some of you skiers might get a kick out of it and some of you jazz lovers might enjoy hearing Paul Desmond and the Dave Brubeck Quartet playing “Take Five” in the background.
I hope that I have encouraged or perhaps even inspired some of you when you work with your patients currently or in the future in this hospital or in your private practices to take the time not only to treat their current illness but to educate your patients and perhaps in doing so prevent or at least delay the onset of severe illness or deterioration in their lives. I hope that this brief presentation has been relevant in helping each of you see this aspect of prevention as an important part of your function as a physician.