Elderevolution - A Recent Speech
Secrets of Successful Aging: An Expert Interview With Dilip Jeste, MD
Successful aging lacks a clear definition. Elizabeth Saenger, PhD, Medscape Psychiatry & Mental Health Program Director, speaks with Dilip Jeste, MD, Director of the Institute for Research on Aging, University of California, San Diego, about the impact of the mind and the body on aging. How do they influence and predict success?Medscape: How do you define successful aging?
Dr. Jeste: Successful aging has not been consistently defined; that is one reason why this area is ideal for research. There have been some studies funded by the MacArthur Foundation beginning in the mid-1980s going on through the mid-1990s. But the [scientific] literature is limited, and there is no consensus on what is successful aging. Our research goals include developing a definition as well as criteria for successful aging.
At this stage, we think that there are several elements or domains that are important constituents of successful aging:
Higher level of cognitive functioning; Adaptation to changes associated with aging; Socialization -- that is, some kind of social activity and/or social contacts; and Life satisfaction.
It is also important to say what is not an essential part of successful aging -- absence of either physical diseases or physical disability is not necessarily a part of successful aging. I want to stress that people who have physical illnesses or physical disabilities can be aging successfully. However, severe dementia or severe mental illness cannot be a part of successful aging. Optimal functioning of the brain and mind are primary components of successful aging.
Medscape: Can you tell us a little bit more about those different components? What has your research uncovered about cognitive functioning, adaptation to change, and so on?
Dr. Jeste: About 1 year ago, when I took on my current position at the Institute, we started to consider what defines successful aging by first reviewing the existing literature. But, as I already mentioned, the literature is limited. There are several reasons for the lack of literature on successful aging:
The definition has been inconsistent.
It is not clearly diagnosable.
It is somewhat esoteric.
In other words, it's easier to do research on, say, cancer or diabetes, even schizophrenia or depression. It is much harder to do research on something like successful aging.
There is a stigma about aging -- a kind of cultural belief that successful aging is a misnomer or even an oxymoron.
Aging is associated with loss of abilities, illnesses, dementia, and depression. Many believe that life just goes downhill in old age. Given that kind of pessimistic, almost nihilistic, attitude towards aging, people have not focused on aging successfully. At the same time, the population is growing older, and increasing numbers of people are living healthy, functional lives well into old age.
After completing our literature review, we started to look at people from San Diego County living in retirement communities as well as those attending an extension course at University of California, San Diego (UCSD) called Institute, available for retired or semiretired people to take classes or seminars. The third and largest cohort from whom we are collecting data is the Women's Health Initiative (WHI). As you and many readers may know, WHI is a very large National Institutes of Health (NIH)-sponsored study that has been going on for the last 12 to 13 years or longer. It involves roughly 150,000 women in the United States. For our purposes, we evaluated the contingent of women from San Diego County; there are about 6000.
We have been conducting surveys in each of these 3 groups of subjects, most of whom are over the age of 60. After gathering background, demographic information, and a medical history, we ask them whether they think they're aging successfully, and we have them rate themselves on a 1 to 10 scale. We also ask about physical illnesses, disabilities, health behaviors (smoking, drinking, etc.), physical activities such as exercise, mental activities like participation in classes, and use of computers. Then, we ask a series of questions about their resilience -- how they adapt to the changes of aging -- and whether they feel that they have control over their lives. Finally, using rating scales, we ask them to rank factors like their level of function and quality of life.
We have found that a surprisingly large proportion of older adults surveyed report that they are aging successfully; our results also suggest that this perspective, this self-perception, is not related to type of physical illness or degree of disability. People can have diabetes, hypertension, arthritis, even cancer, heart disease, or stroke and still age successfully. The key seems to be for one's brain and mind to function at optimal levels.
Medscape: Can you speak more about resilience?
Dr. Jeste: To measure resilience, we use the Connor-Davidson Scale[1] which is designed to find out how people adapt to stress and to change. To some extent, changes are inevitable with aging -- loss of mobility from arthritis, for example, or problems with vision or hearing, financial stress from retirement, and loss of friends, family members, or even one's spouse.
In many cultures, there is a stigma associated with aging -- a sense of lack of value or lack of self-esteem, often related to the way the society views aging. In addition, healthcare costs go up. These particular stresses are, for the most part, universal; the question is how do people adapt to these stresses? That's where people differ. One person may be totally overwhelmed with a physical illness or loss of a near and dear one, while someone else is stressed out for a short time, but then recovers from the situation and adapts to the change in a positive way.
Medscape: What makes some people react in one way rather than another?
Dr. Jeste: That's a billion-dollar question! It seems that both genes and environment play an important role. Genes play an important role not only for longevity, but also for how well people live. There are genes that predispose to diseases and genes that predispose to healthy living, as well as genes for personality, coping strategies, and resilience.
At the same time, I think we are not necessarily slaves to our genes. Many people say that to live a long and healthy life, choose your parents wisely. That's not exactly true. Studies have shown that less than 50% of longevity is accounted for by genetic factors. Plus, environment and behavior have a significant impact on the expression of genes. For example, 2 people may have similar genes, but one develops lung cancer because he smoked, while the other one does not.
Another interesting concept emerging from the literature is neuroplasticity of aging. There are some studies showing that the brain can continue to grow or develop even in old age. In other words, neuronal regeneration can occur, under certain circumstances, as we age. It has been shown in animals, for example, that a stimulating environment facilitates regeneration of neurons in our brains. Just that suggests that [a stimulating environment] might facilitate neuroplasticity of aging and, thereby, successful aging.
Medscape: Can you give a few examples of people who have aged successfully?
Dr. Jeste: Franklin Roosevelt was a great example of somebody with a physical disability -- in a wheelchair most of his life -- who was amazingly successful. Another example is the story of an 83-year-old man named Frank White, published in The Los Angeles Times earlier this year.[2] Until the age of 68, he was aging unsuccessfully. He had severe diabetes, hypertension, and arthritis. He was an alcohol abuser and a dependent person. It looked like his life was going downhill. At 68, he had a turning point and decided to change his lifestyle. He stopped drinking, and took to yoga. (This is not an ad for yoga, but yoga can be more than physical exercise.) Frank became so good at yoga that now he has become one of the most acclaimed yoga teachers in Hollywood, which is a feat, given the numbers of yoga teachers in Hollywood. He still has diabetes and hypertension, but they are under much better control. He is a prime example of how you can take control of your life and change it.
I don't mean to be simplistic, however. Not everybody can make such changes. Many people have serious physical illnesses over which they have no control and, in spite of the best treatment available, cannot do much. Again, I don't want these points to sound naive. The main message is that there are things within one's control, and certain changes can impact one's physical health, even though they don't determine one's physical health.
Medscape: Along these lines, can you talk about physical exercise and its impact on mood and successful aging? For instance, isn't there research suggesting walking on a regular basis instead of going to therapy or in addition to going to therapy is a great mood enhancer?
Dr. Jeste: There have been some great studies in mice and in dogs showing that exercise not only improves physical function but also brain function. In other words, it is not merely improvement in mood -- I mean, it's hard to assess a mood in mice, right? But their neuronal function improves.
There have been several well-controlled studies in people as well that show that physical exercise not only improves mood, but also improves cognitive function. There are studies showing that exercising during your 50s is associated with better functioning when in your 60s. Exercise need not be strenuous exercise; you don't have to climb mountains or anything like that. Just improving your level of physical activity on a consistent basis has a positive impact.
Medscape: Would you say, then, that physical activity is essential for successful aging.
Dr. Jeste: Physical activity is one key element for successful aging, but mental activity is essential as well. You must keep your mind active by reading, writing, attending classes, etc. Aging is often associated with retirement, but that should not mean retirement from learning new things. There is a certain myth that you can't teach an old dog new tricks. In fact, that's totally wrong. Even Freud said something along these lines that was wrong. He said that people over the age of 50 don't have the capacity to learn new things, suggesting that doing any kind of reconstructive therapy in old people is a waste of time. Of course, he was talking about classic psychoanalysis, which may be different, but old people can learn new things. Not only that, people who try to learn new things, actively engaging their minds in the process, are much more likely to age successfully than those who do not.
Medscape: Is there anything you would like to add?
Dr. Jeste: Well, in my opinion, successful aging should be considered a neuropsychiatric entity and, as such, of particular interest to mental health clinicians. To date, we have not been involved enough; I think that should change.
Also, the typical attitude toward aging is quite negative. When we read in the papers about the population growing older, there is a sense of gloom and doom about how much we are going to spend on healthcare and Social Security. As a culture, we need to look at the positive sides of aging; aging can be associated with continued productivity, learning of new things, and better contributions to the society. There are things that old people can do through their wisdom and experience that would not be possible for those who are younger.
Medscape: Thank you very much for sharing your insights and for ending on such an optimistic, positive note.
References
Connor KM, Davidson JR. Development of a new resilience scale: the Connor-Davidson Resilience Scale (CD-RISC). Depress Anxiety. 2003;18:76-82.
Stein J. At 83, this yogi is bending the rules; Frank White likes to mix things up. And his classes are packed. Los Angeles Times. May 10, 2004.
HIDDEN EPIDEMIC
Substance abuse, specifically of alcohol and prescription drugs, among adults 60 and older is one of the fastest growing health care problems facing our nation. Yet, even as the number of older adults suffering from these disorders climbs, the situation remains under-estimated, under-identified, under-diagnosed, and under-treated. Until recently alcohol and prescription drug misuse, which currently affects up to 20 percent of older adults, was not even discussed in either chemical dependency or gerontological literature.
Because of insufficient knowledge, limited data, and hurried office visits, health care providers often overlook substance misuse among older adults. Diagnosis is difficult because symptoms of substance misuse often mimic symptoms of other common disorders in older individuals; such as diabetes, dementia, and depression. Additionally, drug trials of new medications often do not include older subjects, so a clinician has no way of predicting or recognizing an adverse reaction or unexpected psychoactive effect.
Other factors responsible for the lack of attention given to substance misuse in this population include the older adult's disapproval of and shame about misuse of substances, as well as a reluctance to seek professional help for what many in this age group consider a private matter. Relatives of older individuals with substance use disorders, particularly their adult children, are also ashamed of the problem and choose not to address it.
The attitudes of Ageism as well contribute to the problem, and to the silence. Younger adults often unconsciously assign different quality-of-life standards to older adults. Such attitudes are reflected in remarks like, "Grandmother's cocktails are the only thing that makes her happy," or "What difference does it make; he won't be around much longer anyway."
There is also an unspoken but pervasive assumption that it's not worth treating older adults for substance use disorders. Behavior considered a problem in younger adults does not inspire the same urgency of care in elders. Along with the impression that alcohol or substance misuse problems cannot be successfully treated in older individuals, there is the assumption that treatment for this population is a waste of health care resources.
These attitudes are not only callous, they rest on serious mis-perceptions. Most older adults can and do live independently. Only 4.6 percent of adults over 65 are nursing home or personal home care residents. Furthermore, Grandmother's cocktails are not cheering her up. Older adults who "self-medicate" with alcohol or prescription drugs are more likely to characterize themselves as lonely and to report lower life satisfaction. Tragically, many elders lose their “golden years” to alcoholism and chemical dependency, diseases that are very treatable.
The fact is that compared to a national average of from 15 to 20 percent for all other age groups, the recovery rate for older adults is an amazing 75 percent. And those of us who are working to address this hidden epidemic need others to understand that, contrary to popular perceptions, older adults are not simply a generation of has-beens, they are a generation about which much has yet to be discovered.
© Rabon Saip 2009
Elderevolution - A Recent Speech
The good news is - humankind has finally achieved a substantial measure of longevity. There are more people living longer today than ever before: The bad news is - humankind has finally achieved a substantial measure of longevity, and hardly anyone wants to go there. Aging is so associated with losses, with chronic illness, dementia and depression, most of us simply believe that life just goes downhill in old age. But, as we learn more about this curiously new and relatively unexplored stage of life, we find that more and more people are actually aging successfully.
I believe we are in the midst of a profound transition, possibly the most important transition in the history of our species. Today I would like to offer a brief historical overview of aging, speak of how this relates to prescription drug and alcohol misuse among our elders, and then take a brief look at where we might go from here.
For thousands of years, life expectancy remained relatively unchanged, increasing only incrementally over the centuries.. During the Greco-Roman era, average life expectancy was roughly 25 years. For the vast majority of Greeks and Romans, life was short and brutal; but, for a privileged few, life lasted much longer. Hippocrates died at 83. Sophocles wrote his last play at 90. Plato lived to be 80. Socrates drank the hemlock at 70. The reasons for this discrepancy have to do with the difference between life expectancy and life span.
It has long fascinated me that the life span established in the Book of Genesis (120 years) is exactly the same as that established by medical science thousands of years later (for which there is evi-dence we may someday attain). Just for review - life span is our biological potential, while life expectancy is average age at death in a given society.
By 1776 in our culture, life expectancy had increased to 37 years. By 1900, it had increased to 47 years. Then, our life expectancy increased more in just one century than it had in all the preceding 5000 years, rising to 77 plus yrs by the year 2000. And so, just since the founding or our nation, our life expectancy has more than doubled. But what does this mean for us today? How are we affected as a society?
First of all is the unprecedented disconnect between our social systems and biological reality. Century after century, the time frame of our social systems was pretty much in synch with the time frame of our biological lives. Individuals could be born and could die within the mainstream of their social institutions. But now, due to this rash of longevity and increasing numbers, elders are outliving the traditional limits of society. A person can now be biologically alive and yet be socially dead.
“Aging is universally experienced - without regard for race, class, income, education, religion or gender - yet for the most part, it is experienced in isolation.” And, this isolation amounts to psychological death; the loss of identity, the loss of autonomy, and the loss of a sense of control.
If I were to ask anyone in this room “who are you,” you would answer by telling me what you do - that is your identity. Consider the loss many elders face. You have worked hard all your life, paid taxes and raised a family, maybe served in the military, done your part for country and community; but then, medical science conspires to keep you alive as long as possible; for what: so that you can enjoy a quality of life no one wants? Even the pace of technology seems to conspire to rob you of your dignity. The authentic value of what you have to offer your children and grandchildren may seem quaint and out-dated to them.
Nevertheless, Carl Jung observed that: “A human being would certainly not grow to be seventy or eighty years old if this longevity had no meaning for the species..” So why do you suppose we live these additional decades beyond our need to reproduce and raise children? Why do some of us achieve what has been called Post Parental Androgyny, the capacity to embody and balance both the masculine and feminine spirit - in fact, to become more whole human beings? What if the human life course is all about reaching our full potential and we are actually kicking our most realized citizens to the curb?.
Current research shows that the aging brain develops in ways we had never before imagined. Generation of new neurons and dendrites, a high degree of emo-tional regulation and discernment, capacity for holding both positive and negative emotions at the same time; a more detached and universal awareness; a capacity for distraction and dis-inhibition, as in the creative brain; production of novel associations, broadening knowledge base, focus of attention and diminished need to please or conform ---- all these are features now recognized as part of the aging brain; which, when combined with decades of experience and learning, could amount to a uniquely valuable resource.
However, our society has not yet matured to the point of integrating this valuable resource. Unfortunately, we live in a world dominated by a cult of adulthood, a cult that commands the life course in both directions. The young are hurried up to become consuming adults and adults are encouraged to stay young forever, to hang on to youth at all cost. Until we stop comparing youth to old age, seeing elders only as adults in decline, we will continue to feed the despair that ferments at the core of prescription drug and alcohol misuse among elders, and self medicating against the painful indignity of a degrading decline will continue.
Anthropologist David Guttman said: “We do not have elders because we have a human gift and modern capacity for keeping the weak alive; instead, we are human because we have elders.” I really didn’t get the full meaning of that statement when I first read it. But now I realize that if it had not been for the first grandmother to sustain her daughter and help feed her grandchildren, we would not be here today.Joan Halifax said: “The wisdom that we need to solve our problems lies encoded in the depths of our unconscious minds, but it must be evoked by elders who reveal our potentials.”
As I said at the beginning, I believe we are in the midst of an important transition, an evolution of society that will ultimately lead to an active inclusion of all generations. But for now, the coming age wave of boomer-elders will be an over-whelming tsunami for those who are stuck with old age stereotypes and archaic institutions of the 20th century. All they will see is a problem. But for those of us who are willing to embrace the risk of not knowing, the mystery of change could be revealed as a blessing. I believe that many of those boomer-elders now seen as a problem will in fact create their own solutions.This will not be easy. It will require courage, creativity and dedication. So to those of you in this room who will be a part of that movement, my heart is with you. I believe the integration of elders will take place and it will re-define our society. Thank you.
© Rabon Saip 2010