Society is increasingly preoccupied with aging. This interest is reflected in the growing number of movies (“Cocoon, “Driving Miss Daisy”, “Tatie Danielle”), television shows (“Golden Girls”) and ads (television even has brought adult incontinence products out of the closet). Similarly, growing political and economic concerns relate to the effects of aging both on society in general and specifically on our capacity to maintain our present health care system and pension plan. These fears are not unfounded. Between 1981 and 2001, the proportion of the population older than 65 years will increase by 30%, with the proportion of those older than 85 more than doubling.

We have become increasingly preoccupied with life expectancy, defined as how long a given age group is expected to live under present conditions. Active life expectancy is how long we are expected to live an active and independent life. Maximum life-span is the theoretical limit of life, were we to be free of all risk factors and environmental dangers.

When Woody Allen was asked whether he was trying to achieve immortality through his films, he answered that he would rather achieve immortality by not dying. However, most people are interested in not only living longer but also “living healthier.” The goal is to add life to years rather than merely add years to life. There are real concerns about diet, exercise, lifestyle, and prevention, which sometimes become obsessions. There is also a whole industry giving advice on these questions. As a result, schemes such as the Life Extension Foundation suggest that we could all be 21 again if only we shelled out hard cash for their “rejuvenation therapy”. What, then, should we be saying to our patients, genuinely concerned with aging but constantly bombarded with all sorts of advice and solutions?

Preoccupied by longevity

Humans have been preoccupied with longevity throughout history. The ancient Romans recognized the problems of aging and the danger of being dependent. According to their mythology, the goddess Aurora fell in love with a mortal, Tithonus, who was granted eternal life. Unfortunately, he neglected to request eternal youth also. As a result, Tithonus grew older and feebler until he finally begged to be released from life and allowed to die, whereupon Aurora turned him into a grasshopper. Humans have always sought to live long but at the same time have dreaded being old.

Throughout history, aging has either been represented by the dignified sage or by the decrepit old demented person. Browning gave these words to Rabbi Ben Ezra:
Grow old along with me
The best is yet to be
The last of life
For which the first was made.

On the other hand, Freud said, “Maybe the gods are merciful when they make our lives more unpleasant as we grow old. In the end, death seems less intolerable than the many burdens we have to bear.”

Throughout history, there have been three categories of theories on how to achieve old age. The first is the biblical theory, where an extended life-span is granted to the righteous. The second theory holds that there are special places in the world where people live for a very long time. The third, the one to which modern society subscribes, is that you can actually do something to ensure a longer life.

Redefining human aging

During the first 40 years of this century, life expectancy was greatly increased by reducing neonatal, infant and maternal mortality. Yet, for a long time, there was little difference in the life expectancy of a 60-year-old living in 1920 and someone of the same age living in 1950. Recently, there has been an increase in life expectancy even after the age of 60 that is probably caused in part by the decreasing incidence of cardiovascular risk factors. With changes in the environment, decreasing risk factors, and new medical discoveries, Fries hypothesizes that one could remain generalllmedical discoveries, Fries hypothesizes that one could remain generally healthy for the maximum life-span, and then drop dead. This is referred to as “squaring” of the mortality curve.

On the other hand, Olshansky, Carnes and Cassel believe that further gains in life expectancy will be modest, even if major causes of death are eliminated. For instance, eliminating all forms of cancer will add only just over 3 years to the life expectancy of men. Eliminating all forms of ischemic heart disease will increase life expectancy by another 3.55 years, and eliminating combined cancer, heart disease and diabetes increases life expectancy at birth by only 15.27 years. However, morbidity compression might not occur. Even if improved lifestyles and medical technology strip away lethal processes that end life early, left behind will be a rapidly growing elderly population that lives longer, but whose additional years of life are dominated by disabling conditions, such as arthritis, osteoporosis, sensory impairments, parkinsonism, and Alzheimer’s disease.
Ibn Sina, a respected Persian physician (born 980 AD), said that “the art of maintaining the health consists in guiding the body to its natural span of life. It is not the art of averting death or of securing the utmost longevity possible to the human being.” This theme resurfaces in recent articles, which assert that changes associated with aging could have been wrongly attributed to aging itself. Decreased glucose tolerance, relative increase of body fat to lean body weight, declining cardiac and renal functions, osteoporosis, and decline in certain areas of cognition have all been considered as normal age-related changes. Many of these changes can be prevented or modified with diet, exercise, changes in lifestyle, and social support. Rowe and Kahn therefore suggest that we have to distinguish between usual or normal aging and successful aging.

What to say to our patients

Many magazines inform our patients of the latest miracle cures and treatments and how to “stop aging where it starts”. For example, in the January 1991 issue of Longevity, there is a review of Europe’s top age-reversing drugs. One of the drugs mentioned is tetrahydroaminoacridine (or THA), despite the fact that, in a recent Canadian study, it was shown to be ineffective as a treatment for Alzheimer’s disease.

Other, more legitimate, suggestions include taking vitamin E as an antioxidant and lecithin as a choline precursor. Every possible form of fibre has been recommended. It has been suggested that tretinoin will keep our skin free of wrinkles and human growth hormone will maintain our lean body mass. Although some of these hypotheses are based on serious research, none are applicable yet to the general population.
What, then, do we say to our patients about successful aging? The suggestion is that one choose one’s parents very, very carefully! Failing that, what else can we do to optimize our genetic predispositions?

The best advice is what most family physicians are already advising their patients: eat a proper diet with a reasonable amount of fibre and calcium, and a limited intake of salt and cholesterol (depending on the presence of other risk factors); engage in a reasonable amount of exercise; avoid smoking and excessive alcohol intake; wear a seatbelt; protect one’s skin from the sun; keep physically and intellectually active throughout one’s adult life into the so-called golden age; and undergo periodic health examinations with one’s family physician to identify risk factors and determine necessary changes in diet and lifestyle and the use of medication.

To have an effect on successful aging, these habits and lifestyles must be adopted early in life and maintained. However, controlling hypertension, ceasing to smoke and initiating exercise can have a positive effect, even if begun later in life.

Conclusion

There is no fountain of youth and certainly no miracle medication. Reduction in major causes of mortality, such as cancer and cardiovascular disease, will contribute to only a modest increase in life expectancy. More usefully, perhaps, research on degenerative disease, such as arthritis, osteoporosis, Alzheimer’s disease and Parkinson’s disease, will permit us to add life to years and increase active life expectancy.
In the meantime, we should focus our patients on successful aging, rather than on miracle drugs or spas. As George Burns said at his 95th birthday, puffing on a cigar, “I love life so much, I want to do it again.”

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