There is a tyranny in decades; life should not be measured in ten-year packages. Moving on from one to the next is fraught with artificial implications. Whether the number of the supposed turning point is thirty or seventy, it comes with the expectation that we will thereafter be different from how we were before—that we are all at once somehow altered. We treat those seemingly defining moments in what is actually a process of imperceptible transition as though they bear a significance they do not in fact have—as though they are catalysts for an abrupt physical and mental transformation, when they are in reality no such thing. The truth is that the day of transition from one ten-year interval to another is merely a milestone, but we use it instead as a signal that somehow something has changed, or should change. A new set of expectations is inflicted on us—and we inflict it on ourselves—as we leave one cohort and enter another.
Our bodies, for example, do not know the difference. From the viewpoint of their biology, the final morning of fifty-nine is very much like the first morning of sixty. And yet, our minds have already set themselves to a new rhythm. We think we are older. That this calendar-driven self-image is an artifice of culture is not permitted to have bearing on how we perceive ourselves. We give in to this self-image without thinking, as though the jolting acceleration into a new pattern is an inevitability.
What would life be like if we somehow had no way to mark the passage of years? How old would any of us think we were if we had no idea how old we were? We could not act our age if we did not know our age. We could not categorize ourselves into packaged groups of packaged interests and packaged capabilities. We would be much more what we really are: individuals of infinite variation at any age. The lockstep would end.
I am not arguing here for ignoring the passage of time. Nor am I suggesting an insensitivity to internal and surrounding reality. I am merely stating simple biological truth: We live in the biochemistry of our bodies, and not in years; we live in the interaction between that biochemistry and its greatest product—the human mind—and not in a series of decades marked by periodic lurches of change. Each of us exists therefore in a physical, mental, spiritual, and social individuality molded by everything that has come before and that is now brought to this moment of our lives. Each of us is the product of a cavalcade of living, whose sum is in every encounter in which we partake. Each of us is his or her own cohort. No number can define us as middle-aged, or elderly, or the oldest old. We can be defined only by what we have become. Whatever else aging may represent to us, it is first and foremost a state of mind.
And yet all of this is accompanied by that caveat, which needs reiteration here: Age does sometimes forget its own limitations, and inappropriately tries to be youth. Moments of sudden stress are known to encourage such behavior. Refusing to be hemmed in by a number does not mean the number is entirely without significance. Danger can lie in such unguarded spontaneity. Again, think of me, and the incident in the subway.
Many are the reasons for which we try to keep our bodies and minds at their optimal levels of functioning. Among the themes of the forthcoming chapters is the message that the ancient admonition of the Roman satirist Juvenal applies to all of us, no less at eighty than at eight, which becomes more meaningful with each passing year beyond forty. Mens sana in corpore sano, Juvenal advised, or as John Locke would put it a millennium and a half later in a treatise on the education of the young, “A sound mind in a sound body.” But a foolish misapprehension of what is possible must not be allowed to lead one into error.
The danger of forgetting what should be expected of oneself is magnified when reserves have not been maintained, reserves that can respond to the unanticipated demands of everyday life. Though the full vigor of an earlier time is long gone, inner resources may burst forth when an older person has maintained a degree of fitness and self-confidence. We do not necessarily have to conform to society’s traditional notion of what a man or woman should become when the middle years have been overtaken by the years associated in the minds of many with the downward arc of life’s trajectory. I have several times been grateful that I have not been among the conformists, though a few episodes, like the one just described, have occurred because I have overreached, and forgotten to look down.
And so I am offering here what may seem to be a confusing mix of caution and advice: caution about the error of not looking down, and advice about one of the most crucial reasons for maintaining the physical and mental fitness that remains possible as we become older, namely, the possibility of having to call on powers whose use is rarely if ever necessary—whether in a situation of acute danger or in the case of illness. I do not mean to introduce or reveal ambivalence about the relative importance of looking up and looking down—both are equally important. Instead, what I do mean to introduce is the necessity to recognize that as we age, like at any other time of life, we must learn to live with contradictions—and not only contradictions, but uncertainties. The roadway is hardly clear as we attempt to find our way between retaining vigor and a realistic accommodation to its loss, any more than it has ever been clear in any previous era of our lives. That roadway is paved with uncertainty, and in this, too, each of us must find his or her own way, as we always have.
We elders maneuver through uncertainty by paying attention to our minds and bodies more carefully than ever in the past; we must make ourselves keen observers of their needs and their abilities. And in this, the developmental phase that we call aging is indeed different from those that preceded it. We are no longer at a stage where things will care for themselves; nothing can now be taken for granted. We have arrived at a time and place in our lives where we must study ourselves as we have never done before, take care of ourselves, and be attuned to ourselves in ways that are new to us and sometimes burdensome. This requires attention, reflection, and action, not only in regard to ourselves but in regard to the world around us as well. In these ways, we older men and women must all become philosophers.
HOW WE AGE: BODY AND MIND
So accustomed have we become to the portrait of infirmity associated with nursing homes that many of us imagine it to be the norm, and a grim likeness of the waiting future: exhaustion to the point of listlessness, asthenia to the point of sickness, senility to the point of dementia. Visiting those grim holding pens for death, we have become familiar with their sights, sounds, and smells of incontinence, both physical and mental. These are the invariable colors in which life’s final slow decline are commonly painted.
At the same time, each of us prefers to believe that he or she will somehow escape the catalogue of decrepitudes. No matter how close to our lives have been the acquaintances or relatives—including, sometimes, our own parents—who have succumbed to these decrepitudes’ seeming inevitabilities, we cherish the conviction that we can avoid them, not only on account of some magical personal immunity, but also because times are changing so rapidly that such scenes of decline are fast fading from view. We tell ourselves that modern-day medical therapies and increasing knowledge of prevention are markedly lessening the likelihood that we will end our days in a way that Shakespeare’s Jaques in As You Like It described as:
…second childishness and mere oblivion,
Sans teeth, sans eyes, sans taste, sans everything.
But despite reassurances, the specter of dotage does have a way of returning now and then to haunt our darker hours. Even the optimists seem at least occasionally beset by imaginings of themselves tottering unsteadily and oh so slowly toward the grave, finding their grim way by a flickering light barely recognizable as life. Alzheimer’s, Parkinson’s disease, strokes, cardiac crippling, and a generality of similar dwindlings—such are the fears that arise in the minds of those who allow themselves to ruminate on the possibility of end-stage affliction. We encounter the victims of these scourges everywhere, and it is sometimes impossible not to allow the intrusion of their images into one’s own feared future.
Some of us are more resistant than others to such
thoughts, but certain among us are virtually obsessed by them. In attempting to relax the hold these thoughts can have, it helps to know that relatively few of us will ever be confined to a nursing home. In the United States, only 4.5 percent of people over the age of sixty-five are denizened in such places, according to the 2000 census, and the number is gradually declining—in 1982, the figure was 6.3 percent. Not only is the number declining, but the average age of nursing home residents is going up, which means, at least in part, that people are entering such facilities later in life. The decrease in institutionalization may be used as an index of helpless debility in the general population; though plenty of old people are just as infirm in their own homes or the homes of their children, the general statistical trend of dependency appears to be downward, and there are good reasons for the decline.
Whatever other factors may have combined to decrease the frequency of infirmity and institutionalization (such as increased availability of assisted living facilities and adult day care), there seems little question that a changed attitude toward what had always been seen as inevitability has played a significant role. More of physiological loss than was previously realized falls into the category that might be called the atrophy of disuse, a concept clearly stated by Oliver Wendell Holmes more than 150 years ago: “Men do not quit playing because they grow old; they grow old because they quit playing.” Recent clinical studies have confirmed Holmes’s insight. We know important things nowadays about the role played by continued exercise of the body and mind in keeping our machineries running smoothly, whether they be joints, muscles, organs, or the cells and interconnections in our brains.
Advocates of one of several of the major schools of medical thought that existed in the seventeenth and eighteenth centuries called themselves iatromechanists (from the Greek iatros, physician) because they viewed the body as a vast machine made up of innumerable smaller machines. Their philosophy was expressed in a statement made by the Italian medical theorist Giorgio Baglivi in his 1704 book, Opera omnia medicopractica et anatomica:
Whoever examines the bodily organism with attention will certainly not fail to discern pincers in the jaws and teeth; a container in the stomach; water-mains in the veins, the arteries and other ducts; a piston in the heart; sieves or filters in the bowels; in the lungs, bellows; in the muscles, the force of the lever; in the corner of the eye, a pulley and so on…. It remains unquestionable that all these phenomena must be seen in the forces of the wedge, of equilibrium, of the lever, of the spring, and of all other principles of mechanics. In short, the natural functions of the living body can be explained in no other way so clearly and easily as by means of the experimental and mathematical principles with which nature herself speaks.
This simplistic view of bodily functioning would in later centuries be superseded by the realization of biochemical complexity and cellular dynamics, but it retains a certain metaphoric truth that has continued to appeal to scientists and teachers. The most popular small textbook on human structure and function during my medical student days in the 1950s bore the title The Machinery of the Body. Its authors, two physiologists named Anton Carlson and Victor Johnson, chose their title because it reflected with a certain clarity their sense of how best to convey an overall impression of the multitude of physical activities constantly at work within us. First published in 1930, the book required repeated printings of each of its five editions, culminating in the final one in 1961. Even today, a search on the Internet, under “The Machinery of the Body,” lists what are described as “40 Million Books in One Web site. Used, New, Out of Print. Low Prices.” The metaphor continues to be useful.
Especially in relation to running smoothly, the imagery of the body as machine will always apply. With respect to aging, the parallels are particularly apt: Aging parts work better when heed is paid to their maintenance; they require more attention than they did when they were new; they must be not only well cared for, but kept in active, albeit judicious, use.
Such analogies with machinery are hardly perfect, but they can nevertheless be carried just a bit further. As with machines, some human bodies are inherently built to last far longer than others, not only in respect to individual parts but pertaining also to their entire structure. In much the same way, inherited DNA influences longevity of each of our organs and the whole, but proper maintenance and appropriate use will maximize not only function but life expectancy as well.
The point is that individual men and women age at different rates, and much of the difference is dependent upon their inborn genetically determined constitution. Coming from a line of nonagenarians makes one prone to long life, for example, but does not guarantee it. There is, however, a flip side to this: Because of the way DNA does its somewhat haphazard mix-and-match, and because genes can express themselves in different ways depending on various internal and external influences, the predisposition to a long life not infrequently appears within a family whose members have been known to die early or at normative ages. Unfortunately, the opposite is true as well.
And also as with machines, a distinction must be made between parts that are frankly broken and parts that are merely showing the physical evidence of normal long usage. In regard to ourselves, it is important to recognize the distinction between aging and actual sickness. In some respects, this is no simple matter, even for physicians. But in other respects, the difference, once pointed out, is easily appreciated. Though aging does bring with it an increased vulnerability to certain illnesses, they are hardly its inescapable accompaniments. Aging is not a disease. It is a risk factor for many diseases—in the sense that older men and women are progressively less able to marshal the forces to withstand the encroachments of sickness—but it is not in itself a form of pathology.
Another way to look at the relationship between aging and disease is to imagine the later decades as a long continuum whose final destination is one or several named sicknesses—such as stroke, diabetes, or heart disease—but whose intervening points consist of relatively normal, though somewhat modified, functioning.
Stroke, for example, is a pathological condition, and not a normal consequence of aging. Its occurrence is made more likely by certain changes that are part of the ordinary growing older of blood vessels, but it is, most emphatically, a disease. Not only do the vast majority of people in their eighties and nineties not fall victim to strokes, but measures can often be taken to prevent strokes or lessen their effects, by applying awareness that their incidence increases with the passage of time. Alzheimer’s, Parkinson’s disease, coronary heart disease, cancer, diverticulitis, osteoporotic fractures—all of these and many more are examples of pathological conditions to which the older body is more prone than the younger, but which are nevertheless not to be expected as a consequence of normal aging.
Many men and women reach great age without sickness; more remarkably, many men and women reach great age without significant disability, though their machinery has lost some of its previous efficiency. For such men and women, the disease that finally comes along and kills them is likely to be of relatively short duration.
Everyone who has ever owned an automobile knows the importance of maintenance, but its application to the human body has become fully appreciated only within perhaps the last generation. In this as in all other considerations involving ourselves, biology is not necessarily destiny. Take, for example, the predisposition to obesity. Recent research indicates that obesity is largely determined by DNA. But despite that, it is also well known that lifestyle changes can modify—often substantially—what would appear to be the ordained consequence of heredity.
Sometimes, of course, the most scrupulous of maintenance will not add an hour to the life of an automobile whose parts are not built for long wear, but the opposite is far more likely to be the case: Taking good care of parts extends their usefulness and the usefulness of the whole machine. We now know this to be applicable to ourselves. Of the many reasons why a sixty-year-old of today looks, feels,
and acts younger than a sixty-year-old of half a century ago, one is improved attention to upkeep.
Of all the factors that constitute human maintenance, improved methods of medical therapy appear to be among those of lesser importance, at least for any one individual. Responding to breakdown or its imminence is far less effective than prevention and attention to self-improvement, which have become increasingly recognized as the keys to healthy longevity. Even as the relentless inroads of time on our cells, tissues, and organs are taking place, their effects can be mitigated, slowed, and sometimes even reversed by proper attention to the kinds of maintenance that bodies routinely carry out on their own when they are younger. There comes a stage of life when we can no longer depend on the efficiency of nature’s tendency to repair cellular irregularities and preserve physiological balance. As this dependability lessens incrementally throughout the middle years and later, we need gradually to take over the job ourselves.
The Art of Aging Page 2