The Art of Aging

by Sherwin B Nuland

  And major changes are being made. For several decades beyond the time when the nursing homes were beginning to increase in number and the population of frail elderly at home was seen to be rapidly rising, not much progress occurred in ameliorating the conditions faced by old people every day. But the situation began to improve about twenty-five years ago, as more and more studies were undertaken of the factors that determine the disabilities of the aged. At the same time, the still small number of gerontologists—scientists who investigate the process of aging—were increasingly turning their attention toward seeking ways to lessen the ravages of the added years that had been granted to the patients they were studying.

  The field underwent a significant philosophical revamping in 1980, when Dr. James Fries, a gerontologist at Stanford University, introduced a concept he called “compression of morbidity.” By this, Fries meant the attempt to decrease the period during which any elderly person is disabled. In general, most of us are now fated to endure a final period of years during which we become ever more frail, with the trajectory of decline sloping downward more markedly after the age of around fifty. Fries hypothesized that measures could be taken to change the long, gradually drooping arc with a pattern that more resembled a relatively horizontal line ending in a rapid drop-off shortly before death. If this was accomplished, he pointed out, “then lifetime disability could be compressed into a shorter average period and cumulative lifetime disability could be reduced.” In other words, instead of a long period of worsening frailty and illness, our bodies would stay relatively intact and then give out much closer to the time of eventual demise. It is a concept very like the one Oliver Wendell Holmes wrote about in his poem “The Deacon’s Masterpiece,” in which he describes “the wonderful one-hoss shay, / That …breaks down, but doesn’t wear out.”

  You see, of course, if you’re not a dunce,

  How it went to pieces all at once,—

  All at once, and nothing first,—

  Just as bubbles do when they burst.

  There are those, of course, who would like to die “all at once,” but others would prefer a short period of decline, providing that it is not at all like the agonized waning that so many suffer today. For large numbers of Americans, this is precisely what is already beginning to happen. And there is evidence that such compression of morbidity is within the reach of far more of us.

  Among the first steps in the process of change was the realization that physical frailty, and not disease itself or any named pathology, is the most important determinant of whether an elderly person can care for himself and remain a vital contributing member of the community. The older the subject, the more important becomes the role of such factors as muscle strength and bone density, particularly the former. Study after study has confirmed this observation, best stated by a team of gerontologists from the Netherlands in a paper published in Science in 1997, as follows: “In the oldest old, loss of muscle strength is the limiting factor for an individual’s chances of living an independent life until death.” The operative words here are “until death.” Before the publication of the Dutch report, and since, repeated studies have shown that feebleness in the elderly not only is preventable but, with an appropriate exercise program, can actually be reversed. Imagine a world in which every very old person might continue to care for himself, enjoy his surroundings, and sustain his loved ones instead of the other way around. And all of this happy state of affairs would go on until near the time of his death.

  To the amazement of many a physician who has a large geriatric practice, it has proven to be not difficult to build the necessary muscle, even in the very elderly. It is consistently shown that strength can be almost doubled within six or eight weeks in the oldest old, merely by a supervised regimen of high-intensity resistance training and weights. Though the link between exercise and longevity may no longer be news, only relatively recently has loss of muscle strength been recognized as a major element in causing the disabilities that overtake us as we get older.

  In a groundbreaking report published in 1990 in the Journal of the American Medical Association and verified by numerous later studies of both men and women, researchers at Tufts University were able to increase the leg muscle strength of ten frail women between the ages of eighty-six and ninety by an average of 174 percent. This was accomplished in a period of eight weeks through a regimen of supervised high-intensity weight training. Although all of the old women in this first study had chronic diseases or disabilities, none of them sustained injuries as a result of the exercises. Their balance improved and so did their walking speed. Among the surprising findings in the many confirmatory studies done since that time is how rapidly the benefits of resistance training become apparent, both by measurements and by improvement in activity.

  An example of one of the many supporting studies done subsequent to the Tufts report was one that appeared in February 2006 in the Journal of Aging and Health. Gerontologists at the University of South Florida divided a group of sixty-four volunteers with an average age of eighty-four into three groups: no exercise, walking twice a week, and resistance training twice a week. Though generally healthy, some participants needed canes or walkers for their exercise sessions. The results at the end of the sixteen-week study period were not surprising to anyone who had followed the academic literature of geriatrics for the previous decade and a half. The benefits to both categories of exercisers were not confined to improvements in muscle strength. Compared to the inactive group, they had improved not only their upper and lower body strength, but also their performance on tests of agility, balance, and coordination. An added though not entirely unexpected bonus was their lowered systolic blood pressure over the study period. Confirming previous suggestive findings, the researchers pointed out their impression that it may be exercise per se, rather than its type, that results in the observed findings.

  But improving muscular power and perhaps other body functions like blood pressure is only part of the answer—the brain needs plenty of attention too. It is by now no secret that continued intellectual stimulation is the key to avoiding many of the ravages of dementia and the apathy that steals the minds of so many institutionalized and homebound elderly. Granted, all the reading and museum-exploring in the world are not likely to reduce the incidence of strokes both large and small, but such activities maintain synapses and probably encourage the development of new brain cells regardless of age. They keep us alert, mentally vital, and curious.

  If such factors as vigorous mental and physical exercise have such great benefits for the aged, how much better would the situations of old folks be had they started such exercise far earlier than the period of rapid decline? Though the changes that begin in our late twenties are minimal at first, they speed up after about age thirty, when CT scans actually show evidence of the falling off, such as decreased muscular density and narrower cross-sectional dimensions in the thigh, as well as increasing amounts of fat within individual muscles. Once we reach age fifty, our tendency to dwindle really takes off.

  And so, though loss of muscle strength is the limiting factor for the independence of the oldest old, it quite obviously can have profound effects for the rest of us too, and much earlier than most people have realized. But cheer up. As the fitness experts tell us, studies that began with the oldest of the old—those men and women beyond the age of eighty-five—have been extended to younger subjects, with results that are virtually the newest of the new: Such deterioration does not necessarily have to take place. The answer is anaerobic exercise—activity in which the body incurs an oxygen debt. Aerobics—jogging, running on treadmills, pedaling real or stationary bikes, and the like—may do wonders for the heart and lungs, but to ward off feebleness and its associated debility, nothing replaces resistance training with weights. So impressed has the American College of Sports Medicine been by the demonstrable benefits of resistance exercises that it now recommends weight training for all men and women over the age of fifty.

>   Weight training has yet another advantage over aerobic exercise alone: It uses more calories than such activities as walking, running, or swimming. The reason is that heavy exercise breaks down muscle fibers, whose rebuilding into even greater strength by the body’s natural reparative processes requires considerable energy and accordingly burns up lots of calories. On top of that, every new pound of muscle requires thirty to forty calories per day just to maintain it, even when it is at complete rest. So it behooves us all, young or old, to hie ourselves to the nearest gym.

  The atmosphere of the typical gym may not at first lend itself to thoughts of mental improvement, but we should think again. Recent studies have found that aerobic fitness in older men and women appears to reduce the loss of brain tissue and improve cerebral functioning. It does this by elevating the levels of brain-derived neurotrophic factor, to which reference was made in chapter 2. BDNF acts to increase the number of synapses, promote the development of new capillaries in the brain, and protect neurons against the damage caused by free radicals. In addition, there is evidence that BDNF may encourage the development of new neurons from adult stem cells. The good news does not end there. Studies done on subjects who have added weight training to aerobic exercise indicate that the combination results in even greater improvement in cognitive functioning than aerobic exercise alone.

  Such findings need to be snatched up by all people of all ages. Those of us who are getting on in years, in particular, should snatch them up and run with them—literally. Study after study has shown that exercise of mind and body is the key to increased longevity and prolonged independence. Readers of daily newspapers have seen plenty of reports of leading research groups confirming that vigorous activity in middle-aged or older people prevents or at least significantly lessens loss of muscle strength, which is responsible for so much disability and even disease.

  As for intellectual capacity, it has already been pointed out that the best way to maintain mental functioning is to exercise it. The proficiency of the synapse, where an impulse is transmitted from one nerve cell to another, is strengthened by frequent use. The synapse retains its capacity to change, and even to become more effective and stronger, throughout life. This may also be true of the nerve cells themselves. Their ability to generate impulses—what neuroscientists call “electrogenicity”—appears to respond to changes in input. The electrogenic machinery can apparently be remodeled, and patterns of electrical activity altered, depending on the kind and frequency of stimuli that reach the cell. So keep reading this book and plenty of others. You will be strengthening your synapses and building your electrogenicity.

  All of this sophisticated talk adds up to no more than the advice that was so often proclaimed by that syndicated sage, the late Ann Landers: “Use it or lose it.” And it certainly confirms everyone’s daily observations. Simply put, active people remain active. Though it is comforting to have it confirmed by Landers, by laboratories, and by the learned, we have all known for a very long time that the key to productivity is productivity.

  What we have not known are the details. At first gradually and now with increasing velocity, not only scientists but fitness experts too are learning the specifics of just what is required to preserve ourselves—if not necessarily to a greater age, at least to an age less encumbered by the debilities that too often characterize the final years of life. Even should “using it” not succeed in prolonging our days, vigorous activity of mind and muscle is the secret of better aging, or what the gerontologists call “compression of morbidity.” The long-range goal is to make the graph of one’s approach to life’s termination cease its agonizingly drawn-out drooping and come to resemble a vigorous and virtually horizontal line followed by a more or less perpendicular drop-off.

  And as for that end-point date, there is abundant evidence, both anecdotal and statistical, of the beneficial effect of exercise on life expectancy, and it has been accumulating for a long time. For example, a long-term evaluation published in 1998 of 52,000 male graduates who entered Harvard College and the University of Pennsylvania between 1916 and 1950 showed that alumni between the ages of thirty-five and seventy-four who over the years expended at least two thousand calories per week in vigorous activities had a risk of cardiovascular disease and death that was 25 percent lower than that of less active men. Not only that, but men who took up an active life long after college did better than former student athletes who had quit in middle age. Couch potatoes should note the jock-image titles of both the article and the professional publication in which it was printed: “A Natural History of Athleticism, Health and Longevity,” in the Journal of Sports Sciences.

  Lest any reader of these pages think I am one of those above-it-all types who dish out advice and don’t take it, I present here my own personal experience in using the new knowledge. But first I must point out that I did not go gently. For those unconvinced, reluctant, undecided, or indecisive readers—who, in spite of being much impressed with the findings presented in the foregoing paragraphs are nevertheless shuffling their feet or thinking, “It’s all very well and good for you, Mac, but…”—I will simply say that I was once among your number. But I am now a convert and, like so many converts, I have become a zealot. Since the summer of 1998, I have been hauling my aged body off to the gym three times a week, there to sweat among the fit.

  No one—but especially no one as predisposed to vanity as a surgeon—would want to be asked by an elder son, “Hey, Pops, wouldn’t you like to get some tennis shorts that are a little longer, now that your quads aren’t what they used to be?” Coming hard on the heels of a longtime tennis partner’s across-the-net observation that “our legs are starting to look as if they belong on a couple of scrawny chickens,” the thirty-something’s well-intentioned advice was more than a little demoralizing. I decided then and there that the time had come to pay attention to the repeated urgings (truth to tell, they were more like hectorings) of my wife, who had been looking svelter by the week as the result of rising at five o’clock each morning to pump iron, go spinning, and run stationary laps at a local gym.

  Within days, I had signed up for an exercise program at a facility a few miles from my home, called—what else?—the In Shape Fitness Center. Being committed to the principle that all novitiates need a role model, I found myself a deceptively sweet-natured Atlas of a trainer named Dave Butler, and told him that I wanted to be just like him when I grew up. Graciously ignoring the fact that I am thirty-five years older than he, my new mentor took me at my word. Aware that it was far too late to acquire a sweet nature, I nevertheless did harbor an aging male’s fantasy about emulating Dave’s strength. But first, my immediate goal was to get the old legs back and flatten a gut that was just beginning to make itself evident.

  Dave took a long list of measurements, made a series of calculations, and set up a program of resistance training and cardiovascular exercise. It wasn’t a menu for the faint of heart, and in spite of his gentle demeanor, Dave proved to be a young man of forceful determination, setting me loose in the gym on my own with the admonition that he expected real improvement by the time we met again in six weeks.

  In matters like these, it helps to have a compulsive personality, and that is where the three decades in the operating room paid off. I have been religious about my exercise routine, both during those initial six weeks and since. What do I care that just about every other male in the gym is in his twenties or thirties and is pumping as much as twice the iron that I do? And why be concerned that more than a few times I have followed a twenty-one-year-old coed onto a machine and had to remove thirty or forty pounds from the weight pile before lifting?

  The first of my rewards came when Dave did his second set of calculations at the six-week mark, and the rewards have continued. In my initial eight months of sweating and straining, I took off nine pounds of fat and added six pounds of muscle mass. My waist was two inches narrower than before and my chest an inch and a half wider. The percentage of my body that
was fat had dropped from 21 (in the range called “acceptable” on the fitness charts) to 16 (in the middle of the category designated as fit/healthy). The improvements had come about without an iota’s change in my eating habits, although Dave originally outlined a nutrition plan that I had gleefully ignored. I was, in fact, In Shape. I found myself able to run around a tennis court as I had not since my thirties. On my son’s next visit, I put on (short) bathing trunks, in order to show off my newly sculpted chest and abdominal muscles, which by then I had taken to calling pecs and abs. An unexpected dividend was that many of the little muscular aches and pains to which we senior citizens force ourselves to become inured had either disappeared or lessened.

  But I have to confess to a couple of disappointments. It is claimed that consistent exercise lowers cholesterol, and so I followed its blood level periodically for some time. After a small initial drop, it went right back to its previous high, and it has stayed there. And then there was the testosterone story. I had read reports that its concentration rises with anaerobic exertion, and mine did in fact shoot up to a stratospheric level by the four-month mark and continued to rise afterward. With testosterone like that, I should have been bounding around like a satyr chasing nymphs. When I noticed no change in my amatory inclinations, I queried a friend who specializes in knowing a thing or two about hormones. He gently broke the sad news that heavy exercise increases the secretion of a protein that binds testosterone, which is why its blood level rises. But a bound testosterone molecule is like a bound stallion—it can’t run with the herd. It’s the free testosterone that does the real job, and mine had gone up less than 10 percent. And so, the nymphs were safe and I’ve never tested my blood level of male hormone again.

  Here it is necessary to state the obvious. It is clear from this description that my motivation to join the gym had little to do with health per se, and everything to do with vanity. But it hardly makes a whit of difference. The magnet may be the means, but the real object is the outcome. Vanity has its uses, and among them is that ages-old urge that drew Brown-Séquard to his guinea pig gonads and me to my machines. For me, the result of all the years of sweating and straining has been mobility, coordination, strength, weight control, and a sense of pride that buoys me up each time I think about what has been accomplished by sticking to my resolve. And for all I know, the increased BDNF has all the time been doing wonders for my synapses and neurons. And there are all those studies I read about in my medical journals, telling me that there is now statistical evidence that psychological depression is decreased in frequency and degree by vigorous exercise, and the likelihood of certain forms of cancer is lessened. These are bonuses I had not expected when I began on that summer afternoon in 1998, but I accept them willingly. There is a thin and very indistinct line that separates a man’s vanity from his pride—and a woman’s too, I would guess—and I don’t really care which side of it I stand on, so long as it keeps me in the gym, which I have come to think of as essential to my well-being.