A Ripe Old Age A Ripe Old Age

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Hi All,

The PDF is available for the below.

Do we “harbor delusions of immortality”? No, I suggest.

“I am aware of no data to support the premise that you can alter the date of

death”. Yes, there is, I suggest.

“Who are the fortunate survivors? Who die before their time?” CR is not

proven to be effective in humans, but I have confidence in CR nonetheless.

But, I did like ‘The strata of society that dies before its time falls

victim to an " artificial epidemic. " ’

Cheers, Al.

Editorial

A Ripe Old Age

Arch Intern Med. 2003;163:1261-1262.

FORTUNATE, INDEED, are the octogenarians of today who have the wits and

faculties to contend with life's demands. They are enjoying years beyond

many of their birth cohort. None is deluded as to the inevitability of

demise. Can they continue to function highly till death removes the

challenge?

In an elegant study published in this issue of the ARCHIVES, Gill and his

colleagues1 offer the answer. The higher level of functional capacity is

ephemeral; it is to be whittled away. Month by month they will find

themselves faced with days when they, not up to performing as usual, even

feel the need to take to bed. Inexorably, activities of daily living,

activities they always took for granted, become insurmountable challenges.

They will come to take their place among the frail elderly. They will lean

on canes by the graveside.

Can you read this dirge without railing? Can't we interpose the marvelous

fruits of our science between the high-functioning octogenarians and this

fate? Many have subtle metabolic flaws.2 Many are harboring diseases, the

comorbidities documented in the study by Gill et al and in many other

studies.3 Many are coping with musculoskeletal discomforts and incapacities

more often than not.4-5 Yet, in spite of this assault, they are highly

functional octogenarians. Are their functional reserves suffering

incrementally from these and other insults? Probably. Can we mobilize modern

biology to repair some of their frays? Possibly. But I doubt that any such

effort will matter. The likelihood that contemporary science can shepherd

more of the high-functioning octogenarians into the meager ranks of the

high-functioning nonagenarians is more meager, yet.6 I would rather we learn

to better support these octogenarians through the transition toward

decrepitude and comfort them in the final passage.7 Friendship and love are

defensible as both prescriptions and clinical interventions.

To advocate otherwise is to harbor delusions of immortality. I am convinced

that heroic efforts on behalf of the highly functioning octogenarians will

accomplish little of substance. Perhaps one can hope to alter the proximate

cause of death, ie, the diagnosis on the death certificate. But I am aware

of no data to support the premise that you can alter the date of death. This

is not to advocate therapeutic nihilism. It is the invoking of the age-old

art of medicine to contend with the reality of our aging and of our

mortality. When the high-functioning octogenarian suffers the doldrums and

progresses in decrepitude, it is because her or his time is nearing. When

death supervenes, it is because it is one's time. That is the proximate

cause of death. It does not matter how many diseases are vying for coup de

grâce. It only matters that the journey was as gratifying as possible.

A patient cemented this philosophy for me by his example. He was an

illustrious physician who remained an active clinical educator well into his

eighth decade. With a wink, he arranged for annual ultrasonographic

monitoring of his ever-expanding asymptomatic abdominal aortic aneurysm. The

lesion was brimming with surgical indications. Each year he demurred. He was

not willing to incur parasurgical risks to the tenuous compensation of his

anginal syndrome, his congestive heart failure, or his prostatism. A lethal

stroke validated his reasoning. It was his time.

Although my philosophy regarding the clinical management of frailty

countenances only support and comfort, I am disposed to aggressive efforts

to increase the likelihood that more of future birth cohorts will close the

story of their lives as highly functional octogenarians. Such is the

demographic trend in the advanced world. But many lag. Who are the fortunate

survivors? Who die before their time? The demographics of the cohort studied

by Gill et al1 is an object lesson:

All were members of a " large health plan in New Haven " so one might assume

that there was access to quality medical care. Regardless of level of

function at inception, members of the cohort averaged 2 chronic conditions.

One might be tempted to ascribe the longevity of this cohort to past medical

programs that promoted their health and to their ongoing medical care. There

is a science that tempers any such hubris. Health adverse behaviors and

cardiovascular risk factors may relate to the proximate cause of death, but

they account for less than 25% of the hazard to longevity.8-9 This might

explain why multiple assaults on health adverse behaviors and cardiovascular

risk factors have uncertain effects on all-cause mortality.10

Understanding the good fortune of the New Haven octogenarians requires an

understanding of the hazards to well-being that lurk in the course of

living. These life-course hazards are aspects of our interactive and

integrative worlds, our ecosystems, that can powerfully perturb our biology

and, thereby, our fate. Much of this is captured by measures of

socioeconomic status (SES).11 There is an incontrovertible relationship

between SES and longevity.12 But do not be misled into assuming SES is

simply a measure of income status. Longevity is more dependent on how poor

you are relative to those who are advantaged in your ecosystem.13-14 For

example, the greater the gap in income between the rich and poor (the " Robin

Hood index " ) across states in the United States, the greater the effect on

longevity of the poor.15 Also, do not be misled into assuming SES is a

measure of health care expenditures; it isn't.16 Socioeconomic status is a

measure of the salutary nature of the neighborhood in which you live17 and

the context in which you pursue gainful employment.18

A handmaiden of SES is educational status.19-20 Here's the clue to the

longevity of Gill's New Haven cohort. They were born well before World War

II, yet they managed to average 12 years of education. They have long

enjoyed an advantaged SES. They were likely to live some 7 years longer than

the low SES strata of their birth cohort.21 For these advantaged New Haven

octogenarians, the transitions to doldrums, decrepitude, and demise were

telescoped into the last year or so of life. The disadvantaged in their

birth cohort commenced these transitions earlier in life, and suffered

through their painstaking unfolding. They labored in jobs that were less

rewarding, satisfying, or secure. They lived under clouds of persistent pain

and pervasive work incapacity. Their course in life was less sweet and less

long.22

The octogenarian Rudolf Virchow (1821-1902) developed a notion of " natural "

as opposed to " artificial " diseases and epidemics. He considered typhus,

scurvy, tuberculosis, and mental disease to be " artificial " because they

were primarily due to social conditions,

The artificial epidemics are attributes of society, products of a false

culture, that is not distributed to all classes. They point toward

deficiencies produced by the structure of the state or society, and strike

therefore primarily those classes which do not enjoy the advantages of the

culture.23

The strata of society that dies before its time falls victim to an

" artificial epidemic. "

REFERENCES

1. Gill TM, Allore H, Guo Z. Restricted activity and functional decline

among community-living older persons.

Arch Intern Med. 2003;163:1317-1322. ABSTRACT/FULL TEXT

2. Hammerman D. Toward an understanding of frailty. Ann Intern Med.

1999;130:945-950. ISI | MEDLINE

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factors for functional status decline in community-living elderly people: a

systematic literature review. Soc Sci Med. 1999;48:445-469. CrossRef | ISI |

4. Scudds RJ, on JM. Pain factors associated with physical

disability in a sample of community-dwelling senior citizens. J Gerontol A

Biol Sci Med Sci. 2000;55:M393-M399.

5. Leveille SG, Ling S, Hochberg MC, et al. Widespread musculoskeletal pain

and the progression of disability in older disabled women. Ann Intern Med.

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6. Hadler NM. Laboring for longevity: an annotated poem. J Occup Environ

Med. 1999;41:617-621. ISI | MEDLINE

7. ME, Hadler NM. The illness as the focus of geriatric medicine.

N Engl J Med. 1983;308:1357-1360.

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epidemiology in an age of change. Am J Epidemiol. 1999;149:887-897. ABSTRACT

9. Lantz PM, House JS, Lepkowski JM, et al. Socioeconomic factors, health

behaviors, and mortality: results from a nationally representative

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10. Ebrahim S, Davey G. Multiple risk factor interventions for

primary prevention of coronary heart disease [Cochrane Review on CD-ROM].

Oxford, England: Cochrane Library, Update Software; February 1999.

11. Lynch J, Kaplan G. Socioeconomic positions. In: Berkman LF, Kawachi I,

editors. Social Epidemiology. Oxford, England: Oxford University Press;

2000:13-35.

12. McCally M, Haines A, Fein O, Addington W, Lawrence RS, Cassel CK.

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13. Wilkinson RG. Unhealthy Societies: The Afflictions of Inequality.

London, England: Routledge; 1997.

14. Kawachi I, ed, Kennedy BP, ed, Wilkinson RG, ed. The Society and

Population Health Reader. Volume I: Income Inequality and Health. New York,

NY: New Press; 1999.

15. Kennedy BP, Kawachi I, Prothrow-Stith D. Income distribution and

mortality: cross sectional ecological study of the Robin Hood index in the

United States. BMJ. 1996;312:1004-1007.

16. Hertzman C. Health and human society. Am Sci. 2001;89:538-545. ISI

17. Bosma H, van de Mheen HD, Borsboom GJJM, Mackenbach JP. Neighborhood

socioeconomic status and

all-cause mortality. Am J Epidemiol. 2001;153:363-371. ABSTRACT/FULL TEXT

18. Davey G, Hart C, Blane D, Gillis C, Hawthorne V. Lifetime

socioeconomic position and mortality:

prospective observational study. BMJ. 1997;314:547-552. ABSTRACT/FULL TEXT

19. Davey G, Hart C, Hole D, et al. Education and occupational social

class: which is the more important

indicator of mortality risk? J Epidemiol Community Health. 1998;52:153-160.

20. Backlund E, Sorlie PD, NJ. A comparison of the relationships of

education and income with mortality: the national longitudinal mortality

study. Soc Sci Med. 1999;49:1373-1384. 21. Pamuk E, Makuc D, Heck K, Reuben

C, Lochner K. Socioeconomic Status and Health Chartbook. Health, United

States, 1998. Hyattsville, Md: National Center for Health Statistics; 1998.

22. Hadler NM. Rheumatology and the health of the workforce. Arthritis

Rheum. 2001;44:1971-1974.

23. Ackerknecht EH. Rudolf Virchow. Madison: University of Wisconsin Press;

1953:127.

RELATED ARTICLES IN ARCHIVES OF INTERNAL MEDICINE

Restricted Activity and Functional Decline Among Community-Living Older

Persons

M. Gill, Allore, and Zhenchao Guo

Arch Intern Med. 2003;163:1317-1322.

ABSTRACT | FULL TEXT

Alan Pater, Ph.D.; Faculty of Medicine; Memorial University; St. 's, NL

A1B 3V6 Canada; Tel. No.: (709) 777-6488; Fax No.: (709) 777-7010; email:

apater@...