BY the time
he was 76, my father was frail. His balance was poor and he had trouble walking.
He lived alone in Baltimore in a big house full of stairs, and watching him come
tottering down those stairs was terrifying. Each time, I thought he might fall.
He refused to make the house safer — no stair lifts, no grab rails (they would
disfigure the house, he said) — and would not consider living anywhere else.
When my brother and his wife invited my father to move in, the invitation was
vigorously declined. And we lived in three different cities, far apart.
To try to cope better with this situation, my brother and I created a shared
Google calendar — an online calendar in which we could both make entries from
wherever we happened to be. Each time either of us spoke to our father, we
marked it in the calendar — what time of day it was, how he sounded, what we
spoke about. (If one of us called and he did not answer, we marked that, too.
Yes, we both have an obsessive streak.)
For example, on Oct. 13, 2009, at 1:30, I telephoned home, spoke to my father
and wrote in the calendar that he was “just off to see the new doctor, writing a
list of his medications. Nothing else to report; leaves starting to turn and
it’s starting to get cold.” Later that afternoon, he called my brother and said
that he liked the new doctor (she was “slim, tall, pretty, and seemed very
nice”), and that he had indeed discussed his medications with her.
The upshot was that we had an excellent record of how he was — whether he was
getting out, if he was cheerful or feeling low, changes to his medicines, any
falls he said he had had. The calendar also allowed us to make sure that one of
us spoke to him just about every day. And if I couldn’t reach him, I didn’t have
to wonder if he was lying hurt and helpless at the bottom of the stairs for days
— I could look at the calendar and see that my brother had spoken to him a few
We never told my father we did this — he probably would have been furious. There
is, after all, something weird about the idea that people are taking notes on
you, however loving their motives. It was our imperfect solution to an imperfect
setup. And it helped us.
Just before his 79th birthday, my father started collapsing. First, he fell in
the street. He thought he had tripped, but he wasn’t sure. Then he fell several
times in the house (fortunately, not while on the stairs). The calendar provided
a full record of it — and we could both see that there was something new,
something abnormal. It turned out that his heart was stopping. My brother flew
down and took him to a hospital, where he had a pacemaker put in.
But the calendar had other, more subtle effects, too. It was, in essence, a
journal kept by two people who read each other’s entries, and so it gradually
became a conversation between the two of us as well as a straight-up record of
events. One day, he’s infuriating my brother with speculations about two
friends’ having an inappropriate affair: “I said I thought he was being
outrageous and that it was none of his business, even if his wild speculations
were true. I hope he has the sense not to say anything to anyone else about his
unfounded, wild, no evidence claims.” Another day, I’m remarking, “I’m worried
by the extent to which he does not seem to cook for himself anymore.”
As you might expect, there are times when reading someone else’s journal entries
is disquieting and revealing. I discovered aspects of my brother’s relationship
with our father that I hadn’t appreciated. One of his entries said: “Asked about
my accident (first time).” This was more than a year after my brother had been
hit by a car and badly hurt. My heart cracked: I had not realized how
inattentive my father had been.
Going back through the calendar now, more than 18 months after my father died,
the entries chart a relentless physical decline — profound fatigue, sore hips
and knees, aching wrists, swollen legs, inflamed teeth, increasing
forgetfulness, the savage indignities of old age. One day, he took a bath but
couldn’t get out of the tub. Luckily, the housekeeper arrived; she couldn’t get
him out either, so she recruited the postman to help. My father thought this was
hilarious: I admired his ability to laugh.
For through it all, there’s such courage. Yes, he’s just had a pacemaker
installed and he’s feeling rotten, but he’s making strawberry jam. One day, “He
sounded very low — lonely, old, and scared.” But another, he’s reading a history
of some sinister French aristocrats and planning to install a wood stove in the
fireplace. A beloved friend is coming to stay. He’s just learned a new poem.
At the time, I was glad we kept the calendar because it helped us to cope with a
difficult situation. Now I’m glad for a different reason: it helps me remember
small details about him, the little things that slip out of memory, that fade
with time. Laughs, tears, worries, frustrations, joy and love — it’s all in the
is a writer and an evolutionary biologist.
calls from her car: “I’m on my way to Cape Cod to scatter my mother’s ashes in
the bay, her favorite place.” Another, encountered on the street, mournfully
reports that he’s just “planted” his mother. A third e-mails news of her
mother’s death with a haunting phrase: “the sledgehammer of fatality.” It feels
strange. Why are so many of our mothers dying all at once?
As an actuarial phenomenon, the reason isn’t hard to grasp. My friends are in
their 60s now, some creeping up on 70; their mothers are in their 80s or 90s.
Ray Kurzweil, the author of “The Singularity Is Near: When Humans Transcend
Biology,” believes that we’re close to unlocking the key to immortality. Perhaps
within this century, he prophesies, “software-based humans” will be able to
survive indefinitely on the Web, “projecting bodies whenever they need or want
them, including virtual bodies in diverse realms of virtual reality.” Neat, huh?
But for now, it’s pretty much dust to dust, the way it’s always been — mothers
included. (Most of our fathers are long gone, alas. Women live longer than men.)
It’s the ones who aren’t dead who should baffle us. My own mother, for instance,
still goes to the Boston Symphony and attends a weekly current events class at
Brookhaven, her “lifecare living” center (can’t we find a less technocratic
word?) near Boston. She writes poems in iambic pentameter for every occasion. At
94, she’s hardly anomalous: there are plenty of nonagenarians at Brookhaven.
Ninety is the new old age. As Dr. Muriel Gillick, a specialist in geriatrics and
palliative care at Harvard Medical School, says, “If you’ve made it to 85 then
you have a reasonable chance of making it to 90.” That number has nearly tripled
in the last 30 years. And if you get that far... it’s been estimated that there
will be eight million centenarians by 2050.
It won’t end there. Scientists are closing in on the mechanism of what are
called “senescent cells,” which cause the tissue deterioration responsible for
aging. Studies of mice suggest that targeting these cells can slow down the
process. “Every component of cells gets damaged with age,” Leonard Guarente, a
biology professor at M.I.T., explained to me. “It’s like an old car. You have to
repair it.” We’re not talking about immortality, Professor Guarente cautions.
Biotechnology has its limits. “We’re just extending the trend.” Extending the
trend? I can hear it now: 110 is the new 100.
Is this a good thing or a bad thing? On the debit side, there’s the ... debit.
The old-age safety net is already frayed. According to some estimates, Social
Security benefits will run out by 2037; Medicare insurance is guaranteed only
through 2024. These projected shortfalls are in part the unintended consequence
of the American health fetish. The ad executives in “Mad Men” firing up Lucky
Strikes and dosing themselves with Canadian Club didn’t have to worry. They’d be
dead long before it was time to collect.
Then there’s the question of whether reaching 5 score and 10 is worth it — the
quality-of-life question. Who wants to end up — as Jaques intones in “As You
Like It” — “sans teeth, sans eyes, sans taste, sans everything”? You may live to
be as old as Methuselah, who lasted 969 years, but chances are you’ll feel it.
Worse — it’s no longer a rare event — you can outlive your children. Reading the
obituary of Christopher Ma, a Washington Post executive who had been a college
classmate of mine, I was especially sad to see that Chris was survived by his
wife, a daughter, a son, a brother, two sisters and “his mother, Margaret Ma of
Menlo Park, Calif.” Can anything more tragic befall a parent than to be
predeceased by a child?
These are the perils old people suffer. What about us, the boomers, now
ourselves elderly children? One challenge my entitled generation faces is that
many of our long-lived parents are running through their retirement money, which
leaves the burden of supporting them to us. (To their credit, it’s a burden that
often bothers our parents, too.) And the cost of end-stage health care is huge —
a giant portion of all medical expenses in this country are incurred in the last
months of life. Meanwhile, our prospects of retirement recede on the horizon.
Also, elder care is stressful and time consuming. The broken hips, the trips to
the E.R., the bill paying and insurance paperwork demand patience. A paper
titled “Personality Traits of Centenarians’ Offspring” suggests this cohort
scores high marks “extraversion, openness, agreeableness and conscientiousness.”
But even the well-adjusted find looking after old parents tough.
In the mid-’80s, when the idea of the “sandwich generation” was born — boomers
saddled with the care of aging parents while raising their own children — it
seemed like a problem we would eventually outgrow. Twenty-five years later,
we’re still sandwiched, and some of those caught in the middle feel the squeeze.
So what’s the good part? Time spent with an elderly parent can offer an
opportunity for the resolution of “unfinished business,” a chance to indulge in
last-act candor. A college classmate writes in our 40th-reunion book of
ministering to her chronically ill mother and being “moved by how the twists and
turns of complicated health care have deepened our relationship.” I hear a lot
about late-in-life bonding between parent and child.
My mother needs a minor operation. “I’ve outlasted my time,” she says as she’s
wheeled into surgery. “Anyway, you’re too old to have a mother.” Thanks, Ma.
What about Rupert Murdoch? His mother is 102. Also, if I’m too old to have a
mother, why do I still feel like a child?
Two weeks later, Mom comes to Vermont to recuperate. My father, who died a
decade ago at 87, is buried in the field behind our house (hope this is legal).
His gravestone reads “Donald Herman Atlas 1913-2001,” and it has an epitaph from
his favorite poet, T. S. Eliot, carved in italics: “I grow old ... I grow old
.../ I shall wear the bottoms of my trousers rolled.” Mom likes to visit him
there. Standing over Dad’s grave, she carries on a dialogue of one. “I thought
I’d have joined you by now, Donny, but I’m a tough old bird.” As she heads back
up to the house, she turns and waves. “À bientôt.” See you soon.
Not so fast, Mom. I still have issues.
is the author
of “My Life in the Middle Ages: A Survivor’s Tale.”
expectancy at birth for Americans is about 78. But many Americans will die well
before then, while others, like Eunice Sanborn, who died in Texas last month,
will live to be 114.
Anyone planning for retirement must answer an impossible question: How long will
I live? If you overestimate your longevity, you might scrimp unnecessarily. If
you underestimate, you might outlive your savings.
This is hardly a new problem — and yet not a single financial product offers a
satisfactory solution to this risk.
We believe that a new product — a federally issued, inflation-adjusted annuity —
would make it possible for people to deal with this problem, with the bonus of
contributing to the public coffers. By doing good for individuals, the federal
government could actually do well for itself.
The insurance industry sells an inflation-adjusted annuity that goes part of the
way toward helping people cope with the possibility of outliving their savings.
During your working years or at the time of retirement, you can pay a premium to
an insurance company in exchange for the promise that the company will pay you a
fixed annual income, adjusted for inflation, until you die.
But in a world in which A.I.G. had an excellent rating only days before it
became a ward of the state, how can someone — particularly a young person — know
for sure which insurance companies will be solvent half a century from now?
Annuities aren’t federally guaranteed. The only backstops are state-based
systems, and the current protection ceilings are sometimes modest. If an
insurance company goes under, the retiree may end up with nothing close to what
The federal government can offer a product that solves that problem. Individuals
would face no more risk of default than that associated with Treasury bills and
other obligations backed by the United States.
Here’s how it would work. Initially, people who wanted to buy this insurance
would enroll through one of the qualified retirement savings plans already
offered to the public, like a 401(k) plan, and could choose this annuity option
instead of, or in addition to, investments in stocks, bonds or mutual funds.
How much the payouts would be could be based on a variety of factors, including
interest rates on government bonds; mortality tables that, among other things,
take into account that healthier people are more likely to buy annuities; and
administrative costs. This new product wouldn’t cost the government a penny. In
fact, the Treasury would benefit. It is only an incremental move beyond issuing
inflation-adjusted bonds, which the Treasury already does. By allowing the
government to tap a new class of investors, the cost of government borrowing
over all would probably drop.
Moreover, by expanding the government’s base of domestic investors, the plan
would help address overreliance on foreign lenders, who now own close to half of
all outstanding federal debt — nearly 10 times the proportion in 1970. True, the
government would be on the hook if a technological breakthrough caused an
unanticipated increase in life expectancy. But that’s a risk that the government
is already bearing implicitly: that is, a drastic enough increase could threaten
the solvency of private issuers of annuities as well as the many retirees who
don’t have annuities, creating pressure for government bailouts of insurers or
individuals. Taking on the risk explicitly and pricing the fair cost of this
risk into the annuities is a far preferable route.
There is also the concern that government-issued annuities would crowd out
private annuity sales. To the contrary: they could spur growth in private
annuities. Since the inflation-adjusted monthly payments on such risk-free
government annuities would be low, many retirees may choose to supplement them
with riskier, higher-paying annuities.
Furthermore, insurance companies could be allowed to package the
government-issued annuities with their own products, creating appealing
combinations that mix safety and the potential for higher returns.
Our proposal is a winner for everyone. The Treasury could lower borrowing costs
and diversify its investor base while acknowledging and budgeting for risk that
it already bears. Individuals could eliminate the risk of living too long. By
looking at the promised rate of return on the annuities, individuals will have a
better sense of how much they need to save. The Eunice Sanborns of the world, as
well as all taxpayers, would rest a little easier at night.
I RECENTLY turned 65, just ahead of the millions in the baby
boom generation who will begin to cross the same symbolically fraught threshold
in the new year to a chorus of well-intended assurances that “age is just a
number.” But my family album tells a different story. I am descended from a long
line of women who lived into their 90s, and their last years suggest that my
generation’s vision of an ageless old age bears about as much resemblance to
real old age as our earlier idealization of painless childbirth without drugs
did to real labor.
In the album is a snapshot of my mother and me, smiling in front of the
Rockefeller Center Christmas tree when she was 75 and I was 50. She did seem
ageless just 15 years ago. But now, as she prepares to turn 90 next week, she
knows there will be no more holiday adventures in her future. Her mind is as
acute as ever, but her body has failed. Chronic pain from a variety of
age-related illnesses has turned the smallest errand into an excruciating
On the next page is a photograph of my maternal grandmother and me, taken on a
riverbank in 1998, a few months short of her 100th birthday. For one sunny
afternoon, I had spirited her away from the nursing home where she spent the
last three years of her life, largely confined to a wheelchair, with a bright
mind — like my mother’s today — trapped in a body that would no longer do her
“It’s good to be among the living again,” Gran said, in a tone conveying not
self-pity but her own realistic assessment that she had lived too long to live
Yet people my age and younger still pretend that old age will yield to what has
long been our generational credo — that we can transform ourselves endlessly,
even undo reality, if only we live right. “Age-defying” is a modifier that
figures prominently in advertisements for everything from vitamins and beauty
products to services for the most frail among the “old old,” as demographers
classify those over 85. You haven’t experienced cognitive dissonance until you
receive a brochure encouraging you to spend thousands of dollars a year for
long-term care insurance as you prepare to “defy” old age.
“Deny” is the word the hucksters of longevity should be using. Nearly half of
the old old — the fastest-growing segment of the over-65 population — will spend
some time in a nursing home before they die, as a result of mental or physical
Members of the “forever young” generation — who, unless a social catastrophe
intervenes, will live even longer than their parents — prefer to think about
aging as a controllable experience. Researchers who were part of a panel
discussion titled “90 Is the New 50,” presented at the World Science Festival in
2008, spoke to a middle-aged, standing-room-only audience about imminent medical
miracles. The one voice of caution about inflated expectations was that of
Robert Butler, the pioneering gerontologist who was the first head of the
National Institute on Aging in the 1970s and is generally credited with coining
the term “ageism.”
Earlier this year, a few months before his death from leukemia at age 83, I
asked Dr. Butler what he thought of the premise that 90 might become the new 50.
“I’m a scientist,” he replied, “and a scientist always hopes for the big
breakthrough. The trouble with expecting 90 to become the new 50 is it can stop
rational discussion — on a societal as well as individual level — about how to
make 90 a better 90. This fantasy is a lot like waiting for Prince Charming, in
that it doesn’t distinguish between hope and reasonable expectation.”
The crucial nature of this distinction has become foremost in my thinking about
what lies ahead.
My hope is that I will not live as long as my mother and grandmother. We all
want to be the exceptions: Elliott Carter, an active composer when he walked
onto the stage of Carnegie Hall for his centennial tribute in 2008; Betty White,
a bravura comedian who wows audiences at 88; John Paul Stevens, the author of
brilliant judicial opinions until the day he retired from the Supreme Court at
90. I, too, hope to go on being productive, writing long after the age when most
people retire, in the twilight of the print culture that has nourished my life.
Yet it is sobering for me — as it is for Americans in many businesses and
professions that once seemed a sure thing — to see younger near contemporaries
being downsized out of jobs long before they are emotionally or financially
ready for retirement.
Furthermore, I am acutely aware — and this is the difference between hope and
expectation — that my plans depend, above all, on whether I am lucky enough to
retain a working brain. I haven’t mentioned, because I don’t like to think about
it, that my paternal grandmother, who also lived into her 90s, died of
Alzheimer’s disease. The risk of dementia, of which Alzheimer’s is the leading
cause, doubles every five years after 65.
Contrary to what the baby boom generation prefers to believe, there is almost no
scientifically reliable evidence that “living right” — whether that means
exercising, eating a nutritious diet or continuing to work hard — significantly
delays or prevents Alzheimer’s. This was the undeniable and undefiable
conclusion in April of a major scientific review sponsored by the National
Institutes of Health.
Good health habits and strenuous intellectual effort are beneficial in
themselves, but they will not protect us from a silent, genetically influenced
disaster that might already be unfolding in our brains. I do not have the
slightest interest in those new brain scans or spinal fluid tests that can
identify early-stage Alzheimer’s. What is the point of knowing that you’re
doomed if there is no effective treatment or cure? As for imminent medical
miracles, the most realistic hope is that any breakthrough will benefit the
children or grandchildren of my generation, not me.
I would rather share the fate of my maternal forebears — old old age with an
intact mind in a ravaged body — than the fate of my other grandmother. But the
cosmos is indifferent to my preferences, and it is chilling to think about
becoming helpless in a society that affords only the most minimal support for
those who can no longer care for themselves. So I must plan, as best I can, for
I have no children — a much more common phenomenon among boomers than among old
people today. The man who was the love of my adult life died several years ago;
now I must find someone else I trust to make medical decisions for me if I
cannot make them myself. This is a difficult emotional task, and it does not
surprise me, for all of the public debate about end-of-life care in recent
years, that only 30 percent of Americans have living wills. Even fewer have
actually appointed a legal representative, known as a health care proxy, to make
I can see that the “90 is the new 50” crowd might object to my thinking more
about worst-case scenarios than best-case ones. But if the best-case scenario
emerges and I become one of those exceptional “ageless” old people so lauded by
the media, I won’t have a problem. I can also take it if fate hands me a
passionate late-in-life love affair, a financial bonanza or the energy to write
more books in the next 25 years than I have in the past 25.
What I expect, though — if I do live as long as the other women in my family —
is nothing less than an unremitting struggle, ideally laced with moments of
grace. On that day by the riverbank — the last time we saw each other — Gran
cast a lingering glance over the water and said, “It’s good to know that the
beauty of the world will go on without me.”
If I can say that, in full knowledge of my rapidly approaching extinction, I
will consider my life a success — even though I will have failed, as everyone
ultimately does, to defy old age.
SUN CITY, Ariz. — From behind the wheel of his minivan, Bill
Szentmiklosi scours the streets of Sun City in search of zoning violations like
unkempt yards and illegal storage sheds. Mostly, though, he is on the lookout
for that most egregious of all infractions: children.
With a clipboard of alleged violations to investigate, he peers over fences and
ambles into backyards of one of America’s pioneer retirement communities, a
haven set aside exclusively for adults, where children are allowed to visit but
Mr. Szentmiklosi, 60, a retired police officer who settled here four years ago,
has remade himself as the chief of Sun City’s age police, the unit charged with
ensuring that this age-restricted community of sexagenarians, septuagenarians
and even older people does not become a refuge for the pacifier-sucking,
ball-playing or pimple-faced.
One recent morning, as he slowly wheeled between ranch homes and palm trees, Mr.
Szentmiklosi kept a sharp eye on the driveways and yards, surveying for any
obvious signs of youth. It could be a stray ball, a misplaced pint-size
flip-flop. In sniffing out children, he said, he relies on his three decades as
But it is when he strides up to a home, dressed in shorts, sandals and a polo
shirt, and knocks on the door that his detective work really begins. He tells
the suspected violator that a neighbor has complained and he asks gentle
questions to get to the bottom of things, all the while peering around for signs
of youthful activity. His work is helped by a simple reality: children are hard
They leave tracks and make unique sounds. Newborns bellow, toddlers shriek and
teenagers play music that is not typical around Sun City.
Mr. Szentmiklosi and his fellow child-hunters have their work cut out for them.
The number of age violations in Sun City, a town of more than 40,000 residents
outside Phoenix, has been rising markedly over the years, from 33 in 2007 to 121
in 2008 to 331 last year, a reflection of a trend at many of the hundreds of
age-restricted communities nationwide.
This year’s figures are expected to be even higher, said Mr. Szentmiklosi, who
knows that despite his patrols Sun City is probably harboring more children that
have not yet been detected. The economic crisis is aggravating the problem, he
said, forcing families to take desperate measures to cut costs, even if it means
surreptitiously moving into Grandma and Grandpa’s retirement bungalow.
The vigorous search for violators of Sun City’s age rules is about more than
keeping loud, boisterous, graffiti-scrawling rug rats from spoiling residents’
golden years, although that is part of it. If Sun City does not police its
population, it could lose its special status and be forced to open the
floodgates to those years away from their first gray hair.
The end result would be the introduction of schools to Sun City, then higher
taxes and, finally, an end to the Sun City that has drawn retirees here for the
At 50, Sun City is not old by the standards of Sun City, where the average
resident is in his or her early 70s.
To remain a restricted retirement community, at least 80 percent of Sun City’s
housing units must have at least one occupant who is 55 or older, allowing for
younger spouses or adult children. But the rules are clear on one thing: no one,
absolutely no one, who is a teenager, an adolescent, a toddler, a newborn, any
form of child, may call Sun City home.
“Visits are O.K. as long as they’re limited,” said Mr. Szentmiklosi, who
describes himself as a doting grandfather and insists that he does not have an
anti-child bone in his body. “You can have children visit for 90 days per year.
That means if you have 10 grandchildren, each one can visit, but they can only
stay nine days each.”
Mr. Szentmiklosi, the compliance manager for the Sun City Homeowners
Association, said that although the city was scrupulous, it remained
compassionate. For instance, it allowed a young woman with an infant who was
renting a home without the association’s knowledge a year to move out.
But the association also plays hardball, issuing fines and threatening legal
action to pressure youthful violators to leave. One reason Sun City is so
vigorous is because of what happened on the other side of 111th Avenue, one of
the main roads traversing the neighborhood.
Although Del Webb, who developed Sun City in 1960, gets credit for inventing the
idea of a community of active retirees, the concept actually started years
before on an adjacent tract in what was called Youngtown. But the developers
there were not diligent in drawing up their legal paperwork. A challenge by the
family of a teenage boy led the state to strip Youngtown of its age restrictions
So on one side of the road, little people can be seen running around. On the
other side, many people remember the Great Depression, and not from reading
about it in a book.
“It was so much quieter before,” said Librado Martinez, 80, a retired machine
operator who lives on the Youngtown side of the line and has to put up with
children playing ball in the park in front of his house. “You heard no screams
That peace is what Sun City residents want to keep. They rose up last month to
block a charter school, which is not governed by the same rules as other public
schools, from moving in.
“They were concerned about children roaming the streets and terrorizing things,”
said Marsha Mandurraga, who works for the school’s founder.
To prevent future incursions, Sun City’s leaders are using their clout to urge
state legislators to change the law to keep Sun City school-free.
“I’ve raised kids,” said Chris Merlav, 61, breathing through an oxygen tank and
resting on the side of a Sun City pool designed for walking, not swimming.
“After a while you get to the point where you don’t want to be bothered
Mr. Merlav, who moved here from Rochester, had evidence at hand that he was not
anti-child. His 20-year-old stepdaughter, Danielle Anastasia, was lounging in
the pool with him. She understood the desire of Sun City residents to be with
people their own age. “It’s like me hanging with my college friends,” she said.
Some of Sun City’s more hard-line anti-child activists can sound as though they
somehow bypassed youth completely.
“There are people here who have never had children, don’t care for children and
don’t particularly want children around,” said Jan Ek, who runs Sun City’s seven
recreation centers, eight golf courses, two bowling centers and assorted other
entertainment venues, some of which sometimes open up for child visitors.
At Sun City’s museum, the resident historian, Bill Pearson, 62, played a
videotape used to lure retirees to the development in the 1960s.
The narrator said then what many residents still say now: “Of course we love
them and enjoy their visits, but you deserve a little rest after raising your
In an extract from her new book Crazy Age,
the 77-year-old author takes a stark
– and very personal – look
at the realities
of growing old in the 21st century
Thursday 26 August 2010
This article appeared on p12
of the G2 section of the Guardian
on Thursday 26
It was published on guardian.co.uk at 07.00 BST
on Thursday 26 August 2010.
It was last modified at 10.10 BST
on Thursday 26 August 2010.
A statistic from nowhere, or nowhere I remember, but it has
the ring of truth: if most of us can look forward to living for about 10 years
longer than our parents, we can also expect to spend the equivalent of eight of
those years in hospital or doctors' waiting-rooms. When, at nearly 80, Gore
Vidal was asked to explain why he had left Italy for California, he spoke of his
future as "the hospital years".
My local hospital is ugly on the outside and beautiful within, though both the
outside and the inside seem differently determined to masquerade as something
that is not a hospital. Its modern facade was meant to fit into the shops it
sits among, and tucked into it are a post office, a cafe, a mobile phone shop
and another shop that sells the unhealthiest snacks and fizzy drinks known to
the western world. Desperate smokers – patients on crutches, in wheelchairs and
dressing-gowns, nurses, doctors, visitors – cough and cluster outside.
Inside, however, there are constant and changing exhibitions of sculpture,
pictures and mobiles. The building itself is curiously ship-like, constructed to
seem open to the sky. There are wards from which you might gaze out across the
roofs of London with a telescope to one eye, and walkways like gangplanks, and a
chapel suspended in space, a kind of crow's nest from which to survey the
In this surprising building, I have now been in receipt of two new knees and
weeks of physiotherapy in a hot pool and a gym. Twice a year I have my eyes
tested for glaucoma and for mysterious "drusen" growths at the sides of my eyes,
which must be stopped from putting pressure on the optic nerve. Also twice a
year I go less happily through the endoscopy department to emerge bloated and
suffering after a "procedure" I shall decently leave to the imagination. I have
had x-rays of most bits of me and MRI scans, and tests for heart and lungs on a
machine that simulates running uphill. I have been asked to count backwards in
sevens and remember the name of the prime minister (part of a somewhat cursory
test for Alzheimer's).
Only my teeth fail to interest anyone in this glorious NHS galleon, and for
their sorry state I travel by three forms of public transport to north London,
sometimes once a week. All that doesn't quite add up to four-fifths of my life,
but it is mounting up.
I'm not sure this new familiarity with the inside of a large teaching hospital
is especially cheering or enlightening, but it is intrinsic to contemporary
experience. Philip Roth's book Everyman springs brilliantly out of the new
knowingness – no doubt partial and amateurish, but full of relish for the
language and the detail – that we all now exhibit about disease and treatment
and dying. Here, for instance, is Roth's hero talking on the telephone to the
wife of his old friend, who died suddenly at home while she was out to lunch:
"Was it a stroke or was it a heart attack?" he asked.
"It was a myocardial infarct."
"Had he been feeling ill?"
"Well his blood pressure had been – well, he had a lot of trouble with his blood
pressure. And then this past weekend he wasn't feeling so great. His blood
pressure had gone up again."
"They couldn't control that with drugs?"
Roth's unnamed hero, his Everyman, is understandably interested in the manner of
his friend's dying. He probably owns his own blood-pressure gauge too.
I should add that in general I am in remarkably good health. I hardly ever get
colds or flu. I can now walk for miles with my new knees and stand for quite
long stretches at bus stops or in exhibitions. I hardly ever sleep in the day
(but don't sleep nearly enough in the night) and I eat and drink as much and as
indiscriminately as I ever did.
My natural competitiveness let me down badly when I was assessed at the town
hall for a temporary disability parking badge for my car. It was before I'd had
my knees replaced, and I was having difficulty walking. There, in a tiny office,
with an old-fashioned games teacher checking me for any tricks I might get up
to, I found myself unable to resist showing her that I could still touch my
toes, with my hands flat on the ground. Proving, I suppose, that I have long
arms, short legs and little in the way of persuasive gifts. I was denied the
Old people are often told they're "marvellous" for simply being there and not
complaining much. As though our longevity or our susceptibility to disease were
entirely up to us, were choices we make: pain and illness the outward signs of
weakness, vacillation, lack of character; health the well-earned consequence of
courage and the right amount of moral fibre. The man or woman who meekly submits
to illness and death rather than "fighting" it, "putting up a struggle", is
unlikely to figure gloriously in obituary columns.
What are we allowed to say about pain? The hardest aspect of it is the
difficulty of describing it, measuring it, knowing if it is better or worse,
more or less, than anyone else's or, indeed, our own on another day. When a
doctor's report from the endoscopy department included the words "low pain
threshold" I felt accused and slandered. How could he know that? How can any of
us know? Perhaps the pain was beyond anyone's threshold. We'll never know.
This is all the more important now that the sinister word "triage" has been
reintroduced into medical practice, reminiscent of Florence Nightingale and her
nurses patrolling the tents in the Crimea in order to decide which of the
wounded were worth treating, which should be attended to first and which were
not worth bothering about because they were bound to die anyway. It may no
longer be wise to show fortitude under stress if we want our ailments to be
I woke this morning with an ominous pain on the right side of my chest. There
are some good things about new, sharp pains: they tend to blot out the older,
more persistent ones. So, unusually, I had no cramp in my legs, nor could I feel
the sharp agony and intractable stiffness in the small of my back that greets me
on other mornings. The pains of old age are often undiagnosed and perhaps
undiagnosable. Since they are usually produced by the gradual, or occasionally
sudden, wearing out of bits of our minds and bodies, they are often less
frightening than new and inexplicable pains were in one's youth, because for the
most part they don't herald serious illness or catastrophe but simply remind us
of our general and increasing debility. The bad thing about them, however, is
that by and large they are going to get worse.
If I find it painful getting out of bed in the morning, I am likely to find it
harder still in five years' time. Then you have to add that, though that is
undoubtedly so, it is also quite possible that you won't be there in five years.
And given that it's pain you're thinking about, you're faced with a dilemma. Do
you really want to be there having a much worse version of the pain that's
bothering you now? Might it possibly be a relief not to be there?
When Vidal talks of "the hospital years", he means his last years, not just a
passing phase. And when we talk of our state of mind or health nowadays we
probably aren't alluding to a temporary state, but to the present and the future
and to a continuous, declining, but finite condition, and all of it hurtling
along at great speed.
In his Nothing to Be Frightened Of, a meditation on his lifelong fear of dying,
Julian Barnes divides people into those who fear death and those who fear the
incapacities of old age, with subheadings for those who do or don't believe in
God or an afterlife. "I'm sure my father feared death, and fairly certain my
mother didn't: she feared incapacity and dependence more," Barnes writes. I
don't think much about my own death or even fear it, I suppose because I am
unable to imagine it. But I did catch myself hoping the other day that I might
have most of my teeth when I'm dying, if only to spare the sensibility of an
onlooker, should there be one. It is a hope all too likely to be thwarted, I'm
sorry to say.
I can imagine all too easily, on the other hand, the stretch of life preceding
death, and its potential for misery, weakness, dependence, though I don't think
about that very much either, probably because I can't bear to. I am terrified of
having nothing to do and no one to talk to. I avoid all articles and programmes
advising me to insure myself now for dementia and other debilities, book a place
in a home or negotiate a granny flat, let alone join EXIT or look into the fees,
legality and conditions of death-delivering doctors in Switzerland.
I should come clean. I'm not sure that I really believe that I will be dead one
day, any more than I entirely believe that I'm as old as I am. I would like to
think that everyone has moments when they think of themselves as the exception
to the rule. Writing about my own old age is a way of convincing myself that I
really am old and that I really will die.
There are people who see old age as a time of peace, acceptance and the end of
strong feeling. I do know old people who seem to have reached a plateau of that
sort. They are amused, interested, calm, and they appear to have accepted the
inevitability of their distance from a great deal of what goes on in the world.
Yet in their desire both to live a good old age and to control the manner of
their dying I doubt whether many of them would go quite as far as the old or ill
adherents of Jainism in India sometimes do. William Dalrymple talked to a nun
about the Jain custom of gently starving yourself to death, a process she firmly
distinguishes from suicide.
"Sallekhana is a beautiful thing. There is no distress or cruelty. As nuns our
lives are peaceful, and giving up the body should also be peaceful . . . First
you fast one day a week, then you eat only on alternate days: one day you take
food, the next you fast. One by one, you give up different types of foodstuffs.
You give up rice, then fruits, then vegetables, then juice, then buttermilk.
Finally you take only water, and then you have that only on alternate days.
Eventually, when you are ready, you give up on that too. If you do it very
gradually, there is no suffering at all. The body is cooled down, so that you
can concentrate inside on the soul and on erasing all your bad karma."
There is an entirely different version of old age: the old person who is angry,
impatient, full of regrets, nostalgia, distrust of the young; and there's a
particular bitterness and resentment such a person may go in for, stored up from
the past and sharpened now by powerlessness and by embarrassing and ineffectual
efforts to garner and maintain dignity. Dylan Thomas was 37 when he wrote Do Not
Go Gentle Into That Good Night with its injunction that "Old age should burn and
rave at close of day." It was advice I approved of in those days, even though
the poor fellow died two years later, when he was not yet 40. It would be hard
for most of us to keep up all that burning and raving in our 70s.
My old friend Anne Wollheim had a really bad month or two at the end of her life
and was known to wonder aloud, "Where is Dr Shipman now?" In fact, she had more
than a year of knowing she was going to die and refusing to have the treatment
which would probably not have lengthened her life by much. She filled that year
with children and grandchildren and family and friends and travel, so that I
find myself hoping that only the last two months or so were intolerable.
If it is true that we have 10 extra years of life nowadays, but that eight of
them bear more than a shadow of decrepitude and the complicated moral choices
inflicted on us by medical advances, we will need to work out how to get more
control over the ways there may be of ending it all.
Dr. Robert N. Butler, a psychiatrist whose painful youthful realization that
death is inevitable prompted him to challenge and ultimately reform the
treatment of the elderly through research, public policy and a Pulitzer
Prize-winning book, died Sunday in Manhattan. He was 83 and had worked until
three days before his death.
The cause was acute leukemia, his daughter Christine Butler said.
Dr. Butler’s influence was apparent in the widely used word he coined to
describe discrimination against the elderly: “ageism.” He defended as healthy
the way many old people slip into old memories — even giving it a name, “life
In speech after speech, he pounded home the message that longevity in the United
States had increased by 30 years in the 20th century — greater than the gain
during the preceding 5,000 years of human history — and that this had led to
profound changes in every aspect of society, employment and politics among them.
Dr. Christine Cassel, president of the American Board of Internal Medicine, said
in an interview that Dr. Butler had in effect “created an entire field of
medicine.” She said he had helped change attitudes so that aging could be
perceived “a positive thing.”
Dr. Butler was the founding director of the National Institute on Aging at the
National Institutes of Health and advocated for the aging before Congress and
the United Nations. He helped start and led the American Association for
Geriatric Psychiatry, the Alzheimer’s Disease Association and the International
Longevity Center. President Bill Clinton named him chairman of the 1995 White
House Conference on Aging.
“He really put geriatrics on the map,” Dr. David B. Reuben, chief of the
division of geriatrics at the University of California, Los Angeles, said in an
Dr. Butler challenged long-held conceptions about aging, calling it “the
neglected stepchild of the human life cycle.” He helped establish, for example,
that senility is not inevitable with aging. When the Heinz Family Foundation
presented him with an award in 2003, it called him “a prophetic visionary.”
The most noted exposition of his vision was the 1975 book that earned him his
Pulitzer, “Why Survive? Being Old in America.” It went from a bleak explication
of the elderly’s condition to prescriptions to improve it.
“Human beings need the freedom to live with change, to invent and reinvent
themselves a number of times through their lives,” Dr. Butler wrote.
Dr. Butler’s mission emerged from his childhood, he wrote in his book. His
parents had scarcely named him Robert Neil Butler before splitting up 11 months
after his birth on Jan. 21, 1927, in Manhattan. He went to live with his
maternal grandparents on a chicken farm in Vineland, N.J.
He came to revere his grandfather, with whom he cared for sick chickens in the
“hospital” at one end of the chicken house. He loved the old man’s stories. But
the grandfather disappeared when Robert was 7, and nobody would tell him why. He
finally learned that he had died.
Robert found solace in his friendship with a physician he identified only as Dr.
Rose. Dr. Rose had helped him through scarlet fever and took him on his rounds
by horse and carriage. The boy decided he could have helped his grandfather
survive had he been a doctor. He also concluded that he would have preferred
that people had been honest with him about death.
From his grandmother, he learned about the strength and endurance of the
elderly, he wrote. After losing the farm in the Depression, she and her grandson
lived on government-surplus foods and lived in a cheap hotel. Robert sold
newspapers. Then the hotel burned down, with all their possessions.
“What I remember even more than the hardships of those years was my
grandmother’s triumphant spirit and determination,” he wrote. “Experiencing at
first hand an older person’s struggle to survive, I was myself helped to survive
Dr. Butler served in the United States Maritime Service before entering Columbia
University, where he earned his bachelor’s and medical degrees. During his
internship in psychiatry at St. Luke’s Hospital, he had many elderly patients
and realized how little he had been taught about treating them. He began reading
about the biology of aging.
After his residency at the University of California, San Francisco, he worked at
the National Institute of Mental Health as a research psychiatrist. He studied
the central nervous system in elderly people, work that became part of a large
study of aging. He also helped Ralph Nader investigate problems in nursing
The book that emerged from his experiences proposed many specific reforms to
help old people, including a national service corps that would enlist the
elderly as community volunteers.
In 1975 he succeeded in creating a National Institute on Aging and was its head
for six years.
“Nobody thought research on aging was a legitimate field until Bob came along
and convinced them to create a separate institute,” Dr. Cassel said.
In 1982, the Mount Sinai School of Medicine in Manhattan asked Dr. Butler’s
advice on whom to hire for a new geriatrics chair. He proposed instead that the
school create a department devoted solely to gerontology. It did, and was one of
the first to do so.
He wrote numerous articles and several books, including the bestseller “Sex
after Sixty,” which he wrote with his second wife, Dr. Myrna I. Lewis, in 1976.
Dr. Butler’s first marriage, to Diane McLaughlin, ended in divorce. Dr. Lewis
died in 2005. Besides his daughter Christine, he is survived by three other
daughters, Carole Butler Hall, Cynthia Butler and Alexandra Butler; and six
Dr. Butler acknowledged in an interview two years ago with The Saturday Evening
Post that his views on his own aging had changed: he feared death less.
“I feel less threatened by the end of life than I perhaps did when I was 35,” he
No one who knows Justin Kaplan would ever have expected this. A Pulitzer
Prize-winning historian with a razor intellect, Mr. Kaplan, 84, became
profoundly delirious while hospitalized for pneumonia last year. For hours in
the hospital, he said, he imagined despotic aliens, and he struck a nurse and
threatened to kill his wife and daughter.
“Thousands of tiny little creatures,” he said, “some on horseback, waving arms,
carrying weapons like some grand Renaissance battle,” were trying to turn people
“into zombies.” Their leader was a woman “with no mouth but a very precisely cut
hole in her throat.”
Attacking the group’s “television production studio,” Mr. Kaplan fell from his
hospital bed, cutting himself and “sliding across the floor on my own blood,” he
said. The hospital called security because “a nurse was trying to restrain me
and I repaid her with a kick.”
Mr. Kaplan’s hallucinations lifted as doctors treated his pneumonia. But
hospitals say many patients are experiencing such inexplicable disorienting
episodes. Doctors call it “hospital delirium,” and are increasingly trying to
prevent or treat it.
Disproportionately affecting older people, a rapidly growing share of patients,
hospital delirium affects about one-third of patients over 70, and a greater
percentage of intensive-care or postsurgical patients, the American Geriatrics
“A delirious patient happens almost every day,” said Dr. Manuel N. Pacheco,
director of consultation and emergency services at Mount Auburn Hospital in
Cambridge, Mass. He treated Mr. Kaplan, whom he described as “a very learned,
acclaimed person,” for whom “this is not the kind of behavior that’s normal.”
“People don’t talk about it, because it’s embarrassing,” Dr. Pacheco said.
“They’re having sheer terror, like their worst nightmare.”
The cause of delirium is unclear, but there are many apparent triggers:
infections, surgery, pneumonia, and procedures like catheter insertions, all of
which can spur anxiety in frail, vulnerable patients. Some medications,
difficult for older people to metabolize, seem associated with delirium.
Doctors once dismissed it as a “reversible transient phenomenon,” thinking “it’s
O.K. for someone, if they’re elderly, to become confused in the hospital,” said
Dr. Sharon Inouye, a Harvard Medical School professor. But new research shows
significant negative effects.
Even short episodes can hinder recovery from patients’ initial conditions,
extending hospitalizations, delaying scheduled procedures like surgery,
requiring more time and attention from staff members and escalating health care
costs. Afterward, patients are more often placed, whether temporarily or
permanently, in nursing homes or rehabilitation centers. Older delirium
sufferers are more likely to develop dementia later. And, Dr. Inouye found, 35
percent to 40 percent die within a year.
“It’s terrible, more dangerous than a fall,” said Dr. Malaz A. Boustani, a
professor at the Indiana University Center for Aging Research, who found that
elderly patients experiencing delirium were hospitalized six days longer, and
placed in nursing homes 75 percent of the time, five times as often as those
without delirium. Nearly one-tenth died within a month. Experts say delirium can
contribute to death by weakening patients or leading to complications like
pneumonia or blood clots.
Ethel Reynolds, 75, entered a Virginia hospital last July to have fluid drained
that had been causing her feet to swell. She wound up hospitalized for weeks,
sometimes so delirious that “she screamed constantly, writhed,” said her
daughter, Susan Byrd. “I had to get in bed with her because she thought someone
was coming and they were going to hurt us,” Ms. Byrd said.
Ms. Reynolds ended up needing dialysis and surgery after an infection, and she
died in September.
“We got her death certificate, and the No. 1 cause of death was delirium,” said
Ms. Byrd, an ophthalmology nurse. “I was just blown away. As a nurse, I was
expecting a quote-unquote medical reason: kidneys, heart, lung, an organ that I
could understand had failed, and it wasn’t. It was delirium.”
Other triggers involve disorienting changes: sleep interrupted for tests,
isolation, changing rooms, being without eyeglasses or dentures. Medication
triggers can include some antihistamines, sleeping pills, antidepressants and
drugs for nausea and ulcers. Dr. Inouye said that many “doctors don’t know how
to appropriately use meds in older people, in terms of dosing” and compatibility
with other medications.
Earle Helton, 80, a retired chemist hospitalized after a stroke, ordered his
family to “throw a rope over the hedge so he could escape,” said his daughter,
Amanda. He tried removing his hospital gown, loudly sang “Lullaby and
Goodnight,” and doctors had to tie down his hands to prevent him from leaving,
said his wife, Ginnie. Only when Dr. Inouye stopped some medications that other
doctors had prescribed did he become lucid.
Delirium is sometimes treated with antipsychotics, but doctors urge caution
using such drugs.
Delirium can wax and wane, not always causing aggressive agitation.
“It is often the person quietly in bed,” and the condition can linger for weeks
or months, landing patients back in the hospital, said Dr. Julie Moran, a
geriatrician at Beth Israel Deaconess Medical Center in Boston. “We would have
to build 100 more floors to keep everybody until they cleared their delirium.
There are times when we could be working round the clock seeing patients with
Frequently, geriatricians say, delirium is misdiagnosed, or described on patient
charts as agitation, confusion or inappropriate behavior, so subsequent doctors
might not realize the problem. One study found “delirium” used in only 7 percent
of cases; “confusion” was most common. Another study of delirious older
emergency-room patients found that the condition was missed in three-quarters of
People with dementia seem at greater risk for delirium, but many delirious
patients have no dementia. For some of them, delirium increases the risk of
later dementia. In such cases, it is unclear if delirium caused the dementia, or
was simply a signal that the person would develop it later.
Some hospitals are adopting delirium-prevention programs, including one
developed by Dr. Inouye, which adjusts schedules, light and noise to help
patients sleep, ensures that patients have their eyeglasses and hearing aids,
and has them walk, exercise and do cognitive activities like word games.
Dr. Moran’s hospital removes catheters, intravenous lines and other equipment
whenever possible because they can make patients feel trapped, leading to
delirium. She said nurses repeatedly assess cognitive function so patients
“don’t have smoldering symptoms of delirium for days before they end up yelling
Mr. Kaplan, a biographer of Mark Twain and Walt Whitman, later jotted notes
about his hallucinations, including being in a police helicopter “tracking
fugitives with enormous light.”
“Exhilarating until I become one of the fugitives,” he wrote. “End up cold and
naked in some sort of subway passage.”
His fall bruised his elbow, leg and wrist, said his wife, the writer Anne
Bernays. The next day, “he was gaga till about noon,” and even “looked me in the
eye and said ‘I’m going to kill you,’ ” she said. “He didn’t know where he was
and didn’t recognize me.”
Fortunately, his delirium was discovered very quickly and he made a very good
recovery, Dr. Pacheco said. “But,” he said, “delirium is very disruptive for the
patient, family, hospital caregivers.”
As Mr. Kaplan understated later, “It was a lot of unpleasantness.”
ASHBURN, Va. — For generations, the prototypical search-and-rescue case in
America was Timmy in the well, with Lassie barking insistently to summon help.
Lost children and adolescents — from the woods to the mall — generally
outnumbered all others.
But last year for the first time, another type of search crossed into first
place here in Virginia, marking a profound demographic shift that public safety
officials say will increasingly define the future as the nation ages: wandering,
confused dementia patients like Freda Machett.
Ms. Machett, 60, suffers from a form of dementia that attacks the brain like
Alzheimer’s disease and imposes on many of its victims a restless urge to head
out the door. Their journeys, shrouded in a fog of confusion and fragmented
memory, are often dangerous and not infrequently fatal. About 6 in 10 dementia
victims will wander at least once, health care statistics show, and the numbers
are growing worldwide, fueled primarily by Alzheimer’s disease, which has no
cure and affects about half of all people over 85.
“It started with five words — ‘I want to go home’ — even though this is her
home,” said Ms. Machett’s husband, John, a retired engineer who now cares for
his wife full time near Richmond. She has gone off dozens of times in the four
years since receiving her diagnosis, three times requiring a police search.
“It’s a cruel disease,” he said.
Rising numbers of searches are driving a need to retrain emergency workers,
police officers and volunteers around the country who say they throw out just
about every generally accepted idea when hunting for people who are, in many
ways, lost from the inside out.
“You have to stop thinking logically, because the people you’re looking for are
no longer capable of logic,” said Robert B. Schaefer, a retired F.B.I. agent who
cared for his wife, Sarah, for 15 years at home through her journey into
Alzheimer’s. He now leads two-day training sessions for the Virginia Department
of Criminal Justice Services.
Mr. Schaefer told his class of mostly police officers here in northern Virginia
that unlike the ordinary lost child or hiker, a dementia wanderer will sometimes
take evasive action to avoid detection, especially if the disease has made them
paranoid about authority figures.
“We’ve found them in attics and false ceilings, in locked closets — you name
it,” said Gene Saunders, a retired police officer from Chesapeake, who started a
nonprofit company called Project Lifesaver 11 years ago to help find wanderers
or people with other cognitive impairments. The group’s technology, fitting
patients with wristbands that can be tracked by police officers with radio
devices, is in use in 45 states, but its widest use is here in Virginia.
Wanderers often follow fence or power lines, and tend to be drawn toward water,
Virginia state rescue officials said, bound on a mission that only they — and
sometimes perhaps not even they — can imagine. (A search trick: try to figure
what door they exited from, then concentrate first in that direction. But don’t
bother calling out the person’s name, which he or she has often forgotten.)
Searching for them often also means learning a patient’s life story as well,
including what sort of work they did, where they went to school and whether they
fought in war. Because Alzheimer’s disease, the leading cause of dementia, works
backward, destroying the most recent memories first, wanderers are often
traveling in time as well as space.
Some World War II veterans, for example, have gone huge distances believing they
needed to report to base or the front lines. A man in Virginia was lost for days
until searchers, in interviews with his family, learned he had long ago been a
dairy farmer, rescue officials said. It turned out he had headed for a cow
pasture not far from his home, believing it was time for the morning milking.
The all-too-human stories of exhausted family members caring for Alzheimer’s
sufferers must be taken in account as well, searchers say. The son or daughter
or spouse who nodded off or was briefly inattentive, allowing a loved one to
slip out, might feel guilty, and so understate, sometimes by many hours, how
long the person has been gone — a crucial variable because time on the run in
turn hugely increases the potential size of the search area.
Meanwhile, cold cases are piling up.
In Arizona, James Langston, the state’s search and rescue coordinator at the
Division of Emergency Management, is haunted by the stories of people who simply
stride out into the desert in high summer and vanish. A few years ago, a
20,000-square-mile area was searched after an Alzheimer’s patient’s car was
found on a dirt road at the desert’s edge, he said. No trace of the person was
Advanced age, meanwhile, can compound health risks of exposure.
“We’ve had them die in as little as seven hours because they just keep going and
don’t recognize they’re getting dehydrated,” Mr. Langston said.
Many states do not collect or fully categorize local data on search-and-rescue
cases, so it is impossible to gauge the full impact of dementia wandering on law
enforcement. But in Oregon, for example, the number of searches for lost male
Alzheimer’s patients nearly doubled just last year, to 26 from 14 in 2008, and
has more than tripled since 2006, according to emergency management officials.
For many people involved in those searches — or in training rescuers for the
demographic tsunami to come — the turbulent emotions and grief that swirl around
Alzheimer’s disease and dementia are simply part of the terrain. In the middle
of his training courses, Mr. Schaefer sometimes pauses, choked up by memories of
his wife, who received her Alzheimer’s diagnosis at age 50. She died 17 years
later, having forgotten how to swallow, he said, and then finally, even how to
On a recent afternoon at the Northern Virginia Criminal Justice Training
Academy, Mr. Schaefer told his class about the day he asked her if she knew who
he was. He had taken steps by then to keep Ms. Schaefer from wandering away,
disguising their home’s doors, for one thing, covering them with posters that
looked like bookshelves.
But now he could see the panic and horror in her eyes, he said, that she could
not find the right answer to his question. Could she recognize her own husband?
“No,” she answered. “But you take very good care of me.”
For John McClelland, 57, a retired volunteer fire and rescue officer who now
leads training courses in Colorado, the story is even more personal: He has a
diagnosis of Alzheimer’s himself. The disease killed his grandfather and three
other people on that side of the family. He said he has already lost the ability
to remember the faces of new acquaintances, even a day after meeting them.
Knowing what is coming for him as the fatal disease takes its course has made
his training work all the more important and urgent, he said.
“The mission I’m on is that I’m willing to talk about Alzheimer’s as long as I’m
articulate,” he said. “The hell of the disease is that I know what’s coming.”
It is well known that during the nation’s gale-force recession, many older
Americans who dreamed of retirement continued to work, often because their
401(k)’s had plunged in value.
In fact, there are more Americans 65 and older in the job market today than at
any time in history, 6.6 million, compared with 4.1 million in 2001.
Less well known, though, is that nearly half a million workers 65 and older want
to work but cannot find a job — more than five times the level early this decade
and this group’s highest unemployment level since the Great Depression.
The situation is made more dire because of numerous recent trends: many people
over 65 have lost their jobs as seniority protections have weakened, and like
most other Americans, a higher percentage of them took on debt than in previous
The expectation once was to pay off your 30-year mortgage before you retired, or
come close. Instead, the level of indebtedness among older Americans has risen
faster than in any other age group, partly because so many obtained second
mortgages to take money out of their homes.
This financial squeeze is one reason President Obama has proposed giving a
special $250 one-time payment to all Social Security recipients.
Many out-of-work older Americans complain that they face foreclosure or have had
to give up their car.
“It’s a big deal for a lot of these people not to find a job,” said David
Certner, legislative policy director for AARP. “That so many of them are still
trying to find work shows how bad the economic situation is. A lot of people
normally give up at that age.”
The unemployment rate for older Americans is still much better than for others —
6.7 percent compared with 9.8 percent in the general population. But 6.7 percent
is more than double the level of two years ago — and far higher than the
minuscule 1.9 percent rate early this decade.
And unemployed older workers stay out of work longer — 36.5 weeks on average, 40
percent longer than for the unemployed in general.
Patricia Warmhold, who has worked as a translator and telemarketer, would love
to retire, but at age 67, she says that is out of the question.
Her mortgage payment is nearly $1,500 a month, and her car payments and auto
insurance are another $350. She receives $1,071 a month in Social Security and
$918 in pension.
“I have very little after the mortgage,” she said.
Ms. Warmhold, who speaks German, French and Creole, was laid off a year ago from
her job as an interpreter for a law firm. “I’ve been looking for jobs ever
since,” she said. “I applied to Nassau County and Suffolk County, and they don’t
A divorce worsened her financial situation, although her mother, who is in her
90s, helps by sometimes sending her $100.
“In a month’s time, I sent out 101 job applications,” she said, including more
than 50 to school districts, to no avail.
The recession has battered young, middle-aged and old, although several modern
trends have left older workers more vulnerable than in the past — for instance,
the shift toward 401(k)’s and away from traditional pensions that give retirees
a monthly stipend for life has pressured many Americans to continue working well
Another force pushing Americans to delay retirement is that the percentage of
companies that provide health coverage to retirees is half what it was two
decades ago. Moreover, the age to obtain full Social Security benefits has
increased to at least 66 for people born after 1942, from its traditional 65.
The median income for those 65 and over was just $18,208 in 2008 — a quarter of
them had incomes under $11,139, according to Patrick Purcell, an expert on older
workers and pensions with the Congressional Research Service.
The average Social Security recipient age 65 and over receives just $12,437 in
annual benefits, he said, and among individuals 65 and older who received income
from financial assets, half received less than $1,542 last year.
While Social Security keeps most seniors above the poverty line, there are a
substantial number near poverty “who are just getting by,” said Richard W.
Johnson, a senior fellow at the Urban Institute. Many economists say it is good
that Americans are working later in life — many are living longer and able to
Still, many older job seekers insist they are losing out because of age
discrimination. Last year, nearly 25,000 workers filed age discrimination
complaints, a 29 percent jump over 2007, according to the Equal Employment
“I often get told that I’m overqualified,” said Barbara Brooks, 71, who retired
in 2003 after 30 years as an administrative assistant at the University of
California, Los Angeles. She said being told that is code language for “you’re
too old.” But Ms. Brooks said she wanted to work — and needed to — citing her
monthly mortgage of $1,500, which eats up half her monthly pension.
“I would like to be able to treat myself to a couple of dinners, maybe a movie,”
Ms. Brooks said. “I think as long as people have excellent skills, and they can
get around like a 40-year-old — I’ve been told I look 40 or 50 — why shouldn’t I
For years, unemployment among older Americans was largely ignored because so few
of them were jobless. But now more than a million Americans over age 60 are
unemployed, two-and-a-half times the level two years ago.
And at least jobless workers 65 and over are guaranteed health coverage through
Medicare. Workers laid off before that age often have to fend for themselves to
obtain health insurance, which is often prohibitively expensive for those over
One such worker is Michael Husar, 62, a former engineering manager who spent 38
years with General Motors and then its Delphi auto parts spinoff. Mr. Husar, a
resident of Scottsdale, Ariz., retired in 2003 at age 56, but as a result of
Delphi’s bankruptcy, he now has to purchase his own health insurance. He pays
$1,600 a month, which translates to $19,200 a year.
Despite two engineering degrees, his search for consulting work has come up
empty in recent months.
“There are two reasons I feel a need to continue working,” he said. “One, I
still have a lot to offer, and two, I need the money.”
Alicia H. Munnell, director of the Center for Retirement Research at Boston
College, says older workers have fared better by and large than younger workers
in this recession. The percentage of workers ages 25 to 54 with jobs has fallen
to 75 percent, from nearly 80 percent two years ago, while the percentage of
older Americans with jobs has risen slightly, to 16.3 percent.
But that is fewer than the number who want to work.
Patricia Piazza, 66, who worked for Chrysler for 30 years as an analyst, knows
that all too well.
She and her 72-year-old husband, a longtime employee at General Motors
Acceptance Corporation, had planned to retire by now, but she is hunting for
job, and he recently landed one with the local transit system.
Their home in Warren, Mich., has dropped $100,000 in value, Ms. Piazza said,
while their pensions, as former nonunion employees, will be far less than
anticipated because of the auto company bankruptcies.
Chrysler recently took away her life insurance policy and optical coverage, she
“It’s like the bottom fell out of everything” she said. “This isn’t the way we
Like many older people, Paula Rice of Island City, Ky., has grown isolated in
recent years. Her four grown children live in other states, her two marriages
ended in divorce, and her friends are scattered. Most days, she does not see
But Ms. Rice, 73, is far from lonely. Housebound after suffering a heart attack
two years ago, she began visiting the social networking sites Eons.com, an
online community for aging baby boomers, and PoliceLink.com (she is a former
police dispatcher). Now she spends up to 14 hours a day in online conversations.
“I was dying of boredom,” she said. “Eons, all by its lonesome, gave me a reason
to keep on going.”
That more and more people in Ms. Rice’s generation are joining networks like
Eons, Facebook and MySpace is hardly news. Among older people who went online
last year, the number visiting social networks grew almost twice as fast as the
overall rate of Internet use among that group, according to the media
measurement company comScore. But now researchers who focus on aging are
studying the phenomenon to see whether the networks can provide some of the
benefits of a group of friends, while being much easier to assemble and
“One of the greatest challenges or losses that we face as older adults, frankly,
is not about our health, but it’s actually about our social network
deteriorating on us, because our friends get sick, our spouse passes away,
friends pass away, or we move,” said Joseph F. Coughlin, director of the AgeLab
at the Massachusetts Institute of Technology.
“The new future of old age is about staying in society, staying in the workplace
and staying very connected,” he added. “And technology is going to be a very big
part of that, because the new reality is, increasingly, a virtual reality. It
provides a way to make new connections, new friends and new senses of purpose.”
About one-third of people 75 and older live alone, according to a 2009 study
from AARP. In response to the growing number of older Americans, the National
Institute on Aging is awarding at least $10 million in grants for researchers
who examine social neuroscience and its effect on aging.
Online networks may offer older people “a place where they do feel empowered,
because they can make these connections and they can talk to people without
having to ask a friend or a family member for one more thing,” said Antonina
Bambina, a sociologist at the University of Southern Indiana who wrote the book
“Online Social Support” (Cambria, 2007).
For the family members of older people, online social networks can provide a bit
of relief. Chris McWade of Franklin, Mass., the youngest member of a big family,
recently helped his parents, his grandparents and his uncle move to retirement
homes. He said he spent two or three years “just flying cross-country, holding a
lot of hands” and seeing the isolation and depression that came with aging.
That sparked the idea for MyWay Village, a social network based in Quincy, Mass.
Mr. McWade helped found it in 2006 and now sells it to retirement homes. It has
just completed pilot programs in several nursing homes in Illinois and
Massachusetts, and Mr. McWade says he has agreements to expand to several other
Two and a half years ago, Howe Allen, a real estate broker in Boston, moved his
parents to the River Bay Club, a retirement home in Quincy, Mass., that uses
His mother died soon after, but his father, Carl, was able to start making
friends and share stories on MyWay. The older man had never used a computer, but
picked it up quickly; the software includes computer training sessions. And
after he died last December, a memorial service at the home included photographs
he had uploaded to MyWay, excerpts from memoirs he had posted and eulogies from
friends he had made through the site.
“It was as moving a day as I can ever remember,” Howe Allen said. “It’s more
than just the computer. It affected him in ways that are so far from the
electronic age. It allowed this person to grow at an age where you assume most
people stop growing.”
On a recent Monday, Neil Sullivan, a regional manager for MyWay, stood in front
of a group of about 20 River Bay Club residents in the home’s library.
He came prepared with slides and speeches, but mostly the group just wanted to
talk about their lives. When Mr. Sullivan showed a photograph of a 1950
Chevrolet, one resident said, “I had a ’57 Chevy,” and another responded, “Mine
was a ’49 Chevy.” A man in a chartreuse sweater who had been quiet for some time
added, “The best car I ever had was a Dodge Business Coupe.”
Sarah Hoit, a co-founder of MyWay and its chief executive, said that for older
people, learning to get online was not an end in itself. “They want a vehicle to
meet new people and share their lives,” she said. “They want to be stimulated.”
Outside of the weekly sessions, River Bay residents use the site to post stories
like “My Life as a Nurse” or “I Worked at the Howard Johnson in Quincy.” Sunny
Walker, 89, who refused to use an electric typewriter when she was a school
secretary because she hated technology so much, now plays games and sends
friends messages through the site.
“I’m telling you, it’s the best thing for seniors,” she said. “It challenges
their mind, that’s what it does. It challenged mine.”
Some research suggests that loneliness can hasten dementia, and Dr. Nicholas A.
Christakis, an internist and social scientist at Harvard, says he is considering
research on whether online social connections can help delay dementia, as
traditional ones have been found to do in some studies.
“Online social networks realize an ancient propensity we all have to connect
with others,” he said.
The propensity may be ancient, but the means are not. Mollie Bourne, a golf
course owner who lives in Puerto Vallarta, Mexico, half of the year, logs on to
Facebook a few times a week. She likes to browse through her grandchildren’s
posts and photos, even the ones taken at bars and parties that are hardly the
sort that people expect their grandmothers to see.
“For heaven’s sakes, we all acted like that in college,” she said. “That’s one
thing you get with your 76 years. I’ve been around. I’ve seen it all. It takes a
lot to shock me.”
May 24, 2009
The New York Times
By KARL TARO GREENFELD
IN mid-2007, I set off to meet with geneticists, epidemiologists and doctors
who specialize in researching and treating autism. I was seeking a novel therapy
for my 42-year-old autistic younger brother Noah. I was also looking to discover
how heightened awareness of autism — it is now among the most financially
successful and mediagenic diseases ever, with hundreds of millions of dollars a
year going to research, and regular press coverage — might have resulted in new
and innovative programs for adult autistics like Noah.
Autism was already widely being described as an epidemic, affecting as many as 1
in 150 8-year-olds, according to the Centers for Disease Control and Prevention.
We had come a long way since Noah got his diagnosis in the late ’60s, the
so-called dark ages of autism, when many pediatricians believed they had never
seen a case, and so-called refrigerator mothers were mistakenly blamed for their
children’s withdrawn, antisocial condition.
But now, with autism described to me as “the disease of the decade” by Peter
Bell, the executive vice president of programs and services for the advocacy
group Autism Speaks, I thought perhaps there was hope, even for low-functioning
adult autistics like Noah.
Noah has been my family’s focus for decades. As a baby, he had been very slow to
turn over, crawl or walk, and each subsequent developmental milestone was even
more delayed as he grew into adulthood. My parents did everything they could for
him, moving us from New York to Los Angeles in the early 1970s to be closer to a
pioneering autism program at the University of California at Los Angeles,
opening their own day care center for the developmentally disabled, even
creating a one-on-one assisted-living situation for Noah — years before this
became common — so that they could delay institutionalizing him.
I toured those state hospital systems with my parents when we started looking
for a place for a growing-up Noah. Those were terrifying visits: adult patients
wearing helmets and restraints, howling and hitting themselves. This was during
the ’70s when the scandals at state psychiatric hospitals like Letchworth
Village in New York and Camarillo in California were making terrifying
headlines. Clients at Camarillo were dying from neglect and improperly
administered medications. We had to keep Noah out of that system for as long as
Eventually, when he was 22, Noah had to leave home. He graduated from his
special needs school on a bright, sunny Orange County day; he was beaming,
handsome in his bright blue cap and gown.
But for the profoundly autistic, graduation is perhaps the saddest day in their
lives. For those who cannot enter the work force, continue on to more education
or find some sheltered workshop environment with adequate staffing, there are
few options. Far too few programs and resources are allocated for adults with
Noah has been in and out of sheltered workshops, but these are always under
threat because of state budget deficits. Noah has been asked to leave some
programs because he was too low-functioning. For several years, we have been
trying to find a day program where he might interact with others and perhaps
perform some simple, menial job. We have long since given up any hope that he
might continue in adulthood the behavioral therapies that are now considered
standard for autistics; unless the family is willing to pay the bulk of the
cost, there is very little out there for men and women like Noah.
For purposes of fund-raising and awareness-raising, autism has been portrayed as
a childhood disease. The federal Department of Health and Human Services has
characterized it as a “disorder of childhood.” There are practical reasons for
this: early intervention has been shown to be the most effective therapy. The
trend in autism treatment has been to steadily lower the age at which intensive
intervention commences — as early as five months, according to some experts. Yet
autism is not a degenerative condition; the vast majority of those 1 in 150
children who are afflicted will survive to adulthood.
As I spoke with the experts, I began to see that the focus on children had
influenced not only the marketing of autism, but also research and treatment. It
seemed the majority were interested in children only, the younger the better.
“The best time to look is at the early ages, when autism is developing,” Sophia
Calimaro, vice president of research at Autism Speaks, told me a few months ago,
explaining that was also where there had been the most treatment success. “I’m
not making excuses, but that’s really why more research into adults with autism
hasn’t been done.”
Low-functioning adult autistics are viewed with sympathy but not much scientific
inquiry. No one has broken down how many dollars are actually flowing to adult
autistics, but at the International Meeting for Autism Research in Seattle in
May 2007, I counted more than 450 papers and presentations and three dozen talks
on autism given by academics and specialists; of those, only two dealt with
low-functioning adults, and neither included a cohort large enough to be
The careful measurements of brain function, or dysfunction, were almost all done
on children. A few cognitive and emotional development studies dealt with
adults, but these were overwhelmingly focused on high-functioning autistics and
people with Asperger’s syndrome.
Autism Speaks, the major sponsor of autism research projects, has not broken
down the proportion of funds that go to adult-oriented research, but Mr. Bell,
whose teenage son is autistic, laments that “it’s low, too low. ... We have to
change the paradigm for those of us who have kids who are going to grow up and
need more and better services.”
That change can’t come soon enough. Even with state-of-the-art early
intervention — eight hours a day, seven days a week — many autistics will need
support throughout their lives. The reality is that very few, perhaps only 10
percent, of those as severely autistic as Noah benefit from the current
interventions to the point where they become functioning members of society.
If the current C.D.C. estimation of prevalence is correct, then there will be an
awful lot of adult autistics who need lifetime support and care. Noah’s life has
been a grim study in how scarce those resources are. Without them, his behavior
A recent “psychological and psychopharmacological” report by the California
Department of Developmental Services said Noah exhibited a “failure to develop
peer relationships, a lack of social or emotional reciprocity,” and it described
some of his “maladaptive behaviors” like “banging his head against solid
surfaces, pinching himself and grabbing others.”
“Noah may also,” it noted, “intentionally spit at others, pinch or scratch
others, dig his fingernails into others, and/or pull others’ hair. He may bite,
head-butt and hit others; throw objects at others, and hit/slap his head when he
is highly agitated.” He is a handful.
November 28, 2008
From Times Online
A great-great-grandmother who was the world's oldest person has died at the
age of 115.
Indiana woman Edna Parker, who assumed the mantle more than a year ago, passed
away on Wednesday at a nursing home in Shelbyville. She was 115 years, 220 days
Mrs Parker was born April 20, 1893, in central Indiana and had been recognised
by Guinness as the world’s oldest person since the 2007 death of Japan's Yone
Minagawa, who was four months her senior.
Dr Stephen Coles, the UCLA gerontologist who maintains a list of the world’s
oldest people, said Mrs Parker was the 14th oldest validated super-centenarian
in history. Maria de Jesus of Portugal, who was born September 10, 1893, is now
the world’s oldest living person, according to the Gerontology Research Group.
Mrs Parker became a widow in 1939 - the year Judy Garland starred in The Wizard
of Oz - when her husband, Earl Parker, died of a heart attack. She was 48. She
remained alone in their farmhouse until age 100, when she moved into a son’s
home and later to the Shelbyville nursing home.
Though she never drank alcohol or smoked and led an active lifestyle, she didn't
credit this for her advanced years.
A teacher, her only advice to those who gathered to celebrate when she became
the world's oldest person was to get “more education.”
Mrs Parker outlived both her sons, Clifford and Earl Jr. She also had five
grandchildren, 13 great-grandchildren and 13 great-great-grandchildren.
Don Parker, 60, said his grandmother had a small frame and a mild temperament.
She walked a lot and kept busy even after moving into the nursing home, he said.
“She kept active,” he said yesterday. “We used to go up there, and she would be
pushing other patients in their wheelchairs.”
Indiana Governor Mitch Daniels, who celebrated with Mrs Parker on her 114th
birthday, said it had been a "delight" to know her. She must have been a
remarkable lady at any age, he added.
Mrs Parker graduated from the state's Franklin College in 1911 and went on to
teach in a two-room school for several years.
She married Earl, her childhood sweetheart and neighbour, in 1913.
As was usual at the time, her career came to an end with her marriage and Mrs
Parker became a farmer's wife, spending her days tending the home and preparing
meals for the dozen men who worked on the farm.
Last year, she noted with pride that she and her husband were one of the first
owners of an automobile in their rural area.
Coincidentally, Mrs Parker lived in the same nursing home as Sandy Allen, whom
at 7ft 7¼ was officially the world's tallest woman until her death in August.
Professionals call it elderspeak, the sweetly belittling form of address that
has always rankled older people: the doctor who talks to their child rather than
to them about their health; the store clerk who assumes that an older person
does not know how to work a computer, or needs to be addressed slowly or in a
loud voice. Then there are those who address any elderly person as “dear.”
“People think they’re being nice,” said Elvira Nagle, 83, of Dublin, Calif.,
“but when I hear it, it raises my hackles.”
Now studies are finding that the insults can have health consequences,
especially if people mutely accept the attitudes behind them, said Becca Levy,
an associate professor of epidemiology and psychology at Yale University, who
studies the health effects of such messages on elderly people.
“Those little insults can lead to more negative images of aging,” Dr. Levy said.
“And those who have more negative images of aging have worse functional health
over time, including lower rates of survival.”
In a long-term survey of 660 people over age 50 in a small Ohio town, published
in 2002, Dr. Levy and her fellow researchers found that those who had positive
perceptions of aging lived an average of 7.5 years longer, a bigger increase
than that associated with exercising or not smoking. The findings held up even
when the researchers controlled for differences in the participants’ health
In her forthcoming study, Dr. Levy found that older people exposed to negative
images of aging, including words like “forgetful,” “feeble” and “shaky,”
performed significantly worse on memory and balance tests; in previous
experiments, they also showed higher levels of stress.
Despite such research, the worst offenders are often health care workers, said
Kristine Williams, a nurse gerontologist and associate professor at the
University of Kansas School of Nursing.
To study the effects of elderspeak on people with mild to moderate dementia, Dr.
Williams and a team of researchers videotaped interactions in a nursing home
between 20 residents and staff members. They found that when nurses used phrases
like “good girl” or “How are we feeling?” patients were more aggressive and less
cooperative or receptive to care. If addressed as infants, some showed their
irritation by grimacing, screaming or refusing to do what staff members asked of
The researchers, who will publish their findings in The American Journal of
Alzheimer’s Disease and Other Dementias, concluded that elderspeak sent a
message that the patient was incompetent and “begins a negative downward spiral
for older persons, who react with decreased self-esteem, depression, withdrawal
and the assumption of dependent behaviors.”
Dr. Williams said health care workers often thought that using words like “dear”
or “sweetie” conveyed that they cared and made them easier to understand. “But
they don’t realize the implications,” she said, “that it’s also giving messages
to older adults that they’re incompetent.”
“The main task for a person with Alzheimer’s is to maintain a sense of self or
personhood,” Dr. Williams said. “If you know you’re losing your cognitive
abilities and trying to maintain your personhood, and someone talks to you like
a baby, it’s upsetting to you.”
She added that patients who reacted aggressively against elderspeak might
receive less care.
For people without cognitive problems, elderspeak can sometimes make them livid.
When Sarah Plummer’s pharmacy changed her monthly prescription for cancer drugs
from a vial to a contraption she could not open, she said, the pharmacist
explained that the packaging was intended to help her remember her daily dose.
“I exploded,” Ms. Plummer wrote to a New York Times blog, The New Old Age, which
asked readers about how they were treated in their daily life.
“Who says I don’t take my medicine as prescribed?” wrote Ms. Plummer, 61, who
lives in Champaign, Ill. “I am alive right now because I take these pills! What
am I supposed to do? Hold it with vice grips and cut it with a hack saw?’”
She added, “I believed my dignity and integrity were being assaulted.”
Health care workers are often not trained to avoid elderspeak, said Vicki
Rosebrook, the executive director of the Macklin Intergenerational Institute in
Findlay, Ohio, a combined facility for elderly people and children that is part
of a retirement community.
Dr. Rosebrook said that even in her facility, “we have 300 elders who are
‘sweetie’d’ here. Our kids talk to elders with more respect than some of our
professional care providers.”
She said she considered elderspeak a form of bullying. “It’s talking down to
them,” she said. “We do it to children so well. And it’s natural for the
sandwich generation, since they address children that way.”
Not all older people object to being called sweetie or dear, and some, like Jan
Rowell, 61, of West Linn, Ore., say they appreciate the underlying warmth.
“We’re all reaching across the chasm,” Ms. Rowell said. “If someone calls us
sweetie or honey, it’s not diminishing us; it’s just their way to connect, in a
She added, “What would reinforce negative stereotypes is the idea that old
people are filled with pet peeves, taking offense at innocent attempts to be
But Ellen Kirschman, 68, a police psychologist in Northern California, said she
objected to people calling her “young lady,” which she called “mocking and
disingenuous.” She added: “As I get older, I don’t want to be recognized for my
age. I want to be recognized for my accomplishments, for my wisdom.”
To avoid stereotyping, Ms. Kirschman said, she often sprinkles her conversation
with profanities when she is among people who do not know her. “That makes them
think, This is someone to be reckoned with,” she said. “A little sharpness seems
Bea Howard, 77, a retired teacher in Berkeley, Calif., said she objected less to
the ways people addressed her than to their ignoring her altogether. At recent
meals with a younger friend, Ms. Howard said, the restaurant’s staff spoke only
to the friend.
“They ask my friend, ‘How are you; how are you feeling?’ just turning on the
charm to my partner,” Ms. Howard said. “Then they ask for my order. I say: ‘I
feel you’re ignoring me; I’m at this table, too.’ And they immediately deny it.
They say, no, not at all. And they may not even know they’re doing it.”
Dr. Levy of Yale said that even among professionals, there appeared to be little
movement to reduce elderspeak. Words like “dear,” she said, have a life of their
own. “It’s harder to change,” Dr. Levy said, “because people spend so much of
their lives observing it without having a stake in it, not realizing it’s
belittling to call someone that.”
In the meantime, people who are offended might do well to follow the advice of
Warren Cassell of Portland, Ore., who said it irritated him when “teenage store
clerks and about 95 percent of the rest of society” called him by his first
name. “It’s the faux familiarity,” said Mr. Cassell, 78.
But he mostly shrugs it off, he said. “I’m irked by it, but I can’t think about
it that much,” he said. “There are too many more important things to think
HANOVER, N.H. — Edie Gieg, 85, strides ahead of people half her age and plays
a fast-paced game of tennis. But when it comes to health care, she is a champion
of “slow medicine,” an approach that encourages less aggressive — and less
costly — care at the end of life.
Grounded in research at the Dartmouth Medical School, slow medicine encourages
physicians to put on the brakes when considering care that may have high risks
and limited rewards for the elderly, and it educates patients and families how
to push back against emergency room trips and hospitalizations designed for
those with treatable illnesses, not the inevitable erosion of advanced age.
Slow medicine, which shares with hospice care the goal of comfort rather than
cure, is increasingly available in nursing homes, but for those living at home
or in assisted living, a medical scare usually prompts a call to 911, with
little opportunity to choose otherwise.
At the end of her husband’s life, Ms. Gieg was spared these extreme options
because she lives in Kendal at Hanover, a retirement community affiliated with
Dartmouth Medical School that has become a laboratory for the slow medicine
movement. At Kendal, it is possible — even routine — for residents to say “No”
to hospitalization, tests, surgery, medication or nutrition.
Charley Gieg, 86 at the time, was suffering from a heart problem, an intestinal
disorder and the early stages of Alzheimer’s disease when doctors suspected he
also had throat cancer.
A specialist outlined what he was facing: biopsies, anesthesia, surgery,
radiation or chemotherapy. Ms. Gieg doubted he had the resilience to bounce
back. She worried, instead, that such treatments would accelerate his downward
trajectory, ushering in a prolonged period of decline and dependence. This is
what the Giegs said they feared even more than dying, what some call “death by
Such fears are rarely shared among old people, health care professionals or
family members, because etiquette discourages it. But at Kendal — which offers a
continuum of care, from independent living apartments to a nursing home — death
and dying is central to the conversation from Day 1.
So it was natural for Ms. Gieg to stay in touch with Joanne Sandberg-Cook, a
nurse practitioner there, during her husband’s out-of-town consultation.
“I think that it is imperative that none of this be rushed!” Ms. Sandberg-Cook
wrote in an e-mail message to Ms. Gieg. The doctor the Giegs had chosen, the
nurse explained, “tends to be a ‘do-it-now’ kind of guy.” But the Giegs’
circumstances “demand the time to think about all the what-ifs.”
Ms. Sandberg-Cook asked whether Mr. Gieg would want treatment if he was found to
have cancer. If not, why go through a biopsy, which might further weaken his
voice? Or risk anesthesia, which could accelerate her husband’s dementia?
“Those are the very questions on my mind, too,” Ms. Gieg replied. The Giegs took
their time, opted for no further tests or treatment, and Charley came back to
the retirement community to die.
Such decisions are not made lightly, and not without debate, especially in an
Many in their 80s and 90s — and their boomer children — want to pull out all the
stops to stay alive, and doctors get paid for doing a procedure, not discussing
whether it should be done. The costliest patients — the elderly with chronic
illnesses — are the only group with universal health coverage under Medicare,
leading to huge federal expenditures that experts agree are unsustainable as
Most of that money is spent at certain academic medical centers, which offer the
most advanced tests, the newest remedies, the most renowned specialists.
According to the Dartmouth Health Atlas, which ranks hospitals on the cost and
quantity of medical care to elderly patients, New York University Medical Center
in Manhattan, for instance, spends $105,000 on an elderly patient with multiple
chronic conditions during the last two years of life; U.C.L.A. Medical Center
spends $94,000. By contrast, the Mayo Clinic’s main teaching hospital in
Rochester, Minn., spends $53, 432.
The chief medical officer at U.C.L.A., Dr. Tom Rosenthal, said that aggressive
treatment for the elderly at acute care hospitals can be “inhumane,” and that
once a patient and family were drawn into that system, “it’s really hard to pull
back from it.”
“The culture has a built-in bias that everything that can be done will be done,”
Dr. Rosenthal said, adding that the pace of a hospital also discourages “real
Beginning that conversation earlier, as they do at Kendal, he said, “sounds like
fundamentally the right way to practice.”
That means explaining that elderly people are rarely saved from cardiac arrest
by CPR, or advising women with broken hips that they may never walk again, with
or without surgery, unless they can stand physical therapy.
“It’s almost an accident when someone gets what they want,” said Dr. Mark B.
McClellan, a former administrator of Medicare and now at the Brookings
Institution. “Personal control, quality of life and the opportunity to make good
decisions is not automatic in our system. We have to do better.”
The term slow medicine was coined by Dr. Dennis McCullough, a Dartmouth
geriatrician, Kendal’s founding medical director and author of “My Mother, Your
Mother: Embracing Slow Medicine, the Compassionate Approach to Caring for Your
Aging Loved One.”
Among the hard truths, he said, is that 9 of 10 people who live into their 80s
will wind up unable to take care of themselves, either because of frailty or
dementia. “Everyone thinks they’ll be the lucky one, but we can’t go along with
that myth,” Dr. McCullough said.
Ms. Sandberg-Cook agrees. “If you’re never again going to live independently or
face an indeterminate period in a disabled state, you may have to reorganize
your thinking,” she said. “You need to understand what you face, what you most
want to avoid and what you most want to happen.”
Kendal begins by asking newcomers whether they want to be resuscitated or go to
the hospital and under what circumstances. “They give me an amazingly puzzled
look, like ‘Why wouldn’t I?’ “ said Brenda Jordan, Kendal’s second nurse
She replies with CPR survival statistics: A 2002 study, published in the journal
Heart, found that fewer than 2 percent of people in their 80s and 90s who had
been resuscitated for cardiac arrest at home lived for one month. “They about
fall out of their chairs when they find out the extent to which we’ll go to let
people choose,” Ms. Jordan said.
Kendal, where the average age is 84, is generally not a place where people want
heroics. Dr. George Klabaugh, 88, a resident and retired internist, found
himself at the center of controversy a few years back when he tried to revive a
93-year-old neighbor who had collapsed from cardiac arrest during a theatrical
performance. Dr. Klabaugh, who was unaware that the man had a “Do Not
Resuscitate” order, said he regretted his “automatic reaction,” a vestige of a
professional training that predisposes most physicians to aggressive care.
Ms. Jordan surveyed Kendal residents and found only one that wanted CPR — Brad
Dewey, 92, who dismissed the statistics. “I want them to try anyway,” he said.
“Our daughter saved a man on a tennis court. Who’s to say I won’t recover?”
Some of the 400 residents, who pay $120,000 to $400,000 for an entry fee, and
monthly rent from $2,000, which includes all health care, pursue no-holds-barred
treatment longer than others. One woman, for example, arrived with cardiac and
pulmonary disease but was still capable of living in her own apartment. First,
she had cataract surgery that left her vision worse. Next, during surgery to
replace a worn-out artificial hip, her thigh bone snapped. She spent a year in
bed and wound up with blood clots. Then she broke the other leg.
Only then, Ms. Jordan said, did the woman decide to forgo further surgery or
hospitalizations. The woman was too ill to be interviewed.
Some of those most in tune with slow medicine are the adult children who watch a
parent’s daily decline. Suzanne Brian, for one, was grateful that her father,
then 88 and debilitated by congestive heart failure, was able to stop
medications to end his life.
“It wasn’t ‘Oh, you have to do this or do that,’ “ Ms. Brian said. “It was my
father’s choice. He could have changed his mind at any time. They slowly weaned
him from the meds and he was comfortable the whole time. All he wanted was honor
and dignity, and that’s what he got.”
November 24, 2007
The New York Times
By ERIK ECKHOLM
MILBRIDGE, Me. — They have worked since their teens in backbreaking seasonal
jobs, extracting resources from the sea and the forest. Their yards are filled
with peeling boats and broken lobster traps.
In sagging wood homes and aged trailers scattered across Washington County, many
of Maine’s poorest and oldest shiver too much in the winter, eat far more
biscuits and beans than meat and cannot afford the weekly bingo game at the
In this long-depressed “down east” region, where the wild blueberry patches have
turned a brilliant crimson, thousands of elderly residents live on crushingly
meager incomes. This winter promises to be especially chilling, with fuel oil
prices rising and fuel assistance expected to decline. But many assume that
others are worse off than themselves and are too proud to ask for assistance,
according to groups that run meal programs and provide aid for heating and
“One of our biggest problems is convincing people to take help,” said Eleanor
West, director of services for the Washington Hancock Community Agency, a
federally chartered nonprofit group. “I tell them, ‘You worked hard all your
life and paid taxes and are getting back a little of what you paid in.’”
Over the last half century, Social Security, Medicare and private pensions have
lifted most of the nation’s elderly. In 1960, one in three lived below the
poverty line; now fewer than one in 10 do. But in Washington County, the poverty
rate among those 65 and older is nearly one in five and many more live only a
little above the federal subsistence standard in 2007 of $10,200 for a single
person and $13,690 for two.
For thousands on fixed incomes, fuel assistance may decline while Social
Security checks are scarcely rising.
Viola Brooks, 81, worked in fish and blueberry factories while her husband
worked in textile and logging jobs. Now widowed, she gets $588 a month from
Social Security, supplemented by $112 in food stamps and one-time fuel aid of
more than $500 for the winter.
But this year, that fuel aid will not fill a single tank. The average house cost
$1,800 to heat last year, and minimal comfort this winter may require closer to
$3,000; trailers will require somewhat less. Electricity and rent already take
up most of Ms. Brooks’s income.
“I’m broke every month, and the trailer needs storm windows,” she said. “I cook
a lot of pea soup and baked beans and buy flour to make biscuits.”
“Some day I’d like to go to a hairdresser,” Ms. Brooks said of a dream deferred.
Still she says she enjoys her lovebirds and cats, and points out that “some
people have it worse.”
Jobs for the elderly, a growing trend nationwide, are virtually nonexistent in
these hamlets. Many people survive with help from a range of programs including
food stamps, Medicaid, disability and energy assistance; others suffer silently,
long used to hardship and fiercely independent.
In a pattern still common, older people here often held a series of seasonal
jobs, usually without benefits. They worked on lobster boats and dug clams or
bloodworms (to sell for bait) from spring to fall, raked wild blueberries in
August, harvested potatoes and then made Christmas wreaths for mail-order
companies to mid-December. Wives often worked in sardine canneries or in
“By their 50s, their bodies start breaking down,” said Tim King, director of the
community agency at its headquarters in Milbridge, adding that high rates of
smoking, obesity and diabetes also contributed to early aging. The aid programs
define those as 60 and over as elderly.
Because of their irregular careers and payments into the system, many people get
Social Security benefits far below the national average of more than $1,000 a
Velma L. Harmon, a 79-year-old widow, receives only $220 a month from Social
Security and has a grand total of $85 to live on each month after she pays her
subsidized rent and utilities at her apartment complex in Machias, one of a
growing number of such federally aided facilities for the elderly.
She is grateful for free lunches provided by the Eastern Agency on Aging,
another government-financed group, but too proud to apply for food stamps that
would give her a bit more spending money. “Trying to buy Christmas presents,
that’s the hardest thing,” said Ms. Harmon, who has a mangled finger from her
years of snipping sardine heads in a canning factory.
The preoccupation right now is soaring fuel prices: cheaper natural gas is
unavailable in this region, and wood heat is often impractical or insufficient.
But because of limited federal money, average fuel assistance for the 46,000
low-income Maine families expected to apply will probably decline to $579 this
year, from $688 last year, said Jo-Ann Choate of the Maine State Housing Agency.
“Low-income people aren’t even going to be able to fill up a single tank of fuel
oil,” Ms. Choate said. “They already wrap themselves up in blankets during the
winter. This year they’ll be colder.”
The disabled, and there are many, may have it hardest. Dolly Jordan of Milbridge
has a history of two bad marriages, a bone-crushing auto accident and poor
health, and looks and feels older than 61. With osteoporosis, arthritis,
diabetes and obesity, she spends most of the day in a wheelchair and uses a
combination of a gripper, a broom and a cane to make her bed or hang her
Come winter, she hangs a blanket over the front door of her little red wooden
house, where she has lived alone the last 10 years and which sits on concrete
blocks with no foundation. She turns the heat off at night to save fuel.
Her disability payment is $623 a month, plus she gets just $10 from the state
and $74 in food stamps. After paying the housing tax and her utility bills, she
said, she must watch every remaining penny. A daughter drives her to the distant
town of Ellsworth for cheaper shopping.
Like many, she keeps a police scanner on as a diversion and, unable to afford
cable, she watches the same videos over and over — her favorite is “On Golden
“I wish for bedtime to come,” she said. “The days are so long.”
Easing down a ramp to her mailbox is a perilous 15-minute ordeal. Still, she
said, “I wait for Fridays.”
“That’s junk-mail day, and I read all the ads. That’s my best day.”
She added, “There’s always older people out there who have it harder.”
Frederick and Kathleen Call, in Harrington, are in their 60s and live in a 1970s
trailer with buckling walls. They live on his disability check — he has had six
heart attacks — and food stamps and fuel assistance. Like many others in the
region, they buy all their clothes at a church-run thrift shop. They spend their
days playing board games and rummy and watching squirrels on their porch.
“We used to go to the food pantry for a free box,” Ms. Call said, “but I saw an
old woman who looked like she really needed it. She was thin and cold. I gave
her a blanket. We haven’t gone for free food for years.”
Some people here seem to have sunny outlooks no matter what. In the fishing
village of Jonesport, Elizabeth Emerson, 87, is hard of hearing and has a
titanium knee but is spry and irrepressively cheerful.
She lives in the tiny house her husband, a trucker, built in 1949, and has a
view of the gravestone where her name is already etched next to his. Having a
daughter nearby, and a total of 52 grand-, great-grand and
great-great-grandchildren, whose pictures fill the walls and the refrigerator
door, helps in ways practical and emotional.
Ms. Emerson said she “thoroughly enjoyed” the 25 years she spent working as an
aide in a nursing home, and she demonstrated the yodeling she used to perform on
command for one patient.
Each day she walks with her dog, Sabrina, down to the stony beach where her
family once swam. “I saw moose tracks the other day,” she exulted. “Here is
where I used to pick heather.”
With her Social Security payment of $683 a month, she refuses to feel
“I was never a person to be extravagant,” Ms. Emerson said, adding, “I don’t
play beano,” using the local term for bingo.
Besides, she said, she can still afford an indulgence here and there. “My
greatest vice,” she added, “is Hershey bars.”
October 25, 2007
From Times Online
Jill Sheerman, Whitehall editor
Life expectancy for professional women has shot up by 30 months to 85 years
in only the last four years, while the gap between the top and bottom classes
Figures from the Office for National Statistics published yesterday show that
females in high-status, well-paid jobs such as medicine, law and finance are
living longer than ever. Their counterparts in clerical and manual jobs,
however, are struggling to keep pace as their lifestyles and life expectancy
emulate their male colleagues.
Diet, drinking and smoking are taking their toll on women in the lower social
classes but health experts suggest that females at the top are in better shape
than ever, have quicker access to healthcare, are no longer dying from breast
cancer and can afford better holidays. Some epidemiologists also suggest that
women get a psychological boost from a high-status job where they are largely in
The figures show that the life expectancy at birth for women in the top social
class, or those who married into it, jumped from 82.6 years in 2001 to 85.1
years in 2005, an increase of 2.5years. This rise is at a much faster rate than
the rest of the past 30 years where life expectancy has gone up about two years
in every ten. During the same period the life expectancy for women in the lowest
social class — unskilled workers and labourers — rose from 77.9 to 78.1 years,
an increase of only ten weeks.
In male mortality, the opposite appears to be happening. Life expectancy in men
has been catching up with women over the past 30 years, but since 2001 the
increase has dropped slightly and the gap between the social classes has
Life expectancy for men in the professional classes rose from 79.5 years in 2001
to 80 years in 2005. At the same time the life span for unskilled workers rose
from 71.5 to 72.7 years. A similar picture occurs in life expectancy from the
age of 65. A women in Social Class 1 now aged 65 was expected to live to 85 in
2005, but is now expected to carry on to 87. However, the corresponding figures
for women in Social Class 5 only rose from 81.9 to 82.7 years.
Eric Brunner, a reader in epidemiology at University College London, could not
fully explain the acceleration in life expectancy for woman in the top social
classes in the past four years. But he said that access to cash and high
self-esteem has a big impact on health and longevity. “Money, wealth and
resources, particularly psychological, mean that women feel more in control of
Women are also categorised in Social Class 1 if they are married to men working
in the professions, so many of them may be able to take on part-time jobs or not
work at all.
Alcohol, smoking, poor diet and better health services in earlier life would all
be factors in the widening gap between the social classes.
“There are different smoking patterns in men and women over the last 40 years,”
said Dr Brunner. “The peak mortality rates for men with lung cancer was in the
early 1970s while the peak rate for women was in the mid-1990s.”
In addition, there was a much greater class divide in obesity levels among
women, with far more obese females in the lowest classes. There is no
significant difference among men.
Professor Mel Bartley, a director of the Economic and Social Research Centre,
said that women in the top social classes were more likely to get breast cancer
but now less likely to die from it. Better screening techniques and drug
treatments such as Tamoxifen had had a huge impact on mortality in recent years.
Brian Johnson, a statistician for the ONS, said that the figures for Social
Class 1 and Social Class 5 had a higher level of variation than the other larger
social classes so it was difficult to tell if the data marked a trend or a blip.
The 2001 figures had shown a slight shift downwards in female life expectancy
and this data had now reverted to the general trend of growing life expectancy,
he suggested. He pointed to the narrowing of the gap between the manual classes
and non-manual classes in males, particularly those over 65, which he said was
The figures also show that between 1972 and 2005, men and women in non-manual
occupations had a greater increase in life expectancy at birth and at age 65
than those classified by manual occupations.
For men, there was an eight-year increase in life expectancy at birth in
non-manual workers, who range from clerks, cashiers and retail staff to doctors
and lawyers, compared with a 6.8-year rise for those for manual workers, who
range from labourers and cleaners to plumbers and electricians. But for women
the corresponding figures were only 5.2 years and 4.8 years respectively.
Unskilled female workers aged 65 can now expect to live 17.7 years more, on
average, than they did between 1972 and 1976, while women in the top social
class now aged 65 are expected to outlive their mid-1970s predecessors by 22
years. An unskilled man now aged 65 can expect to live 14.1 years longer than
his counterparts did in 1972-76 — to the same age as the professionals of the
day. A 65-year-old high-status man is now expected to live 18.3 years longer
than he would have done 30 years ago.
“There has been a longstanding difference in mortality in social classes,
particularly between the highest and lowest classes,” said Mr Johnson. “But in
women there is no evidence of further widening, and in men there is some
tentative evidence of narrowing in the higher age groups.”
Life expectancy at birth for a particular social class and time period is an
estimate of the number of years a newborn baby would survive if they experienced
average mortality rates of that social class for that time period throughout
Source: Office for National Statistics
A divided society: how Britons fall into their seperate categories
1 This includes members of the top professions such as doctors, chartered
accountants, lawyers, professionally qualified engineers and bankers who earn
high salaries. Women who are married to men in these jobs will also be
categorised in the top social class even if they do not work or work in a less
2 This category covers managerial and technical jobs such as middle managers,
journalists, school teachers, nurses, academics and computer technicians. They
will earn less money and have more stressful jobs than those in the top social
class. Women are more likely to be married and have children.
3 This group is split between skilled manual and non-manual. The latter category
includes clerks, cashiers, call-centre operators, secretaries and retail staff
who are on low salaries and generally have less control over their jobs. The
former category of skilled manual workers includes plumbers, electricians,
builders, drivers of goods vehicles and the supervisors of the above
4 These partly skilled workers include warehousemen, security guards, machine
tool operators, care assistants, waiters and waitresses. They will typically be
on low wages, work long hours and have little control over how or when they
5 This group of unskilled workers includes labourers, cleaners and messengers
who will be earning not much more than the minimum wage. They and the group
above them are much more likely to be heavy smokers and drinkers and prone to
obesity and heart-related diseases. They will tend to be less capable of
accessing quick health or social care.
It is not very clear what the Government is intending to do about funding
long-term care for the elderly and disabled, which is shaping up to be one of
the biggest political problems of the next decades. The King's Fund health
think-tank claimed yesterday it had been briefed that Labour planned to scrap
the current means-testing system, which requires old people to sell their homes
to pay for residential care. But ministers were more circumspect, with the
Chancellor, Alistair Darling, hinting only that reform is needed.
If he is unsure what that should be, then let us tell him. Our national failure
to support frail and vulnerable people is one of the great unacknowledged
scandals of our time. As the years pass, we have ever more old people and yet we
do less and less for them. The same is true of families with disabled children,
nearly half of whom receive no public support at all.
The situation will only get worse. Elderly people are living longer. Disabled
people now expect to live full lives. Scotland has reached a distinct and
admirable solution: the state will pay for residential care for the elderly,
just as it does their hospital care. Helping someone go to the lavatory or wash
– whether in hospital, residential care or their own home – is a form of nursing
care, they argue, and should be provided free of charge, paid for through
This flagship policy is expensive. At present 4 per cent of Scotland's elderly
population live in a care home. Over the next two decades that number is set to
double. Already the system is being squeezed; three-quarters of Scotland's
councils have waiting lists of up to four months because the system is
Government ministers said yesterday that they are open-minded about the outcome
of the consultation they will be launching with a Green Paper. But they also
made clear that the Scottish option is not on. In England and Wales, by 2050,
according to last year's Wanless report, there will be twice as many people aged
over 85 as there are now. (A potent argument, incidentally, for allowing more
not less immigration at the present time.) We will then need to spend four times
more on long-term care for older people. To make care homes free for all would,
ministers claim, take up all the additional public spending now available.
But this is by no means self-evident. France and Germany spend more than double
what we do on caring for older people. The fact is that the current
means-testing system has caused misery to older people and their families. It is
not at all clear how the kinds of "partnership model" ministers were floating
yesterday – with a basic universal entitlement together with a top-up paid by
individuals, or by the state in the case of the poor – get around this.
In any case there is more to the problem than how to fund care homes. The wider
issue is how the state can help older people remain independent and active in
their own homes, for as long as possible, in a way that offers them dignity and
To do that, ministers must reverse the pernicious cuts that have been made in
such services. They must provide more home-helps, not fewer. They need to
reverse the preposterous cuts in services like chiropody which slowly render
some old people immobile and eventually force them into care homes. They need to
chastise the 150 local authorities who have so recast their definition of needs
that even those who need help getting out of bed in the morning now find
themselves excluded from services. State resources must be directed to where
they can have the greatest impact on wellbeing – and where they support, rather
than undermine, the dignity of those in the last age of life.
Many vulnerable people
now face eligibility tests for basic services
councils tighten budgets
Sunday July 1, 2007
Jo Revill, Whitehall editor
Councils have made it harder for the elderly to stay in their own homes by
increasing charges for basic support services such as shopping and laundry.
New research reveals that budget restraints mean that thousands of pensioners
who need help with cleaning or feeding are no longer receiving it free. They
face a battery of tests to determine their 'eligibility' for care in spite of
the fact that the vast majority have been paying council tax for years.
A survey to be published on Wednesday by the charity Counsel and Care will
show that in the past year councils have raised the barriers even higher for
those needing some domiciliary help.
As Britain has an ageing population, the survey shows that local authorities
are providing a larger number of hospital services for a much smaller group of
older people with the most complex needs. That means there is little or no
support for those who are finding it hard to live independently but whose needs
are relatively simple.
The Observer has had a huge response to its Dignity at Home campaign, which has
highlighted how older people trying to access care and support services in their
own homes face huge personal care bills or are forced to rely on over-stretched
voluntary help. Even if the older person is eligible for means-tested services
from their local authority, the charge for this care is increasing. Many
struggle to afford to live at home or to pay the high cost of care home fees.
The survey, based on questions put to local authorities across England, showed
that there was a 15 per cent increase in the number of councils that have
restricted the eligibility criteria in the past 12 months. This will have
affected thousands of people, although the exact numbers are not known.
Some older people are paying up to £320 a week towards domiciliary care costs,
the survey says The price of meals-on-wheels also varies hugely, from £1.40 to
£3.40 per meal. Even community transport, which gives older people a valuable
opportunity to leave their home once a week, is being charged by some councils
at up to £2.60 a trip.
Stephen Burke, chief executive of Counsel and Care, which runs an advice line
for the elderly and their carers, said: 'There is a triple lottery for home care
services: it's based on where someone lives, how their local authority applies
the eligibility criteria for services and the charging policy of the local
The report will spell out that in a number of authorities there is now no
service available at all for anyone with low or moderate needs.
Last year Sir Derek Wanless produced a report into the funding of social care
for older people in which he pointed out that savings can be made by helping
vulnerable people to stay at home. But local authorities say that they cannot
afford to offer all the services to everyone.
Burke said: 'These figures show the social care problem will not solve itself.
Without active intervention, the system is going to collapse as more and more
people need to be cared for at home.'
'I'm 94 - but now I feel more like 24'
It is just after 11.30 on a Wednesday morning and Laetitia Dysart is tired and
sore, but exhilarated after taking part in a fitness class. 'I'm 94 but after
that I feel like I'm 24 or 25. I feel absolutely marvellous,' she says.
The woman everyone calls 'Lettie' has spent the last hour standing, bending,
stretching and marching on the spot alongside 20 pensioners at the Healthy
Living Centre in Worthing, West Sussex. The music has been strictly their
generation: Glenn Miller and Frankie Vaughan.
'You work from the tips of your fingers to the tips of your toes, you use every
muscle, although you do it gently, and it makes you feel that every part of your
body is moving. It gives you the confidence to move around when many people my
age just want to sit down all the time because they are in pain. People love the
classes,' explains Lettie.
The Keeping Fit and Balanced session is just one of the centre's range of
physical activity classes for the elderly including tai chi and seated
The centre also offers massage and beauty therapy. 'We want older people to look
good and feel good about themselves and to be as healthy as possible. It's as
much about their mental as their physical health, and their self-esteem',
explains Jill Lancaster, manager of the centre, which is run by Guild Care, a
local charity for elderly people. Everything at the centre is geared to helping
older people stay in familiar surroundings as long, and as capably, as possible
- happiness and dignity at home.
Experts believe that the first person to live half way
through their second
century has already been born.
Jeremy Laurance, health editor,
reports on the
that science promises,
while Sarah Harris outlines 10
to extend your life
Published: 07 January 2007
The Independent on Sunday
For today's centenarians, living to be 100 is an achievement marked by a
message from the Queen. Within two generations it could be as routine as
collecting a bus pass.
The first person to live to 150 may already have been born, according to some
scientists. Worldwide, life expectancy has more than doubled over the past 200
years and recent research suggests it has yet to reach a peak.
What will the world be like when people live long enough to see their
great-grandchildren and great-great-grandchildren? Extending life by adding
extra years of sickness and growing frailty holds little appeal. Increased
longevity is one of the modern world's great successes, but long life without
health is an empty prize. The aim is for humans to die young - as late as
It is eight years since Jeanne Calment died peacefully in a nursing home in
Arles, southern France in 1998. She was aged 122 years, five months and 14 days
- and no one has yet challenged her title as the oldest person with an
authenticated birth record to have lived. She attributed her longevity to a diet
rich in olive oil, regular glasses of port and her ability to "keep smiling".
Destiny undoubtedly played a part, too. If you want to grow old, choose your
parents carefully. The genetic determinants of long life are gradually being
unravelled, In recent years at least 10 gene mutations have been identified that
extend the lifespan of mice by up to half. The good news is that these
super-geriatric mice are no more frail or sickly than their younger brethren.
In humans, several genetic variants have been linked with longevity. They
include a family of genes dubbed the Sirtuins, which one Italian study found
occurred more commonly in centenarian men than in the general population.
Researchers at Harvard Medical School in the US, convinced they have discovered
a "longevity gene", are now studying whether adding an extra copy of the gene
extends the lives of mice. The long term aim is to find a way of manipulating
the genes to add an extra decade or two to the human lifespan.
Other gene variants affect the production of growth hormone and insulin-like
growth factor (IGF), both of which increase metabolism - organisms with higher
metabolism tend to die sooner. Blocking receptors for growth hormone and IGF, so
slowing metabolism, provide possible targets for anti-ageing drugs.
Also promising, but still far from yielding concrete results, are telomeres,
which are present in every cell. Telomeres shorten with every cell division,
like a burning fuse; when they can shorten no more, the cell dies. Inhibiting
the enzyme telomerase to prevent the shortening of the telomeres in effect
extends the lifespan of the cell, and, as we are comprised of millions of cells,
could extend life.
Ageing cannot be reversed but it may, perhaps, be delayed. The emergence of the
extremely old population has only happened in the past 50 years and is chiefly
due to improvements in the health, lifestyle and environment of the elderly that
started in the 1950s - how we eat and drink, where we live, what we do.
Ageing is an irresistible target for snake oil salesmen and the pharmaceutical
industry. Several hundred medical compounds that can boost memory and learning
ability are being investigated. Research teams are examining genes for
Alzheimer's disease, mechanisms that cause cells to age and die, and brain
interfaces that promise to pump new life into aged or diseased limbs. The aim
here is to add life to years, as well as years to life, but ageing itself is
taking over as the new target for therapeutic innovation.
One promising avenue of research is to increase the resistance of cells to the
stresses caused by free radicals, unstable molecules that disrupt cellular
processes. There is no evidence that the sort of anti-ageing compounds sold over
the internet containing anti-oxidants that promise to tackle free radicals
actually slow ageing. However, delivering antioxidant enzymes direct to the cell
has been shown in mice to extend lifespan by 20 per cent - pointing the way to
But the optimism comes with a warning - that the consistent increase in life
expectancy we have enjoyed for the past 200 years could be about to go into
reverse. Some Jeremiahs in the scientific community claim ours could be the
first generation in which parents outlive their children. The greatest enemy of
extending life further is growing obesity, they say. Its effects could rapidly
approach and exceed those of heart disease and cancer. Calculations by US
scientists suggest that life expectancy would already be up to a year longer but
for obesity. As Jeannne Calment indicated, wisely if unexcitingly, on her 122nd
birthday, those who live moderately live long.
Ten things you can do to help increase your life expectancy
Keeping fit is the elixir of youth. Even 30 minutes of regular gentle exercise
three times per week, such as walking or swimming, can add years to your life
Aerobic exercise preserves the heart, lungs and brain, elevates your mood, can
help ward off breast and colon cancer and prevent atrophy of the muscles and
Gareth Jones of the Canadian Centre for Activity and Ageing in London, found
that for an over-50 who has never taken part in physical activity a brisk
30-minute walk three times a week can "basically reverse your physiological age
by about 10 years." Not exercising can knock off five years.
A 1986 study at Stanford University found that death rates fell in direct
proportion to the number of calories burned weekly.
Mild sunburn, a glass of wine and some low-level radiation sounds like a recipe
for disaster, but many researchers believe that small doses of "stressors" can
reverse the ageing process.
While this "hormeosis", is not a licence to lie on a hot beach all day swigging
vodka, mild exposure to certain harmful agents can trigger the body's natural
repair mechanisms. The body is tricked into producing particular DNA-repair
enzymes and heat shock proteins to fix the damage that has been caused.
Sometimes the body's repair mechanisms overcompensate, treating unrelated damage
- "rejuvenating" as well as repairing it. Hormeosis could stretch the average
healthy life span to 90.
Live in a good area
It is not only how you live, but where you live that matters - and the residents
of Okinawa in Japan seem to know the secret. These Japanese islands are home to
the world's largest population of centenarians.
At 103, the daily routine of resident Seiryu Toguchi included stretching
exercises, a diet of whole grain rice and vegetables, gardening and playing his
three-stringed instrument, the sanshin.
The clean-living Seventh Day Adventists of Utah also do pretty well, living on
average eight years longer than their fellow Americans.
Worst off are those living in poor, polluted urban areas such as Glasgow, where
residents of the poorest suburbs have a life expectancy of only 54.
Overcrowding, dirt and noise all contribute to high blood pressure, anxiety and
depression, which reduce lifespan.
Be very successful
The more rich, privileged, successful and educated you are, the longer you will
live. The Whitehall Studies, 1967-77, examined the health of male civil servants
between the ages of 20 and 64, and found that men in the lowest-paid positions
had a mortality rate three times higher than those at the top level.
The study proved that the more important a task a person is asked to perform,
the longer they are likely to live; that the person at the top with the big
office, shouting orders will have a more relaxed and pleasurable existence than
his frustrated underlings. And it's not only civil servants: Canadian
researchers found that Oscar-winners live longer than other actors because of am
increased sense of self-worth and confidence.
And if you can't manage an Oscar, then only one extra year in education could
increase your life expectancy by a year and a half.
Eat the right foods
Certain foods delay the ageing process and may increase life expectancy. Green
leafy vegetables such as spinach and broccoli are rich in antioxidants and
beta-carotene. Diets high in fruit, vegetables, fibre and omega-3 oils, and low
in fat may prevent high blood pressure and heart disease.
In their low-fat diet of fruit, vegetables and rice, the long-living people of
Okinawa also consume more soy than anyone on earth, and soy is linked to low
cancer rates. Eating cooked tomato daily can slash your risk of heart disease by
30 per cent, found research at Harvard.
An active mind is as important as an active body. Studies show that you can
boost your immune system and delay the onset of conditions from depression to
dementia by keeping your brain engaged and stimulated.
Leonard Poon, director of the University of Georgia Gerontology Center found
that people who reach three figures tend to have a high level of cognition,
demonstrating skill in everyday problem-solving and learning. And Marian Diamond
of the University of California, Berkley, found that rodents who were given
problems to solve and toys to play with, lived 50 per cent longer.
Enjoy your life
Good relationships are the key to longevity. Social contact staves off
depression, stress and boosts the development of the brain and immune system.
Most research shows that people with family, friends, partners or pets, live
longer than those who don't. Marriage is also a good idea if you want to meet
the 100-mark, adding an average of seven years to the life of a man, and two to
Indulgence, too, can be good for you. Chocolate can enhance endorphin levels and
acts as a natural antidepressant, wine contains natural anti-oxidants, and
laughing is good for your immunity.
Find God - or friends
It's official: having religion pays off - and not just in the after-life.
Nearly 1,000 studies have indicated that those who go to a place of worship are
healthier than their faithless counterparts - and live an average seven years
longer. One in 10 of the nuns of the convent of the School Sisters of Notre Dame
in Minnesota have managed to reach their 100th birthday. But atheists should not
despair: experts believe that a sense of community, and of belief in something
larger than yourself, are vital ingredients in a long and happy life.
Jeff Levin, author of God, Faith, and Health: Exploring the Spirituality-Healing
Connection, argues that a place of worship provides a social network and a
source of comfort to the ageing, ill and needy.
Reduce your calories
One hundred years of hunger is what you can look forward to if you follow the
Calorie Restriction philosophy. Practitioners of CR believe that by reducing
your calorie intake (by between 10 and 60 per cent) you can extend life
expectancy by lowering your metabolism and the production of harmful free
radicals. It sounds like torture, but there is research to suggest that it
One study reported that participants who ate 25 per cent less for three months
had lower levels of insulin in their blood, a reduced body temperature and less
DNA damage. Brian Delaney, president of the California-based Calorie Restriction
Society, is aiming to live to 122, and with a diet of barely 1,800 calories per
day (2,500 is the normal for men).
Get your health checked
To last a century, stay ahead of life-threatening illnesses. It is possible with
regular blood tests to detect the first signs of prostate cancer, one of the
commonest causes of cancer deaths in men over 85.
If you're between 60 and 69 you can have free bowel cancer screening, cervical
screening for women aged 24 to 64, and mammograms for women aged 50 to 70.
Figures show that 95 per cent of women who had invasive breast cancer detected
by screening are alive five years later.
How depressing, how utterly unjust, to be the
one in your social circle who is aging least gracefully.
In a laboratory at the Wisconsin National Primate Research Center, Matthias is
learning about time’s caprice the hard way. At 28, getting on for a rhesus
monkey, Matthias is losing his hair, lugging a paunch and getting a face full of
Yet in the cage next to his, gleefully hooting at strangers, one of Matthias’s
lab mates, Rudy, is the picture of monkey vitality, although he is slightly
older. Thin and feisty, Rudy stops grooming his smooth coat just long enough to
pirouette toward a proffered piece of fruit.
Tempted with the same treat, Matthias rises wearily and extends a frail hand.
“You can really see the difference,” said Dr. Ricki Colman, an associate
scientist at the center who cares for the animals.
What a visitor cannot see may be even more interesting. As a result of a simple
lifestyle intervention, Rudy and primates like him seem poised to live very
long, very vital lives.
This approach, called calorie restriction, involves eating about 30 percent
fewer calories than normal while still getting adequate amounts of vitamins,
minerals and other nutrients. Aside from direct genetic manipulation, calorie
restriction is the only strategy known to extend life consistently in a variety
of animal species.
How this drastic diet affects the body has been the subject of intense research.
Recently, the effort has begun to bear fruit, producing a steady stream of
studies indicating that the rate of aging is plastic, not fixed, and that it can
In the last year, calorie-restricted diets have been shown in various animals to
affect molecular pathways likely to be involved in the progression of
Alzheimer’s disease, diabetes, heart disease, Parkinson’s disease and cancer.
Earlier this year, researchers studying dietary effects on humans went so far as
to claim that calorie restriction may be more effective than exercise at
preventing age-related diseases.
Monkeys like Rudy seem to be proving the thesis. Recent tests show that the
animals on restricted diets, including Canto and Eeyore, two other rhesus
monkeys at the primate research center, are in indisputably better health as
they near old age than Matthias and other normally fed lab mates like Owen and
Johann. The average lifespan for laboratory monkeys is 27.
The findings cast doubt on long-held scientific and cultural beliefs regarding
the inevitability of the body’s decline. They also suggest that other
interventions, which include new drugs, may retard aging even if the diet itself
should prove ineffective in humans. One leading candidate, a newly synthesized
form of resveratrol — an antioxidant present in large amounts in red wine — is
already being tested in patients. It may eventually be the first of a new class
of anti-aging drugs. Extrapolating from recent animal findings, Dr. Richard A.
Miller, a pathologist at the University of Michigan, estimated that a pill
mimicking the effects of calorie restriction might increase human life span to
about 112 healthy years, with the occasional senior living until 140, though
some experts view that projection as overly optimistic.
According to a report by the Rand Corporation, such a drug would be among the
most cost-effective breakthroughs possible in medicine, providing Americans more
healthy years at less expense (an estimated $8,800 a year) than new cancer
vaccines or stroke treatments.
“The effects are global, so calorie restriction has the potential to help us
identify anti-aging mechanisms throughout the body,” said Richard Weindruch, a
gerontologist at the University of Wisconsin who directs research on the
Many scientists regard the study of life extension, once just a reliable
plotline in science fiction, as a national priority. The number of Americans 65
and older will double in the next 25 years to about 72 million, according to
government census data. By then, seniors will account for nearly 20 percent of
the population, up from just 12 percent in 2003.
Earlier this year, four prominent gerontologists, among them Dr. Miller,
published a paper calling for the government to spend $3 billion annually in
pursuit of a modest goal: delaying the onset of age-related diseases by seven
Doing so, the authors asserted, would lay the foundation for a healthier and
wealthier country, a so-called longevity dividend.
“The demographic wave entering their 60s is enormous, and that is likely to
greatly increase the prevalence of diseases like diabetes and heart disease,”
said Dr. S. Jay Olshansky, an epidemiologist at the University of Illinois at
Chicago, and one of the paper’s authors. “The simplest way to positively affect
them all is to slow down aging.”
Science, of course, is still a long way from doing anything of the sort. Aging
is a complicated phenomenon, the intersection of an array of biological
processes set in motion by genetics, lifestyle, even evolution itself.
Still, in laboratories around the world, scientists are becoming adept at
breeding animal Methuselahs, extraordinarily long lived and healthy worms, fish,
mice and flies.
In 1935, Dr. Clive McCay, a nutritionist at Cornell University, discovered that
mice that were fed 30 percent fewer calories lived about 40 percent longer than
their free-grazing laboratory mates. The dieting mice were also more physically
active and far less prone to the diseases of advanced age.
Dr. McCay’s experiment has been successfully duplicated in a variety of species.
In almost every instance, the subjects on low-calorie diets have proven to be
not just longer lived, but also more resistant to age-related ailments.
“In mice, calorie restriction doesn’t just extend life span,” said Leonard P.
Guarente, professor of biology at the Massachusetts Institute of Technology. “It
mitigates many diseases of aging: cancer, cardiovascular disease,
neurodegenerative disease. The gain is just enormous.”
For years, scientists financed by the National Institute on Aging have closely
monitored rhesus monkeys on restricted and normal-calorie diets. At the
University of Wisconsin, where 50 animals survive from the original group of 76,
the differences are just now becoming apparent in the older animals.
Those on normal diets, like Matthias, are beginning to show signs of advancing
age similar to those seen in humans. Three of them, for instance, have developed
diabetes, and a fourth has died of the disease. Five have died of cancer.
But Rudy and his colleagues on low-calorie meal plans are faring better. None
have diabetes, and only three have died of cancer. It is too early to know if
they will outlive their lab mates, but the dieters here and at the other labs
also have lower blood pressure and lower blood levels of certain dangerous fats,
glucose and insulin.
“The preliminary indicators are that we’re looking at a robust life extension in
the restricted animals,” Dr. Weindruch said.
Despite widespread scientific enthusiasm, the evidence that calorie restriction
works in humans is indirect at best. The practice was popularized in diet books
by Dr. Roy Walford, a legendary pathologist at the University of California, Los
Angeles, who spent much of the last 30 years of his life following a
calorie-restricted regimen. He died of Lou Gehrig’s disease in 2004 at 79.
Largely as a result of his advocacy, several thousand people are now on
calorie-restricted diets in the United States, says Brian M. Delaney, president
of the Calorie Restriction Society.
Mike Linksvayer, a 36-year-old chief technology officer at a San Francisco
nonprofit group, embarked on just such a diet six years ago. On an average day,
he eats an apple or some cereal for breakfast, followed by a small vegan dish at
lunch. Dinner is whatever his wife has cooked, excluding bread, rice, sugar and
whatever else Mr. Linksvayer deems unhealthy (this often includes the entrée).
On weekends, he occasionally fasts.
Mr. Linksvayer, 6 feet tall and 135 pounds, estimated that he gets by on about
2,000 to 2,100 calories a day, a low number for men of his age and activity
level, and his blood pressure is a remarkably low 112 over 63. He said he has
never been in better health.
“I don’t really get sick,” he said. “Mostly I do the diet to be healthier, but
if it helps me live longer, hey, I’ll take that, too.”
Researchers at Washington University in St. Louis have been tracking the health
of small groups of calorie-restricted dieters. Earlier this year, they reported
that the dieters had better-functioning hearts and fewer signs of inflammation,
which is a precursor to clogged arteries, than similar subjects on regular
In previous studies, people in calorie-restricted groups were shown to have
lower levels of LDL, the so-called bad cholesterol, and triglycerides. They also
showed higher levels of HDL, the so-called good cholesterol, virtually no
arterial blockage and, like Mr. Linksvayer, remarkably low blood pressure.
“Calorie restriction has a powerful, protective effect against diseases
associated with aging,” said Dr. John O. Holloszy, a Washington University
professor of medicine. “We don’t know how long each individual will end up
living, but they certainly have a longer life expectancy than average.”
Researchers at Louisiana State University reported in April in The Journal of
the American Medical Association that patients on an experimental low-calorie
diet had lower insulin levels and body temperatures, both possible markers of
longevity, and fewer signs of the chromosomal damage typically associated with
These studies and others have led many scientists to believe they have stumbled
onto a central determinant of natural life span. Animals on restricted diets
seem particularly resistant to environmental stresses like oxidation and heat,
perhaps even radiation. “It is a very deep, very important function,” Dr. Miller
said. Experts theorize that limited access to energy alarms the body, so to
speak, activating a cascade of biochemical signals that tell each cell to direct
energy away from reproductive functions, toward repair and maintenance. The
calorie-restricted organism is stronger, according to this hypothesis, because
individual cells are more efficiently repairing mutations, using energy,
defending themselves and mopping up harmful byproducts like free radicals.
“The stressed cell is really pulling out all the stops” to preserve itself, said
Dr. Cynthia Kenyon, a molecular biologist at the University of California, San
Francisco. “This system could have evolved as a way of letting animals take a
timeout from reproduction when times are harsh.”
But many experts are unsettled by the prospect, however unlikely, of Americans
adopting a draconian diet in hopes of living longer. Even the current
epidemiological data, they note, do not consistently show that those who are
thinnest live longest. After analyzing decades of national mortality statistics,
federal researchers reported last year that exceptional thinness, a logical
consequence of calorie restriction, was associated with an increased risk of
death. This controversial study did not attempt to assess the number of calories
the subjects had been consuming, or the quality of their diets, which may have
had an effect on mortality rates.
Despite the initially promising results from studies of primates, some
scientists doubt that calorie restriction can ever work effectively in humans. A
mathematical model published last year by researchers at University of
California, Los Angeles, and University of California, Irvine, predicted that
the maximum life span gain from calorie restriction for humans would be just 7
percent. A more likely figure, the authors said, was 2 percent.
“Calorie restriction is doomed to fail, and will make people miserable in the
process of attempting it,” said Dr. Jay Phelan, an evolutionary biologist at the
University of California, Los Angeles, and a co-author of the paper. “We do see
benefits, but not an increase in life span.”
Mice who must scratch for food for a couple of years would be analogous, in
terms of natural selection, to humans who must survive 20-year famines, Dr.
Phelan said. But nature seldom demands that humans endure such conditions.
Besides, he added, there is virtually no chance Americans will adopt such a
severe menu plan in great numbers.
“Have you ever tried to go without food for a day?” Dr. Phelan asked. “I did it
once, because I was curious about what the mice in my lab experienced, and I
couldn’t even function at the end of the day.”
Even researchers who believe calorie restriction can extend life in humans
concede that few Americans are likely to stick to such a restrained diet over a
long period. The aging of the body is the aging of its cells, researchers like
to say. While cell death is hardwired into every organism’s DNA, much of the
infirmity that comes with advancing years is from an accumulation of molecular
insults that, experts contend, may to some degree be prevented, even reversed.
“The goal is not just to make people live longer,” said Dr. David A. Sinclair, a
molecular biologist at Harvard. “It’s to see eventually that an 80-year-old
feels like a 50-year-old does today.”
In a series of studies, Dr. Kenyon, of the University of California, San
Francisco, has created mutant roundworms that live six times longer than normal,
largely because of a mutation in a single gene called daf-2. The gene encodes a
receptor on the surface of cells similar to a receptor in humans that responds
to two important hormones, insulin and the insulin-like growth factor 1 or
Insulin is necessary for the body to transport glucose into cells to fuel their
operations. Dr. Kenyon and other researchers suggest that worm cells with
mutated receptors may be “tricked” into sensing that nutrients are not
available, even when they are. With its maintenance machinery thereby turned on
high, each worm cell lives far longer — and so does the worm.
Many experts are now convinced that the energy-signaling pathways that employ
insulin and IGF-1 are very involved in fixing an organism’s life span. Some
researchers have even described Type 2 diabetes, which is marked by
insensitivity to the hormone insulin, as simply an accelerated form of aging.
In yeast, scientists have discovered a gene similar to daf-2 called SIR2, that
also helps to coordinate the cell’s defensive response once activated by calorie
restriction or another external stressor. The genes encode proteins called
sirtuins, which are found in both plants and animals.
A mammalian version of the SIR2 gene, called SIRT1, has been shown to regulate a
number of processes necessary for long-term survival in calorie-restricted mice.
Scientists are now trying to develop synthetic compounds that affect the genes
daf-2 and SIRT1.
Several candidate drugs designed to prevent age-related diseases, particularly
diabetes, are on the drawing boards at biotech companies. Sirtris
Pharmaceuticals, in Boston, already has begun testing a new drug in patients
with Type 2 diabetes that acts on SIRT1 to improve the functioning of
mitochondria, the cell’s energy factories.
While an anti-aging pill may be the next big blockbuster, some ethicists believe
that the all-out determination to extend life span is veined with arrogance. As
appointments with death are postponed, says Dr. Leon R. Kass, former chairman of
the President’s Council on Bioethics, human lives may become less engaging, less
meaningful, even less beautiful.
“Mortality makes life matter,” Dr. Kass recently wrote. “Immortality is a kind
of oblivion — like death itself.”
That man’s time on this planet is limited, and rightfully so, is a cultural
belief deeply held by many. But whether an increasing life span affords greater
opportunity to find meaning or distracts from the pursuit, the prospect has
become too great a temptation to ignore — least of all, for scientists.
“It’s a just big waste of talent and wisdom to have people die in their 60s and
70s,” said Dr. Sinclair of Harvard.
If you are dying in Miami, the last six months
of your life might well look like this: You'll see doctors, mostly specialists,
46 times; spend more than six days in an intensive care unit and stand a 27%
chance of dying in a hospital ICU. The tab for your doctor and hospital care
will run just over $23,000.
But spend those last six months in Portland,
Ore., and you'll go to the doctor 18 times, half of those visits with your
primary care doctor, spend one day in intensive care and stand a 13% chance of
dying in an ICU. You'll likely die at home, with the support of a hospice
program. Total tab: slightly more than $14,000.
Researchers at the Dartmouth Atlas Project, a program at the Dartmouth Medical
School that evaluates variation in medical care, analyzed Medicare data on
patients with chronic illnesses to develop those statistics, showing that it
costs far more to die in some parts of the country than in others.
While researchers are able to show differences
in costs, the real question remains how much of those additional
hospitalizations, tests and doctor visits resulted in better care or better
quality of life? Finding answers to that question is difficult and
controversial, but health policy experts say doing so will become increasingly
important as the U.S. seeks ways to slow the rapid rise in health care spending.
"There's a tremendous opportunity for both improving quality and enhancing
efficiency in the care of people with very serious illnesses at the end of
life," says geriatrician Joanne Lynn, who spent much of her career at think tank
RAND studying end-of-life care.
She says substantial progress could be made in slowing rising costs if the U.S.
health system could find better ways to reduce hospitalizations for people at
the end of life, such as providing more in-home services.
Portland and Miami reflect that tremendous variation among regions. The most
expensive city out of 309 hospital referral regions is Manhattan, at a cost of
$35,838 for the last six months; the least expensive is Wichita Falls, Texas, at
Estimates show that about 27% of Medicare's annual $327 billion budget goes to
care for patients in their final year of life.
While that's not altogether surprising given Medicare's demographics — most
patients are over 65 — researchers say it's important to find out if that is
money well spent.
While not the major factor driving health care spending, costs involved in
sustaining patients in their final days are likely to get a closer look by both
Medicare and private insurers as health costs continue to spiral and the
Why costs vary
Why is it more expensive to die in some areas of the country than others?
The number of doctors and hospital beds is part of it: The more there are, the
more care a person gets. Also playing roles: the expectations of patients and
the practice patterns of doctors.
Portland has fewer ICU beds and specialists per person than Miami, which is also
more multicultural, with a greater variety of views on end-of-life medical care.
But experts on the end-of-life care say one main reason for the vast difference
between the two cities may be that in Oregon, doctors, or staff at hospitals and
hospices, encourage patients with life-threatening illnesses to talk about the
end of life, what kind of medical care they want and where they want to die. The
state has a history of such debate: Oregon residents have long supported
palliative care, a term usually used to describe medical care for the terminally
ill that focuses more on comfort treatments than cures. And, in 1994, voters
there became the first in the nation to approve doctor-assisted suicide, a
referendum signed into law in 1998.
"We have fewer hospitals and ICU beds than Miami does and, yes, that's a factor.
But making a plan and how everyone supports you to have that plan is what makes
the difference," says Susan Tolle, a medical doctor and director of the Center
for Ethics in Health Care at Oregon Health & Science University.
The ways people die in Portland and Miami illustrate the vast variation in what
is done at the end of life in America.
Across the nation, some patients spend much of their final weeks seeing
specialists, having tests, trying new drugs. Many die attached to machines, such
as ventilators, in hospitals.
For some patients, that's exactly the right care. Doing everything that can be
done to save an 18-year-old motorcycle-crash victim makes sense. But what about
an 85-year-old with heart failure, diabetes and cancer? Do you continue
Then the answers are not so clear-cut.
Complicating matters is that medicine often doesn't know what the most effective
treatments are. And doctors are trained to save lives. As a result, some
patients may be pushed into more than they want by a medical system that values
doing something over doing nothing, even when futile.
"One of the things that frustrates us all is to see care being provided in an
absolutely futile situation ... and doctors and hospitals are not accountable
but are also being rewarded (financially) for that (futile care)," says John
Santa, medical director for the Center for Evidence-Based Policy in Portland.
When not to treat
Not so long ago, Americans were felled by a bad infection or an accident or a
sudden illness, such as a heart attack. Advances in medicine mean more of us are
living longer, but often with disabilities.
"Many more of us make it to older age, and so there's much more we can do
(medically)," says geriatrician Lynn.
But, increasingly, ethicists, economists and patient advocates are questioning
whether the spending mentality is best for elderly patients or the long-term
financial future of programs such as Medicare.
"We are going to double the number of people who are sick, old and frail in
about 15 years," says Lynn. "It would be a good thing to try on some ways of
thinking about how to live that well ... and at a cost the community can
She and others say there's not enough money to give everyone a treatment with a
one-in-a-million chance of success. "None of us wants to bankrupt our community
on desperate, long-shot treatments," Lynn says. "The question is, how do we
build a sustainable health system?"
Those questions about what care to give and when to quit are deeply personal. A
USA TODAY/Kaiser/ABC poll of 1,201 Americans taken by telephone in September
found the public divided on the answers.
When asked if it is better to keep a terminally ill person alive as long as
possible, regardless of the expense, or to make a judgment as to whether it's
worth the expense, 48% said it's better to weigh the costs, compared with 40%
who said to keep the person alive as long as possible, regardless of the cost.
Among those 65 and older, 60% said expense should be considered, compared with
28% who said cost should not enter the decision. The nationally representative
poll has a margin of error of plus or minus 3 percentage points.
Improving quality of care
Still, not everyone agrees that slowing spending at the end of life is a panacea
for rapidly rising health costs. Such costs are driven by a host of factors, of
which the amount spent in the last six months of life is but a part. "There are
so many things that would result in very substantial resources being saved, and
(end-of-life care), on my list of things, is not at the top," says Santa.
Things closer to the top of his list include unnecessary back surgeries,
hysterectomies and what he calls an over-reliance on some expensive brand-name
drugs when generics would work just as well.
But Santa and other proponents of the Oregon model say its importance goes well
beyond any cost savings that might result. Rather, they say it's a way to give
patients more control over their own medical treatment and is changing a culture
of medicine that has been reluctant to discuss dying.
Oregon's program allowing people to register their wishes on the single page
Physician Order for Life Sustaining Treatments (POLST) form began in 1995 and is
widely accepted in the medical community, although it took time to build.
On the forms, patients can say whether they want cardiopulmonary resuscitation,
antibiotics or feeding tubes. Conversely, they can specify that they want full
treatment, including breathing machines and feeding tubes. And for how long.
The forms differ from so-called advance directives, which are also called living
wills, which name someone to speak on behalf of a patient and state patient
wishes. Instead, the forms are doctor's orders, similar to directions written
into medical charts, that are recognized and followed by medical personnel from
technicians on ambulances to staff at hospitals and nursing homes.
Tolle says most of her patients want to talk about their care and the way they
want to die, although the adult children of many are often more reticent.
"It's actually not that difficult to talk to approximately 80% of my patients
for the first time about an advance plan," Tolle says. "What is horribly
difficult is to talk to their children, who are not ready to talk about Mom and
She says younger people or those without life-threatening illnesses are
encouraged to fill out legal documents for an advance directive, mainly to name
a person who can make medical decisions for them if they are unable to make them
The POLST forms in Oregon, which are printed on bright pink paper and can be
transmitted electronically by hospitals and other medical providers, are "for
the individual who is in life's last chapter," she says.
Robert Smith, a 79-year-old retired accountant in Portland, says he brought up
the subject with his doctor and filled out the form as part of his overall
estate planning, which includes a will, a designation of someone to speak for
him if he is unable and funeral arrangements.
His form says he wants antibiotic treatment but does not want to be kept alive
artificially. "If there's no hope of my continuing to live, I do not want a
feeding tube," says Smith, who encourages others to write down their desires and
talk with family and friends about them. "It's part of the care you have for
your family, that you told them what to do," says Smith.
Tolle says the program's designers did not focus on whether it would save money.
"A few individuals might want to spend more and want everything done," says
Tolle. "And we would fight for them, too."
One startling truth stands out among the
accusations about the care of Brooke Astor in her old age: Mrs. Astor is not
simply old, she is 104. That makes her a member of a most exclusive club, the
exceptionally long lived. Route to admission? Mysterious. Benefits of
membership? A blessing, though possibly a curse as well.
Mrs. Astor, the philanthropist and socialite, took her Dubonnet in moderation,
practiced yoga, gave up smoking a lifetime ago. She swam laps all winter, walked
with her dogs, had flocks of friends. She was disciplined, curious, flirtatious.
She had a mission. She was resilient. She never let herself, she said, become
“It didn’t matter if we were at her apartment or the Knickerbocker or the Four
Seasons,” said Graydon Carter, the editor of Vanity Fair and a frequent lunch
companion of Mrs. Astor’s. “She would order a club sandwich or fish and a tall
Campari and soda, which she would drink about a quarter of.”
She was always reading, Mr. Carter said, two books at a time.
Mrs. Astor also comes from a long-lived lineage. Her mother, Mabel H. Howard
Russell, died at 88; her father, Maj. Gen. John Henry Russell, died at 74. Both
grew up at a time when average life expectancy was in the 40’s. A grandfather,
Rear Adm. John Henry Russell, born when John Quincy Adams was president, died at
People who study exceptional longevity — the state of living to 100 or beyond —
say factors like diet, exercise, health habits, social support and the ability
to find meaning in life appear to play a role in getting people to, say, 85.
But, some of them say, they suspect that genes play the dominant role in hitting
100 or above.
“I have no one that was exercising,” said Nir Barzilai, director of the
Institute for Aging Research at the Albert Einstein College of Medicine, who is
studying 400 centenarians. “I don’t have vegetarians. Nobody ate yogurt or
anything like that. If you have longevity genes, well, lucky you. If you don’t,
you know what to do.”
The gift of good genes is not without drawbacks, as the family struggle over the
guardianship of Mrs. Astor suggests. The longer a person lives, the more
generations take their place in line. Anecdotally, it appears to some that more
opportunities arise for squabbling over care, expenses and who stands to inherit
“The longer the person lives, the more generations you have to deal with and the
more your own future becomes an issue,” said Roberta Satow, a sociologist at
Brooklyn College and the author of a book on caring for parents. “We have
70-year-olds taking care of their 90- and 100-year-old parents. Those
70-year-olds are worried about what they’re going to have if they’re spending
the money on Mom and Dad.”
In Mrs. Astor’s case, a grandson, Philip Marshall, has gone to court asking that
his father, Anthony D. Marshall, be replaced as her guardian. He has accused his
father, Mrs. Astor’s only son, of neglect — failing to fill her prescriptions,
cutting her staff, removing art, banishing her dogs to the pantry and forcing
her to sleep on a couch.
Anthony Marshall, 82, a Broadway producer and former diplomat, has said the
charges are untrue. He has said he has always taken good care of his mother,
overseeing annual expenditures of more than $2.5 million “for her care and
comfort alone.” He said she has a staff of eight to provide her with whatever
There is no up-to-date count of centenarians in New York City. But, according to
the 2000 census, there were 1,253 women age 100 to 104 in the city at that time,
and 104 women age 105 to 109. The numbers of men over 100 were slightly lower.
Why some people live to those ages is unclear, researchers say.
Ronald D. Adelman, co-chief of geriatrics at Weill Medical College of Cornell
University in Manhattan, whose mother recently won a golf tournament at 91,
believes the answer is a mix of genes and factors like diet, exercise, social
networks and ability to handle stress.
But Dr. Barzilai, a professor of medicine and molecular genetics, said the
answer might lie in mutations in three genes that have a role in cholesterol and
“I have a 104-year-old lady who’s been smoking for 95 years,” he said. “Her
response is, ‘Every doctor who told me to stop is now dead.’ ”
Mrs. Astor’s life has not been free of adversity. Her first marriage was
unhappy; her second husband died in her arms. Her third husband, Vincent Astor,
died five and a half years into their marriage, but left her with $62 million
along with another $60 million for charity, which she helped parlay into $195
million and gave away over a 40-year period.
She ran the foundation into her late 90’s and remained a fixture on the social
scene. “She had the zest for life and the zest for people,” said John Fairchild,
a retired publisher of Women’s Wear Daily and a close friend. “She used to
drink, I remember, a watered-down Scotch. Nothing was ever in excess. She’s a
wonderful flirt. It kept her young.’’
Elizabeth Corbett, who worked as a dressmaker for Mrs. Astor, said Mrs. Astor
used to advise her to take a vacation: “She said, ‘Elizabeth, you have to get to
the shore, you have to get to the mountains, you have to get to four different
places to stay alive. You have to refresh the body and the mind.’ ”
And did Miss Corbett take the advice? “Of course not,” she said. “I didn’t have
the money or the time.”