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How do you define a healthy 80-something?

By Scott LaFee

UNION-TRIBUNE April 9, 2003

CRISSY PASCUAL / Union-Tribune

Norton Davey, 84, of Oceanside, who competes in triathlons, is an exception to the rule.

Today, an estimated 5,574 Americans will celebrate their 65th birthday. That's 362,310 candles, if you're counting.

Traditionally, reaching age 65 has marked a sort of endpoint. But while that might apply to many careers, it's far from true about life. Americans are living longer than ever. At age 65, the average American can expect to see at least one more generation mature. According to IRS mortality tables, there's a 5 percent chance he or she will even reach 100.

Picture of the aged

A profile of older America, based on census and other data:

 Diversity: Slightly more than 83 percent of the elderly U.S. population (age 65-plus) is white. Eight percent is African-American, 5.6 percent is Hispanic, 2.4 percent is Asian or Pacific Islander, and less than 1 percent is American Indian or Native Alaskan.

 Gender: Older women outnumber older men 20.6 million to 14.4 million.

 Geography: About half of all older Americans live in nine states: California, Florida, New York, Texas, Pennsylvania, Ohio, Illinois, Michigan and New Jersey. Almost 78 percent live in metropolitan areas.

 Marital status: Elderly men are much more likely to be married than elderly women: 73 percent to 41 percent. Almost half of all elderly women are widows (46 percent). In 2001, there were 8.49 million widows and 2 million widowers.

 Living arrangements: Roughly 55 percent of older, noninstitutionalized people live with their spouses. Thirty percent – mostly women – live alone.

 Education: Seventy percent of elderly possess at least a high school diploma, up from 28 percent in 1970. Seventeen percent have a college degree.

 Employment: In 2001, 4.3 million Americans age 65 and older were still working full-time. They constitute 3 percent of the U.S. labor force.

 Income: The median income in 2001 was $19,688 for older males, $11,313 for older females – a decline of 2.6 percent from 2000. More than 10 percent of elderly people – 3.4 million – live below the poverty level.

Not great odds perhaps, but the numbers are compelling. There are roughly 70,000 centenarians living in the United States today. In 50 years, there will be more than 800,000, according to population projections. That's almost double the current total population of Wyoming.

Such longevity presents questions and challenges well beyond finding enough candles. What does it take to live a long life? Are aging and decline inextricably linked? What does healthy mean when you're 80 years old?

"Just as children are not small adults, older people are not simply older adults," said Dr. Dilip Jeste, chief of geriatric psychiatry at UCSD. "They are different due to changes in biology, psychosocial changes, the accumulation of life experience, not to mention diseases common to the aging process."

In some ways, doctors and medical researchers are just beginning to fully appreciate these differences. Gerontology – the study of aging and old age – and geriatric medicine are comparatively new endeavors, said Dr. Dennis Carson, director of the Stein Institute for Research on Aging at UCSD.

"Up until probably this decade, doctors didn't get much opportunity to see normal aging. Most people died from specific diseases," said Carson. "Now we can treat and often prevent many diseases, which means we're getting a better look at what it means to be an octogenarian and older. Still, at the moment, nobody has a complete understanding of what aging means in humans."

To be sure, aging means death – eventually. By most estimates, the maximum human life span is somewhere around 120 years. Jeanne Calment, a French woman who died in 1997, represents the oldest documented life. She lived to be 122.

It adds up

At age 65, the average life expectancy for a woman is 19.2 additional years, 16.3 for a man.

Almost 39 percent of elderly Americans rate their health as excellent or very good, but more than a third also report at least one disability that limits daily activity.

The most common chronic disabling conditions among the elderly are arthritis, hypertension, hearing impairments, heart disease, cataracts, orthopedic impairments, sinusitis and diabetes.

Older Americans average seven doctor visits annually, compared to 3.7 for people of all ages.

The elderly are hospitalized more often – 1.8 days per year compared to 0.4 for younger Americans – and they stay longer. The average hospital stay in 2000 was 6.4 days compared to 4.6 for all patients. This figure, however, represents a decline of six days since 1964.

Sources: Administration on Aging; U.S. Census Bureau; National Center on Health Statistics

But far less certain is the connection between aging and disability. "We all die from something," said Carson, "but there are a lot of very old people who are as smart as ever, who jog, play tennis, do what they've done all their lives. Aging brings general decline, but no one yet can define how much, or what's normal."

Norton Davey is proof of Carson's point. Davey is an Oceanside triathlete. Four years ago, he competed in an Ironman triathlon in Florida (2.4-mile swim, 112-mile bike ride, 26.2-mile run). Davey finished the race, but was declared an unofficial competitor because he took longer than the maximum 17 hours. Davey finished in 18 hours. He was 80 years old at the time.

"I got interested in triathloning in my mid-50s, after my company's medical director said he thought I needed some exercise. I had a pretty sedentary life at the time, a desk job," said Davey, now 84. "Obviously, the exercise has done some good."

Davey, of course, is an exceptional case. Few people in their 80s can reasonably expect to run, swim and bike daily without suffering unwanted consequences. Most Americans really aren't interested in how fast they can run a mile, but they do want to know what it means to be elderly and in normal health.

These days, life expectancy at birth is almost 80 years for women, 74 years for men. The population of older Americans, based on the 2000 U.S. census, stands at approximately 35 million. In less than 30 years, it is projected to double, swelled primarily by elderly baby boomers.

But it is the ranks of oldest Americans that are growing fastest of all. In 1900, there were just 122,000 Americans 85 years or older, a figure less than the current total population of Escondido.

In 2000, however, the number of Americans age 85 and older exceeded 4.2 million, and it is projected to reach 8.9 million by 2030. This total would exceed the current combined populations of Vermont, Maine, Idaho, Hawaii, Delaware, Montana, New Mexico, South Dakota and Alaska.

Decline vs. disease In some ways, medically speaking, it's harder than ever to tell the difference between young and old. For example, doctors once presumed blood pressure inherently climbed with age. Hypertension was inevitable. Now, they're not so sure.

"Blood pressure in a healthy older person shouldn't be much different than that in a young person," said Dr. Joe Ramsdell, head of UCSD's division of internal medicine and geriatrics. The same holds true for most basic blood tests, such as cholesterol levels.

Indeed, the real culprit in hypertension or elevated cholesterol for many people is behavior and lifestyle. "It's related to living a long time in a Western, urbanized lifestyle," said Dr. Elizabeth Barrett-Connor of UCSD's Family and Preventive Medicine program. "It's excesses in food, the amounts eaten and underexercising."

Some standards of health in the elderly simply don't yet exist. There isn't enough data, for example, to categorize pulmonary function, according to Ramsdell. What's healthy for one person may not be for another. It all depends upon individual factors, such as diet, lifestyle, genetics and other health factors.

One major rule of thumb in deciding what is normal, successful aging and what is not, said Ramsdell, is the rapidity of physical change. The effects of normal aging don't happen overnight.

"If somebody suddenly starts complaining of shortness of breath, that's probably not due to normal aging, which tends to be felt gradually and is most often related to diminishing, limited reserves."

For example, a 70-year-old who has exercised regularly likely boasts the same lung capacity as a 20-year-old who does not exercise regularly. "A lot of decline is influenced by activity," said Ramsdell. "Staying active can keep the body working well for a very long time."

The same advice applies to cognitive function. Neuroscientists once thought that the human brain, after childhood, was essentially doomed to lifelong decline. A child began life with a maximum number of neurons and, over time, many of these cells died. They were not replaced. Eventually, neuron loss tipped the scales toward dysfunction, disease and dementia.

But that's no longer believed to be true. "The good news is that there's very little death in the early to middle stages of aging in the brain," said Dr. Mark Tuszynski, a neurologist and neuroscientist at UCSD.

Mental abilities may diminish with age – increasing bouts of mild forgetfulness or memory loss, for example – but many neuroscientists now suspect the cause is linked to changes in the brain's biochemistry.

"The best guess is some decline of expression in some genes that correlates with some loss of function," said Tuszynski.

For example, in studies of aged rats with impaired cognitive function, researchers found that certain cell pathways no longer recognized or reacted to key neurotransmitters, such as growth factors. On the other hand, other rat studies indicate that older brains learn to compensate for age-connected impairments.

"The emerging picture is that the brain is much more dynamic than once thought. Connections are actively changing, turning over," Tuszynski said. "The way we learn things or record experiences is through actual change in the receptors of cells and the literal structure of the brain.

"Animals exposed to an enriched environment show better, improved cognitive function than those who do not. It's no doubt true of humans, too. Staying engaged in life, mentally active, keeps the brain young. The idea that one ought to (mentally) slow down with age is 180 degrees wrong."

The growing number of older Americans poses particular problems for psychiatrists and psychologists. To wit: There are simply more mentally ill people over the age of 65. In fact, the rate appears to be increasing disproportionate to population growth.

In a 1999 paper published in Archives of General Psychiatry by Jeste and colleagues, the number of Americans older than 65 with psychiatric disorders was projected to grow to 15 million in 2030 from about 4 million in 1970.

Jeste cited a couple of likely causes:

 More people with serious mental illnesses were living longer.

"It used to be that many of these patients died young. Ten to 15 percent of schizophrenics committed suicide. But as better treatments have emerged, more mentally ill are reaching old age," Jeste said.

 Aging baby boomers appear to be at higher risk of developing depression and substance abuse than previous generations. Jeste conceded that the reasons why aren't clear.

"There's possibly some sort of biological explanation, but it could also be psychosocial. Families after World War II were smaller and more mobile. Divorce rates rose. There were more broken families, more disconnectedness. Gender roles changed. And baby boomers are more accepting of mental illness. It's more OK to admit to depression."

Everyone at one time or another, said Jeste, gets depressed about aging. It's a normal part of growing old, learning to accept and adapt to changing levels of vitality or ability.

The challenge for mental-health experts is differentiating between temporary melancholy and clinical depression. "Many of the symptoms of depression – difficulty sleeping, loss of appetite – are also signs of normal aging," Jeste said. "It's critical, though, to discern which is which because depression in older people can be especially devastating. The risk of suicide increases with age, especially among white males. It's five to 10 times greater than in younger men."

For a lot of older people, despair begins with the measurable decline of mental abilities. Jeste says the picture is rarely as bleak as people think. Some decline is normal and inevitable, particularly after age 80, but like Tuszynski, Jeste said the human brain seems to possess a remarkable ability to compensate, if given the chance.

And some mental diseases actually appear to diminish with age. The symptoms of schizophrenia, for example, appear to ease in persons after the age of 50, possibly due to dropping levels of dopamine, a brain chemical.

"Sigmund Freud wrote in 1924 that people over the age of 50 were no longer educable. They weren't worth trying psychotherapy," said Jeste. "New research shows Freud was wrong. Older test animals that learn new things actually show better functioning. Increased brain activity promotes efficiency, the regeneration of neurons. This isn't just feel-good science. The notion that old age equals mental decline is really being challenged."

The old standard
For obvious reasons, the aging process has always fascinated humans. The promise of immortality beckons, if not the probability. But while modern medicine has answered many of the questions of how we age, the why remains.

There are multiple theories, from the notion that inevitable cellular repairs become sloppier and less effective over time to the idea that genetics dictates how many times a human cell will be able to divide and live before it finally wears out and dies.

It's a complicated question. Only less daunting is defining a healthy 80-year-old. After age 75, the typical older person suffers from three chronic medical conditions and regularly uses about five prescription drugs. Their bodies work differently. Metabolisms have slowed. Some bodily functions are likely to be restricted or less efficient than in youth.

Doctors expect to see some degree of decline in all elderly patients. It's unavoidable. Disease is a different matter.

"Our ability to diagnose and treat some major diseases has really improved," said Barrett-Connor. "Fifty years ago, we would have said hypertension was just part of getting old. Now we understand that it's a real disease and it can be treated."

One result is that living to old age increasingly emphasizes the living.

"A big issue has been when do you treat a disease," said Carson at the Stein Institute for Research on Aging. "In the past, doctors balked at doing certain procedures or treatments after a certain age. Not as much now. People are getting coronary bypasses and hip replacements in their 90s. They're still quite functional, with years ahead of them."

Perhaps the question, some time in the future, won't be what constitutes a robust 80-year-old, but how healthy is healthy at age 100?


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