Atul Gawande has produced a must-read book on dealing with our inevitable mortality: Being Mortal: Medicine and What Matters in the End
. Gawande, a practicing surgeon and an excellent author and commenter on medical issues, is appalled by the way we have allowed the act of dying be framed not as a very personal social issue, but as a medical issue.
“You don’t have to spend much time with the elderly or those with terminal illness to see how often medicine fails the people it is supposed to help. The waning days of our lives are given over to treatments that addle our brains and sap our bodies for a sliver’s chance of benefit. They are spent in institutions—nursing homes and intensive care units—where regimented, anonymous routines cut us off from all the things that matter to us in life. Our reluctance to honestly examine the experience of aging and dying has increased the harm we inflict upon people and denied them the basic comforts they most need. Lacking a coherent view of how people might live successfully all the way to their very end, we have allowed our fates to be controlled by the imperatives of medicine, technology, and strangers.”
For those who are in a “fragile” state and unable to care for themselves, there are better options than warehousing them in facilities modeled on penitentiaries. Some patients may wish to experience any pain and discomfort in order to try and squeeze a few more months out of their lives; others might wish to spend their last few months under palliative care in their own homes where they can socialize with their friends and relatives while they settle their affairs. Too often this latter option is not presented to the terminally ill by the medical community.
Gawande provides numerous examples of how the healthcare industry can provide better service to aged and seriously ill patients, as well as advice for patients who must take the time to seriously consider what they want out of the remaining life they have.
Gawande also provides a description of the aging process that is useful to all of us as we grow older and must deal with increasing decrepitude of ourselves or others. This aging process will be the subject here.
We are told that there are two main hypotheses that attempt to explain the physical process of aging. The traditional explanation is based on the notion that the performance of various organs and components of our bodies, and their backups, degrade over time until some critical level of malfunction is reached and the body is no longer viable—with multiple organ failures quickly following. This is what is known as dying of old age.
A more recent theory holds that humans are programmed genetically to wind down over a more or less standard time period. One can make evolutionary arguments why a finite lifetime would be of value to a given species. This hypothesis is also attractive to some because it provides hope that there is some physical process that controls our life spans and that process might be modified to produce longer lives. Scientists have been able to demonstrate that longer lifetimes can be produced in some species by introducing genetic changes.
Gawande is a believer in the wearing out hypothesis. For a programmed lifetime to exist it would have to have been favored via natural selection. We clearly have the capability to live to near 100 if we are able to avoid early death by disease or injury. However, all data indicates that our ancestors rarely, if ever, reached such ages. Consequently, it is not clear how natural selection might have programmed in such a long lifespan. Most selection is based on the survivability of offspring. It is difficult to explain how a potential longevity of near 100 years can affect the survivability of offspring when typical longevities might be only 20-30 years.
An even more compelling counter to the genetically programmed hypothesis resides in inheritance data.
“….only 3 percent of how long you’ll live, compared with the average, is explained by your parents longevity; by contrast, up to 90 percent of how tall you are is explained by your parents’ height. Even genetically identical twins vary widely in life span: the typical gap is more than fifteen years.”
Gawande provides us with a list of the various degradations and breakdowns that occur as we age. The elderly need to know what has happened to them, and the young need to understand that it will happen to them as well.
Perhaps the first observation is the graying of our hair.
“Hair grows gray….simply because we run out of the pigment cells that give hair its color. The natural lifecycle of the scalp’s pigment cells is just a few years. We rely on stem cells under the surface to migrate in and replace them. Gradually, however, the stem-cell reservoir is used up. By the age of fifty, as a result, half of the average person’s hairs have gone gray.”
At about the same time, we begin to notice that we are no longer able to read without lens corrections and start surrounding ourselves with brighter light sources.
“The lens is made of crystalline proteins that are tremendously durable, but they change chemically in ways that diminish their elasticity over time—hence the farsightedness that most people develop in their fourth decade. The process also gradually yellows the lens. Even without cataracts….the amount of light reaching the retina of a healthy sixty-year-old is one-third that of a twenty-year-old.”
And then splotchy skin begins to appear.
“Inside skin cells, the mechanisms that clear out waste products slowly break down and the residue coalesces into a clot of gooey yellow-brown pigment known as lipofuscin. These are the age spots we see in skin. When lipofuscin accumulates in sweat glands, the sweat glands cannot function, which helps explain why we become so susceptible to heat stroke and heat exhaustion in old age.”
Most high-performance athletes will have retired by the age of forty.
“Around age forty, one begins to lose muscle mass and power. By age eighty, one has lost between a quarter and a half of one’s muscle weight.”
Cherish and care for your teeth—they may not be with you for the entire journey.
“The hardest substance in the human body is the white enamel of the teeth. With age, it nonetheless wears away, allowing the softer, darker layers underneath to show through. Meanwhile, the blood supply to the pulp and the roots of the teeth atrophies, and the flow of saliva diminishes; the gums tend to become inflamed and pull away from the teeth exposing the base, making them unstable and elongating their appearance, especially the lower ones.”
Care can help maintain the health of our teeth, but the afflictions of aging such as arthritis and tremors make the scrupulous brushing and flossing difficult.
“In the course of a normal lifetime, the muscles of the jaw lose about 40 percent of their mass and the bones of the mandible lose about 20 percent, becoming porous and weak. The ability to chew declines, and people shift to softer foods, which are generally higher in fermentable carbohydrates and more likely to cause cavities. By the age of sixty, people in an industrialized country like the United States have lost, on average, a third of their teeth. After eighty-five, almost 40 percent have no teeth at all.”
As we lose calcium from the places it is needed, it seems to migrate to places where it is harmful.
“Even as our bones and teeth soften, the rest of our body hardens. Blood vessels, joints, the muscle and valves of the heart, and even the lungs pick up substantial deposits of calcium and turn stiff. Under a microscope, the vessels and soft tissues display the same form of calcium that you find in bone. When you reach inside an elderly patient during surgery, the aorta and other major vessels can feel crunchy under your fingers. Research has found that loss of bone density may be an even better predictor of death from atherosclerotic disease than cholesterol levels. As we age, it’s as if the calcium seeps out of our skeletons and into our tissues.”
We can affect the rate of these processes by exercising in an attempt to maintain functionality, and eating a healthy diet, but the processes cannot be stopped.
“Our functional lung capacity decreases. Our bowels slow down. Our glands stop functioning. Even our brains shrink: at the age of thirty, the brain is a three pound organ that barely fits inside the skull; by our seventies, gray-matter loss leaves almost an inch of spare room. That’s why elderly people….are so much more prone to cerebral bleeding after a blow to the head—the brain actually rattles around inside. The earliest portions to shrink are generally the frontal lobes, which govern judgment and planning, and the hippocampus, where memory is organized….Processing speeds start decreasing well before age forty….By age eighty-five, working memory and judgment are sufficiently impaired that 40 percent of us have textbook dementia.”
The accumulated changes lead to some accommodations that we must make. For example, aging causes the shape of the spine to change resulting in your head being tipped forward. If one attempts to swallow while keeping their head looking straight ahead it is easy to choke on food. The elderly tend to eat facing downward.
The loss of muscle strength is one of several factors that increase the risk of falling for the elderly.
“Each year, about 350,000 Americans fall and break a hip. Of those, 40 percent end up in a nursing home, and 20 percent are never able to walk again. The three primary risk factors for falling are poor balance, taking more than four prescription medications, and muscle weakness. Elderly people without these risk factors, have a 12 percent chance of falling in a year. Those with all three risk factors have almost a 100 percent chance.”
People tend to assume that modern medical practices will lead to better, healthier lives for all, including the elderly. If this were the case, one might expect people to age more gracefully, avoiding some of the inevitable disabilities until a more advanced age. This presumed trend is referred to as “compression of morbidity.” Unfortunately, the opposite seems to be the case. There are data that indicate the disabilities associated with aging are presenting themselves earlier, not later.
These data are based on surveys taken in 1998 and 2006. Over the span of just eight years people of all age groups are reporting greater incidences of what the authors refer to as mobility functioning loss. Things like being unable to climb stairs or get up and down without assistance are associated with old age. People seem to be hitting their senior years in worse shape than they were in the past. Other data are presented that indicate increased incidences of non-infectious diseases. We, as a population are becoming less healthy, not healthier. The authors provide this summary.
“Mortality declines have slowed down in the United States in recent years, especially for women. The prevalence of disease has increased….Mobility functioning has deteriorated. Length of life with disease and mobility functioning loss has increased between 1998 and 2008.”
Up to this point, we have developed a picture of inexorable physical decline leading to extreme limitations on possible lifestyles. The elderly have had to shed many of the activities that once were the core of their existence. They also must face their ever nearing mortality. One might expect this to become a period of extreme despair. Surprisingly, the opposite occurs. Psychologists who study such things claim that satisfaction with life becomes greater as one grows older, provided one manages to emerge from the despair and depression that characterizes middle age. This finding is discussed in an article in The Economist
: Age and happiness: The
U-bend of life. This chart is provided.
The questions being asked seem to be concerning psychological well-being, or satisfaction with life. These are not necessarily the same as happiness, but definitely something moving in a positive direction. If one asks about feelings of depression as a function of age the curve turns upside down with the peak being where the valley had been. The aged who are terminally ill are probably not being queried about their satisfaction with life, but it seems that those who are well into the falling apart process are dealing with it quite nicely. This U-bend profile seems to be fundamental to humanity in general. It is replicated in most countries, although the position of the valley will move around from one society to another.
A number of possible explanations for the U-bend phenomenon exist and are discussed in the article. For our purposes here, it is important to note that those who are well along in the falling-apart process have managed to maintain a degree of satisfaction with their existence. They know that they could die at any time, but still persist in having hopes and expectations. They are people who continue to lead a meaningful existence. However, their nearness to eventual mortality means that the medical community owes them considerations that are different from those that would be appropriate to younger people.
Gawande argues that a thirty-year-old who acquires a life-threatening illness has the potential for decades more of a healthy life if that illness can be defeated. In that case, it makes sense to try all options, no matter how painful or uncomfortable they might be to win the battle.
But a similar illness detected in an eighty-year-old provides a different set of considerations. There are no decades of health to look forward to. Instead, trying to defeat the illness may actually lead to a shortening of life, with death coming while hooked up to machines in an intensive care ward and in a state where one is unable to communicate with family or friends. The patient might prefer to make the best of whatever is left of life and forego any heroic medical adventures.
Gawande is irate because too many doctors do not understand the importance of the perspective of the elderly patient and encourage the pursuit of maintaining life, whatever the cost. That is what they are trained to do, but it is also the easiest thing for them to do. What they are least trained to do, and what they seem to find hardest to do, is have an honest discussion with the patient of what a given treatment might entail and what its potential benefit might be—to the patient.
Gawande offers his feelings about how medical professionals should approach treatment of the elderly.
“Sometimes we can offer a cure, sometimes only a salve, sometimes not even that. But whatever we can offer, our interventions, and the risks and sacrifices they entail, are justified only if they serve the larger aims of a person’s life. When we forget that, the suffering we inflict can be barbaric. When we remember it the good we do can be breathtaking.”
Everyone should read Gawande’s book. It has relevance to everyone, no matter the age, and it contains much more than was presented here.
You can learn a little about a lot of things or you can learn a lot about a very few things. Guess which is the most fun.