Foreword

The man said, “Doc, my knee hurts.” “What do you expect? You're 84.” “But, Doc, my other knee is 84, too, and it doesn't hurt.” Jokes, a kind of folklore, not only make us laugh, they communicate important social messages about our values and beliefs. In this joke the physician illustrates long-held beliefs about the later years. Aging-research, represented by the patient, tells us it is no longer acceptable to use age as an explanation for disease. The old man is mentally sharp and gets the best of the doctor. The joke says that people want to be healthy and pain-free, even at the age of 84. Sheer numbers have focused our attention on aging. One third of the U.S. population, the baby boomers born between 1946 and 1964, are approaching their 50s and 60s. The concept of “old age” we choose to embrace as a society will dramatically affect us all. In the first half of the 20th century, advocates publicized the problems of aging, such as poverty, social isolation, and poor health, in an effort to procure services for older people in need. Their efforts led to the enactment of Social Security in 1938. More recently, advocates of healthy and successful aging have stressed the positive aspects of aging, with some ads suggesting that we should all aspire to play tennis at age 70. Both views shortchange seniors. They promote stereotypes and ignore the complexity and variety within this group, aged 65 to 122. In fact, diversity is more pronounced among seniors because innate differences have been compounded over time by variations in life experiences. Late life itself is best characterized by its paradoxes. “Aging is a source of wisdom and suffering, spiritual growth and physical decline, honor and vulnerability.”1 When asked the open-ended question, “How do you feel about the fact that you will one day grow old?” about half of first-year students at one medical school responded negatively.2 The medical school assigns these students to visit the homes of senior volunteers to prepare them for the large numbers of older patients they will eventually care for. The seniors are chosen because they are “healthy,” but students quickly realize that almost all of the volunteers have health problems. Successful management of chronic conditions, combined with social activity and a positive outlook on life, constitute health, not the absence of disease. What was once thought to be the inevitable decline of age is now thought to be a function of the law of thirds: one third genetics, one third aging (a decline in physiological capacity and reserves), and one third environment (physical, social, and psychological). The challenge for us as a society, and as individuals, is to navigate the paradoxes of aging by maximizing independence and function based on each individual's capacity. Lifestyle choices we make have as much impact on how we age as do genetics or the effects of passing years. Just as important are the opportunities and social structures provided by our culture, which will either promote health or set up barriers. Retirement As a fixed rite of passage, retirement is a relatively new phenomenon, one that may not serve us well in the future. The U.S. census of 1900 reported that 70% of men over 65 were still working. When 65 was first designated as a retirement age in Germany in 1881, the average life expectancy was 58. In 1935, when the Social Security Act was passed in the United States, the average life span was 63. Today the average life span is 77, and those living to 68 have a 50% chance of living past 84. Yet retirement age has risen only slightly, to 67. Forty years of inactivity is not economically feasible. In addition, social isolation and the loss of status and purpose that accompany retirement can exacerbate health problems. Retirement can be reconceptualized as a time of reduced income and the pursuit of interests, passions, and second careers more focused on self-actualization and less focused on earning power. Opportunities as part-time workers and substitute workers coupled with flexible schedules and phased retirement can extend active working lives. New roles for seniors such as trainers or mentors to younger employees could also benefit all involved. Health Care Society's current focus is on providing care for those who have lost their health and independence, rather than on promoting and preserving health. Preventative health care, including a focus on mental health, needs to be emphasized and expanded. In addition to expanding primary prevention, we need more focus on secondary and tertiary prevention to help maintain function and independence. Secondary prevention monitors and treats symptoms to avoid acute events. Tertiary prevention aims to minimize loss of function and reoccurrence of problems. Aging and poor health are not synonymous. Aging is irreversible, but illness occurring late in life is not.3 Social Engagement Dr. David Solomon, director of the Center for Ethics and Culture at Notre Dame, suggests that our culture is not lacking in respect for elders, but that we lack the social structures that provide opportunities to interact across age groups.4 We know that social engagement promotes health, yet our seniors are often isolated and lonely. Expanded public transportation systems can make giving up driving as we age less traumatic. A better alternative may be to provide housing for seniors located adjacent to public spaces where people gather. Senior housing can be built with access to libraries, churches, schools, community centers, shopping centers, and recreation facilities. Physical proximity would allow seniors access to activities and make it easier for them to participate in their communities. Death and Dying Denial and discomfort with death and decline are widely acknowledged. Yet, coming to terms with aging and death is essential for both elders and their caregivers. A public health campaign that addresses such issues as aging with dignity, end-of-life decision making, and the process of dying is just as necessary for our well-being as are campaigns on AIDS and tobacco. Labels With the 84-plus age group being the fastest-growing segment of our population and the number of centenarians booming, 80 is what 60 used to be. How old is old? In France, people make a distinction between the young old, 60–70, the “old old,” 70-plus and still active and independent, and the “oldest old,” those truly in decline and dying. These terms seem awkward, but how do we describe a person, still lively and active, living independently, at the age of 80? We say, “She's 80, but you'd never believe it,” implying that what is normal for 80 is dependency and ill health. A simpler approach is to think of the “young old” as people aged 60 to 122 who are still active and independent, in contrast to the “old old” who have become dependent. Imagine our communities full of people enjoying late life. They are independent, resourceful, and mature. They work at what they enjoy, often learning and exploring in new areas. They are knowledgeable and skilled. They have discretionary time. They see current events in the context of lived history and experience. They have strong relationships with others of all ages. They are the “young old.” With increased opportunities and improved social structures this vision can become a reality. Cynthia Alford, PhD Assistant Professor, Department of Family and Community Medicine, Division of Community Geriatrics, University of Texas Medical School at San Antonio