Peter Chow: Aging

“In my next life I want to live my life backwards.

You start out dead and get that out of the way.

Then you wake up in an old people’s home feeling better every day.

You get kicked out for being too healthy, go collect your pension, and then when you start work, you get a gold watch and a party on your first day.

You work for 40 years until you’re young enough to enjoy your retirement.

Your sex life gets better and better, year after year.

You party, drink alcohol, and are generally promiscuous, then you are ready for high school.

You then go to primary school, you become a kid, you play.

You have no responsibilities, you become a baby until you are born.

And then you spend your last 9 months floating in luxurious spa-like conditions with central heating and room service on tap, larger quarters every day.

And then Voila!

You finish off as an orgasm.”

–   Woody Allen
Aging sucks…..but it beats the alternative.

 

In 2011, a milestone in human history was passed.

For the first time, more people died from non-communicable diseases like heart disease, stroke and diabetes than from all infectious diseases combined.

Even with COVID, that remains true today.

 

Today, non-communicable diseases (NCDs) kill 41 million people each year, equivalent to 71% of all deaths globally.

Each year, more than 15 million people die from a NCD between the ages of 30 and 69 years; 85% of these “premature” deaths occur in low-and-middle-income countries.

Cardiovascular diseases account for most NCD deaths, or 17.9 million people annually, followed by cancers (9.3 million), respiratory diseases (4.1 million), and diabetes (1.5 million).

These four groups of diseases account for over 80% of all premature NCD deaths.

We live in an age in which we are killed, more often than not, by lifestyle.

We are, in effect, choosing how we shall die, albeit without much reflection or insight.

About 20% of deaths are sudden and unexpected, as with a heart attack or car crash.

Another 20% come quickly after a short illness.

But the great majority, 60% are the result of protracted decline.

We live long lives; we also die long deaths.

The medical diagnosis for some of the oldest nursing home residents may be “Failure To Die.”

The prevalence of most chronic diseases and conditions increases with age.

Among those aged 85+, the five diseases with the highest prevalence were hypertension (83.4%), osteoarthritis (54.0%), ischaemic heart disease (IHD) [42.0%], osteoporosis (36.9%) and chronic obstructive pulmonary disease (COPD) [27.3%].

Certain chronic diseases are more common among women while others are more common among men.

 

Compared to men the same age, women aged 65+ are:

4.2x more likely to have osteoporosis

3.0x more likely to have multiple sclerosis

2.0x more likely to have lupus

1.9x more likely to have rheumatoid arthritis

1.6x more likely to have mood and anxiety disorders

1.5x more likely to have dementia

1.5x more likely to have asthma

1.4x more likely to have osteoarthritis

 

Compared to women the same age, men aged 65+ are:

2.7x more likely to have gout

1.5x more likely to have ischaemic heart disease (IHD)

1.5x more likely to have Parkinsonism

1.3x more likely to have diabetes

1.2x more likely to have cancer

1.2x more likely to have heart failure

 

In 2017, the five leading causes of death due to a chronic disease among seniors were cancer, ischaemic heart disease (IHD), dementia, COPD and stroke.

Since 2000, mortality rates due to dementia have increased by 59% while mortality rates due to Parkinson disease and hypertension have increased by about 26% and 12%, respectively.

You’ll live to be a hundred if you give up all the things that make you want to.
–  Woody Allen

Some people die at 25 and aren’t buried until 75.
–  Benjamin Franklin

About one person in 10,000 lives to be 100.

The chance of living to 110 is one in seven million.

The longest-lived person ever was Jeanne Louise Calment in France, who died at age 122 years and 164 days in 1997.

She smoked all her life until she quit at age 117.

Her boast in old age was, “I’ve never had but one wrinkle, and I’m sitting on it.”

Calment was the beneficiary of one of the most delightfully misjudged deals ever made.

In 1965, when she ran into financial problems, she agreed to leave her apartment to her lawyer in return for 2,500 francs a month until she died.

It seemed like a pretty good deal for the lawyer as Calment was 90 then.

The lawyer died first in 1995, having paid Calment 250,000 francs for an apartment he was never able to occupy.

The average 65-year-old Canadian can expect to live an additional 21.0 years (19.5 years for men and 22.3 years for women).

However, women spent a greater proportion of their life post-65 years in an unhealthy state (30.9%) compared to men (27.7%).

Reaching 80 is largely the consequence of following a healthy lifestyle, but after that it is almost entirely a matter of genes.

After age 60, the risk of death doubles every 8 years.

If you are a 70 year old man today, you have only a 2% chance of dying in the next year.

In 1940, that probability was reached at age 56.

In the developed world, 90% of people reach age 65, the great majority in healthy condition.

As Yuval Harari points out in Homo Deus, our average life expectancy was half as long 200 years ago, because people died young from malnutrition, infections and war.

But those who didn’t succumb to that trio of destruction usually lived well into their 70s and 80s just like today.

Galileo died at 77, Newton at 84, and Michelangelo lived to the ripe age of 88, without any help from antibiotics, vaccinations, super drugs or organ transplants.

The average life spans in ancient Greek and Roman times were short at approximately of 20 to 35 years, though these numbers are based on “notoriously unrepresentative” graveyard epitaphs.

From the 1500s onward, till around the year 1800, life expectancy throughout Europe hovered around 35.

It does not mean that the average person living in 1650 A.D. died at the age of 35.

Unhygienic living conditions and little access to effective medical care meant average life expectancy was likely limited to about 35 years of age.

That’s life expectancy at birth, a figure dramatically influenced by infant mortality  –  pegged at the time as high as 40%.

Rather, for every child that died in infancy, another person might have lived to see their 70th birthday.

Since the early 1800s, life expectancy at birth has doubled in a period of only 10 or so generations.

Back in the 19th century, infant mortality claimed 37% to 42% of children.

Today, in most developed countries, this figure is between 2% and 7%.

Thus, until the 20th century, more than a third of the population died before the age of 5.

The healthiest or most fortunate survived.

From this it follows that about 6–7 people out of 10 lived to come of age.

Even to get an average duration of 35 years, the remaining six had to live to 50.

This is akin to having a group of 250 people that includes Elon Musk.

The average amount of wealth of each of those 250 people in the group would be over $1 billion.

A study by the Albert Einstein College of Medicine in New York in 2016 concluded that however much medical care may advance, it is unlikely that many people will live past about 115 years.

We’ll have to wait and see.

We have reached a point of diminishing returns.

If we found a cure for all cancers tomorrow, it would add just 3.3 years to overall life expectancy.

Eliminating heart disease would add only 5.5 years.

Eradicating Alzheimer’s would add just 19 days.

That’s because people who die of these things tend to be old already.

The extraordinary improvement in lifespan has come at a price.

Half of all people aged 50 or more suffer from some chronic pain or disability.

The elderly fill half the hospital beds and consume half of all the medicines.

Falls among the elderly alone cost the Canadian economy $3 billion a year.

Aging has inescapable consequences for us all.

Our bladders become less elastic and our prostates get larger, which is why one of the curses of aging is being forever on the lookout for a bathroom.

Skin loses elasticity and becomes more leathery.

Blood vessels become more fragile, break more easily and create bruises.

The immune system fails to detect intruders as reliably.

The number of pigment cells usually decreases, but those that remain sometimes enlarge, producing age spots.

The layer of fat directly under the skin also thins, making it harder for elderly people to stay warm.

More seriously, the amount of blood pumped out with each heartbeat falls gradually as we age.

After age 40, the volume of blood going to the kidneys decreases by an average of 1% per year.

If nothing else gets you first, your heart will eventually give out.

That is a certainty.

Most critically, our brains change as we age – from declines in memory and cognitive abilities, all the way down to microscopic changes to brain cells and chemistry.

Some studies suggest a slow decline beginning as early as age 30.

Certainly, almost all the great mathematicians and physicists in history did their greatest work before age 30.

The overall volume of the brain begins to shrink when we’re in our 30s or 40s, with the rate of shrinkage increasing around age 60.

The normal aging process brings subtle changes in cognitive abilities.

Committing new information to memory and recalling names and numbers can take longer.

Autobiographical memory of life events and accumulated knowledge of learned facts and information – both types of declarative memory – decline with age, whereas procedural memories like remembering how to ride a bike or tie a shoelace remain largely intact.

Working memory — the ability to hold a piece of information in mind, such as a phone number, password, or the location of a parked  car — also declines with age.

Studies suggest a slow decline starts as early as age 30.

Working memory depends on the rapid processing of new information rather than on stored knowledge.

Other aspects of this kind of fluid intelligence, such as processing speed and problem-solving, also decrease with age.

Certain aspects of attention can become more difficult as our brains age.

We may have a harder time focusing on what our friends are saying when we’re in a noisy restaurant.

Our ability to tune out distractions and focus on a particular stimulus is called selective attention.

Splitting our focus between two tasks – like holding a conversation while driving – also becomes more challenging with age.

This type of attention is called divided attention.

Slowed processing makes multitasking, processing and planning parallel tasks much more difficult.

But one fifth of 80-year-olds perform cognitive tests just as well as their 20-year-old counterparts.

“SuperAgers” are a rare group of individuals over the age of 80 years who have memories as sharp as healthy people decades younger.

The term SuperAger comes from the Northwestern University (Chicago) SuperAging Project, led by neuroscientist Emily Rogalski, which sought to recruit and understand people in the fall of life who scored remarkably well on Episodic Memory Tests, or, as they put it:
…individuals with performance levels that are distinctly above the normative range.

To be considered for the SuperAgers study, you had to be over age 80 and have memory performance at least as good or better than individuals in their 50s and 60s.

The SuperAging study team has given a battery of tests to more than 1,000 people who thought they’d qualify, and only about 5% pass.

The key memory challenge:  Listen to 15 unrelated words, and a half-hour later recall at least 9.

That’s the norm for 50-year-olds, but the average 80-year-old recalls 5.

Some SuperAgers remember all 15.

The brains of SuperAgers shrink at a slower rate than their age-matched peers, which results in a greater resistance to the typical memory loss observed with age, thus revealing that age-related cognitive decline is not inevitable.

 

It’s not all downhill after age 30.

In fact, certain cognitive abilities improve in middle age:  the Seattle Longitudinal Study, which tracked the cognitive abilities of thousands of adults over the past 50 years, showed people actually performed better on tests of verbal abilities, spatial reasoning, and abstract reasoning in middle age than they did when they were young adults.

Contrary to the adage that you can’t teach an old dog new tricks, there is growing evidence that we can and do learn throughout our lives.

Neuroscientists are finding that our brains remain relatively “plastic” as we age, meaning they’re able to reroute neural connections to adapt to new challenges and tasks.

Frontotemporal dementia (FTD), is a type of dementia that is often genetic and usually develops in people in their 50s, and causes cell loss in the frontal and temporal lobes.

Individuals with frontotemporal dementia (FTD) experience progressive cognitive and functional decline.

However, this process is not always one of inexorable decline, as occasionally loss in one area of function can lead to enhancement in others.

This phenomenon, known as “Paradoxical Functional Facilitation”, occurs when suppression or loss of activity in one part of the brain leads to a release of activity in another.

For some patients with FTD this means experiencing a sudden onset of artistic creativity and skill  –  Sudden Acquired Savant Syndrome.

One of these was a 53 yr old man who had enrolled in a course in painting at a local community college, though he previously had no interest in such things.

It just so happened to coincide with the onset of his frontotemporal dementia;   a few months later, he was having trouble speaking.

As his illness progressed, so did his painting, advancing from simple still-life paintings to haunting, impressionist depictions of startling quality.

In retrospect, his artistic turn was perhaps the earliest manifestation of illness.

His brain fMRI was notable for cerebral atrophy with disproportionate involvement of the anterior temporal cortex, a common feature of individuals exhibiting “paradoxical functional facilitation”.

It was not until the final year of his life that he developed prominent changes in motor and language functioning.

As for his passion for creating art, he was still painting beautifully up until the week he died.

In FTD, damage to the left frontal and temporal lobes can release inhibition of the right parietal lobe, thereby increasing activity in a brain region critically involved in the visual creative process.

The two halves of the brain specialise in different tasks.

In general, the right side is home to creativity and the left is the centre of logic and language.

But the left side is also something of a bully.

It tends to be the dominant brain region.

It tends to suppress very marginal types of thinking – highly original, highly creative thinking, because it’s beneficial for our decision-making abilities and our ability to function in normal life.

The theory goes that as the patients’ left hemispheres became progressively more damaged, their right hemispheres were free to flourish.

This is backed up by several other studies, including one in which creative insight was roused in healthy volunteers by temporarily dialling down activity in the left hemisphere and increasing it in the right.

 

Within this group of patients, aesthetic sensibilities appear to vary in relation to both the underlying pathology and anatomical site of their disorder and in many cases evolve over the course of illness.

 

Art associated with frontal lobe dysfunction tends to be abstract and deconstructed, with provocative and haunting themes that convey a sense of frenetic energy.

Conversely, the art of patients with primary temporal lobe damage is often representational depicting animals, people, or landscapes.

Patients with temporal-lobe-predominant FTD also often show a new predilection for bold, primary colours even in their daily life, dressing head to toe in Christmas red or deep purple, for example.

Meanwhile, patients with Alzheimer’s disease (AD), a clinical presentation distinct from FTD, display opposite stylistic preferences, with colour palates becoming more muted as the disease progresses.

In AD, artistic expressions become less complex and reductive, as famously documented in the case of the abstract expressionist painter Willem de Kooning, one of the most important artists of the 20th century..

Slowing down, losing vigour and resiliency, experiencing a steady diminution in the ability to self-repair – in a word, aging – is universal across all species.

At some point your body will decide to grow senescent and then to die.

You can slow the process a little by following a carefully virtuous lifestyle, but you can’t escape it indefinitely.

Nobody gets out of life alive.

We are all dying.

Some of us are just doing it more quickly than others.

Telomeres are stretches of repetitive DNA at the ends of each of our chromosomes, that shorten with each cell division.

When the telomere has shortened to a predetermined length, the cell stops dividing and dies.

This was hailed as the secret to aging – arrest telomere shortening and you would stop aging.

Unfortunately, subsequent research has shown that telomere shortening accounts for only a small part of the process of aging.

Researchers from Albert Einstein College of Medicine in New York revealed in a mouse study that stem cells in the brain’s hypothalamus likely control how fast aging occurs in the body.

The number of hypothalamic neural stem cells naturally declines  and this decline accelerates aging.

By replenishing these stem cells or the molecules they produce, it’s possible to slow and even reverse various aspects of aging throughout the body.

Injecting hypothalamic stem cells into the brains of normal old mice and middle-aged mice, whose stem cells had been destroyed, slowed or reversed measures of aging.

The researchers say this is a first step toward slowing the aging process and potentially treated age-related diseases.

We don’t have any idea why we age, or actually, we have lots of ideas; we just don’t know if any of them are correct.

The theories fall into 3 broad categories:  the genetic mutation theories – your genes malfunction and kill you:  the wear and tear theories – the body just wears out:  and the cellular waste accumulation theories – your cells clog up with toxic by-products.

It may be all 3 factors.

Or it may be something else altogether.

No one knows.

The time we spend in retirement has grown substantially, but the amount of work we do to fund it has not.

The average person born before 1945 could expect to enjoy only about 8 years of retirement before being permanently eliminated from the living, but someone born in 1971 can expect more like 20 years of retirement, and someone born in 1998 can on current trends, expect 35 years.

But all are funded in each case by the same average 40 years of work.

We haven’t begun to face up to the long-term costs of all the unwell, unproductive people who just go on and on.

We have a big problem ahead of us both personally and societally.

We don’t let animals suffer, so why humans?
–  Stephen Hawking

2.5% of all deaths in Canada in 2020 were medically assisted.

Canada’s federal MAID legislation, Bill C-14,  (Medical Assistance In Dying), was enacted on June 17, 2016.

There were 9,375 requests for MAID received in 2020.

78.8% of these requests resulted in MAID being provided  –  7,595 cases of MAID reported in Canada, accounting for 2.5% of all deaths in Canada.

By comparison, medically assisted deaths make up 4.1% of all deaths in the Benelux countries: Belgium, the Netherlands and Luxembourg.

Approximately 200 people from other countries travel to Switzerland every year to access physician-assisted suicide, a practice known as “suicide tourism”

The number of cases of MAID during the Pandemic in 2020 represents a growth rate of 34.2% over 2019.

One Toronto doctor said she is seeing a surge in demand for the service  –  and some patients are trying to move up their medically assisted deaths because of the social isolation that Pandemic measures impose.

On Sept. 30, Nova Scotia placed a 30-day hold on referrals to its MAID program because of an increase in demand and the ongoing strain on the health-care system caused by the COVID-19 pandemic.

MAID deaths in Canada are not only increasing, but the rate of increase is growing.

The increase in physician-assisted deaths occurred prior to the passage in March this year of Bill C-7, which could result in even greater expansion of requests for MAID.

 

Bill C-7 eliminated the requirement that a patient’s death be “reasonably foreseeable” in order for lethal drugs to be prescribed.

Bill C-7 was written in response to a Quebec Superior Court decision in September 2019 that found that two people with disabilities who were not terminally ill (one with cerebral palsy, the second with post-polio syndrome) had the legal right to have a doctor end their lives.

Of Canada’s 4,000 suicide deaths per year, 90% involved people living with a mental health problem.

The concern is that Bill C-7 would give people with mental illness a legal impetus to see MAID as a solution to socially inflicted suffering.

Suicide is Man’s way of telling God, “You can’t fire me  –  I quit.”
–  Bill Maher

 

The total number of medically assisted deaths reported in Canada since the enactment of federal legislation in mid-2016 is 21,589.

The average age at time of MAID being provided in 2020 was 75.3 years.

Cancer (69.1%) was the most commonly cited underlying medical condition in the majority of MAID cases during 2020.

This is followed by cardiovascular conditions (13.8%), chronic respiratory conditions (11.3%) and neurological conditions (10.2%).

During 2020, the majority of MAID recipients (82.8%) received palliative care.

In 2020, 43.6% of MAID recipients were reported as requiring disability support services.

68.1% of cases of MAID were administered by a family physician.

In 2020, the primary settings for the administration of MAID in Canada were private residences (47.6%) and hospitals (28.0%).

The most commonly cited intolerable physical or psychological suffering reported by patients was the loss of ability to engage in meaningful activities (84.9%), followed closely by the loss of ability to perform activities of daily living (81.7%).

“My relationship with death remains the same,” Woody Allen said. “I’m strongly against it.”

“I’m not afraid of death  –  I just don’t want to be there when it happens.”

“The idea is to die young as late as possible.”

“I do not fear death.  I had been dead for billions and billions of years before I was born, and had not suffered the slightest inconvenience from it.”
– Mark Twain

It happens to all of us.

I always feel better when my doctor says everything is normal for my age but then I think dying will also be normal for my age at some point.

Every day, around the world, 160,000 people die, 60 million a year.

295,370 in Canada in 2020.

It’s only 0.77 deaths per 100 people.

Less than one person in a hundred dies in a given year.

Compared to other species, we are awfully good at surviving.

Getting old is the surest route to dying.

But interestingly, no one has died of old age since 1951, at least not officially, for in that year, old age was banished as a cause of death from death certificates.