You’re Looking Very Well

by Lewis Wolpert

  Other forms of dementia may be caused by the reduced blood flow to the brain which occurs with ageing. Vascular dementia is a result of damage to the brain caused by problems with the arteries feeding the brain or heart. Symptoms begin suddenly, often after a stroke, and may occur in people with high blood pressure or previous strokes or heart attacks. As well as delivering oxygen and nutrients to the brain, the blood flow removes waste products in the fluid surrounding the brain, and these may include tau proteins and amyloid which are linked to Alzheimer’s. Patients with dementia have evidence of reduced blood flow. A dramatic possibility to increase blood flow involves trepanation, making a hole in the skull which could alter the flow of fluids round the brain in a positive manner. It remains to be seen whether such a procedure can treat Alzheimer’s, and whether it is acceptable.

  Creutzfeldt-Jakob disease, which has been called mad cow disease, is another dementia. This is a rare and fatal brain disorder; most patients die within a year, and it usually occurs sporadically in people with no known risk factors. However, a few cases are hereditary or may caused by eating meat that has been infected. Signs and symptoms usually appear around the age of 60 and initially include problems with coordination, personality changes and impaired memory, judgement, thinking and vision. Mental impairment becomes severe as the illness progresses, and it often leads to blindness. Pneumonia and other infections are also common.

  Mental illnesses with some similarities to Alzheimer’s include Down’s syndrome, which is due to an extra chromosome 21 in the sufferer’s cells; patients have only two thirds of normal lifespan. HIV-associated dementia is not age-related, and results from infection with the human immunodeficiency virus, which causes AIDS, and leads to widespread destruction of brain matter which results in impaired memory, apathy, social withdrawal and difficulty concentrating. Often problems with movement also occur.

  Parkinson’s disease is the second most common neurodegenerative disorder usually occurring late in life and affects 120,000 people in the UK. It is due to the death of nerve cells that signal by the neurotransmitter dopamine, which activates cells in our brains that let us move, for reasons that remain unknown. It is characterised by debilitating symptoms of tremor, rigidity, and slowed ability to start and continue movements. Seventy-five per cent of all cases of Parkinson’s disease begin after 60, and incidence increases each decade after that up to about 80 years of age.

  Depression—which is characterised by negative thoughts, low self-esteem, lack of pleasure, and often physical symptoms—affects three times as many older people as dementia. It varies from mild to severe and affects 10–15 per cent of people over 65 living at home in the United Kingdom. However, the most common age for depression is around 45. There are twice as many depressed women as men. More than 2 million older people over the age of 65 in England have symptoms of depression‚ but the majority are not getting any help‚ according to a report by Age Concern. In the USA severe depression is present in 20 per cent of those over 85, and older people are, in fact, more likely to have mild depression than any other age group. This is not because older age is inherently depressing, but because depression is often a side effect of physical illness. It is the commonest and the most reversible mental health problem in old age.

  The reasons for depression in old age may be different to those for younger age groups but usually involve a loss of some sort. Depression in old age can develop as a result of the complicated and hard events in life—the loss of relatives, loneliness, a change of lifestyle because of retirement, or the appearance of illnesses. Depression is the major cause of suicide. Four out of five suicides in older adults are men. Among men over 75, the suicide rate is around 15 per 100,000 and is similar to younger age groups. Depression can be treated with cognitive therapy and antidepressants. These treatments helped with my own severe depression, which occurred when I was 65. One of the causes for my depression was fear of retirement, but the main cause was anxiety about a heart problem.

  Psychoanalysis is not helpful with respect to depression or dementias in old age, and this was even Freud’s view. In 1905, showing a notably dismissive attitude to the old, he wrote: ‘Psychotherapy is not possible near or above the age of 50, the elasticity of the mental processes, on which treatment depends, is as a rule lacking—old people are not educable—and, on the other hand, the mass of material to be dealt with would prolong the duration of the treatment indefinitely.’

  Age alone does not cause sleep problems. Disturbed sleep, waking up tired every day, and other symptoms of insomnia are not a normal part of ageing, but pain and health issues are often obstacles to sleep for old people. A frequent need to go to the bathroom, arthritis, asthma, diabetes, osteoporosis, night time heartburn, menopause, and Alzheimer’s can cause frequent awakenings.

  Are there any mental gains that come with ageing? Wisdom can be one, along with the advantages of accumulated experience. Older adults are better at comprehension of questions, and detection of absurdities. They are able to give attention to quite complex tasks, including events requiring focused attention, and also when a task requires divided attention. But if things become very complex, they may do less well than the young. There is some evidence that discourse skills improve with age, and the elderly are capable of complex narratives. In spite of the declines mentioned earlier, older adults do very well performing their jobs. Knowledge about the job increases with age and is maintained. Many tasks become almost automatic. Computer skills are significantly less than those of the young, but brain scans have shown that using the internet boosts brain activity of the elderly more than reading, and this could help prevent dementia.

  I talked recently with Dr Martin Blanchard, a geriatric psychiatrist, and asked how he got involved in old age psychiatry:

  I became interested in geriatric medicine when I was a student as it involved many disciplines, and I had a very good experience working in old-age psychiatry, the patients were so grateful. One of our problems in medicine is that we do not think enough about the quality of life, we prolong it. The main problem with our patients is not dementia but depression. There is no real treatment for dementia but rather there is management of the patients lives.

  Did many of his patients actually want to die?

  That is in fact quite rare unless they have a severe depression. Even when frail and with problems they want to go on living. Few of our patients actually remain in hospital for more than several weeks. The number of patients we have to deal with has not increased over recent years, but the number of referrals we get from different GPs varies a great deal as they handle their patients in different ways.

  Given the many problems, physical and mental, linked to old age, we need to look at how the old actually live.

  4. Living

  ‘Old age has its pleasures, which, though different, are not less than the pleasures of youth’

  — W. Somerset Maugham

  The Greek poet Anacreon (c. 572–488 BC) wrote one of the earliest poems about old age, and it strikes a cheerful note:

  Oft am I by the women told

  ‘Poor Anacreon! thou growest old;

  Look; how thy hairs are falling all;

  Poor Anacreon, how they fall!’–

  And manage wisely the last stake.

  Whether I grow old or no,

  By the effects I do not know;

  But this I know, without being told,

  ’Tis time to live, if I grow old;

  ’Tis time short pleasures now to take,

  Of little life the best to make.

  A happy old age is what many people spend their lives preparing for, particularly with regard to financial security and good health. But what is our lifestyle? How varied is it and is there much pleasure still to be had as one ages? Can one enjoy old age? This is an important question. There are at present 10 million in the UK over 65 and there will be double that in ten years’ time. There are one million over 85.

  Nobody wants to be old,
but old age doesn’t have to be a time of despair. Joan Bakewell offers a positive view: ‘In their leisure time, the old aren’t just boozing and cruising: the hardier spirits are climbing mountains, visiting the pole, meeting sponsored challenges. I have a friend in his late seventies who has recently taken up tap-dancing.’ I interviewed Joan after she had been asked to become ‘the voice of older people’:

  When I was 70 I wanted to reinvent myself, it was time to start something new. So I managed to start a column in the Guardian called ‘Just Seventy’. It was up to me to have the idea—no one was going to come to me with it. My column was about being 70 and all the things you have to adjust to. For example, for women I wrote about them having to give up high heels, and children, and other changes. Also old women become socially invisible when they have lost their high heels. Sheila Hancock says she always asks for a corner table and then others around her will have been served before anyone has even brought her the menu. My columns were eventually put into a book which is still in print. And then the government in 2008 came to me—Harriet Harman phoned and said parliament was trying to outlaw ageism and would I be the voice of the older people. I only agreed to do it part-time as I wanted to continue to do my own work. I said I would pass on to her everything they tell me. I no longer do it.

  There are important differences between men and women as they get old. Their patterns diverge as men remain fertile, have children, have second wives, have a renewing life. Women know that they are no longer biologically needed and so they are in a psychological sense ready to grow old. I am rather against that. They can start to wear clothes designed for older people, sensible, rather neutral clothes that do not have any style to them, like your mother and grandmother did, but many are becoming more fashion conscious. I colour my hair as that keeps you looking a bit younger.

  A lot of people worry about money, it’s almost biological. They worry if they will have enough and where it is going to come from. The state pension is tiny and many have to live a lifestyle on a tiny amount of money. There is a sense of loss, things are not what they were—your children have flown the nest and your grandchildren have grown up. Living on your own as I do can present problems unless you have an attitude towards it. Many worry about how they will be right at the end of their lives and not being able to look after themselves—that is what I am making a TV programme about. Will they have to sell their house to pay for a carer, which is very expensive? Will they have to go into care? And that spoils their pleasure in being quite comfortable, having time on their hands, going out, playing golf. The absence of a competitive compulsion in life to do and achieve can make one much more relaxed. I do not get bored—too many books to read and films to see.

  One feature of getting old is that your contemporaries die, and I have begun to make friends with younger people. New friendships are a blessing in old age. I am set on continuing to my mid-nineties—will keep working, travel—but I have signed the documents for non-resuscitation should I get very ill and go, for example into a coma. I am for euthanasia and support dignity in dying.

  An important book that gives accounts of a diverse number of individuals’ views of ageing is About Time: Growing Old Disgracefully by Irma Kurtz. She herself wrote: ‘Talking to men and women of my generation, I am struck again and again about how we shed freight from that heavy goods vehicle, memory, as we age and gently drift back to early events that were the making of us. Growing old, as it separates us from the world, returns us to our original selves.’

  Some researchers into the psychology and social aspects of ageing have distinguished between a third and a fourth age. In the third age, retirees from the work force are in relatively good health and are socially engaged, and it is a time of personal achievement and fulfilment—‘You’re looking very well.’ In the fourth age, usually over 85, there is the onset of most of the negative stereotypes of old age—functional breakdown of the psychological system, loss of positive wellbeing, psychological dependence on others, poor memory and impaired reasoning. Physical and mental deterioration are what we fear most, but in fact many over 85 are well and active, and many of today’s pensioners enjoy a financial security unheard of in earlier generations. No association has been found between levels of mental ability when young and reported happiness when old. Quite the opposite has been found with health, as there is a high correlation between intelligence when young and good health when old.

  Very old people rarely, it is said, covet status, rank or wealth. For many there is no longer the the problem of either looking for or having to work. There is much less anger and anxiety as one becomes more experienced, and understands so much more about life. Then there is the pleasure of becoming a grandparent, and the possibility of pursuing new interests Curiously, the old do not partake of the arts as much as those who are younger. Only a quarter of those aged over 75 have been to a museum or gallery in the last year. But equally, a quarter of those over 75 are involved in volunteering at least once a month for community activities.

  Even at age 75-plus, a majority of people do not think of themselves as old, and many think of themselves as quite a few years younger. Perceptions do matter, and many are concerned that as they age they will lose respect and their health will deteriorate. Those who think of themselves as younger than their actual age have better health than those who think of themselves as older. Which comes first, the attitude to age or the better health, will only be settled as more longitudinal data become available.

  ELSA (English Longitudinal Study of Ageing) found that about half the population of people 52 years and over describe ageing as a positive experience, and this contradicts a widely held belief that ageing is a negative process. But while ageing is described as negative by a minority, negative experiences of ageing are far more common amongst the poorest than the richest. Only one in five worry about growing older, but health is a key feature in their lives. The young perceive old age to start at 68, while the old see it as 75. Three fifths of those aged 80 and older were very positive about their health. A majority believe retirement is a time of leisure. The wealthier think it starts later than those not so wealthy. For many of the old ‘ninety’ is the new ‘seventy’ and these nonagenarians can be very active—travelling, learning and being with their family and friends. It is likely that 80-year-olds will in the future live as 60-year-olds live now.

  Among Americans only 12 per cent said retirement would be the best years of their lives and about two thirds said their biggest concern about old age was becoming ill, and were afraid of losing their memory. About a quarter of those over 65 say they are in good or excellent health. Several surveys of the old show ageing is a positive experience for the majority: they do not think of themselves as old and feel younger than they are. Among those who would prefer it if they were younger, the mean desired age of those aged 65 was 42.

  The elderly’s level of religious participation in the US is greater than that of any other age group. For the elderly, the religious community is the largest source of social support outside of the family, and involvement in religious organisations is the most common type of voluntary social activity. Religious faith among older people effectively offers a sense of meaning, control and self-esteem, and helps in coping with the stress of old age. There is also some evidence to show that the religious live longer.

  A Pew Research survey in the US asked about a wide range of potential benefits of old age. Good health, good friends and financial security predict happiness. Seven in ten respondents aged 65 and older said they were enjoying more time with their family; about two thirds enjoyed more time for hobbies, having financial security and not having to work. About six in ten say they get more respect and feel less stress than when they were younger. Daily prayer and meditation both increased with age. Among those aged 75 and older, just 35 per cent said they feel old.

  The attitudes of the old to being old can, of course, vary widely. The interviews with elderly men in Don’t Call Me Grumpy by Francis MacN
ab are revealing, and the advice in Enjoy Old Age by the psychologist B. F. Skinner and M. E. Vaughan is helpful. I find attractive this comment which they record as being given by several of the elderly: ‘Thank God I no longer have to be nice to people.’ There is also a noticeable tendency in some of the old to look back on their lives and try to make it coherent. And of course some say to themselves that life is no longer worth living: it is the same every day, what is the purpose of going on?

  While the old experience declining health and the sense of being mortal, many maintain their wellbeing and are less troubled when exposed to negative emotions. Older adults are better at avoiding negative affect and maintaining positive affect, and they have better memory for positive pictures than negative ones. But for some old age is not good. I interviewed the Nobel Laureate novelist Doris Lessing, who is 91. What does she feel about being old? ‘I feel irritated. I also do not feel as well as I should and I am not outside gardening. I am irritated that my health is not as good as it should be. I started feeing like this about a year ago. There are no good things about being old and I am short of everything. I am irritable and do not really like being irritable. My son is unwell as well. I would not like to go on living for long—it gets me down. I am not writing.’ By contrast, the philosopher Mary Midgley, who is also 91 and who has just written another book, told me that when she gives a lecture she now enjoys the advantage of no longer minding what people think about her ideas.