Going, going, gone
- Crossing Frontiers: Gerontology Emerges as a Science by Andrew Achenbaum
Cambridge, 278 pp, £35.00, November 1995, ISBN 0 521 48194 5
Ageing can be avoided, but only at the unacceptable cost of dying young. Otherwise, it is inescapable, and it starts younger than we think. If ageing is defined as the sum of those intrinsic processes in the organism that lead to increased probability of death from natural causes, it begins in our early teens and is continuous thereafter. And it picks up speed not only because the physical processes accelerate but also because experienced time is subject to inflation: the successive issues of the London Review of Books that punctuate our trajectory from maternal perineum to council crematorium will seem to come faster and faster.
The dread of getting old is a universal, if intermittent preoccupation. ‘As I give thought to the matter,’ said Cicero, ‘I find four causes for the apparent misery of old age: first, it withdraws us from active accomplishment; second, it renders the body less powerful; third, it deprives us of almost all forms of enjoyment; fourth, it stands not far from death.’ But this preoccupation has emerged only recently as a major theme for scientific investigation. Gerontology – defined, in Crossing Frontiers, as ‘the study of ageing from the broadest perspective’ – is a neonate among the sciences. Indeed, according to Andrew Achenbaum in his perceptive, beautifully written and superbly organised history of American gerontology, it has not yet fully emerged as a science.
There are many reasons why ageing is attracting so much scientific and quasi-scientific attention. For a start, getting old now seems even less of a good thing than it may have done in the past. Death in secular societies is a terminus, not a gateway; we cannot redeem the impoverishments of its anteroom by thinking of them as preparation for the eternal reward. Wrinkles are harbingers of a slide to nothingness, not marks of a transcendence to come. To grow old, as Simone de Beauvoir said, ‘is to define oneself’ and being defined, even self-defined, is privative as well as positive. The ascent to seniority prunes possibility: the old are what they are and, to a lesser extent, what they have been, though past achievements rarely compensate, often seeming more past than achievement. Even for those whose lives have been successful, the accumulation of experience, connections and possessions may seem an inner obesity rather than an increase of spiritual substance, and the many-paged CV a mere waste product. No wonder we prefer to think of ageing as a problem (with the implication of solubility) rather than as the common and permanent condition of humanity.
A more pertinent reason why old age has attracted scientific attention, and research funding, is that there are more old people about. Two-thirds of mankind’s improvement in longevity has occurred in this century and for the first time in history, most middle-aged citizens in some developed countries have more living grandparents than children. And there has been a sharp rise – set to continue for many decades – in the numbers of the very aged: in the UK, the over-85s have increased more than five-fold since 1950; and the Queen sends out ten times as many congratulatory telegrams to centenarians than she did when she came to the throne. For some (with a frequency unprecedented in history), old age is the time of a first encounter with serious bodily difficulties.
This triumph, which has many causes – the application of technology to physiological needs and physical safety, social welfare policies, public health measures and, more specifically, scientific medicine – has been read by many commentators as a disaster. There is much negative hyperbole about the economic threat of non-productive old people, with their burdensome pensions and, more important, their revenue-consuming illnesses and disabilities. The view that added years have been bought only at the cost of added troubles is at odds, however, with the facts. There is already evidence that the period of disability before death is shrinking despite an increased lifespan; that there is, to use Fries and Crapo’s phrase, a ‘compression of morbidity’.
One consequence of the demographic revolution should therefore be a rethinking of our sense of the course of life – and a recognition that perhaps there is more to old age than loss and infirmity and the indignity of being reclassified as a ‘burden’ or a ‘challenge’. Old age holds out promises as well as threats. Many are living to enjoy what Peter Laslett has termed the Third Age: a period of health, often lasting as long as childhood and adolescence together, free from the anxieties of child-care and the pressures of work. Out of such elders, remote from the stereotypes of decrepitude, may come a new understanding of life: ‘old men ought to be explorers’ – old men and old women, students in the University of the Third Age, now can be.
Ageing is difficult to get into focus because it is not one thing but many and far too big to be the province of a single discipline. Gerontologists have to cross frontiers. As Dewey pointed out, biological processes are at the root of ageing, ‘but they take place in economic, political and cultural contexts.’ Gerontology needs to recognise the many layers of its object: social, biological, physical, even metaphysical. This may be why it is, as Achenbaum puts it, still more of a field – using methodologies borrowed from elsewhere – than an autonomous subspeciality.
The state of being old is in part socially constructed. It is others (or the Collective Other) – with their attitudes, stereotypes and laws – who translate wrinkles into incompetence, unattractiveness and, ultimately, evidence of valuelessness. The privileged status of children is inversely mirrored in the underprivileged status of the old. The pioneering geriatrician Nascher pointed out that ‘the idea of economic worthlessness instils a spirit of irritability if not positive enmity against the helplessness of the aged.’ This spirit is expressed in all sorts of ways; for example, finding the hell of dementia funny and describing its sufferers as ‘ga-ga’. And if elders don’t have the decency to be helpless and useless, they are still in the way. Of course, the rich and powerful can resist socially-constructed ageing: politicians are young at 75, while manual workers are redundancy fodder at 55.
Foolishness in old age is regarded as a particularly virulent form of the condition, perhaps because it will not be grown out of. And the two notions of madness and old age are conflated in the ghastly portmanteau term ‘senile’. Alzheimer’s disease is regarded simply as an extreme version of a state in which what old people say, seen anyway as boring and irrelevant, has become yet more mangled. With a bit of luck, one might be regarded as a ‘sage’, but even that may be invalidating. To be told that one is ‘wise’ is not always reassuring in a secular age when wisdom has no transcendent legitimation, and is usually less needed – and certainly less valued – than technical expertise and common sense. To be wise and old is simply to be old in italics and so doubly out of touch. Emeriti are more likely to be patronised than seriously consulted.
Even so, human beings do not, any more than blackbirds, die primarily of marginalisation. The ground on which age is socially constructed is biological. Age usually and eventually brings with it some physical infirmity. Biological and clinical gerontologists are interested in a variety of questions about the complex decrements of older life. The most important is the relationship between ageing and disease. ‘Age changes and age infirmities,’ Wingate Todd writes, ‘are so interwoven that it is not easy to segregate the former from the latter.’ This is dangerously true. The idle or incompetent doctor, presented with an old lady suffering from aches and pains, or shortness of breath, or difficulty with memory, is tempted to collude with the general perception and say ‘It’s your age, dear’ rather than diagnose osteo-arthritis, cardiac failure or the adverse effects of medication. Incompetent medicine of this kind is seemingly expedient, because it is superficially cheaper to pronounce a problem untreatable, on the basis of an inexpensive glance at the patient’s date of birth, than to investigate and treat it. (I say ‘superficially’, because the cost of early treatment, which may prevent or postpone disability, may be less than the cost of long-term social support, though the latter may be borne by someone else’s budget.) The tendency to regard the diseases that come with age as part of ‘the ageing process’ is understandable given that increasing age is associated with an increasing burden of disease. This confusion, however, occurs less readily in the case of rich patients, who will pay more to have specific diseases diagnosed and treated than to be pronounced untreatably old. It is no coincidence that the oldest person to receive a hip replacement was a member of the Royal Family.
Is there such a thing as physiological ageing as distinct from the pathological processes that occur increasingly with age? If all diseases that occurred commonly in old people could be cured or prevented, would we live for ever? Or would we still die of ageing itself, of time-poisoning? Or is so-called ageing actually the sum of subclinical disease processes that have not advanced far enough to assume the distinctive features of decay categorisable according to the International Classification of Diseases?
This question is more complex than it might initially appear. First, subclinical diseases likely to be mistaken for ageing would need to be multiple to have sufficient cumulative impact and one could argue that the general increase in vulnerability necessary to fall victim to a multiplicity of diseases is precisely what ageing is. Secondly, one might expect low levels of disease to cause visible deterioration or death only in an organism that had been brought near to the threshold by other changes – presumably those of ageing. For such an organism, less disturbance would be required for a pathological process to produce dysfunction and, because of a decline in adaptive and compensatory mechanisms, lesser displacements from the normal range would prove irreversible. Thirdly, a disease is subclinical only so long as it has not been recognised by a clinician, and the failure to cross the threshold of recognisability may be maintained, despite a high level of damage, by an age-related failure of the body to produce characteristic (usually adaptive) responses. If ageing is characterised by such a process of de-differentiation of bodily responses we might postulate a point of convergence between ageing and disease, where disease elicits no specific features, only general decline.
These conceptual difficulties in demarcation are compounded by the empirical ones. At present, there are few symptoms and signs that fully meet the criteria for a ‘true’ ageing process: one that occurs universally and exclusively in old age. Conditions that seem to meet those criteria are often trivial (and scarcely life-threatening), such as wrinkling of the skin, or developmental, such as the menopause, which has only incidental dysfunctional consequences. Some significant and serious pathologies come close to universality – senile deterioration of the retina of the eye, osteo-arthritis, benign enlargement of the prostate – but no one is going to suggest that these can be dismissed as ‘mere’ ageing, with the implication they should not be treated.
The uncertainty surrounding the characteristics of the ageing process (or processes) per se – if it or they exist – in part reflects the methodological problem of defining study populations in order to identify ‘pure’ or ‘physiological’ ageing. To detect the effects of ageing, it is necessary to compare healthy young people with healthy old people. But is a perfectly healthy centenarian a freak of nature? Should we be studying average (actual, normal) or ideal ageing? And centenarians will differ in other respects from today’s 20-year-olds: by their education, nutrition and so on in their first twenty years of life. When we compare the two are we identifying the ageing of the human organism or tracking the social history of the century?
One way of resolving the problems of cross-sectional studies is to follow a cohort of individuals over decades. Researchers and grant-giving bodies are, for obvious reasons, less than keen on this more rigorous approach, though there are some important longitudinal studies. Even with such studies, however, there is still the need to classify changes observed as disease-related or age-related. There is often no sharp demarcation between changes that are typically attributed to age and those that are given a specific diagnostic label: for example, the pathological changes seen in Alzheimer dementia that are also seen in normal brains, the difference being only one of distribution and quantity (this may change when more robust genetic markers are identified).
Biological gerontologists (less worried than their clinical counterparts about politicians and idle colleagues) entertain no doubts about the reality of physiological ageing – of a process of decline distinct from the effects of disease or trauma or privation, intrinsic in, and essential to, organisms. It is reflected in the huge differences in lifespans. Biologists have sought to understand ageing within the gene-centred perspective of recent evolutionary thinking. From the evolutionary point of view, there is little point in an organism surviving beyond its reproductive years: after that, the soma (as opposed to the genetic material) may be disposed of. Old organisms are so much clutter, competing with younger ones for resources. This view – which might support the idea of programmed self-destruction to clear the planet of old organisms – is a touch simplistic. Medawar refined it by suggesting that ageing happened because natural selection does not operate on organisms after the reproductive years. Once they are over all hell can then break out, since post-reproductive designer faults would not be weeded out.
Kirkwood, in his compelling and ingenious Disposable Soma theory, has argued that organisms have finite resources which they have to share out between reproduction (creation of more genetic material) and repair (keeping the soma going to permit reproduction). Too few resources allocated to repair will mean that the organism will fall apart before it reproduces itself; too many, and energy which should be going into making more of the species will be wasted in shoring up an organism that will anyway be doomed to die by accident or predation. Species that are usually gobbled up early by predators will be better advised to invest in early and copious reproduction than in meticulous self-repair. A successful organism will inevitably choose a cut-off point at which no more resources should go into repair. Beyond that point, ageing will result. The failure of repair mechanisms may be quite complex and the result of a variety of strategies used by organisms in the allocation of resources between reproduction and repair. Within this conceptual framework, ageing theories are not therefore necessarily monocausal.
The Disposable Soma theory is attractive, not only because it leads to testable consequences but also because it suggests that ageing is not, as some have thought, the unmodified consequence of the Second Law of Thermodynamics, which points to the improbability and inherent instability of complex structures. We may think of organismal self-repair as marking the difference between ageing as a biological and as a physical process. Theories such as Kirkwood’s raise the possibility of significant postponements of ageing by identifying and restoring failing cellular repair mechanisms. To retard or even reverse ageing, it will not be necessary to buck the Second Law or somehow dialyse time out of people. Treatment will simply be an extension of the emergent molecular medicine approach to diseases. The requisite biotechnology does not seem too remote.
Assuming that there is such a thing as physiological ageing, will death by old age – in the interim between the conquest of pathology and the conquest of ageing – be preferable to death as it is at present? It will plausibly be less unpleasant, not being associated with intrusive symptoms such as pain, nausea, shortness of breath and gross disability. Instead, we may envisage extreme old age and dying as a subtle and progressive reduction in life-space associated with an increased probability of a demise that is more easily achieved – as if the distance to be traversed between life and death had been abbreviated. The image of death by ageing as the end-result of a gradual but harmonious failure of all organs is attractive. It might be more conscious, more metaphysical, than death typically is at present.
Some of us are lucky enough to live on the leeward side of history and fortune; but all of us live on the windward side of time. Whatever the means by which death is postponed and palliated, birth remains a one-way ticket to the grave; medicine, public health, technology, social reform cannot cure individual finitude. Not even the quasi-immortal sea anemone – safe from predators in the ocean depths and therefore strongly committed to self-repair – would survive the heat death of the universe.
This does not mean that all our efforts are in vain, only that the ultimate triumph of medicine will not be the immortality of those who can buy it, but a later and better death. Painless decline will be a less opaque window than physical suffering; for to suffer is to be nailed to the particular, to endure an involuntary narrowing of attention made almost absolute. Our awareness of our inescapable transience will not be blunted but purified, winnowed from the kinds of distraction that dominate decline and death at present.
Is a late death, however, ever late enough? Is there ever a right time to die? According to Paul Valéry’s Monsieur Teste, there is a time to let go with equanimity: ‘The natural or true death would be the total exhaustion of the possibilities of the system of an individual man. All the inner combinations of his capacities, incomplete in themselves, would be exhausted. He has told himself everything he knew.’ The natural death – as opposed to what Valéry calls the ordinary death of ‘a man surprised and slightly shocked, impolitely interrupted by some trifle in an interesting conversation’ – is not yet available on the NHS. And clinicians, even in the private sector, are far from bumping against the limits laid down by the Second Law. But, if any human endeavour seems worthwhile, that of one day ensuring that everyone can enjoy a physiological old age and attain a natural death must rank highest in the Kingdom of Means. Meanwhile, there is little to suggest that the long old age already made possible for many by medical and social advance is a cause for regret.