Laura Gardner, MD

[[{"type":"media","view_mode":"media_crop","fid":"17809","attributes":{"alt":"","class":"media-image media-image-right","id":"media_crop_8052988414876","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"1120","media_crop_rotate":"0","media_crop_scale_h":"164","media_crop_scale_w":"160","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"float: right;","title":" ","typeof":"foaf:Image"}}]]The predicted pandemic of disability from the increasing number of adults living to advanced age has not materialized. Nonetheless, there remains a negative connotation to growing old. Ageist stereotypes persist, conjuring images of frailty and depression, rather than resilience and optimism. Increased public awareness of Alzheimer disease, while necessary to advance services and science, may also have led to the misapprehension that if one lives long enough, dementia is inevitable. An unfortunate corollary is that vitality in old age is rare and the result of genes, luck, or privilege. Cost containment has become a frequent policy response. In contrast, scientific findings from 30 years of research indicate that healthy aging, rather than senile infirmity, is the new norm.

In 1980, James Fries was among the first to counter the notion that more people living longer meant pervasive dependency. He found that population survival curves were changing so that a greater number of people were dying at a very advanced age-in effect compressing morbidity into the end of life.

 An even greater number of Americans were remaining independent until the last years before death, causing a proportionately greater compression of disability.

The findings were initially controversial, with the character of the sample and the definition of disability brought into question. However, using multiple measures of disability linked to death records from the 1991 to 2009 Medicare Current Beneficiary Survey data, Cutler and colleagues

 found disabled life expectancy had fallen by 0.9 years and disability-free life expectancy had risen by 1.6 years. The effect was observed among men and women, whites and non-whites. Curiously, rates of illness remained relatively constant, raising the questions of how we are to define healthy aging and how to explain it.

Clearly, old age is associated with unavoidable decline in cardiac output, creatinine clearance, muscle mass, reaction time, and cognitive speed. However, decline that is not the result of illness, injury, or disuse is not substantially disabling and, in some instances, can be mitigated by mental and physical exercise and social activity. How is this preservation of function despite illness and decline accomplished? The answer lies in the realization that aging is not only a biomedical fact but also a psychosocial construct.

At age 75, Henry Tchaikovsky, the concert pianist, still performs worldwide. Audiences love him and are amazed at the emotive, nuanced quality of his performances. When asked how he does it, he tells us that as he gets older, his strategy for performing evolves. He practices daily to sustain the endurance needed for a concert, but he no longer plays some of his favorites from the repertoire because they are too physically demanding. However, he knows his audiences well and plays their favorites instead. Slow pieces always precede those that require a more rapid meter. The results give the impression of undiminished artistry, but the effect is achieved by selection of repertoire and compensation for age-related changes in reaction time and speed of coordination. This approach allows him to remain a popular success despite his advancing age.

 argued that successful aging compared with usual aging is not merely freedom from disease but rather a combination of lack of chronic disease, maintenance of physical and cognitive function, and engagement in social and productive activities. In terms of the sociology of aging, old age is associated with a shrinking social network as friends and family move away or die. Yet most older adults respond by investing greater energy in the members of the network that remain. As a result, few older adults, even those who live alone, describe themselves as lonely.

It is satisfaction with one’s social supports, not frequency of contact or network size that predict freedom from depression. And with the increasing number of active older adults making new friends, new partners in old age are more common than ever. Despite changes in the sexual response cycle, older adults with partners are intimate into very late life. Senior Americans are also better educated and more financially secure than previous generations. Better education is associated not only with economic security but also with enhanced cognitive reserves, which are thought to forestall the emergence of dementia.

What new information does this article provide?

The predicted “Senior Tsunami” of disabled elders has been replaced by data from decades of studies showing both a reduction in the number of disabled years older adults are likely to encounter and an extension of the active, disability-free life span they can expect.

What are the implications for psychiatric practice?

Psychiatrists will encounter an increasing number of older Americans seeking to make the most of their remaining years. This will shift the traditional practitioner’s bias from minimizing the risk of an intervention to maximizing potential benefits. Or stated differently, start low, go slow, but treat to target.

A similar process occurs with the psychology of aging. As a result of either experience or stage of life perspective, older persons are more emotionally resilient and less prone to crippling reactions when stressed. Psychological resilience has been defined as successful adaptation to adversity, “bouncing back” after trauma or loss. It encompasses personal competences across cognitive, emotional, and social domains, including optimism, effective coping, interpersonal skills, and self-efficacy.

Resilience is a dynamic characteristic that may shift according to circumstances across the life span. It is the opposite of vulnerability.

 Older adults seem to be more resilient than younger adults, especially with respect to emotional regulation and problem solving. In the aftermath of the 9/11 tragedy, the incidence of PTSD was lower in older New Yorkers, which suggests that they possessed greater resilience than their younger counterparts.

As one factor that may underpin resilience, the theory of socioemotional selectivity challenged earlier theories that presumed the emotional state would follow the same downward trajectory as biological age.

 This life-span theory of motivation posits that as time horizons shrink with age, people become increasingly selective, investing greater resources in emotionally meaningful goals/activities that then influence cognitive processing. This shift in investment of attentional resources results in relative preference for positive over negative information, dubbed the “positivity effect.”

As people age, regulating emotion becomes more important than other goals that may have taken precedence earlier in life. Life satisfaction and affective well-being appear to stabilize or even increase during aging, likely as a result of this increased emotional stability and its effect on resilience. Consequently, older adults tend to recognize their limitations and become more selective in their pursuits, compensating for weaknesses and optimizing strengths.

Neuropsychological alterations also take place throughout aging, described by the Scaffolding Theory of Aging and Cognition, in which cognitive processes are protected by both structural and functional brain changes.

 Processes such as language that are highly lateralized in youth become redistributed bilaterally. Frontal cerebral areas take on more of the workload. These compensatory changes serve to preserve function by rerouting cognitive processes as overloaded neural circuits begin to fray. This process is aided by neurogenesis, the migration of neural stem cells into the hippocampus to become functional neurons effectively re-scaffolding the hippocampus as older neurons age and die.

Long-term, consolidated memory, both semantic and procedural, is distributed across the cortex, but it is in the hippocampus where learning occurs and new information is prepared for consolidation. The cortex has massive storage capacity, while the hippocampus, because it is responsible for processing, has limited volume. It can be overloaded by excessive demands, such as multitasking. And, it can malfunction if neurogenesis is degraded by depression or Alzheimer disease. Antidepressants restore hippocampal neurogenesis when it is reduced by a depressive disorder. Physical exercise promotes neurogenesis through the enhanced expression of brain-derived neurotrophic factor.

Older adults can make up for loss of cognitive speed by improved pattern recognition based on education or experience. Recent studies indicate that computer-based exercises can repair age-related decrements in reaction time and response accuracy. Challenging intellectual activities also help sustain the quality of cognitive processes in late life. This is evidenced by veteran taxi drivers in London, where the streets are notoriously disarrayed. These taxi drivers have larger than expected hippocampal volumes. If the brain is like a computer in which education and adaptation can upgrade the software and rerouting the scaffold of neural circuits maintains the hardware, then the brain is also like a muscle that needs exercise to maintain good condition.

Keeping in mind that the psychosocial constructs are as important as the biomedical sets the stage for suggestions about how to achieve healthy aging. To achieve a healthy old age, one needs to start young, but middle age and beyond is not too late. Keep a heart-healthy lifestyle with ideal body weight maintained by diet and daily exercise. Stay socially engaged for the positive reinforcement of satisfying relationships. Remain intellectually stimulated by finding an activity that is both fun and challenging. Activities shared with a group or partner may be more easily sustained than those that are solitary.

Two self-help publications provide guidance without touting financial interests or products. Reaching beyond what it means to stay physically and emotionally well, 

 covers the range of topics from economic security to sexual health to altruism.

The SharpBrains Guide to Brain Fitness: How to Optimize Brain Health and Performance at Any Age

 reviews expert opinion as well as scientific evidence that suggests mental exercise is as important for the brain as physical exercise is for the heart.

 Both books indicate that the training regimen must be individualized and that the social dimension cannot be overlooked. The 

Healthy Brain Initiative: The Public Health Road Map for State and National Partnerships, 2013-2018

 is a joint effort by the Alzheimer’s Association and the Centers for Disease Control and Prevention.

 It advances the healthy aging agenda beyond personal responsibility to encompass health policy.

 is timely because there is no guarantee that the compression of disability that followed the advent of Medicare and Medicaid will continue. We need policy that promotes a safe, age-friendly environment and offers easily accessible opportunities for exercise and social interaction for both children and adults. The intergroup contact theory applied intergenerationally suggests that if the young and old have the opportunity to more freely communicate, they will gain a new appreciation and understanding of each other’s way of life.

 The living history and wisdom that older adults possess coupled with the mastery of information technology by younger persons could be a formidable combination to advance healthy behavior.

Preparing younger persons for a healthy old age is then an obvious priority to forestall the onset of both illness and disability. First, public policy should support interventions to promote educational attainment and physical activity and to prevent smoking, obesity, and diabetes. Also imperative are interventions to reduce accidental deaths and injuries as a result of lapses in vehicular, firearm, and athletic safety. Second, interventions to stop smoking; lose weight; and control blood pressure, diabetes, and hypercholesterolemia are needed. Third, we should have interventions to reverse what would otherwise be progressive disability and premature mortality. These include joint replacements, heart valve repairs, pacemakers, and implantable defibrillators. Fourth, long-term–care management to preserve the health of family caregivers of persons with dementia and other persistent, disabling illnesses is essential. Finally, because mental disorders undermine both preventive and restorative interventions, collaborative models of mental health care are integral to healthy aging policies.

The healthy aging phenomenon is genuine, and the science explaining it is well established. However, further compression of disability will likely require public demand for broader health policies that incorporate biomedical and psychosocial approaches. This will require the abandonment of ageist perspectives that see old age as both undesirable and unaffordable.

Why “Subjective Cognitive Decline” Is Important


We have the target protein for Alzheimer disease, the antibody to knock out the protein, and the imaging test to locate the protein in the brain, but there still remains one problem . . . who should receive the antibody?


http://www.psychiatrictimes.com/geriatric-psychiatry/why-subjective-cognitive-decline-is-important


Elder abuse is a concern for all practitioners who care for elderly patients. Here, a quick reference Tipsheet to assist clinicians in identifying suspected abuse.


http://www.psychiatrictimes.com/geriatric-psychiatry/identifying-suspected-elder-abuse

Dr Kennedy is Professor and Director, division of geriatric psychiatry, and Dr Gardner is a Psychiatric Resident, both in the department of psychiatry and behavioral sciences, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY. The authors report no conflicts of interest concerning the subject matter of this article.

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Cutler DM, Ghosh K, Landrum MB. Evidence for significant compression of morbidity in the elderly U.S. population. August 2013. http://www.nber.org/papers/w19268. Accessed September 6, 2013.

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Windle G, Markland DA, Woods RT. Examination of a theoretical model of psychological resilience in older age. 

Bonanno GA, Galea S, Bucciarelli A, Vlahov D. Psychological resilience after disaster: New York City in the aftermath of the September 11th terrorist attack. 

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 De Raedt R, Koster EH, Ryckewaert R. Aging and attentional bias for death related and general threat-related information: less avoidance in older as compared with middle-aged adults. 

Reuter-Lorenz PA, Park DC. Human neuroscience and the aging mind: a new look at old problems. 

. New Haven, CT: Yale University Press; 2013.

The SharpBrains Guide to Brain Fitness: How to Optimize Brain Health and Performance at Any Age.

 2013. http://sharpbrains.com. Accessed September 6, 2013.

 Alzheimer’s Association, Centers for Disease Control and Prevention. 

The Healthy Brain Initiative: The Public Health Road Map for State and National Partnerships, 2013-2018

. 2013. http://www.alz.org/publichealth/downloads/2013-roadmap.pdf. Accessed September 11, 2013.

 Pettigrew TF. Intergroup contact theory. 

Articles

Clearly, old age is associated with unavoidable decline but in some instances can be mitigated by mental and physical exercise and social activity. How is the preservation of function despite illness and decline accomplished? Insights here. . . 

Laura Gardner, MD

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