THE PROBLEM OF OLD AGE

Adding Life to Years

Grow old along with me!

The best is yet to be,

The last of life, for which the first was made . . .

--ROBERT BROWNING

By one of the great boons of modern medicine, the U.S. today has more and older old folks than any previous culture in history. In 1900 only 4.1% of the population were 65 or over; now these "senior citizens" account for 8.4%, and by 1980 they will make up 10% to 15% in a nation of about 225 million. But the boon has brought with it some perplexing problems--medical, social, economic. In Ann Arbor last week at the University of Michigan's annual Conference on Aging, the only such regular meeting in the country, 700 experts from the medical and social sciences put their heads (many greying) together to see what could be done in making Browning's vision a reality. The consensus: there must be imaginative and vast new developments on the social and economic fronts to forestall a future crisis of aged in the U.S., and the major attack on the problems of aging must be medical. That is the key to the others.

The Age of Age. The creed of the gerontologists is not John Donne's imaginative challenge--"Death, thou shalt die" --but "Death, thou shalt wait." Advances in control of infectious diseases, public-health measures, daring surgery and painstaking rehabilitation have combined to lengthen the overall U.S. life expectancy (at birth) from 47 years in 1900 to 69 today. Since life expectancy mounts as the hazards of successive age ranges are passed, a U.S. woman of 65 nowadays still has an average of 15 years ahead, and a man has 13. This is the age of age.

But to what purpose are the added years put? Will these millions of aging men and women be allowed to fall victim to a succession of so-called degenerative diseases, finally become vegetables who have to be diapered and tube-fed and, in the phrase of Philadelphia's Dr. Edward L. Bortz, 60, live as "chemical Methuselahs," a burden to themselves and society? If Bortz and like-minded medicos have their way, the profession of medicine must exert itself so that men and women can go through their eighth, ninth or even tenth decades still hale and hearty, until eventually they die from a swift and general collapse of the body's metabolic processes.

So far, according to the most vocal experts at Ann Arbor, medicine is not yet ready to do its full part. Gerontology and geriatrics* have not grown up enough. Said Dr. Edmund Vincent Cowdry, anatomist at St. Louis' Washington University: "The emphasis is going off youth and going on age. Geriatrics is where pediatrics was 40 years ago. It has been the unwanted child. But grandmother must have her specialist, too. It took medicine centuries to discover that the infant is not just a little man, and to set up the specialty of pediatrics. It has taken longer for medicine to learn that the elderly person is not just an old boy."

Said Dr. Bortz: "Three-fourths of our medical work nowadays is with older people. This makes geriatrics the No. 1 specialty whether we like it or not."

But recognition of geriatrics' special place is not coming fast enough to satisfy Gerontologist Cowdry or swashbuckling, iconoclastic Geriatrician Edward J. Stieglitz, 57, of Washington, D.C. Complains Cowdry: "Medicine has shunned geriatrics. It has viewed the elderly patient as a bad pay risk. It has misdiagnosed and maltreated him." He estimates that fully 30% of mental-hospital inmates over 65 have diseases no more "mental" than partial paralysis, heart trouble, untidiness, nutritional problems, or high blood pressure.

Says Dr. Stieglitz: "Health is a lot more than the absence of disease. Pediatrics has been making healthy children healthier. Geriatrics could do the same. The trouble is that doctors think entirely in terms of disease, and are ignoring their opportunities for making aging people healthier." Until it brings health as well as longer life, he adds, medicine will be "saving some persons who don't want to be saved and are worthless to society. We are coming to a stage where keeping these people alive will jeopardize the lives of those fit to survive."

Nobody Went Home. One place where the opportunities for adding health to age are being exploited with signal success is St. Louis. There, Dr. William B. Kountz, 60, a native Missourian, talked Washington University into putting up $300 to start a research program at the old city infirmary. In 1943 it was shifted to St. Louis Chronic Hospital, where about half the 1,600 patients are afflicted with the disorder of old age. Kountz has raised enough funds (including one $2,000,000 bequest) so that the university has never had to add to its original piddling investment.

"In the early days at the center," Dr. Kountz recalls, "the death rate was 15% to 20% a year. Nobody--and I mean nobody--was going home from the hospital. It was the old story: 'terminal care.' Now we have cut the death rate in half. Every month, ten to 15 elderly patients are returned to their homes and to industry, or to healthy retirement."

A still controversial sex-hormone regimen has played the biggest part in achieving this result. Explains Dr. Kountz: "The layman equates these hormones with sex, but equally important is the part they play in nutrition and the ability of the body to use the food it gets. As we grow old, if we don't have a proper hormone balance, the body burns up its own protein. We lose carbohydrates, fat and minerals as well. Even brain tissue is absorbed. We found that old people suffered this loss even if they were eating properly. Then we found out why--they lacked androgens and estrogens. Without a proper androgen-estrogen balance, proteins are spilled over and lost."

One of Dr. Kountz's first patients for hormone treatment was a woman of 78. She was bearded, diabetic and grouchy; she often used her wooden leg as a club when a doctor approached her. She was put on estrogens. After three months, he recalls, "she became one of the sweetest persons in the hospital. She began to menstruate regularly, her beard went away, and she went home."

Even in Dr. Kountz's enthusiastic estimation, hormones do not suffice in themselves. He cites a depressed man in his 70s. "On hormones, he started coming around, but something was still bothering him. We found out that he was an inveterate gambler. I got him a job with a stock and bond company, and it made him a young man again. In four years he made $200,000. Now he's 93 and retired in Florida. He says his biggest regret is that he didn't grow old sooner."

Double Duty Drug. Most geriatricians use sex hormones more sparingly than Dr. Kountz, and some are dead set against them. They doubt that it does any good to get an old woman menstruating again, point to the danger of excessive vaginal bleeding, and the chance that erotic interests may be overstimulated in either sex. Dr. Kountz recognizes these risks--he has had such cases himself, especially in the early days of the treatment--but claims that it is all a matter of control; if the doses are right, so, usually, are the results.

Among the commonest medical problems of the aged are high blood pressure, which goes with hardening of the arterioles (small arteries), and hardening of somewhat bigger arteries, especially those in the brain. Until recently, virtually nothing could be done for these cases. Doctors faced with senile arteriosclerosis shrugged and said "You can't cure old age."

Then came drugs that did the trick in many cases. First were the hexamethonium compounds (TIME, Aug. 4, 1952), which simply lowered blood pressure. About three years ago doctors began to experiment with reserpine. This did double duty for a fair proportion of such patients; it lowered their blood pressure and also--perhaps more important--being a tranquilizer (ataraxic), it reduced their irritability and insomnia. At the Mental Health Institute in Cherokee, Iowa, Dr. Anthony A. Sainz gave reserpine to 89 patients classed simply as senile psychotics. In 62 cases the symptoms disappeared--agitation, apprehension, dependency, depression, quarrelsomeness. Seven cases showed "satisfactory improvement," and in only 20 were the results inadequate. Since then, at Cherokee and elsewhere, elderly patients have regularly been put on reserpine and newer ataraxics; many general practitioners and psychiatrists treating the aged during office hours prescribe these drugs to control the conditions that so often m lead to hospitalization.

No More. Advances in surgery and anesthesiology have made a tremendous difference in the outlook for aged victims of disease and accident in recent years. They used to be dismissed as "poor surgical risks." But no more. The death rate from broken hips, one of their commonest accidental injuries, was appallingly high because of surgical shock, or infection, or other complications during long, bedridden convalescence. Now surgeons can safely undertake the operation to reduce the fracture in victims as old as 90. The surgeons use a metal nail to fix the bones in place; the use of antibiotics prevents infections; and patients are up and about before complications have a chance to develop.

It is in the seemingly simple matter of diet that medicine has made one of its most conspicuous gains for the aged. In the early 1900s the idea got around that old people needed less protein, and they were often advised to go on a vegetarian diet. Then came low-salt diets. "Don't fall for that old vegetarian routine," warns Dr. Cowdry. "It'll kill you. And a low-salt diet is just as bad unless it's prescribed for a specific reason, such as a certain kind of heart disease." A good average diet for later life, according to Kountz:

Calories: 2,500 (more or less, according to weight and a doctor's advice).

Protein: 1 oz. (equivalent to 5 oz. of beef) for each 50 lbs. of body weight.

Fat: 3 oz. (including the fat in meat, shortening, gravies).

Carbohydrates: 6 to 8 oz. in fruit, cereals, vegetables and bread (not in sweets).

Alcohol: in moderation.

On tobacco there is a difference of opinion: Cowdry okays a little; Kountz rules it out entirely.

Time to Retire? What happens to people when they live to old age? Much emphasis has been put on getting them out of "their children's (and grandchildren's) hair. Too many go to state hospitals, where they do not belong. Even in Massachusetts, a state where (as in New Hampshire, New York, Iowa) formidable thought has gone into programs to bring longer and fuller life to the aged, 5% of people over 65 live in old people's homes. The rest are in their own homes or those of kinfolk.

A major problem is that far too few oldsters have ever been prepared, socially or psychologically, for the adjustments that must be made in the later years. Says Dr. Stieglitz: "Adults need lots of preparation for aging. Far too many men refuse to face the fact that they will have to retire. The physician must help such a man reconcile himself to retirement and prepare for it. Suppose you have a patient of 63. You know he has a one-track mind, and in two years he'll face the bugbear of retirement. Do you wait until he's had his nervous breakdown after retirement, or do you start preparing him for it? Classical medicine would wait; constructive medicine would act."

Cowdry puts it this way: "More important than any other single factor is the old person's need for a community of interests. Nature seems to have ordained that those who abdicate from life socially will soon abdicate from life physically."

To avoid these abdications in St. Louis, Cowdry sparked an all-out drive to keep the aged socially active. With a mayor's committee and other groups in support, there are recreation centers, hobby shows, "golden-age clubs," summer camps, and light industries which rely on the willingness of the aged to do painstaking, detailed work.

Besides preparation for long life, there must also be preparation for death. Cowdry urges old folks to be philosophical about it. "It's not a terrible surprise," he says. "Usually you find that when death is ready for you, you're ready for death. And it's a medical fact that death comes less unpleasantly in later years. Pain is so much less acute. Most old people simply drop off to sleep."

Not One Chair. For all the attention that aging and the aged got last week at Ann Arbor, Cowdry, Stieglitz & Co. were disappointed with the conference's final results. They had hoped that the seminar on geriatric medicine would make a flat recommendation that medical schools set up professorships in geriatrics, thus help their branch of medicine to become a distinct and recognized specialty. But the dead hand of custom--plus the legitimate arguments of some experts anxious not to isolate treatment of the aged from general medicine--denied them this prize. Instead, they won a recommendation that medical schools give "more emphasis" to gerontology and geriatrics. Nowhere in the country is there a chair of geriatrics, or any course specifically devoted to geriatrics in any medical-school curriculum.

U.S. specialists in medicine for the aging and aged may well grow old themselves in the struggle to carry out their motto: "To add life to years, not just years to life."

* Gerontology, from Greek geron, old man: study of the aged. Geriatrics, from geras, old age: healing of the aged.

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