Jul 08 2024

Some Thoughts on Aging

If either of the two presumptive nominees for the major political parties in the US are elected in November they will be the oldest person ever to be inaugerated as president. What implications does this have? As a neurologist who sees patients every workday of various ages, evaluates them, and explicitly investigates the effects of aging on their function, I have some thoughts.

The first thing to realize is that aging affects different people differently. Especially once people get north of 40 you start to see significant and growing divergence in how well people age, in terms of their health and various aspects of functioning. I have seen many patients in their 90s who are completely sharp and fully functional or have just specific issues to deal with, but are overall healthy. I have also seen patients in their 50s who are wrecked and suffering from various aspects of declining health.

This divergence is partly due to the luck of genetics, and partly due to lifestyle. Some people have a chronic illness that dramatically affects their aging. Others may have suffered an injury with long term effects that get more challenging with age. While others have engaged in one or more poor lifestyle choices and have paid a heavy toll. Chronic alcohol use disorder, for example, can be devastating, adding years or decades to one’s apparent age. Smoking also takes its toll.

For these reasons, what we can say about a person based upon just a number is actually quite limited. We can make statistical comments, but that’s all. Even there, we can only describe what is typical, but there are exceptions. There are, for example, so-called “super agers” who do not develop the typical brain changes that most people do with age.

What is average and typical is that as people age they tend to slow down, cognitively and physically. Colloquially the cognitive effects of aging are often referred to as
“senior moments”. What are they, exactly? As we age it is typical for memory access to become more slow. It takes longer to think of a word or a name. However, in healthy aging people will still get there eventually, it just takes longer. On the plus side, as we age we tend to get more thoughtful and complex in our deliberations, so there is actually a trade-off. I heard one researcher describe this as – we develop increasingly more complex algorithms of thought. These take more time, but produce more nuanced and sophisticated outcomes.  We also tend to become more emotionally regulated, less anxious, and have greater life satisfaction.

Also, quite clearly, even the best super-agers, become less resilient.  This is happening on every level, from a cellular level to tissue, organs, and the entire organism. We are less able to deal with stress, and bounce back more slowly. We “pay the price” much more heavily, for a lost night of sleep, any bit of excess, strenuous activity, or even minor ailments like a cold.  We have less biological reserve and our repair mechanisms operate more slowly. This is why one of the most common reasons for ER visits among older women is a urinary tract infection (UTI). When younger a UTI presents likely as some burning urination. When older it can present as delirium. Any physician can also tell you that you have to be more gentle with medications as people get older. They feel the side effects much more extremely.

There is also the frequent challenge of distinguishing healthy aging from pathology. This is an extremely common presentation, for both physical and cognitive complaints. This can be an athlete in their 50s who are losing some ground on performance, or now get significant muscle cramping or some other symptom with extreme activity. It can also be someone in their 60s or 70s who have the typical list of cognitive complaints and are worried it is the beginning of something. That’s my job – to figure out if the presentation is just healthy aging, a functional problem (like getting poor sleep, a medication side effect, or perhaps the effects of anxiety or depression), or if it is symptoms of brain disease. It’s usually not difficult to determine, as by the time someone is sitting in front of me, if they do have organic brain disease, it is detectable.

But still, there are lots of very early or subtle cases, and in any case the patient’s symptoms and concerns have to be addressed. So we typically do a standard workup, especially looking for things that can be treated (like low B12 levels). We then treat whatever we find, go over lifestyle advice, and in some cases treat symptomatically. For those who have signs of organic disease, they go down a different clinical pathway depending on the diagnosis.

How do we apply all of this to the two main presidential candidates? That’s tricky, and it is not my intention to do that here. I will refrain from making armchair diagnoses based upon publicly available video (and so should you). I will say that both candidates have displayed reasons for concern, at least enough to warrant a professional evaluation. That is what I would recommend, and would love to see – a transparent independent full medical, neurological, and cognitive assessment of both (or all) candidates.

I would argue that the American public deserves this information, for all candidates (otherwise it is arguably discriminating based on age).  But I also acknowledge that, especially if not done properly, this can be highly problematic. The results can easily be “weaponized” and taken out of context. There is also a tendency for people to overly rely on numbers, and we wouldn’t want the presidential race to devolve into an IQ pissing contest. A narrative summary by a panel of acknowledged independent experts who were given access to an agreed- upon minimum assessment plus whatever they thought was necessary, and let the chips fall where they may. I doubt this will happen, unless voters insist upon this and get it passed into law. Similarly, I would like to see regulations forcing candidates to fully disclose their financial information.

In any case, this can be a healthy conversation for our society to have in general. We have an aging population. We are dealing with issues of aging in many contexts. It is possible for people to remain functional and productive into extreme old age. We also need to be thoughtful in how we deal with those who are perhaps no longer able to function well enough – when do we take the car keys away? It’s always a difficult conversation. None of us likes to confront the realities of aging. But we have to.

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