Aging Healthfully

These days, it's the serious work of medical research. Scientists are imagining a world where people remain strong and healthy for over 100 years; where they enjoy their lives until they die. No more debilitating disease, no more frailty. No more nursing homes.This new turn has come about in part because the old focus has gotten us into something of a fix. Medical treatments have become more effective and available, and some diseases have been eradicated altogether. The result has been longer life-but not necessarily healthier life. A growing percentage of our elder population requires nursing care and neither the nursing home industry nor the federal government can keep up with the demand. Medicare reimbursements have been cut back in a desperate attempt to salvage the system, nursing homes have been closing their doors and displaced residents have been forced to move farther from families to find available facilities. While politicians and social scientists talk of solving the crisis through legislation, another approach is through medical investigation. Aging research is now beginning to shift toward extending not just life, but health as well.Advances in treating or preventing Alzheimer's disease, in particular, could slash the need for nursing care dramatically. "Over the age of 85, the dementia rate is actually 47 percent-one in two people!" says Emeryville-based gerontologist Ken Dychtwald, who has written extensively on the aging of America. He has a new book coming out next month, Age Power: How the 21st Century Will be Ruled by the New Old, in which he discusses the implications of our burgeoning population of old folks. "Now that we're getting better and better at treating cancer and heart disease and stroke, we're keeping Alzheimer's patients alive even longer. Today there are four million seniors with Alzheimer's. The projections are that by the time the baby boomers reach old age-around the year 2030 or '40-there will be 16 million Alzheimer's patients in this country. It creates a huge demand for home care and institutional care."Alzheimer's disease is the most common diagnosis among people in nursing homes. The chances of developing it double for every five years an individual ages-so, at 80, you're twice as likely to have it than you were at 75; at 85, it's twice as likely than it was at 80, and so on. Dychtwald points out that if we found a way to postpone the onset of Alzheimer's by just five years, it would eliminate the future need for millions of nursing home beds.It's a solution that may be just around the corner. "There are a few things out there now that have shown about five-year average changes," says Dr. Dale Bredesen, president and CEO of the Buck Center for Research in Aging. "For example, there have been a number of studies of nonsteroidal anti-inflammatory agents [drugs like ibuprofen], and it appears that when you gather all the data on people who have been chronically on those agents and compare them to people who haven't been on them, they tend to put off their Alzheimer's, on the average, for about five years."The problem with nonsteroidals is that long-term use can lead to nasty side effects, including gastrointestinal hemorrhage and kidney failure. So people who aren't at risk for Alzheimer's would be ill-advised to take them. But, notes Bredesen, "If we could tell which people should take them and, even more importantly, develop ones that give us 20 years instead of five, then we really would have something that would have a major impact on the way we all live."To that end, the researchers at the Buck Center will be working on developing predictive tests, not only for Alzheimer's, but for other neurodegenerative diseases as well. "You could get your blood drawn and someone could tell you if you're headed for any of these diseases and when," says Bredesen. "We'd like to be able to tell people [at age] 25, 30, 35, 40 who's headed for Parkinson's and when, who's headed for Alzheimer's and when, etcetera." And how close are we to having such tests? "In the genetic cases, where it's very clear that it runs in families, the genes are known," says Bredesen. "But for the majority of cases which are typically not genetic or not obviously genetic, we don't have it yet. But that is our major goal and I hope that we'll have something within five years or so. That's a big plus or minus."Of course, predictive tests won't be much use until we know more about prevention. But that development may not be very far off either. A pharmaceutical company recently announced a possible vaccine that seems to prevent Alzheimer's symptoms in mice. "Whether it's going to be applicable to humans is anybody's guess," says Bredesen. "But I think it's an exciting finding and we're all waiting to see the follow-up. I wouldn't rule it out. It's possible that we'll all be getting vaccinated not only against things like smallpox or other infectious diseases but also for Alzheimer's one day."The long-awaited Buck Center, in the planning and construction stages for years, finally opened its research laboratories in Novato last month. In addition to Bredesen, five faculty members are now on board, a sixth is due next March and a seventh will begin work some time after that. One of the center's major areas of research will be in the chemistry of cell death. Bredesen expects that line of investigation will produce answers not only to questions about neurodegenerative diseases, but to other problems of aging, too."The spinoff of this is there will be effects on cancer as well," says Bredesen, since that disease has to do with the unhealthy overproduction of cells. "Where we can inhibit [cell death], we should also be able to enhance it. We already have some data on that side of things." The research could also lead to more information about osteoporosis, the bone-weakening disease that often leads to fractures-another problem that lands many older people, especially women, in nursing homes. "There's a balance between osteoblasts, the bone producers and osteoclasts, the bone taker-uppers," says Bredesen. "As one ages, there tends to be more resorptive activity and less laying down [of bone]. So if one could skew that by influencing the life and death of the -blasts and -clasts, then one could probably also affect that disease. So, as you can see, there is a lot of fallout from the study of cell death, a lot of potential."While research crews like Bredesen's look for ways to prevent the need for institutionalization, geriatric physicians try to keep their patients out of nursing homes one day at a time. In the case of Dr. William Everett, he's on the job 24 hours a day-he's been caring for his wife at home for the last five years. In fact, he's seen her through all three of the age-related diseases Bredesen hopes to someday conquer: 20 years ago she survived a bout of breast cancer; now she suffers from osteoporosis and Alzheimer's disease. (He asked that his name and his wife's be changed for this story.)I met the Everetts on a recent mild and sunny day in San Francisco. He was taking her on a walk around their neighborhood on a wooded hill above the University of California Medical Center. She walked slowly, with tiny, unsteady steps, taking his outstretched hand as he helped her over curbs and bumps in the pavement. "This is a brain-damaged gait you're looking at," he says, "called a frontal lobe gait. She needs to go for walks like this to keep her strength up because she's at high risk for falling and breaking a hip. She's gotten much weaker. She used to be an excellent hiker."Myra has lost all speech over the last few years. She makes soft sounds-breathy grunts, squealing or hissing noises. "It's hard, first from an emotional standpoint, because she was the brains of the outfit," he says. "It's pretty lonesome for me." I wonder, given her speechlessness, how he knows she has Alzheimer's. "It's a good guess," he says. She's had a complete neurological workup, showing shrinkage in her frontal lobe. At 70, Myra's face is virtually unlined, her complexion dewy and her eyes clear and blue. "She's a beauty," her husband agrees when I comment on her youthful appearance. She stands in front of me, gazing into my eyes, and hisses. "I think I'm upsetting her," I say to Dr. Everett. "No, no," he assures me. "She thinks she's communicating with squeaky sounds and grimaces. She likes you." Maybe, but I can understand why many of their friends have drifted away. "We just have a few friends who have hung in there," Everett tells me.The Everetts have visitors on the day I come by, old friends who now live in Canada. "Home services are provided there," the doctor says. "Here, you have to do it on your own. You can go through an agency. In our case, we advertised at the medical center. A lot of young couples need a place to live." In exchange for room and board, a physical therapy student and his wife take care of Myra while Everett is working. He's 71, but still keeps full-time office hours. He has two younger partners sharing his practice, but he doesn't want to retire. "It would be hard for me to give up my practice," he says. He also gardens to keep up his spirits. Lush, colorful blooms crowd the flower beds in front of the house and line the stone steps leading up to the door. Myra climbs haltingly, leaning heavily on the railing that Everett installed for her."With my patients, I encourage them to get live-in help," he says. "If you can have live-in help, you can avoid institutionalization. But a lot of them won't do it. They want to be independent. For many of my patients, the spouse does everything. One of the toughest things is if the affected person is up all night. Nobody gets any sleep. Then it's almost impossible."Everett advises his patients to stay active, to keep them from needing nursing care. When he sees patients becoming enfeebled, he tries to get the families involved. And he urges patients to plan ahead. "They're in a nursing home because they didn't make it clear ahead of time," he says. But aren't there some people for whom there is no other option? "Well, that's right," he says matter-of-factly, "but a lot of people would rather be dead."At The Centre for Activity and Ageing in Ontario, Canada, the objective is to keep older people alive and well. The center does research into the physiology of aging as well as community outreach, to put its research findings into practice. Kinesiologist and community coordinator Lynn Scholey says that exercise goes a long way toward helping people maintain an independent lifestyle. "It increases mobility, gives you more energy and reduces the risk of heart disease, osteoporosis and diabetes," she says.Scholey recommends 30-60 minutes a day of moderate exercise, every day. "It should include each of the three different components: cardiovascular or endurance activities like walking, swimming or biking; strength and balance activities such as climbing stairs, sitting and standing from a chair, or working out with weights; and flexibility activities like stretching, tai chi and yoga."So far, there is no conclusive evidence that physical activity protects against Alzheimer's disease. But Dr. Bruce Reed, associate director of the Alzheimer's Disease Center at UC Davis believes that it might. "I think there really are [lifestyle] factors but we don't understand them very well," he says. "It's only in the last few years that we've been able to identify people according to genetic risk factors. My thinking is that that's made it hard to measure the environmental and lifestyle factors. There have been studies of identical twins. And if genetics were the only story, they would get the disease at the same age-but they don't. There can be a difference of up to a decade, which is a big difference. So something has happened there besides the genetics. We don't know what it is."Meanwhile, the quest continues for a medicinal solution. UC Davis and UCSF are both participating in a nationwide study of two substances already available: Vitamin E and the drug Aricept, which seems to enhance memory for some people. It's the first nationwide study to test possible preventive agents for Alzheimer's disease. Researchers will be looking at subjects who are beginning to show mild symptoms of memory loss, but are still able to function-the assumption is that they're in a pre-Alzheimer's stage. One group will be given high doses of Vitamin E, another group will take Aricept and a third group will be given a placebo. The idea is to see who, after three years, has gone on to develop Alzheimer's and who has not."Aricept is a symptomatic treatment that generally isn't hypothesized to have protective effects on the brain," says Reed. "On the other hand, Vitamin E is not a symptomatic treatment-it doesn't help memory performance-but there is some evidence that it delays the progression of the disease." It seems to work as an antioxidant, gathering up unstable molecules that are thought to damage nerve cells.Aricept is the only medication currently prescribed for Alzheimer's, but it doesn't have a stellar track record. Dr. Everett tried it on his wife for a while. "It made her a little more perky, but otherwise it was a disappointment," he says. (The herbal treatment gingko biloba is often touted as a memory booster, but Everett dismisses it as "worthless.") Staffers at the UC Davis center observe that Aricept may have a mood-enhancing effect. "It certainly does not cure Alzheimer's disease," says nurse practitioner Jean Coleman. "But what did happen for a lot of people is that they seemed to have a little more confidence, a little more interaction with other people, more willingness to participate in things they had withdrawn from."Estrogen is another already available substance that seems to have some protective effects. But again, the evidence is sketchy. "They've looked at women who have been on estrogen postmenopausally and compared them to women who did not take it and there seemed to be a lower incidence of Alzheimer's disease in the group that took estrogen," says Coleman. "And then there was a study looking at giving estrogen to women who were diagnosed with Alzheimer's and in some of the preliminary studies it seemed to produce a moderate increase in memory function. But maybe postmenopausal women who do not have risk factors for cancer might consider taking it." Because of the link between estrogen and breast cancer, it's a devil's choice for many women. And for anyone with a history of breast cancer, like Myra Everett, the risks outweigh the possible benefits.Ken Dychtwald is both optimistic about scientific breakthroughs and frustrated with the slow pace of medical research. "Very little attention in America goes to investing in research that conceivably could wipe out diseases of the aging," he says. "I think that the amount of funding for Alzheimer's research is probably 10 percent of what it needs to be."Dychtwald believes that our life spans will continue to lengthen, but worries that our health spans might not keep pace. "I think the boomers will be living longer than anyone ever dreamed humans could live."Breakthroughs, he says, are "going to come from a variety of different fronts: all the way from biotechnology to nutrition and neutraceuticals to hormone therapies to bionics to organ transplantation. But unless we also simultaneously figure out a way to wipe out these late-life diseases, you're going to have people living longer but suffering longer and that's not what anybody wants."

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