Old Old Age

The Times published two disquieting articles recently. The first was Jane Brody’s Personal Health column, published last Thursday. She wrote about the dual problem of caring for patients with multiple chronic diseases – conditions that require continuing care - and preventing those diseases in the first place. According to the Department of Health and Human Services, two-thirds of Americans over 65 have at least two chronic diseases as do three-fourths of those over 80.

The prevalence of multiple chronic diseases among the elderly is well known. What was disquieting was the statement by Dr. Mary E. Tinetti, a geriatrician at Yale, whom Brody quotes, that “patients with multiple conditions should always be asked what their goals are: to live as long as possible, to be as functional as possible or to be as free from symptoms as possible? There’s always a trade-off. You can’t have it all.” When the patient suffers from multiple conditions, Dr. Tinetti continued, a treatment that’s effective for one condition might make another condition worse. The patient’s primary care doctor must coordinate the treatments prescribed by various specialists in order to create a program that will best meet the patient’s goal.

Of course I want to live as long as possible but at the same time I want to be as functional and as symptom free as possible. I want it all, in other words, but now I’m told I can’t have it all. I have to choose. Before I had time to consider what choice I would make, I read a review, in Sunday’s Times, of Susan Jacoby’s Never Say Die: the myth and marketing of the new old age. According to the review, it is a jeremiad against the public’s ignorance about the vicissitudes of “old old age” - those 85 and older. “We might not like to think,” writes the reviewer, Ted C. Fishman, “that poverty, social isolation, crippling pain, dementia and loss of autonomy are likely to come calling the longer we live, but it’s a fact.” We are deluded, therefore, if we believe that we're likely to remain physically vigorous and socially active in extreme old age. There are, of course, exceptions to the rule. My spouse’s second cousin lamented, at the age of 100, that she had to choose between swimming and walking when she lunched with friends, since she could no longer do all three on the same day. We would have to be extraordinarily fortunate to be as functional as she was during the whole of a very long life.

“At 85 or 90,” writes Jacoby, “whatever satisfactions still lie ahead – only a fool or someone who has led an extraordinarily unhappy life can imagine that the best years are still to come.” With this in mind, the goal of living as long as possible no longer seems so attractive to me. Of the other two goals, being as symptom free as possible and as functional as possible, I’d choose the latter. “Old age is not for sissies,” said my spouse’s centenarian cousin more than once.