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continuing production of the open mind
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has been made possible by grants from
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the Rosalind P Walter Foundation the
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blue Stein Family Foundation the Joan
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Ganz Cooney and Peter G Peterson fund
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Carnegie Corporation of New York the
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mall can fund the may and Samuel Rudin
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Family Foundation the Joanna and Kenneth
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wailmer Foundation the Alfred P sloan
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Foundation and from the corporate
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community mutual of America
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I'm Richard Heffner your host on the
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open mind
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and there are several compelling reasons
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why would focus our attention today
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on a book I first read a dozen and more
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years ago first because my friend Jane
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Brody wrote right at its publication in
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1998 that quote once in a great while
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and outstanding health book comes along
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that should be featured on every radio
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and television talk show and in every
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major newspaper and that successful
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aging by dr. John W row and dr. Rob
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Adele Cohn is just such a book second
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because only a few months ago when asked
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what do you plan to read next in the
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sunday New York Times book reviews new
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by-the-book interview column with recent
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authors former Secretary of State
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Madeleine Albright also chose successful
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aging third quite honestly because at 87
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I really need to find out much more
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about aging successfully and of course
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because my author guest medical doctor
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John Rowe of Columbia's Mailman School
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of Public Health who led Harvard's
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program and academic geriatrics was
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successfully president and CEO of Mount
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Sinai Hospital and Medical School in New
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York and a vet nur the healthcare
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organization and has long chaired the
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MacArthur Foundation's Network on an
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aging society is so expert in the field
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and my good doctor friend I want to ask
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you successful aging the book has aged
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so well what would you change about it
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the book has aged well dick and that's
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very exciting for the group of
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scientists to work together to do this
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research and bring it to the public's
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attention but there are two chapters of
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that book which are wrong and whoever
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says I am too if I were rewriting or
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republishing the book they would
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two things that I would change I think
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the bulk of our work has been supported
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by additional research and it's proven
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the test of time but there's a chapter
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on menopausal hormone replacement
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therapy that was written before the
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famous women's health study and it's
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quite clear now that a combination of
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estrogen and progesterone based on that
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research and follow-up from the Women's
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Health Study while it reduces the risk
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of getting a bone fracture it increases
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the risk of having a stroke or having
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invasive breast cancer or gall stones or
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blood clots and the legs and maybe even
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dementia and so I would change that
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chapter the second chapter that has to
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be changed is one on vitamin supplements
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research over the last several years has
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fairly conclusively shown that there is
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little if any benefit to vitamin
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supplements particularly high doses of
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vitamin supplements most of us get what
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we need from our normal diet and unless
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you have an unusual diet or medical
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problem one way or another you really
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don't need to waste your money on these
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well Jack you wouldn't you would so
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frankly indicated to me excuse me when I
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said I'd like to do a program about the
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book that these are two caveats that you
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had what occurred to me then and what
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still occurs to me is to what extent you
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feel what we're learning today what
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we're told today by you Doc's
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not just about aging but about so many
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areas of Medicine we have to assume a
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decade from now a dozen years from now
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they're going to change their minds they
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are we really only have excellent
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scientific evidence to answer about 15%
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of the questions that we are asked but
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we have to answer all the questions
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so that when a patient says do you think
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I should take multivitamins in 1998 the
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hard factual research was not yet there
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and the lack of evidence most physicians
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said well we don't think it can hurt you
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you might as well take it there's some
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evidence that people take it seem to do
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better than people donut setter etcetera
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medicine is the application of the
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scientific method to the improvement of
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the health status of individuals and
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what we are doing is accruing scientific
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information over time and sometimes that
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means that what seemed right before is
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wrong now and as long as the advice is
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given in good faith and we make it clear
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to patients what we really know for sure
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and what we think is right and I think
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it's fine okay let's let's turn to the
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rest of successful aging at my age I
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want to know what you mean what do you
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mean by successful aging you're a poster
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child for a success oh come on my wife
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wouldn't say that well our definition of
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successful aging deviated from the
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research prior to the MacArthur
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Foundation is funding our work
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previously most research on aging was
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about avoiding hip fracture or nursing
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home admission or so on we saw more
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broadly we think a avoiding disease and
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disability is important but in addition
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you have to maintain your physical and
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cognitive function and very importantly
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there's a third piece and that is you
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have to maintain engagement what are you
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my engagement a productive interaction
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with society with the community with a
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social network social networks are so
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important Leyton live deck that I would
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tell medical students when I was
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instructing them that if there's an old
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man and
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the next room that you're gonna see as a
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patient and you want to know how he's
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gonna do in the next six months and you
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have one question
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you're better off asking him how many
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interactions he has per week with
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friends and neighbors than asking him if
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he smokes cigarettes that's it keeping
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up with the world very very important
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but you have to have all three three
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avoid disease and disability and that
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means don't smoke and so on you know and
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pay attention to your health and get
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your blood pressure treated as if it's
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elevated and so on
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secondly physical and cognitive function
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exercise is terrifically important and
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thirdly engagement and what we did was a
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series of studies to see what the
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predictors were of who aged successfully
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according to our definition and who
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didn't we found some really interesting
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things I'm a biomedical scientist so I
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was collecting blood samples and 24-hour
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urine collections and I thought the
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answer was going to be some hormone but
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the social scientists and the
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psychologists were right the most
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important factor the best predictor in a
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group of 70 year olds who was going to
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do well X years from that was self
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esteem that's an interesting one what is
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your definition of self esteem do you
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feel that you can influence what's going
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to happen in your life interesting
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question whether you're absolutely but
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if you feel like you're just a cork
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floating on the waves being buffered in
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one way or another by the wind and the
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sea and that you really can't influence
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what's going to happen you have low
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self-esteem by that definition but if
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you feel that you can take charge and
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set a course then you have higher self
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esteem that turned out to be a very
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important predictor another interesting
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thing was support it turns out that
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support comes in two flavors there's
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instrumental support an emotional
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support instrumental support is somebody
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saying to you dad you've done everything
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for me all my life now it's time for you
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to relax I'll do the dishes I'll do the
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cooking I'll do the shopping I'll do the
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cleaning I'll get this for you I'll get
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that for you you just sit there
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that's instrumental support that's
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actually harmful then there's emotional
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support you can do it that got you got
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you and what do you find we Americans
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are indulging ourselves in most which of
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those supports well I think over the
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last 10 or 15 years has been a much
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greater focus on engagement on a civic
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engagement particularly on volunteerism
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employers are developing more flexible
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work schedules for older workers to
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permit them to continue in a work force
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even on a part-time basis which is
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important form of engagement it's not
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just volunteering working for pay is
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engagement so I feel very good about
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that and I think that the image the
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image that we have of older people has
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changed I would tell my students about
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this famous picture of an elderly woman
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whistlers mother
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pale gray-haired dark clothes Whitecap
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looking forlorn li out of window and I
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show them that and I say how old is that
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woman they say 88 90 92 67
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that's what 67 used to look like that's
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not what 67 looks like today you said
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before that you would tell young doctors
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doctors in training if you want to know
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about that elderly gentleman in the next
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room
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ask about his involvement how well did
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you teach I don't really mean how well
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did you teach but how well have we
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taught the medical profession to
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approach seniors in the most productive
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possible way in 1980 when I established
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the division on Aging at Harvard Medical
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School it was one of the first such
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programs in the country there's also one
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at Mount Sinai which was the first
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formal department of geriatric medicine
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in the country now it's very very common
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it's an important part of the curriculum
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in many medical schools and for training
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in internal medicine they take a
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board-certified examined internal
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medicine a significant portion of the
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questions are about old people and about
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the problems of advanced age so we are
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making progress with respect to that and
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the other thing is that we are treating
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older people much more aggressively than
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we used to before people would say you
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well people would say I'm not gonna
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dialyze anybody over 65 I'm not gonna do
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cardiac surgery you know on patients who
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are over 75 but now it's very common and
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in fact the the risk of cardiac surgery
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at age 70 is probably less than 2/3
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percent because the technology has
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improved so dramatically yeah but that
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of course raises for me the question of
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whether that doesn't mean that your
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profession isn't focused overly much on
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simply trying to continue life come on
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may extend life talk to me about that
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well it's not a bad life span it's about
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a health span is it it's about the
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quality of life and I think physicians
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take that into account when they make
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decisions and when they died families
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and patients and nobody's doing heart
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surgery aren't severely demented
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individual it just doesn't happen and so
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it's really about the quality of life
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but you have to understand
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that you know a 65 year old man in this
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country has an average life expectancy
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you know on average 65 year old men of
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life expectancy of another 18 years or
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so and if you have a condition which is
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disabling it could be corrected by some
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intervention and the person is
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functioning well then there's really no
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reason in fact it's less expensive to do
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the procedure than to pay for all the
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treatments that might be needed how long
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will this go on how long do you want it
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to go on how far into an individual's
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future the idea is the one harsh a of
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Oliver Wendell Holmes right so you
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function at a high level until you get
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to a point then it all ends abruptly
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what I'm looking for is the compression
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of morbidity that we have a curve which
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is a survival curve then we have a
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health curve under it and I want to
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press that health curve right up against
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that survival curve I want to squeeze
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out the period of disablement and I want
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to enhance the period of active life
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expectancy you want those two to come
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together right yes what about pushing
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the top one down that mean well that
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might happen that may happen there's
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some very sophisticated folks wrote an
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article in the New England Journal a
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couple years ago well life expectancy
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decrease in the 21st century
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looking at the obesity epidemic
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particularly in youth and young adults
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looking at the emergence of untreatable
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infectious diseases and pandemics
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certainly that could happen what do you
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think about that particularly in Arizona
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it scares me you think that it's
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possible that I I think it's possible
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but I still think it's possible for us
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to increase active life expectancy by
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focusing on the tenets of successful
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aging these three pieces I also
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recognize that the best predictor of
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disability physical disability is
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education what do you mean the more
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years of education you have the less
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likely you are to be disabled at age 65
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if you have a college degree your 1/3 is
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likely to be disabled as if you didn't
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graduate from high school
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okay spell that out why well some people
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think there are a direct effects of
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education but you don't mean that do you
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yes I mean if people are educated less
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likely to smoke you know they're more
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likely to have a better salary that
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gives them access to health insurance
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and health care and so on there are a
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variety of ways that you could see that
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it would maybe it's just a proxy for
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socioeconomic status but it's really
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important and and so I think we
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understand some of the drivers that will
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prolong active life expectancy even more
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than we've seen so far and we understand
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also that it's and this is I think
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important it's not all genetics because
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when you talk like I'm talking with you
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now about the changing things people say
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well no no man in my family has lived
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past 52 hours you know as if there's
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some internal clock but our research has
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shown that that's not the case that if
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you look at the factors that predict
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successful aging only about a third of
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it is heritable the rest of it is
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related to lifestyle and exposures and
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education and that's a very positive
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finding because what that tells me is
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that I'm responsible for my own old age
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that there's not some computer program
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in me that's going to drive me to some
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premature death and that's that's a very
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enabling and power and finding and it's
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a strong scientifically based finding I
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thought when you talked about education
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that you might say the more years of
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education and the better education
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the more you are able to be that active
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person you talked about when we began
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our discussion the more able you are to
00:19:01
go off into different areas to study
00:19:04
more to learn more to do more I think
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that's true I think with respect to
00:19:09
cognitive function I'm I'm certain that
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more educated people read more or have
00:19:16
more intellectual interests and do more
00:19:19
crossword puzzles or listen to more
00:19:20
music or whatever and therefore keep
00:19:23
going and you know it's kind of
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use-it-or-lose-it type of thing it's an
00:19:28
education is really important and and so
00:19:30
when so the answer to in many ways a
00:19:33
successful old life is for society to
00:19:36
focus on the earlier part of life and
00:19:39
make sure that we give young people
00:19:41
opportunity to get education
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what's the lifespan now of a man born
00:19:47
let's say we're doing this in 2012 we're
00:19:52
doing this I would say it depends on how
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much education you get but if you're an
00:20:00
educated white woman you know you're up
00:20:04
around 83 84 years now but you've got to
00:20:08
be white and a woman well if you're an
00:20:10
uneducated white woman you're several
00:20:15
years less education is more important
00:20:20
in race it's really not about race it's
00:20:22
about social class social economic all
00:20:25
that goes with it yes and for men it's
00:20:29
still a couple years less than this for
00:20:32
women but men are catching up they've
00:20:35
narrowed they used to be twenty years
00:20:37
ago there was a seven and a half year
00:20:40
difference between women and men's life
00:20:42
expectancy that's sort of cut in half
00:20:44
now so that so there's a convergence and
00:20:48
actually the reason for that is that
00:20:50
men's life expectancy has continued to
00:20:52
increase and for about 15 years women's
00:20:55
life expectancy went sideways in this
00:20:58
country which is known as the smoking
00:21:01
effect
00:21:02
when smoking became much more common in
00:21:06
women it was quite unusual mm-hmm and
00:21:08
then it became much more common and that
00:21:10
had an adverse effect on survival but
00:21:12
now both curves are going up again what
00:21:16
do you I remember asking Lou Thomas yes
00:21:19
what he thought is there a natural into
00:21:23
it all and he said well I'm not gonna
00:21:26
answer your question but I'll say 125
00:21:29
yeah
00:21:30
well Lou Thomas was a very smart man and
00:21:33
I would support that I think first of
00:21:36
all that we have to understand that
00:21:38
every species has a given life
00:21:40
expectancy mm-hmm I mean there are no
00:21:43
dogs who live to be a hundred years old
00:21:45
okay I mean it's just you know and there
00:21:47
are no mayflies that live more than a
00:21:49
couple of hours maybe or a day and that
00:21:51
and you know and giraffes and elephants
00:21:54
and unicorns every species has an
00:21:56
established life expectancy the question
00:21:59
is when we see this increase in life
00:22:03
expectancy in the unit and the Moomins
00:22:06
is that just removing premature death
00:22:11
that was due to disease and unfit living
00:22:15
conditions and poor nutrition you know
00:22:17
and are we approaching the limit so some
00:22:21
difference between how long people are
00:22:22
living their life expectancy and what is
00:22:25
the human lifespan the oldest documented
00:22:30
person was about 122 women in France
00:22:34
that seems to me to be a reasonable
00:22:38
limit based on the studies I've seen
00:22:40
maybe it's 125 I don't think it's 150
00:22:44
and I don't advocate the anti-aging
00:22:50
notions and potions and creams and
00:22:53
lotions that come at a very very common
00:22:56
a friend of mine jail shamsky says that
00:22:59
longevity salesmen have been around a
00:23:04
long time
00:23:04
perhaps it's the second oldest
00:23:07
profession
00:23:11
Barnum & Bailey PT Barnum who knew about
00:23:15
that but you didn't answer the question
00:23:18
except you were saying maybe about a
00:23:20
hundred and twenty on 21 yeah 125 you
00:23:23
know I you get a lot of arguments from a
00:23:25
lot of people about this let's see my
00:23:29
focus is on what's the active life
00:23:31
expectancy not what's the ultimate human
00:23:35
lifespan and and it's quite possible now
00:23:38
we have shown in in animal studies and
00:23:42
in cell studies and in yeast and in
00:23:44
worms that we can increase lifespan in
00:23:47
those animals by genetic engineering so
00:23:50
it's not completely out of the question
00:23:54
that we could increase lifespan but we
00:23:59
have so many issues about improving
00:24:02
healthy life expectancy that that's
00:24:05
where I think we should focus at this
00:24:07
point and successful living you maintain
00:24:12
your definition it hasn't changed since
00:24:15
you were beginning or Jerry I know we've
00:24:18
been very pleased you know we put this
00:24:21
concept together we tested it
00:24:24
scientifically it was watertight
00:24:27
since that time many Centers of
00:24:30
successful aging have been established
00:24:31
at US universities the federal
00:24:33
government has grant programs on success
00:24:36
so aging most of these focus on the
00:24:38
definition that we use or of course
00:24:40
modifications of it but it seems like
00:24:42
it's held two tests a time jack or other
00:24:45
people's and we just have a couple of
00:24:46
minutes left are other people's around
00:24:48
the world is interested as we are as you
00:24:52
and your colleagues are in this question
00:24:55
of successful aid in many ways we're
00:24:57
behind them so oh they were geriatric
00:25:00
medicine was a specialty and in the
00:25:03
United Kingdom long before the first
00:25:06
program was started here in the United
00:25:08
States how come well maybe we're a
00:25:10
little more too focused on high-tech
00:25:13
rather than high touch on cure rather
00:25:17
than care we've had to learn that lesson
00:25:20
in American medicine are we changing now
00:25:22
yes
00:25:23
I think so and all the medical schools
00:25:26
in your estimation keeping up with that
00:25:29
I think so definitely
00:25:31
no question about it and we see
00:25:36
significant numbers of medical schools
00:25:38
being developed that our their mission
00:25:40
is to establish primary care providers
00:25:42
rather than just you know high tech
00:25:46
specialists and you feel the primary
00:25:48
care providers are well on a brief well
00:25:50
enough educated now whether we instill a
00:25:53
dream that's right we can't rely on
00:25:55
geriatricians we're just not going to
00:25:57
train enough examine it's not enough
00:25:59
interest in the US and being a
00:26:00
geriatrician one of the reasons is
00:26:02
finances you do a special training in
00:26:04
geriatrics your income goes down because
00:26:07
all your patients are Medicare as
00:26:09
opposed to some of them having private
00:26:11
insurance so there's no financial
00:26:12
incentive but we are at the point where
00:26:15
we should be able to train all
00:26:17
healthcare providers in the u.s.
00:26:20
physicians and nurses and others to be
00:26:23
competent in the diagnosis and the
00:26:26
management of the common problems of old
00:26:28
age that's what the practice of primary
00:26:30
care is going to be in the future it's
00:26:32
going to be the common problems of old
00:26:34
age well as a man who's accustomed to
00:26:37
the common problems of old age which you
00:26:39
kids don't know about really yet want to
00:26:42
thank you dr. John Rowe for joining me
00:26:44
today on the open mind
00:26:45
Thank You dick and thanks to you in the
00:26:48
audience I hope you join us again next
00:26:50
time meanwhile as another old friend
00:26:53
used to say good night and good luck
00:26:56
and do visit the open mind website at
00:26:59
thirteen.org/openmind to reprise this
00:27:04
program online right now
00:27:06
or to draw up on our archive of 1500 or
00:27:10
so other open mind and related programs
00:27:13
that's thirteen dot org slash open mind
00:27:51
continuing production of the open mind
00:27:53
has been made possible by grants from
00:27:56
the Rosalind P Walter Foundation the
00:27:59
blue Stein Family Foundation the Joan
00:28:03
Ganz Cooney and Peter G Peterson fund
00:28:06
Carnegie Corporation of New York the
00:28:10
mall can fund the may and Samuel Rudin
00:28:13
Family Foundation the Joanna and Kenneth
00:28:17
wailmer foundation the Alfred P sloan
00:28:21
Foundation and from the corporate
00:28:24
community mutual of America
