The goal: To live long and die quickly

By Ciril J. Godec, MD
Youth is a gift of nature, old age is a work of art.
French proverb
One of my patients who is still working full-time just celebrated his 95th birthday. I see him twice a year for his prostate problem. He has responded well to medications for the last eight years and so far no surgery is necessary. He walks one mile to work every day. He drinks a shot of scotch before dinner and 2-3 glasses of red wine during dinner. He is slightly overweight with a body mass index of 27. He does not smoke and is not diabetic. His only medications are for prostate, for moderately elevated blood pressure, and occasionally Viagra. He eats red meat a couple times a week. Upon my urgings, he goes to a gym once a week. He regularly meets with his group of friends for a game of poker.
Another patient of mine is 68. At 64 he underwent radiation for prostate cancer; he was too sick to be cleared for surgery. Until recently he still smoked. He has already had two stents for coronary disease and is also being treated for chronic pulmonary disease. He is overweight, diabetic, has high blood pressure and high cholesterol. He has never exercised. His favored eating places are fast food eateries. He has been on disability for the last ten years due to his multiple medical problems. Recently his PSA index started to creep up and I put him on hormonal therapy for recurrent prostate cancer. 
These two patients are representative of people we see among our seniors today. The first one, less frequently seen in the doctor’s office, is the model for what we call compression of morbidity. This means he will very likely live to a very advanced age, maybe a hundred, and then die after a very short terminal illness. He represents a healthy aging that we would like to promote. His health care is not expensive. The second patient, on the other hand, represents the majority of patients we see in the office. He is piling up one disease after another, and his medical care is already very costly. His life, plagued by diseases and old age frailties, has been miserable for him and his family for many years. He will very likely be kept alive for many more years through advances in medical technology and pharmacology. He is a paradigm for the costly extension of morbidity — keeping illness going — over many years. 
People die for three main reasons: accidents, diseases, and old age. Especially in developed countries, aging has become the biggest killer. As a biological manifestation, aging is a relatively recent phenomenon. Years back, most animal species, humans included, were biologically encoded simply for early survival and reproduction. Aging at that time did not really exist. Before aging could set in, most living creatures would be killed by predators or die from rampant infectious diseases. Up to 1900 aging was a relatively rare occurrence. Only when we improved sanitary conditions and got most infectious diseases under control did we begin to witness the first wave of aging and age- related diseases as a new medical and social problem. And, after 1950, the second wave of increased longevity emerged, mostly due to decreased mortality from coronary heart disease. 
Aging is under environmental (how we live) and genetic control. We can survive in Greenland or the Sahara because we have a phenotypic, or genetic, plasticity, unique to humans, that enables us to survive under very diverse environmental conditions. The activation or silencing of certain genes is the basis for our amazing ability to survive even under extreme conditions. Up to now we have invested most of our research endeavors in the early and middle stages of life. Hopefully, in the near future the basic sciences will demystify the aging process. 
Health care now costs $2.7 trillion yearly, or approximately 18% of our GNP. For society, the older population represents the biggest outlay of health-care dollars. Over 80% of all diseases and medical expenses involve patients over 65. With rapid progress in pharmacology and medical technology, we have prolonged average life expectancy from 45 years in 1900 to 78.5 today. We are succeeding in extending our life span through joint replacements, curative cancer surgery, stents for coronary disease, pacemakers, and a variety of transplant surgeries. With constant advances in health care delivery, we have increased our life span, but we have also increased morbidity. Obesity, high blood pressure, Parkinson’s and Alzheimer’s are all on the rise, mostly on account of unhealthy living. 
We live longer but sicker. A life with chronic, disabling conditions can become a burden not only for patients themselves but also for their families and society at large. Even though life expectancy is increasing, health expectancy is not, and the gap between life expectancy and health expectancy is growing. To compress morbidity is to decrease the time interval/difference between life span and health span. Even though we may have delayed death from diseases of older age, we have done very little to eliminate or prevent them. The cost of health care would be significantly reduced, by some calculations by one- third, if the debilities of old age could be limited to a shortened period before death. The huge army of baby boomers (all 81 million of them) who are now entering retirement age will put the demand for healthy aging at the center of our health care debate. 
How do we compress morbidity? Is it achievable or mostly wishful thinking? The recipe is simple: don’t smoke, exercise daily, eat mindfully, sleep at least 7 hours a day, and be socially connected. Walking is the best exercise, at least 30 minutes daily, the faster the better; almost everyone can do it, and if you have to use a cane, adjust your pace. If you are more ambitious, you can also do weight lifting every other day. If I would have to single out one factor in our striving for the compression of morbidity, it would be daily exercise. Make regular daily exercise an important part of your life, regardless of age.
If our government wants to reduce health care expenditures, fostering a healthy lifestyle with daily exercise should be implemented in our schools and workplaces. We need more easily accessible recreational facilities. Beside politicians and social planners, health-care professionals should be leaders in this effort.
Healthy nutrition does not require that you be a vegetarian. Limit lean red meat to only a couple of times a week; eat an unlimited amount of vegetables, fruits in moderation (they contain more sugars than do vegetables); reduce intake of pasta, bread, potatoes and rice, especially the white varieties. Drink water when thirsty, limit dairy products, and sip no more than 4 cups of coffee or tea a day. If you like wine, you can have two glasses of red wine for men and one for women. Cook with less salt and more with other spices (pepper, turmeric, cinnamon, red pepper). This is important: eat slowly and mindfully. 
Two recent studies support the benefits of a healthy lifestyle in compressing morbidity. In one from the University of Pennsylvania, 1,700 alumni were followed for 20 years. One group comprised the alumni who smoked, were obese and did not exercise; the other group did not smoke, had a healthy diet, were slim, and exercised. In the healthy lifestyle group, age-related morbidity was postponed for 8 years. In the second study, 537 members of a runners’ club were compared to 423 community control participants. After 22 years of the study, the runners had postponed age-related disabilities by approximately 12 years compared to the control group. 
When I read the obituaries in The New York Times, if old age is given as the cause of death, the person was usually over 90. In very old age death usually is due to “natural causes” or, in medical language, organ failure due to the progressive accumulation of toxic products inside the cells reaching a critical level and suffocating the function of a specific organ. Life comes to an end quickly. This type of “natural” death, still relatively rare, is an example of compression of morbidity. Most of the time, people die after prolonged illnesses involving multiple surgeries, radiation, expensive chemotherapy and the use of numerous medications (9-10 on average) taken daily. 
Life expectancy is increasing all around the world. In 2005 one out of two Americans over 65 was living with a chronic illness and one in four had one or more limitations in their daily living. Compression of morbidity is only the first step in our striving for life extension. Can we increase health expectancy along with life expectancy? Yes, we can.
Surprising data were recently reported from Harvard researchers on 1,314 centenarians (100-plus), 140 supercentenarians (110-plus) and 436 controls who were prospectively followed for 3 years. The older the person was, the later the onset of diseases — cancer, cardiovascular disease, stroke, Alzheimer’s. The same was true for functional and cognitive decline. The bottom line of their research was that time spent with disease decreased as age progressed. The future is bright, especially for the very old. We do not need to see older people in physically and mentally incapacitated states slumped in wheelchairs crowding the hallways of nursing homes. 
Compression of morbidity is possible. We have genetic and phenotypic underpinnings for it. Life with disease, frailty, and infirmity should be reduced to a short period before we die. To a degree, this is in our own hands — not everything is genetic. With improvement in our lifestyle, we can reduce disability at any stage in our lives, but especially in older age. Life should be lived fully, with vigor, not only in youth and middle age but also in advanced age. We should live long and well and drop dead suddenly rather than dying slowly with frailty, infirmity and multiple diseases. Only thus do we fully participate in the adventure we all share — our life.
Dr. Ciril Godec is the chairman of urology at SUNY/Long Island College Hospital and professor of urology. He is co-editor of an international treatise on prostate cancer.
May 2, 2012 - 2:40pm



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