Introduction

We do not choose to age; it happens to us whether we want it or not. Some grow older with a feeling of well-being while others do not.  Active aging or successful aging refers to the concept of making the choices needed to have this sense of well-being by paying attention to the physical, social, mental and spiritual aspects of our lives. As J.K. Rowling wrote in her book, Harry Potter and the Chamber of Secrets, “It is our choices, Harry, that show what we truly are, far more than our abilities.”  

The writer Wendell Berry said: "We live the life we are given, not the life we have planned". How we reconcile the life we are given with the life we have planned is the most important task we have in later life. With increasing age, questions about the meaning of life are no longer philosophical or hypothetical because how we answer these questions shapes us as we age. But asking the question: ‘What is the meaning of life?’ and waiting for an answer is pointless because meaning is created by doing. What we do to live our lives is equivalent to creating a work of art. The meaning lies in the completed life.

Internalized discrimination against aging refers to entrenched beliefs about the adverse effects of aging. This contributes significantly to spoiling the experience of growing older. When aging can be considered as a time to do those things that compensate for the losses we experience, there is a greater chance of being contented with "the life we are given". The art of living is the ability to retain a degree of control over our attitude towards what is happening to us as we age. It requires acceptance over things that we cannot control and a willingness to adapt. Being productive while aging is important for we all "need to be needed". We must have projects to complete and projects that will contribute to the needs of others. Only then can we escape from boredom and decay of our spirit.

Focusing attention inwards to understand the way we react to the world and to others can be an opportunity given to us by aging. This process helps us understand ourselves and re-establish the sense of identity which we may have lost after retirement. It can help us remain hopeful in old age as we find new insights. It can help us to be realistic about the losses we experience without being threatened by the loss of identity that is synonymous with the ending of a life. It gives us the opportunity to become wiser.   

Ageing, from the biological point of view, is not something that starts after the age of 65 years (the age that defines the elderly according to the World Health Organisation). Rather, it is a process that begins from infancy and continues to the very end. But biological aging and "feeling old" are different. Biological ageing is also not a uniform process for everyone because some people show the effects of ageing to a greater degree than others of the same chronological age. A point to note is that chronological time may not have much meaning in certain parts of the developing world where functional ability is the criterion for old age. In Africa, for instance, a person is often considered old at 50 or 55 years of age. 

The United Nations has projected statistics which say that most regions of the world except Africa will have one-quarter of its population above the age of 60 years in the year 2050 (Ref.). People in countries that have already become rich before the percentage of aging population increases will have a better experience when growing older than those in countries which have increases in older adults before they are rich. A long life is only appreciated if it is lived without functional restrictions caused by diseases and disabilities. The impact on the quality of life caused by diseases is often captured by a parameter called disability adjusted life years (DALY). Those with greater DALY are considered to have more disease-span than health-span where Lifespan = Health span + Disease span. It is no surprise that higher income countries have less DALY because healthy choices are often difficult choices for people with lower income and less education. 

Non-communicable diseases like diabetes, hypertension, coronary heart disease and cancers are increasingly responsible for disability and illness in older adults. Depression and dementia are also a concern for those growing older. There are real financial concerns too related to loss of employment income. Financial weakness leads to dependence on others and impacts on well being. The social construct of ageing – how the elderly are viewed by the members of a cultural group – has a significant impact on how the elderly view themselves. The commonly held view that old age is invariably a period of decay and decline of mental and physical functions is not always based on facts. There are very old people who have gone to college and earned undergraduate degrees. The architect Frank Lloyd Wright designed the Guggenheim Museum at the age of 90 years and Benjamin Franklin was 78 years old when he invented bifocal spectacles. 

While most people wish to experience 'a good death' at home, statistics from the UK indicate that the majority of deaths in the elderly happen in hospitals. When people say that they wish to have a good death, they imply that they wish to feel in control of what is happening to them; they wish to be free of pain and unpleasant symptoms; they wish to die in a place of their choosing with privacy and dignity, and they want to have the time to resolve personal conflicts and unfinished businesses.

Recommended reading:
1. Jennifer R Sasser and Harry R Moody. Gerontology the basics. (2018)

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A prescription for well being while growing older

Prescription 1: Nutrition

Think of nutrition as a fence that protects you. The general rules are: 

1. Eat fruits and vegetables with vivid colours. They contain carotenoids (orange for betacarotenoid, pink or red for lycophene, deep yellow for lutein or zeaxanthine). These different carotenoids have been shown to be protective against diseases like prostate cancer, macular degeneration, cataracts and even cardiovascular diseases. They contain vitamins which are necessary for proper cell function.

2. Get your proteins from legumes (for example: baked beans, chick peas, kidney beans) or from fish, eggs, and lean meat. Get your carbohydrates from wholegrain cereals like rice, bread, pasta and noodles. Get your fats from food items like olive oil, milk, yoghurt, and cheese. 

3. Make sure you get the following minerals and vitamins either through diet or as supplements: Iron (reduced gastric acidity in older people can limit iron absorption);  Zinc (it helps the immune system); Calcium (it slows the weakening of bones); Vitamin D (for bones and brain); Folic acid and Vitamin B12 ( these are important for nerves and brain)

4. Take frequent small meals instead of few large meals. This helps digestion better. Take less meat and milk and try not to eat alone if possible.

5. Drink enough water every day (because the protective mechanism of thirst may not work so well)

Ref: About nutrition

Prescription 2: Exercise

Resting has been described as rusting.

1. Walk regularly. More than 3 km every day is good for the heart, brain and longevity.

2. Lift small weights or do push-ups to protect muscles.

3. Do exercises for balance and flexibility of joints like Tai Chi and yoga.

References: Exercises for older people

Prescription 3: Cognitive exercises
Cognition refers to various higher order functions of the brain and includes the things that we attribute to our conscious mind: thinking, memory, attention, reasoning, problem solving and evaluating of information. To "exercise the mind":

1.  Play games or quizzes that test memory and recall (example memory puzzle game)
2.  Play games that require reasoning (example chess, jigsaw puzzles, word games)
3.  Play games that involve speed of information processing (example solving quizzes over a fixed time period and playing video games where speed of response is essential)

The ACTIVE study looked at the effect of specific brain training exercises in older adults on 3 cognitive parameters: memory, reasoning and speed of information processing. Between 1996 and 1999 the study enrolled about 2800 participants with a mean age of 74 years. These participants all had adequate cognitive ability as shown by a MMSE score of 23 or more, needed no help for ADL, and had no physical or mental disability or impaired communication with others. They were randomised to 4 arms of the study: memory training, reasoning training, speed training and no structured training. The training consisted of ten 60 to 75-minute sessions over a period of 6 weeks. A subset of them received booster-training after 1 year and 3 years. The study showed improvements in memory, reasoning and information processing with exercises designed for those cognitive areas. This improvement in cognition was evident even in the long term with booster-training being better than without booster training. Improvement in cognition impacted positively on functional independence, mobility and quality of life and utilisation of health care services.

Reference: ACTIVE study

Prescription 4: Social interaction
Interact meaningfully with other people on a daily or weekly basis for leisure or social purposes (Ref.: Ageing gracefully). A study from Sweden published in 2002 also showed that sharing social and leisure activities with others on daily or weekly basis has health benefits for the brain. 

 Prescription 5: Protect the hippocampus
The hippocampus is intimately connected to the limbic system and is susceptible to the adverse effects of stress. It is an area of the brain that is involved in learning and in the formation of new short-term memories. It is an area of the brain where adults form new brain cells from stem cells enabling us to continuously adapt and learn from new life experiences. Disruption of neuroplasticity in the hippocampus through stress may be one of the possible ways in which the hippocampus is damaged, sowing the seeds for Alzheimer’s disease to develop. After all, we do know that in early Alzheimer’s disease, there is diminished hippocampal volume while the rest of the brain is structurally normal. Memory loss, the earliest manifestation of Alzheimer’s disease, is also a clue that the hippocampus is where the sequence of events that leads to full blown Alzheimer's dementia starts.
( Reference ). We can protect the hippocampus by taking care of our emotional and mental health. A program called Mindfulness Based Stress Reduction (MBSR) has been shown to increase gray matter in different parts of the brain including the hippocampus (Reference) 

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SCREENING AND PREVENTIVE MEASURES FOR THE OLDER ADULTS

A. Screening for cognition (memory, attention, speed of processing information and making decisions)

The following tests can be used:

1. Mini Mental Scale Examination (MMSE) which tests for memory, language, orientation and calculation. (Reference)
2. Stroop Color Word Test. This tests attention and executive function. The speed of identifying colors in incongruously written colored words is measured. See under "Tests" in this Reference.   
3. Clock Drawing Test which tests ability to make appropriate decisions (executive functions) and is a simple screening test for dementia. (Reference)

B. Screening for falls and a measure of healthy life expectancy

1. Gait speed. The speed of walking has been found to have a strong correlation with survival duration. Measurement of gait speed integrates multiple physiological functions into a single parameter. Gait speeds of 1 meter per second or more are associated with healthy aging and average or above average life expectancy. Gait speeds below 0.6 to 0.8 meters per second indicate poor functional capacity and reduced life expectancy. Reference
2. Five Times Sit To Stand is a timed measure of how long it takes a person to stand from a sitting position five times in a row. (Reference)
3. Ankle Brachial Index measurement. This is test for peripheral vascular disease and those whose ABI is less than 0.9 are considered to be at higher risk for CV events. Reference shows "estimating risk of ASCVD" (Reference)