6. Social Factors, Successful Aging

6 SOCIAL FACTORS

Life with people

Philosopher Jean-Paul Sartre famously wrote, “L’enfer, c’est les autres”—hell is other people. No. Not if you want to live long. One of the keys to a long health span and a long life is social connectedness.

Loneliness is associated with early mortality. It has been implicated in just about every medical problem you can think of, including cardiovascular incidents, personality disorders, psychoses, and cognitive decline. Loneliness can double the likelihood of developing Alzheimer’s disease. It increases the production of stress hormones, which in turn lead to arthritis and diabetes, dementia, and increased suicide attempts. It leads to inflammation, increasing proinflammatory cytokines such as interleukin-6 (IL-6), and it negates the beneficial effects of exercise on neurogenesis, the growth of new neurons. Loneliness is worse for your health than smoking fifteen cigarettes a day. If you are chronically lonely, the risk that you will die in the next seven years goes up by 30 percent.

Loneliness and social isolation are not the same thing. Social isolation refers to having few interactions with people and can be evaluated objectively (for example, how many people you interact with in a week and for how long). Loneliness is entirely subjective—it’s your emotional state. Social isolation can be calculated. Loneliness is felt.

People can feel lonely even when surrounded by others, such as in the middle of a party or inside a large family. Loneliness is a feeling of being detached from meaningful relationships, and that may arise from feeling unacknowledged, from feeling misunderstood, or from a lack of intimacy. Having a spouse sometimes helps, and sometimes not. There are certainly people who enjoy being alone and who do not feel lonely, just as there are people who are constantly in the presence of others, perhaps making small talk, but feeling completely alone. Being unmarried raises the risk of loneliness and a host of health-related problems, but being married doesn’t help in all cases—not all marriages are happy ones.

Social isolation can lead to loneliness, of course, and both can increase in old age owing to a variety of factors. People retire and swiftly lose the social contact they had with co-workers. Friends die. Health and mobility problems make it more difficult to leave home. Ageism, present in many modern societies, leaves older adults feeling devalued, unwanted, or invisible. Younger friends and family members become caught up in their own lives and might not take time to visit older people. Government research in the UK found that two hundred thousand older adults had not had a conversation with a friend or relative in more than a month. Clearly that kind of extreme social isolation can lead to loneliness.

This seems to be a modern problem, peculiar to our times. Harvard political scientist Robert Putnam, in his book Bowling Alone, decries the “corrosive individualism” that has infected modern society. He documents what he sees as an unhealthy and mounting trend toward political apathy, retreat from church attendance, eroding union membership, and the decline of bridge clubs and dinner parties, volunteering and blood donation.

Sociologist Eric Klinenberg at NYU adds,

Societies throughout the world have embraced a culture of individualism. More people are living alone, and aging alone, than ever. Neoliberal social policies have turned workers into precarious free agents, and when jobs disappear, things fall apart fast. Labor unions, civic associations, neighborhood organizations, religious groups and other traditional sources of social solidarity are in steady decline. Increasingly, we all feel that we’re on our own.

Klinenberg goes on to implicate the rise of communications technology, perhaps paradoxically, as a cause of loneliness. When Facebook and other social networks began, they, along with tech companies like Apple, Microsoft, and Google, predicted that the Internet would help to create stronger and more meaningful relationships, establishing rewarding and fulfilling online communities. Instead, what we find is that the last several years have brought deepening divisions. We may have thousands of “friends” on Facebook, Instagram, Twitter, Kiwibox, Vine, Tumblr, LinkedIn, Pinterest, QZone, Sina Weibo, and MeWe, but they are rarely fulfilling. No convincing studies have been published on this yet, but I’m willing to bet that interactions in cyberspace do not trigger the release of oxytocin, prolactin, and endorphins the way that real, actual human contact does. (Although as I’ve written about before, getting “likes” can produce an addictive hit of dopamine.) And unfortunately, it is the unemployed, displaced, and migrant populations that suffer the worst—their lives and social spheres have been profoundly disconnected. When they get lonely, they are the least able among us to rebuild a nurturing community.

Social isolation and loneliness are associated with reductions in levels of the neurotransmitter glutamate. Glutamate is the most abundant neurotransmitter in vertebrates and is important for transmission of signals throughout the cells of the brain. If you’re wondering how it relates to monosodium glutamate, the flavor enhancer known as MSG and often used in Chinese food, they are both forms of glutamic acid, one of the amino acids. Proper brain functioning depends on keeping low levels of glutamate in your extracellular fluid, and overly high levels can lead to cell death. A number of mechanisms have evolved to keep those levels low, including an intricate system of chemical scavengers with names like oxaloacetate and glutamate-pyruvate transaminase, which chase down and neutralize glutamate molecules. An unanswered question is whether dietary glutamate can impact brain levels of glutamate (which would be bad). This is where the blood-brain barrier comes in. Any molecules entering or leaving the brain must pass through two membranes, and each membrane has specific properties for keeping different molecules from passing through. These membranes prevent your brain chemistry from going haywire based on eating or drinking too much or too little of certain foods—it is, in effect, a protection that promotes homeostasis of chemical levels in the brain. So far, the weight of evidence seems to suggest that ingesting MSG does not significantly change levels of glutamate in the brain.

In addition to the harmful effects of too-high glutamate levels, too-low levels are associated with loneliness and social isolation, and so increasing glutamate levels in the brain might be helpful in these cases. Researchers have been working on identifying drugs that can help. I’m not implying that we should resort to pharmaceutical interventions for every little thing that goes wrong with us, but for some people, social isolation (and social anxiety) are debilitating, paralyzing conditions. In a finding that may delight certain members of the boomer generation, psychedelics such as LSD and psilocybin have been shown to decrease feelings of both loneliness and depression, with lasting effects, and ketamine has been shown to provide relief, although the relief seems to be only short-term.

Social isolation and loneliness can even change your genes. Social isolation, loneliness, and depression affect gene expression, causing increased inflammation in the brain and decreased production of antiviral interferon. Lonely people have increased activation of the HPA axis, causing them to be hypervigilant about social threats. They might believe that most people in the world are out to harm them, humiliate them, or behave derisively or dismissively toward them. In this respect chronically lonely people resemble people with PTSD.

Social isolation co-opts the fear and aggression circuits in the brain, causing persistent fearfulness, hypersensitivity to threatening stimuli, and increased aggressiveness toward others. For example, mice normally freeze (like deer) when they encounter a threatening stimulus, because most of their natural predators use motion cues to locate them. After the threatening stimulus is removed, normal mice stop freezing right away, whereas socially isolated mice—being hypersensitive to threat—will stay frozen for much longer.

There’s a small structure deep inside the brain called the putamen (pew-TAY-men). I find it mysterious. It keeps showing up in brain imaging studies of music, of neurological disorders, speech syntax, and creativity. It also shows up in studies of emotion, particularly hate—some criminal offenders have structural anomalies in the putamen (as well as in the hippocampus, amygdala, and nucleus accumbens)—suggesting its role in antisocial behaviors. Increases in putamen size are associated with higher aggression toward others, whereas reductions in putamen size are associated with Alzheimer’s disease.

It’s involved in so many different things, and makes connections to so many parts of the brain, that scientists have had difficulty in assigning the putamen a specific role. It seems to me that the unifying thread has to do with reward and motivation, and the putamen’s role in the brain’s chemical-reward system. The putamen may also modulate social anxiety. People who try to avoid others have a low density of dopamine receptors in their putamen, which may block any pleasurable sensations from simply being with others—even people they like.

That this is neurobiological does not mean the brains of such individuals were always destined to be that way. Clearly there are genetic factors, but we also know that the formation of the system that releases dopamine is influenced substantially by environmental and social factors during childhood, including the kinds of social interactions we experience in childhood and adolescence. Together, these can lead in later adulthood to aloofness and withdrawal from others.

But recall the work of David Anderson, the Caltech neurobiologist I mentioned in the previous chapter, who gave the TED Talk on how your brain is not simply a bag of chemicals: Dopamine receptors in one part of the brain do not necessarily do the same things as dopamine receptors in other parts of the brain. In the putamen, they moderate social engagement. But in two nearby structures, the ventral striatum and globus pallidus, lower dopamine uptake leads to increased impulsiveness and hatred of monotony.

Structures such as the putamen, and neurochemicals that reward social engagement, suggest an ancient evolutionary history to our wanting to be with others. Other structures, such as the globus pallidus, suggest an evolutionary basis for managing impulse control. Our social drives and behaviors are influenced by the way our brains have responded to the triad of genes, culture, and opportunity.

Social Development

As we’ve seen so far, the developmental neuroscience triad of genes, culture, and opportunity influence brain development and can affect the course of your life. Social development is no different. As I’ve already touched on, babies need physical contact.

Harry Harlow, a psychologist, performed some of the most harrowing experiments ever conducted. He raised infant monkeys in isolation for up to twenty-four months to see what the effect would be; the young monkeys emerged profoundly disturbed and many never adjusted after the isolation ended. In another study, he put baby monkeys in a cage with two wire monkeys. One wire monkey had a milk-dispensing bottle in it. The second wire monkey had a terry-cloth blanket wrapped around it. Harlow hypothesized that the infant monkeys would want to spend more time with the wire monkey that gave milk—the nutrition they needed to satisfy their hunger. But in fact, the baby monkeys clung to the wire monkey with the soft terry-cloth blanket. The videos of the experiment are heartbreaking. (Harlow and his collaborators give all scientists a bad name even though the great majority of us would never consider such monstrous studies.) There is one video in which a baby monkey continues to cling to its terry-cloth wire mother while straining to reach over and drink some of the milk from the adjacent wire monkey. Mothering is about more than just providing food. It’s about soft touch and warmth, about creature comfort.

Around the same time, a psychologist named John Bowlby was developing attachment theory, the idea that human infants need to develop a relationship with at least one primary caregiver in order to experience successful emotional and social development and to learn to regulate their emotions. The caregiver does not need to be the biological parent, or even just one or two particular people—it can involve a community of caregivers, as is often seen in non-Western cultures.

Research shows that social stress is linked to a compromised immune system. This can happen at any age. But as an early life stressor, social stress is particularly harmful because the effects are long-lasting. Michael Meaney at McGill University showed that the kind of care a mother gives to her offspring actually alters the child’s physiological responses to stress throughout its life span. Rat pups who are licked more in the first ten days of life grow into adult rats who are far more secure and less likely to be destabilized by stress. Baby rats who received a great deal of licking and grooming produced fewer stress hormones when, later in life, confronted with a challenging situation, in comparison with rats who received less care. And these effects persisted well into adulthood, and persisted into the next generation of rats because the female offspring licked their offspring more. Meaney also showed that pups who were exposed to lots of licking and grooming in early life also display better memory performance in adulthood.

Early experience interacts with genetics and brain structure. The mother’s health is critical. Meaney says, “The single most important factor determining the quality of mother-offspring interactions is the mental and physical health of the mother. This is equally true for rats, monkeys and humans.” Parents living in poverty, suffering from mental illness, or facing great stress are much more likely to be exhausted, irritable, and anxious. These conditions are transferred in the interactions between such parents and their children.

Nurture (or lack thereof) early in life selectively affects the development of a number of brain systems, such as glucocorticoid receptors in the hippocampus—part of the feedback mechanism in the immune system that reduces inflammation. Meaney also showed that parenting affects the function of the pituitary and adrenal glands, which regulate growth and sexual function and produce cortisol and adrenaline. Although these effects can last a lifetime, they can be overcome with the right behavioral and pharmacological interventions, but it takes some work. Cuddles count, particularly in the first year of life. Think of it as a plant that has overgrown in your yard: If you prune it and shape it early in its life cycle, it becomes easy to maintain. If you ignore it for a few years until the stem is thick and woody, you can still tame it, but it takes a lot more work, and your efforts go against the shape it has adopted. As parents (and grandparents and teachers), our choices about how we raise our children in their first years will have a far greater role in what their last years look like than was previously recognized.

Don’t forget that humans grow within a socioeconomic context that in turn influences development of the nervous system—particularly of the systems that underlie language and thought. Prenatal factors, parent-child interactions, and cognitive stimulation in the home environment all influence neural development. As one example, educational attainment has been associated with decreased allostatic load later in life. The direction of causality here, though, is not clear. Maybe education helps us to better manage life stressors, or maybe those who already manage life stressors effectively are able to go further in school. (Indeed in rats, environmental enrichment during early life—the rat equivalent of a good kindergarten—has been shown to increase hippocampal volume, decrease stress response, and increase memory function in adulthood.) Or maybe people with an education just earn more money and eat better food. In any case, these findings should direct us toward improving the programs and policies that are designed to reduce socioeconomic disparities in mental health services and academic support.

There are currently estimated to be more than 100 million orphaned or abandoned children in the world—that’s 20 million more than the entire population of Germany. In 1915, Dr. Henry Chapin, a pediatrician and professor at the New York Post-Graduate School of Medicine (now NYU) wrote in the Journal of the American Medical Association (JAMA):

In considering the best conditions for the relief of acutely sick infants and for foundlings or abandoned babies, two important factors must always be kept in mind: (1) the unusual susceptibility of the infant to its immediate environment, and (2) its great need of individual care. The best conditions for the infant thus require a home and a mother. The further we get away from these vital necessities of beginning life, the greater will be our failure to get adequate results in trying to help the needy infant. Strange to say, these important conditions have often been overlooked, or, at least, not sufficiently emphasized, by those who are working in this field.

That was written in 1915. More than one hundred years ago. And yet, the problem of orphaned and abandoned children persists worldwide.

After the fall of the Ceauşescu regime in Romania in 1989, more than 170,000 children were found to have been abandoned at or shortly after birth and kept in overcrowded, poorly administered institutions all over the country. Many Americans learned of the Romanian crisis through a television segment on the ABC newsmagazine 20/20 and rushed to adopt Romanian orphans—eight thousand of them in all. But collectively, the new parents were unprepared for the psychological damage many of these children had already suffered.

Ten years later, the Bucharest Early Intervention Project (BEIP) was begun by American researchers including Charles Nelson and Nathan Fox to study the effects of foster care versus institutionalization. Sixty-eight Romanian infants and toddlers were taken out of institutions and put into foster care specifically set up for the study. The study found that all of the children who had been institutionalized had profound changes in brain development. They were severely impaired in IQ and manifested a variety of social and emotional disorders—depression, anxiety, disruptive behaviors, and ADHD. However, the earlier an institutionalized child was placed into foster care, the better the recovery, especially when placement occurred before the age of twenty months.

When the children were twelve, they were again assessed on a variety of measures including their response to stress, physical health, mental health, substance use, and academic performance. Only 40 percent of children who had ever been institutionalized were doing well at age twelve. But that 40 percent is an average, and marked differences occurred depending on whether they were eventually raised in a family situation or remained institutionalized. For the children placed with a family, roughly 55 percent were functioning well at age twelve. Of the children left in institutions, only 25 percent were functioning well. And of those placed in foster care within the first twenty months of life, 80 percent were functioning well. Early family experience is key not just to socialization, but to overall brain functioning as well. As Charles Nelson notes,

The brain is dependent on experience to develop normally. What happens in situations of neglect, such as kids raised in institutions, is that the experiences are lacking. So the brain is sort of in a holding pattern saying, “Okay, so where’s the experience? Where’s the experience? Where’s the experience?” And when the experience fails to occur, those circuits either fail to develop or they develop in an atypical fashion—and the result, in a sense, is the mis-wiring of circuits.

The big question is, what happens 10 or 20 or 30 years down the line? The speculation would be you will progressively find yourself more and more disadvantaged or more and more handicapped.

There has been a significant increase in the number of children diagnosed with autism spectrum disorders over the last twenty years, and there are probably cultural factors at work here as well. Consider the difference between a typical Mexican childhood and a typical American one. Mexican culture encourages social interaction, family time, and group activities. American children are often allowed to play with tablets, phones, and other electronic devices alone. Although autism has a complex etiology, one culture seems to discourage behaviors that we might characterize as autistic, while the other culture encourages them. Indeed, rates of autism among children raised in Mexico, as well as Hispanic and Latino children raised in the United States, are significantly lower than they are for “white” US children.

What You Can Do about Social Isolation

Is there a cure for loneliness? One of the first steps is to admit that you’re lonely and that you want to do something about it, but this isn’t so easy, according to Dhruv Khullar, an attending physician at New York–Presbyterian Hospital:

Loneliness is an especially tricky problem because accepting and declaring our loneliness carries profound stigma. Admitting we’re lonely can feel as if we’re admitting we’ve failed in life’s most fundamental domains: belonging, love, attachment. It attacks our basic instincts to save face, and makes it hard to ask for help.

And clearly the cure is not simply reducing social isolation, because we can feel lonely in a crowd. But getting out and being among people is a good start.

David Anderson has been studying social isolation in the fruit fly, Drosophila melanogaster. You might think of fruit flies as neurally primitive compared to humans, but they do exhibit social behaviors, and a significant number of proteins associated with mRNA translation are highly similar between fruit flies and humans (in spite of there being 780 million years of evolution between us). This suggests that fear and sociability are linked by a very ancient prehuman mechanism. Once again, we may think that we initiate our behaviors and responses to the environment and other people, but at least to some extent, the hidden strings of neurochemicals and hormones pull on us, making us dance, approach, or freeze, all while giving us the illusion that we are in control.

Anderson has also studied this mechanism in mice. Social isolation for two weeks causes an increase in the production of a particular neurochemical, neurokinin (Tac2/NkB), which engages the stress response. Blocking its production with the drug osanetant (a Tac2/NkB receptor antagonist, or blocker) neutralizes the effects of stress, causing socially isolated mice to behave like regular mice. Conversely, increasing Tac2/NkB causes socially raised mice to behave as though they were socially isolated. Interestingly, after being treated just once with osanetant, the socially isolated mice—who behaved very aggressively toward other mice prior to treatment—could be returned to cages with other mice, where they acted normally and nonaggressively. It is this same neurochemical, tachykinin, that was found to cause aggression in Anderson’s fruit flies. As Anderson says, “It brings up the question whether this drug could mitigate the well-known deleterious effects of solitary confinement, such as increased violent behavior in incarcerated individuals.” Or help people stuck in old age homes, who often feel agitated and disoriented.

The importance of all this goes beyond just conquering the adverse effects of social isolation, to more broadly treating a wide range of mental health disorders. The ability to regulate levels of neurochemicals like Tac2/NkB with great precision may dramatically improve mental health medicine in the coming years. Osanetant is not currently available for humans, but the field is rapidly changing and the coming years promise a number of innovative developments.

The Tac2/NkB story tells us a little about how social isolation causes aggression and fear, but not why some people find it hard to get themselves out of it. Social isolation is often self-imposed because people don’t receive the normal kinds of brain-based rewards from social interactions. That is, under ordinary circumstances, we enjoy being with others—like all primates, we are a social species—and positive social interactions release opioids in the brain, especially in the brain’s most important reward center, the nucleus accumbens. When people have been bullied, taunted, and humiliated by social experiences, their innate experience of pleasure with others may be hijacked by their fear system. People with an impaired reward system, because of either such negative interactions, or organic damage to the nucleus accumbens and associated limbic system, or the natural age-related shrinkage of the brain, tend to socialize less because it has stopped being rewarding. Directly stimulating the nucleus accumbens in mice leads to increased play and social motivation. But so far it is not possible to do this in humans. Indirect stimulation, however, is possible in humans, through the use of drugs that increase the reward center’s activity, such as cannabinoids like marijuana, morphine, and methylphenidate, which, respectively, modulate receptors for endocannabinoids, endogenous opioids, and dopamine. Another agent that increases dopamine levels is armodafinil, which is usually used to combat jet lag or narcolepsy, but in some people it has the side effect of making them more social because it tweaks the novelty-seeking dopaminergic system.

A series of studies that I conducted in collaboration with neuroscientist Vinod Menon showed that music can activate these same reward centers. Music often occurs in social settings like parties, restaurants, and political rallies, and there is evidence that listening to music in groups releases oxytocin, the hormone that facilitates social bonding. Our studies showed that even listening to music alone, inside the sterile confines of a brain scanner, still lights up these reward centers. Without drugs, then, it’s possible that social isolation and feelings of loneliness can be reduced simply by listening to music. After all, when we listen to music, we’re kind of with the musicians, right?

Paxil and Zoloft, two SSRIs (selective serotonin reuptake inhibitors), although they are primarily known as antidepressants, have been shown to ease social anxiety, to help people enjoy their interactions with others. Don’t give up if treatment doesn’t work quickly—they are subject to what we call “therapeutic lag.” Finding the right medication and dose for your situation can take some trial and error.

On the other hand, although drugs such as these are widely prescribed, there are increasing doubts about their efficacy. Patients often feel cheated if their doctors won’t prescribe them something, and it’s often easier for medical doctors to write a prescription than to convince patients to seek psychotherapy, something that in much of the world is still stigmatized. Cognitive behavioral therapy (CBT), which I mentioned previously, was shown in a Norwegian study to be more effective than either drug therapy or the combination of drug therapy and CBT. The problem is that drugs tend to camouflage problems by making people feel better temporarily, preventing them from learning to regulate their emotions themselves.

Regulating our emotions is fundamental to increasing health span. In particular, learning to control lifestyle elements such as sleep hygiene, diet, and physical activity has been shown to reduce feelings of loneliness, as does learning to focus on positive emotions such as gratitude. Gratitude is an important and often overlooked emotion and state of mind. Gratitude causes us to focus on what’s good about our lives rather than what’s bad, shifting our outlook toward the positive. Positive psychology grew out of a belief that psychology’s focus on disorders and problems of adjustment was ignoring much of what makes life most worth living. Positive psychology has found that people who practice gratitude simply feel happier.

Related to this, a number of studies have shown that religious people are happier than nonreligious ones. There are a number of explanations for this but they’re not what you might think: Religious people aren’t happier because they believe in God or because they feel the comfort of God watching over them; these may be important to them and give them a sense of purpose, moral or ethical grounding, or simply the belief that they are doing the right thing, but those are not ingredients of happiness. The research suggests that religious people feel happier because religion promotes gratitude through prayers and gives them a social network, along with a sense of purpose and meaning—three things that benefit most of us, regardless of where they come from. Those social benefits appear also to accrue in the nonreligious who join a music listening group, volunteer in a soup kitchen, or have block parties with their neighbors. And religious people who are not part of a community do not seem to enjoy the high levels of happiness of those who are in one.

Many of us feel socially awkward, and there are programs and interventions that can help to ease those feelings. Joining book clubs, hiking groups, groups like Toastmasters or Rotary Club, and volunteer organizations, both secular and religious, can provide some help.

An innovative program begun by the Palo Alto Medical Foundation is called linkAges (a play on words that can be read as either link ages or linkages). The program functions like an exchange system that encourages young people and older adults to trade services. Members of the linkAges community post online something they want help with. Older members might seek transportation to a doctor’s office or help changing light bulbs; younger members might want to take guitar lessons or learn how to prepare a balance sheet for a new business. Suppose Tiffany, age twenty-seven, helps June, age seventy-seven, to plant a vegetable garden, earning Tiffany two hours of credit. Later, Tiffany wants to take guitar lessons, which she does from Ramesh, age thirty-two; Tiffany trades in her credit, hour for hour, and Ramesh earns new credits. Ramesh wants to start an online guitar lesson company and uses his credits with June, who used to be the comptroller at a large corporation. She teaches Ramesh how to prepare a balance sheet. Tiffany and Ramesh both get to interact with June in different capacities, and June gains an increased sense of purpose and self-worth by being able to pass on her knowledge to someone who needs it. As Paul Tang, a doctor at the Palo Alto Medical Foundation, says, “You don’t need a playmate every day, but knowing you’re valued and a contributing member of society is incredibly reaffirming.”

The Canadian Longitudinal Study on Aging found that 30 percent of women over the age of seventy-five reported being lonely. One creative way to address the problem of loneliness in seniors is intergenerational housing. Programs pair young adults, often students, with seniors, and exist in Ontario, Quebec, and Nova Scotia. Symbiosis, a program in London, Ontario, for example, has university students living alongside seniors in a retirement home. This co-housing project is run by the school of graduate studies at McMaster University and connects students in need of safe, affordable housing and local seniors in need of companionship. International students working to improve their English language skills benefit from opportunities to practice conversational English, and seniors benefit from getting help around the house. Both partners benefit from reduced social isolation and a sense of shared community.

Another new program in Britain, Befriending, matches up a volunteer with an older adult for regular one-on-one companionship. Whereas the Palo Alto program entails the older adult making a contribution to the community in their area of expertise, the Befriending program is less transactional. It is too early to say whether either program will show tangible benefits in terms of increased health span. But Befriending says that the program “often provides people with a new direction in life, opens up a range of activities and leads to increased self-esteem and self confidence. Befriending can also reduce the burden on other services which people may use inappropriately as they seek social contact.”

Losing a spouse, through late-life divorce, illness, or death, can be a time of profound difficulty. My paternal grandmother lost her husband of forty years, my grandfather, when she was only sixty-three, and she lived another sixteen years without him. She was ill prepared to be alone. When he was alive, they had an active social life, mainly with other doctors whom he worked with and had known for decades. My grandmother’s own father was a tailor and an immigrant from Spain. She graduated college in 1923, majoring in philosophy. After she married, she put that philosophy degree to good use in social settings. My grandparents socialized regularly with other physicians and the level of conversation was intellectual and challenging.

But after my grandfather’s death, she was adrift. The doctors who she thought were her friends stopped inviting her to parties. At first, she sought companionship by making appointments to see these doctors in their offices. Twice a week or so, she’d make the rounds of the internist, the ENT, the gynecologist, the foot and ankle surgeon, the dentist—all people she had socialized with when my grandpa was alive. She probably didn’t have anything wrong with her, but this was the only way she knew how to keep in touch. It was awkward for the doctors and took them away from patients who were really ill. And I’m sure it was less than fulfilling for her. Then something clicked. She read about the Head Start program in the newspaper, and that the local San Francisco program was looking for volunteers who could go into classrooms and read to young children. As soon as she started doing that, her entire mood changed. And she stopped visiting the doctors’ offices. Here was a connection that greatly benefited my grandmother and the underprivileged children she met with twice a week. As the British children’s laureate Sir Michael Morpurgo writes,

It is the need of every single one of us, child or grown-up, to feel wanted, to feel we belong and that we matter to someone else in the world. We all know, from our own experience, that feeling isolated from those around us, alienated from society, makes us sad, even angry. The deeper this isolation becomes, the more hurtful and resentful we feel and the more this is reflected in our behavior. Such behavior only leads to greater alienation. Children who from an early age feel alone and apart from the rest of the world, and there are so many of them, who become angry and hurt, have little chance of leading fulfilled lives. They are lost from the start. Above all, they need friendship, the solid warmth of someone who cares and goes on caring. With such lasting friendship, self worth and self confidence can flourish, and a child’s life can be altered forever.

Changes in Sociability among Older Adults

Laura Carstensen was a young assistant professor at Stanford when the AIDS crisis broke out in nearby San Francisco. Back then, being HIV-positive was almost an assured death sentence. As a psychological scientist interested in aging, she wondered how these predominantly young people, whose lives were about to be cut short, would deal with their impending death. In terms of how much time they had left, they resembled older adults—what, if any, psychological similarities were there?

Carstensen proposed that social goals are broadly divided into two categories, the acquisition of knowledge and the self-regulation of emotion. Further, most of us appreciate that our time is eventually going to run out; this in turn influences our goals at different points along the life span. Across our lifetimes, she says, we engage in a selection process of strategically and adaptively cultivating our social networks to help us maximize social and emotional gains while minimizing social and emotional risks. When time is perceived as open-ended—as it is for most young people—goals are most likely to be preparatory, and we spend time on things that will optimize the future—for example, gathering information, pushing ourselves to find our limits, and seeking new skills. Young adults often place great emphasis on activities that will help them later; after all, what is school if not the prime example of things that don’t really help you in the moment?

In contrast, when constraints on time are perceived, goals focus more on meaningful activities that can take place in the present. As a consequence, goals shift from emphasizing future knowledge and contacts to emphasizing emotional states, seeking peace, well-being, and important friendships. When time is limited, goals related to deriving emotional meaning from life are prioritized over goals that maximize long-term payoffs in a shortened future. Of course, younger people sometimes pursue goals related to meaning, and older people sometimes pursue goals related to knowledge acquisition; it’s the relative importance placed on them that is subject to change. And if knowledge or skill acquisition for its own sake is pleasurable in the moment, as it apparently was for Pablo Casals, that goal does not diminish with age.

Carstensen studied young men with symptomatic HIV infections who were approaching the end of their lives and found that their goals for how they wanted to spend their time became very similar to those of older adults near the end of their lives—they wanted to spend time with people they cared about, and whom they were close to, and placed a greater emphasis on activities that were emotionally meaningful in the moment than ones that were preparatory. Carstensen dubbed this socioemotional selectivity theory. Time perspective, not chronological age, drives these changes in social motivations. Why invest time in a new contact if you won’t be there to reap the benefits? What matters, when you’re running out of time, is maintaining the long-standing, deeply meaningful friendships that have nurtured your emotional life.

Another interesting age-related shift has to do with how we relate to the world. Middle-aged adults tend to direct their energy toward bringing their environment in line with their own wishes—they renovate and build houses, for example, and do other things to mold their world to their liking. Older adults typically focus on changing themselves to accord with their environment. To meet the challenges of aging, older individuals increasingly need to resort to strategies of adjusting expectations and activities in order to pursue more attainable goals when the kinds of activities that characterized their youth become more difficult to do.

Fortunately, increasing age, in many cases, is associated with better emotional balance. Part of this balance may be owing to deactivations of the amygdala—we are less likely to experience negative thoughts as we age, and less likely to be fearful. The amygdala is responsible for detecting and responding to threats, and these can result in the secretion of chemicals throughout the brain (norepinephrine, acetylcholine, dopamine, serotonin) and body (hormones such as adrenaline and cortisol). Although you may know older adults who are fearful and emotionally unbalanced, this is not the statistical trend. (It may also be due to comorbidities such as Alzheimer’s or dementia, or just natural individual differences, and a few personally vivid cases don’t negate the overall trend toward better emotional balance.)

Socioemotional selectivity theory states that as we age, we become increasingly aware of our shortening future time horizon. This awareness leads us to prioritize emotional meaning, emotion regulation, and well-being. There is also a developing positivity effect—older adults pay more attention to and remember more positive experiences than younger adults do. Together, these may help buffer against declines in objective well-being and lead to initial increases in subjective feelings of well-being and positivity in older adults.

Self-efficacy

The Bucharest study of orphaned children showed us the critical role of socialization on brain development in early life. But the brain is constantly changing, not just during infancy. This makes me think about how social experiences and family life impact the brain at the other end of the life span. Old age often brings retirement and (hopefully) the independence of our children, and with that comes an important psychological change: We are no longer responsible for performing a particular function within an organization or in society. That loss of a sense of responsibility can lead to a more global loss of a sense of agency—a sense that what we do in the world matters, and that we matter to other people. A belief that we can exert some control over our environment is essential for our well-being and is believed to be a psychological and biological necessity. This environmental control, and the ability to correct one’s own errors, is an important principle taught to young children in the successful Montessori method. If it is important for young children, perhaps it is also important for older adults.

Think about nursing and retirement homes, what we used to call “old age homes.” In many cases, the staff do everything that residents formerly did for themselves, such as cooking and cleaning. Setting aside those individuals who can’t do things for themselves, because of mobility problems or dementia, a number of individuals who could be doing things are encouraged not to, encouraged to “relax and take it easy.” The message that many older adults hear from this is “You are not capable; you no longer matter.” The debilitated condition of many older adults in these facilities may result, at least in part, from being encouraged to live in a decision-free environment. Is this condition reversible?

A landmark study in the 1970s explored choice and responsibility in a nursing home. Half of the residents were given a potted plant and told that the nursing staff would water and care for it. The other half were first given a choice of whether they wanted a plant or not and, if they said yes, were told it was their responsibility to take care of it. This simple, almost trivial-sounding intervention had dramatic consequences. The residents who had even this small amount of choice and responsibility, for a houseplant, were happier and more active. They spent more time visiting with others and talking to staff. They were significantly more alert.

Albert Bandura (now ninety-four years old, and a professor at Stanford who published three major scientific articles in the past year) uses the terms agency and self-efficacy to describe the belief that one can exert control over one’s environment. The higher people’s sense of self-efficacy, the higher the goals they set for themselves. A sense of control is a basic necessity of psychological life. Individuals who perceive that they lack control over their environments may seek to gain control in any way possible, potentially acting out, breaking the law, lashing out at loved ones, or developing eating disorders. Remember that mysterious structure, deep inside the brain, the putamen? People who receive something desirable show great activity in the putamen when they choose the reward rather than having it simply given to them. Choosing, that is, exerting control over one’s environment, activates the brain’s reward system. That’s true even when the choice occurs during a stressful situation, in a “lesser of two evils” context. The very fact that we have options that we can decide to act on seems to reduce stress responses in the brain and can lead to healthier brains as we age.

Closely related to the ideas of choice, control, self-efficacy, and agency is the idea of functional autonomy—are we really free to do what we want? As we age, by necessity we tend to increasingly rely on others as our abilities gradually fade or, in some cases, collapse. My grandfather loved doing his own handyman work around the house—he had built the house, acting as the general contractor, plumber, electrician, and everything else. But by age sixty-two, he found himself calling the plumber to make even minor repairs. He was tired of trying to squeeze into tight spaces or hoisting himself up into the attic. His back hurt. He didn’t have the dexterity in his hands that he used to. In that moving letter to the family that he wrote shortly before he died, he bemoaned and regretted this change in his attitudes and abilities. He felt less like himself. These kinds of shifts are natural. But research shows that, as we age, our friends and family play a critical role in this unfolding story. If the people around us support and encourage our autonomy, we will tend to do better. If we are surrounded by people who discourage our autonomy and try to convince us that we shouldn’t be doing things we’ve always done, our lives can quickly go off the rails. I helped him with the repairs, and my grandfather delighted in having skills he could impart to a future generation.

Of course, there are cases when we must intervene and discourage autonomy in our loved ones. My mother’s mother, battling Alzheimer’s at ninety-five, nearly set fire to her apartment several times by leaving things on the stove and forgetting about them. She forgot to clean. She could no longer live autonomously. After much deliberation and consultation, my mother brought her to a residential home for the aged. It was a good one—the staff there let her make every decision that she was capable of and boosted her autonomy rather than disparaging it. She didn’t get to decide when to eat; that was programmed. And she didn’t get to choose her room in the facility. But she could decide what to eat, where to go, and whom to spend time with. She died in her sleep of unrelated problems at ninety-six, but she had friends in the home and, even in her state of advanced dementia, found some enjoyment in her final year.

There is a trend in the United States toward assisted living (AL) facilities, in which adults typically have their own apartment, and the level of attention and care provided is custom-tailored to the individual, with an emphasis on autonomy. They are hospitality oriented, featuring on-site pubs, swimming pools, and gyms.

They give people socialization opportunities that wouldn’t be available living at home. The problems facing ninety-year-olds are the same at home or in AL, but AL solves many of them. Someone helps them get dressed and then they go to the pub to have a beer.

Work

Walter Isaacson notes that the greatest creativity comes out of associations with others, the kinds of cross-pollination we get from talking to other people with interesting ideas. Da Vinci created his most famous works, The Last Supper and the Mona Lisa, after moving to Milan and being surrounded by people from a variety of endeavors and disciplines—1470s Milan was teeming with creativity. Benjamin Franklin created a club in Philadelphia in 1727 (when he was only twenty-one), the Leather Apron Club, that brought together people of different backgrounds and perspectives for conversation and debate. He continued to stay socially active in this same kind of way to the end of his life at eighty-four.

The emerging picture is clear. When people retire, they tend to turn in on themselves. Then cognitive decline and mood disturbances can take hold. This is not true for everyone, but it is true for a great many. And as depression seeps in, at first unnoticed, it comes on so gradually that we don’t do anything about it while we still have our wits about us and our will to change. Later, someone close to us notices the change in our demeanor, our spark, and it becomes an uphill battle to try to fix it. Retirement from most jobs means a rapid shrinking of the number of people we come into contact with, and the sense that we are engaged in meaningful work.

There are exceptions. Sonny Rollins, the great jazz saxophonist, is one. At age eighty, he moved out of his home in New York City to upstate New York with his girlfriend, “where we were safe from having anybody come by and ring our bell.” For people who are constituted like Sonny, social interaction can be stressful and unhappy making. And although he retired from playing the saxophone in 2013, after being diagnosed with pulmonary fibrosis, he stays active. He spends his time doing yoga, singing, and reading deeply in Eastern philosophies. After a lifetime of touring and meeting thousands and thousands of people, Sonny seems to find joy in solitude. Not everyone finds socialization exhilarating.

But for most of us, the best advice is, don’t stop working. Freud said that the two most important things in life are healthy relationships and meaningful work. There are no controlled experiments on this, no studies in which older adults were randomly assigned either to keep working or to retire—all we have are anecdotes. But the anecdotes are impressive, from Ralph Hall, a Texas Democrat who served as a member of Congress until age ninety-one, to Mastanamma, a woman in India who died last year at 106 years old and whose YouTube cooking channel has more than 1.3 million subscribers.

Or Anthony Mancinelli of New York, who, until his death in September 2019 at age 108, was the world’s oldest living barber, and who still came into work every day to cut hair. His manager at the barbershop had said, “He never calls in sick. I have young people with knee and back problems, but he just keeps going. He can do more haircuts than a twenty-year-old kid. They’re sitting there looking at their phones, texting or whatever, and he’s working.” In a 2017 interview, he said that he continued to work because it helped him stay busy and upbeat after the death of his wife of seventy years, Carmella, fourteen years earlier. (He would visit her grave every day before work.) What he didn’t say was that barbering is a social occupation. He was talking with customers all day, and with co-workers.

Navigating the complex mores and potential pitfalls of dealing with another human being, someone who has their own needs, opinions, and sensitivities, is about the most complex thing that we humans can do. It exercises vast neural networks, keeping them tuned up, in shape, and ready to fire. In a good conversation, we listen, we empathize. And empathy is healthful, activating networks throughout the brain, including the posterior parietal cortex and inferior frontal gyrus.

Imagine what it must be like to live a long and rich life, to feel valued and to contribute to society, and then suddenly be taken out of the loop. This is what happens to older adults all over the world in countries that have compulsory retirement, such as Brazil, China, France, Germany, and South Korea. I find this sad because in every domain of human endeavor, there is still a lot to do, and so many able-bodied and able-minded people with experience and wisdom to help us do it. Older people may be a bit slower and may have need for certain medical accommodations, but younger people are more impulsive, lack experience, and have not yet acquired the pattern-matching skill that comes from a lifetime of using their brains.

Spain, Australia, the United States, and the United Kingdom have outlawed compulsory retirement, but that doesn’t mean that ageism has been eradicated. If your company downsizes or goes out of business and you’re seventy years old, even in one of these countries it can be difficult to find a new job. It’s even difficult after fifty.

There is no shortage of role models for people to keep working. As the number of people over sixty-five soars past 1 billion this year, and the number of people over eighty is now 125 million, we should be looking to expand the number of people who serve as role models to the point that they become the norm.

A few days ago I had a structural engineer over at the house to look at the foundation. (I live in California, in earthquake country.) He was seventy-five and no longer able to crawl around tight spaces or climb up on roofs, but my house was no problem for him. He had been to this house several times, going back long before I owned the house, and his memory for it and knowledge of the surrounding terrain was incredible. An inspector one-third his age had come by the house a year earlier and it took him twice as long to do the job, and he was not nearly as thorough.

Louise Slaughter was a Democratic member of Congress who died in 2018 while still representing her New York district at age eighty-eight. Betty White is still acting in television at age ninety-seven, with recent appearances on Bones and SpongeBob SquarePants. Brenda Milner, one of the towering figures in neuroscience, still comes to work every day at the Montreal Neurological Institute at age 101. At eighty-six, US Supreme Court justice Ruth Bader Ginsburg returned to work less than a week after breaking three ribs. Congresswoman Maxine Waters, who represents the Forty-Third Congressional District in Los Angeles, California, is serving her fifteenth term in the House at age eighty-one. She captured the attention of the entire country in 2018 and 2019 as the chair of the House Financial Services Committee. While she draws the praise of Democrats and the ire of Republicans, everyone on both sides of the aisle regards her as calm, collected, powerful, and brilliant. Love her or hate her, she is a force to be reckoned with. And she prides herself on reaching across generations. “We moan and groan all the time about a lack of involvement of young people,” she said. “But they have taught me a lot about what moves them. It seems like all they are looking for is some honesty and some truth and somebody that they can believe in.”

Engaging Yourself with Others

Aging has beneficial effects on our social behavior. Older adults in general (I know you can probably think of exceptions) are better at emotional regulation; they are better able to control their feelings, are less reactive to insults, and pay more attention to the positive things in their lives. Art Shimamura describes it this way:

One explanation for this maturity is that through decades of social interactions, older adults have confronted the good, bad, and ugly of how people deal with one another. As such, they better understand that choices can be made concerning how we behave and how healthy living is best achieved by focusing on the positive side of life. This positivity bias adheres to the saying, don’t sweat the small stuff, and is important for psychological well-being as life is too short to worry about minor annoyances.

Social engagement helps to maintain brain functions and protects against cognitive decline. Epidemiological studies find that having a large social network and more daily social contacts is significantly protective against dementia. This is true even when other factors, such as age, education, and initial health status, are controlled. Even the likelihood of dying is reduced by engaging in social activities. All this applies only to positive social engagements, however. Abusive, distressing, and otherwise bad social engagements, of course, can increase stress and be harmful.

A recent meta-analysis of seventy-six separate studies concluded that there is an urgent need to identify lifestyle activities that reduce the functional decline and dementia associated with an aging population. Volunteering appears to be one such activity. Volunteering at a local organization, community center, or hospital can have all the benefits of continuing to work: a sense of self-worth and accomplishment, and the daily interaction with others that causes the brain to light up. The data reveal that volunteering is associated with reduced symptoms of depression, better self-reported health, fewer functional limitations, and lower mortality. In the United States one-quarter of people aged sixty-five and older volunteer, and in Canada, more than one-third do (yay Canada!). By even a conservative estimate, such volunteering worldwide contributes almost half a trillion dollars to local economies. Volunteering is an essentially altruistic undertaking, and altruistic acts by seniors—by all of us, really—are associated with better physical and mental health.

Volunteers in a controlled study showed improvements in the ability to switch between two task sets and in verbal learning and memory, and brain scans showed significantly increased activity in the prefrontal cortex—the seat of higher reasoning and executive function. Volunteering in management or committee roles was related to greater positive emotions, but only for women. Why? We’re not sure. Maybe women developed better communication skills ten thousand years ago, keeping the campfire burning and taking care of the children while the men were out silently hunting.

Recall from Chapter 4, on the problem-solving brain, that the more complexity there was in the primary occupation you had while working, the more likely you will be protected from cognitive decline in old age. Complexity includes things like making decisions in a changing landscape of options, interacting with other people, and learning new things—basically jobs that cannot simply be done on autopilot. There is very little research on occupational complexity among volunteers, but since volunteers are essentially performing many of the same functions as paid workers, it is reasonable to infer that this relationship between complexity and benefit holds, as long as we acknowledge that there are probably optimal levels of complexity beyond which any job, even a volunteer one, just becomes annoying.

Of course, not all volunteering is beneficial. If you’re stuck in a windowless room balancing a nonprofit organization’s accounts and you don’t get to move around or interact with anyone, there will be limited benefits, if any. Ideally, you’ll find a position that matches your physical, social, and cognitive abilities, stretching them a bit, perhaps, but not to the breaking point. It can be helpful to talk with a friend or family member to make sure that the requirements of the volunteer position are a good fit with your goals and aspirations.

Surround yourself with people who are better than you at something but who don’t lord it over you. When I began performing music professionally forty-five years ago, I made a promise to myself that I would never appear on a stage unless I was the worst musician on it. I’m happy to say I’ve never been disappointed, and every performance has been a wonderful learning experience for me. Spend time with people who encourage you to grow, to explore new things, and who take joy in your successes. Try to find social situations that respect older adults and a role that allows you to contribute your accumulated knowledge and wisdom to a community organization whose goals you admire. And when you can, go outside. Go outside. Go outside.