A PRESCRIPTION FOR THE FUTURE

‘Is there a prescription for growing old without being old?’ I am often asked this question, and it always makes me feel a little uncomfortable. I do not have a simple prescription that would prevent, solve, or alleviate the impairments associated with old age. There is no miracle cure, and it is not likely that there ever will be. The causes of the damage that arises due to the ageing process are simply too complex and multifaceted.

How different that is from the message we get from the anti-ageing industry. It makes convenient use of what we all want to hear: that the ageing process can be prevented, or at least slowed, by using the product being touted.

There are countless special diets that ‘gurus’ claim can keep you young. There is, however, no evidence for their claims. Fortunately for us, the quality of our food is better than ever before, in the sense that it is not contaminated, toxic, or rotten. Many harmful ingredients have been banned by law. The problem we face today is that we consume too much of some substances and too little of others. Our food often contains too much salt, fat, or sugar, and many of us do not eat enough fruit and vegetables. Nutrition is a complex matter, and experts have great difficulty in formulating precise guidelines. Their advice is highly subject to the vagaries of fashion. Remember the nineteen-eighties and nineteen-nineties, when we were confidently informed that every egg we ate took us one step closer to a heart attack. Now we are allowed to enjoy an egg for breakfast every day. Twenty years ago it was impossible to get hold of butter or bacon in an American hotel; whole grains in all shapes and sizes were the standard. Now, you see Americans tucking into their bacon and eggs every morning, and carbohydrates are the new bad guys. For now, the best advice seems to be to eat a varied diet that includes a little bit of everything. ‘Colourful eating’ is the new buzzword.

Should we then just sit round idly, waiting until it’s time for our final curtain call? Of course not. We can change our lifestyle at any time if it is negatively affecting our health. It is never too early and never too late to start. So why does it go wrong so often? Why are we too fat, why do we drink too much, cycle too little, and stubbornly refuse to give up smoking? Presumably, people underestimate the extent to which the environment we live and work in impacts on us. Advertisers constantly send out massive stimuli to influence our behaviour in a particular direction — often the wrong one. Take electric bikes, for example, the new must-have gadget among older people, which have been promoted massively in many developed countries. But why not just keep cycling the normal way, pedalling under your own power until you get tired? The adverts have the answer: ‘Why tire yourself out pedalling when you can buy an e-bike?’ Unless you use an e-bike instead of taking the car, it stops you from doing what you should: taking active exercise. Riding a real bike requires exertion, but you get a lot in return: health benefits from the positive stress on your heart, lungs, muscles, and joints, as well as an adrenaline rush. If there is one thing that researchers agree on, it is that a sedentary, inactive lifestyle should be avoided at all costs.

It is becoming increasingly clear to researchers that we can influence our behaviour positively by making small changes to our environment. Positive stimuli play a significant role in this. The success of Weight Watchers, for example, is due to the fact that it is not based on punishing its members for being too fat, but on rewarding them for reaching their target weight. Such positive stimuli can easily be integrated into our daily lives, making good habits easier to keep up, and increasing the overall beneficial effects. Research has shown, for example, that employees are willing to take the stairs when the lift is blocked. Scandinavia is the frontrunner when it comes to making such changes in the workplace. High desks and conference tables are installed in offices, forcing workers to stand, and so break the cycle of a sedentary existence. This also results in shorter, more efficient meetings, and lowers employees’ risk of developing cardiovascular disease.

Another example is what happens in a railway station. When the escalator is broken, everyone walks up the steps. If the escalator is working, nobody bothers to climb the stairs themselves. But when some station steps in Stockholm were transformed into giant piano keys that played a note when stepped on, everyone suddenly used the stairs rather than the escalator. This is what researchers call ‘serious gaming’: actively enticing people to engage in healthy behaviour by challenging and rewarding them. The extraordinary growth of the Internet and computer technology means there is still a world of benefits to be gained using such creative ideas to promote healthy behaviour in both young and old.

The most important key to health gains lies in our everyday surroundings. That is why doctors and researchers need to develop new public-health policies. They must use the same weapons as advertisers and promoters do to influence our behaviour. If you are confronted with vegetables at eye level when you open the fridge door, you are more likely to eat them than if they are hidden in the lower drawer. If you see cans, processed meat, and cheese, you will grab them first. These are precisely the tricks that supermarkets use to entice us to buy certain products.

A similar effect applies to the utensils we eat with. Almost without our noticing, the plates we eat from have increased in size over the past few decades. If you happen to come across your grandmother’s dinner set, it is astonishing to see the ‘saucers’ they used as plates. Our wine glasses have become downright enormous. Experiments have been carried out in which large plates were replaced by smaller crockery, while nothing else was changed. The result was the people ate less and lost weight. People also eat less when they use smaller cutlery. If you have to do more spooning, you eat less soup. Not out of laziness, but because you feel full more quickly.

We have only a very patchy idea of the stimuli in our surroundings that prompt us to engage in healthy behaviour, and those that lead us down the wrong path. Much research still needs to be done into this area. In many households, for example, the dining table has ‘disappeared’, and the kitchen is left unused. Fast food, the couch, and the TV have taken their place, especially in families with an obesity problem. How would eating patterns change if the dining table were returned to use?

When it comes down to it, there is no way to prevent impairment to our bodies and brains. In the preceding chapters, I have shown the possibilities currently offered by medical technology and biomedicine for prolonging our functional life. Whatever impairments we develop after the age of 50, they are increasingly repairable. Medical technicians are chomping at the bit to come up with new hips, valves, and lenses. They are busy developing implantable devices to support a faltering heart, and perhaps one day even replace it. Fatal bleeding can be prevented by putting ingenious plastic pipes into dilated blood vessels. It will not be long before we all have a new little microphone implanted in our ear as soon as the built-in one we were born with fails due ageing.

Medical biologists are also busy. We are likely one day to solve the riddle of the hydra — endless regeneration from stem cells. The first step has already been taken. Patients whose bone marrow has been depleted by disease or chemotherapy can already be given new bone marrow made from embryonic stem cells taken from umbilical-cord blood. Scientists are also working on reconstructing the retinas of those who have lost theirs due to diabetes, for example. The possibility of rebuilding damaged gut tissue using deep-layer stem cells shines on the distant horizon.

This may all sound like science fiction, but all such solutions sound unlikely until a breakthrough comes. Before penicillin was available, half of those who contracted pneumonia died. No one thought a solution to the problem was in sight. This is unimaginable to us today. Medical breakthroughs will continue to happen. But no one knows exactly when.

There comes a moment for everyone when life is almost over and there is no point in tinkering with it any longer. Some people say they want to avoid that decline. They want to take action to allow them to end their lives at a moment of their own choosing. It is noticeable that more and more people are expressing such thoughts at an ever-younger age. This is because they prize an ‘unrestricted’ existence, and do not want their lives to be slowly ‘skimmed off’; and it is also because old people are considered undesirable in our current culture.

But are the physical and mental limitations of blind or deaf people, for example, really a disaster always to be prevented? Experience teaches us that most older people do not (want to) take that decision when the time comes. Unfortunately, loved ones and professionals do not always react correctly to increasing impairment. All too often, physical dependency is seen as sufficient reason to write someone off as non-active and to take over control of their lives. This robs a person of their independence and dignity.

In the final, vulnerable stage of their lives, in particular, vitality is necessary if older people are to make their day-to-day life enjoyable. This is all the more true of people who are less able to look after themselves, for whatever reason. In that case, they need someone — a loved one or a professional — to help them fulfil their wishes and meet their needs.

Fortunately, most older people are able to run their own lives. Their failing bodies are then ‘merely’ flaws they can easily live with. Since many older people no longer see their physical, and often also their mental, limitations as a burden, they feel ‘unbound’.

The real answer to the question of how to grow old without being old lies in our own social and psychological flexibility. Old people show us that. Again and again, I am struck by older people who have managed to retain their vitality and sense of wellbeing, despite impairment and limitations.

Aafje is just such a person. At 96, she is a phenomenon. She can often be seen riding around the neighbourhood where I live on her conspicuous scooter, which she handles with skill. You can see her outside the nursing home, or sipping an espresso on the café terrace. At the baker’s she chats with the other customers in the queue. On many occasions I have seen her whizz by in a taxi, a woman on a mission: to get her hair done.

I have also met Aafje a couple of times in my professional capacity. Not that she came to my surgery with a medical complaint; she came to tell people how best to get old. At the Leyden Academy, we organise meetings with older people as part of our course for care professionals. These carers often focus on organisation rather than on the old people they care for. Aafje was one of the ‘experience experts’ invited to come and tell the course participants how old people can deal with loss, illness, and impairment, and a stiff and leaky body, and still run their own lives and retain their dignity. She had lost her husband and had had to move out of her ‘gorgeous’ house. She was no longer able to live alone at home, despite the army of helpers she had drummed up. Dressing and undressing — let alone getting in and out of the shower — were no longer possible without help. However, with her mischievous smile and her freshly coiffed hair, Aafje made a fragile but unforgettable impression. ‘Let it go,’ she told us. ‘You have to let it all go.’