14

Living Better

The greatest days of our lives

If I had known I was going to live so long, I would have taken better care of myself.

—Psychological scientist Eleanor Maccoby, on turning one hundred

At my age, the most embarrassing thing I’ll ever do is probably something I’ve already done.

—David Bradley, actor (Harry Potter, Game of Thrones), age seventy-seven1

There is an ancient story about the tension between longevity and quality of life. According to Greek mythology, Eos was the goddess of the dawn. Every morning she rode on a purple chariot drawn by two horses, wearing a saffron-colored robe, to bring in the day. She fell deeply in love with the mortal Tithonos, the prince of Troy. As a goddess she was immortal and couldn’t stand the thought that Tithonos would eventually die and she’d have to spend eternity without him. She implored Zeus to grant immortality to Tithonos, and Zeus agreed. But Eos didn’t think to also ask for the gift of youth that she and the other gods and goddesses enjoyed. While Eos stayed eternally young, Tithonos became an old man, decrepit, lacking even enough strength to move his legs. He continued to age until he eventually lost his mind. She moved him out of her home and put him in a chamber by himself, where he continued to live mindlessly and infirm. Immortality and youth are not the same thing.

Philosopher David Velleman suggests that we consider two hypothetical lives that represent possible extremes.2

One life begins in the depths but takes an upward trend: a childhood of deprivation, a troubled youth, struggles and setbacks in early adulthood, followed finally by success and satisfaction in middle age and a peaceful retirement. Another life begins at the heights but slides downhill: a blissful childhood and youth, precocious triumphs and rewards in early adulthood, followed by a midlife strewn with disasters that lead to misery in old age.

Now imagine that we could somehow manage to quantify what we mean by deprivation, trouble, struggles, triumphs, rewards, success, and satisfaction. We’d simply assign numbers to these different experiences and tally them up. (You could choose how fine a resolution you want: Was this a good year? A good week? A good day or even a good minute?) Next, imagine that we did this across the life span and compared two lifetimes of exactly the same duration, but with the good times and the bad times distributed differently, as in the story Velleman tells. Numerically, the lives might be identical—that is, the number of bad episodes or moments in each are equal, and so are the number of good episodes or moments in each. If a good life is one in which the good outweighs the bad by a certain amount, and if well-being were simply additive, then these two lives should be seen as equally desirable. But that is not how most people look at it. Given a choice, most people would prefer the life that takes the upward trend and we’d consider the person with that life the more fortunate.3

What Daniel Kahneman found about pleasure and pain—that people were willing to endure pain longer if the ending was relatively pleasant—was found in the narrow context of painful medical procedures, such as colonoscopies. Does this same principle apply to life itself? Psychological scientist Ed Diener found that it does. Diener started with the following straightforward question: Do additional years of lower quality among elderly people enhance or detract from their perceived overall quality of life?4 In other words, he investigated whether people judge it better to have a shorter life that ends on a high note versus a longer life with an end that is marked by misery and discomfort. He also considered that how close a person is to the end of their own life might influence their judgments.

A happy life that ended abruptly was considered more desirable than a happy one with five extra years tacked on at the end that were merely pleasant but not as happy as before. In contrast, a terrible life was considered more desirable if it was longer, provided the last five years—although still unpleasant—weren’t as terrible as life had been before. The same results were obtained from older adults and younger adults, indicating that as the end is near, people still don’t see longevity as the only goal. The study confirms the “end point” effect found by Kahneman. (From a strictly statistical view, these findings are irrational. In a real, numerical sense, the people with good lives who lived longer lives actually experienced more pleasure in their lives than the people who lived shorter lives.) Diener called this the James Dean effect, after the actor who died suddenly at age twenty-four at the height of stardom.

Velleman’s explanation about why we prefer an improving life to a declining one isn’t because we place greater weight on what happens at the end, but because later events can alter the meaning of earlier events. This may derive from our yearning to instill life with meaning. We are drawn to the story of someone who sees the error of their youthful ways and grows, someone who becomes a better person. This makes for a more satisfying trajectory, a more inspirational and aspirational theme, than someone who goes in the opposite direction. When we have the good times and the bad times actually matters. We’re sensitive to the timing of events because we seek patterns in the world around us—including our lives within it.5 A particular success can mean that one’s frustrations are finally over, or it can foreshadow a slump we didn’t see coming, depending on when it happens in our timeline. And that event’s perceived meaning depends very much on the events that happened before and after it.

Taken together, these studies suggest that quality of life is important to consider, not just longevity, and that it may even deserve some of the resources that are being put into longevity research. I raised this idea with the Global Burden of Disease charts, showing that the things people die from (heart disease, cancer) tend not to be the things that impact quality of life (disability, pain, hearing loss, vision loss). Add to that the fact that the medical profession tends to focus on saving lives and cures, with relatively less attention paid to the sequelae of disease—the “What next?” question. This has become such an issue that the journal Nature published an editorial urging researchers to study the long-term effects of therapies that are taken for granted.6 As one example, they tell the story of Gregory Aune, who was treated for Hodgkin’s lymphoma at age sixteen with a combination of drugs and radiation. He saw many of the patients in his ward die. Now forty-six, he has had to deal with hypothyroidism, diabetes, skin cancer, infertility, open-heart surgery, and a stroke, all tied to the treatments he received. Now a pediatric oncologist, he is pushing for more awareness of the aftermath. “The toxicity of the treatment has hung with me,” he says.

Moving in this direction, the World Health Organization has introduced a measure called healthy life expectancy (HALE) that tracks how many years a person lives without significant impairment, defined by objective criteria such as the ability to work, walk, dress, converse, and remember.7

Not everyone agrees with me about the value of balancing longevity and quality of life—some just want to stay alive no matter what. But I think that life endings should be surrounded by positive events and memories and should be as free as possible of physical and psychological pain. Three of my grandparents experienced this gift—they went quickly, enjoying life, and without knowing what hit them. One of them died in a hospital and couldn’t wait to leave this mortal coil. “I feel like a pin cushion in here,” she said, of all the times that nurses came and poked her with needles. Her days were bleak, as she no longer enjoyed her mealtime and didn’t have the energy to enjoy visits from her grandchildren. I am not sure that medicine served her well. And yet I am grateful for the extra months I got to spend with her and know her better, but my happiness is not the issue—hers is.

Well-Being and Happiness

We can change the conversation, throughout society, about what it means to be an older adult. We often look at old age as a time of limitations, infirmities, and sadness. Of course, it’s true that as we get older there are a number of things we don’t do as well as when we were younger. But that doesn’t necessarily mean that all older adults are sad or depressed. Some certainly are, but as a group, they are actually happier than younger people. Happiness tends to decrease beginning in the late thirties (midlife crisis, anyone?) and then begins to increase sharply after age fifty-four. This holds true across seventy-two countries, from Albania to Zimbabwe.8

You might spin a story about this happening because of social factors. As Daniel Pink says about the middle-aged dip:9

One possibility is the disappointment of unrealized expectations. In our naïve twenties and thirties, our hopes are high, our scenarios rosy. Then reality trickled in like a slow leak in the roof. Only one person gets to be CEO—and it’s not going to be you. Some marriages crumble—and yours, sadly, is one of them …. Yet we don’t remain in the emotional basement for long, because over time we adjust our aspirations and later realize that life is pretty good. In short, we dip in the middle because we’re lousy forecasters. In youth, our expectations are too high.

Or maybe it’s Velleman’s explanation again: As a species, we are driven to make sense of our lives. Looking back, we find happiness in seeing that whatever inevitable struggles we had brought us to where we are now. Even if things have taken a downturn, we are happy to be alive and to have had whatever good experiences we had. Yes, we would prefer to have things get better, but we recontextualize and recast our lives in a positive way. This is consistent with and predicted by Carstensen’s socioemotional selectivity theory (as we saw in Chapter 6, on life with people). They live differently than younger adults, spending more of their available time doing things they like. No wonder they’re happier than forty-year-olds who are doing things they don’t like in order to get ahead in life so that they can eventually (they hope) enjoy the fruits of unhappy labor. In addition to this, older adults show a positivity bias—they are much more likely to attend to and remember positive stimuli and experiences. The positivity bias has been found in a number of different contexts, including short-term memory, autobiographical memory, attention to positive emotional faces, recall of positive facial expressions, memory for health information, and the positive interpretation of emotionally ambiguous situations.10

What might be the brain basis for the positivity bias? Carstensen believes that it is caused by top-down (volitional) changes in motivated cognition that shift priorities toward emotionally satisfying goals. Indeed, two areas associated with selective attention and these kinds of motivated cognition are the ventral-medial region of the prefrontal cortex and the adjacent anterior cingulate cortex.11 These areas have been shown to be especially active in older adults, and this may be contributing to older adults’ positivity and well-being.

I mentioned Sonny Rollins, one of the greatest living jazz musicians, in Chapter 6, on life with people.12 He lost his ability to play his instrument a few years ago due to pulmonary fibrosis. In a career spanning seven decades, he has played with the greats—Miles Davis, Dizzy Gillespie, Thelonious Monk, Bud Powell, and Max Roach—and he has recorded more than sixty albums as an acclaimed bandleader. Now that he is eighty-nine, you might expect that his health problems have caused him sadness or frustration, but when we visited, I found him to be remarkably content, philosophical, and upbeat, and focused on quality of life rather than length of life. According to Sonny Rollins:

The purpose of life according to Buddhists and other people that think like that is we live and we learn. We keep learning. It doesn’t mean anything to me, if I lived 144 years. It’s not about 144 years. If I learned everything that I need to advance in Buddhahood or anything like that, where you’re really becoming a more enlightened person … that’s what we’re here for … enlightened soul. We go through who knows how many lives? I don’t know. I don’t try to contemplate that. That’s not my business. People tell me oh Sonny you think about these things a lot—what’s heaven like? And I tell them look, don’t waste my time. That’s not my business what heaven is like. My business is right here on earth. Trying to be a better person, trying to do things which would make other people happy, which as I’ve said makes me happy by making other people happy. That’s what it’s about. This other stuff it doesn’t mean anything. At least that’s my way of thinking. That’s what Eastern philosophy is about. I think I’m happier now than I … I have much more understanding.

Social Comparisons Influence Satisfaction

One of my students, a refugee from Romania who settled in Canada, shared this story with me:

My first encounter with the topic of quality of life was early in my childhood. I was playing with a group of local children in a small Romanian village when a team of North American missionaries approached us and pulled me aside to ask me about what they assumed to be the miserable, poverty-stricken lives of me and my friends. They looked at us dirty, barefoot children with pity, and my friends and I looked back at them with confusion—we couldn’t understand why these foreigners looked so concerned. We didn’t think anything was wrong. One could argue then, that perceived quality of life is more important to an individual’s well-being than objective measures of quality of life.

Social comparison theory states that our life satisfaction tends to be influenced not so much by what we have but by what we have in relation to others. That is, we look to see how others are living, such as whether they have shoes or have fewer aches and pains—and we judge ourselves in comparison. We are a social species, and we are attuned to fairness. If we see others who have things we don’t, like shoes or good health, we feel cheated. If no one we know has shoes or good health, we just think to ourselves, “That’s life.” At eighty-nine, Sonny Rollins is doing well compared to almost any of his jazz contemporaries. Most are dead and suffered from more debilitating health problems than Sonny.

Measuring Quality of Life and Happiness

Happiness is a personal perception, and its determinants differ vastly across cultures. Most quality of life indexes combine objective measures, such as health, independence, standard of living, and security (e.g., freedom from crime), with subjective measures, such as a person’s own self-assessment of their satisfaction about a number of key components of their lives—freedom of choice, social relationships, romantic relationships, meaningful work, and mood.13

You might assume that everyone aspires to more happiness—that is, given the choice, people would want to have the maximum amount possible of something good. But that view is a biased one, held by people who live in individualist societies such as Europe and North America. For people from collectivist and holistic societies—where contradiction, change, and context are emphasized—ideal states of being for the self are more moderate than in other cultures.14 This approach might be called the moderation principle, under which people impose mindful ceilings on how much of a good thing they aspire to in a perfect world. Although he is living in New York, this is the view taken by Sonny Rollins and, in fact, by followers of Eastern philosophies and religions, such as Buddhism, Confucianism, Hinduism, Jainism, and Taoism. You may recognize the similarities with Aristotle’s principle of the golden mean (neither too much nor too little of a thing).

Westerners tend to see happiness and misery as opposites, and life as a challenge to minimize the negative and accentuate the positive. Easterners tend to see happiness and misery as interrelated and mutually necessary, like the yin and yang in Chinese philosophy. Indeed, studies of thousands of people have found that members of holistic cultures aspire to less happiness, pleasure, freedom, health, self-esteem, and longevity than members of individualistic cultures, although their goals for society at large are the same. Russia—which has a sociological history of being somewhat between an individualistic and collectivist culture—fell on the side of the Eastern cultures when included in this study.

Americans have been falling in the world happiness rankings over the past several years, according to The World Happiness Report.15 In their 2019 ranking of 156 countries, the United States dropped one rank to number 19 for its worst rank since the report began. “We finished nineteenth on the list behind Belgium,” comedian Jimmy Kimmel quipped.16 “The people who feel the need to put mayonnaise on their french fries are happier than we are. Cheer up, everybody!”

The report looks at six variables: GDP, social support, health span (not life span!), freedom to make life choices, generosity, and freedom from corruption. “By most accounts, Americans should be happier now than ever,” said Jean Twenge, one of the report’s authors.17 “The violent crime rate is low, as is the unemployment rate.” The authors speculate that the US ranking has dropped due to a spate of addictions—opioids, gambling, social media, and risky sexual behaviors—as well as the rise in obesity and major depression.18

The authors also blame overuse of digital devices.19 By 2017, the average seventeen- or eighteen-year-old spent more than six hours a day of leisure time—in addition to any time spent on schoolwork—on the Internet, social media, and texting, activities that have been linked to increases in depression. With increasing screen time, people became less likely to engage in face-to-face interactions, such as getting together with their friends or going to parties. There was also a decline in other non-screen-related solitary activities, such as reading and sleeping. Although we talk about how social media is bringing us closer to others and making the world smaller, digital devices weaken actual social contact in favor of some kind of amorphous and sporadic virtual contact.

Another part of this nationwide drop in happiness may be the rash of corruption convictions in the United States of people in high-level positions in corporations and in government in 2018 and 2019—freedom from corruption is one of the indexes in quality of life.

The longest study on health and happiness ever conducted is the Harvard Grant Study (now part of the Study of Adult Development). Begun in 1938, it tracked 268 male Harvard students and 456 controls from Boston for more than seventy-five years, without knowing how their life stories were going to turn out. (One of the study members was President John F. Kennedy.) Around 59 of them, mostly in their nineties, are still in the study, and researchers are studying their children and grandchildren and in the early 2000s began collecting data from the participants’ wives also. Psychiatrist Robert Waldinger, who now leads the study, summarized the findings this way:20

The clearest message we get from this 75 year study is this: good relationships keep us happy and healthier, period … social connections are really good for us … loneliness kills. People who are more socially connected to family, to friends and community, are happier, healthier, and they live longer. And loneliness turns out to be toxic …. High conflict marriages without much affection are very bad for our health—worse than getting divorced.

A bigger predictor than cholesterol level at age fifty for health at age eighty is the quality of your relationships.21 Good relationships protect your brain. Especially in their eighties, a person who feels they are in an attached relationship, where they can count on the other person in times of need, will retain sharper memories for longer and better overall health. The Beatles were right about this (and so many other things): Love is the most important thing.22 A second important pillar of happiness is finding a way of coping with life that does not push love away.

The study’s most important finding is the enormous impact of relationships, far larger than we ever realized before. A person could have a successful career, money, and good physical health, but without supportive, loving relationships, they won’t be happy.23 Men’s relationships at age forty-seven, the researchers found, predicted late-life adjustment better than any other variable, except ability to cope with setbacks (what he called defense mechanisms). Good sibling relationships loomed especially powerful: 93 percent of the men who were thriving at age sixty-five had been close to a brother or sister when younger. “It is social aptitude,” wrote George Vaillant, who directed the study for three decades, “not intellectual brilliance or parental social class, that leads to successful aging.”24 Asked what he had learned after thirty years of studying the cohort, Vaillant was clear: “That the only thing that really matters in life are your relationships to other people.”

At age eighty-five, one man in the study described the pleasure of his three-decades-long second marriage as “really just being together.25 Share each other’s lives and our children’s lives. Snuggle on cold nights.” One woman, after fifty years of marriage, said the secret was that they were best friends. “There’s a physical relationship. It’s not quite what it was when we were young, but the main thing is, I adore him. More than I ever did. We laugh a lot, we laugh at ourselves, and we don’t take ourselves too seriously. I don’t know how we got here, but it’s wonderful. Equally important, we hold each other loosely.” (If you love somebody, set them free.)

One interesting finding from the study is that those who married a second time were often just as happy as those who stayed in their first marriage. That is, people who divorce are not, as a group, malcontents who can’t work things out. In the 1960s and ’70s, many researchers thought that divorce was caused by personality disorders, poor coping style, passive aggression, acting out, aggression, and alcohol abuse. But that has not been borne out by research. Marriages fail for a variety of reasons, and often the simplest explanation is the most accurate: The couple were merely mismatched and didn’t realize it until later. And for many, their marriages just get better and better in old age. As Vaillant notes, “In time, hormones can feminize the men and masculinize the women, making the playing field more level.”26 Politics appears to correlate with late-life happiness as well, at least insofar as sex is concerned: Aging liberals have more sex, according to the Harvard study. The most conservative men ceased sexual relations at an average age of sixty-eight, while the most liberal men had active sex lives into their eighties.

Part of the Harvard Grant Study was a control group of inner-city men from Boston—the Glueck Study. Parental social class, IQ, and income did not predict longevity and happiness for either the Glueck or Harvard men. But education mattered a lot, and it didn’t have to be an elite education—at age seventy, the inner-city men who graduated from non-elite colleges were just as healthy as the Harvard men. Interestingly, while the Glueck men were 50 percent more likely to become dependent on alcohol than the Harvard men, the ones who did were more than twice as likely to eventually get sober.27 “The difference has nothing to do with treatment, intelligence, self-care, or having something to lose,” Vaillant says. “It does have to do with hitting bottom. Someone sleeping under the elevated-train tracks can at some point recognize that he’s an alcoholic, but the guy getting stewed every night at a private club may not.” Another interesting fact about alcohol use: Divorced people often say that they drink because their spouses left them. But this is self-deception: In the great majority of cases, the spouse left them because of the drinking.

It’s not just social connections late in life that determine happiness and other measures of life satisfaction. Although they’re crucial, they occur in a context of a lifetime of social connections. Men who had “warm” childhood relationships with their mothers earned an average of $87,000 more a year than men whose mothers were uncaring. (Wow! Thanks, Mom!) Men who had poor childhood relationships with their mothers were much more likely to develop dementia when old. Late in their professional lives, the men’s boyhood relationships with their mothers—but not with their fathers—were associated with effectiveness at work. On the other hand, warm childhood relations with fathers correlated with lower rates of adult anxiety, greater enjoyment of vacations, and increased “life satisfaction” at age seventy-five—whereas the warmth of childhood relationships with mothers had no significant bearing on life satisfaction at seventy-five.

Older couples often find the solution to loneliness in each other, after careers and children are a smaller part of their lives. It can require some effort to get to know each other again. Without that effort, old gripes or a “grass is greener” attitude can cause older couples to feel distant from each other and even seek divorce. In fact, according to the US Census, the divorce rate for couples over sixty-five has tripled in the last twenty-five years. But for those who make it work, the benefits are measurable: Couples who are more satisfied with their spouses have increased longevity—up to 25 percent.28 So there you go—the right romantic relationship wins you the double payout of increased longevity and increased quality of life. Science says so. Love the one you’re with. Making your spouse happy will help you live better.

Work versus Retirement

What is the ideal age to retire? Never. Even if you’re physically impaired, it’s best to keep working, either in a job or as a volunteer. Quincy Jones is in a wheelchair, but at age eighty-six he is still involved in producing music, discovering talent, giving speeches, and being a public spokesperson for the importance of the arts in society. Lamont Dozier, the co-writer of such iconic songs as “Heat Wave,” “Stop!29 In the Name of Love,” and “Reach Out, I’ll Be There” (and with fourteen number one Billboard hits), is seventy-eight and still writing. “I get up every morning and write for an hour or two,” he says. “It’s why the good Lord put me here.” Too much time spent with no purpose is associated with unhappiness.30 Stay busy! Not with busywork or trivial pursuits, but with meaningful activities.

Economists have coined the term unretirement to describe the hordes of people who retire, find they don’t like it, and go back to work. Between 25 and 40 percent of people who retire reenter the workforce.31 Harvard economist Nicole Maestas says, “You hear certain themes: a sense of purpose.32 Using your brain. And another key component is social engagement.” Recall Sigmund Freud’s words that the two most important things in life are to have love and meaningful work. (He was wrong about a great number of things, but he seems to have gotten that right.)

I interviewed a number of people for this book between the ages of seventy and ninety-eight in order to better understand what contributes to life satisfaction. Every single one of them has continued working. Some, like musicians Donald Fagen of Steely Dan (age seventy-one) and Judy Collins (age eighty), have increased their workload. Others, like George Shultz (age ninety-nine) and the Dalai Lama (age eighty-four), have modified their work schedules to accommodate age-related slowing, but in the partial days they work, they accomplish more than most of their younger counterparts.

Staying busy with meaningful activities requires some strategies and reshifting of priorities. Author Barbara Ehrenreich (age seventy-eight) rejects the many tests that her doctor orders because she doesn’t want to waste time in a doctor’s office for something that might only add three weeks to her life.33 Why?

Because I have other things to do. Partly this seems to start for me with the kind of trade-off decision: Do I want to go sit in a windowless doctor’s office waiting room, or meet my deadline, or go for a walk? It always came down to the latter.

Many employers will allow older adult workers to modify their schedules in order to continue working. In the United States, employers are required to make reasonable accommodations, such as start and end times, break rooms, even a cot to lie down on for a nap, and age discrimination is illegal.34 Age discrimination is similarly illegal in Canada, Mexico, and Finland. The laws around the world vary. Generally, the European Union permits termination at the pension retirement age (in Germany, for example, that’s currently age sixty-five and is being extended to sixty-seven). In South Korea the mandatory retirement age is sixty. In other countries, such as Australia, the laws and interpretations of those laws are evolving. (Courts in Australia, for example, found in favor of Qantas Airways, which terminated a pilot at age sixty. Although this was in violation of the country’s Age Discrimination Act of 2004, the high court ruled that because it was a requirement of the Convention on International Civil Aviation that captains aged sixty or over be barred from flying over certain routes, termination of pilots over sixty was lawful.)

Most important, I think we need to work together to fight for changes in the way our societies see older adults, particularly how they see them in the workforce. Corporate culture in the United States has tended toward ageism. It is difficult for older adults to get a job or get promoted. Two-thirds of American workers said they had witnessed or experienced age discrimination at work. Employers should recognize that offering opportunities to older workers is smart business, not just a feel-good, charitable act. Multigenerational teams with older members tend to be more productive; older adults boost the productivity of those around them, and such teams outperform single-generational ones. Deutsche Bank has been at the forefront of this kind of approach, and they report fewer mistakes as well as increased positive feedback between young and old.35

Many countries have passed laws prohibiting discrimination in employment against people with disabilities, including Alzheimer’s disease (e.g., in the United States the Americans with Disabilities Act of 1990, and in the United Kingdom the Equality Act of 2010). The BrightFocus Foundation, a nonprofit, lists the following accommodations among those that might be helpful for workers with Alzheimer’s:36

In recognition of this, Heathrow Airport in London became the world’s first “dementia-friendly” airport, with one thousand employees dedicated to serving the special needs of those with cognitive impairment, and special training for all seventy-six thousand airport employees.37 Researchers at John Carroll University, a private Jesuit university in University Heights, Ohio, created an intergenerational choir, bringing together young people and older adults with dementia.38 It changed the attitudes of the students, who talked about the closeness they felt in the choir and the development of intergenerational friendships. Through singing together, the adults with dementia felt included, welcomed, valued, and respected.

The late Tennessee women’s basketball coach Pat Summitt, who was also a silver medalist from the 1976 Summer Olympics, was diagnosed with Alzheimer’s in August 2011 and continued working, finishing out the athletic season through 2012.39 “There’s not going to be any pity party,” she said, “and I’ll make sure of that.”

If continuing to work in your job isn’t possible after a certain age, and if new employers aren’t willing to hire older workers, there are still many ways to stay actively engaged in meaningful work. I mentioned the Head Start program earlier—the organization that allowed my grandmother to come in and read to underprivileged children. The AARP Foundation has a program called Experience Corps, which matches older adults as tutors in public schools for economically disadvantaged children. The program has had a positive impact on the children in the ways you might imagine—improved literacy, increased test scores, and improved classroom and social behavior. It also has a positive impact on the volunteers. In one study, volunteers felt a greater sense of accomplishment than a group of control participants and had increases in brain volume for the hippocampus and cortex, compared to the controls, who had brain volume reductions.40 This was particularly true of male volunteers, who showed a reversal of three years of aging over two years of volunteering. As Anaïs Nin observed, “Life shrinks or expands in proportion to one’s courage.”41 It’s true of brain volume as well.

That courage, that expansion of life, can come about in a variety of ways for different people: taking classes online, such as from Coursera or Khan Academy (but be sure you interact with real, live people to discuss what you’ve learned; learning in isolation can only go so far in keeping your mind active); joining (or hosting) a book club or current events discussion group; volunteering in a hospital or church; asking your local YMCA or church what they need; working in a soup kitchen. There is a transformative effect in helping others. In his novel Disgrace, the Nobel Prize–winning South African writer J. M. Coetzee wrote:42

He continues to teach because … it teaches him humility, brings it home to him who he is in the world. The irony does not escape him: that the one who comes to teach learns the keenest of lessons, while those who come to learn learn nothing.

I have observed this firsthand in my own life, although I like to think that my students avoided learning nothing. And I am perhaps not so cynical as Coetzee (or at least his character in the novel). I think that the right teacher, the right believer in a child or an older adult, can tip the balance for that person’s life and help them to overcome life’s obstacles, to get on a track toward happiness and success that will lead them into successful aging. My teachers did that for me.

Continuity of Care and Quality of Life

As medicine becomes more automated, and as diagnostic technology has become more sophisticated and impersonal, there have been calls for reducing the personal relationship that doctors and their patients have enjoyed for centuries, in favor of patients seeing whomever is available and for short periods of time. In fact, the New England Journal of Medicine suggested that nonpersonal care should become the default option in medicine.43 This system has already been adopted, if not by plan, then by necessity, in many locations, including Montreal, where, until 2016, there was a severe shortage of doctors. In nearly twenty years of living there, I never had a family doctor because none were taking any new patients. I rarely saw the same doctor twice—not even specialists, and appointments rarely exceeded twelve minutes.

The alternative is the system that I have known the rest of my life, in which I develop a good working relationship with my doctors over time. A systematic review in the British Medical Journal confirms the superiority of this approach, finding that increased continuity of care leads to greater longevity, in studies spanning a variety of cultures and countries.44

A good example of this is the relationship I had with my ear, nose, and throat specialist, Dr. Meyer Schindler.45 My grandfather had seen him, and so had my father, meaning that he knew our family history firsthand, an important predictor of a range of possible conditions and diseases. When I first saw him, he was already old, but his two children had joined his practice and they would sometimes sit in on my examinations. Meyer continued working until he died, and then his sons, David and Brian, took over my care. I got a new family doctor about six years ago, and he is the most attentive physician I’ve ever had. He encourages me to phone him (on his cell) or to email him when questions come up. For the first time in my life I have a doctor who is younger than me, and so I am hopeful that he’ll be with me for a long time. As we get to know each other, I believe the quality of care I get will increase. If I’m hospitalized, or facing a major illness, he will coordinate the care with the specialists, serving as the conductor of the orchestra of care.

Dr. Eduardo Dolhun, a Mayo Clinic–trained physician and the head of the Dolhun Clinic in San Francisco, describes the ideal doctor-patient relationship this way:46

You want to have a doctor who knows you and your family, who knows not just your history but your personality, your habits, and hobbies—who knows how you live and how you spend your time. All of this informs medical decision making and making differential diagnoses. A physician who has to treat without this context is very much handicapped.

Context matters. If the environment can modify gene expression-epigenetics, then it stands to reason that the context within which a person lives is not only important, but critical to understand. The patient-doctor dyad is a dialectic that grows over time, and allows the doctor to more fully appreciate the subtle nuances of behavior and physiology that can signal disease or lack of health. The ability of the doctor to tap into this relationship allows him or her to potentially discover pathology and make early interventions to redirect or steer the patient out of disease and towards health. This is especially important in diseases like cardiovascular disease that generally take years or decades to manifest into a heart attack or stroke.

Increasingly, affluent patients are choosing to see specialists and forgoing a primary care or family physician. Yet, specialization tends to divide the patient into parts.47 It not only increases the cost of treatment but can result in different specialists working at cross-purposes with one another.

“I can’t overestimate the importance of the relationship between the patient and their primary care doc,” said Dr. David Brill, a family medicine physician at the Cleveland Clinic.48 “What we are rediscovering in the U.S. is that the best and most cost-effective medicine is what they practiced from 1910 to 1970: Patients had a relationship with their family doc.”

A movement is building to provide more customized care from family doctors, through what is called a patient-centered medical home.49 The concept is to provide

The patient-centered medical home might typically provide access to clinicians outside of normal practice hours, such as evenings and weekends; provide consistent nurses and care managers to follow up with patients after an office visit, to make sure they’ve gotten their medications and know how to take them, for example; keep track of when patients need to schedule appointments and when they need prescription refills; and monitor them if they’ve been hospitalized.

Doctoring is a difficult job and it’s easy for physicians to suffer from information overload, especially as they try to care for a new patient who is in distress. Here’s where the advantage of having a doctor who knows you and your history is made clear. Consider Dr. Gordon Caldwell, a consulting physician in Oban, Scotland (home of great single malt Scotch).50 During hospital rounds every morning, physicians have a short time to figure out what is going on with patients. He shared the inner dialogue going on in his head one morning for a ward-round review of a lady who seemed to have pneumonia and diabetes with very high glucose levels.

This is the sort of stuff going on in my brain whilst I consult with the patient. “Wow, she looks very thin and has clubbed tar-stained fingers, I wonder if she has lung cancer as well? Have I introduced myself clearly and got a good rapport going? This could turn into a tricky consultation. Oh, she’s mentioned a headache, maybe she has metastases to the brain or temporal arteritis, have we measured the ESR [erythrocyte sedimentation rate], and did we even look at the chest X-ray? Now she says she hasn’t been outdoors for six months, so she could be vitamin D deficient. Will we measure the vitamin D level or just prescribe some? Maybe she was already on vitamin D, she was on a long list of meds. Why is the student looking bored, I’ll ask him to look at the meds list and the F2 [second-year postgraduate student in training] can look for an ESR.

Now should I go on to the high-glucose problem or the pneumonia next? Oh her husband has arrived and he looks angry, where has the nurse gone to? I need her to hear the whole conversation so she can calm the patient and her husband down after I leave, if this all turns difficult. Oh, and I must remember the Medical Director said we are doing poorly on VTE [venous thromboembolism] and Dementia forms and looking for pressure risks, and the 4th target is going badly, could I discharge this lady and do all her investigations as an outpatient and damn there goes Henry the Hoover and the F2 has left to answer her bleep and PACS [picture archiving and communication system] has gone down so we can’t review the chest X-ray, now “how many years have you smoked for?”

Well that’s what it is like for me no matter how calm I look from the outside. This doesn’t leave any residual reasoning capacity for “Could her weight loss be from an overactive thyroid or from badly fitting false teeth or depression or only drinking alcohol and eating no food?”

This kind of thought process is typical, as doctors have to play detective a great deal of the time, and there are an enormous number of variables. You can help cut through the noise by preparing a piece of paper with all your medications—even supplements and nonprescription drugs such as antihistamines and pain relievers. Recall that just because something is available over the counter doesn’t mean that it can’t have a negative interaction with other drugs you’re taking. Turmeric and ginkgo, for example, are anticoagulants. If you’re taking a prescription anticoagulant too, the effects can be amplified, leading to serious situations if you cut yourself or get an ulcer or any kind of internal bleed … or if the doctor needs to perform an emergency surgery or biopsy.

Difficult Conversations

At some point, if you live long enough, you or someone you love is going to experience a marked reduction in some ability, physical or mental, of the sort that may necessitate a lifestyle change. I’m not talking about needing a little longer to leave the house, or having to use a pill-sorting box to avoid double dosing or missing medications—I’m talking about an inability to drive, do housework, prepare meals, or remember important appointments and people. I’ve heard from parents who resent their children telling them what they can and cannot do, and from children who are terrified of their parents driving or keeping the firearms they’ve kept safely for decades. These are difficult conversations to have. Many older adults do lose some abilities and functions and need help. Some are more comfortable asking for help than others, who see the very act of asking as an admission of decline. And no one wants to think of themselves as incompetent or cognitively impaired.

Part of conscientious planning for old age includes having these kinds of conversations ahead of when you actually need to have them. Having these conversations early means that they won’t seem abrupt or sudden when the time comes. It means considering options and making plans in advance, when you’re clearheaded and less emotional. Involve your doctor in these conversations too. Basically, plan ahead. When did Noah build the ark? Before the flood.

Joseph F. Coughlin, director of the MIT AgeLab, poses three questions we should all ask ourselves and our older family members as a way to think about what our quality of life will be as we age.51 Although the particular questions may seem shallow or even whimsical, they are effective stand-ins for our quality of life.

1. Who’ll change my light bulbs?

This is a proxy question for who will do the chores around the house that most of us did when we were younger. Do you really want your ninety-year-old spouse climbing a ladder to replace a recessed bulb in the ceiling? Who will take out the garbage cans on pickup day or lug around the heavy vacuum cleaner? Who’ll chop vegetables when your eyesight is failing and your hands may have developed a tremor? Think ahead not only to who you can call for help, but whether or not you’ll need to pay them, and how much money you need to set aside for it. Find out what social services are available in your area.

2. What if I want an ice cream cone?

The ability to be spontaneous is key to feeling as though you are an author of the script of your own life. If you want to go out for an ice cream cone, who will take you there? Have you situated yourself so that you’re in walking distance? What if the weather is dangerously hot? Is there someone who can drive you? More broadly, Coughlin asks, “Will I age in a community where there are ample activities and people to keep me engaged, active, and having fun?” Quality of life is about being able to easily and routinely access those little experiences that bring a smile.

3. Who will I have lunch with?

As we’ve seen, social isolation is one of the biggest risk factors for older adults. A vital social community—someone nearby you can call up and go to lunch with once in a while—can make all the difference. “Planning where, and with whom to retire may be as important as how much it will cost,” Coughlin says. “For example, a home in the mountains may be alluring as you approach retirement, but it may lead to an inadequate network of friends, or complete isolation during old age. The baby boomers are facing a different retirement than their parents. They’re more likely to live alone, to have fewer children, and to live in suburban and rural locations that may not provide easy access to active and livable communities.”

There are more options now than ever before for how to live out later years when you feel you might need a bit of assistance with day-to-day tasks. Intergenerational families are on the rise, either older parents moving in with their children or the children bringing their own families in to live with their parents in the homes they grew up in.

Although the dark, dank nursing homes of 1950s movies still exist, there is a worldwide trend toward facilities that promote independence. I mentioned assisted living (also called memory care) in Chapter 6 on living with people, as one part of this trend.52 As Argentum, one of the leading advocacy groups, describes it,

Assisted Living is a home- and community-based setting for older adults combining housing, supportive services, and health care as needed. Individuals who choose assisted living enjoy an independent lifestyle with assistance customized to meet each resident’s needs and benefits that enrich their lives. Assisted Living promotes independence, purpose and dignity for each resident and encourages the involvement of a resident’s family and friends. Staff is available to meet both scheduled and unscheduled needs. Communities typically offer dining, social and wellness activities, and personal care services. There are currently 28,585 communities in the United States with more than 835,200 residents calling assisted living home.

As comfortable and convenient as many assisted living communities have become, many older adults want to stay in their own homes as long as they can. There are some things we can do to help make staying at home an option.

Putting Systems in Place: Alzheimer’s, mild cognitive impairment preparedness

One of the greatest difficulties that people with Alzheimer’s and mild cognitive impairment have is getting used to something new. Start planning now so that new systems seem familiar. The idea here is that by the time you need them, all these things will be old hat. Don’t wait until you or your loved one has symptoms—it’s too late then. Introduce these changes early. Make them easy and routine.

Write your address on your cell phone and on a card in your wallet. Add to that card the phone number of your doctor, your spouse, and a family member or friend who can help out if you need it. If you’re in an accident, emergency personnel may need to call these people if you’re unable to respond.

If you take medications, start using a pill-sorting box so that you’re used to using it later when you really need it. CVS and other pharmacies will actually prepare a daily pill pack for you at no additional expense, and they’ll deliver it to your home.53 If you take pills in the morning, noon, and evening, for example, there will be a separate pack for each, clearly marked.

Keep your keys and wallet in a designated place. Consider purchasing a sensing refrigerator that orders food automatically and has it delivered. Or find a local or online grocer that delivers food and place a standing order for certain staples. Put all your bills on autopay. Have a system for keeping track of account passwords, and someone else who knows or could access this information. Work with local police officers or someone close to you to learn how to protect yourself from scammers.

What we can all do now is to be more intentional and mindful of how we live in the world. Remain Curious and mentally engaged. Be Open to new experiences. Keep up your social Associations. Try to be Conscientious. Follow the Healthy lifestyle practices I’ve described regarding diet, exercise, and good sleep hygiene.

Choose the Right Hospital—before You Need It

As with anything, there are good hospitals and bad. Some are good for certain things but not others. Some hospitals are dreadful all around. Medicare’s Hospital Compare website shows rates of surgical complications and infections for hospitals, and which hospitals have lower-than-average mortality rates for six medical conditions—heart attacks, heart failure, pneumonia, stroke, coronary bypass surgery, and chronic obstructive pulmonary disease.54 It also shows which hospitals have higher-than-average readmission rates—patients having to go back because the problem wasn’t solved. Then there is HospitalInspections.org, which is like a city’s restaurant inspector, showing you which hospitals have serious problems.55 Several websites allow you to find the nearest hospital or emergency room and their average wait times.56 Learn now where the good hospitals are, and where the closest ERs are and their wait times. Update your list once a year. Write down this information near the telephone in your home, and if you have a smartphone, put it in there as well.

(When choosing an ER in an urban setting, by the way, you’re better off going to one in a quiet neighborhood, rather than a county hospital in the middle of a major urban center—the latter could be filled with stabbing or gunshot victims, especially on a Friday or Saturday night, and unless you’ve been stabbed or shot, you’ll wait a long time to be seen.)

Advance Medical Directives

In what is perhaps a macabre way to look at things, we’ve reached an awkward point in history in which you get to choose (more or less) what you want to die from. Some interventions we’ve looked at reduce the chance of heart attack but increase the chance of cancer. Some treatments reduce the risk of cancer death but increase the risk of dying from an infection. Particularly if you’re over age eighty-five or so, some surgeries have a less than 50 percent chance of success and don’t extend life for much more than the recovery time.

Science has done a great deal to reduce the risk of dying from heart disease, and all the more so for people who exercise regularly, eat well, don’t smoke, and limit alcohol. If you don’t die of heart disease, you’ll live longer, and then the highest risks are to die from cancer, stroke, and dementia, all comparatively unpleasant things to die from. Physician Alex Lickerman notes this uncomfortable paradox:57

Decreasing the risk of dying from one disease has increased our risk from dying from other, arguably more horrible ones.

It’s helpful to consider these issues when you’re younger and before you’re confronted with having to make a choice—and to share your feelings with your loved ones. In a moment of crisis, your feelings may certainly change, and that’s all right. The point is to be practiced in thinking about these things, in considering the various issues and ramifications. Some questions to consider (I know that these are uncomfortable, but it might be better for you to have a say in these decisions than to have a team of doctors make them for you if you’re unconscious):

And don’t be rash in your thought process about this. As psychological scientist Dan Gilbert at Harvard has shown, we tend to underestimate our resilience. We tend to think that certain setbacks will make us miserable, and we are often surprised to find, if they happen, that we got through them and it wasn’t that bad. Studies with amputees and quadriplegics, for example, have shown that they are not nearly as unhappy as you might think they’d be, or even as they themselves thought they’d be. Life is amazing and beautiful, and yes, challenging and annoying sometimes, even downright depressing; but after adapting to a downward turn, many of us find we still love being alive.

An advance medical directive, also called an advance health directive or living will, is a formal document that allows you to answer questions like these and to specify what you’d like done in various scenarios in which you are unable to respond to health-care workers yourself. They have legal status in some countries, such as the US and the UK, and in other countries they serve as non-legally-binding guidelines. You can find forms online, or—if you want to be extra careful—you can get the help of an attorney. Once you have one of these, you should make sure that family members and your authorized decision maker know where the original document is, and you should provide copies for them, as well as for all your doctors. (In some jurisdictions, copies are not accepted by medical or governmental authorities, and so people should know where you keep the original.)

Dr. Barak Gaster, a professor at the University of Washington Medical School, has designed an advance medical directive for dementia.58 Gaster underscores the uniqueness of dementia in an advance directive context, in an article he wrote for the Journal of the American Medical Association:59

Standard advance directives are often not helpful for patients who develop dementia. Dementia is a unique disease from the standpoint of advance directives. It usually progresses slowly over many years and leaves people with a long time frame of diminishing cognitive function and loss of ability to guide their own care. Advance directives typically address scenarios such as an imminently terminal condition or a permanent coma, but they generally do not address the more common scenario of gradually progressive dementia.

Gaster’s dementia directive presents four health-care goals for three different contexts: mild, moderate, or severe dementia. You choose which goals suit you. Of course, if you change your mind, you can withdraw an earlier directive and replace it with a newer one. The body of the directive looks like this:

If I had [mild/moderate/severe] dementia then I would want the goal for my care to be:

As with any preformatted advance directive, these are just guidelines. You can reword it or fashion it to reflect your own feelings.

End of Life

Like any part of life itself, the end of life is less stressful and potentially more peaceful if we take the time to learn about it. We may decide to not go gently into that good night, but if the night overtakes us, we are better off knowing what to expect of it, and to put ourselves in situations that are of our own choosing, rather than someone else’s. “Death, when it approaches, ought not to take one by surprise,” says Gloria Steinem.60

I want to die at home, surrounded by familiar sights and sounds, preferably with loved ones nearby, and the sounds of nature trickling in through the window, whether it’s songbirds during the day or crickets and owls at night.61 Other people want to be in the hospital to have every chance of claiming an extra hour or day or two—possibly a few extra months. Some don’t want to burden their families and prefer to be in a rest home of one kind or another.

Much of what happens to us when we are terminally ill—shots, tests, various diagnostic and treatment procedures—is painful and anxiety provoking.62 Aversive experiences such as these can undermine patients’ willingness to undergo or continue treatment but can be counteracted by immersion in nature.63 Virtual reality (VR) environments have become increasingly available in health-care contexts and have been found effective for acute pain management. (If you’re unfamiliar, this is essentially like watching a three-dimensional movie; in some versions, you can control the views you see to simulate walking through or interacting with the environment.) Patients who experienced VR scenes of nature reported less pain during a procedure and in their recollections of it one week later than patients who experienced VR urban scenes or no VR, suggesting that it is not just the distracting effects of VR, but the immersion in nature itself.64 Other studies have found that natural sounds, such as birdsong and ocean waves, can even speed up recovery times and reduce stress.65

With this as a background, hospitals and end-of-life care facilities are coming to realize the restorative qualities of nature and are looking at ways to provide their patients with increased access to natural scenes.66 Seen as peripheral to medical care for most of the twentieth century, gardens are back in style now and are integrated into the design of most new hospitals, according to the American Society of Landscape Architects.67

The TriPoint Medical Center in Concord, Ohio, is one example.68 The center is surrounded by mature forest, wetlands, and a pristine freshwater stream. To enter the medical center, you cross a landscaped pond and pass by a waterfall. The natural theme permeates the entire site and sets the tone of serenity and healing, which is reinforced with paintings of natural scenes by local artists. Henry Ford West Bloomfield Hospital in Michigan is surrounded by eighty acres of natural landscape, and the interior spaces are richly filled with trees and shrubs; a fifteen-hundred-square-foot greenhouse is on the property. The Matilda International Hospital in Hong Kong sits high atop the historic Victoria Peak with sweeping views of the South China Sea. The Glotterbad Clinic is in the middle of the Black Forest in Germany.

Rachel Clarke, a physician with Britain’s National Health Service, has seen firsthand that nature can provide intense solace for many who are terminally ill.69 She tells the story of one patient, in his eighties, who had cancer of the tongue and so couldn’t speak—at least not well enough to make himself understood by the hospital staff. Sitting in his chair, he grew increasingly agitated—thrashing around, flailing his arms, grimacing, flinging his head from side to side. No one could figure out what he wanted except for one younger doctor, who simply turned the patient’s chair outward to face the garden. “He sat calmly, transfixed by the trees and sky,” Clarke says. “All he had wanted was that view.”

Another patient, suffering from metastatic breast cancer at fifty-one, was moved to hospice. “My first thought,” the patient said, “my urge, was to get up and find an open space. I needed to breathe fresh air, to hear natural noises away from the hospital and its treatment rooms …. Somehow, when I listened to the song of a blackbird in the garden, I found it incredibly calming. It seemed to allay that fear that everything was going to disappear.” About her patient, Clarke recalls, “Whenever she was able to sit outside in her garden or be somewhere where there were trees and wildlife it gave her this peace, it took her away from all of the fear and loss that accompanied her diagnosis of terminal cancer.”70

In the end, in the battle to hang on to life, nature always wins. The playwright Dennis Potter described the profound effects of immersing himself in nature during his final days suffering from pancreatic cancer, and the refocusing of his attention on immediate, sensory experiences, a Zen-like state:71

The only thing you know for sure is the present tense.

That nowness becomes so vivid to me now, that in a perverse sort of way, I’m almost serene, I can celebrate life. Below my window, for example, the blossom is out in full. It’s a plum tree. It looks like apple blossom, but it’s white. And instead of saying, “Oh, that’s a nice blossom,” looking at it through the window when I’m writing, it is the whitest, frothiest, blossomiest blossom that there ever could be.

Things are both more trivial than they ever were, and more important than they ever were, and the difference between the trivial and the important doesn’t seem to matter—but the nowness of everything is absolutely wondrous.

And if people could see that—there’s no way of telling you, you have to experience it—the glory of it, if you like, the comfort of it, the reassurance …. Not that I’m interested in reassuring people, you know. The fact is that if you see the present tense, boy, do you see it, and boy, can you celebrate it!

Putting It All Together

The single most important factor in determining successful aging is the personality trait of Conscientiousness. Conscientiousness is associated with a great number of positive outcomes in life. As I wrote in the first chapter, the fields of psychiatry and clinical psychology are predicated on the premise that you can change; you can will yourself or train yourself to be more conscientious, even later in life, and the benefits will still accrue to you. The latest science seems to confirm what has been argued, for millennia, by various forms of religion—that personality is malleable and one can learn to interact with the world in new ways, even well into one’s eighties and beyond.

No one said that it’s easy to change, and this is especially true later in life as we become set in our ways—which is just a colloquial way of describing the kind of biological fixedness that is going on in older brains. Adopting new lifestyle choices is difficult. But if you remember why the lifestyle change is important, you’re more likely to stay with it, even when your motivation flags a little bit.

Three additional factors that determine how well we age are more important than the rest. The first is childhood experiences, in particular of parental attachment and of head injury. It’s too late for you to do anything about these now, but you can protect and nurture the young people in your life, and you can predict your own outcomes by thinking about these. Children who are poorly attached, whose parents provide on-again, off-again care and attention, grow into adults who find it difficult to establish long-term intimate relationships.

If you had a concussion as a child, your chances of developing dementia in old age are increased by a factor of two to four. If you had multiple concussions, the increased risk is not additive—that is, each additional concussion doesn’t increase the risk by the same amount, but rather accelerates the chances of a bad outcome in old age. Sports in which a child’s head is used as a battering ram, or other kinds of contact with an object or another person, are dangerous to mental health.

The second most important factor in retaining mental vitality later in life is to exercise in varied, natural environments. You don’t need to run marathons. Power walking in a park or forest, fast enough to get your heart rate up and your brain full of rich, oxygenated blood, is the goal. The varied environment will stimulate your brain and in particular the hippocampus, the seat of memory. And the thousands of little microadjustments you need to make to your gait, the angle of your feet, and maintaining your balance and pace will exercise the circuits in your brain that evolved to adapt to the environment. Adapting to new things, especially in the physical world, strengthening the visual-motor-kinesthetic circuits in your brain, can make an enormous difference in fending off cognitive decline. Even just ten minutes of slow walking every day has long-term benefits for your body and mind. And if that’s not possible, do what you can. “I have a two-story house and a very bad memory,” says Betty White (age ninety-seven), “so I’m up and down those stairs all the time.72 That’s my exercise.”

The third most important factor is social interaction. Interacting with others is among the most complex things we can do with our brains. It could be through playing music with them, playing bridge or golf, acting in community theater, reminiscing, or discussing literature in a book group. Nearly every part of our brains is activated by interacting with others, live, face-to-face, in real time. (Sorry, Skype.) Doing so requires us to read their body language, the emotions in their faces, and the contours of their speech. We have to follow along with what they’re saying and try to figure out a way that we can contribute to the conversation without derailing it. In conversation, we need to employ empathy, compassion, logic, and turn taking—all relatively advanced cognitive operations. Isolation and lack of connectedness are strong predictors of disease and mortality. A study from the Karolinska Institute showed that people with strong social networks were 60 percent less likely to develop dementia.73 “Your brain was built for the very purpose of social engagement,” notes Art Shimamura. One block to that social engagement is the many angers we have collected throughout our lives, sometimes directed at individuals, sometimes only directed toward a political party, group, or class they are members of. The Dalai Lama doesn’t have a monopoly on the view that practicing compassion is healthful. We’ve seen evidence of this from neuroscience as well. A good strategy for life, at any age, is to let go of grievances, both petty and large. Don’t spend your life hating and being angry. As former U.S. senator Alan Simpson (age eighty-eight) says, “Hatred corrodes the container in which it is carried.”

Children have an innate need for physical and emotional connections to their parents, even those children who appear not to need it. For centuries we thought that individuals on the autism spectrum were socially phobic loners—they don’t look people in the eye and seem to enjoy solitary activities. We now know that this masks a deep social anxiety and that most of them desperately want to connect. (Scientists are often perceived as socially awkward, and indeed, many of us in science are on the spectrum. How do you recognize an extraverted mathematician at a party? He’s the one staring at your shoes.)

When it comes to aging, we tend to think that as we get older, our brains slow down. While this is true in some ways, abstract reasoning and practical intelligence increase with age. The more we’ve experienced, the better equipped we are to notice patterns and predict future outcomes. While it may be difficult for older adults to pick up a new skill, they will excel in their area of expertise more than ever before, as George Augspurger and Maxine Waters demonstrate.

Remember that the world is changing, and those changes are at odds with your accumulated experience. Force yourself to update, to keep current with changes in the world. That involves getting out of your cocoon, doing things you wouldn’t normally do, like learn to use a new cell phone app, or preorder and prepay for a coffee at your local café. These things can be annoying, but they will help prevent the mental rigidity that can accompany aging.

Remember also that pain is physical and informed by our senses, yet it is also influenced by emotional and cultural factors. A negative emotional state can lead to increased pain, and an otherwise painful sensation can be interpreted as positive, such as soreness after exercise. Just in the way that we may misattribute an increased heart rate to physical attraction, as I wrote about in Chapter 5 on emotions, so, too, can we misattribute pain to false sources. Our bodies can misinform us, presenting a false reality.

Practice gratitude for what you have.74 This is motivating, alters brain chemistry toward more positive emotions, and oils the pleasure circuits of the brain. It can be as simple as appreciating the taste of your morning coffee or the sunlight peeking through the window. Gratitude is a powerful mind-set. As Walt Whitman wrote,

Happiness … not in another place … but this place, not for another hour but this hour.

Keep Milking the Cows

In 2018, Placido Domingo (then age seventy-seven) sang his 150th role, an extraordinary milestone in opera.75 “If you look at the history of singers in opera, he stands by himself,” said the former general manager of the Metropolitan Opera. And that’s not all. Domingo has recorded more than one hundred albums and CDs and performed nearly four thousand times. When Maria Callas told him that he was singing too much, back when he was forty-one, he didn’t listen. In 2018, he told The New York Times, “When I rest, I rust.” As Neil Young sang, “It’s better to burn out than it is to rust … rust never sleeps.” Although Young wrote that when he was thirty-four, at age seventy-three he is still singing it. At age eighty-six, T. Boone Pickens, chairman of BP Capital Management and an alternative energy activist, said, “I’m going to retire in a box being carried out of my office.”76 He continued to work until his death five years later.

A friend told me the story of how her grandmother lived to 113. She died while milking a cow. Every day she walked to the barn, used her eye-hand coordination and hand and wrist muscles to do the actual milking. It gave her a sense of responsibility and purpose. Individual strivings for accomplishment, persistent dedication to one’s career or to community or, yes, domestic animals, are associated with sizable health benefits.77

By 2030 there will be more individuals in the United States over sixty-five than under fifteen years of age. It’s been estimated that two-thirds of the people over sixty-five who have ever lived are alive today, and three-quarters of the people over seventy-five who have ever lived are alive today.78, 79 We need to change the way our society thinks about the aged. A relationship of mutual respect between older and younger people is one of the greatest enhancers of anyone’s quality of life.

I began this book with a question for us to ask ourselves, one that gets to the heart of how we see the future of aging. What would it mean for all of us to think of the elderly as resource rather than burden and of aging as culmination rather than denouement? I have tried to show here that it would mean harnessing a human resource that is being underutilized. It would mean restoring dignity to a marginalized group of human beings just when they need it most. It would promote stronger family bonds and stronger bonds of friendship among us all. It would mean that important decisions in every domain, from personal matters to international agreements between nations, would be informed by experience and reason, along with the perspective that old age brings. And it might even mean a more compassionate world.

We can have that future if we want it. We need to educate ourselves and our families about the advantages of aging—the wisdom, the bias toward positivity, the compassion that older adults exhibit. As individuals, as community members, as a society, it is in all of our best interests to help construct a culture that embraces the gifts of the elderly, weaving cross-generational interactions into the fabric of everyday experience. By learning from the science of the brain we can create a transformative understanding of the aging process, its human story, and in the process create a richer quality of life. This is the new truth about aging.

In 2018, eighty-four-year-old Gloria Steinem was asked, “Who are you passing the torch to?”80 “Nobody,” she said, laughing. “I’m holding on to my torch. I’ll let other people light theirs from mine.” Hold on to your torch. Do not go gently. And don’t forget to laugh. Whatever’s going on around you, remember to laugh.