how old is too old?
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How OldIs Too Old?
Gene D. Cohen, M.D., Ph.D
Copyright 1993 AmericanAssociation for Geriatric Psychiatl)'
The health care reform discussion now under wayamong lawmakers, policymakers, and economistsnecessarily covers some difficult questions. As we ap-proach the difficult challenge of limiting the costs of healthcare and expanding access to it, debates have beenprovoked abollt the notion of setting limits on health carefor the elderly.t l 2 Some are concerned that too muchmedical time, talent, and resources are being devoted tothe very old, for whom disease and severe disability arecommonplace in the final years before death. Some alsoargue that medical interventions often, despite the bestintentions, reduce the quality of life for the very old. Whenthis happens, many wonder, how old is too old? At thesame time, however, new thinking on longevity stands inmarked contrast to these views of a decrepit old age.Recent findings on longevity assurance genes and ex-tended disease-free lifespans in animal experiments haveawakened people's imaginations, hopes, and expectationsabout late life.
In coming to grips with these paradoxical views,geropsychiatry, with its deep and diverse scientific base,offers insight. Geropsychiatry mixes biological, psycho-logical t and social perspectives, and the fieldts focusranges from molecular biology to manifest behavior, fromAlzheimer's disease to artistic development. The healthcare debate must be viewed with much the same breadthand diversity if questions raised by the current discussionsare to be addressed effectively. When the questions areviewed from this wider perspective, dismissing the valueof life at advanced age is disturbing and not relevant towhat we know about aging.
Alzheimer's disease is a case in point. It is a triplethreat, with intense patient suffering, almost ovelWhelm-ing family burdent and staggering costs to society of over$90 billion in direct and indirect costs per year in the U.S.Some misinterpret the statistics on the significant risk ofAlzheimer's disease after age 80, fearing that the diseaseis synonymous with advanced age, which it is not. More-over, too many practitioners as well as lay persons con-clude that because the cause and cure of the disorder arenot known, there is no treatment. The geropsychiatricview is more realistic and more optimistic. Treatment forexcess disability from a range of behavioral symptoms(e.g., depression, agitation, delusions) lowers patient suf-fering and increases patient coping. Psychosocial supportsare critical in curtailing depression and dealing with stressin family caregivers. Meanwhile, the rapid growth ofresearch on Alzheimer's disease offers new hope forprogress, and the results from these studies affirm that
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Alzheimer's disease is not a part of normal aging.As progress is made on Alzheimer's disease and other
diseases and disabilities prevalent in late life, the fre-quency and intensity of the question uhow old is too old"should, and likely will, wane. Research continues to shedlight on the true picture of aging, and new knowledge isallowing us to enhance independence and reduce the riskof disability in late life. Lewis Thomas reminds us that Utheodds of normal aging are already better than ever beforein human histoty. With a lot of work and a lot of scientificluck, the odds can eventually become wholly on our sideand medicine will have earned its keep.,,3
No area is believed more important generally toachieving healthy aging than that of maintaining normalmental status in late life. One aspect of late life thatrepresents a polar opposite to Alzheimer's disease isartistic development with aging. There is a great deal ofevidence of the maintenance-as well as the emergence-of creativity in late life, with Grandma Moses, paintinguntil the age of 101, being perhaps the best example ofthe concept that one is never too old for creative growth.
Psychodynamic studies of creativity and artistic devel-opment with aging reveal some intriguing relationships.Grotjahn4 wrote about the "reduction of resistance and theincrease of insight in late life." Madur05 described creativeartists as more open to "the nuances of internal chaos andpure intuition, and to conceiving with aging."
In my own studies of creativity in late life, I have beenstruck by the number of individuals who, in the midst ofsignificant loss or change, experience great creative devel-opment. Widowed at age 67, Grandma Moses began toembroider pictures. When at age 78 arthritis forced her togive this up, she began to paint. When Matisse's ill healthin his 80s made painting too difficult, he daringly turnedto cutouts and made a unique contribution to the historyof art, closing the gap between color and form. Finally, areview of folk art in the United States reveals that field tohave been dominated by older artists (especially olderMrican Americans), many of whom began to draw, paint,carve, or sculpt after the age of 65 and many after age 80.
At an exhibit of folk art here in Washington, DC, at theCorcoran Gallery of Art, I was struck by the fact that of 20artists featured in the catalog,6 800Al were over age 65 and300/0 were over age 80. Bill Traylor, an artist whose workwas featured at the exhibit, had been a slave and after hewas freed he eventually moved to Montgomery, Alabama,where he struggled. He was sleeping at night in thestorage room of a funeral parlor and sitting on the side-walk in front of a pool hall by day when, at the age of 85,
VOLUME 1 NUMBER 2 SPIUNG 1993
"it came to him to draw.Jt Folk artists as a group illustratethat creativity in late life is not just the occasional expres-sion of unusual individuals but reflects the potential ofmany older people-including those at very advanced ages.
When in his 60s, William Carlos Williams suffered astroke, was hospitalized for depression, and was unableto continue practicing medicine. He then turned his fullattention to poetry, and at the age of 79, published hisPulitzer Prize-winning volume, Pictures From Bmegheland Other Poems. It is Williams's well-known observationof "an old age that adds as it takes awayn7 that might wellform the framework for answering, uhow old is too old?"
Williams's observation bears on this question in threeways. First, much of the public policy deliberation andsocietal expectation about aging has been influenced bywhat is taken away with aging; moreover, many views onwhat is taken away (through disorders and disabilities) inold age still do not adequately reflect advances in geriat-rics that deal with these losses. Second, far too littleattention has been paid to what can be added withaging-the capacity to cope, adapt, and grow. What canbe added is enormously relevant to an individual's as wellas a community's strategies aimed at maintaining indepen-dence in late life through health and mental health pro-motion programs. Third, it is seldom recognized that inlate life there is a remarkably frequent linkage betweenwhat is taken away and what is added in the face of loss.The frequency with which a.psychodynamic mobilizationof coping skills and adaptive capacities occurs duringtransition or loss in older adults has major relevance torehabilitation programs; rehabilitative interventionsshould not only target loss but also tap into the olderindividual's capacity to compensate creatively with newstrategies. The context of asking uhow old is too old"changes with the recognition that when old age takesaway, it can also add.
1. Callahan D: Setting Limits. New York, Touchstone, 1987, p 132. Binstock lUi, Post SG: Too Old for Health Care? Baltimore, Johns
Hopkins University Press, 19913. Thomas L: The Fragile Species. New York, Charles Scribner's Sons,
1992, p 784. Grotjahn M: Analytic psychotherapy with the elderly, I: sociological
background of aging in America. Psychoanal Rev 1955i 42:419-4275. Maduro R: Artistic creativity and aging in India. Int JAging Hum Dev
1974; 5:303-3296. Livingston J, Beardsley J: Black Folk Art in America. Jackson,
Mississippi t University of Mississippi Press, 19807. Foy J: Creative Psychiatry. New York, Geigy, 1979
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