Is Successful Aging Possible in the Face of Dementia?

We tend to have a dichotomous view of aging. Aging can be great, we imagine, but only if we maintain good physical and mental health into our later years. On the other hand, we imagine aging to be a horror if dementia or some other painful and debilitating condition develops.

These dueling perspectives reflect the reality of aging today: the average life expectancy has increased into the high 70s, while at the same time rates of dementia continue to rise, making Alzheimer disease (AD) the sixth largest killer. Is there a third perspective on aging with dementia that can provide some degree of hope?

Persons with dementia can still retain the capacity to experience humor, joy, and mutual interactions. Therein lie the seeds of a new perspective on aging.

Let’s begin by considering what it means to age successfully. Erik Erikson¹ suggested that developing a sense of integrity was the key task in later life, enabling us to overcome feelings of despair over lost opportunities and grow the strength of wisdom. John Rowe and Robert Kahn² suggested a more specific concept of “successful aging” defined by a decreased risk of disease and disability, robust mental and physical functioning, and active engagement in meaningful activities.

A number of key longitudinal studies of the most successful (and long-lived) aged individuals have found them to have strong marriages and other relationships, healthy defense mechanisms, and conscientious personalities.^3,4

We can extend this notion of successful aging even further, based on the strengths of aging that continue to emerge and develop over time. As we age, we gain more knowledge and experience; we learn lessons that enhance our judgment; we face failures that teach us humility and enhance our empathy for others; we experience heightened levels of creativity; and with the ever-approaching horizon of life, we can gain greater acceptance, insight, and spirituality.

Put together, these age-emergent factors help us to develop a wide range of strengths and roles that constitute wisdom. Such wisdom is supported by research showing that well-being and longevity are increased by positive attitudes towards aging, a sense of purpose, and the ability to adapt to change.^5-8

This whole calculus changes, however, when someone is suffering from dementia. It seems difficult if not impossible to say someone is aging “successfully” when they have progressive cognitive and functional loss. Erikson himself, towards the end of his own productive career, suggested that there was a final stage of life where despair threatened to become the dominant force due to daily struggles and losses.

There comes a point, argues medical ethicist Ezekial Emanuel and others, where we have simply lived too long.⁹ At this stage, our models of aging seem to fail us. Let’s turn back to the question I posed in the opening paragraph: Is there a third perspective on aging here, even in the throes of dementia?

Gene Cohen¹⁰ emphasized that there can be growth, meaning, and purpose even in the face of adversity in late life. We can extend this philosophy to those with dementia who still retain the capacity to remember the past, engage in pleasurable and meaningful sensorimotor activities, experience humor, joy and mutual interactions, and participate with and give to others. Presence can substitute for performance, and the process of connecting with others can substitute for productivity.

Wisdom is still present and can be recognized and shared, as individuals can serve as repositories of knowledge, cultural and religious icons, creators of artistic items, and explorers of art and nature. The difference at this stage is that others are needed to help bring out and engage these strengths. Trial and error and creative exploration are ingredients to discovering which interactions and activities are most relevant and meaningful given the background, preferences, and limitations of people with dementia.

Some of the best examples of these creative engagements include the Alzheimer’s Poetry Project led by poet Gary Glazer; the Opening Minds through Art program created by Dr. Elizabeth Lokon; TimeSlips storytelling created by 2016 MacArthur “genius grant” recipient Anne Basting; and Alive Inside, the program to bring iPods loaded with music to nursing home residents. Each of these award-winning projects taps into the residual strengths of individuals with dementia and brings meaning and joy in ways that are absolutely successful and positive.

Ultimately, this third perspective on aging, which sees strengths endure regardless of our mental or physical conditions, requires us to conjure attitudes of respect, creative engagement, and hope for those who rely on our help, but have much to give back in return.

Editor’s note: This article is a summary of a presentation on this topic that Dr. Agronin gave at the 2017 US Psychiatric & Mental Health Congress in New Orleans, Louisiana. Dr. Agronin is Vice President for Behavioral Health and Clinical Research at Miami Jewish Health in Miami, Florida.

Disclosures:

Dr. Agronin is the author of How We Age and The Dementia Caregiver: A Guide to Caring for Someone with Alzheimer’s Disease and Other Neurocognitive Disorders. His forthcoming book, The End of Old Age: Living a Longer and More Purposeful Life, will be published in January. He reports no conflicts of interest concerning the subject matter of this article.

References:

1. Erikson EH, Erikson JM. The Life Cycle Completed. Extended Version with New Chapters on the Ninth Stage of Development. New York, NY: W.W. Norton; 1998.

2. Rowe JW, Kahn RL. Successful Aging: The MacArthur Foundation Study. New York, NY: Pantheon Books, 1998.

3. Vaillant GE. Aging Well. Boston, MA: Little, Brown and Company, 2002.

4. Friedman HS, Martin LR. The Longevity Project: Surprising Discoveries for Health and Long Life from the Landmark Eight-Decade Study. London, United Kingdom: Penguin Group; 2012.

5. Levy BR, Slade M, Kunkel S, and Kasl S. Longevity increased by positive self-perceptions of aging. J Pers Soc Psychol. 2002; 83: 261–270.

6. Carstensen LL.  A Long Bright Future: An Action Plan for a Lifetime of Happiness, Health, and Financial Security. NY: Broadway Books, 2009.

7. Ryff CD, Singer BH. Know thyself and become what you are: a eudaimonic approach to psychological well-being. J Happ Stu. 2008; 9: 13–39.

8. Baltes PB, Baltes MM.  Successful Aging: Perspectives from the Behavioral Sciences. Cambridge, UK: Cambridge University Press, 1990.

9. Emanuel EJ. Why I hope to die at 75. The Atlantic, October, 2014.

10. Cohen GD. The Mature Mind. New York, NY: Basic Books; 2005.