Ageing

Ageing has many dimensions – from Super Humans who are still going strong in their 80s and 90s to those who are not so lucky and face a range of diseases. Heather Dugmore speaks to some Wits-trained specialists in ageing who can help us understand how to make the best of it.

“We aim for quality of life rather than relentlessly pursuing length of life,” says Dr India Butler (MMed 2017), one of South Africa’s small group of registered geriatricians or ageing specialists. Her practice is at the Wits Donald Gordon Medical Centre in Johannesburg.

Geriatric medicine is a holistic approach to caring for older people – defined by the World Health Organisation as those aged 65 and up. “I’m fascinated by older people and the lives they have lived,” says Dr Butler.

“In our profession we take the time to listen to our patients’ life histories as it is a very important part of deciding on the treatment they need to enhance their quality of life or how they might recover from surgery. You get people in their 80s who are robust, still working, playing tennis and travelling. And you get people a lot younger who are already frail [sometimes as a result of chronic infections such as HIV].”

She says the interventions for each patient are highly individualised: “In geriatric medicine today we are able to tailor therapy down to a DNA level. This, combined with an understanding of their life experience, their background and their beliefs, gives us great insight into how to treat each patient, which makes it interesting and complex.”

Butler mainly sees people with diseases of ageing such as Alzheimer’s and Parkinson’s, as well as patients with osteoporosis, fractures from falling and the side effects of taking too many types of medication (prescribed by different specialists).

A lot can be done to delay disease or improve health, such as bone strengthening for osteoporosis.

People who experience cognitive issues and memory loss could be seeing the onset of a serious disease like Alzheimer’s or dementia, or a thyroid issue. Or the salt levels in their blood could simply be too low. “Reduced salt levels can lead to memory loss, and ageing people’s kidneys are less able to hold on to salt. So we sometimes recommend people have Marmite and Bovril, which are salty and full of vitamin B,” says Butler.

To age well, it helps to exercise, eat a healthy diet, avoid excessive use of alcohol or drugs (including sleeping pills), have your medication checked for side effects, and find out from your doctor about the risk factors for hypertension, diabetes, heart attacks and strokes.

But that’s no guarantee of a problemfree future. “A lot of getting old has to do with luck,” says Butler.

In the lucky corner is the special cohort of survivors called Super Humans or Super Agers.

“We see it in ICU: people well into their 80s who recover faster than many 40-year-olds. Apart from being physically blessed, Super Humans generally lead interesting lives until their last day. They have phenomenal resilience, an iron will, and a strong sense of independence and purpose.”

South Africa has a fascinating population of robust Super Humans, including bubbes who survived the Holocaust and gogos leading hard lives on state pensions and doing physically demanding work such as farming.

Many Super Humans never retire. They keep their minds and bodies active, and keep going strong long after most of their age groups have passed on. Butler cites the example of Ruth Bader Ginsburg, a Justice of the Supreme Court of the United States who took the oath of office in 1993 and fought against gender discrimination her whole career. (A movie about her, On the Basis of Sex, was released in 2018.) At 86 she says she hopes to remain on the Supreme Court bench until the age of 90, and has already hired law clerks for at least two more terms. She works out with a personal trainer and until 2019 had never missed a day of oral arguments. Part of her strength is her independence and refusal to comply with stereotypes: “My mother told me to be a lady,” she once said. “And for her, that meant be your own person, be independent.”

REMEMBER YOUR BONES

"Osteoporosis is common in old people but we do also see young people and children with it,” says Dr Stanley Lipschitz (MBBCh 1980), specialist physician and geriatrician in private practice in Johannesburg. He is an honorary lecturer at Wits, Vice-Chairman of the National Osteoporosis Foundation of South Africa and President of the South African Geriatrics Society.

All people start losing bone in their 50s, he says, but osteoporosis usually manifests later in life. “Today, there is far more focus on prevention, but exciting new treatments are also available and research is ongoing.”

Dr Lipschitz has participated in the research behind many of the drugs currently available and has a research division at his practice, running trials for memory loss and osteoporosis.

“We are now able to treat osteoporosis with tablets, injections and infusions. Most current treatment preserves bone and improves bone quality, but there are now treatments available that actually build the bone. The good news is that people are never too old or too severely affected to be treated for osteoporosis.”

His other research interest is the variety of memory problems that occur with ageing, particularly dementia. “There are exciting developments aiming to prevent Alzheimer’s progression. At the same time we are researching better strategies to identify who is more likely to get Alzheimer’s and to initiate strategies to prevent this,” says Lipschitz.

“In our research we are doing genetic testing, volumetric MRI scanning (which shows the shrinking of the brain as a result of the disease) and assessments on amyloid protein deposits in the brain, which increase the chances of getting Alzheimer’s.

“Worldwide we are busy with clinical trials to try to prevent amyloid build-up and to detect this early. There is no quick fix. While every trial has given us important information, the brain is a very complex organ and there is no cure yet.” But there will be one day, he believes.

Get it seen to

“Ageing inevitably affects the eyes, and the three main visual disturbances are cataracts, glaucoma and macular degeneration,” says Emeritus Professor Neville Welsh (MBBCh 1953). He headed the Department of Ophthalmology at Wits until his retirement in 1995 and then consulted at the Wits Donald Gordon Medical Centre until 2014.

“It is extremely important to consult an ophthalmologist if your eyes are deteriorating, because certain conditions can be very effectively treated but if left too late they can result in permanent, irreversible damage and blindness,” he says. Conditions like hypertension and diabetes are also a risk to eyesight because they affect the blood circulation in the retina.

He has seen giant advances in the treatment of eye problems over his six-decade career. “We are heading into the era of robotic eye surgery. But we still have a way to go as we have not found a way to treat some issues, such as dry macular degeneration.”

The three visual disturbances that affect elderly people are:

Glaucoma

Chronic open angle glaucoma is the most common, with a slow pressure build-up on the blood vessels and optic nerve at the back of the eye. The optic nerves start to degenerate, and this can lead to blindness. If picked up early it can be treated with drops or surgery.

Macular degeneration – dry and wet

The macula is a specialised part of the retina, used for reading and straight-ahead vision. With dry macular degeneration the macula can lose its structure and become an area of scar tissue. There is no treatment for this yet. With wet macular degeneration, which is far less common, the blood vessels grow into the macula and leak, causing swelling of the macula, but this can be treated with injections.

Cataracts

Cataracts most often develop from the age of 70 onwards, says Prof Welsh. “The lens of the eye becomes opaque. With surgery we remove this cataract and put an artificial lens back into the eye. This type of surgery started in 1947 and exponentially advanced from there, with Wits right up there at the forefront. The surgery is fantastically successful.”

HOPE FOR SLOWING ALZHEIMER’S

In 2018 Wits announced that a nasal spray developed by Wits scientists could potentially slow the progression of Alzheimer’s disease.

“To date there have been no substances to treat Alzheimer’s disease; there are only substances to take pain away and there is palliative care,” says Professor Stefan Weiss, head of the Laminin Receptor and Telomerase Research Group in the School of Molecular and Cell Biology.

He is one of the Wits scientists looking for a breakthrough that would change millions of people’s lives.

Alzheimer’s (the most common cause of dementia) starts with loss of memory and problems with thought processing, and becomes increasingly debilitating. It attacks parts of the brain that control walking, coordination and even swallowing.

Mood swings, aggression and volatile behaviour are typical in people with Alzheimer’s, making life extremely difficult for themselves and those close to them.

A hallmark of the disease is the formation of amyloid plaque between nerve cells in the brain. Weiss’s research group found an antibody which could reduce this process in mice and lead to improvements in their cognitive function. The antibody was administered nasally. (Oncotarget June 2018)

Now they are planning clinical trials with human volunteers. There is still a way to go before “Alzheimer’s nasal spray” can be purchased, and a pharmaceutical partner would need to be involved in the next study, but Weiss says he is optimistic.

THE SILVER AGE

Gerontologist Dr Sandrine Rey-Scalco (MBBCh 2007) did her Master’s at King’s College London on the implications of ageing populations for society and policy makers.

Gerontology is the multidisciplinary study of ageing.

“In sub-Saharan Africa the actual number of older people will increase by 40% between 2008 and 2020,” she says. “The speed of growth of an older population has implications for the resources of a country. For example, where a developed country like France has taken 115 years to increase its over-65 population from 7% to 14%, a less developed country like Brazil will take 21 years. Developed countries have more time to create the infrastructure needed to support an older population.”

Policy makers in all countries need to consider health care, social care and labour policies for this population shift. They need policies to do with preventing health problems as well as managing chronic conditions that are more common in an older population, Rey-Scalco says. The most important social care policies pertain to long-term care, whether it be supporting older people to stay at home for longer, supporting families to help care for older family members, or improving and increasing the number of homes for the aged. Labour policies will need to ensure that state pensions and pension contributions are sufficient for all when they reach pensionable age.