Mind the (generation) gap!

Another year and birthday gone, the weighing scales still ringing and the fireworks crackling in the distance. The morning after the day before, and still you cannot comprehend how the Borhani tasted worse than the previous year and why the photos on your Google photos album seem to jog a sense of acute euphoria, but it seems a bit hazy. 

The physiological attributes of ageing are currently an inevitability, much to the annoyance  of many a sovereign wealth fund manager and anti ageing biotech company investor. The numbers are quite discerning. The volume and weight of our brains decline by 5% per decade after the dreaded age of 40, which is thought to worsen after 70. 

As one's grey matter shrinks, this is often attributed to neuronal cell death, coupled with white matter declining and so reducing the insulation of the myelin sheath that envelops normal synaptic transmission from one brain cell to another, all of which does not bode well. Yet, not all regions of the brain are affected equally and this has been shown through cognitive function tests and image-based MRI brain studies. 

Indeed, the Frontal cortex of the brain being the area of the brain synonymous with memory, impulse control, behaviour, problem-solving and social interaction is particularly affected in ageing. The neuroscience of ageing, therefore, explains much of the dwindling attributes we see in patients and loved ones undergoing old age. The pathology of this can be accelerated even more from diseases such as Alzheimer's dementia but that remains an exception to the process of ageing in the brain. 

Mix this with the reduction in neurotransmitter release such as dopamine by 10-12% per decade from adulthood and soon one can understand why there is a global issue with dementia and our ability to manage and care for an increasingly ageing population.

Patience is a virtue and one needs a lot as a carer, but dealing with the elderly who have limited knowledge and understanding of a topic yet remain stubborn in the face of adversity makes this an even more tiring affair. It is compounded when every relative and their neighbour has now acquired a medical degree somehow and knows what is best, from neurosurgery to cardiology to even oncology. 

In Bangladesh, this seems like not an active issue, given the median age of the population is only 29.6 years, meaning the majority of a young population of generation z and alphas will be the norm. Yet in Bangladesh, the number of people over 60 currently is approximately 15 million and this number is set to rise to 36 million by 2050, representing 22% of the whole population. This means one in every five Bangladeshis will be a senior citizen by 2050. 

This is already a reality for many a Western European nations, such as Germany, where 22% of the population was over the age of 65 in 2021. Get your Zimmer frames ready everybody. The first thing on our lips will not be "when are we going to go for chotpoti" or "halwa puri", rather where is the nearest toilet break, please! 

I don't know about you but I am taking no chances. There is data to suggest there are some protective factors that may prevent the draining of brain cognition over time and these are coupled with cardiovascular risk factors. Exercise, a healthy diet, and bouts of increased  cognitive efforts in the form of education or occupational attainment have all been shown to have protective factors in maintaining one's youthful mind! 

However, just because you are a professor does not mean you stop ageing, apparently; it just means you're statistically ageing slower than someone who is not in higher educational strata. Or, in plain English, being of a higher educational background helps you to brag your brain into thinking it's younger!

Yet, as we have our chai with that extra sugar, bakorkhani and toast biscuit, it does raise a rather worrying prospect. Who is going to look after this ageing population? A young demographic population such as Bangladesh has the advantage of having a strong, economically active younger generation, but this assumes the next generation will have the same economic liberties that our forefathers did. That does not seem to be the case. 

One only has to watch the global political news to see that things are not heading in the right direction. With the rate of zero to 14-year-olds dropping in the latest census figures for Bangladesh, the days of large families like the Waltons are long gone. The developed nation's outlook for population structure is slowly becoming embedded, but does this mean the social strata of how we care for the elderly should be planned for? Should we be having these conversations with our aged parents?

I believe we should and for those who have elderly parents who are of sane mind and not obstinate enough not to listen and go put themselves to an early grave, this is something that needs to be discussed. Often, however, it is harder for elderly parents to heed the advice of their own children as they grapple with the reality of a crumbling sense of independence and an inability to comprehend the complexity that belies many a medical case nowadays. 

Money and resources are often wasted, poor decisions are made and then one comes back to the same point in a hospital or medical facility and the discussion on what happens next is rather sheepishly discussed, like a child who cheated in his last maths exam. Remember when that happened, the teacher made you do it again and in less time!

Patience is a virtue and one needs a lot as a carer, but dealing with the elderly who have limited knowledge and understanding of a topic but remain stubborn in the face of adversity makes this an even more tiring affair. It is compounded when every relative and their neighbour has now acquired a medical degree somehow and knows what is best, from neurosurgery to cardiology to even oncology. 

Everyone suddenly having read the Google and WebMD pages and seen all the box sets of House MD gives their small advice to muddy the already-aged brain of the elderly relative in the bed trying to figure out if they give deserts in the hospital. 

But why is it you cannot give firni to my loved one, they ask in the evening. The exasperated nurse and doctor have a gang of family members trying to put more sweets than a sweet vendor in their room and request hourly data as if they knew what to do, like a NASA space rocket launch. 

In the end, it is your own children who will have to bear the brunt, not the distant brother from Neverland and the aunty from the end of the rainbow or the friend who had seen the Facebook status change to "In hospital".

Some elderly patients actually enjoy this attention and I have seen this prop up their spirits, as being the centre of attention always feels good for some. Cynical, I know, but I have seen it happen and it ends badly for the patient. So keep it simple.

Power of attorney is a great legal method if you and your loved one have the sense to do it; giving someone you trust and the necessary knowledge and qualifications to make decisions regarding one's medical decisions, care needs, treatment needs, etc. 

However, some have been silly enough to give this power to people who are not in the country they are having treatment in or have no knowledge of, be it medical or legal in that scenario; the law can be quite difficult in those scenarios and adds to the complexity of a situation. Again you tend to find the more clever someone thinks they are; they tend to be the ones making the silliest of decisions. Don't be that silly person.

Another method is to have an advanced directive which is a legal document to outline your wishes in the event of a change in mental status, increased care needs and often a stagnant or worsening medical condition. 

This was what my own mother did during her years of cancer treatment and she informed me of her decisions as she would like to be undertaken in the event of a change in her medical status. My father is not of medical background but has seen House MD and so it was left to me to execute her directives. This carries a lot of legal weight if this can be put into writing, especially in situations where one as a family tries to instigate medical care and the medical team have other ideas. The situation runs smoothly and so long as communication lines are clear, both family and medical teams remain in unison. 

Yet, in the end, the process of ageing is a difficult one to get over. Many falter and move from one pillar to post, trying to come to terms with it. No amount of hair colouring can get rid of that reality. We all have to currently experience this and much, and though we would rather not experience this, it is best to plan for this and not waste time and resources near the latter part of one's life under any false pretences. 

It is hard for the elderly and hard for their carers. In conservative societies, it is a social norm to look after one's elderly, but the nuances of this are easier said than done without the necessary support packages in place. So get them ready. Happy new year!

Professor Rameen Shakur MD PhD (Cantab) FRSA FIBMS FRSPH FRSB is a professor of genomics and cardiovascular medicine and Director of the precision health and translational medicine centre, University of Brighton, UK.

Disclaimer: The views and opinions expressed in this article are those of the author and do not necessarily reflect the opinions and views of The Business Standard.