Perhaps we should not have been surprised. He was always on the go, ate healthy meals, never smoked, and enjoyed being with friends.

He always seemed calm and collected, so on his 101st birthday, I asked how he had managed his stresses — his ship, the Canberra, was torpedoed during WWII with the loss of many of his buddies, and he was nearly killed. He had lost his daughter to cancer when she was forty, and his wife to cancer when she was 67. Yes, he had grieved greatly, but somehow, he was resilient and came back strong each time. He had been very sad but lived through his grief and always appeared unperturbed. “Well,” he said, “I guess I just let stress roll off my back.”

Organs decline about 1% per year.

One of the most important things that happens with aging, sort of like a car, “old parts wear out.” Most organ functions decline by about one percent per year. Of course, there is great variation from person to person, year to year, organ to organ, but 1% is a pretty good average to consider. We usually think of a person being in their prime through at least age 60. In many ways, that is correct, but you may be surprised to learn that the 1% decline starts in early adulthood and continues throughout life, speeding up as we age. Fortunately, most of our organs have significant redundancy so that we can tolerate these declines without any appreciable impact. But eventually, the decline may get to the point where we have a functional impairment that can be serious or at least impair our day-to-day activities.

I recently turned 84. I don’t feel “old,” but I do know I can’t do everything I used to do, or at least not as quickly. My hearing is less; my vision is reduced. My muscle mass and strength are definitely much less than they were in the recent past. My balance is OK, but not as good as it used to be, and so on. It has been a set of changes that came slowly at first but are now progressing faster. I always enjoyed splitting wood for the fireplace. I kept a woodshed filled with wood split and logs drying for a year before splitting. As time went on, I realized that I couldn’t keep at it for as long before wanting to take a break. As one friend in his early 80s told me, “I was fine until about age 78, and then it seemed that the aging process was suddenly there and moving fast.” Those declines, developing “under the radar” for decades, had accelerated and become overt.

The 1% Per Year Decline, Author’s image

Hearing decline begins at about age 25 but is not noticed until much later. Many of you will need reading glasses by age 40, even though you have had excellent vision for years; cataracts may occur later. Balance starts its inevitable decline early, although it, too, will not be noticed until much later. Meanwhile, internal organs, including the heart, lungs, and kidneys, are slowly declining, and so too is brain function, especially cognition.

This normal aging process of old parts wearing out is universal and is progressive, but you can slow it and sometimes reverse it, at least partially. Let’s use bone mineral density (BMD) as an example. BMD is easily measured to demonstrate the sturdiness of our bones — how strong they are. We start life with cartilage rather than bones. As we grow from toddlers to children to teenagers, calcium and other minerals, along with a protein-collagen matrix, are laid down in our bones, and they become increasingly strong, reaching a peak around the age of twenty. Once that age and that peak are reached, it can’t go up any further — that’s it. Then there is a plateau, and at about age thirty to forty it starts to decline at a rate of about 1% per year. At age twenty, men’s bone mineral density is, on average, higher than women’s.

Nevertheless, for women as for men, the decline is about one percent per year. Menopause changes this; the rate of loss increases to perhaps three percent per year for a few years and then returns to the one percent average decline until reaching osteopenia and then osteoporosis. There are three important points to consider. If you live long enough, your bone mineral density will decline to a level where, if you fall, a bone fracture becomes more likely. Since women start at a lower level and because they have this increased loss of BMD during menopause, they’ll reach that fracture threshold in life earlier than men. Since women tend to live longer than men, in total, more women than men will have a fracture at some point in their lives. We might just say this is one of the risks of living longer.

But why will you fall? Because your balance mechanism is likewise declining, and your muscle mass and strength are not as capable of “catching” your fall. The three combine together in a very negative manner!

Muscle mass and strength decline in a similar fashion, resulting in what doctors call sarcopenia. Most people lose perhaps 30% of their muscle mass between ages 50 and 70, and the loss continues at an even faster rate thereafter. Older individuals who exercise find it takes more effort to maintain their muscle mass and strength, but regular exercise and good nutrition have a significant beneficial impact and slow the process considerably.

Cognitive function is another example; your brain loses some of its abilities as you age. Cognitive abilities and brain volume do not decline in lockstep but do have a clear relationship. A fascinating study published in the journal Nature in April 2022, pulled together 123,984 MRI scans taken at over 100 institutions from 101,457 individuals ranging from 115 days post-conception to 100 years of age — from fetuses to centenarians. At the age of three years, the brain had reached 80% of its maximum size. The gray matter, which consists of the actual brain cells, reaches its maximum by about age 6, whereas the white matter, the inner connections between brain cells, does not reach its peak until the late 20s. The decline in brain volume thereafter is slow but accelerates after about age 50. These changes can be seen in the figure, which shows the growth trajectories of gray and white matter. The charts show volume (in mm3) across age, beginning before birth and ending at about 100 years.

If you are over 65, you have probably noted that you can’t memorize as well, recall names as quickly, etc. When I was in medical school, memorization was relatively easy; not so today! This is normal. This loss of cognitive function over time should not be confused with the disease Alzheimer’s. Nearly everyone who lives long enough will suffer from some cognitive decline, but only some will develop Alzheimer’s. As with BMD, you reach your peak cognitive function around age twenty; it plateaus for about 10 years, then starts that slow decline. Given the great redundancy in your brain, it is not noticeable for some time. Eventually, you reach a functional threshold where your cognitive function begins to impair your ability. This becomes more apparent when an older person is engaged in highly technical activities, very fast-paced activities, or stressful situations (emotional, physical, or health-related). Those cognitive challenges are less apparent in highly familiar situations.

This 1% annual loss is normal. No, it is not an exact number, nor is it the same for every person or every organ, nor is it exactly 1% in the same person at all times. But 1% is a good proxy for what is happening throughout your body throughout adulthood and into your elder years.

Slowing the aging losses

Here are some suggestions to slow that steady decline in functions. If you start at age twenty with very strong bones (i.e., a high BMD), then you have a longer way to go down before reaching that level of potential bone fracture from a fall. Perhaps too late for you if you are older, but encourage your children and grandchildren to eat a good diet, play/exercise daily, preferably outdoors, manage their stress, and get a good night’s sleep. And for their brains, do just the same (quality food, plenty of exercise, sound sleep, and managed stress) as for their other organs. Then, continually challenge their brains with new learning. Those with more years of schooling will start out with greater reserves, so the 1% decline will take much longer to cause difficulties. Muscle mass and strength are similar. Encourage them to build it up now as a teen. No need to be a muscled bodybuilder, but regular exercise and a good diet will mean more strength at the start of that long decline.

Most people seem to accept that, with age, comes a decline in function. “That is just what happens when we get older.” They may not like it, but they do not realize that they can substantially modify the downhill course. You can slow this continuing loss of body functions, including cognitive decline, and you can start at any age. It is never too late. It is not hard to do, and it does not cost money, but it does take time and persistence. It is all about how you move, what you eat, how you manage chronic stress, get adequate sleep, avoid tobacco, not too much alcohol, plus challenge your brain and keep socially engaged.

Stephen C Schimpff, MD, MACP, is a quasi-retired internist, professor of medicine, former CEO of the University of Maryland Medical Center, and author of Longevity Decoded — The 7 Keys to Healthy Aging, and is co-author with Dr. Harry Oken of BOOM — Boost Our Own Metabolism

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On the one hand, we have incredible science, technologies, drugs, devices and providers. On the other hand, we have a truly dysfunctional healthcare delivery system.

America has exceptionally well-educated and well-trained providers committed to your care.

America is the envy of the world for its biomedical research prowess uncovering the basic science of human biology, funded largely by the government via the National Institutes of Health and conducted across the county in universities and medical schools.

The pharmaceutical and biotechnology industries continuously bring forth lifesaving and disease-altering medications.

The medical device industry is incredibly innovative and entrepreneurial. The makers of diagnostic equipment such as CT scans and handheld ultrasounds are equally productive. 

Consider these examples: The science of genomics is revolutionizing medical care in profound ways, such as producing targeted cancer drugs, predicting later onset of cardiac disease, offering prognostic data to guide cancer treatment, rapidly identifying bacteria and its antibiotic susceptibility, indicating whether a drug will work in a specific person and determining if a drug will cause a side effect in that person. 

The pharmaceutical industry has brought us statins to reduce cholesterol, drugs to prevent blood clotting and effective means to control high blood pressure. The rapid development of multiple vaccines and treatments against Covid-19 has been an incredible tour de force.

The device industry has created a potpourri of new approaches that have transformed, for example, cardiac care, including angioplasty, stents, pacemakers and intra-cardiac defibrillators. We even have the ability to replace the aortic valve without major heart surgery. 

Organs can be imaged noninvasively in incredible anatomic detail while also showing their inner cellular workings. The operating room is equipped with devices that make surgery less invasive, more effective and much safer.

Simulation technology has completely changed how trainees learn the basics of procedures from the simple, such as drawing blood, to the complex, such as laparoscopic surgery and cardiac catheterization. Robots are assisting surgeons in open heart and prostate surgery and are integral to today’s large hospital pharmacies and central sterile supply systems.

We may be on the verge of using genetically modified animal organs transplanted to humans for heart, lungs and kidneys.

The electronic medical record allows rapid access to information at any time and place, helps the physician to select the correct medication and dose and speeds up prescription transfer to the patient’s local pharmacy.

Radiology and pathology images can be sent via the Internet to a distant site for interpretation by a specific expert. A video of an ongoing surgical procedure can be evaluated by a distant authority in real time to give advice to the operating surgeon, such as in a battlefield situation far from home. And some surgery can even be done distantly via robotic controls.

We can be appropriately awed, proud and pleased about what is available for our care but to a large degree, we don’t fully benefit because —

We have a very dysfunctional health care delivery system. It is highly flawed and just does not work well.

Image from Peterson KFF Health System Tracker

America spends nearly 20 percent of its Gross Domestic Product on medical care, which is double that of the average of 9.9% for the other 34 economically-developed countries (such as Canada, Britain, France, Germany and Japan) in the Organization for Economic Cooperation and Development. On a per capita basis, America spent ~$12,000 on health as of 2020, which is more than twice the average of the other countries and well above Switzerland, the second highest country in expenditures, at ~$7000.

Despite these expenditures, our lifespans are somewhat shorter with Japan and Hong Kong at the top of the charts averaging 85 years and the United States ranked at number 46 with an average of 79 years and falling somewhat in the past few years. This decline is not for lack of medical advances but is rooted in the social determinants of despair and disease and the linked epidemics of obesity and type 2 diabetes.

There are thousands of preventable hospital deaths each year, and there are ~100,000 deaths due to hospital-acquired infections.

On a direct personal basis, you experience the dysfunction personally in many venues. You pay a high price for your health insurance yet you get only 15 minutes with the doctor. You are frustrated, perhaps angry and the doctor is equally frustrated and increasingly burned out. Tests and procedures are way overutilized. Trips to the ER and admissions to the hospital are much greater than necessary. Plus, these incredible technologies and lifesaving drugs are often used in ways or settings in which the marginal benefit barely, if at all, exceeds the marginal cost.

This is not an enviable record.

A report from the National Research Council and Institute of Medicine, summarized in the Journal of the American Medical Association, found “the health outcomes [of the United States] are generally worse than those of other wealthy nations. People in the United States experience higher rates of disease and injury and die earlier than people in other countries. Although this health disadvantage has been increasing for decades, its scale is only now becoming more apparent.”

Although there is better control of high blood pressure and cholesterol and there are lower cancer and stroke mortality rates, U.S. citizens have a lower life expectancy, higher infant mortality, higher rates of premature birth and thus lower birth weights, a higher incidence of HIV-AIDS, the highest prevalence of obesity and diabetes and the second highest rate of death from coronary artery disease, among other ills. To repeat, this is not an enviable record, especially given the level of expenditures. 

In sum, the paradox is that America has the providers, the science, the drugs, the diagnostics and the devices needed for outstanding patient care. But the delivery of care is dysfunctional at best and far too expensive. You are not getting the full potential of care that could and should be available and you are paying too much for what you do get.

In the articles to follow, I will delve into the what’s and why’s of this predicament along with practical approaches to improvement. Please join me.

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