The Conflict Between Biogerontology and Antiaging Medicine—Do Geriatricians Have a Dog in This Fight?

There is a heated debate going on out there, one that we as geriatricians ignore at our peril. On the one side are the biogerontologists, who claim that only legitimate, critical, and largely basic science research can solve the riddle of aging and lead to breakthroughs to dramatically extend human life (if that is indeed a socially desirable goal). On the other side are proponents of antiaging medicine, gathered under the banner of the American Academy of AntiAging Medicine (A4M), a growing organization whose members substantially outnumber those of the American Geriatrics Society (AGS). A4M proponents use sophisticated and aggressive marketing strategies to attract clients and customers, touting a panoply of remedies from neutraceuticals and pharmaceuticals to ever-finer plastic surgery, ostensibly to cure (or at least paper over) the ‘‘maladies’’ of aging. They argue that such afflictions are, after all, little more than age-related losses of physiological efficiency, each amenable to cure with aggressive preventive or restorative interventionsFcontentions rarely grounded in rigorous clinical trials or even basic research. In this struggle the biogerontologists seek to distance themselves from the claims of A4M and any hint of the age-old quackery that has always tainted legitimate gerontological research (while at the same time promoting their high-minded cause and its bottomless need for investment, largely from the public purse and especially the National Institute on Aging). This debate has recently peaked, generating thoughtful, intense reviews and essays, notably in our companion Journal of Gerontology (Medical Sciences) 1 and a volume edited by Post and Binstock, appropriately titled, ‘‘The Fountain of Youth’’ recently reviewed in the New England Journal of Medicine. But do we geriatricians have a dog in this fight? Do we, who are trained and pledged to provide expert, compassionate care for our patients, need to become engaged? Or should we be satisfied to remain on the sidelines, content to focus our energies on our aging patients, many approaching the end of their lives, folks who have survived into old age without the ‘‘benefit’’ of breakthrough bioscience or the nostrums of A4M practitioners but while accumulating substantial burdens of chronic disease and disability along the way? Enter here pragmatists like Peter Whitehouse and Eric Juengst, who in these pages eloquently frame the several dimensions of this debate. In their essay, they have selected mild cognitive impairment (MCI) as the paradigmatic example of how this debate reflects the politics, the philosophy, the profits, and the practice of geriatrics. In doing so they seek to capture our attention by the use of powerful and charged language: italicizing maladies in the A4M stated goals, medicalization of cognitive aging as a political strategy that carries a huge price tag, the powerful and ominous influence of labels such as MCI to describe those maladies, labels that can themselves contribute to the terror and suffering of age-related declines, the fear of impending Alzheimer’s disease as a source of that terror and a ‘‘funeral that never ends,’’ and the potential futility of wars against inevitable age-related declines programmed into the human genome. Here the authors are to be commended for their language, bold yet carefully chosen, for rather than hide behind our traditional barricade of academic obfuscation, they choose to confront this battle in the public arena and terms in which it is being waged. In publishing their argument in this journal, they challenge geriatricians and the AGS to leave the sidelines and plunge into this debate. In MCI, the authors have selected a particularly compelling example from among the many contemporary matters that challenge our profession. For a quarter of a century, students of the aging process have gathered under the comfortable banner of the ‘‘compression of morbidity’’ theory popularized by James Fries. This hypothesis has proven almost universally popular among professionals and the lay public alike, offering patients (and us) the promise of lives lived to the fullest, pursued in health and vitality, in possession of all our faculties, and ‘‘aging successfully,’’ largely through a healthy lifestyle, common-sense behavior, and personalized strategic ‘‘preventive gerontology. ’’ According to this model, we may expect to enjoy such robust health until shortly before we dieFat an average age of 85, with but a narrow variance about the mean ( 4–7 years), squaring our own survival curves, and telescoping our terminal decline into a few weeks or months before death, a scenario colorfully (but chillingly) illustrated years ago in Aldous Huxley’s Brave New World. However, geriatricians know all too well from clinical experience how frequently this attractive fantasy fails to play, as we focus care on our gradually aging patients who suffer the manifold consequences of parallel failings in multiple systems that surface in the myriad clinical problems we manageFthe comorbidities of old age, notably musculoskeletal, metabolic, cardiovascular, and neuropsychiatric diseases (including Alzheimer’s); the geriatric syndromes, functional disabilities; frailty; and failure to thrive in a scenario of DOI: 10.1111/j.1532-5415.2005. 53414.x