As we were leaving the room, I asked that person why he had had asked that question. He said he wanted to know what he had to look forward to. I took the question to indicate that the questioner sensed that I had a purpose in life and that, to me, age was irrelevant.
Reagan Defies the Finding
Perhaps the most well-known person in recent years who had AD was Ronald Reagan. Before his arrival on the national scene, we all joked about the prospects of an actor with the temerity to run for president of the United States. But nothing stopped him. I cannot speak with any certainty about his purpose in life, but he certainly seemed to be a determined man who went after what he wanted and succeeded in getting it. President Reagan is another example of a successful and purposeful man who ended his life with Alzheimer's.
How do we fit President Reagan and Dr. Ravdin into the model suggested by this study's finding? I am neither a researcher nor a statistician, but my own observations and experience offer many examples of purposeful and driven individuals who were nonetheless stricken with Alzheimer's. The authors are honest scientists and offer some concepts suggesting that the association between the sense of purposeless and development of Alzheimer's raises more questions than it offers answers. “Apathy and other lifestyle factors (e.g., exercise and nutrition) may be related to the level of engagement in purposeful behaviors and may have implications for our understanding of the link between purpose in life and cognition,” they wrote.
Cognition is a mysterious part of mental functioning. We hear advice such as “Keep your mind active” and “Do your crossword puzzles” to prevent AD. The aging process is difficult and fraught with many pitfalls, especially physiologic–heart disease, hypertension, and diabetes–to name just a few.
When older people get together, the conversation often turns to the different ailments from which they are all suffering, the vulnerabilities of old age, and the expectation of some disaster lurking around the corner. Elders get used to hearing that a friend or relative developed cancer or has died. We expect it, and these losses only serve to remind us of our own mortality.
As we age and lose those we love, it is painful and might lead to feeling that life no longer has purpose. I have always tended to see these episodes as depressions and not a precursor to AD. I work with such patients to reignite the spark, that is, their purpose in life.
When my first wife died 24 years ago, I went through a very miserable period, and my friends told me in retrospect that I looked awful. But they all inspired me to return to life–to a purposeful life. Fortunately, I had the support of my children and my friends, and 6 months later, I was as busy as I had ever been.
I do know what the authors mean by a purposeless life. It is a very bad feeling. I imagine that when depressed patients say they feel “empty,” that is what they mean, but I agree with the authors of the study that we need to get a better handle on the concept.
If we decided collectively to do an experiment to explore with all of our patients in therapy how they see their life purpose, I think we would be surprised at the variety of answers we would receive. Individuals might have a narrowly focused, highly narcissistic response. A woman might say her purpose is to see her children all grow up and be successful. A man might say his purpose is to earn a million dollars and not have to worry about money. Another man might say his purpose is to give back to society, and a woman might say her purpose was to help poor children learn to read. Among the elderly, there would be a wide range of responses to the question of purpose in life.
The Rush study found an association between purposelessness and mild cognitive impairment or Alzheimer's in later life, but this association is difficult to explain. After all, mild cognitive impairment, a preclinical symptom of Alzheimer's disease, might itself trigger feelings of purposelessness.
Perhaps we as psychiatrists should approach purposelessness in the elderly much as we would that condition in younger people. It is condition that can be addressed psychiatrically, whether or not it has anything to do with Alzheimer's.