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 March 2001
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Written by
Kris Mamula

Illustrations by
Rob Day/SIS





How Old Is Old?

With $130 Million in More than 100 Aging-related Projects, Pitt Researchers Are Challenging the Inevitability of Disability and Decline in Old Age

The old upright piano explodes into a carnival of melody as 94-year-old Edith Moeller-Schragl peers through clear hazel eyes where sheet music should be, but is not. Moeller-Schragl, who raised eight children, has outlived two husbands, survived two bouts of breast cancer, hip replacement surgery, and injuries received in a serious car crash. Moeller-Schragl sings, fingers floating over the keys, teasing whimsical flourishes, keeping time with chords that stretch her hands and fingers wide: “Da, da, dum, la, la, la.” The song drifts to a close. She shuts her eyes for a moment, then picks up a ragtime riff. “I’m not sure which one this is,” she says, pushing trifocals up the bridge of her nose with her right hand—her left hand, as though with a mind of its own, keeping perfect time. Both hands quickly become a churning blur. The piano roars. Edith Moeller-Schragl shines.

At 94, why isn’t Moeller-Schragl old already? The answer is, nobody knows what old is anymore. Good thing, too. We are too quick to think that problems such as disability, depression, and dementia are unavoidable in old age, that laughing and ragtime piano are only for people under 65. Or 45. The perceptions are as popular as they are wrong. In fact, much of what we thought was an inevitable part of growing old is often little more than myth. “What is normal aging?” asks George S. Zubenko, a psychiatrist and researcher at the University of Pittsburgh’s Western Psychiatric Institute and Clinic. “Those boundaries are not easy to define.” Zubenko is trying to unlock the secrets of Moeller-Schragl’s longevity, for instance, by probing her genes. His study is part of a five-year, $5 million research program. No mystery here, as far as Moeller-Schragl is concerned. “Remember your morning prayers,” she says, eyes twinkling.

Scientifically speaking, the answer is not so simple. Dozens of Pitt researchers in addition to Zubenko are trying to find out how seniors can avoid disability while staying fit—mentally and physically. The starting point is questioning the truisms about getting old that have been gathering dust for generations—in a word, questioning everything. What’s more, other factors, never before considered, have to be looked at. Is Moeller-Schragl’s love of music somehow linked to her success in aging, for starters? Her children think so.

Moeller-Schragl’s musical education ended with two or three piano lessons when World War I was still raging in Europe. She was 9. Everything else was self-taught, including how to play a dozen keyboard and stringed instruments. Closing her eyes tight again, Moeller-Schragl mouths a few words. She explains that she is “seeing” lyrics in her head, then allowing her fingers to “see” the melody on the keyboard. Strings of visualized words become clusters of musical notes. I want to hire a man who is strong and tall/one who knows about a barn and all/one to take care of the cows and the chickens/gather up my sheep and work like the dickens, she sings, laughing her way through a song of her own making. Love of music, good genes, upbeat outlook on life—lots of things could explain Moeller-Schragl’s long, healthy life. But this much is clear: Moeller-Schragl doesn’t know she’s old. What if her oversight could somehow be copied? The possibility is tantalizing researchers.

With the elderly population growing both locally and nationwide, Arthur S. Levine, senior vice chancellor and dean of Pitt’s medical school, and Provost James V. Maher convened a Council on Aging at the University. A working group of researchers under the direction of Richard Schulz, head of the University Center for Social and Urban Research, the council was able to identify more than $130 million in aging-related research money that the University has received for about 100 projects. “You name it, it’s here,” says Neil M. Resnick, director of geriatric medicine. In fact, the University’s aging-related research funding portfolios is among the biggest in America, according to the council, which recommended formation of a University Center for Aging. Think of Moeller-Schragl as the answer. She is the goal, the Holy Grail that all aging-related research seeks to recreate. What had been missing for years were the right questions. Until now.

Are Moeller-Schragl’s genes giving her the gift of a long, robust life? Is there a specific gene—as found in flies, worms and other lower life forms—that determines how long a person lives? No one knows for sure. What is known is that men are about twice as likely as women to die from heart disease. Men also have the edge in death from stroke, car crashes, and cancer. There are lots of theories about why this is so. Zubenko’s early research suggests that the Y chromosome, which determines the male sex, is hiding part of longevity’s secret. “It’s hard enough to find 90-year-old women,” he says. “It’s a lot harder to find 90-year-old men.” He expects to find numerous genes that affect aging and the risk of developing age-related diseases. “But I’m perfectly prepared to be wrong,” he adds quickly, “and that’s part of what’s fun about doing science.” Meanwhile, other Pitt researchers are busy redefining the word “disease.”

The old view was that you were either sick or healthy—nothing in between. The new view is that human life is a series of changes in the brain, heart, skin, and other organs. Some of the changes, like deposits in the blood-carrying arteries, show up sooner in some people than others. Disease and health are no longer all-or-nothing states. Instead, aging is being viewed like individual frames of a film. “There’s no cut-off point between normal and abnormal,” Anne B. Newman, a Pitt epidemiologist and geriatrician, says about the new view of aging. “It’s only a matter of timing.”

Look at what’s happened over the last century. Improvements in public sanitation and the advent of penicillin-like drugs boosted the average life span. The year Moeller-Schragl was born, Kellogg’s Corn Flakes became a breakfast cereal and Alois Alzheimer first lectured on a strange new brain disease. At the start of the twentieth century, flu, pneumonia, tuberculosis, and typhoid were scourges that led the list of reasons why people died. At that time, the average person lived about 50 years. By the end of the century, the death rates from flu and pneumonia had fallen by 83 percent while tuberculosis and typhoid became nearly negligible.

People are living longer as a result of these changes—25 years were added to the average person’s life over the last century. The census bureau predicts that the over-60 population will balloon by 2025. And some age groups, including people over 95, will more than double. Pennsylvania is leading the way in the graying of America. The state’s 1.9 million elderly residents means Pennsylvania ranks fifth nationally in the number of elderly, second only to Florida in the proportion of the total population 65 and older.

We’re not only living longer, but better. Research in the 1980s and 1990s found that each new American generation beginning its 80s had fewer disabilities than the one before it. At the same time, new devices were making it possible to measure things like bone density—an important marker of health. The advancement of technology helped researchers begin rethinking exactly what was normal aging. Take muscle loss, for example. Skeletal muscle comprises about half of our lean body weight. By some estimates, we lose about one kilogram of muscle per decade after age 25 or 30. But in 1994, a landmark study found that muscle loss could be reversed in people as old as 98. The key was simple weight training, according to the findings. Newman calls the 1994 study “revolutionary.” “The idea that you can regain function in old age is very important,” says Newman, who was the first geriatric fellow at Pitt. “That’s what I get most excited about—the potential for improvement.” She wasn’t alone.

For pioneers in the field of geriatrics like Newman and Lewis H. Kuller, chair of Pitt’s epidemiology department, a lightbulb went on: What generations of doctors believed was just part of getting old, such as muscle wasting, may not be natural at all. And if muscle loss wasn’t normal, the question became, what else might not be “natural” aging. But even before that question could be answered, researchers were asking: Were there ways to prevent frailty and disability, the very things that had for generations defined the elderly? The questions led to yet other questions: Was it possible to treat the elderly before the first heart attack, the first fall, the first hip fracture? One of the plums for answering these questions was potentially billions in health care cost savings. Disability is costly.

Think of the expenses incurred by simple falls. One-quarter million Americans, most of them over 70, suffered fractured hips in 1996 alone—90 percent due to falls. The cost of treatment? A cool $10 billion. Prevention and early treatment could slash those costs. More important, early care could allow people to live longer and healthier lives. But first, new tests were needed to measure heart disease, for example, years before an elderly person ever had to be rushed to an emergency room with chest pain. Newman and Kuller led the way with new tests, including measuring the thickness, stiffness, and amount of calcium deposits inside the wall of blood vessels, to predict mobility-robbing health problems. Alzheimer’s Research Center Director Steven T. DeKosky summarizes the shift in approach in this way: “What is the earliest change you can see in this individual that makes you say, ‘I’m worried about this person?’” What researchers wanted were ways to identify heart and circulatory problems before these things could really be called disease—at least in the traditional sense. But then, a lot of the aging-related research at Pitt is turning convention on its ear.

Let’s look again at the wasting of muscle that everyone experiences as they age. Until 1988, this loss of muscle didn’t even have a formal name. It was just what happened when you got old. No more. Today, doctors know the inexorable loss of muscle as sarcopenia—the Greek word “sarco” means flesh and “penia” means deficiency, a condition that doctors are now urging patients to battle through exercise. “Changes in muscle, bone, and fat may be a common link between many diseases such as arthritis and heart disease, which lead to frailty in old age,” Newman says. Almost overnight, what had been considered normal was not normal at all. “We don’t believe that losing muscle mass, bone mass, and memory is normal aging,” says DeKosky. “A lot of things that go bad in aging are disuse related.” Staying active suddenly took on a new urgency for the elderly.

Look,” Moeller-Schragl says, eyes wide as a kid’s on Christmas morning. “Here’s another instrument.” She takes an accordion out of its case on the dining room floor and begins warming up. These days, daughters Audrey and Nancy make sure mother gets to personal care homes and senior centers, where she entertains on the piano, baritone ukulele, Hawaiian mandolin harp, and accordion. “What do you call them?” she asks daughter Audrey Moeller. “My gigs?” Doesn’t matter. The accordion is already rioting in song. Over the years, she made time to write hundreds of poems, short ditties about drafty old houses and farmhands who didn’t want to work. A lifetime of poems fill giant binders, the kind that might have been carried by the schoolgirl she once was. But the child remains.

The questions that were being asked about “normal” aging shifted from muscle to bone loss. Doctors long thought that bone loss ended in old age, according to Susan L. Greenspan, director of Pitt’s Osteoporosis Prevention and Treatment Center. Not true. The reality is that bone loss accelerates in old age. “Another myth was that you couldn’t treat elderly women for bone loss,” Greenspan says. But she is leading a soon-to-be-finished study that suggests that “older women do well” with treatment. Until 1995, estrogen was the only drug to treat osteoporosis, says epidemiologist and osteoporosis researcher Jane A. Cauley. And these questions are leading in some unexpected directions. Cauley is the Pitt principal investigator in a multicenter study involving 10,101 older women that will determine whether raloxifene—a drug already approved for the treatment of osteoporosis—can help prevent heart disease. Cauley also led the research team that determined the drug alendronate stops bone loss in women—the first treatment since estrogen. And bone density matters. Osteoporosis and related fractures cost some $14 billion each year. Complications from hip fractures kill as many people every year as breast cancer—some 43,000, according to Greenspan. What’s more, there are approximately 250,000 hip fractures annually, and a doubling or tripling of those numbers is expected over the next 10 to 15 years as America grays.

But seeing aging as a series of movie still frames is yielding still more opportunities for prevention of disease and disability. The result is a whole new approach to medical care for the elderly. Says Greenspan, “We’re redefining prevention.” Look again at falls. It’s no secret that reflexes in the elderly are slower than in young people. That’s why falls are often so devastating in older people. Greenspan says that seniors may not even fully realize they’re falling until they’re on the ground, which keeps them from breaking the fall with their arms. Newman wants to know, on a cellular level, why reflexes in the elderly are slower. If muscle wasting is caused by disuse, could it be that nerves respond more slowly for the same reason? Research will tell. Similarly, Kuller says that the key to treating Alzheimer’s and other dementias will come from better understanding of how the problems develop on a molecular level.
Insights on a cellular level will create new opportunities to do something about medical problems, perhaps even before they become problems. And when it comes to debilitating diseases, slowing the onset, in some cases, may work every bit as well as a cure. For example, delaying one nursing home admission by a month represents savings of at least $2,000. Two Pitt current clinical trials are searching for ways to delay the onset of dementia. Gingko biloba, a popular plant extract, is one of the drugs being tested in two studies, one in the prevention of dementias such as Alzheimer’s; the other on the effectiveness of Ginkgo in the treatment of Alzheimer’s disease itself. Dementias are no small thing: In 1985 alone, treating people with Alzheimer’s cost between $24 billion and $48 billion. The costs are much higher today. As a society, Kuller says, “We don’t know how to pay for it.”

The questions about aging continued, eventually reaching those who take care of the elderly. Who are these caregivers and how are they affected by providing this care? “Most of the health care that’s provided for the elderly comes from family members,” says Richard Schulz, director of the University Center for Social and Urban Research. “It’s a huge public health issue.” In one study, Schulz found that family caregivers are prone to depression and premature death. Schulz is finishing a study of 1,222 Alzheimer patients and their caregivers, looking at ways to best prevent caregiver burnout. Why is that important? Without family members, the burden of caring for the elderly would shift to the government. No one can afford that cost. The bigger issue will be what role the government will have in supporting family caregivers, says Schulz, who was recently honored by the Gerontogical Society of America for his studies of social behavior and aging. From cellular changes that portend disease to disease prevention to governmental policy for those who care for the elderly, every aspect of aging is getting a second, hard look. “If the only thing you’re talking about in aging is building better nursing homes, then you are wrong,” says Kuller. “The real emphasis in the elderly will be prevention of disease and disability.” Soon, those prevention efforts may reach caregivers as well.

You get old. Loved ones die. You get depressed. That’s life, right? Wrong. Add depression to the list of myths about what is “natural” in aging. The reality is that few problems are as insidious—or treatable—as depression, says Charles F. Reynolds III, director of the Intervention Research Center for Late-Life Mood Disorders at the Western Psychiatric Institute. Between 2 and 20 percent of people over 65 suffer from depression. That’s millions of Americans annually. A variety of health problems can disguise depression, making it difficult to detect—even by family doctors. Loss of appetite, sleeplessness, and other symptoms can replace depression’s classic sign—sadness. Depression robs its victims of joy and hope, and increases the risk of suicide. “It gets in the way of treating these other health problems,” Reynolds says.

Here’s one reason why depression is so insidious. Depressed people are three times more likely to die within 18 months of a heart attack as the person who is not depressed, Reynolds says. For nursing home residents, the mortality rate for heart attack is 60 percent for people with depression. A 20-year study by the Centers for Disease Control found that people with symptoms of depression upped their chances of a having a stroke by 73 percent. Even moderate depression increased stroke risk by 25 percent, according to the CDC. Depression’s effects on health problems such as heart attack and stroke are not well understood. But advances in imaging are making it possible to see structural changes in the depressed brain, which promises new insights. Still, early detection is key.

One Pitt study is testing whether a depression specialist on the staff of primary care centers is a cost-efficient way to increase detection of the disease. Another study is looking at the best ways to treat depression, whether drugs and counseling are more effective than either treatment alone. What’s more, researchers have learned that depression is a recurring disease. “Getting well is not enough,” Reynolds says. “Staying well is what counts.” Moeller-Schragl says she can’t ever remember feeling discouraged, let alone depressed. “I have to laugh at my life,” she says.

Moeller-Schragl began her working career at age 16. Reader’s Digest first rolled off the press that year. The oldest in a family of 10 children, Moeller-Schragl first went to work as a secretary where the boss prized her neat penmanship. She also moonlighted as a piano player in Pittsburgh’s theaters. “Talkie” films were still a couple years off. When Moeller-Schragl was 60, her first husband, Nicholas W. Moeller, died. Seven years later she married a second time, Alexander J. Schragl, a Port Authority Transit body mechanic. Even now, she giggles like a little girl in talking about the fun they had, the fishing trips, the pranks they would play on each other. She leaves the room and returns with a thick black binder.

On a couch in the living room, Moeller-Schragl reads a tribute to her second husband from the binder. Co-workers would rib him about the poems she wrapped with his lunches. She wrote the tribute to mark the first anniversary of his death. He died from a heart attack at home at age 71, just a few days before Christmas in 1983. At first, Moeller-Schragl says she thought he was sleeping. Slowly closing the schoolgirl’s binder, Moeller-Schragl walks across the room and sits at an organ. Her head is high, her steps sure. “I’ll play the first thing that comes to my mind,” she says smiling, ever smiling. The room suddenly fills with music from the movie Doctor Zhivago, “Somewhere My Love.” “Do you remember this one?” she says, lyrics filling her head, hands playing the music only she can see—the music of her youth.



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