"Do not go gentle into that good night,
Old age should burn and rave at close of day;
Rage, rage against the dying of the light."

— Dylan Thomas

Hundreds of years of war, Machiavellian strategies and tremendous energy expended in churning the great ocean. That was the price the Gods had to pay, according to the Puranas, to get amrit-the nectar of immortality and everlasting youth. But that secret had so far eluded mere mortals for whom age, through centuries, had been as inevitable as taxes. It could manifest itself suddenly with an unexpected spasm of the limb while climbing the stairs. Or the process could be gradual, with crucial little facts slipping a once infallible memory. Inexorably, irreversibly, time takes its toll-failing faculties, decreasing energy, unexpected collapse of organs, waning eyesight, fading hearing, wrinkles, grey hair, baldness.

Now with 21st century medicine, man can do easily what the Gods did with so much effort: beat age. Or, at least, ensure that the quality of life does not decline with age. That is certainly what retired bureaucrat R.S. Madhukar has opted for. Now in his late 60s, he found his eyesight deteriorating-a common phenomenon of old age, called Age-related Macular Degeneration (AMD). It affects more than half the population above 55, blurring the sharp, central vision one needs for reading, sewing and driving.

Only a few years earlier, Madhukar would have had to shrug his shoulders, accept he was growing old and go easy on his favourite pastime, reading. Not anymore. New techniques, initially introduced at All India Institute of Medical Sciences (AIIMS) in Delhi, called photodynamic therapy (PDT) and Transpupillary Thermotherapy (TTT) ensure that his eyesight will not decline further. TTT involves zapping the targeted area of the retina with a specific type of laser. In PDT, a light-sensitive dye called verteporfin is used to detect and destroy new blood vessels in the eye. It is painless and takes only 20 minutes, though one has to avoid direct sunlight or bright indoor light for five days after treatment. Both PDT and TTT stabilise vision in 70 per cent of the cases and actually improve sight for a lucky 10 per cent. "But assessing the patient for the right surgery is very important," warns retina specialist Lalit Verma of Delhi's Centre for Sight. Thanks to TTT, Madhukar now happily devotes his hours to writing Buddhist prayer books.

"Skin starts sagging at 40. But we now have the tools to reverse that." Omer Azad, Cosmetic Laser Surgeon

Madhukar's is not an odd case of defying old age. Worldwide, demography is driving technology. With more elderly people than ever before on the planet, there is a fundamental change in attitude towards old age. In the 20th century, 30 years were added to the average life expectancy worldwide. As the baby boomers matured into grandparents, helped by unprecedented advances in healthcare, the 55-plus population has grown at a rapid pace. So has its economic clout-most people at the zenith of their professional lives are in this age category. And they want to stay young forever.

Coupled with the realisation that a large population of the old and unhealthy people is a huge emotional and financial burden on society, this has meant a sharper focus on age-related problems. In the US, $1.6 billion (Rs 7,600 crore)-7 per cent of the National Institutes of Health (NIH) budget for 2003-was dedicated to age-related research. An entire NIH agency, the National Institute of Aging, is devoted to the subject. In most developed countries, an increasing number of universities and medical colleges offer courses in gerontology-the study of old age.

The trend has reached India too. In 1950, 5.6 per cent of India's population was above the age of 60. Today, almost 8 per cent, that is 80 million people, are 60-plus. Another 60 million, 6 per cent of the population, are in the 55-60 bracket. This number is expected to increase to 22 per cent by 2050, according to a report by the East-West Center, Hawaii. No wonder AIIMS has a department of gerontology.

Gerontology can touch every aspect of your life-and all parts of your body. With a dazzling new array of technology at hand, millions now remain young or, at least, look so by opting to scalp or freeze their way to youth: plastic surgery, Botox, chemical peels, laser treatments. Synthetic hormones blow away the blues for both men and women. Wonder drugs build bones so that they last as long as you do. Enlarged prostates are zapped by laser. Electronic devices can stabilise the terrible trembles of Parkinson's patients. One can truly be as young-or old-as one feels.

Ask Brigadier (retd) N.S. Dhaliwal, 59. He thinks he is 40. A fitness fanatic, he walks every day and plays golf. But he could not escape benign prostatic hyperplasia (BPH), a problem for almost half the men above 50. The most common treatment, transurethral resection of prostate (TIR[), involves removing part of the organ and wearing a catheter through the urethra for two or three days while the wound heals. Sounds uncomfortable? It is.

In November 2003, in the Army Hospital in Delhi, urologist Colonel Rajeev Sood used high-energy green light to literally vaporise the enlarged part of Dhaliwal's prostate. Termed photoselective vaporisation of prostate (PVP), the technique is simple and quick and is over in just half a day. And Dhaliwal is now back on the golf course in Panchkula. "I have never felt better," he says, beaming with excitement.

"Thanks to new technology, we need not worry about fading eyesight. " Lalit Verma, Retinal Specialist

In Kolkata, Jayshree Pal Chaudhuri, 46, echoes the feeling. A few years ago, her hectic social life was threatened by a hysterectomy. That was when Chaudhuri's "bad moods" kicked in. "I am a positive person but I suddenly found that I was crying at the slightest provocation," she says. She stopped going out because of her mood swings and nagging aches. "People started wondering if my husband and I were having some differences," she laughs.

After two years of what Chaudhuri calls a "psychosomatic roller-coaster", her mother Anjali Biswas (now 78) insisted Chaudhuri tried hormone replacement therapy (HRT), a controversial treatment. She used a new range of synthetic hormones. The impact was dramatic. She can now "keep up with my 20-something colleagues at work" and relish parties all over again. Compliments about her youthful looks have become passé. Chaudhury is even contemplating taking Kathak lessons. "HRT has brought me the life that I was looking for," she says.

WRINKLES

Whole New Face

SHEELA GUPTA 59 HOUSEWIFE She regularly goes for chemical peels for a fresh and rejuvenated look and says she feels 10 years younger. She is also considering Botox for wrinkles. "Age is a mind syndrome. If you have a young mind, the body can follow." Treatment SKIN REJUVENATION 1 Chemicals like Botox and facial fillers smooth wrinkles and lines on the face. 2 Lasers and chemical peels rejuvenate the skin by stimulating new collagen, an important skin protein. It is quick and safe and lasts several months. 3 Resurfacing of the entire skin can also be done by a laser. It takes 90 minutes. Delicate new skin surfaces in about three weeks.

According to endocrinologist Binayak Sinha, Chaudhuri is a classic case of rejuvenation through HRT. "It was not a magic drug that could cure Alzheimer's or heart diseases," says Sinha, "but many women don't realise that oestrogen protects their heart-by keeping their arteries unclogged-and bones, apart from giving them a sense of mental, physical and sexual well-being."

Nonetheless, HRT remains controversial. While it protects against osteoporosis, hot flashes, heart ailments, some cancers and Alzheimer's disease, it could also increase the risk of breast and uterine cancers. In women with blood clots, HRT may be downright dangerous.

In medicine, as in every other avenue of life, men usually take their cue from women. The Indian man too is waking up to his own rejuvenating hormone therapy, complete with controversies. Says Delhi-based endocrinologist Ambrish Mithal: "After about the age of 40 testosterone levels decrease slowly in men." This leads to fatigue, muscle weakness and libido problems. Testosterone therapy, introduced in India in 2000, not only checks these, it also guards bones against osteoporosis. "But there is a controversy whether borderline cases should be treated with testosterone therapy," cautions Mithal. It could lead to an enlarged prostate and even cancer.

Testosterone alone does not make a (young) man. The sagging muscles that signify age often reflect the dipping levels of the hormone that helps us grow-growth hormone (GH). In two out of 1,000 patients it dips low enough to be a medical problem. A daily shot of GH, and one is raring to go. But at Rs 1,000 per shot, one needs to be very sick. Or very wealthy.

The impact of age is perhaps most acutely felt in the bedroom. Several studies have shown that as many as half of all men over 40 suffer from some form of impotence. Five years ago, Viagra (sildenafil) brought about a revolution. Now the post-Viagra generation of drugs promises greater succour. Levitra (vardenafil), a Bayer product approved for marketing in August 2003 by the US Food and Drug Administration, works within 15 minutes and lasts 24 hours. In comparison, Viagra was effective for only four to five hours. Due to hit pharma stores soon, Cialis (tadalafil) can keep one going for four days. Also in the offing are nasal sprays that could put a spring on the libido.

Before the bedroom, there is the green room. Earlier, plastic surgery was the only option. Later, a neurotoxin like Botox came to the rescue. Increasingly popular as a beauty treatment, it freezes the muscles, smoothing out wrinkles. It is often combined with "collagen fillers". While Botox straightens deep wrinkles, the fillers smooth static lines and give a lift to the face. The effects last around six months and cost approximately Rs 20,000. A warning though: it should only be applied by trained physicians. Injected in the wrong muscle, botox can have disastrous consequences. Says Rekha Seth, president, Cosmetic Society of India: "In today's fast moving and competitive world, how you look and present yourself is extremely important."

That could explain why laser skin resurfacing is a popular technique. Laser Medical Centre, Hyderabad, uses the ultra-pulse CO2 laser to help patients shed old skin and grow new one. The laser removes the top epidermal layer and contracts the collagen. Wrinkles and other imperfections on the skin fade to reveal a younger you. "This fresh appeal will last about 15 years and make the person look at least 10 years younger," says cosmetic laser surgeon Puli Ravindra Reddy.

HORMONE CHANGES

Getting Back the Vitality

JAYSHREE PAL CHAUDHURI 46 MANAGER A few years ago after a hysterectomy, Chaudhury started experiencing frequent bad moods that threatened her social life. Then on her mother's insistence she tried hormone replacement therapy with new synthetic hormones. Today, she is back to her normal lifestyle with youthful looks. She even plans Kathak lessons. "Today, I can keep up with my 20-something colleagues. It's the life I was looking for." Treatments HORMONE REPLACEMENT THERAPY WHAT IS IT? Some swear by it, others won't touch it. The controversial hormone replacement therapy is a combination of synthetic hormones to replace the "female" hormones oestrogen and progesterone. An improved range of these drugs, SERMS, are now in India. THE BENEFITS: Available as pills, it reduces the risk of heart disease in women, osteoporosis and related fractures, and generally provides more energy. There is also evidence that it reduces the risk of Alzheimer's disease and colon cancer. THE DOWNSIDE Women on HRT are at a slightly increased risk of breast cancer. A recent analysis of data on a large scale says that the risk is slightly greater than the benefits. But another report insists the benefits outweigh the risks. The debate continues.

The resurfacing of skin on the full face is a 90-minute surgical procedure done under general anaesthesia and costs about Rs 40,000. It takes about three weeks for the new skin to surface and, like a baby's skin, it has to be protected using sun blocks and depigmentation cream for another eight weeks. Besides filmstars and society hosts, other professionals conscious of the importance of their looks at the workplace are lining up for this surgery.

Photo-facial is a recent, non-ablative and quick laser-based skin rejuvenation. "Sun and stress disfigure collagen, leading to wrinkles and ageing," explains Omer Azad of Delhi's American Cosmetic Lazer Center. "This laser therapy stimulates the top skin layers to produce new collagen." These tighten the skin. Combined with Botox and facial fillers, they wipe away the signs of age.

A combination of crystals, fruit peel and cream is another popular treatment that Azad's clinic offers. "The skin starts sagging at the age of 40. Sometimes rejuvenation with laser may suffice but a combination is best," explains Azad. Ravindra Reddy points out that acid peels, costing between Rs 3,000 and Rs 6,000, and acne scar resurfacing are also drawing clients. He signs off with the "triple S" formula: "More than anything else, regular sex, sleep and shit are important to keep fit and look young."

If you think that is something to split hairs about but don't have any, try hair restoration surgery. "The follicular unit transplantation technique," explains Ashok Vardhan Reddy of the Laser Medical Centre, "offers a permanent result with a natural look." The transplanted hair remains for the rest of the person's life and grows normally. It can be cut, shaved, washed and dyed. The hairline looks soft, natural, undetectable and aesthetic. Baldly told, it's a dream.

Hair restoration surgery transfers the hair from the donor area-back of the head-to the bald area of the patient. There is no gap in the donor area since sutures are put, which heal in two weeks leaving only a thin pencil line scar. The scar is concealed in the hair. "We have people from abroad coming to Hyderabad for this because it costs only one tenth of the $10,000 (Rs 4.5 lakh) they have to pay for a sitting and surgery elsewhere," says Ashok Reddy. Predictably, the cost and the number of sittings will vary depending on the extent of baldness and the restoration plan. Hair restoration surgery can also be used to thicken a moustache or eyebrows or even on women who discover their hair is thinning.

That's something for Ashish Kakkar to chew on. Success, to most Indians, seems timed to coincide with the age of recurring teeth problems. Kakkar, senior consultant orthodontist at Delhi's Indraprastha Hospital, is often busy fixing new titanium screw implants into his patients' jaw bones to support missing teeth or dentures. The screw acts much like the root of the tooth. "It is ideal for busy people, usually doctors and senior executives, as they can sleep, eat, talk with these dentures without a worry," says Kakkar.

That's what prompted 60-year-old P. Jain, a doctor, to opt for titanium screw implants. "I have had these dentures for the past six-seven months. They are much better than other dentures. With these I can easily chew harder things and they don't keep popping out," he says. They are not cheap though, costing more than Rs 1 lakh for a set.

More painful and difficult to control is osteoarthritis. It is caused when the lubricating material between the joints, called the cartilage, wears off, making the movement of the joint excruciatingly difficult. In India, osteoarthritis of the knee is very common. "While osteoarthritis may not be curable," says Rohini Handa, professor of rheumatology at AIIMS, "it definitely is treatable."

For mild to moderate cases, drugs containing glucosamine and chondroitin, the building blocks of cartilage, often keep the disease in check. Three to five injections of the drug hyaluronan too can help one keep pace on the dance floor as long as one can pay Rs 7,000-10,000 for a course of 3-5 shots. New safer and effective painkillers like Celecoxive, Rofecoxive and Weldecoxive go a long way in making life more comfortable. But these are symptomatic.

Another joint structure-modifying drug called diacerein, that arrived in India last year, prevents the cartilage cells from dying. Those with severe affliction can get a new lease of life with a joint replacement surgery. But again it comes at a price-Rs 1-2 lakh.

Medicine can make the body beautiful, but can it mend the mind? Memory often starts failing after the age of 50 and 1.4 per cent of the population in the 65-69 age group suffers from dementia. This rises sharply to 40 per cent among those above 80. Both genetics and environmental factors play a role in it. A recently approved family of drugs, called ACE1 inhibitors, helps in 60 per cent cases of serious dementia. Gingko biloba can be a memory enhancer for mild lapses. Antioxidants work well too. In women, memory is one of the many faculties oestrogen helps protect. Says A.B. Dey, head of the Geriatric Clinic at AIIMS: "In India, the problem is that awareness is extremely low. The tragedy with dementia is that the family suffers as much as the patient does."

If dementia is a tragedy, Parkinson's Disease is a tragedy in sharp focus. It usually hits people in their 50s, wrenching their control over movements and even speech. Consequently, the sufferer cannot walk, eat and constantly twitches, while acutely aware of his or her helplessness. Earlier, surgery of the affected lobe in the brain was the only option. In the past couple of years, a treatment called Deep Brain Stimulation (DBS), involving the insertion of an electrode just below the skull, has proved extremely effective.The battery-operated device sends signals to the part of the brain that causes Parkinson's. It reduces tremors sufficiently for patients to be able to walk independently. "The patient's quality of life improves greatly," says AIIMS neurologist M. Bihari.

Age means different things to different people. For the busy executive, it may mean a slightly slackened pace to a hectic schedule. To a Parkinson's patient, it means indignity. To a man about town, it may be, literally, a cosmetic problem. Modern medicine has something for all of them. The Fountain of Youth has reached India.

— with Amarnath K. Menon, Sheela Raval and Labonita Ghosh