Posts Tagged ‘Aging’

The Thinker

Sex, the aging man and the journey toward being fully human

Men will notice some changes to their libido as they age. With rare exceptions, your libido is going to go down. This is primarily because the level of testosterone in your blood is going down. It decreases with age.

This is generally greatly disturbing to the middle aged man. That’s because they envision themselves as 20-something for life. Their hair may be receding and their gut may be expanding — all typical signs of aging in men — but somehow they figure their penis is exempt. All of this is entirely natural, but sadly a lot of this information is simply not discussed.

Physicians will usually write men a prescription for Viagra or Cialis easily enough. Rarely will physicians clue you in on what’s really likely to happen to your sex drive as you age. What it amounts to is that if you want a sex life after forty or fifty, you need to reduce your expectations. You need to stop chasing the illusion that you are 20-something. You need to communicate really well with your partner. And you need to change how you make love. That’s quite an agenda! No wonder so many men simply withdraw from sex. It’s too much pressure!

It’s also more than a little embarrassing. It used to be that erections just happened. In many cases, they arrived unwelcome and for no reason at all. Perhaps it was a fleeting memory of a previously great sexual encounter that caused you to shift legs on the subway to avoid embarrassment. When you are 40-something or older, the memory is still there, but it’s unlikely to kick off an erection. You may find that given the choice between making love to a willing and decently attractive woman and watching football, you’ll choose the football.

It’s easy for you to feel horny with relatively high levels of testosterone surging through your blood. Most men who use anti-impotence drugs soon realize that while once aroused these drugs help them maintain an erection, there is also now the issue of getting aroused. It usually helps to have a surplus of testosterone in the bloodstream to feel arousal. To the extent men have it, it comes from longer intervals between orgasms. And that’s when it becomes embarrassing. If you are used to shagging with the missus every night or every other night, maybe it’s now once a week, then biweekly, then once a month, and then maybe only on Valentine’s Day. It’s hard to tell your significant other that you just aren’t a stud anymore. Even if she is drop dead gorgeous, that’s sometimes not enough for your body to keep up with your mind.

Not that long ago this wasn’t much of a problem. This was because nature took care of the embarrassment problem, by tipping the scales that you would be dead before it mattered. Men went off to fight in wars and died nastily in the heat of a battle. Or they simply wore out chasing after sheep or hunting a saber tooth tiger. Or they were culled by the many diseases that are now easily prevented. Actually, a lot of men (and women) died from abscessed teeth. There were no schools of dentistry until recently. Now of course fewer of us serve in wars so we get to live to our doddering years. So now we are getting a close encounter with our declining sex drives, and it is often disturbing. It is made more disturbing by the simple lack of quality information on what is normal. You can find it if you look but you have to look real hard. I came across such a site, well actually just a web page, recently. Here it is.

By all means reach for the Cialis or Viagra, assuming you can afford these overpriced anti-impotence drugs. Men often use them to great effect, but soon discover that while it makes sex possible it doesn’t increase the frequency of sex or give you the chronic urge to have sex like you had as an adolescent. That usually just keeps declining with age. Some men figure out the real issue, which is why testosterone supplements are all the rage online. It doesn’t take much Googling to discover these supplements are of dubious value, and likely dangerous, probably much like estrogen supplements are dangerous for women during and after menopause.

The bottom line for men is that nature intends you to slow down. It wants you to smell the flowers instead of the scent of women. This is actually fine for most women your age. Many still want to have sex, but a lot less frequently. A frequent issue with menopause is vaginal dryness during sex, which means there will be a tube of lube in your future, as well as the Cialis, when you do have sex. Moreover, since your sex drive is declining and her sex drive is likely declining as well, you are both more likely to just cuddle instead. The exception may be when you are in your forties. Women tend to peak sexually in their forties while men start to noticeably decline sexually in their forties. That’s when it gets embarrassing for men. She wants it but you don’t necessarily want it, and you can’t always keep up with demand. And that makes you feel, well, less of a man, because real men with a hot woman can keep it up.

So what you might want to do is print out that web page and pass it on to your wife or significant other. First thing you want to do is to remove the shame factor, because shame will contribute to sexual dysfunction when what you are going through is completely normal. Second, if you do value having sex, albeit less frequently than before, you need to educate your S.O. on what she can do to increase the probability of success. You need to educate them that losing an erection during sex is normal for older men but with a decent amount of pressure it is likely to come back and if applied continuously your erection may not fade. All this takes intimate communications, usually a challenge for men who are trained to behave as if they are invulnerable and eternally youthful. If your partner loves you, then it’s not unrealistic to expect them to work with you and your aging body.

It’s also okay to now have sex and not necessarily have an orgasm. If she is horny and you are not, you can use a vibrator on her or better yet your mouth. You may get aroused to the point where you want to have sex, in which case you’ll be raring to go, or not. But most likely next time you will be in the mood. It’s okay. This is what nature intended.

Is there an upside to all this? Actually, there are many upsides for personal growth. First, sex can take on a deeper and richer meaning than it did when you were younger. It becomes more about intimacy and connection that it does about anxiously depositing semen. When you do have sex, it might well be longer and more enjoyable than when you were younger. It becomes more about making love, connecting and enjoying your partner in many dimensions. You can also become more aware that the tactile parts of lovemaking are very pleasurable too: simply touching, or caressing, looking in her eyes, nibbling her ears or kissing her can be very enjoyable.

Perhaps the biggest reason to enjoy your sexual decline is the one so rarely stated: you have the opportunity to see yourself, and your partner, as a human being with many dimensions, of which sex is but one aspect. Having spent most of your life defining yourself as a man, you may discover yourself as a human being instead. Things like sex still matter, but should matter less. You may find yourself being able to see someone as multi-dimensional, rather than as a role or an object. You may have a deeper appreciation for the experience of simply being a human.

These are some of the gifts of age, but they often require giving up some of the fallacious notions of youth and assumptions on how you should be because you are a male. This stuff is a graduate school for human relations. If you live long enough, and are brave enough to try it, you may find that this stage of life can be a great learning experience about what it means to be fully human. These are aspects of yourself that were always there, but which you ignored or deprecated. They too are precious in their own way.

Be brave and take that journey into being fully human.

 
The Thinker

Aging gratefully

Another birthday rolled around yesterday. For once the first of February felt like it should: bitterly cold and snowing. I am not much on celebrating birthdays, which is probably why I scheduled an outpatient procedure on my birthday. Specifically, I had a colonoscopy, a distasteful but necessary procedure for us insured humans age fifty plus. This being my second time, I knew what to expect. When I had my last one at age fifty, I could get it done in a local surgical center. This time, because I was subsequently diagnosed with sleep apnea, it meant going to the hospital instead. It also meant arising at three a.m. to down a second dose of medicine guaranteed to empty your digestive track, not to mention spending the day before at home on a liquid only diet, trying to make a bottle of white grape juice substitute for solid food.

Happily the procedure went well. One reason I was repeating it after only five years instead of the normal ten years is because polyps run on my mother’s side of the family. She never had a colonoscopy and as a result due to a huge polyp had to have part of her large intestine removed. Sure enough, yesterday my gastroenterologist found a polyp, but it was easily sliced off and removed. By ten a.m. I was home eating solid food none the worse for the experience but with lovely color photos of my large intestine showing the emerging polyp.

That’s kind of how it should go at age 56. You have given up chasing immortality and have made peace with conforming to the practices of modern medical science instead. Few men or women my age can credibly claim they have the strength and stamina they had when they were in their 20s. Perhaps I could get the illusion of it if, like some foolish and better moneyed people my age, I ingested steroids and got shots of HGH (human growth hormone). Along with the HGH, regular injections of testosterone probably would make me feel manlier. Marketers think they know what I need and lately it’s been testosterone supplements. I can rarely go to a web site without seeing ads telling me about the benefits of testosterone therapy. I remain skeptical. Estrogen replacement therapy for women has proven to have more minuses than pluses for most women. I doubt testosterone supplements and shots are without serious risks as well. Perhaps it will keep my hairline from receding, or suddenly make me attractive to women half my age, but I doubt that is worth any of the potential complications.

Or perhaps I should do what has worked so well for my father, age 86, still reasonably healthy and walking around. Perhaps I should simply give up on the silly pseudo science, ignore the multitudes of marketers of immortality and pragmatically get regular exercise and regular checkups instead. My father has been battling precancerous melanomas for decades, but he is still alive. This is thanks to regular trips to the dermatologist, which often results in skin removal or replacement. It doesn’t appear that I have inherited that particular condition, but it does look like I have my mother’s tendency toward polyps in the large intestine, so I best better bear the indignity of these colonoscopies every five years.

I also inherited her family’s tendency toward tallness, narrow throats and a large uvula, all of which contribute toward a tendency to snore and which eventually lead to a diagnosis of sleep apnea. For a whole year now I have been sleeping with the aid of a BPAP machine. It regularly fills my lungs with air, even when my body would prefer to stop breathing for a while. For a month or two using the machine was more torture than restful until I figured out how to put the mask on properly so it did not hiss at me during the night. Now the BPAP allows me to get genuinely restful sleep, and many nights I sleep like a baby. Waking rested gives me more energy than any shot of testosterone is likely to provide.

Maybe there is something unmanly about depending on regular checkups and medical science. Real men in their fifties, if you believe the ads, are supposed to be climbing mountains, roping steer, running marathons and bedding women in their twenties. What most real men my age are doing appears to be quite the opposite, at least according to my observations: eating too much crap and limiting their exercise to changing cable channels with their remote controls. I confess to eating too much crap myself, but I also eat plenty of healthy food, and since 1981 I have been getting regular aerobic exercise. My health is obviously not perfect, but it is better than most men my age. I can’t seem to go see any physician without getting blood drawn, so I have constant opportunities to tweak Vitamin D deficiencies, check my cholesterol or measure my triglycerides.

So at age 56 I remain a work in progress. I am realistic enough to know I won’t live forever but stubborn enough to insist that as much as feasible I will enjoy those years that remain. If that means sleeping with a BPAP machine for the rest of my life or having to endure the indignity of having my colon probed every five years, so be it. At least I am still here, in reasonably good health, and with (I hope, no guarantees) much more good life ahead of me. My testosterone levels may be receding like my hairline, but with luck the next thirty years of my life will be happier years with less heartache and struggle.

I’ll keep my physician on speed dial to make it so.

 
The Thinker

Aging: this ride is not an E ticket

Another birthday rolled in today. Curiously, what also came in my mailbox on my birthday was my new drivers license. Before I shredded my old license I looked at its picture, taken ten years earlier. Comparing the two photos was rather shocking. I was ten years older and I looked ten years older. Maybe I looked older.

Drivers’ license pictures have this knack for making you look old and/or ugly. The DMV gloriously succeeded with me, making me scrunch down to get into the camera’s frame. The new photo is in black and white, which by itself is guaranteed to make you look older. It also gives prominence to my receding hairline, something I had not noticed before. I seem to be developing a sag under my chin. Perhaps its worst feature is the dark looking circles under my eyes, something I never see when I look in the mirror, but which a black and white picture adds. I look grandfather-like, sort of like Grandpa from The Munsters. The horror!

It’s a brave new world that I inhabit as I cross a boundary in time between my lower fifties and my upper fifties. In the novel Brave New World, it seemed everyone was on an antidepressant known as soma, which made life feel blissful. Thankfully, I am not on an antidepressant but slowly over the last ten years my medicine cabinet expanded with a host of prescription medications. In order to keep my aorta from getting too big I am on two heart medicines: Flecainide and Simvastin. (The men in my family have enlarged aortas, an effect of Marfans-like symptoms.) To control cholesterol, I am on a statin, specifically Simvastin. To reduce high triglycerides, I was put on a pricey drug that is encapsulated in fish oil called Lovaza. Then there is the nasal spray (Nasonex), which seems to help with the chronic stuffiness and nasal discharge. Plus there is one optional medicine: Terbafine, which is supposed to kill toenail fungi.

So I take six prescription medicines in all, plus a couple of supplemental ones if I need them, including a muscle relaxant for the sciatica. And speaking of supplements, I take a daily Vitamin D supplement because we middle aged people just don’t absorb much of it naturally, no matter how much time we spend in the sun. There is also a silver multivitamin, because I’m over fifty. There are also fiber capsules to make certain things move more predictably. I also take a baby aspirin to reduce the likelihood of blood clots as well as a daily Zyrtec, which I may give up.

Here is a list of the medicines I took at age twenty: nothing. I didn’t need any but that’s because my body mostly worked like clockwork back then and, of course, I had no health insurance. Now, it gets crankier and I feel creakier, resulting in really annoying conditions like sciatica and numerous trips to my chiropractor. All this plus you try to exercise as much as you can with a sedentary job and mind your doctors’ insistent urgings (only partially successfully) to refrain from all the foods you enjoy and eat all the stuff that vegans love but leave you taste deprived.

However, nothing says “old” better than using a BiPAP machine. A BiPAP machine is a close cousin to a CPAP machine, and is used by the millions of Americans like me with sleep apnea. After two sleep studies, the doctor of sleepology sort of knows what’s going on with me, and she is insistent that every night when I sleep I must wear an ungainly facemask and attach it to my BiPAP. What it does is make my breathing regular while sleeping. Thanks to the power of durable medical equipment it pushes air into my lungs while I sleep, preventing snoring and (hopefully) sleep apnea. If you have sleep apnea, you have lungs that like to sleep along with you. They can’t be bothered to provide all the oxygen you need and will even shut down, until your unconscious brain realizes something is wrong, shoots some adrenaline into your blood and you abruptly start breathing again.  This should wakes you up, although most of the time you are too sleepy to notice. Instead you usually arise in the morning feeling tired and tend to want to nap during the afternoon.

If I had been prescribed a CPAP machine, a steady stream of air would go down my windpipe all night, but that’s not the best fit for an old coot like me. Instead, I get the BiPAP machine, which works with my natural breathing. It knows when I am inhaling and pushes extra air into my lungs in a scientifically controlled and measured manner. To accomplish this I wear a large tightly sealed mask over my face and nose all night. The air is delivered through a sealed plastic hose attached to the BiPAP machine. The mask does not seal perfectly because a couple of years back I broke my nose, making wearing the mask somewhat uncomfortable and with some loss of pressure due to mask leaks. But hopefully while I am tethered to this machine the sleep apnea is gone but at least so far my sleep is not comfortable. I hope that I will get used to it in time. It seems I have no choice. Yet, something must be working, as I run to the bathroom in the middle of the night much less than I used to. I have yet to wake up feeling refreshed like a baby after a night on my BiPAP machine, something I hear happens, but perhaps that is coming.

In any event, all these medicines, minor ailments and durable medical equipment simply reinforce the obvious fact revealed in my drivers license: that I am aging, I know it, people who know me know it, and that the black and white camera at the DMV has documented it in its database and on my license. A much different future than my youth awaits. I’d best settle in for the ride. It sure won’t be an E ticket.

 
The Thinker

Transitions, Part 3

When it gets a little too comfortable or too familiar, life seems to conspire to kick you in the pants. If you are seventeen going on eighteen, this is the time of year when you are about to graduate high school and are thrust, usually with some trepidation, onto a larger and more chaotic adult stage. If you are a civil servant like me, age 54 going on 55 next year, you are pondering a looming transition called “retirement”.

For me, the transition from high school to college was more welcome than scary. Unlike the singer Vitamin C (Colleen Ann Fitzpatrick) whose high school memories must be pretty good, mine were anything but that. My fond memories extend primarily to a few teachers who inspired me. The high school I attended did not. I felt bound for success elsewhere whereas my apathetic classmates seemed bound for a surfboard and lives full of loafing. While I hope they did not turn out that way, thirty-five years later I still cannot be bothered to go to my high school reunions. I’m not sure any of my classmates’ names would even ring a bell.

In my spare time at the church I attend I facilitate a youth group. They are a tight, eclectic and interesting bunch, and one of the few reasons I have to hope for our future. It would be hard to overstate how intelligent, compassionate and interesting they are as near adults. It’s unclear to what extent our church molded them, but as long-term recipients of years of religious education this group of high school students have bonded amazingly well. And yet next month they will be handed diplomas and will likely never see each other again, at least as a group. Before they tackle the world of adulthood, they get to lead a youth service planned for later this month and give the congregation their thoughts on this transition. Tonight, as one of the adult advisors, I get to facilitate planning for the service.

Meanwhile, I get to ponder transitions of my own. I am now a year away from being able to retire. I doubt I will retire the day I turn eligible, but it is strange to be able to count when that date could be in months rather than years. While no one is forced to retire when they are eligible, I am beginning to wonder if I will be nudged, if not shoved in that direction. The federal workforce, already actually quite lean (about 150,000 fewer employees than when Ronald Reagan was president) is likely to get leaner in the years ahead. I will be watching legislation carefully. I suspect Congress will be eyeing our pensions fund for cuts. I doubt I will come out unscathed. I may find it advantageous to retire to avoid pension cuts that might happen if I hung around. My pension may be cut regardless. I sense a job transition is ahead for me and it is likely to be sooner rather than later.

Knowing that my time as a civil servant is likely quite limited, last week I was pondering if I should attend a conference in June. I can go myself or send someone else instead. Perhaps I should go and consider it a perk of the job. On the other hand, if I were to retire within the next few years, the value of my attendance would be diminished. Instead, I should send others further away from retirement instead. This is one small sign of many that another transition is looming for me.

Just like the seniors in our youth group so used to hanging with each other that their pending separation is likely a cause of anxiety, I am having mixed feelings about my retirement. If you are happy with your work, why retire? I work with a wonderful staff of dedicated professionals, we do excellent work and unlike many jobs, the meaning of our work is quite obvious and easily measured. Moreover, I am paid very well to do it. In short, I am in my optimal comfort zone, productive and generally happy to do my work. A transition, even for the alleged comfort zone of “retirement”, is not necessarily comforting.

My office

For I know I would miss certain things, like doing excellent and meaningful work. I would also miss my employees and those who work for me who are all wonderful folk. You cannot help but think of them more as friends than colleagues after a while because you see far more of them than you do of any of your friends, including often your spouse. I would miss my boss, who can retire soon herself, my chain of command and the ancillary support staff who supported me. I would miss chatting with Melissa down in the credit union, the wonderful soups in the cafeteria and the opportunities to regularly travel the country on someone else’s dime. I would miss the view from the fifth floor of my office window. At the same time, I know it is pointless to hold onto these things. The institution I am a part of will change with political winds, which are likely to be harsh. People younger than me with arguably more talent are ready to assume my work, and really should. I know I cannot hold onto this good job indefinitely and even if I did it would not stay the way it is.

What would I do to fill the void it would leave in my life? I know I would keep working, at least part time, but I also know whatever I do next is likely to feel anticlimactic. Professionally, I have peaked. Teaching or whatever next career I pick will probably have its own unique challenges. Like the seniors in our youth group, I too will have to step into my own murky future.

Just like our youth, which get to try to enjoy the ephemeral feeling of a last month together before they step across a one-way threshold, I too sense a one-way threshold ahead of me and I sense I will be taking that step sooner rather than later. Life is mostly about change. It is sometimes good, sometimes bad but most often a mixed experience. It’s about moving outside your comfort zone whether you like it or not if life gets too comfortable and embracing the less comfortable. Ideally retirement is about moving toward a more comfortable zone, but there is also a great deal of comfort from forty years of meaningful work in the workforce. Finding a next job, albeit a part time one will be in some measure a move back toward the comfort of the workforce. My boss will likely be younger than me, my coworkers probably far less fun to be with.

And the comforting view outside my window is definitely going to change.

 
The Thinker

The View at 54

Today happens to be my birthday, my 54th birthday in fact. I tend to largely ignore my birthdays and this one in particular is not noteworthy. There were a couple of birthday cards on the breakfast table, and my friends on Facebook have been offering felicitations, since now they know these little secrets.

If you are behind me in time stream, you may wonder what your life will be like at 54. Your view at 54 will doubtless look different than mine, but I can probably set some realistic expectations.

At 54, my life feels very settled and mostly comfortable. With the current economy, I am fortunate to have a job because many men my age who lose their job are fortunate if their local Wal-Mart will hire them. For much of my life, I felt like a salmon swimming desperately upstream. At 54, you may be over the hill, but you (hopefully) are done with the arduous climbing. At this altitude, you can see a long way. This vision is something akin to wisdom, which, if you are learning lessons from life, comes naturally with age. At my advanced age, you should know what to do and what not to do, and are painfully aware of the consequences if you act against your better judgment. You realize you got a pretty good thing going and are more concerned with preserving what you have than boldly trying new things.

No doubt about it. I am settling down. Retirement is no longer an abstraction; it is something I am already grappling with. I am making choices that in some ways are as complex as those I endured to get here, but largely these choices are more fun to deal with. Knowing that I won’t be salaried forever, I am paying a lot more attention to figuring out how I will navigate the fixed income world. Right now this includes paying down the balance on our mortgage and slowly shifting investments away from stocks into safer securities like bonds. Since I am in my prime earning years, I am also saving more than I ever have. I am maxing out my 401-K. At the end of the month, whatever income is left over goes toward paying down the mortgage balance. $79,266.91 to go. I can theoretically retire next year, but will pick up another job when I do retire at least until the mortgage is fully paid off. With luck it will be a part time job, something I truly enjoy doing and something I can do for a lot less money.

It’s not all terrific at age 54. I miss the body I had in my 20s. Age has taken its toll. I have dealt with an enlarged aorta, an irregular heartbeat, a vasovagal syncope that broke my nose and put me in the hospital, high cholesterol, high blood pressure, then low blood pressure, tarsal tunnel syndrome and painful, persistent sciatica that increasingly feels incurable. Aside from these issues, I am in good health, a little overweight but not too much, with thinning hair slowly mixing with grey. My libido has sagged, which is entirely natural but which, oddly, is rarely discussed among men my age. I still feel reasonably sharp although with so many memories keeping it all sorted is increasingly a challenge. My brain purges a lot of detritus, like hundreds of emails that I scanned over the course of the day.

The years keep tumbling by, so much so in that they all sort of run together now. It’s getting to the point where I can no longer keep my decades straight. I have to think hard when someone asks where I was or what I was doing in a certain year. Listing my employment history would be a real challenge. Who supervised me thirty years ago? When did I start and leave that job? How much did I earn back then? Why should it matter?

Time moves much more quickly but oddly I feel much less anxious about it. Aging was much more traumatic going from 29 to 30 that from 49 to 50. Turning 54 is a piece of cake. Yes, I know I have more years behind me than ahead of me. Death bothers me a lot less than it used to. At age 29, death was big and scary principally because (in retrospect) aging was big and scary. Now death is more of a known commodity. I know sort of what to expect by seeing my mother go through it, and while dying is no fun with its mystery gone so is much of its terror. I am accepting aging so much better than I used to. If you are lucky, you make it to old age. None of us gets out of life alive. We are born to die. The pragmatist in me says just enjoy each day as it comes and don’t spend too much time fretting how it will end. End it must. I hope not to escape death, but to live as healthy and as meaningful a life as nature will let me, and to accept it gracefully when it won’t.

While I am far down life’s runway, there is much more runway ahead and it is some of the best runway: straight, level with no potholes or grooves in the pavement. Life may be comfortable at 54, but life still throws the occasional curve ball, some of which let you know there is so much life worth living ahead of you. Last year, my father remarried at age 83. By doing so he singlehandedly redefined my expectations of old age. Just this week I received another surprise. I may be 54, but I am not too old to have a new niece or nephew. My youngest brother’s wife is pregnant, with a baby expected in six months or so. With a little assist from medical technology (they are in their mid forties), my brother will also join the fatherhood club. I am sure like with everything else he does that he will excel in the role.

Maybe it’s good that those first 54 years are all blending together. Now I can anticipate what adventures may lay ahead when I turn 55.

 
The Thinker

Welcome to Middle Age, Part One

They say you are as young as you feel, but if you just hit the big 4-0, most people would agree that you have entered middle age. By my count, I am about halfway through middle age, which broadly ends around retirement age (age 65). I thought when I entered middle age that I had a good idea of what was coming. I had a few things right, but mostly I learned that I was wrong. So I thought it might be useful to set some expectations for new classes of middle agers about this time of your life.

  • Midlife crises. Contrary to what you might think, not everyone in middle age has a midlife crisis. Sometimes it amounts to midlife discomfort rather than a crisis. Do not expect that when your midlife “crisis” hits that you will divorce your spouse, find a new job and wholly reorder your life. Because of some internal unsettled feeling of angst, you may do all these things or none of them but doing one or two is not atypical. Don’t fret about your coming crisis. It may be wasted energy.
  • Gaining weight. Most middle-aged people gain weight. You may have noticed this already if you compare your weight now to your weight at, say, 25. There is some evidence that this weight gain may be in part due to your metabolism changing. However, it is most likely due to the fact that your live a more sedentary lifestyle while your diet has not changed. There are no silver bullets here, I am afraid. You must either embrace your new and larger self or go through a likely painful process of eating less and exercising more. It is likely that you will yo-yo between gaining and losing weight unless you do something even more painful: permanently change your eating habits. I’m afraid the odds are against you but you may find that some inner angst will make you try anyhow. Good luck. Eating, not smoking or drugs, is your (and my) generation’s biggest health problem. Let’s hope the National Institutes of Health are working hard to find our silver bullet.
  • Sex drive. The good news for women is that if they were having trouble finding their sex drive in their 20s they are likely to find it in full flower, at least until they hit menopause. The bad news is that their husbands may not be able to keep up. Ladies, there may be times when you want to be a “cougar” just to get the sexual satisfaction you want. Meanwhile men, who were used to excruciatingly high levels of testosterone, are likely to find their sex drive ebbing. This may lead to one or more periods of impotence followed by the sudden desire to see your doctor for a prescription for an erectile dysfunction drug. The good news about drugs like Viagra is they can help you sustain an erection. The bad news is that they cannot make or keep you horny. So your sex life is probably going to change to be less frequent, which is Nature’s uncomfortable way of telling you that you are aging. If you want to maintain a healthy sex life, you will need to develop excellent communications skills with your partner. This is because you are likely to find that the relationship part of sex, which hitherto you have paid little attention to, is the only way that sex will happen at all. You may find yourself anxious for moonlit walks with your significant other, relationship time and longer foreplay. However, your wife has finally gotten used to not having these things, and may not crave them anymore. You may have to accept the idea that sex will take longer, you may not always succeed and you may not be rock hard through the whole experience.
  • Doctors. You really, really want to be insured in midlife, because you will be seeing plenty of doctors. If you do not see plenty of doctors, it is because you cannot afford to do so, which means you will need to either see a lot more doctors later on, you are going to be quite miserable or there is a good likelihood you will die prematurely. It will likely start out gradually but you will probably find you must succumb nonetheless. That’s because your body is getting tired. It’s been working non-stop for forty plus years. Age and gravity are taking their toll and those bad eating habits you acquired as a teen are catching up with you as well. In addition, you are unlikely to have excellent posture or spend most of your day on your feet. This will contribute to common middle age problems like lower back pain. If they haven’t started yet, men will find themselves up two or more times a night to empty their bladder as their prostate begins to puff out. You will probably not make it to 50 without experiencing one weird condition that you would never guess in a million years that you would have to worry about. Attempts to be as physically active as you were as a teen will impart costly lessons. Basketball probably won’t work because it will make your knees hurt or buckle. Volleyball may cause broken tendons. Even if you hit the Gold’s Gym every day and press weights, you will never have the same potential physical strength you had when you were young. The progression will be downhill and the best you can do is slow it. Sorry. Treat your body with care. Get regular checkups, including blood work, and keep up with your vitamins and nutritional supplements. Your body is literally irreplaceable.
  • Children. Any children you may have spawned or fostered are likely entering their teenage years. You will probably expect your teens to either be model teenagers or, failing that, at least not do stupid stuff like you did. While you will always love your children, you may find yourself liking them less. In fact, there may be times when you just loathe them. This is completely normal. You are going through a phase too. Eventually they are forced to deal with adult responsibilities and the phase will pass. All that teenage angst will affect your marital relationship, and may contribute to the sex and midlife crises issues. (See above.)
  • Age regression. You may also find yourself envious of your teen because they have freedoms that you used to have before you became a sober member of society. Women may want to become cougars and guys will find themselves attracted to younger women. It’s probably not their freedom that you envy. It is their youth because you are realizing the hard truth that the aging clock only goes forward, not backward, you were young and healthy then, and now you look middle age like Sheriff Taylor or June Cleaver. These feelings are natural but look; don’t touch. Only a very usual teenager or young adult is going to be attracted to someone twice his or her age, and if they are it probably will be for your wallet, not your looks or stellar personalities. Moreover, if they happen, it is likely to be ephemeral.
  • Groundhog Day Syndrome. The years will zoom by and the older you are the faster they will go. Moreover, you will feel a lot like Bill Murray in Groundhog Day. You will feel like you have been down this path many times before. You may marvel at going through two or three sets of appliances while living in the same house. The past will seem crowded together and dates like 1990, 2000 and 2010 will all sort of run together. It will be hard to remember exactly what you did or accomplished in any year. You may wonder how you made it to age 40 at all. Why is this happening? It’s because you are and have been awfully…
  • Busy. Unless you have the misfortune to deal with long periods of unemployment and/or have no children, you no doubt have discovered that you are really, really busy almost all the time. You may wonder how anyone has the time to watch TV, let alone blog and surf the Internet. I started this blog in 2002 at the age of 45. It wasn’t until that age that my life became ordered enough where I could take up such a time consuming hobby. When I did of course, I still found it challenging to find the time to blog. To do it, other things were reduced, principally sleep. At age 53, this is still true. The good news is I finally have more time to do things I like, rather than things I must do, but even on a good week it’s about 90% work or sleep, and 10% play.

There is much more to this topic that I will digress on in future posts… if I can find the time.

 
The Thinker

Creeping toward decrepitude

When I turned fifty a couple of years back, I was okay with it. Yet for some reason now that it is 2010 and we’ve started a whole new decade, I am not okay with that. Just slipping into this new decade has made me feel old.

As if I wasn’t feeling old enough, I spent Sunday night having a discussion about the last decade with a group of youth. I am helping to oversee a youth group at my church so a look back at the last decade seemed an appropriate topic. For us rapidly aging still technically middle aged adults, the 2000s was just one decade of many. However, the youth are of high school age. For them the 2000s was the decade they began to retain memories. They sort of remember September 11, 2001 (they were in elementary school) but did not quite understand what all the fuss was about, why some of their classmates were abruptly pulled out of schools and their teachers were whispering in the hallways. Of the 1990s, they have fragmentary memories at best. Having finished their first proper decade, since they had nothing to compare it with, the last decade seemed all right. Whereas to the other adult leader and me it was, what a rotten decade! Good riddance! Of course, these youth were kept well insulated from reality by school, family and friends. The dramatic swings in the stock market never bothered them. Neither did the high unemployment or mortgage foreclosures. Their parents had stable enough jobs where they were not impacted.

For me personally, the last decade was a blur. I was busy being a working adult and I had my hands full. The decade felt like it was squeezed into two years or so. I keep asking myself, can it really be 2010 already? Where did the hell did the decade go?

One thing is certain: I feel ten years older. As readers know, my body has been complaining about this aging thing for a while. I had two relatively minor surgeries last year and will have tarsal tunnel surgery next week. Despite valiant efforts, my body is definitely moving toward decrepitude. I know none of us escapes this world alive. In the 2000s, I sort of lived on the illusion that I might be an exception. “I am not planning to die,” I would tell people who asked, and sometimes even those who did not.

Tackling the unpleasant business of creating my will last year was the extent that I planned for death. I am much more engaged in planning for a happy retirement, which I hope will have most of the joys of living minus the long workweeks and other family responsibilities. Now that it is 2010, old age, which used to be an abstraction, feels uncomfortably close. If nothing else, I can technically retire from my job in two years, though I am unlikely to do so.

One way I can get a sense of time passing is to simply add up the decades on my fingers. For me five decades are in the past so there is one whole hand accounted for. I hold up my other hand. Will I live another five decades? The odds are stacked against me. Living to a hundred is almost certainly out, barring some miraculous drugs or medical procedures that I probably could not afford. If I manage to make it to ninety, I will likely be in a nursing home or assisted living facility somewhere. If I am lucky, I will make it to age eighty and still be in good health, like my father. Yet if, like my father, I manage to live that long, I will likely end up in somewhere like where he is, a retirement community.

A retirement community has many great features but is also your easy gateway to an assisted living facility, which in turn is a gateway to a nursing home. There (if you are lucky) you probably leave this life reasonably well tended but not pleasantly. I imagine I will leave it like my mother did, unable to control your own bowels or get out of your own bed unassisted. In a retirement community, death is not an abstraction. It is all around you. People you see bounding down the hallways one day are in intensive care the next, and planted underground a few weeks later. You can see it in the hallways where many of the still mobile are pushing around walkers with little tennis balls on their feet. Many of the rest are in wheelchairs. Their bathrooms come with sturdy stainless steel railings on the sides of the tub and extra wide doors. That’s why the bathrooms have convenient pull cords to summon help in an emergency. You can count on someone on your floor passing away during the year, and chances are there will be two or three more. The most popular activity at my father’s retirement community is not dipping in the community whirlpool tub, but checking out the death notices in the lobby.

Aside from the problems of holding my body together (which used to never complain) there are increasingly visible signs that I am aging. My facial skin is sagging. My neck is looking somewhat saggy and wrinkled. The other day I looked at my left knee and the skin on it was drooping. Where did that come from? Age spots have been developing for years, but now my skin in general looks like sand on a beach, blown into drifts by the omnipresent wind. My eyes look more bloodshot than I remember. At least my hair has not gotten more noticeably gray in the last few years. However, that could be due to faltering vision.

Now that I am in a new decade and feel sufficiently aged, I am realizing that dying is actually a very long process. It starts around age eighteen when your first brain cells die off. Part of declining the right way is apparently gracefully accepting your increasing decrepitude. Those aches, pains and surgeries are your war wounds. In my case, they are the result of dodging and parrying with life for five decades. I am fortunate that this is all I am dealing with. Just a few generations removed from mine at age 52 I would more likely be planted six feet under. If I were still alive, I would likely be in a lot worse shape and in a lot more pain. Many of my joints would be inflamed (since anti-inflammation pills had not yet been invented), and I would probably stoop or need a cane. On the plus side, death and dying would probably be a lot less mysterious. It would be common to see your peers go to your reward. Attending funerals would be routine rather than an exception. Perhaps you would be grateful even to be alive in any pained or infirmed state.

In any event, I am still disgruntled that it is 2010 already and I probably will feel this way for a while. Like it or not I am moving rapidly toward an older stage of life. While it may be more painful and infirmed than in the past, at least it is still life. Perhaps time will reveal some compensation for aging that currently eludes me.

I can hope. It’s not like I have any choice in the matter. I am caught in a system beyond my control. It is only now that I am feeling this truth.

 
The Thinker

The years, they pass so quickly now

So I was wasting time in my hotel room this week and found the TV Land Channel. It was M*A*S*H night and they were playing shows from its first season, which by my recollection was 1972. I must have been watching one of the very first episodes because it was full of characters that would disappear within a few years including Major Burns, Trapper John and Colonel Blake. I knew it had to be first season because the show was pure comedy and had yet to take on a serious tone. In this episode Hawkeye and Trapper were spending inordinate time annoying and embarrassing Majors Burns and Houlihan.

It was great to see an old M*A*S*H episode. Like most families back then we were glued to our TV when M*A*S*H was on the air. The show lasted much longer than the actual Korean War, embarrassingly long, in fact. The actors that made it to the show’s end eleven years later by then looked really aged. Jamie Farr was 48 and Alan Alda was 47 when the last episode was filmed. But in 1972 they all looked fresh. Alan Alda, who I remember most recently playing Senator Arnold Vinick in the last two years of The West Wing, looked in The West Wing about as old as John McCain. There was a logical explanation for this. They are about the same age. (Alda is actually a year older and is 73.) Nearly forty years have passed since the first episode of M*A*S*H was aired. Alan Alda was actually 36 in 1972, but looked much younger. Alda though is one of the lucky ones. At least he is still alive. Larry Linville (Major Burns) died in 2000. McLean Stephenson (Colonel Blake) entered immortality in 1996. Harry Morgan, who was already pretty old when he played Colonel Potter, passed away in 2008 at the age of 93.

Age happens. Aging is fine when it happens to others, but not so fine when it happens to me. Because I, like most of the baby boom generation (and our remaining parents still with us) actually remember when M*A*S*H was on the air. Goodness, Richard Nixon was president when it first aired, and it did not go off the air until Ronald Reagan was in the Oval Office. Likely, most Americans have little or no memory of M*A*S*H, or The Mary Tyler Moore Show, or Laugh In, or the original Star Trek, or The Bob Newhart Show because they were not even alive or more interested in Saturday morning cartoons. Some small minority of them might watch an episode of M*A*S*H on TV Land but are unlikely to try to follow the series forty years later. It has about as much appeal to them as The Lawrence Welk Show did to me. What was with all those dancing ladies in high heels and champagne bubbles anyway?

I was fifteen when M*A*S*H first aired and I remember it like it was yesterday. Like most of us aging boomers, I am having a hard time grasping that nearly forty years have passed by since then. Where did all those years go? My recollection is pretty hazy, but I guess I must have been busy because they passed in a haze. Mentally, I am 18 or so but a glance in the mirror confirms that I am age 52 instead. Little incidents like this bring home how quickly life passes. I don’t look for them; I just stumble across these incidents periodically. When I do I get a feeling of vertigo. I want to look at myself in the mirror and pinch my face to verify I am still in this world. I mean, it’s practically 2010 already!

Another incident occurred at the hotel on Monday night. I found myself at the front desk talking with the hotel manager, a woman named Kelly. I did a double take when I saw her title because I figured she was a clerk. Gosh, she looked awfully young to be the manager of this large hotel. Before I could check myself I blurted it to her aloud. “I’m 26,” she said cheerfully, and then she went on to tell me that this is the fifth hotel she has worked at. She is 26 and running a suites hotel for one of the Marriott hotel chains. When I was 26 I was making my first acquaintance with a Wang 2200-T “calculator”. It would transform my life, leading me into a career in information technology. I sure was not up to the task of managing anything, particularly a hotel. Paying the rent was challenging enough.

Twenty six is exactly half my current age. I was 26 in 1983. This woman was born in 1983. In fact, she is just seven years older than my daughter, who may be attending community college and who is quite responsible but is someone who (in my mind at least) is maybe fourteen or so. Some part of my mind was also 26 while I was talking with this manager. Some part of me had not spent the last twenty something years married to my spouse and was checking her out. Then I realized: I am probably older than her father!

I wish there was a pill I could take that would tell my brain, “Well, you are basically an old coot now.” I need this wakeup call because my brain continues to disbelieve the facts. The body may be temporal but the mind likes to operate under the illusion that it is immortal. The incongruity can at times be wrenching. I saw my mother go through this process during her long decline. Mentally she was pretty sharp until a few months before she died. Her body could just not keep up with her mind.

Will I even be alive in another 26 years? According to insurance actuary tables, because I am a male I am more likely to be dead than alive at age 78. Most likely I will beat the odds, as both my parents lived into their 80s. My father is still amazingly spry at age 82. One thing is for sure: should I encounter another hotel manager age 26 when I am 78, I will not only be old enough to be her grandfather, but potentially even her great grandfather.

My oldest brother recently announced that their daughter was pregnant. She has several more months before she delivers her baby (she is 21) but when this blessed event occurs it will also mean that I will be a great-uncle. Doubtless in time other nieces and nephews will follow her as parents. My daughter says that she has no plans to get married and she finds the whole idea of having a baby ghastly, so I am unlikely to be a grandparent. Yet at 52 I am a virtual great uncle already. I am likely to have this title for others of Generation Z.

So perhaps this is why whenever I travel anywhere I am scouting for possible retirement communities. On Sunday my youngest brother, who I was visiting prior to enduring the business part of my trip, took me to Fort Collins, a city about an hour north of Denver. It is rated as one of the most livable retirement spots in the country (unless you don’t like snow). It hugs the Rocky Mountains and has a beautiful and expansive main street, plus it has all the advantages of a college town (Colorado State University is located there). While I am not sure living in the west agrees with me it is a place to consider. My wife and I also plan a trip to the Pacific Northwest in the next few years. Along with seeing places like Crater Lake and Mount St. Helens we will be watching the towns and cities we pass through, and wondering if any will call to us as a beacon for our retirement years.

Perhaps acting my age will work if I take active steps toward fogey-hood. I need to purchase striped shorts, Hawaiian shirts, golf shoes and white socks that go halfway to my knees. I need to check the prices for Polident and the cost of AARP membership. Age is calling me but I am proving amazingly tone deaf. It is telling me to accept that I am a rapidly aging American.

Right now I mainly prefer to remain in my state of denial.

 
The Thinker

More adventures in aging

Aging is an experience we only go through once, thank goodness. Perhaps that the ultimate effect of aging is death is not an entirely bad thing. At some point, the downsides of aging outweigh the benefits of being alive. As readers know, last December I received another unpleasant wakeup call that I too was aging. It resulted in subjecting myself to myriad medical tests and finding myself on Weight Watchers. Some of the more common aging signs I have experienced in my now fifty two years on this planet: loss of near term vision, age spots, odd aches and pain, joint pains, back aches, a diminished sex drive and an inability to hear very high frequencies. Now I can add one I did not expect to my list: I get colder easier.

It used to be that I was the most comfortable around seventy degrees. Now seventy degrees, even with a sweater on just feels cold. Why is this? Apparently, it isn’t due to a paucity of body fat, or I would not be on Weight Watchers. The only thing I can infer, since this was never a problem in my younger years, is that this is yet another symptom of aging.

I remember being amused when I visited my late grandmother and found that it was eighty degrees in her house and she was wearing a sweater. She was one of these petite women with neither much body fat, nor much in the way of muscles (but was always in a dress). I could rather see why she might want to wear a sweater. I found the time I spent in her home both enjoyable (in being able to see her) and oppressive (in that I wanted her to crank down the air conditioner, but I couldn’t work up the nerve to ask her).

My office is maintained at a uniform temperature of seventy degrees, which should feel comfortable. Most of the people on my floor seem perfectly comfortable. Me? I have a heater on. The moment I open my office door I rush to the heater by my window and crank it up. It could be that because I have an office with a view, it would be naturally colder in the mornings. Yet, if I leave the heater off, it feels just as cold to me at noon as it does at eight in the morning.

Often using the heater does not do the trick. So I keep a pullover sweater behind my door and put that on. It seems to work well for my upper extremities but not on my lower ones. Since I typically wear jeans to work, you would think that would keep my legs sufficiently warm, but it does not. My legs feel cold. Relief does not really arrive until the afternoon. Then the sun comes through my window. This heats up my office nicely. Sometime after two p.m. I can take off the sweater and turn off the radiator.

During the summer, you would think the situation would be reversed, but it gets worse. The uniform seventy degrees is maintained in the summer as well as the winter. However, my radiator vent will only blow out cool air in the summer. Since the sun is higher up in the sky, less sun shines through my windows, meaning my office is less likely to warm up in the afternoons. Therefore, I am more likely to wear my sweater in the office during the summer than in the winter.

At home, we keep the thermostat at seventy-two. I would like to notch it up a few degrees to maybe seventy-four, but my wife simply cannot tolerate it that warm. This often means I am putting on a sweater at home too. I am hoping since she is only three years younger than I am that she will eventually develop my condition so I can feel more comfortable around the house.

Yes, aging is full of discoveries that you can no longer take things for granted anymore. Exercise used to be optional. Now it is required. Eating healthy all the time used to be optional. Now it is required, or you may suffer devastating consequences to your health. I recently found something else that used to be optional: drinking water only when you get thirsty.

Since I am a largely indoor denizen, I tend to only sweat when I exercise or am outdoors in a temperate climate. If I need water, I always thought my body would tell me by sending the hitherto reliable thirst signal. Now I am learning that is not sufficient. If like me you are one of the Dilbert’s of the world, you need to start guzzling water. Keep a water bottle at your desk and plan to go through three or four bottles a day at work. You may think you are doing a disservice to your kidneys by running to the bathroom so often, but in actuality, you are doing a kindness to them. You are also being kind to your body in general. If you do not regularly replenish your body’s water, your body will assume that you need to retain water because your survival is at stake. Retaining water is not a good thing because it can raise your blood pressure. At worst, it can lead to heart disease and other conditions.

Because it is a complicated machine, your body should come with an owner’s manual. The body has its own needs. Some it will tell you what they are and sometimes it will leave you blissfully ignorant. That is the purpose of getting a physical: to discover those things that it is not telling you.

At least my body is quite clear about preferred temperatures. Seventy degrees is about four degrees too cold to be comfortable. As I write this, I just returned from exercise. For a while, I can coast in the glow of the extra heat that I put out during exercise. It will be an hour, perhaps less, before I will find myself reaching for my sweater.

 
The Thinker

The physical

When you hit the big 5-0, your doctor will prod you into coming back annually for another physical. Now I know why. It is because no matter how healthy you think you are, by the time you are fifty something your doctor is bound to find something he doesn’t like.

If you are fifty something, be grateful if the doctor finds just one thing. I emerged from my annual physical last week with a long list of appointments and prescriptions. Of course, just the afternoon before I had been at the gym. I had gone through a routine of an hour of aerobics followed by pressing many weights. I do this three or four times a week. If it were biking season, I would get even more exercise. So what is with all these tests and prescriptions? I thought I inhabited the world of the very healthy.

What happened is I became a fifty-plus American. Things are bound to be less than optimal because, well, I am fifty-plus. Actually, I am 51. Maybe I could be healthier. Maybe if I had spent much of my life as a vegetarian my cholesterol would not be high. On the other hand, maybe it would not be high if I hadn’t eaten eggs for breakfast every day for a year. Supposedly high cholesterol should not be that big an issue if your HDL level is relatively low, which mine was, which was supposed to be the magic of eating eggs. My doctor still did not like the numbers. The solution was more exercise and less cholesterol. I could get more exercise but I felt like I got plenty already. Nor do I actually eat that much meat, and what I do eat is mostly boneless chicken. I now I eat eggs maybe once a week. So far, I have avoided statins but I have a feeling they are in my future.

While the doctor was using his stethoscope, he paused when he pressed it up to my left carotid artery. He wasn’t hearing the same thing on the right carotid artery. It could be a sign of cholesterol buildup in the left carotid artery. This is a bad place to have cholesterol build up, of course, since if the build up dislodged it would take a beeline into my brain and possibly cause a stroke. So now on my agenda for Thursday is a Carotid Echo Doppler exam.

These were just the start. The doctor also took an EKG and frowned when he showed me the result. It seems I have a case of Poor R-Wave Progression. This could be caused by lots of things including heart disease or it could be nothing. So Wednesday I have an appointment with a cardiologist. Me? The same guy who when he exercises routinely gets above 130 beats per minute and sustains it for thirty to sixty minutes?

Doctors are one of the few people who have permission to touch me in private spots. The doctor was manipulating one of my more private of private spots and I went “ouch”. You are not supposed to say ouch when he manipulates this part. He gave me a prescription for Cipro to cure a likely infection down there and sent me for an ultrasound. Thus, today I found someone else, a female this time, touching me in one of my private spots. Fortunately, they found nothing worse than an enlarged varicose vein.

Next, I confessed that sometimes I felt like I had trouble swallowing. This concerned me because my mother died of Progressive Supranuclear Palsy and this is a classic PSP symptom. I was wondering if this might be an early symptom of PSP. My doctor had no idea what PSP was (he is only a family doctor, after all) but before I could argue he had written an order for me to see a neurologist. It turns out that virtually every neurologist in my county is affiliated with my wife’s employer, so I will see one of their experts next week. I hope that there is nothing to worry about there. There are worse ways to die, but watching my Mom go through it, I sure do not want to go through it too.

Then there was the longstanding problem of numbness in my right foot. It hadn’t completely gone away and recurred after lifting weights, which makes sense because that was when I applied a lot of pressure to my feet. I probably should not be lifting those kinds of weights. I did learn more than I wanted to know from my doctor about foot disorders, specifically that you could get the equivalent of carpal tunnel syndrome in your feet. For me it is back to the shoe insert that my podiatrist gave me some years ago.

While he was examining my feet, I pointed out a small amount of toenail fungus. I mentioned I had tried many things and never gotten rid of it. One thing I had not tried was Lamisil, probably because it is so freaking expensive that insurance companies will not pay for it unless it is first confirmed by a test. I am waiting for the lab results. Ninety days later, I hope that I will be cured.

The nitrate levels in my urine were high. That wasn’t good but he will just monitor that for a while. As for Vitamin D, I need more: 1000 mg. a day. This is a hazard from being a cubicle dweller during the day. Maybe I also need to take walks outside during my lunch hour.

Physicals are doubtless beneficial because they help address issues when they are relatively small and can be rectified. Yet, I also find them unwelcome because they remind me that I am an aging American in my decline. Overall, I have enjoyed remarkable health, but age is catching up with me. This suggests that at my next physical, I will have more issues and maladies like these. They will be a recurring feature of the rest of my life. As if drooping skin, grey hair and age spots were not enough.

Thus far, I have gotten through the aging process by mostly denying it. I assumed that with a decent diet and plenty of exercise I could maintain something resembling youth virtually forever. Now it is clear that I must disabuse myself of my foolish notion. Perhaps when these medical issues feel routine rather than exceptional I will feel less irritable with my aging process.

All I know is that nature is telling me that Madison Avenue was wrong. There is no fountain of youth, not even for me. I too must grapple with my aging and my slow decline. I cannot change it; I can only accept it.

This time, my follow up is in three months.

 

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