Unlocking secrets of Malaysian superagers on how to age really well
“Ageing is a privilege,” says Tan Leok Teok, 81. “Well, as long as you are healthy, that is. If not, it can be miserable.”

Thankfully, Tan is not only healthy, she’s also active, fit and alert with a strong sense of humour that, she says, keeps her joyful most of the time.

In fact, Tan is one of eight “superagers” identified by a group of researchers from Universiti Malaya (UM) in their ongoing study on Malaysian superagers – a construct that describes high-performing seniors aged 80 and above whose cognitive and functional abilities are comparable to those 20 or 30 years younger.

The aim of the local research initiative titled “Exploring the construct of superageing/superagers in the Malaysian Elders Longitudinal Research (MELoR) cohort” is to find the “secret sauce”, (i.e. lifestyles and practices) to these seniors who are ageing not just well, but “so well”, says Prof Dr Tan Maw Pin, professor in geriatrics and consultant geriatrician at Universiti Malaya Medical Centre (UMMC).

Prof Tan hopes the project will reveal a ‘secret sauce’ about ageing not just well, but really well.Prof Tan is one of the three academics leading the study; the other two are UM neurogeneticist Dr Azlina Ahmad Annuar and doctoral student Moses Raj Muraly.

“So far, all the research (on seniors) have been focused on problems ... what makes things go wrong and how we can fix it. That grain of thinking has now changed and, in fact, many scientists now believe that we should be looking at what makes things go right.

“We are now going with the flow of what the United Nations (UN) is advocating through their Decade for Healthy Ageing (2021-2030) and going just that bit further to see what makes people superhealthy,” says Prof Tan.

This study will provide a characterisation of what a superager is in the Malaysian context which could be used as a standard for “maintained functional ability in seniors” in Malaysia and also, possibly, populations within the region ancestrally similar to Malaysia, the researchers explain.

In essence, says Prof Tan, the goal would be finding a “magic pill” that can be shared with everyone for the country to have a population that ages very well.

“The benefits are pretty obvious: immediately, we have identified role models for others to follow. Historically, people have modelled their lives on famous people who so happen to be old. What we really need as role models to age well are people who have aged really well.

“There are people who others can look at and say ‘I can be like them too’. These are ordinary people who have looked after themselves well and become extraordinarily healthy in old age. I want to be just like them when I grow old,” she says.

“What we will have, hopefully, is that magic pill that will make it possible for every Malaysian to age like them, and that would be the real point of this research.”

Thavamoney (front) leading the group in not one, but three dances. — Photos: TJ Danaraj Medical Library, UM

What’s a superager?

The term superager was first coined by The Mesulam Centre for Cognitive Neurology and Alzheimer’s Disease at the Northwestern University Feinberg School of Medicine in the United States in 2008 when researchers were looking into genetic, brain and lifestyle factors that helped play a part in how superagers retained their memory so much better than their peers.

The focus of this study was the cognitive function of superagers.

“There have been studies that are more extensive than ours. Some of these used brain imaging data which is very powerful in looking at the ageing brain of seniors. These studies tend to focus on the cognitive capabilities of seniors, looking at things such as their memory.

“In our case, we had data on cognitive as well as physical assessments of a cohort of seniors and we decided to look at both their physical and cognitive health. We are currently also gathering brain images of the participants who consent so that will be a useful future analysis to correlate,” explains Dr Azlina.

Dr Azlina says the study has been enriching not only for the research but also on a personal level, getting to listen and learn from the superagers.

Adds Prof Tan: “We could of course look at every single area, but it’s important in research to stick to what has been done and to work on it incrementally. At the end of the day we have a responsibility to deliver on the study’s public funding, hence we do have to play it safe, and not just base our research on curiosity which could then not lead to any useful findings.

“The incremental step here is to look at both memory and physical abilities. We have, therefore, identified those who have maintained their brain and physical health above normal levels throughout the 10 years they had been in the study and looked at what have made them so special.”

The UM research looks at three established criteria to measure fitness: Vitality (assessed through their handgrip strength; locomotion (assessed through timed-up-and-go tests where the participants have to get up from a chair, walk to a marker 3m away, turn, walk back, and sit down again); and cognition (through the Montreal Cognitive Assessment that tests attention and concentration, executive memory, language, orientation and so on).

Through these tests, a Functional Ability Score (FAS) was calculated to aid in identifying participants who would fit the construct of superagers for this Asian population.

With Dr Azlina being a neurogeneticist, the study also plans to extend our understanding into possible genetic factors that could play a part in how well these superagers have aged.

The superagers were celebrated at a recent event at UM.

Pioneer group

The idea for the superager project originated from Dr Azlina.

“When (Tun Dr) Mahathir (Mohammad) became prime minister for the second time, Prof Tan and I actually went on radio to talk about elderly folks of his age who are still very cognitively capable and that’s when I became a bit more familiar with the concept of superager. But I have always been fascinated by how some people age really well,” says Dr Azlina.

The two women then realised that they could leverage on the large pool of seniors as well as the data they have from past research projects to realise this study on superageing seniors.

“Since we have this cohort of elderly people whom we have been tracking, I thought that maybe we could identify some of them who fit the definition of a superager. And, it was great that this cohort had been doing physical and cognitive assessments at various timepoints across the years which was valuable data for us to mine,” Dr Azlina explains.

(The Malaysian superagers were selected from a large cohort of seniors who have participated in MELoR (which has since been renamed as the Ageless project) that ran between 2013 and 2015.)

And that’s exactly what happened. Out of 185 participants who attended the assessments, 11 seniors fit the criteria and out of these, eight agreed to participate in the study.

“These seniors have maintained their fitness, particularly their physical fitness, form their initial assessment (when they were in their 70s) which was enough for us to want to meet them and interview them.

“Madam Tan, for example, has really good grip strength which actually is in the male range and that’s probably because she has played table tennis throughout her life,” reveals Dr Azlina.

Although the eight superagers have diverse backgrounds and life experiences, they all have maintained a high level of physical activity throughout their lives, says Moses.

Ageing very well

Healthy ageing isn’t about having perfect health or being as healthy as when someone was younger, explains Moses.

“It’s more about function – how well are you able to do things as you age – and resilience,” he says.

Adds Dr Azlina: “It is about how your overall fitness can healp sustain function and get you back on your feet after sickness of injury.”

Although the research is still at the preliminary stages, the researchers say that there are already a few findings that have stood out about the eight superagers.

“These eight individuals come from very different backgrounds. Some grew up very poor while others were from well-to-do families; some have gone through some major challenges in their lives.

“One of our superagers was involved in a major accident where he suffered major thoracic injuries. But he recovered due to sheer determination ... he was adamant that he would remain functional.

“Another had third-stage cancer, after which she became more health conscious and active and still plays table tennis. So there are all these differences.

“But what they have in common are very strong physical and cognitive health,” says Moses.

One of the commonalities the group shares is their continued active lifestyle.

“It is really about certain lifelong habits that they practise such as being active throughout their lives,” says Dr Azlina.

“We need to understand that we cannot wait until we retire to start living healthily. Because, unfortunately, while this may mitigate some of the ageing that will happen, a lot of what is going to happen in your 70s and 80s begin when you are much younger.

“The middle-aged population and youth need to realise that they have to start now, if they have not already,” she says.

Adds Moses: “Although not all of them did sports, they all were active in one way or another, consistently, throughout their lives. And they all have maintained a good level of social interaction. They are all also very driven and are very resilient, no matter what life gives them.”

Being mentally active doesn’t just translate into academic excellence, points out Dr Azlina.

“We tend to think that mental stimulation has to be something formal and structured but it’s actually a combination of a lot of things. For example, one of our superagers had to leave school after primary education and she did not have a career – but she kept herself busy as a housewife, which involves organising, planning, managing – skills typically seen in formal work so she was able to stay cognitively healthy,” says Dr Azlina.

The study’s potential to inspire Malaysians to make lifestyle changes towards healthy ageing is huge. Already, the superagers have had an impact on those who have had the chance to interact with them and listen to their stories.

Final year geriatric medicine fellow Dr Nareshraja Janardana isn’t a part of the study but he had the opportunity to meet with and talk to the superagers whom, he says, defy “the usual image of an older adult who is frail and teeming with diseases”.

“They remind me how fascinating older adults can be and how older adults can age healthy, gracefully, and still contribute to society. Many of them have stories and experiences that are diverse and full of wisdom.

“They are robust and can still dance, work and volunteer in their church,” says Dr Nareshraja, who is currently doing his subspecialty training in Geriatric Medicine at UMMC.

“The thing that stood out most about these superagers is their approach in life,which can be summarised by three Ps: a Positive outlook in life, a Purpose for living and a Passion in the things they do.

“The significance of this study is to understand the factors contributing to healthy ageing and subsequently, promote a better way of growing older. It is important for older adults to live healthy and be disability-free, and not just have long lives. This study reminds me of the adage ‘prevention is better than cure’,” says the young doctor.
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Universiti Malaya researchers embark on a study on high-performing seniors over 80, with hopes of finding the 'magic pill' to ageing well.