I've seen this clinical course many times:

[PCIntern]

In a career with 60000+ patients, I have noted a particular path for these male individuals (in general females exhibit a significantly different clinical regression ):

1. Upon meeting him in his 50’s the individual is obese with a sallow complexion, taking medications for high BP, high cholesterol, urinary issues, and ED (often times Flomax and Cialis are combined to assist in prostate maintenance as well as ‘the other’ thing). The patient is fully functional and energetic despite the weight and metabolism issues.

2. As time goes by, say 5-7 years, the clinician notices a series of losses: skin and muscle tone, kinetic energy drops off somewhat, a look of sadness and resignation when not engaged, and importantly a paucity of intellectual dynamism, almost a retreat from active consideration and originality. My personal interpretation of this is a physiological exhaustion-there’s just so much energy which can be channeled to cognitive interactions due to the strain imposed by the body.

3. Suddenly, there appears to be a decompensation: the BP becomes less-easily controllable and the individual manifests symptoms visibly: skin color, emotional agitation, edema even in the face and hands. We often casually say, with some surprise, “he’s aging quickly”. The clinician makes a mental note to keep an eye on this fellow. The gestalt is that he’s not doing well. The agitation is a combination of visceral emotional upset and untoward physiological strain.

4. This may persist for a highly variable length of time, while doctors try different medications and perhaps once again attempt a weight-loss program. The patient quietly or not so quietly knows he’s deteriorating.

5. There comes a point when you look at him and say “something is really wrong here” and the countdown begins. And then, and you aren’t easily able to predict but you know it’s coming, you get the phone call or the information through the family or mutual acquaintance that he’s in the hospital or worse.

I believe we are in Stage 5 at this time.