Elderhood

by Louise Aronson

  This book is my attempt to fill in those gaps by looking at old age in new ways. It draws from science and medicine, history, anthropology, literature, and popular culture. Who we are and what we value and believe is revealed in how we care for the sick. But although many of the stories in this book involve people who are old and sick, this is a book about life. If we want old age to be something other than a loathsome expanse of years or decades, we need to begin examining the hows and whys of our current approach.

  For most of us, Act III is long and varied. If we see it differently, our feelings about it might also change. And if we see and feel differently about old age, we can make different choices, ones that change our experience of elderhood for the better.

  CHILDHOOD

  We’re all old people in training.

  —Joanne Lynn, MD

  2. INFANT

  MEMORIES

  Among my earliest memories of old age are breasts. The sighting took place on the eighth floor of the hilltop building where Kim Novak’s character lived in Hitchcock’s Vertigo. Twelve years after that movie made audiences scream, my great-grandmother casually removed her robe and I willed my six-year-old self not to gasp. Granny sat on an overstuffed stool in her dressing room, a narrow space with mirrored closet doors and small windows whose lowered shades glowed with yellow light. The air smelled sweet and stale, like used books in a space too long without fresh air. She must have been just out of the bath or shower. My little sister and I held hands but didn’t dare look at each other as Granny eased one gigantic breast and then the other into her bra and pulled the straps up over her shoulders, chatting as she moved through her tasks. It’s hard to say, even now, what made me most uncomfortable, the shock of her nudity, the heft of her bosom, or the strangeness of her aged body.

  Granny would have been in her eighties then, and since I considered my grandparents old, my great-grandmother clearly qualified as ancient. In some ways, my grandparents and great-grandparents were members of that large category known as adults, people who knew a lot and could tell a kid what to do. But they were also clearly an altogether different class of person than my parents and their friends, and only part of what distinguished them came from their wrinkled skin and gray, white, or absent hair. The older generations of my family also had more formal clothes, behavior, and belongings. If they joined our regular Sunday picnics in Golden Gate Park, the women wore dresses or skirts and sat on folding chairs instead of with the rest of us on blankets spread on the grass. With the exceptions of pajamas at sleepovers and bathing suits on the beach, we never saw the men in anything but collared sport tops or button-down shirts. Their apartments were similarly distinct, with furnishings that made family dinners feel more like visits to an old hotel or historic site than a meal in someone’s home.

  During this same phase of my life, I would sometimes find myself with my sister and cousins just a block away from Granny’s at the top of a steep hill with an incline so acute, most locals drove around it, sparing their engines, brakes, and nerves. Not my grandfather, especially not if he had one or more of his five granddaughters in the car. After a Chinatown dinner and before the ice-cream cones, he would drive us to the top of that crazy hill and let the car teeter on its precipice. Then he’d release the hand brake, let go of the steering wheel, and put his hands up in the air. Each time, we grabbed each other and squealed, gasping and laughing. And each time his foot was still on the brake pedal and the pace, though it felt like speed to us, would have elicited honks and frustration on most other blocks. Each time we spent a night out with Gramps, it was hard to imagine having more fun.

  Those two memories show why I should have known better about old age. But, like many people, I never gave it much thought, even when it was right in front of me. I thought more about Granny’s exposed breasts than about how her softened skin, odor, and the look and feel of her apartment affected my experience of them. And I thought about all the fantastic nights out with my grandfather but not about how much fun he was having being a grandparent, a role that not a few people describe as the best of their lives. Nor did I really consider how being from different generations of old age affected what more senior members of our family could or would do, or the larger social factors that enabled the men’s more relaxed, engaged, and fun-loving approach to life. I was three when Granny’s husband died, leaving her a widow for the second time. Still relatively young when my great-grandfather died, she had been free to remarry. But the script for elderly widows required that Granny lead a quiet life of occasional outings and family, eschewing exercise, solo travel, and romance. She seemed happy enough in her life and healthy to my child’s eyes, yet she made me nervous. She was strict and quick to reprimand, sure of her authority. We had to dress up to visit her, then sit in a “ladylike” pose on her furniture. When once, discussing some athletic event, I described myself as having been sweaty, she told me ladies didn’t sweat, they glowed. I felt entirely justified in my mild fear of her and my suspicion that she was as foreign as she was family.

  Granny died in her early nineties and her daughter, my grandmother, at only seventy-eight, after years of alcoholism. A family history of a long life doesn’t guarantee you’ll get one. Granny and Grandpa, her son-in-law, didn’t get along. For years they didn’t speak, and my grandmother was caught in between, the two central figures in her life each constantly fighting and enumerating the other’s failings. Although her children were grown and settled, a woman of my grandmother’s background and time couldn’t seek out a divorce, job, or therapist for escape, distraction, or fulfillment. Instead, there was alcohol, which worked as most drugs do when abused. It dulled the pain, providing brief, blissful moments of respite, and it ruined her life and health. What I remember most vividly about her is how she would choke at dinner, eyes bulging, face panicked, sweating and unable to breathe. The adults at the table ignored her when this happened. It took me years to gather the courage to ask what was going on and why they behaved that way. She was drunk, they said, and she brought these episodes upon herself. I understood that their refusal to help her was punishment for disappointing them in so many ways, but I could not understand how they could sit so calmly in the presence of her distress. When Grandma choked, the dining room turned to ice. Finally, she would gasp or put a hand to her mouth and leave the room, and dinner would continue as if nothing had happened. A person’s age may have little or nothing to do with the ways in which they suffer.

  Fewer restrictions existed for men: my grandfather could retire in his sixties from the job he’d done for forty years and begin new, more intermittent work. Because he had health, education, and enough money, his new job could be one that indulged his interests in furniture and travel while taking advantage of his business and social skills. He had the time and resources for all those activities he’d always loved but couldn’t pursue in earlier years when supporting his family and building his company. When he became a widower in his late seventies, he continued to enjoy an active social life. Although Gramps had always been charming and interested in everybody and everything, his eighth and ninth decades were the best dating years of his life. Lucky for him: a scarcity of males in the oldest age groups meant that even a short man with little hair could go out with a different woman every night of the week if so inclined—and he was.

  There were fewer old people then, and the world paid them less attention. I heard about the Gray Panthers, but the civil rights movement and feminism seemed more visible and relevant. Stories about old-age trials, opportunities, and accomplishments didn’t appear daily in the news, and older adults hadn’t yet been classified by society as a problem of “silver tsunami” proportions. That metaphor, implying that new human longevity and the aging population would bring tsunami-like overwhelming destruction to society, didn’t enter our lexicon until the 1980s. Now it appears everywhere, from Forbes and the Economist to the Washington Post, the New England Journal of Medicine, and the National Council of State Legislatures. I
ts relatively recent ascendance is why I was so surprised—looking back not only at the sixties and seventies but even farther back still, to ancient Egypt and China, the Greek and Roman Empires, and the earliest periods of U.S. history—to discover how much of what we believe is unique to aging in this “tsunami” moment isn’t new at all.

  LESSONS

  In June 1992 I moved from Boston to San Francisco, my brand-new MD in hand, and began answering to the word Doctor. In many ways, this was absurd.

  Graduating from medical school doesn’t mean a person has the knowledge or skills to independently diagnose and treat patients. That’s why new doctors do residencies: the three- to eight-year phase of doctor training that comes after the degree but before adequate competence for unsupervised practice. A primary care internal medicine residency had brought me back to my hometown. At San Francisco General Hospital’s Emergency Department, where I did my first rotation, being an inexperienced doctor didn’t seem so worrisome because I was surrounded by highly skilled nurses and doctors. More concerning was what happened in a small, fluorescently lit room on the fourth floor of a Parnassus Avenue medical office building each Tuesday afternoon. There, people ranging in age from nineteen to ninety would show up for an appointment with their new internist, and what they got was me.

  Every three years, clinics are passed from graduating residents to new interns, and often they have a particular focus, usually a category of disease or type of patient. It’s unclear how intentional this is—for example, a future oncologist referring her hospitalized cancer patients to her own outpatient clinic for follow-up—or whether clusters of patients with certain illnesses or traits gravitate toward a particular doctor by some other means. It could be word of mouth, ethnic and linguistic compatibility, or an appointment scheduler’s hunch. What was clear for my group of residents was that Arlene had a disproportionate number of patients with diabetes, Sammie’s often used street drugs, Rafael’s were more likely to speak Spanish or have HIV, Danny’s had complicated heart disease, and Gerda’s preferred a female physician. Many of my patients were old.

  I was in my twenties, and old looked different to me than it does now. Although I cared for more octogenarians than my fellow residents, I also had more patients in their sixties and early seventies, some of whom I would now consider middle-aged. But in those days, “old” was for me a large, fairly uniform category defined by an unspecified but self-evident amalgam of age, attitude, and appearance. Had anyone asked, I’d like to think I would have noted the considerable differences between sixty-five and ninety, but in my day-to-day doctor life, patients at those different ages, although a generation apart, seemed more similar than not.

  At eighty-nine, by anyone’s definition, Anne Rowe was old.

  I met her on a warm Tuesday afternoon about a month into my residency. Perched on the edge of our clinic’s tan vinyl, one-size-fits-all chair, Anne’s feet dangled above the floor, swinging like a schoolgirl’s. She wore what she called her “old lady shoes” and one of what I would soon learn was a handful of cheerful dresses that pulled over her head, allowing her to avoid buttons and zippers that challenged her deformed fingers.

  As we exchanged greetings, she studied me from above the bifocal wedges of her gold-framed glasses. She had a humped back and compressed torso, perfectly white hair with a hint of curl, and a smile of crooked teeth.

  “What happened to the other doctor?” she asked.

  “He moved back east,” I answered, trying my best to appear a worthy replacement.

  Departing senior residents were supposed to tell their clinic patients they were leaving, but I had already learned that didn’t always happen. Losing their primary care doctor could be hard for patients, but, unique in my clinic, Anne seemed to understand and accept the system. That meant we could jump right into discussing her history and current concerns. She had a routine assortment of conditions—high blood pressure, arthritis, allergies, constipation, heartburn—and a long list of medications.

  As we shifted to the physical exam, she asked, “What kind of name is Aronson?”

  “Jewish,” I said. “It was given to my father’s family at Ellis Island because theirs was too hard to pronounce.”

  She grinned. Her family had a similar story, except it wasn’t Anne’s grandparents who had fled the eastern European pogroms of the early 1900s but Anne herself. She had been three years old in 1906 when her family left Belarus and somehow landed in North Dakota.

  Eventually I learned Anne’s life story. On that first day, I heard enough to get a glimpse of one of the great pleasures of talking to older people. Anne’s life spanned the better part of a century and many continents, and, like all lives, it had included an assortment of personal tragedies and accomplishments. Talking to her was like getting paid to listen to excerpts of a long, captivating novel.

  Anne escaped North Dakota by earning a teaching degree and taking a job overseas. I learned later that she’d fallen for and married a British artist-activist, that perhaps she might have been a better mother to their son, and how, after a few years, she had divorced her unreliable husband and supported herself by teaching in Puerto Rico and Michigan. At that first meeting, we did not discuss her years in Mississippi during the civil rights movement or her retirement to San Francisco to be near her four still-living siblings, although I’m certain she told me about her most recent job: caregiver for her sister Bess, a role Anne had acquired gradually and by default. The two siblings, one divorced and one widowed, shared a house.

  At the time, I didn’t know how hard the job was or how dangerous and damaging it could be to the physical and psychological health of the caregiver. I’m pretty sure this was not a topic covered in medical school, where the social and personal aspects of health are only infrequently mentioned. A doctor’s job was to treat disease.

  As a first-year resident, I was required to discuss all my patients with a more experienced clinician who would make sure I hadn’t missed anything. As I learned more, I could be more selective, presenting only those patients where I knew, felt, or suspected I didn’t yet have the necessary knowledge or skills. During these consults, the senior doctor would ensure I was providing high-quality care and also teach me about clinical assessment, reasoning, or treatment. This was almost always a pleasure.

  In caring for Anne, I learned a patient’s target blood pressure differed in patients over age eighty, and why I should steer clear of common arthritis medications even if they were inexpensive and likely to help her pain. Although readily available over the counter, my teachers said these drugs would put Anne at high risk for kidney failure and internal bleeding. That last, life-threatening side effect occurred only rarely in young and middle-aged patients, but, as I quickly discovered on my hospital rotations, it routinely happened among the old. Drugs that pose serious danger to “adults” in general—no matter the age—aren’t available over the counter. However, even today, an obvious oversight in over the counter drug labeling persists: while precautions specify risks to children, pregnant women, and people with certain diagnoses, they do not mention possible harms to older people.

  Because my supervisors pointed out differences between younger and older adults and helped me make treatment plans that hewed to the latest standards of care, I thought I was learning everything I needed to take good care of my many old patients. Unfortunately, later that year it became clear that I wasn’t, and the consequences of the mistake I made under the close supervision of my outstanding doctor-teachers would not only land Anne in the hospital and endanger her life; it would show me how medicine and society’s choices undermine old people. Too often old age itself is blamed for realities created by our choices and policies.

  * * *

  As we got to know each other, among the things I came to like most about Anne was her smile. Her face lifted, her eyes flashed, and if she found something funny, she’d throw her head back to laugh. Her neck was short by then and the hump in her upper back pronounced, bu
t in those moments of humor and comradery, her face became the embodiment of mirth and joy. At each visit, I would get to see her smile when I entered the exam room, when either of us made a joke, and when we worked together to get her abbreviated self onto the relatively high exam table and out of her shoulder-to-knee slip, an undergarment of a type with which I had no familiarity.

  I knew there was something very wrong the day that winter when she didn’t smile at all.

  “How are you?” I asked, scooting my wheeled desk chair toward her and feeling stupid, since the answer to the question seemed obvious.

  “I had to put Bess in a nursing home,” she said in a voice so quiet I could barely hear her. Her eyes seemed smaller, darker. Tears traced the creases of her cheeks.

  I moved the box of tissues to the corner of my desk where she could reach it.

  “I couldn’t lift her. I couldn’t keep her clean. I’m just not strong enough.”

  I resisted the temptation to mention that she was nearly ninety and four feet nine inches tall, traits that make it close to impossible to provide total care to a bedbound person. I did point out that she had taken care of her sister for nearly a decade and that most people wouldn’t have lasted nearly as long.

  A doctor’s instinct is always to try and fix, soothe, reassure. In moments like these, those tendencies can be the opposite of helpful.

  Nothing I said offered much comfort. Finally, I shut up. I let Anne talk, and I listened. Eventually I asked about symptoms of depression and suicidality. Then I went to consult with my supervisor. We discussed the difference between grief and depression, and I told him that Anne was definitely grieving, but I worried that she was also depressed.