“Do you think she needs medication?” he asked.
I didn’t want to medicalize the normal sadness of grief, but I also didn’t want to leave major depression untreated.
I decided not to give Anne a prescription that day but to add her to my schedule the following week. At that next appointment, she still wasn’t smiling, and she told me she wasn’t eating, sleeping, or doing her usual activities. Nothing really interested her.
She needed medication.
I told Anne we were lucky because for years the only drugs for depression had dangerous side effects, but now there was a new medication with few side effects, most of which went away after a few weeks. I relayed this information with great authority, since I had read the latest literature in preparation for a clinic talk and had successfully treated several other patients in my practice with antidepressants. I handed Anne a prescription, scheduled a follow-up visit in a month, and told her I’d give her a call soon to see how she was doing.
When I phoned the next week, I got her answering machine and left a message. I hoped that meant the drug was working and she was out and about again. Even in the moment I recognized my own wishful thinking. In truth, I was relieved, at least as much for my own sake as for Anne’s. It was much easier and more efficient for me to reach her machine than to speak to Anne if she was feeling better. Having left a message, the onus for communication moved from me to her. I could take “Call A. R.” off my to-do list and move on to my next task. I was on an inpatient rotation that month, and my team was on call from eight in the morning of my clinic day until eight A.M. the next day. Though I usually loved outpatient work, on that day it was an unwelcome interruption in a busy shift that would last at least thirty-six hours. My goal that afternoon was to finish as soon as possible without compromising the care of my clinic patients and get back to the hospital.
You could argue that that setup, a typical one, is a failing of medical training. But it’s also prescient training for the realities of primary care medicine, where too often doing the right thing for the patient and getting through the tasks that enable a clinician to complete the workday in just ten or twelve hours are in direct opposition. Tasks such as phoning to check on at-risk patients like Anne, refilling medications, responding to patient queries, and determining whether a patient needs an appointment or if you can spare them an unnecessary trip to the clinic. Tasks like working with hospital doctors or visiting nurses to ensure safe transitions from hospital to home and speaking to caregivers or concerned family members. None of these activities count as part of the scheduled workday, although they can take one, two, or three hours and are essential to patient care. This reality is one of the key ingredients in our primary care and burnout crises, which might be jointly defined as the willful mismatch between what is best for patients and clinicians and what the health care system prioritizes and pays for.
Two weeks later, the clinic medical assistant stopped me as soon as I arrived.
“You have an add-on, and they’re already here.” She handed me a chart with Anne’s name on it. “Her son Jack is with her.”
Anne looked even tinier than usual, perched on the vinyl chair as a younger, stockier, and decidedly male version of her paced up and down between the door and far wall.
“I’ve never seen her like this,” Jack said. “She’s just not herself.”
I turned to Anne. “Can you tell me how you’re feeling?” She hadn’t looked up since I’d entered the room.
“I just don’t see the point,” she said, her words emerging at half speed. I had to crouch beside her chair to hear her.
“Of what?”
“Of anything.”
She was nearly catatonic. My supervisor and I agreed that Anne needed to be admitted to the psychiatry hospital. I filled out the necessary paperwork, called the admitting psychiatry team, and stayed with Anne and Jack until one of the nurses wheeled her across the street to the hospital.
The rest of my clinic shift was fairly frantic. I was running over an hour late and each patient visit began with their frustration and my apologies. By six o’clock, when the psychiatry hospital extension came up on my pager’s flashing green display, every doctor but me had finished seeing patients and the support staff had all gone home. I punched in the number, eager for news about Anne.
The psychiatry resident had been nice earlier in the day. Now he didn’t waste time with pleasantries.
“Her sodium is 121,” he said. “I can’t believe you didn’t check it before sending her. You need to arrange her transfer to the medical service.”
Anne wasn’t depressed—or not just depressed. Her critically low level of blood sodium was why she’d appeared catatonic, and for all I knew, it was what had been causing her depression from the start. Shortly before she moved Bess to the nursing home, I had adjusted her blood pressure medications. The new combination can lower sodium levels. Although I’d checked it once in keeping with standards of care, I hadn’t thought to check it again when she became depressed because Anne had such a good reason to be depressed.
Horrified and ashamed, I made the necessary calls. As I was doing that, my pager went off again. It was the hospital operator who said a patient’s son was demanding that I call him. Jack was furious and questioned whether I knew what I was doing. All I could do was apologize.
In medicine, when something unexpected happens and certainly when patients are harmed, we review the case to identify missteps and learn from them in order to take better care of future patients. After Anne’s hospitalization, the attendings, my co-residents, and I discussed the need for blood tests in patients on multiple medications when their health changes, even if there appears to be another plausible explanation. We also uncovered several recent case reports describing elderly patients developing critically low sodium levels on the type of antidepressant I’d given Anne, the then relatively new class called selective serotonin reuptake inhibitors that are now among the bestselling drugs on the market.
But we did not discuss why we had all assumed treating depression in an octogenarian would be the same as treating it in younger adults. Or how it could be that anyone was surprised when a diminutive ninety-year-old developed complications from the same medication dose I had last given to a hundred-and-sixty-pound thirty-nine-year-old.
Fortunately, in this instance Anne and I both got lucky. In the hospital, she steadily improved, and when she went home, Jack was there to help. I remained Anne’s doctor until her death five years later. Jack is now himself an octogenarian, and we are still in touch. Some patients give more to their doctor than the doctor could possibly give to them. Anne gave me geriatrics, though I didn’t know that for several more years.
3. TODDLER
HISTORY
Eight hundred years before Christ and a hundred or so after, leading Greco-Roman and Egyptian thinkers put forth an array of sometimes contradictory ideas about aging. Hippocrates cataloged ailments particular to old people and believed medicine had little to offer them, while a key medical text from Egypt around 600 B.C. included “the book for the transformation of an old man into a youth1 of 20.” Plato’s Republic opened with the elderly Cephalus describing the variability of old age2 and how often old people blamed problems on aging even when most older people didn’t have those problems. Aristotle advanced his theory of pneuma, in which finite life force decreased over time, taking with it vitality and the ability to fend off disease and death. In de Senectute, Cicero noted that “since [Nature] has fitly planned the other acts of life’s drama, it is not likely that she has neglected the final act.” The older man, he argued, “does not do those things that the young men do, but in truth he does much greater and better things … by talent, authority, judgement.” Galen asserted that aging was a natural process and only disease counted as pathology. He taught that self-care through diet and behavior could slow aging.
Two millennia later, our response to old age isn’t so different. Google, the National Acade
my of Medicine, and a host of other public and private researchers, echoing the Egyptians, have launched campaigns to “end aging forever.”3 Perhaps in agreement with Hippocrates, in 2018 the UK appointed a minister of loneliness instructed to pay special attention to the elderly, and the United States passed the RAISE Act to support family caregivers. Recapitulating Aristotelian fatalism, the medical care of older adults is often unstandardized and unpopular. Although researchers have been required to include women and people of color in their studies for decades, similar stipulations for older adults,4 a group that uses health services at much higher levels than the young, were only passed in 2018. Meanwhile, in a blending of Cicero and Galen, the terms healthy or successful aging have become the catchwords for acceptable old age, and thought leaders are competing to coin a word to distinguish the younger, fitter old from the truly old and frail.
And that’s only the beginning of the story.
From earliest recorded history, even those who agreed on pathological mechanisms of old age adopted different interpretations of the same findings. Greek doctors considered old people members of the adult group and their age just one factor among many with relevance to diagnosis and treatment. At the same time, while recognizing them as different, they lumped old people of both genders—because they were “too cold”—with children and women, who “exhibited excessive dampness.” Everyone but adult men were assigned a status somewhere between health and illness (and a legal status of less than full competence) as a result of their inherent “pathological dyscrasias,” or bad mixtures of elements. From earliest recorded history, many societies have considered their oldest citizens less than fully human.
After the fall of Greece, numerous advances in scholarship about the care of older adults came from the Middle East. In Arabia in the tenth century A.D., Algizar detailed ailments of aging, including insomnia and forgetfulness, and wrote books on maintaining health in old age. In the eleventh century, a Persian polymath named Avicenna, often described as the father of early modern medicine, published The Canon of Medicine. He advocated health through exercise, diet, sleep, and management of constipation,5 echoing Galen’s Hygiene. That classic from over a millennium earlier was rediscovered and became a bestseller in the late twelfth century. It went through 240 printings in European and Middle Eastern languages under the title Regimen Sanitatis. Building on Avicenna and Regimen, the Franciscan friar and thirteenth-century physician Roger Bacon revived Galen’s idea of aging as heat loss, also suggested the still-popular wear-and-tear theory, and advanced the Christian idea that behavior determined longevity. His book The Cure of Old Age and the Preservation of Youth was translated into English four hundred years later and well circulated. Little changed over those centuries in Europe, where understanding of illness and aging came primarily from the religious view of humans as immortal and death as the wages of sin.
In the fifteenth and sixteenth centuries, Europeans began taking inductive and empirical approaches to medicine. By observing a range of older adults, philosophers and clinicians concluded that behaviors and interventions could delay and improve but not prevent old age, and also that aging and death were inevitable. In Italy, Gabriele Zerbi’s 1489 book Gerontocomia described physiological changes of age from skin wrinkles to shortness of breath, illustrating that aging was a physical and physiological process. The Italian octogenarian businessman and philosopher Luigi Cornaro, the “Apostle of Senescence,”6 based his work on self-observation. Although senescence refers to age-related cellular damage and biological old age, Cornaro saw old age as a time of promise and fulfillment. He advocated moderation and personal responsibility7 for health so people could experience its rewards. His Discorsi della vita sobria was first published in the 1540s, translated into English in the 1630s, and came out in fifty editions through the 1700s and 1800s. That Cornaro lived to one hundred suggests he was onto something.
In Britain, Francis Bacon studied long-lived people8 and observed that multiple factors, including diet, environment, temperament, and heredity, influence aging and longevity. Studies in recent years have proved time and again that he was right on all counts.9 The French physician Andre du Laurens’s 1594 text, Discourse of the Preservation of the Sight;10 of Melancholic Diseases; of Rheumes and of Old Age, also went through many editions and translations. Its title alone provides insight, calling out vision loss, depression, and arthritis in old age. At regular intervals throughout the nineteenth century, popular books offered rules for extending life, while others, notably William Thoms’s Longevity in Man: Its Facts and Fiction, provoked controversy by questioning whether anybody had ever really lived past one hundred.
With the Scientific Revolution in the sixteenth and seventeenth centuries, when physicians began dissecting and analyzing the anatomy and pathology of subjects both living and dead, increasingly accurate specifics about the aging body emerged. The preeminent philosophers of the time, including René Descartes and Francis Bacon, like the scientists of today, believed that humans could prolong life and cure disease through healthy living and interventions uncovered through medical research. The Marquis de Condorcet correctly predicted that science would improve the physical health of populations, while Napoléon believed humankind would eventually be able to engineer its own immortality. A few thinkers questioned this goal in various ways. Thomas Malthus raised concerns of overpopulation, and, in Gulliver’s Travels, Jonathan Swift imagined the people he called Struldbruggs11 living the dispirited, purposeless lives of people absent the ticking clock of their own mortality.
Over those centuries, too, some saw old age as a disease in the Galenic tradition, an intermediate condition between health and illness. In France, François Ranchin’s 1627 Opuscula Medica distinguished between “natural senescence” because of waning heat and “accidental senescence” as a result of disease. In Germany, Jakob Hutter gave away his main point in the title of his 1732 book, That Senescence Itself Is an Illness. According to him, people died of old age itself, and he developed a theory to explain the underlying pathology. With aging, he wrote, people developed a “progressive hardening of all fibres of the body,”12 which eventually obstructed blood flow and led to “fatal putrefaction.”
Beginning in the eighteenth century, European understanding of the biology of aging rapidly advanced, distinguishing normal aging from disease and recognizing apparently symptomless diseases and organ pathologies in people who appeared to be experiencing healthy old age. This led to the recognition of chronic diseases and of the different presentations of disease in old age. It became clear that death in old age was due not to the waning of invisible humors or heat but to one or many diseases; in other words, it wasn’t a disease itself. The accumulation of chronic diseases, which might remain silently asymptomatic for years, was documented in 1761 by Giovanni Morgagni in De sedibus, et causis morborum. In 1892 Heinrich Rosin, a German professor (of law, not medicine) wrote, “Extreme old age, with its natural degeneration of resources and the natural decline of organs, is a condition of development of the human body; old-age infirmity is no illness.”13 Meanwhile, in the United States, Benjamin Rush’s 1793 Account of the State of the Body and Mind in Old Age, with Observations on Its Diseases and Their Remedies noted that old age was only rarely the sole cause of death. Yet even then the messages were mixed. Long-standing preventive regimens for optimal aging persisted even as new ones emerged. Rush also discussed the influence of genetics on aging and the benefits of being married and having a calm temperament.
The nineteenth century brought a significant reconceptualization of aging. This occurred partly as a result of scientific advances, but larger social forces also played a role. Increasingly, the impact of poverty and social policies on health became apparent, and communities and the state were seen as having social responsibilities for their older citizens. In the final decades of that century, the Victorian focus on the behavior of individuals and notions of life as a journey were denounced by modernists as “creating respectable
cowards14 rather than morally empowered individuals.” By the early twentieth century, Americans rejected the earlier religious, metaphysical, and cosmologic explanations of aging and began putting their faith in the biological sciences to explain not so much why we age but how. Understand the how, they reasoned, and you could control it. If you could control it, the why was irrelevant.
Despite these scientific and societal changes, the medical care of the elderly garnered relatively little attention. This was largely due to a belief that older adults were doomed and incurable. The focus on pathological changes with age in the nineteenth century and the emphasis on cures in the twentieth put the needs of many old people at odds with the goals of medicine. There were exceptions to this inattention, particularly by German researchers, including Alois Alzheimer and Emil Kraepelin (who named Alzheimer’s disease after his mentor), and British clinicians. They produced descriptions of dementia15 and the impact of early life habits16 on health in old age, as well as an elaboration of the challenges posed by the coexistence of several diseases in older patients, now known as multimorbidity.17 Still, by the early twentieth century the lines between normal and pathological aging remained unclear.
Most physicians at the time (as now) deemed old people less worthy of medical attention than younger adults who were easier to treat and more fixable. The common approach to their care was neglect, a relatively inexpensive strategy that required little from doctors and had the added advantage of being a disincentive to malingerers. Old patients were confined to beds in dismal surroundings with few activities and scant stimulation, and provided with little more than food and shelter. This led to depression, obesity, muscle atrophy, and pressure ulcers until the 1930s, when the surgeon Marjory Warren, “the mother of British geriatrics,”18 advocated for the physical rehabilitation of the sick elderly.19
Elderhood Page 3