Elderhood

by Louise Aronson

  I had to try and behave professionally, even if what I wanted to do was curse and lament, not just those particular paramedics but our entire health care system with its devastating ignorance about old age. I was also already thinking about who we’d need to contact to provide geriatrics training to our city paramedics and all the reasons they would give for not needing it or not having time for it.

  “You weren’t wrong.”

  Shaming a patient’s concerned relative is, under any circumstance, unacceptable professional behavior. “What happened next?”

  She said they looked through her mother’s medications.

  That was a good next step. Of the many conditions that can cause delirium, drugs are among the most common offenders. Starting a new medication can do it, as can stopping certain types of medicines abruptly without tapering the dose. Occasionally, people can react to something they’ve been on for years as their body’s ability to process the drug changes.

  I scrolled down Lynne’s medication list in our electronic record. But what appears on our official logs and what a patient is actually taking often differ, so I also asked Veronica what her mother was on and if there had been any recent changes.

  Veronica read me the list, then said, “The paramedics checked all the bottles and said she seemed to be taking everything except the antidepressant. I guess she stopped that three weeks ago, though I didn’t know about it. They said that was it. That was the problem. They gave her a pill at two thirty this morning and told us both to go back to bed.”

  I took a deep breath. Suddenly stopping an antidepressant can cause a bad reaction, but the withdrawal would manifest gradually over days, not suddenly three weeks later.

  “How is she this morning?” I asked.

  “Sleepy. And still not at all herself.”

  Since Lynne was a fairly healthy seventy-nine-year-old and because the basic activities questions hadn’t led me to any specific diagnosis, it now made sense to run through the review of symptoms, or ROS. After discussing the patient’s primary concerns, doctors use the ROS to fill in details and ensure nothing else is missed. The questions progress from head to toe, grouping organs by location, such as eyes, ears, nose and throat, and physiological role, such as cardiovascular or nervous system.

  Veronica answered some questions herself but mostly she repeated my queries to her mother. I could hear faint nos periodically in the background. No fever, cough, shortness of breath. No increased urination or new incontinence. No chest pain. No weakness in a limb or changed vision, speech, or swallowing. No belly pain, nausea, or vomiting. Some diarrhea for a few weeks, but that happened. No blood in her bowel movements.

  But then, there it was: Lynne had a headache, and not just any headache. The worst headache of her life. She described it as a ten on a scale of one to ten, where ten is the most severe pain imaginable. That she said she felt fine while experiencing that kind of pain was another worrisome clue.

  I told Veronica that we needed to get her mother to the emergency department right away.

  “I wanted to take her yesterday and earlier but she wouldn’t go.”

  “She’s not herself and she can’t make good decisions. Just tell her what’s happening.”

  We agreed that Veronica would phone for the ambulance and I’d call ahead to the hospital. Before we hung up, I told her how glad I was that she had called, that her instincts were just right, and that her mother was lucky to have such a perceptive and persistent daughter. I also promised to give the paramedics feedback on their care of her mother. At the very least, they needed to know that most older adults are not confused, that sudden confusion always indicates a problem in need of medical attention, and that ignoring a family member’s concerns is bad medicine.

  After a few hours, I logged back into the medical record. On the CAT scan of Lynne’s brain, it looked as if someone had spilled black ink onto a white picture. Sometime between when she’d gone to bed Friday night and when her daughter had gone into her bedroom on Saturday morning, she’d begun bleeding into her head. By Sunday morning, she’d had a large hemorrhagic stroke.

  Three months later, I recognized Veronica’s name in my e-mail inbox. In her message, she apologized for not writing sooner and thanked me for my help and support. She then gave me an update on her mother, who was finally back home: “It has been a difficult journey, but I was able to come home this afternoon and give my Mom a hug. I was able to ask her what she might like for dinner. I was able to plan her eightieth birthday celebration in September.” Lynne was changed by the stroke, but her life still provided pleasure and meaning to them both.

  Veronica admitted she was still stunned by the paramedics’ comments about her mother. The reality is that they probably meant well. They might even have been following procedures. Across the country, the police are called and often make arrests of people with dementia who get lost and trespass or who fight back when “a stranger” (a caregiver they don’t recognize) appears to be trying to take off their clothes or make them go somewhere they don’t want to go. In cities and prisons, older people are shot when they are “not cooperating”23 because they cannot hear commands or can no longer fall to their knees. In some cases, as with Lynne, they are assumed to have dementia when they do not, and in others they are assumed to be fully responsible for their actions when they are not because of dementia. Yet when e-mailed about a course designed to fill in geriatrics education and training gaps among practicing health professionals, a locally and nationally prominent physician leader said he couldn’t think of anyone who would benefit. In medicine, clinicians often believe that taking care of older patients is the only necessary qualification24 for taking care of older patients, a logic they would never consider applying to the care of children or people with cancer.

  But change is coming. Many police departments, including ours in San Francisco, increasingly recognize the unintended harms25 to older adults from their lack of geriatric knowledge and have begun training programs. Their efforts may be paying off. In a recent viral news story, a Southern California police officer called by a bank to arrest an upset nonagenarian instead took the man to renew his expired driver’s license, then brought him back to the bank, where he successfully cashed his check.

  4. CHILD

  HOUSES

  Growing up, I had a rotating assortment of dreams for my future, but none of them included old people or a career in medicine. In my childhood home, books were everywhere. New and used, paperback and hardback, they overflowed from bookshelves and teetered in tall stacks in the family room and on bedside tables. My mother mostly read literary fiction, social and political histories, and the sorts of writing that eventually would be called ethnic literature1—books she passed on to me, shaping my worldview and my ambitions for who and what I might become. My father, a research physician, read novels, nonfiction, and medical journals, and when he made an important point about anything, from politics to sports, he quoted facts and numbers gleaned from those sources in the way others might quote scripture. As a result, scientific thinking provided the pillars and joists in the cognitive architecture with which I interpreted ideas and experiences, even in the days when I planned on becoming an anthropologist, editor, or English teacher.

  By my teens my greatest interests lay in people, cultures, and stories, not in figuring out how things worked, testing hypotheses, or fixing broken parts. When my high school college counselor gave me a list of colleges to consider, I crossed off every school with math or science requirements. I didn’t have a definite idea of what I wanted to do with my life, but knew it wouldn’t involve calculus, physics, chemistry, or biology. Once in college, I focused on learning how to read and think critically and on gaining a better understanding of the world and the people in it, finally settling on a double major in history and an “independent concentration” that included hefty doses of anthropology, psychology, literature, and ethnic studies.

  The one group I didn’t think about was old people.
In young adulthood, they seemed to have little relevance in my life. Once I moved across the country for college, my grandparents were far away, and although I passed older adults on the street, saw them in restaurants, and occasionally had them as teachers, these relationships were by chance, casual, and situational. Children, by contrast, were the subjects of volunteer programs, classes, majors, and career options at my university. Their rearing, education, welfare, and even medical care had also been for many years among the few sectors available to working women, so those fields came replete with female role models, increasing their appeal for me. In college, I tutored kids at an inner-city school, volunteered in a program for autistic children, became a Big Sister, and took summer jobs with psychologists studying childhood development. I thought I’d devote my career to children. After all, by helping them you were potentially influencing an entire life. What could beat that?

  Beginning my junior year, I volunteered at a health coordination unit for Southeast Asian refugees and learned two things that would change my life: who you are in the world influences your health, and power sometimes stems as much from position and social expectations as ability. Nurses and social workers did the unit’s day-to-day work, but once a month a doctor showed up for an hour or two to make all the big decisions. I wondered whether it might be possible to combine the physician’s knowledge and authority with the compassionate, collaborative approach the nurses used with our refugee clients, families who had survived war and genocide only to find themselves in a world that didn’t welcome or understand them. It was then that I realized that what I wanted most from my career were the skills and position to make a difference in people’s lives. Becoming a doctor was a straightforward path to that end and came with the added benefits of job security, a decent income, and society’s approval. For me, it took far less courage than heading to New York to work in publishing or joining the amorphous nonprofit sector, and I have always been a coward.

  After graduation, I enrolled in a crash-course, postbaccalaureate, premedical program to complete the math and science classes I’d so carefully avoided. Over the next fifteen months, I applied to medical schools and worked as director of special education in a refugee camp on the Thai-Cambodian border.

  In Khao-I-Dang, doctors were consulted about everything: not just medical issues but psychological, social, and existential problems as well. That reinforced my view of doctoring as a human enterprise in the broadest sense. The camp’s refugees had lived through bombings, starvation, work camps, displacement, and the deaths of countless friends and loved ones. Their past influenced which illnesses they developed, whether they would believe a diagnosis or follow a treatment plan, and their chances of surviving, much less thriving, in their lives. Knowing that, I entered medical school with a different perspective than many of my peers. I didn’t think science and medicine had all the answers or that the same disease affected different people in the same ways. I had seen how proximity to death changed how a person lived, and that fixing the body didn’t always alleviate suffering.

  I expected those facts to inform my medical training. What I found instead was a divide between the goals of health care and the practice of medicine. My training as a doctor focused almost exclusively on science, relegating everything else to, at best, second-class status. When treatments didn’t work, instead of recognizing the impact of societal, personal, cultural, and systemic factors or limitations of our research and care, we blamed the patient or moved on to a better case. She is noncompliant, we said. Or, He failed the treatment. Also, It’s hopeless; there’s nothing more we can do. Such comments were particularly likely to be invoked for populations and diseases that, overtly or covertly, earned the label of “difficult”: the homeless or mentally ill, people with obesity or chronic pain, the worried parents of sick children and the frantic adult children of old patients.

  But really, anyone was fair game, particularly if they had different priorities than we did or didn’t get better. In medicine, it seemed we preferred certain sorts of people and ailments to others. We were most comfortable with problems—like broken bones and inflamed gallbladders, heart disease and cancer—that we could manage either successfully or with the drugs and procedures we knew best. According to studies, most of us also did a better job when treating bodies2 and lives that might have been our own. Not that we acknowledged that truth. And not that I recognized it in myself when it stained my thoughts and actions during those early years.

  Acculturation to the profession’s ways of thinking and doing things is essential in medical training. Still, even after I’d bought into the science-as-king party line, it was impossible to train in medicine in Boston and San Francisco in the early 1990s and not see how medical and social values interacted to affect illness experiences. It was also hard not to notice that, after AIDS patients, many of the people we took care of were old, and that often the things we did to help younger patients either didn’t work very well or didn’t address what our older patients seemed to care about most. Notably, while most doctors refrained from racist, sexist, and homophobic slurs, few seemed to mind disparaging old people. As Samuel Shem’s semi-autobiographical bestselling medical novel,3 The House of God, made clear, old people were “gomers,” an acronym for get out of my emergency room, and defined as “a human being who has lost—often through age—what goes into being a human being.” The book is about medicine and medical training, and has remained popular for over forty years because its story is as essentially true and prescient today as it was in the early 1970s. Looking back at it now, among its most remarkable insights is one lesson the narrator learns from caring for his older patients: if he follows the standard rules of medicine by ordering tests and procedures, they will die. He copes with the horror at this outcome by breaking rules and also, tragically, by learning not to care. “Before the House of God,” the narrator tells us, “I had loved old people. Now they were no longer old people, they were gomers, and I did not, I could not love them, anymore.” Confronted with medicine’s dehumanization of older patients, he and the other young doctors become desensitized and dehumanized themselves, perpetuating the harmful cycle.

  From my earliest student days in several of this nation’s top hospitals—including the one where The House of God takes place—it was clear the lowly status of old people extended to the medical specialty dedicated to their care. Just as gerontology, the multidisciplinary study of aging and older adults by people with master’s degrees and PhDs, had been relatively invisible compared with child development during my undergraduate studies, geriatrics, unlike its child-focused equivalent, pediatrics, was barely acknowledged during my medical training. Part of the problem was that geriatrics specialists didn’t play by the rules of medicine any more than older bodies did. Rather than give physiology, diseases, and curative treatments exclusive primacy, they also considered other factors that might compromise a patient’s health or well-being: where they lived, whom they could count on, what they needed to be able to do to maintain their independence, what was most important to them in their health care and lives, and how they were eating, sleeping, moving, eliminating, feeling, and thinking.

  We budding doctors had devoted years of our lives to studying science, learning so many new words along the way that we’d essentially become fluent in a new language. We knew most of what there was to know about organs and diseases, bugs and drugs, and we had mastered a stunning array of technologies and procedures. We only had to look around us in the hospitals and clinics of our training centers to see what medicine was and what it looked like at its best. The low and falling ranking of the United States in patient health outcomes relative to other countries didn’t bother us because all over the world everyone knew we had the best medical care. After all, we had the most cutting-edge devices and produced the lion’s share of medical studies and innovations. Geriatrics included some of that but focused on all those other things too. Where was the fun in that, we asked, and what was the point of it?<
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  RESURRECTION

  Entering my new patient’s room, I found him in bed with his eyes closed. Though in his late seventies, Dimitri Sakovich had a head full of mostly dark hair and a model’s sculpted cheeks and chin. The day before, he had been admitted to our nursing home’s advanced dementia unit.

  Having come from home, Dimitri arrived with little more than lists of his medical problems and medications. From those few pages, I learned that Dimitri had end-stage Parkinson’s, dementia, and several other common chronic diseases, and that he took ten medications, many several times a day. Irina, the unit’s head nurse, told me he’d been living with his wife and adult daughter but they could no longer manage his care at home.

  I said his name, but Dimitri didn’t respond. Then I touched his arm. Nothing. I shook him a bit, repeating his name in a louder voice, and finally his eyes opened. Irina explained in Russian who I was and why we were there. It wasn’t clear he could understand her.

  With Irina translating, I asked Dimitri two questions: What was his name? Was he having pain? Because Parkinson’s slows people down, we had to give him time to respond. I sang a chorus of “Happy Birthday” in my head to make sure I waited long enough.

  In response to the first question, Dimitri’s lips moved but no word emerged. He didn’t even try to answer the second one, so we skipped ahead to the physical exam.

  Although one of his hands shook and his limbs showed the rigidity and ratcheting movements characteristic of Parkinson’s, he otherwise seemed quite robust. He had well-formed muscles and joints; all his organs looked, felt, or sounded as they should.

  Back at the nurses’ station, I studied his medication list. On admission to the nursing home, we usually just continued whatever the person had been previously taking, at least until we got a sense of them and their medical history. Dimitri’s medications were all commonly used and each was associated with one of his diagnoses. That was a good start. But two appeared on the Beers Criteria, a national list of potentially inappropriate medications for older adults. The list warns of increased risks for adverse reactions. The hope is that doctors will think twice before prescribing such medicines to patients over seventy and, whenever possible, use alternatives.