Helping an older adult find a caregiver, delineating the caregiver’s tasks, monitoring the caregiver’s work with the older adult, and ensuring the caregiver’s own well-being are not traditional medical tasks, nor do they need to be done by a physician. They can be, however, among the most important interventions to ensure the well-being and safety of frail older adults. Eva’s geriatrician could speak accurately to those needs and was willing to do such uncompensated, “nonmedical” work for the sake of her patient’s health and well-being. Once in place, Eva’s caregiver picked up medications (so she didn’t have to pay for home delivery), assisted with cooking and exercise, and cleaned the apartment. She also provided Eva with social interaction and foot care.
Nearly three years later, Eva was looking forward to her ninetieth birthday. She was frailer than when I first met her, and turned out to be a “difficult patient” who would fire her caregivers, not do her exercises, and sometimes even refuse the care she’d been so enthusiastic about when her health was better. Still, she remained out of the hospital, out of a nursing home, and in her beloved apartment with Heathcliff, who, thankfully, did eventually come home.
BIOLOGY
In the sixteenth century, when Shakespeare wrote As You Like It, he divided life into seven stages.35 By middle age, he said, “all the men and women” develop wisdom but also a “fair round belly,” which in older age turns into “spectacles on nose” and a “shrunk shank,” and finally, in “the last scene of all, that ends this strange eventful history,” the oldest old end up “sans teeth, sans eyes, sans taste, sans everything.” It’s this final fate that gives aging such a bad rap.
With advancing age, our cells and molecular building blocks change and break down, losing the ability to self-regulate36 and repair damage. This has anatomical and physiological consequences for organ function. Some changes are unique to a particular part or system; the immune system’s dendritic cells, for example, are less and less able to effectively respond to threats. Others affect multiple systems; as enzymes form cross-links in skin, cartilage, and bones, those tissues become less elastic and resilient. All body parts are eventually affected, although different parts age at different rates, and some changes are more apparent than others. We can easily see wrinkles as our skin thins and loses elasticity, or gray hair as the pigment cells called melanocytes disappear from the bases of our hair cells. Less obvious until something goes wrong are changes such as the hardening of arteries from thickened blood vessel membranes and calcification, or thinning of bones as they lose essential minerals. In many places, the deterioration manifests as decreases: shrunken brains, less muscle mass, thinner intervertebral disks, sunken eyes, smaller kidneys. In others, it’s about increases: the heart gets bigger and heavier, ears continue to grow, the lens of the eye thickens.
Most people think of these changes as exclusively negative. Also, ugly. Angela Morales offers another perspective. In “Nine Days of Ruth,” she describes her grandmother’s dying: “Her skin feels like the surface of a mushroom (amphibious perhaps), and I wonder if decomposition has already begun … Autolysis37 means ‘self-digestion’ … thus, the body begins the recycling process. Such beauty, even in reverse!” I have had similar thoughts watching an old person die. It’s nature at work, and nature is beautiful. It’s a different beauty than a young body in motion, quieter and more understated, and also less pleasurable to witness, even if the person is ancient and ready. Still, being with such a body, all the senses are involved and the feeling is one of symmetry and completion. We call our excursion from birth to death a life cycle for a reason.
Not all species age, and those that do don’t all age in the same ways. There is no indication that prokaryotes, organisms such as bacteria or blue-green algae that lack chromosomes, a nucleus, and other membrane-bound organelles, undergo senescence. Among eukaryotes, there is good evidence that single-celled populations are immortal38 and that senescence occurs in all multicellular organisms—plants and animals—that undergo somatic, that is, non-germ-cell, differentiation. Organisms age at wildly different rates. Flies die suddenly right after maturation. Pacific salmon reproduce and die soon thereafter. Humans and other placental mammals gradually deteriorate from maturation39 onward, while trees and reptiles don’t appear to experience postmaturational increases in mortality.
Although scientists have made progress in documenting what happens to the human body as it ages,40 determining why and how those changes occur has proved more challenging. Of the dozens of circulating theories, not one is universally accepted. Because evolutionary, psychosocial, and physiological theories tackle the same questions in different ways, it may be that some combination of them offers the most accurate and comprehensive explanation for why we grow old.
Evolutionary theories41 come in two basic types. One posits that natural selection doesn’t affect genes that act primarily once we’ve reproduced. The second suggests a package deal with harmful aging traits bundled with highly prioritized others needed for successful reproduction. Psychosocial theories explain aging in relation to behavior. They view old age in three primary ways: as a process of natural maturation; as a coping strategy for adjusting to biological changes; or as the progressive confirmation or rejection of past perspectives, relationships, and activities. These processes aren’t mutually exclusive with each other or with physiological theories that explore what’s going on at the cellular level. Physiologists offer sometimes competing ideas of aging as genetic damage from radiation and chemicals, accumulating errors in genes and proteins, or depletion of necessary cells or cell parts. Here, too, it seems likely that several types of changes might be happening at once. Physiologically, senescence could be a state of declining immunity and chronic inflammation and also the result of wear and tear after longer use and exposure to disease risk factors, as well as time enough for even slow-moving pathologies to do damage. Genetic factors clearly play a role too.
The speed and degree of aging vary widely not only between people but also within the same individual. The biology of aging mirrors its lived experience: cellular changes depend on a multitude of factors both inside and outside the individual. Like diseases, aging disorders bodily structures and functions. It also increases a person’s vulnerability to injury and illness. Perhaps the most accurate understanding of aging, then, is as the biological manifestation of living.
One cool October day a few years ago, my colorist, who is only somewhat younger than I am but whose smooth skin and black hair expand the gap between us, met me with a bemused grin. I had reached the three-month mark in my effort to grow in my gray hair. That past summer, I had come to the conclusion that I should be doing a better job of embracing my own aging. What kind of hypocrite, I asked myself, champions old age while masking at least part of her own aging? I resolved to see what my head would look like au natural.
I went gray in my early thirties, an event unheard-of on either side of my family and one that I attributed to the stress of medical training. At thirty-four, still single, I asked the man who cut my hair to return it to its original dark brown. For the next nearly two decades, I steadfastly refused highlights and other embellishments, insisting that I wasn’t going for glamour, I just wanted to look my age. Once in my early fifties, that argument no longer worked. Almost all fifty-year-olds have gray hair, whether you see it or not.
“So?” My colorist stood behind my chair as we stared at my head in the long mirror in front of us. In honor of our appointment, I had not used my trusty color wand to hide the gray and white hair at my hairline and along my part.
I admitted to relief each time the magic wand obscured the gray demarcation line.
“You’re not into it, then,” she said, again looking amused.
I explained that I was fairly sure—if not entirely certain—that my objection was to the telling transition between dyed and native hair, rather than to the white-gray hairs themselves. It looked sloppy and ugly to me. In a context in which most women dye their
hair, I also worried that I would appear older than I was or somehow less professional. And more than anything, I felt horrible about feeling that way.
My colorist suggested she add highlights to blur the demarcation line, and I said yes.
Biology is only part of the story of aging. Call it the nature portion of a complex process in which “nurture” plays an equally critical role. How and when we age, and how we experience that aging, also depends on our environment, coping mechanisms, health, behavior, wealth, gender, geography, and luck. All humans belong to the same species and have the same biological life span, but these “nurture” factors greatly influence aging. In wealthy Monaco, the average life expectancy is nearly ninety years,42 which means people are counted as among the aging for nearly a half century and among the old for decades. By contrast, in impoverished Chad the average life expectancy is below fifty years, aging begins earlier, and old age is shorter. Even within the United States, discrepancies are marked: Asian Americans in Massachusetts live, on average, to age eighty-nine, while South Dakota’s Native Americans die on average a generation earlier, before their seventieth birthday. Biology matters, but it’s not everything.
In the early 2010s, a colleague and I did geriatrics consultations at a local prison. We saw every inmate aged fifty or older. When a fifty- or sixty-something prisoner was on his first incarceration and less than a few years into his sentence, we could speed through the evaluation; the man was middle-aged and had no geriatric issues. But if an inmate in the same age range had lived his entire life in poverty, been in and out of prison repeatedly or incarcerated for decades, or if he had serious mental or physical illness, his body resembled that of a seventy- or eighty-year-old.
Anyone born healthy begins life with organs working far better than they need to. Biologically, this phenomenon is called redundancy, and it’s present in all organs. Our eyes, ears, lungs, kidneys, ovaries, or testes are redundant because most of us have two of them, although we can manage well enough with just one, even one that’s less than perfect. Our single organs also have enough excess capacity that they can decline yet continue to function adequately under normal conditions. That caveat, “normal conditions,” is key. Above all, aging is a loss of homeostasis, a decline in our ability to self-regulate and maintain equilibrium under duress. So thinner bones seem not to matter until you fall, resulting in a fracture you wouldn’t have sustained in younger years when you had stronger bones. And the heart pumps less effectively as it thickens and stiffens with age, although you probably can’t tell while sitting in a chair or walking on the flat. But ask it to work harder, by climbing stairs or getting sick, and the presence and degree of compromise may become apparent.
The Berkeley professor Guy Micco’s napkin drawing of a relentlessly downward trajectory with age appears to accurately capture the biology of aging. Choose any anatomical or physiological component of a human body at the level of a tissue or organ: numbers of sensory nerves or fast-twitch muscle fibers, blood flow through the kidneys, amount of circulating sex hormone, saliva production, or lung capacity. Across the life span, each of these steadily decline: fewer neurons and fibers, less blood flow and saliva, lower hormone levels and lung capacity. It’s enough to make a person agree with Philip Roth that “old age isn’t a battle; it’s a massacre.”43
This is precisely where medicalization does us a disservice. Looking through that single lens, we see only part of the larger picture. Most of us are far more interested in what we can do at the level of the whole human than in what’s going on with our parts. Notably, a person’s ability to perform a task—as opposed to a cell’s or an organ’s—depends on more than biology. This plays out in a variety of ways.
Some functions decline but not to a point that is noticeable. Others can be slowed with choices and behaviors—actions that are easier for some people than others. As with most things in life, the fortunate have more health-related resources, access, and education, and this helps them make better choices. Some communities also support healthy options44 more effectively than others.
Perhaps most important from a policy perspective, how well a person functions often depends on factors that have nothing to do with biology. For example, if we chart the hearing of an average twenty-year-old, fifty-year-old, and eighty-year-old, the image is one of decline. But whether the decreased hearing matters in their lives depends not just on their auditory function but on where they are. All three of our hypothetical people may have little trouble at home or work, but put them in a busy restaurant or conference hall and the eighty-year-old may struggle to hear above the background noise. In that situation, it’s not the person’s function that’s changed—certainly they didn’t lose more cochlear neurons, hair cells, and hearing on their way to dinner—but the threshold itself. If there’s enough noise, even the fifty-year-old, who under normal conditions can’t tell any difference between their current hearing and their hearing thirty years earlier, may have trouble. And if it’s louder still, the twenty-year-old will also struggle, even though their ears function optimally. Worse, those healthy ears may be getting injured, increasing the person’s chances of later deafness. Thus, the impact of biological changes on our lives at all ages can be made worse—or better—by our environment.
Despite the highlights added by my colorist, as my gray hair grew in I found it was a disappointingly nondescript shade, without enough silver or white to make a fashionable salt-and-pepper mix or luxurious-looking new age-appropriate look. This posed a problem, and not just aesthetically.
Discrimination against workers over forty is well documented across employment sectors. To many people, gray hair signals old, and old means out-of-date, used up, on the way out. I wanted to look “normal,” and normal in the segments of society I inhabit generally does not include gray hair on women until old age, and for a good many not even then, unless it’s beautiful. We are supposed to pretend we’re not aging, and many of us comply, not wanting to stand out as Other, especially when that Other comes with so many prejudices and assumptions about one’s appearance, competence, and relevance.
Gloria Steinem summed up the situation well in 1974, describing an exchange at her fortieth birthday party: “And a reporter said to me, kindly, ‘Oh, you don’t look 40.’ And I said, just off the top of my head, ‘This is what 40 looks like45—we’ve been lying for so long, who would know?’ ”
Just after Thanksgiving, I called the salon and told them I could come in anytime. When I arrived, my colorist smiled sympathetically. She knew I’d be back. Although the Bible states that “gray hairs are a crown of honor,” times have changed.
Two years later, I’m trying again, and I’m not the only one. To many of us, hair suddenly seems an important form of political and social action. Biology means fifty-five looks different than forty. I’d rather live in a world where I could spend less time, money, and effort on delusion and put all those precious resources toward showing what each of life’s decades actually look like and how they can be enjoyed. And every day I wonder whether I’m being brave or foolish.
ADVOCACY
Four weeks after his quadruple bypass and valve repair, three weeks after the bladder infection, pharyngeal trauma, heart failure, nightly agitated confusion, and pacemaker and feeding-tube insertions, and two weeks after his return home, I was helping my seventy-five-year-old father off the toilet when his blood pressure dropped out from under him. As did his legs.
I held him up. I shouted for my mother. As any doctor would, I kept a hand on my father’s pulse, which was regular: no pauses, no accelerations or decelerations.
My mother was seventy-one years old and, fortunately, quite fit. She had been making dinner and said she dropped the salad bowl when I yelled. She took the stairs two at time. Something about my tone, she said.
We lowered my father to the bathroom floor. I told her to keep him talking and to call me if he stopped, then I dialed 911.
In the emergency department, after some fluids, my fa
ther felt better. My mother held his hand. We compared this new hospital with the last one where we’d spent so many weeks. The doctor came in and reported no ECG changes and no significant laboratory abnormalities, except that the test measuring the effect of his blood thinner was above the target range. The doctor guessed the trouble was dehydration. He would watch for a while, just to be safe.
My mother waited with my father. The rest of us filed in and out, not wanting to crowd the tiny room. Then my father’s blood pressure dropped again. I told the nurse and stayed out of the way. She silenced the alarm, upped the fluids, and rechecked the blood pressure. It was better. But less than half an hour later, we listened as the machine scanned for a reading, dropping from triple to double digits before it found its mark. The numbers flashed, but the silenced alarm remained quiet. I pressed the call button, and when the nurse arrived, I asked her to call for the doctor. When no one came, I went to the nursing station and made my case to the assembled doctors and nurses. They were polite, but their unspoken message was that they were working hard, my father wasn’t their only patient, and they had appropriately prioritized their tasks. I wondered how many times I had made similar assumptions and offered the same assurances to patients or families.
After weeks of illness and caregiving, it can be a relief to be a daughter and leave the doctoring to others. But I had been holding a thought just beyond consciousness, and not just because I hoped to remain in my assigned role as patient’s offspring. I didn’t want to be the sort of family member that medical teams complain about. Now that I’d apparently taken on that persona, there was no longer any point in suppressing the thought. His medical history and overly thin blood suggested internal bleeding to me.
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