Elderhood

by Louise Aronson

  Nascher noted that “in institutions where the aged have light tasks assigned to them, they do not break down mentally, either as soon or as completely as whenever the aged have nothing to do but sit56 on a bench and brood.” Marjory Warren, confronted with so many delirious and defeated old patients in West Middlesex, similarly insisted any life could be improved by more stimulation and pleasant surroundings, and it was worth determining recovery potential in people with any disability. A notable percentage of her patients returned home, and even those whose improvement was limited led more comfortable and meaningful lives.57

  In 1950, fifteen years after Warren transformed her patients and unit, the UK Ministry of Health announced: “The workhouse is doomed. Instead local authorities are busy planning and opening small comfortable Homes where old people … can live pleasantly and with dignity. The old ‘master and inmate’ relationship58 is being replaced by one more nearly approaching that of a hotel manager and his guests.” But the tides of history wax and wane. Governments choose their weapons from a limited arsenal. Ahead of the 2016 Super Bowl hosted in the Bay Area, San Francisco’s mayor had the homeless population moved and removed, housed and given tents in out-of-the-way places. That same year, our local newspapers featured articles about our aging homeless population.59

  “Nursing homes are charged with an incredible endeavor—taking care of the failing,”60 Robin Young commented in Here and Now. Yet we keep using them. We put “loved ones” in them, underfund them as a society, and hope never to need one ourselves. It sounds better to say We’re sending her back to the home, or He lives in a home now than to say We’re sending her back to the institution where she will spend the rest of her life bored and unhappy until she dies, or He lives in an institution now because we couldn’t fit his care into our lives. But it’s too easy to blame individuals for something that is complex, multifactorial, and at least partly structural. That last quote should finish with these words: given how little our society supports such efforts.

  ZEALOT

  Sometimes I hate my colleagues.

  When he developed cancer, Juan was eighty-six years old. Already, he had heart disease, arthritis, and diabetes, as well as one-sided weakness and mild dementia from a stroke. The oncologists put him through ten months of permanently debilitating chemotherapy and radiation and then said the disease wasn’t curable and there was nothing more they could do.

  Another day, Deborah, a patient who’d just signed up for hospice, was sent to the emergency department by someone at her assisted living facility who had neglected to check her file before calling for an ambulance. Her distraught and disappointed family called her primary doctor, who called the emergency department, explained the situation, and asked them to send her home. The hospice and primary care teams would take it from there. The emergency doctor said they needed to do a CT scan because Deborah might be having a stroke and need a potent blood thinner. He could not understand that he didn’t have to do those things, that they wouldn’t change the fundamentals of Deborah’s life at that point, or that it was not only legal but ethical and kind to respect the patient’s wishes at the end of her life. He said, “We can’t just not provide care.” For him, only certain sorts of activities (scans and certain drugs) and places (hospitals and emergency departments) counted as medicine and health care.

  Then there was Albert, my ninety-four-year-old patient who was cut off from friends by his deafness, unable to hear much despite his hearing aids. He increasingly struggled to walk, spent most days alone, and was getting sick more and more often, when he fell outside his building and hit his head. A passerby called the paramedics, who wanted to take him to the hospital. Albert refused, since he didn’t have a cut that needed sutures. The paramedics argued that he might be bleeding into his head. A doctor himself, Albert said, “So what?” Given where his life was and where it was headed, lapsing into a coma and dying in his bed would be a better end than anything the hospital had to offer for a brain bleed. He microwaved a frozen dinner, watched some television, and finally went to bed, where, to his disappointment, he didn’t die.

  Albert was unusual. As the end of life nears, most people don’t know what they want or can expect. They do as they are told, deferring to the knowledge and assuming the benevolence and objectivity of their physicians. But doctors are flawed and fallible, the products of their culture and time like everyone else. As the Canadian physician Balford Mount, who coined the term palliative care, wrote years ago: “We [in medicine] emerge deserving of little credit; we who are capable of ignoring the conditions which make muted people suffer. The dissatisfied dead cannot noise abroad the negligence they have experienced … We don’t imagine that we, who strive to be and view ourselves as well-meaning and competent, might be neither … And patients are afraid of insulting or upsetting those responsible for their care.”61

  Since the twentieth-century medicalization of aging and dying, medicine has mainly seen itself as a means to wage battle against death, not as one of many tools with which to ease that inevitable transition. Education about how to conduct so-called difficult conversations, give bad news, assess patient priorities, and manage symptoms at the end of life only became standard in medical schools in the 2010s, and remain ignored or underutilized by many specialists. Geriatrics and palliative care, the two fields in which those tasks are elemental, are called in—or worse, they’re not. Indeed, ongoing efforts at reform notwithstanding, medical culture and financial rewards for dialysis, chemotherapy, and procedures persist, even when they are unlikely to benefit a patient.62

  Meanwhile, death is outsourced to palliative care, as if it were something uncommon.

  9. MIDDLE-AGED

  STAGES

  Throughout ancient and medieval times, old age was defined as a distinct life stage. Though the number of stages varied, most commonly including three, four, six, or twelve,1 each stage was thought to have unique behavioral and health attributes but unclear transition phases. Aristotle identified three stages: growth, stasis, and decline,2 the last two correlating roughly with later notions of fit and frail elders, respectively. Perhaps in part because of mystical notions of the number seven, the Ninetieth Psalm fixed the life span at seventy years with seven age groups.3 This view of the human life span as made up of distinct stages persisted in the West until the eighteenth century.

  The industrial age called for specialization of social and work functions for adults and a more distinct phase of childhood, and it deemed old age a brief period defined by the mixed messages of well-earned retirement and uselessness. “Middle age” came later, propelled initially by efforts to distinguish increasingly powerful midlife adults from older ones, and as a catchall for the decades between young and old as lives lengthened. New institutions and terminology developed in response to each new life phase. Here is the social historian Tamara Hareven:

  The “discovery” of a new stage of life is itself a complex process. First, individuals become aware of the specific characteristics of a given stage of life as a distinct condition. This discovery is then passed on to society in popularized versions. If it appears to be associated with a major social problem, it attracts the attention of agencies of welfare and social control. Finally, it is institutionalized: legislation is passed and agencies are created4 to deal with its special needs and problems.

  Through this mechanism, society both supports its citizens and reduces them.

  In the modern era, a variety of substage names have been proposed for old age. The psychologist G. Stanley Hall proposed senescence as a late-life analogue of adolescence5: “There is a certain maturity of judgment about men, things, causes and life generally, that nothing in the world but years can bring, a real wisdom that only age can teach.”6 In 1974 it was the psychologist and aging scholar Bernice Neugarten7 who divided old people into young-old, meaning those between the ages of fifty-five and seventy-five, and old-old for those ages seventy-five and above. Ten years later, to capture the distinct characte
ristics of the increasing numbers of people over age eighty-five,8 Richard Suzman and Matilda White Riley added oldest old to Neugarten’s model. In the public arena, three stage divisions are also common, particularly the catchy and somewhat irreverent go-go9, go-slow, and no-go.

  Geriatricians also divide old people into stages, most commonly identifying four based on disease and function: healthy, chronically ill, frail, and dying.10 A more relational five-stage approach has been proposed by Dr. Mark Frankel as independence or self-sufficiency, interdependence (when occasional help is needed), dependence (when a person needs regular, daily life help), crisis (when professional care may be required), and death.

  The stages of old age are complicated by the fact that people can move forward and sometimes backward among them, something that never happens in earlier phases of life. After an accident, or heart surgery, or chemotherapy, a person might appear “aged,” looking years older than they did just months earlier. They might even skip forward a stage or two of development, requiring a walker or wheelchair and help bathing. But months later, after time for healing and physical therapy, they might get “younger” again. Similarly, if an older adult decides to start exercising or begins an exciting new job or falls in love, they can suddenly seem years younger or as if they “had a new lease on life.” The stages of old age are more fluid than those of childhood and adulthood. They can be skipped and returned to, though overall, in old age as in its predecessor stages, there is a typical progression.

  * * *

  Trajectory matters. Like babies and children, very old people are often small and dependent. But while our landscapes at life’s start and end share some attributes, they are fundamentally different, and not just because in youth we know little but are headed toward most of life and in old age we have already traversed that territory and are closer to death. Ignatz Nascher used biology to refute the notion of advanced age as second childhood:

  A comparison of the organism in childhood with the organism in old age will show that there is not an organ or tissue, not a function, mental or physical, identical at the two periods of life. Vitality, metabolism, even instinct differ. The process of senescence is progressive, not retrogressive,11 there is no reversal in the order of development and not a single tissue reverts to an earlier type.

  Physiologically as well as developmentally, then, the Victorians were right: life is a journey, not a cycle.

  Nascher also recognized that medicine’s approach to childhood health offered an ideal model for approaching health in old age. We don’t think of childhood as an immature perversion of adulthood, characterized by an underdeveloped psyche, intellect, organs, and tissues. Anatomical structures (an infant’s big head, a child’s smaller body and parts), physiological functions (what counts as normal in muscle strength or pulse rate), appearance, and behaviors that would be deemed pathological in adulthood are considered normal and natural in childhood. “We must,” Nascher advised, “take a similar view of senility.”12

  A little over a decade later, in her 1930 book Salvaging Old Age, the American psychologist Lillien J. Martin suggested the problem of old age in America was conceptual, not biological: “When we have arrived at the place of looking at old age as a period of life rather than as a bodily condition,13 we shall give it the intelligent and careful study that we have applied to other such periods, infancy, childhood, adolescence … as a period with its own struggles, its aspirations and its accomplishments.”

  I have begun to think of life this way: it’s as if child, adult, and elder are life’s three primary colors and all its substages are derived from those three fundamentals, just as all other colors are made by combining red, yellow, and blue.

  HELP

  The frantic call came from Frank Cavaglieri’s assisted living facility just after two in the afternoon. I was in my office catching up on paperwork.

  “Oh, God,” I said after taking the call, pushing back my chair and reaching for my visit bag. “Tell them twenty minutes.”

  When I arrived at the handsomely restored building with its English manor house landscaping and City Landmark status, the knife had been removed from the table next to Frank’s lift recliner. He’d set it beside the jar of sour lemon candies his daughter, Susan, kept continuously stocked because he loved sweets and his mouth was always dry, and because she loved him.

  The cut was on the back of his hand an inch down from the knuckles. It bled, though not much, and not nearly enough for his purposes. Shallow as it was, it wouldn’t even require stitches. He’d used the only instrument he could find, a butter knife lacking a true blade, worn nearly smooth from years of institutional use.

  Seeing me, Frank tried to smile. Well dressed as always, he wore a soft gray sweater over a patterned maroon shirt, and his white hair was neatly combed.

  “I can’t even do this,” he said. “I can’t even kill myself.”

  I squeezed his hand but didn’t speak right away. I didn’t want to insult his intelligence by pretending this was a problem I could fix.

  With Frank’s soft, warm skin against mine, I struggled to show I cared without actually crying in front of my patient, this lovely ninety-two-year-old man who desperately wanted to be dead, and found himself, day after meaningless day, still alive.

  Three years earlier, I had pulled up to a pale green house with rows of flowering geraniums below each front window in rectangular planters painted to match the white trim. On the passenger seat of my car sat two folders of new patient paperwork. The couple, both in their late eighties, had lived in the same modest home for sixty years. It stood on a short street overlooking a freeway in a rapidly gentrifying once working-class neighborhood.

  My visit was supposed to be a consultation. They already had a primary care internist they liked, as well as a bevy of specialists: a cardiologist, neurologist, podiatrist, and pulmonologist for him, and a neurologist and dermatologist for her. But their daughter was convinced they weren’t getting what they most needed, though she couldn’t say exactly what that might be. She hoped someone with expertise in the care of the very old might help her figure out what to do to improve her parents’ lives. All she knew for sure was that they were neither happy nor thriving. That wasn’t like them at all, even if it was how most people think of advanced old age.

  When Frank tried to kill himself, he was widowed and lived in a studio apartment in the assisted living facility. His room was large and the place fairly nice, but it was an institution. Even with some of his own furniture and photographs, it wasn’t home. There were group meals and activities, but by his second year living there, he couldn’t taste much or hear very well, despite expensive hearing aids. He stopped participating in card games when he began regularly making mistakes, and he no longer went to performances by visiting musicians. He couldn’t walk either, and although he received regular visits from his attentive and loving family, they had jobs and school and travel, so mostly there he was, alone in his room.

  The staff came in to help him dress, wash, and get to meals. They cut the meat on his plate, gave him his medications, and told him what time to eat, get up, dress, bathe, and go to bed. He regularly fell while trying to transfer himself from chair to wheelchair or wheelchair to toilet, in part because he wanted to do such basic things himself and in part because even when he did call for help with these tasks, the wait often was longer than he could tolerate. Eventually, the facility’s caregivers insisted on diapers, and he conceded.

  Frank told me he wished he were dead. We tried antidepressants, which didn’t help. Though worth a try in case they might mitigate his distress, it seemed unlikely to both of us that they could address his fundamental problems.

  Frank had three of the six conditions participants in a recent study identified as worse than death14: bowel and bladder incontinence, the inability to get out of bed (he could still get up, but at least one person and a mechanical lift device were required to transfer him from his bed into a wheelchair), and needing around-th
e-clock care.

  He would never develop two of the other three unacceptable states, needing a feeding or needing a breathing tube, but in the slow lead-up to his death he would have more and more of the sixth, being confused all the time. There was nothing he or I or anyone could do about it.

  That helplessness, of course, is part of what people dread about old age. It’s not just the lost functions and roles, from the fundamental to the just plain fun, but the loss of control over one’s body, situation, and life. Given sufficient longevity and a certain balance of luck, both good and bad, that outcome seems biologically determined. At some point the good luck of not dying early and of developing conditions that medicine can at least partially treat begins to look like all loss and no gain, an inexorable accrual of negatives with no potential upside. The fortunate live this way for days to weeks; for the less fortunate, it can go on for years.

  While not rich, Frank had more advantages and resources than many people, including a family who loved him, who regularly showed up to visit and always when called, and who never stopped trying to find ways to make life better for him. Yet he clearly suffered. But the changes that eventually became his advanced old age actually started earlier—for him, as for the rest of us, in our forties or fifties, though at that stage they don’t dominate, presenting instead as small flares on the larger background of our functionality and engagement.

  We joke about worn-out knees and receding hairlines and find work-arounds for nouns or facts we can’t quite locate at the exact moment we’d like to use them. Those are serious and real changes, and only the beginning of a process that becomes advanced old age decades later.

  There is old and there is ancient. Live long enough and eventually the body fails. It betrays us. Our flesh wrinkles, sags, and sinks. Strength wanes. We lose speed, agility, and balance. Abilities once taken for granted are accessed only verbally, using the past tense. Sometimes the mind follows the body’s descent, words, logic, insight, and memories dropping away. We fall ill more often and more gravely. We become frail. The smallest, most ordinary tasks—eating, showering, walking—become time-consuming, difficult, dangerous, or impossible. Absent purpose or agency, frustration, boredom, and discomfort provide the landscape of our days. In the end, we are defined more by what we are no longer than by what we are. We fight and flirt with death.