Elderhood

by Louise Aronson

  The same thing happens in science and medicine every day. Lifesaving advances sound like a good thing, something definitely worth funding. Often, they are—at first. What is not funded are the downstream consequences, the consequences geriatricians try to help people live with every day.

  CHILDPROOF

  Partway through Five Flights Up42, a movie about an aging couple who decide it’s time to sell their Brooklyn walk-up, Morgan Freeman’s character tries to open a pill bottle. He pushes, pulls, twists, and shakes, but the white cap remains resolutely in place.

  Just as it seems he will find no pharmacological relief from the stress of strangers touring his treasured apartment, a child finds him struggling. She is nine or ten years old, with pigtails and the eyeglasses Hollywood puts on kid characters to indicate preternatural intelligence.

  Quickly appraising the situation, she takes the bottle from him and opens it with ease.

  “Childproof,” she quips, handing it back. He shakes his head.

  The humorous scene touches on one part of a larger, decidedly unfunny problem with how we do and don’t regulate medication safety in the United States. As is often the case, well-intentioned efforts to protect one group end up hurting other groups when regulations take a widespread approach to a situation problematic for only a minority. Without question, that minority—in this case, children—deserves protection, but, as is often the case, the intervention’s impact was studied almost exclusively in the minority target population (kids) and not the rest of us, the adult majority.

  Anyone who has been around toddlers knows of their tendency to touch everything, insert their bodies everywhere they might fit, and put anything they come across into their mouths. That’s why we childproof homes, putting plugs into electric outlets and gates across stairs, and making slats between railings too narrow for even the smallest human heads. In the 1960s pediatricians documented alarming numbers of child deaths from medications.43 Not just toddlers but older kids as well would come across colorful pills and capsules when exploring their homes. Either assuming they were candy or just curious, they ate them. In 1970 the Poison Prevention Packaging Act44 was signed into law to protect kids from unintentional drug overdoses, and pharmaceutical companies began using “child-resistant” bottles—no one ever actually claimed such containers were entirely childproof. As a result, poisoning deaths of children under five years old were nearly cut in half.45

  For almost fifty years now, child-resistant containers have been standard. Unfortunately, such containers offer little deterrent to older children, and even children as young as two and three can open many of them. Early benefits have been lost. A key reason for this is the protective medication packaging. Because child-resistance makes it hard or impossible for the people who need medications most—the sick, disabled, and elderly—to open their pill bottles, they leave them open, accessible to all.

  The Consumer Product Safety Commission has addressed these problems in multiple ways. In 1995 revised requirements mandated testing not only on children46 between forty-two and fifty-one months but on “seniors” ages fifty to seventy. While this was an improvement, they added middle-aged and young-old testers and still left out most old people.

  It’s true that the people most likely to be stymied by childproofing are harder to study than their healthier, younger counterparts, but that’s at least partly because the same challenges that render bottles inaccessible make the personal costs of research participation higher for them. Getting into child-resistant bottles often requires a combination of grasping, pushing, squeezing, and twisting. Such efforts may be fun for a small child but can be painful, difficult, or impossible for a person with impaired or feeble hands. If that person also has arthritic joints, weakness, or mobility challenges, as many old people do, getting to and from a testing site might require more of their energy or considerable discomfort.

  More inclusive testing groups weren’t the only consumer protection intervention. Manufacturers were again allowed to make easy-opening versions of products with labels specifying “for households without young children,” and pharmacies could dispense medications without child-resistance packaging if requested by the prescriber or patient. Over twenty years later, many people, clinicians and patients alike, don’t seem to know about these work-arounds, and the default remains adult-proof child-resistant packaging. Clearly, these efforts have been insufficient, or a recent movie featuring a septuagenarian actor wouldn’t include a gag about a pill bottle he can’t open.

  To get a sense of the number of people affected, consider the prevalence of just one common health condition. According to the Centers for Disease Control, in 2012, 52.5 million adults—23 percent of the U.S. population—had been told by a doctor they had some kind of arthritis.47 Fully half of adults over age sixty-five were given that diagnosis. While not all arthritis affects the hands, a multitude of other conditions also affect general strength and manual dexterity. And for some Americans, wrestling with pill bottles isn’t just an inconvenience; it can be life-threatening.

  When I made a posthospitalization home visit to Nina, a widow who lived alone and had just had a heart attack, I found all her discharge medications unopened. Those medications are so important that hospitals are evaluated on the percentages of heart attack patients who receive them. But they were dispensed in child-resistant and thoroughly Nina-proof bottles.

  When I met Edward and Carmen, they explained that they had their son empty their child-resistant bottles of medications into bowls each month when he visited from out of town so they didn’t have to contend with the annoying containers. Their system worked fine until Edward developed dementia and took the wrong pills.

  This is not just an issue for older people. An Internet search on the topic yields dozens of sites with instructions on how to change childproof bottles into “easy open” ones.48 Regrettably, my patients are not the target demographic for such websites.

  Public health measures are necessary to save lives. But the facts of widespread circumvention of child-resistant bottles and the country’s growing numbers of multigenerational homes indicate a dire need for better public safety strategies—ones that consider the safety and well-being of patients of all ages. The key question is whether we can decrease medication poisonings in children without preventing adults from accessing the drugs they need.

  New approaches should look beyond containers to the entire pill-to-person trajectory and take advantage of how our lives and world have changed since the 1970s. Potential solutions include targeted rather than universal use of safety lids and dispensing systems using the same fingerprint, face, and voice recognition software already being used on smartphones. Equally important going forward, we must learn from the flawed assumptions that made the “child-resistant” packaging policy less effective—and more harmful—than it might otherwise have been. The original legislation stated that packaging should be “not difficult for normal adults” (italics added), discounting those adults most likely to take pills.49

  Forty-five years after the Poison Prevention Packaging Act, new packaging is still not tested on the oldest Americans, the age group with the highest per capita pill consumption. Maybe more shocking still: we have no idea how many adults of any age have been harmed by medication safety caps; we don’t count those events the way we count poisoning events in children.

  RECLAMATION

  Many Americans near or past fifty remember their first solicitation from the organization once known as the American Association for Retired Persons. It’s not quite up there with one’s first sexual encounter, first paycheck, or first child, but it has the feel of a momentous life initiation.

  My AARP solicitation arrived in a stack of largely useless mail: unwanted catalogs, a journal renewal notice, a bill. The logo’s wavy red, white, and blue lines caught my attention. Then I saw the name.

  I wrote “OMG” on the white envelope and left it propped on the front hall chest for my spouse to see. We were forty-e
ight years old that year, so, really, we only met old by Silicon Valley or Hollywood standards. Also, AARP is actively trying to be the voice of the Third Agers and those, like us, in middle age headed toward Third.

  Another truth cannot be denied: it was one of those moments when the world reminded me that I, too, would become old. Not only was I was shocked; my first reaction was one of distancing and denial.

  Simone de Beauvoir captured this stance in The Coming of Age: “When we look at the image of our own future provided by the old we do not believe it: an absurd inner voice whispers that that will never happen to us—when that happens it will no longer be ourselves that it happens to.” This divorce of the current self from the future self distances us from the biological and social diminishment of old age. Such actions are essentially human. Almost everyone can relate to them. We cleave toward those like us and toward those who make us feel like our best and most powerful selves.

  The people who push back most ferociously against the label “old” are people in their sixties, seventies, and eighties who don’t (yet) conform to stereotyped associations with that word. They make comments along the lines of: “I am still active and looking forward to the future so find having the word old attached to me disconcerting.” Their argument is that they are not ill or disabled, despondent or dependent, and therefore not “old,” their chronological age notwithstanding. Since the definition of “old” is having lived a certain number of years, usually sixty or seventy, it seems we have created a society in which carrying that label is so awful that octogenarians leaning on walkers adamantly assert they are not old. Clearly, the human life cycle isn’t the problem. Societal prejudice is so strong, and the category old so stripped of respect and social worth, that old people feel compelled to argue against the obvious.

  They also inflict violence on their future selves. A typical anecdote from continuing care communities goes like this: A couple moves in. Healthy and active, they easily make friends and join in social activities. Then something happens to one of them: a stroke, dementia, cancer, heart failure, and suddenly one of the two is “old.” Now they have a problem at mealtimes, because they can’t eat together at their usual table. Their limitation is not the result of the ill spouse’s medical condition but of policies passed by the community that say only healthy people can eat in the independent-living dining hall. Thus the healthier half of the couple may eat in the dependent residents’ dining room but not vice versa. Or each must eat without their partner. In this way the hale, who are more likely to hold governance positions in such communities, protect their current selves from reminders of their potential future. They also maximize the chance that they, too, will be ostracized and treated without compassion when they reach the later substages of old age.

  Imagine a forty- or fifty-year-old saying, “I don’t like to think of myself as an adult. I’m just a kid who’s been around a few extra years.” Or a children’s hospital that eschews the term child because of its association with immaturity and instead markets itself as serving short, unemployed people. It’s ludicrous.

  Too often, the world gives considerable credit for what young people might do in the future and little or none for what old people can do or have already done. Too often, it assumes old people can do nothing and are good for nothing. This lose-lose equation is applied to anyone who lives past middle age, compromising both their individual life and our collective social potential. It also conflates vastly different substages of old age, devaluing the envied years while creating a hostile world for anyone who survives to advanced age.

  With current generations transforming what it means to be in one’s sixties, seventies, eighties, nineties, and hundreds, it’s time for elderhood to take its rightful place alongside childhood and adulthood. Each of life’s three acts is made up of many scenes. If we can accommodate infancy and adolescence under the umbrella of childhood, we also should be able to accommodate the young-old and old-old, and all those in between, under the umbrella of elderhood. Routinely using this long, varied stage of life’s name is a small but essential step toward recognizing and optimizing the full trajectory of our lives.

  A revised version of the life cycle, including its expected phases of dependence and independence, might look something like this:

  Given the variety and opportunities of twenty-first-century elderhood, anyone already in Act III and all of the rest of us who hope to avoid a premature death would do well to begin following the examples of the civil rights, women’s, and LGBT movements. Each reclaimed, created, or repurposed simple words to redefine themselves and their place in society: black was reclaimed as beautiful; chairman became chair and stewardess became flight attendant; queer is so popular that young people keep expanding its reach and inclusivity. Despite the backlash against those changes in some social sectors, those reclaimed words give me hope. I’ll be old in another ten years, more or less, and I’d like an elderhood as long and varied and hard and happy and legitimate and acknowledged as my first two acts.

  ELDERHOOD

  For age is opportunity no less1 / Than youth itself, though in another dress

  —Henry Wadsworth Longfellow

  11. OLD

  EXCEPTIONAL

  The year my mother turned eighty-one, not long after I dropped her off at the airport she got into a kerfuffle with a Homeland Security officer. Having put her bag and jacket in bins and on the moving platform, she was waiting her turn in the line for the body scanner when the official pulled her from the line.

  “Ma’am,” he reprimanded, “you need to take off your shoes.”

  “No, I don’t,” replied my mother with a smile.

  He insisted. Shoe removal was required for security purposes. No exceptions.

  “But I’m old,” my mother argued.

  “Ma’am,” he said, “you have to be seventy-five or older to keep on your shoes.”

  She matter-of-factly informed him of her age.

  He stared, muttered, “That’s incredible,” and waved her toward the body scanner, shoes still firmly on her feet.

  This Homeland Security officer assumed old age signaled infirmity without exception, and perhaps his views were consistent with what he had seen until that day. He didn’t check my mother’s ID, presumably because, like many, he saw old age as so undesirable that a person would never claim to be older than she actually was. Unlike a young-looking twenty-five- or thirty-year-old who must produce an ID with a birth date to buy alcohol, older people are rarely carded. So sixty-year-olds get into movies by saying they are really sixty-two, betting that no one will ask for proof. After all, who in their right mind would pretend to be old?

  * * *

  Health, appearance, and function are more varied in our later years than at any other period of life. Age alone isn’t the issue; it’s as much about appearance, behavior, experience, and expectations.

  The “successful aging” movement celebrates true stories about incredible resilience and accomplishments in old age. Its message is accurate, helpful, and sometimes nefariously counterproductive.

  In fairness, the notion of successful aging started out as one thing and became another.

  In 1997, in their landmark MacArthur Foundation study of successful aging,1 the physician-researchers John W. Rowe and Robert L. Kahn found three key ingredients for a high quality of life in old age. People who felt and functioned the best maintained (via healthy behaviors) a low risk for disease, a high level of engagement with the community, and high physical and cognitive function for longer than the average person.

  If the only way to describe older adults who are active, engaged, accomplished, or attractive is either to say they don’t look or act their age or to add words like successful or exceptional to the word aging, then we are implying that being old, by definition, means a person is none of those things—an obvious falsehood.

  The notion of successful aging is ancient. In Western cultures, it might be said to have its origins in the Fall in Eden,
a perspective that sees a difficult old age as one consequence of humankind’s moral failure, being cast from the Garden of God. Christianity held that God created man as perfect and possibly immortal, but illness and death were introduced after the Fall. This view implies that life span is preordained by God—not amenable to human tampering. It promises the possibility of longer health and life by spiritual redemption through Christ.

  In Rhetoric, Aristotle used the word eugeria2 to mean a good old age—eu means in a good manner, and geria refers to the treatment of old age. A good old age might include what Rowe and Kahn defined as successful and also advanced years where none of their three factors are maintained, yet the person is comfortable and cared for.

  * * *

  By any measure, Britain’s Queen Elizabeth is an “exceptional senior.” Around the time of her ninetieth birthday, the palace announced that she had had 341 engagements in the previous year, a record for a British monarch of any age. But while that accomplishment may make her exceptional among English royalty, it isn’t what puts her in the exceptional senior category, the label commonly used to describe a healthy, active, and engaged old person.

  My octogenarian mother is also an exceptional senior. She exercises six or seven days a week, volunteers as a docent at a science museum, takes several classes in every enrollment period at a university lifelong learning program, and has a social schedule of meals, movies, theater, and group walks that makes me feel like a recluse. She became “exceptional” in equal parts by inclination, effort, and good luck.