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Elderhood

Page 33

by Louise Aronson


  Decades before the constituents of an optimal diet became the subject of books, videos, scientific papers, and government public service campaigns, my mother ate huge quantities of vegetables, fruits, lean proteins, and nuts. She liked them and was sure they were good for her. But she wasn’t equally prescient in other areas. She only took up exercise at age sixty when, in the span of just a few months, she found herself struggling to open jars and unable to make it back up the Grand Canyon without help on a family hike. Still, many people would have shrugged and said, What do you expect? I’m not getting any younger. My mother took up walking and joined a gym where she could do strength and balance training.

  Even more impressive than these accomplishments, however, has been her attitude as she becomes less “successful.” Planning a dinner party for a younger friend’s eightieth birthday and acknowledging that she was slower than she used to be and tired more easily, she spread her preparation over a week, doing one key task each day. The next year, recognizing that at some point she would need to stop driving, she often took buses, walked, and got rides to her activities. She told me her friends said that the worst thing about giving up their cars was the sudden loss of the easiest way of getting places. She was practicing so she’d be ready when the time came, as it inevitably did.

  The degree to which this approach is smart and sensible is remarkable. I’m less psychologically resilient than my mother, so I probably won’t do as well as she’s doing, though I’d like to try.

  If only that were enough.

  These anecdotes make my mother’s successful aging sound exclusively like a matter of willpower and wise decisions. In reality, although those elements are fundamental and she excels in both, the lion’s share of her success comes from several other attributes she shares with Queen Elizabeth. Both are lucky in three critical ways.

  First, they were born into privilege: white, citizens of developed countries, wealthy (far more so in the queen’s case than my mother’s, but, from a global perspective, both qualify), and educated. Second, women live longer than men almost everywhere, and since each has at least one relative who lived into their nineties or hundreds, they may be genetically advantaged for longevity. Finally, both have had the good fortune of not having been assaulted, abused, felled by an advanced cancer, or in a debilitating car accident, to name just a few of the random insults that can derail a life.

  These advantages are not a matter of character. Indeed, willpower and capacity for wise decisions are often by-products of fortunate lives.

  Different people use the term successful aging to mean different things. For health professionals and researchers, it’s the absence of disease, maintenance of physical and cognitive function, and a full engagement with life. For psychologists and social scientists, it has more to do with life satisfaction, social functioning, and psychological resilience. Finally, when older adults themselves invoke this concept, they generally mean independence, spirituality, comfort, coping, meaningful relationships, and contributions to society. The first definition focuses on the body, the second on the psyche, and the third on the experience of life. An optimal life at any age would include all these attributes.

  Although some of how we age is determined by personal choices, much of the aging process is the result of genetics, social situation, and the public policies that shape our day-to-day world.

  Technically, of course, anyone who is old has succeeded at aging. And anyone, from any background, can become an “exceptional senior.” But if we step back far enough to look at ourselves as a population, it’s clear that while healthy habits, effort, and attitude matter, many older adults who earn the “exceptional” and “successful” labels look very much like the people who earn those labels at other ages: born into privilege, bred in safe neighborhoods with access to healthy foods, able to lead lives absent many of the stressors known to accelerate aging.

  I understand the appeal of successful aging and the vibrant, exceptional senior concept. We all want that scenario for ourselves and those we love. But we need to beware the deceptive implications for those who acquire the label and the harmful blaming of those who don’t. Our society equates disability with lives not worth living and aging with bad news. Yet their presence doesn’t necessarily deprive people of happiness.

  A few years ago, a video of a 103-year-old playing the piano went viral. Some of this was the usual exceptional elder fascination: She’s ancient! She’s still playing! She’s really good! But of equal note was Alice Herz-Sommer’s life story: a fortunate childhood, studying piano with Franz Liszt, marriage, a son. Then came Adolf Hitler. Her husband and most of both their families were killed. Her son survived but died suddenly at age sixty-five. She remained alive, living in a one-room flat in a country to which he had moved her when she was already quite old. Look closely at her expressions. Watch her play. She looks happy, relaxed.

  We can’t all accommodate loss and hardship as well as Alice, nor do we fully understand why some among us remain optimistic despite tragedy, while others, even people with lives that might be described as fortunate, suffer and feel defeated in the face of far lesser life stresses. The Puritans believed the right attitude would lead to happiness, health, and prosperity. Failure to achieve those in life indicated sin and distance from God. Many people today similarly believe success and happiness are solely the product of effort and character, the “born on third base, but thinks he hit a triple” mentality. We provide universal early childhood education and school lunches because it’s clear the foundations are laid before we control any aspect of our lives; hunger impairs learning. Attitude helps—centenarians are more likely than the rest of us to handle stress well and have a good sense of humor; conversely, people with fatalistic views of old age are more likely to develop disease—but attitude is just one piece of a complex reality.

  FUTURE

  In 2016 Facebook’s CEO Mark Zuckerberg and his physician wife, Priscilla Chan, announced a three-billion-dollar investment “to cure, prevent or manage all disease in our children’s lifetime,” and some months later the first of their Biohub grants was announced. This was great news for science and medicine, but not necessarily for American health and health care.

  In his remarks at the Biohub’s launch, Zuckerberg stated that we, too, often tackle diseases once people are sick and don’t do nearly enough to prevent them from getting sick in the first place. That’s right, but their project goal—disease eradication over the next century—isn’t the fastest way to make prevention a bigger part of health care. It may not even be the best way.

  Well-studied, proven-effective, and cost-effective strategies already exist and could be preventing illnesses and injuries right now if only we sincerely supported and actively disseminated them. In the face of this considerable evidence, the Biohub venture claims that scientific progress is the single best key to helping more people live healthy lives. Advancing science advances health—sometimes. It can also lead to the replacement of one set of problems with another, as happened when recent advances generated our current epidemic of chronic diseases. Anyone who has ever received or provided health care can tell you science is just one part of human health’s more complex equation.

  The list of strategies known to prevent disease or improve its management is long. It contains such disparate measures as exercise, education, access to primary care, antismoking campaigns, availability of food, not building factories and toxic chemical waste sites near poor communities, intolerance for racism, taxation of sugared drinks, home health care, reduction of added salt, and particular communication styles, among many, many more. Although I applaud the Chan-Zuckerbergs’ generosity and ambition, I question their decision to categorically accept that science is the best means to their laudable end. Curing disease is an important and inspiring goal, but we could make huge strides toward better health and health care for people on this planet right now by focusing less on the pursuit of what isn’t known and significantly more on making bette
r use of what is. That’s the approach the Gates Foundation has taken, with remarkable results.

  Some will argue that I have missed the point; advancing science and technology is the mission of the Biohub, and others can work on the issues I raise. True, except the larger Chan Zuckerberg Initiative mission is “advancing human potential and promoting equality.” Ignoring all the many proven approaches to prevention and valuing future generations over current ones does little to promote equality.

  A second overlooked failing of this venture is its assumption that disease eradication is an unequivocal positive. If we focus on diseases affecting particular individuals—if you have cancer or your parent has heart disease—it may be. But we must not confuse the elimination of disease with the eradication of suffering. Whenever we have fixed one problem in the past, others have become prominent. Critically, too, for our species and planet, if eliminating disease means that all humans live longer, then surely a project with that aim should invest a considerable proportion of its resources into considering how communities, countries, and the environment will handle so many more people, however healthy they are.

  What will happen if humans begin living our full life span of 125 years, give or take? If the years of childhood and parenting are just the first third of the whole? If there are even more people and we’re alive for three times longer than humans have been through most of history? It’s not as if our doubling of the life span is going so smoothly. What happens to jobs, food, housing, war, competition, greed—to all those things we already have either too little or too much of today? Shouldn’t medicine be thinking rather more about the consequences of its strivings instead of continuing its myopic investment in a single strategy?

  The prospect of a species with little or no disease raises significant philosophical questions. Is no disease really possible or desirable? How would a life cycle progress, or end? What might this goal might mean for our species, other species, or our planet?

  Such theoretical and philosophical questions are light-years from the laboratories where the genome gets sequenced and a cell atlas elucidated. But continuing to ignore or underfund known tools for preventing disease and improving health is a moral and political decision. We have seen far too often in human history the dangers of pursuing scientific and technological advances without consideration of their social and practical consequences. Certainly, Mr. Zuckerberg is familiar with that scenario.

  I am not anti-science-and-tech or antichange or antiprogress. Like many people, I routinely use science and technology to work for change and toward progress. My hope is that we might try to advance in each of these areas in ways that don’t just pursue what can be done but also consider the potential consequences of each innovation for our cities, country, planet, and, most important, for people. Not just a select few people either, but all of us.

  That’s unrealistic, I know. But we won’t begin to have an ethical, humane future if we don’t at least try to create one.

  There are many ways to make the world better, now and for the future. In medicine, I can’t help wondering whether the most radical move of all would be a leader, investor, or institution with the courage to tackle the policies, biases, and structural incentives that are sickening the health care system itself.

  DISTRESS

  I started my new clinical role, as the geriatrician on our new hospital geriatrics unit, in October 2017. I had mostly been an outpatient doctor in my career, but after more than two decades on the literal and metaphorical other side of the medical street, I walked straight toward the sliding glass doors I had first crossed twenty-five years and four months earlier as a nervous, excited new doctor.

  Inside, everything was at once familiar and strange. The building was pretty much as it always had been: linoleum floors, pale walls, harsh light, people in scrubs, white coats, or uniforms. Those in ordinary clothes looked serious, scared, dazed, or lost.

  At the end of a hallway, I waited for an elevator. My floor was the last one, the top. I had been up there just twice before. My inaugural visit to the fifteenth floor had taken place over a half century earlier, when the floor was still obstetrics and my mother gave birth to me. In 2015 obstetrics had moved to our medical center’s new, state-of-the-art, LEED Gold–certified “next-generation” hospital complex in a part of town that once upon a time was a marsh and lagoon.

  My second visit had been the previous month, when I’d gone to see what the hospital and my colleagues were calling “the new ACE unit,” that word connoting expertise and success serving in hospitals as an acronym for Acute Care for Elders.

  The ACE unit concept dates from the early 1990s, when a group of doctor-researchers at the University Hospitals of Cleveland decided to test whether a hospital ward geared to the unique needs of older adults3 might improve outcomes (and therefore lives) in much the same way as children’s hospitals had already been proved to save and better the lives of children. The idea made good sense, and it worked. The ACE unit improved function and independence on hospital discharge, decreased institutionalization, reduced readmissions to the hospital, lowered costs, and improved patient and family satisfaction with care. The first few items in that list tend to be what older adults care about most, and the last few capture what matters most to health system leaders. In the more than twenty years since the initial research came out, studies had continued to show benefits, and hundreds of ACE units had opened across the country. Now, at last, our hospital was starting one too.4

  Just a few years earlier our medical service chief had said he didn’t see any point in starting one unless we could do something original with it, something we could study and publish. The patient benefits alone weren’t enough. Now the tune from on high was changing; for the first time in my twenty-five-year association with this institution, words like old and aging appeared in the hospital and medical school’s strategic plans. This wasn’t because our center lagged. There are over five thousand hospitals in the United States, and most don’t have ACE or other geriatric-specific units.

  On the wards of the old hospital, things looked pretty much as they had when I was a trainee. The fifteenth floor was a long rectangle, with patient rooms arranged along the outside walls on three sides, and the nursing station, medication room, kitchenette, resident workrooms, and offices at the center. The wing had been given a new coat of paint, and I could see the recently installed handrails running down the corridors. There was also a multipurpose room with soft chairs in one far corner, although no signage to let patients and families know it was there for their use. Nor was there anything green there, either literally or environmentally, and certainly nothing interactive, high-tech, playful, or inviting—those much-lauded attributes of our new hospital. Also, unlike the wards across town, this unit offered no natural light, no clues about whether it was day or night, and no chairs in the hallway for people who might need to rest while making their way down its long expanse.

  The art was standard-issue institutional with the ironic exception of a bulletin board featuring photographs of “exceptional seniors.” There was a centenarian runner and an ancient woman doing the splits, one leg on the sidewalk and the other extended upward along a lamppost at 180 degrees, something I couldn’t do at age eight or eighteen and certainly wouldn’t attempt now.

  Medical professionals clustered around computers, and the nursing station was populated by administrators and nurses who didn’t look up when I stood on the other side arranging my face into the sort of pleasant, expectant expression I hoped would inspire their attention. (I like to do this in facilities; it gives me a sense of how patients and families are treated.) Walking down the hall, I heard one patient cursing, another moaning, and many beeping machines. I also had my usual response: it amazed me that anyone got better in such a noxious environment.

  ACE units were designed for frail older adults, people in the Fourth Age, not the Third. They can be run as primary or consult services (ours was the latter) and have four defining fea
tures: elder-friendly surroundings, independence-promoting design, early discharge planning, and interprofessional team oversight to reduce complications of hospitalization.

  The specially designed hospital environment usually includes carpeted floors, and a common room for both meals and family visits. Feet don’t slip or stick on carpets and they are quieter, allowing for better sleep, as well as more homelike, which might reduce patients’ fear and confusion. People eat more and better in social environments; it’s more fun, reduces isolation, and makes eating the expected activity. Our unit didn’t have any of those features, but it had a few of the other design elements that promote independent functioning: those new hallway handrails to enable safe walking; large signs in patient rooms showing the day and date and whiteboards with large print listing the day’s treatment plan; and some rooms also had raised toilet seats to facilitate self-transfers.

  In the studies, discharge planning began immediately, with the team’s social worker or case manager working to identify what needed to be done to get the patient back home. On my first day on our unit, I discovered that case managers didn’t come to the ACE team meetings, and their primary goal was getting patients out of the hospital as quickly as possible. Whether the person went home or to an institution seemed to matter very little.

  The last proven trait of effective ACE units stipulates that interdisciplinary teams of nurses, doctors, aides, dietitians, social workers, and rehabilitation therapists meet regularly to review patients’ medical care and reduce avoidable hospital complications. We did this. Sort of. The rehab staff wasn’t allowed to attend, the nurses often refused, and no one seemed to expect the other disciplines to show up at all. For all our academic emphasis on evidence-based medicine, our institution apparently didn’t feel the need to apply that standard to its oldest patients.

 

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