Elderhood

by Louise Aronson

  That made me sad. Once I finished my decade of medical training, I started doing some of those things, like reading literary fiction in my free time. Eventually, I got a master’s degree in creative writing. Now, you might think, as I did, that fiction writing can have nothing whatsoever to do with doctoring, but it transformed my career.

  It wasn’t just that writing skills helped me get grants, though they did, or that learning to put myself into other people’s minds made me a better clinician, though that happened too. It was also that, by combining my particular interests and skills, I was suddenly getting published in leading newspapers and journals, giving me access to tens of millions of people. Suddenly, I wasn’t just taking care of my patients; I was also influencing health care. And once I saw how owning up to my nonscientific interests and engaging my imagination actually helped my medical career, I gained the courage to write about things that I saw differently from the medical establishment.

  Finally, I became what only I could be, and that made me very happy.

  I said all these things in my commencement speech, defining my terms like a good scientist and using stories to make my case like a good humanist. I concluded the talk by mentioning that the word imagination comes from the Latin for “picture to oneself.” I told the new graduates that their education had given them a certain set of pictures; yet, as Einstein said, those pictures were limited to all we now know and understand. To make a difference in health and health care, they needed to use all they’d learned and their imaginations too.

  That afternoon, I flew back to San Francisco, where it occurred to me that medicine and old age might just be related in more than the obvious way of medicalization of aging. Maybe the problems with American health care and the challenges of elderhood were both consequences of failures of imagination, of how we picture ourselves, our lives, and our work, and how we don’t but could.

  BODIES

  You don’t have to be a doctor to recognize that the body changes with age, and you don’t have to be officially old to know from personal experience that many of those changes are unwelcome. The physical and physiological changes that accrue to “old” begin subtly and early, in a person’s thirties or forties, and at some variable point in our sixth, seventh, or eighth decade, we pass the physical, social, and legal thresholds of old age. The negative parts of this transformation—the losses—initially require adaptation, then limitation, and sometimes, finally, renunciation or the need for work-arounds. None of us want a cane, much less a walker, or help with finances or driving or grocery shopping. And uniformly, we don’t want to end up hopeless, helpless, and institutionalized—most people’s image of advanced old age and, often enough, at some late point, its reality. If you also consider that—unlike the terrible twos, a traumatic adolescence, a squandered young adulthood, or a midlife crisis—what follows being old is death, it becomes clear how old age achieved its current reputation.

  Healthy, able-bodied people often say they wouldn’t want to live with grave disability. Meanwhile, a majority of people who become disabled36—after an adjustment period—report good and, not infrequently, very good quality of life. Yet, when I suggest to friends in their seventies and eighties that a good part of the suffering in old age is manufactured by our policies and attitudes, they work hard to fill their expressions with nothing but curiosity and interest. In their eyes, I see suspicion, disbelief, and several unspoken retorts: She’s too young to understand. Facts are facts, biology is biology, and we are all destined for more or less the same downward slide to oblivion.

  Their reaction depends a bit on what kind of day or week or month they’re having. Being sick or in pain or the recent death of a friend colors everything, and each of those things is increasingly common with age. People who are relatively healthy but have the pain or limitations of chronic diseases wonder what will happen next, and when. They worry about suffering and dying, about the loss of the people they love best, about being alone and about being gone. Those who are frail and sick or heading that way worry they won’t die as soon as they’d like to. Others, with lists of ailments and medications long enough to unfurl like scrolls, fight to stay alive, even as ever greater proportions of their days are devoted to the basics of body tending: hygiene, and food, and medications.

  People with highly restricted lives—the sorts of people in our housecalls practice, for example—lament less their lives’ small stages than the accompanying isolation. The official term for the space we move through in the world, whether large or small, is life-space.37 Mine extends to continents; theirs is often limited to their home, a single room, or a bed. They would like to get out, to again be the sort of person who could or would go more places. But that’s not the source of their greatest hardship. What they miss most, what they are starved for, is engagement, touch, conversation, and connection, those basics of being human that come in just above our needs for food, shelter, and safety on Maslow’s hierarchy. Much has been made of what missing touch and connection did to Romanian orphans. The impact of isolation in old age, of never or rarely being touched or talked to or loved, is less formative but no less profound. Social isolation and loneliness38 worsen physical and mental health, leading to nursing home placement and premature death. In the UK, a young man spent a week alone39 in an apartment as part of the Loneliness Project, and although he started out okay, over the week he became increasingly frustrated, bored, despondent. He focused on small daily tasks, little things gnawed at him, he tried to turn off his brain, and he watched TV or went to bed for lack of other options.

  On FaceTime, my mother, in the lobby at her gym, holds her phone midway between her mouth and ear. In public, she doesn’t want it too loud, but in each of the last two years, she has consulted an audiologist, wondering whether the time for a hearing aid has arrived; on her most recent visit, they agreed she was getting close. I’m on my computer. Her cheek, one eye, and parts of her nose and lips fill its large screen. This close, the softness of her skin seems visible. It has a laxity, a slight droop, creases and texture. It is subtly colorful, a canvas of tans, pinks, and off-whites. She has blemishes, too, darker patches hinted at beneath the makeup she has put on to hide them. At the corner of her lips, I see an irregularity, and the doctor in me considers diagnoses to explain it. I smile at the sight of the small pale pouch under her eye; she hates it, just as her father in his old age hated his. For fifteen minutes, I talk to my mother while watching this video of the side of her face. It’s no less captivating than the several art films I have recently seen, and no less beautiful.

  Do I imagine I see the softness of her cheek because I have kissed that cheek and know the feel of it on my skin? Is it because her cheek is so familiar—likely the first skin I kissed over a half century ago—and because I love my mother? Or is it because I know in some essential way that if something looks as her cheek does, it’s soft to the touch, warm, yields on impact with a gentleness that is inviting and comforting. A younger cheek, taut and smooth, is more like a trampoline; a touch doesn’t sink in so much as bounce off. Later than night, climbing into bed, I realize that, for me, faces are like bedsheets in winter. My favorites are our oldest, soft and welcoming from years of use. When we use the newer ones, my heart sinks. They are nicer to look at but crisp and cold on my skin.

  There is a photo of me at age twenty-two, stretching before a run. I remember the orange tank top, my favorite at the time, and the now exquisitely dated white shorts with blue piping. I recall the feel of that lean, fit, youthful body, how I could simply take off running with no thought to anything beyond loosening up my hamstrings. I didn’t have to consider ominous tweaks of tenderness in my lower back, searing foot pain, a catching hip, cramping muscles, or the snap-crackle-pop of joints. I never gulped air on inclines or worried that my pace, never fast enough to make a school team, might appear pathetic. Instead I looked at myself in that fitted tank top and those hideous shorts and felt simultaneously exultant in and dissatisfied with my body.
I wanted it to be leaner still, faster, and more graceful. At all ages, we interrogate and shame our bodies. We always want something more than or different from what we have. I often look at straight hair and think: How great would that be? And most weeks someone approaches me to say, I love your hair; I wish mine would curl like that. But wanting to be other than you are isn’t the same as feeling that either the body you inhabit lies about who you are or that, because of features beyond your control, people looking at you see not you but a stereotype of the category that includes you.

  At a party where the people present ranged from their late twenties to early eighties, a woman with pink-streaked white hair and considerable wrinkles took the makeshift stage, five huge badges with photographs on them pinned to her shirt and sweater. She explained that in order to get people to really see her, she’d made the badges to show pictures of herself at different ages. Each told part of her story, and together they offered a more complete portrait of who she was than people got from just looking at her. At any age, it’s interesting to look back and learn how a person has, and hasn’t, changed. It’s also often helpful to have a physical object and story as a conversation starter among strangers at parties. And still, her badges made me sad. Here was this clearly interesting woman with a body that moved easily around the room and whose clothing and grooming playfully expressed her big personality, yet she was convinced that her current face did not represent the real her. With it as her only introduction to strangers, she felt unseen or inaccurately perceived. She wore her giant badges to prove she hadn’t always been old, as if to say: See me, I, too, was once a person who counted.

  CLASSIFICATION

  Many stakeholders determine who and what counts in medicine. How we approach vaccines provides insight into how we handle many other aspects of health (and life) as well. Doctors determine which shots patients should get,40 and when, based on the Centers for Disease Control’s recommendations. The CDC guidelines are presented in two “schedules”: one for children, the other for adults, both divided into age subgroups based on developmental biology and social behaviors common at different stages of the life span.

  The 2018 schedules included seventeen age-based subgroupings for kids from birth through age eighteen. This makes sense: a six-month-old has had little time to develop immunity, weighs far less than an eight-year-old, and is exposed to different people and places than a teenager. There were five subgroups for adults. All Americans age sixty-five and over are lumped in a single subgroup, as if our bodies and behaviors don’t change in any meaningful ways over the half century of life from the mid-sixties forward. Like so much in medicine (and society), the CDC guidelines acknowledge the diversity in two life stages while ignoring equivalent diversity in the third.

  It’s not difficult to distinguish sixty- and seventy-year-olds from the nonagenarians and centenarians a generation ahead of them. These two groups—the young-old and old-old41—don’t just differ in how they look and spend their days; they differ biologically.

  Aging progressively affects the function of our cells, tissues, and organs. With advancing years, both innate and acquired immune functions gradually decline, people develop more diseases, and the body’s ability to fight infection and respond to immunizations decreases. As a result, older adults are more susceptible to infections—more likely to get sick from them, more likely to require hospitalization, and more likely to die.

  Our one-size-fits-all approach undervaccinates some older adults whose immune response can’t keep pace with their longevity or whose behavior doesn’t conform to stereotypes, and it gives others vaccines that do little or nothing to help them. The infections most likely to sicken and kill us in old age42 differ from those that do the most harm in earlier decades. While the current approach acknowledges some of those differences with its recommendations for flu, pneumococcal, and zoster vaccines, the approach is far less targeted and comprehensive than it is at younger ages.

  Given our waning immunity with age (a phenomenon known as “immunosenescence”), coupled with increasing longevity, some researchers are exploring novel strategies of infection prevention. These include “priming” immune systems of younger adults to stimulate responses that will endure into advanced old age, developing vaccines for infections that preferentially affect old people, use of adjuvants to boost the response of older adults to current vaccines, and not just vaccinating against individual diseases but enhancing the aging immune system43 itself.

  Optimal vaccination requires recognition that immunization and other medical decisions cannot be based on age alone. They must also factor in health and physical function. Most healthy eighty-year-olds will outlive frail seventy-year-olds with multiple diseases, and many of us will reach a point toward the very end of our lives when even annual flu vaccines either don’t work because our immune systems can no longer respond to them or when getting vaccinated is inconsistent with our end-of-life preferences.

  Human diversity reaches its apex in old age. There is no set age when we transition from adult to elder, and both the speed and extent of aging vary widely. As geriatricians are fond of saying: “When you’ve seen one eighty-year-old, you’ve seen one eighty-year-old.”

  A large and growing literature illustrates why age differences matter, both for immunizations and in health care more generally. Older bodies respond differently to vaccines and treatments, and disease biology can differ among different age groups too. In a series of recent studies of treatments for common urologic conditions, so-called minor procedures such as cystoscopy, bladder biopsy, and transurethral resection of the prostate that help healthier and younger men not only had no efficacy in frail older men but caused functional decline and death.44 In lymphoma and breast and lung cancers,45 cellular alterations and tumor behavior often change with increased age. In acute myeloid leukemia,46 studies report significantly lower treatment responses in older patients. (In part, this is because treatments target the biology of younger adults’ cancers.) Additionally, changes in the kidneys, heart, skin, and other organs as people move through elderhood steadily increase their risk of toxicity and decrease their ability to tolerate chemotherapy and radiation.

  Biology matters in other ways too. The older-old have more functional impairments47 than the young-old. From prevention to intensive care, old people with greater debility and shorter life expectancies48 often incur all the immediate harms of treatments developed for younger adults without living to see the benefits.49 Although older adults are getting more attention now in many sectors of health care than previously, they are still primarily presented as variants of a middle-aged norm, an exception or outlier, even in management of diseases like cancer where the majority of patients are old.

  Even in studies when treatment of the oldest-old is specifically addressed, outcome measures frequently reflect the priorities of the (younger) researchers, not their old patients. Studies of hip, knee,50 or aortic valve51 replacement in the very old, for example, assess length of hospital stay and mortality, when most old people are at least as interested in staying out of nursing homes and retaining the ability to think and walk. In the twenty-first century, when numbers of older adults will surpass numbers of children globally, we need to target elder health with the same life-stage lens we have already used for adults and children. Failing to fully acknowledge the ongoing human development and diversity of older Americans is bad medicine and flawed public health.

  There has been much discussion lately of how poorly equipped and organized our health care system is52 to address the needs of the chronically ill and old. That’s changing—slowly, reluctantly. Look at the advertisements for most medical centers, and you’ll find their messages still emphasize the acute care save—lives brought back from the brink. Those stories make great marketing, but these days a health system not focused on treating chronic disease and old people is like an education system that can’t handle children.

  There is one easy step that would not only help the CDC correc
t the deficiency in its vaccine recommendations but would increase structural equality throughout medical science and our health care system: whenever we apply something to people by age and are tempted to divide the life span into just childhood and adulthood, we should add elderhood to the list as well.

  12. ELDERLY

  INVISIBILITY

  Often, people’s worst nightmare about old age looks like this: a bent old woman with wild hair, missing teeth, a hooked nose, and bulging, unfocused eyes—a crone, a hag, a witch. This is the stuff of the original fairy tales collected in the cold north by the Brothers Grimm, considered on their first printing to be unsuitable for children.

  That was why I tried to schedule my housecalls to Betty Gallagher on days when I didn’t have medical students working with me in our geriatrics housecall practice.

  As if following the fairy-tale script, Betty lived at house number 666 on a flat street in a neighborhood that looked postapocalyptic. In place of front gardens, most houses had cement driveways, scruffy shrubs, and lawns of pocked, dead grass. Even the well-tended homes registered as drab and worn. On days dark with San Francisco’s famous fog, I sometimes wondered whether the area’s absence from tourist maps and most local news reports meant the lives lived inside those homes mirrored their exteriors. In our rapidly transforming city of techies, foodies, start-ups, and Silicon Valley multimillionaires, Betty lived in one of the few areas that had failed to capture anyone’s imagination or interest.

  Betty wasn’t rude or dangerous. She never hit, swore, yelled, bit, kicked, spat, leered, or grabbed, as disturbing patients of all ages sometimes do. Although blind, she always smiled when she heard my hello, never failed to ask how I was, patiently answered my many questions, and put up with my ministrations without complaint. When I stuck her with needles to monitor the progression of her diabetes and kidney disease, undressed her and turned her over in bed to inspect her skin, or poked and pushed in other ways that even if they don’t hurt aren’t much fun, her most evident complaint would be a silent grimace.