I suspect there is a second reason why the man’s voice stuck with Gornick all day. Toward the end of the scene, she says that as they “stood together—he not pleading, I not patronizing—the mask of old age slipped from his face, the mask of vigor dropped from mine.” Given the essay’s date of publication, Gornick would have been in her mid- to later seventies when she played the role of the younger person in this scenario, the one lending a hand and making an effort not to flaunt her vigor or patronize the older person. That’s unlikely the age most readers who don’t know her would assume when reading these excerpts, making them all the more powerful. Directly and indirectly, Gornick reminds us that old age is only partially determined by biology. It’s long, varied, relative, and relational. By contrast, our assumptions about old age often persist in the face of refuting evidence, which may be why so many people deny their old age until they are frail. Anecdotes like Gornick’s demonstrate the physical changes of old age and the experiences we have as a result of them are not linked by some biological necessity beyond our control. It also makes me wonder how often I, intending to offer help and care, am actually contributing to what might be called “an attitude of frailty.”
What, then, is the “right” attitude about old age? There are well-known positives of our third act beyond not being dead. Strengths. Joys. A satisfaction with the self as is. A lesser striving for external validation. Newfound freedoms. A clearer sense of what matters. Of course these aren’t the case in every life, any more than the positives in younger years are. Since studies of life satisfaction in wealthy English-speaking countries show marked increases in old age,11 and also marked ageism,12 we can only imagine the potential satisfactions of aging in a culture that doesn’t ignore or deride old people.
Importantly, a person’s attitude about oldness doesn’t just affect how they feel about growing or being old; it affects their health, how they spend their time, and how long they live. Preventive health measures improve health13 at all ages, yet older adults are the age group least likely to engage in them. In one study controlled for age, race, gender, education, self-rated health, and function, people with more positive attitudes about aging14 practiced more preventive health behaviors such as exercise, nutritious eating, and taking prescription medications as directed. In another notable study, people ranging in age from sixty-one to ninety-nine showed more improved physical function from an intervention that strengthened positive age stereotypes15 than from an exercise intervention.
Beliefs about aging are self-fulfilling prophesies;16 our health and well-being in old age often become what we imagine they will be, whether what we imagine is good or bad. Biology matters, but it’s only one part of a far more complex equation that includes attitude, behaviors, relationships, and culture. That’s a terrifying thought in a culture where ageism is more common than sexism or racism,17 and most people of all ages see old age through a window rendered dark and dirty by negative stereotypes. But there’s hope—beliefs have frequently changed through history, and for individuals, they can change at any age. And when beliefs about elderhood change, the culture and experience of old age, in life and in medicine, will change too.
DESIGN
I heard about the new building for months before I saw it. Part of a leading medical center, its “green” architecture and design were getting a lot of attention, as was its integration of top-notch modern medicine with health and wellness spaces inspired by cultures from around the world. My father’s doctor had moved there, and driving to his appointment we looked forward to experiencing the cutting-edge new building firsthand.
Outside, I unloaded his walker and led my father through the sliding glass doors. Inside, there was a single bench clearly made of recycled materials but without the arm supports a frail elder requires to safely sit down and get back up. It was a long trek to the correct clinic, and I was double-parked outside. “Wait here,” I said, hoping he would remember to do so long enough for me to park and return.
He nodded. We were used to this. It happened almost everywhere we went: at restaurants, the bank, movie theaters, the airport, the hospital, City Hall, and department stores. Like the new clinic, many of these places were gorgeous—historic City Hall with its wide steps and renovated dome; trendy restaurants where design features served as metaphors for food that could pass as fine art; a futuristic movie theater.
Not one of them was set up to facilitate access by someone like my father. That may have been intentional. A few years earlier, I’d heard about our supposedly ultra-welcoming city’s new LGBTQ community center, where the older adult program was positioned so attendees entered via a nondescript side entrance in order not to “scare off” the younger people the center hoped to attract.
Such approaches may make sense from a business perspective—or might have, until recently. Philosophical arguments for less ageism aside, demographic realities are increasingly creating financial and practical reasons to build more senior-friendly homes, businesses, health care facilities, and public buildings.
Healthy, literate adults can successfully navigate any structure. There may be frustration with confusing signage and other inconveniences, but they manage. The same cannot be said for old people with one or more physical, sensory, and cognitive challenges, or for the frail elderly who have many. The Americans with Disabilities Act’s accessibility design standards help, but do not ensure access or safety for this unique and rapidly growing population.
To some, this may sound like a small issue, a special interest group adding its lament to the cacophony of gripes about modern life. It’s not. Eleven million Americans—the fastest-growing segment of the population—are over age eighty. Over forty million Americans are sixty-five years old or older, a group that is accustomed to active, engaged lives and has considerable financial power.
Too often, current buildings turn impairments—a bum leg, less-than-perfect hearing, the inability to walk long distances—into handicaps. Ironically, this includes not just restaurants, multilevel houses, and large businesses but most health care structures. I heard about this regularly in my years as a housecalls doctor. While patients often end up in our Care at Home practice because they can no longer leave their homes, not infrequently the problem is at the other end: the hospital or clinic is too difficult to navigate.
It wasn’t until I left my father at the much-lauded green clinic that it occurred to me the challenges he and my patients faced navigating medical facilities were symptomatic of a larger problem. Just as eco-friendly architecture and design came into being as a response to the energy crisis of the late 1980s, in the twenty-first century we must proactively and creatively build to meet the challenges of our aging population. Some architects and designers are doing this. Most are not.
Green is a natural label for environmental causes and eco-architecture. It was less clear to me at first what word might capture elder-friendly building design. A recent NPR survey indicated that no words used to describe old age have much appeal to either the old or the young. But silver has positive connotations of beauty and value, as well as associations with old age. Silver architecture and design therefore follows in the semantic footsteps of the green movement while invoking its unique mission.
A silver medical building would offer easy, safe access that doesn’t require walking long distances, opening heavy doors, going to multiple locations, or standing in long wait lines. Its building materials would reduce noise, and design features would optimize lighting and minimize overstimulation, distraction, and risk of falls. Doors, rooms, and public areas would accommodate walkers, wheelchairs, and a person walking side by side or arm in arm with a friend, family member, or caregiver. Space use would prioritize navigation and accessibility, offering regular places to rest and regroup. Such changes would increase accessibility, nonpunitively acknowledge patient challenges, recognize old people as valued customers, and create a safer, more pleasant, and welcoming environment for all patients and families.
; Architecture and design strategies that improve the safety, health, and well-being of old people are already in use in many long-term care facilities and in specialized areas of hospitals, such as geriatric emergency departments or ACE units. But they aren’t nearly as prevalent and valued as they should be. Surely such design elements should be universal, at least in health facilities, present at entrances, exits, cafeterias, hallways, and other public-access spaces, as well as anywhere else an old, ill, or disabled person might be, which in a medical center is almost everywhere.
This isn’t just an issue for public or health care buildings either. In an era when almost all of us grow old, shouldn’t homes be silver too? Yet much home architecture seems based on the assumption that people should move into “special housing” or institutions when stairs become challenging. Doing housecalls, I frequently entered supposedly accessible apartment buildings where residents had to climb at least a few steps from street level to reach the elevators. And almost all bathrooms are designed without grab rails or shower seats. Perhaps the most important reason people don’t install them until they need them is because they are so ugly. They don’t need to be. Imagine what they might look like, how they could add to a home, if designers thought as much about their aesthetics and variety as they do for other functional household items, from cabinets to handles to sinks and stairways. Imagine if they were good-looking and as expected as a towel rack, so they’d be there when you needed them—if you break your leg, are very pregnant, or grow old.
Imagine, too, public spaces where you could have a conversation with the person you’re with—an issue not only for old people. In San Francisco and many other cities around the turn of the millennium, restaurants intentionally became louder to seem more successful. This is a problem for middle-aged people, since hearing loss begins for most of us in our fifties, and for younger people who want to talk, not yell, and hear their companions without straining. Imagine movie theaters without steep steps, or where you can easily see the steps and seats, not just vague shapes in the dim light, or that can be accessed at multiple levels. A sixty-five-year-old eye admits only one-third the amount of light as a twenty-year-old eye, yet in places where we expect many sixty-year-olds, the lighting is set for twenty-year-olds. Imagine restaurants and bars with a degree of illumination that allowed for both menu reading and mood setting.
In health care design, prototypes already exist that could easily be applied or adapted to create silver hospitals and clinics. A 2018 magazine advertisement showed a labeled photograph of a kid- and family-friendly patient room at a newly renovated children’s hospital. Accompanying text explained the features identified by numbered red dots on the photo. They included smart monitors that identified staff on a TV monitor as they came into the room, a service helpful to any patient but even more useful in a person with dementia, delirium, or impaired vision or hearing. Every patient room had a window with a planter box and outdoor view. No less important for the children of old patients as for the parents of young ones, each room also had a pullout couch bed, second TV, and privacy. Evidence-based design studies have shown that such patient-centered design features18 don’t just increase patient satisfaction; they can improve hospital safety and health outcomes.
Architects, city planners, business leaders, and ordinary citizens should take note of what works best in hospitals and clinics. And health care leaders and designers should follow innovations in the new arena of aging-in-place homes. The most successful and competitive new buildings, homes, neighborhoods, and cities will help people remain where they want to be and continue living full (if changed) lives, usually in their homes and communities, through the stages of old age. When communities review plans for new or improved buildings, they should ask questions not only about job creation and traffic flow but about how well the design meets the needs of residents and consumers of all ages, prioritizing equal access, health, and safety across the entire life span.
Some might say that buildings can’t cater to every group with special needs. But silver architecture and design aren’t about indulging a special interest group. They’re about maximizing quality of life and independence for a life stage most of us will reach.
Green architecture is good for the environment; silver architecture is good for humans. The best new buildings will be both—inside and out.
HEALTH
A scientist hoping to understand something looks for the most fully realized examples of it. In geriatrics, that means patients who best conform to our very particular social notions of “old.” Much of geriatric care and research focuses on the needs of the sickest, frailest, and most aged old people, rather than on elderhood in its entirety. Additionally, as is typical of medical specialties, most of our work is aimed at treating established problems instead of preventing them. Here is a common view:
I believe our main emphasis today should be oriented to the so-called “geriatric patient” and to frail older individuals. We must convey a key message to patients, colleagues, and society: defining a geriatric patient is not only a matter of age … but besides they must have chronic diseases … polypharmacy, functional limitations … and social problems.19
The main argument for this approach is that, since there are not enough geriatricians, we old-age specialists need to focus on the people who need us most. This view is ethically sound, practical, and popular within the field. But if the goal is to have a medical system that provides high-quality care for all Americans across the life span or a life-stage-based specialty, it doesn’t work.
It’s counterproductive in several other ways as well. Associating geriatric care with the oldest, frailest elders reinforces misconceptions and partial stories about old age. This makes geriatric care less an analogue to pediatrics and internal medicine and more akin to a subspecialty. It also makes it less appealing to many of the people who would benefit from age-tailored care throughout their decades of old age, which simultaneously reduces demand for it and keeps the specialty so small that it can’t even adequately care for all the people in its narrowed purview. As is always the case, circular logic leads nowhere.
Since geriatricians are notoriously happy, the people harmed by this approach are patients whose medical care doesn’t take their elderhood into consideration. By ignoring younger and fitter old people, geriatrics increases the conceptual distance between young and old and the chances that younger and healthier old people will become sick or frail sooner than they would have with proactive geriatric care. The circumscribed approach to geriatrics in favor these last forty to fifty years has meant most American elders get care from doctors who know little about aging bodies, late-life development, and old age. By reinforcing the conflation of the large category of “old” with its extremes, it has made it harder for people to see connections between their present and future, themselves and others, and easier for them to fill those gaps with prejudices. Surely, if a strategy has failed for nearly half a century, it’s time to try something new.
Like many geriatricians, I chose my specialty because I found working with very old, frail people endlessly interesting and deeply fulfilling. Yes, dementia, debility, and death make me, my patients, and their families sad. But they are also among life’s most defining events. If they are not as celebrated as new babies, graduations, weddings, and retirement, they are no less significant or meaningful. A job that allows me, year after year, to do something significant and meaningful with and for other human beings has made me a fortunate, happy person. But to give a comprehensive, accurate view of old age for this book, I had to draw from other books, the media, my family, and friends. We geriatricians can’t claim to be aging specialists if we don’t study and practice with patients in all the substages of old age. We also can’t narrow our scope of work and then complain when others see our field as small and limited.
The solution is simple. Geriatrics means care of old people. All old people, in all settings. If there aren’t enough of us and we are helpful, patients and
families will make demands. To meet those demands, politicians and health system leaders will have to remove the structural and financial disincentives to a career in geriatrics—by removing barriers to all comprehensive, whole-person focused specialties. Medicine needs to stop letting diseases develop and organs fail and then providing subspecialists and costly, high-tech care to tend to the parts that broke down while it looked the other way. We will never have Population Health until that happens.
If the baby boomer generation’s reputation is to be believed, few will accept a clinical team without a quarterback, or with a quarterback whose primary sport is basketball or tennis. Most have already seen what that approach did to their parents, and it’s not what they want for themselves. Because a long life includes childhood, adulthood, and elderhood, a person should have a specialist for each of these major life phases: first a pediatrician, next an internist, and then a geriatrician.
PERSPECTIVE
In response to all the media attention on the UK’s aging population, the writer Ceridwen Dovey tried to write a novel from the perspective of a man in his late eighties. In describing this experience, she wrote, “I’m in my mid-thirties, but felt confident that I could imagine my way into old age.20 How hard could it be, really?” Her protagonist was grouchy, computer illiterate, miserably caring for his dementia-addled wife until he met a magenta-turban-wearing radical and fell in love again. After reading the first draft, an editor asked, “But what else are they, other than old?” In making her characters old, Dovey had not thought it necessary to also make them human. Instead, she created variants of two common stereotypes, the frail old depressive whose life is miserable and meaningless, and the wise eccentric who doesn’t act her age.
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