Elderhood: A Geriatrician’s Eyeview

Published In Aging in a Home Environment

Geriatrician Louise Aronson set out to write a book that promises to “look at old age in new ways.” But the first challenge, she explained recently, was the title she chose. “I wanted to call it ‘Older,’” she says. “But then a woman in the publishing industry took me aside and said: ‘I think you have a grammatical problem.’”

Just published as Elderhood: Redefining Aging, Transforming Medicine, Reimagining Life, the book makes clear that the “grammatical problem” still remains — a metaphor for American society’s still-raging struggle with the topic of aging. Though the actual definitions of “old” and “elder” are identical, Aronson underscores that people meet them with vastly different connotations. “Old” calls to most minds annoying dodderers smelling of mothballs; “elder,” on the other hand, signals a wise and thoughtful leader to be emulated.

“Old age is defined as setting in between the ages of 60 and 70, so most of us will be in elderhood for many decades,” Aronson says. “What we need is a commitment to making those years the best they can be. We need to make elderhood a long and varied experience, just like childhood.”

Doctors, Heal Yourselves

Aronson joins the growing cadre of doctors-turned-authors — including Atul Gawande (Being Mortal), Paul Kalanithi (When Breath Becomes Air), and Abraham Verghese (Cutting for Stone) who have recently become willing to break the medical profession’s Code of Silence to expose some of the infirmities of the current health care system.

But the Elderhood author’s main bone to pick is that seniors are given short shrift. “In medicine, we do what society does,” she says. “There are only two hours of instruction about older patients offered in medical school.”

Doctors are trained to treat diseases, not people — and the medical establishment keeps its blinders firmly in place, failing to recognize that a 60-year-old elder is likely to have far different needs, physical tolerances, and goals for healthy living than a 90-year-old one.

In the book, Aronson recalls sitting in on her first geriatrics conference, when one of the lecturers, Ken Brummel-Smith, now a practicing geriatrician in Tallahassee, Florida, “blew her mind” with his talk on rehabilitation and older patients. In it, he suggested: “To empower people in their lives and restore their independence to the greatest extent possible, you also had to work on their environment, social network, community, imagination, and adaptability.”

That sounded like an epiphany to Aronson, who had never heard such a paradigm shift of med school and post-grad training. “It was also the moment when I realized that medical training doesn’t just erode doctors’ empathy; it brainwashes the common sense right out of us,” she writes.

Geriatrics Still Not What You Hope

Niceties lectured and mind blowing aside, however, geriatrics is mostly not the kinder, gentler practice we envision or hope it would be. Part of the problem is the intractable and enduring hierarchy in medical practices, as measured in prestige and reinforced by doctors’ annual incomes. Aronson notes: “Geriatrics and palliative care, despite their advanced training and certification procedures, decades-old professional societies, and presence throughout the country, don’t even appear on most specialty ranking lists.”

And in reality, geriatricians today focus on the oldest, frailest, and most neglected people — which makes their work less “sexy” to the world in general and less attractive to would-be do-gooder docs living in it. But the problem is beyond people. The current medical system, Aronson notes, is fairly primed to pay for procedures — and older patients are generally subjected to the most expensive ones — but does not shell out much for the care that would allow them to stay at home or return there after a hospital stay.

Science and drug companies pile on. The efficacy of neither over-the-counter nor prescription drugs is tested on older people. And while drugs’ printed packages commonly come with warnings for children and pregnant or nursing women, there are no warnings about how older people’s metabolisms may react or how the drugs may interact with the many other drugs the older patients have been prescribed to take.

Given the current state of fragmented care portioned out among the multitudes of specialists, older patients are also more apt to fall victim to what Aronson calls a “prescribing cascade,” in which one or more drugs are prescribed to counteract the side effects of another drug — often with dangerous and even fatal results as they clash and interact.

She also finds a good illustration in the Poison Prevention Packaging Act, signed into law in 1970 to prevent children from unintentional drug overdoses and largely responsible for those confounding “child-resistant” caps on medicine bottles. Those caps produced some good news at first, as poisoning deaths in children under five were reduced by about half. But soon that benefit was lost, as many of those most in need of the medications — the sick, disabled, and elderly — often found it impossible to open the bottles and commonly went without their meds, or else opted to leave the bottles open and accessible to anyone of any age.

Aronson notes that decades after the Poison Prevention Packaging Act was passed, new packaging is still not tested on the oldest Americans: a/k/a the 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.”

Redefine, Transform, and Reimagine?

Aronson is at her most compelling when recounting the lives, deaths, and medical care of patients she has known who define elderhood.

She is less successful in pointing the ways for “redefining aging, transforming medicine, and reimagining life” as her book’s broad subtitle promises. In fairness, though, each one is a tall order.

Outside the confines of the book, she does offer some advice: “It’s fine to talk to your health care provider about what you need,” she says. “Get clear on what matters most to you. And seek out organizations and people who will listen to your preferences.”

Aronson also advocates the need to make aging something that’s no longer shunned or ignored: “Whenever you hear people talking about childhood and adulthood, ask about elderhood.”

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