Society gives short shrift to older age. This distinct phase of life doesn鈥檛 get the same attention that鈥檚 devoted to childhood. And the special characteristics of people in their 60s, 70s, 80s and beyond are poorly understood.
Medicine reflects this narrow-mindedness. In medical school, physicians learn that people in the prime of life are 鈥渘ormal鈥 and scant time is spent studying aging. In practice, doctors too often fail to appreciate older adults鈥 unique needs or to tailor treatments appropriately.
Imagine a better way. Older adults would be seen as 鈥渄ifferent than,鈥 not 鈥渓ess than.鈥 The phases of later life would be mapped and expertise in aging would be valued, not discounted.
With the growth of the elder population, it鈥檚 time for this to happen, argues Dr. Louise Aronson, a geriatrician and professor of medicine at the University of California-San Francisco, in her new book, 鈥.鈥
It鈥檚 an in-depth, unusually frank exploration of biases that distort society鈥檚 view of old age and that shape dysfunctional health policies and medical practices.
In an interview, edited for clarity and length, Aronson elaborated on these themes.
Q: How do you define 鈥漞lderhood鈥?
Elderhood is the third major phase of life, which follows childhood and adulthood and lasts for 20 to 40 years, depending on how long we live.
Medicine pretends that this part of life isn鈥檛 really different from young adulthood or middle age. But it is. And that needs a lot more recognition than it currently gets.
Q: Does elderhood have distinct stages?聽
It鈥檚 not like the stages of child development 鈥 being a baby, a toddler, school-age, a teenager 鈥 which occur in a predictable sequence at about the same age for almost everybody.
People age differently 鈥 in different ways and at different rates. Sometimes people skip stages. Or they move from an earlier stage to a later stage but then move back again.
Let鈥檚 say someone in their 70s with cancer gets really aggressive treatment for a year. Before, this person was vital and robust. Now, he鈥檚 gaunt and frail. But say the treatment works and this man starts eating healthily, exercising and getting lots of help from a supportive social network. In another year, he may feel and look much better, as if time had rolled backwards.
Q: What might the stages of elderhood look like for a healthy older person?
In their 60s and 70s, people鈥檚 joints may start to give them trouble. Their skin changes. Their hearing and eyesight deteriorate. They begin to lose muscle mass. Your brain still works, but your processing speed is slower.
In your 80s and above, you start to develop more stiffness. You鈥檙e more likely to fall or have trouble with continence or sleeping or cognition 鈥 the so-called geriatric syndromes. You begin to change how you do what you do to compensate.
Because bodies alter with aging, your response to treatment changes. Take a common disease like diabetes. The risks of tight blood sugar control become higher and the benefits become lower as people move into this 鈥渙ld old鈥 stage. But many doctors aren鈥檛 aware of the evidence or don鈥檛 follow it.
Q: You鈥檝e launched an elderhood clinic at UCSF. What do you do there?
I see anyone over age 60 in every stage of health. Last week, my youngest patient was 62 and my oldest was 102.
I鈥檝e been focusing on what I call the five P鈥檚. First, the whole person 鈥 not the disease 鈥 is my foremost concern.
Prevention comes next. Evidence shows that you can increase the strength and decrease the frailty of people through age 100. The more unfit you are, the greater the benefits from even a small amount of exercise. And yet, doctors don鈥檛 routinely prescribe exercise. I do that.
It鈥檚 really clear that purpose, the third P, makes a huge difference in health and wellness. So, I ask people, 鈥淲hat are your goals and values? What makes you happy? What is it you are doing that you like best or you wish you were doing that you鈥檙e not doing anymore?鈥 And then I try to help them make that happen.
Many people haven鈥檛 established priorities, the fourth P. Recently, I saw a man in his 70s who鈥檚 had HIV/AIDS for a long time and who assumed he would die decades ago. He had never planned for growing older or done advance care planning. It terrified him. But now he鈥檚 thinking about what it means to be an old man and what his priorities are, something he鈥檚 finally willing to let me help him with.
Perspective is the fifth P. When I work on this with people, I ask, 鈥淟et鈥檚 figure out a way for you to keep doing the things that are important to you. Do you need new skills? Do you need to change your environment? Do you need to do a bit of both?鈥
Perspective is about how people see themselves in older age. Are you willing to adapt and compensate for some of the ways you鈥檝e changed? This isn鈥檛 easy by any means, but I think most people can get there if we give them the right support.
Dr. Louise Aronson(Anna Kuperberg Photography)
Q: You鈥檙e very forthright in the book about ageism in medicine. How common is that?
Do you know the famous anecdote about the 97-year-old man with the painful left knee? He goes to a doctor who takes a history and does an exam. There鈥檚 no sign of trauma, and the doctor says, 鈥淗ey, the knee is 97 years old. What do you expect?鈥 And the patient says, 鈥淏ut my right knee is 97 and it doesn鈥檛 hurt a bit.鈥
That鈥檚 ageism: dismissing an older person鈥檚 concerns simply because the person is old. It happens all the time.
On the research side, traditionally, older adults have been excluded from clinical trials, although that鈥檚 changing. In medical education, only a tiny part of the curriculum is devoted to older adults, although in hospitals and outpatient clinics they account for a very significant share of patients.
The consequence is that most physicians have little or no specific training in the anatomy, physiology, pharmacology and special conditions and circumstances of old age 鈥 though we know that old people are the ones most likely to be harmed by hospital care and medications.
Q: What does ageism look like on the ground?
Recently, a distressed geriatrician colleague told me a story about grand rounds at a major medical center where the case of a very complex older patient brought in from a nursing home was presented. [Grand rounds are meetings where doctors discuss interesting or difficult cases.]
When it was time for comments, one of the leaders of the medical service stood up and said, 鈥淚 have a solution to this case. We just need to have nursing homes be 100 miles away from our hospitals.鈥 And the crowd laughed.
Basically, he was saying: We don鈥檛 want to see old people; they鈥檙e a waste of our time and money. If someone had said this about women or people of color or LGBTQ people, there would have been outrage. In this case, there was none. It makes you want to cry.
Q: What can people do if they encounter this from a doctor?
If you put someone on the defensive, you won鈥檛 get anywhere.
You have to say in the gentlest, friendliest way possible, 鈥淚 picked you for my physician because I know you鈥檙e a wonderful doctor. But I have to admit, I鈥檓 pretty disappointed by what you just said, because it felt to me that you were discounting me. I鈥檇 really like a different approach.鈥
Doctors are human beings, and we live in a super ageist society. They may have unconscious biases, but they may not be malicious. So, give them some time to think about what you said. If after some time they don鈥檛 respond, you should definitely change doctors.
Q: Do you see signs of positive change?
Absolutely. There鈥檚 a much larger social conversation around aging than there was five years ago. And that is making its way to the health system.
Surgeons are thinking more and more about evaluating and preparing older adults before surgery and the different kind of care they need after. Anesthesiologists are thinking more about delirium, which has short-term and long-term impact on older adults鈥 brains. And neurologists are thinking more about the experience of illness as well as the pathophysiology and imaging of it.
Then you have the age-friendly health system movement, which is unquestionably a step in the right direction. And a whole host of startups that could make various types of care more convenient and that could, if they succeed, end up benefiting older people.
