Society
gives short shrift to older age. This distinct phase of life doesn’t get the
same attention that’s 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 “normal” and scant time is spent studying
aging. In practice, doctors too often fail to appreciate older adults’ unique
needs or to tailor treatments appropriately.
Imagine
a better way. Older adults would be seen as “different than,” not “less than.”
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’s 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, “Elderhood.”
It’s an
in-depth, unusually frank exploration of biases that distort society’s 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 ”elderhood”?
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’t 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?
It’s
not like the stages of child development — being a baby, a toddler, school-age,
a teenager — which occur in a predictable sequence at about the same age for
almost everybody.
People
age differently — 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’s
say someone in their 70s with cancer gets really aggressive treatment for a
year. Before, this person was vital and robust. Now, he’s 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’s 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’re more likely to fall
or have trouble with continence or sleeping or cognition — 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 “old old” stage. But many
doctors aren’t aware of the evidence or don’t follow it.
Q:
You’ve 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’ve
been focusing on what I call the five P’s. First, the whole person — not the
disease — 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’t routinely
prescribe exercise. I do that.
It’s really
clear that purpose, the third P, makes a huge difference in health and
wellness. So, I ask people, “What 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’re not doing anymore?” And then I try to help them make that happen.
Many
people haven’t established priorities, the fourth P. Recently, I saw a man in
his 70s who’s 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’s thinking about what it means to be an old man and
what his priorities are, something he’s finally willing to let me help him
with.
Perspective
is the fifth P. When I work on this with people, I ask, “Let’s 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?”
Perspective
is about how people see themselves in older age. Are you willing to adapt and
compensate for some of the ways you’ve changed? This isn’t easy by any means,
but I think most people can get there if we give them the right support.
Q:
You’re 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’s no sign of
trauma, and the doctor says, “Hey, the knee is 97 years old. What do you
expect?” And the patient says, “But my right knee is 97 and it doesn’t hurt a
bit.”
That’s
ageism: dismissing an older person’s 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’s 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 — 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, “I have a solution to this case. We just need to have nursing homes be
100 miles away from our hospitals.” And the crowd laughed.
Basically,
he was saying: We don’t want to see old people; they’re 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’t get anywhere.
You
have to say in the gentlest, friendliest way possible, “I picked you for my
physician because I know you’re a wonderful doctor. But I have to admit, I’m
pretty disappointed by what you just said, because it felt to me that you were
discounting me. I’d really like a different approach.”
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’t respond, you should
definitely change doctors.
Q: Do
you see signs of positive change?
Absolutely.
There’s 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’ 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.
https://khn.org/news/navigating-aging-a-doctor-speaks-out-about-ageism-in-medicine/
