Medicine + The Older Body.

How Western Medicine Continues to Fail Older People.

Photographer: Massimo Bietti. Gujurat, India.

One of the things I decided as a kid was that when I got older, I was not going to talk about medical stuff all the time. In fact, I promised myself not to think of health at all. I took it for granted. Ah, youth.

I thought older people talked about their medical issues too much, too often. In fact, complaining about bum knees, and weird sounding ailments, like gout, bursitis and the supremely unsexy, goiter, were all too much for me. I watched my mother and her friends and aunties talk about hospital visits, procedures, medicines, and cardiologists they liked, and didn’t, and why, in great detail. To me, they seemed weirdly obsessed. The older they got, the more obsessed they became with their own decline.

Why were they talking about their medical procedures all the time? Why were they so open about bodily functions, like bouts of diarrhea, constipation, puking? What it felt like to have a catheter removed from your urinary tract? What happens in the bathroom after you drink that white chalky pre-drink for colonoscopies? Did we need to know how many sticks it took to hit the vein? Or how hard it is to poop in a bed pan? Or what a good, healthy poop looked like floating in the toilet bowl?

I mean, the kid in me was thinking: I had chicken pox twice, but did I have to discuss the specifics with all my elementary school friends? No. No, I didn’t.

For me, talking about intimate medical details marked my mother and her friends as old. And not in a good way. They existed in a world of physical malady, where those physical maladies only compounded and got worse. There was no end, and no final solution, besides death. It was a world filled with reams of receipts and bills in manila folders, notes scribbled in the margins in pen, and labored over. There were heated calls to insurance companies, long periods on hold, tense words with customer service people, and later, answering machines that left my mom irate over the disconnectedness and uncariness of it all. Would anyone call me back? was one of her biggest concerns.

What made it worse was that as she grew older, the game changed on her. Our whole lives we had a small town doctor who ran a small, crowded, dark paneled office where everyone knew each other. And he made house calls. The intimacy and connectedness were built in. Dr. Pitkin was the kind of doctor who would stop by and check in on you, because he happened to be on your street. She was probably in her 70’s when he retired. (He had to have been in his 90’s or close to it.) And he took with him every good and connected part of medicine for her. She was relegated to months-away doctor appointments with seemingly toddler-aged physician assitants she didn’t know and who didn’t know her, hellish, prolonged emergency room visits, and crowded urgent care clinics. If she had a problem with her medicine, what office with the sweet ladies at the front desk that she had known her whole life, could she call for help? Instead she ended up fighting people so they would provide the correct treatments and prescriptions. How could she believe in the medical system when her idea of care was an old white-haired, country doc with his beaten leather medical bag, telling jokes in her living room and handing her some freebies until she could get out to the pharmacy.

This was all old people stuff. It wouldn’t burden me. I would be flexible, adaptable and I wouldn’t complain about my ailments. In fact, maybe I’d be the outlier and I wouldn’t have any ailments? Maybe I wouldn’t age at all?

But of course I’m now re-thinking all these narrow, youth-biased ideas as I write this essay. I’m reading Louise Aronson’s NY Times Bestselling, Elderhood: Redefining Aging, Transforming Medicine, Reimagining Life, which was a finalist for a Pulitzer and long-listed for the Andrew Carnegie Medal for Excellence in Non-Fiction. Aronson is a Geriatrician and Professor of Medicine at the University of California, San Francisco. I learned a lot from this book and it is transforming the way I understand medicine for older people.

Photographer: Massimo Bietti. Ziro, India.

Old people diseases are not exciting.

One of the reasons that people often go into medicine is to heal. To cure diseases. But with older folks, the proximity to death signals that there is no need for a cure. Aronson writes about a resident who described how he had allocated just 15 minutes for the admission of…”yet another dying old woman” (69). That woman turned out to be forty- years-old and when he discovered this, he changed his protocols to focus on her cure and providing her with more time and thoughtfulness.

What was clarifying for Aronson was how the resident believed the solution going forward should be to make sure age is clearly written in the charts. He missed the bigger problem: He couldn’t acknowledge, or see, his own entrenched biases. That an older, dying person still deserves excellent medical care and extended attention. That this patient was considered more valuable and worthy of care, simply because she was younger. Aronson writes:

Most physicians at the time (as now) deemed old people less worthy of medical attention than younger adults who were easier to treat and more fixable. The common approach to their care was neglect, a relatively inexpensive strategy that required little from doctors and had the added advantage of being a disincentive to malingerers.

Photographer: Massimo Bietti. Nepal.

Entrenched cultural biases around aging are real.

The problem is that younger people view old age with a kind of uniformity (70). They see older folks as overwhelmingly senile, cranky, disabled, uncooperative, and hopelessly diseased. Close to being extinct. It’s easier for us to feel sympathy for people who get a bout of freak lung cancer at age 32 or 50, or for distant families in African nations, who contract malaria, HIV/AIDS or tuberculosis, because those diseases probably won’t happen to us. (81) Playing the odds gives us a flawed vantage point.

The infirmed elderly, though, make us cringe. Because they might be our future. It can happen to us and we know it in some deep deep place. So, the propensity to push them aside and out of view, is real. Older people remind us of our own frailty and humanness.

Aronson wants us to look beyond what we think, to what is factual and true: That only about 13% of our older folks ever go to a nursing home (71). That older folks who are doing well, and are physically and mentally vital, get lopped into the midlife category because of the way they are viewed as being close to youthfulness. Do you think of Bruce Springsteen as elderly, Aronson rightly asks the reader, when he is touring around the world, and doing three hours of energetic, physically-demanding sets every night (75)? No. Bruce is mid-life.

This leaves the most frail and diseased folks to represent the group as a monolith. And people are scared of growing old and frail because the language around getting older has been changed to compensate for our fears. Words like “geriatrics” and “aging” can now sink a clinic or medical practice. We prefer buzz words, like “wellness” and “longevity” (73).

I even considered this when writing about this topic for this newsletter. I wonder how many readers I might lose because this essay doesn’t focus in on the most vital and exciting parts of aging; the celebratory parts, the new-found free time, the fucks we no longer give, the great sex we are having, the greater acceptance of our naked, wrinkled beautifully-imperfect bodies. What will happen to our conversations when we turn our faces to the darker parts? Our fears? Surely we can’t demure away from those more complicated parts of life, right?

And yet, my last essay on invisibility triggered a slew of medical stories in comments, which led me to Aronson’s book. Apparently, one of the places we feel most invisible and the least valued, is when we try to access medical care as an older person. Here are some reader comments from that essay:

Research + science are not including us.

Pushing back on this, Aronson calls this time the longest, most varied, period of our lives. (73) Getting older is not a monolith and it isn’t a disease. There are healthy 90-year-olds and disabled and diseased 50-year-olds. And yet, the medical community sees us all as one in the same.

This is compounded by the fact that older people are often not included in research studies and trials that impact our health. Women, LGBTQ folks and people of all races and ethnicities have been included in studies for decades. But older people, generally, are not. Take atrial fibrillation, an irregular and rapid heart beat, which happens mostly to older people. Aronson notes that older people are not required to be in AF studies, left out because they have compromised test results around organ function and diseases. It’s also more complicated to get a person with dementia, or some senility, to prove informed consent. Researchers and doctors take the easiest route and simply, leave them out. (95)

This is partly why osteoporosis is still mostly studied in people in their 60’s. For this condition with a mean age near eighty-five, Aronson writes, a quarter of all trials excluded patients on the basis of age, This is like studying menopause in 30-year-old women. (96)

This creates all kinds of poor healthcare outcomes because medicine that works for younger people can often create adverse symptoms in older people. This might mean confusion, more intense dementia, loss of balance, and the dreaded, falling. (Oh, I’m soooooo going to write about the stigma and biases around falling.) All things that are often attributed to growing older. The patient can decompensate from the meds and everyone misses it because failing is synonymous with aging. This wouldn’t happen to someone who was under 50.

In fact, the entire health and wellness industry is about curing aging, reversing aging, with the implications that this natural process is actually something to be reviled, changed, hidden and conquered. Our growing older - despite the health and wellness industrial complex’ desire to stop the process in its tracks and make bank off of their treatments, procedures and pills - is a constant reminder to the medical community that they are impotent to cure our progression towards the end of life.

Photographer: Massimo Bietti. Xingping, Guangxi, China.

One porridge is too hot. One is too cold. Can we get it just right?

Sometimes the issue is medical neglect. Not enough attention. And sometimes the problem is inappropriately rigorous treatments that make no sense.

Older folks can get procedures like dialysis to keep them alive, surgeries to excise tumors, chemo that might give them a bit more time. And this sounds great, except sometimes it’s too much. The treatments can wreck the quality of their lives. Aronson writes about an older patient who was very healthy and active, whose personality and physical presentation changed suddenly. One of his many doctors had prescribed him a daily aspirin for stroke prevention. But the imapct of aspirin has only been tested on younger people, and it only works on younger people. Aronson raises a 2011 study, which found that aspirin is one of the top four drugs associated with emergency hospital visits, in people over age sixty five (94). Taking aspirin off his laundry list of meds, brought him back to full energy and cognition.

What older people really need, Aronson tells us, is what my mother had in Doctor Pitkin. It wasn’t that he was a world-class doctor. It was that he provided something critical for her to feel cared for, like: 1) more time with the doctor in their office, 2) more opportunities for appropriate physical, social, creative and mentally stimulating activities, 3) practical devices like hearing aids that can improve communication, mobility, and ease isolation, and 4) being treated like a whole person and not someone with one foot inside God’s Waiting Room.

These things matter, maybe more than the chemo.

This is really about the pervasiveness of how we view older people and then how those views keep older people from getting the best care possible. And it’s not just doctors in offices and hospitals. It’s paramedics, police, prison guards, fire fighters. They are often under-prepared for managing older people in crisis. Older people with dementia get confused and can fight people who are trying to help them. Cops have shot unarmed older people who became aggressive and violent, because they didn’t understand what was happening to them.

No wonder young people worry about growing older. And fret about it. And search for ways to look younger and stave off appearing old for as long as they can. It has to feel grim. This is the picture we paint for them.

Photographer: Massimo Bietti. Gujarat, India.

I now understand, as a woman standing on the precipice of sixty, why my mother and her friends talked about their medical issues so much, and with such passion, anger and obsession. They were not just managing pain and decline and physical discomfort with their poop explosion stories, as if that was fascinating on its own.

I was missing a much larger context.

The stories they told, and laughed at, and raged over, were shared in the spirit of resistance. They were making sense of how they were being treated. Why their treatments, and the people charged with caring for them, made them feel small and vulernerable and invisible. This is where they felt safe, and had the agency to rail against the injustices that presented themselves. To find commonality. To assure themselves they weren’t imagining it. That they weren’t alone. That the medical system is actually just as fucked as they thought. They had to find the connective tissue in each other, because they couldn’t find it in their doctor’s office.

Aronson closes her beautiful book with this quote, from the Pulitzer Prize-winning Geriatrician, Robert Butler, who wrote this fifty years ago:

It’s not the fact that each of us must grow old and die, but that the process of doing so has been made unnecessarily and at times excruciatingly painful, humiliating, debilitating and isolating. (399)

We must resist this with everything we have. And teach people how to treat us. Your stories and lived experiences matter. You matter. I will keep reminding you.

___________

END NOTES:

Last week, I did a Q+A with author, Monica Macansantos at her book launch for her beautful collection of essays, In My Father’s Kitchen. I also did two book clubs over zoom. Love book clubs. Best part of having a book out, by far.

Hi: Just wanted to say thanks to all the people who are subscribers. And also to the paying subs, thank you so much! I’m not paywalling my essays here, because I don’t want to exclude anyone who can’t pay. But if you can and want to support this work financially, it does help us support the family and I am soooo grateful.

Another way to contribute is to comment: We have a lively comment section and I often get an idea for the following week’s essay from the things you are writing there. So, thank you to the people commenting and responding to other people’s comments. If I miss responding to your comment, know I’m on it, but I miss some occasionally. It’s not you, it’s me. :) Thanks for being patient. Everyone is welcome to DM or email me anytime if you prefer privacy.

Photography: Please check out the gorgeous photos of Massimo Bietti. I included them today because they really show the inner beauty of this period of our lives. Who we really are and not who western medicine tells us who we are.

Last thing: I’m about half way through with Louise Aronson’s book, Elderhood and am learning so much. I highly recommend if you enjoy substantive non-fiction with vividly-told supporting stories, a non-academic, fiercely-readable style, and strong foundational research. Highly recommend.

Thank you, as always, for reading. xo Kim