Envisioning a Better 'Old Age:' A Q&A With Dr. Louise Aronson
The geriatrician and 'Elderhood' author calls for society to embrace and honor aging
Dr. Louise Aronson brings vast experience and compassion as a geriatrician, writer and educator to the pages of her new book, Elderhood: Redefining Aging, Transforming Medicine, Reimagining Life. Aronson is professor of medicine at the University of California, San Francisco (UCSF), where she directs UCSF Health Humanities.
I recently spoke with Aronson about how American society views aging and her particular approach as a physician fighting to provide humane, age-appropriate care. Her perspective is often at odds with society’s (and the medical field’s) view of older people.
Here are highlights from our interview:
Liz Seegert: There already are numerous books about aging. How do you think Elderhood is different from the others?
Dr. Louise Aronson: There are, but not a lot by geriatricians. I felt like I brought a unique combination of perspectives, as a geriatrician for several decades, a daughter of older people, an aging person, a person who reads and knows the scientific literature, the literary literature, who can read and understand the historical literature and read things anthropologically.
That’s the only way to really tackle the topic of age, and particularly in the health systems. I like to think I'm using the health system as one case example of what's happening in the larger society. I thought I could offer a perspective I hadn't seen out there.
"No one wants to think about aging. We've made progress about other prejudices, but one that has endured is ageism."
Why did you include your personal story here, describing the struggle of finding your niche?
With any sort of literary writing, you need to get to the universal. Being part of the narrative opens up conversation. Maybe if I’m honest, other people will be, too. And that's the only way we're going to have the conversations we need to have to make lives better for all of us as we age.
Why do other medical specialists, and even some patients, seem to look down on geriatricians?
No one wants to think about aging. We’ve made progress about other prejudices, but one that has endured is ageism. People don't question it in the way they might question some of their other beliefs or instincts. Throughout history, there has been this ageist tendency — that these people are of no value, so just put them out to pasture or get rid of them or put them in institutions.
The ascension of medical science, particularly in the second half of the 20th century, really turned old age into a disease, instead of just one of life's natural phases.
You also write about goals of care and why doctors should be discussing that with older patients. How is this approach important?
What happens to old people is just a more blatant case of what happens to everyone. We rush in with our fancy technology, we spend all this money on intensive care, and procedures and drugs. And all of those things are wonderful. It’s fantastic that we can do those things; it helps save lives.
But actually, all the best functioning health systems put way more money and skills and resources into prevention. And the outcomes you get for the dollar spent, the value of earlier care and primary care and preventive care, is so much better. And the evidence for it is so good. If we were really thinking in terms of economics and scientific evidence, we'd basically flip the current priorities on their heads.
How can our health system better address these challenges?
We spend way more money than any other country and we have bad, and falling, outcomes. So we have to change what we're doing.
There are ways to easily improve care for older adults. It’s the same thing we need to do for everybody — more prevention, being proactive. We know ways of keeping people fit longer, of delaying frailty.
On the flip side, we have some really good ways of making life still feel valuable when we're not torturing people at the very end.
We also have this cycle of polypharmacy and overprescribing. How do we get out of that spiral?
We train doctors on how to take care of people in childhood and adulthood. But we really do little training on elderhood, certainly way under proportion to the representation in the health system.
Older adults are by far the most likely to be hospitalized. They’re about fifteen percent of the population, but thirty-nine percent of hospital discharges, and sometimes higher. Outpatient care is even more skewed.
Part of training is understanding the interactions of the drug with the aging body, which is different — (it’s about) the interactions of the drugs with each other, the fact that the life horizon is shorter, and the physiology is different.
The risks often go up and the benefits go down. We really need to be considering in this very specific individual person, 'Am I doing more harm than good? Is there something else we could be doing that would do more good than harm?'
We also need to think more holistically. We've created this assembly line medicine, where this person thinks about your heart and that one thinks about your knees and this one thinks about your gut. Each person treats their little part. They don't think about how what they're doing interacts with what everybody else is doing, or most importantly, with that particular human life.
That's where we really see the harms; these cascades of disease-based prescribing that don't take into account the human being.
One of the other topics you write about is end-of-life planning. Why is it still so hard to talk about death and dying?
I do think we're getting a bit better at it. But it just scares people. And, it's taboo in so many different cultures. So, I feel like it's almost something intrinsic, like, it's this big, scary, unknown: we are, and then we're not.
"The biggest thing we need to work on is not apologizing for being old, and not making old a bad thing."
On the other hand, again, the less you can talk about it and plan for it, the less likely you are to get the end that you would hope for. The best way to ensure an end of life and a death that is in keeping with what you would prefer, is to talk about it. And make sure the people who love you and take care of you understand what your priorities are and what you hope for, and to structure your life accordingly.
What’s your advice for those caring for an aging parent or who are thinking about the decades ahead themselves? How can they make sure their loved one is getting age-appropriate care and that they will?
It all starts with clarifying what means the most to you, and the person you're caring for. This is a way in which having that conversation as a family is really helpful, because it enables the person in their fifties and sixties to stop putting that idea aside. It's demystifying something that can be really scary.
For people going into this later version of adulthood, think about how you want to live at this point in your life and what you want to do for work or relationships, or whatever.
You're probably going to learn things about the parent or relative that might surprise you. Put yourself in your parent’s shoes and ask yourself if you’d want to live that way. If you don’t want to go there, what makes you think your parent does?
Just because you're old, doesn't mean you’re not entitled to an opinion or that you should be stripped of all your rights. Unless you want that for your own future, you've got to try not to do it to your parents.
How can older people reclaim their place in society? How can we reframe elderhood?
The biggest thing we need to work on is not apologizing for being old and not making old a bad thing.
We probably move into the elderhood phase by age sixty or seventy. Yet, people in their eighties, using walkers, will say, 'Well, I'm not old yet, because I can still take care of myself.' But that's obviously not true.
It's not true socially, it's not true physiologically and worse, by pushing old so far to the extreme and really associating the most challenging parts of old age with the word 'old,' you make it something nobody wants to address, or be associated with.
If you make it as big and diverse a life phase as we have for childhood and adulthood, then it becomes something more people can deal with. And it's appreciated more for what it really is, which is a decades-long phase with lots of different sub stages, like adulthood, and childhood. And you also enable us as individuals and as a society to deal with those later stages in a more compassionate way.
By ignoring it, by pushing it away, we create the very future we fear most.
We treat elders as if they're dysfunctional adults, instead of inhabiting a normal, expected arc. Let's prepare for it and let's enjoy it. Let’s set up a world where you can still live well instead of a world that says you don't fit anymore.
Despite the difficulties, you’re optimistic about changing people’s thinking about aging.
I am. If we go in with high hopes, and we all get on board with this, we can absolutely change.