I recently finished the book Elderhood by Louise Aronson (2019). While it was a bit repetitive and poorly organized, I learned quite a lot from it. I am writing this post to summarize and synthesize what I’ve learned into a few major points. Feel free to skim the numbered, bulleted, and bolded points below.
Louise Aronson is a geriatrician – a physician who specializes
in the care of the elderly. She has been immersed in the medical field for
decades, so the book is written from the perspective of a medical professional
and focuses on health-related aspects of “Elderhood.”
The overall gist, as I understood it, is this: In the
United States, our society and health care systems do not adequately care for
the elderly.
The book’s main points can be grouped into three thematic
areas: (I) how we fail the elderly; (II) the underlying causes for those
failures; and (III) how we can do better.
I.
How We Fail to Care for the Elderly
Aronson offers numerous illustrations of ways that our society and health care systems fail the elderly. Because the critiques were wide-ranging and sometimes hard to keep track of, I grouped them into the following three categories
1. Problems With Medical Education:
In medical education, there is generally very little emphasis on geriatrics. As a result, many doctors do not adequately understand issues that more commonly affect elderly patients, like dementia or mobility issues. Medical textbooks can also be problematic because they typically devote minimal pages to elder-specific issues, and often lump all people over age 18 together as “adults,” ignoring the unique needs of older patients.
2. Problems With the Health Care System:
Aronson repeatedly challenges what she perceives as the limited
scope of what counts as medical (i.e., the work of doctors counts more than the
work of nutritionists, physical therapists, and social workers). She says that “the
line between medical and social care is created by politics, not biology. Most
European countries began providing glasses, hearing aids, walkers, and dentures
as part of National Health care.”[1]
However, in the United States, these same treatments are often viewed as
nonmedical, and therefore receive less attention and resources.
Another major problem is the health system’s focus on
medicalization rather than care. This results in over-medication and over-hospitalization.
According to Aronson, it’s far too common for older persons to be given
medications that are not appropriate, which then cause hospitalization, where
other adverse events follow.[2]
Moreover, a fragmented medical care system – i.e., a system composed of many
specialists who don’t communicate – results in “prescription cascades” and redundant
tests and procedures.
Here are a few of the other major issues with the health care
system and its treatment of the elderly:
· Scientific medical research/studies on the effects of medications often ignore the unique needs of the elderly or fail to include adequate numbers of older persons in study populations.
· In the medical field, “normal” is often defined in terms of a middle-aged adult. This means that something normal for an older person is often perceived as a problem to be fixed, rather than a natural development to be accommodated.
· Too many older people are forced to go on once they’ve passed their natural and preferred thresholds because of medical “care.”[3]
· Nursing homes are often so fearsome and have such terrible conditions that many older people won’t admit to serious needs for fear of ending up there.[4]
· There is a lack of home-based care and support. This results in over-hospitalization, which can be traumatizing and lead to worse outcomes.
3. Problems With Society’s Treatment of Older Persons:
The lack of attention and care dedicated to older persons is
not only a feature of the health care system; it permeates society at large.
Some of the major problems include:
· Lack of
accessibility. It is often difficult for the elderly to navigate
basic public spaces and services because they are not designed with older
persons in mind.
· A cultural
fear of death and an emphasis on prolonging life at all costs,
even where not appropriate or wanted. This means that many older people endure
prolonged suffering even when they would prefer to end their lives because our
society generally does not deal well with death. As Aronson notes, “different
people draw the line in very different places as far as where they would like
to die.”[5]
· The segregation
of older people. Many families have transferred their
responsibility for care to the state, via nursing homes and institutions. This puts
elders “out of sight and out of mind,” similar to how those with mental illness
are often treated. We still haven’t found a satisfactory solution for the segregation
of older persons. Aronson suggests that this means our approach to care is
probably fatally flawed.[6]
· Failure
to respect privacy and autonomy rights of the elderly. Too
often, the privacy rights of the elderly are not respected: “Too often younger
people assume incapacity in old people until proved otherwise, instead of the
other way around.”[7]
· Arbitrary
age lines: “[T]he dividing line of sixty-five is historical and in many
lives outdated.”[8]
This line – designating people over 65 as elderly – can result in an older
person’s autonomy and agency being taken away if a younger person disapproves
of their lifestyle choices and calls Adult Protective Services.
· Marginalization
and lack of purpose. For many older people, the deepest pain is
caused by not having a reason to get up in the morning. Many older persons, wanting
“to make a difference in the world but, finding no role for themselves, [are]
treated as socially useless and even invisible.”[9]
II.
Underlying Causes of the Failure to Care for
the Elderly
After detailing the problems with the health care system and
society’s treatment of older persons, we must ask: Why is this the case? What
are the causes of our failure to care for the elderly?
One reason is that: “We treat old age as a disease or
problem, rather than as one of three major life stages.”[10]
So, we would do better to treat old age as a natural stage of life. We could
properly acknowledge its upsides: “the decreases in family and work stress
or the increases in contentment, wisdom, and agency that accompany most years
of old age.”[11]
But why isn’t this done in the first place?
A possible explanation is that ageism – age-based
discrimination – is deeply rooted in our society. Ageism dehumanizes the
elderly; it means seeing older persons not as unique human beings but as group representatives. Ageism results in othering and stereotypes; casting
the elderly as sick, frail, lonely, senile, and rigid in their thoughts and
beliefs.
But why has old age come to be so reviled in our society? What
is the source of this ageism against the elderly? As one explanation, Aronson observes
that the United States is a “productivity”-centric society (where productivity
is measured in conventional economic output, defined as increasing monetary
wealth). Therefore, the ability to produce consumable goods and services – creating
monetary wealth – is valued. And, because a person’s function, efficiency,
and therefore conventional economic output, typically decrease with advanced age
(i.e., they can’t work as hard or as fast or for as long), a productivity-centric
society values them less. This is especially so when their care requires
more resources and time from younger people.
Of course, this is not the case in all societies. And it’s not
the case in many cultures, communities, and families with the United States.
But the devaluing of the lives of older persons is a dominant reality in the
United States that is reflected in policies and practices at nearly every level.
III.
How We Can Do Better
“The first step toward a less ageist health system is
acknowledging the problem.”[12]
First, we need to understand that our society marginalizes older people and neglects
their health. Then we can begin developing solutions to fix that problem.
Aronson suggests a new paradigm focused on care that “begins
with the desired outcome, rather than an approach that may or may not lead
to that outcome.”[13]
In other words, instead of linking treatment to what is deemed medically wrong
with patients, we should focus on finding out what a person needs to do to
be happy and safe in their individual daily life.[14]
Once we know this, we can work together to achieve those daily life goals.
More specifically, Aronson makes several policy recommendations.
First, she suggests that, whenever we apply medical science or care “to people
by age and are tempted to divide the lifespan into just childhood and adulthood,
we should add elderhood to the list as well.”[15]
This would apply to CDC health guidelines and FDA approval of medications, for
example.
Second, she proposes “Silver” building standards to increase
accessibility for the elderly and disabled: easy, safe access that doesn’t
require walking long distances, opening heavy doors, climbing stairs, etc. It should
accommodate wide walkers and wheelchairs and offer spaces to rest. Ideally,
this would be implemented in all public spaces and homes.[16]
Aronson observes that “lives can have meaning despite
significant decline and disability.”[17]
But meaning is rarely found in segregation. Therefore, we should aim for
more integration of the elderly in society, and more opportunities for
community participation and purpose.
In sum, there are many things we can do as a society to improve
the care of older persons and work towards meaningful lives for every person,
at every age.
