Understanding Living At Old Age: Some Comments On Elderhood By Louise Aronson

In 2014, Zeke Emanuel, brother of Chicago then-Mayor Rahm Emanuel, wrote an article at The Atlantic, “Why I Hope to Die at 75.” The title misleads; he did not explicitly say in the article that he hoped to die, per se, but that he would reject lifesaving medical treatments once had reached that age, with the reasoning that “by 75, creativity, originality, and productivity are pretty much gone for the vast, vast majority of us” and instead of being “active, vigorous, engaged, animated, astute, enthusiastic, funny, warm, loving” we become burdens on our families. We are no longer able to “contribute to work, society, the world” — and without this ability to live in the same “meaningful” way as he was accustomed to at age 57, because “meaning” was, for him, tied to the sorts of professional achievement he himself was accustomed to, there’s little point in trying to prolong life.

Now, one might, as a general principle, reject the notion that life is only “meaningful” when one achieves and contributes, but let’s set that aside and look more specifically at aging, and, in particular, with the perspective offered by Louise Aronson in her recent book Elderhood.

Aronson is a geriatrician and a professor at the University of California, San Francisco; her biography provides a long list of awards and accolades, but her writing makes it clear that she is not primarily an academic but a caregiver, and the book shares innumerable very human stories from her experiences caring for aging patients. She recounts circumstances in which hospitalized patients were not given proper care because the hospital staff shrugged off their symptoms as “normal” for their age, or failed to understand how a particular medical condition can differ in the elderly.

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One such case that was especially jarring was the story she recounted of “Dimitri,” a new patient in the advanced dementia wing of a nursing home, who appeared wholly incapable of communicating. Aronson gathered his medical history from his family, and investigated the past progression of his dementia, only to learn that he was actually the victim of a “prescribing cascade,” with a series of new prescriptions each aiming to remedy the side effects of the prior one, resulting in what appeared to be a rapid slide into dementia. When the medications were stopped, he improved dramatically, moving from the nursing home unit to the assisted living unit six weeks later, and eventually taking up painting. In another instance, an over-the-counter sleeping medication was the culprit behind vision loss and kidney failure, initially blamed simply on aging. In a third case, a medication’s dosage was too strong because the dosing was based on younger women.

All of this goes towards building a case for geriatrics to be a standard part of medical care, every bit as much as pediatrics, rather than being reserved for the toughest cases or in special situations, and for medical education to educate future doctors in the medical care of the elderly.

But — back to Emanuel and his opinion that life loses its meaning when one can no longer “contribute”: Aronson addresses Emanuel’s article directly (p. 309-310), saying that he has “blind spots.”

“Emanuel appears to assume decline and disability cannot co-occur with contributions to ‘work, society, and the world.’ He cares so deeply about his legacy of public achievements that he denies the possibility of meaningful relationships with people who are or have become enfeebled and further devalues the majority of human lives, ones in which his notion of ‘legacy’ is irrelevant. . . .

“For Zeke Emanuel, meaningfulness has to do with the ability to do a certain sort of work, the sort of work he has always done and values most. . . . [This view] discounts the value to society and in individual lives of the same sorts of work that often go unpaid or underpaid — so-called women’s work, most particularly caregiving and volunteering of all sorts. . . . To Emanuel, ‘meaningful work’ implies a paycheck and perhaps even an influence on the world. The sort of work he does, in other words, though not the sort done by most women and men. He also adopts the modern industrial notion that what counts most is productivity, raising the question of whether learning or art or relationship building qualify as productive activities.”

Emanuel continues with a statement that a life “where the dominant thing is only fun or play” is “not a meaningful life” and, further, “I don’t think anyone should find that life fulfilling.” Aronson writes that this statement “judges others in ways that deprive them of what he is asserting for himself: the right to assign value to their own lives.” And his statements go beyond asserting personal preferences, to causing harm when that attitude is shared by/adopted by others and impacts policy decisions.

Elsewhere, Aronson addresses life satisfaction, and the “U-shaped” nature of what are called “happiness curves” — that is, the fact that there is, generally speaking, a nadir in terms of life satisfaction in midlife, rebounding to even higher levels exactly when our fears of aging tell us we should be most unhappy. (Curiously, the experts who write about this tell us it’s universal, but outside the Anglosphere, they have to put quite some effort into manipulating the data to get this result, where it’s quite pronounced within the Anglosphere; see my 2018 article on the topic.) Aronson writes that, despite our fears that “we don’t want to end up dependent, hopeless, helpless, and institutionalized” (p. 254), in reality,

“[D]epending on the measure, by their late sixties or early seventies, older adults surpass younger adults on all measures, showing less stress, depression, worry, and anger, and more enjoyment, happiness, and satisfaction. In these and similar studies, people between sixty-five and seventy-nine years old report the highest average levels of personal well-being, followed by those over eighty, and then those who are eighteen to twenty-one years old” (p .255).

Aronson also observes:

“Healthy, able-bodied people often say they wouldn’t want to live with grave disability. Meanwhile, a majority of people who become disabled — after an adjustment period — report good, and, not infrequently, very good quality of life. Yet, when I suggest to friends in their seventies and eighties that a good part of the suffering in old age is manufactured by our policies and attitudes” they are suspicious and unbelieving (p. 317 – 318). She observes that the “greatest hardship” of those who are homebound is not their inability to be active, but their isolation; “they are starved for . . . engagement, touch, conversation, and connection.”

And one final anecdote: she quotes a woman who was diagnosed with esophageal cancer who, after surgery, was no longer able to eat or swallow and needed a feeding tube. Though she had become so weak and ill from the cancer treatments that she moved into a nursing home, upon meeting the woman, on the day of her discharge:

“When Maggie approached me and introduced herself, I thought she was a patient’s daughter.

“She laughed at my confusion and lifted up her blouse to show me her new, permanent feeding tube. ‘I never thought I’d want one of these,’ she said, ‘but I also always thought if I needed one I’d be totally out of it instead of just the same old me who can do everything but eat’” (p. 371).

So what’s the bottom line? I am not necessarily recommending readers run out and add the book to their bookshelf. She says the book “doesn’t walk in a straight line” but rather “dances”, yet she isn’t as successful in this as she wants to be and it makes the book feel a lot more disjointed than it should be. But it’s nonetheless a means of reminding ourselves that, in debating Social Security, Medicare, long-term care, public pensions, and the rest, we’re talking about real people, whose lives have real meaning. And it’s an important corrective against assumptions that old age is lived in misery.

As always, you’re invited to comment at JaneTheActuary.com!

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