January 22, 2019

Gray is In

This past week, the Wall Street Journal ran an article titled, “The Hottest Hair Color of the Moment is…Gray.” Granted, it was in the “style and fashion” section (who knew there was such a thing?). Presumably, the WSJ was interested primarily because the market for hair dye is enormous. What is the significance of this trend? 
The article raises the possibility that the development represents a changing view of beauty, and perhaps even more fundamentally, a changing view of aging. Change in societal attitudes towards aging would be most welcome—and with the proportion of the American population that is over 65 now 15 percent, and expected to rise to 24 percent by 2060, overdue.
It would not be the first time that attitudes underwent a profound shift. In colonial America, historians David Hackett Fischer (Growing Old in America, NY: Oxford University Press, 1978) and W.A. Achenbaum ("Old Age in the New Land," Baltimore: Johns Hopkins University Press, 1980) both argue, most older people received “deference and respect [although] little love or affection.” This attitude reflected the Calvinist tradition, which venerated old age as “proof” of God’s favor. In New England, the choicest seats in the meeting house were accorded the oldest members—not those who made the largest donation. Distinguished statesmen wore white wigs as a mark of sagacity. 
George Washington on his horse
But the view changed by the post-Civil War period: Fischer says the transition to a youth-biased culture occurred between 1770 and 1820; Achenbaum places it in the 1860s, but somewhere during that time, old people fell out of favor. Arguably, things got worse in the twentieth century, with social security resulting in resentment towards older people.
But whether it was a social revolution (the rise of egalitarianism after the French Revolution) or the industrial revolution (the decline of agrarian paternalism and the demise of primogeniture that had kept the young under their father’s yoke) that triggered the shift, there is no doubt there was a shift. Today, by contrast, the major change is demographic (in 1700, an estimated 20 percent of the population could expect to live to age 70; today, 80 percent can) and medical (today, many older people remain vigorous for many of their post-retirement years). The social reality is that older people in the workforce limit the possibilities of the young—the most egregious example is the university tenure system, which can literally fossilize an entire department. And while physical function often remains good as Americans age, the scourge of dementia remains, especially among the oldest old, or those over age 80.
It’s hard to be sure what the interest in gray or silver hair dye signifies. My suspicion is that gray is just another color on the palette and thus represents a new market opportunity. Just as the past few years have brought us pink hair and purple hair, orange hair and blue hair, so now we are adding shades of gray to the list of options. There is no evidence presented in the article that a larger number of older people are opting to stay gray—evidently, they continue to dye their hair blond at the same time that younger people choose gray. 
At the heart of the issue is whether people are willing to accept themselves, and others, as they are. As long as older people opt in large numbers to dye their hair, we can be pretty sure that attitudes towards aging remain unchanged.

January 03, 2019

Who Cares?

As an ever-growing percentage of Americans live to extreme old age, with a correspondingly large proportion surviving long enough to become frail, family caregivers play an increasingly pivotal role in their care. Previous studies have documented how widespread caregiving is, how intense, and how medically oriented. But these studies typically are snapshots, looking at a single point in time. A new study, “Family Caregivers of Older Adults, 1999-2015,” uses several national surveys to examine changes in caregiving over time.
The take home message of this comparison is that the job of caregiving has become more challenging as the care recipients have become sicker and more disabled. In 1999, 18 percent of care recipients needed help in three or four areas. By 2015, this had risen to 26 percent. Caregiving has become more intense and of longer duration, with 45 percent of caregivers providing help for over four years in 1999, compared to 64 percent in 2015. 
What this means is that for caregivers to do a good job, they need to be more medically sophisticated today. In the groundbreaking 2012 study, “Home Alone: Family Caregivers Providing Complex Chronic Care,” 46 percent of family caregivers were found to provide one or more types of fairly sophisticated medical care. This percentage has undoubtedly grown over time, just as all the other indicators of complexity have grown. But there is no reason to believe that today’s caregivers are any better equipped than their predecessors to manage chronic disease.

The consequences of this shift are profoundly under-appreciated. Increased demands on caregivers result in emotional, cognitive, and financial stress. At least as important, and almost never addressed, are the consequences to the care recipients. Unless their family caregivers develop greater medical knowledge and unless they learn to navigate the maze that is our current health care system, they will pay the price in the form of more trips to the emergency room, more hospital admissions, more tests, and more procedures. 
If today’s frail older people wish to avoid burdensome and often unnecessary and even ineffective medical treatment, and if our society wants to avoid the financial cost of such treatment, then it behooves us to provide better support for caregivers. Caregivers are the key. In the next few months, I will take a small step in that direction with the publication of my book for caregivers, tentatively titled “Taking Care.” This book, to be published by Johns Hopkins University Press, will provide caregivers with the knowledge they need as their relatives make their way to the office, the hospital, the skilled nursing facility. It will teach them enough medicine to help them manage the acute symptoms and chronic diseases they are likely to encounter. Above all, it will help them think through decisions based on their family member’s underlying health state and preferences for care. Stay tuned!