Elderhood

I particularly like the title of geriatrician Louise Aronson’s new book, Elderhood. I appreciate that she does not shy away from calling old people “old.” She cringes at euphemisms like “seniors” and seems to find "older adults," the formulation that the American Geriatrics Society deems politically correct, a bit affected (or so I infer from her conspicuous failure to use the phrase). Dr. Aronson also declines to talk about “successful aging” (a phrase that suggests that anyone who isn’t aging successfully is a failure) and scoffs at the term currently in vogue, “flourishing.” Not that she thinks old people can’t flourish, but after 30 years of practicing medicine she’s a realist. That means accepting that aging comes with a good deal of loss and deterioration. The challenge is not to halt that process—though prevention, when feasible, is a good thing—but rather to find ways to enable older people to derive meaning and satisfaction from their lives despite those losses. Old age is simply a phase of life with its unique challenges and opportunities, like childhood or adulthood. Hence, elderhood.

The book is a wonderfully readable and accessible introduction to geriatric medicine. Through clinical anecdotes and accompanying commentary, Aronson teaches the reader all the basics: she discusses falls, polypharmacy, delirium, dementia, and depression. She also touches on the perils and potentials of the institutions where today’s old people receive medical services such as hospitals, rehab facilities and the office, with special attention to the merits of house calls. And she discusses the backdrop against which all this medical care takes place—the ageism of the surrounding society, the misconceived (or so she argues), expensive, and distracting effort to extend the lifespan, and the poor design of the environments in which most old people live.

The organization of “Elderhood” is somewhat opaque. It is divided into sections: birth, childhood, adulthood, elderhood, and death, which seem to reflect the author’s early life, adulthood, and incipient elderhood. But the structure breaks down because the sections on elderhood and death clearly refer to the author’s patients and not to herself, though she reflects on how she experiences their life stories. After a while I gave up trying to make sense of the book’s structure and just followed the author wherever she led me, from one story to the next, with thoughtful meditations on each vignette. It’s a wonderful ride.

No single volume can possibly capture all aspects of aging. If there’s one thing missing from this rich and satisfying book, it’s a deeper understanding of the forces that both create and sustain the maladaptive system Aronson so eloquently describes. She is well aware of the social dimension of her tale and in fact explains early on that she had been “an unlikely medical student,” regularly substituting literature, psychology, and anthropology college courses for math and science courses whenever she could. She spends a good deal of time talking about medications but not so much on the pharmaceutical industry; likewise, she discusses the baleful effects of hospitals on the physical functioning of old patients but not on prospective payment or the device manufacturing industry that led to the the prevailing system. One consequence of this omission is that Aronson cannot quite succeed in fulfilling the ambitious mission of her subtitle, “redefining aging, transforming medicine, reimagining life.” She hasn't yet come up with ways to change the powerful institutions that shape contemporary reality--maybe in her next book. 

But that’s all right. The book is a treasure. Perhaps its most fundamental lesson is that what matters most in medicine is the relationship between patients and physicians. And through her engaging style, her allusions to her personal life (hence, presumably, the birth-childhood-adulthood-elderhood-death structure of the book), and her emotional reaction to what she observed in her patients, we come to know and respect Louise Aronson. We trust her. The secret to the care of the patient, George Peabody famously said and Aronson quotes, is caring for the patient. Maybe the secret to improving geriatric care is designing an educational system that will produce more physicians like Louise Aronson.