Episode 38: Elderhood with guest Dr. Louise Aronson
About Dr. Louise Aronson
Dr. Aronson is a leading geriatrician, writer, educator, and professor of medicine at the University of California, San Francisco (UCSF). She is a graduate of Harvard Medical School and the Warren Wilson Program for Writers. She’s received the Gold Professorship in Humanism in Medicine, the California Homecare Physician of the Year award, and the American Geriatrics Society Clinician-Teacher of the Year award. Her writing appears in publications including The New York Times, Washington Post, Discover Magazine, Journal of the American Medical Association (JAMA), Bellevue Literary Review and the New England Journal of Medicine. Her work has been featured on TODAY, CBS This Morning, NPR’s Fresh Air, Politico, LitHub, Kaiser Health News, and Tech Nation. In her, interview we discuss her New York Times bestselling book - Elderhood: Redefining Aging, Transforming Medicine, and Reimagining Life.
Misconceptions about Getting Older
Interestingly, what the data show is that most people begin to get happier in their late 50s and into their 60s. A part of that seems to be a real comfort with the self, a sense of what matters to you. As people become more mature, more emotionally intelligent, more comfortable with themselves, and they know they have a shorter horizon and fewer options, it's easier to pick the ones that really matter and to invest in them. This leads to a real satisfaction with self and life that transverses through the 60s, 70s, 80s and into the 90s.
Why does “getting older” have such a negative connotation?
Interestingly, there hasn’t always been a negative connotation associated with aging. Dr. Aronson believes that the negative views on aging come as a result of looking at people through an industrial lens. Basically, as a society, we are prioritizing efficiency and speed. Well, speed does decline with age (in most areas). But, it is important also to consider that people who do things really quickly, don't necessarily do them well. So, it isn’t always the case that speed matters the most. The issue of negative connotations associated with aging really comes from humans being viewed as machine. From this perspective, old age gets the worst rap.
Furthermore, the body does change and, as a society, we tend to value youth. Susan Sontag wrote about this (years ago) in a really interesting way, talking about how it started as a marketing thing. When we got mass production, they could make things quickly, but the sellers wanted you to want a new one. So, they started this huge marketing thing about “the latest thing” and “the newest thing,” which can be interpreted as prioritizing “the youngest thing.”
Now it's built into certain machines, and you see that your software isn't compatible because your computer is three years old. Also, you see these people in their 20s having serious plastic surgery to look younger, not just better, but younger. Prioritizing the newest, latest and the youngest thing has become part of our culture. Unfortunately, this perspective screws everybody, for most things that we do as humans, 20 years old is not the “peak.” Yet, if you value the “newest” things, you would think 20 was the peak, which means that the next 60 or 80 years of your lifespan are downhill. This, fortunately, is not most people's experience of life.
Ageism in Public Parks
If you go to a public park, you see cute, colourful things for kids: jungle gyms, playgrounds, etc. You also often see tennis and basketball courts, etc. for adults. But, what do you see for old people?
What should you see?
Dr. Aronson believes that it is interesting because most people don't even know the answer to this question. But, what Louise thinks we should be seeing in parks for older adults include:
Tai Chi courts
Bars to build muscle strength, which is essential for function and fitness and old age.
Really smooth walking paths where people could tabulate their distance and be in conversation.
Pickleball courts, which are smaller than tennis courts, but allow a similar social and physical engagement.
We say that social and physical engagement is so important to support healthy aging and that all communities must have parks; but, then we still build parks for children and adults and completely leave out of elders.
Ageism in Medicine
Dr. Aronson favourite example to illustrate ageism in medicine is vaccines. Vaccine schedules are based on people's social behaviours, their biology, their physiology, etc. Kids obviously change a lot across a short period of time. So, over the first 20 years of life, there are 17 different vaccine schedules. Adults, in contrast, change a little slower and a little less dramatically. As such, over the years of adulthood, which is age 20 to age 65 (45 years), there are five different vaccine schedules. Then there's this category called “over 65”. Now, with the average lifespan is somewhere from the late 70s to the low 80s in the United States. From age 65, a person can live another 15, 20, 30 and sometimes 40 years, and the assumption in the medical field is that people aren’t going to change very much socially or physiologically. This is – of course – incorrect; Sixty-five is different than 85, which is different than 105. A little kid can tell those people are different. Classifying “over 65” as one category is basically like looking at old age and saying, “Oh, we're not even going to deal with that. They're not worth our time and energy”. Consequently, we are letting people get sick and die. Who dies mostly from the flu? Older adults.
For the first time last month, there was a study where they gave people a drug which sort of primed the immune system in a certain way. It was developed for diabetes and then gave them flu shots and they had much more robust responses.
This already happens for kids and it’s called “booster shots”. Why do we do that? Because little babies come out into the world without much immunity.
The medical community already knows that the immune system changes in old age, but we have yet to adapt our practices to this knowledge because of the bias or prejudice. There are these fixed notions about old age, and it is basically creating the old age that most people fear - where you're ignored or thrown out or allowed to get sick, because you're a second-class citizen. There's no group or population for which this is acceptable behavior.
Hierarchy of Care within the Medical Field
Dr. Aronson uses a “follow the money” approach. Which services get reimbursed? For doctors, reimbursement is much, much higher for procedures than it is for using their brain to build relationships and motivate patients. Reimbursement is so much higher for using disease treatments and using equipment, as opposed to person based care and motivating people in ways that keep them from getting the diseases in the first place.
Let's say you have a 20-year-old son. If he is playing soccer and breaks his leg -the orthopedist gets paid a lot to set that leg. Now, if it turns out, because he is a 20-year-old, he gets schizophrenia (a lifelong, gravely disabling condition that is really hard to treat) - the psychiatrist who sees him will get paid a small fraction, maybe a seventh, of what the orthopedist gets for their yearly salary.
Bodies are valued over brains, minds and mental health
Physical health matters much more than mental health
Parts are valued more than the whole
Doctors who just take care of skin, get paid more than people who take care of entire children, including their lives and well-being.
There are these hierarchies which really mirror some pretty nefarious social prejudices but it also means that doctors are primed to look at diseases instead of the social determinants of health. How do social determinants interact with the disease that a person gets and how they cooperate with treatment.
Expanding our Vision of Geriatrics
The term geriatrics was coined in 1909 and it was intended to be an exact analog of pediatrics (entire spectrum for kids). Geriatrics was to be the entire spectrum of old age. But, what happened (probably because of pretty intense ageism), was that not that many people went into geriatrics. So, the geriatricians said to themselves, “OK, there aren't enough of us. So, we should focus on the people in whom old age is most flagrant or robust. We need to focus on the oldest and the most frail - the people who are least like adults physiologically”.
This, of course, is an issue because there is a wide variety of different types of older adults, including healthy aging and prevention, as well as frailty and disease.
We also know that 70% of health is social determinants, but we spend 97% of healthcare dollars on medicine (treating disease) and only 3% on healthcare (preserving and maintaining health).
It is important to start viewing older age as a spectrum and studying the variety of individuals who fall into the “older age” category. If you go to the hospital, your body will respond differently to medications because your kidneys and liver are 70 years old. Although you may function very well on a day to day basis, your reserve is also going to be lower because of the way organs change. There are increasing data that show when we study elders and try and find the right treatment for their bodies, they can have outcomes just as good as adults. It is no longer acceptable to study 40 and 50-year-olds and then apply the results to older adults. The results are not good.
Keeping People Healthier for Longer
The medical field knows how to keep people healthier for longer, but it is more lucrative to let you have heart disease and then make a lot of money and have a lot of fun sticking tubes into you. The alternative would be to take the time to try and figure out what lifestyle behaviours are contributing to the development of heart disease. For example – perhaps you love cookies. The question then becomes, “How can we get you to eat more fruit and fewer cookies”? If we are able to reduce how many cookies an individual eats, it will impact many health outcomes:
You're not going to get high blood pressure
You're not going to get arthritis
You're going to feel better
You're going to sleep better
You’re going to move more quickly
You're going to think better
You're less likely to get diabetes
You’re less likely to get heart disease
You're less likely to have a stroke
You're less likely to get dementia
There’s nothing that works as well as exercise, nutrition food, and certain attitudinal psychological elements to keep people healthy and functional. But, instead, the medical field sends the message that they can fix you, and this is just a normal part of aging. But, it doesn't have to be. Of course, you still have to get old, but you can actually feel so much better and function well for so much longer by making healthy lifestyle choices.
Age prejudice against the self makes a huge difference in health or the lack thereof. The people who thrive in old age do all the things necessary to keep themselves functioning, but they also have a degree of adaptability.
Some people end up more adaptable than others, but there are also motivational techniques that can help people get there. Interestingly, doctors aren't given the time to do that. In addition, some people don’t even see that as medicine, because they only think of medicine as treating disease.
Dr. Aronson strongly disagrees.
The words “medicine” and “healthcare” are not interchangeable.
“Medicine” is the treatment of disease
“Healthcare” is caring for health and trying to preserve it. The aim of healthcare is to help individuals live the best lives they can.
Of course, medicine becomes very important once you get sick, but Dr. Aronson wants to point out that they are both really important. Unfortunately, at the current moment, 97% of doctors’ time and healthcare money is spent on medicine as opposed to “health care”.
Dr. Aronson’s hope is that geriatrics will be one of the fields that leads the way in shifting our focus towards “health care.” There's now lots of discussion about lifestyle medicine, anti-aging or age-management medicine, because people are so interested in aging well and feeling well as they age.
Just as geriatrics currently reflect the prejudices of 20th century medicine, in the 21st century - by expanding our purview and shifting our focus at least some of the time towards health – perhaps geriatrics can now steer 21st century thinking more towards health and less about disease.
Dr. Aronson’s view on “Successful Aging”
Successful aging was initially coined in reference to people who keep themselves healthy and functional all the way into old age using a variety of approaches:
Lifestyle
Diet
Exercise
Attitude
Etc.
But when you really think about it, every animal that we know of has a life cycle: birth to death, and a certain lifespan. At the current moment, humans have a life span which has a max of about 120 years. In Dr. Aronson’s view, successful aging is making it into advanced old age. It is living through all of the stages of human life, as we have known it thus far in the existence of the human species.
This is successful aging to Dr. Aronson - remaining alive until you're very old and very frail. If success is making it to the end, then that's what it is.
Dr. Aronson likes this view on successful aging better for an important reason:
If we define “successful aging” as being healthy, we set all of us up for failure because eventually, we're all going to die and most of us will grow old first and most of us will have chronic conditions.
Now, sometimes, could you have done something about your chronic conditions? Yes. But, it also means that you're a failure if you had a stroke or you got cancer for reasons you can't explain. The world calling you a failure if you have a chronic condition is not helpful, supportive, caring or useful in any way.
Conclusion
Dr. Louise Aronson is the author of the New York Times bestselling book - Elderhood: Redefining Aging, Transforming Medicine, and Reimagining Life. Elderhood has been praised as a “monumental book about growing old in America--with powerful arguments and revolutionary conclusions that will challenge your assumptions and open your mind about aging.”
To learn more about Dr. Louise Aronson and her book Elderhood: Redefining Aging, Transforming Medicine, and Reimagining Life, you can:
Visit Dr. Aronson’s WEBSITE - by clicking here