Reimagining Aging and Later Life

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Advances in modern medicine mean a greater proportion of people today will live well into old age than ever before. Despite the seemingly encouraging trend, geriatrician Louise Aronson, MD, argues that we have made old age into a disease, a condition to be dreaded, denigrated, neglected, and denied. Aronson has made it her life’s work to help us reimagine the rich possibilities of human longevity and later life. Her bestselling book, Elderhood, was a finalist for the 2020 Pulitzer Prize for general nonfiction.

In this episode, Aronson joins co-hosts Henry Bair and Tyler Johnson, MD, to explain what makes geriatrics a meaningful career for her, discusses the faults in our society’s conception of elderhood, and shares her humane and hopeful vision for the future of aging.

In this episode, you will hear about:

• 1:47 An overview of what geriatrics entails
• 4:42 The need to recognize elderhood as a distinct life stage
• 6:15 Aronson’s reflections on what drew her into caring for older patients
• 8:24 The ways goals of care change in elderhood
• 13:27 Aronson’s approach to caring for her patients holistically
• 17:34 How physicians can change the “losers and winners” paradigm in healthcare
• 23:03 A discussion of structural and cultural ageism and the insidious ways it harms our society
• 30:59 How American culture and medicine elevates patient autonomy and how this can sometimes be harmful to older patients
• 38:49 A discussion of Aronson’s writing and what motivated her to become an author
• 42:57 How Aronson experienced and overcame burnout
• 46:08 Advice to new clinicians on how to connect with patients and create a more meaningful career path

Following is a partial transcript (note errors are possible):

Bair: Louise, thank you so much for joining us and welcome to the show.

Aronson: It’s my pleasure. Looking forward to it.

Bair: So, you are just about the most well-known geriatrician in the United States for your writings and for your leadership role in various advocacy groups for geriatrics. But I think there’s still a lot of people both in and out of medicine who don’t really know what geriatrics is, or when you tell them geriatrics, nothing really comes to mind — unlike, say, pediatrics, right? Everyone has their own experiences with that. So for those of us who might not know what geriatrics is, can you tell us briefly what you do?

Aronson: The way I like to explain it — it’s very apropos what you said about pediatrics — because I basically say we do for older adults what pediatricians do for children and internists do for adults. Family docs often take care of everybody. But just as we can all tell a kid from an adult from an elder, people’s needs — medical, social — change. So what do I do? I provide medical care to old people and actually increasingly a range of old people.

Geriatrics has traditionally focused on the oldest or sickest old — the argument being that there are relatively few of us, and I would argue that is both historical, that there are fewer old people, and ageism, which is alive and well pretty much everywhere, including in each of us. We don’t mean to be that way, but we’re all born young. We imprint on ourselves young. So what I think we do differently is we consider how the patient’s functional status, life expectancy, different illnesses, medications, and priorities influence their healthcare.

So as an internist, I was trained to think about diseases and organs and to look at the literature and apply that to my patient’s disease or organ. But you can take something relatively simple, like a broken arm, if you are an older person who already has some trouble walking, you might not be able to use a walker. So for me, just to put a cast on and say bye, that’s not going to help the person and what else they need to do in their life. And if they’re younger-old, a lot of people will put the cast on and say bye, because that works.

But we need to think about why were you falling, because there is lots of data on how to keep that from happening and also lots of data that people fall for different reasons in different stages of old age. And then I need to think about your bones and your osteoporosis and have we diagnosed it or treated it. So it’s really, I don’t know. It’s fun because it stretches over decades and it includes not just organs and diseases, but human beings and their social systems and physical environments.

Johnson: For those who are just getting into the medical field, you may sometimes hear pediatricians will sometimes chide internists and say, you know, children are not just small adults, meaning that they have a sort of a very different set of things that you have to think about, because the world is different if you’re approaching it as a child. And as a cancer doctor, I’ve come over time — so we’re starting to have some geriatric oncologists where that’s really their field of specialty — and I have started to appreciate as I talk with them and look at the work they do, that it’s also true that I think elders are not necessarily just old adults, right? You can’t just think of them as adults who are a little bit older. You have to think, as you were explaining so nicely, that they really do have a distinct set of concerns and a distinct set of parameters that you have to consider when you’re figuring out how to best take care of them.

Aronson: I think that’s absolutely true. And it’s so funny with the precedent of pediatrics being what it is, that in our daily lives, it’s so obvious that 80 is different than 40. A small child knows that they’re different. We also have known about changes to the immune system for over 100 years. We know that outcomes are bad, but so often when older adults have bad outcomes, it’s because we have applied data from research studies on middle-aged people to them, and then we blame old age as opposed to the science that had a fatal flaw from its inception. So I think you’re just right. And I am hopeful that we are beginning to acknowledge that and act accordingly.

For the full transcript, visit The Doctor’s Art.

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