Old

How old is old? When you are 30, 55, 62, 65. . .dare I say 85? Well, I’ve never met an 85 year old who didn’t know they were old. What do 85 year olds know that we don’t? That after an accumulation of time, impairments (loss of hearing and vision the most likely) and cultural bias, they know that time has passed.

I have a dear friend whose career was consulting with specialty medical practices around the United States on how to improve their business. One might think the job entailed how to bill more while doing less, or maximize billing, or promote the latest medication or procedure, but this was not what he spent his time doing. He spent his time reminding the personnel in the physicians’ offices - including the M.D.’s - who the patient was. I had the opportunity to observe him at a very large ophthalmology practice located in a well to do senior retirement community. A critical stumbling block to patient use of the practice was that the forms were all printed with small 8 point type size. True, every question was on the page but of course the ophthalmology patient had a tough time reading and then completing it. My friend the consultant knew to look at this, as he’d found this many times before.

The rate of hearing loss in those of us over the age of 65 is one in three (1). And the likelihood is that we will need services - social, medical, or legal - is undoubtedly 100%. But almost no one is expected to accommodate this loss of hearing. I walked into a nursing home’s therapy department a few weeks ago and saw one of the clinicians talking to their patient using a microphone. That was unusual. The patient wore a headset, and offered those who spoke to him a microphone. He couldn’t hear without it, but could hear fine with it. Simple, cheap, let’s order them for everyone!

We are getting older. And we will achieve the status of being old. But the duration of old age seems so much longer because the world keeps behaving as if we are aging in the opposite direction – as if our vision is more acute as our medical needs become more complicated, and as if our hearing gets sharper in new and noisy surroundings.

Failure to accommodate for one’s capabilities seems likely to continue unless, of course, those of us in our young adult and middle years begin to observe how one’s time is spent differently. In other words, experience a moment in time from another’s point of view. Otherwise, life gets old fairly quickly.

(1) Surveillance for Sensory Impairment, Activity Limitation, and Health-Related Quality of Life Among Older Adults -- United States, 1993-1997, Morbidity and Mortality Weekly Report, Vincent A. Campbell, Ph.D., John E. Crews, D.P.A., David G. Moriarty, Matthew M. Zack, M.D., M.P.H., Donald K. Blackman, Ph.D.

Relax

“Just relax, this won’t hurt” and then the skin is pierced, the tissue squeezed or the joint twisted. The word relax is related to the word laxative which is related to the word many say after the doctor, nurse or therapist say “just relax, this won’t hurt”. A person might just be reluctant to participate in further care.

Although, I’m not an etymologist, I do wonder about the words we choose and the expressions we depend on when treating patients. Another is, “don’t worry”. To worry is to think about the future as in, what will happen if I have this test, or take this medication. Naturally, most of us do not want to be in a chronic state of worry but given what life presents us, to worry may be an appropriate response.

And then the movie-like dialogue “you’ll never walk again”. I had a patient over 30 years ago, whose pelvis was partially severed along with multiple crush injuries due to an accident on a freeway shoulder. While she and her husband were outside their parked car, on a slope adjacent to the freeway trying to figure out what caused the breakdown another vehicle rammed through them.

I met Eleanor approximately two and half weeks later after she’d coded and been resuscitated numerous times. I was a weekend therapist, the first P.T. to have seen her. When I introduced myself she forthrightly stated, “I’ve been told I won’t walk again, but I will. Do you want to help me?” A marvelous person, determined, willing, knew things would be difficult, knew things would hurt.

Now my work is devoted to keeping the frail elderly in my community mobile. For some, they want to drive a car; others want to use a 3-wheel rather than a 4-wheel walker when attending a luncheon outing. Each knows – at some level - that they may not achieve their desires and they know they don’t have much time. To tell them “not to worry” would be disingenuous but to tell them “to worry” would be thoughtless, if not cruel.

A few decades ago there was discussion in my profession about what skills or behaviors were found in a master clinician. Distinct attributes would be culled and analyzed to replicate in future generations. A part of my definition of a master or effective clinician is one who develops a basis for trust with each of their patients by providing useful information. When I move this leg, Mrs. Connelly it may be uncomfortable; let’s try to avoid that by doing it this way. Or, I know Mr. Grant you want to return to driving, here are some things you need to be able to do to drive safely.

As a doctor, nurse or therapist you say you don’t have the time to prepare your patient for a test, treatment or decision? How would you rather spend your time?

Eleanor not only walked – but devoted her life to volunteering at a hospice near her home. I was teaching a course on the Psychology of Disability a few years after working with her, and was able to renew contact. I asked her to visit the class. Not knowing she would be a guest, I’d prepped them about the accident event, the extent and nature of her injuries, the rehabilitation effort. I played an audio tape that I’d asked her to make at the time about her near death experience. And then, she walked in the room, sat down and spoke to the group about what it means to own one’s life.

Broke

Students at the school in my neighborhood who are without health insurance can’t get fractures fixed. The scene: the child comes running in from the playground cradling his arm, goes to an adult who directs him to the nurse’s office, but because there are school cuts she’s not in so the principal calls the parents. The parents arrive quickly and take the child home. They apply warm compresses and salves. No, they do not go to an emergency room. No way to pay.

Plans are underway to gut Medicaid, our societal safety net for healthcare. It’s going to be broke and once cut, there are no plans to fix it. We can fight in many ways- or can we? After letters voicing our outrage, what can we really do? If we are health professionals we could start voicing alternatives, best ways to use a shrinking budget, strategic and tactical methods to spread the budget effectively over the largest number of people. In addition, we could attend planning and action meetings in our community and voice concerns and options. We can volunteer to sit on panels and commissions. State health departments could help some of us remobilize to perform critical community based services.

Some of us already do this; some of these methods are in place. Now we need to link them together as a cohesive service. Who are “we”?

View

I’m still taken aback, that after 38 years in practice as a health professional, that what a patient tells me is not what they report to their family. It is not because they have two faces or a peculiar cognitive condition. It may be that the patient has become the interpreter of medical events to their outside world. Isn’t that worth pondering?

The trajectory of medical and health services begins with the point of view that the person (the “patient”) seeking those services has also given them high priority. The healthcare professional proceeds on the following:

• Once in a patient-clinician conversation we think that the person believes we know more than they do.

• And, because we are knowledgeable we believe our corrective procedures will solve the problem.

• The problem solved?

If in the conversation of treatment the patient balks, changes subject, or dismisses the topic what is our response? Become more emphatic, offer mild threats or do we check to see if we are in the ball park?

Imagine what they are telling their family, friends, and neighbors. That the solution was a one-week stay in a place that neither speaks their language or serves their food and comes with a 2-hour surgical procedure that it will takes weeks to heal from. Or, that they will need to secure transportation, have family take a loss of half-day’s pay, travel to an unfamiliar place and repeat 3 times a week for months. Everyone shakes their head and then offers their suggestions.

Arthur Kleinman, psychiatrist and medical anthropologist lays out eight questions to prevent us from continuing to miss the boat. Many other sages remind us that we need to change our ways and not measure compliance but the degree to which we can have a meaningful conversation and where that will lead us in clinical practice.

The patient as interpreter, the patient as conversationalist, the patient as source of wisdom is not a frightening prospect. Even with significant cultural, language, historic differences the patient almost always wants you to succeed.

Waiting

With the sea change of baby boomer demographics, marketing efforts are underway to seize the day: how to make money in the population bubble of those over 65. Our response to the success of our culture lacks the sensitivity and romanticism found in studies such as Blue Zones. We do look at what our elders will tell us – although they have been for decades – we want to “play elderly”, a version of playing “grown-up”, and then get individuals to change their behavior.

It has been said that our older years represent our greatest time of personal change. We fear the probable altered physical, mental, emotional states that vary randomly. Decisions are made that change our life: where we live, who we live with, where the remains of our monies will reside.

What would happen if on our 45th birthday we each made a statement about where we’d be at 85? What if scholars developed a happy aging index, a test that monitors not just personal financial success but those indicators that have been cited repeatedly as critical to optimum health and mental health over the life span? What if we had in-home units that told us not only our body weight, but stress response status, need for a check-up or education? What if we accepted that we will age earlier in our lives?

How could we change in mid-life for a more successful late-life? What are we waiting for?