An Aging Un-American
http://www.100md.com
《新英格兰医药杂志》
My new patient barely returned my handshake. Instead, she hurried to the cramped center of the exam room and knelt on the yoga mat she had placed on the floor. Within seconds, her nimble body twisted into implausible forms — a human pretzel, a sailor's knot, a fleshy corkscrew.
"You see," she explained while extending her spine into an improbable arch, "I can't do the cobra or downward dog like I used to. I just want to know if there's something wrong with me."
I reread her doctor's referral note: "76-year-old woman, complains of gradual stiffening over last several years. Requests rheumatology consult."
Decades younger than she, and having failed repeatedly to progress beyond the first few poses in many "beginner's yoga" video guides, I had to quell my envy and surprise. The patient informed me that she had been in "perfect health" throughout her life, a state of grace that she attributed to her wholesome diet and exercise regimen. It simply made no sense to her that she would lose hard-earned flexibility despite invariably maintaining her regimen.
At the end of the consultation, neither of us seemed fully satisfied with my assessment. "I think you're healthy," I said. I explained that losing elasticity and flexibility with aging was a natural and regularly observed human phenomenon.
"Well," she replied, "just because that happens doesn't mean that it's healthy or inevitable, right? It's a physical process, so there must be a supplement or hormone or something physical I can take to counteract it."
In my own way, I bent over backward trying to answer her questions. But the profound mystery of human life embedded within time only expanded after each earnest round of inquiry. A student of the Internet, she had compiled several theories of aging that she wanted to explore — fantasizing, I think, that we might stumble on an antiaging secret the experts had overlooked. We discussed genetic theories that bleakly revealed our programming for planned obsolescence. We reviewed the telomerase theory, positing that as go our telomeres, so go we. And we addressed neuroendocrine hypotheses that link the cause of aging to increasingly imprecise and inefficient functioning of hormones and tissue-receptor networks.
Perhaps because of her political activism in the 1960s, she was most drawn to the free-radical theory — a potent metaphor for agency and power. On the basis of abundant marketing graphics produced by the antioxidant-supplement industry, she could conceive a convincing explanation for aging: nefarious free radicals roam the body, oxidizing and damaging DNA, leading to widespread cell dysfunction and death. (A friend of mine queasily describes this process as "humans rusting to death.")
I had scored no points by serially offering, throughout our conversation, the same remark about each theory, concluding that each was . . . well, a theory. The patient left my clinic with a list of questions considerably longer than the one she had brought with her.
I am often reminded of this woman when I meet patients in my current geriatrics practice. I hear her incredulity about aging echoed by elderly people who seem to be truly bewildered by their forced residency inside bodies made strangers by time. Somehow, unannounced and unceremoniously, old age has snuck into their experience of themselves. It has crept in at some inexact moment, through unseen cracks in imagined future selves, and it refuses to go away.
Certainly, we are all on a learning curve about aging, as the life span continues to increase (at least in certain populations), requiring continual repositioning and reinvention of developmental markers. The relatively short life span that was characteristic of the average American born a century ago more easily abided the dichotomous division of life into "young" versus "old." But as life expectancy has expanded incrementally, midlife and old age have had to be remapped constantly, while we simultaneously attempt to assess our unfolding human experience of aging.
The confusion reflected in our culture's muddled vocabulary about growing older further heightens our incredulity about aging. It is difficult to articulate one's position on life's spectrum within a culture that declares "80 is the new 60" and "today's old is tomorrow's young." It's hard to prepare for aging when even the AARP (formerly the American Association of Retired Persons) equivocates about the proper manner in which to address and subcategorize its members.
Medical language that describes human aging also equivocates — it struggles to differentiate aging from disease, healthy aging from unhealthy aging, and optional aging from obligatory aging. Is growing old pathological? Is mild cognitive impairment a disease or just an age-adjusted normal state of mind? Was my patient's loss of flexibility an illness, a healthy aging phenomenon, or some neutral occurrence?
Genuine epistemic uncertainties and cultural confusion about aging notwithstanding, we are also regularly consumed with explicit commercial messages that promote an experience of aging that is far more possible on billboards than in the three-dimensional lives of most elderly people. Certainly, it is uplifting to see happy older people who appear to be enjoying vigorous and healthy lives, to read about the 90-year-old marathoner or the octogenarian concert pianist. But these selective representations of old people create a compelling mythic structure that obscures a view of death, of real people's lives marked by chronic illness or functional decline, of caregiving gaps that are stretching dangerously, and of the critical need for health care reform to meet the real demands of our aging populace while not ignoring those of the young.
Our culture's compulsive spinning of old age into gold can inflict psychospiritual harm when it lures people into expecting a perpetually gilded existence, with an infomercial alchemist available at every rough and turbulent bend in the road to provide correctives that keep our lives shiny. Without more prevalently honest cultural representations of aging to inform our sensibilities, many of us approach the prospect of becoming old as though it were an option, and we view any failure to grab the gold as an anomaly, a personal flaw, the result of a doctor's incompetence, an HMO's stinginess with resources, or some great cosmic unfairness.
My geriatric patients often wonder why they are unable to ride the horse, hop the plane, join the stock club, or dance the tango as the old folks in the ads do. They painfully wonder what's wrong with them or their enfeebled partners, why and how they have failed to thrive. They are sometimes miffed and advise me, "Never believe anyone who tells you that these are the golden years."
Accepting the reality of aging may be uniquely problematic in the United States, because aging is so downright un-American. We are engorged with a fierce national narrative about our individual freedom and independence, our self-sufficiency, our autonomy, our perennial powers to reinvent ourselves — a narrative that aging frequently and potently dispels. When this fiction collapses, we find ourselves stranded within uncertain personal and cultural identities, and our forced dependence on others becomes both shaming and depersonalizing.
On Super Bowl Sunday, I leaf through my journals and newspapers. In the local paper is a photograph of a smiling, well-dressed woman celebrating not only her 105th birthday, but also the baptism of her 88-year-old son. The real estate section promoting senior housing and assisted-living facilities pictures remarkably agile and youthful-looking residents. The purportedly older couple in an advertisement for living-trust services appears to be at the height of some ecstatic state I hope someday to achieve. The obituaries show photographs of the recently dead that were taken years, even decades, before their deaths. The papers announce the death of author Betty Friedan at the age of 85, reminding me of her insistence in The Fountain of Age that getting old is just a state of mind — a Cartesian sentiment based on dissociation from the fact that getting old is also a state of the body. Today, though we may not know what aging is, a Google search for "anti-aging" produces nearly 18.7 million hits.
Meanwhile, the Rolling Stones finish their half-time performance at the Super Bowl, singing "I Can't Get No Satisfaction" yet one more time.
Source Information
Dr. Scannell is a practicing rheumatologist and geriatrician in Oakland, CA; an assistant clinical professor at the University of California, San Francisco, School of Medicine, San Francisco; and the regional director of the Department of Medical Ethics at Kaiser Permanente Northern California, Oakland.(Kate Scannell, M.D.)
"You see," she explained while extending her spine into an improbable arch, "I can't do the cobra or downward dog like I used to. I just want to know if there's something wrong with me."
I reread her doctor's referral note: "76-year-old woman, complains of gradual stiffening over last several years. Requests rheumatology consult."
Decades younger than she, and having failed repeatedly to progress beyond the first few poses in many "beginner's yoga" video guides, I had to quell my envy and surprise. The patient informed me that she had been in "perfect health" throughout her life, a state of grace that she attributed to her wholesome diet and exercise regimen. It simply made no sense to her that she would lose hard-earned flexibility despite invariably maintaining her regimen.
At the end of the consultation, neither of us seemed fully satisfied with my assessment. "I think you're healthy," I said. I explained that losing elasticity and flexibility with aging was a natural and regularly observed human phenomenon.
"Well," she replied, "just because that happens doesn't mean that it's healthy or inevitable, right? It's a physical process, so there must be a supplement or hormone or something physical I can take to counteract it."
In my own way, I bent over backward trying to answer her questions. But the profound mystery of human life embedded within time only expanded after each earnest round of inquiry. A student of the Internet, she had compiled several theories of aging that she wanted to explore — fantasizing, I think, that we might stumble on an antiaging secret the experts had overlooked. We discussed genetic theories that bleakly revealed our programming for planned obsolescence. We reviewed the telomerase theory, positing that as go our telomeres, so go we. And we addressed neuroendocrine hypotheses that link the cause of aging to increasingly imprecise and inefficient functioning of hormones and tissue-receptor networks.
Perhaps because of her political activism in the 1960s, she was most drawn to the free-radical theory — a potent metaphor for agency and power. On the basis of abundant marketing graphics produced by the antioxidant-supplement industry, she could conceive a convincing explanation for aging: nefarious free radicals roam the body, oxidizing and damaging DNA, leading to widespread cell dysfunction and death. (A friend of mine queasily describes this process as "humans rusting to death.")
I had scored no points by serially offering, throughout our conversation, the same remark about each theory, concluding that each was . . . well, a theory. The patient left my clinic with a list of questions considerably longer than the one she had brought with her.
I am often reminded of this woman when I meet patients in my current geriatrics practice. I hear her incredulity about aging echoed by elderly people who seem to be truly bewildered by their forced residency inside bodies made strangers by time. Somehow, unannounced and unceremoniously, old age has snuck into their experience of themselves. It has crept in at some inexact moment, through unseen cracks in imagined future selves, and it refuses to go away.
Certainly, we are all on a learning curve about aging, as the life span continues to increase (at least in certain populations), requiring continual repositioning and reinvention of developmental markers. The relatively short life span that was characteristic of the average American born a century ago more easily abided the dichotomous division of life into "young" versus "old." But as life expectancy has expanded incrementally, midlife and old age have had to be remapped constantly, while we simultaneously attempt to assess our unfolding human experience of aging.
The confusion reflected in our culture's muddled vocabulary about growing older further heightens our incredulity about aging. It is difficult to articulate one's position on life's spectrum within a culture that declares "80 is the new 60" and "today's old is tomorrow's young." It's hard to prepare for aging when even the AARP (formerly the American Association of Retired Persons) equivocates about the proper manner in which to address and subcategorize its members.
Medical language that describes human aging also equivocates — it struggles to differentiate aging from disease, healthy aging from unhealthy aging, and optional aging from obligatory aging. Is growing old pathological? Is mild cognitive impairment a disease or just an age-adjusted normal state of mind? Was my patient's loss of flexibility an illness, a healthy aging phenomenon, or some neutral occurrence?
Genuine epistemic uncertainties and cultural confusion about aging notwithstanding, we are also regularly consumed with explicit commercial messages that promote an experience of aging that is far more possible on billboards than in the three-dimensional lives of most elderly people. Certainly, it is uplifting to see happy older people who appear to be enjoying vigorous and healthy lives, to read about the 90-year-old marathoner or the octogenarian concert pianist. But these selective representations of old people create a compelling mythic structure that obscures a view of death, of real people's lives marked by chronic illness or functional decline, of caregiving gaps that are stretching dangerously, and of the critical need for health care reform to meet the real demands of our aging populace while not ignoring those of the young.
Our culture's compulsive spinning of old age into gold can inflict psychospiritual harm when it lures people into expecting a perpetually gilded existence, with an infomercial alchemist available at every rough and turbulent bend in the road to provide correctives that keep our lives shiny. Without more prevalently honest cultural representations of aging to inform our sensibilities, many of us approach the prospect of becoming old as though it were an option, and we view any failure to grab the gold as an anomaly, a personal flaw, the result of a doctor's incompetence, an HMO's stinginess with resources, or some great cosmic unfairness.
My geriatric patients often wonder why they are unable to ride the horse, hop the plane, join the stock club, or dance the tango as the old folks in the ads do. They painfully wonder what's wrong with them or their enfeebled partners, why and how they have failed to thrive. They are sometimes miffed and advise me, "Never believe anyone who tells you that these are the golden years."
Accepting the reality of aging may be uniquely problematic in the United States, because aging is so downright un-American. We are engorged with a fierce national narrative about our individual freedom and independence, our self-sufficiency, our autonomy, our perennial powers to reinvent ourselves — a narrative that aging frequently and potently dispels. When this fiction collapses, we find ourselves stranded within uncertain personal and cultural identities, and our forced dependence on others becomes both shaming and depersonalizing.
On Super Bowl Sunday, I leaf through my journals and newspapers. In the local paper is a photograph of a smiling, well-dressed woman celebrating not only her 105th birthday, but also the baptism of her 88-year-old son. The real estate section promoting senior housing and assisted-living facilities pictures remarkably agile and youthful-looking residents. The purportedly older couple in an advertisement for living-trust services appears to be at the height of some ecstatic state I hope someday to achieve. The obituaries show photographs of the recently dead that were taken years, even decades, before their deaths. The papers announce the death of author Betty Friedan at the age of 85, reminding me of her insistence in The Fountain of Age that getting old is just a state of mind — a Cartesian sentiment based on dissociation from the fact that getting old is also a state of the body. Today, though we may not know what aging is, a Google search for "anti-aging" produces nearly 18.7 million hits.
Meanwhile, the Rolling Stones finish their half-time performance at the Super Bowl, singing "I Can't Get No Satisfaction" yet one more time.
Source Information
Dr. Scannell is a practicing rheumatologist and geriatrician in Oakland, CA; an assistant clinical professor at the University of California, San Francisco, School of Medicine, San Francisco; and the regional director of the Department of Medical Ethics at Kaiser Permanente Northern California, Oakland.(Kate Scannell, M.D.)