Mental Wellness In The Elderly

America’s elder population is 40 million and growing; living longer and dealing with sickness and loss. And now, going into therapy to help. We’ll listen.

America’s elder population is exploding — doubling between the year 2000 and 2030.

Already, 40 million Americans are 65-plus. By 2030 it will be more than 70 million — almost 20 percent of the population.

Some will be vigorous and in the workforce, or on the golf course, well past that time of their parents and grandparents. But all will face the challenges of aging. Eventual losses of capacity, friends, loved ones.

And then there’s death to deal with. How do we do all that?

This hour On Point: a doctor who works with the aging on the best path through.
- Tom Ashbrook

Guest:

Dr. Marc Agronin is a geriatric psychiatrist and medical director for mental health and clinical research at Miami Jewish Health Systems. He's author of "How We Age: A Doctor’s Journey Into The Heart of Growing Old."

Excerpt: How We Age
By Dr. Marc Agronin

Trees

A magnificent date palm tree stands a few paces outside of my office window. Beholding its thickly ribbed and fern-bearded trunk and majestic crown of fronds, I understand why eighteenth century Swedish doctor and botanist Carl Linnaeus labeled palm trees the “princes” of the plant kingdom. Like the tree outside my window, Jacobo was a prince of a man—a robust and bearded figure with a perpetual smile. He used to visit me often to teach me Spanish and to talk about his life both before and long after he had fled Cuba. My office was a refuge for him, a bower of books and papers that made him feel at home, as if surrounded by his own library. Over time he even planted parts of himself in my bookshelves with select volumes he brought as gifts. Several years ago he proudly presented me with a copy of his own recently completed magnum opus, Lógica Transcendente, the product of decades of deep thought and several years of diligent work in his study. Unlike most of the older men and women who visit me in my office, Jacobo was not a patient; he was my friend.

In my profession such a friendship is not unusual for me, even when the difference in ages spans thirty to fifty years and a generation or two. I still marvel at how both the content of our conversations and the mutual regard rarely betrayed our ages. I had first met Jacobo seemingly by chance—although he would argue that nothing is by chance—during my first year as the psychiatrist at the nursing home.

While tending to several consults one afternoon, I walked by the bearded, garrulous figure of Jacobo speaking in an animated tone in Spanish to his daughter. They had arrived that day to visit a beloved family member. We exchanged greetings and sort of tumbled over each other in conversation as I tried in my halting Spanish to welcome him to the “Home,” as we called it. Before I knew it, Jacobo had designated himself my personal Spanish tutor, and I suddenly had an eighty-year-old friend with whom to discuss history, religion, and the meaning of life.

Mahogany Tree

The parking lot outside the nursing home in which I work is surrounded by mahogany trees. They appear as sentries along the walkways and parking spaces, with thin, angled trunks, wizened barks, and small-leafed crowns that provide only limited, dappled shade. These trees are young, however, because the mature West Indian mahogany that once grew in abundance throughout South Florida can average up to eighteen feet in circumference and soar to more than seventy feet, earning the moniker “King of the Forest.” Most captivating is the woody mahogany seedpod, which from the outside resembles a small brownish-gray potato. Once opened, however, it reveals an intricate, five-chambered array of winged seeds imbued with the rich reddish-brown color that makes mahogany such a desirable wood.

Like these trees, my patients surround and guard the passageways around the nursing home, sharing an outward appearance of frailty but containing within lustrous seeds of history and wisdom that have been spread, year after year, throughout the lives of so many others. I have grown close to these patients, even though the time I know them is short because I lose to death almost as many as I gain each year. They are patients, not friends, although sometimes the lines between can get blurry. This is one unique feature of working with the elderly that every doctor discovers with time. Even when attending to the strictest boundaries in the doctor-patient relationship, the burden of illness and the proximity of death force a special bond with patient and family. At that point small decisions, such as a medication dose or a lab test, can have far-reaching consequences.

In geriatrics, facing the death of so many patients is part of the job. Clinical decisions are often shaped by this reality, as maximal gains from therapies are necessary in minimal time frames. The emotional toll varies, but the loss of a patient who is closer to the line of friend evokes a greater level of grief. I have noticed, however, that the practice of medicine has evolved away from this line, in some ways making it easier to bear these losses. In her book How Doctors Think, Kathryn Montgomery describes how medicine has increasingly become a business transaction between strangers; the more objective and scientific it has become, “the more easily it can be commodified, detached from a caring physician, and judged by its ‘product,’ health.” She does not, however, propose a “medicine of friends,” despite how attractive the virtue of friendship may be to the doctor-patient relationship. For example, she notes that many physicians value the moments of deep connection with patients and their families that sometimes occur during crises as antidotes to “the alienation and detachment of medicine understood as a science.” Although friendship between doctor and patient is a lofty ideal and serves a rhetorical purpose in juxtaposition to a medicine of strangers, Montgomery asserts that such friendships are fraught with risks and ethical concerns.

Instead, as a middle ground Montgomery proposes a “medicine of neighbors”: “Neighborliness implies a duty, especially in time of need, but a limited duty that leaves considerable room for both self-preservation and performance above and beyond its call.” This proposed metaphor for the doctor-patient relationship is valuable, especially as it stipulates “attention and respect” for patients without the emotions and obligations of friendship, which can be intrusive and burdensome for doctor and patient alike. At the same time, however, the very presence of extant or impending losses, hovering over both doctor and older patient, sometimes demands something more than just a good neighbor.

Apple Tree

During a visit with Jacobo one spring, he appeared tired and depressed. After an hour of conversation, however, he was en-livened, and I felt reassured that all was well. Several weeks passed and I didn’t hear from him; I called but got no answer. I persisted, and a weakened voice finally answered the phone: “Mi amigo, no estoy bien. I am not well,” he told me. I was alarmed and insisted, “Jacobo, I must see you soon!” The next day Jacobo came to my office, unable to walk, with an aide pushing him in a wheelchair. The color was drained from his skin, and he appeared gaunt and exhausted. We barely spoke as I beheld his image. The timelessness of our friendship had suddenly hit the reality of aging, and I knew he was dying. At that moment my friend became my patient, and I quickly made arrangements for Jacobo to go straight into the hospital. Within two weeks Jacobo was gone, drifting off to eternal sleep one morning as his liver shut down from an unknown malignancy. It was a startling departure to me, as I had previously tried to deny that, despite our close friendship, Jacobo’s eighty-five years always meant that death was not far off.

And so it was with our friendship, a refuge of time we spent together that was unknowingly and perilously a little way away from the end. Jacobo knew this better than I did. He was an incredibly spiritual man who believed with certainty that God created the world and that it was logic, not just emotion or spirit, that could bring this understanding. But when he once spoke of death to me, it was not logic but pure poetry: “When I die,” he offered with a mischievous smile, “perhaps I will be buried close to an apple tree, and I will reach out and pluck a fruit from the branch.” I looked at him and chuckled, then reassured us both that there were no trees in the near future. But the image remained in me—this gleaming apple, the symbol of all the worldly knowledge that Jacobo so eagerly sought.

As much as I agree wholeheartedly with Montgomery, I must confess what I, and many of my colleagues, have learned: Sometimes older patients become friends and older friends become patients, either way driven by the nearness of death, which eventually comes, often stealthily, and fells another soul from our practice. We are left as the final witnesses to a life long lived, once full of dreams and memories planted lovingly in this world. This is a special honor, one that grows with time if we are able to hold fast to it:

Beloved, gaze in thine own heart,
The holy tree is growing there;
From joy the holy branches start,
And all the trembling flowers they bear.

From "How We Age: A Doctor’s Journey Into The Heart of Growing Old" by Marc E. Agronin, M.D. Copyright © 2011. Reprinted by permission of Da Capo Lifelong Books.