Thursday, June 23, 2011

Aging with Meaning

Review: How We Age: A Doctor’s Journey into the Heart of Growing Old

By: Stanley Slater M.D., D.F.A.P.A.

In How We Age, writes Dr. Stanley Slater, Marc E. Agronin presents a balanced view of aging stemming "from his concern for understanding the lives of his patients through listening to what they have to say and his ongoing devotion to bettering their lives."

Marc E. Agronin, a practicing psychiatrist who treats older residents at Miami Jewish Health Systems, the site of one of the largest nursing homes in the United States, has written a wise and enlightening book on how we age. The author is unfailingly curious, reflective, and ever respectful of his patients. In a personal, easy-to-read style, he offers insights on aging from his clinical experiences, as well as from the writings of past and contemporary psychologists, philosophers, spiritual leaders, writers, and poets.

Included are portraits of Dr. Agronin’s mentors, chief among them his grandfather, a practicing physician in rural Wisconsin. His grandfather’s intensity of caring, ongoing involvement in the lives of his patients, and resolute pursuit of their betterment made a huge impact on his patients and their families. This dedication to wise care clearly guides his grandson.

Dr. Agronin’s patients also inspire him as he attempts to understand their past experiences and current concerns. While listening to a 100-year-old woman speak about her life, for example, Dr. Agronin became aware that “someone living with the daily infirmities of aging and approaching death could still enjoy most of the same human experiences we find so precious in younger years.”

The book’s emphasis is not on avoiding or reversing the inevitability of aging by finding a modern-day fountain of youth, but on dealing with the reality of aging in a more balanced way. It does not promote the hope of avoiding age-associated changes in body and mind through the use of hormones, plastic surgery, medications, or even diet and exercise. Instead, it acknowledges that changes will occur with aging, though at varying times and to different extents among individuals. Physical frailty, dementia, and multiple social losses often accompany aging. However, Dr. Agronin observes his 70- to 100-year-old patients’ positive experiences: the preservation of vitality, spirit, and hope, and even a new creativity, a sense of meaning, and enhanced wisdom. The book contains many evocative and touching descriptions of Dr. Agronin’s patients, which often illustrate the resilience and emotional resources older people exhibit as they continue to derive pleasure from their lives.

Dr. Agronin also recounts his personal interactions with well-known people who have contributed to his understanding of aging’s positive aspects. As an undergraduate at Harvard, he attended a seminar with Erik and Joan Erikson. The Eriksons described how older people can cultivate meaning, a sense of rightness, harmony, and purpose with “a broader sense of integrity in day-to-day existence” as a feature of development in aging. The description of his interaction with Erik Erikson includes a humorous and poignant moment. Throughout the multiple sessions of the seminar, Erikson exhibited a quiet, apathetic demeanor and spoke very little. During one session, Dr. Agronin attempted to engage Erikson in discussion about his attempt to replicate one of Erikson’s studies. Erikson waved him off, saying, “I am trying to eat a cookie.” In retrospect, Dr. Agronin recognizes this as a product of Erikson’s early-stage dementia. Erikson’s participation in the seminar, despite his cognitive decline, likely contributed to an ongoing sense of purpose in his life. Patients with dementia retain many aspects of their personalities until quite advanced stages of the illness and continue to derive satisfaction from social interactions despite a progressive decline in cognitive capacity.

Dr. Agronin also knew Gene Cohen, M.D., one of the founders of geriatric psychiatry. Dr. Cohen’s interest in aging began in biology. As a high school student, he discovered how to determine the age of a fish called the longhorn sculpin by closely examining a small bone in its inner ear. Later, while working at the National Institute of Mental Health, Dr. Cohen created a national program to support research and research training in geriatric psychiatry. The support and guidance this program provided was central to the development of the field. His scientific focus shifted to non-biological aspects of how people age and how to age well.

Dr. Cohen recommended that each of us create a “social portfolio” in which we inventory assets including personal interests, skills, resources, and relationships to build up a kind of “insurance” against expectable future losses. We can adjust our activity patterns with age, as in relinquishing skiing for hiking or nature walks. Dr. Cohen also wrote about satisfaction in developing new skills. He was excited by his observation that older individuals often take advantage of newfound personal freedom and creativity to develop new interests. He emphasized that ongoing participation in activities that contribute to society are valuable, as they continue to be a source of affirmation and meaning. Dr. Cohen exemplified this approach. After retiring from an eminent career at the National Institutes of Health (NIH), he continued his research in aging as head of the Center for Aging and Humanities at George Washington University until his death.

Dr. Agronin also writes about the inspiring example of a onetime candidate for the U.S. presidency, Sen. George S. McGovern, who, despite a stunning electoral defeat and later the loss of his wife, has continued an active life driven by meaning and purpose. Dr. Agronin’s portrait of an 85-year-old man, pulling his own suitcase through airports to speak to groups of young people around the country about the value of public service, is a memorable depiction of successful aging. The senator’s vitality and strong sense of purpose clearly sustain him. Transmitting long-held values to the next generation continued to give his life enduring meaning. Sen. McGovern told Dr. Agronin that with age, he had gained wisdom characterized by more-integrative assessments of situations, including the ability to see both sides of complex issues. He said that with this new wisdom, he believed he could be a better president than he would have been at a younger age, had he been elected.

This story reminded me of another U.S. senator who was hospitalized at the NIH Clinical Center during his dying days. The senator had a visit in his hospital room from a college student from his state who was serving as a volunteer on a psychiatric research unit elsewhere in the hospital. The aged senator, despite being in pain, strongly commended the young student, congratulating him on this form of public service—a value that had clearly animated the senator’s life. While at the NIH, I also observed many older patients participating in research on dementia. This research included the need for collection of cerebrospinal fluid with lumbar punctures (spinal taps), which sometimes resulted in transient, yet somewhat painful, headaches. During periods of considerable personal stress, older people willingly accepted the discomforts of research participation, commonly explaining their participation as a contribution to the well-being of future generations. Their participation clearly lent meaning to their lives through a connection to deeply felt social values.

This book will help general readers understand some of the major issues in geriatric psychiatry. Of particular value are the discussions of depression, delirium, dementia, and the use of psychotropic medications in older patients. Here the injunction to “start low, go slow, but go” is an important maxim. When treating older patients, we must be especially careful with psychotropic medication, using smaller doses and increasing them slowly. Because benefits can be considerable, such treatment is often worth attempting. Physicians use a risk/benefit assessment in deciding whether to start medication. When medication fails to improve the situation, they may consider other, less common treatments. Dr. Agronin describes an elderly, manic woman who, though unresponsive to medication, had a dramatic, life-changing benefit from electroconvulsive therapy.

Above all, I believe that the balanced view of aging Dr. Agronin presents in this book stems from his concern for understanding the lives of his patients through listening to what they have to say and his ongoing devotion to bettering their lives. A quote from Professor George Vaillant of Harvard Medical School is a useful guide: “Old age is like a mine field; if you see footprints leading to the other side, step in them.” Among these footprints are the need for ongoing caring relationships, the attribution of meaning to our lives, and an enduring capacity for joy in everyday life.

Dr. Agronin has written a wonderful book for all audiences.



About Cerebrum

Bill Glovin, editor
Carolyn Asbury, Ph.D., consultant

Scientific Advisory Board
Joseph T. Coyle, M.D., Harvard Medical School
Kay Redfield Jamison, Ph.D., The Johns Hopkins University School of Medicine
Pierre J. Magistretti, M.D., Ph.D., University of Lausanne Medical School and Hospital
Robert Malenka, M.D., Ph.D., Stanford University School of Medicine
Bruce S. McEwen, Ph.D., The Rockefeller University
Donald Price, M.D., The Johns Hopkins University School of Medicine

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