In Focus

HEALTHY AGING: MANAGING THE HARD REALITIES

By PATRICK ARBORE and TESSA TEN TUSSCHER

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A robust-looking man of 78--we'll call him Mr. Lee--was the primary caregiver for his wife until her dementia progressed to a level where placing her in a nursing facility became the least troubling of his remaining options. On the surface, Mr. Lee seems like a model of healthy aging. He is in good health; he owns a comfortable home in a suburb of San Francisco; and his adult children, who live in another state, call him regularly and supported the decision to place their mother in a nursing home.

At a caregiver support-group meeting, however, this picture of health shifted noticeably. Speaking of his life, Mr. Lee lamented, "Although my wife is alive, she may as well be dead. She is lost to me; she doesn't know who I am and hasn't recognized me as her husband for a couple years. We've been married 50 years; I live in the house we bought when the kids were little. I'm alone and have no reason to live. My two children have their own lives and families; my wife doesn't need me. Why go on living?"

Aging and health have become a contradiction in terms for many Americans. The assumption that aging inevitably involves loss, depression and decay, that it is a prelude to death, abounds in clinical and popular literature. The recent trend toward laying a pathway to successful aging with such flagstones as good diet, exercise (often supplemented by yoga or tai chi) and strong social contacts, has
focused on being "vital." The assumption is that if people do all the right things, they will age with health, equanimity and grace. This model of health, although it includes much worthwhile advice, misses one critical point--that aging is difficult.

Aging comes with losses, dilemmas and developmental tasks, which people seldom think about when they are younger and which usually surprise them in their later years. Mr. Lee, despite his good relationships, physical heartiness and openness to receiving help, still struggles with the extraordinarily difficult task of losing his life partner to dementia and having to move her out of their home. This reality is not something that millions of people like Mr. Lee anticipate, much less plan for, each year.

 

FEELINGS AND 'MARBLES'
As one of the authors of this article was facilitating a discussion on grief and loss during a support-group session, he asked Mr. Lee whether he wanted to talk about his feelings. Mr. Lee politely declined the invitation and stated flatly, "My doctor says I have the health of a man half my age. What good does health do me now? I am alone." Asked whether his physician had spoken to him about mental health concerns, such as depression, he replied, "No, he thinks I have all my marbles."

Even though older adults like Mr. Lee may have their "marbles" intact, they might experience depression as a result of long-term caregiving, as well as repressed grief over making the hardest of choices. According to the Family Caregiver Alliance website (www.caregiver.org), among spousal caregivers almost a quarter of husbands and half of wives become seriously depressed.

Authors Patrick Arbore, bearded, and Tessa ten Tusscher, seated on the right, are shown during a recent training session on the caring process in working with elders. In the photograph are Anna Shorenstein and Mike DeBellis, doctoral candidates in clinical psychology at the Wright Institute in Berkeley, Calif.

Recognizing depression in older adults is not easy. Some professionals may even think that the life of someone such as Mr. Lee is better once his caregiving responsibilities have ended. Members of his support group expressed admiration over Mr. Lee's ability to care for his wife for so long, and some commented that now he can go on with the rest of his life. But whatever relief caregivers such as Mr. Lee may feel when their loved ones are first placed in a facility, that relief soon may be replaced by a sense of worthlessness, loneliness and hopelessness.

Fortunately for Mr. Lee, the facilitator of his large respite support group was concerned and asked if he would be interested in contacting a grief counselor. He agreed, and during grief counseling he acknowledged his loneliness and cried. Mr. Lee began to tell the story of his relationship with his wife, expressing and experiencing his complex feelings about how it feels to grow old in America.

 

HEARING THEIR STORIES
The telling of a story--a story that professionals need to hear as real and unique--enables professional helpers to connect to the suffering of clients, the people whose cases have to be managed. Only by listening patiently and compassionately to Mr. Lee, as he described his experience of watching his wife slip away into dementia, could the professionals working with him truly grasp his pain and begin working with him to relieve it.

Helping professionals need to see each older person in the context of his or her reality. Although service professionals often acknowledge that society is rapidly aging, it is crucial that we in the field of aging keep in mind that individuals face genuine obstacles along the longevity continuum--not the least of which is ageism in America. In his book White Apples (New York City: Tor Books, 2002) Jonathan Carroll observes, "Growing old here is a process of gradually turning invisible. Haven't you noticed that yet? The only time old people are ever noticed is when they make trouble, or they're difficult, or they die. Otherwise no one sees them because they're of no importance. They have nothing to contribute except what they learned from life, and who wants to sit around hearing that?"

Everyone wants to age, but no one wants to be old. When professionals are interacting with older adults, they need to be able to do more than assess for health or mental health problems. That demands accompanying elders into their pain. To be healthy and deal successfully with a disease, an older person must be able to receive help, express and experience feelings, and connect with those who care.

 

MORRIE'S WORDS
Morrie Schwartz, best known as the subject of the bestseller Tuesdays With Morrie (New York City: Doubleday, 1997), described his experience of amyotrophic lateral sclerosis in his book Morrie: In His Own Words (New York City: Dell, 2000). Writing about the importance of receiving help and sharing real feelings with others, he states, "Grieving, mourning, crying are natural emotions. They come easily and readily if they're not subverted by cultural prohibitions, expectations and distortions. Grieving is an important part of living because experiencing loss is inevitable for everyone. The older you become, the more losses you sustain. Therefore, you need to work out a way of handling grief. The best way is to let yourself grieve freely and mourn losses. You may want to cry about them. Without this kind of release you're apt to be left with an inner pain that can affect your life in many ways."

Schwartz continues, "We ordinarily think of mourning for others--our parents and our other loved ones--but we don't think very much about mourning for ourselves. Mourning for myself has made an important contribution to my composure. How do I do it? I let myself experience the grief, the sadness, the despair, the bitterness, the anger, the dread, the regret and the sense of finishing before my time. I let the tears flow until they dry up. And then I start to think about what I'm crying about. I'm crying about my own death, my departure from people I love, the sense of unfinished business and of leaving this beautiful world. Crying has helped me gradually come to accept the end--the fact that all living things die."

As professionals, we providers and managers of care need to be aware that healthy aging is not the exclusive terrain of those older adults gifted with strong genes, but is an inclusive place for all older people. Healthy aging is achieved neither through denial of the hard realities and challenges, nor through false equations between sickness and age. Rather, healthy aging emerges through finding internal and external resources that buffer the challenges, allow for the wonder of living, and, most important, keep older people connected to life and community.

Tessa ten Tusscher is the president of Bay Area Psychological Testing Associates, and Patrick Arbore directs the Center for Elderly Suicide Prevention and Grief Related Services at the Institute on Aging, both in San Francisco.

 

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