How We Age

My purpose in this book is to talk about aging by describing the lives of several individuals in a manner as humane and respectful as possible. To this end, I have retained the actual names of certain individuals with their permission only and have changed both the names and certain identifying biographical details of others so as to render them wholly anonymous. In several instances I created a composite of two similar individuals in order to retain the basic condition without allowing identification even by those who as clinicians or caregivers knew these individuals personally. Finally, there are several individuals portrayed in this book whose deaths have made it impossible to obtain permission. In those instances I have again changed names and other details to preserve anonymity. My sincere hope is that these efforts have yielded a work that respects and even extols its subjects.

"Please help your labmates remove the plastic coverings on your cadaver," the professor called out, "and then strip off all of the gauze to expose the entire body." A shudder went through my own body, and I cringed. The entire body? "Yes, the entire body," the instructor continued, as if she were reading my mind, "and then pick it up and flip it over—get a good look." This was surely a technique not meant to teach as much as to flood our psyches with the glory of gross anatomy, dispensing all mystery and anxiety in one fell baptism of formalin. Entering the room had been unsettling enough, but at least then the cadavers had been covered. I had honestly never seen a dead body before and was hoping to put off the experience as long as possible. But within minutes I was surrounded by teams of sweating medical students piling up strips of smelly, greasy gauze and struggling to pick up rigid and very heavy formalin-logged bodies. I remember one particularly surreal moment as I watched four classmates bearing the strangest of grins as they hoisted the cadaver off the table, grunting at its weight and struggling to grip the slippery, leathery skin.

The unmasking of the face of our cadaver unnerved me the most. I had hoped in vain to skip that altogether and heed the words of the second anatomy instructor, who was strutting through the room and cautioning against removing too much gauze so as not to dry out the body. He argued gruffly with the first instructor that her shock treatment was unnecessary, finally shouting, "If they can't stand looking at the body, they shouldn't be in medicine!" My labmates were more obedient to the initial instructions and summarily removed the plastic bag from the head and began to unravel the gauze. I stood back and envisioned seeing what archaeologists had discovered in the mummified faces of pharaohs—coal-black visages with bony physiognomy and time-scorched skin that resembled cracked china. Those ancient, royal faces looked more skeletal than human and lacked all of the machinery of expression that might have betrayed a final emotion.

When the last strip of gauze was peeled away, I looked down on the face of our cadaver, mesmerized by her silent, still expression, her upper cheek muscles and eyelids slightly scrunched as if a puff of air had been blown into her face at the moment of death. The face appeared inert, like a totem permanently carved into clay or stone and so different from the blushing, breathing face of a living person. And yet this had been a person, I realized, who once had walked the earth and lived a life like everyone else in the room—working, loving, running, eating, perhaps bearing and raising children. Although the identities of and any biographical information about the cadavers used in medical school anatomy courses are never revealed to the students, the unmasking of our cadaver revealed numerous deep facial wrinkles and a few thin strands of silver hair matted on her head that betrayed one critical fact: She had been quite old when she died. We later learned that she had been ninety-eight at the time of her death from a heart attack.

After we rewrapped the head and limbs of the cadaver, the dissection of the torso began in earnest, initiated by a brief instructional paragraph in the course manual: "Palpate bony landmarks on cadaver: clavicle, jugular notch, sternal angle, sternum.... Incise skin from jugular notch to 3 cm above the pubic symphysis in mid-line cutting around the umbilicus.... Then incise superficial fascia." These instructions sounded straightforward, but they underestimated the magnitude of the task. We did not merely "incise" superficial fascia (the elastic connective tissue that covers and supports the muscles), but we cut, slit, ripped, pulled, melted, and gushed it all over instruments, hands, table, and cadaver, all while we were constricted by two to three layers of gloves and heavy blue smocks.

If we were exceedingly careful and dexterous, the dissection proceeded smoothly over the ensuing months and actually taught us, as budding doctors, some human anatomy—even though a living patient is wholly unlike a cadaver in color, form, and feel. But for the average student, the time spent with the chopped and tattered remains of the cadaver cast a certain spell of nonchalance and banality over behaviors that would otherwise have been deemed inappropriate and even atrocious. One cadaver in our lab, for example, wore a pair of plastic Groucho Marx glasses throughout the course. Another cadaver in the room was decked out one morning with a party hat, balloons, and a sign that read, "Happy Birthday" for the celebrating student. And there were worse examples.

But what struck me most from the very beginning of gross anatomy was how the ninety-eight-year-old "she" lying before me was repeatedly designated an "it," a mere object to be manipulated, incised, cracked open, and explored throughout the dissection process. And this is where gross anatomy began to change from a respectful and educational part of the medical school curriculum into a dehumanizing rite of passage, what eminent cardiologist and Nobel Prize winner Dr. Bernard Lown calls a "grievous error" as a way to start off medical training. He goes on to deride the "denaturing of human values" that follows when students come to view the "repulsive formaldehyded body being dissected as an inanimate object, forgetting that it was once a fellow human being."

Lown's perspective hit me acutely one evening when I had been assigned to bring home the "bone box," a small hinged maple coffin that carried the ossified and disassembled remains of some poor soul. The bone box was meant to afford the student a more intimate educational communion with a human skeleton: a time to study the intricacies of each bone, to search for the hidden grooves where ligaments and tendons anchor themselves, and to palpate the angles and contours of the shafts and joints. Of course, the bearer of the bone box was also the subject of much, well, ribbing from other students, who warned of the midnight knocking and clacking that might emanate from the box. By that point in the course I thought I was inured to any such jibing and imaginings, but the box sat uneasily beneath my bed. I contemplated the bones and wondered whose form they had once supported. "Alas, poor Yorick!" I imagined a ghostly Hamlet cry as he cradled his jester's skull, "I knew him.... / Here hung those lips that I have kiss'd I know not how oft." William Shakespeare understood well the transformation from being to bone: So too, these dry bones resting beneath the springs of my cot would remain the permanent dry relics of an unknown soul. There would be no prophetic cry from Ezekiel to God to bind them back together, to layer on muscle, sinew, and flesh and have them walk the earth again, resuming whatever holy or unholy tasks this person had once engaged in.

Over the months of gross anatomy the old woman who lay on our slate table slowly disintegrated, torn apart bit by bit until the final coup de grâce at course end: "Make a midsagittal cut completely through the entire head and neck. Leave the nasal septum attached intact to one side of the split head by cutting the septum free from the palate and skull."

From the very first day of gross anatomy, I had dreaded this lab, having already read the last page of the course manual, just as many people do with a good mystery. I was horrified then by the instructions, and yet when the time came, I found myself fearlessly and robotically sawing through the skull and neck and splitting the two halves of the head from each other. With the brain and skullcap already removed and most of the face and neck cut away, what remained looked only remotely human. This final lesson ended the course unceremoniously, and we all fled the lab, relieved to finally be free from the stink of the formalin. But a lesson on the meaning and end result of aging had been imprinted indelibly on our delicate doctor psyches.

That lesson learned in the first few months of medical training and reinforced in nearly every other experience was unmistakable: Aging equals death. Every course throughout the next few years, from pathology to physiology, and then to clinical work on the wards, focused on how the workings of the body could go awry. From a young doctor's vantage point, the aging process brought only decay, decline, and disease until the inevitable demise of the body. This depressing view of aging, reinforced during my years of internship and residency in medicine, neurology, and psychiatry, was then coupled with a new equation: Aging equals dementia (the brain disease that robs people of memory and other parts of their intelligence).

This second aging equation was represented by a common derogatory term I heard used to describe older demented patients: "gomer." I am not certain of the etymology of this word, but it was popularized by Samuel Shem's famous novel The House of God, a book about medical internship that has been read often by every frustrated, overworked, and cynical doctor-in-training since the book's publication in 1978. Shem's character the "Fat Man" serves as a wise but crass senior resident and mentor for neophyte hospital interns, and he introduces them to the world of gomers on day one: "'Gomer is an acronym: Get Out of My Emergency Room—it's what you want to say when one's sent in from the nursing home at 3 A.M. . . . But gomers are not just dear old people,' said Fats. 'Gomers are human beings who have lost what goes into being human beings. They want to die, and we will not let them. We're cruel to the gomers, by saving them, and they're cruel to us, by fighting tooth and nail against our trying to save them. They hurt us, we hurt them.'"

During training I discovered that these so-called gomers (or "gomes," for short) were ubiquitous figures in every medical setting. They were individuals with Alzheimer's disease or other forms of dementia who were permanently disoriented and unable to effectively communicate, care for themselves, and control their behaviors. On psychiatric wards my compatriots further nicknamed a subset of the gomes the "shriekers and smearers," inspired by episodes of blood-curdling screams or the throwing or smearing of feces that were viewed as repulsive and completely off the rails of rational human behavior. The primary care doctors and geriatricians who attended to them in nursing homes were typically referred to as "gome-docs" and dismissed as either incompetent or overly sentimental individuals who couldn't hack more illustrious or challenging medical specialties.

This perceived equating of aging with death and aging with dementia represents a pervasive societal view that stigmatizes the elderly and denigrates the individuals who tend to them. These equations are the core premises of what noted gerontologist Robert Butler first called "ageism." And they have a basis in what we all see as the undeniable truths—indeed, the defining aspects—of aging. Our bodies change irrevocably and not, it seems, for the better. We see our most beloved ones suffer from illness, frailty, and loss. Skin pales and droops. Hair becomes brittle and colorless. Voices quiver and fade. Muscles wither. And personalities who once worked a trade, soldiered in battle, or mothered a beloved child falter and fade with time. Parents age and die.

In response to these "grim years of debilitation and disease with which most people's lives currently end," biogerontologist Aubrey de Grey and a small wave of researchers contend that science should be able to find a cure for aging. In this model, age is a disease that warrants treatment. And for some entrepreneurial individuals who lack both the patience and the scientific acumen of de Grey and simply want some part of the fountain of youth, aging is also an economic opportunity. Witness the rise of the multi-billion-dollar industry of antiaging products and clinics. Whether it is a costly wrinkle cream, a deluxe series of hormone shots, or a facelift, a growing number of people are willing to pay top dollar for such treatments. Many of my colleagues are less sanguine about reversing the effects of aging and focus instead on promoting a triad of physical exercise, healthy diet, and mentally stimulating activities to preserve both intellect and physical strength as long as possible.

To the extent that we think about the inevitability of aging and death, we usually have great trepidation—a sentiment captured well by Psalm 71:9: "Do not cast me off in old age; when my strength fails, do not forsake me." Face-to-face encounters with older individuals force us to look momentarily into an eternal abyss and trigger unanswerable questions about life and death that can bring wonder as easily as fear and despair. For the young doctor, the antidotes to these fears are corpse and gome—dehumanized bodies that the doctor can easily poke, cut, and crack open without a lot of emotion. When reduced to objects, the aged don't seem so bad, we reason, because they are not us. For the rest of society, there are many other ways to dehumanize the elderly and hide from what gerontologist Lars Tornstam aptly labels age-centric perceptions of the "nuisances and miseries" of old age.

I have learned since then that these dismal equations of aging with decrepitude along with the rigid and defensive attitudes that they inspire are only one side of the story. The other side is too often overlooked in our dread of aging. This realization first came to me several months after completing gross anatomy when I began volunteering at a nursing home down the street from the medical school. I was assigned to visit Esther, a one-hundred-year-old woman who, I must admit, looked uncannily like the cadaver I had just spent the previous six months with! Surprisingly, this realization was not eerie but comforting. And Esther could not have been more of a delight to be with. Her mind and wit were sharp, she smiled constantly, and she reveled in our time together. One day she described to me in detail the births of her three children, then extended their life stories over decades to the present. One moment I was hearing about her beloved young children, and the next moment I was meeting them in person—then in their seventies! There were many moments when I closed my eyes and simply listened to Esther, losing track of the nearly eighty years between us. And I began to see age in a different context: 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. Unfortunately, we often fail to see these positive elements in the lives of our elders because we are so focused on the physical or mental decline of aging. The body will certainly reach its limits, with death beyond our ability to predict or control. But the true failure here is not old age; rather, it is the failure of our own creativity and willingness to conceive that life up until its last moments has its own ways and meanings.

In the spring of my second year in medical school, Esther died several weeks after suffering a stroke. During our last visit she struggled to talk and reach out to me despite the loss of speech wrought by a small clot in her brain. As with so many of the older patients with whom I had grown close over the years, I had put the possibility of her death out of my mind, imagining that she was actually my own age but just looked a little different. In fact, I have often employed such mental gymnastics to deal with aging and death in my own family. Shortly after my grandparents passed away, I compressed much of my grief into an odd fantasy that in the afterlife they had moved down to Miami Beach and were experiencing eternal bliss together, with endless sunny beaches and Early Bird Specials. Florida, I imagined, was actually some form of Shangri-La where all of our deceased elderly could be found happily wandering around if we just looked hard enough.

As fate would have it, I currently live and work in Miami as a doctor for old people—the very profession so derided in my early years of training. In this location, I frequently encounter several unique groups of elders, including aged Holocaust survivors and Cuban exiles, who have exerted a disproportionate influence on my clinical work and have inspired so much of my writing. To be more specific, I am the psychiatrist at the Miami Jewish Health Systems, the site of one of the largest nursing homes in the United States. Although people sometimes call my place of work "God's waiting room," they miss a much bigger picture. True, the average age of my patients is about ninety years old, meaning that I see a lot of people close to one hundred. The eighty-year-olds who come to see me are like teenagers on my scale of things and the seventy-year-olds—babies! And true, my job is to tend to all of the maladies and infirmities of aging. But as I first learned from Esther and then from countless others, the true scales of aging are not one-sided; the problems of aging must be weighed against the promises. In my work as a geriatric psychiatrist I have learned that aging equals vitality, wisdom, creativity, spirit, and, ultimately, hope. And for an increasing number of aged individuals, these vital forces are growing by the day.

Part III discusses the changing role of memory in old age, telling some surprising stories of how life persists and even thrives in the face of memory loss. Part IV looks at the meaning and development of wisdom and how it is practiced by our elders—as well as by the caregivers for these elders. In both parts I highlight several sages who exemplify all that is right about aging. In Part V, I extend the discussion of aging to the very frontiers of life, exploring how certain lessons learned from the aged can serve as beacons for all of us as we head into those very same waters. These lessons promise not the end of aging, but a new beginning even as we continue to age.