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Old age is a majority female terrain. Finally, they're largely rid of us men. According to the Census Bureau, in 2005, sixty-five-year-old men had a life expectancy of sixteen years versus nineteen years for women. Contrary to the notion that longer-lived wives get to enjoy their dead husbands' estates, the data show that old women have fewer material resources than old men. In 2003, the median income for men over sixty-five was $17,359 versus $13,775 for women. Staying married--if you can manage to keep your husband alive--is the best of all, with a median income of $36,606. Older single women were almost twice as likely to live in poverty as single men--13 versus 7 percent.
But whatever your gender, if you live long enough, the alternative to death is an ever increasing prospect of disease. Aside from such cheery prospects as heart disease, osteoporosis, arthritis, and stroke, if you reach the age of eighty-five, your chances of dementia are one in two. Before modern medicine and public health, most people died off before they had the opportunity to experience old-age misfortunes. Until quite recently, "live fast, die young, and leave a good-looking corpse," was the way of all human flesh.
Prehistoric folks had a life expectancy of eighteen. But this brief span was world enough and time for reproduction and survival of the human species. They died too young to have a legal drink, but they had quite enough life span to discover fire and invent the wheel. A handful of twenty-year-old elders was sufficient to pass along a modicum of culture--how to organize the hunting and gathering, how to bury the bodies. Over the next several millennia, as life expectancy crept up to thirty, there was plenty of time to be Alexander the Great, Jesus, or Mozart.
Fast-forward to 1946, the year I was born, and life expectancy was sixty-seven--approaching the Biblical three score and ten--quite enough time to invent the computer, triumph over Fascism, and replace swing with bebop. People considerately exited before becoming complete demographic undesirables to TV advertisers. You could briefly savor your life achievements in full command of your senses and then leave the scene.
What's the meaning of the extra twenty or thirty years we have attained since my birth? Life remains mortal and finite. Spirituality aside, when you're dead, you're dead forever. There's a movie scene--I think it's Marcello Mastroianni--in which a dinner-party host cuts some flowers but doesn't put them in water.
"Why not put them in water?" asks a guest.
"It only prolongs their agony."
With all the recent longevity gains, how can we say we're not just prolonging the human agony? Thomas Hobbes--who lived more than three hundred years ago in a time of warfare and upheaval--mused that life is nasty, brutish, and short. Does three centuries of progress mean we can now say that life is nasty, brutish, and long?
The young have a delusion about longevity. They think of the big number but not the frailty, the illness, and the confusion. Ask a typical twenty-year-old, "Would you like to live to a hundred?" and the answer is usually yes but it's always the Dorian Gray ideal--where you get old but don't age.
Or consider this thought experiment.
Mens sana in corpore sano. A sound mind in a sound body.
If you have both, you will not be in a nursing home. If you don't have one or the other, you probably will be.
I often wonder, and sometimes even ask a patient who can appreciate the question: would you prefer to have dementia but be physically healthy, or would you like all your marbles in an ailing body? Either is a bad bargain. Do you want full awareness of your frailty, pain, and suffering? Or would you want to be addled but fit to ambulate purposelessly down the halls of the nursing home? Complainer that I am, I would still choose the sound mind in the unsound body--although it depends on how unsound.
My dog appears perfectly happy lying on the couch near me by the fire in January, but does he know--is he conscious--that he is happy? The pleasantly confused type of dementia lacks human awareness. As the parts of the brain that underlie our self-consciousness are destroyed, we are left with animal awareness without the animal's skills for survival. A human with serious dementia has the real-world survival skills of a Pekingese dog, which were bred by the Chinese to sit on laps, look like miniature lions, and not much else.
Although our understanding of aging is limited, we can easily enumerate its afflictions: chronic obstructive pulmonary disorder, diabetes, macular degeneration, glaucoma, heart disease, gastroesophageal reflux disease, strokes, gout, arthritis, Parkinson's, cancer, and osteoporosis. Common to these conditions is the lack of any real cure. These are not infections, for which antibiotics can bring a reversal. For the most part, these are chronic conditions that we can manage but not eliminate. It is ironic that so many of the nursing homes label themselves health care centers, when disease care centers would be far more accurate--but admittedly bad for marketing.
In the nursing home, I walk each day through the terrain of medical care. There are oxygen tanks, IV machines, various kinds of wheelchairs, various kinds of beds, and the cyclical progression of the med pass nurse working her way up and down the halls.
The nursing home looks like a hospital, but it is also the workshop of entropy. Time's arrow leading us to disorder and chaos. All of us worker bees moving on the assembly line from room to room. Each of us turning a screw, emplacing a widget, removing a blemish--fingers in the dike against disease.
"Mr. Harrelson, I see you have oxygen. How long has that been?"
"Since I came here, a couple of weeks ago."
"Did you smoke?"
"I did, but I quit."
"It's always a good idea. When did you quit?"
"Oh, a couple of weeks ago. When I came here."
He's been there for a year. But he knew precisely that it was January 16, 2008, and that he was born in 1926.
"How old are you, sir."
"Somewhere in my fifties."
"Who is the current president?"
"Reagan."
"And who was the president before him?"
"Carter."
It does fit together in a kind of coherence. He says he's fiftyish and those were the presidents when he actually was fifty.
"I'm very sorry to hear about your wife."
She died last week.
"It was sad," said with surpassing dispassion.
"I'll be back to talk to you from time to time."
"That would be nice."
I mark down "rule out denial versus dementia." It's my feeble attempt at understanding--as I turn my own little screw in the production line.
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This post was adapted from my book, Nasty, Brutish, and Long: Adventures In Eldercare (Avery/Penguin, 2009), which was a Finalist for the 2010 Connecticut Book Award. Click here to read the first chapter.first chapter. It provides a unique, insider's perspective on aging in America. It is an account of my work as a psychologist in nursing homes, the story of caregiving to my frail, elderly parents--all to the accompaniment of ruminations on my own mortality. Thomas Lynch, author of The Undertaking, calls it "A book for policy makers, caregivers, the halt and lame, the upright and unemcumbered: anyone who ever intends to get old."
