The Elderly in Our Midst.

A few weeks ago, I had to have some dental work done. The procedure was simple enough; it involved putting a bridge across a few teeth.  The process included removing the remnants of an old tooth, putting a temporary crown over the gap, and after about two weeks, put in a permanent crown in that space.  The temporary crown was not gummed in too fast, as it will need to be removed soon, and a couple of days after it was inserted it became loose. No big deal, really, as long as it did not fall off. But the experience was quite a revelation!  It was a long crown --- covered about 4 or 5 teeth, and every time I spoke, or ate something, I could feel it shake. It was so disconcerting, that eating became a worrisome activity.  I also tried to avoid speaking too much, and those of my readers who know me will probably appreciate what an ordeal curtailing speaking was for me. During those few days, the last few months of my father’s life kept coming back to me. He was in his 89^th year, with gradually failing health. One of the outcomes of ageing was that his dentures started becoming loose --- a very common phenomenon with the elderly as the jaw bone mass gradually shrinks.  Sometimes it would happen while he was in the middle of a conversation with someone, sometimes while eating.  We, the family members took it in our stride.  We sympathized with him. It was only now, with my crown becoming loose, that I realize what he was going through! Only now am I being able to empathize with him!

This is what this post is about --- the elderly in our midst. As the elders who have been the pillars of my world are ageing, as some have left us forever, this is a thought that is very much on my mind. As I watch the seniors in my family gradually change with age, a lot of what I had studied in my gerontology classes take new meaning.  Especially during the last two years of my father’s life, I spent a lot of time reading about and analysing the ageing body with him, as both of us tried to make sense of these changes. I am piecing together some of my own understandings that came out of those readings and discussions.

A book that we discussed during that time was ‘Being Mortal’ by Atul Gawande. In his book Gawande, himself a practicing surgeon, explores the processes of aging and its ultimate outcome, dying. The book is an interesting read.  The style is anecdotal, but based on research and stories from his patients, family and a range of experts in the field. A key premise of the book is that medical training teaches doctors to prolong life. It is ill equipped to handle end of life situations. He says that most medical professionals are “good at addressing specific, individual problems: colon cancer, high blood pressure, arthritic knees. Give us a disease, and we can do something about it. But give us an elderly woman with high blood pressure, arthritic knees, and various other elements besides --- an elderly woman at risk of losing the life she enjoys ---- and we hardly know what to do and often only make matters worse”.

One of the experts he talked to was Dr Felix Silverstone, a leading specialist in Geriatrics in America for five decades. When Gawande met him, Dr Silverstone was himself 87, still practicing, and adding his own personal age-related experience to his research.  “He was trying to note the changes he experienced objectively, like the geriatrician that he is. He noticed that his skin had dried out. His sense of smell was diminished. His night vision had become poor, and he tired easily. He had begun to lose teeth.”

As a person ages, several things he or she took for granted starts to diminish.  The most important are sight and hearing.  Of the two, sight is easier to fix. Wearing the right lenses makes the world a lot clearer.  Hearing, on the other hand, is a much more difficult ball game.  A lot of the hearing aids are merely amplifiers.  They amplify everything --- including the sound of the fan, the crowing of the crows, the honking of a car. For most regular people, filtering out these extraneous sounds become second nature. But with a senior person, re-learning to filter out these outside, amplified, cacophonic noises is not very easy. Hence, many tend to avoid wearing the hearing aid.  Being the intellectual that he was, my father analysed his hearing situation. He said that even after he got used to the machine in his ears, another problem prevailed.  He saw that people tend to shout at the elderly to make them hear better.  However, though he heard less, and wore a state-of-the-art hearing aid, he said his real problem was not the lack of volume. He felt that the connections that a person makes between words, which enable them to make sense of a sentence, and which is like second nature for a younger person, had slowed down for him with age. Therefore, when someone said something to him, while he was struggling to connect the first word to the second, the speaker had finished entire sentence. Hence, it was difficult for him to instantaneously piece together what the speaker was saying.  Even a two second time lag made a difference in comprehending the sentence in its entirety. The speaker, however thinks it is because of lack of hearing and says the same thing, perhaps with different words in a louder voice. Whenever someone spoke slowly and distinctly to him, he said he had no problem.  This was a great insight, something that people with non-ageing brains do not experience and hence cannot understand. And because we do not understand, we get very impatient when trying to communicate with the elderly.

Another sense that goes with age is taste. We often disregard this as it is not as visible to us. The idea of not being able to taste well does not usually occur to us, because it is so beyond our experience.  Most of us cannot even imagine a situation of tastelessness. Many older people complain about their food being insipid --- we interpret that as fussiness and wanting to get attention, rather than an age-related physical debility. My father had analysed this debility very early on. Towards the last three-four years of his life, the only taste he could get was sweet. Hence, everything he ate during those year had to have Sugarfree on it to make it appetising. He was a diabetic for more than 50 years, and had managed his diabetes in an exemplary manner --- he was very adept at avoiding any bit of sugar in anything that he ate for half a century! If there was sugar even in something savoury, like a curry, he could detect it immediately!  He felt that perhaps his taste for sweetness survived other tastes because those taste buds had hardly been used for more than half his life.  Thankfully, it was this previously unused taste that made his food palatable now.

One of the conversations Dr Gawande had with Dr Felix Silverstone was while they were eating dinner at the restaurant-like formal dining room at the retirement community that Felix and his wife lived in.  Felix’s wife had lost her vision with age; her husband had to first cut up her food into bite size pieces, then guide her hand, explaining where each item was, so that she could eat. While they were eating, she choked on her food, and Felix told her to go slow, chewing each bite well. Felix told Gawande that as a person gets older, lordosis of the spine tips the person’s head forward.  This makes swallowing difficult and choking on one’s food very common.  During the course of the dinner, Gawande could hear someone choking on their meal every minute or so. Soon after, Dr Felix Silverstone himself choked. He started coughing, and turned red. Finally, he was able to cough up the bite. It took a minute for him to catch his breath. “Didn’t follow my own advice,” he said.  Again, being able to swallow each bite is something we take for granted, while for the elderly, this mundane task may even become life threatening.

When food becomes unpalatable and the process of eating becomes prone to choking, many elderly cut down on its intake. Added to this are factors like a sluggish stomach, gastrointestinal issues and other diminished functions which lead to problems of incontinence, constipation, abdominal discomfort and other things. For most of us, just one of these problems would be enough to make us distressed, embarrassed, anxious and uneasy. And in the elderly, a whole lot of these problems come together, along with things like weak knees, aching bones, and so on!

As I studied the aged in my family and in my acquaintances’ families, what I realized was that though medical science has made leaps in prolonging life and well-being of the physical body, it has not been able to do much about the ageing mind. Perhaps because medical science does not see it as a priority. In his book, Gawande says that Dr Felix Silverstone was able to manage the physical disabilities fairly well. He switched to an electronic stethoscope to counteract his hearing loss, he took measures to keep himself healthy and fit. He was however,

most concerned about the changes in his brain. “I can’t think as clearly as I used to”, he said. “I used to be able to read the New York Times in half an hour. Now it takes me an hour and a half”.  Even then, he wasn’t sure that he understood as much as he did before, and his memory gave him trouble.  “if I go back and look at what I have read, I recognize that I went through it, but sometimes, I don’t really remember it,” he said. “It is a matter of short term registration. It’s hard to get the signal in and have it stay put.” (Atul Gawande, in Being Mortal).

My father could relate very well to this. He was a voracious reader. He was a person who always had a book by his side. He too felt his concentration decreasing with age. During the last few years, he re-organized his reading --- he did most of his heavy philosophical reading and writing in the morning, when his concentration was the highest.  Later in the day, he read lighter material, as well as watched television.  Watching television too, however was not easy.  Hearing and a loss in instant registration made comprehension a little sluggish.  But I heard him, and several other seniors say that while watching the news, the news ticker, where the headlines are repeatedly scrolled across the bottom of the screen is a useful tool to make sense of what is going on in the world.

I am only touching the tip of the iceberg here as to what happens when a person ages.  A point that Gawande makes has stayed in my mind.  He said that several very old people have told him that it is not death they fear. It is what happens before death --- losing their memory, their best friends, their way of life. Felix Silverstone put it to him as “Old age is a continuous series of losses”.

This post was predominantly about this --- how do we reach out to those among us who may at this point be losing some of their shine and lustre; who may be feeling an immense sense of loss. Perhaps it is this sense of loss that is there behind their silences, their crankiness or their apathy towards things around them.  How do we help them cope with this final stage in their lives, when they need us the most? Most of the time, we are unable to even comprehend what is going on in their minds, as it is so alien to us who are much younger.  A lot of times, we have the image of the person in their prime, and do not realize the changes that age has perhaps brought about on their minds and bodies. 

Why have I written this post on a blog on Critical Thinking? Because a key component of critical thinking is being able to change lenses and see something from someone else’s perspective. I am sure many of my readers have an elderly in their midst. By looking at their realities through their eyes may make our interactions easier and enable us to make their evening years better.

Critical Thinking is also about questioning our own actions and ideas. I know it is not always possible for a younger person to empathize about what the very old are grappling with.  But most of the time, we do not even realize that age may bring in changes, and that the elderly may themselves be struggling to make sense of these changes.  This is what this post asks us to do, to question ourselves --- are we by any chance forgetting that they are no longer in their prime? Are we perhaps overlooking the changes that their minds and bodies are going through? 

Please feel free to continue this conversation and respond with your own experiences.