The age demographics of the world’s population are changing. In 2015, 9% (617.1 million people) of the globe’s estimated 7.3 billion people were aged 65 years and older.¹ That number is projected to increase to 12% (1 billion people) by 2030 and to 17% (1.6 billion people) by 2050.¹ Within the United States, a rise in the percent of the population aged 65 and older, from 13.7% in 2012 to a projected 20.3% by 2030,² will inevitably impact the makeup of the patient population throughout the American health care system. According to a recent New York Times article, a federal model estimates 30% of those over 65 would benefit from specialized geriatric care, though there is a dearth of geriatricians trained to supply that care in the United States.³ Even in the microcosm of academic medicine, age demographic changes are impactful, with the percentage of faculty members over 60 increasing from 15.5% in 2005 to 23.5% in 2015, confronting medical educators and institutions with their own aging-related issues and challenges.^4,5

Responding to the needs and concerns of a growing population calls out for attention and creative thinking. Elderhood: Redefining Aging, Transforming Medicine, Reimagining Life⁶ answers that call. In this work, Dr. Louise Aronson, a geriatrician and highly regarded medical educator, takes an ambitious approach to examining the roots of ageism within the United States that have led to a detrimental “othering” of older adults within American society, within American teaching environments, and, particularly, within the American health care system. In sweeping fashion, she weaves together personal, historical, medical, philosophical, and cultural perspectives to build a multidimensional and fully realized representation of aging and the aged.

Dr. Aronson’s critiques of the status quo are deep and persuasive. Old age, she contends, has too often been reduced to a stereotypical, fundamentally undesirable, and misunderstood condition. The collective dehumanization and devaluation of older adults is reflected in a health care system that medicalizes aging and dying by emphasizing standardized interventions and procedures without full consideration of their impact on older patients, while simultaneously deprioritizing social and wellness initiatives that could maximize the purpose, well-being, and dignity of older adults. On the other hand, Dr. Aronson offers a clear and compelling alternative vision: Old age or “elderhood” should be appreciated by society, by doctors, and by the health care system as life’s natural “third act”—a full and varied stage accorded as much value as childhood and adulthood, during which elders are accorded as much individualized care and attention as their younger counterparts.

In urging her readers to reimagine elderhood as a valued and integral part of an expanded lifecycle, Dr. Aronson challenges them to reconsider some of the most fundamental principles and assumptions of prevailing medical education and practice. Particularly relevant for academic physicians, she urges a dismantling of the near-universal medical education standards that devote precious few resources to developing students’ knowledge and expertise in geriatric care. The current model of training, which also emphasizes algorithmic and uniform protocols, risks excluding older adults and others who are outside a narrowly defined medical conceptualization of “normal,” and therefore systematically reinforces ageism in the health care system at large. In place of this model, Dr. Aronson calls for a robust age-inclusive curriculum for students at all stages of medical education. Even more broadly, she proposes replacing American medicine’s current disease-focused, science-driven paradigm with a new “care paradigm,” emphasizing concern for the human needs of patients of all ages and stages of life.

This is a big ask, requiring medical educators to consider significantly altering the ways in which they disseminate knowledge to learners, recognize the value of collaborative work, and communicate priorities to patients. But reflecting on existing shortcomings within these and other areas of the health care system allows the reader space to imagine how things could be. Because of this, it is difficult to come away from Elderhood without seeing an abundance of opportunities to change the American health care system for the better. Particularly as someone early in my career as a geriatric psychiatrist, this is both motivating and inspiring.

Ultimately, Elderhood is, as Dr. Aronson herself puts it, a battle cry. It is raw and unapologetic. She shines a bright and necessary light on the insidious ageism that pervades health care, advocating for conversations and policies that restore the normalcy of old age and reframe societal and institutional stigma. While it is certainly a book that physicians should read, it is truly a book for anyone who plans on getting old.

By: Isela R. Pardo, MD

I.R. Pardo is a psychiatry resident at the Stanford University Medical Center in Palo Alto, California. She is going into geriatric psychiatry.

References

1. Roberts AW, Ogunwole SU, Blakeslee L, Rabe MA. The Population 65 Years and Older in the United States: 2016. American Community Survey Reports; ACS-38. Suitland, MD: U.S. Census Bureau; 2018. https://www.census.gov/content/dam/Census/library/publications/2018/acs/ACS-38.pdf. Accessed January 17, 2020.
2. Ortman JM, Velkoff VA, Hogan H. An Aging Nation: The Older Population in the United States. Population Estimates and Projections; P25-1140. Suitland, MD: U.S. Census Bureau; 2014. https://www.census.gov/prod/2014pubs/p25-1140.pdf. Accessed January 17, 2020.
3. Span P. Older People Need Geriatricians. Where Will They Come From? New York Times. https://www.nytimes.com/2020/01/03/health/geriatricians-shortage.html. Published January 3, 2020. Accessed January 17,2020.
4. Cain JM, Felice ME, Ockene JK, et al. Meeting the late-career needs of faculty transitioning through retirement: One institution’s approach. Acad Med. 2018;93:435–439.
5. Onyura B, Bohnen J, Wasylenki D, et al. Reimagining the self at late-career transitions: How identity threat influences academic physicians’ retirement considerations. Acad Med. 2015;90:794–801.
6. Aronson L. Elderhood: Redefining Aging, Transforming Medicine, Reimagining Life. New York, NY: Bloomsbury Publishing; 2019.