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To Live (and Die) as an Original

To Live (and Die) as an Original Poetic license does not generally lend itself to dispute. Yet occasionally even the most beautiful poem contains a gritty kernel that works its way to the surface and provokes a late inflammatory intellectual response. For me, this moment came with a signature poem of one of the major poets of the 20th century, Patrick Kavanagh. In the opening lines of his “Memory of My Father,” the great poet of the commonplace alludes to the old men that he sees on the streets of Dublin and London: “Every old man I see reminds me of my father.” As a schoolboy and young adult, I was seduced by the beauty of the language, its compression of a world of bereavement and loss into a few spare stanzas, its juxtaposition of the urban and the celestial. Yet as a geriatrician, and increasingly as the son of an aging and eventually dying father, I was aware of a growing unease with the allusion. For in my practice, not a single older man I saw in more than two decades of practice ever reminded me of my father, a truly remarkable and individual man who defied pigeon-holing as a Stradivarius defies replication. Not only that, but one of the rewards of working with older people is that not a single older man I had ever seen truly resembled another, a reflection of the key gerontological principle that an increase in interindividual variability is one of the defining characteristics of aging. Born as copies, as we say in the trade, we die as originals, and in every department of geriatric medicine I have ever worked in, this formula provided an unstated but rich counterpoint to our work. For geriatricians the work/home divide in this regard is more porous than for any other specialty—the cardiologist and endocrinologist may have no one in the family with either heart disease or diabetes, but virtually every geriatrician has older relatives and is both an observer and a participant in the aging process across generations, simultaneously watching the enrichment of the life course review and the losses of aging. Yet in all of our own homes, whatever our specialization, this truth is inescapable: was your grandmother really like anybody else’s? Despite this near-universal experience, one of the greatest tensions for those who love older people is that we see in clinical settings (other than in geriatric medicine) a widespread and perverse tendency to ignore this complexity and richness in favor of a deadening simplification, neglecting the many components of care of older people in favor of single-organ diagnosis. The failure to recognize, investigate, and treat delirium, a neurological emergency affecting one in six older people admitted to hospital, is illuminating. In over a decade of leading post-take ward rounds in my hospital, not once has a trainee outside the specialty of geriatric medicine made this diagnosis. Their continued application of the term “poor historian” to patients is troubling. In the context of patient care, it usually indicates a physician unschooled in the skills appropriate to modern care of older people and a patient with undetected cognitive impairment: it is the clinician who is the poor historian in this instance. Sometimes it seems as if an occult curriculum, some demon spawn of The House of God, has been in operation, with Tutorial 1—how to avoid diagnosing delirium—a particularly popular module. The key elements are to keep any talk with patients to a minimum, and above all not to assess cognitive function. If by mischance cognitive impairment is identified, assume it is long-standing. Never talk to nurses, especially night staff, who have observed the patient over a period of time. If the patient is withdrawn, start an antidepressant: if noisy, start a benzodiazepine. Tutorials 2 and 3—avoiding diagnosing failures of mobility and continence—seem also to have gained remarkable pedagogic traction. This collective agnosia, and indeed anosognosia—the failure to recognize the deficit—of the medical profession is doubly distressing: at one level that a group of intelligent and sensitive people (most of whom, thanks to the longevity dividend, presumably have not only remarkable parents but also highly individual grandparents, uncles, and aunts) fails to engage with the remarkable complexity of aging, but equally seriously neglects the abundant evidence that tackling this complexity in a systematic way reduces death, disability, length of stay, and institutionalization.1 But in human and medical terms, perhaps the richness our colleagues are missing most is in stepping back and wondering at the marvel that is the interaction between age-related disease and the complexities of later life. For older people are at once tough and frail: the meek and the weak die young. Experience and cognitive wisdom give the survivors strategies that allow them to tread water in the direst of circumstances, and the probing of cognitive status of those with dementia and delirium is a marvel of avoiding direct questioning that would impress a seasoned lawyer. Of course they know where we are! And why would we bother about the day and date now that we are retired? Subtracting 7 from 100—“Ah, I was never good at math, Doctor.” And so it goes: it is no wonder that the unversed are so easily hoodwinked by the retained social façade, the artful circumlocution, and the enviable retention of social cognition that draws one back from “harsh” questioning. One of the routes to illuminate such complexity and individuality is through the metaphors provided by popular culture and the arts.1 The simultaneous combination of tough and frail that I see at the clinic or in domiciliary visits invariably reminds me of the marvelously unpredictable old man in the Pixar movie Up.2 Those surviving at home with extreme and multiple disabilities bring to mind the Black Knight in Monty Python and the Holy Grail, who dismisses each successive limb amputation with phrases such as “’Tis but a flesh wound” and remains raring for action. Artists also provide fantastic insights into what might otherwise appear to students and trainees as desiccated theory. For example, one of the most promising insights into this late plasticity is the Selection, Optimization, and Compensation theory of Margaret and Paul Baltes.3 Observing how older people adapted in nursing homes, they noted a pattern of selecting activities that they could best master, optimizing their performance on these through practice, and compensating for those which they could no longer perform well. Arthur Rubinstein, who eventually retired from the concert platform at the age of 89, unwittingly gave a wonderful example of the theory when explaining his continued success at a time in his life when the vicissitudes of age were beginning to affect his dexterity. He explained that as he grew older, he reduced his repertoire (Selection), practiced these pieces more intensely than he had previously (Optimization), and played the slow passages ahead of fast passages more slowly so as to maintain an impression of speed in the fast movement (Compensation). Appreciating this resilience is the key to understanding that the impact of modern geriatric medicine arises from freeing older people from unnecessary restrictions—whether from illness, iatrogenesis, unremediated disability, or lack of appropriate services—so as to let them capitalize on the myriad, as yet incompletely documented, survival stratagems to live their own lives. At the heart of this approach is a rigorous search for the neurobiological causes of frailty and disability. For this approach to work, we need to radically think how we teach and practice the medicine, and in particular neurology, of later life. We serve our students and trainees ill if we retreat to a Victorian model of narrow neurological localization, with a strong emphasis on the hard wiring and intense concentration on the paths of cranial nerves. Instead, we need to get a better grasp of cognitive and integrative neurobiology and start providing useful overviews of the much more common deficits of later life: higher-level gait disorders and cognitive deficits, and in particular executive dysfunction, agnosia, anosognosia (“No, I don't have a memory problem, Doctor”), and dyspraxia. So doing, we can create practical guides of greater relevance for our patients and utility for our colleagues. A good example is the Bermuda Triangle syndrome for those who frequently fall. Instead of confusing the picture with reams of unhelpful tests—echocardiograms, 24-hour ECGs, and carotid Doppler studies—we recognize that the three most common features of those who fall in later life are gait disturbance (often vascular higher-level gait disorder), cognitive impairment, and orthostatic hypotension. When detected, these are all treatable conditions, where small improvement in each condition can lead to a big change in stability and quality of life. In addition, the iconoclastic temperament of older people (and geriatric medicine) allows us to understand that fear of falling, usually spoken of in pejorative terms, might actually be a critical success factor for avoiding falls! For geriatricians, the challenge is also to expand our discourse from an emphasis on the deficits of later life and what we can do for them—which may inadvertently feed into the negativity surrounding aging—to a discourse that emphasizes more the individuality, complexity, intellectual challenge, and humor of later life. Practical demonstration of effectiveness of the geriatric medicine approach—the first Cochrane review showing the highly effective nature of acute geriatric medicine was published in 20114—is helpful, but equally important is to cultivate the desire to do better, to make a linkage between that frail, delirious lady in the emergency department cubicle and the warmth and curiosity you feel for your grandparents. In the final analysis, the most potent avenue to promote this frame of mind is the humor of older people, one of the less widely recognized pleasures of working with older people. There is no finer avenue to their enriched human spirit than this idiosyncratic wit, and maybe, just maybe, we as physicians might get infected and eventually get hooked on the flowering originality of becoming an older person, a spirit caught beautifully by Hokusai in his postscript to One Hundred Views of Mt. Fuji,5 written at the age of 73: Although I had produced numerous designs by my fiftieth year, none of my works done before my seventieth is really worth counting. At the age of seventy-three I have come to understand the true form of animals, insects, and fish and the nature of plants and trees. Consequently, by the age of eighty-six I will have made more and more progress, and at ninety I will have gotten closer to the essence of art. At the age of one hundred I will have reached a magnificent level and at one hundred and ten each dot and each line will be alive. I would like to ask those who outlive me to observe that I have not spoken without reason. Back to top Article Information Dedication: In loving memory of James P. O’Neill, B Comm, MCH, FRCSI (1916-1999). Conflict of Interest Disclosures: The author has completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported. This article was corrected for errors on August 14, 2012. References 1. O'Neill D. The art of the demographic dividend. Lancet. 2011;377(9782):1828-1829Google ScholarCrossref 2. O'Neill D. Up with ageing. BMJ. 2009;339:b4215Google ScholarCrossref 3. Baltes PB, Baltes MM.European Network on Longitudinal Studies on Individual Development. Successful Aging: Perspectives From the Behavioral Sciences. Cambridge, England: Cambridge University Press; 1990 4. Ellis G, Whitehead MA, Robinson D, O'Neill D, Langhorne P. Comprehensive geriatric assessment for older adults admitted to hospital: meta-analysis of randomised controlled trials. BMJ. 2011;343:d6553Google ScholarCrossref 5. Katsushika H, Smith HD. Hokusai: One Hundred Views of Mt. Fuji. New York, NY: George Braziller; 1988 http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png JAMA American Medical Association

To Live (and Die) as an Original

JAMA , Volume 308 (7) – Aug 15, 2012

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Publisher
American Medical Association
Copyright
Copyright © 2012 American Medical Association. All Rights Reserved.
ISSN
0098-7484
eISSN
1538-3598
DOI
10.1001/jama.2012.9200
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Abstract

Poetic license does not generally lend itself to dispute. Yet occasionally even the most beautiful poem contains a gritty kernel that works its way to the surface and provokes a late inflammatory intellectual response. For me, this moment came with a signature poem of one of the major poets of the 20th century, Patrick Kavanagh. In the opening lines of his “Memory of My Father,” the great poet of the commonplace alludes to the old men that he sees on the streets of Dublin and London: “Every old man I see reminds me of my father.” As a schoolboy and young adult, I was seduced by the beauty of the language, its compression of a world of bereavement and loss into a few spare stanzas, its juxtaposition of the urban and the celestial. Yet as a geriatrician, and increasingly as the son of an aging and eventually dying father, I was aware of a growing unease with the allusion. For in my practice, not a single older man I saw in more than two decades of practice ever reminded me of my father, a truly remarkable and individual man who defied pigeon-holing as a Stradivarius defies replication. Not only that, but one of the rewards of working with older people is that not a single older man I had ever seen truly resembled another, a reflection of the key gerontological principle that an increase in interindividual variability is one of the defining characteristics of aging. Born as copies, as we say in the trade, we die as originals, and in every department of geriatric medicine I have ever worked in, this formula provided an unstated but rich counterpoint to our work. For geriatricians the work/home divide in this regard is more porous than for any other specialty—the cardiologist and endocrinologist may have no one in the family with either heart disease or diabetes, but virtually every geriatrician has older relatives and is both an observer and a participant in the aging process across generations, simultaneously watching the enrichment of the life course review and the losses of aging. Yet in all of our own homes, whatever our specialization, this truth is inescapable: was your grandmother really like anybody else’s? Despite this near-universal experience, one of the greatest tensions for those who love older people is that we see in clinical settings (other than in geriatric medicine) a widespread and perverse tendency to ignore this complexity and richness in favor of a deadening simplification, neglecting the many components of care of older people in favor of single-organ diagnosis. The failure to recognize, investigate, and treat delirium, a neurological emergency affecting one in six older people admitted to hospital, is illuminating. In over a decade of leading post-take ward rounds in my hospital, not once has a trainee outside the specialty of geriatric medicine made this diagnosis. Their continued application of the term “poor historian” to patients is troubling. In the context of patient care, it usually indicates a physician unschooled in the skills appropriate to modern care of older people and a patient with undetected cognitive impairment: it is the clinician who is the poor historian in this instance. Sometimes it seems as if an occult curriculum, some demon spawn of The House of God, has been in operation, with Tutorial 1—how to avoid diagnosing delirium—a particularly popular module. The key elements are to keep any talk with patients to a minimum, and above all not to assess cognitive function. If by mischance cognitive impairment is identified, assume it is long-standing. Never talk to nurses, especially night staff, who have observed the patient over a period of time. If the patient is withdrawn, start an antidepressant: if noisy, start a benzodiazepine. Tutorials 2 and 3—avoiding diagnosing failures of mobility and continence—seem also to have gained remarkable pedagogic traction. This collective agnosia, and indeed anosognosia—the failure to recognize the deficit—of the medical profession is doubly distressing: at one level that a group of intelligent and sensitive people (most of whom, thanks to the longevity dividend, presumably have not only remarkable parents but also highly individual grandparents, uncles, and aunts) fails to engage with the remarkable complexity of aging, but equally seriously neglects the abundant evidence that tackling this complexity in a systematic way reduces death, disability, length of stay, and institutionalization.1 But in human and medical terms, perhaps the richness our colleagues are missing most is in stepping back and wondering at the marvel that is the interaction between age-related disease and the complexities of later life. For older people are at once tough and frail: the meek and the weak die young. Experience and cognitive wisdom give the survivors strategies that allow them to tread water in the direst of circumstances, and the probing of cognitive status of those with dementia and delirium is a marvel of avoiding direct questioning that would impress a seasoned lawyer. Of course they know where we are! And why would we bother about the day and date now that we are retired? Subtracting 7 from 100—“Ah, I was never good at math, Doctor.” And so it goes: it is no wonder that the unversed are so easily hoodwinked by the retained social façade, the artful circumlocution, and the enviable retention of social cognition that draws one back from “harsh” questioning. One of the routes to illuminate such complexity and individuality is through the metaphors provided by popular culture and the arts.1 The simultaneous combination of tough and frail that I see at the clinic or in domiciliary visits invariably reminds me of the marvelously unpredictable old man in the Pixar movie Up.2 Those surviving at home with extreme and multiple disabilities bring to mind the Black Knight in Monty Python and the Holy Grail, who dismisses each successive limb amputation with phrases such as “’Tis but a flesh wound” and remains raring for action. Artists also provide fantastic insights into what might otherwise appear to students and trainees as desiccated theory. For example, one of the most promising insights into this late plasticity is the Selection, Optimization, and Compensation theory of Margaret and Paul Baltes.3 Observing how older people adapted in nursing homes, they noted a pattern of selecting activities that they could best master, optimizing their performance on these through practice, and compensating for those which they could no longer perform well. Arthur Rubinstein, who eventually retired from the concert platform at the age of 89, unwittingly gave a wonderful example of the theory when explaining his continued success at a time in his life when the vicissitudes of age were beginning to affect his dexterity. He explained that as he grew older, he reduced his repertoire (Selection), practiced these pieces more intensely than he had previously (Optimization), and played the slow passages ahead of fast passages more slowly so as to maintain an impression of speed in the fast movement (Compensation). Appreciating this resilience is the key to understanding that the impact of modern geriatric medicine arises from freeing older people from unnecessary restrictions—whether from illness, iatrogenesis, unremediated disability, or lack of appropriate services—so as to let them capitalize on the myriad, as yet incompletely documented, survival stratagems to live their own lives. At the heart of this approach is a rigorous search for the neurobiological causes of frailty and disability. For this approach to work, we need to radically think how we teach and practice the medicine, and in particular neurology, of later life. We serve our students and trainees ill if we retreat to a Victorian model of narrow neurological localization, with a strong emphasis on the hard wiring and intense concentration on the paths of cranial nerves. Instead, we need to get a better grasp of cognitive and integrative neurobiology and start providing useful overviews of the much more common deficits of later life: higher-level gait disorders and cognitive deficits, and in particular executive dysfunction, agnosia, anosognosia (“No, I don't have a memory problem, Doctor”), and dyspraxia. So doing, we can create practical guides of greater relevance for our patients and utility for our colleagues. A good example is the Bermuda Triangle syndrome for those who frequently fall. Instead of confusing the picture with reams of unhelpful tests—echocardiograms, 24-hour ECGs, and carotid Doppler studies—we recognize that the three most common features of those who fall in later life are gait disturbance (often vascular higher-level gait disorder), cognitive impairment, and orthostatic hypotension. When detected, these are all treatable conditions, where small improvement in each condition can lead to a big change in stability and quality of life. In addition, the iconoclastic temperament of older people (and geriatric medicine) allows us to understand that fear of falling, usually spoken of in pejorative terms, might actually be a critical success factor for avoiding falls! For geriatricians, the challenge is also to expand our discourse from an emphasis on the deficits of later life and what we can do for them—which may inadvertently feed into the negativity surrounding aging—to a discourse that emphasizes more the individuality, complexity, intellectual challenge, and humor of later life. Practical demonstration of effectiveness of the geriatric medicine approach—the first Cochrane review showing the highly effective nature of acute geriatric medicine was published in 20114—is helpful, but equally important is to cultivate the desire to do better, to make a linkage between that frail, delirious lady in the emergency department cubicle and the warmth and curiosity you feel for your grandparents. In the final analysis, the most potent avenue to promote this frame of mind is the humor of older people, one of the less widely recognized pleasures of working with older people. There is no finer avenue to their enriched human spirit than this idiosyncratic wit, and maybe, just maybe, we as physicians might get infected and eventually get hooked on the flowering originality of becoming an older person, a spirit caught beautifully by Hokusai in his postscript to One Hundred Views of Mt. Fuji,5 written at the age of 73: Although I had produced numerous designs by my fiftieth year, none of my works done before my seventieth is really worth counting. At the age of seventy-three I have come to understand the true form of animals, insects, and fish and the nature of plants and trees. Consequently, by the age of eighty-six I will have made more and more progress, and at ninety I will have gotten closer to the essence of art. At the age of one hundred I will have reached a magnificent level and at one hundred and ten each dot and each line will be alive. I would like to ask those who outlive me to observe that I have not spoken without reason. Back to top Article Information Dedication: In loving memory of James P. O’Neill, B Comm, MCH, FRCSI (1916-1999). Conflict of Interest Disclosures: The author has completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported. This article was corrected for errors on August 14, 2012. References 1. O'Neill D. The art of the demographic dividend. Lancet. 2011;377(9782):1828-1829Google ScholarCrossref 2. O'Neill D. Up with ageing. BMJ. 2009;339:b4215Google ScholarCrossref 3. Baltes PB, Baltes MM.European Network on Longitudinal Studies on Individual Development. Successful Aging: Perspectives From the Behavioral Sciences. Cambridge, England: Cambridge University Press; 1990 4. Ellis G, Whitehead MA, Robinson D, O'Neill D, Langhorne P. Comprehensive geriatric assessment for older adults admitted to hospital: meta-analysis of randomised controlled trials. BMJ. 2011;343:d6553Google ScholarCrossref 5. Katsushika H, Smith HD. Hokusai: One Hundred Views of Mt. Fuji. New York, NY: George Braziller; 1988

Journal

JAMAAmerican Medical Association

Published: Aug 15, 2012

References