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Any man or woman in his or her mid forties, like Marc Agronin and me, will have many questions about old age. One's grandparents go, then one's aunts and uncles, and then there are one's parents. Even some friends, the same age or younger as a middle-aged proband, go. If you live through your youth, which is full of questions, you reach the middle of life, where even more questions arise. When does it ever end? What is it like to be old? And then what?
Agronin has a special perspective: he is both a middle-aged, red-blooded American male. And he is a geriatric psychiatrist. He asks these questions in his professional, as well as his personal, time.
These personal questions also have a social component.
About a century ago, William Osler was the most famous physician in the US: head of the new department of medicine at Johns Hopkins and author of the preeminent textbook of medicine for half a century. His medical prestige was, and is, immense. Yet his public notoriety came, at least in such vaunted scientific circles as the New York Times, from a talk he gave on aging. Taking a cue from the title of an Anthony Trollope novel, he asserted that there was a "Fixed Period" in a person's life, a time of creativity and activity, before which all was preparation, and after which all is denouement. This fixed period extends roughly from age 25 to 60.
Osler argued that almost no great human creative achievement -- artistic, scientific, literary, political, economic, military, philosophical -- has been conceived after the age of 60. Indeed the vast majority of creative new ideas occur before the age of 40. They may be proven later, or fleshed out, but novelty is rare in the latter half of one's life.
One should retire at age 60, Osler concluded, because after that age, not only are new ideas rare, but one's activities only impede the ability of others, younger and more creative, to do their work. Perhaps even a touch of chloroform might be good to move things along.
Osler's reference to euthanasia was almost certainly tongue in cheek; but coming from him, and consistent with the dystopian vision of Trollope's novel, it raised a cry. (He had to clarify and retract the chloroform statement.) Despite being depressing, Osler's insights might be true. At least from a social perspective, there seems much to commend older generations moving aside for younger ones, and quickly, without resistance, as tends to be the case. I can think of numerous issues in current psychiatry where, writing as a 45 year old, smack dab in the middle of generations, it seems to me that most colleagues above 50, and certainly 60, years of age, have outdated ideas that they continue to try to impose on the profession. Not to mention many of those in their 70s and 80s, whose ideas sometimes seem positively antediluvian.
This is not to say that the psychoanalytic heritage of pre 1990s psychiatry has no use; it does; but not in the way those who were trained in that era continue to think. Similarly, many of those who gave us DSM-III in 1980 and DSM-IV in 1994 think about psychiatry today as if Ronald Reagan was still president. They appear to have little ability to critique what they did at that time, to see what was good about it and what doesn't make sense in retrospect. Such blemishes, totally opaque to the elders, are clear to the younger generation. And yet, the older generation tends to hold the reins of power.
Maybe Osler was right that we would all be better off if they let go at age 60 at least. But this is all only from a social perspective.
What about from a personal perspective. What are all these 60 year olds to do with themselves? Even if one banishes Osler, we still know that human beings today need to retire at some point, usually by their seventies, and they become much less active in affairs by their 80s and 90s. Let's hope we continue to be blessed with a lengthening life span. How are we to live in our 70s, 80s, and 90s?
To me, this seems like the question Marc Agronin tries to answer in How We Age. I will use his first name, because I've known Marc since we both were residents together at McLean Hospital twenty years ago. For a reviewer, personal friendship makes some things easier and some things more difficult. I think I know what Marc is trying to say, and I won't misinterpret his personality. But it is difficult to be objective -- not only in the positive, but in the negative direction.
That said, I'll try.
Marc Agronin is a lyrical psychiatrist. His style is pleasant and flowing, and story after story, case after case, goes by full of allusions and allegories, lulling the reader as if in a bedtime ritual. But beyond the pleasantness of his book as entertainment, there is, throughout, a serious theme: how can we make sense of old age?
Marc tries to explain what old age means through many cases of his patients, interspersed with interviews or encounters with famous older people he has met: the great psychologist Erik Erikson, Sophie Freud (granddaughter of the second-most cited entity, according to Google, in modern writing, after God), the cardiologist Bernard Lown, and George McGovern. Sometimes Marc comes across as too earnest; I think this reflects who he is, in a positive way: he is a sincere and optimistic person. But a consequence of this positive trait is that his interviewees seem one-dimensional because he doesn't ask any hard, even impolite, questions. (One doubts: They couldn't all have been such wonderful people.) Nonetheless, the interviews and cases are interesting and well-presented. My favorite piece of advice comes from McGovern, who, when asked to summarize his life wisdom, said (in paraphrase) that one should be intellectually honest; don't shade the truth, but also be open and tolerant to opposing views. "You can't just plow straight ahead…it just doesn't work that way with human beings." Despite these pearls of wisdom, I was more interested in what Marc himself had to say about the value of old age. Where he was going with it all?
One should read the book to understand, but personally I thought the most meaningful insights were present in his interactions with older Jewish patients who were survivors of the Holocaust. One conclusion is that just being alive is what matters, even when one's life is circumscribed in many ways, by illness, failing cognition, even depression. Marc repeatedly returns to the view that our American culture has many ageist assumptions, that we view older life as nothing but decline, as Osler did. At the level of each individual, there is still more good than bad in living, even in very old age, which Holocaust survivors remind us is nowhere near as horrible as life can be.
Maybe Osler was wrong even in his social conclusions. There's Colonel Sanders, starting his KFC chain at age 65 when the new 1950s highway system ruined his motel restaurant business. There's Toyo Shibata, a best-selling poet in Japan who began to write poetry at age 92. There's Grandma Moses. These may be exceptions that prove Osler's rule. But combined with the everyday liveliness that Marc Agronin describes among his patients, these exceptions are enough to prove that although life changes at each stage, it is still worth living -- a good lesson for any age.
© 2012 Nassir Ghaemi
Nassir Ghaemi, MD MPH, Professor of Psychiatry and Pharmacology; Director, Mood Disorders Program, Tufts Medical Center