"I can't tell my patients the truth any longer because they get upset, as if I were insulting them."
This is what a colleague of mine said after his 85-year-old patient, whom I will call Kathy*, expressed dissatisfaction with the office visit. Attributing her knee pain to degenerative joint disease and explaining that this is a common occurrence "later in life" was apparently perceived as a slight. The x-ray report, clearly documenting the changes of arthritis, was not enough to satisfy Kathy who, reportedly, could not understand why her symptoms or condition should be attributed "just to old age." She was tired of hearing that so many of her ailments were part of the aging process.
I'm not foreign to this type of interaction, where patients seem to reject that physical and cognitive decline are expected with aging. Perhaps they are just in profound denial regarding the effects of age. Although the aging process differs significantly from person to person, it seems disingenuous that our patients could believe that age will have little to no effect on their functional abilities. "No one wants to admit they're old," my colleague concluded.
So, what's the best way to communicate with older adults about their age-related health conditions?
Reconciling a History of Ageism With an Aging Population
Society and nature are not kind toward elderly people. Ageism is a reality. Suffice to mention the recent dispute ignited by President Joe Biden's performance at the presidential debate with former President Donald Trump. Although some concerns were certainly legitimate, there is no doubt in my mind that the controversy was also spurred by the many prejudices against older adults.
The term "ageism" was coined in 1969 by Robert Neil Butler, MD, to describe discrimination against seniors. In a society obsessed with youth and beauty, ageist beliefs against older adults are commonplace, leading to derogatory attitudes, rejection, and isolation.
Long lives are our new normal, thanks in large part to modern medicine, with all the advancements in therapeutics and technology and improved living conditions. But long lives are not necessarily happy and fulfilling lives. A dear patient of mine, who was in her mid-80s and lived at home with her 93-year-old husband, always used to say, "The Golden Age is not so golden."
The optimistic scenarios of pro-aging writers, although inspiring, often don't account for the progressive and unpredictable nature of human frailty. Aging is a complex biological process caused by many co-conspirators: nuclear and mitochondrial DNA damage, progressive telomere shortening, defective DNA repair pathways, and cellular senescence, leading to unavoidable tissue and organ atrophy, with resulting loss of function. Many factors, including lifestyle, can have a positive or negative impact on biological aging. But the bottom line is that the depredation of age cannot be avoided, unless people die young.
Help Patients Navigate, Not Deny, Their Age
How can we reconcile our desire to live longer with the challenges brought on by aging and by society's treatment of older people? Between the threat of ageism on one hand and the many betrayals of the golden years on the other, is anyone surprised that some people might oppose the suggestion that they are losing physical and cognitive capabilities due to old age?
I am not anymore. I used to be puzzled by what I perceived to be a lack of common sense, a form of unreasonable denial, and a bold disregard for the truth despite all the available evidence. I'm not puzzled any longer. I am concerned.
I have seen too many of my patients, including family members, launching into exhausting and wasteful quests to find answers to their ailments that do not include the word "age." Being labeled with a specific disease seems to provide some people with a more palatable and more socially acceptable excuse for their decline.
"They will keep on changing doctors until they hear what they want to hear," another colleague commented when his 84-year-old patient consulted several neurologists to find the answer to his declining motor skills. Eventually, an expert in the field told him that although nothing was found on physical exam, "You might have a mild case of Parkinson's disease. If you feel like the medications help you, take them." Aging wasn't mentioned at any point in time during the office visit.
The problem is that, far from providing psychological relief, these alternative diagnoses might eventually result in more anxiety and depression, an endless sequence of time-consuming tests and doctors' appointments, hence a diminished quality of life, not to mention escalating medical costs. These "maybe" diagnoses, made with a cavalier attitude, might even prompt families to push their loved ones toward alternative living arrangements and nursing home placement, and not always in good faith. Family dynamics and societal expectations are very complex. A neurodegenerative disorder might be seen as a socially more acceptable reason to put "pops" away than just old age.
We should never forget that we are our patients' best advocates. This requires an honest and objective assessment of our aging patients, and frank, realistic conversations with both the patients and their families. Aging can be a messy business and there is not a lot of grace in it. People can choose to ignore it and look for answers elsewhere, but we, as physicians, should not become part of the problem. Fueling the denial comes at a great cost to our patients and society.
Let us instead help our patients navigate older age with sound medical advice and great compassion.
*Patient's name has been changed for confidentiality.
is an internist and faculty member at Baylor College of Medicine in Houston. She is also a Doctors for America A. Gene Copello health advocacy fellow.