by Meika Loe
Oxford University Press, 2011
Review by E. James Lieberman, M.D. on Aug 13th 2012
Sociologist and author Meika Loe (The Rise of Viagra, 2004) teaches at Colgate University. For this excellent book she spent three years meeting with 30 people aged 85 to 102, 23 women, 7 men, who were living at home in upstate New York. People in this age group can remember living through the great depression and two World Wars.
The ranks of the very old are growing here and elsewhere in the world. In the U.S., between now and 2030 the population over 65 is expected to double, and the number over 85 will almost triple. By 2020, for the first time Americans over 65 will outnumber those under 15. While the young generation will be ethnically diverse and gender-balanced, the elderly will be mostly white and female. The very old are quite healthy despite declining physical and mental abilities, though "perspective, social values, emotional regulation, and experience may all increase with age and can contribute to adaptability in old age." (p. 5) They are role models for the "aging in place" movement, reflecting the preference of most Americans in, or contemplating, old age. Some 87 percent have children, 80 percent have grandchildren.
Meika Loe observes with engagement, to understand and learn from people who have arrived where we are all going. She sums up the findings in 13 "lessons for living" presented as separate chapters from (1) "Continue to Do What You Did" to (13) "Accept and Prepare for Death." Lesson/chapters between these include design of living space, moderation, asking for help, tomfoolery, caring for others, family redefined, and "Insist on Hugs." Most of these elders have no interest in "defying or denying age" unlike so many in our culture. Loe downplays the usual recipe of exercise, diet and attitude in favor of a "spirit of prudence and persistence, coupled with meaningful social connections," confirming research by H. Friedman and L Martin (The Longevity Project, 2011).
By the end of the three-year study (she was able to get feedback on the final book outline from all but five of the 30 participants), 21 were still at home, six had died, three moved in with family and three were in assisted living. Most said they would rather die than go to a nursing facility. Independent and strong-willed, they learned to ask for help--sometimes under duress, as after a fall.
Loe describes Ruth L., 95, holocaust survivor, music and book lover, who uses a walker in the house and an electric scooter outside. A security system includes locks and an alarm. Because she "asked for and accepted little assistance with her daily life and care, this system was crucial for supporting her aging in place and made her role as designer and implementer of it all the more evident. Eventually Ruth L. will be forced to accept some assistance, though many aspects of her mobility routine remain in place." (58) Later we learn the importance of plants: she associates them with positive memories of her married life, and can "celebrate natural beauty and longevity, experience pride, and share this pride with special people....[plants] listen and respond to her, and she can protect them from dying." (173)
Interspersed with such case vignettes are relevant themes from other research: "sometimes the sadness of an elder is not to be healed but shared"--citing Marc Agronin (How We Age). Loe's own comments, clear, thoughtful and heartfelt, complement the stories of the subjects she knew well and obviously cared for: "many elders create proximal bonds within their immediate communities that can substitute for kin and, in the process, redefine family." (209) In Chapter 11, "Insist on Hugs," she says: "While scholars are increasingly focused on aging and sexual intimacy, little has been done to consider other forms of intimacy, sensual pleasure and tactile gratification. In fact, if it is human touch in infancy that makes us human and social creatures, then it makes sense that human touch and sensory stimulation would contribute to a sense of vitality and connection throughout one's life. In an ageist society our view of elders as unattractive or sickly makes it all the more difficult for those elders who are not partnered to receive hugs, touch, or even eye contact." (215)
The last Chapter takes up dying: "even at her most frail, Olga was vitally engaged in letting go." (247). As for the group: "Their own sense of mortality animates their lives." (250) Loe emphasizes the active role of the very old at the end of life. They are resilient and multifaceted. The important role of hospice is presented, but I wish the fact was emphasized that it is primarily in home, not hospital or another facility. Most Americans want to die at home, but most get into hospice late if at all, and still die in institutions. Physicians are loath to talk frankly about dying, and most people have a week or two in hospice, missing its major benefits.
An epilogue provides an updated list of the study participants. In an appendix on best practices, Loe notes that "America lacks a cultural infrastructure for supporting aging. Our medically based health care structure is too narrow and insufficient to support comfortable aging and dying." (278). This book, unique in its content and approach (as far as I know), is a timely, important and enjoyable addition to the literature of this increasingly important social issue.
© 2012 E. James Lieberman
E. James Lieberman, M.D., Clinical Professor of Psychiatry, Emeritus, George Washington University School of Medicine