Chapter 3
Age Points
THE SEASON BEGAN like every previous year, with heavy snowfall in the mountains each night and early treks to the slopes in the morning. My in-laws Fred and Marlene were like giddy seventy-year-old teenagers on those days, swaggering through the ski lodge, leaping on the chairlifts and then careening down the runs. Friends cajoled and sometimes dared them to try higher and steeper black diamond runs, and they often complied, eager for both the camaraderie and the gut-satisfying sense of control over their body and the white face of the hill. For the past few years it had been retirement heaven for Fred and Marlene and their close circle of friends in Colorado. The only recent glitch had been a bad virus Fred suffered in the early winter, but he passed it off as a nagging cold and had mostly recovered by the time the ski season was in full gear.
But the year abruptly turned in a different direction one morning as Fred was carving his way down the undulating slopes and rises of his favorite run, a beauty called Claimjumper. As he rocketed across one of the final hills with his eyes eagerly searching for the approaching chalet, his left ski hit an unseen patch of ice, scratched out of control, and then twisted abruptly and unnaturally out of rhythm. Fred face-planted on a shelf of snow and then tumbled violently for a few seconds until he plowed into a drift. From the crest of the slope, Marlene saw an explosion of white powder and heard staccato thuds as Fred’s body thrashed about. She skidded up behind him in a panicked state, but quickly calmed when she saw him sit up and brush off the snow. He slowly looked up and laughed: he was okay! This reassured Marlene and gave her license to curse him out for being so reckless. As they slowly made their way back down the hill and into the warmth of the chalet, they realized that the fall might have been the result and not the cause of something deeper. Fred had felt winded before the fall and now felt worse. As the day wore on he felt increasingly exhausted, to the point where it was difficult for him to even lift one leg in front of the other. He tried to brush it off, thinking that maybe his virus was back, or perhaps the altitude was bothering him, but Marlene wasn’t buying either. A visit to the doctor the next day revealed no physical trauma—no bruises, broken ribs, or even red snow burns on his nose or cheeks that had plowed a path down the icy patch. But he was so pale, and Marlene insisted that the doctor take a closer look. To humor her he drew some blood, and they left for the day with Fred feeling reassured and Marlene apprehensive.
The next day the doctor called with some bad news. Fred’s blood counts were all perilously low, with every component of his blood—corpuscles, platelets, and white cells—dangling well below a danger zone where there was great risk of infection, bleeding, and ischemia. Fred needed to be seen in the nearby clinic in Frisco immediately, which led within days to a hematologist in Denver. A slew of tests, including the first of what would be many bone marrow biopsies, revealed a grave-sounding diagnosis: leukemia. For Marlene, the news hit her like a terrible spill she had taken down the slope her first year skiing—tumbling and flailing painfully out of control and feeling battered and bewildered afterward. Fred’s initial reaction was silence and morbid shock, and it triggered immediate memories of the blood disease that had killed his middle-aged mother many decades before—far too early in both of their lives. Surprisingly, the doctor was less concerned and he explained his chipper demeanor: Fred had a form of the blood disease known as hairy cell leukemia, a less common but eminently manageable condition that often responded to initial treatment with long-term remission. This clarification brought Fred and Marlene a sigh of relief but the shock was still there, and they understood intuitively that the trajectory of their lives had taken a major deviation. Nothing would ever be quite the same.
A New Question of Why
We face challenges and struggles most days of our lives. Sometimes we take them in stride and have well-worn pathways to address them, and sometimes they push us off our game. In both cases, we typically take note of the stress, pivot, and move on. For example, Fred and Marlene had both fallen before, been sick before, and faced medical issues before. In fact, they had been through lots of stressful situations in the past and always coped well. In this case, however, there were new and unexpected elements. Marlene had a fleeting thought that Fred was seriously injured or even killed by his fall. In an instant, she ran through a deck of cards in her mind that contained most of her existential worries: Fred’s being disabled and her needing to be his caregiver, the end of skiing and biking, the end of her halcyon life in Colorado, and the end of her life with Fred if he died. In previous contemplations of these inevitable scenarios, she didn’t have a vision of getting beyond them. She conflated them with the end of her own life. Fred’s diagnosis splayed these cards in front of her, and she was overwhelmed with the worry that her doomsday was beginning. Fred did not brood over this scenario as Marlene did, but his diagnosis connected the very raw loss of his mother with fears of his own mortality. It was as if a phantasm had risen from the grave and grabbed his heel as he was zooming down the hill, pulling him facedown in his exuberance and pride.
Their shock was compounded in short order by the sudden illness and death of a woman in their close circle from leukemia, the divorce of a couple they had known for years, and the onset of Alzheimer’s disease in another lifelong friend. In a matter of months, their world seemed to be tipping over into the old age they had feared for so long. They had been enjoying aging up until this point, guided by a clear mission that answered their personal question of why age. Now, a new and more insidious question appeared: Why survive? In the face of a direct threat to the most cherished aspects of an aging lifestyle, what is the point to living in the face of such daunting struggles? How does one find a way to navigate challenges that seem insurmountable? Where is the meaning and joy in it?
Age Points
One way to frame our experiences and response to adversity is through a concept I am calling an age point. An age point is a period of time in which an event or situation prompts a significant disruption in our initial ability to understand and cope with it. It exposes a gap between the challenges or demands of a life event and our existing strengths, values, skills, and connections. An age point might begin with a moment of crisis, trauma, or even terror, and causes us to feel temporarily stunned or paralyzed, and uncertain about what to do. We may want and need to respond, but we don’t know what will be effective to resolve the situation and regain our balance. Even though an age point exposes a weakness, it is also loaded with the potential for tremendous growth if we can navigate the two sides of the gulf and create a bridge to link them together. Resolving an age point makes us into more developed and capable aging adults. The greatest challenge of an age point is having to give up previous notions, identities, and ways of doing things in the service of a solution.
Age points fall into four distinct stages:
1. Event: The circumstances strong enough to prompt an age point
2. Suspension: The period of profound uncertainty and paralysis
3. Reckoning: The intellectual, emotional, and behavioral process of weighing, confronting, and attempting to reconcile the gaps between what we have and what we need
4. Resolution: A new way of looking, thinking, feeling, and doing that bridges the gap and allows us to regain our balance and move forward
An age point can take days, months, or even years to unfold and resolve, and the outcome is not necessarily a positive one. Fortunately, we can prepare for age points and actively guide the process to something positive even if we cannot imagine what that may be. The key is to optimize one’s reserve and wisdom ahead of time and develop our age-conferred strengths of resilience and creativity. Let’s explore the stages of age points in more detail.
Event: The nature of the event or situation that triggers an age point is less important than how it is experienced and interpreted. Common triggers include a major injury or illness in oneself or a loved one; a major life stress, such as a divorce or financial setback; a failure of a major task or project; a significant role shift, such as due to retirement; and even a positive milestone, such as a major birthday or the wedding of a child. Not every trigger has to constitute a clear crisis or trauma, but it must have sufficient emotional and intellectual impact to disrupt a person’s underlying script. Life events are more likely to trigger age points in individuals who have brittle supportive relationships (e.g., a loveless marriage), rigid beliefs (e.g., absolute opposition to mental health care), or singular attachments (e.g., reliance on one adult child for all needs).
Suspension: The Greek philosophers believed that the suspension of judgment and commitment (what in Greek they called epoché, pronounced “eh-poh-kay´”) provided an ideal state of mind in which to examine the world. A later school of philosophy called phenomenology believed that this suspension provided a method of experiencing things more freely and less influenced by all the assumptions that color our perceptions. Thus, it is a state of mind suspended from our normal script. As an age point unfolds, this “suspension” is an ideal term to describe the deep state of uncertainty and confusion that occurs when our established assumptions or scripts cannot understand and process our current circumstances. We might liken this to the state of shock that occurs during a trauma, but without the depth of physical and emotional detachment. The suspension can be a positive state when we put aside previous assumptions that are prejudiced and limiting, and begin to think in broader and more creative ways. When negative, however, the suspension of the age point is a muddled state of mind with significant emotional tension that makes decision making difficult. We may lose our sense of meaning in the world, leaving us feeling shattered and vulnerable. Individuals who are emotionally overwhelmed by the suspension may lapse into deep anxiety or depression, have severe panic attacks, or even succumb to transient moments of psychosis in which they lose touch with reality.
Reckoning: The term reckoning refers to the act of estimating the amount or cost of something as well as facing a day of judgment when a debt, verdict, or decision is called. During age points, the process of reckoning forces us to examine our shortcomings and acknowledge that there is a problem. We must estimate the cost of reconsidering certain beliefs, relationships, or behaviors and face moments of change. We begin such reckoning from a previous position of strength that we relied upon, trusted to be our guide, and are reluctant to give up. By the definition of an age point, however, this position is not working. One can certainly try to avoid such reckoning, but there is great risk of perpetual suspension in which we regress into rigid and dysfunctional patterns of thought or behavior.
During the stage of reckoning, we begin to question our beliefs and our abilities. We may have a crisis of faith. It is painful to realize that trusted things have failed us in some way. We begin to enumerate what’s not working and consider alternatives. We calculate the process and price of making changes. We wonder how others might respond to our tribulations, and conjure up images and voices of parents, grandparents, and other authority figures in our lives. By its very nature, the process of reckoning might be the longest part of the age point, since we have to weigh whether we really want to make changes, imagine all the permutations, and allow both our emotions and our intellect to sit with each consideration and decide whether it feels right and is worth pursuing. As we begin to make decisions and mobilize our energy, we engage in self-monitoring of our actions and strategies to gauge whether they are meeting our goals, and if not, we correct course.
Resolution: A resolution to an age point is composed of a new set of beliefs and behaviors that close the gaps between the individual’s abilities and the demands of the situation that triggered the age point in the first place. Ideally, a new person arises from the age point with a more flexible and functional approach and a greater sense of well-being. Pathologic components of the age point, such as depression, anxiety, or substance use, should be improved if not resolved. The resolution may also reflect a failure of development and growth, due to resistance or regression. We may refuse to make changes or give up long-held beliefs or behaviors, and instead create a protective but limited and fragile bubble around us or regress into behaviors that provide immediate gratification but stunt our growth.
On the other side of their age point, in the resolution stage, Fred and Marlene have little memory of their visceral reactions to Fred’s illness. The fears, sadness, anger, and confusion of the suspension have receded and are difficult to conjure. During the period of reckoning, they began to question how they could maintain their previous lifestyle. They returned to skiing for a while, but began to focus more on the downside as a way to rationalize giving it up: achy knees, fear of injury, and disdain for the growing crowds on the slopes. Their previous avoidance and skepticism of doctors had to be reconsidered since Fred’s condition was a matter of life or death and they had no choice but to rely on them. Marlene had her battles with the doctors and nurses and had to carefully decide when to resist and demand and when to acquiesce. Both Fred and Marlene had to learn to trust a much wider circle of people.
As this reckoning unfolded, each wore his or her crown of wisdom well. Marlene became Fred’s sage, weighing each medical fact and figure presented to her by the doctors, asking question after question, and then advising Fred what he should do. Her role as a savant for organization kicked in, since she had to plan their calendar around his medical care and ultimately organize regular trips to the National Institutes of Health to enable Fred to receive experimental treatment. Fred emerged as a seer, finding acceptance and even some serenity in knowing that somehow everything would work out. “The situation made me stronger because I didn’t have a choice,” he recalled. “I had to do what I had to do. Eventually, I was able to look to others and get strength from them.” This was a huge change for a fiercely independent man who was used to running the entire show.
The resolution followed from their wisdom and adaptation. They sought out the best care they could find and then trusted the doctor to work his magic—which he did, to a complete remission after four lengthy attempts. They moved from a community up in the mountains down to the city of Denver and started a new life without skiing and hiking, but with many other meaningful pursuits. Fred retired from the pressure of his accounting practice. He is no longer preoccupied with work and is able to spend more time with friends and family in a relaxed and free-flowing manner. Marlene was clear about the change: “I grew up a lot in the last six years.” She adjusted her expectations of what she could do in life and found greater acceptance of her limitations. Many years ago, she once told me that I ought to “shoot her” if things got really bad in her old age. I don’t see that Marlene anymore: she is able to adapt. I am confident that Fred and Marlene will be able to face the changes ahead with newfound strengths, and it was the age point surrounding Fred’s illness that made all the difference.
What Do Age Points Give Us?
Age points illustrate the transitions we make in life, and can occur at any time and under many circumstances. Although they might occur within a major stage or change of life, such as midlife, menopause, or retirement, they also allow us to examine our own experiences in the moment, untethered from any developmental milestones or scheme. Age points can even apply to individuals in the ninth stage, who are otherwise effectively left out of all current life cycle theories and models.
When I first met Arturo and Flavia, I met the whole family. They came to my office accompanied by their two sons and daughters-in-law in person, and their daughter joined via phone. Arturo’s brother came, since he was a physician and wanted to offer his thoughts. Flavia’s sister and housekeeper also attended. My assistant had already circulated through the crowded room and offered bottles of water and small cups of Cuban coffee, and by the time I entered it sounded like a raucous family reunion, fueled in part by potent jolts of caffeine. In my past lives as a doctor in Boston and Minneapolis, such a scene would have been overwhelming, but this was Miami and it was just another Monday morning clinic. Arturo and Flavia’s large group, all originally from Venezuela, were like many of the Cuban and South American families, Christian and Jewish alike, who come to my memory center as la familia enterra or die gantze mishpocha—the whole family—seeking my counsel and wanting to give input and provide support from every angle.
Arturo spoke first. He was seeking a second opinion because his wife had recently been diagnosed with Alzheimer’s disease by a local neurologist, but he didn’t believe it. He argued that the memory changes reported by his children and sister-in-law were exaggerated. Flavia had always been somewhat absent-minded, he argued, and this accounted for most of the negative assessments, including that of the neurologist who “really didn’t know her.” Flavia’s provisional diagnosis, however, had thrown him into a deep state of anxiety, and he reported difficulty sleeping and eating. Because he ran a successful import-export company, which took him out of the country for long trips, he urgently needed to know that Flavia would be okay.
I turned to Flavia, who was sitting quietly next to her husband with an anxious smile on her face. She was impeccably made up and beautifully dressed, as if she were attending a dinner party and not on a visit to the doctor. She spoke to me in English with frequent lapses into Spanish when she couldn’t come up with the right word. She was aware of her family’s concerns, but didn’t see the same problems with her memory. As she spoke, she often would pause to search for a word, and look to her husband for a hint. “You, you have to tell him!” he bellowed at her each time.
Her daughter Sofia suddenly broke in over the phone, and implored me to take their concerns seriously in contrast to what their father was saying. Flavia’s sister Patricia started crying and nodding her head in agreement as she listened, and then interrupted to add that their mother had suffered from Alzheimer’s disease and she was seeing the exact same symptoms in Flavia. Arturo’s brother spoke up next, expressing exasperation at the previous doctor’s hasty diagnosis and insisting that a full workup had not been conducted. The two sons listened and seemed to be torn between their father’s and sister’s differing opinions. Their questions focused on how I could help them find more resources for their parents. When they finished speaking, all eyes turned toward me.
Up to that point, the meeting had been a little bit like the 1950 Japanese film Rashomon, where a single event gets described from multiple contradictory angles. It was clear that the couple was facing a major age point, and in the throes of this crisis they were tasking me to guide them through to the other side. But I had to somehow find a way to harmonize the disparate voices into a common pitch. Clearly, the tentative diagnosis of Alzheimer’s had thrown Arturo into the suspension of an age point, causing him to be stunned, deeply anxious, and uncertain about where to turn. He resisted the diagnosis and tried repeatedly to explain away Flavia’s symptoms. He was stuck at that point, lacking the knowledge to make further conclusions and preoccupied with suppressing his anxiety. Flavia was equally uncertain and frustrated, wanting to please both her husband and her sister at the same time that she was clearly struggling with increasing short-term memory deficits.
Sometimes the best approach during the suspension is to get people back to their safe spots. Arturo needed a logical process of inquiry and some hope, and Flavia needed some reassurance and family harmony. I knew I could help here but that the patch would only be temporary. Still, I hoped it would give the whole family more time to absorb the changes and marshal resources. I began by thanking all of them for coming and acknowledging the power of their family unity. I praised Arturo for his fierce dedication to Flavia and stated my commitment to finding a solution. I gave them a vision of a comprehensive assessment and treatment plan that transcended the diagnosis; in other words, we would work together no matter what was revealed. Everyone could feel as if he or she was actively working on a solution, even without knowing the exact diagnosis. After a lengthy explanation of the necessary workup, including brain scans and cognitive testing, I listened to the family’s concerns and answered their questions. Even in the midst of this age point, Arturo and Flavia were able to have a moment of hope.
Age points do not unfold in linear patterns. There is much seesawing between the gaps of the situation before strengths can begin to emerge and create a solution. Such was the case with Arturo and Flavia, and they struggled for some time. Flavia was not fully aware of her short-term memory loss, but was noticeably frustrated, confused, and resistant to help. She insisted on taking her own medications but made regular mistakes that resulted in several medical crises, including sky-high blood pressure when she forgot to take her medication and a fainting spell when she took too much.
Arturo was acutely aware that Flavia’s memory had declined, but he detested and resisted the idea that she had Alzheimer’s disease, to the point of full denial. Out of frustration and avoidance, he began taking long business trips out of the country for weeks on end. He began drinking more alcohol, sleeping less, and driving himself to expand his business, as if that would somehow compensate for Flavia’s losses. Every discussion with his children became an argument. He accused Flavia’s sister of creating the whole situation in the first place and stopped talking to her. His brother tried to intervene, but Arturo simply couldn’t discuss the inevitable diagnosis. Even as his suspicions grew, however, he avoided setting up a follow-up appointment until his sons forced the issue.
When we met to review the test results, I suggested gently that everything pointed toward a likely diagnosis of Alzheimer’s disease. Arturo wanted to know what Flavia’s PET scan showed, and I told him it was positive, meaning that it showed evidence of significant amounts of the toxic beta-amyloid protein in her brain. He looked at me in disbelief, and then the emotional dam broke. He began sobbing uncontrollably, as if the entire weight of evidence had finally sunk in. It was a painful, agonizing moment for everyone in the room, but provided the necessary emotional release to unblock Arturo’s avoidance and endless, rigid reckoning. He was ready to move forward.
Navigating the Age Point
In this case, Arturo and Flavia were surrounded by supportive family and doctors who could stand by during the age point and help craft a solution. Some people are not so fortunate, and end up spinning and spinning in the suspension without being able to face reality. To relieve such emotional turmoil, these stuck individuals often end up retreating into depression, anxiety, substance abuse, compulsive behaviors, or rigid lifestyles. These responses are only partially helpful as they replace one form of distress with another that initially feels better but stunts personal growth and carries a risk for further crises and paralysis.
Other people can move beyond the suspension and into a period of reckoning, but they cannot reconcile opposing perspectives or ideologies and stretch their intellect beyond a very narrow and fixed worldview. As a result, they abandon any meaningful discussion or consideration of their circumstances and plunge or retreat into false beliefs, ideologies, estrangements, or contradictory relationships. Such aging brings a fierce circling of the wagons and an unhealthy narcissism. Think of an aging dictator who cannot accept the possibility of relinquishing power and maintains an oppressive and sclerotic regime at any cost. On a smaller scale, these are aging individuals who cut themselves off from family members who refuse to follow their dictates or who live lifestyles they find unacceptable. There is simply no compromise, but this rejectionist approach carries great risk of further impasses and crises.
There are also individuals who bail out of the reckoning stage by refusing to do anything: they disengage. They may do this because they don’t believe that they have the mental or physical ability to change. They might be frightened of the consequences. They might be exhausted or preoccupied by some other stressor. Or they might not actually have the resources to effect change because they are in the ninth stage. We used to believe that disengagement was a natural part of aging, and so we didn’t expect people to change and we stereotyped them as rigid and impaired (we sometimes still do!). There is simply no significant research to support such a theory, and we know instead that aging often brings the opposite—engagement across a wide swath of issues and activities. Nonetheless, we should view a disengaged aging person as someone who is struggling with the possibility of change and still retains the capacity to move forward, even if he or she doesn’t believe it.
Up until his emotional release, Arturo was trying to find an easy out of the reckoning phase. He was faced with trying to reconcile his enduring belief in Flavia as a cognitively intact, full partner in their marriage, with an image of her as diminished and dependent. In clinging to the former belief, he began to disengage with anyone who suggested otherwise. He contemplated a complete rejection of all her doctors and instead began researching several radical and wholly unproven therapies that promised an instant cure. Flavia was having a difficult time herself, since her insight into her memory changes was poor and getting worse, and she resented anyone’s labeling her as impaired and treating her like a child. She also began to disengage from friends and relatives. How was it possible to breach this impasse with them?
Getting beyond the point of reckoning and into the resolution stage of an age point requires two strengths that may seem to be moving in opposite directions. On the one hand, people need to grab on to their anchors of reserve, represented by beliefs, skills, memories, and relationships that provide stability and consistency. On the other hand, they need to follow the path suggested by French author Marie de Hennezel to “let go of our past, become reconciled with ourselves, and accept that we will be diminished in one respect in order to grow in another.” Accomplishing both tasks seems contradictory, but is necessary and has a cabinet of allies in our five wise selves. The savant brings the necessary skills, while the sage forges a compromise; the curator engages with the desired customs and communities, while the creator crafts new ways to think and act. Finally, the seer harmonizes the various perspectives into a vision of life that enables us to fully accept and find meaning in the resolution.
Arturo could no longer push away the reality of Flavia’s illness. In his catharsis during our meeting, he bent but didn’t break by leaning on his core strengths: his street smarts and business acumen, his family connections, and his deep and abiding love for Flavia. He also let go of the impediments to change. Within a few weeks of our meeting, he took several radical steps that seemed unlikely the month before—but now flowed easily. He turned over his business to his sons and assumed an advisory capacity. He decided to manage Flavia’s care with the same energy and creativity that he had managed his business. He reengaged with his entire family and began directing them in ways to be most useful. It was a stunning turn of events, but the seeds of it were always present and it took the rocky ride of the age point to break them down and grow them. The end of the age point revealed two more age-emergent strengths that pushed it along: resilience in the face of stress, and a deep sense of purpose.