Laura Lamar is a registered nurse, attorney, and hospital risk manager in Chicago. Her father was a pharmaceutical salesman. Years ago, she took a vacation on the central California coast and struck up a conversation in a restaurant with a retired teacher in her late seventies named Marj. The two women quickly bonded: both had wicked senses of humor and plenty of joie de vivre. Marj had come into her own after the death of her husband, an architect, and she was making the most of the time she had left.
The two kept in touch. Whenever Laura was on the West Coast, she and Marj got together for cocktails and outings. Time passed. Marj had a few mini-strokes, turned ninety, sold her house, and moved into an assisted living complex in Monterey with a view of the sea. Her balance grew wobbly. She got dizzy frequently and sometimes lost her train of thought. She started using a walker. But the friendship stayed strong and Laura kept visiting.
One summer day, as the two were sitting down to lunch in the residence dining room, Marj realized she’d forgotten her mealtime medications and asked Laura to go to her unit for them. In the kitchen cabinet, Laura found twenty-two pill bottles neatly lined up, prescribed by six different doctors and filled at four different pharmacies. “Nobody had any oversight,” said Laura. “It was a disaster waiting to happen.”
Marj was taking drugs for hip pain, sleeplessness, constipation, itchy skin, high blood pressure, acid reflux, and other common late-life miseries. For high blood pressure, her cardiologist had prescribed Lopressor, which can cause insomnia, so another doctor had prescribed a sleeping pill. A second blood pressure medication, Lasix, was making her skin itch, and for that she was taking Benadryl. The Benadryl made her constipated, so she was told to take Dulcolax, a suppository that can cause dizziness. And so it went. Almost every drug on the shelf had a side effect that had led to a new drug that had led to yet another drug to counteract yet another side effect. Dulcolax, Benadryl, and another of her drugs, Tagamet, all caused dizziness, a serious risk for an elderly woman with brittle bones whose balance was unstable enough to require a walker. Benadryl and the sleeping pills are also anticholinergics, an insidious group of commonly prescribed drugs that befuddle thinking and substantially increase the likelihood of developing dementia.
Laura returned to the dining room with a few of Marj’s pill bottles in hand and sat down with her friend. “Marj,” she said. “This is really, really dangerous. I would have a difficult time managing all these different medications—and you’re ninety-two! Do you mind if I have a talk with your son?”
Later that night, she phoned one of Marj’s three sons, all of whom lived more than five hours away near the Oregon border. “This is not my business,” she said. “But I’m going to put my nose in because I love your mother.” She laid out the situation: the pills, the numerous doctors and pharmacies, the right hand not knowing what the left was doing. Laura suggested a “medication review” with a geriatrician—a specialist in the health problems of old age. After a prolonged search—there are only 7,500 geriatric specialists nationwide for an older population of over twelve million—her son found one thirty miles from his mother’s home and set up an appointment. Marj put all her medications in a paper bag, got in the car her son hired, and went.
In the geriatrician, Marj finally had a doctor who looked at her as a whole person, rather than a collection of malfunctioning organs. Over the course of the following year, her new “umbrella doctor” weaned her off Benadryl, Lopressor, Dulcolax, and another fourteen of her medications. The process was slow. Her doctor tried drugs with less drastic side effects, reduced dosages gradually, and recommended nondrug alternatives. Marj began swimming five days a week rather than two, which reduced her hip pain. She ate more fiber-rich fruits and vegetables, which diminished her constipation and acid reflux. By the time the year was over, she was taking five prescriptions, saving money, and feeling better. “Her mind was clearer, she wasn’t dizzy anymore, her gait and balance were better, she was sleeping better, and she was no longer losing her train of thought,” Laura said. “She just needed someone to stand up for her.”
Decline, as experienced in the phase I’m calling Slowing Down, is more often felt than seen. Eyes cloud, joints ache, muscles wither, stamina thins, the immune system weakens, bones grow brittle, minor slips of memory bedevil the day. Maladies accumulate.
The medicine cabinet fills with pill bottles, the calendar with doctors’ appointments. The body becomes increasingly vulnerable to tiny blows it once shrugged off. Recovery takes longer, and sometimes people never get back to their old “normal.” Most people slowing down are in their seventies or older, but some people in their fifties and sixties who are coping with several chronic illnesses are keenly aware they’re in this stage.
Continue with the lifestyle changes suggested in the previous chapter, especially exercise, as it will lengthen your time on a high plateau of decent functioning. But one way or another, decline will come. Living the happiest, healthiest possible life is made easier by simplifying daily routines, creating a coordinated team out of a fragmented jumble of doctors, making peace with loss, and understanding the limits of medicine in the face of advanced age and chronic illness.
As energy becomes a precious and limited resource, simplifying is a survival skill. I’ve learned to beware “the disease of one more thing”—the attempt to squeeze just one more movie, dinner, car trip, or party into a weekend. My husband and I find that when we do less, we enjoy what we do do, more. We try to let go of the unimportant and stick with what gives us the most meaning, comfort, and joy. This is a fine time to think about what you hold dear and make sure you are spending your precious life doing it.
Moving to a smaller house, reducing the size of a lawn and the number of mutual fund accounts, putting bills on auto-pay, and decluttering possessions can help you stay independent longer. Keep the tasks of daily life manageable as energy and mental clarity wane. You can also apply the principle of simplification to the doctors you see, the health screenings you permit, and the pills you take.
This is a time to reorient your expectations of medicine. What worked when you were younger may not work now. Earlier, the rapid deployment of tests, drugs, and surgeries might have meant the difference between living and dying. But fast medicine can expose aging, fragile bodies to unnecessary risk. Thoughtful, well-coordinated, less aggressive care, supervised by a single doctor, often produces better results. Look for medical allies in geriatrics, primary care, and family medicine, all of whom understand that the health problems of later life are usually caused by multiple factors. What often works best is not a silver bullet, but a lot of modest tinkering.
First formulated by cardiologists in Italy in 2002, the philosophy of Slow Medicine was popularized in the United States by the late Dennis McCullough, MD, a geriatrician at Dartmouth Medical School and author of the landmark 2008 caregivers’ manual My Mother, Your Mother: Embracing “Slow Medicine,” the Compassionate Approach to Caring for Your Aging Loved Ones. Slow Medicine for elders, as McCullough described it, is characterized by medical minimalism, thoughtful collaborative decision-making, and protection from overtreatment. He cautions that at this health stage, “ill-considered testing, drugs, or medical procedures may pose a greater threat than taking no action at all. Poor sleep, indigestion, incontinence, constipation with soiling, and depression are seldom ‘fixed’ by a drug alone.” Look for doctors who take time to create a relationship of trust. Try to find someone who asks about symptoms, takes a careful medical history, touches you, listens, and thinks things through without haste. In the words of cardiologist and Slow Medicine pioneer Alberto Dolara, “To do more is not necessarily to do better.”
Given the gaps in our health care system, this may prove impossible. But it’s worth a try. Unfortunately, doctors who work as solo practitioners and are paid on a fee-for-service basis are not reimbursed well for giving any patient this kind of thoughtful care. “Spending proper time to deal with several medical issues in one visit,” said one former primary care physician, “can take an hour . . . and more time after that for phone calls, notes, and paperwork. Medicare does not pay the $300 to $400 per hour that it takes to run an office, so having such patients is a losing proposition. This is why primary care physicians refer them to specialists and neglect to discuss the big picture.” The result is a collection of specialists who don’t talk to each other.
For this reason, many good primary care doctors have fled to health maintenance organizations (HMOs) where they are paid on salary and freed from the headaches of running a small office. If you’re lucky enough to live in an area with a good HMO or Medicare Advantage plan, and your health problems are not exotic, consider leaving fee-for-service medicine for an HMO.
All-under-one-roof HMOs, like the sprawling, highly rated Kaiser Permanente systems, provide your health care for a set monthly fee or, if you’re over sixty-five, via a Medicare Advantage program. Because they are responsible for all your medical costs, HMOs have a vested interest in keeping you healthy and out of the hospital.
Your medical care is usually better coordinated, and HMOs like Kaiser often score high on national ratings of quality and safety. They aren’t reimbursed per procedure, so you aren’t given treatments because they’re remunerative rather than good for you. HMOs often offer classes and support groups to help you to prevent falls or diabetes, thus helping you to stay in charge of your own health. Their doctors make their decisions using “evidence-based medicine”—providing treatments with proven benefits rather than those favored on the basis of a random combination of tradition, physician habit, “gut instinct,” reimbursement incentives, and pharmaceutical promotions.
HMOs aren’t for everyone. Their doctors also juggle too many patients in too little time. Seeing a specialist requires a referral from your primary care doctor. An HMO doctor won’t prescribe a new drug because you saw an ad on television and it won’t pay to send you to the nation’s expert in your disease unless you can prove it to be “medically necessary” via a time-consuming process.
When you’re young and healthy, or have a rare cancer that benefits from specialty treatment, these restrictions may persuade you to keep your options open. In a one-off health crisis, you (or someone who loves you) may have the time and energy to sift through Internet rankings and find a specialist who takes your insurance. But as you age, and your garden-variety health problems multiply, consider the time and energy costs of all that chaotic and fragmented free choice. Many Medicare Advantage programs have lower monthly premiums than traditional fee-for-service Medicare and others offer perks like exercise programs, dental care, and eyeglasses.
If you are lucky enough to live in an area with a Kaiser Perma-nente organization, or another one of the excellent nonprofit Medicare Advantage plans listed in the back of this book, I strongly suggest checking it out. Advantage plans have a built-in financial incentive to offer better coordinated care to people with multiple health problems, and a better record in caring for the dying. “On almost every quality metric for end-of-life care, terminally ill patients enrolled in Medicare Advantage plans received better care than those enrolled in fee-for-service Medicare,” bioethicist Ezekiel Emanuel, a health policy consultant to the Obama administration, wrote in JAMA in 2018. Fewer were hospitalized or admitted to an ICU in their last three months, more enrolled in hospice care, and more died at home rather than in a nursing home.
But the quality of Advantage Plans vary wildly by region. Speech therapist Amy Lustig cautions that many of her clients had access to a better array of covered services when they were in standard Medicare. Check the annual listings of the stellar ones in US News and World Report.
In an area without a good freestanding HMO or Medicare Advantage plan, ask around for a regional nonprofit health system with a good local reputation, started by community leaders, with a tradition of collaboration among diverse providers (such as doctors, hospitals, nursing homes, and home care agencies). Then find insurance that covers it.
Another option, if you can afford it, is to join the “concierge practice” of a good primary care doctor. In exchange for a fee (ranging from about $100 a month to many thousands) on top of usual health insurance costs, these doctors devote more time to fewer patients. The phrase may sound snooty, but many concierge doctors are dedicated to delivering time-intensive, high-quality medical care and have patched together a funding model, within a broken system, that permits them to do so. The people I know in concierge practices tend to be much more satisfied with their first-line medical care.
Americans have the dubious distinction of being the most medicated people on earth. With a few notable exceptions, all this pill-taking has not produced significant improvements in health. More than two-fifths of Americans over sixty-five are on more than four medications, and many of those drugs increase their risk of falling, developing dementia, or damaging a vital organ. Medication reactions in people over sixty-five account for a quarter of all emergency room visits and half of all hospitalizations for medication errors, some of which prove fatal. The problem is so widespread that it’s earned its own medical label: polypharmacy.
Because your kidneys and liver now work less efficiently, drugs remain longer in your tissues and create more side effects. A medication that causes grogginess may be no worse than a hangover for a young person with the surplus neural connections that scientists call “cognitive reserve.” The same side effect might cause an older person to fall or to forget about a pot on the stove, prompting pressure from anxious adult children to make a premature and unnecessary move to an assisted living complex.
The root cause of most overmedication is having multiple doctors write prescriptions. The long-term solution is better coordinated medical care, and the interim solution is to simplify your drug regimen. If you are on more than five medications, set up an appointment for a medication review (and no other purpose) with your primary care doctor, a geriatrician, or a pharmacist with specialized knowledge of geriatrics. (You can also consult the website Drugs.com, or the Physician’s Desk Reference, available at most libraries.)
Put all pill bottles, including supplements, in a paper bag. Ask the practitioner about the purpose of each drug, and whether it could be causing a bothersome symptom, especially dizziness, falling, or confusion. Is it amplifying, canceling out, or interacting with another drug on your list? Does it increase your risk of dementia? Is it the lowest effective dose of the cheapest, safest option? Is it working? If you haven’t noticed a positive effect after six weeks, can you drop it? Was it prescribed to address another drug’s side effect? If so, might you be better off skipping both drugs and just tolerating the original problem?
My watchword here is discernment. Controlling blood pressure and blood sugar, for instance, is proven to save lives and postpone disability. Effective pain management is equally critical, because people in pain exercise less, feel more miserable, get isolated, and function poorly. But I suggest turning a cold eye on the following drugs because of the risks they pose to balance, brain, or continuing independence:
Cholesterol-lowering statins have dubious advantages for people over seventy with no history of heart disease. The benefits, in the form of reduced risk of a heart attack and stroke, are minimal for anyone likely to live less than another decade. Side effects can include fatigue, cognitive impairment, diabetes, and muscle pain and damage, all of which increase fall risk. If you are suffering a difficult side effect, geriatrics specialist Eric Widera, MD, of the University of California medical school in San Francisco, suggests that you and your doctor ponder dropping them.
Drugstore painkillers are useful in moderation, but not harmless. Ibuprofen can raise blood pressure, and repeated overdoses can cause kidney damage severe enough to require dialysis. Many people with chronic pain benefit from low round-the-clock doses of Tylenol (acetaminophen), but overdoses are the nation’s leading cause of liver failure. Aspirin in excess can cause stomach bleeding. Rotate minor painkillers and don’t take more than labels recommend. Explore managing pain with nondrug remedies, such as yoga, massage, meditation, exercise, physical therapy, or mindfulness-based stress reduction (MBSR), offered by many hospitals and health systems.
Anticholinergics radically increase your risk of developing dementia. They are contained in many over-the-counter and prescription drugs for sleeplessness, allergies, acid reflux, colds, incontinence, irritable bowel, muscle spasms, and anxiety. Staying away from them may be the easiest and most powerful way to protect your brain. As a rule of thumb, beware any drug whose label warns against drowsiness, confusion, or operating heavy machinery.
Be skeptical of drugs containing the anticholinergics chlorpheniramine (in Actifed), diphenhydramine (in Benadryl), and loratadine (in Claritin). One or the other is frequently present in drugs like Excedrin PM, Advil PM, Aleve PM, Nytol, Simply Sleep, Tylenol PM, Chlor-Trimeton, Codeprex, and Advil Allergy and Congestion Relief. A landmark study in Washington State involving more than three thousand people, found that those over sixty-five who used anticholinergics heavily were 50 percent more likely to develop dementia than those who took very few. Many anticholinergics are taken for minor problems; find nondrug remedies, or wait it out.
Prednisone and other steroids reduce pain and inflammation by dampening the immune system. They increase the risk of falls and cognitive impairment. Find alternatives unless life is at risk, and even then take the lowest dose for the shortest possible time. Noted side effects include depression, confusion, mood swings, muscle weakening, temporary psychosis, and long-term heart damage.
Benzodiazepines and sleeping pills increase dizziness, fatigue, and falls. If you are anxious or suffer from sleeplessness, be cautious about Valium, Librium, Xanax, Ativan, and Halcion. Daniel Hoefer, MD, who oversees serious illness management programs for the Sharp Rees-Stealy Health System in San Diego, suggests aggressively exploring nondrug remedies. Once again, start with what requires the most from you and the least from medicine, before escalating step-by-step to drugs with greater potential for harm. Benzodiazepines are addictive and should be used only short term; weaning yourself must be done very slowly, under a doctor’s supervision.
See if incremental fixes will improve your sleep quality, which naturally declines with age. Many people do better when they skip caffeine after noon; get more exercise in daylight; keep a regular bedtime; replace a lumpy mattress; wear socks to bed; shut down computer and TV screens after dinner; and keep the bedroom cool, quiet, and dark, using earplugs and a sleep mask if necessary. Others improve their sleep with bedtime rituals, like drinking chamomile tea; taking a twenty-minute hot bath shortly before bed; making a to-do list for the next day; or listening to a relaxation or self-hypnosis audio. Some people swear by the hormone melatonin, available over-the-counter, but its long-term effects have not been studied.
In all things, don’t let the cure be worse than the disease. A leaky bladder, for example, is an embarrassing and common old-age inconvenience—but the Ditropan (oxybutynin) often prescribed is an anticholinergic. When people on it seem befuddled, the antidementia drug Aricept is added, often worsening the original incontinence. Another common side effect of Aricept is a slowed heartbeat, which can lead to the unnecessary implantation of a pacemaker. Better to eliminate both drugs and see whether you are any worse off. Once again, start by exploring nondrug remedies: ask your doctor for a referral to a continence training class, learn to do Kegel exercises, use pads and time bathroom breaks, or try taking a postnatal yoga class to strengthen your internal musculature.
A “screening” is a search for a health problem in the absence of symptoms. Some, such as Pap tests, have proven their worth by catching treatable diseases early. But they’ve also led to medical overkill, and geriatrics specialists recommend against many of them because they promote unneeded worry and overtreatment.
The American Academy of Family Physicians, for instance, recommends against a PSA (prostate cancer) test for men over seventy-five without a family history of fast-moving prostate cancer. A high PSA reading often creates emotional pressure to undergo surgery and radiation, which can leave you with incontinence and impotence without extending or improving your life. Most prostate cancers are so slow-growing that older men die with them rather than of them.
Colonoscopies save lives by detecting precancerous polyps. The United States Preventative Task Force does not recommend them for people over age seventy-five without a family history of colon cancer. They usually require sedation and large co-pays, and they carry a small risk of perforating the colon—a potentially devastating physical setback to an older person. (They are, however, very well reimbursed.) The polyps can take five to ten years to develop into cancerous lesions. If you’re unlikely to live that long, or are too fragile to withstand surgery in any case, skip the screening. An annual twenty-dollar noninvasive FIT screening (fecal immunochemical test), or the higher-priced Cologuard, will look for hidden traces of blood in your stool, and will do almost as good a job of detecting problems in your lower colon at a fraction of the cost and risk. You collect a sample in the privacy of a bathroom, put it in an antiseptic bottle, and mail or deliver it to a lab. You can find other “not recommended” screenings, vetted by the relevant medical specialty, on the Choosing Wisely site of the American Board of Internal Medicine (ABIM).
Loss is a given in this life stage. Grieving—for people who have died, for a job you once enjoyed, for physical powers that are fading—is not depression. Don’t pathologize sorrow, it’s a healthy and common human emotion. Antidepressants cannot cure it, and many that work well in midlife, such as Prozac, increase the risk of falling.
After his wife, Clydene, died of pancreatic cancer in 2006 at the age of sixty-nine, Doug von Koss spent months mourning her. Clydene had been a knitter and an award-winning quilter, making all her own clothes on her prized Bernina sewing machine. Every closet and drawer, every square inch of their shared house, was stuffed with boxes filled with materials for her crafts.
“Evidence of her passions was everywhere,” Doug told me. “A closet bursting with costumes and dresses she had designed and crafted, each with a particular memory for me. The smell of her perfume—Shalimar. Enough fabrics in the basement to supply a quilting society for a year, and enough yarn to make sweaters for two kindergarten classes. There were carefully labeled boxes dedicated to holidays and birthdays, each carrying a memory of friends and family and, of course, Clydene. There was an enormous hole in our home and in my heart.”
After the memorial service, he created an altar to Clydene on top of the grand piano in their dining room. Atop a piece of brocade fabric, he placed emblems of his dead wife: her lace handkerchief, a pair of her earrings, a pincushion, her knitting needles, embroidery scissors, a tape measure, a favorite teacup and saucer, and a framed photo of her when she was still radiantly healthy. He covered the altar with a piece of lace, so that most of the time he could see only the vague outline of her precious things.
Each morning, in a private rite marking his transition from husband to widower, he would uncover the altar and have a conversation with Clydene—“sometimes internal, sometimes aloud,” he told me. He wept in seemingly endless sorrow. “Sometimes it was really raw, but grief isn’t pretty. When I felt complete, I covered the altar and got on with the day.”
Occasionally he came across an object or a photo that carried a new memory and placed it on the altar, so that it wasn’t static. After months of mourning, he reread the marriage vows they’d taken and came to the place that reads “ ’til Death do us part.”
He had kept his vows and completed them. Death had parted them. He was husband no more. “The sense of loss diminished and a gratitude for what we had took its place,” he said. “This was a welcome surprise.” He took down the altar and left the company of mourners. He emptied the closets, distributing Clydene’s treasures to her friends, her daughter, her daughter-in-law, and her granddaughters. He gave clothes to Goodwill and fabrics to quilters.
One day he felt the urge to paint what had been their bedroom (and was now only his) a burnt orange, even though he was sure she’d have disapproved. Next he painted the bathroom a sea green—surely too bright for her taste. The dining room and living room followed, painted a beautiful Mexican yellow gold. He bought wall-to-wall carpeting, put down new linoleum in the kitchen, and hung up pictures he knew she wouldn’t have liked. The colors are unusual, harmonious, and beautiful.
“Her voice was over my shoulder a lot,” he said. “Oh Doug, you’re not going to do that, are you?
“And of course, I did. And clearly, I love it! Rugs, bedding, towels, curtains, upholstery, and much more were changed to accommodate a widower who needed a sanctuary for the long haul,” he said. “It is quite enough to carry the memories of our lives together in my heart and imagination. I can visit them at my choosing now, instead of living in a constant reminder of what once was and is no more.”