The body’s decline creeps like a vine. Day to day, the changes can be imperceptible. You adapt. Then something happens that finally makes it clear that things are no longer the same. The falls didn’t do it. The car accident didn’t do it. Instead, it was a scam that did.
Not long after the car accident, Alice hired two men to perform tree and yard work. They set a reasonable price with her but clearly saw her as a mark. When they finished the job, they told her that she owed nearly a thousand dollars. She balked. She was very careful and organized about money. But they got angry and threatening, and, cornered, she wrote the check. She was shaken but also embarrassed and told no one about it, hoping she could put it behind her. A day later, the men returned late in the evening and demanded she pay more. She argued with them, but in the end she wrote that check, too. The ultimate total was more than seven thousand dollars. Again, she wasn’t going to say anything. Neighbors, however, heard the raised voices at Alice’s doorstep and called the police.
The men were gone by the time the police arrived. A policeman took a statement from Alice and promised to investigate further. She still didn’t want to tell the family about what had happened. But she knew this was trouble and after a while finally told my father-in-law, Jim.
He spoke to the neighbors who’d reported the crime. They mentioned that they had become worried for her. She no longer seemed safe living on her own. There was this incident and the Impala in the bushes. There was also what they observed of how difficult managing matters as ordinary as getting her trash to the curb had become.
The police caught the scam artists and arrested them for grand larceny. The men were convicted and sentenced to prison, which should have been satisfying for Alice. But instead the whole process kept the events, and the reminders of her growing vulnerability, alive and lingering when she would have dearly loved to have set them behind her.
Soon after the scammers were caught, Jim suggested that he and Alice go together to look at retirement homes. It was just to see what they were like, he said. But they both knew where this was going.
*
DECLINE REMAINS OUR fate; death will someday come. But until that last backup system inside each of us fails, medical care can influence whether the path is steep and precipitate or more gradual, allowing longer preservation of the abilities that matter most in your life. Most of us in medicine don’t think about this. We’re good at addressing specific, individual problems: colon cancer, high blood pressure, arthritic knees. Give us a disease, and we can do something about it. But give us an elderly woman with high blood pressure, arthritic knees, and various other ailments besides—an elderly woman at risk of losing the life she enjoys—and we hardly know what to do and often only make matters worse.
Several years ago, researchers at the University of Minnesota identified 568 men and women over the age of seventy who were living independently but were at high risk of becoming disabled because of chronic health problems, recent illness, or cognitive changes. With their permission, the researchers randomly assigned half of them to see a team of geriatric nurses and doctors—a team dedicated to the art and science of managing old age. The others were asked to see their usual physician, who was notified of their high-risk status. Within eighteen months, 10 percent of the patients in both groups had died. But the patients who had seen a geriatrics team were a quarter less likely to become disabled and half as likely to develop depression. They were 40 percent less likely to require home health services.
These were stunning results. If scientists came up with a device—call it an automatic defrailer—that wouldn’t extend your life but would slash the likelihood you’d end up in a nursing home or miserable with depression, we’d be clamoring for it. We wouldn’t care if doctors had to open up your chest and plug the thing into your heart. We’d have pink-ribbon campaigns to get one for every person over seventy-five. Congress would be holding hearings demanding to know why forty-year-olds couldn’t get them installed. Medical students would be jockeying to become defrailulation specialists, and Wall Street would be bidding up company stock prices.
Instead, it was just geriatrics. The geriatric teams weren’t doing lung biopsies or back surgery or insertion of automatic defrailers. What they did was to simplify medications. They saw that arthritis was controlled. They made sure toenails were trimmed and meals were square. They looked for worrisome signs of isolation and had a social worker check that the patient’s home was safe.