The Care of the Older Person

By Ronald Caplan

Crucial information for those who care, provide, create, and build for our rapidly growing-and cherished-senior population.

Society as a whole is getting older. As a result, more and more of us are living and engaging with an aging population in both our personal and professional live

• Language: English
• Publisher: Ronald Caplan
• Release date: Mar 11, 2021
• ISBN: 9781735009322

Book preview

THE CARE

of the

OLDER PERSON

Fourth Edition

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The Care of the Older Person

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DISCLAIMER: The contents of this book and e-book and all materials contained in this book and e-book are for informational purposes only. The materials and information contained in this book and e-book are not intended to be a substitute for professional medical advice, diagnosis, or treatment. You should always seek the advice of your physician or other qualified health provider if you have questions regarding a medical condition. Never disregard professional medical advice or delay in seeking it because of something you may have read in this book and e-book. Medical professionals should not rely on any drug, drug dosage, or other information in this e-book and book, which is for informational purposes only.

If you think you may have a medical emergency, call your doctor or 911 immediately. The authors do not recommend or endorse any specific tests, physicians, products, procedures, opinions, or other information that may be mentioned in this book and e-book. Reliance on any information provided in this book and e-book is solely at your own risk.

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CONTENTS

DISCLAIMER

EDITORS/CONTRIBUTORS

CONTRIBUTORS

INTRODUCTION

Caring for the older person

Frailty

Physical activity as a countermeasure to frailty

Doctor, my wife is getting forgetful

Update on Alzheimer’s disease diagnosis and management

Navigating the journey of dementia as a caregiver

How to diagnose and manage delirium

Why does my patient have gait & balance disorders?

Could my patient be malnourished?

Are the immunizations of my patient up to date?

Management of older patients in the emergency department: this man is old, but is it an emergency?

Critical care of the older person

COVID-19 in long-term care

Stroke prevention in the elderly

Advances in cardiac care for older persons

How to manage type 2 diabetes in frail elderly patients

Cancer in older adults

Cancer screening in the older adult

Psycho oncology: living with the fear of death

Incontinence in older adults

Polypharmacy and deprescribing in the elderly

After the menopause

Skin care of the older person: the skin and its associated changes

Elder abuse

Late-life anxiety

An overview of late-life depression

Assessment of decision-making capacity

How do I protect my patient?

Financial guidance for seniors

The role of religious belief in the end-of-life care of older persons

Glossary: medical terms and their meaning

Bibliography & Supplemental Bibliography

EDITORS/CONTRIBUTORS

Olivier Beauchet, MD, PhD, Professor of Geriatrics, Dr. Joseph Kaufmann Chair in Geriatric Medicine, Director of centre of excellence on aging and chronic diseases, McGill University

Howard Bergman, MD, FCFP, FRCP(C), Chair, Department of Family Medicine, Professor, Departments of Family Medicine, Medicine, and Oncology, McGill University

Ronald M. Caplan, MD, CM, FACS, FACOG, FRCS(C), Clinical Associate Professor Emeritus Obstetrics and Gynecology, Weill Medical College of Cornell University

Abraham Fuks, MD, CM, FRCP(C), Professor, Department of Medicine, McGill University

Serge Gauthier, CM, CQ, MD, FRCP(C), Director, Alzheimer Disease Research Unit, McGill Center for Studies in Aging, Professor, Departments of Neurology & Neurosurgery, Psychiatry, Medicine, McGill University

Phil Gold, CC, OQ, MD, PhD, FRSC, DSc (Hon), MACP, FRCP(C), Douglas G. Cameron Professor of Medicine, Professor of Physiology and Oncology, McGill University, Executive Director Clinical Research Center (MGH) McGill University Health Centre

Jose A. Morais, MD, FRCP(C), Professor, Faculty of Medicine, Director, Division of Geriatric Medicine, Lead, Dementia Education Program, McGill University, Co-Director, Quebec Network for Research on Aging

CONTRIBUTORS

Karen C. Altfest, PhD, CFP®, Executive Vice President and Principal Advisor, Altfest Personal Wealth Management, New York City

Paulina Bajsarowicz, MD, FRCPC, Geriatric Psychiatrist, Douglas Mental Health University Institute, Assistant Professor McGill University

Guy Hajj Boutros, MSc, Kinesiologist and Research Assistant, Research Institute of McGill University Health Centre

Lysanne Campeau, MDCM, PhD, FRCS(C), Assistant Professor of Surgery, Division of Urology, McGill University

Julia Chabot, MDCM, FRCPC, MSc, Assistant Professor, Faculty of Medicine, McGill University

A. Mark Clarfield, MD, FRCPC, Professor Emeritus of Geriatrics, Ben-Gurion University, Medical School for International Health, Faculty of Health Sciences, Ben-Gurion University of the Negev

Philippe Desmarais, MD, FRCPC, MHSc, Assistant Clinical Professor, Faculty of Medicine, University de Montreal

Liam Durcan, MD, FRCPC, Assistant Professor, Department of Neurology and Neurosurgery, McGill University, Consultant Neurologist, Stroke Service, McGill University Health Centre

Hao Feng, MD, MHS, Assistant Professor, Director of Laser Surgery and Cosmetic Dermatology, Department of Dermatology, University of Connecticut Health Centre

Catherine Ferrier, MD, Assistant Professor, Department of Family Medicine, Faculty of Medicine, McGill University

Jess Friedland, MD, FRCPC, Geriatric Psychiatrist, Douglas Mental Health University Institute, Program Director, Geriatric Psychiatry Sub-Specialty Residency Program, McGill University

Catalina Hernandez-Torres MD, FRCP(C), Geriatric Oncology, Ottawa Hospital Cancer Center

Tina Hsu, MD, FRCP(C), Assistant Professor, Division of Medical Oncology, University of Ottawa

Antony Karelis, PhD, Professor, Department of Exercise Science, Universite du Quebec a Montreal

Sathya Karunananthan, PhD, Postdoctoral Fellow, Ottawa Hospital Research Institute

Aziz Khan, MD, Assistant Professor, Department of Internal Medicine, University of Connecticut Health Center

Young-Sang Kim, MD, PhD, Associate Professor, Department of Family Medicine, CHA Bundang Medical Center, CHA University

Cyrille Launay, MD, PhD, department of medicine, division of geriatrics, University Hospital of Lausanne, Switzerland

Artin Mahdanian, MD, MSc, Department of Psychiatry, McGill University

Louise Mallet, B.Sc. Pharm., Pharm.D., BCGP, FESCP, FOPQ, Professor in Clinical Pharmacy, Faculty of Pharmacy, University of Montreal, Pharmacist in Geriatrics, McGill University Health Center

Silvia Monti De Flores, MD, FRCPC, DFAPA, Department of Psychiatry, McGill University

P. David Myerowitz, MD, FACS, FACC, Former Karl. P. Klassen Professor and Chairman Thoracic and Cardiovascular Surgery, The Ohio State University

Randy S. Perskin, Esq., JD, Elder Law Attorney, New York

Astrid F. Pilgrim, MD, MS, Fellow, Critical Care Medicine, University of Pittsburgh Medical School

Michael R. Pinsky, MD, CM, Dr hc, FCCP, MCCM, FAPS, Professor of Critical Care Medicine, Cardiovascular Disease, Anesthesiology, Clinical and Translational Sciences, Bioengineering, University of Pittsburgh Medical School

Samer Shamout, MD, MSc, Fellow, Division of Urology, McGill University

Michael Stiffel, MD, FRCPC, Assistant Clinical Professor, Faculty of Medicine, Universite de Sherbrooke

Norman Straker, MD, DLFAPA, Clinical Professor Weill Cornell Department of Psychiatry, Consultant, Sloan Kettering Cancer Center, Division of Behavioral Science

Dominique Tessier, MD, CCFP, FCFP, FISTM, Clinical Instructor, Family Medicine Department, University of Montreal, Medical Director, Travel Health Group, Montreal

Doreen Wan-Chow-Wah, MD, FRCPC, Assistant Professor, Faculty of Medicine, Division of Geriatric Medicine, McGill University Health Centre

Claire Webster, PAC, CPCA, Founder, McGill University Dementia Education Program

Mark J. Yaffe, MDCM, Professor of Family Medicine, Department of Family Medicine, St Mary’s Hospital Centre and McGill University

Haibin Yin, MD, CCFP (COE) Assistant Professor, Director of Undergraduate Medical Education, Division of Geriatric Medicine, McGill University

INTRODUCTION

Jose A. Morais, MD, FRCP(C)

Professor, Faculty of Medicine, Director, Division of Geriatric Medicine, Lead, Dementia Education Program, McGill University, Co-Director, Quebec Network for Research on Aging

It is a well-recognized fact that our society is growing older. This aging of the population is observed in developed as well as in developing countries, albeit at a faster pace in the latter. From the days of the Roman Empire to the early XIX century, average life expectancy at birth remained stable at about 45 years. Since then, there has been a progressive increase in life expectancy with the introduction of improved hygiene and availability of food. The improvement in medical care also contributed to improved survival, especially in older individuals with chronic conditions. Nowadays, a cohort of newborns is expected to live an average of 80 years, with an excess of 3-4 years for baby girls compared with boys. The net effect of this increased longevity combined with the decline of birth rates is practically a doubling of the percentage of older adults, to reach about 25% of the population by 2030 in most developed countries. The prevalence of those above 85 years, the so-called old-old will in fact triple to attain 8% of the population. According to the World Health Organization, the aging of the population is an unprecedented phenomenon in human history. Although many anticipate this demographic revolution with apprehension, it is in fact a triumph of humankind over the adversities of the environment. Among many societal challenges posed by the aging of the population is a growing prevalence of multiple chronic diseases and functional impairments of older adults, giving rise to the geriatric syndromes, especially in those above 85 years of age. The shift in the prevalence from acute and communicable diseases to multiple chronic diseases calls for a realignment of the healthcare system that was previously organized to treat acute conditions. The solution resides in an integrated and coordinated system that is more expensive than one dealing with short term interventions, although many inefficiencies in care delivery and inappropriate interventions contribute to heighten the cost.

Why do we age?

Aging is a universal phenomenon defined as a progressive decline in the functional reserves of many body systems and organs once an individual has reached maturity, which in humans occurs between 20 and 30 years of age. These degenerative changes in organs are responsible for the loss of adaptive responses to stress and an increased risk for age-related illness and death. The theory of evolution proposes that the natural forces that shaped life allowed aging to occur because it would be better to perpetuate the species by investing in mechanisms promoting a high reproductive capacity in young individuals rather than in bodily mechanisms that would maintain individuals indefinitely but at greater risk of dying in a hostile environment. There are a number of theories of aging organized in several categories, but those gaining in popularity among scientists fall under the mechanistic theories of aging, grouped as the somatic mutation theory and the free radical theory. Both of these mechanisms are likely to be involved in aging as they implicate basic cellular processes and can explain other derangements at more complex levels of bodily organization such as dysfunction of neuro-endocrine and immune systems. The somatic mutation theory suggests that most somatic cells undergo replication and in this process, acquire damage by spontaneous mutations or by exposure to toxic products. The accumulation of damage will degrade cell function, leading to senescence. The telomere shortening theory can be considered as a special case of the mutation theory. The free radical theory explains that life is a dynamic process requiring metabolized energy that generates free radicals as by-products of normal redox reactions, e.g., reactive oxygen species. Such free radicals are the cause of oxidative damage to cell structures and impair their functions. The mitochondrial theory is considered a subcategory of the free radical theory. Although the body possesses many enzymes and surveillance systems to prevent cellular damage and mutations it is not a foolproof defense mechanism, which is in keeping with the theory of evolution.

What is Geriatrics?

The term Geriatric refers to old age that in most advanced societies has been set arbitrarily at 65 years. It is of interest that this age limit was proposed more than a century and a half ago by a German statesman, Baron Otto von Bismarck, based on the observations that at that time, life expectancy of civil servants aged 65 was on average only 2 years. He calculated that it would be more profitable for the state to offer them a retirement pension and to hire new, more productive young people. Since then however, life expectancy at age 65 has steadily increased in most developed countries to reach current levels of about 20 years for women and 15 years for men. Thus, even at age 65, there is opportunity to introduce preventive medicine and to educate people to adopt healthy and active lifestyles. At the same time, the prevalence of chronic diseases increases steadily with age, giving rise to co-morbidities and functional decline. Among older adults, 40-50 % have arthritis, hypertension and hearing deficiencies, 20-30% suffer from cardiovascular diseases, dementia, cancer, diabetes, chronic respiratory conditions, lack of teeth and impaired vision, and another 5-10% have strokes, Parkinson’s disease and asthma. Hence, concomitant conditions, known as multimorbidity is highly prevalent as are impairments in activities of daily living. For the age group between 70-85 years of age, 25% have 5 or more diseases, another 25% will experience disabilities in basic activities of daily living, while 50% will be deficient in the instrumental activities of daily living. Geriatrics refers to the practice of medicine caring for older adults afflicted with many diseases and functional impairments. Geriatricians and family physicians with experience in the field know that a care plan needs to address not only a specific condition but also the interaction that results from all of them and their combined impact on the patient’s autonomy. Fortunately, there is recent evidence from scientific literature that we are aging better compared with the previous generation with a decline in the incidence of dementia and disability. For many years, there was debate about the different rates at which the decrease in morbidity and mortality would progress. If lower morbidity would outpace mortality, then we would age better and into older years whereas the converse would have the opposite effect. These recent findings are optimistic, in that if further confirmed, persons can expect to live longer with less disability.

Active aging

Aging is a heterogeneous phenomenon that is the result of the interaction between the individual genetic background and environmental factors, not the least of which is the adoption of a healthy lifestyle. Certain families are more prone to develop specific diseases but the appearance of many of them can be delayed or even averted by the adoption of healthy habits. For example onset of type 2 diabetes can be delayed or prevented by regular physical activity and heathy eating habits. There are also several social and psychological determinants of health, including education, income, social status, social participation, perceived control over one’s life, positive attitude, to name but a few. With so many factors at play, it is little wonder that each individual ages at his or her own pace. Gerontology has classified aging into three main categories: active aging (previously called heathy aging or successful aging), normal aging and frail aging. The distribution of these different types of aging varies according to different criteria but the majority falls within the active and normal aging categories with 15-25% considered to be frail. According to WHO (2002), active aging is the process of optimizing opportunities for health, participation and security in order to enhance quality of life as people age. The word active refers to continuing participation in social, economic, cultural, spiritual and civic affairs, not just the ability to be physically active or to participate in the labor force. Older people who retire from work, those who are ill or live with disabilities can still remain active contributors to their families, peers, communities and society.

Contribution of older adults to society

Contrary to common beliefs, many older adults are in good health, enjoying life and contributing to society. Such contributions extend to practically all domains of social life despite the challenge of ageism. At the familial level, older persons through their experience of life are of great support to their middle-age children, in counselling on many matters and in the upbringing of the grandchildren. In many instances, they provide financial support to them. At the community level, other than assisting a friend or a neighbor, they participate in organizing cultural and social events, thus to enriching their communities. Volunteering is definitely another non negligible contribution of unremunerated work of older people for the wider community. We all have had the experience of receiving information at the entrance of the hospital by an older person who is volunteering, but they also participate actively on boards of museums, art centers or charitable agencies, or in directly providing services to youth organizations and to more dependent older adults. By so doing, those engaged in volunteering also benefit from being socially active, since outreach and engagement enhance their own well-being and happiness. Finally, remaining part of the workforce is another way of contributing as well as of maintaining physical, cognitive and mental capacities. Society will need to continue its efforts to allow older adults to maintain their societal role as all derive benefits. The change in policies to make retirement age non-compulsory is a first step since we all age differently. Furthermore, facilitating different types of work and adjustments of schedules will permit older people to remain active and to contribute to society.

References

United population world Ageing 1950-2050, Population division, DESA, United nations, 2002, http​://www​.un​.org​/esa​/population​/publications​/world​ageing​1950​2050

Brian T. Weinert and Poala S. Timiras. Invited Review: Theories of aging. J Appl Physiol 95: 1706–1716, 2003

Marti G. Parker, Mats Thorslund. Health Trends in the Elderly Population: Getting Better and Getting Worse. The Gerontologist 2007; 47:150–158.

World Report on Aging and Health http​://www​.who​.int​/ageing​/publications​/world-report-2015​/en/

The Chief Public Health Officer’s Report on the State of Public Health in Canada, 2010: Growing Older – Adding Life to Years. http​://public​health​.gc​.ca​/CPHO​report

CARING FOR THE OLDER PERSON

Abraham Fuks MD, CM, FRCP(C),

Professor, Department of Medicine, McGill University

"…the secret of the care of the patient is in caring for the patient."

The epigraph is a phrase from a talk by Dr. Francis W. Peabody to medical students at Harvard and published in JAMA in 1927 under the title, "The Care of The Patient." It has been cited countless times over the past century by those describing a mode of medical practice that is desired, yet too often lacking. The idea has been repeated and promulgated by many speakers at medical school convocations and graduations and remarkably, Peabody’s observations and admonitions remain vibrant and cogent today, and, I shall argue, are especially germane to the care of the elderly. The phrase served as an inspiration for the title of this book and certainly for this chapter whose objective is to examine the implications of the concept for contemporary practice and education.

We can better discern the intent of Peabody’s comment by examining the words and syntax of his distinction. To be entrusted with the care of the patient is to receive a mandate to fulfill a duty. This is an obligation for a caregiver in any domain of medicine and is never taken lightly. Indeed, it is helpful to appreciate that clinical care is a duty of physicians, rather than a right that accrues to patients. That does not detract from a societal obligation to provide health care as a right that is owed to all persons rather than a transactional process. However, provision of care is the responsibility of the physician, though of course, the patient must provide consent. Peabody teaches us that care has additional dimensions and desiderata beyond the simple mandate or duty. Caring for a person refers to someone who is important or valued, often in a relationship, and for whose well-being one’s concern may extend beyond the requirements and duty of care. The distinction can also be applied to objects, as care of a car indicates a need for maintenance and function while care for a new automobile suggests a deeper connection than with a simple mode of transport.

Peabody explains the relational aspect implicit in caring for the patient as follows: The significance of the intimate personal relationship between physician and patient cannot be too strongly emphasized, for in an extraordinarily large number of cases both diagnosis and treatment are directly dependent on it, and the failure of the young physician to establish this relationship accounts for much of his ineffectiveness in the care of patients. This description is important in that Peabody’s reason for stressing the imperative for a relationship is not one of warmth or friendship or even a moral obligation. Rather, the clinical relationship is valuable in leading to accurate diagnoses and effective treatments. He provides a helpful exposition, What is spoken of as a ‘clinical picture’ is not just a photograph of a man sick in bed; it is an impressionistic painting of the patient surrounded by his home, his work, his relations, his friends, his joys, sorrows, hopes and fears. This is a simple but wonderful description of the clinical method that chooses to understand the patient as a person embedded in a family, community and possessing an emotional inner life. It also notes that clinical observations are shaped by the observer who gathers meaningful impressions of an ill person and not simple black and white photos of a diseased patient. I should hasten to add two glosses: Peabody today might have referred to both male and female patients rather than a man sick in bed. Second, when he speaks of the ineffectiveness of young trainees, Peabody does not attribute this to ignorance or apathy but simply to the need for clinical experience accrued over time with strong role models.

Peabody tells us that clinical work is painstaking and demands time and effort. Yet, the human relationships so constructed are rewards in themselves. Finally, he concludes that an appreciation and regards for persons in their full humanity is both necessary for good clinical work and is also the source of its deep satisfaction: The good physician knows his patients through and through, and his knowledge is bought dearly. Time, sympathy and understanding must be lavishly dispensed, but the reward is to be found in that personal bond which forms the greatest satisfaction of the practice of medicine. One of the essential qualities of the clinician is interest in humanity, for the secret of the care of the patient is in caring for the patient.

Older Persons

The use of the word older, rather than old, indicates that there is no clear line of division between those who are old and those who are not. We live on a functional continuum and each person’s trajectory depends on the individual’s sense of self, functional capacity, physical capability, and ability to accomplish those aspects of life that bring satisfaction and a lived sense of well-being and purpose. The use of the word person, rather than patient, notes that care for the elderly is not primarily an activity that takes place in a hospital or even a clinic, but enfolds the older person in all aspects of daily life. Clearly, the caregiver must be concerned not simply with the intercurrent episodes of acute illness that readily come to medical attention but the demands of daily living and the impositions on the person by chronic maladies that may not be cured but whose burdens may be lessened.

The misplaced emphasis of care on acute illnesses and the hegemony of diagnosis that afflicts most systems of health care are articulately described by Dr. Jason Mutter in an article entitled, Neglected in the House of Medicine that appeared in the Hedgehog Review in a special issue whose theme was The Evening of Life. These entrenched elements of the US health care system have an especially deleterious effect on care for the elderly. The author states that the American health care system that, despite its remarkable technological capacities, achieves poor outcomes for older adults. He attributes this failure to several factors including an emphasis on acute care, urgent care, trauma, and high-tech interventions. While these are certainly necessary, such spheres of medical care have displaced attention to chronic illnesses and the needs of the older person whose ailments need a more deliberate, longer-term horizon with different goals and aspirations. Dr. Mutter goes on to note that a person becomes visible to the health care system when diagnosed with an acute ailment but then returns to invisibility once that episode has been managed. This stems from a model of care that is focused on diseases, the ICD classification and supported by payments based on DRGs, complex diagnostic tests and expensive atomized interventions. Lastly, he draws a sharp contrast between two rather different visions of care: If diagnosis asks, ‘What does this person have?’ then prognosis asks something quite different: ‘In view of the whole person—health, illness, vulnerabilities, and social supports—how is this person doing, what is their probable course, and how can we alter that course for the better?’

This proactive and expansive vision of health care is appropriate for all but especially germane to care for older persons. Individuals are complex systems with a biopsychosocial nexus within which multiple functions are interconnected and socially embedded. Many components may each function at the limit of capacity yet the whole works in a set of precarious balances. Intervention in one may disrupt the efficacy of another, seemingly unrelated organ system and upset the fragile functional web. In that sense, ‘care of’ may permit an adjustment of a single anti-hypertensive medication in response to blood pressure readings whereas ‘care for’ insists on a concern with a broader assessment of risks and benefits to daily function. Thus, Peabody’s call to care for the patient entails an integrative, holistic perspective of clinical practice.

The Current State of Care

Both basic research on aging and clinical research to improve the management and support for the frail elderly have advanced significantly over the past three decades. Peabody’s plea has been echoed over the past hundred years and calls for holistic models of care are heard regularly at conferences and in articles and editorials. Why then is the state of care for the elderly still a poor relation and a neglected domain in health care systems throughout the Western world? Part of the explanation lies in the stigmas associated with aging that are evident in our culture and reflected in our language and behaviors. We have become accustomed to phrases such as silver tsunami, grey plague, and impending demographic disaster that consider the aging of the population in the same urgent terms used to address climate change. The descriptions of dementia and memory loss in apocalyptic terms evokes fear and dread amongst those who wish to grow old, namely, virtually all of us. We now launch wars against amyloid as a newfound enemy and bemoan the failures of such heroic interventions as intrathecal monoclonal antibodies. In brief, the barriers to improving care for the elderly may lie not in a lack of innovative concepts for support, care and the amelioration of the quality of life, but rather in our entrenched attitudes to those who grow old. This bias, often referred to as ageism, is reminiscent of ancient stigmas associated with mental illness and creates perceptions of aging as a period of decline and dependence and the elderly as the corresponding book end to infancy and its need for constant support. Other societies and cultures appreciate the later years of life as a period of continuing growth with new opportunities but that is hardly the case in Western society. It is little wonder then that health policies favor the young and those with acute conditions—these reflect superficial considerations but stem from deeply embedded biases. This was sadly evident in the enormous rates of mortality in residences for the elderly and related health care facilities during the COVID pandemic and in the results of subsequent investigations that uncovered the poor care and inappropriate living conditions in many such institutions. A society’s interests and concerns can be assessed in part on how it rewards various occupations: perhaps it is not by accident that we underpay teachers and caregivers while concurrently trumpeting our commitment to growing children and aging adults. In reality, we may have simply decided that the tough challenges of both public education and health care are too complex and difficult to repair; we now simply ignore them, hoping they will somehow disappear while placing our societal investments in other domains, for example, space travel and military technology. Nonetheless, we continue to pay the enormous costs for our biases and consequent neglect. Becca Levy and colleagues examined the economic consequences of ageism that they described as discrimination aimed at older persons, negative age stereotypes, and negative self-perceptions of aging. They found that the 1-year cost of ageism was $63 billion…and ageism resulted in 17.04 million cases of eight expensive health conditions in those aged 60 or above. They conclude that reducing bias would result in major economic gains and concurrently improve the lives of the elderly by decreasing the risk of major illnesses. A win-win for all!

Care for the older person cannot be provided in models used to look after younger patients who often need management for acute illnesses or those in middle-age who may require intensive high-tech but short-term interventions. While such transactional systems are not ideal, they work to provide care in well-developed societies and for patients with significant personal resources and independence. However, staccato care from referral networks of specialists cannot be expected to offer the requisite quality of care for the elderly. Older persons require and respond well to relational models of caregiving, in which attention is continual and anticipatory rather than stroboscopic and reactive. Support and trust are the results of a personal bond with a clinician who is willing and able to listen and who is able to enjoy the anecdotes and reminiscences of older patients and consider these as benefits, not burdens, of caring for those with a wealth of instructive experiences of long and rich lives. Thus, it helps to genuinely care for such individuals since that will motivate clinicians to provide the attention required to nurture and maintain the sense of well-being that enriches daily life—for both parties.

Language and Rhetoric

As noted above, the words we use may reveal our biases and perceptions of aging. Moreover, and perhaps more powerfully, language may shape our thinking and our consequent behaviors. A very instructive example was presented in an experimental study of the effects of ‘elderspeak’ in a facility caring for patients with dementia. Elderspeak describes a mode of infantilizing speech sometimes used by caregivers working with elderly persons that uses syntax and words more commonly heard in addressing the very young. For example, how are we doing today, my dearie? couched in a singsong prosody, or, are we ready for some treats? The research compared the behaviors of elderly subjects addressed in one of three registers, elderspeak, normal adult speech, or silence. The highest incidence of aggressive behaviors, such as resisting care by kicking or biting was displayed by persons addressed in elderspeak and the lowest in those spoken to in a normal voice. Silence led to an intermediate level of resistance. It is quite remarkable that in patients with dementia for whom the words themselves may have lost clear meaning, the sensitivity to the disrespect and perhaps degradation of infantilizing speech is retained and is robust.

A counterexample of the benefit of careful linguistic choices was provided by Daniel Busso and colleagues who examined the effect of different framing interventions on implicit age bias in a large sample of American adults. They found that messages that describe aging as building momentum and The energy that we build up as we get older is what powers us to take up new ideas, advance toward new goals, and continue to move our communities forward, reduce bias against aging. A similar effect was noted after messages that speak of intergenerational communities, By providing opportunities for older people to participate in and contribute to their communities, intergenerational community centers provide benefits for older people and strengthen the whole community. Thus, just as language can reflect and elicit inappropriate behaviors, thoughtful framings and an attention to different tropes may help ameliorate the problem. Judy Segal, a scholar of rhetoric, noted that simply convincing the elderly that aging can be successful and healthy runs the risk of blaming the older persons when growing old proves difficult. Rather, she recommends that understanding aging as a normal phase of life, and an identity that we all will share, shifts the discourse from a rhetoric of classification and hierarchy to a rhetoric of identification. As Segal notes, "Becoming