THE MEDICALIZATION OF OLD AGE

Like religion and law, medicine is a moral enterprise as it defines and manages individuals deemed undesirable by the broader culture (Eliot Freidson, The Profession of Medicine). Over the course of the twentieth century, deviance has increasingly been medicalized, as is evident in our public discourse: one is no longer a drunkard but rather "suffers" from alcoholism; the slow-learner in school is no longer stupid but rather has a "learning disorder;" and instead of viewing the disorientations of older persons being the result of personal and social change, they are viewed as symptoms of "senility."

If it is the contemporary old who are trailblazing a new stage of the life-cycle, then it is the physician who is their trail guide. In mass media advice columns, public seminars and professional journals, it is the physician who informs the elderly on such non-biological matters as retirement, friendships, finances and leisure.

In the Greek tale of Tithonus, a beautiful young man asked Aurora, the goddess of morning, to make him immortal. She does, and he ages continuously. Finally, pitying his never-ending dissolution, she makes him into a grasshopper. Consider medicine's role in the lives of those most likely to die in our culture. Instead of making the oldest of the old into grasshoppers, the medical establishment has produced a population requiring ever greater services with advanced age--including the million or more nursing home residents so disabled that twenty-four hour care is required, and the ten thousand individuals existing in irreversible vegetative states. Old age has increasingly become equated with the dying process. Our cultural gerontophobia derives from our cultural thanatophobia; the myriad of anti-aging products and services are in our youth-oriented culture, in actuality, potions and rituals to avoid death. Click here for consequences of medicine controlling the final rite-of-passage.

Medicine's Biases Against the Old

Given the medicalization of old age, the dramatic increases in their numbers, and the fact that those 65 and older account for 44% of all days spent in the hospital and one-third of the nation's health care expenditures, it is ironic how, as of 1993, only eight of the nation's 126 medical schools required separate courses in geriatric medicine and there were only about 4,000 board-certified geriatricians in the United States. Reasons for such shortages vary: in the hierarchy of medical specialties (and its specialty status is not fully recognized in the U.S., as it is in many north European countries), geriatric medicine may not be the most glamorous nor lucrative; care for older persons is not the most reinforcing professionally, with irreversible physical declines and death being the long-term outcomes; difficult (check out the paperwork required for Medicare and Medicaid) and poor reimbursements for medical services; absence of professional role models; and the negative aged stereotypes and death fears of physicians. Whatever they are, the consequences have been significant. Among the stories of medical mistreatment of older persons over the past decade are:

In addition, there are the home horror stories emerging from some of the nation's 16,700 nursing homes. For instance, in 1999, experts of the Nutrition Screening Initiative, a broad coalition of health care groups, claimed that as many as 2 out of 5 of the nation's two million nursing home residents are malnourished.

Nursing Homes and the Challenge of Long-term Care

In our death-denying culture where one dies a series of mini deaths before physiologically expiring, where the dying process can be stigmatizing for both the dying and survivors-to-be, the nursing home industry has emerged as depersonalization machines to absorb the shock of the dying process.  As Richard Garvin and Robert E. Burger wrote in Where They Go to Die: The Tragedy of America's Aged (1968), nursing homes are the "halfway houses between society and the cemetery." In 1996, about $80 billion was spent on the care of 1.6 million Americans-- two-thirds of whom are women--residing in more than 17,000 nursing homes.  Three years earlier, in 1993, it was estimated that the use of nursing homes would grow by 76% over the next 30 years. 

In the United States, nearly one-half of women and one-third of men will spend some part of their lives in these facilities before they die--25% for at least one year and 9% for five years or more, according to the Health Care Financing Administration (check out its "Guide to Choosing a Nursing Home"). In 2002, Medicare put online a nursing home comparison guide and a checklist for rating different facilities.  In 2006 appeared Consumer Report's Nursing Home Guide. 

Among the stories of nursing home abuses over the past decade are:

In 1996, the Clinton Administration considered scaling back inspections of many nursing homes that care for elderly people under Medicaid and Medicare even though government data showed more than two-thirds did not fully comply with federal standards (which is required for Medicare and Medicaid reimbursements). The proposal was eventually dropped.

GERIATRIC MEDICINE RESOURCES

According to a report ("Geriatric Medicine Training and Practice in the U.S. at the Beginning of the 21st Century") of the American Geriatrics Society, in 1999, though comprising roughly 13% of the total population, Americans 65 and older made 25% of the office visits to physicians and were more than twice as likely as the overall population to be hospitalized.  And yet of the 144 medical schools in the country, there are only 6 departments of geriatric medicine.  Of the nearly 10,000 physicians who graduated from family practice and internal medicine residency programs, slightly more than 3% subsequently entered geriatric medicine fellowships. In 2001, there were only 9,000 certified geriatricians.

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