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A LITTLE AGE NEVER HURT ANYONE
Reminiscence offers access to the patient's health and strength

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There is nothing wrong with getting old, when you consider the alternative.

When you get old you will have some special difficulties getting understanding and help from clinicians and others who are supposed to be understanding and helpful.  I have tried here to discern what are the special difficulties in our clinical relationships, to be able to instruct clinicians in effective approaches to older patients.

Age itself is not harmful.  It is an accomplishment.  Persons who have achieved age should have respect, because unless they had some strength and health they would not accomplish age.  It is so that as an inevitable concomitant of age comes susceptibility to various degenerations, but it  is my absolute experience that something central to the person--personality or soul or whatever you will call it--is not a part which dissolves or disappears.  The character of a person is retained, and perhaps refined, despite the degeneration of various parts and systems.

Charles Reznikoff, the modest poet who is most remarkable for his literary renderings of the realities of human history3, lived quietly and effectively, then quietly went to sleep one night in his eighties without ever having relinquished his working or his walking.  In the two simple poems I have chosen above he projects degeneration onto external objects--the clock, the fish, the watermelon.  He implies himself essentially himself, intact.  Whatever weakness seems his has come about because the outside world has changed in relation to him.

Even when a person perceives in himself diminution as an internal process it need not threaten the integrity of his self.  That loss is too often the sad unnecessary result of attitudes shared by persons aging, their children, their doctors and other "helpers".  It is a self-fulfilling prophecy that in aging a person will change centrally, become dependent and degenerative, change from within from a competent person to a burdensome non-person.  Perhaps horror and rejection in facing age and illness are common (and ineffective) defenses against suffering them.  Clinically (literally "at the bedside") we identify as agents of degeneration conditions we clinicians often characterize as progressive and hopeless.  As long as we do this the healthy patient will be wise to avoid us, stay alone with his problems.  If we can learn a better response, our older or sicker patients may be able to get some real understanding and practical help from us (rather than sympathy and placebos).

A person who was physically active becomes limited by soreness, stiffness and even deformity and immobility of joints where bones had been able to move well in relation to each other, and now cannot be so moved.  Besides medicines to reduce pain and inflammation, therapies to strengthen muscles and maintain mobility, et cetera, must this person now experience himself as hopelessly helpless, essentially different from before in relation to other persons?

A person who previously was able to keep in mind all the practical details of accounts, telephone numbers, the location of keys, the ingredients and actions required for preparation of meals, et cetera, now has difficulty with each of these mental retentions and connections.  Must he be called "senile" and no longer expect or be expected to be competent?

A person whose tumor has been growing in such a way that he and his clinical consultants are convinced it is of such a type and in such a location that it will rapidly progress and not be stopped by any means, that he will soon perish--must he in fact be treated as if his death had already occurred, as if he had no business in the world, no loves, no hates, no feelings, no future?

These are three shorthand references to common conditions we tend to respond to in fixed ways:  physical debility, mental degeneration and terminal illness.  Each has gotten some attention recently, but too much of our attention takes the form of desperate attempts to develop technology to overcome the inevitable "evils" of the condition; to "cure" physical, mental and terminal diseases.  Too little attention has been paid by patients, families and clinicians to what remains intact--the essential health of the debilitated person.  It is lost by the ignoring of it--the lack of recognition of health, which lack of recognition becomes a self-fulfilling prophecy of the gloomiest sort.  "Cure" means "care:"  to care for the person is our task, not to cure away pathology.

It is not so much my purpose here to lay a groundwork for rehabilitation of the older debilitated patient as it is to describe tools for clinicians to use in meeting with patients, and to exhort them to use their tools well.  You will not be reading or listening to my notes unless you are likely to agree that debilitated or older patients should be given attention which treats them as if they were human and had some sort of future.  They are human and they are welcome to future.  You may still be convinced that developments in medical technology are more to be sought than developments in clinical humanism--but that is comparing apples to oranges.  We will sooner reach agreement and move on if we simply posit that both are needed.

If we look for improvement in attitudes toward the aging (and all patients) it will not be a good enough goal.  Bleeding-heart sympathy will merely enhance debility by making more dependent those who are lured into clinical care, and drive away those who have enough integrity to avoid it  (as very many proud and strong persons do, as well as those who wish to deny disease and degeneration).

The conceptual tools clinicians need must consist in concrete logical syntheses based  on accurate observations of realities.  No coherent clinical action can come from unfounded assumptions.

I call the attitude we seek "realistic optimism," which is the clinical application of a practical  aphorism I have watched patients (and  my grandmother) use--"Every day I do what I can."  Simply, we emphasize the strength of the patient in our perceptions and formulations, and make investments of our energies in enhancing those strengths; and when there are irreparable weaknesses we acknowledge and minimize them, skillfully side-stepping rather than dwelling upon them.

The attitude is "realistic optimism" and  the  pattern of assessment and decision-making is "clinical  phenomenology."  The etymological roots are right:  "clinical" because our setting is at the bedside or as if at the bedside, "phenomeno-" because we must first pay attention to appearances, "-logical" because the simple realities appearances represent are available to us through our mental associations to the basic science the clinician brings and the life-history the patient brings.

What is implied in "clinical phenomenology" can be put in order for this analysis, but must be practiced all at once, that is the clinician must integrate it into his approach so that it can be used flexibly.  This is no more difficult than the integration of complex tasks of perception, decision-making and action required for driving an automobile.

Although the processes of clinical relationship are validly applied to all patients, it is the older patient who often may be more needy of insightful care, and therefore may more specifically appreciate the openness and coherence a clinician offers through such proper clinical behavior

It is important to see that if a clinician is prepared to recognize only the illness of the patient (which  is only one appropriate focus for attention), and neglects acknowledging strength and wellness, he will have enhanced the illness and suppressed the wellness--not proper clinical behavior!

Respect,  even  admiration  for  the  patient's health, strengths and personality is not merely a desirable addition, but essential to a productive clinical relationship.  The strength and respectability of the older patient may often seem to him and to the clinician more to reside in his past than in his present or his (sometimes  dubious) future.   In order appropriately to appreciate the older patient's strengths and personality—to enhance his wellness--it may be helpful, and not at all regressive, to use reminiscence as a clinical tool.

Time taken to bring to the surface the patient's life-history is not at all wasted.  It is essential to the establishment of respect for this unique person, upon which productive clinical action can be taken.  It is what will allow the patient to become the clinician's partner in the processes of evaluation and treatment.

Practical maneuvers in meeting older patients may include many aspects, but cannot be applied without sincere respect and realism.  Some aspects are listed and briefly exemplified.

Enhancing reminiscence (as justified above) may allow a basis for the clinician's respect of the patient's personality and health, and becomes an activity through which the patient can enhance his own self-respect.  If in the process of reminiscence, poignant awareness of what has been lost in the course of various degenerations should occur, realistic acceptance on the part of the clinician ("It is true,  Ms.  Smith, we sincerely doubt we can make this cancer go away...") may be mirrored by the patient, who has reason to attend the clinician because of his previously demonstrated interest and reliability, ("I really knew that, Doctor--felt it for a long time...") and can lead to optimistic realism upon which action can be based ("...but we certainly can try to keep it from interfering with your nourishment.  I want to help you stay on your feet, not to give up.  That wouldn't be the you I know.")

That the clinician may be rewarded personally by the warmth and intimacy he has enhanced, that he may be highly valued by patients who respond to what he offers because it truly carefully  is suited to their needs--these are not so important.  There is no way to measure exactly such human interactions, and if the clinician were not invested in them from the beginning he would never have begun at all.

Aging itself is not primarily a clinical problem, but its secondary complications, especially those resulting from attitudes which serve as self-fulfilling prophecies, are often devastating.  Although  the majority of older  persons manage to maintain themselves, by the time clinicians encounter those who do find their ways to hospitals and nursing homes they have become debilitated.  In order not to render degeneration inexorable we need conceptual tools characterized here as  "clinical  phenomenology" and "realistic optimism."  When applied to older persons those tools often will make use of emphasis on the past (reminiscence), as that is when this patient's strength  may more easily be demonstrated.  It is appropriate to adapt these tools to meeting with older patients, as they are merely a way to accomplish the simple clinical tasks we try to perform for all patients through good clinical relationship.

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1Reznikoff, Charles.  "Jerusalem the Golden" #63 (1934), as published in The Complete Poems of Charles Reznikoff, Volume I, page 120, (Santa Barbara:  Black Sparrow Press, 1976).

2 Reznikoff, Charles.  "By the Well of Living and Seeing", (1969), I, 50, as published in The Complete Poems of Charles Reznikoff, Volume II, page 104, (Santa Barbara:  Black Sparrow Press, 1977).

3 Perhaps the best American history written comes from this careful poet-scholar, who after his legal training and his work editing a legal encyclopedia developed a poetic rendering of real cases involving real persons, Testimony:  The United States (1885-1915), (Santa Barbara:   Black Sparrow Press, 1977 and 1979, Volumes I and II).  He later applied the same technical approach to the transcripts of the Nuremberg trials in Holocaust (Santa Barbara:  Black Sparrow Press, 1975).

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