“Perhaps being old,” Philip Larkin has it, “is having lighted rooms...

Inside your head, and people in them, acting
People you know, yet can’t quite name; each looms
Like a deep loss restored, from known doors turning,
Setting down a lamp, smiling from a stair, extracting
A known book from the shelves; or sometimes only
The rooms themselves, chairs and a fire burning,
The blown bush at the window, or the sun’s
Faint friendliness on the wall some lonely
Rain-ceased midsummer evening. That is where they live:
Not here and now, but where all happened once.

Larkin was a nasty fellow in so many ways. But he became one of the most celebrated English-language poets of the 20th century because of this kind of frigid empathy. Indeed, in the next stanza of “The Old Fools,” he moves that cold eye of his from the old folks to the young, watching them. He wonders if, given all of the foregoing, that’s why old people give...

An air of baffled absence, trying to be there
Yet being here. For the rooms grow farther, leaving
Incompetent cold, the constant wear and tear
Of taken breath, and them crouching below
Extinction’s alp, the old fools, never perceiving
How near it is…

What Larkin confronted is what so few seem to want to confront: Getting old and, eventually, dying—is hard work. 

The thing is, it’s only going to get harder.

Talkin’ ’Bout Their Generation

It is by now notorious that the baby boomers—the echt generation, the generation, for better or worse, that gave Americans most of their modern concepts of generation (right down to the ad man’s most sinister science, demographics)—are getting on in years. A body can’t read a mainstream news story about Alzheimer’s (say) without reading a graf that begins, “As America ages…”

“If you watch TV for even a second, you’ll see this pill helps you revive your sex life, burn that fat, take off that wrinkle,” says Chris Perna, chief executive officer of The Eden Alternative. (Television is, of course, the Rosetta Stone of boomer culture.)

Chris PernaSo the baby boomers are growing old. The question is, are they growing up? Because the generation that more or less invented youth culture (or, had youth culture invented for it) is now more or less in charge of the money, the politics, and even the means of cultural production that will shape the future of how people care for, and think about, all of their elders.

“It’s always difficult for America when the post-war generation moves from one life stage to the next,” says Bill Thomas, the doctor who has spent his career trying to get long term care to rethink the way it does business.

“In the 1960s and 1970s, they left childhood and entered adulthood. And now, quite reluctantly and quite disjointedly, they’re going to leave adulthood and go into elder-hood.

"And they have no idea what’s going to happen.”

Thomas has just released his new book, “Second Wind.” He says that eldercare can’t simply be contested in a few paragraphs of legislation or regulation: What’s needed is a thorough-going “deconstruction” of cultural paradigms, he says (see sidebar).

From the view of those who work hard to improve quality of care (and of life) for elders, the situation can feel every bit as bleak as Larkin sees it.

“I think the general prevailing view is that is that it sucks to get old,” Perna says, encapsulating Larkin in a more demotic idiom.

“The view is that illness is a curse and that dying should be put off as long as possible and you should spend whatever it takes. People want to live and be well forever and take whatever heroic measures it takes to preserve it.

“We’re a society of doers,” Perna adds. “As a society of doers, as we age, when we get sick, we’re able to do less. I think there’s a latent fear in everybody—and not just latent in many—that, God, the less I can do, the less valuable I am. I think aging is met with fear and dread.”

Stereotypes: Unsafe At Any Speed?

This isn’t an extended kvetch about commercials. The research is piling up, and it’s pointing to an overwhelming conclusion: Stereotypes about the elderly aren’t just nasty, they’re dangerous:

■ A 2013 study led by Yale psychologist Becca Levy found that older folks with positive views of aging were 44 percent more likely to recover fully from severe injuries or disabilities than those who held negative age stereotypes.

■ A 2012 survey of public health majors and graduate students by University of Northern Iowa gerontologist Elaine Eshbaugh found that the biggest obstacle for students pursuing a career in long term or post-acute care was their fears of aging, death, and dying. (“It’s a tough sell to 18- to 24-year-olds,” Eshbaugh told Provider at the time.)

■ A study published in the March edition of the Journal of the American Medical Directors Association (JAMDA) found that frontline workers—nurse assistants, volunteers, and the rest, were most likely to struggle with guilt and anxiety over their residents’ deaths. (Overall, only 30 percent of long term care professionals reported having trouble with death—but that’s precisely the turnover benchmark set by quality advocates at the American Health Care Association.)

“Death is a taboo subject in our society,” the JAMDA researchers wrote. “Workers need to demonstrate empathy with their residents, be compassionate, and be willing to take the risk of personal involvement. Dealing with residents and their families can be very emotionally demanding. Facing it every day requires a degree of distancing for providers.”

For most providers, of course, this is perfectly obvious. But the JAMDA study notes that the more advanced a worker’s education, the better he or she was at dealing with death and dying. Could it be that the emotional rigors of climbing extinction’s alp might explain why so many frontline workers drop off so often?

Or, as Larkin has it (and he might as well be speaking directly to frontline workers):
At death you break up: the bits that were you
Start speeding away from each other for ever
With no one to see. It’s only oblivion, true:
We had it before, but then it was going to end,
And was all the time merging with a unique endeavour
To bring to bloom the million-petalled flower
Of being here. Next time you can’t pretend
There’ll be anything else. And these are the first signs:
Not knowing how, not hearing who, the power
Of choosing gone. Their looks show that they’re for it:
Ash hair, toad hands, prune face dried into lines—
How can they ignore it?

Stereotypes Of Stereotypes

If long term care professionals themselves struggle with questions of aging and dying, how can they expect their friends and relatives (and regulators and Congress-folk) to have a healthy attitude toward aging and dying?

The work there, in the hearts and minds of business, may not be as hard as one may think. Yes, Americans generally love to think of themselves as perpetually young. And yes, baby boomer Americans in particular love to think of themselves as perpetually young. But the broader culture may have a more tolerant view than one would think.

Corinna Loeckenhoff“I think in some respects the U.S. is getting a bad rap,” says Corinna Loeckenhoff, an assistant professor of human development at Cornell University.

Five years ago, Loeckenhoff and her colleagues looked at cultural attitudes toward aging in 26 cultures. America scored solidly in the middle, with a generally more positive attitude toward the elderly than even supposedly filial-centric Japan.

Positive Signs

“At the same time, U.S. culture is strongly focused on renewal and innovation—and some may have the impression that older adults can’t really keep up with that,” the German-born Loeckenhoff says. “But the U.S. has done a lot to protect the elderly, with laws against age discrimination, mandatory retirement.

They’re actually ahead of other countries. In some parts of Europe, it’s expected to give your date of birth on your resume.” Additionally, Americans are much more open to reinvention, Loeckenhoff says. On her own campus in upstate New York, she routinely sees middle-aged (or older) students coming “back” for further education. Such a thing is relatively unheard of in her native Europe, Loeckenhoff says.

That doesn’t mean the United States is the land of milk and honey for seniors: Negative aging stereotypes are perpetuated by the media, she says. Loeckenhoff says her blood still boils every time she thinks of the Snickers commercial where a man who’s hungry morphs into Betty White. “How bad is that?” Loeckenhoff asks (see sidebar).

Mixed Signals

What Loeckenhoff and others have found, though, is a much more complex attitude toward aging and dying than many would have believed.

For instance, people may not view older relatives or friends as “old” until the friend or relative enters what scientists unsentimentally call “the terminal drop”—that last five or so years of a person’s life where, all other things being equal, they go into a relatively rapid decline from disease that swallows them.

“But that’s not healthy aging,” Loeckenhoff says. “In part, it’s a just perceptual mechanism. People may not really think of people as being old until they view people as dying.”

Further, Loeckenhoff and others have found that the higher the percentage of elderly in a population, the more negative views the society will have toward aging and dying.

And—perhaps most surprisingly in results if not in hypothesis—Loeckenhoff and her colleagues have found that aging stereotypes correlate pretty well with economic development. In China, for instance (long and lazily thought to be the country of filial piety par excellence), the more rapidly industrialized or industrializing a region was, the less support the young showed toward the old, Loeckenhoff says.

“As society develops, the means of production spread away from the people,” she says. “That basically takes power away from older people. Potentially, there’s a post-industrial phase, where egalitarian values and a more realistic view of aging kick in.”

Thomas, the veteran firebrand, says he thinks the country has a long way to go. And “you don’t have to look any further than the capital,” he says.

“First off, the No. 1 public policy debate that has obsessed Washington for at least the last three years—and really, longer—is how older people are a plague of locusts that are going to bankrupt us if we don’t do something about it,” Thomas says. “Why is long term care so underfunded? Why are wages in the sector so low? I think it’s evidence of a very conflicted society.”

Navigating Complexities (And Ironies) Of Aging

If Loeckenhoff is right that American attitudes toward aging are more complex than all that, it means that providers must rethink their own cultural attitudes first. “As a society, it will mean really valuing people who have experience and wisdom,” Eden’s Perna says. “I’m a class-A doer, and I always have been. One of the reasons I took the job at Eden was because I knew the things I had to work on: to not get caught up in the day-to-day doing, to really reflect on relationships and a deeper knowing.”

A deeper knowing, indeed, and not a deeper marketing slogan. For Perna, it’s an increasingly bitter irony for him and his colleagues—having spent decades pushing providers to rethink everything—now seeing “person-centered care” become the boilerplate language of every brochure, every regulation, and every piece of legislation.

“If you traveled around the country and talked to people and asked them to show what person-centered care looks like, you’ll see a pretty broad spectrum,” he says. “It’s not a word that has been nailed down.”
In one way, it’s a great victory that Perna doesn’t see anyone argue against person-centered care, at least in principal. But Perna is worried that “person-centered” is becoming a brand and not a culture.

“For us [at Eden], it translates to, how close to the elder is the decision-making made?” he says. “Where are the decisions made in the organizations? And if the answer you get is the administrator, then they’re not doing person-centered care, I’ll tell you right now.”

For Perna, the matter can’t wait.

“Boy, as a society, what the heck are we going to do with all these baby boomers? We aren’t going to care for all these people in the 16,000 nursing homes that exist today,” he says. “First of all, there isn’t enough capacity. Secondly, the baby boomers don’t want to go there. They just don’t. They see it as a last option.”
In any case, as Larkin understood, the question will find people, no matter how long they ignore it. Speculating about extinction’s alp, he wonders if this is what keeps old folks quiet:
The peak that stays in view wherever we go
For them is rising ground. Can they never tell
What is dragging them back, and how it will end? Not at night?
Not when the strangers come? Never, throughout
The whole hideous inverted childhood? Well,
We shall find out.