Aging / With a whimper instead of a boom

A Bittersweet Season: Caring for Our Aging Parents - and Ourselves, by Jane Gross. Alfred A. Knopf, 368 pages, $26.95 Never Say Die: The Myth and Marketing of the New Old Age, by Susan Jacoby. Pantheon, 352 pages, $27.95

Two thousand and eleven is a watershed year in the United States. This is the year the first baby boomers turn 65. They have become what is now called the "young old" (65-75 ), with some of them caring for their own parents, the "old old" (85 and older ) - the fastest-growing segment of the U.S. population. By 2030, some 20 percent of the country's population, or about 70 million Americans, will be older than 65.

Two books by respected New York writers illuminate society's current knowledge and thinking about old age. In "A Bittersweet Season," Jane Gross, a longtime reporter and blogger for The New York Times, writes a how-to book based on her own experiences caring for her aged mother. "Never Say Die" is an analysis by author and former Washington Post journalist Susan Jacoby of how American society handles old age and what we can do to make our last years better.

Gross' book is both heartwarming and heartrending, a story of the relationships within a family that is not particularly close, but that comes together at a time of crisis.

The author's mother, Estelle, was a fiercely independent widow living in Florida until 2000, when her health began to decline. She was 85, with no life-threatening illnesses, but was obese and suffered from arthritis, dizziness, diabetes, high blood pressure and depression. That was when Gross, then 52, and her younger brother Michael, also a journalist and writer, decided to move their mother back to New York. Thus began a tortuous three-year odyssey through the American health and welfare system.

Gross writes of the shock she and Michael felt "when our competence and resources proved all but useless in the face of America's incoherent and inadequate safety net for the frail elderly. We were flattened by the enormous demands on our time, energy and bank accounts; the disruption to our professional and personal lives; the fear that our time in this parallel universe would never end and the guilt for wishing that it would." And then, accepting the paradox of her new reality, she adds: "I can tell you now that it was worth every dreadful minute, a transformative experience."

"A Bittersweet Season" is an all-too-familiar account of what adult children experience with their elderly parents. The book resonated with me on both the personal and professional levels. In 2007, the year before I made aliyah from the U.S., my husband of 55 years died, following six years during which I cared for him as his physical and mental capabilities declined. In the years 1995 to 2003, I was also a caregiver at different times for my father, mother, sister and two aunts before their deaths.

Unlike Jane Gross, I knew my way in that world. I was a social worker with several positions related to senior citizens. In the late '70s I helped to establish the first apartment housing for independent elderly in the Jewish community in Cleveland, Ohio, and worked at a county-run nursing home and a county office of senior services. After retiring 11 years ago, I volunteered on the boards of the Northeast Ohio agency on aging, and the Jewish nursing home auxiliary and county planning committees for the elderly. These opportunities provided me with the skills and knowledge that enabled me to help my own family members live out their last years with dignity.

Medicare, Medicaid

Interspersed with the saga of her mother's declining years, Gross describes the state of medical care, housing and financing for the elderly, and the complexities of Medicare and Medicaid, both federal health insurance programs enacted in 1965 in the United States, with frequent references to other people's experiences. It's an effective way to deliver heavy material. The information is never boring because we want to know what's going to happen to Gross' mother.

In 2000, soon after Gross and her brother moved their mother to an assisted living facility in New York, called Meadowview ("No meadow, no view," Gross tells us ), Estelle Gross revealed to her daughter that she was incontinent. Gross recalls that her mother "asked me to take some money out of her wallet and go buy her adult diapers. And oh, by the way, while I was at the store, she could use some oatmeal - the instant kind - and Sweet'N Low in the individual packets. She relayed the information like the nurse she had been, clinically and matter-of-factly. There was nothing matter-of-fact about it to me." This reviewer can vouch for the emotional flash of lightning that hits a caregiver when the time comes for adult diapers. It's the dreadful realization that an independent, intelligent person who has been in control of life has become dependent on someone else. As Gross admits, "For me ... it was an abrupt, disorienting change."

Gross had a hard time finding a doctor for her mother after her move from Florida. Primary health care for all Americans 65 years and older is covered by Medicare. But many established physicians will not take new Medicare patients, because the program's predetermined payments are less than the doctor's actual charges. In addition the elderly, who are often accompanied by their caregivers, require more time with their doctors, meaning that physicians cannot see as many patients in a day. After a four-month search, they found a young doctor with a new practice who took her mother as a patient. (Gross advises that, if possible, the elderly should go to geriatricians. These specially trained doctors don't only seek cures; they deal with their patients' chronic illnesses and focus on their quality of life. )

As she arranged for her mother's moves to different homes and hospitals, Gross discovered the intricacies of housing services for the elderly in the U.S. She thought that her mother was secure in an assisted living environment, with meals, activities and caring staff. However, the management at the facility would repeatedly send Gross' mother to the emergency room whenever she fell or felt ill as a way of protecting itself from potential lawsuits, since there was limited medical service on-site. One of Gross' strongest recommendations is to keep elderly people out of emergency rooms and hospitals. They can leave the hospital disorientated and weaker than when they came in.

Indeed, hospital visits can be quite taxing for patients' families as well as for the patients themselves. Although my husband had a deteriorating neurological condition, he was able to live at home until the last five months of his life. Once, a severe drop in blood pressure precipitated an emergency room visit. First a young medical student came by to ask questions. She was followed by a young medical resident, who asked the same questions. Then a house doctor stopped by and admitted him, but not before asking the same questions. Not until he was taken to a hospital room six hours after arriving at the emergency room did a neurologist come in and give us the answers, with his diagnosis. I can imagine that frequent visits like that one, especially if they are unnecessary, could be more harmful than helpful.

September 11

I found the two chapters entitled "September Eleventh" and "September Twelfth" particularly poignant. On September 11, 2001, Gross' mother was in the hospital following surgery. "As the cataclysm unfolded," Gross writes, "all of us at the [New York] Times worked the story." That day the hospital called Gross to tell her that all the patients, including her mother, were being discharged to make beds available for any possible survivors of the World Trade Center attacks. Already knowing that her mother could not return to her assisted living facility after surgery, Jane had contacted the Hebrew Home for the Aged, the Bronx geriatric center where she had applied to have her mother rehabilitated. Fortunately, a bed was available there. Her brother, Michael, spent a harrowing day trying to find an ambulance to transport their mother to her new home. Upon arriving at the nursing home their mother's angry response was, "I wish those planes had hit this building." Gross acknowledged her "mother's lament, that we live too long and die too slowly."

Estelle lived at the Hebrew Home for almost two years, until her death in July 2003. Although families usually dread placing a parent in a nursing home where there is around-the-clock care, they often find that their loved one's quality of life can be enhanced in a good long-term care facility. By the end of Estelle Gross' life, at age 88, "she was paralyzed, incontinent, could not speak, was losing the ability to swallow, and wanted nothing so much as a dignified way to die." The health care team and her family respected her wishes. She stopped taking food, refused hydration and was given comfort measures for pain. After 12 days she died peacefully.

While admittedly "clueless" at the beginning of the three-year ordeal, Gross and her brother navigated these difficult, all-consuming waters. And despite strains and challenges with her mother, the author came to cherish the time she had with her in those final years. In 2004, after her mother's death, Gross launched her New York Times blog, "The New Old Age," which offers valuable advice to readers who may find themselves in similar situations. She wrote the blog until 2008, and continues to contribute while she freelances with The Times.

Although the subtitle for "A Bittersweet Season" is "Caring for Our Aging Parents - and Ourselves," Jane Gross didn't spend much time caring for herself. And, I might add, she had it easier than most caregivers. Gross was financially comfortable and was able to rearrange her work schedule to tend to Estelle. According to Gross, all too often, caregiving responsibilities cause workday interruptions and absenteeism, and for some employees that means they have to quit or work part-time. Neither Gross nor her brother had children. Gross empathizes with caregivers in the "sandwich generation," those who have to juggle the care of elderly relatives with their responsibilities to their own children and spouses. That's a tough job.

I really enjoyed "A Bittersweet Season." Gross is an engaging writer, using both pathos and humor as she shares her mistakes and offers valuable advice to readers. It's an essential guidebook, with nine pages of "Resources."

Caustic critic

In "Never Say Die," Susan Jacoby seeks to help boomers understand and accept the reality of their coming old age, and to anticipate their own needs as they grow old.

Jacoby is a caustic critic of the social order in America. In her 2008 best-selling book "The Age of American Unreason," she argued that America faces a "crisis of memory and knowledge," in which "anti-intellectualism is not only tolerated but celebrated by those in politics and the media." In her new book, she painstakingly analyzes the history, attitudes, socioeconomic issues and policies of old age.

Here, Jacoby highlights what she sees as an overemphasis on youth culture in American society and media. Jacoby, who herself turned 65 this year, offers compelling evidence that America has always been a "youth culture," dating back to the republic's early years. When Thomas Jefferson wrote the Declaration of Independence in 1776, he was 34; John Hancock was 39, James Madison, 25; Alexander Hamilton, 21; John Adams, 40; and George Washington, a venerable 44.

What Jacoby sees as particularly invidious about the current boomer age is the myth that we can stay young. More than previous generations, Jacoby maintains that baby boomers are particularly obsessed with youth and in denial about old age. Having embraced the outer-directed social protest movements of the '60's and the inner-directed self-help movements of the 1970s, they are now having cosmetic surgery to look younger and joint replacements to get themselves back on the tennis court. She writes that "movements asserting that 90 can become the new 50 if we only try hard enough are the direct descendants" of these earlier movements. Jacoby is trying to impress upon members of the boomer generation to take responsibility for their impending old age.

In discussing the ethics of longevity, Jacoby questions allocating monies to basic scientific research aimed at extending the current life span to the biblical 120 rather than targeting specific diseases or helping today's old people live a life of higher quality. Clearly, medical advances have indeed extended our ability to live longer, healthier lives. Jacoby writes, "The boomer generation has had a ringside seat for the unveiling of each new [medical] marvel, from the polio shots we received as kids to the stents that are now keeping Dick Cheney and Bill Clinton alive." The expanding numbers of old people in America can largely be attributed to medical advances and improved public health.

But that's only part of the story. For one, notes Jacoby, there are huge class and racial disparities between the rich and the poor and between Americans with the best and worst education. Poor Americans of all ages tend to have worse health habits than their wealthier counterparts; they are more likely to smoke and less likely to eat healthfully. And because of financial constraints and a lack of the medical awareness that education can provide, they are also less likely to receive the high-quality health care that prolongs life.

But though the poor may be less likely to live to old-old age, that doesn't necessarily mean everyone else has it better. As Jacoby makes clear, living longer doesn't always mean living better. Once we pass age 85, the deterioration can be pretty horrible. Jacoby points out that more than 50 percent of people 85 and over have some form of dementia, the risk of which doubles every five years after 65. There is no cure for Alzheimer's disease, a severe form of dementia. (Jacoby movingly describes how the two men she "loved the most" her father and her lifetime partner - died from Alzheimer's disease. ) She notes that more than two-thirds of Alzheimer's patients are cared for at home, usually by a spouse and usually, in view of the gender gap in life expectancy, by a woman. Institutionalization in a nursing home doesn't generally happen until the final stages of the disease, when the spouse can no longer handle the physical needs of the patient.

Jacoby goes on to note "the cruelest paradox of all is that while women outlive men, they are two and a half times more likely than men to suffer from serious disabilities in old age. Alzheimer's and other forms of dementia, crippling arthritis, diabetes and obesity are more common in women than in men. When men die at younger ages, it's often from heart attacks or strokes."

Jacoby adds, "Poverty in old age is also a women's issue, and poverty itself plays a role in the higher disability rate among women. Obesity and diabetes, in particular, are much more prevalent among the poor in all age groups than among those with higher incomes and more education." She explains that most poor elderly women who were in the workforce when they were younger were employed part-time or in low-paying jobs, or took a break from their careers to raise children - meaning that they receive lower pensions when they retire. Divorce too often puts women at a disadvantage.

Because men tend to die earlier, many single women are lonely and can become socially isolated. Assisted-living facilities and nursing homes - "the last homes of the last survivors," as Jacoby puts it - are inhabited almost entirely by women.

Supported by an awesome amount of statistical information, Jacoby's liberal social policy views make good sense. She makes a strong case for legislation to mandate government funding to help keep frail, elderly people in their own homes with paid caregivers. She further advocates for the government to pay for palliative, or comfort care at the end of life. Jacoby claims "that it would be much cheaper, not to mention more humane, as opposed to forcing couples to spend their life savings in a nursing home and then be forced to go on Medicaid, with the government paying the high costs in the end. She states that "healthy old old age is costly, and unhealthy old old age is even costlier. If, as a society, we see longevity as a good thing, then we're going to have to pay for it." She worries about her fellow boomers in their old age, particularly as many were hurt financially by the crash of 2008, and she asks "whether today's teenagers will be prepared in their middle age to foot the long-term-care bills for the growing number of octogenarians, nonagenarians, and centenarians."

Despite all this gloomy data about what we might face in our future, most people refuse to face mortality. They put off discussions with their loved ones about end-of-life wishes. Jacoby tells us that only 50 percent of Americans have written wills, and 70 percent have no living will, a simple document that spells out the types of medical treatments and life-sustaining measures we do and don't want, such as mechanical breathing, tube feeding or resuscitation. And most of those who do have living wills have never provided their doctors with a copy of the document, meaning that their wishes may not be known or honored.

This procrastination, due to both denial and ignorance, can result in extraordinary efforts to keep old people alive, regardless of their wishes. Jacoby asserts that "One-third of the entire Medicare budget is spent on care in the final year of life. Patients are often subjected to painful medical intervention that does not end up extending their lives by more than a few months."

My husband and I had living wills in the state of Ohio. Our family respected his final wishes not to be kept alive artificially when he went into a coma. After moving to Israel, I went to an attorney to draw up a living will here. The lawyer told me that a living will can be hard to realize in this country, mainly because your primary care doctor does not see you in the hospital.

Susan Jacoby covers a tremendous array of topics in "Never Say Die." She includes many research studies and interesting historical developments, along with a sprinkling of personal stories. I was particularly moved by the few times she speaks of her own family experiences. Her themes of the reality of old age and practicality of facing it openly spoke to me. In anticipating my own last years following my husband's death, while still of sound mind and body (reasonably! ), I made all the arrangements for aliyah three years ago, at the age of 79, so that I could enjoy life with family in Israel. It's been a successful, gratifying experience.

We in Israel can learn much from Gross and Jacoby. Of course, they write about many of the same topics, but their different approaches and styles reinforce the importance of their material. Although Israeli health care is more universal than American, the two health-care systems have much in common: Israel's health funds are analogous to HMOs, the National Insurance Institute is like the Social Security Administration and the Health Ministry provides the same kind of health care subsidies for low-income elderly, similar to Medicaid. In addition, nursing homes are expensive in both countries.

Jane Gross and Susan Jacoby are two talented writers whose insights cross borders, with Gross inducting us into the emotional and practical realities of caregiving, and Jacoby entreating us to accept the eventuality of old age, however unpredictable it may be. Both books advocate preparing for old age with autonomy and dignity, if we're lucky enough to get there.

Edith Paller is a retired social worker in planning and program development. She made aliyah from the United States in 2008.