 All right, welcome everyone. Thank you for joining us for our online program at Mechanics Institute. We're very pleased to have a program, Elderhood, Redefining Aging, Transforming Medicine, Reimagining Life with author, Dr. Mies Aaronson. I'm Laura Shepard, Director of Events at Mechanics Institute. Now, for those of you who are new, Mechanics Institute was founded in 1854 and is one of San Francisco's most vital literary and cultural centers in the heart of the city. It features a general interest library, an international chess club, ongoing literary and cultural programs, and of course our Friday night Cinema Lit Film series. Please visit our website, milibrary.org for all of our programs and also the library's closed, but of course you can order your books online and pick them up at the front door. There's more information at our website. This talk will be followed by Q&A and we look forward to your participation. So please, at the end of the program, put your questions in chat and we'll have a conversation with you. Now I'd like to introduce our program. Even though we're living longer and even healthier, even with COVID, most of us regard old age as something to be dreaded, denigrated, neglected, and denied. In her new book, author Dr. Louise Aaronson uses stories from her quarter century of caring for patients and draws from history, science, literature, popular culture and her own vast experience to help to redefine and celebrate elderhood. We're very pleased to also say that this book, which is so beautifully written, was a Pulitzer Prize finalist. Dr. Aaronson is a leading geriatrician, a writer, educator, and professor of medicine at UCSF. She's a graduate of the Harvard Medical School and received the Gold Professorship in Humanism in Medicine. She also received the California Home Care Physician of the Year Award and the American Geriatric Society Clinician Teacher of the Year Award. And her writing credits include The New York Times, The Atlantic, Washington Post, Discover, Vox, JAMA, Lancet, and the New York Journal of Medicine. And she's also been featured on NPR's Fresh Air Today, CBS This Morning, NBC News, Warning Edition, Politico, Kaiser Health News, Tech Nation, and the list goes on. So we're really honored and pleased to have Louise Aaronson with us for her new book, Elderhood. Well, Louise. Thank you, it's a pleasure to be here. So I was just telling Laura before you all arrived that I just finished clinic and I haven't done a straight book talk. I've done a lot of pandemic talks since pandemic, but I haven't done a straight book talk and I feel a little rusty on that. I don't know about you, but to me it feels like I don't know about a decade ago that I was traveling the country talking about elderhood. And yet part of why this moment has been so powerful has been the ways in which it has shown up a lot of the things I talked about in elderhood, both for better and worse, honestly. So among the key points in this book and I should actually start by talking about the title of elderhood, which I didn't make up and I actually cannot find the originator of that term. So if any one of you wants to find that, that would be awesome. When I first had the notion of this book, I wanted something that was a parallel to childhood and adulthood, right? Because right now we sort of talk about all of this something that happens to other people. So when old begins in most people's imagination depends a lot on how old they are now. If you ask people in their 20s, they'll say old age begins at 50 or 60. If, yeah, I know, seriously, like I'm not kidding. But if you ask people who are older, they will usually say, oh, maybe 70, 75. And I actually gave a talk once that, I think it was at Rossmore, where the average age in the room was clearly well into the 80s. And so I was having people raise hands for which decade is old. And when I got to the 90 and 100, just the room, everybody was giggling because there were some people still unwilling to raise their hands. This in contrast to Silicon Valley, a few years ago there was a New York Times article talking about how they were having retreats, sort of relaxation retreats for older workers in Silicon Valley. And you had to be 30 or older to arrive to show up. So do we have a problem with old age? We do. So my initial thought was to try and reform the word old, that I was gonna call this old hood. Cause, you know, anyway. And then I actually, stupidly, used this in the New York Times and a woman, clearly very smart, kind woman in New Jersey, whom I don't know and whose name I'd have to look up, sent me a note and said, you have a real grammatical problem, right? Because child, childhood, adult, adulthood, old hood, what's an old, you know? So anyway, so that's how we got to elder hood, which, you know, not every audience appreciates that, but grammatically I was just a pulp, of course. And one of the arguments that I sort of like to make is in the first place that we need to recognize that old age isn't just something that happens for a few weeks, months or years before you die. Like, we all kind of know this. I'm already shocked. I'm still, I'm in the tail end of my fifties and just the difference between this and my forties is just completely shocking to me. You know, it's like, and that's actually been super helpful. I think I was only able to write this book because I was finally in my fifties. When, and I watch my young geriatrician colleagues do similar things where it's like the other. You know, it's like, oh, some people are going to work in Uganda and these young doctors are going to work with old people. You know, it's really just something people can't get their heads around. And at the same time with longevity, we are living decades in elder hood. And we all know if we're paying attention that elder hood has at least as many sub phases as childhood, right? So childhood, you're born, then you have all these sub stages and we have an entire vocabulary for them. So you have neonate, infant, toddler, young child, child, tween, teen, and young adult. And at this point, you're what, 18 or 19. It's not even two full decades. And yet if we're saying old age begins, even if we take the legal definition of 65, which I have to mention was set as the legal definition when the average age of death was 67, which is not the case anymore. But let's say we take that definition. A lot of people will live in elder hood for 20, 30, 40, and occasionally 50 years. So to say that a half century of life or even a quarter century of life has no variation, doesn't deserve subcategories makes no sense. And yet we reduce it in that way. At the same time, and this is, that was actually like the longest digression in history. And I'm good at digressions as you will learn over the next little bit. The pendemic in some ways refuted part of my argument. On the one hand, age matters, but age isn't everything. But if you actually look at the death curbs for COVID, they start going up at about age 45. So probably when you're getting into sort of middle age, maybe, I don't know, I saw something recently that started middle age at 30, and that just did not sit well with me. I don't know if that's like my own perspective currently, but anyway, I feel like I'm in middle age. I'm not sure a 30-year-old is. So it starts going up at 45. Definitely an uptick in the 50s, goes up significantly more in the 60s, a whole lot more into the 70s, and really very high into the 80s. So that shows the way in which biologically anyway, age matters in terms of at least this one infectious disease. At the same time, we have things going on like a current president and president-elect who are both in their 70s. We have Nancy Pelosi leading the charge in the House of Representative, age 80. We have people all over the place doing things across the decades of old age. Prior to the pandemic, people in their 70s were the fastest growing segment of the American workforce. Now the oranges of that have two parts and that sort of speaks to the pandemic too. Part is economic. If people retire, ironically, some people are retiring earlier. If people retire in their 50s and 60s and they don't die until their 90s, their retirement savings may be inadequate. And as pensions and retirement funds increasingly show themselves historically to be an epiphenomenon of the late 1800s and the 20th century, a lot of people simply can't afford to retire, which is how it was through most of human history. And then there are all the more fortunate people. I actually had a patient this afternoon ask me, if I was thinking about retiring, I was like, absolutely not, I love what I do. I'd like to do it a few hours a week, but no. So we have the ability to do more for longer and then there's the notion of encore careers. So we're at this pivot point and never before in history have there been so many old people. So I also feel like this is the moment we're gonna start recognizing the subcategories. COVID has been complex. So COVID showed us the complexity of old age in the sense that yes, risk goes up dramatically with age. On the other hand, you even get to the highest risk category, people over age 80, and let's say let's even take people in nursing homes. Yes, larger numbers of people die than in say a college dormitory. But not everyone dies, right? 80% don't. And some people are asymptomatic and they're 80 or 90 or 103 years old. So what's up with that? This is so varied. And it has sort of brought home this point that as part of elderhood and yet, I feel it's even more important is if there was one thing we could do that would change the way we get to age, it would be for an appreciation of the diversity of old age. Not just that there are many stages, but that it's more diverse because the truth is that if you take a two-year-old across the planet or a 22-year-old across the planet, those people will be more similar than different barring some medical catastrophe in their intellectual, emotional, and physical abilities. But the same is not true if you take 82-year-olds. Even if you take 82-year-olds in the same city. So there is a diversity and complexity. And in some ways, the way we approach problems as a society doesn't like complexity. We like black and white. We like good and evil. We wanna categorize things. The human brain needs to categorize things. So how do we think about elderhood in a way that both enables people to live fully until their deaths, regardless of age and the age-related changes? Because let's face it, they're age-related changes from before you're born. It doesn't matter what age you are, you're changing. But somehow we're penalized for the ones in the last third of life, they're rewarded for the ones in the first third and it kind of depends in the middle. That's a choice, that's a somewhat of a cultural decision. So how do we get people to grasp the complexity and variability of old age and to create a world that acknowledges that and that offers opportunities? I feel like this is in some ways starting to happen. We have never before seen more mentions of older people in the press. When I first became a geriatrician, if I saw something in the popular press once a year, once or twice a year, it'd be great. And then maybe 10 years ago was once a month and now I can't keep up, I literally can't keep up. I'm not sort of the demographic imperative, but people are stuck in some of the comments they make about aging. And that has to do with how we all think about old age. So Laura asked me to read a bit from the book and I'm just gonna read a bit from the beginning because it speaks to how language and really all of us can be part of the problem and also part of the solution. So apologies to anyone who's already read this. But I think for a library audience starting with the words seems like a good place. On a foggy morning in 2015, I arrived at the University of California, Berkeley for an appointment with Professor Guy Niko. I had heard about an exercise he did every fall with his new medical students and I wanted to see it for myself. Standing at the front of a cramped classroom, Niko asked a group of 16 medical students to put down the first words that came to mind when he used the word old in reference to a person. Don't filter, he said, just right. The young men and women around the single large table were first year students in a joint medicine public health graduate program that describes its matriculates as quote, passionately dedicated to improving the world's health, end quote. They ranged in age from early to middle 20s and their resumes attested to extraordinarily idealistic good intentions. The students began scribbling on the scratch paper Niko provided so he could collect responses and assess trends over time. When one minute elapsed, he told them to stop and then he repeated his instructions but this time with the word elder. A few students shook their heads. They knew they were being manipulated. Niko had been doing this exercise with his students for years. The faces in the room changed but their responses to the two prompts did not. There were no trends reflecting shifts in how his students thought and felt about old age. So he wasn't surprised when the most common associations with the word old included wrinkled, bent over, slow moving, bald and white hair. Many also wrote weak, fragile, feeble, frail or sick, a sizable minority put down a variation of grandparent and several listed their mothers though generally the parents of medical students age and age from late 40s to early 60s. Here's most people consider part of middle age. Some used words like wisdom but more chose sad, pejorative, stubborn and lonely. One wrote smelling of mothballs and stale smoke. For elder, the list looked different. By far the most common word was wise. Other responses were respect, leader, experience, power money and knowledge. So the really interesting thing about that is that if you look up the word old as applied to a human being and you look up the word elder the definitions are identical. So this is a cultural overlay we bring to the word old and we bring to it in ways that do all of us a disservice. I will not become a Somali in my lifetime. I suppose I could become a man but that is still rare even in the 21st century and I'm probably gonna choose not to. Perfectly happy the way I am. I will become old barring a premature death and that is true for everybody. And yet somehow we avoid it, push it away, say bad things about it and are somehow unable to hold some of these dual realities together. I am by no means saying that old age is all joy. I've just come from clinic where a couple people said, oh, I used to be able to do this and now I can't and COVID has been even worse for it. My mother's doing this and I'm doing that. So it's not that things don't change with old age and that it doesn't bring disappointments. At the same time it brings opportunities and a comfort with the self. There's actually something called the U-shaped curve of happiness which has been shown across almost all countries. So most societies except for the very poorest of the poor. And what it shows is that people are fairly happy in childhood. They're pretty miserable in mid-life sort of 40s and 50s especially and around 60 it starts going up again and it remains up. Now, could there be a little bias because if really you've had a big stroke and you're feeling miserable you might not participate in a survey when if you're 88 or 92 or whatever you are. Yes, of course. And yet these are things that are replicated again and again and what's that about? Well, that's about comfort with self. It's also about, and this is the duality that comes from the language and the duality that we have to figure out a better way of communicating, living and working into policies and structures because one of the things people talk about that makes elderhood such a challenge is the fact that it ends in death. You're a child, you end by becoming an adult most people wanna become an adult. You're an adult, you end up by becoming an older person an elder I would prefer to say and that already for many people feels like a step down but it's not as bad as being dead to most people. So, but it is probably that clock and because this is a reading group you might appreciate better than most audiences. When you set a clock, if you're reading a novel, a mystery, a historical something, a clock leads to tension, it propels the narrative forward it creates purpose and urgency. And so it may be that the comfort with self the ability to better prioritize which is found in older adults comes in part from knowing that time is limited and so each day is felt to be more precious or each year and people make better decisions. Now, some decisions are made for us. Maybe you're no longer gonna run a 10K or maybe you're not gonna, I was thinking that I had to teach it last night after a long day's work and I couldn't remember a certain study. Now that would not have happened to me 20 years ago. I would have been able to tell you like the date of publication and how many people were in the study and whatever else, terrific. So now I can actually integrate it better into a large amount of knowledge but it was a little hard not to be able to tell them where it was. And yet when we talk about aging we tend to talk about what is forgotten and not what is gained which was the way in which I was able to integrate it into what was going on in that course. And so we tend to make this mistake and tell the good story and not the bad story. So we tell the story of old and not the story of elder. We have actually some good friends, a couple who are in their early 80s and they'll, yes, they've got aches and things and he's having trouble walking and her hip is hurting and so there's all this and then there's also the fact that they have spoken with all their friends, they have been able to go outside for walks every day, they're reading books, they're watching television shows, she's made all kinds of incredible food, he's fixed stuff around the house, et cetera. And I haven't had time to do one of those things. My rear end is in this chair working for like 12 hours a day. So we have to be careful in how we're telling stories and I think being honest about the good parts as well as the bad parts and learning how to see those parts. I'm sorry, I'm winding and winding. It's been a long week and a long year. I'm one of those people who are accounting, this is still 2020, this is day 370 something or 300 days something because it just goes on and on and on. But when we hear about the pandemic and its impact, there's sort of some sympathy, but also a sense of like I can do what I want because it's about those old people and people will simultaneously say things like, well, I'm okay, so it doesn't matter. So we also need to work on the connectedness of all of us, the fact that, well, those old people include your teachers, your bosses, your grandparents, your parents, whoever else and make it real for everybody. And part of that comes with embracing elderhood. So it's really the only stage of life where people will say, oh, I'm not old or if you say you're old or you're showing your age, people will say, oh, you're not old or you look great, by which they don't usually mean you look great. They mean you look great for your age or what do they mean? And yet I think as we age, we see that people look great and they legitimately look great. Is it different from looking great at a younger age? It absolutely is. But I think until we all start embracing it and using the language, raising up the elderhood, pulling it into conversation, feeling comfortable with it with ourselves, then society doesn't feel comfortable. And in some ways, the pandemic has been a little bit of backsliding there. There's actually a guy in Singapore called Ruben Ng who does research on ageism and he thinks this has increased it. And part of that I think is, and this shows the structural ageism and how it does harm. So part of it is the fact that the greatest number of deaths have been in skilled nursing facilities. So nursing homes to a lesser extent assisted living. So when I'm speaking to groups, particularly younger groups, and I say what percentage of older people live in nursing homes? People will raise their hands at 80%, 70%, 60%, 50%. And in any given moment, it's 1%. Lifetime risk is higher and it's higher for women because women tend to live longer. But the fact that all the publicity has been about nursing homes shows a few things. One, it reinforces this notion that all old people are in nursing homes and at the end of their lives. And realize that for some people, this is starting at age 60. As opposed to the reality, which is that the vast majority of people are out and about. But what often happens cognitively in people's minds is if somebody is out and about, if they're working, if I'm having a good conversation with them, then they are by definition not old. And it's only, so this happens with individuals, but as a group, they sort of throw away all of old. So I would love it if people like Nancy Pelosi would say, yeah, I'm old and I'm running the House of Representatives. This is what it all looks like. And at the same time, we can't do that to the exclusion of the person who is the same age and is in a nursing home because that devalues that person. So another negative thing that has been happening for years but has been in some ways made worse by the pandemic has been some younger old people saying, well, I'm not really one of those frail people. So these things don't apply to me. And the problem with that is that in the first place, it's not showing empathy for the people to whom it does apply, but it also sets ourselves up to be one of those discounted people later because the fact of old age is that most of us will have a point of needing help. And so unless those of us who are younger old and more fit old can embrace the entirety of old age, we continue to perpetuate a system in which human beings are devalued. On the basis of what they can and can't do instead of just valued because they are human. There's also this phenomenon where we say, well, we must save the children. And I realize that's an instinct and it may be biologically inbred because species can't survive if that doesn't happen. And I'm by no means anti-children. I'm saying we can casually sacrifice anyone for somebody else. But one of the big arguments that people often make about, oh, we've got to focus on the children. Not the children get such a good, get good resources or anything else compared to adults. I mean, adults are definitely top dog in this game. But we'll say it's because children are the future. Well, yeah, children are the future. They're the future heroes. They're also the future sociopaths and the future cheaters and the future people who don't do anything and the future. And why is it that a potential future counts more than an actual past? And these are the sorts of questions we don't ask that we all internalized ageism now that homophobia has actually gotten better and internalized homophobia is way down. The greatest internal prejudice is internalized ageism. And so this seems like an opportunity because COVID has adversely affected older people because we found that the places where we put frail or older people aren't so safe. This actually isn't so much news. Like families will say it's so hard to take care of this loved one or the loved one will say it's so much work I'm not gonna impose on my family. So I'll go to this place. So we've all decided this is hard work. And usually when something's hard work, what happens? You get paid a lot of money to do it. But instead in this instance, you get paid what is not a living wage to do something that everyone agrees is really hard and really important. So this COVID moment seems like an opportunity to really push back. In this book, I spent a lot of time also talking about the healthcare system and its many biases. So doctors in training and I guess I should say just pause for a minute to say, I don't wanna medicalize old age. And that's maybe another COVID lesson that across the 20th century really sort of medicalized old age. Well, and it's true that older people use a disproportionate share of health services. And there's a lot of political pushback against that. Well, here's some analogies. So children hands down no contest disproportionately use educational services in this country and educational services are really expensive. Adults hands down no contest disproportionately are part of and further military service. And that is really expensive, right? But we don't give them trouble for their things. So there is this double standard that's built in to medicine and to society. The first draft of this book, I looked at all the doctor books that had done well and I analyzed them. This is probably my internist self or maybe just my intern nerd. So I looked at them. And what I found was that most had nine to 13 chapters and each chapter was 25 to 36 pages or so. So I wrote that book. And then I thought I'm bored. And my editor and agent said, this is great, keep going. And I thought, no. But I realized it wasn't just that I didn't wanna write the same book necessarily. It was also that I think one of the things we don't realize when it comes to aging is the way in which the social notions of old age are tied up in the medical notions, are tied up in the social notions, are tied up in the historical notions. And so when this book really came together, I was actually at the McDowell Colony, which is this gorgeous place in New Hampshire. Yeah. So I got this big room with windows onto a meadow and deer would come and wild turkeys and stuff like that, which is fantastic. What I realized was that I had to have smaller subsections that would jump among story, history, science, medicine, society, et cetera, to show in the form of the book, what it actually happens in our lives and in our society, which is that these things can further each other for good or for ill. So how do we create a better elderhood? Well, we've learned that with long-term care facilities, it's been good for some people because they're able to see friends when there's no outbreak and it's been really bad when there are outbreaks because everybody's part of a large community. We have seen that everyone else is kind of invisible and discounted like just stay locked down for now almost a year. The vaccine hopefully will start changing that any minute now. But if you look, so for example, and I spend time in this book talking about the ageism of the health system. So I have been volunteering, well, and then working with our Department of Public Health in San Francisco and at the state level now since late spring, and nobody knows anything about old people, nothing. They have a huge Department of Youth and Family Services. If you look on the website on the COVID-19 website for the San Francisco Department of Health, you know, older people are maybe 20% of, it sort of depends on the San Francisco population, but 88% of COVID deaths in the city. If you look on the website, they have, you know, quick links for COVID and mention of children and youth, but no mention of older people. You can find on the CDC website, relative risk. So they take as the average. So this is the point between lower risk and higher risk. People between the ages of 19 and 20, 18 and 29. So kids are nine to 16% less likely to get really sick or die. Older people above age 60, I think it goes up to 200% higher. And over age 80, it's 630% higher risk of death. But you look on these websites and what do you see? You see here are the symptoms in children. You see, here's what we're doing to reopen schools. You can, I actually have slides for medical talks I give on this where you see the normal, and this is true of CDC or San Francisco or anybody. There's the lists of items. And most of these are reference to adults. Then they'll have a section for kids. Sometimes they'll have a section for older adults. The CDC actually doesn't. Older people come under special populations. Can you imagine if either children or adults were being disproportionately affected in this way, that it would not appear on the landing page of a website, that it would not unfold into a sub-menu that was enormous? And yet the CDC and everyone else will tell you they have normal symptoms of COVID and then they have special symptoms in children. They still do not have special symptoms in older adults, although we know particularly older and frailer people, so over age about 75 or anybody with frailty, have different presentations as much so as children. And there's an abundant literature showing that and it doesn't appear. So this is structural ageism. We've been hearing a lot about structural racism, but it's structural ageism. And I feel like it's a loop of people denying their old age, so becoming invisible. So it looks like there aren't so many old people. So old people become an abstraction and then the structure category of people who all live in nursing homes and that we don't really have to worry about and we can lock them away. As opposed to every other movement where people really sort of stand up. If you think about the civil rights movements from the second half of the last century, there was I'm here, I'm queer, or black is beautiful. We need to do something similar for old age and stop denying. That was why I began the book with old elder because everybody's so busy trying not to be old that there's no recognition of how many elders there are and how everyone knows many elders, loves many elders, works with or is in family with, is in conversation with elders. So we have to make it more visible to make it more acknowledged. I do talk about in elderhood also thinking about the sub stages of old age and I'd love your thoughts and impressions on this. So one of the tricks of old age is that you don't necessarily march through stages in an orderly way the way you do in childhood and adulthood. I mentioned earlier the stages of childhood. In adulthood, you're a young adult, you're an adult, you're middle-aged. It's just an orderly progression. But with old age, there's this sort of mixture of chronology because if you're a hundred, even if you're in really good shape, you're still old. I mean, hopefully we can agree on that. But there are people we've all seen who might be 68 and have been really sick or had really hard lives and they just seem really old. And there are other people who seem younger than their chronological age. Now in the first place, I sort of question whether we should be using the terms young and old for that. And I did it very intentionally just then because it seems we all understand what that means. And yet every time we do that, on the one hand it's a good shorthand. We know what we mean. It also again diminishes old age. And it suggests that old is always something that is defined by its absence. So if you think of, so it becomes the negative space in the sculpture. So if all things good, if somebody seems to be functioning well or seems healthy or seems vibrant, we say they look young instead of, why couldn't we just say they look healthy? They look vibrant. They're so engaged, right? Because whenever we say we equate that with young, it means old is the opposite of that. And then you have a losing battle. Then you have governments that don't even list old because and the symptoms of a pandemic that disproportionately affects old people don't even list that. Because they're so discounting those people. And I guess I should also say that I think one of the hardest things for all of us and in addition to sort of grasping old age in all its diversity. Oh, I should finish the previous thoughts. Sorry, really the brain not working well. So one of the challenges of elderhood is that sometimes a person might have been really sick and they will look, quote unquote, older. They will look more frail. They will look less vital. But let some months elapse, you know, some rehab, some, you know, some, some, some good time and they will, they will go back, seem to go backwards in time, right? They'll seem to get younger. We also know that some people are really healthy and really fit and then seem much older, quote unquote. So we need a language. This is something that we can all be working on. It is different. Once you're two, you're always two and we know what that means. And once you're 12, you're never two again. But there is this notion that you could be 62 or 72 or 82 or 92 or 102. And one day you look 102 and another day you look, you know, 10 years younger or 10 years older. So how do we, how do we deal with all that? How do we deal with the language of that and the different sub-stages? I think part of it is asking questions, you know, if in your healthcare system, if they don't have geriatricians or they don't have any aging services, say, I notice you have this much for adults and this much for kids. And I'm just wondering, given the disproportional usage, I would think you would have three times more for old people and I'm not seeing that. And you call yourself old and, and live and own that. And hopefully this COVID moment as it gets better will enable us all to really think about how do we redefine and re-approach aging? How do we make sure that when people are in charge of a public health pandemic, they actually know something about elder care facilities because let me assure you they know nothing. And each time it, every three months it turns over and we have to educate them again. So how do we create a world where that isn't true? And also perhaps where we can keep going with the movement that's already so big, which is aging in place. So, I mean, I could obviously, you know, it's a long book I could go on, but Laura's reappearance reminds me that it's time for Q and A. So I'll just apologize for a sort of circuitous talk. It is the state of my current condition under pandemic. I believe not at all, it's so informative and so heartfelt as well. I'm gonna start off with a few questions. You know, what we're talking about is a certain bias of ages. And then I'm wondering if you can give us an example of other countries and of course, different cultures of different attitudes about aging and what are some of the cultures around the world that have a different kind of framework and a way of speaking about aging. And my second question is about our aging, a baby boomer population and what solutions and models if you had, if you were in a position of power and advocacy, what model would you like to see for the future and the near future? Okay. In time for all of us in other words, yes. So to the first question, it's really varied which societies have done old age better across time. We tend to think of the East Asian societies as doing better, although on some of the more recent metrics of ageism, places like Japan and South Korea don't actually score very well. So it may be that we have exported that, with the internet and McDonald's and cigarettes and so on. So that's changing. It's also true of prejudice generally which has been talked about for decades now that the more people there are in a certain group, there often is a proportional rise in prejudice even as there may be a civil rights movement simultaneously because the people who were previously the more powerful feel more threatened by those larger numbers. So ironically, the increased numbers of older people may be accelerating ageism even as it sort of simultaneously empowers everyone and creates this whole body of people to help make change. You see this mostly in employment, like they should move out of the way it's our turn now. At the same time, there have been reviews by Harvard Business Review, et cetera, that age diverse teams are the most productive teams in the workplace. And part of that is that people have really different skills and if you can assign tasks relevant to skills. And I actually wanna have been thinking lately that I would add to that. It's not just skill sets because yes, the brain is different across time and what you tend to be best at and not. I also think there are generational differences that add to the strength of multi-generational teams, particularly in this age of accelerated science and tech. You see huge differences between the learning styles of a five-year-old and 15-year-old and certainly of a 15-year-old and 55-year-old. So we really bring whole different cognitive architectures to the table, which is really interesting. There are societies that have respect in that wisdom. There's this hypothesis about, almost in prehistoric societies, the grandmother hypothesis, it turned out then that grandfathers were less useful, but what would happen was that when the child, and this is like in the times when you became a grandmother at 40 or 50 or something like that too, which still happens sometimes, but less commonly. Maybe even at 35. So you would have the generation that was bearing the children, which would usually be the generation doing most of the work, so that the generation that's working most is also the generation with children and the grandmother would be there to take care of the children so that the working generation could work. We're seeing some of that now. The economic recession brought some of that back, but in that situation, there is a value, an essential value. There have been other situations where it's been about wisdom, so people push back, well, do you need wisdom if you have Google? I will say I do consult Google frequently, but particularly when I'm cooking or doing something like that, if I get stuck and Google can't help me, if I call my mother, who's 87, she has yet to fail me in giving me a solution to my cooking problem. So I think there's still wisdom. The society's that respect older people more tend to live with them instead of isolating them, which could tie into the whole aging in place, maybe I'll move now to boomers. It's when we don't have as much distinction, I mean, in this country now, we have huge separations in where we live based on age and race and political affiliation and stuff like that, and that makes it harder to speak across those divides. And we've had this thing of when part of adulthood in this country, as you leave home, and then parents, adult parents often feel guilty moving back and delay it. And so sometimes what happens then is when they move to be near kids, it's because they need help. And if they need help, they may have missed that opportunity to actually develop their own friendships and relationships within a given community. So the more I'm hearing these stories and thinking about this, I'm thinking about, should we sooner, or should we at some point by middle age be moving into the place where we hope to spend the last decades of our lives so we can be forming our own relationships? For aging in place, everybody's focusing a lot on this and the pandemic and long-term care has been really interesting in a few ways. So the places that are communities, but communities with smaller pods, kind of like the social pods, we've been allowed to form with a handful of other people if we're all taking the same precautions. They have basically had those built in where there are these little, there may be a building where there are six apartments. And it's part of a larger complex, but if you were locked in, you'd at least be locked in with the residents of the other five apartments instead of your choice being, you're locked in your own room. You don't see anyone, but the four walls, especially if you're a widowed, widower alone for some reason, or you're in a huge congregate area. Most people wanna stay at home. They wanna age in place. And yet, probably 99.8% of people refuse to make the changes that will make that possible. I don't know for this year, but I know in 2017 at UCSF Health and our Medicare Advantage Program, the number one reason older people had to go to skilled nursing after a hospitalization for anything small or big was not medical reasons. It was because of the functional mismatch between the person and their home environment because they kept saying to themselves, I'm fine, I can do everything I need to do. I don't have to make changes yet. If you haven't made the changes before you need the changes, you often lose the opportunity to make the changes to age in place. I am currently working on a project called Age Self-Care, which is an acronym. I always have it written on my whiteboard because even though I made it up, I cannot remember this so I don't expect anyone else to, but it stands for adaptation, growth, and engagement, community activation for resilience and elderhood. And it's a partnership with San Francisco Village and at Home with Growing Older. So SF Village is also sort of working on this, but a different way of providing social networks. And at Home with Growing Older was started by an architect and a social worker. And they really, one of the things, so Suzy Stadler is the one who started that. And one of the things she's taught me that I love. I always believed, okay, we have to do things earlier, but she talks about the lived environment trying to find delight in it. So you make these modifications. So one of my arguments, if you read Elderhood, you'll see is that we need a silver architecture. So that's an analogy to green architecture. Green is good for the environment. Silver is good for aging because usually when we make things in a home or anywhere else for kids, we make them cute and colorful and just charming. And we make things for adults. We make them sleek and sexy and all these other things. And when we make things for old age, we make them hideous as if no one cares, as if nobody wants to look good or have a bathroom that looks stylish or anything else. And so that's changing, but Suzy sort of adds to that argument. And you just have to demand that it's good looking because you can make anything good looking and companies need to get on this market because it's huge. Because if you could imagine that if when people initially built buildings, they made them so you could age in place, that would be terrific. And people, but most buildings aren't like that. So we all have to make changes in where we live. And there are increasing options for doing this in a way that makes the place look better, not worse or fun or stylish or any of those things. But Suzy adds to that thinking about how the home can be a source of delight and making the home your ally. So at some point it might become ridiculous to use your bottom shelves and your really high shelves for different reasons. Maybe bending, it's harder to stand back up or your hip hurts or your knee hurts or your back hurts or whatever else. So you feel dizzy or things happen. And for the high one, maybe you don't want to get on the ladder or maybe you've gotten a little shorter because we all shrink as we get older and you're not gonna be able to reach it anymore. And there are really simple things like what about the things you use every day? Can you put them on a level where you can reach them or can you move cupboards around? Can you move the chair by the window so that you're always getting daylight and that actually if you're on the ground floor, you get to know some of the people who routinely pass by. I mean, there are all these things we can do to be parts of communities. But it starts with thinking about where you live and what resources you use and are you close enough to the things you want and use most? And if you're not, there are options. Should you move now while it's easy, while you're in control? There's no age in my experience at which people like being out of control. And you can get out of control with aging if you haven't planned for yourself such as when the hospital sends you to a nursing home when you'd rather go home. But if you have planned for yourself, you can go home. If you have planned for yourself because you know you can call your friend who's gonna come help you because you have a reciprocal deal, you're gonna go help him or her if something happens. You can do all these things that augment your sense of control but it requires acknowledging that you're old, acknowledging that bad things will happen and planning for them while you can still make them delightful and under your control. So that was, I'm very long-winded tonight. Let me see what's in the question. Well, Margaret Vogelsang is asked and everybody just to remind you if you have a question, just type it into chat and I'll pass it on. Marlene Vogelsang asks, how can we keep in touch with what Louise is talking about with aging in place? Great talking, thanks. So lots of opportunities. This organization I mentioned at home with growing old or at home with growing older, the website is one and the email is the other. So, but anyway, if you go there, you'll find it. They have good talks and resources. If you're interested in the age self-care program or starting to roll it out and study it, so that would be great. Ah, so good question. So you can get in touch with me or people at UCSF if you're interested in this. There's lots and lots about aging in place lately and actually the Village Network. This was something that was started in Boston a couple of decades ago and the idea was older people banding together to help them stay at home. So maybe let's say I don't cook, but Joe who lives six blocks away is a really good cook, but he's having trouble with his computer but I'm good at computers. So I'm gonna go help Joe with his computer and he's gonna make me dinner and we're both gonna be happy. And these organizations now also have volunteers which reminds me of a point I meant to make earlier. So the other critical conceptual change is to recognize that you can be a person who needs help and gives help simultaneously. I think this is a key to aging generally and to aging in place. We tend to have a sharp divide like either I'm the fit vibrant person, I don't need any help or I'm one of those old people and I need tons of help. And there are stages, for most of us we will start in the first stage and we will end in the last stage, but for most of our lives we're gonna be somewhere in between. And so it's really good to join communities including the villages which offer, like right now Zoom exercise, Zoom intellectual conversations, neighborhood groups, et cetera. Yeah, Ashby Village is another one of the villages. There's like 300 and some now nationally. So depending on where you are. So to join these communities early when you can simultaneously be a member and a volunteer. It helps you make connections. I also think the more we all help other people growing older, the more we'll know how to handle it ourselves. People will often say, I don't wanna look at that. But if you don't wanna look at it then expect not to be looked at when you get there yourself, right? So instead apply your industry, your abilities, your creativity to making life better for yourself and others. Another big thing I like about the age in place movement and that I think is really critical to elderhood is finding purpose and meaning. We talk about, oh, you need to control your blood pressure and you need to do whatever else. Well, the data on purpose and meaning right now are really strong in terms of people's health and wellbeing. So just because let's say a person is, we actually had this in our first age self care group, a person who had multiple sclerosis, she was in her later seventies and she was pretty well incapacitated. So luckily had had enough resources that she and her son were able to make a good place to live. But she was mostly an electronic wheelchair or in bed but she could get around in the wheelchair. But it also turned out that having adjusted her life and changed her apartment so that she could live there, she was a total expert in how to make an apartment work as you had more challenges. And then it turned out she was a really good teacher and she could add her personal stories of things. And so it's just finding like, what is that thing that will make you feel like you're doing something for someone else? People often think like, oh, I have so many problems. I don't have time for someone else. Almost without exception, people feel better if they have a purpose and if they contribute something in some way to an organization or other person. It's that which gives you your self-worth. So thinking in ourselves and in others, how can we set up either aging in place or programs that are less about, oh, here are we able-bodied come to rescue you? And more about how can we work together to enable you to do those things that matter most to you? To give your life meaning and purpose and to help you in those places where help is what you need most. I just also want to say about Ashby Village because my mother had lots of friends who were involved with that in Berkeley and it's an organization that not just is a service and a resource for seniors living and staying at home but that the seniors are also participating as volunteers in the organization. So there's this whole huge network of the various ages and various people who are members, you become a member and that it's just a very active group with events and programs and outings and all kinds of things. And I was very impressed with the interaction between the members and how that creates all these different levels of support. So these groups are really wonderful resources. And also, Louise, I wanted to ask you about on the mega level are organizations such as the World Health Organization doing anything to promote elderhood and various attitudes and biases to change those attitudes and biases towards aging and also promoting systems and models around the world in different countries? Yeah, so the WHO has been not bad about this. They really talk about, they've had a big initiative for some years now about age friendly communities. So I like to draw a distinction between disability and handicap app. So disability is something you can't do but you're only, so disability is some part that doesn't work. Like it's not able to work. Let's say I can't use my right arm. So, but I'm only handicapped if whatever I wanna do I can't do, let's say with my left arm or with some other device that I can use. So age friendly cities means, for example when you have to retire from driving you can get public transit that is easy to access affordable and safe. You know, it means that if there's a pandemic and you're not supposed to be going around everywhere you can buy the food you need at a reasonable cost near your home. You know, that we don't make all movie theaters. I was walking by the one in Japan town which was near my clinic the other day. And I was remembering there are like these stairs that are like almost entirely vertical. So if all movie theaters were like that at some point everybody would stop going to the movies. Now it may be based on pandemic nobody's gonna go to the movies ever again anyway. I don't know, but you would just make it so that it's accessible across the lifespan. We do all these things where it's child friendly but what about elder friendly because certain things just do change even in the healthiest of us growing older. And so, so WHO does that. There are more and more movements. I find that some are better than others. So some things to look out for in pro-aging organizations would be the ones that throw advanced old age under the bus while they're complimenting the vibrant younger old. You can be useful to both simultaneously. You can even address just one group not the other, but you don't have to, you don't wanna have one get advantage by crushing the other. And sometimes that that's really, if worth is vibrancy or still working full-time then everybody becomes worthless by definition as they continue to age. So it's just not a helpful dichotomy. There are other things that really foster what we call learned dependence. So if you're old, you need help, it's that we're coming here to save you as opposed to, and it doesn't also recognize the structural bias, like that somebody might need saving not because of decisions that were made at a structural level such as maybe you're having trouble leaving the movie theater and it's because the steps are hyper vertical which is simply not necessary. Those are maybe ageist steps, or maybe you can't get somewhere like when we went to telehealth. And I had a lot of phone calls initially with patients because they couldn't use Zoom yet. And some of the first handouts that went out about Zoom had print that was about, like you just, you're like looking for your magnifying glass, it was so little or it was written by a 21 year old for 21 year old. So we had a meeting at UCSF about, people having difficult internet and what do we do about digital literacy? This well-meaning young man said, well, just tell them to go stand by their router. And I was like, I can't tell you what percentage of my patients know what a router is and A, what it is, B, where it is, it's just not helpful. So I think be careful of organizations that number one, say they're gonna save as opposed to help you, listen to what an older person really wants and needs most. And aware of the structural ageism that creates needs where there don't need to be needs, that produces handicaps where there might only be disabilities. And we really need to push back and rethink. And it's hard, I think, because we're all brainwashed. This is another reason why I think I was able to write this book when I did was that I started being a just, I who've spent my whole career. I started making comments to my cute little 22 year old students who are like, oh, now I'll go run 15 miles after working 12 hours, which I'm like crawling to the kitchen. So it just makes you realize that we can all be part of the problem and we can all be part of the solution. And I feel like so many of the conversations and questions asked really politely and acknowledging, like it gets important to say, you know, I thought that too. And then I learned that that's actually structural ageism. And I think all the talk about structural racism, which is absolutely real and true, has enabled us to have better conversations about other structuralisms, including this one. Here's another question. There's one question from Wendy Beck. Oh, okay. Is anyone working on developments for seniors that include housing for gerontology students? That's such a great idea. I have not heard of that. Should totally do that or speak to somebody at SF State gerontology. That is such a good idea. There are all these movements of, you know, older people, it's, you know, people usually who have lost their partner or spouse and whose adult kids are elsewhere who have apartments or homes that are good size. And they're, you know, feeling, I mean, this is even pre COVID, you know, maybe you have plenty of friends and activities, but you're feeling a little lonely. It's not as much fun to eat on your own necessarily. And then students who really can't afford rent, especially in places like San Francisco and the Bay Area. So having people, you know, inexpensively rent out rooms and maybe along with it comes, you know, a little, my computer is doing something weird. Can you help me? Or, oh my God, you know, my boyfriend or girlfriend or whatever just broke up with me. It's the end of the world, you know, so there are ways in which they end up helping each other or being friends or it turns out, you know, we both like to bicycle or we both like to read the same books or all these things. So that's definitely an option, but I hadn't thought of gerontology students so that they would like have on, they would learn so much from the realities as opposed to the abstraction of old people. Well, I wanna thank Dr. Louise Aronson for her incredible insights and her experiences that you shared with us today. Her book is phenomenal. I'm so glad you got to the McDowell Colony to do the rewriting of your book because it is so personal and it is so informative and it reads beautifully. The writing is wonderful. So I hope everyone will pick up a book through our local bookstore, alexanderbook.com and really enjoy her writing and really take to heart this really important message of aging with grace and respect into elderhood. So thank you, Louise. And thank you everyone for attending and come back to our next programs and we'll just say hello and goodbye in the last minute. Thanks, everyone. Everybody can unmute themselves and say a quick goodbye. It's good to see everybody. Bye, Pam. Bye-bye. Bye, Laura. Thanks. We'll speak to you later. Bye. Thanks, Louise. Thank you. Thank you. Very good to hear you. Thank you for the help. It was great. Thanks. So I'm going to go ahead in just a minute and close the doors. It's great seeing everybody and hope to see y'all again soon. Take care.