This is often how the story emerges: the cold, metal scale in the geriatrics clinic betraying a tightly held secret. "You've lost another four pounds," I say to my patient, an 85-year-old woman who layers multiple shirts against the season's chill and peels them off to reveal skin that hangs on her stooped frame. She wears an oxygen cannula and is mildly short of breath after this exertion. With some taps of the keyboard, I note a 22-pound weight loss in the past two years.
The true tally of her losses is more significant. First there was her husband, who died unexpectedly in the emergency room one winter day. She still will turn and expect to find him sitting in the chair beside her. Another loss was the home they shared. Her children moved her to a senior apartment building so she could be nearer to them. A fall resulted in a fractured pelvis, so that now she slowly negotiates a wheeled walker through the shrinking sphere of her life. It has all been an adjustment. She does not feel like eating when she is alone.
"The art of losing isn't hard to master," writes Elizabeth Bishop in her poem "One Art." "So many things seem filled with the intent to be lost."
In my third year as a geriatrician, a doctor who specializes in the care of older adults, I find these words are often in my mind as I listen to the stories of my patients. I've learned from them that aging is an emotional experience as much as a physical one. Doctors and nurses caring for the growing numbers of elderly need to recognize this.
I take histories from patients well versed in the art of losing: The widower who tries, unsuccessfully, to recreate his wife's pork chops, and instead sustains himself with whiskey and cigarettes in front of a flickering late-night TV. The Air Force veteran with swollen legs who can no longer walk to the bathroom and smells faintly of urine, swearing he would rather take a gun to his head than move to a nursing home.
Sometimes the metal scale is a cruel accomplice, uncovering lapses that can no longer be ignored. One woman, a wisp over 100 pounds and disoriented about time and place, has put plastic storage dishes in the oven and served raw hamburger to her husband. Both of them are shedding pounds, alarming their daughter, who accompanies them from the waiting room and gently, tearfully mentions the slips. Within the year, the husband will be dead and their children will have boxed up the contents of the three-story home where they lived for more than half a century.
One reason I chose geriatrics is that it offers the chance to help older adults have an excellent quality of life, in spite of disability and illness. And for sure, many of my patients continue to lead vibrant, joyous lives in their 80s and 90s — volunteering, traveling, remarrying, spending time with family. One is 97 and takes classes in memoir-writing, music and the Supreme Court. Another, 93, sings in his church choir, bowls in a league and dances the shag at the American Legion.
Still, I know there are some calamities I cannot fix, tragedies so ordinary and yet so singular: A patient, down nine pounds in the past year, who hits her face on the curb when she trips on the way to the store. Her daughter flies in from across the country and finds the refrigerator empty. The older woman misplaces the car keys, accuses the daughter of stealing, grows suspicious that people have been breaking into her house.
When I administer a short test of her memory and executive function, the ability to plan and organize behavior, she becomes flustered and annoyed. She looks at her daughter imploringly, but continues out of politeness. Young enough to be her grandchild, it feels cruel to ask her such ridiculous questions, but I know it is a necessary part of my assessment. I feel crueler still when she is unable to complete the task, and later, when I have to say, "You should not drive anymore."
I can only begin to imagine what it is like for her, and for other patients who lose spouses, confidants, homes brimming with memories. Mobility, independence, dignity. Their minds. Their identities. This is what I'm learning: Although I can't fix everything, I can ease suffering, and offer hope, understanding and dignity.
My patient's daughter has been taking notes in a spiral-bound notebook throughout the visit. I wonder if she will show them to her mother later, as proof of my conclusions and recommendations. When we are finished, the daughter returns the notebook to her tote bag, gathers their belongings – their role reversal an act of love that signifies how much has been lost. They walk down the hall away from here, the old woman taking small, cautious steps, heading out into the waning sunlight.
Ariel Green is a geriatric medicine fellow at the Johns Hopkins University School of Medicine in Baltimore.