In his well-written and provocative book, How We Age: A Doctor’s Journey Into the Heart of Growing Old, Dr Marc Agronin helps reduce the stigma of ageism and provides clinical guidance for seasoned geriatric psychiatrists, primary care clinicians, and medical students alike. He shares his experiences as a psychiatrist for Miami Jewish Health Systems, the largest nursing home in Florida, a state often described as “God’s waiting room.” There he treated Cuban American immigrants and centenarian Holocaust survivors. He initially developed a hopeful perspective on aging through childhood experiences with his grandfather, who was a coun-try doctor, and later refined it during a human development course with Erik Erickson as a Harvard undergraduate.
Any clinician with a passion for the mental health needs of older adults faces the challenging reality of treating a dually stigmatized cohort: the elderly patient who also suffers from mental illness. To choose to work with such individuals is “not an accident.” Stirring anecdotes and clinical pearls are a primary focus as the reader travels with Dr Agronin into the “heart of growing old.” The author tackles critical clinical issues, such as the interacting syndromes of dementia, delirium, and depression, that must be appreciated to provide evidence-based, humane care for the fastest-growing segment of our population.
Going beyond pharmacological evidence-based approaches, Dr Agronin provides thought-provoking clinical vignettes that highlight the influence of ageism on physicians who may misdiagnose or provide inadequate treatment. One such vignette is the case of “Dr Summerhill,” thought to have an “old pickled brain.” Dr Summerhill has a long-standing history of alcohol and benzodiazepine abuse and persistent narcissistic and obsessive personality traits. To arrive at the complex differential diagnosis of mania, delirium, and dementia, a geriatric psychiatrist is more like a detective.
Dr Agronin describes the effective treatment of Summerhill’s “mental bonfire” as a potentially deadly combination of severe mania with psychosis and superimposed delirium. After a few months of inpatient treatment, Summerhill finds a girlfriend and is able once again to drive a car and to manage his finances independently. His brain turns out to be “not quite so pickled” after all—a lesson to clinicians who may react with helpless posturing when confronted by an older individual with profound behavioral changes, narcissistic personality characteristics, and cognitive impairment. This case underscores the importance of geriatric psychiatry expertise in managing such clinical syndromes that will only become more prominent with the aging of the population.
The reader is challenged to look beyond the frail, confused, and irritated older adult and to consider the perspective that although cognitive decline, medical comorbidity, and a loss of independence may be associated with aging, later life does not have to be filled with despair, loneliness, and fear. Rather, the later years can be a time of increased creative productivity, new relationships, and wisdom.
How We Age is highly recommended reading for seasoned clinicians, medical students, and general psychiatry trainees who seek to better appreciate the aging process and develop a humane approach to caring for this ever-growing segment of our population that deserves and will increasingly demand cutting-edge treatment.