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Chapter One

Another Country

The trouble is, old age is not interesting until one gets there. It's a foreign country with an unknown language to the young and even to the middle-aged.

--May Sarton,

As We Are Now

The metaphor of aging and death as visiting another country is at least 1,500 years old. Thomas Cahill quotes St. Patrick in his book How the Irish Saved Civilization: "In the end, your hungers are rewarded: you are going home. Look, your ship is ready." Old age, especially in the last hard years, is really a search for a place in the universe, both figuratively and literally. The old look for their existential place. They ask, "How did my life matter?" "Was my time well spent?" "What did I mean to others?" "What can I look back on with pride?" "Did I love the right people?" And they search for a home and a village where they will be comfortable, useful, and loved.

    This search for place becomes the central issue during people's final years. Family members want to help, but we live in a culture in which this journey into another country is hard for everyone. We are scattered across the continent living hurried, scheduled lives. We have few road maps to help us navigate the new lands. Aging in America is harder than it needs to be.

    As we approach the millennium, we are entering a new territory, with very different family structures, work options, kinds of old age, and choices about living situations and health care. Earlier in the century, Robert Frost wrote, "Home is the place where, when you have to go there, they have to take you in." That has been less true in the last half of our century.

    Families are struggling with all the common problems of aging relatives plus the new dilemmas of the nineties. There aren't many rituals to guide us. Asian, Native American, and African-American cultures have rich traditions of caring for the aged, but nobody is prepared for managed care or housing units that require $200,000 deposits. In short, we are not ready for today.

    We've experienced enormous demographic changes across this century. In 1900, the life expectancy at birth was forty-nine; today it is seventy-six. Today one family in four is caring for an older relative. As James Atlas wrote in "The Sandwich Generation" in The New Yorker , soon, for the first time in history, many middle-aged people will have more parents alive than they have children. He bemoaned the distance between modern parents and children: Geographic freedom means we are dispersed." He wrote of the hassles of caring for children and parents at the same time: "All of a sudden you must rescue the people you thought were superhuman. To see your parents as vulnerable is hard. At the same time you feel sorry for yourself. It's tough on your own kids. You want to spend time with them but there are only so many hours in the day."

    We are in a new world with no real prototypes for dealing with all these aging people. Medicine has both helped and complicated our situation Many people live longer and healthier lives. But unhealthy people live longer, too. We have thousands of citizens who lie comatose in long-term health-care facilities. Bodies last longer than brains, support systems, or savings accounts. We don't have the resources, the rituals, or the institutions to make our old feel like elders.

    There is an urgency to understand and accommodate an aging culture because most of us baby boomers have aged relatives. We are the pig in the python, the big demographic bulge that has moved across the last half of our century. What happens to us happens to millions of people at once. Right now our parents are becoming old people.

    Of course, everything we do to help the old surely will help us all later on. Soon our country will be avalanched by old people, and those people will be us. In a few decades, our solutions to the dilemmas of caring for our elders will be applied to our own lives. The kindness, the indifference, the ignorance, and the wisdom will be passed on. The more we love and respect our elders, the more we teach our children to love and respect us. The more we think through problems today, the more organizational and cultural structures will be in place to handle our generation's needs.

    Right now we don't even know how to talk about our problems. We have no language for nurturing interdependency. The traditional ways of caring for our parents don't work, and new ways haven't been invented. Decisions about living arrangements, money, and health are complicated, and much of the information that would help is not available. We don't really know how long we or our parents will be healthy, what will happen to the economy, or how much medical care will cost.

    Our general confusion is compounded by a new kind of ignorance. Until late in this century, we humans spent time with people of all generations, but today we aren't likely to have much contact with old people until we are relatively old ourselves. We baby boomers live in what Robert Bly calls "sibling societies," and we are educated away from relationships with our elders. We are not taught how interesting they are. We don't know their needs, and they don't know ours.

    Many old people live in segregated communities. Some choose to live separately from the young--they don't like their noise and bother--but most just slowly become more isolated. For example, I know an Italian immigrant who moved into an assisted-living unit for health reasons. He deeply misses his old neighborhood, his friends of a lifetime, his grandchildren, the cafe on the corner that served real Italian pizza, and his boccie-ball-playing buddies.

    We group people by age. We put our three-year-olds together, our thirteen-year-olds together, and our eighty-year-olds together. Children and teenagers can go months at a time with no contact with the old. Adolescent peer culture is especially noxious, but so are the cultures of isolated day-care centers or senior citizens' homes.

    A great deal of the social sickness in America comes from this age segregation. If ten fourteen-year-olds are grouped together, they will fight with one another. They will form a "lord of the flies" culture with its competitiveness, social anxiety, and meanness. But if ten people aged two to eighty are grouped together, they will fall into a natural age hierarchy that nurtures and teaches all of them. Because each person has a niche, competition will subside. Each person will have something unique to contribute. Values will deepen, and experience will grow richer. For our own mental and societal health, we need to reconnect the age groups.

    My client Irena just returned from visiting her parents in a Southwestern retirement community. She talked about how depressing it was, rows of identical suburban houses baking in the 110-degree weather. There was no one on the streets. Pollution and heat kept everyone trapped in air- conditioned houses, "waiting to die," as Irena put it. "My parents' lives have become their medical conditions," she told me. "It was the worst week of my life."

    The two biggest changes over the course of this century have been our move from a pre-psychology to a post-psychology culture and our move from a communal to an individualistic culture. Most older people grew up surrounded by family. They shared bedrooms with half a dozen siblings and had grandparents or great-aunts in their homes or living nearby. They knew their neighbors, and their fun was other people. They tend to be gregarious and communal and turn toward others for support and entertainment.

    There are very real cultural differences between generations that create what I call time-zone problems. Generations have different attitudes about everything from authority to expressing feelings to R-rated movies. The generations have different attitudes even toward attitudes. My generation is more comfortable being sacrilegious, skeptical, and ironic.

    Our parents' generation was pre-irony. Of course, some people were ironic, but most were not. Irony implies a distance between one's words and one's world, a cool remove that is a late-century phenomenon. One theory is that irony became widespread in this country during World War I, when soldiers realized the gap between their own experiences and civilian perceptions. Freud also helped create the culture of irony. He gave my generation the notion that underneath one idea is another, that behind our surface behavior is a different motive. Advertising also layers meaning in a way that teaches ironic thinking. There is an apparent message, and a subliminal message about something very different. By now we all learn to think ironically. But many people older than a certain age grew up believing that the surface is all there is.

    The old, like the young, come in all varieties. However, differences aside, there are some things we can say about the old as a group. The old are segregated by interests, by history, by physical health, by attitudes about mental health, and by shared trauma. They have in common three sets of experiences--they have participated in the events of the twentieth century, they have passed through the same developmental hurdles, and they now live in the landscape of old age.

    They have lived before television, cars, electricity, Playboy , and the Green Revolution. Older African-Americans had parents who remembered slavery. Older Native Americans had relatives who fought in the Indian wars of the last century. Rural old men know how to mend harnesses, butcher hogs, build fences, cut hay, slice the testicles off a bull, and fix an engine. Older women can bake, quilt, make soap, sew trousers, and doctor sick animals. Many of the old know how to play instruments, sketch portraits, and recite poetry.

    Older people have passed through seven of Erik Erikson's eight stages of development. Middle age is in the distant past. Most of the old have been parents and grandparents. They have lost parents, siblings, and friends. They have seen vigorous bodies grow frail, and active minds grow forgetful.

    In his book The Summing Up , Somerset Maugham noted that with old age, one is free of certain passions. Most people become less sexual, less competitive, and less envious. Most people have figured out that life is tough for everyone. They tend to be kinder and more compassionate than they were as young people. Many are like Gladys, described below--as sweet as honey over sugar. Generally, the old like verbal and physical affection and, unlike the young, are under no illusion that they do not need love.

Gladys (age 90)

"TV is my best friend."

Gladys was referred to my office by her family physician after she talked to him about what she called her "weird eye problem." When she was alone, she hallucinated bugs, squirrels, and rotting food. The people on TV talked to her and sometimes even stepped out of the screen into her living room. Gladys knew these experiences weren't normal, but she thought her eyes were playing tricks on her.

    Gladys's son, Roger, drove her to my office. Gladys dressed carefully in a mauve suit, a pink silk blouse, and a cluster of pink costume jewelry. She had sparkly blue eyes and soft, powdered skin etched with delicate lines. I invited Roger to come into the session, but he politely declined by saying he wanted his mother to have her privacy. As I escorted Gladys into my office, Roger pulled a James Lee Burke paperback out of his pocket.

    I asked Gladys if she knew why she was here. She answered, "Aren't you a nerve doctor?"

    "I'm a psychologist," I said. Gladys shook her head in confusion, and I added, "We listen to people's problems and help find ways to solve them."

    "Well, that sounds lovely," she said amiably. I offered her some tea and asked about her situation. She explained that her husband had died when she was in her sixties and that Roger was her only child. "I wish we'd had some daughters," she said sadly.

    When Gladys retired from the hospital where she cooked, Roger and his wife, Nell, had invited her to move to Nebraska. On their acreage, Roger and Nell had fixed her up a trailer with central air and a big-screen TV. Until Nell died, Gladys had been happy there. However, when she mentioned Nell, the sparkle left her eyes and her shoulders drooped. She told me that Nell had been a wonderful wife to Roger and a great daughter-in-law to her. They had canned peaches and chowchow, made slaw and homemade ketchup, and gone "garage saling" on weekends. Gladys boasted, "Nell could refinish furniture, sew a dress in a morning, and fix the plumbing in the afternoon. When she was around, something was always going on."

    However, Nell had died of breast cancer two years earlier. As she spoke of Nell's death, Gladys got a hanky out of her purse and wiped her eyes. Since Nell died, Gladys had been lonely. Roger was busy with his work for the railroad and sometimes gone for days at a time. When he was home, Roger liked to putter around in his shop and garden. He made Gladys nice furniture, but he rarely ate with her. He believed in minding his own business. He was a big kidder, but, as Gladys said, "if he doesn't feel like answering me, he doesn't answer."

    Gladys also missed her granddaughter, Molly, who lived in Los Angeles with her husband and baby. Gladys was far from her friends in South Dakota, most of whom could no longer write her. She rarely left her trailer. Her town had no public transportation, and she didn't ask her son for rides. She hated to bother Roger, who "works so hard and deserves a little peace and quiet when he's at home."

    Gladys told me how Nell had come over first thing every morning for coffee. She said, "We'd gab all morning long. I'd help her shell peas or cut corn. We'd think up mischief if there wasn't work to do. Now days pass slowly, and at night I am tired. But I wonder why. I haven't gone anywhere or seen anyone. What have I done to tire myself out?"

    To pass the time, she watched television. She said, without a trace of sarcasm, "TV is my best friend. I get sixty channels."

    While we talked about TV, Gladys brought up her "eye problem." She knew that she saw things that weren't really there and that her problems went away when she was busy. "Like today," she said as she took my hand in hers, "when I see people, my eyes don't act up."

    I was grateful that her doctor had sent her to me instead of giving her tranquilizers or antipsychotic medications. I had a hunch we could treat this eye problem. We scheduled another appointment, and I walked her back to Roger. He stood up immediately and gallantly helped Gladys with her coat.

    After Gladys left, I thought about how she insisted on nothing. She was grateful for a ride from Roger and forty-five minutes of my time. Like so many older people, she would rather go mad quietly than be a bother. I thought about Roger, a good son who had been concerned about his mother's physical comfort but less aware of her other needs and unsure how to help without interfering. Plus, Roger had needs of his own. As a grieving man with a job that required constant travel, he might well be lonely and depressed himself.

    Gladys reminded me of another client who, when speaking of her loneliness, had said, "For the elderly there is no village." That was the essence of Gladys's problem. Her heart was strong, and her memory was good. If Roger could help her develop a community, Gladys could have a mostly "good time" her last years. I was sure that with more activity, Gladys would stop seeing things that weren't there. At the next session I wanted to work with Roger and Gladys together.

Session Two

This time Roger agreed to come into my office with his mother. He looked uneasy but determined to do the right thing for Gladys. Gladys patted his arm and said that after our visit, Roger had volunteered to take her to church and Sunday school. Roger shrugged and said, "Mom perked up after seeing you. I figured she needed to get out more."

    I asked how he thought his mother was doing in general. Roger answered, "She's been lonely since Nell died." His words caught in his throat. "We both have. Maybe I should take her more places. But when I get home from work, I just want to stay put."

    Gladys quickly reassured Roger that he did all he could, and he didn't disagree. She explained to me that Roger had work piled up when he got back from his train trips. She told me again how much effort Roger put into making her trailer comfortable.

    In this difficult situation--a widowed middle-aged man and his slightly unstable mother--I observed how kind these two people were to each other. Roger was proud and independent. He didn't want to ask for help or admit he couldn't do everything that Gladys needed done. He thought a good son should be able to provide for his mother totally, but he was wearing out and failing at his self-imposed goal of doing it all. Gladys was deteriorating, mostly from loneliness and uselessness. And yet I could tell each one was determined not to blame the other for their misery.

    Gladys showed me pictures from her ninetieth birthday party, the biggest get-together in the history of the family. She wore a silver silk dress and a corsage. Nell had died before this party, but Gladys said, "She helped me plan. The last week of her life we sent out the invitations." Molly had come home to help. They made mints together and fixed the nut cups and punch. Her best friend, Amalia, had ridden the bus down from South Dakota. "Over one hundred people were there," she said proudly.

    "Mom has lots of friends," Roger interjected, and he winked at her. "Her secret weapon is her pies."

    Gladys laughed and told me about cooking for the hospital. Some days she made as many as twenty pies. Her specialty was lemon meringue, but she also made a killer chocolate pie, Roger's favorite. I asked if she still made pies and cakes. She sadly said no, that she couldn't see to read the spice cans. Gladys was now eating mostly TV dinners and pot pies. She said, "I miss my own cooking, especially on holidays."

    Roger said he generally ate whenever he felt like it. His work kept him from having a regular schedule, and he thought he saved his mother trouble by eating fast food or microwave meals. I asked Gladys if it was trouble to cook for Roger. She said, "It wouldn't be if I could see."

    Gladys said that she still had her eye problems, but maybe not quite as much. She'd had one bad day when her old boss in South Dakota died and Roger couldn't drive her to the funeral. That day she had seen rabbits and weasels running around the living room.

    As Gladys told me about the funeral, Roger looked at his hands and mumbled that he was sorry he hadn't been able to drive. I agreed it was too bad, then I asked him how much fun he'd been having lately, a question that clearly surprised him. He said, "I didn't think shrinks cared about stuff like that."

    I knew that these two people would live together more happily if both were able to get some needs met. If Roger sacrificed too much to care for Gladys, he might be resentful. Roger needed both free time and the feeling that he was a good son. I thought of the Buddhist Middle Way. Extreme heroics usually don't work over time. People do best with balanced lives in which they care for themselves and for others. On the other hand, if Gladys didn't get out more, she would become increasingly addled. Balancing needs is tricky. When two people live together, either both people win or both people lose. I wanted to find some new resources for Gladys and take some of the burden off Roger.

    I suggested that they look for a teenage girl to come in after school to help Gladys make pies and soups. She could read the recipes and labels, and Gladys could orchestrate the cooking. I also encouraged Roger to eat with his mother at least one night a week. He joked that it would be easy to agree to that if she would make him a chocolate pie. I suggested that Gladys spend a little of her money calling Amalia in South Dakota and Molly at least once a week.

Session Ten

Gladys had been coming in for four months. As her eye problem had improved, I had seen her less frequently. Today, the girl whom Roger had hired drove Gladys to therapy. Katie was seventeen, good-natured, and proud of her responsibilites. She explained that she and Gladys had baked ginger cookies for our session.

    We left Katie in the waiting area with her homework, and I made tea. The cookies were delicious and took me back to my own childhood, to my grandmother's ginger cookies. I spoke approvingly of Katie. "Oh, you don't know the half of it," Gladys enthused. "She is a good worker and so clean. She reads me my recipes and gets out the right spices. I'm teaching her to can. Just last week she helped put up twenty quarts of pears. I gave her two quarts plus her pay. Next summer I'll teach her to make ketchup."

    Katie had made a big difference in Gladys's life. The six hours a week they spent together was all talking time. Afterward, Gladys had her own foods to enjoy and share with Roger, who was now eating with her several times a week. Also, he was dating a woman he'd met when he drove his mother to church. Gladys said happily, "She tells me stuff about Roger that he would never think to mention."

    I said that I was glad that she had two new women in her life. She said, "There's more than that. Amalia and I talk every Sunday night. Molly calls me once a week, and I am making friends at church."

    I told Gladys about a study that found that old people are not generally lonely if they have three regular contacts. Her isolation had caused the eye problems, but now she had many people in her life. If her daily companion wasn't a television set but rather a real person, I didn't think she would have more trouble.

    Gladys always would miss Nell. I encouraged her to keep a picture of Nell handy and to sleep under a quilt Nell had made (she had been storing it in a closet). I wrote Roger a note complimenting him on his care for his mother. We hugged good-bye, which is something I often do in my therapy with the old. I walked Gladys out to Katie in the waiting room. As Katie held the door open for Gladys, I heard her say, "Let's stop by the grocery store and pick up some ginger."

    Gladys's story illustrates some of the difficulties that arise when everyone has "good intentions and honorable mentions" but are still flawed humans in a culture that doesn't offer much support. Gladys didn't want to be dependent, and Roger was unsure how to help. He didn't want to be intrusive, and he was unable to give his mother all the social contact she needed.

    Fortunately Gladys and Roger were willing to seek help. I encouraged them to connect with others, not to carry all the burdens of making things work on their own shoulders. I also helped Roger have reasonable expectations about the situation. He couldn't do and be everything for his mother. I warned him to expect frustrations and misunderstandings. Just because she was old didn't mean she was a saint, and just because he was kind didn't mean he couldn't have bad days too. Even in young people's lives, not everything goes well. Old age is a genuinely difficult situation with lots of sadness and frustration. Many things will not go well.

    I tried to show Roger that guilt wouldn't help. I encouraged him to do what he reasonably could and to find others to do what he couldn't do. Mainly, I acknowledged that both Roger and Gladys had needs that shouldn't be sacrificed or taken for granted. Because Roger and Gladys had the money and energy to set a few things up, Gladys was cured of terminal loneliness. She was pulled back from the edge of despair. Roger was able to be a good son, and Gladys had a home where she was useful and connected to others.

The old are segregated not only physically--by their living circumstances and their ill health--but also by their worldview. Language is different. The old may call oatmeal porridge and refrigerators iceboxes. Depression refers to a time when money was tight, not to a mental-health problem. Consumption refers to tuberculosis rather than spending. Metaphors come from communal life or from the war years. My father would say when it was hot, "There's nothing moving out there but the neighbor's dog." My mother, who was in the Navy during the war, talked about "hitting the deck" and keeping our place "shipshape." And many of our elders are shocked by the swear words and sexual innuendo of younger people.

    The old are segregated by tempo. Doing interviews for this book, I learned to let the phone ring fifteen times. I learned to wait at doors five minutes after I rang the bell. I had to slow down to work with the old. Their conversation is less linear, and there are pauses and repetitions. Points are made via stories; memories lead to more memories. Details are debated and relished. People long dead are explained at length.

    With the old I walked slowly and held hands at intersections or when sidewalks were slick. Many of the old show up early for events and are the last to leave. Many need help getting out of chairs, and many don't go out at night because they might stumble. Because their bones break more easily and mend more slowly, the old are afraid of falling. Many of their homes have upstairs bathrooms and bedrooms, and a broken hip can mean that independent living is over.

    Doris Grumbach wrote, "I hear less, see crookedly, lose weight and grow crooked and stolid, placid and inept. My age is my cage. Only death can free me."

    In health as in wealth, there is no equity. In spite of our very American belief in our individual powers to control fate, people do not always get what they deserve. Nonsmokers get cancer, and people who religiously count grams of fat have heart problems. Simone de Beauvoir understood this when she wrote, "The years do not weigh with the same burden on all shoulders."

    Bernice Neugarten at the University of Chicago made a distinction between the young-old and the old-old. She considered the loss of a spouse, retirement, and also changes in physical health to be the critical determinants of young-old versus old-old age. My own belief is that loss of health is what delineates the two stages of old age. Until people lose their health, they are in the young-old category. Until people are ill, many keep their old routines and add some new pleasurable ones. Even if they lose their spouses they still can enjoy friends and family. Retired people travel, do volunteer work, pursue creative activities, and play cards or golf. However, poor health changes everything.

    In America, the young-old are mostly in their sixties and seventies. When health falls apart, generally in the mid-seventies or later, the young-old move into the old-old stage. Susan Sontag described the difference between the two stages of old age this way: "Everyone who is born holds dual citizenship, in the kingdom of the well and in the kingdom of the sick."

    Recently I told a clerk at my grocery store that I was writing a book on old people. She said rather adamantly that I should interview her. Helen looked about sixty and very vigorous. I answered, rather too glibly, that she wasn't really old, that I was mostly interviewing old-old people, people who were sick and coping with loss. She said, "Last month I would have called myself young, but I have ovarian cancer and today I am old."

    For this book I interviewed both the young-old and the old-old. It was particularly striking to me that most people enjoy being young-old. They take pleasure in many things, including grandchildren and opportunities to study and develop new skills. The young-old have time to read, play cards, care for their pets, and visit their friends. My friend Sally practices her violin an hour a day. When Aunt Betty was young-old, she walked four miles each morning and traveled with her church group to China.

    Many young-old savor the ordinary. As the poet Issa wrote, "Fiftieth birthday, From now on, it's all clear profit, every sky." As people grow older, time, not money, becomes the precious commodity. They are appreciative. Bert and Nan are an example of a young-old couple.

Bert and Nan (ages 67 and 65)

"We're having so much fun,

we should be illegal."

For every joke about old geezers traveling the country in Winnebagos, there is an actual old couple happily traveling the country in a Winnebago. Nan and Bert are in their late sixties and have been on the road for four years. Since his father's death when Bert was twelve years old, Bert had been the man of the family, supporting first his mother and sisters and later Nan and his own kids. Bert worked long hours at his corner grocery store in Detroit. However, in the last few years, the lifting was hard on Ben's back and he worried about robberies.

    When Bert turned sixty-five, he sold the store to his youngest daughter and her husband. He had good health, a modest savings account, and enough money to pay cash for a Winnebago. Nan sewed curtains, and Bert built extra cabinets. They pored over maps and guides to national parks, Bert took fly-fishing lessons, and Nan bought a book on low-fat cabin cooking.

    On May Day of Bert's sixty-sixth year, they headed south from Detroit. They camped in state and national parks and KOA campgrounds, and they visited relatives, old friends, and historic sites. That summer they toured Gettysburg; Washington, DC; and Fort Sumter. They fished in Kentucky and walked through Mammoth Cave with hundreds of other tourists. They followed what used to be Route 66 across the Southwest. Nan read novels and bought a small turquoise ring. Bert caught a trout while fly-fishing near Mesa Verde.

    In July, they swung north along the California coast. In Big Sur, they watched the sun set over the Pacific and ate cracked crab. In San Francisco, they rode the cable cars and ate pork fried rice at Sam Wo's. They saw whales and seals, redwoods and waterfalls. Nan wrote home, "We're having so much fun, we should be illegal."

    In August, camping on the Oregon coast, they met Belle and Stewart. Stewart had been a produce wholesaler all his life. The couples traveled in tandem from one KOA campground to another. Every night they had a potluck dinner followed by a horseshoes tournament.

    In September, Belle and Stewart headed south toward their trailer in Florida. Nan and Bert crossed Idaho and Montana. They saw the leaves turn gold in Glacier, and they were on a North Dakota prairie for the first frost. They pulled into Detroit on September 28, just in time for their oldest grandson's birthday party.

    At the party, they showed their kids pictures of their trip and of Belle and Stewart, whom they planned to visit in February. They announced they'd had the best summer of their lives. Next year they would leave in April, but they promised to make it home by Thanksgiving. "Thanksgiving," their kids said in unison and dismay. Bert joked, "If I'd known it would be this fun, I would have robbed a bank and retired earlier."

The old-old are less sanguine. They walk a road filled with potholes of pain, low energy, poor appetite, and inadequate sleep. They lead lives filled with the loss of friends and family, of habits and pleasures, and of autonomy. One of the cruel ironies of old-old age is that often when people suffer losses they must search for new friends and new homes. It's a horrible time to try to "solve problems with a geographical." Yet moves cannot be avoided.

    For our elders, many questions arise. Which relatives should they settle by? Should they stay where they are and watch friends move away, or should they be the ones who go? What can they really afford? Will they be a bother or a help to children? Is it better to escape Northern winters and be far from grandchildren, or vice versa? Their search for a home is made more frightening by our deep cultural mistrust of institutions for the aged. Many people feel they would rather die than be in a rest home. And yet at a certain age, many people need assisted living.

    Families have a primal need to be together physically, a need that is now often unmet. I think of Regina, who lives five states away from her mother, who is ill in an assisted-living unit. Regina would like to care for her mother, to bring her flowers and read to her, but she has a full-time job and financial worries. I think of Francine, the head of an independent school in California, a warm-hearted woman whose mother has suffered a series of small strokes. Francine goes to visit her mother every weekend, buys her groceries, cleans her apartment, and refills her prescriptions. Her mother lives in Colorado.

    Adult children want to welcome their parents to their communities and even into their homes, but they worry the parents will be unhappy. They may live in homes or neighborhoods not conducive to the needs of elderly people, and they may have children who require all the energy they have. They may work full-time and be unsure how to manage care during the day.

    Adult children worry about family tension. Maybe their relationships with parents have worked because of distance. What will happen when there is no distance? Perhaps the family has never been close. What will happen with enforced closeness? And yet, no one wants a three-hour commute or a transcontinental plane trip between them and a needy parent.

    Dreams turn into nightmares. A mother moves across the country to be near her daughter, who then is transferred to a job five states away. A couple moves into a retirement community by a golf course, and three weeks later the husband dies. The wife is stranded a thousand miles from home in an expensive apartment near the seventh hole. A daughter welcomes her mother into her home, only to have her mother begin ruining her life. The mother constantly picks on the daughter's son and never allows the daughter a moment to herself. The mother has no friends and is upset when the daughter wants to spend time with anyone else. When the daughter tries to assert herself, her mother goes on a hunger strike.

    One of the biggest problems is that the situations that work for people in the young-old stage are not feasible for the old-old. Young-old people may love their mountain cabin or Manhattan townhouse, but old-old people need relatives nearby. Usually it's a crisis that moves a person from the kingdom of the well to the kingdom of the sick. A spouse dies, a wife gets cancer, or a husband goes blind. That's a terrible time to make major life changes. And yet, not to make changes is even harder.

    There are rarely simple choices. It's good to move slowly, to think, and to talk things through. It's good to have a test period or trial run before making long-term decisions. I encourage older people to rent before buying and to live a month with a roommate before making a long-term commitment.

    My bias is that luxurious surroundings, entertainment options, natural beauty, and good weather are less important than people. As songwriter Greg Brown said, "You can't have a cup of coffee with the landscape." At bottom, I think the search for the right place is a search for the right people. It's a search for love and respect. What's important is a community of friends and family.

Randy and Lois, (Ages 58 and 86)

"I found out how strong and

interesting my mother was."

    The experiences of Randy and his mother demonstrate the complexities of these American dependency isues. Randy's father died when his mother was in her early sixties. Lois had been a stay-at home mother, who never learned to drive or cash a check. Initially, of course. Lois was overwhelmed by her grief and by her own inadequacies. Randy suggested that she move to his town so that he could help her with finances, transportation, and social life. At the time, Randy had three teenagers and a struggling business and this was no small offer. However, to his surprise his mother refused his offer. After a few months of floundering she rose to the occasion. She took driving lessons, joined an exercise club and a craft guild. After about a year, she sold her house in Cleveland and moved to a condo in Florida.

    Randy was surprised but pleased by his mother's independence. He heartily approved her decisions even though Florida was 1500 miles away from him. A small part of him was even relieved. He had worried that his mother wouldn't be happy with the level of emotional and social support he could offer her had she moved to his town.

    This new arrangement worked well for almost twenty years, the years of his mother's young-old age. Lois never re-married. She told Randy that when a man wants a wife her age, it was either for a nurse or a purse and she wasn't willing to offer either. In fact, she did have money which she managed very well. She could afford to travel and buy a beach front condo. She and her women friends formed the Golden Gifts Club and watched that show together every afternoon. For the first time in her life, Lois was a competent ,autonomous adult. And Randy was happy with a financially independent, socially active, faraway mother.

    Then, old-old age caught up with Lois. She had a variety of chronic problems, a thyroid disorder, diabetes and asthma. In the winter she caught pneumonia and was hospitalized. Her health care program didn't allow her regular doctor to see her in the hospital. Instead she was assigned a new physician, who was very overworked and had little time to get acquainted. The new doctor changed her medications and Lois became woozy and incoherent. At first Randy tried to deal with these issues over the phone, but Lois' health and mental status deteriorated rapidly. The new doctor hadn't contacted Lois' regular physician. Lois didn't know where she was and, in fact, no one in the hospital really knew who she was. Randy flew down.

    When he saw his mother he was shocked. She looked ten years older and wasn't even sure what year it was or what state they were in. Randy insisted that the new doctor call the original physician and review the medications. When this happened, the hospital doctor discovered that Lois hadn't been confused a month ago. Her original doctor recommended a return to the pre-pneumonia medications and, as soon as this happened, Lois became mentally clear again.

    Randy was gratified but angry. He said, "If I hadn't been there to push, mother could have been put in an Alzheimer's unit for the rest of her life and been pumped full of the very drugs that were confusing her."

    Randy stayed almost a week. Lois was ready to leave the hospital but not ready to go home. The assisted care facilities in the area were all full. The family had choices to make. Should Lois stay alone in Florida in a new facility until she recovered and returned to her condo? Both Lois and Randy doubted she would ever recover that fully. Should she move in with Randy and his wife? They had finally gotten all their children launched and were busy with various projects themselves. Randy didn't really want his mother to move in with them, but he felt guilty. His mother had taken her parents in when they were old. He was in the first generation to say no. Well, he wasn't exactly saying no, but his mother could read his mind.

    Lois also hated to burden Randy and his wife. She was proud of her life in Florida. She liked the weather and her Golden Gift friends, although many of them had died or moved into assisted living situations. Yet she felt vulnerable. Until Randy flew down, she'd been out of her head with no one to represent her. Being confused, ill, and surrounded by strangers had been the worst experience of her life. Lois could safely predict that she would get ill again. Her medical care wasn't consistent and her health seemed broken. She was afraid to move into a new facility, especially one that wasn't on the recommended list.

    In the end Lois moved to Randy's town, not into his home, but into an assisted living facility nearby. The move was stressful for both financial and medical reasons, but now it was better. Randy and his wife still traveled and had their projects, but when they were in town, they dropped in to see Lois every day. Randy supervised her medical care and her money. Occasionally it was inconvenient for him, but feeling overburdened was better than feeling guilty and stressed about the inadequate care of a faraway mother.

    Randy was surprised by how much he enjoyed his visits with Lois. He told me, "I found out how strong and interesting my mother was." They talked about old times and Randy realized that she was the only person who remembered his kindergarten teacher and Little League coach, his sixth grade girl friend and his fondness for grilled peanut butter sandwiches. Lois could tell him if his father was good at basketball or allergic to eggs, and she could laugh with him about his grandparents' idiosyncracies. Suddenly this all seemed interesting and important. Lois missed the ocean and her remaining friends, but she was grateful to have someone looking out for her. Her favorite moment of any day was when Randy walked into her room.

    This family made a difficult set of decisions in the absence of optimal resources or good information. The decisions about moving were complicated enough under ideal conditions. But in our culture, we don't even have the language to talk about the interpersonal problems old-old age brings us. Of course, an ill 86-year-old was dependent. She needed someone to check in on her, monitor her health if she was hospitalized, and pay her bills if she could not. However, Lois was fearful of interfering with Randy's life. And Randy was reluctant to ask his wife to make sacrifices as well as unsure he could keep commitments to his mother. They danced around the issues, loving and respecting each others' autonomy so much that Lois was almost abandoned half a continent away from anyone who loved her.

    Lois and Randy's dilemmas are far too typical. Our lack of facilities that truly work for the old puts us in difficult binds. The choices for people who are in the young-old stage may not be the best for people in the old-old stage. Many young-old people prefer to rely mainly on friends for social support and plan lives of activity and autonomy, perhaps far from family. Old-old people often need family nearby. Yet few people have the resources and energy to make new plans when they are ill and in their nineties.

    Few of us younger people realize how important relationships with our elders can be. We are educated to segregate. When I began this book, I had the same culturally-induced prejudices about the old as have many Americans my age and younger. For example, I noticed when an old person drove poorly or slowed down traffic while I didn't necessarily notice all the old who drove well. I noticed when old people repeated themselves: however, when I repeated myself, I ignored it. Spending time with old people disabused me of my prejudices.

    In the last few months, I've felt nurtured and cheered, and I've laughed more with the old than with my younger friends. I've heard lots of corny jokes, but some good ones too. Aunt Henrieta told me, "by the time people have money to burn, the fire has gone out." One man, celebrating his fiftieth wedding anniversary, told the secret of his marital success. He woke up every morning, looked in the mirror and said, "You're no prize either."

    The women always offered food and tea or coffee. Many were good talkers. They came from a time when conversational skills were highly valued. The beauty of certain people's spirits took my breath away. Many had what Hemingway referred to as "built in, fool-proof bullshit detectors." Furthermore, they generally had their priorities in order and, after I was with them, mine were rearranged in more sensible ways as well.

    While I enjoyed the interviews. I saw lots of suffering. I saw people waiting in rest homes for calls that didn't arrive and for birthday visits that didn't happen. I met people who weren't well-served by their doctors or caregivers. I saw people facing surgery alone, eating institutional food on Thanksgiving or weeping because they wanted to take a ride on a spring day and see some flowers. I saw old people scrambling to touch a baby, to get near a child, any child.

    Some of it was inevitable, but much of the suffering was needless. Younger relatives had lives that kept them away. Misunderstandings made get-togethers unpleasant. For example, when Marie stopped being able to cook Sunday dinners, her children stopped coming by. She didn't feel right asking them to come over when she couldn't feed them. The children knew of Marie's "forced retirement" from the kitchen and they didn't want to stress her by coming over when she shouldn't be cooking. No one quite knew how to make new plans, so a year went by with little contact and many hurt feelings. One family therapy session sorted things out. The family decided to take turns ordering take-out food on Sundays. As Marie put it proudly, "The most important is we are together."

    For every sad old person I know, I also know several happy ones who take great joy in their relationships with their families and young friends. I think of my uncle teaching his great-grandchildren to build bird houses. I think of my neighbor who makes it a point to talk to young children as she gardens. She keeps a jar of cookies filled for anybody in the neighborhood who needs a chocolate chip cookie right away.

    I think of a client whose grandaughter was blind. She helped Marissa learn braille and read to her for hours a week when she was young. She took a part-time job so that she could earn money for special camps for Marissa. My client went along on family vacations with Marissa and her mother, and she walked Marissa home from school every day. In Marissa's high school graduation speech, she thanked her grandmother for helping her grow up strong and confident. "I wasn't lucky to be born blind," Marissa said. "But I was lucky to be born with a grandmother."

    I think of my client Linda who takes her mother to Hawaii every February, and who drives fifty miles on Sundays to spend the day with her. Linda is an attorney whose mother is her only family. She laughs when she tells me that her mother is always trying to fix her up. Whenever Linda drives her mother to a new doctor, the another asks if he is married. If he says no, she winks at Linda.

    Being with the old, I've learned things about survival. I've come away feeling calmer, more accepting and more grateful. I don't know if I'll be able to be as courageous and kind as many of the people I have met, but al least I have had good role models. I have pictures in my head of courages and dignity under tremendous adversity.

    While I was willing this book, people called and wrote me about incredible people in their family, on their block, or in their church. Many didn't seem to realize that great old people are everywhere. They thought their particular experience was unique. From these people, I learned that many of us have been saved by an old person, but these stories are rarely told. In our cultural script, heroes are young, attractive and faraway.

    Fortunately many of us find our way to the old. I had an acquaintance who was an artist always seeking truth far from home in ashrams and workshops. Just as Maeve was leaving for Europe one summer, her grandmother became ill. The family asked Maeve to care for the grandmother. She protested, but there was no one else and the need was undeniable. Maeve moved to Kansas and lived with her grandmother for six months until she died Maeve handled her grandmother's medical needs, cooked for her and bathed her. For the first time in Maeve's life, her concern for another person became as great as her concern for herself. This experience changed her life more than all the therapy and gurus had changed it. She grew up and learned to love other people.

    We can learn a great deal from the old. They can leach us about the importance of time, relationships, and gratitude. They can teach us how to endure and how to be patient. They can help us put our own pains and problems in perspective. I have a New Yorker cartoon entitled "Yuppie Angst." The man is saying, "Oh no, I spilled cappuchino on my down jacket." Old people who have lived through the Depression, the blizzards, the wars, and the death of friends and family have a somewhat broader perspective on tragedy.

    Freud taught our generation the importance of parental love. We know that parental love is formative, but no one has really taught us about the importance of grandparental love. Especially as we get older, the bonding and nurturing go both ways. Connectious help our children, our parents and us, now and in the future. Only by caring for our parents will we be able to ask our children for help later. And only because of our children's love of the old will they be able to say yes.

Copyright © 1999 Mary Pipher, Ph.D.. All rights reserved.