Excerpts from Nasty, Brutish, and Long: Adventures in Old Age and Eldercare

(Paperback coming March, 2010 from Avery/Penguin)

Who are You?

I approach an eighty-five-year-old woman asleep in her bed. Waking with a start, she screams at me, "Who are you and what are you doing here?"

I am a psychologist who travels around to nursing homes and talks to sad, confused, and, occasionally, happy old people. I work for a company that provides a range of psychiatric services -- a team of a psychiatrist, a psychologist, a nurse, and a social worker. Unlike the medical staff that deals in a tangible and ingestible commodity -- drugs -- I offer an intangible -- me. You tell a psychiatrist that the ninety-two-year-old lady in Room 12 is calling out in the middle of the night for her mother, she gets labeled as agitated, and there's a pill that will fix her right up -- or so they believe. Sometimes they ask me to change a prescription. "When you guys lowered Mrs. Brown's Risperdal, she became much more delusional." I remind them I'm the psychologist and I only talk to people.

"It's the psychiatrists who do drugs," is my joke.

I get a confused shrug or condescending smile. Then they ignore me.

Not only do they ignore me, they pretend I'm not there. I can be in the middle of Mike Mindykowski confessing, "I beat my kids. That's why they never visit," when an aide will walk right in and start changing the bed. The maintenance man might saunter in with a mop to clean up the vomit from Mike's roommate. The cable guy might follow the vomit cleanup to fiddle with the TV.

Are you expecting privacy?

The residents themselves are often eager for the chat, even if they display an initial reluctance. I have many faults, but in the lives of many of these old folks, I might be the only person who sits down, establishes eye contact, and simply listens.

The Med Pass

The nurse in the hallway is mixing up some crushed medicine in a little cup with applesauce -- the kind of cup in which you get a side of coleslaw at the diner. She's on her med pass, another of the many daily routines.

The nurse pushes a cart quite similar to the cart a flight attendant pushes down the aisle of an airplane. Many of the folks complain about the "service" as if they were in a bad hotel: "I ring this bell, but they never come."

The top of the med cart is loaded with carefully counted medications. There are cups for water and tools to crush meds for the toothless or for those with swallowing problems. Orange juice or ginger ale is also there for a chaser. There are high-calorie, vile-tasting health shakes to fatten up those with a "failure to thrive." This happens three shifts a day, one med pass per shift.

There's a long list of drugs, predominately gastrointestinal, analgesic, cardiovascular, and psychoactive -- but no Viagra or Ortho Tri-Cyclen.

The elderly represent a license to print money for the pharmaceutical industry. A particular nursing home may go bankrupt, but drug use is always on an upward trend. This is a landscape where the only spontaneity might be the screams of a person with not enough medication.

Everything is scrupulously documented. There is one set of books -- procedure books -- telling you what to do. There's another set of books -- record books -- in which you write down what you have done.

In and out of the rooms the nurse goes dispensing the pills one by one, checking off each on her clipboard. If this were fiction, I'd write I hear the tune "Candy Man" coming from one of the rooms.

Fly Me to the Moon

Singing appears to be one of the last things of normal life to go. Stutterers gain fluency with singing. People with dementia stare blankly or erupt irrationally at bingo, but music taps into deeply laden pathways. Songs like "Home on the Range" or "Bicycle Built for Two" remain earworms stuck in the minds of the most addled. My father, joyless in many ways -- he once told me in his cogent days that it's hard for him to smile -- would pace around my childhood apartment singing his songs, not a bad voice. We call them standards today -- "Fly Me to the Moon," "Love is a Many Splendored Thing." He could hit the high notes and the fortes. I enjoy going to the sing-alongs at the nursing home, a short wheelchair push into the dining room. He's there before he can object. The activity worker is comely, plays the guitar, and I tap my feet right along.

I buy him a CD player along with Frank Sinatra, Dean Martin, and Perry Como albums. Occasionally, I'll put on "Catch a Falling Star" and think of Dad and Mom still together. It's a childhood memory. The Perry Como Show. Something my parents could agree about. In harmony. Except for me. I want Jackie Gleason.

On the weekend, my whole family shows up, and we wheel him into the courtyard. Chocolate-chip cookies for not just Dad but the kids. We sit in the sun, and there are other families. Some smokers in the corner. As the shadows shift, we follow the sun. We're a tableau. Could be Seurat. Sunday Afternoon in the Courtyard with Dad.

I experience twinges of guilt when I see the involvement of others. Some residents require no recreation schedule, no psychiatric intervention, no bingo. They seem to be always there. If Mom can't be at home, we'll bring home to Mom.

Junior Hospital

The first thing you notice when you approach a nursing home is that there's not much to notice. These are aggressively bottom-line, no-frill institutions. There's no reason to splurge on Frank Gehry or Frank Gehry wannabes. I Googled "nursing home architecture" and I found mention of safety, cost-effectiveness, and efficiency -- nothing about curb appeal or interior design. These buildings share their design ethos with banks, schools, and prisons. They are institutions that are, well, institutional.

The most likely building will be a one-story affair surrounded by a parking lot -- ranch style on steroids. A fraction have a couple of stories. Five stories is probably the record.

When I assess a resident's mental status, I ask, "Where are we?"

"We're at the hospital?" they often say.

My patients are often confused, but you don't have to be too addled to conclude that a nursing home is a hospital. The resident likely just came from a hospital and it is hard to see the difference.

But it's kind of a junior hospital -- hospital-lite. It looks like more like the hospital in Young Doctor Kildare -- black and white, 1938, starring Lew Ayres and Lionel Barrymore -- before the invention of beeping and flashing high tech medical equipment.

Pushing Drugs

Everywhere I go, I see tokens of the drug companies -- Zoloft pens, Lipitor Post-it notes, Aricept tote bags. If the drug companies could get away with it, I'm sure they would trick out medical uniforms the way the suits of NASCAR drivers are arrayed with alcohol, tobacco, and lube logos. We are long past our annoyance with stadiums named for beer, telephone companies, banks, and the embarrassingly named Enron Field. I'm surprised that a drug company hasn't joined the naming -- rights trend -- Eli Manning throwing miracle passes in Eli Lilly field.

Life Interrupted

Living in a nursing home is life interrupted. Your door is always open. The staff views closed doors with the suspicious eyes of a teenager's mother. But these people aren't sneaking joints or downloading porn. Walking down the hall on a typical morning, peering through the open doors, they're mostly lying in bed -- some eager for the staff to come, others hoping they won't bother.

The morning nursing home ritual is a parody of the morning levee of King Louis XIV. When the Sun King rose at 8:30 a.m. each day, the First Valet de Chambre would pull the curtain surrounding the bed and announce, "It is time, Sire." Louis would open his eyes to a group of courtiers -- each ready to play a precise role in his theatrical routine. In the nursing home, two or three aides enter the room and announce, "Time to get up, Joe."

The aides' white outfits are an upwardly mobile step up from the blue jackets of Wal-Mart -- changing diapers over flipping burgers. They'll get Joe dressed and deposit him in his wheelchair. Maybe they'll turn on his TV and pause for Jerry Springer before moving on to the next room. Louis would move on to being the King of France.

There is another parallel. Most of us flow between a public and private zone. We have at least one door we can close to the world. People in nursing homes have lost this door as, like Louis, they live their life in public.

Finding Contentment

I could maybe find contentment with life in a nursing home. If I couldn't swing a private room, I'd try for a bed by the window. Staff wouldn't always be walking by my bed to tend to the guy by the window. I'd be the guy by the window. I'd want a roommate with moderate dementia -- pleasantly confused. I'd want him to be what we call redirectable. I'd tell him to wander off, giving me some privacy. Too much profound dementia and he'd be high maintenance -- plenty of staff in the room diapering, feeding, medicating, restraining. Mild dementia, and he'd want to talk nonsense all the time. I'd know how to work the system. Nobody would bother me, because I'd be a nice and compliant unsqueaky wheel. Lots of yes sirs, and yes ma'ams. I'd mouth the heavy tranquilizers and spit them in the toilet. "Such a sweet old man," I'd hear them murmur. And they would leave sweet-old-me alone. I for once would catch up on my reading. I might actually crack open Remembrance of Things Past. I'd read all of Jane Austen again, but just for fun not for credit. For something light, I'd work in Sue Grafton from A to whatever. Maybe she'll have Z done by then -- or even have gone on to AA Is for Alcoholics Anonymous. On nice days, I'd sit in the sun affecting a wide straw hat -- maybe take up smoking again. I'd chat up the nurses. But no pinching. It almost sounds like one of the plausibly Mittyesque lives I imagine when the kids and the wife are too much. Maybe I'd write a bit, but for art and posterity, not for commercial success. Every day, I'd take a nap or two, and there would be no leftover tasks when I woke up just in time for dinner. No garbage to take out. No dogs to walk. No one to yell at. No one to yell at me. I'd be Burgess Meredith in The Twilight Zone -- the only survivor of a nuclear holocaust who only wants to read without the bother of a wife or boss, who finds his paradise in a library just before he steps on his glasses. But I'd take good care of my glasses. I'd have the nurse keep a spare for me. "Such a sweet old man." Unknown to her, my eyes would follow her butt as she exits.

Making Whoopee

A recent study of sexuality in older adults confirms they're making lots of whoopee often as much as people many years younger. But there's little of this in the places I visit.

We could chalk up the absence of sex in nursing homes to poor heath and frailty. But I'd like to move beyond bingo, to utter the word "sex" in a nursing home without modifying it with "harassment" or "offense." It's arguably illegal to prohibit sexual activity in the nursing home. OBRA commands facilities to "support residents in preferred activity" and it established a bill of rights that includes the right to privacy; the right to the accommodation of medical, physical, psychological, and social needs; the right to be treated with dignity; and the right to self-determination. How could privacy, dignity, meeting one's personal needs, and self-determination not add up to sex? Do we have to wait until my iconoclastic boomer generation shows up to make a major stink out of this?

Among the retarded citizens community, there is an ongoing conversation about sexuality -- about the tricky balance between sexual rights and sexual exploitation. Most adults in nursing homes -- unlike many retarded persons -- are legally competent. Old age and sex are not oil and water.

I'll admit it could lead to some intriguing new job responsibilities for the activity director. Tuesday at three: Viagra versus Cialis versus Levitra. Wednesday at ten: Sex toys for the single octogenarian.

The Unhappy Ending

Nobody "dies" in a nursing home. The euphemistic leitmotif for all things eldercare extends to the final chapter. Recently, I walked into a nursing home with a referral to see Joyce Bellanino. I can't find Bellanino.

"Where's the Bellanino chart?" I ask one of the nurses.

"Oh, she passed."

"Passed," "expired," "gone" are the usual euphemisms. We're too secular to say that Joyce Bellanino has gone to her reward, and we're not flip or hard-boiled enough to say she's kicked the bucket or having a dirt nap or the big sleep. We keep it pleasant and innocuous.

There is little memorialization. Some homes have a party for each month's birthday boys and girls, but I've never seen a memorial service for the passed and expired. The other day I saw a little obituary -- a paid listing -- for a woman I had met a couple of times. Someone had posted it on the bulletin board behind the nursing station. My act of remembrance was to read it. Mother of four. On the production line at Pratt and Whitney for twenty-five years. Predeceased by her husband. Wake tomorrow night. Burial Friday. And so she passes into history. I'm sure the obit will be gone the next time I show up. On the counter, her chart is being deconstructed, an empty binder sits next to its innards -- a thick stack of paper on its way to its own burial in the records room. Next week, the binder will be reborn, filling up with paper for a new resident in my little world of aging, dying, and death.

The staff knows whom to call. After a death, I'll see a couple of sturdy young men in dark suits enter a room with the curtain drawn around a bed, and leave it wheeling a cart with a cloth-covered corpse. They manage this with a minimum of fuss, often when the residents are at lunch or asleep. Never through the lobby. Always a side or back door. We don't want to upset the residents.

The Happy Ending

Not every nursing home story has an unhappy ending.

Consider Sean Hanrahan. When I met him, he was one of the few humans alive to have had the personal enjoyment of the last two Red Sox baseball championships -- 1918 and 2004.

Born in Boston, 1908, he wasn't at the 1918 World Series clincher. He was poor, plus there were only 42,000 seats.

"I didn't even hear it on the radio. There was no radio. I heard the newsboys down the street hawking the late-edition extra."

I met Sean on my fifty-eighth birthday, October 27, 2004 -- almost old enough to cash in my IRA but still too young for Medicare. Sean along with all the other residents provide me with -- apologies to Wordsworth -- intimations of my own mortality.

I also remember that date because in the evening the Sox were to finish their four-game sweep of the Cardinals. Despite the nurse's warning, Sean was in a celebratory, talkative mood -- wearing his Bosox hat.

The following week, I'm back, and Sean is gone. My heart skips a beat, but he's not dead. He's back home. Even at ninety-six, life can go on.