Overcoming denial about age.

Mary Pip her, PhD, is the author of Another Country: Navigating the Emotional Terrain of our Elders (Riverhead Books, 1999), An internationally noted psychologist, she decided to write Another Country after caring for own mother until her death five years ago. Now in private practice in Lincoln, Nebraska, Pipher is also a visiting assistant professor at the University of Nebraska.

Could you comment on the title of your book?

Pipher: Well, old age really is a foreign country in the sense that we've all been 14, but we haven't been 85. We don't empathize well with older people. In addition, the old are segregated--sometimes physically and often by their world view. Values about community, individualism, and mental health are very different now than they were when our parents and grandparents were young. There are language barriers as well; the old may call oatmeal porridge and refrigerators iceboxes, for instance.

Would you say long term care residents are segregated?

Pipher: In the course of setting out to visit nursing homes over the years, I started out feeling like most people: I'd rather die before going to a nursing home. But when I actually visited many, I was impressed by the staff. There were many people working for very little money yet very committed to helping the people they served. We've seen many improvements, including the spread of the Eden Alternative, aviaries, bringing in children, adopt-a-grandparent programs, that sort of thing. Those programs help ease the feeling of isolation.

There were also cases in which I met old people who were doing much better in the nursing homes than living independently. Socially, they had more contact there than alone in their homes.

Still there are some essential problems. [Long term care facilities] do tend to segregate old people from the rest of us. They are built around the concept of old people wanting to rest. And most lack a vital feature: institutional support for people to be useful. The need to be useful goes away about the time the need for oxygen goes.

Do you think other types of long term care promote a better view of aging?

Pipher: Well, there are so many different names and types. I don't like the kind of unit that makes a distinction between healthy old people and old old people, who are in frail health. I'm thinking of one place in particular. There were independent living apartments, and if a resident living there had a health problem, if she broke a hip, for example, she would be moved through what people living there call "the tunnel" to the building for the old old. Even those who remain in the "young building" end up losing a lot of freedom--to live with their spouses, for example.

What's your ideal living arrangement for people in their later years?

Pipher: I would like to live with friends when I grow old. I'm sure there will be one of us with good eyes, one with enough marbles to do math and pay the bills, one who still cooks, one who can drive and so on. In my view, that's a much better concept of aging than waiting to go through the tunnel, which is just a horrible metaphor. The message is: Abandon hope all ye who enter here.

We can also learn from other cultures. Okinawan women never stop working. An older woman who sells fish won't continue to be the primary seller of fish, but people will continue to buy one or two fish from her on occasion. There's a real sense in that culture that one needs to stay active and useful. It's vital to remain part of the social fabric. Losing that affects mental health and physical health as well.

How can we move toward being better prepared for old age?

Pipher: The main argument in the book is that our culture in general isn't prepared for caring for our elders, and individuals aren't well prepared for dealing with their own old old age or their parents'. People are not educated very well and make poor choices as a result. For example, a lot of the education older people receive about where to live has been by real estate developers; there's much more money to he made selling condos in the Sun Belt, even though most would be more comfortable knowing that family is nearby.

Providers and other professionals dealing with older adults need to encourage families to start early in speaking with their parents about old age. Get some sense for resources available, parents' wishes. Encourage talk about finances.

One big problem we have to overcome is denial. Most people don't think of old age as old old age. People plan for young old age--Winnebagos and visiting national parks.