Old Age, Disease, and the Discourse on Risk: Geriatric Assessment in U. S.

Health Care
Author(s): Sharon R. Kaufman
Source: Medical Anthropology Quarterly, New Series, Vol. 8, No. 4, Conceptual Development in
Medical Anthropology: A Tribute to M. Margaret Clark (Dec., 1994), pp. 430-447
Published by: Wiley on behalf of the American Anthropological Association
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SHARONR. KAUFMAN
Departmentof Social and BehavioralSciences and
Medical AnthropologyProgram
Universityof California,San Francisco

Old Age, Disease,and the Discourseon Risk:

GeriatricAssessmentin U.S. Health Care

Thisarticleexploresone way in whichmedicalpractice confrontsold age,

disease, and conceptions of risk through an examinationof geriatric
assessment,a recentlycreated health care modalityin the UnitedStates.
Theprocess of geriatric assessment is shown to extendmedicine's gaze
to all aspectsof bodily,mental,and social existence,therebycontributing
to widespread cultural confusion about the equation of old age with
disease. Geriatric medicine's representationof old age and disease is
embedded in a risk discourse permeating contemporarysociety. An
analysis of geriatricassessmentconferencessuggests thattheold become
thefield on whichthe imperativeto reduce risk by behaviormodification
and supervisioncompeteswith the deeply held value of autonomy.Medi-
cine is assumedto be the appropriateinstitutionfor managingboth the
risks associated withaging and disease and the conflictbetweensurveil-
lance and care on the one hand, and freedom and neglect on the other.
[old age, geriatricmedicine,risk assessment,United States]

edicine, as institution,system of knowledge, andpractice,has become a

dominantframeworkfor confrontingthe lives andproblemsof manyold
people in the United States. Its contemporaryrole in addressing the
problemsof old age is not unexpectedconsideringthe fact thatmedicinehas been
an extremelypowerfulforce in shapingknowledge in late 20th-centurylife (Lin-
denbaumandLock 1993;Lock andGordon1988; WrightandTreacher1982). The
"biomedicalizationof aging" (Estes and Binney 1989), the most recent charac-
terizationof medicine's power to define aging, is thoughtto resultfrom, first, the
dominanceof scientific models for understandingthe life course and, second, the
use of proliferatingbiomedical technologies both for solving the problems of
disease associatedwith advancedage and for staving off deathin late life. Indeed,
Cole (1992:xxii) suggests that medicine, together with science, has replaced
religion and possibly the family and community as the most powerful meaning

Medical AnthropologyQuarterly8(4): 430-447. Copyright? 1994, AmericanAnthropologicalAsso-

ciation.

430

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OLD AGE, DISEASE, AND THE DISCOURSE ON RISK 431

system for conceiving the capabilities, limitations, and role of the aged in the
Westernworld.
I have previouslydescribedtheproblematicnatureof boundariesof authority,
responsibility,and control in contemporaryU.S. medicine in the case of stroke
survivors'chronicillness experience (Kaufman1988). In this article,I extend the
discussion of ways in which medicine's power both responds to and affects the
older person turnedpatientby looking at encountersof patients,family members,
andhealthprofessionalsin outpatientgeriatricassessment.The analysisfocuses on
the multiple meanings of old age and risk for patients, families, and health
practitionersand how the constructionof those concepts shapes medical practice,
patientcomplianceand resistance,and family dilemmas aboutintervention.

Ageism and the Problematic Relationship between Aging and Disease

Ageism, well documented in society in general (Butler 1975; Clark and
Anderson 1967) and in medical care specifically (Adelmanet al. 1990; American
Medical Association 1990; Greene et al. 1986), contributesto the widespread
equation of old age and disease (Estes 1979; Sankar 1984) and prevents the
clarificationof relationshipsamong specific disease processes and normalphysi-
ological developments in later life. Many physicians without training or much
experiencewith the elderly attributesymptomsof medical disordersto aging, for
example, falls, memory loss, vision and hearing impairment,depression, and
incontinence."Whatcan you expect at yourage?"is a well-knowncliche. The aged
are viewed as asexual, mentally impaired,and otherwise limited in their human
capabilitiesby many practitioners(Adelmanet al. 1990; Cohler 1993; Thomasma
1991). The documentedfact that physicians spend relatively less time with their
elderly patients than with younger adults contributesto their lack of knowledge
about the relationshipbetween aging' and disease and to misconceptions of the
older person and older body (AmericanMedical Association 1990). Elderly pa-
tients, moreover,are sometimes not offered preventive measures, such as breast
exams and pap smears, as thoughthoroughhealth care was not necessary for this
age group.When illness is assumedto be synonymouswith old age, opportunities
to prevent,evaluate,and treatspecific problemsare ignored.
In contrast,physicians who specialize in geriatricmedicine (whetherboard
certified geriatriciansor not) and some internistsand family practitionershave
worked to disentangle normal aging from disease. They claim that identifying
disease is important;once it is treated,it need not interferewith a person's life and
normal aging (Somers and Fabian 1981). Geriatricmedicine defines old age as
normaland nonpathologicalyet ironicallystakes its identityon the claim thatold
people are best served by specialists trainedto view them as separatefrom other
adults (i.e., not normal) with different problems and medical needs (Cohen
1992:89-91).
In addition,geriatriciansandsome otherphysiciansexpandthe domainof their
carebeyond biomedicaldiseases andview theirrole as one of helpingto maximize
physicalandmentalfunctionfor as long as possible despitebothdisease andnormal
aging and frailty. They view medicalpracticewith old patientsas a combination
of internalmedicine and awarenessof the familial, social, and economic circum-
stancesand emotionalstatusof the patient(KaufmanandBecker 1991). They treat

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432 MEDICALANTHROPOLOGY
QUARTERLY

emotionaland social needs, as well as physicalproblems,throughthe provisionof

psychological counseling, social work, and the linking of patientsand families to
communityservices wheneverpossible. It can be arguedthatgeriatricians'concep-
tions of the patient and his or her sources of suffering are, along with some
psychiatrists,family practitioners,and general interists, the most broadly con-
ceived of all the medical fields. The irony is that while physicians in geriatrics
attemptto separatenormalaging from diseaseprocesses in theirclinical workand
to educatepatientsandfamilies aboutthatdifference,theirstatusas medicalexperts
on aging reinforces the idea that clinical medicine is the frameworkfor both
understandingaging and dealing with old age.
Both ageism and geriatricmedicinecontributeto the equationof old age and
disease. Old age-as-diseasehas become a morecompelling"truth"thanold age as
one of several normal developmentalprocesses. The lack of clarity about what
constitutesnormalaging and normalold age anddistinguishesthem from disease
has significantramificationsfor societal perceptionsof frail old people and their
healthcare.This articleillustratesthis ambiguityas a source of tension aboutwhat
can and should be treatedin old people, and why.

Geriatric Assessment

Geriatric assessment is a medical idiom speaking to contemporaryU.S.

medicine's power to createknowledge aboutold age itself and aboutrelationships
betweenthe old andyoung. Specifically,the ideaof assessmentimpliessupervision
of the elderly by other membersof society, an idea that is difficult for some old
people andtheirfamily membersto accept.The emergenceof geriatricassessment,
however,pointsto thefact thatinformalsocial supportsystems areofteninadequate
to deal with frailty, senility, and conditionsassociatedwith old age. The medical
practiceof assessingold peoplecrystallizesa culturalconflict betweenthenecessity
of caringfor declining elderly relativesand the value of individualism.
The medical practiceof geriatricassessmentemerged in the United States in
the 1970s2as a response to a numberof factors,social and medical.First, it was a
response to the demographic shift in the population and the fact that medical
technologies proliferatingduring the 1960s were saving more and more elderly
lives. In the process of saving old lives, medicalinterventionprolongsdebility and
dependence.People who survive pneumonia,heartattacks,and variousinfections
may live on with arthritis,vision and hearing losses, stroke-causeddisability,
Parkinson'sdisease, cardiacdisease, incontinence,and dementia,making it much
more difficultfor themto do whatthey have always done-rely on themselvesfor
physical, social, and emotionalwell-being.
Second, geriatricassessmentdevelopedduringthe periodwhengeriatricswas
becomingestablishedas a medicalspecialty3in its own right.The specialtyneeded
to affirmits identity throughspecific activities that differentiatedit from general
internalmedicine. Various observers have noted that medical specialties distin-
guish themselvesfrom one anotherthroughthe developmentof discretetechnolo-
gies (Epsteinet al. 1987; Kane 1988; Stevens 1971). Geriatricassessmentbecame
"the technology" of geriatrics,thus legitimatingits existence as a separateand
necessarymedical field.

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OLD AGE, DISEASE, AND THE DISCOURSE ON RISK 433

Third,medicine's systems approachto the patientwas widely acceptedby the

1970s. The movement to look beyond the confines of the body to intrapsychic
processes, emotional states, social relations, and the entire environmentof the
individualaspatienthad gainedadherents.As the notionof diseaseanddiagnosable
problemexpanded,so did the role of the physician, who focused now on patient
managementin addition to disease treatment(Arney and Bergen 1984). The
socially constructedneed for patientmanagementlent authorityto the concept of
geriatricassessment.
In the United States, specialized geriatric assessment services (also called
geriatricevaluationunits)have appearedprimarilyin academicmedicalcentersand
Veterans Administrationhospitals (American GeriatricsSociety 1989). Those
services have been set up in acute care hospitalwards,long-termcare institutions,
and outpatientsettings (Rubensteinet al. 1982). Theirrangeof goals differs from
place to place, but everywhere includes "comprehensivediagnosis" (American
MedicalAssociation 1990). Some centersor unitsincludetherapeuticinterventions
and long-termmanagement,especially rehabilitation.The hallmarkof all these
services is thatthey are staffed by a multidisciplinaryteam of health care profes-
sionals, not simply one physician. Core staff usually includesphysician (internist
or geriatrician),nurse,psychiatristor psychologist, andsocial worker.The teamis
frequentlyaugmentedby otherhealthworkers,includingphysicalandoccupational
therapists,nutritionists,dentists,and optometrists.
The NationalInstitutesof HealthConsensusConferenceon GeriatricAssess-
ment Methodsdefined comprehensivegeriatricassessmentas follows:

evaluationin whichthemultipleproblems
a multidisciplinary of olderpersonsare
uncovered,described,andexplained,if possible,andin whichtheresourcesand
of thepersonarecatalogued,
strengths needfor servicesassessed,anda coordi-
natedcare plan developedto focus interventions on the person'sproblems.
[American Geriatrics
Society1989]

To work towardthat goal, tests are employed to measurementalstatus,cognitive

impairment,mobility,physicalfunction,andself-care.Staff inspecthomes for ease
of movementandsafety with wheelchairs,walkers,canes, andotherdevices. They
also scrutinizehomes in regardto handrails, good lighting,and shower stools, for
example,and advise the removalof scatterrugs, loose cords,and otheritems that,
accordingto professionalsin geriatrics,could cause accidents.Social networksare
evaluated for their adequacy in terms of assistance with personal care, meal
preparation,transportation, andrecreation.The patientis evaluatedpsychologically
for resilience in the face of loss or illness and ability to respondto disability by
makingchangesin personalbehaviorand in the environment.
An assumptionof the field of geriatricsis that once the old person's body,
mind,behavior,routines,andrelationshipscan be characterizedandapproachedas
a system,the patientcan be managedmore effectively. Cliniciansin geriatricsaim
for improvedcognitive and physical function and greaterlife satisfactionof their
patients.The totalizingideal of more precise diagnosishas not been consideredas
morepervasiveor insidious surveillanceby cliniciansor by most olderpersonsand
theirfamilieswho need assistanceandseek out this modelof care."Comprehensive
diagnosis,"however, challengesculturalideals of personalagency in adulthood.

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434 MEDICAL ANTHROPOLOGY QUARTERLY

Expanding Medicine's Gaze: Assessment as Risk Awareness

The emergenceof geriatricassessmentas a medicalmodalityextendedmedi-
cine's gaze (Amey andBergen 1984;Foucault1975) andexpertisebeyondthebody
to the old person's behavior,social system, and environment.The point I wish to
highlight here is that geriatricassessment-a health care delivery model charac-
terized by the use of objective methods to achieve surveillanceof all aspects of
bodily, mental, and social existence-further solidified and refined the notion of
old age as a medical problem in need of a specialized, scientific, and totalizing
approach.Geriatricassessmentbroadenedthe scope of "diseases"thatcharacterize
aging by formallyincorporatingpsychological and emotionalstates, family prob-
lems andfamily life, habitsandroutines,andpersonaldifficultiesandvalues of old
people into its purview. Virtuallyall aspects of the old person became subjectto
scrutiny,evaluation,and diagnosis. The personal,social, legal, and political con-
sequencesfor olderpersons-and, indeed,for society-of exposingmoreandmore
areasof life to the clinical gaze and medical interventionare only beginningto be
explored. At stake in the broadeningof the gaze are the social constructionof
"normal"and "pathological"vis-a-vis the elderly4and public acceptanceof the
importanceof medicine in managingaging (Binney et al. 1990; Estes and Binney
1989; Lyman 1989; Miller et al. 1992).
The U.S. version of geriatricassessment emerged in the context of a risk
discoursepermeatingpostindustrialsociety. It has been notedthatrisk is on the rise
as a culturalcategory(Douglas and Wildavsky 1982). It has become a framework
for understandingthe perils of the Westernindustrialworld (Clark 1984).5It has
been said thatwe live in a "risksociety" (Beck 1992), a worldmade dangerousby
technologies of war and industrythat producepollution.Much understandingof
what constitutes danger, some criteria for decision making, and some public
policies turnon questionsof risk assessment,avoidance,and acceptancein every-
day life. Public consciousness of risk and its reverberationsin all areasof life has
perhapsneverbeen higher(Nelkin 1989; Slovic 1987).
Risk awarenessas both function and expressionof medicine is now firmly
embeddedin understandingsof the role of medical care in late 20th-centuryU.S.
society. For example, genetic counselinghas become well establishedas a means
of discoveringand reducingrisk associated with birthdefects (Bosk 1992; Rapp
1993). Medicine'sresponseto AIDS includes a detailedvocabularyof risk behav-
iors in sexual activity. Medical care for cancer and cardiovasculardiseases is
framedmoreandmoreoften in termsof preventionandriskreduction.6The Human
Genome Project,with its promise of unlocking the mysteriesof precise relation-
ships among heritabilityand disease, provides a new framework-that of the
genetic code-for thinking about risk in relation to disability, responsibility,
knowledge, power, and surveillance(Flower and Heath 1993). In the context of
expandingknowledgeaboutwhatconstitutesriskandourawarenessof ever-greater
exposureto risk, we are forced to rethinkour notionsof our bodies, our identities,
our relationshipsto people and environment, and, in the case of reproductive
decisions, the lives and futuresof others.
In geriatrics,the expandedgaze embraceda languageof risk and converted
risks into diseases (Porter 1994). Thus, much activity in the medical care of old
people concernsthe biomedicallyframed"need"to assess and minimize the risks

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OLD AGE, DISEASE, AND THE DISCOURSE ON RISK 435

thatbothhealthprofessionalsand the broaderpublic feel olderpeople areexposed

to, or that theirfunctionallylimited bodies, selves, and lives apparentlyembody.
While I do not deny the very real need for help, care, and securityexpressed by
both older people and families when faced with declining abilities, I wish to
emphasizethatthe conceptualizationof the elderly"atrisk"for institutionalization,
physical disability,depression,and dependencyis a recentculturalphenomenon.
It emerges partiallyfrom the equation of risk with danger in the public view
(Douglas 1992). It reflects the fear of litigation so prominentin clinical medical
practicein recentdecades. It is due also to the translationof epidemiologicaluses
of the term"risk"to clinical andlay experience(Gifford1986;Nelkin 1989). Thus,
althoughmedicalrisk originatedfrom a statisticalconceptreferringto a measured
propertyof a groupof people, it is broadlyunderstoodin the contemporaryUnited
States as a state of being or symptom of future illness that individualsneed to
consider, take responsibilityfor, or avoid. Clinicians speak of risk as a specific
propertyof an individual,thus translatingor convertingthe epidemiologic usage
for their own purposes(Gifford 1986:216-217; Kaufertand O'Neil 1993). Older
persons and theirfamilies who seek medical expertise througha geriatricassess-
ment service wonder whetherrisks should be ignoredor treated,and when, how,
and to whatextent interventionshould occur.
An old personis linkedwith the notionof riskwhenhe or she, familymembers,
social service agency personnel,or health careprofessionalsperceive a change in
the person'scondition,whetherit be due to diminishingfunctionalability,the onset
of illness, or the intuitivefeeling that somethinghas gone wrong. Then the health
care system and its medical experts are sought to controlor diminishrisk.

The Setting and the Study

The GeriatricAssessment Service I observed in 1992 and 1993 is affiliated
with a university teaching hospital in northern California. It is located in a
residential neighborhoodclinic, a "satellite" branch of one of the university
hospitals.It servespoorandmiddle-classpeople, predominantlywhite, withhealth
care paid by Medicaid, Medicare,or private insurance.During the period of my
observations,the multidisciplinaryassessmentteam included:(1) universityaffili-
ated physicians in either private or clinic practice and physicians preparingfor
geriatricboardcertification;(2) a nurse;(3) a social worker,and(4) a psychologist.
The team expanded at times to include an occupational therapistand several
podiatrystudents.
I observedthe teamdiscuss the cases of 43 individualsaged 80 or more whose
health statuseshad recently declined. Two patternsemergedamong the 43 cases
regardingwhy the assessmentwas sought.Half of the patientswere broughtto the
service, usuallyby family members,becausethey had experienceda rapiddecline
in functionalstatus-mental, physical, or both-following an acute-carehospitali-
zation, a fall, or anotheracute medical incident in the precedingsix months. The
family wantedto know what was wrong and how the olderpersoncould be helped
to function better.The other patients were broughtto the service because family
members or others were experiencing new difficulty in caring for a debilitated
person or could no longer cope with the growing strain of caring for another
person's body,home, andfinances.Functionalstatuswas not consistentamongthe

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436 MEDICALANTHROPOLOGY
QUARTERLY

43 people. Some of theold peoplewere drivingcars,managingexpenses,andliving

life as they had for years, while othershad become dementedor physicallyfrail.
The team had a highly structured,ritualizedprocedurefor examining,evalu-
ating, andmakingrecommendationsto patientsand theirfamily members.Incom-
ing calls were directedto the social workerwho sought the goal of the assessment
and scheduled appointmentswith the other team members. The patient, almost
always accompaniedby family or a friend, was seen privatelyby a physician(and
sometimes the nurse as well) for a complete physical exam and medical history.
The patient then had psychological tests to determinecognitive competenceand
mental status.If a podiatristwas available,there was a detailedfoot and mobility
examination.If the occupationaltherapistor nursewas available,a home visit was
includedto determineequipmentneeds and to assess functionalabilityand safety
in the home. Theseproceduresaretypicalof outpatientassessmentservices.Unlike
some inpatientunits,the multidisciplinaryteam providedno follow-up diagnostic
tests or therapies.
Following the individualexaminations,the multidisciplinaryteam met each
week to discuss two patientsundergoingassessment.The meetings were informal
but highly routinized.The sequenceof presentationand rangeof discussionnever
deviated from a carefully scripted format. The physician presentedhis or her
findings first, followed by the psychologist,andthenthe social worker.Otherteam
membersinterjectedcommentsandaddedto the discussion afterthe social worker
made her remarks.Individualpresentationswere followed by generaldiscussion
in which the separateviews of the patient and family described by each staff
member were analyzedand integratedfirst, to arriveat a pictureof the patient's
medical problems, social support, and living situation and, second, to create
consensus regardinghow to present the diagnosis and team recommendations
duringthe conferencewith the patientand family.
I observed 25 patient-familyconferences with the assessment team. The
conference,staffedusuallyby a physicianandsocial worker,was carefullyscripted
as well: first the physicianmade one or morediagnoses, sometimesconfirmingor
refutingdiagnoses made by the patient'sown doctor.The physicianreviewed the
patient's bodily systems, with attentionto symptoms and complaints,and noted
which systems were functioning normally, which needed further diagnostic
workup,and which needed treatmentor othermanagement.The list and analysis
was followed by the physician'sreferralto otherhealthprofessionalsand sugges-
tions for behaviormodification,including stopping smoking or driving, using a
cane, eatingregularmeals insteadof snacks,or socializingmore.The social worker
then elaboratedon some of the physician's directives, especially those involving
referralto otherprofessionalsandthe need for behaviorchange.Thesession always
concludedwith a briefdescriptionof the durablepower of attorneyfor healthcare
and the suggestion thatpatientsput theirhealth care stipulationsin writingif they
wanttheirdesiresaboutmedicalinterventionhonoredin the event of laterincapac-
ity. Depending on the circumstances,the social worker also suggested that the
family get the patient's finances in order, especially by taking control of the
patient'scheckbook,bankaccounts,and financialaffairs;recommendeda medic-
alert identificationbraceletin case the patientwanderedfrom home and got lost;

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OLD AGE, DISEASE, AND THE DISCOURSE ON RISK 437

andprovidedwritteninformationfor family membersaboutdementiaanddementia

supportgroups.
Both physicianandsocial workerrecommendationswere understoodby them
as naturalresponsesto the broadlyconceived diagnoses.The teamalwaysassumed
that patientsand family memberscould and would follow their line of reasoning
regardingthe necessity for the suggested treatmentplan. The recommendations
were intended to fit or channel the patient into medical and social services
regardless of the patient's diagnosed diseases, personal choices, or behavioral
idiosyncrasies. Health care providers assumed also that placing patients into
existing structureswas the appropriateresponse to the presentingcomplaintsof
persons or families and would resolve the diagnosed problems, at least partially.
The "rules"thathealthcare professionalsplay by-fitting diagnoses into existing
avenues for treatment-become the "facts" of geriatric assessment (Arney and
Bergen 1984:5) andthe mode of actionof all healthprofessionalsinvolved.Those
rules are the knowledge thatprovidersinvoke and impartto patientsas bases for
decision makingand coping with debility and dependence.

The Dialogue on Old Age, Disease, and Risk

Whatdefinestheactof medicalknowledgein its concreteformis not,therefore,
theencounter betweendoctorandpatient,noris it theconfrontation of a bodyof
knowledgeanda perception; it is the systematicintersectionof two seriesof
information, eachhomogeneous butaliento eachother-two seriesthatembrace
an infiniteset of separateevents,butwhoseintersection reveals,in its isolable
dependence,the individualfact.[Foucault 1975:30]
I turn now to narrativeexamples of the team-patient-familyencounterto
illustratefirst, the vocabularyand approachof geriatricassessment;second, the
kind of knowledge it produces;and third,the difficulty of reconcilingthe impor-
tance of autonomy,privacy, and individualism in the contemporaryU.S. value
system with the declining health and increasing frailty of many elderly people.
Abouthalf the conferencesI observedinvolved family memberswho felt theymust
exercise decision-makingcontrolover theirelderlyrelative.The otherconferences
dealt with patientswho acceptedassistance with daily living, behaviormodifica-
tion, and othermedical and social service interventionand who acknowledgedas
appropriatethe reducedfreedomthat would accompanyintervention.
The two case studiespresentedbelow are examples of the conflict generated
when family membersfeel they mustmake decisions for the patient.The two cases
follow the scriptedformatof the 25 conferencesI observed.I have chosen them to
illustratethe expansionof the clinical gaze to encompass the olderpatient'sentire
life and medical efforts to direct the patient and family to specific "normalizing
strategiesthatpermeatethe intimatelife of individuals"(Rhodes 1993:132,follow-
ing Foucault1975, 1977).The two cases also documentthe discomfortmanypeople
feel in limiting the autonomy of the infirm elderly to provide care and the
apprehensioncreatedamong participantswhen limitation is suggested. The case
studies representthe following four concerns:(1) the ways in which the discourse
on risk is formulatedand understoodby health practitioners,patients,and their
families; (2) the vulnerabilityof the patientto the organizationalimperativesand
the structureof healthcare delivery thatdictatepatientneed (Dill 1993); (3) how

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438 MEDICALANTHROPOLOGY
QUARTERLY

features of the expanded medical gaze are defined as "good" for the patient
(Mattingly 1993); and (4) the apparentimpossibility of reconciling the cultural
themes of individualrights and choice on the one hand with family responsibility
for sick, frail, and declining relativeson the other.

Mrs. A
A daughterbroughther 80-year-oldmother,Mrs. A, to the geriatricassess-
ment service becauseshe was concernedthather motherwas no longertakingcare
of herself.Mrs.A residedalone in an apartment20 miles away fromherdaughter's
home and, accordingto the daughter,had been calling on the phone almost daily
to say that she was "blue and lonely."Her daughterhad noticed that she had lost
interestin personalhygiene, preferredto stay in her pajamasall day ratherthan
dress and go out, had no social contacts,and was experiencingsevere short-term
memory loss. A Medicaid-paidattendantwas supposed to assist Mrs. A with
grocery shopping, house cleaning, and cooking, but had stopped doing so. The
daughter,a single working mother, felt that her mother needed to change her
behaviorandthatsomethingneededto be done for hermotherso thatherown stress
abouther mother'scondition could be relieved.
In theirreporton Mrs. A, the assessmentteam notedthatshe had a historyof
coronaryarterydisease, alcohol abuse,andbleedingulcers.She hadfractureda hip
years before, which still caused constantpain. She walked slowly and haltingly
with a cane. She had smoked a pack of cigarettes a day for many years. Most
important,from the team's point of view, earlydementiawas diagnosed.The team
also noted thatMrs. A was able to performall self-careactivities,handleher own
finances, and that she drove a car.
The diagnosis of dementia,assessmentof otherhealth problems,prognosis,
and recommendationsfor care were presentedto Mrs. A, her daughter,and her
college-aged granddaughterat the family conference, which was staffed by the
assessmentteam physician (MD) and social worker(SW). The following excerpt
from my field notes recordsthe conversationat thatconferencebeginningwith the
physician's opening statement.
MD:I won'tbeataroundthebush.Youhavea declinein mentalfunction,mostly
memory.It'sin theearlystages.
Mrs.A: Whatmakesyousaythat?
MDandSW:Thetestswiththepsychologist.
MD: The problemswith your memoryarethe main problem.It would be good to
have calendars,clocks, etc., as reminders.
Mrs. A: I don't forget appointments,only what I want to forget.
MD: You should also avail yourself of a power of attorneyand a durablepower
of attorneyfor healthcare.
Mrs.A: ForwhenI'm six feetunder?I'm shocked.I knowwhatI'mdoing.Do
you thinkI'm ready to kick the bucket?
SW: No, these things are for when you're living. These things are for all adults.
They are if you are temporarilydisabled,if you can't express yourself.
Mrs.A: You don't have to worry;I don't have any money.
MD: Even if you don't, it's to takecare of your finances.
Mrs.A: You are makingme feel awful. I'm going to go home and get a cane and
shawl ....

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OLD AGE, DISEASE, AND THE DISCOURSE ON RISK 439

MD: I'm going to ask you to stop drinking.

Mrs. A: I don't drink.
MD: That's good. And stop smoking.
Mrs. A: I enjoy smoking.
MD: I want to impresson you the complicationsof smoking.
Mrs. A: I know, heartdisease, lung disease.
MD: And you should stop driving.
Mrs. A: I can't stop driving. I go to the grocery store. I've got to get groceries.
I've neverhad an accident.I've always lived alone. I take careof everything.I
feel terrible.I shouldn'thave come here.
MD: We arehereto makerecommendationsonly. We can't takeyourrightsaway.
Mrs. A: That seems like what you are doing.
MD: We can only impresson you what we recommend.
MD and SW:We're being straightwith you. This memory loss will progress.
Mrs. A: Whatmakes you say that?
Daughter: All the testing shows that.
MD and SW:The tests, the day we and the psychologist spent with you.
SW: We have identifiedthe problemof memory loss. We're looking to find the
cause.
MD: Our concem is thatalcohol aggravatesthe condition.
Mrs. A: I don't drink.
MD: Our concer is thatyou're alone.
Mrs. A: I like being alone. I've got neighbors.
MD: We'd like you to avail yourselfof a day center.
Mrs. A: No way. I've worked my whole life on women as a beautician.I don't
want to be aroundwomen.
MD: There aremen. You don't have to do it everyday.It's an option,so you don't
feel isolated.You can go once a week.
Mrs. A: I don't feel isolated.
SW: I know you've said your friendshave died and you're alone.
Mrs. A: Those were old friends,older thanme. I'm aroundpeople.
MD: The day centeris to be aroundpeople, to be busy. It's an option for you.
Mrs. A: I don't want to be busy. I enjoy being alone. ...
MD: We also want to do a home evaluationfor safety.
Mrs. A: My home is safe.
Daughter: I talkedto your doctor and told him I'm bringingyou here.
Mrs. A: Don't send my doctoryour report.
Daughter [with a greatdeal of concernin her voice]: We're worriedabout you.
Mrs. A: So it's you who says I'm forgetting!
SW:The tests are independentof your daughter.This is real.
Daughter: We have to make adjustments.This is real. It happensto everyone.
MD: With memoryloss, therearethingswe can do to help you. We're not putting
you down.
Mrs. A: You make me feel like I'm losing my mind.
SW: I know this is harderto graspthana brokenleg, but it's there.
MD: We'd like to continuethe home attendant.
Daughter: They aren'tcoming.
Mrs. A: They haven't come for threedays.
Daughter: They've got to come daily. We need to get hooked up to a service.
Mrs. A: I'm not readyfor a rest home.
Daughter:This has nothingto do with a resthome. We need to do somethingnow.
SW: Our assessment of your memory loss is objective.... Your daughter's
concerns arejustified.

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440 MEDICAL
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[The physician admonishes the patient to see her regulardoctor again and to
carefully watch her diet because she has elevated cholesterol and coronary
arterydisease.]
Mrs. A: I'm going to go home. This depresses me.... Don't you people know
I'm enjoying living by myself? I can do whatI want. I've been busy all my life.
SW: We just want to make the argumentthat things have changed in your
retirement.And you need to compensatefor being a little less functional.We
need to make suggestions and plan for the future.We call this shoring things
up, to keep you independent.
MD: You're very high functioningand we want to plan ahead, to work through
the memory loss, so we can preventyour daughterfrom being in a dilemma.
This is the way thatyou andyourdaughtercan help each other.So she isn't left
deciding for you....
[Physician discusses her hip pain and recommendsthat she see an orthopedic
surgeon to discover whether or not the problem causing the pain can be
corrected.He also suggests she have her hearingevaluatedand have a routine
eye exam.]
Mrs. A [in good humor]:Will you write all these things down because you say
I'm losing my memory.
Daughter [very emotional]: Mom, we need to plan and get a handle on this
together.It's not bad;we have to plan. It's a stage of our lives and we have to
deal positively with it. We need to plan before it's too late, before a crisis. But
I need your help. We have to help each other. I want you to be here for her
[pointsto granddaughter]graduation.I don't know what to do if you won't do
anything.You're over therein your apartmentin a haze. We need to get some
services to supportyou. This wouldhelp me, so I'm not so stressed.I want you
to take advantageof services. You need them consistently.
SW:Thingsjust need to be organizeda little.... We don't want this to become a
problem.It could be a problem.The homemakerneeds to be formalizedso you
get consistent help.
MD: We'll help you get the services.We're not just lettingyou loose.
Mrs. A: Help is not dependable.
SW:We realizethat.We wantto get someonewho oversees that.I need to do some
homeworkto find thatfor you.
[Endof conference.]

Mrs. B

Mrs. B, age 80, was brought to the assessment service by her daughter. Mrs.
B's husband had died a year before, and the daughter had moved into the mother's
home to care for her during a long period of bereavement and depression. The
daughter was about to move away to attend professional school and was extremely
concerned about her mother's living alone. She reported to the team that her mother
was "losing her train of thought," not cooking, not eating well, and always tired
since her husband's death.
Preparing for the family conference, the team outlined three points for discus-
sion. First, the patient "needs activities." They would discuss with her the possibil-
ity of "hooking her up" with a day center, or having someone come in to provide
companionship and to help her cook and clean. Second, they would pursue the topic
of psychological counseling or drug therapy for her depression. Third, they would
discuss the idea of her moving to some type of senior residence so that she would

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OLD AGE, DISEASE, AND THE DISCOURSE ON RISK 441

have the company of other people and regular meals. The physician, social worker,
patient, and patient's daughter were present at the conference.
MD: Yourcognitive functionis prettygood. Depressioncan makea personunable
to care for oneself and stop a personfrom eating. The questionis how will you
managewhen your daughteris gone?
Mrs. B [very quiet and subduedthroughoutconference]:I'm not sure. I may not
be able.
Daughter:We're seeing a social workertomorrowaboutsomeone coming to live
in.
MD: Or you can move to a placewheretherearebuilt-infriendsandmeals.I want
to know from you [Mrs.B] if you'd be interestedin moving or if you're really
attachedto the house?
Mrs. B [quietfor severalminutes]:I hadn'tthoughtaboutit. It doesn't soundlike
a good idea.
MD: We felt that if you can work on your mood and emotions and get some
activities, you'd be OK in your house. We're not convinced that you need
someone in the house 24 hoursa day. Seeing a counselormay be a good thing,
to talk aboutwhy you haven't been as active as you could be this past year.
[Mrs. B has her eyes closed while the physicianis speakingto her. It appearsthat
she only speaks when she feels she must.]
MD: We will makea recommendationthatyou talkwith someoneto workon your
sadness. It may meantakingsome medications.
SW:Whatdo you thinkaboutseeing a counselor?
Mrs. B: No objection.
MD: There are also social programsaround.Activities are very important.
SW:You need to have projectsgoing. We've found thatpeople who do thingsare
happier.
Mrs.B [quietfor a few minutes]:I preferto be alone, butrealistically,I don'tthink
I can. Just in case, what if I fall? A buttonis very appealing.
SW:We're going to recommendthat.
[She proceedswith a discussion aboutcooking meals.]
MD: Would you cook for yourself?Are you interestedin trying?
Mrs. B: I don't know.
MD: Medically, we thinkyou are doing well. Five years with no complications
from dialysis is reallywonderful.
[The physiciantalks for a few minutesaboutMrs. B's medical conditions.]
MD: Do you have any questionsor concerns?
Mrs. B: [silence]
MD: We'd like to help you make some plans, but you have to let us know what
you want. You have some choices.
Mrs. B: I'm not interestedin moving to a nursinghome.
MD and SW:We're not talkingnursinghome. We're talkingapartment.
Mrs. B: I want to stay home. I'm so used to my house. The mere idea of
transplantingmyself is not acceptable-right now.
[The physicianand social workerthen ask if she'd like someone to live in, or have
someone come in a few times a week to clean and cook. They discuss the
advantagesand disadvantagesof each option, and then talk about how to get
"linkedup"with activities.]
Daughter: I see the need for live-in help because she backslides. The daily
maintenancegoes. The whole thingis self-neglect.She didn'tget upon Tuesday
or Sunday.It took me all day Sundayto get her to eat an egg. I can't do thatany
more.

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442 MEDICAL ANTHROPOLOGY QUARTERLY

SW: It's a good idea for a case managerto be involved. These discussions are
going to take time. We see a greatdiscrepancybetween what you are capable
of doing and the neglect your daughterdescribes. You could startout with
live-in help and a therapistto workwith you. You need to worktowardthe goal
of greaterindependence.Thereneeds to be a case managerto oversee this goal.
... We'd like you to see it as being moregoal-oriented.Therewill be multiple
adjustments.A live-in personis just the first stage.
[At thatpoint the social workerpresentsinformationto the family on the durable
powerof attorneyanddurablepowerof attorey for healthcare.Theconference
then ends.]

Disease, Problem, Responsibility

The team-patient-familyconferenceis an importantevent and process: it is
the spacein whichideology andexperiencecollide, wherespecific geriatricmedical
knowledge is "triedout," and where clinical medicine's reach is painfully con-
fronted and sometimes contested. The conference is also one arena in which
ultimate responsibilityis shown to be problematic.The health care team claims
respectfor individualautonomyandshareddecision makingwhile projectingfinal
authority.The family is caughtin a bind of tryingto reducerisk and ensuregood
health while serving as advocatefor the patient,who may not perceive any health
risks at all.
The identification of problems is not necessarily perceived similarly by
patient, family, and health care provider. The patient or family come in with
complaintsthatemerge from theirdaily experience,includinga perceivedchange
or decline in the patient'sfunctionandthe caregiver'ssense of impendingcrisis or
greaterdependence.The health care team constructsa discreteproblemlist-the
diagnoses-from the medical history,psychological tests, and patientand family
narratives.The task of geriatricassessment, after constructingdiagnoses, is to
formulatemanagementsolutionsin the formof a recommendedtreatmentplan.The
family usually accepts diagnoses and managementstrategiesand feels responsi-
ble-even when tornby the patient'sopposing wishes-for ensuringthe patient's
compliancewith recommendedtreatments.
Thus, Mrs. A's problem was identified by her daughteras loneliness and
depression,lack of self-care,memoryloss, and inconsistenthouseholdhelp. In the
conference,Mrs. A claimedto have no problemsat all. In contrast,the healthcare
team's diagnosisof herconditionincludedprogressivedementia,isolation,alcohol
abuse, smoking,and driving.They recommendedhouseholdhelp, socializing,and
the terminationof drivingwhile also acknowledgingthatshe was havingno trouble,
for the moment,meetingherdaily needs.The effortof Mrs.A's daughterto support
the team recommendationsproduceda struggle with her mother over control,
neglect, and autonomy. Mrs. B's daughtersought help because of her mother's
fatigue, depression,and unwillingnessto cook, eat, and care for herself. Mrs. B.
acknowledgedher ambivalenceabout self-care and her fears of living alone, yet
she expressed no desire to change her behavioror alterher living situation.The
team suggested the need for activity, company, and psychological counseling to
improve her mood and her ability to care for herself. Mrs. B's daughtersaid she
needed the team's help and she wantedto implementtheirsuggestionsbecauseshe
was moving away and feared for her mother'swell-being.

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OLD AGE, DISEASE,ANDTHEDISCOURSEON RISK 443

These case narrativeshave their limits as representationsof the medical

practiceandideology of geriatricassessment.They areonly partialrepresentations.
I did notobserve otherphases of assessmentincludingphysicalexams,psychologi-
cal tests, and social workerinterviews,andI did not see patientsor families in their
homes. A number of conferences I observed did not produce family conflict,
generatethe outrageexpressedby Mrs. A, or lack resolutionas in the case of Mrs.
B.
At the conference,interactionsamong healthcare professionals,family, and
patientlocate risk in the old person (Rhodes 1993). In U.S. geriatrics,old people
who do not exhibit complete autonomy,who cannotcare for all their own needs
independently,who have functionallimitations,are thoughtto embody risk.7The
taskof the practitioneris to specify the natureandextentof thatrisk-as disease-
so it can be containedand diminished.These case studies illustratethe mannerin
which risk is defined in old people with compromisedabilities througha process
of transformingthe experience of daily life into diagnoses, prognoses, treatment
plans, and, finally, negotiatedcompliance.While physiological markersof risk in
the elderly(e.g., high blood pressure)arenotedby practitioners,they often receive
less attentionthan behavioralmarkersof risk that emerge during dialogue with
patients. Pills can control blood pressure or infection; complex claims about
responsibility,authority,and doing the right thing, however, are evoked to deal
with the more complicatedphenomenaof inactivityand isolation.
Althoughnot all old people view themselves,or areviewed by others,as sick,
frail,or in need of assistanceor supervision,the expandedgaze of geriatricsplaces
old people who seek out assessment services in a state of risk all the time. Health
care professionalsin geriatricassessment aim to reducerisk by convertingit into
disease and treatingit accordingto imperativesof the healthcaredelivery system.
In that process, they contribute to the tension expressed by some families and
patientswhen treatmentconstrainsautonomy.
The team-patient-familyconferencesof geriatricassessmentillustratea seem-
ingly insoluble tension between safety and supervisionon the one hand, and risk
and independenceon the other. In the highly individualisticsociety of the United
States, these values compete in the delivery of health care to old persons. Health
professionals,families, andelderlypersonsthemselvesstrugglewithdecisions over
how much independenceto curtail and when, how much behavioralor environ-
mentalchange to introduceor demand,andwhich methodsof careand supervision
will be the least offensive andproblematicto the old person.Many view the health
care system as the most appropriatearenafor managingaging and decline, yet the
culturalideals of personalautonomyandfreedomfrom institutionalconstraintand
domination compete for expression in medical decision making. Satisfactory
solutions to problems of frailty and decline in old age are elusive because the
competingvalues areso tenaciousin U.S. society: individualismhas been a deeply
heldvaluefor generationsandtheriskdiscoursehas becomemorewidespreadsince
the cold war era.
Exploringways in which the tensions betweencare and control,surveillance
and choice play themselves out in one medical context forces us to consider the
following questions: How does risk language in clinical medicine, in general,
geriatricmedicine, in particular,shape ways of understandingold age and the

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444 MEDICAL
ANTHROPOLOGY
QUARTERLY

limitations and frailties of old people? What should the goals of medicine be in
light of both the legitimacy of the risk discourse and the strong need for autonomy
in late life? Is the cultural construction of medical knowledge about old age all
pervasive? Can other paradigms compete in social, legal, and ethical discussions
about the "problem" of old age in Western, especially U.S. society? Acknow-
ledging the conflict between the risk discourse and the value of individualism can
potentially open up other ways of knowing old age, ways that consider dignity,
interdependence, and self-esteem (Agich 1990; Clark 1987; Moody 1992) rather
than emphasize risk assessment. Perhaps in that way, society and, thus, clinical
medicine can devise other models for representing senescence and its problems.

NOTES
Acknowledgments.The research on which this article is based was supported by
NationalInstituteon Aging ResearchAward#AG09176, "FromIndependenceto Depend-
ence among the Oldest Old," Gay Becker, PrincipalInvestigator,Sharon R. Kaufman,
Co-PrincipalInvestigator.I wish to thankthe geriatricassessmentteam for allowing me to
observetheirwork. I am indebtedto Gay BeckerandLawrenceCohenfor theirsuggestions
on an earlierdraft.The thoughtfulcommentsof two anonymousreviewerswere extremely
helpful in refiningthe final version.
Correspondencemaybe addressedto theauthoratDepartmentof Social andBehavioral
Sciences and Medical AnthropologyProgram,N631, University of California,San Fran-
cisco, CA 94143-0612.
1. LawrenceCohen (1992) points out that the term "aging"is used alternatelywith
"old age" in the gerontological literature,without conscious regard for their separate
meanings.Thatusage seems to be an unarticulatedeffort to mute or deny the negative value
associatedwith the term"old age." I use "aging"here to referto a biological and develop-
mentalprocess, especially as it takes place in old age. "Old age" is used to refer to people
consideredto be old; it is a staticconcept.
2. Americangeriatricassessmentunits are an outgrowthof the special purposewards
for evaluatinggeriatricpatientsthatwere establishedin GreatBritainyears earlier(Brock-
lehurst 1975).
3. Technically,geriatricsis a subspecialtyof internalmedicineor family practice.
4. The social construction of "normal"and "pathological"aging is an ongoing,
complex phenomena.Fromthe 19thcentury,at least, medicalresearchersand practitioners
in Europeandthe UnitedStateshave debatedwhetheror not old age is a disease-infectious
or chronic-or a normaldevelopmentalprocess (Achenbaum1978). Although biological
knowledge has become more sophisticatedduring the past century, the debate remains
unresolved(Forbes and Hirdes 1993; Von Dras and Blumenthal1992).
5. An anonymousreviewer of this articleobserved thatthe U.S. style preoccupation
with risk is less prominent,and indeedabsent,in manypartsof the worldwhere the realrisk
of disease, death,displacement,andimpoverishmentarefargreaterthanin the UnitedStates.
6. The popular literatureon reducing one's risk for these diseases-through diet,
exercise, stress reduction techniques, etc.-is enormous and is created both by health
practitionersand healthcare consumers.
7. I use the term "embody"here in its standardAmericanlanguage usage: "to give
bodily form to; make corporeal"(Webster'sNew WorldDictionary 1979).

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