Dependent aging: what does cinema show?

This paper is an essay that understands art, particularly cinema, as a complementary resource for discussing health issues, and it is part of a reflection on multicentric research on dependent older adults conducted in eight Brazilian cities. The paper analyzes two movies that address the contingencies of dependent old age and the relationship between caregivers and people cared for. “Poetry” shows the impasses of an elderly woman who is economically and emotionally overburdened, with early symptoms of Alzheimer’s disease. The second movie, “What ever happened to Baby Jane?” exposes the delicate and complex relationship between the caregiver and cared person dyad. The paper aims to broaden the understanding of social processes such as aging, through cinema, encouraging the use of movies in continuing education settings involving researchers, students, and health workers.


introduction
This essay on the use of movies related to dependent human aging dialogues with research data on the topic 1 and aims to contribute to the training of professionals in the field.The authors hypothesize that the cinematographic language, translated by characters who play symbolically relevant roles to express health problems or human suffering, complement the scientific view 2 with other perspectives and sharpen the sensitivity of professionals to understand the narratives of their patients.As Gadamer 3 points out, he helps them empathetically put themselves in the other's shoes.
A seminal author used here to understand the relationship between art and science is Walter Benjamin 2 , who, through his critical view, confronted what he called "science of syntheses" that adds up every detail of what is observed to obtain the truth in a final whole.The author showed the power and the increasingly influential presence of imagery in the human perceptual and communicative definition in the face of what he called political and cultural authoritarianism that parameterizes daily ideas and actions.Benjamin believes that information and communication technologies allow experiencing the individual and collective, temporal and spatial order, focusing on human intensity and sensitivity.
The articulation of art with science is not new.Historical examples of this interaction are identified in Aristotle and, more closely, in Leonardo da Vinci, who used mathematics and geometry to revolutionize human representation and nature.Benjamin's great originality was to perceive and create conceptual tools that would enable the contact between the logical and rationalist thought of philosophical-scientific discourse with artistic language, both based on literature and materialized in photographic and filmic images.His thesis is that a human sense to manifest and demand possible interpretations is found in each object studied by science.It is important to remember that the author lived the dark times of Nazism and Stalinism, an era overloaded by the technical and administrative elements of the urban-industrial world, whose references were these grand theoretical narratives.
Faced with modern life's crumbling, the nightmare of the capitalist economy machine in the period of the Great Wars, Benjamin identified art as an influential factor in elaborating meaning and possibilities for expression.He stressed that the most plausible meanings of the human con-dition emerge from art.Therefore, he proposes a dialogue between the two languages (technoscience and art) and their rationale, overcoming interpretative and methodological borders.He also stresses that, in favor of art, the narrative of individual experience can express the group's scalar context experienced by the social majority.The author shows a dialectical interaction between the individual and the universal and between the senses and meanings of human actions.
We can assume from Benjamin's work 2 the universal concept of "idea" symbolically expressed in words and, at the same time, that contains the world's image.It is up to human knowledge to relate it to particular objects.Thus, word and image cannot be defined from a conceptual generalization: they interact from the artistic aspects in all human experiences that make the narratives conducive to meaning and understanding.
The theme of this paper, cinema allows us to look at the details of what human beings do in their daily lives through techniques and a specific language in the form of images and narratives.This focus on particularities, typical of the cinematographic language, establishes conditions for human sensitivity to grasp the logic of the society of its time, through the action of heroes and villains.Thus, a conscious fragment (the movie) becomes an unconscious viewpoint, generating a process similar to that of psychoanalysis.This process includes a dialogue between knowledge and truth, sensitivity, and understanding, which includes passions and utopias indispensable to life, without which there is no possible humanity.
It is within the viewpoints mentioned above that this writing aims to encourage possible readers to add the perspective of art, particularly cinema, to the themes of research, study, and education, whatever these may be.As one of the cinephile researchers mentions the importance of art in health professionals' training processes, he who only knows medicine knows nothing about medicine 4 .
Despite technological advances, medicine continues to work with words, and one of its main instruments, anamnesis or clinical history, is focused on the patient's account of the suffering and discomfort caused by the disease that affects him.In an exhibition on the importance of literature [and we could add cinema] in medical training and practice, Baños and Guardiola 5 state that the suffering and the physical and psychological consequences of the serious illness suffered by Emperor Hadrian in imperial Rome, described by Marguerite Yourcenar 6 , are not different from those presented by heart disease patients currently living in western capitalist countries.In other words, historical, literary, and filmic accounts allow us to understand with sensitivity the illness and human behavior of any era.
In particular, first of all, cinema can contribute to knowing clinical cases by broadening the understanding of the lives of people from other social classes, ethnicities, genders, or territories.Second, it can assist in training doctors and other health professionals through the development of competencies, habits, attitudes, values, and skills.Third, it shows the importance of empathy, discipline, humility, perseverance, intellectual and personal honesty, and cognitive and intellectual capacity.Like other authors, it is believed that literature and cinema reveal more about society and everyday life than many technical textbooks and scientific papers 2,7 .
This essay discusses the use of cinema in health education and medical training.It contextualizes the research scenario to which this text is articulated, outlining a brief profile of the situation of dependent aging in Brazil and, in the end, movies "Poetry", which portrays the difficulties of an elderly woman with Alzheimer's disease, and "What ever happened to Baby Jane?", an approach to the delicate and complex relationship between the caregiver and the dependent person, are analyzed.

Methodological path
This essay aims to reflect on the theme of dependent aging through filmic language.Theodor Adorno 8 believes that the essay is a critical and reflective intellectual exercise in which the author's subjectivity appears and, unlike the classificatory form of science, supports the qualitative changes that occur in the analyzed events through the emotion that art awakens in the observer 9,10 .
The reflection on dependent aging is nested in the research called "Situational Study of Dependent Older Adults" 1 (free translation from Portuguese), which mainly aimed to understand the situation of this group that lives with their households and their caregivers to subsidize proposals for a policy on dependent old age in Brazil.
This essay aimed to bring cinematographic reflections about dependent old age and the complicated relationship between caregivers and people receiving care to the research setting 1 .Two works were selected for analysis among the extensive cinematographic production produced in recent years addressing aging-related themes.The first of these is "Poetry" 11 , an oriental film directed by Lee-Chang-Dong, in 2010, which shows the situation of older adults suffering from the loss of physical, mental/emotional, cognitive, and social autonomy.The second one, "What ever happened to Baby Jane?" 12 , an American film from the 1960s, explores the strategies of care, in this case, non-care used by relatives to address dependent older adults.Although in the sixties, the movie remains current concerning the problems presented.The two movies discussed portray some of the countless problems faced by dependent older adults.In "Poetry", the main issue is Alzheimer's disease and, in "What ever happened to Baby Jane?", it is the physical dependence caused by a car accident, along with the experience of violence perpetrated during a lifetime of resentment between the elderly woman and her caregiving sister.
No interviews were conducted with older adults with Alzheimer's disease during the research 1 because they could hardly interact with the researchers.Even so, a movie addressing this disease was selected due to the high prevalence of this condition in Brazil, and because older adults and caregivers of this research verbalized many accounts of memory loss.The movies were analyzed from the themes related to the vulnerabilities of gender, social class, and dependent aging and, although not part of an essay's methodology, the situations presented in the movies can be extrapolated to other locations.
Both movies break down the subjective, social, and economic implications and management of different situations experienced by older adults and their caregivers, who, in most countries, as well as in the movies shown, are women.Articulating a cinematographic vision to research means adding to the empirical data a comprehensive look and viewpoint to the theme that often remains opaque in clinical or research interviews.

Brazilian dependent older adults
In Brazil, Alzheimer's disease (AD) is responsible for 50% to 60% of cases of dependence in older adults and is the most frequent cause of senile dementia in the world.AD is a syndrome characterized by a progressive chronic-degenerative decline in the areas of cognition, function, and behavior, with impaired activities of daily living.The disease has a slow and progressive course and several deficit patterns, the most common of which has an insidious onset, with early deficits in recent memory 13 .Early diagnosis of Alzheimer's is crucial to delay the development of the disease and improve well-being and quality of life.The declining memory and ability to think are reflections of the progressive cell death that occurs with the development of the disease, unlike the relatively minor loss of brain cells in the natural aging process 14 .
Brazil records more than 30 million older adults, resulting from a 50% demographic growth in the last 10 years.In 2007, 17 million people were over the age of 60 and, in 2027, this population is estimated to reach 37 million, up from 8% in 2000 to 19% in 2030.Currently, most Brazilian older adults are active, operational, and contribute socially, politically, and financially to society 15 .
Families are the primary support for a healthy or dependent older adult, providing care and economic and social support.However, the protective home may also be the violent environment that hinders older adults' autonomy, discriminates against them, and lead them to desire or attempt suicide due to financial difficulties or internal conflicts, as found in research on suicide in this age group [16][17][18][19] .
In the elderly population, the most vulnerable group consists of the poor, women, people living alone or in the streets, or social distancing.Of this group, those who suffer the most are dependent people, that is, those who lose their functional capacity, autonomy, or are socially disadvantaged and, thus, demand permanent family care and increase the demand for medical care and social services 20,21 .The latest study that outlines the profile of dependent elderly Brazilians was carried out by the National Health Survey (PNS) conducted out jointly by the Brazilian Institute of Geography and Statistics (IBGE) and the Ministry of Health (MS) in 2013.These data were analyzed by authors such as Lima-Costa et al. 22 , and show that 23,815 people were heard in a nationally representative sample of the entire population over 60 years.A prevalence of 30.1% of at least one limitation for the performance of activities of daily living (ADL) -a concept universally used to define dependence -was found, reaching 43% among the illiterate, 29% among those with primary education, and 13.8% among people with higher education.This information shows the high proportion of dependents, as well as the effects of persistent social inequality.

about the film "Poetry": the feminine and vulnerable face of old age
Considering the high prevalence of Alzheimer's disease in the Brazilian population, the film "Poetry" was chosen to represent an elderly woman's life scenario in an early stage of the disease."Poetry" is an Asian film released in 2014, which according to film critic Inácio Araújo 23 , shows the meeting of "subtlety and violence".
Although it is Asian, the film transcends the place of origin and could refer to any urban region of peripheral capitalist countries.The main character is Mrs. Yang, a 65-year-old woman who lives modestly in a city in the inland region of South Korea.The character is in a situation of poverty, receiving a negligible retirement pension, which requires her to supplement her income by working as a caregiver and housekeeper in the home of another older adult, and this is the situation of many older women in several countries, and is observed in the field research mentioned here 1 .
In Brazil, population aging is happening at an accelerated rate in a scenario of extreme social, racial, gender, and structural unemployment, with no guarantee of equity between the age groups in the sharing of resources and health care.The change in the social security regime now in place is expected to imply, as in other countries, in increasing poverty among older adults, a historically disadvantaged group 24 .The feminization of old age and the accumulated care functions towards other relatives are observed in this context.Women are more exposed to asset and economic violence, and one type of violence is the provision of unpaid informal care 25,26 .
In "Poetry", the first scene -a body floating downstream on a river -will repeat itself in the last scene, in a cyclic fashion, so dear to Asian movies.Boys playing on the banks identify the body of a young girl who committed suicide.Later, it is revealed that she was the victim of sexual abuse perpetrated at school by six schoolmates, one of them the leading role's grandson.The rapists are children of wealthy families, except for the last one living with his grandmother, Mrs. Yang, since his mother works in another city.
Mrs. Yang goes to the hospital for an outpatient visit complaining of musculoskeletal pain and is impacted by the mother's despair in front of the body of the girl who threw herself off the bridge.The doctor at the office relativizes the bone problem and is attentive to the patient's selective forgetfulness, which foreshadows Alzheimer's disease, although she does not seem to care about this diagnosis.
Mrs. Yang takes care of her teenage grandson, serves him meals, takes care of his clothes.She remains standing, silent, ready to serve him, while he chews on dinner, complains about the food, watches television, or checks on his cell phone.She talks to her daughter every day on the phone, but she only tells her good news, as if following the script of a society where everyone is forced to be happy.In a playful tone, she tells her daughter that she enrolled in a poetry course and that she needs to write a poetic text.Because of this initiative, she starts to make observations about everyday life and writes them down in a notebook, looking for inspiration and meaning.
Mrs. Yang is called in for a meeting of the parents of the boys who sexually abused the girl who committed suicide, and she notes that these men show no compassion for the raped teenager and her family.The indifference to the girl's rape and suicide, the neglect of the old lady, and multiple excuses concerning the abusive behavior of their sons appear clearly in the meeting of the rising middle-class parents.These men gathered to drink and free their children from any punishment, which evidences the intersectionality between gender, social class, and generation.Their only concern is to save their children's image and cover up the case.
As a solution to the situation, the parents propose to split an amount among themselves to compensate the mother who lost her daughter and ask her to forget what happened.The proposed compensation amount was too high for Yang.However, besides not waiving her share of the stipulated amount, she was given the task of going to the mother of the suicidal young girl carrying the group's proposal, because, as they said, she would know how to talk better being a woman.
Unlike men, Mrs. Yang grows increasingly sensitive to what has happened.She meets the mother of the suicidal girl who works in the countryside.However, while on the way, she no longer remembers what she went there for.She steps on one apricot that fell from the trees, tastes it, and writes in her notebook, as a premonition: the apricots throw themselves onto the ground.Trampled and crushed, they move on to the next life.She then walks ahead and meets the woman, talks nicely to her, and then leaves.Suddenly, her memory returns as she heads back.With a strained countenance, she walks away from the woman, without mentioning the settlement proposal.
While the facts occur, Mrs. Yang persists in the poetry course, struggling with words and paying attention to the small facts of everyday life.She is distressed because she has no money to pay her share of the parental agreement.One of the parents forces her verbally to honor her part of the deal.Thus, having no other choice, she turns to the older adult under her care, who harassed into a sexual intercourse a few days earlier, and asks him to provide her with the money with no questions asked, which he does somewhat reluctantly.She gives the money to the other parents and walks away.The movie highlights the permanence of female vulnerability to sexual violence and male chauvinism in old age.
A police inspector, responsible for investigating the rape and death case of the young student, also takes part in the poetry course.Knowing that Mrs. Yang is the grandmother of one of the boys involved, he asks her trick questions, and she gets confused when she answers, believing later that she could have inadvertently framed her grandson.In one of the movie's final scenes, she plays shuttlecock with her grandson in the residential block's courtyard where she lives, when the police vehicle approaches and the boy is taken by the police officer.Although she did her part in the economic compensation to the suicidal young girl's family, her grandson, the poorest boy in the group, is arrested and held responsible.The drama's author suggests the social class bias within the legal and police system, as he was the only young man taken to prison.
In the last class of the course, the grandmother leaves poetry in memory of Agnes, the raped girl.Sensitivity and suffering, "subtlety and violence".Physically and emotionally burdened by poverty, the need to continue working as a housekeeper to survive, the young girl's suicide, the care of her grandson and the unsuccessful attempt to free him from punishment, the unfair treatment by the justice system, her memory fading away, the old lady writes a poem and throws herself into the river, like the apricots throw themselves onto the ground.Trampled and crushed, they move on to the next life.
A movie is always polysemic.However, the personalized issues in influential leading figures as in "Poetry" allows many observations: (1) the overburden of the grandmother responsible for an adolescent grandson who ignores the work spent to maintain him; (2) a lady who hides information about her problems and suffering from her daughter, so as not to upset her; (3) a wealthy, authoritarian and abusive dependent older adult who pays poorly to his caregiver to the point of making her feel obliged to offer him sexual favors, which is violence endorsed by pa-triarchal society; (4) being a woman, poor and elderly, Yang is disrespected by the parents of the boys, by the police inspector, by the daughter who outsourced the care of her grandson, by the older adult who harasses her; (5) without the time and conscience to take care of Alzheimer's, the old lady commits suicide, throwing herself into the river, which is the result of an unprotected and helpless life.
Elderly and children suicide, addressed delicately by the movie, is one of the problems experienced in many countries, including Brazil, particularly associated with social and emotional isolation and the ensuing violence.It may seem insoluble, but in general, is associated with psychological, relational, sexual, economic, or generational issues 16 .

about the movie "What ever happened to Baby Jane?": love and hate between caregiver and dependent person
A clear sexual division of roles is observed in family care for dependent older adults: mothers, spouses, daughters, or relatives are the majority.In the research cited here 1 , they represent 88.7% of family caregivers and 93.3% of formal caregivers.These women do, free of charge or with negligible wages, much of the care work, whether for children, people with special needs or older adults 27 .In Brazil, while public policies to support older adults include the family, the State, and society equally responsible for the care, in practice, it has been realized as a matter of private life, so that its performance is left to the family, materialized in the figure of women 28 .
Thus, care provided to older adults, primarily dependent ones, represents a financial, social, and emotional burden on those who care.Feelings of despair, fatigue, anxiety, anguish, helplessness are frequent in families of caregivers of chronic and severe patients, besides resentment and social exclusion that they suffer by not finding time and space to carry out professional, self-care and leisure activities [29][30][31] .
Physical dependence requires much effort on the part of the caregiver, as this person starts to complement what the other person may or may not do.Because they are intrinsically linked to the relationship with the other, older adults who lose their autonomy to carry out activities of daily living tend to suffer all kinds of mistreatment when those who provide care to them were mistreated by them during their life or when there are resentment and lack of empathy between both 21 .
Many movies show a current situation in Brazil, that of older adults caring for other seniors in the family, financially and emotionally overburdened.The movie "What ever happened to Baby Jane?", a psychological drama from the 1960s, shows the troubled relationship between two elderly sisters.Jane, the caregiver, had been a child movie star, and Blanche, the one being cared for, had been an adult film actress, and currently suffers the aftermath of a car accident.Both are marked by the mistreatment suffered in childhood.Jane did not go to school or live with other children, as her time was devoted to rehearsals and presentations, pressured by her parents to achieve fame and wealth.Blanche was ignored, considered dull and talentless 32 .Over time, the script is reversed, Jane is forgotten because her performance is considered mediocre, and Blanche becomes a recognized and wealthy actress.
The old age of these two women occurs in a large and comfortable house, where the money is no problem.However, the relationship of care and partnership that could be established between them emerges as a relationship of violence, whose intensity increases throughout the plot.Jane is addicted to alcohol and, due to circumstances, becomes a caregiver for Blanche, a role she plays in a rude, authoritarian, and unempathetic way.
Communication between the sisters is permeated by secrets that are gradually revealed.Blanche wants to sell her house and put his sister in a clinic to treat alcoholism.However, Jane controls the space: she listens to Blanche's calls, prevents her from communicating with the outside world, simulates her voice to authorize the purchase of drinks, cancels her medical appointments, and tampers with her checks.She crowns her wickedness, dismissing the maid who served them and was sympathetic with the dependent older woman.
In the movie, abuse intensifies and becomes more serious.Jane kills Blanche's pet bird, offers her spoiled food, or leaves her starving, sedating, subduing, hurting, and placing her under house arrest.The drama shows an extreme case, but it shows situations of malaise, neglect, abuse, and violence, often hidden by caregivers.Two sisters, lonely, sick and fragile, experiencing feelings of competition and anger that they nurtured throughout their lives and became a gift in which both remain trapped in a careless relationship.Jane is anesthetized by alcohol, the memories of the past, trying to relive the lost youth and fame.
On the other hand, Blanche is unable to speak frankly with her sister and keeps her trapped in guilt and ignorance of a secret that the audience only learns at the end.That is, male chauvinism and patriarchy include men and women in the same culturally reified pattern.
The violence between Jane and Blanche is not an unprecedented situation.In Brazil, "Disque 100-Idoso" (Toll-free line for elderly support) received, in 2019, more than 37 thousand elderly violence complaints, which should be considered as a small sample of what happens (most of them do not have the courage or the strength to complain about the mistreatment they suffer, particularly from relatives).Of the total notified, 38% were due to negligence, 26% to psychological violence (insults, humiliation, for example), 20% to financial and asset-related abuse, and 12% to physical violence 33 .All these modalities are found in Blanche's situation.While most mistreatments do not leave marks on the body, Jane deprives the older woman of care, affection, and food, attacks her morals and self-esteem, besides enjoying her sister's property and assets, as observed in several studies 21,34 .
In the research that motivates this paper and addresses dependent older adults and their caregivers 1 , many relatives made statements of affection, care, and empathy, although there were reports of fights, negligence, and neglect.In some interviews, the criticisms were verbalized by professional caregivers and omitted by relatives, to show due diligence in care and avoid any complaint or "save their face", as noted in Ostermann 35 .The studies on elderly perpetrators establish abused children and violent or little affective environment during their lifetime as some of the causes associated with the abuse they suffer at the end of their lives 21,[36][37][38] .
The film speaks particularly of women, who, at some point in their lives, had fame and power and face abandonment at the end of their lives.It also speaks of social isolation, considered one of the most critical factors of violence against older adults.It also highlights how the media, including cinema, contribute to upholding stereotypes.When referring to older women, they still do so, considering those who conform to old age and behave per the gender norms intended for them.In general, those who wish to appear young are mocked.The faces and bodies of Blanche and Baby Jane reveal what patriarchy demands of women: they cannot grow old, because the aged female body is viewed with contempt and decrepitude by patriarchal, chauvinist and sexist society 32 .
It is essential to point out that aging is gender-sensitive, and cruelly affects women who are impoverished or overwhelmed with caring for themselves or other relatives.The first, regarding their appearance, the second when they are considered "natural caregivers".The same patriarchy that assesses women by their appearance gives them little-valued domestic chores and encourages strife, competition, and a lack of empathy.Many fulfill this "naturalized destiny" in an isolated and solitary way, in the absence of public policies and social support that sustain and protect them 39 .
While the movie exacerbates the dramatic hues of the relationship between the sisters, the competition between them, secrets, ill-treatment, lies, and violence, it brings a reflection on the role of those providing care and those who receive it and allows analyzing critically gender, generation and class aspects that can sensitize caregivers and health professionals.

Some considerations
One might ask how movies contribute to the understanding of research topics, including those of aging.A movie is always polysemic and captivates the viewer by the sensitivity it can awaken, as Benjamin 2 recalls.The hypothesis is that when personalizing human issues of immense significance, they touch hearts and souls' depths.From a human viewpoint, nothing not traversing affections can become a transformative practice.
One aspect to consider when using cinema as a complement to research activities, clinical observations or pedagogical activities is the decoding of the visual language that includes observation, analysis, and reading of images, use of plans, understanding of the plot and interweaving of stories, and the non-linear sequence of the narrative, including different times and reconstruction of memories.Samain 40 believes that there is much to unveil inside and behind the images, without forgetting the expanded aesthetic experience they produce.However, its use is complementary and does not replace technical themes and debating real-life situations 41 .
This text seeks to reinforce the power of art in the study of aging, regarding the training of students, the continuing education of health workers, and the discussion of research topics and clinical cases.Because of its reach as a means of communication, which combines art, science, technique, experience, and creativity, cinema is a powerful means of societies, enabling them to look at themselves, identifying their problems and social problems, thus contributing to increased self-criticism and self-knowledge 42 .
Currently, older adults have increasingly appeared in movies as a character and leading figure, breaking somehow the long conspiracy of silence concerning old age, as stated by Guita Debert 43 and establishing a new type, the gerontocine 44 .It can be said that this art form is contributing to the construction of a more accurate and adequate social perception of aging, although many movies still associate old age with illness and death.
In short, the symbolic, imagistic, and metaphorical language of cinema provides resources to learn about sociocultural constructions about health-disease and singular disease and pain situations, share experiences of care, health and life promotion, and expand the possibilities for understanding human suffering and limitations, such as dependent old age.