Hospital Hazards for the Elderly

Most people know that being a patient in a hospital can be dangerous while, at the same time, providing critical care. This post catalogs the dangers of hospitalization, particularly for older people and recommends some ways of lessening the hazards. The next three paragraphs are a direct quote from an NPR report on the program “All Things Considered.”

“Until March of this year, Janet Prochazka was active and outspoken, living by herself and working as a special education tutor. Then a bad fall landed her in the Zuckerberg San Francisco General Hospital.

Doctors cared for her wounds and treated her for pneumonia, but Prochazka, who Is 75, didn’t sleep or eat well in the hospital, and she became confused and agitated. Then she contracted a serious stomach infection.

Patients over 65 tend to be less resilient during a hospital stay than younger patients, research finds, and more vulnerable to mental or physical deterioration, even if they recover from the illness or injury that brought them there. One study, published in 2011, found that about a third of patients older than 70 and more than half of the patients over 85 left the hospital more disabled than when they came.”

The sobering case described is not unusual. In fact, hospitalization can be the beginning of a downward slide for an elderly person, followed by declining function, reduced quality of life, placement in a skilled nursing facility or nursing home, and death. This post shares some of the common factors that cause complications and how they can, where possible, be prevented.

Conceptually, all of us have physiologic reserves that we call into play when there are challenges to the body’s well being. However, reserves decline with age due to loss of muscle strength, heart and lung capacity, immune function, cognitive function and general physiologic resilience. At the extreme, there are the “frail elderly,” who are most likely to do poorly in the hospital. Add the challenges that greet people in a hospital to the underlying loss of reserves, and it is a recipe for disaster. What are those challenges?

Immobility: It is surprising how many complications can be caused by the inability to get out of bed and ambulate. In no particular order, immobility can lead to pressure sores, rapid development of muscle weakness (which in turn contributes to falls), under expansion of the lungs (contributing to pneumonia), blood clots that can break loose and go to the lungs and loss of orientation.

Hyper-stimulation: Patients in hospitals must endure the almost constant noise, lights, machines, waking to be checked and other interruptions to sleep and rest. This is particularly true for patients in an ICU. Adding this to an unfamiliar environment can cause disorientation or a delusional state complete with hallucinations. Over medication can be another contributor to this set of events.

Infections: Hospitals are associated with many factors that lead to infections. Breaking our first line of defense, the skin, and invading the body through surgery, bedsores or procedures that puncture, reduce the body’s natural defenses. Similarly, organisms can invade the body through catheters placed in the bladder and through the air that is breathed, particularly if tubes are used for ventilation. Urinary infections are very common in people who have catheters in their bladder for more than a couple of days. Recumbence, pain and loss of muscle strength can make it more difficult for a person to fully expand their lungs, and partially collapsed lungs are a setup for pneumonia to develop. Add to that the proliferation of “super bugs,” virulent and resistant to antibiotics, any of the above sites can be susceptible to life-threatening infection. These organisms are carried from patient to patient primarily by the hospital staff, such as physicians and nurses who don’t always wash or disinfect their hands when going from patient to patient.

Our bodies are home to literally billions of organisms with which we live in harmony. These organisms are kept in check through barriers to entry, the skin, the lining of the gut and respiratory tract, through secretions like saliva and mucous and by the immune system. Patients who are sick, and particularly the elderly, have depressed immune function and less able to fight off microbes. When they have a chance to invade through breaks in the normal defenses, even ordinary cohabitants can become the cause of serious infection.

Errors: Medical professionals are subject to errors. They are caring for a large number of very sick patients in a complex environment, and it is easy to become distracted, overlook something or make an outright mistake. Some mistakes are egregious, like removing the wrong limb. Some are easier to understand, like misreading a doctor’s order and giving the wrong dose of medication. The elderly generally cannot tolerate medication doses that are standard for younger patients. Many errors are preventable by using standardized procedures and protocols and by putting in safety checks. Quality hospitals are implementing the tools of modern industry in the hope that like modern industry, errors can be reduced to one in a million.

Accidents: Falls are the most common accident occurring in a hospital. A combination of weakness and disorientation are usually responsible. After that, accidents can be caused by equipment malfunctioning, by a medical procedure gone awry or by failure to adequately supervise a young professional.

So to what end this litany of medical woes associated with hospitalization? What can we do to lessen these dangers given that although they are best avoided, hospitals can be life saving and are absolutely necessary at some points? I would give the following advice to someone entering a hospital and to their significant others who may need to be on guard if the patient can’t be. It is easy to be passive and compliant in the confusing setting of a hospital, but it is important to be one’s own advocate.

Avoid immobility: Even seriously ill patients including patients with recent surgery or on a respirator can be gotten out of bed to sit in a chair for a while, and preferably to walk short distances. My wife was hospitalized in an ICU for several days after a biking accident. She complained bitterly about how uncomfortable she felt when she sat up in a chair, but the staff persisted in getting her out of bed for short periods.

Advocate for periods of uninterrupted rest: It is difficult to avoid the consultations and monitoring of vital functions, particularly with patients in an ICU. However, protecting some time to sleep quietly is essential to avoiding exhaustion and disorientation. Talking to the staff about scheduling events in bunches, leaving time for rest, can help the patient recover.

Understand what is being done and why: It is difficult to get physicians’ attention in the hospital. They are usually in a rush when making rounds, and getting them to stop and answer questions can be a challenge. When my wife was in the hospital, doctors seemed invisible. They made rounds at 6 or 7 am, and they were often in the operating room or somewhere else during the day. I had to be persistent to get someone to talk to us. Other than in an emergency, you should understand the rationale for major tests and treatments, the benefits and the risks.

Be your own (or family members’) best advocate: When things are going well, compliments go a long way. However, if you are concerned about something, respectfully speak up; it may be a clue that something is awry. Know what medications you are being given and what they look like. I’ve had nurses bring a medication to my bedside that was actually intended for another patient. In the extreme case, chemotherapy has been given to the wrong patient.

Don’t be intimidated by the technology or staff: At times, the hospital procedures seem bewildering, and the staff may seem busy and brusque. As a patient, it is your right to know what is happening and as a visitor, you provide an important function, namely, being a friendly point of reference reminding the patient of who they are outside. If a patient can’t be their own advocate, it is best if one person speaks for the family so that the staff is not getting repeated or conflicting questions. Hospital staffs are usually concerned human beings who want to do what’s best for the patient, but they are busy and working in a complex environment. It’s often best to begin your inquiry with the nurse, who can bring in the physician as needed.

Hospitals can do miraculous things, and at times they are absolutely essential, but they can be dangerous. It is best to know where the dangers lie and to take steps to prevent them.

Why does Health Care Cost So Much?

Health care costs in the US continue to rise at an unsustainable rate. I remember studying this subject when I was early in my career, when health care costs represented about 8 percent of GDP, and reading predictions of it rising to 15 percent over the coming decades.   It is now 18 percent of GDP and predicted to rise to 20 percent in the not too distant future. Make no mistake, rising costs are a problem throughout the world, but it is a uniquely American problem in that the US spends about double the amount per capita that other developed economies spend and has inferior outcome measures. It is clearly a problem that affects what we earn and can spend as well as the competitiveness of the country as a whole.

It is a problem that is getting surprisingly little attention in this crazy presidential campaign of 2016. Donald Trump promises to abolish Obamacare, and Hillary Clinton wants to expand coverage to more of the poor, neither of which will help to control the cost problem that is the driver of many economic concerns. This brief post will not contain all the answers to a tremendously complex problem, but I will try to summarize the main issues. First, I’ll focus on the principle drivers of increasing cost.

Aging of the population: It ‘s well known that providing health care for older people is much more expensive than the young. Our population is aging, and calculations project that this is some of the cost increase, but it is nowhere near the total problem. Besides, it doesn’t explain the US costs as compared to other developed countries, since their populations are aging too.

Expansion of the use of technology: In the last 30-40 years, there has been bonanza of new technologies that have vastly increased our capabilities and improved outcomes. Imaging (CT scanning, MRI, PET scan), minimally invasive surgery, new drugs for the treatment of cancer and other diseases, genetic diagnosis and improved treatment modalities (targeted radiation therapy, joint replacement, microsurgery) are some of the things that have improved what we do.   The problem is that each of these innovations is expensive, and once they are available, their usage expands to problems where they have no incremental value. It would be great if they substituted for other less effective, costly procedures, but they tend to be incremental. No one is going to suggest forgoing a valuable new tool, but our payment system (next section) encourages their overuse.

A system of payment that clearly incentivizes doing more: The following is complex but important. In fact, if I had one thing that I could do to control costs, I would change the reimbursement system. With some notable exceptions (such as Kaiser), health care in this country is paid for on a fee-for-service basis. In other words, a doctor or a hospital provides a service, and they are paid a fee, usually pre-negotiated, for that service or procedure. The main thing that insurance companies, Medicare and Medicaid negotiate are the fees, and providers of care are paid sharply discounted fees as compared to their “usual charges”. If you are unlucky enough to not have health insurance, you will be charged the full fee. In other words, you will be charged the retail price, not the wholesale that everyone else is paying.

The perverse problem with fee-for-service is that it controls unit price but not volume. So what has happened is that providers have increased the volume of services that they provide. By doing more procedures, providing more services and seeing patients more quickly, doctors, hospitals, laboratories, etc. have been abLe to maintain a high level of income. The effects of this are obvious to most. Visits tend to be brief and rushed. Unable to take the time for a careful history and physical exam, doctors send patients for multiple scattergun tests, and physicians have a strong incentive to do more procedures, such as surgery, because it pays well. Young physicians are gravitating to specialties that are more procedure oriented, in part for life-style reasons, but in part because procedures pay better and take less effort than talking to a patient. Consequently, there is a growing shortage of primary care physicians to coordinate care, because it is hard work that doesn’t pay well. It is difficult to make changes that might make healthcare more efficient and rational, because the payment system holds everything in place. There are no financial incentives to do it better, only to do more.

Patients’ demand for services: A colleague of mine, spent a year in Europe studying the health care systems, particularly the British National Health Care System. He said that one of the contrasts between there and here is that the British are much less demanding about their care and more accepting of limitations. The average American expects to have the latest care technology and care available immediately, and can be very impatient with advice that it may not be needed. Until recently, comprehensive health insurance shielded them from the cost of  care.  Health insurance was designed when the costs were an order of magnitude lower and was often given away by employers as a way of avoiding wage increases. It wasn’t unusual to total coverage with minimal to no co-pays and deductibles. That is changing with high deductible policies that don’t pay until the patient has paid a $3,000 – $5,000 deductible, thereby giving the patient a reason to hold down costs. It appears to have had some effect, but to a great extent, we are spoiled and expect to have access to the most expensive technology without having to pay for it. As a country, we have not had to balance the tradeoff between access and cost. That is true except for the poor and uninsured who have limited access.

Absence of a system of care: The fundamental problem is that we don’t have a system of care. We have many silos, physicians, nurses, hospitals, insurers, pharmaceutical companies, laboratories and the government each trying to optimize the care process to enhance their own incomes and leverage. There are no villains and no heroes. Each is trying to turn a profit within their own domain without considering the effect that it has on another silo or the overall product. No one is in charge of the quality, efficiency or the rationale of the enterprise as a whole. It makes it very difficult to assess what needs to be done no less bring about a fundamental change.

In a subsequent post, I’ll discuss solutions that have been suggested and my own ideas.

Can We Prevent Cancer?

Status

A recent Op-Ed in the New York Times by a physician, Aaron E. Carroll asked the question, “Are we helpless to prevent cancer?” Although it causes fewer deaths than heart disease, cancer is the most feared affliction for most people. When and if cancer strikes seems like pure bad luck, putting aside the few people who have a known genetic predisposition. There has been so much progress in the prevention of heart disease that it feels more controllable whereas cancer seems like it strikes out of the blue.

Dr. Aaron’s message is that many forms of cancer can be significantly reduced or prevented by attention to the risk factors that contribute to its developing. Our medical system is very physician centered. Since most physicians are usually not focused on disease prevention, they pay most attention to testing for early detection of relatively few cancers for which there are effective screening tools and the treatment of already established disease. The public tends to mimic this medical model and puts off doing the things that can reduce its risk of cancer. Thus cancer is often discovered at a stage requiring treatment, resulting in much less chance of success in becoming disease free, much more arduous treatment with many more adverse effects on the patient. Obviously, it is far better, cheaper and less uncomfortable to prevent the disease if at all possible.

It is difficult to assess the impact of behaviors or the percent reduction of cancer risk. Most of these suggestions do not come from controlled studies where people are randomly assigned to implement the behavior or not. More often they are the result of observational studies that note the number of times a cancer is associated with a particular behavior. For example, 80 percent of people with esophageal cancer smoke, much higher than the general population. There are geographic locations where the incidence of a particular cancer is much elevated, and people from low risk areas acquire the elevated risk when they move into a high risk area. These observations strongly support the presence of extrinsic factors that influence how often cancer occurs, factors that can potentially be controlled.

The following lists the five behaviors for which the evidence is strongest that there are risks that we can reduce in the formation of cancer:

Avoid tobacco – Strongest evidence of risk. Cancer of the lung, esophagus, stomach, throat, larynx, kidney, pancreas, bladder. Substantial risk with second hand smoke, and risk of cancer of the mouth, tongue and throat with chewing tobacco

Protect skin from sun exposure – Skin cancer, melanoma, squamous cell, basal cell, particularly if fair skinned. Evidence well established

Drink alcohol in moderation – Cancer of the breast, colon, liver, mouth, throat, larynx . Moderation is 1-2 drinks per day.

Eat a healthy diet – Fruits and vegetables, 5 servings per day, is associated with reduction of many forms of cancer. There is some evidence that cooked red meat increases cancer incidence, but it is not yet strong enough to recommend. Healthy diet can help reduce obesity, which is independently associated with many kinds of cancer.

Exercise regularly – (150 minutes of active exercise per week) Aside from the many cardiovascular benefits, there is also linkage to lack of exercise to breast, colon and endometrial cancer as well as longevity.

I can’t vouch for the accuracy of the number, but it is estimated that 40 percent of the incidence of cancer can be reduced by following these five suggestions. Obviously, there is much that is unknown, such as the mechanisms of the effects and other risk factors as yet unproven or undiscovered. Of the thousands of chemicals to which we are exposed, there are undoubtedly many that are going to prove causative to developing cancer. For any who want to read more detail about the strength of evidence related to the above behavioral factors and some that are less proven, a reference on the Internet is www.nap.edu/read/10263/chapter/5 . It is from the National Academy Press, “The Behaviors Contributing To The Burden of Cancer”.

So knowing all of this, why don’t we follow more healthy behaviors? Well there is some evidence that we have improved. The incidence of smoking is down substantially, exercise seems more common, and there is some evidence that people eat healthier diets (beef consumption has dropped dramatically in recent decades). However, most of us fall short of addressing all five behaviors. Unfortunately, there is no pill to take for any of these, and behavioral change is hard. As many times as I have reminded myself, I routinely forget to apply sunscreen. I recently had my first basal cell carcinoma removed.

There are also five screening tests that have been proven to be of benefit in finding cancer at an early enough stage to reduce mortality. Screening is tricky because it tests a large population most of whom do not have the of cancer being screened for. Even with a very good test, the result is often more false positives than true positives. (If a test is 98% specific, then 98 % of the time when the test indicates disease, it is, in fact, present. Obviously, 2% of the time, the test is a false positive.) If 1000 people are being screened for cancer that occurs in 1% of the population, then ideally 10 people will have a test result that indicates disease. However, false positive results will occur in 20 people, so that only one third of the people with positive results will have the disease. This results in a large number of follow-on tests or treatments that are not needed.

The U.S. Public Health Service Task Force (USPHSTF) has looked at all of the evidence on the benefits and risks of screening, and they recommend five screening tests to be promoted to the general population. Other tests may be indicated depending on a person’s unique situation, but these five have been proven to reduce mortality.

Pap Smear – For the early detection of cervical cancer in women, screening should begin at age 21 and continue to age 65. Screening should begin yearly but once there has been 2-3 negative tests, screening should proceed every 3 years.

Screening for Human Papilloma Virus (HPV) – Should be done in conjunction with Pap smear at age 30 to 65. HPV is the putative cause of most cervical cancer and genital war ts. It is more sensitive than Pap Smear in finding early stage changes, and, consequently, a positive test should be followed up with colposcopy. Negative results on both tests indicates that screening can be done every five years.

Mammography – for women between the ages of 50 to 74. Negative results mean that screening can be done every two years (This does not apply to women who are being followed for an abnormality or who have had previous breast cancer.) There is controversy over whether screening should begin at age 40, the USPHSTF has left the choice up to women and their doctors.

Colonoscopy – Recommend this being performed at age 50 and every 5 years thereafter until age 75 for the detection of colon cancer.

Skin Examinations – There is only fair evidence for the effectiveness of having a doctor survey your skin every year or two. The purpose is to look for skin cancers including melanoma. As I have gotten older and lesions are more common, I personally have seen a dermatologist every year for an examination.

Most of the guidelines recommend the cessation of screening at age 65 – 75. However, as people live to an older age, this will need to be re-evaluated. The question to ask yourself at that age is, “Would I do anything about it if I found an abnormality?” If you are healthy enough to say yes, then you and your doctor should consider continuing screening.

 

Falling into a New Age

The following post was written by Diana, reflecting on her experiences recovering from a bicycle accident and its physical and psychologic aftermath.

Two years ago, I had a bike accident that – literally and figuratively – threw me for a loop. I recovered physically and then found myself in a psychological quagmire that took me a much longer time to sort out. I was 68 years old and vigorously healthy at the time, and I wasn’t thinking of myself as anywhere near old. The accident changed all that.  I no longer felt sure of how to regard myself on axes of age or health.

Now I am turning 70, grateful to be alive and healthy, still enjoying my work although at a lesser pace than before, and I know for a certainty that although I am full of energy and gusto and knowledge, that I am a senior, and the future is uncertain. I have trained myself to enjoy the present, to do as much as I can, and not to look at the future as an inevitable downhill slide. (Of course it is an inevitable downhill slide, but I don’t have to focus my energy on it all the time.)

Four of my good friends or family members – all in their seventies and reasonably healthy – have each taken a fall within the last year. Fortunately, their physical injuries were relatively minor. But for each of them it has revealed a trajectory that I recognize only too well, and each of them has experienced a psychological reckoning. Each of them either tripped over some small ‘bump in the road’ or lost his/her balance. On getting up, each one felt embarrassed first and only gradually realized he/she was injured and needed medical care. Physical recovery has been smooth for all of them, but each has had a deeper reckoning as a consequence. Not everyone was willing to talk about his or her own recognition of frailty as a fact of life.

I too have tripped and fallen recently, fortunately without injury. But I know that my balance is imperfect, a factor of simple aging. The recognition that we can no longer take for granted navigation with our own feet is (forgive me) a first step. I can hike at least as far as I could ten years ago, but now I will happily use a walking stick on uneven ground. The second step is not to feel diminished by this.

I have eliminated from my life certain physical sports and risks I used to enjoy, with the conscious recognition that I don’t want to invite injury. And I enjoy, at least as much as before, all that I can see and do. I admire those of my peers who are more physically adventurous and adept than I, without wishing I could still compete with them. Losing the sense of competition is one of the under-celebrated blessings of this time of life. Another is abandoning any striving for perfection, a perennial frustration best left to the young.

This sense of wellbeing has been a gradual acquisition over the past two years. Each of us finds our own way through this labyrinth of growing older. It helps that my friends and I can laugh about our frailties of memory and balance. It helps immeasurably that we can share with each other the beauty that surrounds us, and the inspiration of the young people in our lives. My sense of dread has been replaced with these gifts.

Philosophy For Old Age

This wry look at aging was sent to me by a friend. It is circulating on the Internet, and I thought it was worth sharing. The only attribution is the name He Yan Jan. In its original form, it comes with lovely pictures of nature, but I couldn’t copy those.

Do you realize that the only time in our lives when we like to get old is when we are kids? If you are less than 10 years old, you are so excited about aging that you think in fractions.

‘How old are you?’ ‘I’m four and a half.’                                                                        You’re never thirty-six and a half. You are four and a half going on five.                          That is the key.

You get into your teens; now they can’t hold you back. You jump to the next number or even a few ahead.                                                                                                        ‘How old are you?                                                                                                          ‘I’m gonna be 16.’                                                                                                            You could be 13, but hey, your gonna be 16.

And then the greatest day of your life, you become 21!                                                   Even the words sound like a ceremony.

But then you turn 30. Oooohh, what happened there?                                               Makes it sound like bad milk!                                                                                            He TURNED; we had to throw him out.                                                                     There’s no fun now; you’re just a sour dumpling.                                                         What’s wrong; what changed?

You BECOME 21. You TURN 30. Then you’re PUSHING 40….                                   Whoa, put on the brakes. It’s all slipping away.                                                             Before you know it, you REACH 50,                                                                                 And your dreams are gone.

But wait!                                                                                                                         You MAKE IT to 60.                                                                                                         You didn’t think you would.                                                                                           So you BECOME 21, TURN 30, PUSH 40, REACH 50 and MAKE IT to 60.

You’ve built up so much speed that you HIT 70.                                                             After this, it’s a day-by-day thing.                                                                                     You HIT Thursday, June 23, 2016.

You get into your 80s, and every day is a complete cycle.                                                 You HIT lunch; you TURN 4:30,                                                                                       And you REACH bedtime.

And it isn’t done there.                                                                                                       Into the 90’s you start going backward.                                                                               I was just 92.

Then a strange thing happens.                                                                                             If you make it to 100, you become like a little kid again.                                                       I’m 100 and a half.

May you all make it to a healthy 100 and a half.

Tips for staying young:

  1. Throw out the nonessential.
  2. Keep cheerful friends.
  3. Keep learning.
  4. Enjoy the simple things.
  5. Don’t sweat the small stuff.
  6. Laugh long and loud.
  7. Let the tears happen.
  8. Surround yourself with what you love.
  9. Cherish your health. Take steps to preserve it.
  10. Don’t take guilt trips.
  11. Tell the people that you love……you love them.
  12. AND ALWAYS REMEMBER

Life is not measured in the number of breaths that we take, but in the moments that take our breath away.  Be Well

Redesigning Your Life

You may not think of it this way, but we redesign ourselves constantly throughout our lifetimes. The most obvious ways are the changes that occur at different ages.   We move from infancy to childhood, to teenager to young adult to mature adult to middle age to being a senior. Parenting fits in there somewhere as one of the most profound periods of change. With each of those time periods, we change roles, jobs, attitudes, perspectives, friendships, relationships and the way that we see ourselves. This evolution is much more true today that it was during our parents and certainly grandparents’ day, or at least the changes were more predictable then. People often grew up and lived in one geographic area, went to work in a job or company which could last throughout their work life, stayed married to the same person, for better or for worse and retired to a quieter life of hobbies and memories.

It’s very different today. We are much less rooted geographically. It is unusual for people to work in one job or one company for their lifetime. The best advice you can give to a Millennial is to be prepared to redesign yourself to another work role or occupation at least once in your life. Hopefully marriage is long term, but in a high percentage of cases, it is not.

Somehow, old age is seldom mentioned as a time where redefinition of oneself is necessary. Writers have treated old age as a “thing”. You are old and you are retired, out to pasture, quietly descending down hill. The one area where seniors are acknowledged as taking on a new role is as grandparents. At no age is the need for constant redesign more important than when we become seniors. Aging brings illness, disability and limited energy, all of which change what we are able to do, and that means that we must find our satisfaction in new places.

Many hang on to the roles that they are familiar with, sometimes work beyond their effectiveness, because it is too daunting to contemplate giving up the familiar. But, inevitability, change will occur that constricts what we are able to do, for some earlier than others. Father Time has a way of forcing adjustment whether we like it or not. Actually, changes in our status, such as retirement, can lead to the freedom to pursue other interests, which can be a very good thing. Some people blossom in their later years in unexpected ways. Today, we live longer, and often are capable of active physical and emotional lives into 70s, 80s and even 90s, so we have an opportunity to find roles that are personally satisfying, albeit different than what we did before. Some modification of one’s role is not only necessary, but healthy. It could mean cutting back on work and starting to develop new interests or pursuing a radically different set of goals for one’s life.

The question that is put to us is, can we continue to grow and explore during old age.   Can we begin new things? Can we remain vital and creative at a time when the common expectation is slowing down and withdrawing from life. I think that there are two things that most get in the way of people branching out in new directions. The first is fear, fear of incompetence, of looking stupid of having others think you are being foolish. The second is the concern that we will never be excellent at the new things that we try. Doing things for their own sake, because it gives pleasure is not something that most people are accustomed to. In our utilitarian, pragmatic world, there is a desire to do things that have a purpose and to use external standards of judging whether an activity is valuable or not. One of the first challenges in redesigning how you are going to spend time is letting go of the expectation that everything we do, we must be good at, and it should have a purpose.

When I retired, I decided to take up photography as an avocation. I took several workshops with professionals, and after a while, I became a reasonably competent photographer. I made slide shows and calendars for my friends, and received positive feedback for my work. Then I wanted to show it off more broadly, so I found a restaurant that would display my work and put on an art show at a local school. Now my old instincts kicked in. Could I sell my work? That seemed like the ultimate test of whether what I was doing was worthwhile, at first not realizing that I was taking something that I did for pleasure and making it into a job. Fortunately, when I looked more closely, I realized that commercial photography was a very competitive world. It takes substantial effort to take the best pictures with the right lighting and perspective. Photographers can work a whole day to get just the right vantage point. Then you have to be willing to hustle your pictures in a world with intense competition.   Fortunately, I realized that this isn’t the way that I wanted to be spending my time and energy.

Often when freed from work, people choose things that are spiritually pleasing and are emotionally satisfying. I know at that for most of my life, I worked with my intellect, and I found that retirement is a time to bring the other dimensions of being human into play. I think that is why many people in late life seek experiences in the arts and in serving others. It is a time that can bring deep emotional satisfaction if you are willing to seek just what makes you happy.

The bottom line is that change will come. Grieve what you are giving up and then embrace it. It can be an opportunity to explore different parts of yourself and to be creative about your life.

 

Diets – Do They Work?

There has been a spate of articles in the press recently claiming that weight loss diets don’t work. Many diet researchers have been saying this for a long time, but what has caught peoples’ attention is the longer-term outcomes of the contestants on the TV show, “The Big Loser”. The contestants started out grossly overweight and competed to see who could lose the most weight. Indeed, they did lose weight, an average of 129 pounds, some with even more dramatic results. Unfortunately, that’s not the end of the story. As it turns out, most of the contestants regained most or all of the weight that they lost, an average of 70 percent regained.

This has been the result of most of the scientific studies of weight loss. Dieters struggle to lose weight, but even those who are successful eventually see that weight regained. It appears that the body has a “set point”, a weight that it will fight to maintain. The level of the “set point” seems to be determined by genes and by life experience. For example, babies who are overfed will become obese setting up the likelihood that they will be obese throughout their lives. One comes into this world with a “set point”, but eating the wrong foods, eating too much, lack of exercise or stress can modify it. If one gains significant weight, the “set point” will be modified up, making it very difficult to take the excess weight off.

When one lowers weight below that point, the body interprets it as starvation, an emergency, and puts into effect a series of compensatory mechanisms to move the weight back up. First it slows down a person’s metabolism so that one burns as few as 500 calories a day, a level that is almost unsustainable by dieting. In addition, the body releases a series of hormones that increase hunger and make eating feel more rewarding. So, a person who is dieting must have tremendous will power and/or do a prodigious amount of exercise to take the weight off, levels that rarely can be sustained long term. Hence, the often seen yo-yoing between weight loss and weight gain.

Worse yet, according to Sandra Aamodt, a neuroscientist writing for the New York Times, dieting seems to predispose to weight gain. To quote her, “Long-term studies show that dieters are more likely than non-dieters to become obese over the next one to fifteen years. That is true among men and women, across ethnic groups, from childhood to middle age. The effect is strongest in those who started in the normal weight range, a group that includes almost half of the female dieters in the United States.” Without going into detail, there are several studies that indicate this relationship of dieting leading to long-term weight gain is causal.

Why would that be so?  According to Dr. Aamodt, dieting is stressful, and stress is one of the factors that lead to weight gain. Weight anxiety and dieting also predict later binge eating as well as weight gain. A study showed that teenage girls who dieted frequently were twelve times more likely than non-dieters to binge eat two years later. All in all, the evidence that dieting produces beneficial results, either in long-term weight loss or in health, is very sparse. I believe the evidence that dieting is beneficial for seniors is particularly scarce.  However, anecdotally, as a physician, I believe that some who start out obese, improve their blood pressure and control of their blood sugar by losing modest amounts of weight.

There are reasons why obesity is so common in Americans besides stress.  Many people have poor eating habits. Americans, in particular, eat large portions of food governed by what we are served rather than by a feeling of fullness. We are told not to leave food on our plates. We eat the wrong foods, sweet desserts, sugary drinks, junk food and starchy food. We are subject to the pervasive influence of marketing about food. It starts in childhood when kids see TV adds pushing McDonalds’ Big Macs, sugary cereals or fatty foods like nachos, and overweight kids often lead to overweight adults. Once the pattern is set, it tends to reinforce itself.

There are many reasons why people decide to diet. It is often to improve one’s body image, since obesity is viewed by many as self indulgent and unattractive. It might be a way of reducing stress on joints and muscles such as knees and hips or of lowering cholesterol, blood pressure or the propensity for Type 2 diabetes. Also, someone who is severely obese is in real danger of a wide variety of health side effects. The problem is that rapid weight loss is often followed by weight gain as the body fights to maintain its “set point.” Is there any way of changing or modifying the “set point”? That’s not clear. There aren’t good studies to prove that any method works long term.

So, are there any recommendations for people who are overweight? Yes.

1. Set a clear goal of how much you intend to lose, so that you have a target.

2, Don’t lose weight by crash dieting. If you take weight off fast, it’s likely to be gained back fast as the body adjusts to prevent weight loss. It is recommended that you slowly take the weight off, a pound or two per week, to about 10% of your desired weight loss and then stop and maintain. So if you want to lose 30 pounds, you try taking off 3 pounds and then try to maintain the new weight for a month or two. This is less of a challenge too your set point and gives it time to adjust. Then take off another 10 percent. This slow and steady approach requires more patience, but it builds the habits that are necessary to maintain your new weight.

3. Obviously, watch what you eat. Avoiding or minimizing very sweet, starchy and fatty foods is important. Eat more lean protein, salads and vegetables that tend to produce more filling meals and reduce hunger. The problem is not that people don’t know what to eat and avoid, but don’t consistently do it. Since all of us are tempted by “forbidden foods”, take a bite and then stop. If you really take the time to taste and savor the bite, it is surprising how satisfying that can be.

4. Eat at regular times if possible. Don’t skip meals and get so famished that you can’t control what you eat.

5. Eat slower. Gobbling down your food doesn’t give time for your body to register fullness. Stopping when you start to be full is more important than finishing your plate.

6. Exercise, in whatever forms you enjoy. Exercise alone won’t cause you to lose weight, but burning more calories helps to make the needed dietary restriction more moderate. It also reduces abdominal fat, which is associated with health problems.

To date this is the best information available. There is always the desire to find a quick painless way to do dieting, and everyone is aware of the various fad diets. However, following these principles seems more likely to build the habits necessary to prevent long term weight gain, if not loss.

The Gifts of Aging

I recently attended a sad event, the funeral of a friend. The theme of many discussions with friends at the funeral was the number of funerals that we had attended recently. It seemed as if we were all losing friends at an ever-increasing rate, and we probably are. It is one of the realities of growing old, and one of the common topics that older people discuss along with slowing down, physical ailments, doctors we’ve seen and things that we can’t do any more. Aging is difficult, and conversations about it often dwell on the things that are sad. And yet, research shows that one’s 60s and 70s are among the happiest times of adult life. In surveys, people in their 20s and 30s are usually focused finding a place in the world and don’t have time to think about happiness. The 40s and 50s tend to be a nadir of happiness, coping with work, aging parents and the almost inevitable question of whether one’s career choice and sense of purpose measure up to what one hoped. Older people tended to be more satisfied with their lives.

There are many gifts that come with aging, unfortunately not for everyone but for most. What gifts? It is easy to look around and see bodies stooped by aging, slowed responses, chronic illnesses, preoccupation with bodily functions that were previously automatic and to question whether there can be anything good. We are slowly or quickly slipping towards our demise, and death of friends remind us of that. But there is much to appreciate. It takes focusing on the gifts of everyday life rather than the inevitable end game when things are likely to be sad. It is a human tendency to pay attention to negative emotions rather than the positive ones. It is likely consistent with a brain that puts a higher priority on things that may hurt us in the future. Someone has said that bad news is like Velcro; it tends to stick in our minds. Whereas, positive experiences are like Teflon; they slip away.

So if I look at my own life, what have been some of the positives aspects to growing old?

The gift of time. My time is largely my own, and I can choose how I want to fill it. I, like everyone, has obligations, but for the first time in my life, I have discretionary time, which I can use to do things that I like or that I find meaningful.   So I write a blog, spend time out of doors, tutor in a grade school, travel and do other things. Each chooses differently. Often, the biggest obstacles are the willingness to leave the structure that we have always known and to try new things, to take risks. New things can be professional or personal.

Appreciating the ordinary. How often do we forget to be grateful for the day-to-day things that make life more joyful? I admit this is something that I neglect. Rushing through life, I either don’t notice or don’t register a satisfying interaction, or a beautiful day or the blooming of wild flowers. Remembering the Velcro/Teflon analogy, at the end of the day, we will remember failings and unpleasant things, and tend to forget the good. An excellent practice is to make a list at the end of the day of what you are grateful for that day.

More time and attention for loved ones, whether they are friends or family. I think that as we age, we become more appreciative of the people that we are closest to and are willing to forgo seeing people that are less meaningful to us. I have become more impatient with cocktail parties or gatherings where the conversation tends to be about the superficial and more appreciative of emotionally honesty. Grandchildren are a major source of pleasure for most people. I’ve been amazed seeing friends whom I didn’t believe had a vulnerable emotion in their body, go gah-gah over their grandchildren.

A willingness to say what is true for you. For much of my life, my priority was “to fit in”, so I avoided conflicting viewpoints, or I blurted them out in anger. Age has made me less patient with conversations that are “make nice”, holding back what I believe. However, I still have to become better at expressing my opinion in a way that isn’t unkind and leaves space for the other person.   It is a skill to be able to express what we really feel or believe in a way that doesn’t hurt or attack others. To do otherwise just makes you a curmudgeon.

Giving back. Serving the community, giving back to society some of what we have gained is one of the most satisfying of activities. Of course, it is possible to do this at any age, but the flexibility that comes from not having a crushing work load and relative freedom from child rearing duties makes it more possible as we age and retire. Having meaning in ones life is a tonic for unhappiness, and giving back is one way to find that meaning.

Perspective and maybe wisdom I am amazed by how much less seriously I take things that used to be upsetting or a source of anger.   By this point in life, most people develop some perspective about what is really important.  I think when one has lived long enough, it is easier to have some sense of what turns out to really matter. I find it a lot more pleasant to ignore many upsets. It makes life a lot more peaceful not to be so emotionally triggered. I think that perspective plus experience lead to wisdom, the ability to make better choices and decisions. It’s something to which we all aspire, and hopefully it comes before dementia sets in.

These to me are some of the blessings of aging. On my better days, I can pay attention to what is happening now rather than what may happen in the future. Live in the moment.

“When Breath Becomes Air”, A Book Review

This book is a memoir written by Dr. Paul Kalanithi, a neurosurgeon in training at Stanford Medical School. Dr. Kalanithi was in the final stages of his long, arduous training in Neurosurgery when he discovered that he had metastatic lung cancer, which was to cause his untimely death. It is difficult to imagine that a book about someone’s death from cancer could be inspiring to read, but this book is simply stunning, full of pathos, wisdom and a fierce human spirit. Dr. Kalanithi is a gifted writer who has the ability to capture the subtle challenges of his own development as a physician as well as his journey from his promise and ambition to his death.

Dr. Kalanithi begins his story with an announcement of his fatal disease presaged by months of back pain and weight loss and then finally an x-ray revealing the advanced stage of his cancer. He is the son of two South Indian parents, his father a physician and his mother, a well educated woman who overcomes the limitations of finding herself in Kingman, Arizona and is determined to ensure her sons of a good education.

As an undergraduate at Stanford, he was enamored with the English language and philosophy with no intention of becoming a physician. He consider a career as a writer or a philosophy academic. Like many coming-of-age college students, he was fascinated by questions of who we are as humans and what is the meaning of our lives. However, he looked at these questions more deeply than most. At some point, he concludes that a career in medicine will actually bring him closer to the issues of life, death and purpose than simply studying them from afar, and he elects to attend medical school.

Having lived some of the experiences that he describes in the long journey from medical student to someone who embodies the skills and the caring of a capable physician, I found his descriptions crystalline. He describes his feelings on encountering and dissecting a cadaver, a rite of passage in medical school. To quote,

“You would think that the first time you cut up a dead person, you’d feel a bit funny about it. Strangely though, every thing feels normal…..” “Cadaver dissection is a medical rite of passage, trespassing on the sacrosanct, engendering a legion of feelings: from revulsion, exhilaration, nausea, frustration and awe to, as time passes, the mere tedium of academic exercise.”

To me, this describes the unreality of the event, the sense that you are witness to something that you are not prepared for, yet knowing that it is a necessary step in your development as a physician. So too is the imperative of technical competency for which endless hours are spent in residency to achieve. But this competence comes at a price, the temptation to see “cases” rather than people, to focus getting the job done rather than developing the empathy to help people through their medical journey.

Dr. Kalanithi: “I had started this career, in part, to pursue death, to grasp it, uncloak it, and see it eye-to eye, unblinking. Neurosurgery attracted me as much for its intertwining of brain and consciousness as for its intertwining of life and death. I had thought that a life spent in the space between the two would grant me not merely a stage for compassionate action, but an elevation of my own being, getting as far away from petty materialism, from self-important trivia, getting right there, to the heart of the matter, to truly life-and-death decisions and struggles… surely a kind of transcendence would be found there”?

“But in residency, something else was gradually unfolding. In the midst of this endless barrage of head injuries, I began to suspect that being so close to the fiery light of such moments only blinded me to their nature, like trying to learn astronomy by staring directly at the sun. I was not yet with patients in their pivotal moments, I was merely at those pivotal moments. I observed a lot of suffering; worse, I became inured to it.”

Amidst, interesting descriptions of neurosurgery and his training, Dr. Kalanithi describes his gradual transformation into a fully present physician who, with kindness, must consider the patient’s fears and wishes, realistic and unrealistic expectations and recommend a course of treatment, while maintaining the possibility of hope.

The books third section describes his confrontation with his own illness, his initial response to treatment and his inevitable decline and death. While not pleasant to contemplate, he experiences it with such trenchant observations and human vulnerability, that they are described in a manner providing a model for all people going through the ultimate challenge, the end of life.

Needless to say, I would recommend this book to anyone. Paul Kalanithi was a dedicated and wise neurosurgeon, a gifted writer and an exceptional human being.

 

Parkinson’s Disease From Inside Out

This posting is a personal look at my experiences with a chronic brain disease — Parkinson’s Disease (PD) — in contrast to the way that the experience looks to others. We view problems that affect the brain with particular dread, because we see the brain as the determinative of who we are as people. Diseases may seem fearful or tragic to those who don’t have them, but the experience may be quite different for the person with the problem. Friends often aren’t comfortable asking about the details, and the person with the problem may not feel comfortable volunteering them spontaneously. As a result, an important part of someone’s interactions can be governed by assumptions. In the following paragraphs are some of my experiences with PD. Neurologic problems are extremely common in older people whether it be PD, like mine, stroke, cancer or, most commonly, some degree of cognitive problem including dementia.

My story begins in 2008-09. For some time, I had noticed a deterioration of my handwriting, which I attributed to the kind of tremor and unsteadiness that lots of older people get when they try to do fine work   I also noticed trouble buttoning my buttons. In fact, I asked a friend of mine, a neurosurgeon, if he noticed any similar difficulty with aging. He laughed that his terrible handwriting had gotten worse, and passed it off as normal aging. In the latter part of 2008, I began to notice chronic fatigue and over the next few months, the fatigue worsened, and I began to lose weight. My immediate concern was some hidden form of cancer, and in early 2009, I saw my internist, who, although he didn’t say it, had the same concern. He began ordering tests, at first a panel of blood tests and a chest x-ray, and eventually a CT scan of the abdomen. All of them were normal, and we were stumped.

On a chance, I mentioned the trouble that I had over two years, deteriorating handwriting and poorer coordination of my right hand.   He referred me to a neurologist, who within 10 minutes told me that I had PD. Among other things, he could see the stiffness in my movements and noticed that I didn’t swing my arms when I walked. He referred me to a Parkinson’s specialist, who confirmed the diagnosis and started me on one of the milder drugs for the disease.   It helped. My symptoms were very mild at the time. No one else noticed them. I could do virtually everything that I used to do, and my fatigue lessened. I was surprisingly incurious about the disease. I had, of course, learned a little about PD in medical school, the rhythmic tremor (which I didn’t have), the stiffness, rigidity, lack of facial expression, and the tiny shuffling steps. I didn’t want to know any more. As long as I was functioning well, I wasn’t interested in knowing more details about where this train was going.

Although tremor is the best-known symptom of PD, its hallmark is what is called bradykinesia, a slowing of movement and stiffness of muscles that eventually can result in immobility. PD is due to death of nerve cells that produce the neurotransmitter Dopamine, particularly in a midbrain collection of deeply pigmented neurons called the Substantia Nigra (black substance). This lack of Dopamine results in the typical symptoms of PD, tremor, bradykinesia, rigidity and difficulty with balance. As PD has become better understood, it is clear that the disease causes much broader symptoms including difficulty with speech, voice, swallowing, constipation, weakness, double vision and in some dementia. It is a disease that is readily treated with medication early on, but which progresses despite treatment with medication eventually becoming less effective.

My reaction to being told I have PD was very consistent with the well-known process of grieving any loss. The first stage for me was denial. I was told that I had PD. I knew what it was supposed to do, but I felt almost no emotion. The long-term consequences were abstract to me. My symptoms were mild; I could do almost anything that I used to do, and it wasn’t visible to others. I didn’t speak about it to friends. The few times that I did, the friend would look like I just said I had untreatable cancer and say something like, “Oh my god; I’m so sorry,” which I wasn’t ready for at that point. At times, I questioned whether I needed the Dopamine medication or even whether the diagnosis was correct. Maybe I would be the one where it didn’t progress or would spontaneously go away. When I saw someone with severe PD, I might be briefly shaken, but then put it out of my mind.

After 3-4 years, it became evident that the disease was slowly progressing, and the diagnosis was undeniable. I threw myself into an exercise program in the hope that through muscle strength, it could be overcome. I read that exercise, particularly that which involves movement, like biking, swimming, walking or tai chi, is important because it does help loosen the muscles, but I couldn’t exercise my way out of the disease. What started as a little stiffness, at times has become the sensation that my muscles are in glue and that any sustained physical effort is very hard. My voice has become soft; I tend to walk with a stoop and my face transmits less expression unless I pay attention to it. When I get up from a chair, I have to take several shuffling steps to get my balance and my legs moving. With PD, one’s muscles don’t automatically cooperate as they used to. It is said that you are damned to a conscious life, because you need to concentrate on everything you are doing and how to do it.

I am aware of what advanced PD looks like to others. Moving slowly with stuttering steps, a trembling hand and a blank stare showing no emotion makes it appear that the person is not really there. I am not at that point, but if I live long enough I probably will be. Similar to someone who has had a severe stroke, outside impressions may be worse than the reality. The disability is real, but most PD patients are mentally intact despite responding more slowly. Most PD patients are quite ‘with it’ and anxious to be engaged socially.

PD seems to hold a particular place in people’s minds as a terrible progressive disease from which there is no recovery. True as that is, most people with Parkinson’s live long and productive lives, albeit with handicaps that must be addressed. But as with any chronic disease, one manages the best one can and usually remains the same person inside of all of the daunting, outward physical signs. It is important to patients like me that people around us realize that, or one can become socially isolated.

Eventually, as with any chronic disease, I have to plan for the future. Planning for later is of course wise, but it confronts me with a reality that I would just as soon forget. As the complications worsen, I have to deal with more limitations. As much as the limitations may look terrible to someone on the outside, one learns to live within them and find new sources of satisfaction. It may sound Pollyannaish, but in some ways, it is a good time to grow internally, a time to appreciate life in a deeper way, to take one day at a time and to appreciate the companionship of people I care about. We don’t get to choose our diseases, and the worst curse is to withdraw and become isolated because your illness makes people anxious.