About Albert

I am a 75 year old retired physician. My life now includes various volunteer activities, out of doors activities like hiking and biking, travel and photography. I, like others my age, am trying to make sense of the physical and emotional changes that come with growing older. Rather than trying to avoid or ignore the changes, I chose to be active in exploring them, and I invite others to join me on my adventure.

Dying

Aging can be a constant process of contraction, contracting function, contracting friendships and readjustment to new realities. It can also be a time of renewed interests and exploration. One of the realities to which we must adjust is the prospect of dying. Dying is not so much an event but a process which we experience throughout our lives, but it is much more evident as we age. It is unavoidable, and we must come to terms with it. Most of the time, we go through life as if we had infinite time, waiting for good things to happen and hoping that bad things won’t. If misfortune befalls us we curse our bad luck and hope that it will go away soon. When life pleases us, we hope it will go on forever. But life is constantly changing. Neither the good nor the bad last forever. However, that we will die is a constant.

How can we come to terms with dying, the ending of our existence on earth? Obviously there is no one answer. From different religions and different belief systems there are many different views about what happens when we die, from our “going to a better place” to being resurrected in a new form to simply ceasing to exist. Many of us say we simply don’t know. However I view death, its prospect makes me more serious about life. Suppose you could live forever; there would be no urgency to living, nothing to make us appreciate the wonder of life.   The inevitability of death makes me want to use the time that I have to the fullest and to appreciate the people and the things that are meaningful.

To paraphrase Frank Ostaseski, a Zen master and counsellor to the dying, the only way to prepare for death is to live life to its fullest. “Don’t wait”. Whatever you can do or think you can, begin it. Death will come when it does in whatever form it takes. Rather than worry about how I will die, I want to focus on how I live. Some denial, probably, but it encourages me to make good use of the time that I have.

I find myself much less attached to the accomplishments of the past and interested in how I can contribute to the present, not necessarily through great or notable deeds, but in a more personal way.

For me living life to the fullest looks much more like engaging genuinely with people that I care about. We spend so much of our life living out roles that we created when we were young as ways that we thought would get us the approval and affection of others. We learn from early experiences that certain behaviors will please our parents or teachers, and that a certain persona is necessary literally to survive the circumstances we live in.   At the extreme, a young man growing up in a neighborhood where there are gangs will learn that having a tough exterior is the only way to keep from being abused or even killed.

So as I age the question is how do I want to live, really. I learned as the oldest son of an immigrant father that I had neither a father nor an older sibling to introduce me to the things that seemed so important at the time, sports and fitting in socially. My friends played ball with their fathers, went on camping and fishing trips and seemed confident about their place in the world. I decidedly didn’t. I felt like an outsider, something that has stuck with me all of my life. For a while, I hung out with the dropouts because I wasn’t part of the “in crowd”.   When I tried to participate in sports, I had some notable failures that made me gun shy about trying again. I saw myself as “other”, formal and careful about what I said or did.

At some point, I found a place where I could be successful. By being a good student, I opened a new set of possibilities, particularly as I reached that point in high school where preparing for the future became important. I found that being “smart”, competent, predictable (at least on the surface) and being knowledgeable were traits that others valued, and they developed as my adult persona was formed. These are not bad traits. They contributed to many of the successes in my life, but they didn’t encourage a fuller exploration of what was possible in my life. As most people do, I conformed to a role that was imbedded from my childhood and reduced the opportunity for growth and limited the ways in which I could engage with other people.

I have had a good life. I have been fortunate, and I’ve had a reasonable amount of success. At eighty I’m not going to fundamentally change my stripes, but I hope to get freer from the limiting myths about myself, that I have to be careful and hold myself at a distance from others, that I have fundamental shortcomings, ways in which I feel that I am flawed, places that I don’t go. What I found is that when I strip that away the self-protective armor, what’s left at the bottom is a genuine desire to engage fully with people,  to appreciate who they are and to appreciate the every day beauty that surrounds me. I have lost many of my physical capabilities, which makes what I can do all the sweeter. Rather than waiting anxiously for the end, I would like to engage fully with the present. I don’t know what the final days will bring, but while I have days, I want to use them well, even if it is just in little ways.

It is also important to bring closure to the scars of the past, to put to rest the resentments that I have had and to make amends with those that I have hurt, in other words, while living as fully as I can, to close the books on the past. This isn’t always easy to do. Some of the key people are dead or estranged. For example, I was angry at my father for not participating more in my life and for being an immigrant, not like my friends’ fathers. However, what I’ve come to realize is that he was imperfect like every one else’s father, and that he gave me a great deal of love and encouragement. If I take an inventory of my life, there are many hurts, resentments and regrets that I have. One cannot settle them on one’s death-bed; it is unlikely that there will be time or capacity to do so. “Don’t wait.”

So for me the recognition that I am dying is an impetus to live life more fully and to do things that are new and to explore relationships more fully and settle with the past. That is plenty to keep me busy.

Falling Into Grace Part 2

Falling Into Grace, Part 2

Rehab, Rebuilding Lives: As an acute medicine doctor, I realize that I haven’t had a clue as to what went on at a rehabilitation center. If you had asked me before to describe the role of physiatry, I would’ve been at a loss to do so. Rehabilitation medicine is truly an example of some professionals’ dedication and devotion to helping others reclaim their lives. It is a noble and, I believe, a satisfying, profession. As an acute care physician, I focused on dealing with short-term episodes of care, leaving the patient to manage most things on their own. However, when illnesses are devastating to one’s functioning, that doesn’t suffice. When I entered the hospital, I was unable to do virtually anything. Eating, moving, bodily functions were all things that had to be cared for by other people. I had to be re-taught how to do most things including the simple things that most of us take for granted. The incredible skills of the rehabilitation specialists are what has carried me through. Their kindness, devotion, encouragement and perseverance are an expression of one human being’s love and devotion for others. It requires skill, great patience, optimism and deep caring.

The Invisible People: As skilled as the neurosurgeon and rehabilitation professionals were, the unseen, anonymous nurses aides and technicians were also essential to my recovery. In this facility, many of them are people who grew up in poverty and/or were refugees from other countries who were working to become a part of the national economy. They often do the dirty, unglamorous job of taking care of the basic necessities of people. I’ve met people who grew-up poor in the United States, boat people from Vietnam, people who immigrated from the Philippines, Ethiopia, India, Indonesia – all of them have a similar story. They wanted to start up the economic ladder from  very modest positions, and, almost all of them are working full-time jobs and going to school at night, or on weekends, to better themselves and create more opportunity. Several of them have been on truly heroic journeys. One I recall in particular is a nurse who was born in Vietnam and whose family escaped by setting out to sea in a small open boat, his family trusting that they would find some form of rescue. They were fortunate in finding a barge that picked them up and took them to an America military ship. They were taken first to the Philippines and then to Guam where they lived in a refugee camp for some number of months. They were then transferred to Arkansas and eventually found a placement in St. Louis. The young person then did odd jobs and construction to help earn money for the family. Finally, he managed to attend nursing school part time and eventually get his nursing degree and began to work. His story is just one of many that are similar. Many of them work on the margin with families to support and kids to take care of. I call them invisible people, because most of us hardly register that they are there, but I will tell you that the hospital wouldn’t operate without them.

This is a story that has a long way to go, but I will forever be grateful to the people, professionals, family and friends who have supported me through this odyssey.

Falling Into Grace

I am an 80-year-old retired physician, and I recently had a serious fall, fracturing my neck. In the long course of my recovery, I am humbled by how much I didn’t know about recovery from serious injury and about the people who make that possible. This has been a difficult period of time, but in many ways it has been transformative, teaching me about myself and about caring.

This adventure started when I was walking up a hill near our summer home in the Sierra Foothills, and as I approached the top, I felt my heart racing and pounding. Feeling light headed. I stopped, waited for it to pass, and then tried to walk the rest of the way up the hill. The last thing I remember is that I was turning to try and sit down. I apparently passed out, fell backward and hit my neck on the edge of a concrete foundation. When I came to, I attempted to get up and realized that I couldn’t move my arms or legs. Fortunately, I heard my wife who was in the house near me, and I called out to her. As I lay there with my face in the dirt, waiting for her to call 911, I realized that I had encountered my worst nightmare: being completely paralyzed and totally helpless…

Fortunately, as the minutes went by, I could feel some sensations returning to my legs, and over the course of the day, my motor strength mostly returned to my legs but not my arms. The medics, of course, arrived, strapped me onto a board, and transported me by helicopter to a nearby trauma center. It was evident from the CT scan and MRI that my neck had been severely damaged, with one disc torn in half and fractures at a couple of levels (C4, C5).

Then ensued a confusing two days. Somebody at the hospital recommended that I be transferred to a spinal rehabilitation center in the Bay Area, near my home, and I was transferred by ambulance – a two-hour trip. There was confusion about my physical status. The rehab center attempted to start rehabilitation exercises almost immediately after I arrived and quickly discovered that I was unable to function that well. They also noticed that I was in atrial fibrillation, probably the cause of my passing out and subsequent fall. I was very fortunate to find a superb neurosurgeon, who told me that I needed to be operated on immediately to decompress the spinal cord and rebuild the damaged vertebrae. The fourth cervical vertebrae was virtually shattered, and the ligament between other vertebrae badly torn. After four days of medical stabilization, I was operated on and had my cervical spine rebuilt. I am now almost three weeks post surgery, and, slowly beginning to see some return of the function, and the surgeon and I have hopes for a reasonable recovery of the function of my arms. This has been a cataclysmic experience from which I’ve learned many things some of which follow:

  1. Bad Things Do Happen to Good People: Life is more a game of risk then we like to acknowledge. Some of us choose to play the game like a meteor, lighting the sky briefly and then flaming out. Others take a more measured approach, but none of us can avoid the inherent risk that we live with every day. Of course, I’ve known that theoretically, but it takes a lesson like this to drive it home. I have been on the relatively cautious side, certainly taking some risks but generally choosing to preserve my body.

Generally, when we hear about some bad personal event, we look for some cause to         explain why a bad event happened to that person. We want to wall off the possibility           that it can happen to us. We look for something that we can use to explain why the           event occurred. “He was on a horse that threw him.” “He dived into shallow water.”             “He was driving too fast in a car.” “He was playing football” In truth, life is to some                extent a game of chance and one of the things we live with is the randomness of               events. It was not my fault that a cardiac arrhythmia occurred when I was walking up         a hill that I had walked up dozens of times before. Why does someone get hit by                 lightning or die of influenza when they are healthy and going about their days? No               matter how we may try, It’s impossible to protect yourself from everything. And we             live  by the grace of God or fate or whatever we want to call it.

  1. Health care is about caring : More than we realize in our techno-centric medical world, loving and supportive people are essential to the healing process. In the past, when people talked about love being the unique and positive force in our lives, I tended to react by thinking of it as some ethereal vapor that didn’t sound quite real to me or certainly not have the importance of “good medical care”. This experience has been transformative for me. I’ve been bathed in the love, concern, and caring of family and friends and the dedicated staff of a wonderful hospital. Of course they’ve taken care of the mechanical things that I needed. But more than that, they’ve displayed a commitment to my getting better. I have had many days of fatigue, discouragement and uncertainty about whether I could overcome my tremendous injury. The progress has been amazingly slow, literally two steps forward and one step back. My family, friends and the wonderful hospital staff at times have patiently willed me to continue. My wife has been unstinting in her attention. They have literally taken care of my most basic needs and maintained an optimism that I could return home to a reasonably normal life. Their love has been a living presence for me. You might object to my calling this love, but I can think of no other way to describe the warmth and caring that goes beyond ordinary duty.  The love of one person for another is what holds us together as a society. By love I mean empathy, compassion, and the willingness to listen to and devote oneself to the good of others. It’s what all of us want to experience but we get distracted by material things – money, accomplishment, prestige that seem more important at the time, but these are just substitutes for the love that we really wish for. It’s too bad that I had to sustain this injury to fully realize that. I have been good at living a competent and responsible life, but I have not been as good at giving and receiving the love of others.

I’ll discuss more lessons in a subsequent blog.

How We Manage Dying – I

It is challenging to write about death, but a blog on aging would not be complete without discussing it. I do not claim to be an expert on death and dying, and the following thoughts are from a composite of many people’s ideas including my own.

When I started medical school at age 21, I had virtually no experience with death. I had never been to a funeral or seen a dead person. In retrospect, it seems shocking, but death is so sanitized in this country, it is kept largely out of sight. My grandfather had died, but he lived 3,000 miles away.

In my first year anatomy class, I helped to dissect a cadaver, but this embalmed, sinewy being hardly seemed to have ever been alive.   Our focus was on learning the muscles, organs and bones. There wasn’t much thought given to whom this person was.

My first direct encounter with the death was on a Saturday morning when as an intern, (first training year after medical school) I admitted a lady to the hospital with severe congestive heart failure. She was terribly sick with extreme shortness of breath, severe edema in both legs and great anxiety from her breathlessness. Congestive heart failure is the result of damage to the heart muscle from any cause. The weakened muscle does not adequately pump the blood forward, and it backs up into the lungs and causes edema elsewhere. The patient was in severe distress, and since my supervising resident had gone home for the weekend, I called the senior resident on-call to come and help me decide what to do. Nowadays, there are powerful diuretics that can help the patient’s kidneys drain the excess fluid from her body and allow her heart to compensate, but the diuretics that were available at the time were relatively weak and ineffective to treat an emergency.

I was delighted with the resident who answered the call. He was someone that I looked up to and admired. He assessed the patient and thought that there was little that could be done other than to give her morphine which would allay her anxiety and sometimes improves congestive heart failure, potentially easing her breathing, Then he raced off to see other patients who needed him saying that I should do the best that I could. I was dismayed having been left on my own with this very sick patient. I gave her such diuretics as we had and administered morphine in a modest dose, which didn’t touch her symptoms. So, I gave her more morphine, hoping to find a dose that would make her more comfortable. After her third dose of morphine, her breathing slowed, much to her and my relief, but then she stopped breathing and died.

It was a shocking introduction to dying, and for a long time, I carried the belief that I was the cause of it, either because of my lack of knowledge of what else to do or because of giving too much morphine. After many years, I realized that what I did was an act of empathy. The lady was on the cusp of dying when she came to the hospital, and, in the absence of an effective treatment, what I did was to relieve her distress. At that time, CPR had recently come into existence, and virtually no one in a hospital was allowed to die without going through CPR as his/her terminal event. Trainees were taught that this was standard practice. Even though it was usually unsuccessful, it was done routinely. The health care culture operated on the principle that there is always something else that can be done. Death is a defeat.

In the mid 1960s, a different approach to the treatment of dying patients began to emerge; the concept of hospice was introduced in the United States. It was originated in England by a physician, Dame Cecily Saunders, and in 1963, she came to the US and started the first hospice unit in this country affiliated with Yale Medical School. In 1969, Elizabeth Kubler-Ross published her book “On Death and Dying”, which became a best seller, and in it she made a plea for allowing people die at home. She also testified to Congress that…

“We live in a very particular death-denying society.  We isolate both the dying and the old, and it serves a purpose.  They are reminders of our own mortality.  We should not institutionalize people.  We can give families more help with home care and visiting nurses, and so give the families and the patients the spiritual, emotional, and financial help in order to facilitate the final care at home.”

In 1979, congress funded an experiment with 26 hospices. Since then, the hospice movement has gradually spread throughout the country. Hospice operates on the principle that as one nears the end of life that the focus should shift from curative medicine to supportive care and comfort, including pain management, nutrition, counseling and facilitating the dying person’s last wishes. It has proven to be cost-effective and more satisfying for patients and family. To enter a hospice program and have it paid for by Medicare, one needs to discontinue curative treatments like cancer chemotherapy and have a life expectancy of six months or less.

Palliative care, a specialty that has grown quickly in the last decade, has a similar focus on comfort and quality of life improvement for patients with severe chronic diseases, but it allows simultaneous disease treatment and doesn’t have any time requirement.

So slowly the practice of medicine has incorporated practices and expertise that can make the end of life more comfortable and appropriate. Pain can almost always be managed, and the dying patient is generally more comfortable in familiar surroundings. Surveys indicate that up to 80% of people say they would prefer to die at home. So from my days as a trainee 50 years ago to now, we are slowly starting to realize as a society that there is a time when persisting with medical treatment really doesn’t do patients a service. We can’t escape death but we can make the time before we die more manageable.

Stress and Illness

It is a well-known phenomenon. A grieving wife or husband has a cardiac event and dies suddenly soon after the death of a spouse. We attribute this to stress as we do other physical breakdowns that occur at times of high pressure. Deaths are more common around major holidays or on the anniversary of a tragic event. How does that happen? Is it real? The facts are incontrovertible. We say, “He/she died of a broken heart,” and attribute it to stress.

There is increasing evidence that how we live our life is directly related to our health and longevity. Eating well, getting enough sleep, exercising regularly and managing stress are being shown in study after study to have important effects. The effects and mechanisms of stress have been more clearly elucidated in a recent article in the journal Lancet and summarized in the April issue of the Harvard Heart Letter. The study looks at the means by which stress brings about physical changes to our bodies.

The amygdala is an almond-sized area in the center of the brain that mediates our responses to perceived threats. The amygdala stores our emotionally charged experiences from the past and reacts instantaneously to events or situations that resemble them. It is this location in the brain that triggers an immediate response to perceived threats, including the “fright or flight” reaction. The amygdala can’t distinguish whether the threat is real of not, just that it looks like something it remembers to be threatening. When that happens, the amygdala lights up on brain scans indicating that it is actively processing the information and sending signals to other parts of the body.

Two areas that receive these signals are the hypothalamus and the pituitary gland. The hypothalamus signals one area of the adrenal glands to immediately secrete adrenalin, and the pituitary signals another area of the adrenal to secrete       cortisone. The adrenaline acts immediately, speeding up one’s heart, redirecting blood flow to the muscles and brain, and it triggers heightened awareness, dry mouth, increased sweating and it raises the blood sugar, all events that we associate with the “fight or flight” reaction. The body gears up for battle or to escape the threat. If the threat becomes longstanding, as with chronic stress, the secretion of cortisone increases over time, which has a number of deleterious side effects, like high blood pressure, stomach ulcers and malfunction of the immune system.

It has been shown in animals that chronic stress activates a third area of the body, the bone marrow. Stress activates the bone marrow to make and release white cells, infection-fighting cells. White cells are associated with inflammation, and inflammation encourages the buildup of fatty deposits in the walls of arteries, including the coronary arteries. So chronic stress in animals triggers a process that heightens the risk of coronary blockage and heart attacks.

It has not been known whether this same mechanism occurs in humans until the recent Harvard-Lancet study. The study, through the use of PET/CT scans of the brain, looked at the activity of the amygdala, the bone marrow and the presence of inflammation in the arteries and found that heightened activity in the amygdala was associated increased activity of the bone marrow, inflammation in the arteries and a higher risk of heart attack or other cardiac events. These findings confirm that stress has real physical consequences and helps to explain the mechanism. The amygdala helps people to sense and evaluate external stress and to mount an internal physiologic response. However, this response can be dysfunctional in people who are subject to sudden severe or prolonged stress or people who have higher levels of amygdala activity. How we manage our lives and what we feel and think has real consequences to our health.

What to do? Well, there is no glib easy answer. Ideally, if it is possible to reduce the stress by modifying your circumstances, that is the best answer, but very often this is not possible, at least not in the short run. Other methods of reducing stress are exercise, yoga and meditation. Walking, running, biking and swimming are all potentially good stress reducers. It depends on the person and what relaxes him or her. For some people, just getting out of doors for a period of time is enough to reduce the stress. It is highly recommended that you break up a long day with one or two short bits of activity. Even 15 minutes of walking or quiet meditation can lower body’s stress reaction.

Meditation has become a much more acceptable form of stress reduction. It was originally associated with certain religious practices, particularly Buddhism.   However, in the 1980s, Herbert Benson at Harvard Medical School discovered that by sitting quietly and narrowing your mental focus to a single thing (a sound [Om}, a word [peace}, or your breath) for 20-30 minutes each day that your physiology changes. Blood pressure lowers, muscles relax, and brain waves change from an alert pattern to a more relaxed state. It takes some practice to do this, and the alert mind tends to want to focus on the problems and thoughts of the day, but it can be learned with practice, and it has carryover effects to the whole day. There many classes that teach meditation, or as Benson called it, “the relaxation response”. The practice can also be called upon when facing a highly stressful circumstance. For example, I’ve had several MRIs in my life, and I have learned that when I feel claustrophobic to narrow my focus to my breath so that I can detach from the circumstances.

So in summary, stress has real effects on our physiology, potentially destructive effects if it goes on chronically. These effects are mediated through the brain, which activates hormones (adrenalin, cortisone) and inflammatory cells, which in turn negatively affect the blood flow to our heart and other organs. Learning means of managing stress is important to our health and longevity.

Falls In The Elderly

Injuries from falls are a significant hazard for older people, and often they are the precursor to significant decline in function. An NIH white paper on falls in the elderly had this to say about some of the consequences of falling:

Each year, more than 1.6 million older U.S. adults go to emergency departments for fall-related injuries. Among older adults, falls are the number one cause of fractures, hospital admissions for trauma, loss of independence, and injury deaths.

Fractures caused by falls can lead to hospital stays and disability. Most often, fall-related fractures are in the person’s hip, pelvis, spine, arm, hand, or ankle. Hip fractures are one of the most serious types of fall injury. They are a leading cause of injury and loss of independence, among older adults. Most healthy, independent older adults who are hospitalized for a broken hip are able to return home or live on their own after treatment and rehabilitation. Most of those who cannot return to independent living after such injuries had physical or mental disabilities before the fracture. Many of them will need long-term care.”

One-third of community dwelling elderly fall each year, and up to 60 percent of those residing in nursing homes fall each year. Falls account for over 90% of hip fractures, most of them occurring in people over 70. Falls are a marker of declining function and also the cause of declining function. People who fall have a greater functional loss, greater social and physical impairment, and a greater risk of institutionalization. Most falls occur in the home or in close proximity to it.

Over 50% of elderly who survive a hip fracture, are discharged to a nursing home and one half of those are still in the nursing home one year later. Falls are very serious contributor to physical decline in the elderly and are a significant cause of death.

There are many risk factors for falls. Some are the following:

Hazards in the environment particularly the home Muscle weakness and balance problems

Visual impairment

Vertigo

Medications (particularly anti-anxiety, sedative and anti-depressant)

Alcohol misuse

Poly-pharmacy (14% increase risk for every medication above 4 medications)

Confusion or cognitive impairment

Acute illness (such as pneumonia or urinary tract infections)

Neurologic disease (stroke, Parkinson’s disease or neuropathy)
Loss of consciousness for any reason.

Drop Attacks – Sudden collapse due to falling blood pressure, early stoke or heart problems such as arrhythmias.

It’s not unusual for more than one of these conditions to be operative in elderly individual, and a minority of people over 70 years do not have at least one.

Falls are obviously a serious threat to one’s health, mobility and independence. I have had two falls in the last year, probably contributed to by my Parkinson’s Disease. In one, I didn’t lift my foot high enough to clear a curb and fell on my left side. I was fortunate enough not to fracture anything, but I had prolonged pain from a muscle tear in my left hip. The other fall occurred when I was on a path and turned suddenly to look behind me, lost my balance and landed on my right side with much less in the way of injury. They were enough to make me pay attention when I am walking. No one whom I saw medically provided me with systematic counseling about fall prevention.

It is difficult to summarize what one should do to prevent falls. The list above is a brief summary of the factors to explore, but each of those categories has many subcategories for specific conditions. However, I believe that the primary factor that has to be overcome is mental. It is reluctance to admit that falls are a serious threat and to take action. I’ve watched my own procrastination in doing some of the things that obviously make sense. I now use a walking stick when I walk on an uneven surface, use a handrail when going up or down steps, exercise regularly for balance and strength and have started taking up carpets on which I could and have tripped, but I avoid using a cane which I probably should.

Here is a list of some of the common, general preventive measures for avoiding falls leaving aside treatment for specific diseases:

If you have fallen, talk to someone knowledgeable (doctor, physical or occupational therapist) about the specifics of your fall in order to focus your preventive efforts. If your fall involved loss of consciousness, this mandatory

  • Fall-proof your home.
    1. Keep small objects such as clutter, electrical cords or low furniture off the floor and out of walking paths.
    2. Throw rugs or small carpets should preferably be removed or have non-skid backing or non-skid mats. Use non-skid wax for hardwood floors.
    3. Stairs should be well lit and have handrails.
    4. Bathrooms should have grab bars in showers, tubs and by the toilet
    5. If you live in an environment where it freezes, be careful when stepping out of doors onto a deck or stairs, Sand or salt icy surfaces.
  • Exercise regularly. This should include exercises to improve balance as well as maintain muscle strength.
  • Be cautious about alcohol. Alcohol plus diminished inherent abilities can be a lethal combination.
  • Wear sensible shoes.
  • Avoid sedatives and tranquilizing medication that can alter your sense of consciousness. Work with your doctor to reduce the number of medications that you take. There is a 14 percent increase risk of falls for every additional medication above four. Be especially cautious with medication for blood pressure. These can cause of sudden drop in blood pressure when moving from sitting or lying to standing. Dehydration can cause the same phenomenon.
  • Have your vision checked regularly.
  • Be conscious of what you are doing. It is easy to do things suddenly assuming that your body will remain in balance while the reality is that you have lost the reflexes, strength or capacity to do so.

This is a quick tour of falls. Hopefully readers will better understand the potential seriousness of the problem and can avoid some of t he hazards discussed above.

Test post

This is a test posting to my subscribers.  The last posting, March 11 didn’t get distributed to my subscribers.   I think the problem has been fixed, but this is a test to see if it works now.

Another View of 80

A few weeks ago, I posted a blog that indicated some of my feelings about approaching my 80th birthday. Today I’ll share with you another person’s view of 80, that of Oliver Sacks, the neurologist and author.

Dr. Sacks writes, ” My father, who lived until 94, said that the 80s had been one of the most enjoyable decades of his life. He felt, as I begin to feel, not a shrinking but an enlargement of mental life in perspective. One has had a long experience of life, not only one’s own life, but others too. One has seen triumphs and tragedies, booms and busts, revolutions and wars, great achievements and deep ambiguities. One has seen grand theories rise, only to be toppled buy stubborn facts. One is more conscious of transience and, perhaps of beauty. At 80, one can take a long view and have a vivid, lived sense of history not possible at an earlier age. I can imagine, feel in my bones, what a century is like, which I could not do when I was 40 or 60. I do not think of old age as an ever grimmer time that one must somehow endure and make the best of, but as a time of leisure and freedom, free from the factitious urgencies of earlier days, free to explore whatever I wish, and to bind defaults and feelings of a lifetime together.

I’m looking forward to being 80.”

This was part of an essay written as he was approaching 80 years old. It was spoken by a man who knew that the end of his life was near. Years earlier, Oliver Sacks was found have a melanoma in his eye, and he wrote this knowing that the melanoma had spread widely throughout his body. He lived until 82 when he succumbed to his disease.

He retained his optimism and continued his writing until just before death. You may know that Oliver Sacks was a neurologist for some note. Aside from his last book, Gratitude, from which this essay was taken, Dr. Sacks wrote 13 other books, the best known of which were Awakenings and The Man That Mistook His Wife for a Hat. Awakenings was made into a movie with Robin Williams playing Dr. Sacks.

We all know that we are going to die at some point.   It seems to me that one of the challenges, if you are lucky enough to reach 80, is to really acknowledge that and come to terms with the inevitability of your death in order to move past it and focus on the opportunities that we still have to savor life. It requires living intensely in the present rather than looking ahead and anticipating the future. It’s the difference between waiting for the string to play out and investing in the possibilities that still exist.  The final chapters of life can be a very creative time if one doesn’t get bogged down anticipating the worst. It takes courage and discipline. Oliver Sacks embodied that.

Approaching 80

Approaching my 80th birthday is a psychological marker for me. It signifies that I have reached old age. This is completely personal. Not everyone views 80 as a marker. Actually, I read recently about an 86-year-old man who is still capable of running a marathon in less than four hours and about a 102-year-old man who completed a bicycle time trial averaging 17 miles an hour. That is truly remarkable, and there will be more people achieving results like that as life expectancy extends.  But for me. 80 signifies old.

I will reach 80 in a few months. I never expected to reach 80. The males on my father’s side of t he family all died in their 40s and 50s of heart disease, and I had coronary bypass surgery at 56, so I expected to be long gone. My experience will not be the same as others, although at some age, I think most will experience many of these feelings.  People age at different speeds, and some defy the norms. But for most of us, some point about 80, or slightly above, is a time of change in perspectives.

So, what does reaching 80 look like to me?

Well, it feels different from other birthdays. It is a point where it is difficult to deny that I am old and that I have some limited number of years left on this planet. Who knows how many, but it is probably a number less than ten. That’s okay. I doubt that it would be fun to live longer than that, but I feel exposed not having a decade between me and the hereafter. Nevertheless, I am starting to embrace my age; there is a certain pride in living this long. We live in such a youth-oriented culture that signs of aging are viewed as somewhat unseemly and something to be slightly ashamed of. Why else do we try so hard to maintain our youthful appearance and behavior? I am finally realizing that age, for all of its disadvantages, is something to be proud of.

As I’ve disconnected from my busy life of achieving and collecting, what I call the “noise of life”, and I have space to enjoy the perspectives and hopefully wisdom that comes with living a long time. I’m trying to get rid of “the shoulds” and spend my time doing the things I like or that challenge me in new and different ways. There is a constant temptation to fill all my time with tasks and activities that are familiar and that I know how to do. It is easy to fill a day or a week with chores, which I can do on automatic pilot and are not particularly satisfying. It has been necessary to release some of the things that have driven me and to tolerate the silence in order to find and create what comes next.

My time is sufficiently precious that I don’t have the inclination to carry grudges or to get angry at the things that I can’t control. It has always seemed good to me to accept people for who they are, even though I may not be attracted to some. (So far, our recently elected president is challenging that acceptance.) With people who are important to me, it seems much more sensible to respectfully say what may be troubling in the relationship and to avoid living in silent resentment. This can be difficult to do, and I’m not always successful, but at this point in life, I have only so much time to clear up misunderstandings and to express gratitude for the good things that have come.

I am confronted with the things that I just can’t do any more. Virtually everyone at 80 has some physical limitations. I love to be out of doors, to travel and see new things, to hike in the forest, and even to chop wood. Chopping wood would undoubtedly lead to days or weeks of back pain, and it just isn’t worth it. Hiking in the forest has to be calibrated with my Parkinson’s Disease to be confident that I can get back before I get exhausted. I’ve been fortunate enough to have had a lifetime of travel to exotic places, India, Africa, most of SE Asia, Bhutan, Nepal, South America. When my wife and I were traveling in the mountainous tribal areas of North Vietnam a couple of years ago, I became physically ill, and there was no doctor. It was not a serious illness, but it made me realize that I was at the end of my adventure travel. I need to be in places where there is reasonable medical care.

Whether we are extreme athletes or take more pedestrian risks, there are times when things don’t go smoothly or the unexpected happens. When that happens, one needs to fall back on reserve energy, strength and flexibility. People who climb mountains have told me there is no way to predict what will be encountered on a trip. They depend on the skills they have learned and physical fitness to find a way past their obstacle. To a lesser extent, unless one lives a very constrained life, our reserves of strength and experience allow us to explore the world with some confidence. For me at 80 those reserves are diminished.   There are things I would have taken on without thinking just a few years ago that I now need to carefully plan or forego for in order to avoid problems. In many ways, I am starting to understand the old person’s preference for predictability and routine.

Caution leads many seniors to live a severely constrained existence. One needs to find a balance between comfort and the thrill of adventures, no matter how small. I realize it is important to keep as active as possible and retain challenges even if modified to fit capabilities so that I don’t give up everything I enjoy. At 80, once you give something up, it is unlikely to come back. I’m lucky to have a supportive partner who encourages me and provides a safety net for trying new things.

At 80, I am no longer able to deny the presence of death. We spend a lifetime grappling with death in some way. When we are young, we ignore it. At other points, we are afraid of it. When we accept that it will occur to us, we wish that it will occur in a way that doesn’t involve too much suffering (not dementia, please).

Denial seems like a useful strategy for fending it off, but it doesn’t encourage coming to peace with one’s life, one’s accomplishments, one’s disappointments or with the people who really count in life. Preparing to accept death when it comes is a task of the elderly.

I recently saw the movie, “Fences,” in which the main character, Troy, sees death as an external force coming to get him. He challenges Death in his black robe with his sickle to come get him, and he is prepared to fight. I see death as more internal, as result of the inevitable struggle of a weakening body to deal with the challenges of living. If we are lucky enough to live until 80, death is a natural process of the wearing out of a machine. Plus, death is what makes life so precious. I think of the efforts of millennia to find the path to immortality. Major current research is devoted to extending life indefinitely. I think that it would be a bit boring after 100 years or so to keep hanging onto life. Knowing that it is all going to end motivates me to try to squeeze as much juice as possible out of the present and gives me the courage to try things that I might not do if I had infinite time.

“When signs of age begin to mark my body

(and still more when they may touch my mind),

when the ill that is to diminish me or carry

me off strikes from without, or is born within me,

when the painful moments come,

when I suddenly waken to the fact that I am ill or growing old,

and above all at the last moment when I feel that I am losing hold of myself

and am absolutely passive in the hands

of the great unknown forces that have formed me.

In all those dark moments, O God,

grant that I should understand that it is you

(provided only my faith is strong enough)

who are painfully parting the fibers of my being

in order to penetrate to the very marrow of my substance

and bear me away within yourself.”

Pierre Teilhard de Chardin

Senior Living Facilities

 

One of the worst fears for many people is that they will end up in a nursing home. If you are over 60, you probably have at least thought about whether at some point, you will have to move into a community designed for seniors. More often, this consideration occurs because something has changed, making living independently in you own home more difficult. It could be triggered by the death of a spouse or an illness that makes it difficult to function alone, or it could be due to advancing age and infirmity. Most people, like myself, don’t want to think about such a possibility, preferring to assume they will stay in their home, and consequently until the decision is thrust upon us don’t think about it and don’t know what alternatives there are. Fourteen percent of working people think they are likely to need such services at some point. In fact, sixth-six percent do.

What follows are brief descriptions of the major alternatives that represent different needs and levels of care.   It is useful to know the choices whether for yourself or a family member or a friend. If nothing else, it is worth being acquainted with the vocabulary. The choices are arrayed from the least intense to the more intense services.

Senior Communities: These are residences set up for seniors. They may be arranged as town houses or as an apartment complex. They are appropriate for relatively independent seniors who are ambulatory and have little in the way of disability.   Often, they have recreational facilities, such as a gym or swimming pool, and they may offer services such as housekeeping and dining, but they don’t offer nursing care or help with “Activities Of Daily Living” (ADLs such as independently ambulating, dressing. bathing, self feeding, personal hygiene and grooming, toilet hygiene and continence). Therefore, these communities are for high functioning seniors, who will have to move elsewhere if they become unable to care for themselves.

 Home Health Care: Home health services are adjunctive services that can be brought into a home of someone who is unable to travel to receive care, and which are essential to a person who wants to remain at home rather than in an institution. The services are generally adjunctive to the care provided by family or friends. They include, intermittent skilled nursing care (such as physical evaluation, wound care, IV administration), physical and occupational therapy, speech therapy, medical supplies and devices. Medicare parts A and B will pay for most of these things. Medicare does not pay for 24-hour home care, meals, homemaker services (laundry, shopping, house cleaning, personal care). To receive Medicare coverage, a doctor must certify that the person is housebound and must order the services, and the nursing services must be intermittent, not continuous. Often, home health care is supplemented by a home health aide who takes care of the more custodial tasks and is paid by the patient or family. Other services that can be added to home health services are senior day care centers, meals on wheels and senior transportation services.

Assisted Living Facilities: For some, it may be too expensive or difficult to remain at home. In the last two decades, there has been an explosion of alternative care facilities, sparing seniors the agonizing choice between home and nursing home. The alternative is an Assisted Living Facility where the person can live in a group setting in which they have a room and can get assistance with ADLs, such as dressing, bathing, grooming and has someone available on site 24 hours a day. The individual must be ambulatory and generally takes meals in a communal dining room. The facility usually provides services such as house keeping, shopping, assistance with medication, ambulating outdoors, but does not provide medical or nursing services. Board and Care facilities are another form of Assisted Living, but it is provided in a private home.

Skilled Nursing Facility (SNF): SNFs are one step up from assisted living and one step down from a hospital.   In fact, a SNF is often used following a hospitalization as a transition to going home. A SNF can provide full time nurses, a doctor who rounds daily. In addition to help with ADLs, they can provide medication management, wound care and a variety of rehabilitation services such as physical therapy and speech therapy. The differences between Assisted Living and a SNF is the availability of these nursing and rehabilitative services. Medicare provides coverage for a SNF, for up to 100 days after an acute hospitalization.

Nursing Homes: What is the difference between a SNF and a Nursing Home? Unfortunately, the terms are sometimes used interchangeably. In fact, some facilities may have both SNF and nursing home sections. Basically, a SNF must be licensed by Medicare and usually meets a higher standard of care than that required of a Nursing Home. Nursing homes are usually licensed by the state. Nursing homes are staffed by nurses and nursing assistants who can provide assistance with ADLs, meals, medication and management of minor wounds and catheters.   Generally, they provide care that a healthy person could manage on their own. They generally don’t provide rehabilitative services or care of more complicated problems. A nursing home may be the permanent residence of handicapped (physically or mentally) or frail individuals, and such is considered to be “custodial care”. The cost of a nursing home can run $100,000 to $200,000 per year depending on location and the facility. Medicare will not pay for custodial care. Medicaid will pay, but the person must spend down their financial resources to qualify for Medicaid.

Continuing Care: These facilities provide multiple levels of care, independent living, assisted living and skilled nursing, and a person moves up the scale as they age and need more care. They generally require a person to be independent when they enter. They are a good choice for someone who is still independent and wants the security of knowing that they can remain in the same facility when their needs become greater. These facilities usually provide various forms of recreational facilities, meals and transportation. They are expensive and not affordable for most. There is usually a substantial fee to buy in ($100,000 to $1,000,000, depending on what is covered, the desirability of the location and the facility) and a significant monthly charge ($1,000 to $6,000).

Other resources:  Long-term care insurance is a policy usually purchased while one is working, which will defray a proportion of the things not covered by Medicare.  Aging Life Care Professionals, or Geriatric Care Managers, are individuals who are expert at knowing the resources available in their geographic area. They can help guide a client and/or their family to the local resources, examine the alternatives, help assess costs and be an ombudsman for the person involved. If they have been certified as an Aging Life Care professional by the ALCA, it guarantees a level of knowledge and training.

Obviously, this is a cursory look at a very complex subject. It is a starter kit. If possible, it is worth consulting with an Aging Life Care Professional if one is in the process of considering alternatives.