Caring for Aging Parents - The New Old Age Blog

Nov 7 1:47 pm

Hello, Green Man

A few days after I wrote about conditions that can mimic dementia, reader Sue Murray emailed me from Westchester County. Her subject line: “Have you heard of Charles Bonnet Syndrome?”

I hadn’t, and until about six months ago, neither had Ms. Murray.

Her mother Elizabeth, who is 91, has glaucoma and macular degeneration, and has been gradually losing her vision, Ms. Murray explained. So at first, her family was excited when Elizabeth seemed to be seeing things more clearly. Maybe, they thought, her vision was returning.

But the things she was seeing — patterns and colors, strangers, a green man — weren’t there. She insisted that “there were people in the cellar, people on the porch, people in the house,” Ms. Murray said. “She’d point and say, ‘Don’t you see them?’ And she’d get mad when we didn’t.”

Elizabeth and her husband Victor, 95, live in Connecticut, in a house they bought 50 years ago. For a while, the Green Man, as Elizabeth began calling him, seemed to have moved in, too. “She’d start hiding things in the closet so the Green Man wouldn’t take them,” Ms. Murray said. “There wasn’t any real fear; it was just, ‘Look at that!’”

Elizabeth’s ophthalmologist promptly supplied the name for this condition: Charles Bonnet Syndrome, named for a Swiss philosopher who described such visual hallucinations in the 18th century. “We were relieved,” said Ms. Murray. What they feared, of course, was mental illness or dementia. “To have an eye doctor say, ‘I’m familiar with this,’ it’s still jarring but it’s not so terrible.”

Bonnet Syndrome (pronounced Boh-NAY) isn’t terribly rare, it turns out. Oliver Sacks described several cases in his 2012 book, “Hallucinations.” Dr. Abdhish Bhavsar, a clinical spokesperson for the American Academy of Ophthalmology and a retina specialist in Minneapolis, estimates that he has probably seen about 200 patients with the syndrome over 17 years of practice.

Nov 5 1:28 pm

A New Face on the End-of-Life Debate

By Paula Span

The two videos in which Brittany Maynard explained her decision to end her life under Oregon’s Death With Dignity Act put a human face — and a very young one — on a sometimes abstract debate.

Viewers saw her walking in the woods with her husband. There were glimpses of the small purse that held bottles of legally prescribed barbiturates and the sunny bedroom where she intended to take a lethal dose. They heard her mother tearfully support her decision.

As mournful piano music played, they heard Ms. Maynard, 29, express relief that she would be able to die peacefully, when she chose, rather than wait for an aggressive brain tumor to kill her.

And they heard her offer hope that her story could influence the nation’s end-of-life discussion. She had moved from California, where physicians cannot legally prescribe drugs to end the lives of patients, to a state where terminally ill patients have had that option since 1998. “I would like all Americans to have access to the same health care rights,” she said.

Advocates say that Ms. Maynard, who ended her life on Saturday, has indeed advanced that cause. The two videos — shot for Compassion and Choices, a national organization supporting legal aid in dying, and released in early October and then last week — have drawn more than 13 million views on YouTube.

Ms. Maynard appeared on the cover of People magazine and on CBS’s morning and evening news programs, and made headlines internationally. More than five million people visited her page on the Compassion and Choices website; 400,000 signed an online card. On Sunday, as news of her death spread, the website drew 240,000 visits an hour, the organization said.

“Our phones are ringing, ringing, ringing,” said Peg Sandeen, executive director of the Death With Dignity National Center in Portland, Ore. “We see people having conversations around dinner tables or with friends at work, and this time we see those conversations among young people.”

In Compassion and Choice’s 30-year history, “Nothing has touched as many people as Brittany’s story and changed the dialogue around death with dignity the way this has,” said Mickey MacIntyre, the group’s chief program officer. “We saw people running for office put this story on their Facebook pages or talk about it when they were campaigning, which isn’t usually the case.”

Nov 2 11:01 am

A Rise in Falls

By The New York Times

As the population ages, hospitals and retirement communities are bracing for an increase in the number of falls among the elderly, The Times reports. Read the full story. Update: A second story on falls was published in Science Times.

Oct 30 12:25 pm

A Workout for the Mind

By Paula Span

Becca Levy, a psychologist at the Yale School of Public Health, has been measuring the impact of stereotypes about old age for close to 20 years. They have potent effects, she and her colleagues have found.

The researchers developed an “image of aging” scale to determine whether subjects are likely to see old people as “capable” and “active” and “full of life,” or as “grumpy” or “helpless” or other negative attributes. They’ve used the scale to measure how much those descriptions match older people’s own self-perceptions.

Over and over, they’ve found that those who hold more positive age stereotypes behave differently as they age from those with more negative stereotypes, even when the groups are similar in other ways, including health status.

Older people with more positive views of aging do better on memory tests. They have better handwriting. They can walk faster. They’re more likely to recover fully from severe disability. Those with more positive self-perceptions of aging actually live longer, by an average of 7.5 years. (Other kinds of stereotypes, about race and gender, have also been found to influence behavior.)

But can you help older people to acquire those positive views? In their latest study, Dr. Levy and her colleagues tried to strengthen positive age stereotypes and make them last, and then see what effect they had on physical strength.

Negative stereotypes about age (like those groan-worthy insurance ads about an older woman who can’t quite seem to grasp the Internet) are of course rampant. “Children as young as 3 or 4 have already taken them in,” Dr. Levy told me in an interview. “Then they’re repetitively reinforced.” By the time those preschoolers become old themselves, “they’ve had decades of exposure.”

Yet the researchers have now reported, in the journal Psychological Science, that an “implicit” intervention works subliminally to strengthen older people’s positive age stereotypes. That leads, in turn, to stronger physical functioning. The effects were still evident three weeks after the intervention ended.

Here’s how it worked with a group of 100 older adults (average age 81) living New Haven, Conn. Once a week over four weeks, these volunteers were exposed to what’s sometimes called an “implicit association” exercise.

Insomniac, but Not Sleep-Deprived

By Paula Span

First, an acknowledgment: Insomnia bites.

S. Bliss, a reader from Albuquerque, comments that even taking Ativan, he or she awakens at 4:30 a.m., can’t get back to sleep and suffers “a state of sleep deprivation and eventually a kind of walking exhaustion.”

Molly from San Diego bemoans “confusion, anxiety, exhaustion, depression, loss of appetite, frankly a loss of will to go on,” all consequences of her sleeplessness. She memorably adds, “Give me Ambien or give me death.”

Marciacornute reports that she’s turned to vodka (prompting another reader to wonder if Medicare will cover booze).

After several rounds of similar laments here (and not only here; insomnia is prevalent among older adults), I found the results of a study by University of Chicago researchers particularly striking.

What if people who report sleep problems are actually getting enough hours of sleep, overall? What if they’re not getting significantly less sleep than people who don’t complain of insomnia? Maybe there’s something else going on.

It has always been difficult to ascertain how much people sleep; survey questions are unreliable (how can you tell when you’ve dozed off?), and wiring people with electrodes creates such an abnormal situation that the results may bear little resemblance to ordinary nightlife.

Enter the actigraph, a wrist-motion monitor. “The machines have gotten better, smaller, less clunky and more reliable,” said Linda Waite, a sociologist and a co-author of the study.

Essay Oct 23 4:27 pm

When Death Approaches Again

By Jane Gross

“And Then There Were None.’’

The title of Agatha Christie’s 1939 mystery, her masterpiece, spooled through my mind on a recent visit to the Hebrew Home at Riverdale, where my mother died 11 years ago.

Out on the patio, one man sat in the sunshine with his visiting children and grandchildren. On his left forearm was the telltale tattoo of time spent in Auschwitz, marking him a survivor of the death camp where one million Jews lost their lives.

The string of letters and numbers, vivid more than 70 years later, is a ghastly sight no matter how many times you’ve seen one. But each year, at an accelerating pace, there are fewer survivors left to remind us of the last century’s atrocities.

The number varies in different accounts, but Vice President Joseph R. Biden Jr. recently told the Senate’s Special Committee on Aging that 140,000 survivors remain in the United States. A decade ago at the Hebrew Home, there seemed to be hundreds. Now there are 40, among a total of 800 residents.

They are cared for as the deaths they once barely escaped are bearing down again. Some have always lived in a fog of fear. Others are grateful to be alive, to the point of exuberance, and still others are guilty to have survived for no reason other than luck. None are like the other aged residents here, facing death in its expected time. They have spent too long already staring into the abyss.

Rabbi Simon Hirschhorn, himself the son and grandson of Holocaust survivors, said that his multigenerational work with these families is the most satisfying and important work he does. As a nursing home clergyman, he is always guiding parents and their adult children through what is arguably the most difficult transition of their lives.

Some of the elderly survivors cry inconsolably but wordlessly, incapable or unwilling to articulate anything about the past. Others, often dry-eyed, incessantly discuss the terrible things they saw and had to do to save their lives.

Oct 21 1:22 pm

Is It Really Dementia?

By Paula Span

Maybe it’s something else.

That’s what you tell yourself, isn’t it, when an older person begins to lose her memory, repeat herself, see things that aren’t there, lose her way on streets she’s traveled for decades? Maybe it’s not dementia.

And sometimes, thankfully, it is indeed some other problem, something that mimics the cognitive destruction of Alzheimer’s disease or another dementia — but, unlike them, is fixable.

“It probably happens more often than people realize,” said Dr. P. Murali Doraiswamy, a neuroscientist at Duke University Medical Center. But, he added, it doesn’t happen nearly as often as family members hope.

Several confounding cases have appeared at Duke: A woman who appeared to have Alzheimer’s actually was suffering the effects of alcoholism. Another patient’s symptoms resulted not from dementia but from chronic depression.

Dr. Doraiswamy estimates that when doctors suspect Alzheimer’s, they’re right 50 to 60 percent of the time. (The accuracy of Alzheimer’s diagnoses, even in specialized medical centers, is more haphazard than you would hope.)

Perhaps another 25 percent of patients actually have other types of dementia, like Lewy body or frontotemporal — scarcely happy news, but because these diseases have different trajectories and can be exacerbated by the wrong drugs, the distinction matters.

The Caregiver's Bookshelf Oct 17 11:44 am

A Doctor Discovers Dying

By Paula Span

It is possible to savor every moving anecdote, graceful paragraph and astute observation in “Being Mortal,” the latest book by surgeon/writer Dr. Atul Gawande, and still find yourself wanting to pose a few impatient questions to the author.

“This comes as news to you? Were you not paying attention?”

Subtitled “Medicine and What Matters in the End,” the book skillfully maps out the quandaries facing both health care professionals and patients and their families when they come up against the limits of contemporary medicine at the end of life.

As a newly minted physician, “I knew theoretically that my patients could die, of course, but every actual instance seemed like a violation, as if the rules I thought we were playing by were broken,” he acknowledges. “I don’t know what game I thought this was, but in it we always won.”

By now, though, Dr. Gawande has come to understand this territory well. He has seen his grandmother-in-law falter and die; he has helped his once unstoppable father enter hospice care. He has worked with many patients, young and old, whose diseases and disabilities can’t be fixed, though that generally doesn’t stop them or their doctors from trying.

In his hospital and in his life, he sees the evasion of discouraging realities, the pressure to do something when just standing there might be more helpful, the conveyor belt that carries ailing patients and their hopeful loved ones from emergency room to hospital bed to nursing home when staying home is what almost everyone claims to want.

He passes all this along, laced with relevant research findings. He visits nursing homes and geriatricians’ offices and tags along with a hospice nurse. He also explains the medical, financial and other systemic factors that shape our sometimes limited choices.

Oct 13 5:00 am

Treating C.O.P.D. in the Elderly

By Judith Graham

Which medications work best for older adults with chronic obstructive pulmonary disease?

Doctors aren’t entirely sure: Despite the fact that C.O.P.D. is the third-leading cause of death, there is scant research on the comparative effectiveness of treatment options in seniors. But a study recently published in The Journal of the American Medical Association provides valuable new information.

C.O.P.D. refers primarily to two conditions that compromise breathing: emphysema and chronic bronchitis. Nearly four million seniors have been diagnosed with the condition.

For their new study, researchers in Ontario combed through records of all adults ages 66 and older with C.O.P.D. who had started taking two types of medications: long-acting beta agonists and inhaled corticosteroids.

Long-acting beta agonists (sold under brand names like Foradil, Oxis, Serevent) help relax muscles around the airways in the lungs, allowing air to flow more freely. Inhaled corticosteroids (Flovent, Azmacort, Asmanex and others) act against inflammation and swelling in airways, making breathing easier.

Clinical guidelines recommend that doctors begin treatment for C.O.P.D. with long-acting beta agonists (or another set of medications called long-acting anticholinergics, not studied in this report), then add other medications if necessary. But it has never been clear if this is optimal for older adults.

The Canadian study is the first to focus on seniors in real-world settings who tend to have lots of complications, unlike people included in gold-standard clinical trials, which tend to exclude patients with multiple medical conditions.

Oct 10 1:19 pm

A Leap in Lifespans

By Paula Span

The annual report on mortality rates by the National Center for Health Statistics, released this week, tells a now-familiar story: In 2012, life expectancy for older Americans continued to climb.

People who reached age 65 could look ahead to an average additional 19.3 years on the planet, an all-time high. Men could anticipate another 17.9 years, on average, and women another 20.5.

The numbers inched up only slightly from 2011 — seniors gained an extra five weeks or so, on average. But the longer-term trend has been dramatic, said Robert Anderson, chief of mortality statistics: “There’s been a fairly substantial increase just in the past decade.”

Take a look: In 1960, an average 65-year-old had a life expectancy of 14.4 years. A big jump came between 1970 and 1980, to 16.5. Remaining life span stretched to 17.3 years in 1990 and 17.8 in 2000. But in the 12 years after, we gained another year and a half.

Disparities related to race or ethnicity have narrowed, Dr. Anderson also pointed out. Statistics from 2011 show that among 65-year-olds, life expectancy was 20.7 years on average for Hispanics, 19.2 years for whites and 18 years for blacks.

The latest report points to some familiar reasons for this increased longevity, including significant declines in age-adjusted death rates (across the whole population) from cancer, heart disease, stroke, lower respiratory disease, diabetes, flu and pneumonia — even from Alzheimer’s disease, for which there’s scant effective treatment.

Of the leading causes of death, only suicide has risen. But although suicide rates among older people have crept up from their low point in 2006, they are still much lower (at 15.3 deaths per 100,000 population in 2011) than at their recorded peak (22.1 in 1987). The recent increase in suicide doesn’t appear to be driving the increase in the overall suicide rate, Dr. Anderson said.

Oct 8 12:53 pm

In Nursing Homes, Eyes That Never Turn Away

By Paula Span

Should you be able to place a video camera in your parent’s room at a nursing home?

Cindy King votes yes. Her mother suffered a major stroke, and when Ms. King could no longer care for her at home, she started looking for a decent facility.

“I did a lot of research,” she told me in an interview. “I was under no illusion that there was a perfect place.”

The home she chose in 2011 was a short distance from her house in Chicago, so she could visit two to three times a week. She made a point of coming on days when her mother, who no longer spoke much, was given a shower. “It gave me a chance to look at her body,” said Ms. King, alert for bedsores or bruises.

So it came as a shock last year when her mother, taken to an emergency room because of unusual blood test results, began to talk, haltingly, about a “mean” aide who had elbowed her in the chest.

“I hadn’t heard her speak so much in over a year,” said Ms. King, 43. Apparently prompted by the sight of a police officer who happened to be in the E.R., her mother described the aide but didn’t know her name or exactly when the assault had happened. But, she said, “I fought back.”

Ms. King fought nausea.

She decided to buy an inexpensive video camera and install it in the room where her mother lives alone, without a roommate. “She is less and less vocal, less and less alert,” Ms. King said of her mother, who’s 72. “How can I protect her?”

Wage Protections Postponed for Health Aides |

The Obama administration has postponed enforcement of new minimum-wage and overtime protections for two million home-care workers, The Times reported on Wednesday. Under the rule, home-care workers are to receive the federal minimum wage of $7.25 an hour and time and a half when they work more than 40 hours a week. Numerous states, already facing budget strains, had complained about increased costs. Read the full story.

Oct 6 5:33 pm

Extra Scrutiny for Hospices

By Paula Span

Bipartisan legislation, that increasingly rare phenomenon, will soon bring greater federal oversight to hospice programs across the country.

The Impact Act, signed into law today by President Obama, is chiefly concerned with how nursing homes, rehab centers and home health agencies assess and report data on quality and other measures. But tucked into the legislation are provisions increasing the frequency of hospice inspections and allowing Medicare to review programs in which a large proportion of patients receive care for six months or more, considered a long hospice stay.

That’s good news, said J. Donald Schumacher, president of the National Hospice and Palliative Care Organization. “A lot of things can go wrong when no one’s looking,” he told me.

Like nursing homes and home health agencies, which also rely heavily on Medicare and Medicaid, hospices undergo periodic state surveys in order to be recertified for reimbursement. But until now no federal law specified how often those surveys must take place.

Medicare aimed to conduct surveys every six years, but after budget cuts extended that to every eight years — compared with every three years for home health agencies and every 15 months for nursing homes. A lot of hospices don’t draw even that limited scrutiny.

Investigations by the Department of Health and Human Services inspector general found that in 2005, about 14 percent of hospice organizations had not been recertified in the previous six years. By 2013, that proportion had climbed to 17 percent.

Medical Issues Oct 2 12:00 pm

Some Good News on Pneumonia

By Paula Span

We discuss a fair number of grim topics hereabouts, so when I hear about good news, I figure I should grab it.

So let me pass along two encouraging developments on the pneumonia front. First, the Centers for Disease Control and Prevention has just issued new vaccination recommendations for older adults that should bolster their protection against this dangerous lung infection.

Second, a large-scale study has found that when older Americans do land in hospitals with pneumonia, those hospitals are doing a measurably better job of treating them.

Each year, pneumonia sickens three million to four million American adults, most over 65, according to Dr. Michael Fine, who studies the epidemiology of the disease at VA Pittsburgh Healthcare and is the senior author of the study, published in JAMA Internal Medicine. More than a million adults are hospitalized because of pneumonia, but hospitalization becomes much more common at older ages.

In 2003, the Centers for Medicare and Medicaid Services — which tracks how well hospitals do at treating pneumonia — established seven performance measures. To receive reimbursement, hospitals had to report how frequently they took these steps, including taking cultures in the emergency room to diagnose bloodstream infections, starting appropriate antibiotics within six hours, and offering flu and pneumonia vaccines and smoking-cessation counseling to prevent future infections.

(Viruses, fungi and aspirated food can also cause pneumonia, but only bacterial causes can be effectively treated with antibiotics.)

To gauge how hospitals responded, the researchers examined the records of 1.8 million Medicare beneficiaries hospitalized with pneumonia between 2006 and 2010. They not only looked at how frequently the 4,740 hospitals managed to complete each of the seven processes; they also constructed a composite — an “all-or-none” measure — which showed how often hospitals took all the required actions patients were eligible for.

In 2006, less than 60 percent of hospitals took all the required steps for all eligible pneumonia patients, the researchers found. Five years later, that proportion had risen to more than 87 percent. “There’s been major improvement over time,” Dr. Fine said. In fact, some measures became so universally practiced that Medicare stopped tracking them.

Wage Protections Postponed for Health Aides |

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