Caring for Aging Parents - The New Old Age Blog

Dec 4 1:45 pm

A Focus on the Heart for Older Patients

The first geriatric cardiology clinic in New York opened at N.Y.U. Langone Medical Center in August. It’s different.

For starters, an older patient’s first visit with cardiologist Dr. John A. Dodson, the program’s director, takes a full hour. Beyond taking a complete history, Dr. Dodson looks for frailty by measuring things like gait and grip strength and administers a short test of cognitive ability – things geriatricians routinely do and cardiologists mostly don’t.

“The No. 1 difference is time,” he told me in an interview. “To be able to spend an hour with a new patient is a gift.”

In January, when a pharmacist joins the program, Dr. Dodson will start asking patients to bring in all their prescription drug bottles for review. “They may be taking redundant medications or the wrong medications,” he explained. “Where we can, we will peel away what’s not essential.”

The conversation expands to include less medical topics, too: the patient’s goals, the extent of family support, end-of-life preferences.

The N.Y.U. program is one of only a handful of geriatric cardiology programs that have sprouted up around the country, including the first (so far as we know) at Vanderbilt University Medical Center, in 2012, and a similar program at the University of Pittsburgh Medical Center. More are likely to follow.

At Vanderbilt, “I talk about living wills and health care proxies and why they’re important,” said Dr. Susan Bell, a cardiologist and geriatrician the clinic director. “Is this the person who wants quality of life or the person who wants to push for longevity as much as possible?”

This is mostly common sense – treating an individual, rather than an organ – but it is particularly crucial for older adults.

Dr. Dodson’s patients at N.Y.U. are mostly in their 80s; the oldest is 96. Whatever has gone wrong with their cardiovascular systems, they are usually also coping with several other chronic conditions and disabilities, from diabetes to hearing loss. They take a raft of drugs. They may not cope well with procedures and regimens effective for younger patients.

Part D for Drug Coverage — and Drudgery

By Jane Gross

Death and taxes have always been twinned in cliché for their unavoidable awfulness. But death only happens to each of us once, not annually. Wouldn’t our annual encounter with the Internal Revenue Service be more aptly paired with the Medicare Part D open enrollment period, a yearly torture between mid-October and early December? Both take days out of our lives and leave us sitting in a heap of papers with a splitting headache and residual worry that we got something wrong and will wind up in jail or the poorhouse.

It’s my third year of eligibility for Part D, the Medicare option, added in 2006, that provides coverage for prescription drugs. When I turned 65, I had nothing but good things to say about Medicare Parts A and B, the 1964 hallmark legislation that covers hospital and outpatient medical care. That’s still mostly true, but for the growing numbers of doctors who have “opted out’’ of the government program because of inadequate reimbursement and onerous paper work. Part D, designed as a public/private hybrid, is another story. Forgive my cynicism, but any “benefit’’ that twins the insurance industry with Big Pharma can’t really have the public interest at heart.

My first experience choosing a drug plan was chronicled here, after a Fourth of July weekend that will live in memory as the worst I ever spent. I should have expected as much, since my colleague Gina Kolata, a whiz at math, wrote of her effort to choose a plan for her father, testing if the Centers for Medicare and Medicaid Services website was as simple as promised and found it an exasperating mess. Since my mathematical abilities are limited to counting on my fingers, and Gina had struggled, I was braced for trouble. But not the trouble I found myself in.

Year two I had an excuse not to try, even when the booklet of changes for the coming year arrived from my insurance carrier and everything was more expensive by many multiples. In the midst of selling one home and buying another, who could fault me for taking a slide? And how comforting to find out, and recount here, that a Kaiser Family Foundation study had found 87 percent of Part D policyholders between 2006 and 2010 made no change, even when they knew they were overpaying, because it was too hard. Kaiser went so far as to say that the Part D plans had observed and responded to this behavior, offering reasonable rates one year and over-the-moon rates the next in a classic bait-and-switch.

Aggressive Neighbors in the Nursing Home

By Paula Span

It will not surprise people who spend time in nursing homes — who live or work there, who volunteer or visit family members — that residents can lash out at each other.

“Resident A is sitting in a wheelchair in a common area, yelling out,” said Karl Pillemer, a Cornell University gerontologist and researcher, recounting an actual, and typical, example from his latest study. “Resident B goes over and says, ‘Be quiet, stop yelling.’ Resident A hits Resident B on the hand. The nursing aide separates them, then sees someone else wandering and has to leave. When she does, Resident B kicks Resident A, and the cycle continues.”

It happens. Nursing facilities house people who are disinhibited, who have dementia, who share close quarters with strangers, who may suffer pain or lose their ability to communicate in more acceptable ways.

On occasion, some will hit, kick, grab, bite and shove. Or threaten, bully and fling insults, including racial slurs. Or say and do things that are sexually inappropriate.

What may surprise people — and it certainly stunned Dr. Pillemer and his fellow researchers — is how often such incidents occur. Their five-year study, presented at the Gerontological Society of America’s annual meeting in Washington earlier this month, found that 19.8 percent of nursing home residents had been involved in what the researchers call “resident-to-resident elder mistreatment” — verbal, physical or sexual — in the previous month.

Nov 20 3:08 pm

An Easier Death, and Less Costly, Too

By Paula Span

Saving money isn’t really the point of hospice care. Helping dying patients have the best possible remaining life, followed by a good death, is really the purpose.

But whether hospice care saves money has prompted debate for years. Most hospice patients die at home, which is what the great majority of Americans say they prefer, or in nursing homes. Wouldn’t that save money compared with the cycle of 911 calls and hospitalizations that characterize so many American deaths?

Studies of this question have been small and have reported contradictory results. “There hasn’t been a lot of consensus,” said Dr. Ziad Obermeyer, an emergency physician and health policy specialist at Harvard Medical School. “There are people in the policy establishment who are still skeptical about whether the costs are lower.”

He hopes the large study he and his colleagues at Brigham and Women’s Hospital in Boston published recently in JAMA will finally put that concern to rest. It matched two groups, each containing more than 18,000 older Americans with metastatic cancer, comparing patients who enrolled in hospice with those who had the same poor prognosis but didn’t use hospice. The researchers tracked participants in both groups until their deaths.

The hospice patients had far fewer hospitalizations and less than half as many intensive care unit stays, their Medicare records showed. They endured half as many invasive procedures. They were five times less likely to die in a hospital or nursing home.

And yes, care in the last year of their lives cost an average of about $8,700 less than for the nonhospice patients. Costs for patients in the nonhospice group were $71,517 on average in the last year of life, compared with $62,819 for those in hospice. If extended nationwide, the difference could save Medicare billions of dollars.

Nov 17 1:51 pm

Seeing the ‘Invisible Patient’

By Jane Gross

Not once in the years I cared for my mother did any of her physicians ask me how I was doing. When was the last time I saw my own physician? Was I eating properly? Sleeping enough? Depressed?

What did I do for fun?

Frankly, I didn’t notice their apparent lack of concern, nor had I considered it since — until hearing a recent talk by Dr. Ronald D. Adelman, the co-chief of geriatrics and palliative medicine at Weill Cornell Medical College in New York City.

The subject was caregiver burden and how physicians ought to be attending to the “invisible patient,” the one supporting an elderly family member with dementia or a heart condition or diabetes — or all of the above. Given that there are currently 43.5 million people providing this kind of support to adults ages 50 and older, and that without them the long-term care system would collapse, you’d think the proposition that somebody ought to be paying attention to them would be a no-brainer.

Sad to say, physicians often look right past caregivers. Earlier this year, Dr. Adelman published an article in JAMA detailing the problem, along with recommendations for addressing the burdens of this group.

Nov 14 11:33 am

Dreaming of the Departed

By Paula Span

I ran into my father at a deli the other day. An undramatic encounter: I was waiting at the counter for a takeout order when I spotted him sitting at a corner table, yakking with friends from his senior residence, their walkers and canes carefully folded or propped against the wall.

I was happy to see him, and we had a hug and a few words. I kibitzed with his buddies for a moment, too. Then we said goodbye and I went on my way without thinking much about it because, after all, we would go out for lunch together on Saturday the way we usually did.

Dad looked fine, except perhaps for a less-than-flattering white sweater he didn’t, in reality, own. In my dream — that’s what this was — I didn’t know that he had died.

He has been gone for nearly two years now, so I was glad to have this fleeting visit. I once dreamed of my late mother, too: a hippie version of Ruth Span, standing on a hilltop in a gauzy flowered dress and long, windblown curls. (She actually wore polyester pantsuits and had sprayed hair that gales couldn’t rearrange. Are people undergoing makeovers in the afterlife?) My sister has also occasionally dreamed about our parents.

Seeing Dad left me wondering how often deceased family members enter their survivors’ dreams and what we know about what — if anything — that means. So I called Alessandra Strada, a clinical psychologist and director of integrative medicine and bereavement services at MJHS Hospice and Palliative Care in New York. She has listened to patients talk about their dreams for 20 years.

“Dreams are quite a prevalent component of the bereavement process,” Dr. Strada told me. In fact, a study recently published in The American Journal of Hospice and Palliative Care surveyed 278 caregivers (mean age: 63), nearly 60 percent of whom reported dreaming of relatives who had recently died in hospice care.

Nov 7 1:47 pm

Hello, Green Man

By Paula Span

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.

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