Don’t Blame the Chickens or the Foxes

I have been teaching a university course on programs for older people for ten years. Every year I get some of my bright students come back to tell me that the program does not run as it was intended. The program that they interned in (clinical experience) operated differently from how it should have operated. Most reduced their services to make a larger profit. At first, I thought that this was an anomaly, infrequent events. But it happened with many of my students across a broad range of services. At one time one of my students, an ex-military intelligence in his previous life, wrote a critique of hospice services. I thought it was intriguing so I followed up and did my own research. What I found was that not only was he right, but there were other ways that he missed that hospices use to increase their profit and unfortunately reduce their care to older adults that are dying. How can this be?

I then decided to research all services to older adults. The results were devastating but informative. In the United States, every service that is provided for older adults is designed to increase profit generation. Every single one and it did not matter if they were “for-profit”, or “not-for-profit.” There are only two ways to increase your profit, you either increase prices for your services, reduce the number of services, and/or reduce their costs. What I found is that across a broad range of services, the preferred method was to reduce services. This had the direct effect of causing harm to the older client. It is predictable institutional abuse at a level that is difficult to comprehend in a developed and rich country. But my task was not simply to document these abuses, but to find a solution. That is when I came up with a parable.

A farmer has a brood of hens, he sells their eggs. Next to the farm there were a couple of foxes with their own small family to feed. They often got into the chicken coop and helped themselves to some of the chickens. This continued to happen year after year. I ask my students, who is at fault? Are the chickens at fault as they remain defenseless? Are the foxes at fault since they attempt to feed themselves and their families? Or is it the farmer who is incompetent at protecting the chickens? You cannot blame the chickens or the foxes which is what the media does. They blame people for not doing their homework and checking up on nursing homes, or hospices when they are at their most vulnerable stage in their life. Others blame the medical and pharmaceutical companies for their greedy behavior as they need to make a profit to survive. No one seems to blame the farmer, the government. We have regulatory agencies that are designed to safeguard our citizens, but they are not doing their job. Like the farmer they are incompetent, but unlike the farmer who loses the sale of his eggs, these administrators still get a hefty paycheck every month. When I figured that the solution was to enhance and strengthen government regulatory agencies, I formulated a theory that explains all of this and predicts that these abuses will continue to increase unless we enhance oversight. The book was published as Critical Age Theory on Kindle an Amazon company. It was generating some interest, but not a blockbuster, but then one day my account on Kindle was deleted. No explanation was given and no apology for deleting more than 12 books I had online.

I remember a friend of mine Allen Smith, a Professor of Economics at Eastern Illinois University, who published about similar institutional abuse this time on social security. He published The Alleged Budget Surplus, Social Security, and Voodoo Economics and in 2000, The Looting of Social Security. All of these books were critical of what the government was doing. Strangely, the last of these books was stopped from being published. Someone bought the rights and stopped printing it. At the end of his life Professor Smith bought the rights back and made it public again. I distribute it free to my students.

Basically, he is saying the same thing, don’t blame the chickens or the foxes.

We must hold our government to a higher standard as their only job, their sole reason for existing, is to better the lives of its constituents, the chickens. If they are not doing that then they have relinquished their right to govern. Most radical governments now, the populists, want to overthrow all our institutions and start again. But that is wrong; these institutions developed for a reason. Just because they are not functioning properly does not mean that they cannot be fixed. Look at the motive for their inception and you will find the answer of how to fix them. Perhaps we can regain a system of care that promotes health and dignity in our last stages of life.

Many Dementias

My mother, of 86 years of age, has dementia. But we do not really know what that means. At first, she was slow and fragile; her short-term memory was shot. The doctors found high calcium in her blood and diagnosed a benign tumor in the hyperthyroid. They operated and she came back energetic, hyperactive, and hallucinating and talking with her dead mother and sister. Then she stopped eating and only drank when directed. She shrank in weight and became nearly catatonic. I met with the family as I predicted a quick death. I made the family take uncomfortable decisions.  We admitted her to a nursing home, and when my sister visited her four hours later and saw how anxious she was, mum came back home. She had an infection, ended up in hospital, and came back with a bloody nose. This abuse further solidified the primary caregiver, my younger brother's determination to protect mum by keeping her home. Then she started independently eating and drinking and while still looking for her dead relatives, she was getting more exercise than anyone else. She was physically getting stronger. She is in constant motion and repeats nonsensical words as though she is praying. From the moment she wakes up to the last breath at night she is in motion and vocal.

It seems there are layers of diseases, one waiting for the other to emerge and take priority, or both acting at the same time. Our categorization of diseases is not designed for older people with multiple diseases. Especially in psychiatric nosology, the idea of identifying specific diseases as distinct and independent diseases is nonsensical. As we get older the body ages across the board. A weaker heart, lung, muscles, skeleton, joints,  everything is diminished, some more than others. An emerging disease is not independent but can be an expression of all of these small deteriorations. My mother had a hyperthyroid tumor that created a calcium imbalance that slowed her cognition and body down, and she also had Lewy Bodies Dementia that created the hallucinations, and ontop of these she also must have Vascular dementia or Alzheimer’s disease that destroyed her memory. All of these were acting upon her at the same time. Then there are other neurological diseases that we still have not identified. Her improved eating habits cannot be explained by the dementia diagnosis alone. There are other changes that are hidden from us. Among 90-year-olds half of the cause of their dementia is unknown as there are so many other biological changes happening. When there are neurological deficits you can be certain that other diseases will emerge at the same time. Aging might be the most obvious factor, but that does not inform us on how to prevent or delay dementias as we cannot stop aging, but we can improve how we age.  Psychiatric nosology will eventually be dragged kicking and screaming through this terrain of older patients’ maladies until we finally admit that unless we start looking at the whole person, studying aging and not just diseases, we will never get a handle on dementia.