Dying Older Adults

How would you like to die?  Gilbert Meilaender from Valparaiso University in Indiana suggested a one-word answer: Suddenly!  The idea is to live as long as we can at the peak of our powers, then fall off a cliff.  Doubtless he is right about contemporary attitudes toward death. If we have to go, let it be quickly and painlessly.

Last month a local woman, Sharlotte Hydorn, gained a measure of negative notoriety by offering to mail you, for only $60, a package containing a plastic bag, medical tubing, a canister of helium and instructions on how to commit suicide—by placing the bag on your head and filling it with helium which deprives the body of oxygen. The State of Oregon, one of the few states where physician assisted suicide is legal, was exploring the possibility of suing her.

These two perspectives point to the schizophrenic relationship many of us have with death. What we say we want is frequently quite different from how we deal with death. Since more than a quarter of us will likely die in an emergency room, our final departure might look more like a medical failure rather than a dignified release of life.

Despite the availability of hospice care—both at home and at hospitals, which often involves palliative care targeted to relieve pain—most older adults still experience widespread distress in the final stages of life. We have few guidelines how to deal with death or bereavement in older adults—even when death is not only inevitable but desired. The now classic Kubler-Ross’s process of bereavement—involving phases of denial, anger, rationalization and acceptance—was developed by her observation of children’s reactions to death.

Sherwin Nuland, an American surgeon, has made the point that death in older age is often a protracted affair, rather than a clear-cut process that allows patients and those bereaved to go through the classic end of life stages. He quotes an elderly patient as saying, “Death keeps taking little bits of me.”

Ever since it was eliminated as an official “cause of death” in 1951, we cannot die of old age. We have to die of a disease or trauma. In truth, there is only one real cause of death—oxygen starvation to the brain. The cause of death listed on death certificates is really the cause of the cause. As simple as this might seem, formalizing a definition of death was not easy, but we have been pioneers in California.

In 1973 hospitals threatened to cease organ transplants since criminal defense attorneys argued that harvesting a victim's organs while his heart was still beating caused the death. Dixon Arnett (R-Redwood City) introduced emergency legislation to recognize death when brain activity ceases.  This definition of death is now accepted across the world.  Despite such advancement, we still have difficulty preparing for death. Dying suddenly and painlessly might be our ideal, but we do very little as a society to give older adults that option.

Mario Garrett, Ph.D., is a professor of gerontology at San Diego State University and is currently on sabbatical at the University of Melbourne, Australia. He can be reached at mariusgarrett@yahoo.com

Brain Fitness and Dementia and How We Can Re-Program Our Mind. The Story of Hormesis

Hormesis is the term used to explain the benefits of low exposures to toxins and other stressors as a kind of vaccination. Some of us take vaccinations every ear against the flu, so the concept of hormesis “what does not kill you makes you stronger” is not new. But can we apply the same concept to learning and developing our brain?

Psychologists think about learning in stages of development. Jean Piaget, a Swiss development psychologist, asserted that you can only teach infants what their development allows them to learn. Sigmund Freud also discussed stages of psychosexual development where each stage has its own set of learning requirements that determine our future emotional development. These stages have primed researchers to assume that changes to the brain stopped at adulthood. It is of little surprise, therefore, that anyone studying aging before 1960 looked at aging only as a period of loss and attrition.

David Snowdon’s research with Catholic sisters of Notre Dame living in Mankato, Minn., highlighted one of the paradoxes of aging—why some people who have the disease in the brain (neuropathology) continue to function normally; while others who do not have the disease seem to express demented behavior.  This study has made us re-evaluate how we think about dementia and learning in general because it shows us that we seem to have a reserve of brain cells. The question is how do we grow that reserve?

A developing body of knowledge shows that undertaking certain activities enhances and grows the brain in adults.  For example, studies show that London taxi drivers develop a larger part of their brain while learning different routes in London, than bus drivers who have a set route. Other studies that show that brain increases in size when medical students study for their exams, compared to brains of students who were not studying for exams.

Another popular and consistent finding relates to music and dancing. In a longitudinal study, growth in the hippocampus part of the brain was recorded among music students after two semesters of intensive musical training. A further study showed that participants over 75 years who frequently played a musical instrument and/or danced were less likely to have developed dementia over a five- year period.

These studies repeatedly show that the brain of older adults can develop a reserve of cells. The question is what works best in growing these extra cells?

In understanding what is happening scientists have come up with the Japanese term 苦労 (kurou), which stands for “hardship” and “labor.”  Learning happens when we are uneasy about what we know and make ourselves learn. Geoff Colvin In his book Talent is Overrated similarly argues that there is a learning zone which is above the comfort zone and below the panic zone—where all learning needs to take place. This mirrors Jean Piaget’s definition of intelligence —". . . what you use when you don't know what to do." We need to put ourselves in learning situations that make us uncertain. The uniqueness of the situation will trick our brain to develop ways to learn. What does not kill you makes you stronger.

Mario Garrett, Ph.D., is a professor of gerontology at San Diego State University and is currently on sabbatical at the University of Melbourne, Australia. He can be reached at mariusgarrett@yahoo.com

Ageism-Modern Variants

Robert Butler, who died last year—was a physician, gerontologist, psychiatrist, Pulitzer Prize-winning author, and the first director of the National Institute on Aging—introduced the term “ageism” in 1969. By assigning a word to the practice of discriminating against older adults, researchers gained a focus. Words serve as bridges between action and understanding. By selecting specific words, we provide a strong indication about our beliefs—and probably actions—in relation to members of a group.
Ageist vocabulary—like other forms of prejudicial communication--is potentially harmful. Certain negative words refer to older adults’ physical appearance (decrepit, frumpy, wrinkled); behavior (crotchety, fussy, garrulous, grouchy, grumpy, miserly); physical ability (debilitated, feeble, infirm, rickety); sexuality (unattractive, impotent, sagging, droopy); and mental ability (doddering, eccentric, feebleminded, foolish, rambling, senile).
Despite the abundance of disparaging expressions for older adults, however, a few favorable terms, such as mature, mellow, sage, venerable, veteran, and wise, describe positive aspects of aging. “Old” has a negative connotation only when applied to people. Old implies positive meanings when applied to objects such as money, brandy, wine, cheese, lace, and wood.
Gerontologists still debate the appropriate designation for people older than 65.  A classic 1979 Harris Poll conducted for the National Council on the Aging indicated that the most-favored descriptive terms for older Americans were senior citizen, retired person, and mature American. While gerontologists Carole Barbato and Jerry Feezel, by sampling 162 people in 1987, also came up with those same three terms and added three more in order of preference—retired person, golden ager, and elderly. These terms seem antiquated today in reference to emerging baby boomers.
In contrast, the Thesaurus of Aging Terminology (8th edition 2005), an AARP publication, advises readers to use the expression “older adults.” In politically correct environments, older adults do not represent an end but a process (older vs. old.) The term is inclusive.
Because older adults (aged 65 years to theoretically 122) are extremely heterogeneous, it makes little sense to put a 65-year-old in the same category as a super centenarian (110 years old). “Old person” is a conceptual metaphor that considers old age as a terminal period. “Older adult” does not designate a terminal stage. It implies that you are still growing old, but with the emphasis on “growing.”
Another subtle expression of ageism occurs when referring to part of a person. Whether it is age, or another aspect of that person, the use of a part for the whole is termed a metonymy. Within health care and social service settings, metonymy is a common way to allude to older adults. The use of such expressions; the care recipient, the dementia, the broken hip, or the cancerous liver, are examples.
In some respects, these references underlie the intent of service providers to address specific issues rather than the individual. But words we use determine how we are treated. Part of the secret of long life is not to accept negative terms for us. How long we live is related to our perception of how long we expect to live, and what we allow others to dictate for us. 

Dancing away Dementia

As we age, we experience an increase in body fat, reduced muscle mass, strength and endurance, and diminished balance and aerobic capacity. Normally these deficits result in slowly diminished levels of our functional ability. The resulting loss of functional ability can result in susceptibility to falls, inactivity, and depression.  This in turn can exacerbate existing conditions or contribute to new, chronic diseases such as diabetes, stroke, cardiac infarction, or cancer.

The advice we hear usually involves “exercise and diet.”  But there might be more to this than meets the eye.

The benefits of dancing, for example, exceed mere physical exercise. One can easily see the primary benefits include improved balance and a reduced risk of falls. Dance has also been shown to have considerable physical benefits for older adults with arthritis, osteoporosis, and neurological conditions.

As early as 1989 Robert Katzman and Joe Verghese (2004) from the Albert Einstein College of Medicine were researching other benefits from dancing. In a 21-year study of older adults, 75 years and older, they examined the extent to which physical or mental recreational activities influenced brain health.  They studied mental activities such as reading books, writing for pleasure, doing crossword puzzles, playing cards and playing musical instruments.  And they studied physical activities like playing tennis or golf, swimming, bicycling, dancing, walking for exercise and doing housework. One of the surprises of the study was that almost none of the physical activities appeared to offer any protection against dementia with one important exception:  frequent dancing. Mental activities that offered similar protective benefits included playing an instrument and playing board games.

Music and dancing are becoming central features of healthy longevity.   Perhaps dancers and musicians are more resistant to dementia as a result of having greater cognitive reserve. They have more ways of thinking.  We have a word for this--neurogenesis--where our brain constantly rewires its neural pathways through dancing and playing music.

Gerontologists still argue why dancing shows benefits and playing tennis for example, does not.  Research using computer exercises show that engaging in unique events stimulates the brain to react and develop. Unstructured dancing, which requires instant reaction to your partner’s movements, stimulates the connectivity of your brain.  Unique and even frustrating classes have better results, as they create a greater need for new neural pathways. Dancing also makes your gait look better and you become more attractive.

In a study in 2005 William Brown and colleagues at Rutgers University found that people appear to be able to pick desireable partners based on the way they dance. The researchers analyzed 183 young dancers by attaching infrared markers and filmed the markers for one minute. Then they asked peers to evaluate how well the computer-generated figures danced. They found that skillful dancing is associated with desirability and attractiveness.

Dancing simultaneously involves movement, social engagement, musical appreciation, emotional expression and makes you more desirable. Repeating the poet Edwin Denby, “There is a bit of insanity in dancing that does everybody a great deal of good.“ 

HIV/AIDS among Older Adults

Hollywood sells the sexual revolution with ever changing but always young protagonists.  The reality looks much different, with older adults having more sex than we expect. A recent AARP study published in 2010 reports that for older adults aged 60 to 69, 42 percent of males and 32 percent for females had sexual intercourse in the past week or month. Although sexual activity declines with age, it does not go away. Even those 70 years and older, 22 percent of males and 11 percent of females report having sexual intercourse at least once a month.

Sexual activity comes with the risk of Sexually Transmitted Diseases (STDs). STDs refer to more than 25 infections transmitted primarily through sexual activity. Despite STDs being preventable, these diseases remain a significant issue, especially because some—especially HIV/AIDS—can kill.

STDs remain a hidden and quiet epidemic among older adults. But a perfect storm is brewing. Older adults who recently divorced or widowed started entering the dating scene again. Older women may be especially at risk because age-related vaginal thinning and dryness can cause tears that increase susceptibility to infection. Older men—although lacking experience and knowledge of STDs—seem to have an aversion to using condoms and other safe sex methods. With new easier access to partners through Internet dating, perceived lack of susceptibility and the use of Viagra, older adults are prime candidate for STDs, and statistics are now proving this susceptibility.

The Center for Disease Control and Prevention (CDC) reports that the number of persons aged 50 years and older living with HIV/AIDS continues to increase. In 2005—the latest data we have for older adults—one in four persons with HIV/AIDS was an older adult. This rate increased from one in six in 2001. Of all new cases of HIV/AIDS, one in seven is among older adults and a third of all deaths with AIDS are among older adults.

This increase is partly due to people living longer with the disease—especially due to the highly effective antiretroviral therapy (HAART)—and partly due to new infections.  However, it does not affect older adults equally.  HIV/AIDS rates among older adults are 12 times higher among Blacks and 5 times higher among Latinos compared with Whites.

The lack of testing, and subsequent identification of HIV/AIDS, prevents early detection and early treatment.  Health care professionals may underestimate older adults’ risk for HIV/AIDS. Also some symptoms mimic conditions wrongly associated with aging, for example, fatigue, weight loss, and mental confusion. Early diagnosis, which typically leads to the prescription of HAART and to other medical and social services, can improve a person’s chances of living a longer and healthier life.

Although the sexual revolution continues into older age, be wise and take care of your health by practicing safe sex. For HIV testing the county has a number of sites (including at all STD clinics). You can reach County Health Services Complex at 619-296-2120. The same number also connects you to an HIV Mobile testing unit that does home visits. In addition, people can reach the San Diego LGBT Community Center at 619-692-2077.

Plastic Surgery-Looking Younger in Older Years

Unsatisfied with living longer, some of us also want to look younger. In 2010 the American Society of Plastic Surgeons published national statistics on plastic surgeries. This report tells a story about vanity and the unyielding pursuit of youth.

Last year, Americans spent $10.1 billion on plastic surgery, more than the 2010 budget for the National Science Foundation (and close to the budget of the Environmental Protection Agency).

The surprise is that following the 40-54 year olds--who account for nearly half of all plastic surgery procedures--the main clients are seniors--those 55 years and older!  This older group had more surgeries, cosmetic procedures and minimally invasive procedures than 20-39 year olds.

While most popular procedures among young adults focus on their bodies, older adults are apparently more concerned about more visible features, such as their faces.

Americans aged 55 years and older had 3.3 million cosmetic procedures. Most involved having no surgery at all, opting instead for injections. The most popular procedure--performed 1.2 million times last year--was botox injection, followed by more than a half-million soft tissue fillers (injections of Hyaluronic/polyactic acid, fat, collagen, or calcium hydroxyapalite).

In comparison, for surgeries, nearly a third of these 349,000 procedures involved  eyelid surgery (100,000), followed by facelifts (74,000), dermabrasions (27,000), nose reshaping (24,000) and hair transplantation (23,000). Two out of three facelift surgeries in 2010 were performed on patients who were 55 years and older.

Even though plastic surgery might belong primarily to the wealthy, it is no longer the exclusive domain of Whites. Since 2009, all minorities have shown an increase in the use of plastic surgery--up by 6% for African Americans and 2% equally for Latinos and Asian Americans. The trend is one of convergence. While for African Americans the top procedures include liposuction, nose reshaping and breast reduction, for Asian-Americans it is breast enlargement, nose reshaping and eyelid surgery. Latinos’ top procedures include breast enlargement, liposuction and nose reshaping.

Apparently, Americans of all races share a fixation with physical appearance--one that seems to increase as we age. Do we think we can cheat death by looking younger? In a seven-year study led by Kaare Christensen of the University of Southern Denmark, researchers found that people who looked younger lived longer. Their report published in 2009, asked people to guess the age from photographs of faces of 387 pairs of twins in their 70s, 80s or 90s. They found that the older looking twin is more likely to die first. Surprisingly, the older looking twin also had shorter telomeres--telomere length indicates cell longevity, the longer the telomere the longer the cell will live.

Does plastic surgery, by making us look younger, also “teach” our telomeres to grow? Probably not.

People who have had a tougher life are more likely to have such stress etched in their faces, while at the same time the stress shortens their telomeres. We might modify how our faces look, but those telomeres are still getting shorter. 

Rich Man Poor Man

Three out of five of this year’s Forbes top 100 richest Americans were older adults 65 years and older. These affluent older Americans individually own enough capital to compare with most developing countries. But poverty is the side that we are more likely to hear when we discuss income of older adults. Income of older adults sits along a very very long continuum.  Therefore, talking about average income of older adults hides these extremes.

Most reports on income among older adults talk about poverty.  The reason is easy is to see. In a 2009 Congressional Report, Patrick Purcell reported the median income of individuals aged 65 and older as $18,208. The same report finds that one in four had incomes of less than $11,139.  It is not surprising that for 41% of elderly recipients, Social Security accounted for more than 90% of their total income. Even when older adults worked to supplement their income—the reality for 20% of individuals aged 65 and older in 2008—the median earnings of workers aged 65 to 69 were $25,000.  Clearly, Social Security on its own elevates some older adults out of poverty.

The rate of poverty among older Americans fell from 33% in 1960 to 9.7% in 2008—a rate lower than poverty rates among children under age 18 (19%) and adults aged 18 to 64 (11.7%). However, this low overall rate of poverty among older Americans is not shared by older women (unmarried and/or widowed), minorities, less educated, and adults over the age of 80.

Wealthy older adults comprise the opposite facet of this reality. The Social Security Administration Chartbook of 2008 (the most recent) reports that 23% of older adults aged 65 and older reported incomes of $50,000 or more; while 8% had incomes of more than $100,000.  There is a stark contrast between the very poor and very rich older adults.

A Pew Research study in 2009 asked a sample of adults to identify the most prevalent conflict in America. After conflicts of immigration—nearly half of respondents (47%) identified conflicts between the rich and poor as the most important social conflict. In this same survey, older adults are significantly less likely to see such conflict than those under the age of 50 (36% vs. 51%).

These contradictory worlds—extremely wealthy older Americans and their poor neighbors— highlight why some programs should address needs rather than age. Surprisingly, these two obvious extremes among older adults share a common behavior.

In the Anatomy of a Giver, Tim Stafford reports that in the United States both the poor (those making less than $20,000 per year) and the rich (those making more than $100,000 per year) give the highest percentages of their income to charity. Middle-class Americans—those making between $40,000 and $100,000 per year—donate at the lowest percentage.  Older adults are a disparate group. The older we get the more variance there is among our peers. One such measure of variance is income. We do however share at least one attribute. This attribute is our appreciation that our lasting legacy is to give back.

Sex, Romance and Relationships of Older Adults

The state of well-being among older adults does not seem to be improving. A recent AARP report compared sex and well-being in 1999, 2004, and 2009. Although overall, midlife and older adults currently have a positive outlook on life, this is less so than in 2004. Both the frequency of sexual intercourse and overall sexual satisfaction are down close to ten points since 2004.  Just over four out of ten say that they are satisfied with their sex lives, down from half in 2004. While the frequency of self-stimulation and sexual thoughts remain unchanged. Younger respondents, men, and Hispanics in general are more likely to report being satisfied.

Why should older adults report a decline in general well-being, particularly sexual experience? Several key factors influence sexual activity, including health, medications, stress, finances, and exercise. Health—as reflected by increased use of prescription medications--seems to mirror this decline in general sexual satisfaction and well-being. The most prevalent medications are for cholesterol, taken by 36 percent of all older adults—a number that has doubled since 1999. A similar increase appears in the use of blood pressure medications, which 43 percent of the older population takes--up from 36 percent in 1999. There was an increase in diagnosis of erectile dysfunction for 23 percent of men in 2009, compared to 17 percent in 2004.

Men continue to think about sex more often than women. They see it as more important to their quality of life, engage in sexual activities more often, are less satisfied without a partner, and are twice as likely as women (21 vs 11 percent) to admit to sexual activity outside of their relationship. Distinct male-female differences exist across age groups.

Men report less sexual intercourse, kissing or hugging, touching and caressing, self stimulation, oral and anal sex with increasing age (from45 to 70+).  Women—although the overall percentage is nearly half of that for men—tend to report a peak of activity at age 50-59, with hugging and kissing remaining stable over all ages.

The good news is that those who have sex at least once a week, 84 percent, are satisfied.  Those less satisfied report having sex less frequently. Half of all single and dating males report that they rarely or not at all, use protection during sex. This rate goes down to 29% for women. The statistic is still troubling, given that one in four persons with HIV/AIDS was an older adult in 2005. A fascinating paradox is the quality of life rating. Although both male and female—whether with a current or recent partner or not—show a decrease in reporting high overall quality of life since five years ago (48% from 50%), everyone expects their quality to increase in five years time, in some cases above the peak of five years ago (57%). By age 70, this optimism for the future diminishes, although one in three still report that the future appears more positive!

Sexual activity and well-being are intertwined. We should be aware of the impact that medication, stress, financial situation, and exercise have on our overall sexual health and well-being.

Falling for You

Falling is the leading cause of injury hospitalization and death among Americans aged 65 and older. Fall injuries, including hip fractures, deep bruises and head trauma, represent a growing public health problem that remains under-recognized and under-treated. Sadly, all falls are preventable.

Each year, falls occur for more than one in three (35% -40%) of older Americans who live at home. The older you are the more likely you are to fall.  In nursing homes and hospitals, rates triple (1.5 falls per bed annually). Women sustain about 80% of all hip fractures.  In 2000, the total costs of treating fall-related injuries among older Americans exceeded $19 billion. By 2020, these numbers are expected to climb to $59 billion as a consequence of the growing number of aging baby boomers.

Self-imposed activity limitations from the fear of falling affect more than half of all community-dwelling older adults, leading to increased risks for further falls, depression, social isolation, and a drastic decline in quality of life. In a study of 540 community-living adults aged 70 years and older, Jolanda van Haastregt and colleagues reported that more than half of all study participants said they fell at least once in the previous six months. More than one in four (28%) said they had severe fear of falling and severe avoidance of physical activity.

In 2009, one out of every 27 older adults aged 85 and older called 911 in San Diego County because of a fall. Falling was the fourth most common pre-hospital call, resulting in nearly one in ten of all calls (5,606 in 2009). Falls remain the leading cause of unintentional injury hospitalization for those over 55 years. In 2006 in San Diego County, two thirds of all falls occurred at home--nearly half from slipping (43%). Of these, “emergency room discharge with a fall injury” was highest for the east county cities of Lemon Grove, La Mesa and El Cajon. SANDAG projects that the older adult population for 2015 for San Diego county would be 435,805 it is expected that one in three (145,268) will fall that year. Of these, three out of four will fall a second time.

Aside from substantial medical cost, the individual cost involves more than money. Fall-related injuries are often single most common event that alter mobility and limit independent living.  Many fall injuries, such as hip fractures, increase the risk of premature death. For example, a recent survival analysis of men and women aged 50-plus years who had a hip fracture concluded that hip fractures increased all-cause mortality 5- to 8-fold during the first three months after the injury. Such negative outcomes persist over time. Life is not the same once you have had a significant fall.

Falling does not have to be a death sentence. Many of these risk factors are manageable and potentially correctable. Sensory problems and medications can be address with your health care provider. Since gait and balance problems are strong predictors of falls, yoga, exercise, and the use of assistive devices can reduce the likelihood of a fall. 

Sleep is the Best Medicine

Sleep is the best medicine. Although older adults need as many hours of sleep as younger adults—7-9 hours each night—we often hear the commonly-held but mistaken belief that you need less sleep as you age. Disruption of sleep can cause memory problems, depression, and a higher susceptibility to falls.

In the United States, insomnia is the third most common reason for a medical visit, behind only headaches and the common cold.  As sleeping patterns change for older adults—going to sleep earlier, getting up earlier and napping during the day—it becomes more difficult to fall asleep at night. Once asleep, older adults spend less time in deep sleep—rapid eye movement (REM) sleep—and are often therefore light sleepers. By themselves, even these normal changes can to disrupt sleeping patterns. More than half of older adults have a sleep disorder. The rate is higher among long-term care facility residents. Although researchers have described more than 70 sleep disorders, four disorders hold top billing.  These include insomnia, , sleep apnea, restless legs syndrome, and narcolepsy.

Among older people, women experience insomnia than men.  Insomnia—which is the most common sleep problem in adults age 60 and older—results in trouble falling and staying asleep. About 60 million Americans a year have insomnia, which tends to increase with age. It affects about 40 percent of women and 30 percent of men.

Sleep apnea is a disorder of interrupted breathing during sleep. It usually occurs in association with fat buildup or loss of muscle tone associated with aging. These changes allow the windpipe to collapse during breathing when muscles relax during sleep and is usually associated with loud snoring (though not everyone who snores has this disorder). An estimated 18 million Americans have sleep apnea.

Restless legs syndrome (RLS) and periodic limb movement disorder (PLMD)--an unpleasant crawling, prickling, or tingling sensations in the legs and an urge to move them for relief--affects as many as 12 million Americans.  In one study, RLS and PLMD accounted for a third of the insomnia seen in patients older than age 60.

Older adults with narcolepsy have frequent "sleep attacks" at various times of the day, even if they have had normal amounts of night-time sleep. Narcolepsy affects an estimated 250,000 Americans who have attacks lasting from several seconds to more than 30 minutes. The disorder is usually hereditary, but is occasionally linked to brain damage from a head injury or neurological disease.

Disruption of sleep becomes more common  as we get older. Some clinical research now focuses on the role of melatonin in this cycle. Some serious conditions need consultation, while others just require a more disciplined approach to going to sleep.

Amanda Dew and her colleagues at the University of Pittsburgh, USA looked at one such reflection of peace of mind, sleep and how it can influence an early death. After controlling for things that can also influence death, such as age, gender, and how healthy they were, they then could predict death based on their sleep patterns. Individuals who take longer to sleep than 30 minutes were more than twice at risk of death. While those who sleep for less than 4/5th of the time while in bed were nearly twice as likely to die earlier. Even those who either dreamt too much or too little (Rapid Eye Movement sleep) were nearly twice as likely to die earlier. Sleeping just right is an important process that can promote longevity.

Follow a regular sleep schedule. Go to sleep and get up at the same time each day, even on weekends. Try to avoid napping and make an effort to get outside in the sunlight each day. Stay away from caffeine late in the day. Exercise and light meals also contribute to better sleep. You can sleep yourself to good health.


Refernces

Dew, M. A., Hoch, C. C., Buysse, D. J., Monk, T. H., Begley, A. E., Houck, P. R., ... & Reynolds III, C. F. (2003). Healthy older adults’ sleep predicts all-cause mortality at 4 to 19 years of follow-up. Psychosomatic Medicine, 65(1), 63-73.

Tele-Intensive Care Units: Technology at the end of life.

Intensive Care Units (ICUs), representing a major facet of health care in U.S. hospitals, now treat six million of the sickest and oldest patients every year. One of every five older adults dies in an ICU. The Health Resources and Services Administration (HRSA)—remains the primary federal agency for improving health care access for people who are uninsured, isolated or medically vulnerable. HRSA reports that patients in acute care hospitals receive more than 18 million days of care in ICUs each year. Already costing almost one percent of U.S. gross domestic product, the demand for ICU services is projected to grow rapidly during the next decade as the older adult population increases. The ability of critically ill patients to receive adequate care depends upon a number of factors. A 2002 HRSA Report to Congress projected that there will be a shortage of highly-trained ICU physicians (known as intensivists), the other possibility to meet the demand is to see if health care efficiency can be improved.

This is where “telemedicine ICUs” come in. In Tele-ICUs an intensivist physician and four nurses in one command center can oversee the care of up to 75 patients in distant ICUs. These clinicians are aided by “smart” databases that track patients’ clinical values and alerts the local ICU staff when signs indicate a negative trend or when a change in treatment is scheduled according to protocols. The local ICUs, staffed with physicians and nurses providing direct care to patients, do not have to be intensivists.

A recent study in 2007 by Massachusetts Technology Collaborative (MTC) and the New England Healthcare Institute (NEHI) reported that Tele-ICUs saved lives. The study found other benefits. Tele-ICUs decreased mortality by 20 to 36 percent, shortened ICU stays by 30 percent, and recovered up-front investment costs in less than one year. Tele-ICUs also enabled community hospitals to care for a substantial portion of patients who would have been transferred to teaching hospitals. Retaining these patients in community hospitals saved the payers approximately $10,000 per patient. Although these outcomes may vary, Tele-ICUs are providing a reasonable way of addressing the projected cost increases of ICU care. Our investment in improving this technology merits close attention. And there are some applications that are at the forefront of technology right here in San Diego.

The Veterans Administration Desert Pacific Healthcare Network runs the Care Coordination Home Telehealth program (covering San Diego) using nurses who can provide care coordination services to up to 150 patients a day. While at a more local level, the San Diego-based Council of Community Clinics is using telemedicine to reach and serve residents of rural community clinics and health centers by using video conferencing to  provide rural residents with access to specialty clinical services and to educate and train rural healthcare providers. Although these are still at an early stage of development, it will only be a matter of time before technology will be applied to tailor health care to frail and dying older adults.

Volunteerism and Wellbeing among Older Adults

Volunteerism has long been one of America's traditions. Since Benjamin Franklin's founding of the first volunteer firefighter company in 1736 we have not looked back. Currently, promoting volunteering and civic service is a major policy agenda of President Obama's Administration. Defying the popular notion that hard economic times suppress civic participation, the number of Americans who volunteer grew last year at the fastest rate in six years. The report, released in 2010 by the Corporation for National and Community Service, says that 63.4 million adult Americans—nearly 27 percent of the population—volunteered to help charitable causes last year. That’s an increase from 2008 of roughly 1.6 million volunteers, the largest single-year jump since 2003. In total, 2009’s volunteers donated about 8.1 billion hours of service, valued at nearly $169-billion, says the report, which is based on annual and monthly surveys of roughly 100,000 Americans age 16 or older, conducted by the U.S. Census Bureau for the Bureau of Labor Statistics.

Older adults are the backbone of this tradition. Although sometimes taken for granted, without this volunteering most agency or cities cannot function at the level that they do today. To define the importance of volunteers, a unique study was undertaken in 1998. Dixon Arnett, who then headed the California Department of Aging, conducted an extensive survey to find out how many volunteers there were in all of its programs provided through some 720 separate entities.

The findings showed that throughout the state there were an incredible 67,620 volunteers. These volunteer contributed to a total of 757,120 hours. Multiplying that by California’s minimum wage at the time ($5.75/hour), the total value of those hours – per week – was $4,353,440 – an annual national value of $226,378,880 in 1998! At that time the total federal and state taxpayer-provided appropriations for these older adults programs was $159 million. With the volunteers, the federal and state governments realized a 142% return on its investment.

But the real value is far more in the giving of one’s self then in the receiving of care. A growing body of research is pointing to the social, emotional, and even physical health benefits of volunteering. A study published last year led by University of Pittsburgh researcher Fengyan Tang, found that the volunteers reported significant improvements in their mental health, along with a greater feeling of productivity, increased social activity and an overall sense that their life had improved. What’s more surprising is that the less affluent the volunteers the higher their reported benefits. In this way, all older adults are able to enhance their sense of purpose, satisfaction, and good health later in life at the same time that they give back to society. It also helps our economy. For volunteering in San Diego check out volunteer San Diego at http://www.volunteersandiego.org/ and you can also go to your local faith-based organization and other organizations including Oasis at http://www.oasisnet.org/.

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Mario Garrett, PhD, is a professor of gerontology at San Diego State University. He can be reached at mariusgarrett@yahoo.com

Homeless Older Adults

The economic downturn continues to affect older adults, as evidenced by AARP’s recent suit against the Department of Housing and Urban Development (HUD).  It’s about reverse mortgages.  AARP argues that HUD—by insisting that surviving spouses (who are not named on the mortgage) pay the full loan balance to keep their home—is pushing older adults into foreclosure. And in fact, this policy ignores HUD’s own provisions against displacing a surviving spouse.

Reverse mortgages, which pay older homeowners a regular sum against the equity in their house, were designed to shield borrowers from economic upheaval. More than a half-million people have received reverse mortgages since Congress authorized the program a quarter-century ago. Those who withdraw equity cash through this program must be at least 62 years old. Participants receive either a lump sum or monthly payments from lenders. After their death, the house is sold and the mortgage is paid off. However lenders sometimes encourage only the elder member of a couple to put his or her name on the mortgage—hence the issue with the surviving spouse having to pay-off the mortgage.

Since last year, more than 32 percent of all San Diego County homeowners with mortgages were upside-down—owing more on their mortgage than the house is valued—according to CoreLogic. During the past three years, more than 640,000 Californians have lost their homes. This statistic reflects other key indicators of economic health. The average credit card debt among adults aged 65+ was $10,235. The consequences of the burst housing market and the resulting loss of equity have resulted in one in seven older adults facing retirement with a negative net worth.  It comes as little surprise that AARP in 2008 reported that Americans aged 50 and older accounted for approximately 28 percent of all delinquencies and foreclosures.

One repercussion from these events is that over the next ten years, HUD projects a 33 percent increase in homelessness among adults over the age of 62. This was unheard of in the past. In HUD data for San Diego County in 2009, individuals aged 51 years and older occupied 28% of local emergency shelters (933) and occupied 25% of all transitional housing (1018). Two years ago, Los Angeles-based Shelter Partnership, an advocacy group, released a study showing that among Los Angeles’ homeless population, 3,000 to 4,000 are over 62 years old and more than two-thirds struggle with some disability.

In our nation’s history, homelessness has rarely been an aging issue. With social security, Medicare, and rising home equity, older adults were unlikely to be displaced. The new economy has changed that. To help the homeless San Diego has eleven agencies and you can access their contact information at http://allcare.net/s2/sd.php#shelters. If you are having trouble with your mortgage and need free unbiased advice, try San Diego Home Loan and Education Center tel: 619-624-2330. Sometimes bad things happen to good people but it is prudent to check out all options beforehand. It is important to realize that this is happening across San Diego County and that you are not alone.

Sex, Drugs and Rock & Roll

Today's older adults are the generation that created the culture of sex, drugs and rock and roll. The 1960s rallying call of that generation was best exemplified by Timothy Leary's "Turn on, tune in, drop out."  This year, the first wave of the counterculture generation becomes eligible for social security, Medicare, and discount early bird meals at the local cafeteria.

Researchers report that the baby boomers who discovered marijuana, cocaine and other drugs as young people apparently haven't given them up. All these studies refer to older adults as any adult 50 years and older.

Two new federal studies support this assertion.  Although substance abuse is more common among younger adults (aged 18 to 49), the rate of illicit drug use among older adults aged 50 to 59 increased from 2.7 percent in 2002 to 4.6 percent in 2008 and continues to climb.  This statistic comes from a new study by the Substance Abuse and Mental Health Services Administration (SAMHSA). This report indicates that 4.3 million older adults (4.7 percent) used an illicit drug in the past year. Men are more likely than women to abuse alcohol, marijuana and other illicit drugs. Male and female older adults report similar rates for abuse of prescription drugs.

The SAMHSA report also shows that there are differences between aging cohorts, with older adults using marijuana as the drug of choice, while old older adults (65 years and older) prefer prescription drugs. Additionally, many older adults use prescription and over-the-counter medications that could interact adversely with illicit drugs and may themselves have the potential for abuse. This does not include the use of legal drugs such as alcohol.

Older adults abusing drugs are more likely to end up in an emergency room. The Drug Abuse Warning Network estimates that 118,495 emergency visits involved illicit drug use by older adults in 2008. Cocaine was the most common cause of emergency room visits (63 percent), followed by heroin (27 percent), marijuana (19 percent), and illicit stimulants (5 percent). Nearly a third of these visits also involved alcohol.

Of these visits one in ten were referred to psychiatric or chemical dependency/detoxification services. It is becoming increasingly important to understand and plan for substance use prevention and treatment needs of this vulnerable population since the numbers will inevitably grow.

The number of adults over 50 with substance abuse problems is projected to double from about 2.5 million in 1999 to about 5 million in 2020. These numbers directly translate to increased demand for treatment.  According to one study by Gfroerer and colleagues, treatment for illicit drugs use for older adults is projected to increase more than 500 percent between 1995 and 2020.

Reducing and treating drug use problems among the growing older adult population requires both medical and behavioral intervention. Although older adults are less likely to abuse substances, when they do they are more likely to end up harming themselves. If you need help with substance abuse call the hotline provided by the San Diego County Adult Emergency and Crisis Mental Health at 1-800-479-3339. Turn on, tune in, drop out.  Just don’t drop dead.

Facing the Music

Carroll Pratt delivered a talk in 1950 entitled “Music as the Language of Emotion.” Gerontologists are increasingly finding how different spheres of aging—genetic, biological, psychological, and social—all interrelate. We are looking more closely at the role emotions play in mediating these different spheres. If Carroll Pratt is correct, and music is indeed the language of emotion, then we need to start examining how music relates with emotions and affects longevity.

We all know that playing or listening to music can be pleasurable. But is it also beneficial? Social and psychological researchers repeatedly find benefits in listening to music. Studies looking at how music reduces or increases stress include a classic 1993 study by JoAchim Escher in which a group of patients undergoing gastroscopy were allowed to select and listen to music during surgery, while a control group heard no music. The study showed a much-reduced rise in stress hormones—ACTH and cortisol--for the music group. It seems that music mitigates negative experience.

Apparently, rather than music by itself eliciting these changes, they are a result of how we interact with music. Whether music speaks tranquility or excitement depends on how the music is interpreted. Some music is intuitively “soothing” and “relaxing.” Martin Möckel and his colleagues at the Free University of Berlin found that meditative music was best at reducing levels of cortisol and noradrenaline, but even this effect depended on the listeners. Some listeners, especially music students, showed increased cortisol levels regardless of the type of music. It seems that these students were actively engaged in analyzing the music.

The paradox of aging also rears its complex head. Increased levels of stress hormones do not necessarily have just negative effects, but also has some benefits. Hormones can enhance muscle and skin tone for the short term and can enhance memories of events that occurred concurrently. Thus, if one wants to increase memory, music that produces transiently higher hormone levels might be beneficial, for the short term.

It could be that healthy older adults already self-select music in order to arouse or soothe their autonomic nervous system. The crucial study, conducted at Loma Linda University School of Medicine and Applied Biosystems in 2005, revealed that listening to music can turn off DNA-based switches that determine human stress response. The potential of inducing and subsequently reversing gene expression in this manner may suggest new and exciting possibilities for testing and tailoring specific treatments to an individual, rather than a group. Music and how we interact with it is seems to be a language of how we communicate with our bodies. San Diego offers many opportunities to learn how to appreciate music, or to start playing an instrument. Perhaps for some, it might be reuniting with a childhood instrument. Check out the classes at your local adult enrichment center, or call 1-800-510-2020 for the one nearest you. If music is the language of emotions, then we need to open those channels of communication.
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Mario Garrett, PhD, is a professor of gerontology at San Diego State University. He can be reached at mariusgarrett@yahoo.com.

Collecting problems: Hoarding

We have all known pack rats.  Maybe we have occasionally been guilty of stockpiling unnecessary stuff ourselves. But when this behavior starts interfering with our daily routine it becomes hoarding. Hoarding—the excessive collection of items, along with the inability to discard them—often results in cramped and unhygienic living conditions in homes, resulting in narrow pathways winding through stacks of clutter. 

Although hoarding can be found in people of any age, race, education, socio-economic status, gender or nationality—it is more prevalent in older adults.  They are unaware that their living circumstances pose a danger to themselves and to others, yet they are unable to change their behaviors on their own.

We do not know how many people are hoarders in the country because most do not seek help. Some studies estimate that two to five percent of Americans exhibit hoarding behaviors. One of the few comprehensive studies—a 2009 initiative of the Department of Aging and Adult Services and the San Francisco Mental Health Association—estimated that between 12,000 to 25,000 people in San Francisco struggle with hoarding behaviors.

People who hoard often don't see it as a problem, making treatment challenging. Not enough is known about the disease to determine whether it's an addiction or a compulsion. But intensive treatment can help people who hoard understand their behaviors and live safer, more meaningful lives.

Hoarding—also called compulsive hoarding and compulsive hoarding syndrome—can be a symptom of obsessive-compulsive disorder (OCD). Most people with OCD know that their obsessions and compulsions make no sense, but they can't ignore or stop them. Most older adults who hoard don't have other OCD-related symptoms. 

The National Institute of Mental Health reports that OCD affects about 2.2 million American adults.  The problem can be accompanied by anxiety disorders or depression. It strikes men and women in roughly equal numbers and usually appears in childhood, adolescence, or early adulthood. One-third of adults with OCD develop symptoms as children, and research indicates that OCD might run in families. The course of the disease is quite varied.

Initially, families or caregivers might approach the problem as simply an issue of cleaning up the house or apartment. But compulsive hoarding is not only a health and safety issue, it is also an expression of psychological trauma. If we don’t address the underlying problem—the reasons for hoarding—the behavior will come back within a few months.

If you suspect a hoarding situation in your neighborhood or with a family member you need to seek professional help. A comprehensive list of resources for San Diego can be accessed through telephone listings through the San Diego Boarding Task Force, which include a list of county, city, university and private agencies that treat hoarding victims and their families. The website also includes local support groups and vendors:  http://www.hoardingtaskforce.org/san-diego-hoarding-collaborative/.  Addressing the root of the problem of hoarding might resolve long standing issues, and make their lives safer and more meaningful.

Oldest Boldest

We want to retain our youth—our vigor—-for longer periods of our lives.  We should heed the lesson of Tithonus, a mythological Greek king whose lover granted him immortality but not eternal youth.  He eventually become so wrinkled and incapacitated that his lover turned him into a cicada—eternally living, but begging for death. What we seek is not just longevity but vigor, and a lot of older adults are finding it and holding on to it.

Louis Armstrong was 66-years-and-10-months-old when his career peaked with "What A Wonderful World" and "Cabaret" in 1968.  Armstrong is one of many who continued to be especially productive into older age. Numerous examples exist of artists, actors, writers and academicians who continue to produce great work at older age. A half-century ago, Harvey Lehman showed that our most creative period is between ages 33-36.  But the formula is not prescriptive, and exceptions are common.  When it comes to health and longevity, we all want to be the exception. It is not that we just want to live longer, it is that we want to live longer, healthier.

More and more older adults are breaking conventional expectations about physical barriers. In 2006, Maria del Carmen Bousada Lara gave birth to twin boys in Barcelona, Spain. Nothing remarkable about that except Lara was within a week of her 67^th birthday.  Although older adults are breaking records across the board, 2002 was a banner year. Tamae Watanabe reached the summit of Mt Everest at the age of 63. Jenny Wood-Allen completed the London Marathon at 90-years-old. James Talbot Guyer  parachuted off the 148 m (486 ft) high Perrine Bridge near Twin Falls, Idaho at age 74 years. More recently, Robert McKeague, age 80, completed the 2005 Ford Ironman World Championship. Two years later, Linda Ashmore swam the English Channel at age 60. After that, Bahadur Sherchan reached the highest point on Earth—summiting Mount Everest at the age of 76.

Thomas Perls, a gerontologist who studies centenarians, has shown that although income and education increase our survival rate to age 85, the rest of our survival is pretty much determined by genetics. We can’t do anything about that, at least for now. Still, it seems that a lot more older adults are reaching older age while they’re healthy and active.

We will see more of these "exceptions"—older adults who are not only productive in the arts and sciences, but also in sports. For some people, we might see our vigor extending to later life. But with this vigor comes responsibility. We shouldn’t believe that being healthy equates to unlimited longevity or immortality. In a way it reminds us that the best we can hope for is to die while we are healthy. Remembering the story of Tithonus, we don’t have much of a future as cicadas.