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.

Old Problems New Approaches : mHealth

Mobile Health (mHealth), a new initiative in health delivery—involves telemedicine, wireless health, and electronic health.  It refers to the use of mobile phones to provide limited but essential health care, that is being driven especially by older adults and the parallel increases in the prevalence of chronic conditions they experience. Chronic conditions can often be prevented by behavior change or treated through frequent monitoring and medication. An essential strategy for keeping older adults healthy means preventing chronic diseases and/or reducing associated complications. Older adults who take advantage of preventive services are more likely to remain healthy, live independently, and incur fewer health-related costs. About 80% of older adults have one chronic condition, and 50% have at least two. For those 65 years and older, the most common chronic diseases are heart disease, cancer, stroke, lower respiratory diseases, Alzheimer’s Disease and diabetes. All of these conditions benefit from close monitoring.

The growing use of mobile phones, with their increasing capacity for more applications, has opened opportunities to monitor patients frequently by using personal mobile phones.  As cell phone use becomes increasingly cheap and accessible, mHealth technology becomes that much more viable.

Part of mHealth’s great potential for older adults, is that it brings the caregiver into the picture by allowing family or providers to access the health status of their care recipient from remote locations. The provision of an effective way to monitor a care recipient’s status from a distance has never before been so cheap and attainable.

A 2011 report by the National Alliance for Caregiving, asked caregivers what technology they desired most and what barriers stopped them from using it. They reported that the three favorite applications would include one that tracks a care recipient’s vital signs, symptoms, medications, and other information. Another would be a shared electronic log for the care recipient’s medical appointments and other caregiving needs.  This application would include an interactive feature so family members and other caregivers could use it to sign up to help. The third application was an electronic system that reminds the care recipient about their medication and dispenses pills on schedule. This application, would alert caregivers by phone or e‑mail if a dosage is not removed from the dispensing device within a certain time period.

Such applications—unimaginable only a few years ago—are within our grasp.  However the most commonly reported obstacle is still the belief that such technology would be too expensive. While today’s younger caregivers are more likely than their parents to expect more “high tech” benefits from programs like mHealth, everyone can now benefit from this technology.

Many now believe that mHealth can help with saving time, facilitating caregiving, making the recipient feel safer, making sure that medication is taken, and closely monitoring the care recipient. With Medicare and Medicaid considering charge codes for mobile health it is only a matter of time before mHealth becomes part of the arsenal within San Diego’s healthcare system. Is it time to see your phone as a health care provider?

Pet Therapy: Four-legged Florence Nightingales

The story that older adults benefit from pet therapy is misguided. EVERYONE benefits from pet therapy. Who ever thought that a four-legged bundle of soft fur or a smiling dolphin can make you feel better and actually healthier? Pet therapy, also known as Animal Assisted Therapy (AAT), is a broad technique involving any interaction that patients have with animals to make them feel better. In 1859, Florence Nightingale wrote that a small pet “is often an excellent companion for the sick, for long chronic cases especially.” Apart from the possibility of small pets causing falls for frail older adults, pets provide multiple benefits to their companions. It not only feels good to be around pets, but it makes you healthier. Emerging studies show that pet therapy translates to positive clinical outcomes.

Even just owning a pet has been found to be beneficial. Dog ownership is associated with lower heart attack risks and increased survival one year after a heart attack. Older pet owners walk significantly farther when they walked with a dog, which might contribute to their making fewer visits to the doctor. And it is not just having a companion—talking to a pet rather than a person was associated with lower heart rate. Even in nursing homes, the presence of a dog is associated with reduced need for medication, improved physical functioning, and improved vital signs—even when patients are suffering from dementia. The list of benefits includes reductions in loneliness, agitated behaviors, and depression, and increases in engagement, well-being, nutritional intake, and social interactions. It sounds like a panacea. But what is the reason for these health-boosting outcomes?

One line of aging research that shows great promise investigates how pet therapy generate hormones that affect mood. The University of Missouri-Columbia, currently conducting research in this arena, suggests that hormonal changes that naturally occur when humans and dogs interact could help people cope with depression and certain stress-related disorders. Preliminary results show that a few minutes of stroking our pet dog prompts a release of a number of these "feel good" hormones in humans, including serotonin, prolactin and oxytocin. In addition, decreased levels of the primary stress hormone cortisol, the adrenal chemical responsible for regulating appetite and cravings for carbohydrates, occurs.

If you already have a pet, one of the hidden added benefits is that you can share them and help others. This is not only beneficial to patients but also to the volunteer on a number of fronts. Older adults can volunteer by going to nursing homes, hospice, clinics or schools and providing pet therapy with their pet. Before heading out the door with your little puppy you need to make sure that you are certified. The San Diego Humane Society and SPCA has been bringing the joys of animals to people for more than 30 years through its Pet-Assisted Therapy (P-AT) Program. For more information contact them at (619) 299-7012, ext. 2271 or pat@sdhumane.org. Paw’sitive Pals is another well-established program here in San Diego paws@pawsteams.org. While more information about the Pet Therapy Program at San Diego Hospice can be accessed at http://www.sdhospice.org/pdf/.pdf By training your dog to become a service dog you not only become better engaged with your pet and the community, you will become part of the therapy for frail older adults.

Mario Garrett PhD is a professor of gerontology at San Diego State University. He can be reached at mariusgarrett@yahoo.com © Mario Garrett 2011 blogs at http://iage-marius.blogspot.com/

Retirement: a Gold Watch or a Golden Nest Egg

Retirement is a construction of modern society. It was created when the German chancellor Otto von Bismark succeeded in launching the first social security program in 1889. The introduction of social security followed a decade of smaller workers’ programs addressing the economic insecurity at that time. By the end of the Second World War, the UN General Assembly adopted the Universal Declaration of Human Rights, whose Article 22 recognized that “Everyone, as a member of society, has the right to social security . . . .”

Americans, 120 years later, are now revisiting the “right to social security.” With an increasing older population, lengthening of life expectancy, diminishing personal savings, and an elusive government social security fund, we have started questioning the viability of retirement. Although current discussion under the Obama administration centers around raising retirement age and reducing benefits, a more radical debate centers on whether we can afford retirement at all and whether we deserve it. In San Diego, retirement news has become synonymous with the greedy geezers syndrome. The reality is however more complex.

Variations in wealth among older Americans are striking. Americans in the lowest fifth of the wealth distribution spectrum have little, or negative net worth. This contrasts with households in the highest fifth, averaging $1.5 million and $800,000 net worth. The recent downturn in the economy will see more people pushing back retirement. One survey found that about 40 percent will delay retiring by four or more years.

It seems that many Americans are still shell-shocked after losing much of their 401(k) nest eggs during the last two years. Even though many workers might have partially regained some of their investments, others are still concerned about their ability to save for the long term. Only 16 percent of baby boomers said they have confidence in their ability to save enough for a comfortable retirement. The rest—83% of the baby boomers— intend to keep working after retirement. A hardy group (14%) is reporting that they will never retire from their current job. But sometimes we have no choice.

Health problems can have a big influence on the decision to retire early. One analysis suggests that poor health is a stronger influence than financial variables on people's decisions to retire. Financial well-being is strongly related to the health of both partners. Average household net worth was $31,000 when both partners were in poor health but more than $400,000 when they were in excellent health. People who had a major unexpected health event, such as heart attack or stroke experienced an average cumulative income loss of nearly $37,000. On average, loss of earnings, rather than out-of-pocket medical costs was the major factor in the loss of wealth.

Studies show a consistent lack of knowledge among older workers about their pension plans. Lack of knowledge appears to be related to lower savings and wealth. Such findings underscore that education about retirement planning makes a difference in how we plan for our future. Staying healthy to enjoy the benefits is another story altogether.

Mario Garrett PhD is a professor of gerontology at San Diego State University. He can be reached at mariusgarrett@yahoo.com © Mario Garrett 2011 blogs at http://iage-marius.blogspot.com/

Anti-Aging : A New Windmill for Don Quixote

In 2009, the American Medical Association (AMA) assessed the risks and benefits of growth hormone, testosterone, estrogen and DHEA for anti-aging. The AMA concluded that the risks outweigh the potential benefits. As part of the anti-aging industry that has mushroomed in the last decade, growth hormone offers the most illustrious of histories.

Although much maligned, the 19th Century scientist Adolphe Brown Sequard provided his elixir for free—an extract in water from the testicles of two-year old dogs and guinea pigs mixed with semen and blood from the testicular veins—to anyone that requested it, at an estimated cost of $42,000 in today’s money. His search for the anti-aging hormone testosterone did, however, lead to the birth of the science of endocrinology. His philanthropic donation was a far cry from today’s industry. Global Industry Analysts report that the world market for anti-aging products reached $115.5 billion last year, roughly the size of Iraq’s gross domestic product.

The findings by the AMA expose a paradox of using powerful chemicals for anti-aging purposes. Although most of these hormones help the body look “young,” there are dangerous side effects. For example, adults whose pituitary glands overproduce growth hormone have premature heart and lung failure, as well as abnormal growth of other organs and tissues. We know that the steroid testosterone produces muscle mass, but it also results in short-term sexual and reproductive disorders, fluid retention, and severe acne. Possible long-term effects may include heart damage, stroke, and brain tumors.

In fact, lower growth hormone levels may indicate good health. So, although research with hormone replacement has resulted in some positive short-term results, it is clear that negative side effects also may occur as increased risk for cancer, cardiovascular disease, and behavior changes. This evidence still leaves us with a safer path—one of the best known methods for increasing the lifespan is simply consuming fewer calories. A low caloric diet reduces hormone levels and seems to activate specific genes that are responsible for longevity.

As far back as 1935, Mary Crowell and Clive McCay of Cornell University conducted experiments on laboratory animals to determine if caloric intake affects longevity. The results have shown that laboratory animals—across all species studied— extended their lives by 30% to 40% and age more slowly when they are fed healthy, very low calorie diets that contain essential nutrients.

In his book, Beyond the 120 Year Diet: How to Double Your Vital Years, Roy Walford proposed that longevity can be significantly increased by a diet that is high in nutrients but contains about a third less calories. Although Walford died of Lou Gehrig's disease at age 84, he expressed one of three distinct pathways that we know that affect longevity — the other two being insulin/IGF signaling and the mitochondrial electron transport chain pathway (see future articles). While the National Institutes of Health undertake their first preliminary study on caloric restrictions with humans, we can promote our chances of longevity by not over-indulging and consuming quality rather than quantity.

Mario Garrett PhD is a professor of gerontology at San Diego State University. He can be reached at mariusgarrett@yahoo.com © Mario Garrett 2011 blogs at http://iage-marius.blogspot.com/

A Century of Living:Centenarians and Living Longest

Biblical belief holds that “our years are threescore years and ten; and if by reason of strength they be fourscore years, yet is their strength labor and sorrow…” (Psalms 90:10). For those that have reached 100 years old (centenarians) and have broken through the barrier of fourscore years (80 years), what is their strength, labor and sorrow?

The United States currently has the greatest number of centenarians in the world, estimated at 70,490 on September 1, 2010. This statistic is partly a result of America's large population. California being the most populous state also has the largest number of centenarian residents at 5,341.

Since Methuselah--from the Old Testament of the Bible, who was erroneously reputed to have lived to 969--accuracy has always been an issue. With recent inaccuracies uncovered in Japan where officials now say that they are unable to account for more than 1,000 of the country's 44,449 listed centenarians, it is likely that our figures are still, similarly overinflated (last year the estimates were adjusted downwards from 96,548). Despite these inaccuracies, even if we account for a high margin of error, centenarians are one of the fastest growing segments of our population. In developed countries, the prevalence of centenarians is about 1-in-6,000. Supercentenarians, those who reach 110 years or more, are rarer with 1-in-7 million people living this long.

Although genetics play a dominant role, luck and money contribute. We cannot do very much with luck. Jean Calment who was the longest living human being dying at the age of 122 years, outlived her daughter Yvonne who died of pneumonia and her grandson Frédéric who died of a motorcycle accident. Both died at the age of 36.

Being rich helps. Although not all centenarians are rich, rich people are more likely to survive to old age then poor people. The secret with money is not being rich but having enough, and that can be very subjective. Although researchers found that 67 percent of 100-year-olds had income below the poverty line, 95 percent indicated to the researchers that they had enough money to meet their needs, and 76 percent reported they had “enough to buy extras.”

Although most centenarians live independently until age 92 by the time they reach the century mark, half are living in nursing homes, while 15 percent are still living alone. The rest are living with someone, or in assisted living facilities. And about 85 percent are women. Researchers indicate that centenarians tend to have an extroverted personality. Centenarians will often have many friends, strong ties to relatives and a healthy dose of self-esteem. This is true of Laura Simon, a La Jolla resident, who at 105 qualifies as one of the oldest residents in San Diego. Attitude is important.

In Blue Zones--Dan Buettner's analysis of region of the world where people commonly live active lives past the age of 100 years--the zones are not based on geography but based on clusters of people that share common practices. Apart from not smoking, eating healthy, and constant moderate physical exercise, the other contributing factors relate to family and social engagement. Invite your family and friends over, they will be the ones that will support your longevity.

Caregiving : Providing care for a loved one: what’s the harm?

Caring for a loved one defines the purest expression of love. And there is a lot of love out there. A 2009 AARP report indicates that more than 48.9 million Americans care for an adult family member or friend. Caregivers are predominantly female, have an average age of 48 years and are mainly caring for a relative. One out of three has been providing care for more than five years. Almost all caregivers report adverse effects on their emotional health, social activities, leisure time, and more than half reported adverse effects on family relationships.

In a 6-year study of elderly people caring for spouses with Alzheimer's Disease, Janice Kiecolt-Glaser found a significant deterioration in the health of caregivers when compared to a similar group of non-caregivers. She found a four-fold increase in an immune system protein—interleukin 6 (IL-6), a protein that indicates stress on the body— as compared to an identically matched control group of non-caregivers. All other factors, including age, were not significant to the outcome. Even the younger caregivers saw an increase in IL-6.

The study also found that the caregivers had a 63% higher death rate than the control group. About 70% of the caregivers died before the end of the study. Another surprising result was that high levels of IL-6 continued even three years after the caregiving stopped. The blood sample was also used to measure the lengths of telomeres—bits of DNA on the ends of chromosomes—which have been associated with aging. The shorter the telomeres the shorter their life. Caregivers showed significantly shorter telomere length than did non-caregiving participants.

Earlier research had already established that caregivers have higher rates of depression and poorer health. Their wounds heal slower, they respond poorly to influenza and pneumonia vaccines and they suffer more inflammation. When subjects were given intravenous fat injections during times of stress, it took longer for the fats to be filtered from the bloodstream. Residual fat in the blood stream is one of the causes of heart disease. Caregiving becomes more stressful the longer you do it.

Being aware of this and planning to minimize as much of the stress as possible can be achieved by following some direct approaches:
1. Ask for help: Start off with a sibling, spouse, friend and neighbors and get written commitments from those willing to help.
2. Seek care management advice: Go to http://eldercare.signonsandiego.com/?q=taxonomy/term/457 for county lists of agencies. Or call the hot line 211 for general information.
3. Make time to rest: Taking a break (respite) from caregiving is important for your health. Make arrangements with family or friends or plan to take your loved one to an adult day care center for short periods. Visit: http://eldercare.signonsandiego.com/?q=taxonomy/term/455 for services to provide you with respite
4. Use assistive technology: Use wheelchairs, canes, ramps, bathroom rails, and other assistive devices to help with caregiving. Go to http://eldercare.signonsandiego.com/?q=equipment to identify services that can help you with assistive technology.

Caring for someone you love is, or will be, one of the most stressful events in your life. By recognizing this and managing your obligations so that you give yourself respite will go some way to not becoming ill or harming yourself.

Mario Garrett is a professor of Gerontology at San Diego State University can be reached at mariusgarrett@yahoo.commariusgarrett@yahoo.com
© Mario Garrett 2010

Loneliness & Depression You Are not Alone

From the moment we are born we struggle to establish self-identity. We separate ourselves from others by becoming aware that we are unique beings. With this realization comes the awareness of loneliness. Uniqueness comes at the price of realization that the “I” cannot be shared. This is the essence of existential loneliness. But another kind of loneliness exists as well. This is the “emotion” of loneliness—the feeling of not belonging, of feeling unloved and unwanted.

This year, in a national internet study for AARP, Gretchen Anderson reported that just over one-third of the survey respondents 45 years and older, reported being lonely. More then two thirds reported that they had no specific reason for this feeling.

A general assumption exists that older people are lonelier then other age groups. In the AARP study older adults reported lower rates of loneliness than those who were younger (43% of those age 45-49 were lonely compared to 25% of those 70+). Being married, having higher income, attending religious services, volunteering, having a hobby, being in your current home longer than a year, and reporting better health all contributed to feeling less lonely.

Researchers often confuse loneliness with depression. The two are related, but while depression can be long lasting and might have a biochemical component, loneliness tends to be more short term. The two are however intertwined.

Depression may be described as feeling sad, blue, unhappy, or miserable. Although most of us feel this way at one time or another for short periods, clinical depression changes our mood so much so that it affects sleeping, eating, energy levels, and concentration. It impinges on everyday activities and affects health, relationships, health care use, quality of life, and even mortality.

Depression can creep up on you—especially since most older adults might have multiple ill-health issues at the same time—it can be easy to overlook that depression might be causing some of the symptoms. Steps to address depression should be taken seriously since it correlates with other chronic diseases.

Depression might be an early sign of Parkinson’s disease. The disease affects cells that produce brain chemicals such as serotonin and norepinephrine, which can play a role in depression. In addition, because a chronic vitamin D deficiency can cause both depression and osteoporosis, depression might be the only visible sign of osteoporosis. On of the first signs of Depression, as with Alzheimer’s disease, is the loss of smell. So depression could indicate that there are other, life threatening, neurological changes.

Depression, especially severe depression, eventually reacts favorably to medication, and by alleviating depression loneliness might be mitigated. Realizing that you are depressed and that you need help opens up several good resources. In San Diego the National Alliance on Mental Illness can be reached at 1-800-950-6264, while the County Aging and Independence Service has a Senior Mental Health Team, which provides crisis assessment and assistance, at 1-800-510-2020. Feeling lonely and depressed do not have to be endured alone.

Mario Garrett is a professor of Gerontology at San Diego State University can be reached at mariusgarrett@yahoo.commariusgarrett@yahoo.com
© Mario Garrett 2010

Services for Older Adults in San Diego County Self Help Guide

Most older adults live independently. The majority still work and/or volunteer and are active members of the community where they live. When people refer to frail older adults, they are actually referring to a very small segment of this population. Some individuals become increasingly frail while others have short episodes of ill health in an otherwise healthy and active life. These unexpected challenges—some short, others more long-term—require adaptations and adjustments. In most cases they require support from sources other than friends or family. Sometimes, older adults might feel lost and confused—not knowing where to go for help.

A survey of San Diego County by Aging and Independence Services (AIS) found that 31 percent of older persons said they had problems “getting information about services/benefits.”

Although numerous agencies—government, nonprofit and private—are trying to help, each has its own set of guidelines and requirements. Some individuals have additional questions like, “How do I find out if an agency is better than another?” or, “Which senior center is closer to my house?” Knowing where to go, or who to call to get answers has just been made easier and is as close as your telephone.

San Diego County has a “call center” for older persons, with counselors who are skilled in assisting with most issues. The number is 1-800-510-2020. It works throughout the county and if you have a relative or friend in another part of California, that same number will connect them with their local call center. A national phone number also exists to find out about services across the US. The “eldercare locator,” at 1-800-677-1116—will connect anyone with the local information and assistance center just by providing the local zip code.

The call center and the "network of services" assist not only frail elderly but also active elders. It seems that no one comes equipped to handle aging. We learn about aging through experience and hopefully through education. Active older adults might need advice on where they can work, where can they get involved in their community, or how can they continue with life-long learning. These and many similar questions come from active, healthy older adults. The call centers provide answers and options.

If you are familiar with the internet, the level of helpful resources increases. You can check out the availability of individual services for yourself. In the San Diego area, two major directories contain all the available information about services for the elderly. One is sponsored by AIS and contains most of the information the call center uses. It’s known as the San Diego Network of Care http://sandiego.networkofcare.org/aging/ The second is the San Diego Eldercare Directory, http://eldercare.signonsandiego.com, which is sponsored by the Union Tribune. Living independently—despite some limitations—can be made easier by accessing this vast support network that exists to keep you that way.

Mario Garrett is a professor of Gerontology at San Diego State University can be reached at mariusgarrett@yahoo.commariusgarrett@yahoo.com Joaquin Anguera is a professor of Gerontology at San Diego State University can be reached at joaquin.senior@gmail.com
© Mario Garrett 2010

Loving your Brain Emotional Maturity in Older Age

Although Hans Selye wrote more than 1,700 papers promoting the idea that stress translates to physical problems, only in the last two decades have scientists looked seriously at the mechanics of this connection. Chemicals released under stress can change cell behavior and make you ill.

Recent pioneering work by Janice Kiecolt-Glaser and Ronald Glaser professors at Ohio State University, have established the role of stress on the immune system. In an early study they found that students’ responses to hepatitis B vaccine—which mimics an infectious agent—was diminished in those with higher anxiety, higher stress and less social support. This validated an earlier finding that healing of wounds was much slower in psychologically stressed adults.

These studies are unique in that by taking blood samples, researchers could identify chemical changes in the body that might be creating these variances. Analysis points to a specific cytokine –Interleukin-6 as the mediating chemical.

These same researchers spent more than a decade studying the way married couples argue. They found that the more sarcasm and hostility a couple expresses when fighting, the higher their hormone levels rise and the more their immune functions are compromised. The chemical culprits are increased levels of epinenphrine, norepinephrin, growth hormone and ACTH. Women, having a greater sensitivity to marital conflicts, suffer greater changes in immune function. The very existence¬ of anger creates damage, not just how we express it. Research has started to show that a stressful lifestyle could also lead to the premature death of a group of neurons, whose loss triggers the symptoms of Parkinson's disease. Feelings have physical consequences.

Empathy—the human ability to feel the pain that others experience¬—predisposes understanding, attachment, bonding and love. Using a brain-scanning technique called functional magnetic resonance imaging (¬fMRI), researchers found that women who reported the strongest feelings of empathy while watching their loved ones endure simulated bee stings showed the greatest activity in the pain regions of the brain. Empathy in these women created levels of pain equal to that of the actual victims.

The reverse is also true. Believing that you are protected from pain because of a pill (placebo) or when someone you love is with you, the brain creates less pain. Yoga has been shown to increase the level of gamma-aminobutyric acid, or GABA, which regulates nerve activity. GABA activity is reduced in people with mood and anxiety disorders, while drugs that increase GABA activity are commonly prescribed to improve mood and decrease anxiety.

The secret to loving your brain is to surround yourself with people you love, doing activities that enhance your well-being and minimizing stress. Start by minimizing situations that aggravate stress.

1. Learn what triggers your anger, and remove yourself temporarily from that situation 2. Always use clear, respectful, and nonaggressive language to make your feelings known.

These techniques help keep the problem in perspective and the resulting damage from anger to a minimum. Yoga allows us to gain an added boost, while being around people who love us protects us from damage. This is not easy. Loving your brain takes discipline.

Mario Garrett is a professor of Gerontology at San Diego State University can be reached at mariusgarrett@yahoo.commariusgarrett@yahoo.com
© Mario Garrett 2010.

Aging and Dental Problems: Getting Long in the Tooth

Ever hear the expression “getting long in the tooth?” The meaning lies in horses’ teeth, which unlike humans', continue to grow with age so that it is possible to estimate a horse's age by examining them. In humans, teeth do not continue to grow after adulthood but we might still be able to tell the age because of the conditions of oral health among older adults.

Severity of periodontal (gum) disease increases with age and about 23 percent of 65- to 74-year-olds have severe disease. At all ages men are more likely than women to have more severe disease. Overall, people at the lowest socioeconomic level have the most severe periodontal disease. The result is that close to 25 percent of adults 60 years old and older no longer have their natural teeth. In California-- -a richer state--this rate declines to 13 percent. Having missing teeth, or dentures, can affect nutrition, since people without teeth often prefer soft, easily chewed, heavily processed foods and avoid more nutritional fresh fruits and vegetables.

Oral diseases affect our most basic human needs beyond just eating. Social communication can be greatly impacted by the ability to smile, and speech may also become difficult to produce and to be understand. Oral health might also influence the overall health of the body. Bacteria has been shown to go from the mouth to the heart through the bloodstream. In fact, a recent consensus paper calls for cooperation between cardiologists and periodontists in helping patients reduce their risk of these associated diseases.

The mouth provides a good indicator of the condition of the body as a whole. People with diabetes are at special risk for periodontal disease. Dry mouth, often a symptom of undetected diabetes--but is also often caused by a host over 400 commonly used medications--can cause soreness, ulcers, infections, swallowing difficulty and tooth decay. Smoking makes these problems worse.

Geriatric dentistry is a growing approach of providing treatment to the unique needs of an aging population. As the population of older adults in San Diego continues to increase, the dental profession is becoming better equipped to meet the older adult population’s special needs. Certainly mobility is one of those special needs, and in San Diego County, dentistry is beginning to mobilize to take dental care to where the patient needs it most-- homes, care facilities and private care residences.

Functional limitations such as difficulty in holding a toothbrush due to stroke or arthritis can make daily dental care difficult. And certainly lacking the cognitive capacity to care for oral health can place an individual at risk for aspiration pneumonia due to bacterial plaque buildup on oral surfaces. Aspiration pneumonia is a significant risk for those suffering from dementia.

Many older Californians do not have dental insurance. Often these benefits are lost when they retire. And although MediCal, which covers low income and disabled elderly, can cover some costs, it is difficult to find dentist that take MediCal. Medicare, which provides health insurance for older adults, was not designed to provide routine dental care. Good evidence exists that oral health improves quality of life. It is not just about the smile, it is about having something to smile about.

Mario Garrett is a professor of Gerontology at San Diego State University can be reached at mariusgarrett@yahoo.com
Julie Sugita, is a dentist, gerontologist, and private licensed fiduciary for older adults, and can be reached at j.sugita5@gmail.com.

© Mario Garrett 2010

Aging in Prisons Who is ultimately responsible for our aging needs?

The prison system is a cemetery for hope. We need only to consider some basic statistics to realize the futility of rehabilitation in our penal system. The aging of prisoners further continues to bear witness to this persistent failure.

Statistics on prisoners are dramatic. According to the U.S. Bureau of Justice Statistics, in 2008, more than 7.3 million people were on probation, in jail or prison, or on parole—1 in every 31 adults. Of these, 2,304,115 were incarcerated in U.S. prisons and jails-- more than the population of 83 countries in the world. This level of incarceration is not only a waste of human resources, but it diverts resources from other social programs.

Although extreme variations exist in costs, we spend more on most prisoners than we do to educate an Ivy League student. And this cost will continue to increase with an aging prison population. The American Civil Liberties Union estimates that it costs about $72,000 to house an elderly inmate for a year, compared to $24,000 for a younger prisoner.

While these statistics hide the fact that older prisoners (61 years and older) constitute a small minority of the prison population (3 percent) this percentage is projected to increase dramatically. The U.S. Bureau of Justice reports that the number of prisoners 55 years and older grew 76 percent between 1999 and 2008—from 43,300 to 76,400—compared with an overall prison population growth of 18 percent. Ronald Alday, a professor of aging studies, predicts that by 2020 one out of six prisoners in California will be serving a life sentence and that 16 percent of those will be elderly.

With more and more prisoners suffering from debilitating diseases, the role of prisons is changing from one of warehousing to one of caregiving. Who is ultimately responsible for their needs? And, if it is the government, who is then responsible for our own aging?

A recent 2010 poll conducted by Lake Research Partners and American Viewpoint report that 58 percent of registered California voters age 40 and older say they feel unprepared to pay for services if they needed long-term care. Many just simply cannot afford it, and since at least 70 percent of older Americans will need long-term—like prisoners—we are trapped in a cycle of increasing and predictable needs with reduced resources.

The reason we find ourselves facing these issues is the veracity of short term concerns over long term needs. Like Oscar Wilde’s character Dorian Gray—transferring his aging to the image in a painting while he remains unscathed by age—we criticize the lack of long term planning in prisons and yet assume that we do not have to prepare for our own aging.

We need to ultimately initiate long term care provisions for ourselves and our communities. We need to educate ourselves on what services exist, their costs, and availability. We need to look at communities that provide local support services such as Naturally Occurring Retirement Communities. San Diego has a comprehensive eldercare directory. Visit http://eldercare.signonsandiego.com/ and take the first step by examining the local support system available.

Mario Garrett is a professor of Gerontology at San Diego State University can be reached at mariusgarrett@yahoo.com

Chris Murphy is a gerontology graduate student at San Diego State University can be reached at snochicky@gmail.com

© Mario Garrett 2010

Minority Aging The Canary in the Mine

We are all born with a lifetime guarantee, except that as Americans it is worth less for people of color than for the white population. People of color live shorter lives by as much as six years.
When we compare the life expectancies for different races and ethnicities, we see that some Americans are expected to die younger than people from some developing countries. We have known this fact for nearly 30 years, and this inequity continues to be documented annually by the Agency for Healthcare Research and Quality (AHRQ) as mandated by Congress. Some of this increased mortality is due to lack of health insurance that results in 22,000 avoidable deaths a year in the United States. However these disparities exist despite insurance coverage, and seem to persist even when there is a single payer health care system as in Europe.
Former Surgeon General David Satcher estimated that some 83,000 deaths could be prevented each year if the Black-White mortality gap could be eliminated. Unfortunately this mortality gap is increasing. For example, racial and ethnic groups have higher disease rates—notably for cancer, vaccinations, tuberculosis, sexually transmitted diseases, and chronic diseases such as arthritis and diabetes. In addition, although racial and ethnic groups tend to have higher hospitalization rates, they tend to receive less and poorer hospital treatment and less nursing home care. Additionally, research has identified that racial and ethnic groups are disabled for a greater portion of their shorter life expectancies, and are likely to experience higher levels of pain while dying. The dementia pandemic looming upon us will also affect ethnically diverse older adults more than for the general population. Studies undertaken with Ramone Valle at SDSU have shown how the increase prevalence of dementia among the Latino population in San Diego and Imperial counties will mushroom over the next 30-40 years.
The Institute of Medicine (IOM) called these disparities a “quality chasm.” This is not an easy topic to discuss. Disparities in health and health care point to systemic weaknesses in our public health system. When life expectancy starts to diminish for the first time in the history of our country, the effects are felt not just by racial and ethnic groups, but by all Americans. Based on self-reported illnesses and biological markers, U.S. residents are less healthy than their English counterparts. Here, too, the gap between U.S. health and that of other countries is becoming wider. Despite being the most lavish health care spender, the United States is falling farther behind other industrialized countries in overall health outcomes.
Improving public health systems for all older adults, and increasing access to services not only improves the health of ethnically diverse populations, but it also improves the overall well-being of our society. Today’s older adults will set a precedent for how the next generation of older adults will be treated. We have an obligation to talk about our health concerns, and to seek support from existing systems in order to stop the cycle of inequity for subsequent generations.
Mario Garrett is a professor of Gerontology at San Diego State University can be reached at mariusgarrett@yahoo.com
Dave Baldridge, is the Director, National Indian Project Center, Albuquerque, NM can be reached at dave@nipcinfo.com
© Mario Garrett 2010

Sex and Old Age Same Old same Old?

Sex and old-age; only in the past 15 years could you put those two words together and be taken seriously. It wasn't that older people weren't interested in sex, it is that our culture just told us that they weren't supposed to be. This is all changing. As far back as Kinseys groundbreaking reports sixty years ago, there is evidence documenting interest and ability for sex in both men and women as they age--interest similar to the level they had in youth and an ability that is dependent on health status.

This initial validation was followed by Masters & Johnsons studies that reported a basic pattern to human sexual response (excitement, plateau, orgasm, and resolution) and also identified several important biological differences in those responses between young and old.

The most obvious has to do with erectile changes in men. However, what some might label as dysfunction may actually be the impact of biological changes which can begin as early as the 40s. As men age, it is more likely that their erections become less firm, the recovery time between them increases and the force of ejaculation is lessened. Ostensibly this might seem that the man is less virile and less able to please his partner. On the other side, his partner might think that he is less aroused by her and her self-esteem is negatively affected.

The same can be true of the biological changes in women: thinning of the vaginal walls may result in small tears and discomfort during intercourse, and an increase in the time required for lubrication. This might also be perceived by both the man and the woman as a failure to become properly aroused.

These misperceptions about biologic changes often create a vicious cycle. It starts with partners becoming more and more anxious about their abilities to perform and to excite each other, and ends with an unwillingness to initiate love-making for fear of failure. Its a lose-lose situation. Research repeatedly shows that increased sexual enjoyment and satisfaction is possible even well into our 90s. Starr & Weiner, authors of the first major study that focused solely on sexuality and older adults, report that we just need to be flexible and creative to remain sexually satisfied. When understood, these biologic changes can be accommodated fairly easily.

However biology is only one part of the complex changes in older adults. The number one problem for couples--of all ages--is mismatched sex drives. He’s in the mood, she’s got a headache; she’s in the mood, he’s watching football. And the fact is that many older women do not have a partner at all. While some people remain very interested in sex, some have never been; some adjust well to age-related changes, and some don't. Regardless of where you are, knowledge is power; the more you learn about your own sexuality, the easier it is to accommodate your needs and desires. The largest sex organ is the brain. Maintaining a healthy lifestyle improves the biology of the act, but enriching the mind improves the quality of your relationships in general, including sexual gratification.


Mario Garrett is a professor of Gerontology at San Diego State University can be reached at mariusgarrett@yahoo.com
Patrice H. Blanchard, Consulting Gerontologist, Crestwood, Kentucky, can be reached at PBlanchard@aarp.org

© Mario Garrett 2010

The Cost of Dying Is Over-Pricing Death the Solution to an Eternal Life?

During the five-year period 2001–05, nearly a third of total Medicare spending went toward the care of dying patients during their last two years of life, which translates to $140 billion. Eli Ginzberg, the noted economist, has called it, “the high cost of dying.”

Medical care costs peak at the end of life. An implied assumption is that the high medical expenses at the end of life are due largely to aggressive, intensive, expensive, and high-technology interventions for some patients who are dying. Contrary to this popular belief, data show that the number of patients with very high medical expenses is quite small.

Geography can help us understand the variability in health care costs, and why. The highest spending states consumed more than one and a half times the Medicare dollars spent by the lowest spending states. If you examine total Medicare spending during the last two years of life for patients with at least one of nine chronic conditions, three states—New Jersey ($59,379), California ($57,914 per person), and New York ($55,718 per person)—spent at a level more than 20% above the national average of $46,412 per person.. As an extreme case, Hahnemann University Hospital-Philadelphia, PA, spent an average of $117,998 per dying patient during the last two years of life.

A recent study in California—one of those expensive states—has reported that between 1999-2003, Medicare patients in Los Angeles made 2.3 times more visits to specialists than did comparable patients in Sacramento. They also spent twice as many days in intensive care and were hospitalized 1.6 times longer. The argument is that if facilities and services exist, everyone, including dying patients, gets to use them. This is known as supply-driven demand—if you have it, they will come. The projected Medicare expenditure for the remaining life of a 65-year old in Los Angeles is $84,000 greater than for a 65-year old in Seattle.

Despite the fact that Los Angeles has a greater number of specialists and hospital beds per person than most regions of the state, hospitals in Los Angeles were less likely to provide proper care for patients suffering from heart disease, congestive heart failure, or pneumonia than were hospitals in the far less expensive Sacramento region. Los Angeles-region hospitals also ranked lower on patient satisfaction surveys.

Supply-driven demand assumes that the patient wants the treatments being offered. But it is becoming increasingly likely that patients do not want, for example, invasive treatments (e.g. as with advance directives, and do not resuscitate directives). It is also becoming more likely, because of the increasing rate of dementia, that dying patients might not be cognitively competent to assert their wishes. This exposes that our health care system is set up to save us from dying. We need to better communicate our wishes of how we want to die. In the Patient’s Bill of Rights one of the precepts is the right to die in peace and dignity. We need to make the choice to opt out and to communicate this. It is only then can we truly express the fundamental right of patient autonomy our choice in how we die.

Mario Garrett PhD is a professor of gerontology at San Diego State University can be reached mariusgarrett@yahoo.com
© Mario Garrett 2010

Staying Fit Eating Right Live Long and Prosper

Nutrition gurus often assume that living healthy extends lifespan. Eat well and you can live forever, or at least up to 120 years. It seems that wherever you turn there is a new fad for eating “right” and a new savior to tell us how to do it. But what are the actual nutritional needs of older adults?

In California, as with the rest of the country, we see two polarizing realities. We have an obesity epidemic on one hand, with half of older Californians, predominantly men, being overweight or obese.

On the other side of the coin, more than 20% of the older adult population experiences food insecurity, and about (4%) experience hunger in a given year. With recent reductions in federal funding for welfare programs, and local news reports of increasing demand by food programs, this unmet need for food assistance is probably underestimated.

In the middle of these two realities, are older adults trying to eat healthy while being bombarded with ever-changing advice on what to eat in order to reduce disease and increase their lifespan. But science shows that apart from reducing the risk of ill health, good nutrition is, like air, necessary but not proportional in its positive effect on aging.

Gurus who claimed to hold the nutritional secret share one common characteristic--they are all dead. Some notables include Adelle Davis (1904-74) who often said she never saw anyone get cancer who drank a quart of milk a day, as she did--who died of bone cancer at age 70. Nathan Pritikin (1915-85), after being diagnosed with heart disease, advocated regular exercise and a low-fat, high-fiber diet. He committed suicide at age 69 while suffering from leukemia. Robert Atkins (1930-2003), the proponent of a high protein, low carbohydrates diet, died of a brain injury. Roy Walford (1924-2004) a proponent of caloric restriction as a means to extending life, died of Lou Gehrig's disease at age 79. Jim Fixx (1932-84) who championed the health benefits of running and claimed that regular running offered virtual immunity to heart disease, died of a heart attack while jogging at age 52. Alan Mintz (1938-2007) a controversial proponent of using human growth hormone—an anabolic steroid—died at age 69 from complications of a brain biopsy. Brain cancer seems to be a particular risk to anabolic steroid use.

The real truth is that scientists know very little about aging. Caloric restriction is the only known intervention shown to prolong life in multiple species, but is not yet proven with humans. The oldest person that has ever lived, Jeanne Louise Calment, might have some secrets herself. When she died in 1977, Calment was 122 years and 164 days. She started smoking when she was 21 years old and did not stop until the age of 117. She ate nearly two pounds of chocolate every week, and drank port wine. She ascribed her longevity to olive oil, which she said she poured on all her food and rubbed onto her skin. Despite the luxury of her daily habits, it is likely that marrying into money probably had a significant influence on her longevity. Circumstances made it possible for her to never having to work and to instead live a leisured lifestyle, pursuing hobbies like tennis, cycling, swimming, roller skating, piano and opera. Rich, educated people live longer. So, in the end longevity comes down to genetics, money, and luck.

You cannot go wrong with trying to live a healthy life, but it does not mean that you will cheat death.

Mario Garrett PhD is a professor of gerontology at San Diego State University. He can be reached at mariusgarrett@yahoo.com © Mario Garrett 2010

Elder Abuse The Quiet Violence

Some studies are showing that most people who commit elder abuse have themselves been abused as children. The perpetuity of abuse does not lessen the horrendous impact this crime visits on the victim’s state of mind, physical well-being, and dignity. Older adults who are abused and neglected are three times more likely to die earlier than those who are not abused. Although statistics hide the personal degradation of abuse, it is important to understand the context so that we can lessen its cancerous growth in our community.

In the United States more than 360,000 new cases of elder abuse are reported each year, which sadly translates to 40 new cases per hour. In San Diego County, Adult Protective Services deals with around 5,000 confirmed cases of elderly abuse every year. With a doubling of the aging population by 2030 to more than 70 million, we will continue seeing a burgeoning of elder abuse cases. San Diego County is home to the second largest elderly population in the state and the fourth largest in the nation with an estimated 342,000 older adults.

By understanding the context of elder abuse, it is possible to address it before it happens. Most elder abuse cases involve a caregiver--usually a family member or a friend--who has become dependent on the older adult for their livelihood. The victims of elder abuse are more likely to be female who are frail and dependant living with their caregiver. In most cases victims are more likely to have varying stages of dementia and are already socially isolated from their peers. On the other hand, most perpetrators of abuse are caregivers who have a history of some mental illness or substance abuse, and who are economically dependent on the older adult they are supposed to be caring for.

While self neglect and abandonment comprise two out of three cases of abuse, financial abuse in California constitutes 13% of cases. With more seniors becoming computer-savvy, internet financials scams now account for a large number of financial abuse cases.

In San Diego County we have not invested enough in prevention strategies. Community involvement is one possible solution, where volunteers befriend vulnerable older adults and establish contact (by phone or visits). The less invisible vulnerable older adults become, the less likely that they will be victimized. Connecting with vulnerable adults can be accomplished in many ways.

For example, Julie Sugita, a dentist who graduated from the SDSU gerontology program, developed awareness training to help dentists and oral hygienists—who have long periods of close examination with patients— identify potential elder abuse.

If you are an older adult that relies of caregivers for your day to day activities, ensure that you communicate with family and friends about your arrangement. Do not feel guilty about reporting abuse. In San Diego call the elder abuse hotline (800) 722 0432. Abuse almost always gets worse, and it never improves on its own. Although we might be able to predict abuse, we need to be better able to prevent it in order to break the cycle.

Mario Garrett is a professor of Gerontology at San Diego State University can be reached mariusgarrett@yahoo.com
© Mario Garrett 2010

Dying to Live Longer The weird and wonderful attempts at prolonging life Science : PART 2

A public perception exists that is at odds with our knowledge of aging. The first misunderstanding is the difference between lifespan and life expectancy. While lifespan is the maximum number of years humans have ever reached, life expectancy is the age before which half of the population is expected to die. Not one single study exists that shows the extension of lifespan in humans. And as for the much-touted increase in life expectancy, this is due to reduced child mortality and has virtually little to do with advances in treatment of older adults. In the last century life expectancy at 65 has increased by only 5.7 years, which tells us that medicine exerts little influence on population aging. Despite the lack of evidence of prolongation of human life, folklore themes pervade commonly-held beliefs, which then seep into the science of aging.

The complex science of aging can be succinctly summarized under four basic inclusive themes. These are 1) a slowing down of metabolic rate; 2) an accumulation of toxins; 3) a wearing down of the body; and 4) entropy--randomness and disorder within the body. In some contexts all of these themes play a role in death. The umbrella concept is that of entropy.

Entropy is the second law of thermodynamics and explains the loss of energy. Only recently have we considered accepting this concept to explain aging. In folklore it was assumed that humans did something wrong to deserve death—such as eating from the forbidden tree; or the Taoist’s loss of Ching; or with Aristotle’s loss of innate moisture. All of these imply that we are immortal except that we are doing something wrong. This was epitomized by Nobel prize winner Alexis Carrel who stated “that all cells explanted in culture are immortal . . . .”

It was Leonard Hayflick who broke this established dogma. Unable to reproduce Carrel's results, Hayflick exposed the error in Carrel's experiment, which consisted of daily addition of chicken embryonic stem cells to the cell culture. Carrel was in fact replacing the cells not just feeding them, and hence why they never died. In his own experiments, Hayflick found that a normal human fetal cell divides between 40 and 60 times. It then enters a phase where it dies—The Hayflick Limit. Each replication shortens the life of the cell.

We now know, thanks to Alexey Matveyevich Olovnikov, that with each replication the cell losses a part of its DNA called telomeres. When the telomeres become too short, the cell dies. Shortened telomeres are found in atherosclerosis, heart disease, hepatitis, and cirrhosis. It is of no surprise that the bio-tech industry in San Diego, working on cancer research, is intricately associated with aging research. Cancer cells are immortal.

The science of aging is still a long way from advancing from staying healthy to assuring the prolongation of life. Eating good quality food, moderate consumption of (red) wine, and enjoying the company of friends is not only good for longevity, it is one of life’s great pleasures. We do not need science to tell us that. We have a lease on life. If we use it wisely and cultivate quality, it will eventually contribute to the quantity of life as well.

Mario Garrett PhD is a professor of gerontology at San Diego State University can be reached mariusgarrett@yahoo.com
© Mario Garrett 2010

Dying to Live Longer The weird and wonderful attempts at prolonging life Folklore: PART 1

All religions reflect on death, and most of the biological sciences have at some point in history attempted to cheat death. Although life is one game where we all die, that has not stopped great thinkers throughout history trying to prolong this ultimate exit.

Folklore and Science play a duet in this field. Both feed off of each other and only meet in the court of law. In the latest instance, the co-founders of the Academy of Anti-Aging Medicine sued professors Olshansky and Perls for mocking their claims for anti-aging therapy, saying it does not exist. Although both sides settled, the case highlights the divide that has grown because of our ignorance about aging. This is a two part story exploring the interesting history of how this schism emerged.

Folklore gives us three basic themes of the prolongation of life. The classic theme is the “Antediluvian,” referring to the time before the biblical flood, when people are said to have lived much longer. According to the Book of Genesis (5:27), Methuselah lived 969 years, dying in the year of the Great Flood, which has been interpreted as a turning point when humankind lost this enhanced longevity. Although Methuselah’s age is an error in translating units of time, his name remains as the catchphrase for longevity.

The second theme is “Hyperborean,” referring to the belief that people live longer in some parts of the world, ostensibly to the “north.” This folklore cropped up recently in a 2009 National Geographic article by Dan Buettner, where he referred to communities that have a high concentration of centenarians as “Blue Zones.” Aging clusters exist all over the world, due to a myriad of factors that contribute to longevity. Geography is only one of these. More likely, longevity is a result of common dietary, spiritual and lifestyle practices which are shared in these Blue Zones.

And last, but certainly not least, the most tenacious and pervasive concept is that of the “Fountain of Youth,” which refers to the ability to ingest or administer some substance that enables people the power to live longer. Although incorrectly associated with Ponce De Leon (1535) a Spanish explorer in Florida, the concept of rejuvenating springs has a much longer history, going back to Herodotus in the 5th century BC .

More recently in 1889, Adolphe Brown-Séquard injected himself under the skin with an aqueous extract of dog and guinea pig testicles. Although it did not catch on, this practice led to more ambitious experiments by Serge Voronoff, who started transplanting chimpanzee thyroids on people suffering from thyroid problems and later grafting monkey testicles into human scrotums. By the early 1930's, more than 500 men had undergone this surgery. It became so popular that the supply of monkey testicles was insufficient, so Voronoff built his own monkey house.

The Fountain of Youth theme persists today, embraced and promoted by the Anti-Aging movement. As elusive as this theme is, it is our desire for youth that still nourishes the fountain.

Mario Garrett is a professor of Gerontology at San Diego State University can be reached mariusgarrett@yahoo.com
© Mario Garrett 2010

Residential Care Facility for the Elderly (RCFEs) A Cost Effective Compromise?

Nearly 9,000 Residential Care Facilities for the Elderly (CFEs), known as assisted living facilities, exist in California with a capacity of almost 225,000 beds—equaling the population of Chula Vista and more than 186 U.S. cities. These facilities are the least-regulated class of care facility in California, resulting in an enormous variability in quality. Some offer exemplary care, while others are seemingly in business for profit alone. Facilities provide a non-medical housing alternative for individuals 60+ requiring assistance with activities of daily living. With facility inspections conducted only every seven years, the best advice is to make sure that you do your research beforehand. But what should you be looking for?

Find a facility that looks good by visiting its website, taking a tour of the place, and talking with the administrator. These are good starting points, but in themselves might not be enough. You also need to be aware of specific issues:

It is not mandatory to have liability insurance when providing 24/7 care and supervision to frail elders in these facilities. Owners usually carry property insurance but frequently opt not to protect against the risk of injury, harm, or death to their client caused by their actions, or omissions. If there are accidents, there is no recourse for compensation.

The state requires only that staff be ‘sufficient in numbers’ to provide care consistent with residents’ needs. In small facilities, which are the majority, the facility will usually have two staff members on duty during the day, but at night, it drops to one. The state requires facilities serving dementia residents with a penchant for wandering, to field only one “awake” caregiver.

The law also allows facilities to assist residents with medications, to retain clients on hospice or with other medical conditions, and those who are permanently bedridden. Yet facilities need only hire unskilled caregivers, and still be in compliance with the state laws.

With an increasing aging population and a concomitant increase in frail older adults, these types of facilities will become more attractive. With the economy eroding personal investments, it is likely that the attractiveness of services to frail older adults might be tainted primarily by considerations of cost. But because these facilities provide non-medical care, the competition is not for stringently-regulated nursing home care—but for “aging-in-place” with fulltime care. To help with these decisions, Chris Murphy, a SDSU graduate gerontology student, is developing a website that allows you to evaluate these facilities on the basis of no-compliance reports and other outcomes.

San Diegans need tools like this that will allow them to judge the quality of care in these emerging assisted living cities. In the meantime there are a number of thoughtful approaches to choosing a facility. Be nosy. When you visit the facility watch what's going on, who’s on duty, and ask questions. Ask to check the medication log for your resident to make sure medications are being given and in the right dose. And finally do not hesitate to complain. If anything is suspect, call the local complaints number (619) 767-2300. Improving tools that allow us to be more vigilant will positively influence the care older adults receive in San Diego.

Mario Garrett PhD is a professor of gerontology at San Diego State University. He can be reached at mariusgarrett@yahoo.com © Mario Garrett 2010

A Legacy of Debt Social Security and Medicare

Americans have a looming obligated deficit of $63.6 trillion--a figure which is more than what the entire world produces (Gross Domestic Product-GDP; $61.1 trillion), and about four times higher than all the products we produce in the United States (GDP; $14.6 trillion) in a year. This is like having a mortgage that is four times what you earn, except that you do not have a house to show for it.

These numbers are so large that only a few people think they understand them. Some argue that increasing cost in health care spending and Social Security are the main culprits of this obligated debt. Others point to the growing deficits that we build annually into our federal budget. This year we have added an additional $1.3 trillion to the deficit. If, as some economists predict, our current ailing economy will continue to suffer stresses, then it is becoming more important to question this legacy we are leaving our children and grandchildren.

The two largest federal spending obligations are Social Security and Medicare. We euphemistically refer to Social Security as a “pay-as-you-go” system. This means that money that we pay today goes to support the benefits of retirees. Any surplus is spent by the government (for which we get IOUs and treasury bonds). Unlike other countries who invest their surplus, the U.S. government spends it. This year our annual Social Security surpluses will disappear, which means that not only do we have to contend with a deficit every year (with no surplus money coming in from Social Security), but we have to find money to start paying retirees from other sources other than Social Security contributions.

The other part of this double jeopardy is Medicare. By 2007, total spending on health care in the United States was $2.3 trillion or $7,600 per person. The percentage of GDP that is spent on national health is projected to continue to increase (from 5.2 percent in 1960 to 20 percent in 2016), which translates to $4.2 trillion. Rising health care costs are an emergent issue especially for the United States, unlike other countries which seem to have essentially contained costs.

The latest report by the Social Security Trustees in 2008 summarized the situation in stark terms by stating that, “Projected long run program costs are not sustainable under current financing arrangements. Social Security's current annual surpluses of tax income over expenditures will begin to decline in 2011 and then turn into rapidly growing deficits as the baby boom generation retires. Medicare's financial status is even worse.” Despite this overwhelming evidence, Americans are becoming more optimistic about Social Security’s and Medicare’s future.

We need to narrow this gap between reality and wishful thinking. Our failing economy will compel us to examine our practices around borrowing. Individually we need to educate younger people about how to use money, to become fiscally aware. Since they will bear the cost of our spending spree.

The argument is not that it is too costly to borrow, but that it is too costly to borrow without planning how our children and grandchildren are going to pay it back.

Mario Garrett PhD is a professor of gerontology at San Diego State University. He can be reached at mariusgarrett@yahoo.com © Mario Garrett 2010

Dementia A Pandemic in the Making

Dementia is the signature disease of an aging society. It affects both patients and the families who look after them. With a growing aging population we will see an increasing number of cases of dementia. Some have called it the silver tsunami. Alzheimer’s disease (AD), which constitutes 60-80% of all dementia cases, passed diabetes in 2006 to become the sixth leading cause of death in the United States. For San Diego County it is the fourth cause of death. An estimated 72,914 Americans died of Alzheimer’s disease in 2006. A recent Alzheimer's Association report estimates that 5.2 million people in the United States have the disease, which is expected to afflict 20 million Americans by 2050.

Dementia means a gradual and progressive decline in memory, thinking and reasoning skills. Living with a degenerating disease that erodes an individual’s ability to think and behave rationally has many social implications, one of which is making decisions. Having problems with thinking also leads to an increased rate of physical decline. However, although we are learning more and more about the disease, we have not managed to find, or come close to finding, a cure.

It has often been assumed that cognitive decline, especially related to AD, is related to deterioration in the brain’s mechanism. This theory, however, does not fully explain new evidence. For example, autopsy studies have shown that approximately a third of individuals with the disease exhibit no sign of dementia at the time of their death. AD is unlike Parkinson’s disease. With Parkinson’s, 80% or more of cells in specific part of the brain must be lost in order for the initial symptoms to appear. With AD there seems to be a reserve or capacity for deterioration before symptoms of the disease appear. Building one’s brain capacity is therefore important.

Although a healthy brain reflects a healthy lifestyle, it is not necessarily true that a diseased brain reflects an unhealthy lifestyle. Although one’s ongoing problems with health can lead to dementia, no one is immune from the disease. For example, diabetes, heart disease, high cholesterol, and high blood pressure all contribute to the development of vascular dementia. Therefore physical exercise is essential for reducing and delaying the emergence of these risk factors. Statistics show that if the onset of Alzheimer’s could be delayed by five years, the number of people with the disease would be cut in half. Even delaying the onset of Alzheimer’s symptoms by as little as one year would reduce the occurrence of the disease by 12 million cases according to a 2050 projection. Despite all these precautions, the disease cannot be avoided. As a society we need to accept this disease and work with caregivers to provide support and alleviate the guilt that so often accompanies AD.

SDSU gerontology program is looking at ways to support family members who are caring for their loved ones by helping them also care for themselves. If you suspect you have dementia, or a loved one has dementia, first talk to someone. Apart from friends, relatives, and neighbors there are a number of agencies that offer free support in San Diego County.

Do not blame the victim. They are frightened, too. Do not blame yourself. Preparing for the disease of the 21st Century involves working with the whole family, not just the patient.

Mario Garrett PhD is a professor of gerontology at San Diego State University. He can be reached at mariusgarrett@yahoo.com © Mario Garrett 2010

Brain Plasticity in Older Adults: You Can Teach Old Dogs New Tricks

Our brains can continue to grow at any age. One of the startling revelations of the 21st century is the improvement in our knowledge of nerve cell development among older adults. Known as neurogenesis or brain plasticity, this new knowledge is showing us that the brain has the ability to CHANGE throughout life by forming new connections between brain cells, and to alter function. For a long time, it was assumed that as we become older, the connections in the brain became fixed, and then it was just a matter of time that we started “losing” brain cells. However this assumption is being aggressively challenged by recent studies showing that the brain never stops changing.

This evidence comes from a number of different observations. In a study of London taxi drivers who are learning some 25,000 streets, researchers found that compared with bus drivers (who had a fixed route), taxi drivers’ brains changed, with more brain cells growing in one part of their brain that is related to knowledge of maps. This study shows that the brain is an active neurological mechanism and not just a warehouse for cells. The brain is more than a reserve gas tank, switching from tank A to tank B, but has ‘plasticity’, a flexibility that can change the capacity and function of specific areas.

Plasticity can also be observed in the brains of people who speak more than one language. It appears that learning a second language is possible through functional changes in the brain: the left back part of the brain is larger in bilingual speakers than in the brains of those who just speak one language. Differences also occur in musicians’ brains compared to those of non-musicians. Brain volume was highest in professional musicians, intermediate in amateur musicians, and lowest in non-musicians in several brain areas. Finally, extensive learning of abstract information can also trigger some changes in the brain. By looking at the brains of German medical students three months before their medical exam and right after the exam, then comparing them to brains of students who were not studying for exam, students’ brains showed changes in regions known to be involved in memory retrieval and learning.

This growing evidence is popularizing the idea that the adult brain is more malleable than assumed and that it can regenerate throughout life. Decreased mental capacity is something that occurs through physical and functional changes in the brain. It can be avoided and even reversed through a variety of environmental enrichment activities, including physical and mental training exercises. The secret is to challenge the brain, to do novel and stimulating tasks that do not rely on established ways of doing things.

A number of new computer programs can help accomplish this. San Diego County is lucky to have a community college system for older adults that offer these programs for free. Working with Pat Mosteller, SDSU gerontology program is looking at how effective these programs are among older adults of different ethnic backgrounds. Other novel things you can do independently—start writing with your opposite hand, learn an exotic language, listen to bird songs and figure out what birds they are, learn to play an instrument, or learn mathematics.

Hopefully we will be able to show that we can teach old adults new tricks after all.

Mario Garrett PhD is a professor of gerontology at San Diego State University. He can be reached at mariusgarrett@yahoo.com © Mario Garrett 2010