Dementia and Sex in Nursing Homes

This affair was between an older couple. He was single, a bit of a ladies’ man in his younger time. She was still married but now separated. They met by chance. But they gravitated towards each other whenever they came across each other. They were often seen holding hands, and were relaxed and mellow when they were together. This older couple enjoyed moments of intimacy and friendship. If this was anywhere else it would elicit a smile. But this affair occurred in a nursing home and the couple suffered from dementia. 

In this case, the nursing home was the 120-bed Windmill Manor in Itoralville, Iowa. The man was 78, while the woman was much older at 87. Three and a half years of private litigation ended with the elderly couple becoming separated to different nursing homes and each died within a few years. While the administrator and the director of nursing home were both fired.

The issue is whether they had consensual sex and how you determine that.  The woman referred to her lover as her (living) husband. Was she confused and therefore agreed to have sex under a delusion.

The sad story here is that the law attempts to define edges. To enumerate a black and white picture in an otherwise blurred context. Sometimes we have to look at how unique individuals deal with such cases to find a moral or ethical compass. The law is too clumsy a tool for us.

Supreme Court Justice Sandra Day O'Connor’s husband was suffering from dementia and was placed in a nursing home. While there he become romantically attached to another resident. Justice O'Connor decided that this made him happy and sanctioned their behavior. It takes courage to understand the disease for what it is., a disease. And sometimes how we react to people suffering dementia is more a reflection of our fears, prejudices and moral expectations, as much as it is about the degenerative disease itself.

It is not that these moral and ethnical dilemmas exist. It is that they are still dilemmas. In an age when the tsunami of dementia will push us more frequently against the reality of older adults with dementia we should have better tools than the law to deal with such radical changes in human intimacy. For some couples coping with dementia, physical intimacy continues to be a source of happiness. In others the dementia brings about behavioral changes that might increase or decrease the need for physical expression and relief. There might also be changes in sexual etiquette and expressions of sexual urges (or not). It is difficult to separate the person from the disease. But the disease can change the behavior of the person to such an extent that you cannot rely on past experience in responding to them.

By the time the person is in a nursing home, there are already noticeable changes in behavior. What this teaches us is not to rely on the law but to examine what the home will allow and what we are comfortable accepting.

© USA Copyrighted 2013 Mario D. Garrett

Accepting Our Losses and Living Longer

Happy people live longer. Even happy countries have higher life expectancy. Scientists have even documented orangutans living longer if they are happy. It would seem that happiness is an important commodity. With older adults there is a conspiracy to be happy. Not only do happy people live longer but older adults are more likely to become happier with age.

What makes us so happy? In The Paradox of Choice: Why More Is Less, Barry Schwartz documents that the secret for happiness is not having a great choice or achieving your goals and dreams. No. Happiness comes from accepting what you have, being happy with the choices that you made.  Having more choices makes us less happy. And it does not matter what those choices are. Which is why Daniel Gilbert's cheerfully engaging "Stumbling On Happiness" is so good. The argument that it is not choices that make us happy,  but our acceptance of the choices we make has generated a lot of interest. In psychology Paul Baltes's model of selection, optimization, and compensation (SOC) argues that it is essential for successful development that older adults maximize their remaining capacities and minimize their losses. We do not choose to experience losses. But we choose to accept them. 

In 2010 Alex Bishop and his colleagues working with the Georgia Centenarian Study found that happiness among these exceptionally older people was determined by “congruence” which was defined by three statements one of which was ‘I would not change my past life even if I could’.  

"Even if I could". This is an important admission. If you are getting frailer, becoming more diminished, experiencing the loss of lovers, friends and colleagues, and facing increasing challenges you have limited options, and none of them include reversing this trend. The best utilization of your energies is to accept the changes and assume that you are destined to be here. Wherever “here” is.  What psychologists call a positive character-disposition and strong adaptability to the adversities of their life.  You are meant to be where you are. 

And this attitude starts earlier in life, not learned when you become an older adult. Accepting “bad” choices, painful loss, forgiving people, being content with what you have in terms of money and health is how you tell your body that you are happy where you are and that you not ready to go just yet. You belong here still. Even if you could change circumstances, you would choose the same path because that is what made you. 

Happiness tells your body that you are still present. That you are needed. 
W.P. Kinsella in his book "Shoeless Joe" admits that "Success is getting what you want; happiness is wanting what you get." We are too concerned with success and our expression of that. What we should be looking at are vestiges of happiness. Smile wrinkles and laugh lines. Perhaps then we might stop trying to hide how we look.

© USA Copyrighted 2013 Mario D. Garrett

Fibs, Puffery, Lies and Immortality: Telomeres and Telomerase the Snake Oil of the White (Coat) Man

The University of California San Francisco's (UCSF) website  is selling immortality. On September 16, 2013 Elizabeth Fernandez reports "Lifestyle Changes May Lengthen Telomeres, A Measure of Cell Aging." Reporting on a small study by Dean Ornish, Elizabeth Blackburn and eight other colleagues published in the Lancet Oncology journal. *

What the UCSF website reports is that "A small pilot study shows for the first time that changes in diet, exercise, stress management and social support may result in longer telomeres, the parts of chromosomes that affect aging." If this was true (ie valid) then it is indeed a revolutionary finding in science. Baiting all those venture capitalists to rush to the laboratory to invest their money.

Within a day the rest of the world news media started falling over themselves to report this story.  Invariably ignorance and expediency did not help them from repeating the same mistake as UCSF had the day before.

"Lifestyle Changes Could Lengthen Telomeres, Life" reports the Voice of America. "Better diet and less stress can reverse cell ageing" shouted the Irish Times.  "Healthy Lifestyle Changes Might Reverse Cell Aging, Study Suggests"  the serious Huffington Post asserts."Lifestyle Changes Could Lengthen Telomeres, Life" Voice of America parroted.  And on and on, ad nauseam.

Only Larry Husten in Forbes had the right title  "No, Dean Ornish And Elizabeth Blackburn Have Not Discovered The Fountain Of Youth" but even he mistakes the result by reporting that “We noted a correlation between the degree of positive lifestyle change and increase in telomere length when all participants were assessed together, which supports the internal validity of this study." First of all a non random assigned study can never ever be an adequate study for causality. There is no part of this study that remotely contributes to internal validity. Not only that, but because the two groups where different to start, before the intervention took place (the control group versus those following diet exercise and yoga), completely erodes its internal validity. Two different groups will be found to be different even after nothing is done to them.

If we look at the original published paper the conclusion simply acknowledges "...showing that comprehensive lifestyle changes—or any intervention—are significantly associated with increases in cellular telomerase activity and telomere maintenance capacity in human immune system cells" (pg 1053)

Telomerase activity is very very different from telomere length. And telomere maintenance capacity is not equated with increase in telomere, it simply means that the decrease was slower. There is confusion about telomeres and telomerase in the newspaper reports. A short introduction to these two terms.

Most cell in our body have a nucleus. that contain 23 pairs of chromosome structures that hold "genes" which are a series of codes written with nitrogen-containing biological compounds. Each chromosome has two chromatid structures (left and right) connected at the center making an X. Each of the two chromatids have a special protective cap at each end called a telomere. Telomeres function by preventing chromosomes from losing base pair sequences at their ends. They also stop chromosomes from fusing to each other. However, each time a cell divides, some of the telomere is lost (usually 25-200 base pairs per division). The telomere can start off with length of 15,000 base pairs. The longer the telomeres the more times a cell can divide before it dies. Telomere maintenance is controlled by an enzyme called telomerase. Telomerase allow the telomere to maintain structure and in some cases to grow.Which is a good thing in most cases.

However, telomerase is also found in fetal tissues, adult germ cells, and also cancer cells. The connection between cancer research and immortality has not been closer. Since cancer cells are immortal (the HeLa cell lines are a prime example). Telomerase has been detected in cancer cells and is found to be 10-20 times more active than in normal body cells.

So when the authors of the article report that "...increases in cellular telomerase activity..." (pg1053) I do not think about immortality but about expedited mortality through cancer.

This is not to say that there are no benefits to exercise and low fat diet in maintaining organ health. But it is not a panacea for longevity.

There have been other promoters of the “clean living” argument. The following is a list of gurus of the clean living argument. What is unique is not only that these people are all dead (what an argument for internal validity), but that they died earlier than their life-expectancy (at the age that they started their intervention), and they died of the disease that they aimed to ameliorate through their intervention:

• Adelle Davis who often said she never saw anyone get cancer who drank a quart of milk a day, as she did.

• Nathan Pritikin after being diagnosed with heart disease, advocated regular exercise and a low-fat, high-fiber diet.

• Robert Atkins proponent of a high protein, low carbohydrates diet.

• Roy Walford a proponent of caloric restriction as a means to extending life.

• Jim Fixx who championed the health benefits of running and claimed that regular running offered virtual immunity to heart disease.

• Alan Mintz a controversial proponent of using human growth hormone—an anabolic steroid.

Francois Henri "Jack" LaLanne died  in 2011 at the age of 96, due to pneumonia. He is a real hero. According to his family, he had been performing his daily workout routine the day before his death. When he was asked about the difference in public attitude between today and when he first opened his gym decades ago, Jack saw where we were going with our health kick, he said: "Then I was a crackpot and a charlatan, today I am an authority… and believe me I can’t die, it would ruin my image." His image is not ruined because through his death we have realized that mortality is not the fact that we are doing something wrong, but that there is a system of order in the world. Death is the price we pay for living. We do not need to fight death, we need to enhance our life. Exercise, diet and self awareness through meditation is an excellent way to improve the quality of our life. It might enhance our longevity because we are happier. But it will not reverse or stop aging.

The funding for the UCSF pilot project was supported by the U.S. Department of Defense among other entities.

* Dean Ornish, Jue Lin, Jennifer Daubenmier, Gerdi Weidner, Elissa Epel, Colleen Kemp, Mark Jesus M Magbanua, Ruth Marlin, Loren Yglecias,  Peter R Carroll, Elizabeth H Blackburn Increased telomerase activity and comprehensive lifestyle changes: a pilot study.2011. Lancet Oncol, 9, 1048-57.

© USA Copyrighted 2013 Mario D. Garrett

Longevity and Reilgion/Spirituality

A rare study--where a group of individuals born in 1920s were followed over several decades looking at their spiritual beliefs--reported that significant increase in spirituality was evident from late middle age (mid-50s to late 60s) to older adulthood (late 60s to mid-70s). This was irrespective of gender. Similar snapshots of people's beliefs have been substantiated by survey research and public opinion polls since the 1930s. The consistent finding is that older means that you are likely to become more religious/spiritual.

Because aging is correlated with spirituality it is not surprising to find that spiritual people are older and that older people are spiritual. Aging is correlated with spirituality. Spirituality does not, by itself, confer increased longevity. Being spiritual or religious is not a good predictor of how old you will live to, although it might tell us how old you are now. This is despite anecdotal “secrets” for longevity that people older than 85 years, gave for their good health and long life, which were "faith in God" and "Christian living." All valid responses but perhaps not accurate in this diverse society of today.

Allison Sullivan from the University of Pennsylvania published a study in 2011 showing that Jews have lower mortality than the rest of the USA. All other religions were comparable or, as with Black Protestants, had a life expectancy as much as five years lower than the average US citizen. So religion by itself is not a good predictor. 

Religious affiliation follows other variables. For example, those that reported being Jewish reported lowest prevalence of drinking alcohol, were mainly women (comparable only to Catholics), were nearly exclusively White, and were the richest by a very wide margin. These are all factors that by themselves, regardless of their religious affiliation, promotes higher life expectancy. Religion and spirituality, by themselves, are not very good predictors of long life. Where religion and spirituality show distinct advantage is in coping with imminent death. 

In an Australian study, which conducted detailed interviews of older adults in nursing homes and independent living homes, it was reported that religious older adults reframe memories and experiences linked with final meanings, transcend their losses and suffering, reported intimacy with God and others, and found hope. God for them was the ultimate consolidator.

Reporting religious beliefs is also associated with how your caregivers treat you. Nursing assistants who held similar beliefs as their elderly long-term clients, expressed more meaningful connections with them which resulted in better care. Which brings up the issue of what happens when societies are becoming more diverse both in terms of culture and religion and also in term of sexual preferences?

Spirituality does not confer longevity although having meaning in life does--not necessarily spiritual. Especially if you compare people’s religious participation with other older adults participating in other social events, the difference in longevity between religious and non-religious participants disappears. Being religious by itself does not promote longevity, but it might help how you are treated should you lose your independence.

Depression without Sadness

Depression is a seriously debilitating disease that increases your chances of early death. In a report that looked at twenty five separate research studies the conclusion was that depressed people are nearly twice as likely to die early when compared to non-depressed people.

Depression affects about fifteen in every hundred older adults. There seems to be less of a difference between gender than at younger ages and affects different ethnicities equally. Although these studies find that depression is less common in older age, it might be argued that we are not measuring depression correctly among older adults.

An emerging argument is that depression in older adults is more subtle and remains undetected. While on the other hand depressive symptom checklists are inflated as they include symptoms that are directly linked to a physical illness or bereavement, both of which increase in frequency with age. How good are we at identifying depression among older adults?

Although we normally associate depression with sadness, studies are now showing that older adults are generally less likely than young adults to report sadness--dysphoria--when they are depressed. Joseph Gallo from John Hopkins University and colleagues reported that in a number of different studies older adults were less likely to report being sad than younger persons.  And this seems to be an aging effect rather than to a particular generation. People who might have expressed sadness with depression when they were young, as they get older they are less likely to express sadness with their depression. Depression among older adults is related more to listlessness and lack of interest in life rather than sadness.

It could be that older adults are better at separating sadness from depression. However studies show that older adults are not very good at identifying facial expressions showing anger, fear, happiness, and sadness. And it is the more subtle expressions of emotions that older adults have trouble with.  Andrew Mienaltowski and his colleagues in Bowling Green, Kentucky show that in general, older adults have more difficulty discriminating between low intensity expressions of negative emotions than did younger adults.

The issue is that older adults not only do not express sadness with their depression but that they are less likely to see sadness in others. With health care professionals getting older, it is not just depressed older adults that we need to be concerned about but also their physicians. If older physicians are less likely to see sadness then they are less likely to notice depression. Depression without sadness is not only difficult to detect by physicians it is also a silent killer. In a 13-year follow-up, older adults who reported  depressive symptoms without dysphoria--nondysphoric depression--were at increased risk for death, functional limitation, cognitive impairment and psychological distress. Among suicide victims 55 and older, 58 percent visited a general physician in the month before the suicide. In fact, 20 percent see a general physician on the same day and 40 percent within one week of the suicide.

Depression among older adults is a serious issue and it is not part of the aging process. The lack of expression of sadness and the diminished ability by others of perceiving sadness further hides this silent early killer.

Painful Religion at End-Of-Life

In the United States nearly eight out of every ten hospital deaths have no formal pain management. More than eight out of every ten older long-term care facility residents experienced untreated or under-treated pain at the time of death. While seven out of ten people on Medicare who are dying, regardless of their age or where they died, received inadequate amount of pain management. People in the United States are dying in pain.

Most Americans--three of every four--do not fear death as much as we fear being in pain at the time of death. Despite these clearly stated and seemingly universal preferences, too many of the 3 million Americans who die in health care settings each year suffer needlessly in pain at the end of life.

Persons dying from prolonged illnesses can, and should, experience a “good death”. And we know exactly what that means. For most of us a good death consists of dying at home, surrounded by family, and free from pain and suffering. And our preference to die in such a dignified manner is consistent regardless of one’s age, gender, ethnicity, or religious background.

However, by following Christian and Protestant fundamentalist beliefs people who are dying are less likely to have access and select methods for hastening the process of dying. In the United States, approximately 25% of all U.S. deaths occur in the long-term care setting, and this figure is projected to rise to 40% by the year 2040.

The belief in an afterlife--and the support from caregivers who share the same belief--must contribute to the fact that being religious is negatively associated with fear of death.  But there is also the worry that some religious beliefs, because of their emphasis on natural death, preclude you from pain medication that might hasten death and taking control over what for most of us will be a painful final passage through life.

Although religious doctors were significantly less likely than their non-religious colleagues to provide treatment with at least some intent to shorten life, when religious doctors did provide such treatment they were significantly less likely to have discussed this with their patient. And this is the unspoken secret of hospitals.

Physicians prescribe pain medication that hastens the final passage of death in a clandestine manner. We live (or die) in an atmosphere of silent favors to alleviate pain.

The Universal Declaration of Human Rights: Article 5 “No one shall be subjected to torture or to cruel, inhuman or degrading treatment or punishment.” The renowned physician Jack Kevorkian’s final push to bring this issue to the Supreme Court--where it should be legitimately decided and which they arrogantly refused to hear—only resulted in pushing him into jail. Because  of religious self-censoring we are not approaching the issues head-on. We are therefore resigned to repeating the same mistakes. Older adults in the United States will continue to die in pain.

As Susan Imhof and Brian Kaskie have argued,  “we can only conclude that public policies will fall even further behind the advancement of evidence-based pain-policy guidelines, and the number of Americans who continue to suffer needlessly in pain at the time of death will only increase.”

© USA Copyrighted 2013 Mario D. Garrett
In memory of Uncle Freddie who died after a protracted illness.

Last Will and Testament

Legacy: an enduring gift after death. It has often been the vision of humans to become immortal. Apart from science fiction, the reality is that the only way to become immortal is to leave something behind that endures--in what the philosopher Karl Popper referred to as  “World 3.”  These are items that are shared in the world after we are gone: articles, prose, paintings, music, inventions, buildings, policies, social transformations. For all others that have not had a chance for such Popperian creativity,  there is the last will and testament to ensure that after their death, their estate is left to those that they choose.

But sometimes, people have left some weird and wonderful requests. The notoriety of these requests are perhaps more of a legacy than the distribution of the wealth itself. One such area of puzzlement has been the bequeathing of large sums of monies to dogs and cats.

Leona Helmsley the "Queen of Mean" established a $12 million trust to her Maltese dog while leaving $5 million each to her grandsons. Meanwhile Eleanor Ritchey, enriched by the Quaker Oil State Refining Corporation business, left about $14 million to her 150 stray dogs. A California prune rancher Thomas Shewbridge's left all shareholder rights of his estate to his two dogs, who regularly attended stockholders' and board of directors' meetings. The British singer Dusty Springfield left instructions stipulating that her cat was to be fed imported baby food and serenaded with Springfield's songs. Increasing the cat's romantic ambience by also arranging for the cat to marry his new guardian's pet cat. While Doris Duke heiress of the American Tobacco Company—and founding of Duke University--stated that $100 million was to be secured in a pet trust for her dogs.

While some final instructions are not ultimately upheld in a court of law, they have redefined our meaning of legacy. Perhaps there is a deeper message. One impression from these last wills and testaments is how inconsequential money is and that the best way to transmit this message is by giving it away to pets that do not understand its value. Perhaps there are better ways of transmitting such a message. But is there a better way?

In 2005, a study by Allianz found that leaving a legacy (an emotional inheritance) was far more important to peoples than leaving an inheritance, and that 77% of both “baby boomers” and their parents rated “values and life lessons” as the most important legacy they could receive or leave. Would it be better to write an "ethical" will? A parent’s insight, knowledge and wisdom to transfer to younger generations.

The importance of writing down one's innermost concerns is demonstrated in an old study--which has been repeated many times since--by James Pennebaker from the University of Texas. He found that when people--who had experienced significant trauma--wrote about their experience, they showed positive effects on blood markers of immune functions, and that this continued for six weeks.
Ethical wills are valued by the recipient as well as being beneficial to the writer.

We need to include ethical wills as part of Popper's World 3. What better way to leave the world but to transmit the knowledge that you have gained so that future generations can stand on your insights and reach higher ideals. For most of us, that is all we have to transmit, and it might not be such a poor option.