Dying for Real

It is estimated that 100 billion people have died since humans emerged on earth. So by now, we should know something about dying.

In 19th-century Europe there was so much fear that people were mistakenly being buried while still alive, that cadavers were laid out in “hospitals for the dead” while attendants awaited signs of putrefaction. The Jewish (Shemira) and Muslim (Salaat-ul Janaazah) practice is still with us today. The practice of viewing the body of the deceased—with such euphemisms as Funeral Visitation, Calling Hours, Reviewal, or a Wake—comes from the practice of making sure that the person we are about to bury is dead.

Lyall Watson in his classic book "The Romeo Error: A Matter of Life and Death" talks about such errors where people are buried alive. Stories of people buried and later, when the tomb was exhumed, found unsuccessfully attempting to escape. But after more than 350,000 years of burying Homo Sapiens—more accurately the species Homo heidelbergensis—we should have learned how to identify death.

The USA Uniform Determination of Death Act (UDDA), states that patients may be pronounced legally dead either when they meet the traditional criteria for death—the cessation of breathing and the absence of a heartbeat—or when they are diagnosed as brain dead. Brain dead is the "irreversible cessation of all functions of the entire brain, including the brain stem."

Due to the development of artificial life support, many patients are now pronounced brain dead before their hearts and lungs stop functioning. This distinction arose when lawyers were arguing that if the plaintiff was not dead—ie they were still breathing albeit on mechanical support—then the person who "killed" them was not their client—who caused the victim to go into life support—but the physician who switched the machine off.  A logical, but not altogether an accurate medical argument.

Being first introduced in 1968, UDDA is a more fail-safe method of determining death, but there are exceptions. Alan Shewmon, Professor of Pediatric Neurology at UCLA Medical School cites 140 cases of prolonged survival—from a few months to one case of fourteen years—by brain-dead patients. Very few patients recover consciousness from being brain dead, but there are few singular reports of such exceptional cases.  Indeed, people who deal with methodology argue that brain-dead confuses prognosis with diagnosis. The prognosis that the patient will not regain consciousness is different from the diagnosis that the person is dead.

No discussion of brain death can take place without a companion discussion of organ transplantation.  If we are to use the Pope's language, that death needs to involve "decomposition," disintegration," and "separation," then it will truly stop most organ transplantation.

Without brain death there will be a dramatic deterioration in the quality of organs that can be harvested and transplanted to save other people’s lives. And it does not help that a mirror argument relates to abortion and the discussion of when life starts.  Creating life and dying are related. And the reason these are still incendiary topics is because we have learned very little after 100 billion people have been doing both fairly successfully.


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

Cemeteries as Toxic Landfills

Traditionally, burying and cremation were sustainable. But with our urban lifestyles and density of populations, such practices are becoming unsustainable. In 2003 Mary Woodsen reported that we are turning cemeteries into toxic landfills by burying 827,060 gallons of embalming fluid—including formaldehyde; 180,544,000 pounds of steel; 5,400,000 pounds of copper and bronze; and 30 million board feet of hardwoods every year. We are polluting the living through our death and leaving behind a toxic legacy.

Which is why there is now talk of green burials. Green burials are organic burials, with a sustainable mission. A philosophy that aims to have the burial site remain as natural as possible without added chemicals, metals or gases. Green burials also allow for the natural decomposition of the body.  Bodies are buried without preservatives, in bio-degradable caskets, shroud, or blanket.   No embalming fluid, concrete vaults, or non-degradable metals are used.

Except for dignitaries who are still preserved and mummified for prosperity, most traditional religions prescribed that the body is buried in a natural environment to promote contact with the elements and the environment. Although in most countries there are laws prohibiting this, there is a new movement across Australia, New Zealand, Canada, United States and the United Kingdom promoting green burials. This is more in line with the UN Conference on Environment and Development Environmental Program Agenda 21 (for the “21”st Century.)

Green burials are more than just choosing from a variety of biodegradable coffins made from recycled materials. It is about the preparation of the body and the footprint that is left behind. In a 2007 survey by the AARP, 21 percent of Americans older than 50 said they would prefer an ecofriendly end-of-life ritual. And the end-of-life business is responding.

Although cremation has been a greener alternative, using far fewer resources than almost any other option of dealing with the remains, cremation pumps dioxins, hydrochloric acid, sulphur dioxide, and carbon dioxide into the air. Mercury is also emitted when a person with dental amalgam fillings is cremated as well as heavy metals from tatoos. A new alternative to cremation is resomation—bio-cremation—which emits no carbon in the air. Resomation involves placing the body with water and an alkaline (potassium hydroxide) into a stainless steel tank and heating it for several hours until the remains melt. While some of the residue can be placed in an urn, the rest is flushed through the local sewage system. This technique has attracted the unpleasant name of  "toilet burial".

For more exotic burial practices we have to go to the Far East and look at the practice sky burial practiced by Buddhists in Tibet. After carefully preparing the body and making strategic incisions, the body is left on a ledge on a mountaintop, exposed to the weather and to foraging animals—especially predatory birds. The body remains part of the cycle of life.

Although sky burials are not feasible in most urban settings, the business of dying is looking at alternative ways to leave less toxicity in the ground. Re-examining our practice of burial and cremation so that we leave less of a toxic legacy is perhaps our final responsibility in life.

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

Happiness and Dementia

Happiness and dementia. Rarely do you see these two words used in the same sentence, let alone in a title. Dementia is a devastating disease that can produce terror at diagnosis, anguish in managing the disease, despair in the final stages and death might provide little respite for the caregiver. So where is the happiness in this vortex of human tragedy?

The work of Heather Urry of Tufts University and James Gross of Stanford University have examined why older adults report feeling happier than younger cohorts. It seems like a paradox,  although older adults are more likely to be physically weaker and socially less mobile than their younger cohorts, yet they report feeling happier.

What we are beginning to understand is that older adults are more adapt at regulating their emotions. Older adults are more sensitized to interpreting happy moments in a situation, while they are less concerned with negative events--they see these as fleeting events. The older we get the more that we seem to regulate our emotions. This ability to manage emotions is further supported by research that shows that older people are better at predicting how a certain situation will make them feel. They manage their environment and how they respond to it.

In psychology this management strategy is known as SOC--Selective Optimization with Compensation theory. Older adults learn to deal with a changing environment. The way we do this is by selecting our environment more carefully. We then optimize what we are good at and for those few failures we compensate by using other skills and attributes.

The older we become the more that we use SOC in our emotions. We become more careful in selecting situations that make us feel good--Selection. We also see the good in situations more and if there are negative events we tend to diminish their permanence--Optimization. If we have very little control over these two factors--as is the case with people suffering from dementia who have lost their independence--then we compensate by comparing ourselves to others in the same situation--Compensation. This final process is reflected in the seemingly morbid interest some older adults have with newspaper obituaries. You are always better off than someone who is dead.

Older adults with dementia seem to follow these strategies as well, especially compensation. Despite what we would expect, older adults with dementia do not focus on the disease when talking about their happiness. What we have learned with other groups as well is that how healthy we feel is very different from how healthy our doctors tell us we are.

In all studies where people with mild cognitive impairment or early dementia participated in some form of prescribed mental exercises, half of the participants report some improvement in behavior and thinking.  But whether you improve or not, nearly all participants reported feeling better after the exercises. Becoming engaged in activity improves how you feel about yourself.

In contrast, such improvements in wellbeing have not been shown in studies looking at medication alone. Medication does not bring about happiness. It is the social interaction that improves how we feel, whether we have dementia or not. Some people with dementia suffer from mood and personality changes, but their experience of happiness remains firmly grounded in their social relationships.

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

Aging Tattoos

For older adults, tattoos were exclusively for sailors, convicts, bikers and indigenous groups. However, now, more than a third of 18-25 year olds in the USA have a tattoo adorning their body. Despite the recent tattoo boom there has been a dramatic decline in reports of infections that were associated with tattoos. But there are other concerns with tattoos, least of which is the aging of tattoos.

Aging skin changes shape, composition and elasticity and tattoos, because they are embedded in the skin, reflect these changes. Ian Eames at the University College London studied this change by developing a mathematical model of how tattoos ‘move’ with age.  There is physics, chemistry and biology.

Tattoos are ink suspended in a solution made up of ethyl alcohol, purified water, witch hazel, listerine, propylene glycol or glycerin (typically obtained from animal fats.) Tattoo inks can be made up of various particles. Although there are non-metallic colors (black which is made by burning animal bones down to charcoal), most colors can only be achieved using metals—heavy metals—including mercury, lead, cadmium, nickel, zinc, antimony, beryllium, chromium, cobalt, nickel, arsenic and iron.

In California after 1986--when Proposition 65 was passed--most tattoo parlors had to warn their patrons that tattoo inks contain heavy metals and are known to cause cancer, birth defects, and other reproductive harm. However some colors can only be achieved by using metallic ink. The metals are suspended in the skin by puncturing the top layer—some at 3000 punctures a minute—and leaving ink embedded within these punctures.

To protect itself the body's immune system reacts to this trauma by sending white blood cells to the area—causing visible redness. White blood cells attack the area and attach themselves to some of the heavy metals and clear them out of the body. The rest of the heavy metals are encased in protective cells and sealed within the skin.

With time, as these protective cells divide, or die, they exit the body taking with them the heavy metal that they have encased.  Laser treatment to remove tattoos speed up this process by killing these cells—and increasing the exposure to toxicity from newly released heavy metals. Like a fading colored cloth, the tattoo simply looses its detail both in terms of colors—some colors being more prone to fading than others—and definition. Intricate details in a tattoo are lost first. Also with older tattoos  the ink particles move deeper into the skin over time making the tattoo less distinct and harder to remove using laser treatment. Metallic tattoos also distort magnetic resonance imaging.

A study conducted in 2008 reported that up to 20% of the tattooed individuals regret their decision and many of them sought advice for tattoo removal. But the aging of tattoos is not related to physics, chemistry or biology, but is related to mindset. What you think is cool at 18-25 might not be so cool once you have grandkids. The aging of tattoos is related to leaving a permanent testament of a bygone era.

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

Aging Movie Stars

Tonsillitis and aging

Crying among Older Adults

There is a hint of disgrace associated with crying, especially among older men.   The stigma is not surprising since most scientific studies attempt to associate crying with depression. In fact, among older adults, depression is often not related to feeling sad. What emerges is that  we know very little about crying. Not only is there no clear-cut association that crying is a sign of depression, there are also very few studies reporting the opposite—that crying has healing benefits, when crying is not a response to pain or anger. 

A popular view is that crying can have a positive psychological as well as a physical benefit, a  view shared in popular literature. In a review of 140 years of popular fiction, crying is promoted not only as beneficial, but most warned readers that keeping back tears would harm them. Even Hollywood knows this and makes money selling us tearjerkers.

Lauren Bylsma now with the University of Pittsburgh, and her colleagues reported that when 4000 men and women in more than 30 countries were asked about crying, most people—in retrospect—reported improved mood, reduced tension and feelings of relief after crying. But this report of benefits from crying is not repeated in a laboratory setting,. When adults are made to cry in response to a sad film, report feeling worse—increased sadness and distress—than those who did not cry. Of course it could be a matter of timing. Using another example, people are more likely to report being relaxed an hour after jogging than immediately after. And the same might be the case with crying. There might be a time lag in reporting positive effects from crying.

And what about gender differences? Women cry more often and more intensely than men, although both report equal benefits. Interestingly what researchers have found is that people who suffer from alexithymia—the lack of understanding of emotions—reported fewer episodes of crying and reported less positive mood benefits as a result of crying.

What is missing from these analyses is the fact that crying can be a social behavior. Many of us cry, some privately and infrequently, others more consistently and publicly.  In some cultures there are criers who are paid to cry at funerals. There is a social context as well as a psychological one. Crying is also a learned behavior. Men are taught not to cry from an early age, while women elicit support and compassion when they cry. Social crying might be a form of social behavior in order to elicit empathy from others. And the cues of crying are so strong that even dogs express empathy when strangers are crying.

Crying among older adults is complex. There is evidence of benefits but it depends on who you are. If you are a happy person you gain more from crying than if you are a sad person, if you empathize you are more likely to benefit. There is also a positive social component to crying that women might have been exposed to more than men.  The benefits of crying might reflect more who you are than what you are emotional about.

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

We are all Becoming Demented

For the first time since 1984 there is a new clinical diagnostic criteria for Alzheimer's disease dementia.  Published in April 19, 2011 in Alzheimer's & Dementia: The National Institute on Aging working with the Alzheimer's Association have expanded what we now consider  dementia.

While the previous guidelines only recognized one stage—Alzheimer’s dementia—the new guidelines propose that Alzheimer’s disease progresses on a continuum with three stages—an early, preclinical stage with no symptoms; a middle stage of mild cognitive impairment (MCI); and a final stage of Alzheimer’s dementia.  

These new guidelines forge a solid causal link. What was before just a probability of association is now seen as a causal progression from changes in the  brain that have no symptoms, to mild problems with thinking and memory and ending with dementia.

What made this possible is the introduction of new tests that can measure the health of the brain while the person is still alive. In the past, the only way to get a definitive prognosis of dementia was through an autopsy. Nowadays, especially with functional magnetic resonance imagery, the use of biomarkers makes it possible to measure changes in the brain before any symptoms appear, hence the new guidelines.

This ushers in a new era of fatalism. Unintentionally, these new guidelines are stoking the fear of dementia.  A MetLife Foundation study in 2010 reported that people over 55 dread getting Alzheimer’s more than any other disease--other then cancer. These new guidelines raises our sensitivity to subtler decline in thinking and memory. However it is important to stress that this linear connection is not as clear-cut as neuroscientists would have us admit.

MCI indicate difficulty with memory and thinking that are not normal but still allow the individual to  function independently. Many--but not all--people with MCI progress to Alzheimer’s dementia. However there are some important causes of MCI other than dementia--which the guidelines do not address--including medications, stroke or depression.

There are other inconsistencies in the logic of this causal path. As far back as thirty years ago M Marcel Mesulam with Northwestern University, reported 6 patients with progressive word-finding and naming difficulties that worsened over the years, but who did not develop a more generalized dementia.  Even if the connection between MCI and dementia is established, Mike Martin and his colleagues from Zurich, reported the results from their meta-analysis and concluded that cognitive interventions do lead to modest performance gains with older adults.

Even if the brain starts has the neuropathology it does not dictate the behavior. In the famous "Nuns Study" David Snowdon first reported this very strange anomaly. He found that a third of the nuns who behaved and acted free from dementia, were found to have the disease of Alzheimer’s during autopsy. Numerous studies have also found this lack of correlation between the disease and the behavior. More recently, Archana Balasubramanian with colleagues at UCLA reported that for 58 individuals, 90 years and older--who did not have any signs of dementia during three years prior to their death--at autopsy had evidence of the disease of dementia. All these studies erode the direct linear link between the disease and the behavior. There seems to be other mediating factors that the NIA guidelines need to address.

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

Smell and Dementia

The sense of smell is accomplished through our olfactory system, which is an old system in our biological development. It is also one of the most evocative.

Smell acts as a portal to our emotions. It transports us directly to another time, another place and the only other medium that does this so quickly is the auditory sense--through music. But unlike music-- which can be written down and transferred in what Karl Popper calls World 3--smell is ephemeral.

Smell is somewhat undefined. Good, bad, sweet, acrid, then we loose track of translating the subtle smells into language. Smell has its own language and it cannot comfortably be translated into words.

Smell has power, it is evocative and nuanced so that a particular smell can immediately transport us to our first kiss, or the fear of high school, or your first child being born. Visceral and strong emotions which are hidden in the recesses of your mind. Never lost but subdued until dementia starts to erase them.

The olfactory system has a direct path to the brain. With humans, this system starts with the nose and ends a short distance away at the base of our brain. Olfactory receptors, with very thin fibers,  run  from the roof of the nasal cavity through perforations in the skull ending in the olfactory bulbs, which are a pair of swellings underneath the frontal lobes. It is the only sense that has such a direct physical connection to the brain. It is is also the first to be affected with the onset of dementia or Alzheimer’s. When the brain is affected by dementia, the area that deteriorates first is the area that is responsible for smell.

There is currently a patent, by researchers from Columbia University lead by Davangere Devanand, for a test using scents that include cheese, clove, fruit punch, leather, lemon, lilac, lime, menthol, orange, pineapple, smoke and strawberry. Using this test, the clinicians can predict that an individual who cannot recognize three of the ten scents are five times more likely to develop Alzheimer’s. It has also been found to predict Parkinson’s disease as well as certain types of schizophrenia and brain tumors.

Many people who lose their sense of smell also complain that they lose their sense of taste. Smell enhances the information we get from the mouth; salty, sweet, sour, and bitter tastes. Loss of taste might explain why weight loss is also an indication of dementia. It is not the weight loss on its own, but rather the loss of smell, which brings about the loss of appetite and consequently to diminished appetite.

There are some sixty seven medical conditions identified as possibly causing loss of smell--dementia being one of them. Some of these causes are temporary, such as colds, and nasal allergies such as hay fever.  It may also occur due to some medications and localized nasal polyps and tumors. Such factors reduces the odds of making the patent smell test a very reliable indicator in predicting dementia. But for individuals, it is important to notice changes in how well we can smell. So if you are having trouble with smell, check with your physician first to make sure that this is not a temporary condition.

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