Leaving Behind the Victim of Dementia

Unfortunately, I come across many anecdotal stories of caregivers dying.  And as a result, leaving behind the person who depended upon them. Increasingly, those left behind are suffering from dementia.

This observation raises two questions. The obvious one, which is an emotional question; who will look after the care recipient now? But a second question has a more radical focus; why are these caregivers dying earlier?

What has been described as a ‘living bereavement’, caring for a loved one with dementia becomes increasingly difficult the further the disease progresses. Unlike most other caregiving, where the care, in most cases, becomes less stressful because the person improves (eg some stroke patients) or they grow up (eg children) or they die quickly (eg some cancer patients) , with dementia the diseases progressively incapacitates the victim. With further incapacity comes a greater burden on the caregiver. Caregivers of loved ones with dementia carry an extra burden that is reflected in more sever and negative effects.

Although David Roth and his colleagues, in their study of 3,503 family caregivers, reported that caregiving was not associated with increased risk of death, they failed to identify the specific type—and intensity—of care being provided. Not all caregiving is the same. And you learn that when you look after a victim of dementia.

As early as 1990, Janice Kiecolt-Glaser from Ohio State University and her colleagues measured the different impact caring for a patient with dementia had on their caregivers. They reported that caregivers of people with dementia had significantly more depression, reported less support and fewer important personal relationships, and experienced more days of illnesses from infections, when compared with caregivers of non-demented loved ones. What was convincing in their argument is that these caregivers had physical immunological deficiencies. They were sicker.

Richard Schulz and his colleagues from the University of Pittsburgh in 1999 showed how even after adjusting for a variety of factors, caregivers who are experiencing strain had mortality risks that were 63% higher than non-caregiving controls. The beneficial spiritual and physical effects of caregiving do not override the negative effects of caring for someone with dementia.

One indicator of sickness, which also reduces your lifespan—is the size of your telomeres. These DNA blocks at the end of each of our 46 chromosomes have been likened to an aglet—the plastic at the end of shoelaces. The size of these telomeres determine how many times each cell can replicate—the longer the telomeres, the more your cell can replicate, the longer they live, the longer you live. There are numerous studies being published showing how stress and trauma reduces telomeres. With varying intensities of care there are reduction in these telomeres. Dementia caregivers not only have vastly shortened telomeres, but this change is permanent even after their loved one dies. Despite most caregivers of dementing illness being older and frailer than other caregivers, most choose to look after their loved ones. The decision, of whether providing this care accelerates your mortality faster than the mortality of your care recipient, is not an easy one to make.

© USA Copyrighted 2014 Mario D. Garrett

Older Adults' Fascination with Obituaries

The fascination of reading the obituaries forms a purely older adult phenomenon. And it is not a morbid fascination with death, but a testament that the reader is still alive. Longevity is related to being happy with your lot. Even if you could change events, you wouldn’t--that kind of happiness. Because the only anti-aging that nature knows is death, nature rewards those who accept aging and the losses we experience on the way.

How older adults deal with loss points to effective strategies that they have learned to use in maintaining an optimistic perspective. These are patterns of coping that start early in life. These coping strategies result in less damage to the body and result in greater longevity. One theory popular in the 1980s is now known as the Baltes’s Selective Optimization with Compensation—SOC—theory. Here Baltes describes strategies of how we address physical and mental losses as we age in order to minimize their effect.

Let's take for example that you are becoming deaf. The theory predicts three main strategies that older adults follow. First you become selective. You will increasingly choose quieter social settings without conflicting noises. You stop going to loud parties. Then you will optimize those situations that you choose to participate in.  You will choose to be with people that you can hear better, sitting closer, giving them your best ear, you optimize what hearing you do have. This optimizes your remaining ability to listen. Lastly, you will start to compensate. You might start going to the cinema or theatre more where you do not have to converse with anyone. You might do more activities where you do not have to talk (running, swimming, hiking.) You might also compensate by learning to use hearing aides. These three SOC strategies allow you to participate without drastically changing your lifestyle. SOC is a strategy for accepting your losses. To focus on what you can do rather than what you cannot do. This strategy, learned earlier on, gets more useful with increasing age as we experience more deficits.

One of the uniquely frequent experiences in older age is the death of a close friend. Although death never becomes easier to accept--it is so final--there is a greater appreciation of acceptance. In 2001 Christopher Davis from St. Francis Xavier University and Susan Nolen-Hoeksema from the University of Michigan reported that older adults who have lost a loved one often try to extract some meaning of their loss. Even if meaning cannot be found the authors report that older adults search for some benefit in the loss. This is different from grief of younger adults or children. The belief that there is meaning or some benefit even in anguish of loss suggest a positive strategy. Again, the strategy of SOC is to accept the reality and to try and compensate the loss by finding some hidden meaning or benefit.

The philosophy is “it could be worse.” Which brings us back to the fascination older adults have with the obituaries. You are always better than those who are dead.

© USA Copyrighted 2014 Mario D. Garrett

The Death Experience.

Older Adults do not fear death they fear dying. Specifically, we fear a prolonged process of dying—the agonal image of death. This is not a new observation.
Lora-Jean Collett and David Lester made this distinction in 1969 and devised a scale to distinguish between the fear of death from the fear of the process of dying.  Some older adults are better at confronting death than others. In an interesting study, James Griffith from Shippensburg University, Pennsylvania and his colleagues examined attitudes toward dying and death among older men who had different experiences with danger. The group of men included skydivers (high death risk), nursing home residents (high death exposure), volunteer firefighters (high death risk and high death exposure), and a control group. Their analyses identified that accepting death by risking death, reduces the fear of death.  High death riskers are better at accepting death. It seems that the fear of death can be minimized, perhaps not only by risking death.
Studies with nurses have reported that working with dying patients diminished their fear of death. This acceptance of death occurred while in nurse training as well. As always, the fear is brought on more by the unknown. And this fear determines how we behave.  Balfour Mount, a palliative care specialist suggested that deep-rooted existential fear of death prevents healthcare professionals from providing good and compassionate care for the dying.
Maturity involves an appreciation that dying is itself a process. A process which, at the very end, we seem to share with other people across many cultures.
Raymond Moody coined the term “Near Death Experience”—NDE. As early 1975 Moody described survivors who ‘let go’ and accepted their death, but when they survived, reported experiences of great joy. Although there are exceptions—especially with the use of medications at the end-of-life—Moody describes how after travelling through darkness they came against a bright light, accompanying “beings of light” that helped them to review their life. Such experiences have been shown to be experienced across many cultures. And the interesting outcome after these NDEs is that these individuals report having a diminished fear of death.
It was up to a chemistry professor with West Texas A&M to find some of the physiology reasons for NDEs.  James E. Whinnery studied fighter pilots subjected to extreme gravitational forces in a giant centrifuge. What he found is that under extreme g-forces, fighter pilots experience gravitationally-induced loss of consciousness—G-LOC—similar to NDEs in many of its characteristics, including the tunnel experience and the bright lights. Only when Whinnery went beyond the pilots losing consciousness, to the brink of near death, did the fighter pilots have a near death experience.
We are conscious of our death and we have developed an evolutionary positive method of dealing with it. Death, as defined by our evolution, is a positive experience. Death might be detrimental to the individual, but it is imperative for the specie to survive. It is appropriate that evolution honors this. The way to reduce our fear of death is to confront it, dying itself is a positive experience.

© USA Copyrighted 2013 Mario D. Garrett

Cougar Sex

David M Buss has been writing about older women’s sexual adventures for some time. He notes in “Why Women Have Sex” that women use sex as a defensive tactic against a mate’s infidelity (protection), as a ploy to boost self-confidence (status), as a barter for gifts or household chores (resource acquisition), or as a cure for a migraine headache (medication). Like most of men's evaluation of women’s sexuality, pleasure is not one of the reasons explored.

Using Craigslist to enlist three quarters of their volunteers Buss and his colleagues found that women aged 27 through 45 years of age report having more sexual fantasies, more intensely and engaging in more sexual encounters than their younger cohorts. The impact of marriage and having children was not found to be as important as age . Only age had a strong positive effect on women's reported sexual interest and behavior. Women’s sexual awakening seems to be formidable.

Women’s sexual interest was believed to peak and then fall precipitously after menopause. But this drop might be a misinterpretation by some researchers.

Susan E. Trompeter, and her colleagues from the University of California San Diego looked at women 25 years after their menopause. Half (49.8%) reported sexual activity within the past month with or without a partner. Sexual activity included arousal (64.5%), lubrication (69%), and orgasm (67.1%) at least most of the time. Only a third reported low, very low, or no sexual desire. Although frequency of sexual activity decreased with age, they all reported increased satisfaction when they did have an orgasm.

Having the brain as one of the largest sex organ—together with the skin—determines that emotional closeness is associated with more frequent arousal, lubrication, and orgasm during sex. Overall, two thirds of sexually active women were moderately or very satisfied with their sex life. With such statistics, the idea of peaking only before menopause seems a myth. For some women they keep on going.

Little is written about late life sexual activity except for educational purpose. What has been written is about marriage from public records. In a recent article in an unlikely journal of Review of Economics and Statistics, Hani Mansour and Terra McKinnish from the University of Colorado reported that couples with big age differences are typically less attractive, less educated and make less money than couples of similar ages. The more pronounced the age difference the less positive attributes they had.

Interestingly, they make a class issue (using education as a proxy for class.) More educated people tend to interact more with people their own age while those with lower formal education and who work in low-skill jobs are more likely to socialize with people of a wide range of ages. Poorer people have networks that are more age diverse. But this might be about marriage, a social contract.

Pleasure comes in many forms and sexual gratification is one of them. Marriage is not an indication of pleasure, but age is. Maurice Chevalier’s "never date anyone under half your age plus seven" might be appropriate for most people but it might not apply to some older women. Sexual arousal for older women matches those of younger men.

© USA Copyrighted 2013 Mario D. Garrett

Children Killing Their Parents

As upsetting as it is, there are numerous blogs on how to kill your parents. Unlike elder abuse, killing younger parents seems to be voyeuristic entertainment. This surprising revelation is worrisome

The animosity children feel towards their parents provides a necessary feeling of detachment, augurs for a healthy separation process from their parents. It is how they differentiate themselves from their primary influences in life in order for them to become whole persons. Such feelings are nothing new. The surprise being websites devoted to killing one’s parents, with instructions. Then the second surprise was the statistics.

For more than two decades, Kathleen Heide from the University of South Florida has been conducting analysis of homicides where children kill their parents. In the USA about five parents a week are killed by their biological children. Matricide—where the mother is murdered--and patricide—where the father is murdered—are both very rare events and constitute about 1 percent of all homicides in the United States—but we have a lot of homicides in the US.

In a 2011 report from the Department of Justice, Alexia Cooper and Erica L. Smith reported a change in trend of family homicide. The most common were homicide by a spouse or ex-spouse, which is declining from 52% of all family homicides in 1980 to 37% in 2008. Children killed by their parents were the second most frequent type of family homicide. This is seeing an increase, from 15% in 1980 to 25% in 2008. But the fastest growing homicide is the last category where parents are killed by one of their children. This type of homicide has been increasing steadily from 9.7% of all family homicides in 1980 to 13% in 2008. Children killing their parents is the fastest growing type of family homicide. In the latest federal statistics both matricide and patricide is committed primarily by sons between 16-19 years and then declines rapidly at older ages.

In 1993 Clifford J. Linedecker wrote a book on “Killer Kids” where he reports that there were over a million assaults in the USA by children on their parents, some were fatal. He documents some of the most horrific cases. Most use their parents’ guns, others use knives, axes and any available weapon. The younger killers are more likely to use their parents’ gun.

Since patricide is most frequent (nearly twice as likely as matricide) and  increasing, there might be a number of reasons for this. With increasing breakdown of family structure in the USA--with one in two marriages ending up in divorce--there is a risk of one parent alienating their children against the second parent. Parental alienation is on the increase as are children killing their fathers. Very often the father (rather than the mother) becomes portrayed as the reason for all the negative emotions. Parental alienation does not start or end with divorce. But there are reasons for this behavior. We just need to find that reasoning, however repugnant and irrational.

© USA Copyrighted 2013 Mario D. Garrett

Dying to Be Born

Mekayla Storer, and her colleagues in Barcelona, and Daniel Muñoz-Espín, and his colleagues in Madrid, just published interesting findings about death. When a cell dies, it was always assumed that it is in response to age, stress or trauma. In fact, the anti-aging industry is built upon the foundation of stopping cell death with the hope of making us immortal.  But these Spanish researchers have shown that cell death is a necessary process for development. That in order for other cells to grow they need some of the cells to die first and create a pattern. What is unique in these studies is that the information comes not from older adults but from studies on the embryo.

For the first time, there is evidence showing that cell death is programmed in order for specific organs to be able to develop. Cell death is not only a part of development but is a required part it. They are like the advance party that charts out a territory and then die, sending out directions for the main party. In the embryo, when a cell dies, its death instructs new tissue growth. The necessity of cell death has been shown to help control normal limb formation, nervous system development, development of kidneys and ear formation.

These studies are showing that cell death is a necessary part of development of normal organs. This is new. Such studies are a death knoll to the anti-aging industry, since such knowledge destroys the concept of eradicating cell death in order to gain immortality. Cell death is a necessary process in order to pave the way for other cells to grow and to enable the growth of different parts of our bodies.

The process is determined by how the dead cells are cleaned by specialized cells that leave behind them a pattern that is followed by the new cells. When cells do not die, then there are problems with development. It is no wonder that birth defects are in parts of the embryos where these dead cells occur. The death of cells and how they are cleaned up is instrumental for the normal growth of cells.

This is important for older adults because dying cells and how they are cleaned up have complementary functions in cancer. We do not know the exact relationship (whether one encourages the other or not) but we know that they are related because we can listen to them communicating. Cells communicate in short distances—known as paracrine—and long distances—through hormones and endocrine system. This language could be what differentiates good dying cells from bad dying cells—cancer. Good dying cells have a different short distance message from cancer cells. Good dying cells might call out to the cleaner cells while cancer cells give short messages that keep the cleaner cells away. How these two different types of dying cells work in aging is still unknown, but we now know that cell death communicate with those living cells. Can you hear me now?

© USA Copyrighted 2013 Mario D. Garrett

Aging Plastic Surgery: How does invasive cosmetic surgery stand the test of time.

Despite a lengthy economic recession, cosmetic surgery is still on the increase throughout developed countries. What Roberta Honigman and David J Castle call the “looks industry” is alive and well. It seems everyone is doing it. It is a quick fix to a perceived embellishment.

But the fix might be more in the head than on the face.  Joshua Zimm, from the University of Toronto and his colleagues published a study in 2013 showing that facial cosmetic surgery does not significantly enhance attractiveness and only reduces perceived age by 3.1 years. So objective improvement is, at best, minimal.

The growth of cosmetic surgery is not a reflection of the increasing ugliness of people but a reflection of our increasing negative self-perception. The fact that cosmetic surgery is still increasing in popularity despite showing little positive outcome—objective measure of attractiveness or youth—points again to our desire to become perfect.

Body image is closely aligned to self-image and self-esteem. The sad part of this “looks industry” is that the problem is not how people look, but how they think they look. Because of this, surgery is often ineffective in changing this psychology.

The Norwegian researcher Tilmann M Von Soest, from the University of Oslo, followed 1,500 teenage girls for 13 years where 78 girls had cosmetic surgery. Those that had cosmetic surgery tended to have a history of poorer mental health for which cosmetic surgery showed no improvement. If the issue about our body image is a psychological one, and even when successful—and most people report that they are happy with the surgery two years on—the intervention will not change your negative self image. In severe cases of such negative self-image—body dysmorphic disorder—there is no surgical solution but psychological.

If you undergo any surgery when you are younger, the effect might look more unnatural since aging will include loss of skin elasticity and collagen, along with loss of skin fat across your body. You might have a newly formed nose but the rest of your face (and body) will be sagging.

In one such example of balance, Teri L. Hernandez and Robert H. Eckel of the University of Colorado, found that liposuction may slim one problem area but after a year it will create another problem area. Women who had fat suctioned from their thighs and lower abdomen ultimately put weight back on in often less flattering areas like the upper abdomen, back and arms. What we are learning is that the body controls the number of its fat cells as carefully as it controls the amount of fat. We need to work with the body to maintain healthy good looks rather than cutting it up.

There is no data on the number of repeated surgical procedures.  Because the problem is psychological, it is likely that most people will continue chasing their ideal image through surgery, until either their money or body gives up. At some point you will have to address the problem in your head.

© USA Copyrighted 2013 Mario D. Garrett

Intergenerational Conflict and the Addiction to Money

There is a social contract between generations that we learn to accept.

The contract simply states that we look after you until you grow up and then when you start working, you look after those who helped you. Sounds decent. Except that this social contract, when managed by politicians, translates into conflict for the obvious reason that administrators and politicians are addicted to spending money.

Back to the social intergenerational contract.

If the social generational contract was working why do we have such negative outcomes for children and older adults? In 2010 the 112th Congress Senate introduced bill 294 highlighting that Congress finds the following:
 (1) The United States ranks 17th in reading, 31st in mathematics, 23rd in science, and 18th in overall secondary education out of 36 developed nations, according to the Organization for Economic Co-operation and Development (OECD).
(2) According to data compiled by the OECD, in 2008 the United States had a child poverty rate of 20.6 percent, which  is the 4th highest child poverty rate of the 30 OECD countries that are ranked in this category...

In 2011 we now have a child poverty rate of over 22% with single parents with children having the third highest rate among all OECD countries.We are losing ground.

This is not a successful intergenerational contract. But the litany of woes continues.

Once our children mature and start going to college, there are other pitfalls that do not exist for children in other developed countries. Of the 20 million students that attend college every year in the US, close to 12 million borrow to help cover costs. The August 2013 Federal Reserve Statistics student loans amounted to $1,178 Trillion. Student loans are hovering around $100 Billion a year in new loans per year. Students in the US owe more than the total GDP of over 180 countries and territories (out of 194).

It surprises Europeans to learn that this cost is in addition to state funds that contribute more than $1,060 per student per 3-unit class. An enviable sum for any Country offering free education. All this cost ensures that from infants, to children, to adolescents to adulthood young Americans are enslaved in an economic stranglehold.

From the very young to young adults, between 25%-50% of  Americans are destined to remaining in poverty, becoming debt ridden or electing to be uneducated and join the daily cycle of minimum work at $8:50 an hour.

So the social intergenerational contract is not working so well for our children. But at least, for older adults in the USA, there is some benefit to the social intergenerational contract.

Back to the social intergenerational contract.

We need to examine the federal figures more closely for this one.

The most successful social programs in the US has been the introduction of Social Security in 1935. Social Security has been instrumental in lowering poverty levels among older adults. But if we look at the metrics—without denying the comparative improvement of welfare of millions of older adults—the improvement does not translate to economic security in older age.

The 2010 Current Population Survey reported 43.6 million people living in poverty—the largest number in the 51 years for which poverty estimates have been published. Surprisingly, the same report shows that between 2008 and 2009, poverty increased for children under age 18 (from 19.0 to 20.7 percent) and people aged 18 to 64 (from 11.7 to 12.9 percent), but decreased for older adults (from 9.7 to 8.9 percent).

The federal poverty level was defined by Mollie Orshansky between 1963-1964 while she was working for the Social Security Administration. Ms Orshansky used the U.S. Department of Agriculture’s economy food plan for families of three or more persons and multiplied the costs by a factor of three. A sensible enough metrics in 1960s.

Fast forward to 2013. The US is very different from the US of 1960s. The poverty metrics does not take into account housing costs, differences in living expenses across the country, child care, health care costs, medications and transportation.  National Academy of Science developed a new formula to account for these changes. And in January 2011, the federal government officially but reticently acknowledged the need to improve the outdated federal poverty level by releasing a ‘Supplemental Poverty Measure.’

The new index, now known as the Elder Index, was calculated by the UCLA Center for Health Policy Research on behalf of the Insight Center for Community Economic Development, and Wider Opportunities for Women. The Elder Index shows that the cost of living for most US older adults far outpaces the Federal Poverty Level. The Elder Index estimates that 18.6 percent of Americans over 65 live below the poverty line, which translates to 6.8 million older adults. This index is more accurate than either the antiquated Federal Poverty Level or the Supplemental Poverty Measure because it takes into account the costs of child care, health care and transportation. 

How can this happen when the US planned for the aging of the baby boomers? Ronald Reagan established the 1982 Commission to study and make recommendations to Congress on how to solve the Social Security obligations when the baby boomers mature. The venerable Alan Greenspan chaired the Commission. The recommendations, which become law in 1984, was for a major payroll tax hike to generate Social Security surpluses for the next 30 years, in order to build up a large reserve in the trust fund that could be drawn when the boomers become retirees—which is now. This created a massive surplus of $2.7 trillion.

Unlike other countries in the world, the United States is alone in that the surplus is spent, every cent, every year. There is even a law to stop Congress from doing this. The Budget Enforcement Act—Section 13301—made it illegal for Congress to use Social Security funds by excluding Social Security from all budgets including the congressional budget. However the intent of the law is ignored.

The 2013 Social Security Trustees Report states that "Redemption of trust fund bonds, interest paid on those bonds, and transfers from the General Fund provide no new net income to the Treasury, which must finance these payments through some combination of increased taxation, reductions in other government spending, or additional borrowing from the public." This means that these are no bonds that could be sold. In order to pay this money back the government will have to raise, borrow, or print additional monies to honor them.

The "special issue Treasury Bonds" are not bonds, because they cannot be bought, sold or bartered, but simply IOUs that Congress is NOT obligated to pay back. There are Supreme Court decisions, especially the 1960 Flemming v. Nestor. where the Court denied Nestor's benefits even though he had contributed to the program for 19 years and was already receiving benefits. The decision states that there is no obligation for the federal government to honor its commitment to provide social security regardless of your contribution. It is an entitlement as long as we say it is.

Back to the social intergenerational contract.

On the younger generational side there is Infant mortality, child poverty, educational debt encumbered, while on the older adult side we have an increasing number experiencing poverty--despite Social Security--and  a Congress that has expropriate--illegally under Section 13301--all of our Social Security Trust Funds. Older adults insurance no longer exists.

Lets look at the social intergenerational contract again.

Intergenerational "conflict" is a product of abuse of funds. It is a creation of politicians and administrators who abuse the implicit agreement we have across generations. When we allow for this to happen--for administrators to expropriate our investment--then we allow for our society, our community, to fend for itself. There are no safety nets. How did we get to this place and what are some of the solutions?

We got to this place because we keep being distracted by peripheral issues that have no significance to our well being. Whenever there is an issue that hits at the core of our being, our civic society, we are distracted by jingoism and national pride or petty politics. The solution is education. Not a radical idea, but one that sounds simpler than it is. Education, not in a formal sense of going to college (which we should if we can afford it or have that inclination) but in terms of being open to discussing everything. To fight for an truly open society. To invest time to understand the issues and not to settle for sound bites. This is hard. Attend a council meeting. Participate. You do not have to say anything, just listen and be aware.

© USA Copyrighted 2013 Mario D. Garrett

Epigenetic and Dementia

Epigenetic is a process where so-called "dormant" genes are switched on or off in response to specific chemical triggers. The best example we have in aging is the increasing differentiation of identical twins—twins that developed from a single egg. In the 2005 proceedings at the National Academy of Science where a group of Spanish, Swedish, Danish, English, and American investigators report their study conclusions, it was reported that whereas young identical twin pairs are essentially indistinguishable in their epigenetic markings, older identical twin pairs show substantial variations. Resulting in increasing differences between the pair. This has been termed as “epigenetic drift” which is associated with aging.

Differences in gene expression among older twin pairs were some four times greater than those observed in young twin pairs. And the environment plays a significant role in this differentiation.  The more different the twins' upbringing, the greater the difference in their epigenetic makeup and observable differences between the two twins.  In some cases there is enough of a difference so that one twin gets dementia and the other does not. Although some genes have been identified for some early-onset forms of Alzheimer's disease, genes only explain 10-5% of diagnosed Alzheimer's disease, the rest remain unexplained and epigenetics might hold the answer.

Paul Coleman, from Sun Health Research Institute, in Arizona, looked at one set of identical twins—one who died of Alzheimer's disease, while the other twin died without Alzheimer’s disease. Coleman and his colleagues found that the twin that died from Alzheimer's disease not only had the characteristic disease in the brain but he also had less epigenetic activity (DNA methylation) indicating that this might be the reason for getting the disease in the first place. The twins attended the same schools and both worked as chemical engineers. However in their adult life, the one that died from Alzheimer's disease at the age of 76 was exposed to extensive pesticides at work, while the healthier twin worked in a different environment and died of prostate cancer at age 79.

Because there are so many factors involved in daily living, there is an issue in saying that the environment switches on/off specific genes that causes changes in the brain. However, emerging new results in dementia, are exposing examples where people with the disease—plaques and tangles throughout the brain—are escaping the expression of dementia. The only feasible answer is the possibility of epigenetic influences.

Epigenetic process has also been shown why certain diseases promote the expression of dementia A study by Jun Wang and her colleagues from New York Mount Sinai Hospital demonstrated that diabetes may bring about epigenetic changes. Having diabetes switches on a disease mechanism in the brain that makes the diabetic patient more prone to dementia. For the first time there is a study that shows why diabetic patients are at an increased risk of developing dementia. This new evidence, that diabetes might be the trigger to dementia, is a more likely cause given that approximately 60 percent of Alzheimer's disease patients have at least one serious medical condition associated with diabetes.
Epigenetics might hold the key in consolidating research findings that we could not explain before, while at the same time  provide a theoretical explanation of how environmental and external factors contribute to the expression of dementia.

© USA Copyrighted 2013 Mario D. Garrett

Childhood disability and Aging

Elo and Preston (1992) completed a review of the literature examining the effects of early life conditions on adult mortality. Their review begins with a discussion of the epidemiologic evidence for some of the major mechanisms whereby exposures and morbidity in childhood may have health consequences for adults. Initially, they examine a number of specific infectious diseases of childhood with well-documented, long-term health effects among adults (tuberculosis, hepatitis B, rheumatic heart disease) and then look at the growing literature suggesting that a number of chronic cardiovascular and pulmonary diseases may be related to a range of risk factors beginning in the intrauterine environment (e.g., intrauterine growth retardation) and extending through disease exposures and behavior patterns acquired in childhood (e.g., acute respiratory infections, dietary consumption of fat and salt). They examine other associations including a number of studies postulating that viral infections acquired in childhood may be linked to a wide variety of chronic diseases ranging from cancer to multiple sclerosis, juvenile diabetes, rheumatoid arthritis, and presenile dementia, as well as the extensive literature linking short stature and adult mortality.
Childhood Precursors of Adult Morbidity and Mortality in Developing Countries: Implications for Health Programs
W.Henry Mosley and Ronald GrayPerinatal conditions

Low birthweight
Growth stunting, chronic obstructive pulmonary disease
Birth trauma, asphyxia, metabolic disorders
Brain damage, cerebral palsy, mental retardation
Congenital and perinatal infections

Hepatitis B
Liver cancer, chronic liver diseases
Syphilis
Blindness, deafness, paralysis, bone disease
Gonorrhea
Blindness
Infectious diseases of childhood

Tuberculosis
Tuberculosis
Rheumatic fever
Chronic rheumatic heart disease
Poliomyelitis
Residual paralysis
Trachoma
Blindness
Chagas’ disease
Heart failure
Schistosomiasis
Liver cirrhosis, general debility
Helicobacter pylori
Stomach cancer
Epstein-Barr virus
Nasopharyngeal cancer, Burkitt’s lymphoma
Nutritional deficiencies in infancy and childhood

Protein-energy malnutrition
Growth stunting, obstetrical complications, cardiovascular disease, chronic pulmonary diseases, intellectual impairment
Micronutrient deficiency

Iodine
Cretinism, intellectual impairment
Iron
Learning disabilities, intellectual impairment
Vitamin A
Blindness
Environmental hazards

Indoor air pollution
Chronic obstructive pulmonary disease, lung cancer
Lead exposure
Intellectual impairment

Faith Leaders in End-Of-Life

Although we assume that faith leaders are experts in dealing with death, we might be surprised to find that they are not at all that comfortable with the topic. In master of science unpublished research conducted by three separate gerontology students at SDSU, we find that across all religions, faith leaders are poorly trained in end-of-life issues. Most faith leaders reported little to no formal training, and even those that have been exposed to some training admitted that they are ill-equipped to deal with end-of-life issues of their followers. And this finding was consistent for all religions studied.

We find the same story in other research. In a 2008 report by the Duke Institute on Care at the End of Life they also reported that faith healers were least comfortable and least prepared working with children, health care providers and providing grief support when death is unexpected. As you would expect, faith leaders reported being more comfortable with the rituals of their religion than with initiating discussions on end-of-life issues or training others to provide such support.

Kaye Norris and her colleagues, reported similar results from two separate 1997 studies. One is a Gallup survey which describes how people may not always receive the level of support and spiritual care they desire, which is not surprising since respondents in the survey also reported low expectations of clergy. This finding was supported by a survey from Missoula community--68 percent  describing themselves as religious or spiritual--that reported that people as they near life's end, are more likely to rely for support on in order of importance; a spouse, children, immediate family members or relatives, friends and than on a faith-leader or faith community.

Faith leaders' lack of education and training about end-of-life issues and grief counseling is an obstacle that prevents them from being more effective support to the dying and the bereaved. The surprise in the research is that all faiths seem to lack end-of-life training.

But at least the issue surrounding end-of-life has entered into a discussion. Especially around the highly divisive issue of assisted end-of-life. Some religions embrace the option. Such as the Unitarian Universalist, United Church of Christ, Evangelical Lutheran Church of America, Methodists, Mainline and Liberal Christian denominations, Episcopalian (Anglican) Unitarian, Methodist, Presbyterian and Quaker movements. Even the American Baptists Churches--in contrast to the Southern Baptist Convention--support the right to decide.

It is not that we should completely eliminate religion from any discussion relating to discourse about social issues as Sam Harris crudely argues in the 2004 book The End of Faith: Religion, Terror, and the Future of Reason. We need religion because people expect their religion to console them in moments of need. The issue is that with the medicalization of death there is a passive acceptance by faith-leaders that death is a medical event rather than a spiritual journey. They need to reclaim their right. They must however first re-learn about the complex issues surrounding end-of-life.

© USA Copyrighted 2013 Mario D. Garrett

Diversity and Elder Abuse

Abuse is legally defined. The law has exact definitions and boundaries about what is considered abuse. However in social settings, abuse is necessarily a relative term.  But ignorance of the law is no excuse.

Older adult law in California is unique in that if the government decides that a crime has been committed against someone who is 65 years and older--whether that older adult wants to or not--the government will prosecute. Elder abuse is not different from any other type of abuse. In some instances the victim might not understand the act of abuse, in most cases the abuser—the perpetrator—is a relative of the victim, and in some circumstances the victim does not want the abuse to be exposed. What is different in elder abuse is that the victim is an older adult.

Although all elder abuse victims are vulnerable, most are just ashamed that it happened to them and that a family member whom they trusted has so wronged them. Even with the belief across most cultures that older adults, especially mothers, should be honored--which Asian cultures calls filial piety--the practice is rapidly being abandoned and becoming...old fashioned.

The problem is that we have very little information about elder abuse in general and ethnic minorities specifically. The lack of information is primarily because lawyers are weary of sharing information about their clients, or allowing their clients to be researched since any evidence that is obtained can be subpoenaed by the defense. Also some of these incidents have a long history within the family.

In the late 1970s Suzanne Steinmetz  reported that half of abused children grow up to abuse their elderly parents. There seems to be a social learning component to elder abuse. If the situation at home promotes certain behaviors as acceptable then those behaviors will be reflected back at the aging parents. For lawyers, identifying that abused children are repeating learned behavior makes it that much harder to prosecute the case.

In addition, anecdotal evidence suggests that a majority of older adults have some early stage dementia, which makes them vulnerable and in some cases unable to cope with aggressive and insistent demands. How a court deals with the victims’ evidence in such cases is predictable which is why researchers and lawyers rarely collaborate.

Cultural differences bring an extra layer of consideration. Some ethnic groups, view families as a unit rather than as individuals and therefore deal with "common property" as such. There are also cultural norms in dealing with erratic behavior in families. The legal system does not acknowledge that there are different cultural impressions of what is defined as abuse. Different agencies keep different data, and reporting of abuse is not uniform across ethnicities.

Elder abuse is a growing torment in our society. It is so widespread that we fail to notice it because we ascribe such behavior to culture or, at least, to family idiosyncrasies. We also ascribe behavior as cultural, but it is likely to be a learned behavior rather than culture. There is no culture that allows for the derogation of our elders. And there is an urgency to elder abuse cases. The victims have a high--natural in most cases--mortality.

© USA Copyrighted 2013 Mario D. Garrett

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.