Dementia and Gambling

In 2013 the gambling industry reported that more than half of its customers are 50 years and older. David Oslin at the University of Pennsylvania reports that 70 percent of the older adults 65 years and older had gambled in the previous year and that one in 11 had bet more than he or she could comfortably afford to lose. Using this percentage—despite older adults having the lowest rate of pathological gambling—in 2013, there were potentially more than four million older adults with a gambling problem.

Although there is very little independent research—that which is not sponsored by the gambling industry—on pathological gambling older adults, what we know is that they are likely to have poor mental and physical health and have less income. Although these are not the cases that make the news, these are the gamblers that fuel the profit margins of the gambling industry.

Most older adults are hesitant talking about their addiction—as Oslin found when half refused to participate. Most will not come out of the closet since it involves money-secrets at both ends. How you obtain money to gamble and what you do with the losses or the wins. For addicted gamblers both the winning and losing are highs, either way, casinos always profit. Casinos will not make a profit if they do not have compulsive gamblers.  The Wall Street Journal reports how Harrah's Entertainment Inc. in 2007 derived 5.6% of its Las Vegas gambling revenue from just one man, Mr. Terry Watanabe—despite their competitor Steve Wynn barring Mr. Watanabe because he was a compulsive gambler and alcoholic. 

Pathological gambling, or Gambling Disorder (GD)—as the DSM-V defines it now—is characterized by consistent, repetitive gambling and unsuccessful attempts at quitting. GD is seen an impulse control disorder and has been reported in patients with Parkinson's disease, frontotemporal dementia, and amyotrophic lateral sclerosis.   

However, there is no comprehensive study of how many patients with dementia gamble. Studies that show the benefits of gambling among nursing home patients do not report control studies or the amount of money being gambled and lost. There are also inconclusive results about the effect of dementia or Parkinson’s medication. One outcome is certain however. Gambling disorder responds to medication—either positive or negative. While 30-50 percent of adults with gambling disorders also have substance abuse—medication (such as opioid antagonists) used to treat drug and alcohol dependence also seems to work for gambling addiction. 

Gambling Disorder (GD) is argued to be different from recreational gambling.  However with an increasing aging population that exhibit more and more cognitive decline and impairment, the lines are becoming blurred. But this is not a no-cost venture. Older adults are unlikely to recover lost savings, while their families are usually the ones left without any resources. In the award winning and highly readable 2013 book “Addiction by Design”, anthropologist Natasha Dow Schüll from Massachusetts Institute of Technology defines exactly how slot machines, and the casinos that contain them, are designed specifically to create addiction and encourage their users to 'play to extinction'. 

© USA Copyrighted 2014 Mario D. Garrett

Casinos Preying on Older Adults

After it was revealed in February 2013 that San Diego’s former mayor, 67 year old Maureen O’Connor, lost more than a billion dollars at casinos, the gaming industry shed its disguise and became the gambling industry again. This was definitely not entertainment.

Maureen O’Connor reported that she was suffering from a brain tumor that might have impaired her judgment. A vulnerability that was not moderated by Las Vegas casinos sending private jets to fetch Ms O’Connor from San Diego. A trend that was also seen with Terry Watanabe who risked more than $825 million in 2007 at two casinos owned by Harrah's where it is alleged Harrah's senior management made a conscious decision to exploit his well-known addiction with alcohol and prescription drugs. No lawsuit has ever won. But what they do is expose the human tragedy fueled by the industry’s predatory use of complimentary services called “comps” against the increasing vulnerability of some older adults.

Bill Kearney—a staunch advocate for effective regulations of casinos—defines the world of comping in his excellent 2001 book “Comped”. Comping might start off with a free room, meals, free drinks and then, like Ms. O’Connor, ends up with to limos, helicopter and Lear Jet flights, interest-free loans, and lavish penthouse suites that the casinos provide as they cultivate their profits. These comps are in addition to exemptions that the gambling industry has gained, including no-limit ATM machines, sales tax exemptions, smoking exemptions, and many others. All these exemptions and comps transform the industry from one of entertainment—where you pay a predefined cost for a service—to predation.

Predation involves monitoring older adults’ gambling behavior and promoting both the frequency—through comping—or the amount—through interest-free loans, cashless gambling, free alcohol and medication pills. When you have older adults with obvious cognitive impairment then you need to question if such predatory behavior constitutes financial elder abuse under state laws.

In California, financial elder abuse has both criminal and civil definitions that apply to anyone 65 or older regardless of whether they have any diminished physical or mental capacity. Financial elder abuse occurs when any person or entity—takes, secrets, appropriates, obtains or retains real or personal property of an elder for a wrongful use or with intent to defraud—including assisting. “Wrongful use” is when a person “knew or should have known that this conduct is likely to be harmful to the elder.” Cal. Welfare & Institutions Code §15610.30.
This definition makes for a perfect storm. With increasing penetration of the gambling industry into nearly all States, increasing prevalence of older adults with cognitive and physical frailty, and an increasing awareness by families of the signs of financial elder abuse we might see our first test case of financial elder abuse laws against casinos. When Harrah’s comps $1.1 million to AARP we have to question what AARP is gambling with, and what are we likely to lose. Thom Reilly, executive director of the Harrah’s Foundation explained that “This relationship with the AARP Foundation allows us to extend our reach into that community and help them address caregiving issues.”

© USA Copyrighted 2014 Mario D. Garrett

Cholesterol and our Aging Brains

Cholesterol is in every cell in our body and becomes concentrated in our brain. Our brain is 60% fat, with over 25% of that being cholesterol. Most of the cholesterol in the brain is produced in the hypothalamus itself, establishing cholesterol as an integral part of our brain.

One of the most dramatic difference between young and old brains is the reduced myelination—fat sheathing—around nerves, which might explain why aging brains shrink at 1% a year. Myelin is a sheet of lipid, or fat, with the highest cholesterol content of any brain tissue. Even neurotransmitters, the chemical words used in the language that the brain communicates in, are made of cholesterol. George Bartzokis, with UCLA, and his colleagues, found a correlation between diminishing speed of performing tasks and diminishing level of myelination. The older we get, the less myelination we have. And in older age we can destroy this protective layer much faster through excessive alcohol intake and some non-/prescription drugs.

Myelination seems to be important in how we learn. Although grey matter—on the outside of the cortex made up of neurons—carry messages and does the “thinking”—white matter—the myelinated part of the brain—controls the strength of signals. Myelination is how we learn, strengthening some signals above others. Myelination also occurs in at different ages. Starting from the back of the brain as children, and finishing off at the front of the brain in adulthood. This explains why certain tasks are easier when you are a child then at older ages (learning to speak without an accent.)

And the role of cholesterol seems crucial to this process of myelination. In 2008 Rebecca West and her colleagues from Mount Sinai School of Medicine, New York, unexpectedly found that among normal—no expression of dementia and not having the genes that predispose you to get dementia—older adults aged 85 years and older, high total cholesterol and high LDL (bad) cholesterol were associated with higher memory scores.

Other evidence is mounting. Elizabeth Johnson and Ernst Schaefer with Tufts University, Boston, MA conjectured that one commercially available fish oil capsule per week—180 mg dietary DHA/d—might reduce the risk of dementia by half.  On the negative side, two small trials published in 2000 and 2004 by Matthew Muldoon from the University of Pittsburgh, suggest that prescription medication we use to lower cholesterol—statins—might bring about cognitive decline. He reported that participants taking placebo pills improved on repeated tests of attention and reaction while those on statins did not.  This was further confirmed by anecdotal evidence published in an article in 2003 in Reviews of Therapeutics which reported  that among 60 statin users who had reported memory problems to MedWatch, when they stopped taking the medication more than half reported  improved memory.

Science is not truer than religion. Science is being able to challenge the accepted reality of today. Science is a method rather than a body of truths. The method is to question beliefs, to test expectations. The problem with science in large U.S. institutions is that it has become a religion.

© USA Copyrighted 2014 Mario D. Garrett

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