Lost with Dementia

Patterns exist for people who get lost. Whether joggers, hikers, children, or those diagnosed with dementia, different groups exhibit different lost person behaviors. Knowing these patterns would help in finding them. Robert Koester's groundbreaking research has greatly expanded our understanding of “Lost Person Behavior” (Koester, 2008).  

This evolving line of inquiry  is becoming the bedrock for Search And Rescue (SAR) protocols. SAR  personnel consider variables such as behavioral profiles, activity, terrain, health, and personal characteristics to help predict the behavior of people who are declared lost. Koester has analyzed more than 50,000 cases world-wide to identify patterns of behavior that lost people tend to follow, including a special section for people with any variant of dementias—Koester’s specialty.

Older adults with dementia typically get lost through wandering behavior. Six in 10 people with dementia will wander—take off in an aimless way—becoming disoriented and perhaps not remembering their name, address, or their location.  Although effective programs exist in the United States—including MedicAlert®, Safe Return® Comfort Zone® and Comfort Zone Check-In®—the majority of people are not enrolled in such electronic tagging. Either they cannot afford the monthly premiums or they assume that they would never need such services. Due to America’s demographic changes, one thing is certain—people with dementia comprise an increasing concern for volunteer SAR teams, as well as state and federal agencies.

For SAR teams all dementias are treated the same. Koester & Stooksbury (1995) reported that when normal older adults got lost they traveled on average a greater straight-line distance (2.56 km) from the Point Last Seen (PLS) than older adults (in this case older than 40 years of age) with dementia (0.88 km). Although statistics indicate greater variability of distance traveled among dementia patients,here are some outliers where some might only travel a short distance while others travel greater distances (one in ten travel an average of 52 miles). Surprisingly, age did not emerge as an important consideration in how people with dementia behave when they get lost.

Dementia patients generally leave their own residence or nursing home and start traveling along roads. The patient is usually located (in 89% of cases) within one mile (1.2 km) of the PLS.  If the patients were not on a road (14%), they were usually found in a creek/drainage (28%), and/or caught in briars/bushes (33%).

The majority of patients succumb to the environment. One in five dementia patients (42 cases in this study) were found deceased due to hypothermia, dehydration, or drowning. No fatalities were found among dementia patients when they were located within 24 hours. If they were not found within this 24-hour window, half of dementia patients were likely to be found dead.

Consequently, searches for dementia patients are considered urgent and require an aggressive SAR response. Koester highlights that the diagnosis of dementia is important to elicit urgency. However, he also points out that most primary care physicians fail to administer cognitive status tests, and therefore only correctly identify 58% of the cases as possible dementia. This is particularly true of patients who become lost in wilderness and rural settings, who often belong to disadvantaged socioeconomic groups and who receive minimal health care. Not knowing that the lost person has dementia diminishes the search’s urgency, with potentially detrimental effects.

A key hypothesis  among SAR responders when looking for lost dementia patients is referred to as the “path of least resistance.”  This theory states that when people with dementia start wandering they tend to follow terrain that provides less resistance (down rather than uphill, roads rather than meandering paths, or railway tracks rather than steps).

A considerable number (28%) of dementia patients were found in drainages or creeks—indicating that they most likely walked downhill—supporting the path of least resistance hypothesis. Another 33% of the patients appear to have become stuck in thick brush or briars. This insight is important because untrained searchers, or searchers working at night often avoid looking into brush or briars because most people tend to try to make themselves visible. Getting stopped in drainages, creeks, brush and briars  support research indicating that lost patients with dementia are traveling a path of least  resistance until they reach an insurmountable barrier.

Because prevention is the best cure, reducing wandering becomes the best first line of defense. A personal care plan that reduces agitation and depression will help minimize wandering. Because people with dementia tend to leave few clues when they are lost and often do not respond to shouts or voice-based searching, getting expert help as early as possible is crucial. Knowing how to look for lost people with dementia requires an urgency that only expert help can provide.

Local dementia organizations counsel families that when someone with dementia goes missing, SAR efforts should be initiated immediately. Ninety-four percent of people who wander are found within 1.5 miles of where they disappeared. After the family and/or caregivers search the immediate area for no more than 15 minutes, they should call "911" and report to the police that a person with dementia—a vulnerable adult—is missing. Reporting parties should provide enough detail, including any places nearby that might have been important in childhood for the missing person.  Reports should include information on fears or phobias that the person might have, and what medications they are on.  A Missing Person Report should be filed so that police will also initiate a search.

In addition, even if a concerned party is not enrolled in a locator program, they should file a report with MedicAlert+ Alzheimer's Association Safe Return at 1-800-625-3780.  First responders are often trained to check this resource when they locate a missing person with dementia. Additional help can be accessed from the Alzheimer's Association 24/7 Helpline, 1-800-272-3900, which provides information and support to those who need assistance.Getting help as fast as possible might be the strategy that saves the lives of lost people with dementia.

Further Reading:

Perkins D & Roberts P (2000). Search Management for the Initial Response Incident Commander 2000. ERI International Inc. 

Twardy CR, Koester R & Gatt R (2006). Missing Person Behaviour An Australian Study Final Report to the Australian National SAR Council. Accessed online: http://www.esf.com.au/documents/reports/RobertGatt2002VicPol.pdf (link is external)

Koester RJ & Stooksbury DE (1999). Behavioral profile of wandering Alzheimer’s patients.  Wilderness and Environmental Medicine, 6,34-43 (1995)

Koester RJ (2008) Lost Person Behavior: A Search and Rescue Guide on Where to Look - for Land, Air and Water. Dbs Productions; Spi edition.

© USA Copyrighted 2015 Mario D. Garrett

Legal Consequences of Dementia

In most states, dementia is a reportable disease. Since 1988 physicians in California are required by law to report patients with dementia to their local health departments, information that is then shared with the Department of Motor Vehicles (DMV). Similar to sexually transmitted diseases, infections, and food borne illnesses, dementia is reported to both state and federal agencies. Unlike transmittable diseases however, the diagnosis and reporting of dementia initiates a cavalcade of medical, financial and legal consequences that might strip you of some of your rights as a citizen.
If you are diagnosed with dementia the first thing that you will notice is that the DMV informs you that you need your driving skills to be re-examined—if you are lucky and your physicians indicated that you have mild rather than severe dementia which in the eyes of the DMV renders you unsafe to drive and you automatically lose your license.  Statistically drivers with dementia are eight times more likely to be involved in a car accident. The DMV will schedule a meeting for you to meet with one of their driving instructors to determine your level of awareness, cognitive processes, and perception. Failure to pass these tests will results in your driving privilege being revoked. But if this meeting goes well then you will be scheduled for a special drive test, which includes vision screening. If you are successful at this test as well, then your license might be re-issued but it might come with some restrictions (driving at night driving on certain routes). From here on you will be reevaluated usually every 6 months or less. If the tests are unsatisfactory, you will lose your license.  This loss will jeopardize your ability to work and provide for your dependents, restrict your social participation, diminish your involvement in personal interests, and severely curtail participating in community activities.
The second metamorphosis will involve your relationship with your bank. Banks are catching up slowly to the consequences of dementia both in terms of financial abuse and mismanagement of accounts. Banks are however blind to the diagnosis unless your diagnosis is reported by your spouse, business partner, or family. If you owe a lot of debt, own or manage or a company with a board of directors then it is likely that knowledge of your diagnosis will change your status dramatically. At this stage you can be declared incompetent and treated as such. But you might also be tricked into buying or investing in low-interest or volatile stocks/shares, or sign over assets by your bank or lawyer. Although rare, bankers and lawyers have been found guilty of such abuses. Especially when banks are actively trying to sell new policies, you might be an attractive customer to them despite your diminished capacity. Bankers cannot judge your capacity, and in most cases will not assume that you are incompetent, unless it is to their determent. Whether you like it or not, your spouse or family will become more important to you. Not only because they are privy to your diagnosis but because they can also determine your legal standing. They can submit legal motion to declare you incompetent and take over your estate and business dealings.
A diagnosis of dementia is life changing. In the eye of a personal storm there are important legal and financial questions. In a complex legal field that is evolving, your best bet is to access professional legal advice as soon as possible.   Legal Aid Society, the local Area Agency on Aging, or the Alzheimer's Association might be able to provide you with the names of attorneys practicing in your area who deal with these issues. The obvious start should be determining your eligibility for Medicaid, investigating long-term care insurance, writing a living will and assigning a durable power of attorney for health care.

https://stocksnap.io/photo/6D2BBBEF99
Source: https://stocksnap.io/photo/6D2BBBEF99
For those that have assets,, gather your wills and trusts, prior tax returns, health and life insurance policies, pension information, deeds, mortgage/s, bank accounts (and PIN numbers), and information on other financial investments including ownership of property. Discuss the benefits and implications of transferring assets. If you do not have family or friends that can manage your accounts or business there are fiduciary agents who are certified to do this work for you. In some states you can prepare all your documents and then have them applied at a later period when your diagnosis become more severe. For those who have no or few assets, it is important to realize that you still need help with living arrangements and health directives.
In some cases, especially among people with extensive wealth, the strategy is not to get the diagnosis of dementia in the first place. They either go abroad where mandatory reporting is non-existent, or they go to a private physician and present a different identity. There are obfuscations from the patient as well. The central kingpin in all this is the family practitioner. His or her determination will guide bankers, lawyers and fiduciary agents. This is why a relationship with your primary care physician is important because he or she can help you coordinate and in some cases maneuver this complex medical and legal field.

© USA Copyrighted 2015 Mario D. Garrett

The Psychology of Physics

Physics—the study of the material world—was transformed in the late 1600s by the all-pervasive power of (Isaac) Newton's mechanics and then again in the late 1800s by (James Clerk) Maxwell's electromagnetic theories. These two British men established the Classical Theory in physics. Isaac Newton’s work was the culmination of centuries of philosophical debate about the nature of the world and the composition of material objects. The vindication of these philosophical thoughts came by Newton’s Classic Mechanics which pictured the universe as a perfect machine. Classical Mechanics uses common-sense notions of how matter and forces exist and interact. It assumes that matter and energy have definite measureable attributes such as where an object is in space and its speed. It also assumes that objects may be directly influenced only by their immediate surroundings, known as the principle of locality. The universe was seen as a tangible, orderly system that followed very exact and specific mechanical rules:

1. A body remains at rest or moves with constant velocity when an external force acts on it.

2. The rate of change of momentum of a body is proportional to the force on the body

3. When two bodies interact they exert on each other equal, but opposite forces.

Maxwell's electromagnetic theory, expanded this view of the world, and by consolidating a lot of independent research, established a classic view of electrodynamics. Primarily this theory explained how the related fields of electricity and magnetisms behave through waves. Although Maxwell’s electromagnetic theory was a stepping-stone for Einstein’s 1905 paper “On the Electrodynamics of Moving Bodies” (the first sentence starts by referencing Maxwell), at the time this theory was the ultimate expression of Classical Theory.

The beauty of Classical Theory was that it worked. Classical Mechanics had specific and definitive applications. We could predict the motion of objects in the world and the motion of celestial bodies in the Universe. All that we could observe was explainable. Best of all, Classic Mechanics is intuitive and all encompassing. For more than half a century Classical Theory reigned supreme to such a degree that physicist in the 1900s believed—as Philipp von Jolly counseled the 16-year-old Max Planck when he was admitted to the University of Munich—that the objectives of physics in explaining the material universe was more or less accomplished. The belief was that the main theories were in place and that all the great discoveries had been made, and only a few minor details needed filling in. Classical Theory was that good.

But Classical Theory was short on explaining constructs that we intuitively “knew.” What is “force” “body” and “interact” what is “attraction”, “gravity” and “energy”? These concepts have no explanation in physics. Our current knowledge is limited to defining how they behave, but we are unable to understand what these concepts are. The only place where these concepts have meaning is in our thinking because these concepts are intuitive. We know instinctively what a “body” is, or gravity or energy. These are constructs that we seem to accept readily as though we see the world through such constructs. Our perception—of seeing reality in chunks and simplified action—is so strong that we seem to preconceive the world, without questioning.

It was the work of Gestalt psychologists that brought such preconceptions to light. In 1912, Max Wertheimer published his paper on phi motion—which examined the impression of movement through flickering of lights—widely recognized as the start of Gestalt psychology. Together with Wolfgang Köhler and Kurt Koffka they helped establish theories of Gestalt psychology. The central theorem was that the whole is other than the sum of the parts and they argue that the whole exists independently from its parts. That is why we “see” a body, we see “interactions” and movement and “force” (push and pull). The fundamental principle of Gestalt perception is the law of prägnanz (German for pregnant but meaning pregnant with meaning as in brevity)—a shorthand and simplified version of reality. Gestalt psychology argue that we simplify the world in order to perceive it. We tend to organize our experience of the world in a manner that is regular, orderly, symmetrical, and simple. Gestalt psychologists have identified eight methods we use to simplify the world, primarily by grouping objects together. In an every changing world, having the ability to summarize and simplify the world means that we can perceive situations quicker, predict outcomes faster and thereby gaining time in order to be able to react earlier. We group things together and make them coherent. These are the tricks of magicians. Gestalt psychologists have defined such methods as laws and include the Laws of Proximity, Similarity, Closure, Symmetry, Common Fate, Continuity, Good Gestalt and, Past Experience.

1. Law of Proximity—When objects are close to each, sharing similar motion or sequence we see them as related. We see the behavior of one influencing the other so they share an affinity a similar fate.

2. Law of Similarity—Similar objects on the basis of function, behavior, shape, color, threat and other characteristics that we are sensitive to are seen as related.

3.Law of Closure—Our intent on making things whole extends to when objects have missing parts. This eliminates a lot of the variance so that despite the uniqueness of faces, for example, we see the face despite irregularities. If the law of closure did not exist we will have to interpret each face as a jumble of features.

4.Law of Symmetry—We balance objects in space. A symmetrical field of vision is easier to see because it simplifies the multiple objects into aa pattern, a perceptual algorithm. All we need to see is the symmetry, the uniform pattern rather than individual elements.

5. Law of Common Fate—We see the path that objects travel from and heading towards. We see objects that share similar paths of motion, or direction of motion as grouped together.

6. Law of Continuity—when an object is hidden from view we tend to still see it despite that the object might be behind another object, or when an object is partly hidden we assume that it is whole the the object in front is obscuring the backround object. We are less likely to see objects that change direction quickly or change shape quickly.

7. Law of Good Gestalt—We aim to eliminate variance, complexity and unfamiliarity which implies a global order to the world.

8. Law of Past Experience—history and temporal association implies that under some circumstances visual stimuli are categorized according to past experience. The experience of grouping two objects together in the past determines that we are likely to see them as grouped in the future.

These individual laws of grouping are not separate processes. They define a perceptual bias to group objects into a pattern. Each of these laws defines how we conceive of the world as a model with individual units sharing common attributes. We can say that the capacity to group things together exposes our perception as an algorithm, a formula. We do not perceive a visual reel of reality, a cinematographic version of reality in our heads—although we might conceive of our perception as such. In fact what these Gestalt laws tell us is that we see patterns in our experience of the world—we are not forming patterns, we are seeing patterns.

Algorithms, patterns, formulas or heuristics simplify the world into generalizable configurations.  This view of perception is supported by studies from preliterate societies and how they manage to count and subtract. Like a map that represents the geography of a place, preliterate societies have mathematical maps that help them to work out numerical outcomes. We simplify our experience with the physical world through formulas and algorithms. This is how our brain works.  In 2008, Michael Frank with the Department of Brain and Cognitive Sciences, Massachusetts Institute of Technology, and his colleagues reported how the Pirahã Amazonian tribe despite having no language to express numbers, not even one, are able to perform exact matches with large numbers of objects perfectly. Although they were inaccurate on matching tasks involving memory, because they did not have the benefit of language to retrieve information, their capacity to conceive of numbers was equal to other literate groups. They had a schematic way of conceptualizing numbers. We do this algorithmically, using perceptual formulas and patterns to conceive our material world.

Having such a translation of reality embedded within us, the question is whether we also preconceived classical physics. Whtether Classical Theory was indeed physics or a study of our own preconceived perceptual biases. We can see the similarity between the laws of Gestalt psychology and those of Classical Mechanics: 1. A body remains at rest or moves with constant velocity when an external force acts on it, 2. The rate of change of momentum of a body is proportional to the force on the body, 3. When two bodies interact they exert on each other equal, but opposite forces. All of these laws conform to the laws of Gestalt perception. Our perceptual biases are in tune with Newtonian physics. So is Classical Mechanics similarly a biased view of the world?

The fact that we have a mathematical formula—through Classic Mechanics—that predicts the speed, direction and change of objects is an indication of how we perceive objects in motion rather than an indication of the reality. Although our perception is necessarily based on a physical reality that we—like physicists—are trying to predict, our perception is not a reflection of reality but a translation. A translation based on prediction. Predicting reality is very different from “seeing” reality. Just because I can predict an outcome does not mean that, because of my accurate prediction, I understand the reality. Betting shops do this all the time. The problem is Quantum Mechanics. Here comes a theory that challenges what reality is, not as we perceive it to be (Classic Mechanics) but as it seems to be (Quantum Mechanics).

In physics, a quantum is the minimum amount of any physical entity involved in an interaction. Although many scientists have used the term before, it was Max Planck in 1900 that used "quanta" to mean "quanta of matter and electricity, gas, and heat.” Leading Albert Einstein to suggest in 1905 that radiation existed in spatially localized packets that he called "quanta of light". Einstein renamed Planck’s quanta packages as photons and used Planck’s quantum theory to describe the photoelectric effect, for which he would receive his Nobel Prize in 1921. The penultimate expression of quantum physics is Schrodinger’s cat paradox where quantum superposition—entanglement theory—dictates that a cat (in Schrodinger's example) has to be both simultaneously alive and dead at the same time. Although this IS weird—leading Einstein to talk about “spooky action at a distance” and Schrodinger himself to give up quantum physics to focus on philosophy and biology—this is a reality that must be necessarily uncomfortable because it disrupts our own perceptual framework of how the world behaves. Our psychology is insulted.

For the first time we are exploring the world as it truly is rather than how we think it should be. The Greek philosopher Heraclitus wrote around 500 BCE that we can never step in the same river twice. With this observation we have some semblance of what true reality looks like. A universe eternally in a state of flux, having multiple realities, depending on where I—the observer—am.

Did Classical Mechanics simply reflect a detailed exposition of Gestalt psychology? Quantum physics is saying yes. We do not know what reality is except what we are now learning through Quantum Mechanics. Classical Mechanics exposed the psychology of perception. Quantum physics will start to help us understand the weird and the wonderful—what we will come to know—reality.

References:

Franka, M. C., Everettb, D. L., Fedorenkoa, E., & Gibsona, E. (2008). Number as a cognitive technology: Evidence from Pirahã language and cognition. Cognition, 108, 819-824.

For an intriguing perceptive of how psychology was enfluence by physics--which was brought to my attention after this blog was published--please refer to this very readable paper, I have Dave Edwards to thank for this edification:

Wilcox, S., & Edwards, D. A. (1982). Some Gibsonian perspectives on the ways that psychologists use physics. Acta Psychologica, 52(1), 147-163.

© USA Copyrighted 2015 Mario D. Garrett

Ontological Question

Relationships have history. The relationship we have with our environment has a history, a memory. The relationship we have with others has a history, and the relationship we have with ourselves also has a history. Our history determines how we interact with all these facets of life.

As very complex beings we learn, and continue to learn throughout our life, how we interact with our environment in the most efficient way possible. Efficient might mean taking shortcuts however.

Our brain does most of this automatically. We are not aware, unless we need to address something unexpected or something of importance. Most of the time we interact with the world through shortcuts. If we are wiping our hands we pick up a towel and use it. We might not be aware of the towel unless it is different (bright pink with green dots.) Otherwise, the utility of the towel suffices. We do not need to go deeper than that. The brain is very efficient at parsing the reality that we need, and nothing more. This is efficient and sensible with wiping our hands, but limited when we try and understand our world.  Martin Heidegger the german philosopher in Being and Time (1927) called this form of shortcut "ready to hand." Such an awareness of an object that is limited to its utility. We forget the structure of an object and focus on its utility, it function gains prominence in our mind and all else is diminished. Taking this idea further, we can (and do) apply this utility to people around us. We forget the humanity behind a person and get angry when their utility is not realized (they wanted to do something other than fulfill our desires or needs.)  And we do this with our own behavior as well.  Most of the time we function as complex robots. We undertake repetitive task unconscious, as a matter of habit. Driving to work, driving back home, it is all done with minimal conscious thought. This is Pierre Bourdieu's concept of habitus, action that is relegated away from consciousness. And there other other facets of life where we hold a subconscious reality of networks.  Especially as we become older and have more experience living, we build these habitus events to such an extent that we live our lives in an unconscious trance, what Heidegger calls "the nothing". Older adults get very good at this until something unexpected happens. Then what we thought was a simple task like driving, becomes an extremely complex and confusing task.

The reduction of competence among frail older adults is a perfect example of examining how these concepts determine our lives without us being aware of them. The easiest way to perceive this relationship with the world is that these layers of habitus build up into a source of capital. Capital refers to an investment--that we or others make--that we have access to.  In most cases, capital resides independent of us.  Bourdieu (1977) identified and separated such accumulated experiences into four basic capitals: individual’s economic capital (material wealth), social capital (social networking our friends and contacts) and cultural capital (knowledge, skills, education, and advantages that a person has, which give them a higher status in society), later he included symbolic capital (honor, prestige or recognition). To this list we also included body capital (Antoninetti & Garrett 2012) which is the expectation, by you and others, that your body will function as expected within a familiar environment. And there are other types of capital. Civilization is an investment, a civic capital that we can access. Economist talk about "human" capital. The investment in yourself which is normally defined by formal educational. While biologists talk about biological capital (Kemp & Moore 1979). Geography has “place capital” (structures that enhance the utility of a place, eg roads, walkability, street lightning). The interaction between individuals and their environment takes place in a nebulous dimension. And you can further break the type of capital  into different dimensions. But the gist is that relationships have history and build habits.

All philosophers extoll us that despite these unconscious constraints, we are however free. We are free to decide and self-determination. From Martin Heidegger to Paul Sartre there is this belief that being human means that we have some control. But why would we suffer this "anguish" of existence when we can ignore it and live in an unconscious mode? Why is Dasein--being in the present-- so important for Heidegger? Being a contrary, why not live in "they-selves" if the "our-selves" is so painful? If I was designing a new way of existing, would I elect to be aware of "being" and why?


Further readings:
Antoninetti, M., & Garrett, M. (2012). Body capital and the geography of aging. Area, 44(3), 364-370.
Bourdieu, P. (2011). The forms of capital.(1986). Cultural theory: An anthology, 81-93.

© USA Copyrighted 2015 Mario D. Garrett

Fluoride Levels and Falls Among Elderly

In May 2015, the U.S. Centers for Disease Control and Prevention (CDC) released its mortality report showing that the only increase in unintentional injury that lead to mortality was due to falls among older adults.  While all other causes of mortality remained fairly stable, between 2000 and 2013, death from falls in older adults nearly doubled, from 30 to 57 deaths per 100,000 older adults.  In any given year, one in three older adults will have a fall and 20-30% of these victims will suffer a moderate or severe injury. A quarter will die before the year is over. This is a public health tragedy.
Men are 40% more likely than women to die from a fall. While older Whites are 2.7 times more likely to die from falls as their Black counterparts.

Falls are the most common cause of traumatic brain injuries (TBI).5
Half of all fatality because of falls  are due to TBI.7

The most common injuries when older fall are fractures to spine, hip, forearm, leg, ankle, pelvis, upper arm, and hand.  Of these, the most serious is hip fracture. In a large number of cases leading to death. In contradiction, although falls remains on the increase from 1996 to 2010, hip fracture rates declined significantly for men and women (13). Over 95% of hip fractures are caused by falls. It is not known what factors are contributing to this trend. This seemingly contradictory evidence

A woman's bone density declines by about 30% between the ages of 50 and 80 increasing 5 years after menopause. Although bone density is not the only factor in hip fracture risk. Over 90% of hip fractures occur upon falling. Although many elderly people suffer spontaneous hip fractures because of advanced osteoporosis, the immediate cause is a fall. But this information is not validated. If a fall was instigated by a spontaneous hip fracture, the older adult is more likely to find an "excuse" for the fall rather than accept (and understand the mechanics) or a spontaneous fracture. There are distinct breaks if it is due to a fall or due to a spontaneous hip fracture.


Falls can be complex, and the literature has numerous causal pathways--from increased medication, older and frailer adults, better reporting, better health surveillance,  heavier older adults--all of which are valid. But there is one cause that is not mentioned.

Most researchers assume that an older adult fall and then break their hip. Or if they fall, they try and find behavioral reasons for the fall.  However it is also likely that there is a spontaneous hip fracture which causes the older adult to fall. There is a spontaneous hip fracture and then the person falls. Such fracture can easily be determined. As yet CDC has not undertaken this study. It would be relatively easy to review the X-rays from those that died. This study would not even need an Institutional Review Board. But until that study is done we can only conjecture the cause of these hip fractures.

It could be that there is an environmental cause to the increase in fractures related to state policies that the Federal agency supports: fluoridation of our water. There is overwhelming evidence that fluoridation in our water is toxic. Although the topical application of fluoride on teeth has been found to be beneficial, the ingestion of fluoride continues to receive negative outcomes. The argument that it improves dental health becomes less realistic when more than a quarter of adults over the age of 60 have dentures. The fact that this policy of water fluoridation ignored older adult health is already established. What is being established now is that it is harmful to older adults.

One of the reasons why falls are on the increase is because the bones of older adults in the U.S. are being made brittle because of fluoridation of water and that these spontaneous fractures are causing some or most of the falls. Multiple studies support this assertion: Fluoride therapy may be implicated in the pathogenesis of hip fractures which may occur in treated patients despite a rapid, marked increase in bone mass. (6)  Fluoride appears to be a key factor in the pathogenesis of stress fractures (7) [T]he six hip fractures occurring in patients receiving fluoride during 72.3 patient years of treatment is 10 times higher than would be expected in normal women of the same age (8) Thirteen cases of spontaneous fissure or fracture of the lower limbs observed in 8 patients under treatment with sodium fluoride are reported (9). (Fluoridation)...to worsen a patient’s clinical state (1) Increasing the dose of fluoride increases the risk of nonvertebral fractures  (2) 1 year of fluoride administration seemed to reduce bone strength by 17-30% (3) patients treated with sodium fluoride,...All fractures were spontaneous in onset... three times that in untreated osteoporosis. (4) Fluoride treatment was “associated with a significant three-fold increase in the incidence of nonvertebral fractures (5) fluoride-induced microfractures (10)

sustained spontaneous bilateral hip fractures during treatment with fluoride, calcium, and vitamin D for osteoporosis (11) Three or four of the fractures in the fluoride group appeared to be spontaneous hip fractures...the fluoride treatment here was probably partly responsible for the fractures in our cases. (12)
CDC needs to review the X-rays of all older adults that die due to falls. Ascertain the level of spontaneous hip fractures. Examine the correlation with fluoridation in the public water system. Measure the accumulation of fluoride in older adults. Engage in a systematic review of fluoridation on older adult comprehensive health including skeletal, digestive system and neurological.

• There is no correlation among countries that fluoridate their water and hip fractures. 
  In 2002 in an international comparative study John Kanis from the WHO Collaborating Center for Metabolic Bone Diseases, University of Sheffield Medical School, Sheffield, United Kingdom and his colleagues reported some dramatic variance in hip fracture incidence from different regions of the world. Lifetime risk at the age of 50 years varied from 1% in women from Turkey to 28.5% in women from Sweden. The risk for women was correlated with that for men. Countries were categorized by 10-year probabilities comprising very high risk (Norway, Iceland, Sweden, Denmark, and the United States), high risk (Taiwan, Germany, Switzerland, Finland, Greece, Canada, The Netherlands, Hungary, Singapore, Italy, United Kingdom, Kuwait, Australia, and Portugal), medium risk (Hong Kong, France, Japan, Spain, Argentina, and China), and low risk (Turkey, Korea, Venezuela, and Chile). Only 6 OECD countries have more than 50% of their populations drinking fluoridated water: Australia (80%), Chile (70%), the Irish Republic (73%), Israel (70%), New Zealand (61%), and the United States (64%).

1. Gutteridge DH, et al. (2002). A randomized trial of sodium fluoride (60 mg) +/- estrogen in postmenopausal osteoporotic vertebral fractures: increased vertebral fractures and peripheral bone loss with sodium fluoride; concurrent estrogen prevents peripheral loss, but not vertebral fractures. Osteoporosis International 13:158-70.

2. Haguenauer D, et al. (2000). Fluoride for the treatment of postmenopausal osteoporotic fractures: a meta-analysis. Osteoporosis International 11:727-38.

3 Sogaard CH, et al. (1994). Marked decrease in trabecular bone quality after five years of sodium fluoride therapy–assessed by biomechanical testing of iliac crest bone biopsies in osteoporotic patients. Bone 15: 393-99.

4. Schnitzler CM, et al. (1990). Bone fragility of the peripheral skeleton during fluoride therapy for osteoporosis. Clinical Orthopedics (261):268-75.

5. Riggs BL, et al. (1990). Effect of Fluoride treatment on the Fracture Rates in Postmenopausal Women with Osteoporosis. New England Journal of Medicine 322:802-809.

6. Bayley TA, et al. (1990). Fluoride-induced fractures: relation to osteogenic effect. Journal of Bone and Mineral Research 5(Suppl 1):S217-22.

7. Orcel P, et al. (1990). Stress fractures of the lower limbs in osteoporotic patients treated with fluoride. Journal of Bone and Mineral Research 5(Suppl 1): S191-4.

8. Hedlund LR, Gallagher JC. (1989). Increased incidence of hip fracture in osteoporotic women treated with sodium fluoride. Journal of Bone and Mineral Research 2:223-5.

9. Orcel P, et al. (1987). [Spontaneous fissures and fractures of the legs in patients with osteoporosis treated with sodium fluoride]. Presse Med 16:571-5.

10. Dambacher MA, et al. (1986). Long-term fluoride therapy of postmenopausal osteoporosis. Bone 7: 199-205.

11. Gerster JC, et al. (1983). Bilateral fractures of femoral neck in patients with moderate renal failure receiving fluoride for spinal osteoporosis. British Medical Journal (Clin Res Ed). 287(6394):723-5.

12.  Inkovaara J, et al. (1975). Phophylactic fluoride treatment and aged bones. British Medical Journal 3: 73-74.

13. Stevens JA, Rudd RA. The impact of decreasing U.S. hip fracture rates on future hip fracture estimates. Osteoporosis International 2013. DOI 10.1007/s00198-013-2375-9.

Geography of Aging and the Illusion of Self

I think of myself as an entity, as "me."  Separate and distinct from "them" and the outside world. This "me" allows my mind to cleverly edit, interpret and re-interpret the world as though I am consistently at the center of everything that I interact with.  My mind also draws a linear story-line from my childhood directly to my older-adulthood.  I do not have to think about it because my mind automatically narrates a story for me that is complete where I am at the center and the rest is on the periphery. A story of "me" and "them", a logical relationship. I have an explanation for everything even though most events in my life are outside of my control.  This gives me the impression that I am "me", separate, distinct and unique, and then there is a "them" an outside. I have conscious will and participate in the world as a free unique and independent agent.

But this belief is a mirage, an illusion of the mind. The idea that we are separate from others is not the complete picture, and this knowledge is just now starting to be exposed. To re-envisioning who we are we have to understand how the "me" came about. This is a radical idea. Such radical ideas have happened before in our collective history and they have changed how we think about who we are.

There have been a number of radical thinkers who transformed how we think of ourselves.  The first such radical thinker moved us away from mythology, and the notion that everything that happens is because "god wants it to happen." Thales of Miletus was a 6th century BC  philosopher who suggested that we should observe physical events without assigning the cause to "god." He admonished philosophers to try and understand what they observe as separate from god. This was the birth of science. As a result we began to understand that there is a causal pattern to the world. That there is a logical sequence that does not require the intervention of busy gods. The development of science took us into an amazing logical world that was hidden to us before. We came to see the world in more detail. As a finely tuned mechanical watch. This assurance of solidity was however shattered in the early 1900s on two fronts. The first to dispel the solidity of how we see our world was Sigmund Freud. Freud developed the concept of an unconscious mind that hid psychological energies from us such as the Oedipus complex, libido and death drive among others. Freud's main contribution was the acceptance that we do not know "us", that we have a reality that is hidden from us.  What Freud did for psychology, Albert Einstein did for our concept of outside reality. Einstein, a theoretical physicist, developed a general theory of relativity which together with quantum mechanics and the law of the photoelectric effect evolved into quantum theory. Einstein transformed Newtonian mechanics—where object were treated as physical representation but much smaller—to one where at great microscopic details these realities changed into energy and shivering mass. He conceived of the world as composed of waves of energy,  a vibrating nexus of excited mass. These ideas later flourished into an idea of reality as a probability of energy waves. Completely transforming how we look at the universe we believed to be solid.

These ideas came from a culmination of prior small developments that helped Thales, Freud and Einstein make a conceptual leap. We are now ready for another leap. Another way of looking at ourselves...again.

It started when scientists started finding that conscious thought is a product of an unconscious process. We are "aware" because there is an earlier process that we are not aware of that wants us to be aware. The late Benjamin Libet from UCSF was a pioneer in showing that a conscious decision can be monitored neurologically sometimes as much as ten seconds before the activity appears—which he termed readiness potential. In effect, by monitoring the brain's EEG we can predict rudimentary activity before people become conscious of it—such as moving your index finger. More recently, Itzak Fried from UCLA recorded single neurons and found that the readiness potential isn't a diffuse state of readiness, but is a very specific set of instructions. Our consciousness was an after thought to a specific decision that has already been taken.  This resulted in what Daniel Wegner called in his 2002 book "The Illusion of Conscious Will." It is an illusion that we cannot dispel, despite knowing that it is an illusion, because it is how we think. We think that we have conscious will.

If there is no conscious will, then it brings into question the validity of the division of self/mind and brain/body that René Descartes defined in the 1600s. This Cartesian Dualism has constrained our thinking for more than four centuries. This belief is that there is a separation of the mind from the body and that the self is not defined by the mind but something higher. But this is proving to be wrong. But more important than this—although for academics this is really important—is that if our consciousness is part of a pre-determined process, then what other realities are there that we are not aware of? If there is no such thing as a self/mind and brain/body division, then what is there?  I think of "me" as the product of a coherent sequential story that lead me here as a sentient being in a determined place, undertaking a conscious activity. I feel responsible for where I am and what I am doing. Which is why nationalism is so strong even though where we are born is a random event. Most people take ownership of their situation.

Because our brain is so vast in its complexity it is able to create a representation of the world. It uses this model to predict. That is how we survive and flourish. Prediction is also the basis for all scientific theory. My brain builds a virtual reality and interacts within this model. Very much like a computer game where I "am" the avatar. And very much like the avatar, my mind makes me unique, distinct and sequential being with a history that I own. Our reality is a creative process. We create this reality. We negotiate with our body and our mind about how to tell this story of reality. On one side is the concept of "me" and on the other the story of "others." The reality is that there is a place where there is no distinction. Our body holds that special place. It is both part of the environment and part "me". The illusion is the "me."  This is especially true of routines of everyday life—those activities and customary habits that are expected and anticipated. Routines are patterns of behavior that we build over time and internalized. We are unaware of these habits of behaving. And it is not just that we are unconscious of them but that our body has adapted without making us aware, and we know about these changes because we can measure them.

Stress chemicals in the body—such as the allostatic load and IL-6—is higher in people that live in communities with greater densities of poor older adults and in racially segregated communities. This relationship was found to be independent of important individual level risk factors (e.g. smoking or obesity). A stressful environment—such a poor neighborhood—results in negative changes in the chemical composition in our bodies. These chemical states initiate other changes. Changing chemical composition in our bodies have lasting effects because they switch the expression of some genes. These epi-genes can be switched on and off, establishing a consistent optimum level of chemical balance within the body. Environmental factors such as mercury in water, second-hand smoke, diet including foliate, pharmaceuticals, pesticides, air pollutants, industrial chemicals, heavy metals, hormones in water, nutrition, and behavior have been shown to affect epi-genetics.  Furthermore, epi-genetic changes are associated with specific outcomes such as cancer, diabetes, obesity, infertility, respiratory diseases, allergies, and neurodegenerative disorders such as Parkinson’s and Alzheimer’s diseases. Our body changes our epi-genes—which establishes an optimum level of chemical balance in response to our environment. Richard Rorty in 1979 said this beautifully “So the paradoxical conclusion offered earlier—that had physiology been more obvious psychology would never have arisen—can be reaffirmed. Indeed, we can strengthen it and say that if the body had been easier to understand, nobody would have thought that we had a mind.” (p 239).

Who we are is not who we think we are. Thales, Freud and Einstein have shown us how our perception is incomplete. The next frontier is the idea of self. Our body has a memory that we are unaware of. There is a reality in our body that reflects the geography of our communities, including people that we interact with on a consistent basis. This is necessarily unconscious since the body is complex. Our consciousness is an afterthought of decisions already taken in order to provide the illusion of active participants, an avatar. It provides us with the illusion of "me". But it is an illusion.  The reality is that there is no "me" but a place of interaction. A place where the illusion of a unique "me" interacts with the outside world, the geography the community and significant others.Who I am is not who I think I am. And we feel this reality sometimes as a spiritual existence. Something that extends human identity beyond the self. Learning compassion, empathy and love is when we truly become one with this reality. Try and translate love without referring to a world where their is a union of beings, of community of geographies. All religions start from this understanding, but the way that our mind works—needing to create separateness and pushing us into an egocentric world view—corrupts this initial insight and re-interprets it as "them" and "us." But what we are learning is that there is a union of those around us and the geography that we live in. Our identify of self is an afterthought.

The body and the mind  have already determined its strategy for existence. And if I accept that there is not just a "me" but also a "we" inside my body then I can understand how my environment, my community, family and friends can determine my behavior and outcomes, as much as I think I do myself. My interaction with the world leaves evidence in my genes just as I leave traces in my world.

The symbiotic relationship exposes humans to a greater sense of belonging within their geography since we carry our geography within us in our bodies. If we are going to understand how extreme-longevity occurs we need to understand this construct much better than we do today. And perhaps our understanding of why happy people, people that volunteer, people that are religious, people that are in love, live longer should not be seen as a strategy but as an expression of people that are in touch with this reality of who they truly are...a union of their geography and their community.
 

© USA Copyrighted 2015 Mario D. Garrett

Further Reading:

Libet, B. (1985). "Unconscious Cerebral Initiative and the Role of Conscious Will in Voluntary Action". The Behavioral and Brain Sciences 8: 529–566. doi:10.1017/s0140525x00044903.

Wegner, D. M. (2002). The illusion of conscious will. MIT press.

Garrett M. D. (2014) Geograph of Elderly. Oxford Bibliography.
Online: http://www.oxfordbibliographies.com/view/document/obo-9780199874002/obo-9780199874002-0062.xml

Humans are Cleverly Stupid Beings

Quick note to put things in perspective:  If the whole of the electromagnetic spectrum were positioned on a tape measure and it was stretched to 2,000 miles, the amount of visible light that humans see is less than one inch.  So, on a logarithmic scale of frequency, visible light is 2.3% of the whole electromagnetic spectrum, while on a linear scale it is 0.0035%. The human eye see less than 100th% of the universe.The perception of loudness relates roughly to the sound power to an exponent of 1/3. For example, if you increase the sound power by a factor of ten, listeners will report that the loudness has increased by a factor of about two (101/3 ≈ 2). This is a major problem for eliminating undesirable environmental sounds, for instance, the beefed-up stereo in the next door apartment. Suppose you diligently cover 99% of your wall with a perfect soundproof material, missing only 1% of the surface area due to doors, corners, vents, etc. Even though the sound power has been reduced to only 1% of its former value, the perceived loudness has only dropped to about 0.011/3 ≈ 0.2, or 20%.

The range of human hearing is generally considered to be 20 Hz to 20 kHz, but it is far more sensitive to sounds between 1 kHz and 4 kHz. For example, listeners can detect sounds as low as 0 dB SPL at 3 kHz, but require 40 dB SPL at 100 hertz (an amplitude increase of 100). Listeners can tell that two tones are different if their frequencies differ by more than about 0.3% at 3 kHz. This increases to 3% at 100 hertz. For comparison, adjacent keys on a piano differ by about 6% in frequency.