Monday, May 1, 2017

Learning about Aging through Film: The Narrative Arc


The use of film to explore concepts in gerontology. This is one of a series of five lectures on the role of film in gerontology. Spoiler alerts, if you have not seen these films, this analysis necessitates exposing the plot. These notes are intended for you to click on the movie trailer sequentially with the analyses.


The narrative arc in film is a static story board of how a story evolves and develops, both evident as well as imagined. How older people are portrayed in film is best described through the interpretation of this narrative arc. An arc is the linear development of a story—a beginning, a middle and an end.  An alternate method of analyses would be through the more limited interpretation of context, character, symbolism, and other constructs.

One of the first films describing a simple story about older people is the 1952 Japanese film Ikiru by the acclaimed director Akira Kurosawa—acclaimed for the Seven Samurai, Rashomon, and Ran. Ikiru has a fairly simple narrative arc. A bureaucrat, on the cusp of retirement, is informed that he has terminal cancer. The narrative arc focusses on the main character in the film attempting to find meaning and leaving behind a legacy in his life before he dies.


This simple story highlights that after one’s entire life spent doing what you are supposed to do—work, maybe family—that at the end what is important is relationships. At the end, he finds some solace among his younger mates, where he finds friendship.

This narrative arc, an old man at the end of life, was further developed by another seminal director, Ingmar Bergman who in 1957 wrote and directed Wild Strawberries.


Filmed in black and white, perhaps in homage to Ikiru, the film goes further in search of the meaning of one’s life and leaving a legacy. Following a fairly similar story of an accomplished bureaucrat—this time a professor—Wild Strawberries explores the question of what was it all about? The lost meaning is a reflection that the character’s internal story did not go far enough to include getting old. We do not have ambitions for getting old, and once we get there, we remain without a plan. Wild Strawberries has been described as Bergman’s attempt to justify himself to his own parents. The narrative arc told through actual and dream experiences, mixes ghosts, fantasies and reality. Admired but not loved, the protagonist starts to explore what the continuation of his story in older age should be. Like Ikiru, relationships seem to be the answer.
Such a conclusion is not far-fetched from what we observe at the end of life.

In 2012 Bronnie Ware, an Australian palliative care nurse, wrote The Top Five Regrets of the Dying: A Life Transformed by the Dearly Departing. Our two male protagonists in Ikiru and Wild Strawberries follow these regrets. These misgivings focused on having unfulfilled dreams and unrequited loves. Not having the courage to follow their dreams, where (mostly) men tended to regret working so hard. Stifling feelings in order to settle for a mediocre existence. And not staying in touch with their friends, and loved ones. And the final regret is not allowing oneself to be happy. They got stuck in a rut. The agreement between the narrative of these two films and the five regrets of dying people is stunning.

The films’ narrative arc, from a negative view of aging, exposing a slow hemorrhaging of life force, the story transforms to positive highlights of friendship and family. That it is not too late to address these regrets.  But what if this transformation did not take place? If the dystopian view of aging remains without the salvation of a new-found narrative what would be the result? This is the story of the two protagonists in the 2015 Italian film Youth.


Paolo Sorrentino’s film centers on two close friends sharing a vacation at an exclusive Swiss spa. The two protagonists are, a director who continues producing the same kind of films, surrounded by increasingly younger writers. While the other protagonist is a music composer who has decided to retire. What we have to work out is that the composer stopped composing—to the chagrin of many—because of his wife’s dementia which he hid from everyone including his daughter. He has made changes to address this trauma and his aging. Negative events in life change our narrative arc. In contrast, the other character, the director, only had one story—to remain doing what he did in the past. He did not have a different story for when he got old, and the quality of his work diminished. At the end, his suicide was the only answer to his failing career since he did not have a plan B, an evolving narrative arc. We have a starkly different outcome for what is portrayed as equally successful early careers.

This theme of different projections of the story line is best seen in the whimsical 2013 documentary, directed by Zachary Heinzerling, on Cutie and Boxer. Two married aging Japanese visual artists, living in New York city, where one reached their azimuth of success a few decades ago, while the unknown and subservient wife is launching her trajectory of ascendence in her narrative arc.

https://www.youtube.com/watch?v=YXS6Aby5AUg

Cinematographically, a narrative arc can also be reversed. This is the beauty of film, we can explore the importance of a narrative arc by manipulating the sequence. This is a popular method in film, to imaging that a life’s story can go backwards or stay static, anchored to a particular age where you do not have to have a narration for an older age.

The digital masterpiece of the 2008 The Curious Case of Benjamin Button directed by David Fincher—of the fame, Fight Club, Se7ev, and Gone Girl—is based on the premise that while the main character is born old and starts becoming younger, everyone else gets older and dies. The only connection the main character develops in the film, is when his (descending) timeline converges with another character’s (ascending) timeline. This is the meaning of the story, that a meaningful relationship is shared with people in similar (time) context.


This theme is again is explored in the later 2015 film the Age of Adaline by Lee Toland Krieger where the main character is involved in a car accident resulting in a traumatic physical shock that enigmatically stops her aging.


The story focusses on two aspects of how meaningful relationship is shared with people in similar (time) context, when she experiences the aging and ultimate death of her daughter and the aging of her lovers.

What if you can go back and change your narrative arc. What would you choose? In Francis Ford Coppola’s 2007 Youth without Youth an older man is struck by lightning and starts to regress into his past. Not only was he getting younger, as the cases with The Curious Case of Benjamin Button, in his mind time was flowing back as well. This is the proverbial what would you do if you had to do it all over again.


Another technique used in film is to explore the “What If?” question. Made in 2009 Mr. Nobody was written and directed by Jaco Van Dormael. In this science fiction world where the last mortal is about to die at age 118, the protagonist explores three options that he could have made differently. Would the narrative arc result in a better outcome at the end of life?


In the end, the protagonist acknowledges that although every choice he has made had far reaching results in the future, ultimately none of the choices are good or bad. The interpretation is that as long as we make allowance for getting old everything will turn out well. Each will option will result in slightly different outcomes but all will have a coherent story. The narrative arc is written as we live life, and sometimes we are just too “busy” to envisage that anything will change. Despite us knowing, intellectually at least, that everything changes all the time.

A limited narrative arc, one that is missing a component for later life, relegates older age to a dystopian existence. Only by having an internal narrative that includes future dreams can there truly be a fully lived life. What better than a story of Burt Munro, a New Zealand amateur motorcyclist who wanted to break the world speed record and in so doing ignored age completely. This is the adaption of his story: The World’s Fastest Indian.



It took 20 years for the New Zealand director Roger Donaldson to make this film. In it, the protagonist narrative arc is changed when he tells of the death of his brother Ernie by a fallen tree—and, in Burt Munro’s real life, his stillborn twin sister—which changes the real life Burt Munro’s story and view of life. Negative events in life change our narrative arc. The beauty about this film is that the narrative arc ignored age completely. Suffering from angina and later a stroke in 1977, the real Munro at the age of 68 while riding a 47-year-old machine continued to set world speed records for 1,000 cc bikes. He did not use his experiences to dictate his age and his narrative arc did not stop at older age. He had his own ongoing story. In the film although there are characters that try and stop him from pursuing his narrative, the protagonist simply ignored them. Some of us are not so lucky.

Where we collude in this restriction is that we promote a restricted narrative arc for older people. Do a little exercise for me.

Let’s imagine that you have a 100-year-old woman that you are going to interview. What is the single question that you will ask her.

Write it down.

Then assume that you have a 16year-young girl coming to be interviewed. What single question would you ask?

Write that down.

The prediction is that you probably ask the older woman about her past and the younger woman about her future. You have already hemmed them into you view of what their narrative arc should be. With this knowledge in hand, let’s review a recent interview with Jerry Lewis.


An awkward exchange where Jerry Lewis’s narrative arc focusses on the future while the reporter is trying to force him—unsuccessfully, to the great strength of Jerry Lewis—to focus on his past.

To age successfully we must not only have a story that goes beyond adulthood—to extend into older adulthood—but we must also be vigilant against those who unintentionally try and demolish our narrative for living in older age, by translating it to “old” age. Our narrative arc is important because it is how we conduct our life, including into older age.

© USA Copyrighted 2017 Mario D. Garrett 

Saturday, April 1, 2017

Big Pharma Against Dementia

The World Alzheimer Report of 2011 reported that we do not know the benefits of screening and early diagnosis of dementia. We all assume that people should be checked early for dementia, but we do not know whether there is an advantage to be diagnosed with the disease. There are definitely negative repercussions—losing your driving license, right to conduct professional duties, enter into financial agreements, and sometimes even the right to conduct your own affairs. It seems that once you get diagnosed with dementia then you are left to fend on your own with your loved ones if you have any.

There is a disconnect between diagnoses—the identification of the disease—and prognosis—forecasting the progression of the disease and suggested treatment, therapy or support services. In the field of dementia, as with other diseases especially cancer, there lies an expectation that an early detection brings better outcomes: You live longer with less pain. But the reality is very different. New emerging research shows that our ambition to help dementia patients because of an early diagnosis is failing miserably.

In a French study in 2015, ClĂ©ment Pimouguet and his colleagues reported that people with dementia who had consulted a specialist at the start of their disease, died earlier than those who only saw their general practitioner (GP) or did nothing. Sadly they found that there was no difference between participants who visited their GP and those who went without any clinical care.  Although those that went to see a specialist had much faster functional decline, their thinking ability was not much different from the other group. Why would seeing a specialist increase your likelihood of dying?

The lack of follow-up by the specialist was one of the reasons given for the higher rate of death. In 2017 Paula Rochon  and Jeremy Matlow and colleagues in Toronto, Ontario, reported that half of 2,998 nursing home residents with dementia were still getting questionable medication in their last year of life.  These medications might have had some benefit at the early stages of the disease but definitely have negative affect on the wellbeing of these confused patients. That a third of the residents did not see a specialist in the last year of life suggests that the medication was prescribed earlier on in the diagnosis and had not been reviewed since. Regular medication reviews will help to curtail unnecessary prescriptions.

It is likely therefore that too much and inappropriate medication is a culprit. In France only the specialist can prescribe drugs and this study found that half were prescribed antidementia drugs (46.2%); while the rest 12% prescribed antipsychotic drugs, 28% anxiolytic drugs, and 9% took psychostimulant. It is only when the diagnosis of dementia was vascular dementia and where some fo these drugs are not to be prescribed that seeing a specialist was found to be beneficial. Amelie Bruandet with the university of Lille, France and her colleagues found that with vascular dementia the shorter the delay between first symptoms and first visit, the longer patients survived. It could be due to medication, specialist do not prescribe medications that are killing dementia patients earlier.

It seems that we do not have any medication for dementia that is both effective and safe. In fact, all evidence points to dementia medication as being ineffective and in most cases dangerous. A conclusion that was arrived at by a 2014 study by two Dartmouth professors Steven Woloshin and Lisa Schwartz reporting for Consumer Reports. In addition to their costs—ranging on average $177-$400 a month—there was not one drug that they could recommend. Not one drug.

The logical assessment would be that since physicians have no medication to provide patients with dementia then following the Hippocratic Oath and “first, do no harm,” no medication should be prescribed.  But a 2015 study of elderly patients showed that anticholinergic medications given to patients with dementia—including antimuscarinics, tricyclic antidepressants, and first-generation antihistamines—are associated with an increased risk for dementia. Drugs being prescribed have an established evidence to increase dementia. Sometimes this dangerous medication is given for non-life-threatening disease such as overactive bladder. Christian Meyer from the University Medical Center Hamburg–Eppendorf in Germany, and his colleagues reported that more than one-quarter of older Americans with overactive bladder are given a prescription for oxybutynin, and one-third are given a refill, despite the established link between this drug and cognitive dysfunction in the elderly. In a 2015 survey of Medicare patients with dementia more than one in four were being prescribed "potentially inappropriate" anticholinergics.

The overuse of prescription of medication among older patients is ageist. We need to address this final bastion of stereotyping. We know that younger people with a similar disease are more likely to get therapy. But there is another negative consequence of this lack of knowledge. Physicians become shy at making prognoses. Although diagnosis is relatively easily, they can easily say it is Alzheimer’s disease or Vascular dementia without any liability issue, and most do despite evidence that they are likely to be wrong.  The patient is seriously sick, we can all see that. But once physicians start to define a timeline or sequence of how the disease will enfold, then they become exposed not only to the patient, but more importantly to the patient’s family, their medical institutional and legal liability.

In a short paper, Sonali Wilborn, and Navdeep Grewal, with Seasons Hospice and Palliative Care, Madison Heights, Michigan USA found that predicting mortality using current prognostic guidelines, fails in approximately a third of Alzheimer’s patients. Nicholas Christakis, a hospice physician takes it much further. He rightly laments the neglect of prognosis in medicine. Making a prognosis is messy and inaccurate. In 2000, he reports a study where only one in five timelines were accurate in forecasting death, more than half were over-optimistic while one in six were over-pessimistic. Being over-optimistic ensures that patients delay too long in sorting out their affairs.

The symbol of medicine is the rod of Asclepius—which has a snake coiled around a cane. It is carried by the Greek god Asclepius, a deity associated with healing and medicine. It is often confused with the caduceus which has a very different meaning.

The caduceus—depicting two snakes wrapped around a winged rod—is carried by Mercury the mythical messenger of the gods. Mercury is the guide of the dead and protector of merchants, shepherds, gamblers, liars, and thieves. In dementia care we might be confusing both the symbol and the objectives becoming the protectors of big pharma: merchants, gamblers, liars, and thieves. The abuse of older patients with dementia remains an unwritten chapter in the low point of medicine.

© USA Copyrighted 2017 Mario D. Garrett 




References
Bruandet, A., Richard, F., Bombois, S., Maurage, C. A., Deramecourt, V., Lebert, F., ... & Pasquier, F. (2009). Alzheimer disease with cerebrovascular disease and vascular dementia: clinical features and course compared with Alzheimer disease. Journal of Neurology, Neurosurgery & Psychiatry, 80(2), 133-139.

Pimouguet, C., Delva, F., Le Goff, M., Stern, Y., Pasquier, F., Berr, C., ... & Helmer, C. (2015). Survival and early recourse to care for dementia: A population based study. Alzheimer's & Dementia, 11(4), 385-393.

Rait, G., Walters, K., Bottomley, C., Petersen, I., Iliffe, S., & Nazareth, I. (2010). Survival of people with clinical diagnosis of dementia in primary care: cohort study. Bmj, 341, c3584.

© USA Copyrighted 2017 Mario D. Garrett