Older Smell

On their return from visiting a nursing home, my children when we were in kindergarten happily shared with me their impression that the residents “smell.” A nursing home is not the best place to get to know older adults, but the stereotype remains. There are even some fancy scientific theories to explain why this is so. We know that taste and smell diminish with age, but that older people also have a distinct odor is worth exploring.

Visiting Japan, one is immediately faced with the strict culture of washing and bad odor is frowned upon. The Japanese even have a distinct name for the body odor of older people Kareishu. After conducting a poll of 150 men and women, the Japanese Shiseido Group found that odor from older people is the second most offensive scent behind bad breath. We will return to this study later on. 

Body odor in humans is determined by various factors, including genetic background, physiological conditions, behavioral patterns, food ingestion, and disease types, but most often there is a stereotype that it relates to getting old. The theory is that older people smell because of their aging biology. One theory suggests that aging causes hormonal imbalances resulting in more lipid acid in our skin. And as skin matures, its natural antioxidant protection decreases, resulting in greater oxidation of this lipid acid resulting in Nonenal. The smell of this chemical compound is similar to oil that goes rancid when left out. This chemical is more common among people over 40 years of age. Another biological theory is that the major contributor is the bacterial activity in skin gland secretions. Numerous skin bacteria help produce smelly substances and as we get older this bacteria seems to be more common. 

It could also be related to diet. In 2017 Jun Nishihira with Hokkaido Information University and his colleagues reported that eating a mushroom extract (Champignon) was found to improve body smell, as well as bad breath and smelly poo. The idea that perhaps we can counteract this Kareishu was explored by Dae Youn Hwang with Pusan National University, Republic of Korea, and his colleagues. They found that extracts of Spiraea Japonica—a deciduous, perennial shrub native to Japan—reduced the odor of older adults. 

Developing products to counteract Kareishu opens the market to businesses making money off older people’s fears and stereotypes. Shiseido Group at one point developed a perfume "Harmonage Fragrance" specifically formulated to neutralize older people’s body odor. Then there is the line of anti-age-stench soaps by Mirai Clinical that this time uses persimmon extract as a natural deodorizer. The issue is not that body odor changes with age, it does, the issue is whether this smell is bad. 

Researchers have shown that the body odors of some animals—including mice, black-tailed deer, otters, owls, and rabbits—change with age and that animals can distinguish their young and old peers by smell. Even people can tell the difference between old and young otters and rabbits by how they smell. 

Older people might smell differently from younger people, but this is not always a bad smell. We know for example, that some frail older people experience difficulties in mobility and getting washed, but those that are still functional and maintain good hygiene might be different.

Johan Lundström and his colleagues at the University of Pennsylvania stitched absorbent pads into the armpits of T-shirts and asked volunteers of different ages to sleep in the shirts for five consecutive nights. During the day, the volunteers stored the T-shirts in sealed plastic bags; avoided spicy foods, cigarettes, and alcohol; and showered with odorless shampoo and soap. After the fifth night, blindfolded volunteers rated the pads and found elderly people's odors both less intense and less unpleasant than odors from young and middle-aged people. Middle-aged men had the most unpleasant odor while the odors of middle-aged women were judged to be the most pleasant. Old people's smell was often instantly recognizable and not necessarily in a bad way. The result from this study is different from the earlier study by the Shiseido Group. But then again if I am selling a fragrance I want to create a market of smelly older adults so that they will buy my fragrance. In reality, older adults might smell differently but not in a bad way. The lesson is how easily we accept the negative stereotype of older people smelling.

Kenkou to Yoi Tomodachi  4

References

Nishihira, J., Nishimura, M., Tanaka, A., Yamaguchi, A., & Taira, T. (2017). Effects of 4-week continuous ingestion of champignon extract on halitosis and body and fecal odor. Journal of Traditional and Complementary Medicine, 7(1), 110-116.

Kim, J. E., Choi, Y. J., Lee, S. J., Gong, J. E., Seong, J. E., Park, S. H., & Hwang, D. Y. (2022). Evaluation of Deodorizing Effects of Saccharina japonica in 10-Month-Old ICR Mice Using a Novel Odor Marker Associated with Aging. Evidence-Based Complementary and Alternative Medicine, 2022.

https://www.scientificamerican.com/article/old-person-smell/

Mitro, S., Gordon, A. R., Olsson, M. J., & Lundström, J. N. (2012). The smell of age: perception and discrimination of body odors of different ages. PloS one, 7(5), e38110.

https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0038110

Hospice

When talking about gerontology—the study of older people—most people assume that it is a new study as they have not heard of it. The same goes for hospice. If you bring it up in a conversation most people will know of someone who went through hospice, but again they think that this is a current trend, something new. So, it comes as a bit of a shock when people learn that gerontology is as old as writing itself. The first known record of writing is the Sumerian Saga of Gilgamesh about 4,000 years ago. The most famous of the five poems is "Gilgamesh, Enkidu, and the Netherworld." a poem that describes the love that King Gilgamesh has for Enkidu, a half-god when he tragically dies. An event that sets Gilgamesh on a search to find a cure for aging and to death in order to bring his friend back from the dead. The story has spawned many others, and there are traces of this story everywhere, including in the bible. It is important to understand that the first evidence we have of literature dealt with getting old and dying. 

Even the term “gerontology” was used in 1903 by Ilya Mechnikov, an immunologist who with Paul Ehrlich was jointly awarded the 1908 Nobel Prize in Physiology or Medicine. Gerontology even fathered the discipline of endocrinology (the study of hormones) and transplantation (transplanting organs). A hundred and twenty years later, people still think that gerontology is new because they do not want to think about aging and about dying. This is very much true in Japan as well. In 2016 Mitsunori Miyashita with the University of Tokyo asked Japanese people about a ‘good death’ and showed that they tended to avoid thinking about it. The study also found that they gave their family a large say in how they should die. We do not want to think about death. 

Hospice provides care for people who are dying. Such care was first established during the Crusades in the years after 1000 and became widespread in the Middle Ages. It formally became a branch of medicine when Cicely Saunders founded St. Christopher’s Hospice in London in 1967. This first hospice set the stage for other hospices throughout the world. In Japan, the first systematic palliative care service was launched at Yodogawa Christian Hospital, Osaka, in 1973, and then in 1981, the first palliative care unit (PCU) was opened at Seirei Mikatahara General Hospital, Shizuoka. After 1990 when insurance started covering PCU treatment, hospice grew into a national service that covered all of Japan. By 2017,  there were 394 PCUs with 8,068 beds. All of the designated cancer hospitals have PCUs. 

In Japan, like in every other country, most people want to die at home and a third want to die at PCUs. However, the reality is that most die in hospitals. Masanori Mori and Tatsuya Morita have identified the need for more training and better specialization in Japan to promote better and more accessible care for the dying. And there have been great advances. By 2015 there were more than 50,000 physicians trained in palliative care. While a study that started in 2008 to monitor palliative care in Japan called the Outreach Palliative Care Trial of Integrated Regional Model (OPTIM) has recently found that Nurses' palliative care knowledge, and practice improved with more training. 

The fundamental problem with hospice relates to what we discussed earlier in the introduction, people do not want to talk about it, and that includes physicians and nurses. Health care workers do not want to go into hospice. If you are part of a profession of saving people’s lives then helping them to die seems contradictory. Most people leave hospice till the very end. Others shy away from contacting hospice, even though most hospice services can be delivered to your home. The only way to change this is to accept death as part of the cycle of life. Talking about death does not have to be sad as it can highlight the privilege of being alive. By appreciating that having a good death needs to be planned. We have known this for centuries perhaps now is the time to accept it for ourselves.

Kenkou to Yoi Tomodach 3

References

Mori, M., & Morita, T. (2016). Advances in hospice and palliative care in Japan: A review paper. The Korean Journal of Hospice and Palliative Care, 19(4), 283-291.

Nakazawa, Y., Kato, M., Miyashita, M., Morita, T., & Kizawa, Y. (2018). Changes in nurses' knowledge, difficulties, and self-reported practices toward palliative care for cancer patients in Japan: an analysis of two nationwide representative surveys in 2008 and 2015. Journal of pain and symptom management, 55(2), 402-412.

What are the main challenges facing palliative/end-of-life care today in relation to Japan’s ageing society

Posted on January 31, 2018 by pallcare

Mariko Masujima, Principal Investigator, and Zaiya Takahashi, Core Promoter, the Center of Excellence for End-of-Life Care at Chiba University, describe the present situation, policy and cultures about end-of-life care in Japan.

Accessed: https://eapcnet.wordpress.com/2018/01/31/what-are-the-main-challenges-facing-palliative-end-of-life-care-today-in-relation-to-japans-ageing-society/

Drugs and Older Adults

America is the country for sex, drugs, and rock and roll….well maybe just drugs and rock & roll.  Americans can be very traditional when it comes to discussing sex, but as for drugs we use medication as much as the Japanese. Most Americans are on some kind of medication or illicit drug. During 2015–2016, almost half of the U.S. population, including children, used one or more prescription drugs.  If you include recreational drugs, alcohol, and tobacco then you can assume that nearly everyone is on some kind of mood-altering drug. In addition, nearly everyone takes caffeine, either from coffee, soft drinks, or tea. Drugs are everywhere and they are differentiated only by whether they are legal or not and whether they are prescribed by a doctor or self-administered.

When discussing the problem of drugs, most people fall into the habit of automatically blaming recreational drugs. There is a long-standing myth that drug abuse is rare among older adults. The belief was that long-term drug addicts either recovered or died, and that addiction and use of illegal drugs by older adults were restricted to a small group of older criminals. But when we look at reality a different picture emerges. It is prescription medication among older people that is a primary concern. It is legal medications that cause more harm--those prescribed by your doctor--or those that you can buy from a pharmacy off-the-shelf. Prescription drugs are more popular with older people, especially older women. Pain relievers remain the most popular drug for the last two decades. Nearly a third of adults over 65 are on prescription medication. Most of these are not addictive, but the most popular medicines are, especially those for pain relievers.

While we see older men being addicted to alcohol and illicit drugs, older women are more likely to be addicted to pain medication like sedatives, hypnotics, and anxiolytics for anxiety. One type of anxiolytics is Benzodiazepines, which treat anxiety, pain, or insomnia, and are highly addictive and common. There are also common medications that older adults should not be taking. These drugs are updated every year under the BEERS criteria. 

Some medications might also be used inappropriately either intentionally or through forgetfulness. Older adults forget what medications they are on, and when and how to take them. Even though the US spends more on medications than any other country—mainly because we pay more for drugs than most countries—Japan leads the world in prescribing medications for older adults. 

When the world saw a decline in life expectancy for the first time this century in 2014, that was not due to wars, in the US this was attributed to the over-prescription of opioid medication. Promoted by big pharma, opioids were sold with the lie that they were not addictive. There was a fivefold increase in prescription opioid overdose deaths from 1996 to 2016 in the US. While newspapers focused on younger adults who misused prescription opioids, it was middle-aged and older adults between 50-64 years and older that use prescription opioids at a higher rate than any other group.

Combined with alcohol, prescription drug abuse among older adults is one of the fastest-growing health problems in the US. Alcohol and prescription drug abuse affect up to one in six older adults. Since older adults have a decreased ability to metabolize chemicals, the drugs stay in the body longer and our brains seem to get more sensitive to these drugs. This makes it dangerous for older adults to use any drug, even if the person is not addicted. On top of this, there is self-abuse. One-tenth of all older adults are also binge drinkers—five or more drinks at a time. Binge drinkers were more likely to be male and more likely to also use tobacco and/or cannabis. In the US cannabis use among older adults increased to one in twenty people, especially among older men younger than 69. Prescription medication combined with other drugs does not mix well.  With increasing access to geriatric doctors, nurses, and gerontologists we see a reduction in prescriptions and an overall improvement in life. In a complex world, having someone help you to navigate around these many drug options will benefit you to get the most from medications.

Kenkou to Yoi Tomodachi 2

References

Han, B. H., Moore, A. A., Ferris, R., & Palamar, J. J. (2019). Binge drinking among older adults in the United States, 2015 to 2017. Journal of the American Geriatrics Society, 67(10), 2139-2144.

Han, B. H., Sherman, S. E., & Palamar, J. J. (2019). Prescription opioid misuse among middle-aged and older adults in the United States, 2015–2016. Preventive medicine, 121, 94-98.

Tsuji‐Hayashi, Y., Fukuhara, S., Green, J., & Kurokawa, K. (1999). Use of prescribed drugs among older people in Japan: association with not having a regular physician. Journal of the American Geriatrics Society, 47(12), 1425-1429.

https://www.addictioncenter.com/addiction/elderly/

https://acpinternist.org/archives/2021/03/cannabis-use-increasing-among-older-adults.htm

https://www.verywellmind.com/us-has-highest-levels-of-illegal-drug-use-67909

https://www.cdc.gov/nchs/products/databriefs/db334.htm#:~:text=During%202015%E2%80%932016%2C%20almost%20one,the%20pattern%20varied%20by%20age.

https://rehabs.com/blog/most-popular-drug-in-us-by-decade/

Ending our Story

We have an image in our minds of how our life will progress. This is usually formed when we were children, so it is simplistic. It goes something like this: we grow up, make lots of money, get married, have kids, and live happily ever after. We quickly find that this story might not be true for us. But even though we might be disillusioned, what this tells us is that with these stories we like to predict. We like to tell a coherent story about our lives. It is part of how we are designed and we like to guess what will happen in the future, and we seem to do it for our own death as well.

When we ask people how long they expect to live they will be surprised to learn that they are fairly accurate. We tend to underestimate how long we live but otherwise, it is fairly accurate. It is so accurate that statisticians who work with life insurance (actuaries) use this to adjust how long they expect us to live and therefore adjust how much we pay for life insurance.

David Phillips, with the University of California San Diego, has been looking at this phenomenon.  In 1992 Phillips and his colleagues examined three million deaths from natural causes.  Women are more likely to die in the week following their birthdays than in any other week of the year. It seems that females are able to prolong life enough it seems until they have reached a positive, symbolically meaningful occasion—their birthday. For women a birthday seems to function as a “lifeline.” In contrast, male deaths peak shortly before their birthday, suggesting that their birthday functions as a “deadline” for males. Older men are more likely to experience their looming birthday as a negative sign. The importance of a “lifeline” or a “deadline” also works for other significant days.

In 2016 Andrew Stickley and his colleagues looked at over 27,000 suicides in Japan between 2001–2010. What they found was that males were more likely to commit suicide around their birthday—5 days before and a week after their birthday. While females, they committed suicide 7–11 days before their birthday. In Japan, birthdays seem to be a deadline for both males and females. We find cultural variations throughout the world.

David Phillips and Elliot King showed that in a small Jewish group death declines by about a third below normal before the Jewish holiday of Passover and then peaks by the same amount the week after. It seems that Jewish people hold on to life a little bit longer to celebrate Passover. In contrast, non-Jewish deaths showed no such pattern around the same period.

The same is found for the Chinese who are less likely to die the week before the Harvest Moon Festival but peak the week after. In the West deaths spike during Christmas and New Year’s holiday period possibly because these periods are both stressful and indulgent. Also, people might delay seeking medical treatment during the festive season. 

Another interesting observation centers around Tetraphobia, the fear of the number “4”  that is common in Japan, as well as in China, Taiwan, Singapore, Malaysia, Korea, and Vietnam. This superstition seems to have arisen from the similarity of the pronunciation of the word “four” and “death” in Japanese as well as in Mandarin and Cantonese. When looking at death from heart disease among Japanese and Chinese Americans we find that there are extra deaths on the fourth of the month. No such increases showed up among other populations. 

It is difficult to make any conclusions. Certain days such as our birthdate can have significance. We might see it as an accomplishment (for women) or as a deadline (for men), or as evidence of loneliness among suicidal Japanese.  Some festivities which are stressful likely to hasten our demise (Christmas and New Year) while other holidays we might withstand till after they pass (Passover for Jews and Harvest Moon Festival for Chinese.) Then there are days that we fear that act as a self-fulfilling prophecy (the 4th of each month). What seems to emerge is that how we think about death influences when we die, at a minimum by a few days and at a maximum by some years.

Kenkou to Yoi Tomodachi  1

Long Hiatus

 After a long hiatus, more than two years off this blog post, I have decided to return to this medium. It is not that I have not been writing. I have published three books during this break from blogging, but I realize that my blogs reach more people that need to read about these advances in gerontology. 

I have also been writing blogs for a Japanese newspaper called the Kenkou to Yoi Tomodachi. I have been writing monthly editorials, so I should start by reproducing them here first.

Most Popular Gerontology Professor in the USA according to Authority.org

 https://www.authority.org/rankings/best-colleges-for-gerontology/professors

Do older people have a chance of escaping COVID-19?

Everyone wants a simple answer to this 2020 COVID-19 pandemic. We have politicians forecasting that a vaccine is on its way that will save us. We are told that this is the only answer. But such predictions are misguided and wrong, especially for older people. A vaccine will not end the threat posed by COVID-19 or other viruses following. To appreciate this view, we need to understand how vaccines work.

We have a lot of experience with flu vaccines. The flu is much simpler than a cold virus (COVID-19 is a cold virus.)

Although there are four types of influenza (flu) viruses—A, B, C, and D—influenza A and B viruses are the only ones that cause flu pandemics. A-type viruses have two proteins called H and N. Since there are 18 types of H and 11 types of N there can 198 different A-viruses. B viruses have two types—Victoria and Yamagata—with sub-types. Every year we check what is happening in Asia and then we select a few flu viruses from there and develop vaccines. Vaccines usually include inactive viruses, dead viruses. In some cases, however, attenuated viruses (weakened live viruses) are used. 

Vaccines work by pretending to infect the body and then the body reacts in three ways. It is best to see the body's reaction as a war with different types of defense: soldiers, mercenaries, and intelligence units.  

The first line of attack are antibodies produced by B cells. Antibodies are soldiers, that either go out into the bloodstream to fight the viruses or stick close to the fort on the B cells. Antibodies have five methods of killing the virus and are therefore effective soldiers. Newly infected people are unlikely to have detectable antibodies during the first few days, but most develop them after one to three weeks. In the meantime, the second cell type that fights infections is T cells. One type of T cell is mercenaries that inject the virus with a lethal poison. Unlike antibodies, these T cells only fight one specific type of virus. They are very specific. Another type of T cell calls for help, especially from antibodies. In the absence of antibodies, T cells can control infection by themselves. What is interesting is that T cell responses are found in most COVID-19 patients that may last longer than antibodies. The third way the body reacts is through Natural Killer (NK) cells. If B-cells are soldiers, and T-cells are mercenaries, then NK-cells are the CIA, the intelligence unit. They kill viruses, cancer and they play an important role in pregnancy by differentiating the fetus as a special foreign body. Aging reduces the number and effectiveness of NK cells. Taken together, with reduced efficiency at generating antibodies due to reduced B- and T-cells, aging brings about a reduced resilience to infections in general and specifically to COVID-19.

Even with an effective vaccine, sometimes the vaccines completely miss the viruses that are around. The U.S. Centers for Disease Control and Prevention found that in 2018-2019 vaccines were effective between 12%-16%. with older adults having the lowest effectiveness despite having the highest vaccination rates. Meaning that on average the vaccines do not work in seven out of eight cases among older adults. Older adults do not produce enough antibodies even if they take the right vaccine. Most older adults are inefficient at producing antibodies. This is why even though older people take a flu vaccine they still get infected and some eventually still die from the flu. Flu deaths are higher among older people. Also, as Asim Biswas just discovered in 2020, because older adults have had many different colds and flu infections, these earlier antibodies may conflict with current vaccination. Our memory of infections reduces our ability to generate new antibodies. As a result, older adults are not only at greater risk of death and sickness from influenza than younger people, but they also have greater difficulty in developing protection when given the vaccine. 

What is surprising is that sometimes it looks like the vaccines not only do not help but they might be detrimental. When the Canadian researcher Melissa Andrew and her colleagues in 2017 compared older adults who were vaccinated with those who were not vaccinated, they found that infections were higher among those who were vaccinated. The argument is that those that get vaccinated are more likely to be frail and prone to get infections in the first place. Most of the time there are other viruses that cause similar symptoms, but they are missed by the vaccines for that year. Tom Jefferson and his colleagues looked at many studies and found no evidence of a benefit of influenza vaccination in older adults. Meaning that it does not matter whether you take the vaccine or not.  This is because there are many other viruses floating around at any one time, and that older adults, with or without a vaccine, do not cope well with these other viruses. 

The complexity of flu is nothing compared to the complexity of the cold viruses. In addition, cold viruses persist in the environment and are resistant to most household disinfectants—which is why washing our hands is so important as we wash the viruses off our skin, but washing does not destroy them. Some cold viruses are lethal, killing more than a third of those infected, such as MERS-CoV, and some are inconvenient but harmless, such as the common cold. 

There are two types of cold viruses either Adenovirus or Coronavirus. Each type has many, many subsets with a lot of variabilities. For example, there are 57 Adenovirus types (and hundreds, or maybe thousands, of sub-types). Then there are seven types of human Coronaviruses with many sub-types and mutations. With flu having two proteins in comparison cold viruses have many: COVID-19 for example has 29 proteins.

Because the T-cells are too specific and the COVID-19 mutates quickly—already in three months Los Alamos National labs found 14 strains—it is unlikely that T cells will be effective. Antibodies are still the best attack, except for older people who are not efficient at producing them, even with a vaccine. The Natural Killer cells are still an unknown in this fight and might be another avenue for controlling COVID-19 but we know older adults have fewer of these cells as well. Overall the only sure way we have of combating this disease is through social measures of reducing the probability of infection and reducing the infection load. Both can be achieved through the well-known drill of distancing, hand washing, wearing masks, and most importantly, not to gather. The world is going to be a distinctly different place. 

The activity by drug companies is to develop therapies rather than vaccines. Therapies that address some of the effects of the disease, in particular, the lung infections that leave some of the COVID-19 victims scarred for life. But there is another side of the infection that is more worrisome, the infection to the brain. Recent studies showing that COVID-19 causes dementia takes us back to an awareness of how few tools we have to combat this disease. We know how difficult it is to treat the brain, as research on dementia has taught us, so this will be a challenge to address. In the end, we need to rely on preventing rather than attacking. The world has changed for all, but it will be especially different for older adults.

Further Readings

Andrew, M. K., Shinde, V., Ye, L., Hatchette, T., Haguinet, F., Dos Santos, G., ... & Chit, A. (2017). The importance of frailty in the assessment of influenza vaccine effectiveness against influenza-related hospitalization in elderly people. The Journal of infectious diseases, 216(4), 405-414.

Bernstein, E., Kaye, D., Abrutyn, E., Gross, P., Dorfman, M., & Murasko, D. M. (1999). Immune response to influenza vaccination in a large healthy elderly population. Vaccine, 17(1), 82-94.

Biswas, A., Chakrabarti, A. K., & Dutta, S. (2020). Current challenges: from the path of “original antigenic sin” towards the development of universal flu vaccines: Flu vaccine efficacy encounters significant hurdles from pre-existing immunity of the host suggesting assessment of host immunity before vaccination. International Reviews of Immunology, 39(1), 21-36.

Centers for Disease Control and Prevention; Seasonal Influenza (Flu) (2017) Seasonal influenza vaccine effectiveness 2018-2019. Available at https://www.cdc.gov/flu/vaccines-work/2018-2019.html Accessed June 25, 2020

Jefferson, T., Di Pietrantonj, C., Al‐Ansary, L. A., Ferroni, E., Thorning, S., & Thomas, R. E. (2010). Vaccines for preventing influenza in the elderly. Cochrane database of systematic reviews, (2).

Varatharaj, A., Thomas, N., Ellul, M., Davies, N. W., Pollak, T., Tenorio, E. L., ... & Coles, J. P. (2020). UK-wide surveillance of neurological and neuropsychiatric complications of COVID-19: The first 153 patients. The Lancet Psychiatry.