Slow medicine for the old

Time to "rescue the elderly from standard medical care"? Geriatrician Dennis McCullough says it is in his new book, My Mother, Your Mother. Embracing "Slow Medicine," the Compassionate Approach to Caring for Your Aging Loved Ones. I haven't read the book but the New York Times review makes me want to.

The book is aimed at children and relatives who, McCullough says, are the best medicine--along with a slower, simpler, less expensive, family based approach to medical care. In interacting with the medical system, frail older people need an advocacy team of friends and relatives for protection and moral support.

Among the changes to consider for people at advanced ages: manual breast exams instead of mammography, stool tests for blood instead of colonoscopy, revisiting hypertension medication that works differently in the very old, companionship instead of antidepressants.

Reviewer Abigail Zuger, also a physician, calls the book valuable, "chilling and comforting in equal measure."

The topic is especially timely as we think about our July member meeting. We'll be building on the dialog with discharge planners in January. This time, we'll be considering how family members can talk about "advance directives" that go beyond end of life hospitalization. As McCullough says, hard conversations about topics like when to stop driving and what to do when you can't manage at home anymore need to start early, while the parent is still vital and lively.

It's about anticipatory guidance. The Library Journal's review says that the book will help readers:

—form an early and strong partnership with your parents and siblings;
—strategize on connecting with doctors and other care providers;
—navigate medical crises;
—create a committed Advocacy Team;
—reach out with greater empathy and awareness; and
—face the end-of-life time with confidence and skill

Please let us know your experiences and thoughts about how professionals in aging might help families talk about and plan for all of the transitions from fully independent to needing a wide circle of concern and care!

Ageism and drug safety

The Need for Drug Safety-the Older Person and Ageism grabbed me when it came across my desk through the Badgeraginglist. The listserv is a wonderful source of information for professionals in aging, and the source of many reports the Milwaukee Aging Consortium describes in our newsreel or information links.

Drug safety is not just an abstract good idea to me: it’s personal.

At Christmastime, my 87-year-old mother’s slow deterioration accelerated. It turns out that one of the prime causes was prescription medication toxicity. Another was electrolyte imbalance, a medication side-effect.

I haven’t looked at the bill yet to see what this episode cost in dollars. I won’t try to figure in the days lost from work and from our children for my sister and me. But I have a good sense of what it cost in pain and suffering, not just for my mother but for all of us.

The issue brief from the International Longevity Center-USA points to problems resulting from rapid approval of new medications and the lack of long-term “postmarketing surveillance”—research on what happens to 30,000 users, not just the 3,000 studied before release to the market. In 2007, the report says, the pharmaceutical industry “conducted only 7% of the studies they had promised.”

Drug problems affect older people disproportionately. Only 12% of the population, they use 40% of all prescription medicine. Physiologically, older people process drugs differently. They have the most problems with drug interactions. And yet there is no requirement that older people be included in clinical drug studies.

Report author Robert Butler, MD, uses some strong language: “Because medicines in the United States are disproportionately used by older persons, we must conclude that failures in drug safety are due in part to the belief that older persons, having lived their lives, are expendable. This is a manifestation of ageism.”

The brief calls for significantly increasing FDA funding and power to monitor drugs on the market and in older adults. The up-front cost, Butler says, “will likely save time, energy, and money, not to mention lengthening and improving the quality of lives.”

After a couple months of emergency rooms, hospitalization, skilled nursing facility stays, and rehabilitation, Mom's doing beautifully in an assisted living facility. In fact, she’s doing better than before. I wonder if, had her primary physician been monitoring her better, she could have stayed in independent living. But that’s a moot point now.

We’d love to hear your responses, ideas, experiences. Please comment here or send a message to cmclaughlin@milwagingconsortium.org.

Everybody's doing it: Caregiver help sites

You may have noticed a proliferation of all kinds of websites for caregivers. According to Mass High Tech: The Journal of New England Technology, the surge is partly a response to need--and partly a response to commercial opportunity.

“All of a sudden, it’s like caregivers have money,” said Gail Hunt of the National Alliance for Caregiving. “The baby boomers have to care for their parents, and there’s money to be made.”

Some of the sites, in other words, are all about the advertising.

But folks who run “altruistic” sites with no profit motive can learn some lessons from the often young entrepreneurs who understand social networking. Chief among these: the term “caregiver” doesn’t resonate with Boomers. We don’t see ourselves as caregivers but as family members—or even “baby sitters.” Caregiving is a market with more than one niche.

Realizing that, some sites are including services for the other side of the Boomer sandwich: childcare and tutoring, for example.

One site is called Lotsa Helping Hands. Developed in cooperation with the National Alliance for Caregiving, it has “created 6,000 ‘communities’ for users, mostly networks focused on a specific patient’s circle of caregivers,” according to article author Christopher Calnan.

Sites that list providers often offer a free basic service and charge monthly rates for “premium” services as well as using advertising.

Hunt warns that most of these businesses will disappear like the dot.coms – unless they develop the “Holy Grail:” comprehensive information combined with a database of local resources for users.

In Milwaukee, the Family Caregiver Support Network offers diverse help and information and a social support network for caregivers--for free.

Other excellent noncommercial sites include the Family Caregiver Alliance, and Hunt's organization's website Caregiving.org.

Strength for Caring is a great site owned by a commercial enterprise, Johnson & Johnson.

We’d love to hear about the best websites for caregivers—and what’s needed but not there. Comments and guest blog entries are most welcome!

What's your priority for making communities elder-friendly?

In the newsletter Connections, American Society on Aging (ASA) members identified as their top three policy priorities to make communities more elder friendly:

• 59% Public transportation improvements
• 25% Universal design requirements in building codes
• 10% Walkability mandates in urban planning

Public transportation improvement has been a chronic need for older people in this community since the days of the Older Adult Service Providers Consortium, the Milwaukee Aging Consortium's predecessor organization.

Are those the priorities you'd list, too? What could we do to fix the problems of getting around? We'd love to hear from you.

Some good news about aging societies

There’s an upside to aging societies that most of us haven’t much thought about. According to new information from The Gerontological Society of America published January 25 in ScienceDaily, as a society ages, it loses the taste--and the opportunity--for political violence. (World's Aging Population to Defuse War on Terrorism)

If you look at the Mideast, Iraq, Pakistan, and Saudi Arabia, you’ll see what happens with “youth bulges” in which there are proportionately more young people than usual. The youth bulge creates lots of people with “strong grievances against current political conditions and little stake in society.”

Population age cycles. In about 20 years, an aging, invested population creates political stability and economic development. Think about the US during—and 20 years after—the Vietnam war. You get the picture.

When the population continues to age and stops working, the period of economic development can slow or stop. Then a developed country will likely have to choose between accepting a high level of poverty among the old—or diverting money from military spending to avoid that poverty.

I will leave you to draw your own inferences. But I for one prefer the second option.

Author Mark Haas of Duquesne University says that the aging trend is starting to affect all the most powerful nations. By 2050, Russia’s working age population will shrink by 34%, and China’s median age will be almost 45. Will they choose impoverished old people or reduced military spending?

Apparently, the US will be less affected than China, Russia, Britain, France, Germany, and Japan. “In 2050, this country’s median age will be the lowest of any of the great powers,” ScienceDaily reports. At the same time, “the working age population in the US is expected to increase by 31%.”

While the article doesn’t mention it, I bet that the “youthing” of the US depends partly on immigration.

Makes you look at politics, the future, the economy, and aging a little differently.

Can we please talk about this?

If it’s sex or giving up driving, Mom doesn’t want the conversation.

Death, on the other hand, is okay to talk about, according to a recent Canadian study, The 40-70 Rule, by Home Instead Senior Care.

The title refers to the report’s suggestion that by the time you are 40 or your parents are 70 (whichever comes first), it’s time to start talking—and keep talking--about the hard subjects.

The 40-70 study found that the easiest topics to discuss were end-of-life wishes, living will, health concerns, and legacy. The hardest topics for Boomer children and their parents were independence (when Mom needs to move out of her home), personal hygiene, money, and when it’s time to quit – working, driving, and so forth.

Aside from parents refusing to talk, the main block to the conversation seems to be unprepared and fearful children.

Just how hard those conversations can be, and how little skilled most of us are in having them, is a message we keep hearing.

• At our January Member Meeting, Dialog with Discharge Planners, it became clear that no matter how good a job we do at discussing options at the end of life for advance directives, we haven’t really begun to talk about the shifts before the end. “Don’t resuscitate me” might be a much easier decision than what to do when Mom needs more help. We’ll pursue this topic further at our July 10 Consortium member meeting on Advance Directives. Check the calendar at our website.
  

• Yesterday (January 22), at WALA’s Aging In Place. . . Prepare for Evolution conference with Jim Moore, it was clear that senior housing operators also need to have clearer conversations with residents and family about changes in functioning that call for changes in housing or service.

David Solie’s blog entry, No Easy Way Out, has a wonderful discussion of the conversation problem. Solie is author of How To Say It to Seniors: Closing the Communication Gap with Our Elders.

As my mother approached 90 and despite increasing frailty and her super human responsibilities for my special needs brother, she simply refused any assistance. Every approach was rejected. The best we could do was build support scaffolding around both of them for when “the bottom fell out.”

This went on for years. Airline flights, phone conversations, involvement of other family members, protracted conversations with our family lawyer, meetings with my brother’s case worker, and endless strategy sessions with my wife all ended with the same outcome. It was my mother’s way or the highway.

So we shored up the situation the best we could. Despite my mother’s derogatory objections, we purchased long term care insurance when she was in her late seventies. We petitioned the court so she and I could have co-guardianship of my brother. We got her to sign a Medical Power of Attorney. Then we waited.

His recommendations?

1. Advance as far as you can go based on the personality and the nature of your relationship with the parent.

2. Retest the boundaries of that advance periodically even if they appear initally absolute. You never know when there is some give in the system.

3. Build the best scaffolding you can with what you have.

4. Keep asking yourself this question: What am I responsible for?

5. Draft a “When The Bottom Falls Out” list of the items that will require your management. Print it out and then start making weekly annotations. Your brain works better with a “starter” document. I think just “pre-thinking” about the house, the Medicare forms, the Power of Attorney steps, and so on will give you greater stability in the midst of the actual chaos.

6. Rethink what you know about the final mission of life. Most of what we are seeing in our aging parents is a need to maintain control in a world where all control is being taken away. Nothing is going to change that. It is not a rational need; it is simply a developmental task. We have all lived them in our own lives. The problem with the last one is how deeply it is connected to our family systems. However, knowing its true magnitude reduces the guilt over trying to craft a perfect ending or trying to control things that beyond our capabilities.

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We'd love to hear your comments, as always.

Make sure you can get there from here

A service and support program is only as good as the ability to access it. This concern was raised at the January 16 meeting of the Make It Work Milwaukee Coalition of health and human service providers. Cutting funding for intake and other staff—or not increase staff along with increasing caseloads—can put people in jeopardy. It also can waste the money poured into the program itself.

The Milwaukee County Department on Aging has built some economic support positions into its own budget to make sure that older adults get into and through “the system” without the delays and frustrations that others may encounter.

Milwaukee Journal Sentinel editorial cartoonist Stuart Carlson weighed in on the subject with this cartoon January 15. We’d love to hear from you about your solutions to intake and access problems you’ve encountered!