Is it a 'senior moment' or something to worry about?

More and more I find a blank spot where a word, a name, a book title, or a phone number should be. Even though I have been a student of all manner of dementias  and brain dysfunction, there's a little voice inside my head that wonders, "Is this the beginning of something progressive and very depressing?" I reassure myself that I"m over-tired, stressed, or multi-tasking too much, but to be honest, the reassurances aren't very successful. I double up on brain apps on my phone, workouts with my trainer and organic vegetables--all in the hopes that the next time I lose something like a word, my cell phone, or my car keys, I'll find them in a second instead of spending the next few hours trying to remember what the name of that song was I loved back in high school. The worry persists.
I found some reassurance lately, thanks to a recent white paper on memory issued by Johns Hopkins University School of Medicine. (www.johnshopkinshealthalerts.com/alerts_index/memory/23-1.html) The author, Dr. Peter Rabins writes (a) "reassuring difference between normal forgetfulness and dementia is that people who worry about memory loss are unlikely to suffer from a serious memory condition. By contrast, people who do have a serious memory impairment tend to be unaware of their lapses, do not worry about them, or attribute them to other causes."
Okay, I do use that "not-enough-sleep, too-much on my mind" excuse a little too much. At what point should I or any of us start to think about seeing a doctor? Rabins states, "If there are activities that a person has always done but now has difficulty doing, then it's time for a professional assessment."
To Rabins' point, I thought about talking to my primary care doctor about the fact I can't stay up all night like I used to always do when the need arose, but I have a feeling he'd lecture me again about the importance of getting  7 or 8 hours of sleep. (It's a good goal, but I haven't gotten that much sleep since I hit puberty unless I was recovering from surgery and/or anesthesia.)  To give my doc credit, Rabins says the best way to maintain cognitive health is to exercise, get more sleep, lower stress and eat a lot of fresh fruit and vegetables.  Maybe he reads my doctor's chart notes. Rabins adds that people should do more things they enjoy both socially and intellectually.  We should definitely  do all of these good things anyway, but life keeps getting in the way.
In the mean time, if you are seriously concerned, there are several nice little short quizzes available. Check out the five quick Alzheimer's tests. (http://www.alzheimersreadingroom.com/p/test-your-memory-for-alzheimers-5-best.html). I would have taken at least one of them myself but I had a lot of other pressing things I needed to do at the time so decided I would do it later. Then I forgot.

Forbidden Subjects

   This past week a family I know made a very tough decision to discontinue aggressive medical intervention for a son/husband/father. He wasn't old. He didn't have multiple chronic diseases. His family had informed themselves with good information about the outcome of his injury, knew what their loved one who could no longer speak for himself would want and then acted accordingly. The selflessness of this choice and the compassion with which it was made inspired me to once again press all my friends, family and residents to have what is often perceived as a very difficult conversation.
   The Center for Medicare/Medicaid requires skilled nursing facilities to complete documentation of person's wishes to receive or refuse certain kinds of treatment (tube feedings, cardiopulmonary resuscitation, etc.). We have to ask and complete what is called a POLST form. The problem is that the form is only as good as the conversation that accompanies it. After forty years, I'm pretty sure many people do not fully understand what they may or may not be choosing.  I'm also convinced that these forms, which can serve as physician orders and travel with a person to the emergency room or hospital, are reviewed often enough.  As many in the health care field know, clinicians may also find it difficult to be candid about probable outcomes and effectiveness of aggressive interventions in cases of multiple disease processes, metastatic cancers and advanced age. It's no secret that 90% of our health care dollars are spent in the last thirty days of life.
   Why is our culture so opposed to talking about one of what my grandmother called the only certainties in this life, "death and taxes?" None of us likes to think about the end and no one who loves us likes to think of the world without us. There is a flip side.  As I mentioned in my last blog, it's a very small group that get to be healthy until they go to sleep and don't wake up.  Talking to my husband this morning, I asked him again what he might want.
"Well, if I knew my time was short, I wouldn't want aggressive medical procedures."
"How about if you had an unanticipated stroke that left you unable to walk, get yourself to the bathroom or swallow?" I asked.
"No, I draw the line at someone having to take me to the bathroom or clean me up."
"What about if you could get around but were in middle or advanced stages of dementia?"
"I wouldn't want that either."
    My point with my husband is that it is easy to project what we might want if we know the end is near, but so often, our families are left to figure things out when an unexpected crisis occurs. My husband is in terrific health and jogs several miles a day. He would expect full resuscitation and likely get it if he collapsed out on a run. He also will be 79 on his next birthday. As each year passes, the chances that he will continue to enjoy exceptional well-being diminish. If we don't review his choices periodically, he will also have full measures ten years from now when the outcome might not be what he desires.
   Unlike my husband, I already have succumbed to several chronic diseases for which there is treatment but no reversal. Being in health care, I have made my wishes clear to my family for three decades. I've seen how CPR turns out most of the time. As a recent editorial in The Journal of Post-Acute and Long Term Care Medicine states, "The public's impression of the success rate of CPR (and the kind of shape people are in after receiving it), thanks in large part to the entertainment industry's portrayal of it, is wildly optimistic." (K.E. Steinberg, JAMDA, 15 (2014). 455) People who have observed videos of actual CPR being performed-even on a manakin-often change their minds about electing for it.
   Unfortunately, some people feel that if they say they don't want us to try to save them after they stop breathing, their heart stops or they can no longer swallow, we won't try to fix anything. That isn't the case. Even if you are declining all the life-prolonging options, we will still prefer to treat those things we can reverse. That gets confusing for families. When my husband's father who was in the late stages of dementia developed a urinary tract infection, we treated it. My mother-in-law was unhappy about this, feeling she had been specific about his wishes. I explained that although this might prolong his life a little, not treating it would make him most uncomfortable, so why not make his remaining time as pleasant as it could be.
    There are people that can help you  understand what your options are. They can help your family understand. But nothing can take the place of your candid conversations with your kids, your spouse, your closest friends. It will assure that the right decisions honoring your wishes are made when the time comes without terrible stress on those who must make them if you can't. And let's be realistic. As I heard an Englishman say on television years ago, "America is the only country in which people think death is optional." It isn't.  Do advanced care planning. You can always change that plan with good information from your doctor and/or your personal preferences. Have those forbidden conversations today.

Do We Really Need Nursing Homes?

The August edition of McKnight's Long Term Care News reports Sen. Tom Harkin (D-IA) unveiled a bill to direct more Medicaid funding to home and community-based health care and away from nursing homes. You might think that considering my job, I'd be against this but I'm all for people being able to be where they want and I've yet to meet anyone who says "I want to be in a nursing home." But if you've ever been in the position of being told you are to be discharged from the hospital in two hours on a Friday afternoon with no one at home to help or medical treatments more complicated than once a day....well, there you are. You are glad we're here or if not glad, a little relieved and hoping it isn't going to be some nightmare of dark halls, bad food and people crying for help all night.
Usually after a day or two of adjusting to the idea and learning our goal is your goal, to get you home as quick as possible, you realize it isn't at all what you feared. Some people even find it less difficult than being in the hospital and certainly more entertaining.  Here's the rub. 'Back in the day' as we say, your hospital stay would have been two to three times longer. Nursing homes changed their roles in communities when Medicare encouraged us to provide those extra days you would no longer be having in the hospital because skilled nursing care is less expensive  We became facilities that could provide less urgent hospital services at 1/3 the cost.  It was and still is a pretty smart way to stretch our tax dollars.  The same services at home would be cost prohibitive.
We seniors are not going to let anyone mess with our Medicare, or at least not if we know about it, but Senator Harkin was talking about Medicaid, wasn't he? So that's a whole different matter. Those residents of nursing homes who don't have hundreds of thousands of dollars and/or have needs too complex for families, assisted-living facilities or adult family homes, those people who no longer have assets to divest or incomes to invest--those people should, according to Harkin, get their care at home or at an out-patient clinic.
Remember when we 'deinstitutionalized' the chronically mentally ill, only to learn that they didn't get care at home or at out-patient clinics? They live under bridges. But that's a subject for another time.
This is today and the health care crisis in this country gets ever more terrifying. My advice is borrowed from the poet, Robert Frost, "Provide! Provide!" Frost was not a man to use exclamation points liberally.
It's clear that unless we get informed and politically active, we'd better get serious about maximizing our health.

•  It's not too late to eat better food. Take advice from Michael Pollan, "Eat real food, but not too much." Real food tastes great when it hasn't traveled very far so support your local farmers.
• Work on your balance. A lot of long stays begin with a fall. Strengthen your core. Do some dynamic movement. Try yoga. Studies find dancing is great for balance. And if you can't dance, rock out in your chair. Other researchers found this to be excellent for core strengthening. 
• Work on your brain. It gets stiff if you don't challenge it. There are some very senior brain strengthener apps for iPads and other tablets. I'm doing Luminosity every day. I'll let you know if it isn't working. 
• Make new friends and keep the old ones. Social support does more than you can imagine in keeping us healthy and independent. If you have trouble finding new friends, come volunteer at the nursing home. You'll have a whole large family before you know it

We can all hope for a day when nursing homes are no longer needed, a day when we live full productive lives into our hundreds and then simply lie down and pass away. At least, that's what I hope for as I navigate my 'golden years.' But diverting more funding away from the services we provide won't be adequate to the costs in tax dollars and, even more importantly, human suffering. It isn't a real solution. It panders to that clear feeling all of us have that, "I don't want to end up there." Keep yourself informed. They are arguing about our future.
Until next time,
Andy