Diversity & Inclusivity at AAGP 2018 Annual Meeting

Weeks before the 40^th anniversary meeting of the American Association for Geriatric Psychiatry (AAGP) in Honolulu, I received a “Know before you Go! AAGP 2018” email from AAGP regarding recommended attire “due to Hawaii’s year-round warm climate and the local culture”: 

·       for men: button-down shirts and pants/slacks, covered shoes with socks

·       for women: sleeveless dresses/blouses ok, dressy sandals/slides ok

Four days later, AAGP sent a follow-up email apologizing for its error after members pointed out that its recommended attire “was not in step with current customs …nor with recommended practices regarding how to acknowledge, validate, and make welcome individuals who are members of gender or sexual minorities.”

Day 1 

Aside from this misstep, AAGP 2018 appeared to live up to its theme, “Diversity & Inclusivity: Achieving Excellence in Geriatric Mental Health.”  Given geriatric workforce shortages and dry spell of new blockbuster drugs, AAGP sessions covered social determinants of health, positive psychiatry, wellness and recovery, use of community health workers, more collaborative care, technology—less traditional psychiatry with its emphasis on pathology. 

Global Brain Health Research: Collaborative Partnerships to Advance Care and Build Research Capacity - Martha Sajatovic, MD (Case Western) and discussant Vikram Patel, MD (Harvard) discussed power of low-cost interventions such as embedding front-line community health workers in health promotion activities in households to detect depression and medication adherence for chronic conditions. 

Origins, Past, Present and Future of Geriatric Psychiatry - Sandy Finkel, MD, had 10 years of practice as a geriatric psychiatrist when he became the founder and first President of AAGP 40 years ago.  In 1977, Sandy met Gene Cohen, MD, founding Chief of Center on Aging at National Institute of Mental Health (NIMH) about establishing and growing the incipient medical specialty of geriatric psychiatry:  Gene’s focus on research, education and public policy; Sandy’s focus on establishing an organization that would serve as home for geriatric psychiatrists.  In 1978, Sandy founded AAGP by calling a meeting in a hotel suite in Atlanta; within a month, 300 members joined after paying dues at $3 per membership.  In 1993, AAGP began publishing its monthly scientific peer-reviewed journal, The American Journal of Geriatric Psychiatry, with Gene as editor.

In 1978, geriatric patients were hospital patients with personality disorders, Holocaust survivors, state hospital patients (mostly with schizophrenia), African-Americans from Southern origins, homosexuals, people in “old folks homes”, people with impotence (pre-Viagara).  Future geriatric patients might include opioid addicts, prisoners, war veterans, indigent baby boomers, record numbers of unemployed due to changing technology.  To serve diverse populations, clinicians need familiarity with a broad range of topics (alternative medicine, nutrition, sleep, sexuality, religion, ethics, technology). 

Later, Sandy joined a panel that included Elliott Stein, MD, Director of Psychiatry at Jewish Home in San Francisco and past AAGP President. In 1979, Drs. Finkel and Stein published special treatment planning for elderly to integrate DSM-3 clinical criteria to older adults.  

Hula entertainment during Opening Plenary 

AAGP President and University of Hawaii Clinical Professor of Geriatric Medicine Ike Ahmed, MD, mentioned this year AAGP celebrates its 40^th anniversary and merger with Geriatric Mental Health Foundation into a single non-profit organization under 501(c)(3). AAGP President-Elect Melinda Lantz, MD (Mount Sinai, New York) delivered Plenary Address focused on search for empathy:  patients are often wiser and empathic than we are; we start out life with empathy, especially first year medical students but then empathy declines in 3^rd year when they start wearing white coats; role models are best example, need to promote and embrace diversity to enhance empathy; barriers to empathy in clinical practice are technology (email, LCD screens) and multi-tasking to keep away distraction.  Solution is communication, face-time, and elevate empathy leaders. 

Reception in Great Lawn – live band, finger foods and sunset.

Day 2 

Breakfast Symposium: LTC for Patients with Parkinson Disease Psychosis (supported through unrestricted educational grant from biopharmaceutical company). 

Meet Me Where I Am: Expanding the Reach of Mental Health Services with Home and Community-Based Services -  Older adults with mental health issues are less likely than younger adults to present for care in specialty mental health clinics, due to barriers such as stigma, transportation, accessibility and motivation to engage. Yet the negative effects of untreated mental health problems in later life call for the use of alternative treatment models that meet older people where they are.

• Renee Pepin, PhD (Dartmouth) presented Tele-Visiting for Home-Delivered Meals Clients, or use of video technology to deliver psychosocial interventions to Meals on Wheels clients.

• Kimberly Van Orden, PhD (University of Rochester) presented Participation in The Senior Corps as Mental Health Promotion, targeting social isolation.  According to the interpersonal theory of suicide, people die by suicide if there is both desire (thwarted belongingness, perceived burdensomeness) and capability.  Increased social connections can lower risk for suicide by changing perception; her study looked at peer companionship through The Senior Corps, a low-cost intervention that was associated with reduced perceived burden, depression and anxiety.
• substitute for Jo Anne Sirey, PhD, on SMART-MH: Reducing Depression and Suicide Risk by Integrating Brief Therapy into Senior Centers of NYC, with outreach and service delivery (brief needs assessment using PHQ-9, GAD-7, Suicide risk; referral; offer brief psychotherapy ENGAGE to adults with significant depression or suicidal ideation) to meet needs of older adults in aftermath of Superstorm Sandy.

 

• Discussant Martha Bruce, PhD (Dartmouth) showed prevalence of major depression and rates of antidepressant use among older adults across the continuum of care.  She spoke of expanding intervention targets and strategies to address complex biopsychosocial needs and circumstances (translational science), and improving access for vulnerable older adults by taking advantage of existing service infrastructure and workforce for screening, assessment, intervention and referrals (implementation science).  She reviewed Penchansky's and Thomas' 5 A's of Access to Care: Affordability, Availability, Accessibility, Accommodation; and Acceptability.

Plenary: Universal Mental Health Coverage Realizing Aspiration of Sustainable Development Goals, Sociocultural Determinants and Treatment of Mental Disorders - Vikram Patel, MD, said he traveled 36 hours from New Delhi on his first trip to Hawaii! He reviewed WHO Sustainable Development Goal 3 for health targets (improve mental health and well-being, prevention and treatment of substance abuse, achieve universal health coverage) and WHO mhGAP Intervention Guide Version 2.0 (2016) .

Vikram showed this “reality” graph illustrating divide between low-middle income countries and high income countries, in both mental health care spending and people diagnosed with depression who receive treatment.  The majority do not access quality mental health care.  The solution is not putting more money into the problem, but innovating to address barriers:

·       human resource gap: Vikram, author of When There Is No Psychiatrist: A Mental Health Care Manual (2003), wants to train members of communities (community health workers, paraprofessionals, peers) to give mental health interventions, empowering ordinary people to care for others; this task-shifting to low cost health workers would be supervised by specialists to optimize efficiency.

·       treatment gap: deliver at home; self-management; e.g., home care project for dementia uses non-pharmacological intervention, preventing depression in late life (DIL) uses lay health counselors.

·       credibility gap: prioritize patient needs; care not contingent on diagnostic labels; engage with personal and community resources; address social determinants by incorporating social work elements with mental health interventions.

He called for a collaborative care model, involving a case manager who coordinates patient care with primary care provider team, psychiatric/behavioral and medical team to optimize quality.

Lunch Symposium: New Options for Old Problem: Tardive Dyskinesia Assessment and Treatment in Older Adults (supported through independent educational grant from biopharmaceutical company).

Sociocultural Perceptions of Normal Aging—A Review and Media Presentation - Discussant Francis G. Lu, MD (UC Davis) (cultural formulation) with Ali Ashgar Ali, MD (Houston)(perceptions of aging more positive in Asian cultures; characters defy stereotypes in The Best Exotic Marigold Hotel) and Kristin Jones, MD (Baylor)(social constructs influence opportunities of Sadie and Bessie in Having Our Say: The Delaney Sisters First 100 Years).

Early Investigator Poster Session and Exhibit Hall Reception 

Author George T. Grossberg, MD, autographed free (thanks to pharma company exhibitor) copies of his book, Psychiatric Consultation in Long-Term Care (2010).

Embracing Hawaiian Culture: Applying Traditional Hawaiian Values to Modern Ethical Decisions, presented by Joseph Dragonetti.

Physician Aid in Dying: Overview of Current Legal Status in the U.S. and Issues Pertinent to Geriatric Psychiatry, presented by Sarah Kleinfeld.

Social Work Shortage: Can a Resource Packet Bridge the Gap in Care? presented by Chelsea Pluta.

Day 3

Positive Psychiatry in Geropsychiatric Clinical Practice: in Schizophrenia, Cognitive disorders, and Affective disorders - Chair Dilip V. Jeste, MD of UCSD introduced discussion on positive psychiatry, which is the “science and practice of psychiatry that seeks to understand and promote well-being through assessments and interventions aimed at enhancing positive psychosocial factors among people who have or are at high risk for developing mental or physical illnesses.”  Positive psychiatry views mental health and illness as existing along a continuum (“wellness within illness” is possible).  While traditional psychiatric treatments (psychotherapy, psychopharmacology) focus on correcting deficits (checking off symptoms for insurance claims), positive psychiatry focuses on building strengths to promote wellness and recovery.  In positive psychiatry, there is partnership with patient who is empowered to actively engage in intervention (“this is your care”).

Ellen E. Lee, MD, of UCSD presented on Childhood Adversity and Schizophrenia: Role of Resilience.  Her research found that psychological resilience in adulthood appeared to counteract the negative effects of childhood adversity on mental and physical health in both adults with schizophrenia and non-psychiatric comparison adults. 
People with schizophrenia experience earlier onset of aging-associated pathological changes (e.g., insulin resistance, immune activation, inflammatory syndrome, larger brain ventricles), as well as 2-12 times higher mortality, and 15- to 20-year shorter lifespan. 

Resilience is the ability to adapt positively to, or to recover readily from, adversity; it is associated with medically desirable behaviors (self-care, treatment and exercise adherence), better health outcomes (emotional health and well-being, less pain, better physical health) and greater longevity.  People in their 90s who endorsed higher levels of resilience had 43% higher likelihood of living to 100 years. 

Resilience-enhancing interventions include Stress Management and Resilience Training (SMART based on adaptation of attention and interpretation theory), Mindfulness-Based Stress Reduction (MBSR based on meditation, mindfulness, guided imagery and hypnosis), and novel biological interventions (training to modulate one’s own brain activity with real-time MRI-based neuro-feedback). 

Here are 10 steps to Resilience, from Resilience: The Science of Mastering Life's Greatest Challenges (2012) by Steven Southwick and Dennis Charney:

1.   Positive attitude (optimism)

2.   Cognitive flexibility (reframe, assimilate, accept, recover; failure is essential for growth)

3.   Personal moral compass (set of core beliefs)

4.   Role model (imitation is powerful mode of learning)

5.   Face your fears (fear is normal, facing fears can increase self-esteem)

6.   Develop active coping skills

7.   Establish and nurture supportive social network (very few can “go it alone”, considerable emotional strength accrues from close relationships)

8.   Attend to physical well-being (exercise)

9.   Training (discipline and practice)

10.Recognize, utilize and foster your strengths (engage character strengths to cope with stress)

Brenna N. Renn, PhD (Seattle) explained depression as ineffective problem-solving that leads to poor coping, low self-efficacy and negative emotions.  She described a 10-week, 7-step Problem-Solving Therapy (PST) that slows down frontal lobes:

1.   Problem definition: reframe “a problem well-stated is a problem half-solved”

2.   Goal setting

3.   Brain storming: break negative spiral

4.   Considering pros and cons

5.   Decision making

6.   Action planning

7.   Evaluation

Taya Varteresian, DO of Los Angeles, presented on Complementary Alternative and Integrative Medicine (CAIM) & Whole Medical Systems.  At $33.9 billion, CAIM accounts for about 1.5% of total health care expenditures, and 11.2% of out-of-pocket health care expenditures in U.S.  Mind-Body medicine, such as yoga, meditation (Kirtan Kriya is user-friendly for older people), natural products and supplements (adaptogens such as St. John’s wort, SAMe, melatonin, etc.), have potential to enhance resilience to stress by rebalancing autonomic nervous system (increasing parasympathetic and decreasing sympathetic output, increasing GABA levels), decreasing inflammation, changing epigenetic and gene expression, and by direct neuroplastic effects on the brain.  She also discussed value of interdisciplinary team (social workers, case managers, RNs, geriatricians, psychiatrists) and benefits of geri-psychiatry home visits (removing stigma of visiting mental health clinic, gaining knowledge of home environment). 

Plenary: Cultural Neuroscience by Joan Chiao, PhD read through power point presentation just under 30 minutes, followed by a few questions and brief answers … then we were out early for beach time 😊. 

Aging and Post-Intensive Care Syndrome (PICS): The Burden on Older ICU Survivors and Their Families based on article published in February 2018 issue of The American Journal of Geriatric Psychiatry, by Chair Sophia Wang, MD, and colleagues from Indiana University—Babar Khan, MD, Noll Campbell, PharmD, and You Na P. Kheir, MD.  Highlights:

·       More than 50% of Intensive Care Unit (ICU) admissions are patients age 65+ and 70% of them develop delirium.  Due to rapid improvements in ICU care, survivorship from critical illness is “now the defining challenge of critical care medicine” as ICU survivors may develop long-term cognitive, psychological and physical impairments from their critical illness—aka PICS, which is more likely to affect older adults.

·       Only about 50% of all older adult ICU survivors have functional recovery after their critical illness, with median recovery time of 3 months and increased need for support outside the hospital.  Higher body mass index and functional self-efficacy associated with better post-ICU recovery.  Physical disability was significant contributor to depression at 3 and 12 months after ICU hospitalization.

·       Risk factors for ICU-acquired long-term cognitive impairment (LTCI) in older adults include neurologic dysfunction, infection or severe sepsis, and acute dialysis.  Yet evidence does not strongly support that older adults at higher risk than younger adults for LTCI. 

·       Depression, anxiety and post-traumatic stress disorder (PTSD) are mental health impairments in PICS.  However, patients who develop critical illness may be more likely to have premorbid psychiatric illness, compared with those hospitalized in general wards and the general population.

·       ICU-related risk factors for PICS-Family impact include perception of patient being very near death, unexpected/sudden patient illness, family members with greater levels of anxiety and depression about ICU hospitalization, and poor communication between family members and ICU physicians.  Interventions for PICS-F include diaries and educational materials; condolence letters written to family members may actually worsen their depression and PTSD-related symptoms.

·       Indiana University’s Critical Care Recovery Center, first dedicated post-ICU survivor clinic in the U.S. created in 2011, uses innovative collaborative care model (including family conference, recovery care coordinator follows to outpatient setting) that has been shown to be successful in older adults with dementia and late-life depression.   

Improving Mental Health Care Access, Engagement and Delivery among Diverse, Underserved Populations: Collaborations from Geriatric Mental Health Services Research T32 Postdoctoral Fellowship - Mentor Steve Bartels, MD of Dartmouth noted that older adults age 65+ with mental health or substance use disorder receive inadequate care: only 10% receive any treatment, and mere 1% receive specialty mental health services.  

Accurate and effective implementation of research-based practices takes 17 years!

People with serious mental illness, about 6% of the U.S. population, have one of the greatest health disparities of any group, with a life expectancy up to 25 years less than the general population from complications of unhealthy risk factors that may be preventable. Fellows presented data on disparities in mental health care and then addressed the diverse, complex mental health needs of older adults through adapting evidence-based prevention and self-management programs to improve effectiveness and uptake:

·       Chair Daniel Jimenez, PhD (Miami) on Happy Older Latinos are Active (HOLA), multicomponent health promotion intervention to prevent anxiety and depression in older Latinos.

·       Mijung Park, PhD (UCSF) on Family-Centered Care for Older Adults with Multiple Chronic Conditions (FACE):  Adding family components to Collaborative Care Model for Older Adults with depression and chronic medical conditions.

·       Matthew Lohman, PhD (SC) on Hospitalization Risk with Potentially Inappropriate Medications.

·       Karen Whiteman Fortuna, PhD (Dartmouth) on PeerTECH: Peer-Delivered and Technology Assisted Psychiatric and Medical Illness Self-Management for Adults with Serious Mental Illness. 

Improving Competency in the Care of the Older Transgender Patient: A Case Study with On Lok social worker Wing Yee Wong, MFT from San Francisco.  I mentioned that I referred a homebound transgender woman client to On Lok, and then realized this client was the subject of her poster! Small world.

Day 4

AAGP Advocacy: Strengthening Our Mission in Geriatric Mental Health - Ilse Wiechers, MD, Chair of AAGP Public Policy Caucus, provided advocacy tips.  Becky Yowell, American Psychiatric Association (APA)  Regulatory Policy Deputy Director, delivered Legislative and Regulatory Update:

·       Federal legislative successes (Comprehensive Addiction and Recovery Act, 21^st Century Cures, Defeat of ACA Repeal/Replace Legislation); budget deal; Medicaid work requirements (Section 1115 waivers); opioid epidemic (funding, legislation); substance use disorder confidentiality (42 CFR Part 2 reform); Mental Health Parity; telehealth/telepsychiatry (CHRONIC Act, CONNECT for Health Act, Veterans E-Health and Telemedicine Support), workforce development (Resident Physician Shortage Act).

·       State legislative issues: scope of practice; network adequacy; mental health parity; Medicaid (funding, expansion, physician reimbursement); medication access (prior authorization, step therapy); access to telemedicine/telepsychiatry; state opioid epidemic measures (PDMP reporting); inpatient/outpatient involuntary treatment; criminal justice (“drug courts”, solitary confinement); maintenance of certification; tort reform; state suicide prevention/anti-bullying initiatives.

https://engageforchange.org/

Cultural Competence in Palliative and End-of-Life Care: Understanding Your Patient’s Context - Chair Greg Sullivan, MD provided introduction on History of Cultural Competence in EOL Care (person-centered care, AAGP’s Best Practice Highlights for Treating Diverse Patient Populations) and Symptoms at EOL (meanings of pain).

Patricia W. Nishimoto, DNS, self-described Iowa farm girl who moved to Hawaii to work as oncology nurse, presented on The Magic of Expressive Arts in Palliative Care and Cultural Complexities.  Her presentation, illustrated with photos of patients, asked us to consider:

·       Cultural curiosity approach when interacting with patients: listen with humility, ask respectfully about their beliefs, and view world through their cultural lens.

·       Conflict is more about emotions than factual misunderstandings. 

·       Role of family: who makes decisions? Who’s included in discussions? Is full disclosure acceptable?

·       Verbal communication: if insulted when offered interpreter, explain interpreter is for medical, not language; do not ask, “do you understand?” instead ask them to repeat information back to you.

·       “Difficult” usually means there are unmet needs.  Look for red flags: repeat visits without resolution of problems; demanding; dependent; manipulative; stubborn; nonadherent; power struggles; self-destructive behaviors; focus on seemingly unrelated issues.

·       Self-reflection: how you identify racially, ethnically, and culturally? When were you first aware of your own culture? What is the first memory you have of someone dying in your family? What were the rituals, practices or behaviors that your family observed at that time? What aspects of your cultural background do you feel strengthen your caring for dying patients and their families?

Matthew W. Warren, MD (Tampa) presented on End-of-Life Issues for Non-religious Patients:

·       Informed patients are less likely to receive invasive procedures or die in ICU

·       Existential distress (mortality, freedom, meaninglessness, isolation)

·       Sigmund Freud: death is the aim of all life; death cannot be feared since it has never been experienced

·       Existential psychotherapy: Choron’s 3 types of death fear (what comes after death, event of dying, ceasing to be); competing death defenses (schizoid=independent of all control, passive-dependent=give up all control); death as opportunity (rearrange priorities, enhanced sense of living in present, deeper communication with loved ones); awareness (ultimately no escape from death, face life alone, ultimate responsibility for way one lives); activities that provide sense of life purpose (altruism, dedication to cause, creativity, hedonistic value, self-actualization, self-transcendence)

·       Atul Gawande’s Being Mortal: Medicine and What Matters in the End (2014)

·       Irvin Yalom’s Staring at the Sun: Overcoming the Terror of Death (2009)

·       Approach: start conversations using patient’s own words; clinician may ask, “are you at peace?”; allow patient to retain sense of dignity (show interest, allow choice, respect privacy); assess how much patient would like to know; engage in conversation about hope (legacy potential); address patient’s preferred “place of death” (only 1 in 3 patients in U.S. die at home)

Kenneth M. Sakauye, MD, presented on Cultural Competency in Palliative Care about a mandatory month-long, pass-fail Geriatrics-Palliative course at University of Tennessee.  APA Council on Aging has 3 cultural competency guides, updated about every 10 years:

·       APA Culture, Heritage and Diversity in Older Adult Mental Health Care (expected 2018; Maria Llorente, Chair)

·       APA Ethnic Minority Elderly Curriculum (2006; Ike Ahmed, Chair)

·       APA/AAGP Curriculum Resource Guide for Cultural Competence (1997; Kenneth Sakauye, Chair) 

Managing Behavioral Health Needs of Older Adults in the Emergency Department -- According to WHO in 2016, an estimated 15% of adults over age 60 are living with a mental health disorder.  Hospital Emergency Departments (EDs) are often on the frontlines of mental health crises, and may be overwhelmed.  

Laurel J. Bessey, MD (Madison) provided an overview of substance use disorders (alcohol, illicit drug, opioids), depression (affects 3-7% of older adults, 1/3 of older adults seen in ED screened positive for depression) and suicidal ideation (older adults accounted for 16% if all suicides, though only 12% of adult population), anxiety (most common psychiatric symptom affect 15% in community populations) and panic in older adults in ED.

Rebecca M. Radue, MD (Madison) provided an overview of psychosis (most common etiologies are dementia and delirium), agitation (common, life threatening emergency; non-pharmacologic interventions include warm blanket, get down to patient’s level, provide nourishment, use calm voice and short, simple phrases, validate).  Management principles call for trying non-pharmacologic strategies first; then if pharmacologic strategies are needed, use lowest possible dose, consider black box warnings and avoid benzos in delirium.

Discussant Lisa Boyle, MD (Madison), asked Brent Lu, MD, about the situation in Hawaii, which he described as challenging due to shortage of mental health services and geriatric psychiatry beds for older adults, reluctance of long-term care facilities to admit psychiatric patients, caregiver burnout, etc. – resulting in increased reliance on emergency services often involving law enforcement. 

Lisa noted to consider context of local policies; for example, Wisconsin has restrictive involuntary mental health statute that requires “treatable mental illness”—some interpret Alzheimer’s as not treatable so no access, and people end up in jail due to misunderstanding that no cure, but can treat to alleviate suffering; psychiatrists do not have final say in emergency detention, but defer to county crisis worker and police.

Death Café + Dementia Care

People with mental disabilities, including dementia, often get “stuck in place” or confined in locked facilities and out-of-sight from the broader community.  As a gerontologist, I have sought to gain experience at each level in the continuum of care: aging in place, family care, senior centers, adult day care centers, home care, retirement and independent living communities, and assisted living.  As new staff in an assisted living community, I did a stint in “memory care”/locked facility floor (residents with varying levels of memory loss mixed with other residents who were high functioning but somehow determined to need higher level of care than assisted living), which I found oppressive so immediately ended that not-to-be-repeated experience.  Imagine if I had been a resident on that floor, I’d be dead due to transfer trauma. 

I suspect transfer trauma contributed to my grandmother’s death shortly after she moved into a nursing home for dementia care. Before my grandmother’s death, I never gave any serious thought to anything beyond aging at home.  After all, filial piety was ingrained in my Chinese immigrant family so it was assumed family members took care of one another at home.  In my previous career in banking, my high net worth clients could afford live-in home care to support aging at home.  But people have always moved for mobility, so Hawaii’s Brain Drain makes it harder for offspring living outside Hawaii to be physically present to provide care to parents aging in Hawaii.

During my visit to Honolulu last fall, I attended a workshop taught by Dorothy Colby, certified Positive Approach to Care trainer, but did not have time to tour the memory care home where she is administrator.  In the AAGP 2018 Annual Meeting Schedule, I noticed Dorothy was scheduled to present Challenging Behaviors in Dementia Care: Recognizing Unmet Needs – A Positive Approach to Care Seminar. 

Honolulu is a small town as I ended up meeting Dorothy when we both showed up at 11^th Death Café Honolulu, organized by Leilani Maxera, whom I met during HPGS conference over three years ago.   

At Death Café, participants drink tea, eat cake, and discuss death with “aim to increase awareness of death to help people make the most of their (finite) lives.”  

As contribution to potluck, bought Leonard’s Bakery malasadas coated in plain sugar, li hing mui and cinnamon. 

Over two hours, we enjoyed potluck treats while covering a broad range of topics from UH Willed Body Program, sea burials, Death Over Dinner, death doulas, hospice volunteering,… 

reactions to facing death during false missile threat, Jewish death rituals, films about death, Philip Roth's Patrimony, aid in dying, etc.  Always good to know options!  Most attendees were women, who are leading movement to bring back home funerals! 

After reconnecting with Dorothy at Death Café, I visited Hale Ku’ike for a morning tour with Dorothy and Community Relations Director Scott Gardiner.  There were 26 residents, mostly female, with average age 91 years.  

View of courtyard from inside common area 

Namaste Care room 

Sorting/folding laundry table 

Access to outdoors with labradoodle named Pepper

Other home-like design features: human-scale, picture windows that bring in natural sunlight, laminate flooring, memory boxes outside room doors, greenery, spacious common area, etc.  During morning tour, all residents were congregated in common areas while resident room doors were left wide open (no photos allowed).  Monthly cost of private room is $9,770, and semi-private room is $8,110.  Instead of TV watching, daily schedule of activities include:

Hale Ku’ike Nu’uanu Club

7:30 am BREAKFAST (protein, starch, fruit, skim milk, fluids)

8:30 am Volunteers at Work and Gardening (includes sorting activities and other meaningful “work”, taking care of outdoor planter boxes)

9:30 am Morning Greeting Songs (singing Star Spangled Banner, Hawaii Ponoi, God Bless America to open up day)

9:35 am News and Views (current events, seasonal talk, horoscopes, weather, etc.)

9:45 am Eldercise (exercises focusing on range of motion, flexibility, mobility, strength and balance)

10:30 am Morning Garden Walk

10:45 am SIT & SIP (AM snack: fruit slices, water)

11 am Morning Surprise (changes daily: food trivia, remanence time, armchair travel, special entertainment, etc.; Tuesdays Tai Chi at 11:15 am)

12 noon LUNCH (meat, vegetable, soup, starch, fluids)

12:45 pm Games People Play (small group activities include variety of cognitive exercises and table games; Mondays Song & Dance with Nalani at 1:45 pm)

2 pm Fun & Games (physical activities focusing on fun & fitness)

3 pm CHAT & CHEW (PM snack: fruit slices, water)

3:15 pm Afternoon Delight (group activities with occasional holiday specific ones; 2^nd, 3^rd & 5^th Friday with Pastor Dan at 3:30 pm)

4:15 pm Brain Teasers or Music Moments (cognitive word games, trivia, sing-a-longs)

4:45 pm Evening Garden Walk (outdoor walk before dinner to stimulate senses)

5 pm DINNER (meat, vegetable, starch, skim milk, low-fat dressing/butter, fluids)

6:30 pm Evening Cinema

BEDTIME SNACK (skim milk, water)

As an introvert, I need quiet time to doodle which is best done in solitude and not group setting.  For people who are religious minorities (e.g., Jehovah’s Witness or Jewish), participation in singing patriotic/nationalistic songs, horoscopes, and holiday activities would be uncomfortable.  In person-centered care, these preferences should be respected.

Aging in place

According to AARP, nearly 90% of adults age 65+ want to stay in their current home and community as they age, which is associated with maintaining independence, autonomy, and social connections in their neighborhoods and community. The benefits of a community of strong connections, which require time to develop, come from the fact that it is rooted in place, such that people have a relationship with a place they call home, which is “integral to their identity and well-being, and to their cultural and political values,” as noted by Naomi Schoenbaum, in “Stuck or Rooted? The Costs of Mobility and the Value of Place,” Yale Law Journal (October 30, 2017). 

However, many homes may not be designed to accommodate the needs of aging residents.  During my visit, Honolulu Mayor Kirk Caldwell signed a moratorium on monster homes while Hawaii legislature considered mandating visitability standards on publicly funded housing (SB 2594).  Aiyah! Because my parents’ privately funded, custom designed home includes many visitability features, such as wheelchair accessibility, it is a spacious monster home intended for my parents to age in place.  My parents completed their accessible home nearly 15 years ago—long before LineSync’s Wheel Pad came into the picture.