Lifelong learning

“Regarding people as having lives of equal worth means recognizing each as having a common core of humanity. Without being open to their humanity, it is impossible to provide good care to people…To see their humanity, you must put yourself in their shoes. That requires a willingness to ask people what it’s like in those shoes. It requires curiosity about others and the world beyond…

We are in a dangerous moment because every kind of curiosity is under attack…This is what happens when the abiding emotions have become anger and fear. Underneath that anger and fear are often legitimate feelings of being ignored and unheard—a sense, for many, that others don’t care what it’s like in their shoes. So why offer curiosity to anyone else?

Once we lose the desire to understand—to be surprised, to listen and bear witness—we lose our humanity. Among the most important capacities that you take with you today is your curiosity. You must guard it, for curiosity is the beginning of empathy. When others say that someone is evil or crazy, or even a hero or an angel, they are usually trying to shut off curiosity. Don’t let them. We are all capable of heroic and of evil things. No one and nothing that you encounter in your life and career will be simply heroic or evil. Virtue is a capacity. It can always be lost or gained. That potential is why all of our lives are of equal worth…”

—Atul Gawande, MD, MPH, “Curiosity and What Equality Really Means,” The New Yorker (June 2, 2018) 

In this month’s National Resource Center for Engaging Older Adults webinar, 

engAGED: Increasing Social Engagement through Lifelong Learning, National Resource Center for Osher Lifelong Learning Institutes (OLLI) presented OLLI members' top interest topics, in this order: history, fine arts, current affairs, literature, religion and philosophy, and health and wellness.  With my insatiable curiosity (like Albert Einstein, who said, “I have no special talent. I am only passionately curious”), my idea of recreation is leisurely lifelong learning. As I go about my existence as a lifelong learner-gerontologist, I am always scouting for activity programming ideas to bring to older adults at their residential community or scheduled outings. 

Fine arts

Sixty Plus—OLLI at SFSU’s Theater Showcase previewed upcoming productions from local theater companies:

·       Golden Thread Productions: Founding Artistic Director and SFSU alumna Torange Yaghiazarian introduced Melis Aker’s Field, Awakening with its main character reuniting with friends from high school on the eve of the 2016 attempted military coup in Turkey.  Liked line, “You get to do what you wake up for,” but trigger alert for lot of “f-ck” word in script. 

·       San Francisco Playhouse: Patron Services Manager Tiiu Rebane sang title song from Stephen Sondheim’s Saturday in the Park with George and “Maybe this Time” from Cabaret.  She likened theater participation to an “empathy gym” to practice compassion.

·       Bay Area Musicals: Founder and Artistic Director Matthew McCoy discussed the role of theater to make us think, reflect and feel.  Juan Castro and Loreigna Sinclair sang “In a Place of Miracles” and “God Help the Outcasts” from Disney’s Hunchback of Notre Dame, exploring themes of disability, immigration, and discrimination.

(SFSU’s College of Extended Learning offers Elder College for people age 50+ who pay $55 per semester to sit in any regular university course on a space available basis with instructor approval.  City College of San Francisco's Older Adults Program offers free, non-credit courses designed for people age 55+, which are open to all; its Free City Program recently received funding for two years to offer free summer courses.)

Outing to 42^nd Annual SF Free Folk Festival’s Jug Band Jam, with Christopher Richard, Miller Wise and Wayne Hagen, inviting folks of all ages to bring their own instruments to join in on jug-band classics, with songbooks provided.  

Director/Choreographer Bruce Bierman and Musical Director Ellen Robinson brought along Stagebridge participants to older adult communities for live performances of A Chorus Line. 

In this adaptation of A Chorus Line, Stagebridge participants audition by introducing themselves, sharing events that shaped their lives and decisions to become dancers.  Of the ten in this ensemble, only one was male.

History/Literature

Laura Bock, author of Red Diaper Daughter: Three Generations of Rebels and Revolutionaries (2017), and friend Sally Goldin, at this lively book reading/discussion party. As an only child, Laura wanted to pass on her family legacy by publishing her memoir at age 70, sharing stories of her “red” grandparents who sought to overthrow the Russian czar before immigrating to the U.S., her anarchist/communist parents who were labor organizers, and her own life as “red diaper daughter” carrying the tradition of activism (as she left for college, her parents advised her, “Now, make sure you get arrested for something political, and not just for drunkenness!”) through the 1960s civil rights and anti-war movements, 1970s women’s liberation and disability rights, 1980s fat and LGBT liberation, etc.  A self-described "groupie," Laura has been a model for community building and interdependence—running a bed and breakfast business in her family home; co-founding Fat Lip Readers Theater; joining/starting support groups for fat women, coming-out, disabled lesbian, Jewish women’s study, hard-of-hearing, old lesbian grief and loss, break-up, etc. Red Diaper Daughter is accessible via Bookshare for people to read with eyes, ears or fingers.

Health & wellness

Brain fitness

June is Alzheimer’s and Brain Awareness Month, and Jewish Community Center of SF (JCCSF) hosted its 2^nd Annual Brain Fitness Forum.  Some highlights:

Serggio Lanata, MD, of UCSF presented Alzheimer’s Disease Prevention: What’s the Evidence. 

Caitlin Moore, PhD, founder of California Brain Health Center, presented Lifestyle and Brain Aging: A Multimodal Approach for Optimal Brain Health.

·       Exercise: anything better than nothing; recommend 30 minutes moderate intensity 5x/week (can’t sing, but can comfortably talk, during activity)

·       Diet: Mediterranean (fruits, green veg, healthy fats—nuts, seeds, avocado, dairy and poultry once/week, wine in moderation), DASH (more grains, few times meat, fewer fats); best diet is one can stick to, fit into lifestyle (drink greens “quick way to choke down,” whole fruits as dessert, healthy fats like nuts and olive oil, whole grains, limit sugar intake, stay hydrated throughout day)

·       Sleep: 6-8 hours, but more is not better; schedule bed time and wake time; no digital screen 30 minutes before bedtime to give brain break from stimulation; if not sleep within 20 minutes, do something mindless; address issues that interfere with sleep—mood/worry, frequent bathroom breaks, pain (treat perception, avoid “PM” meds)

·       Habits: quit smoking; control heart risk factors

·       Hearing loss:  tied to memory loss, as part of brain responsible for hearing next to hippocampus (memory), tend to isolate due to frustration in social situations; Medicare covers hearing evaluation; wear hearing aids

·       Stay engaged: participate in mentally and socially stimulating activities to maintain cognitive reserve (amount of brain damage before show symptoms, influenced by high education/IQ/complex occupation use brain), find activities that bring passion involving emotion/spirit—don’t do crosswords if you hate to; challenge real life—walk dog, memoir writing, gardening, volunteering, find purpose; avoid loneliness by being proactive like organize outings

·       Compensatory strategies for memory and attention: minimize distractions, organize/clear clutter; buy pillbox to avoid risk of missing medication dose; use calendar to immediately record appointments, prioritize and check off to-do list, store frequently used items like eyeglasses and keys in memory table; keep positive mindset; seek help from family, friends, therapist to treat anxiety and depressed mood

·       Subjective memory loss:  talk to PCP about concerns; early diagnosis is opportunity to treat symptoms with medication and lifestyle modification, decide what to do with remaining years

·       Marijuana: causes memory problems, especially avoid after age 60  

JCCSF Lifelong Learning Programs Manager Shiva Schulz introduced Just Do It: Exercising Your Way to Brain Health presenters Larriana Williams, CCC-SLP from ONR, Inc. and Christine Roppo Soares, LCSW from San Francisco Campus for Jewish Living.     

·       Plasticity: brain’s ability to change in response to experience continues throughout lifespan, remap brain circuits especially after stroke (use non-dominant to create new pathways)

·       Enriched environments

·       Power naps help consolidate new information

·       Focused concentration most important, attention equivalent to endurance

·       Multi-tasking is myth: tasks are done sequentially, not concurrently

·       Cognitive reserve: challenge brain to learn new

·       Puzzles and games may improve working memory, not improve brain function

·       Aerobic activity increases blood flow, oxygenation, neural pathways

·       Just do it: mindful movement (meditation, prayer), breathe, engage, relax, keep healthy brain vision statement

Meet the Author Francine Toder signing her book The Vintage Years (2013), with husband Joe at her side, as she chats with psychologist Beth Krackov. 

Game room featured tables with Scrabble (70 years old!), Scattergories, Taboo, and jigsaw puzzle.

Video Center included Citizen Brain: The Empathy Circuit with Josh Kornbluth 

about how empathy works in the brain with the potential to save the world because empathy allows us to get along with one another.  Empathy is when you imagine what it might feel like to be in someone else’s shoes.  UCSF researcher Virginia Sturm, PhD, called empathy “the most important thing.”  UCSF neuroscientist Bruce Miller, MD, discovered that people with frontotemporal dementia (FTD) lose their empathy, so they are often alone and isolated.  When empathy circuit is broken, we connect less especially with people outside our group; due to divisions, we cannot work to solve problems.  In contrast, people who care about and connect to others can unite humanity.  Our empathy circuits can be strengthened—take a deep breath, imagine why and how the other person is feeling … 

Forum concluded with a screening of the 95-minute documentary, In Search of Memory: The Neuroscientist Eric Kandel (2009).  Austrian-born American neuroscientist Kandel’s trauma as an Austrian Jew who fled from the Nazis at age nine contributed to his curiosity about the contradictions of human behavior and research that won the 2000 Nobel Prize in Medicine for discovering the central role of synapses in memory and learning.  
The film also showed Passover Seder with his family discussing Nobel Prize-winning physicist Isidore Isaac Rabi: when asked why he became a scientist, he replied, “My mother made me a scientist without ever knowing it. Every other child would come back from school and be asked, ‘What did you learn today?’ But my mother used to say, ‘Izzy, did you ask a good question today?’ That made the difference. Asking good questions made me into a scientist.” 

Shout out to the many awesome experts who meet older adults where they are (in their residential communities) to engage in the lively exchange of ideas and information to promote health and well-being.

Serggio Lanata, MD, of UCSF Memory and Aging Center, presented on Brain Health, including ways to reduce risk of Alzheimer’s disease and related dementias:

·       Modifiable medical factors:  hypertension, hyperlipidemia, type 2 diabetes, smoking, untreated depression.

·       Modifiable lifestyle factors: cognitive stimulation (diversify mental activities by exposure to new/different stimuli; engage different regions of brain—e.g., occipital lobe in back of brain processes visual information, so engage it by looking at things that are stimulating like art; temporal lobes at ear level associated with memory and hearing interpretation, so music stimulates emotion and better if you can play instrument or sing); physical activity (older adults who maintain physically active lifestyles reduce their risk of serious illness by up to 50%, compared to sedentary older adults; chart shows muscle mass and strength peak at age 30, and how an active person can minimize muscle loss and remain above disability threshold into old age); nutrition (check vitamin B12 and D levels); social engagement (lessen loneliness by connecting with other people, empathy helps); and adequate sleep. 

Dr. Lanata gave way more than the usual 15-minute doctor visit, ably answering questions based on his training in biological sciences, food science and nutrition, physiology, complementary and alternative medicine, and neurology.

Hearing

Jessie Johnson, Clinical Practice Manager from Hearing and Speech Center, presented on Cognition and Hearing: Hearing loss, if untreated, puts people at risk for dementia and social isolation.  Hearing aids and aural rehabilitation are evidence-based treatment options for improving hearing (sense) and listening (skill).  

Jessie also presented on Assistive Listening Devices and Hearing Related Apps (tinnitus, sound level meter, aural rehab, communication). 

California Phones Outreach Specialist Casey Kho, MSW, presented demonstration of specialized phones to make it easier to hear, dial and call.  These phones, as well as cellphone amplifiers, are available at no cost through California Telephone Access Program, to California residents who have difficulty using a standard telephone. 

End-of-life (EOL) starring medical doctors

Is the brain, which stores memory, overrated? According to Dr. Kandel, “Memory is everything. Without it we are nothing.” A related view holds that “brain death means really dead” because without brain function, the body eventually shuts down unless there is medical intervention. 

This month I attended two short Netflix documentary screenings about EOL care focused on palliative care doctors in San Francisco Bay Area, and attended a presentation on advance care planning by a local patient advocate MD. 

JFCS’ Seniors At Home's Palliative Care Program hosted a screening of Extremis (2016), the Oscar and Emmy-nominated short (24 minutes) documentary about end-of-life decision making in an intensive care unit (ICU) at Highland Hospital in Oakland.  Extremis features Jessica Zitter, MD, MPH, who practices ICU and palliative care medicine, treating patients with no hope of getting better.  She told us that she got into medicine wanting to save lives, her medical training taught her to see patients as a collection of organs like fixing broken machines, and hospital hierarchy was like the military lacking reflection and humanism.  As a result, the default is to prolong life, without considering quality of that life. She discussed need to change this culture, after she learned to be reflective, collaborative and supportive from a nurse, chaplain and social worker in the palliative care consult team.  She said humility and courage is needed to say what will happen to patients and families, providing realistic information including breaking bad news compassionately and discussing option to “pass naturally” when medicine has no cure.  Dr. Zitter is also author of Extreme Measures: Finding a Better Path to the End of Life (2017).

Ungerleider Palliative Care Lecture Series at California Pacific Medical Center (CPMC) hosted a screening of End Game (2018), a short (40 minutes) documentary film starring UCSF palliative care doctors, Steven Pantilat, MD, and BJ Miller, MD (also former Executive Director of Zen Hospice Project’s six-bed Guest House, which recently closed).  My favorite soundbites:

“It’s healthy people who think about how they want to die, and sick people who think about how they want to live.” – Dr. Pantilat

“There is nothing inherently medical about dying. It’s much larger than medicine.  It’s purely human.”—Dr. Miller

This screening was followed by a CPMC bioethicist moderating a panel discussion with Dr. Pantilat (Founding Director of UCSF Palliative Care), Bridget Sumser (UCSF palliative care clinical social worker), and Shoshana Ungerleider, MD (CPMC hospice and palliative care physician who also produced End Game and funded Extremis).  As Dr. Zitter discovered, there is more to medicine than performing procedures to prolong life; palliative care is the art and science of healing that integrates the medical and social models of care, so honest conversations can take place enabling patients (or their proxies) to make informed decisions about their EOL care. (Check out, “Is hospice on your bucket list?” by Kimberly Baumgarten, RN, FCN.) In a nutshell, know what matters in your life and communicate with your loved ones and doctor. 

At North Beach Library, NEXT Village SF hosted a presentation on Patient Advocacy, Difficult Medical Decisions, Advance Care Planning with Jennifer Brokaw, MD.  Dr. Brokaw worked with NEXT Village co-founder Jonee Levy during her 1-1/2 year struggle with stage 4 lung cancer through Jonee’s death in her home in February.  

During nearly 15 years of practicing emergency medicine, Dr. Brokaw noticed patients were older and sicker yet she was asked to “do everything” because patients did not understand the course of their disease.  With Lael Duncan, MD (now Medical Director at Coalition for Compassionate Care), Dr. Brokaw started Good Medicine Consult & Advocacy Services in 2008--“5-1/2 years ahead of time,” before Medicare created billing code for EOL discussions. 

Dr. Brokaw led an exercise to create our own advance care plan on 3” x 5” index card.

Side 1: 

·       Appoint health care agent (HCA) who knows you, are in touch frequently       with open line of communication, knows and honors your values and beliefs,   ideal if live nearby, and comfortable in medical setting to ask difficult   questions.

·       Goals: address how you want to be until you die

·       Values: priorities

·       Beliefs: spiritual statement that give survivors comfort

Side 2

·       Finances: assets to pay for LTC

·       Fears: what experience that you do not want to repeat

·       Funeral: memorial, donate body to UCSF

Next steps:  You and 2 witnesses sign card.  Call HCA to talk about your wishes.  Notify Primary Care Physician: Medicare/Medicaid will pay for advance health care discussions ($170 for 1^st discussion, $80 for 2^nd discussion with HCA)

Other documents: 

·     POLST/MOLST: medical orders that specify interventions, signed by MD; seek national registry

·     Living will: not medical order, but expresses preferences for EOL care; co-opted by attorneys, not practical, few are actionable, “doctors get hives from attorneys”  

Why the relatively low interest in health and wellness?

In my experience, it has been easier to promote health education programs among healthy older adults in independent living than frail, older adults in assisted living where staff take control over many of their activities of daily living (preparing meals, managing medications, bathing, etc.).  When assisted living residents tell me they’ve had enough health education from doctors’ visits (and one centenarian resident walked out half-way through Extremis documentary, complaining that it was repetitive), I have to examine programming to ensure it’s not presenting just the medical model (defining aging like a host of diseases to be cured), but also addressing the bigger picture of non-medical needs that matter for a meaningful life such as purpose, truth, beauty, empathy, creativity, generativity, etc.--long live the humanities in lifelong learning!