Existentialism

“Where’s the energy? I wonder,

Where’s the productive life?

It’s not in Bingo or Yahtzee.

These activities fill waiting time until death.

Am I unique to avoid them?

Do others in the ALF have longings to explore away from here?

Can we not provide for residents who want to do something in and for the outside community? …

I’m not psychologically ready to live institutionalized, physically I am.

That’s why while living in an ALF, I’ve engaged in the outside world.

I teach, volunteer, write, take courses, work out.

I pursue acts of giving back to society.

That’s what one who is living long, like me, should do…

It takes a village to accompany elders on their final journey of life.

But in today’s fragmented and mobile society,

families no longer live together in a single household

Once it took a village, today it takes an ALF.”

“The Thin Edge of Dignity: Assisted Living Documentary” (2014)   
by Dick Weinman, Assisted Living Guru and AARP Blogger 

At age 65, Dick Weinman retired from Oregon State University to care for his wife who had Alzheimer’s disease.  At age 72, while driving to visit his wife at a care facility, he was involved in a car crash that put him in a coma, then rehabilitation and a wheelchair.  Next his children sold his house, decided he could no longer live alone and placed him in an assisted living facility (ALF), where he became “108” (his room number) and dependent on the kindness of caregivers.  Since then, this former Speech Professor has used his eloquent voice to advocate for improved long-term care facilities.  Though residing in an ALF, Dick epitomizes community living!

I like this diversified Life Portfolio (Health + People + Pursuits + Places) for Retirees by Anna Rappaport, a 78-year-old retirement benefits consultant who shifted her focus from plan sponsors to individuals during her phased retirement of the past 15 years.   Her point is people who view retirement as an endless vacation (a break from what we normally do) likely will be disappointed or bored within a year or two, so diversify your life!

Since residents in assisted living and skilled nursing facilities have their basic physiological and safety needs met, one would think they have time for higher needs such as belonging, esteem and self-actualization. (After working with older adults struggling to remain in their homes and avoid homelessness, this sounds almost like a suburban Problem that has No Name created by Betty Friedan?)  Instead, they tell me they are lonely among “peers” (who may have cognitive/sensory impairments so meaningful interpersonal interactions are more challenging) and staff (professional boundaries prevent closeness) in their age-segregated (ranging from age 55 to 111 years old!) environment.  They exist outside the Grandmother Hypothesis: traditionally women lived long beyond childbearing age because they had a purpose for their existence—helping to raise their grandchildren within extended families (which made up 17% of U.S. households in 2014).  The occasional outings and visits by family, friends, volunteers and contractors from the community are not enough to address loneliness.

At Loneliness & Brain Health Forum, Community Living Campaign (CLC) Community Connector Glenda Hope talked about joining CLC to get to know her neighbors through organized activities after her retirement; she challenged us to think, “What makes you come alive?”  I sat next to a recently retired school teacher who told me she missed socialization at work, and retirement is not just about keeping busy with activities, but belonging to a community.

UCSF behavioral neurologist Serggio Lanata, MD, discussed the challenge of operationalizing the concept of loneliness, which is not the same as being alone.  For example, many younger people are surrounded by people yet they feel loneliness, which might be defined as “too few nurturing connections”—a condition that may be exacerbated by social media use (virtual v. tactile experience).  Dr. Lanata said our brains are hardwired to connect, so living alone may place people at higher risk for loneliness: in San Francisco, nearly 30% of adults age 65+ live alone.  This isolation can affect behavior, which gives cues of not belonging to the environment; and the health effects of loneliness include cardiovascular disease, mood disorders, immune conditions, the equivalent of smoking 15 cigarettes per day, etc.

(Dr. Lanata, who is a familiar face on this blog here and here again, received the 2019 UCSF School of Medicine Population Health and Equity Scholar Award for his outreach work to vulnerable groups, which include old people.) 

Phaedra Bell, an Atlantic Fellow at the Global Brain Health Institute (GBHI) at UCSF Memory and Aging Center, mentioned social prescribing in the UK and the nexus between loneliness and substance use to compensate for not belonging.  She then discussed her proposed intervention to reduce loneliness by pairing an older adult with two younger students to produce a creative project for 3 to 6 months, and then showcase the project to celebrate new friendships.  She said something about allophilia, building cognitive reserve by face-to-face interactions, … and then she was cut off.  This evening program started late, but needed to end on time.  When an audience member attempted to ask a question about cholesterol-lowering statins that bring on brain fog, Glenda said presenters would be available to answer questions one-on-one, and then invited us to visit resource tables.

I’ve been reading about interventions for loneliness, a common complaint of residents in long-term care facilities.  Different approaches are needed to address the different degrees (sometimes, always), types (emotional, social, collective, existential) and causes (perception, disappointing relationships, loss of hearing or mobility, death of loved one) of loneliness. John Cacioppo, PhD, who coined the term “social neuroscience,” was researching a pill (based on pregnenolone) to cure loneliness before his death last year. His widow Stephanie Cacioppo, PhD, of University of Chicago’s Brain Dynamics Laboratory, continues his work on loneliness and offers this advice:

·       Introspection: express daily gratitude, have a sense of purpose in life

·       Connection: do something helpful or nice for others (give without expecting anything in return)

·       Interaction: engage with people (including strangers) on different levels and on a broad range of topics, and listen to them; share positive news (rather than negative information) and expect the best from people

Older Women’s League (OWL) San Francisco hosted Advocating for Important Issues Affecting Older Women in 2019 at Northern Police Station Community Room (“Feel More in the Fillmore”).  California Alliance for Retired Americans (CARA) Executive Director Jodi Reid, presented on the following priority bills:

·       HR 1384 Medicare for All Act of 2019: introduced by Congresswoman Pramila Jayapal, would include comprehensive long-term care, hearing, vision and dental coverage so Nancy Altman urges, “Seniors Should Be The Strongest Supporters Of Medicare For All.” 

·       SB 228 Master Plan on Aging: direct Governor to appoint an Aging Czar and 15-member Aging Task Force to work with state departments and stakeholders to develop a Master Plan for Aging, including expanding access to coordinated, integrated systems of care.  California’s long-term support services (LTSS) are very fragmented, involving multiple entities including the Departments of Health Care Services, Social Services, Aging, Rehabilitation, Transportation, Housing and Community Development, Insurance, Veterans Affairs, etc.  (In his January 2019 State of the State Address, Governor Gavin Newsom called for a Master Plan for Aging after losing his father to Alzheimer’s over the winter holidays.) 

·       SB 512 LTSS: request $1 million budget to study benefits and costs of subsidy program to help middle-income seniors and people with disabilities who do not qualify for Medi-Cal/In-Home Support Services to buy LTSS, including home care. 

·       AB 1434 Increasing SSI/SSP grants and COLA: reinstate SSI/SSP COLA in 2020, mandate monthly payments to 100% of 2019 poverty level.  

E. Anne Warren, Legislative Committee Chair of California Senior Legislature (CSL), discussed transportation to medical appointments for seniors and persons with disabilities who live in rural areas (her proposal was picked up by Assemblymember Rudy Salas, AB 970), affordable rental housing for veterans (SB 725), and fall safe housing (SB 280).  She also mentioned the need to raise $250K each year to maintain California Senior Citizen Advocacy Voluntary Tax Contribution Fund (Code 438) on the California Personal Income Tax Return; this fund is used to pay for one staff and to conduct work of CSL. 

My last OWL-SF attendance was almost three years ago, when I attended Empowered Elder Workshop and Women & Money panel.  At this month’s meeting, I saw many of the same faces from three years ago.  Then I learned that the national OWL dissolved two years ago due to aging leadership: OWL-The Voice of Women 40+ (1980-2017) R.I.P.  However, local chapters continue, like OWL-SF The Voice of Midlife and Older Women.

At UCSF Medical Center’s Asian Health Institute, bioethicist Anita Ho, PhD, MPH delivered a bilingual Cantonese/English presentation on Advance Healthcare Directives.  She shared her own family’s experience, including her grandparents who were in and out of hospitals until their deaths at age 98 and 99, and the Chinese culture of filial piety, living life seriously and accepting its end peacefully.  While we still have capacity, we can prepare ourselves psychologically and document our own decisions about health care, including what makes life meaningful, deathbed wishes, spiritual needs/religious beliefs, and life sustaining treatments (cardiopulmonary resuscitation which has 10-20% recovery rate, ventilator, dialysis, feeding tube, blood transfusion, surgery, etc.).  We should distribute executed copies to our family, friends and medical provider; have discussions; and update should circumstances change.