Oldness

“Oldness, it’s everywhere. And if you’re lucky, it can happen to you!”

—Power of Oldness, Australian Human Rights Commission 

At Institute on Aging, Jenny Yen, PsyD, presented ageism awareness training, Hear My Story: See the Invisible.  At 31 years old, she reflected on how age 30 over-the-hill jokes made her feel less competent, internalizing ageism, so she found herself unable to perform her usual exercises.  She discussed sources of ageism from aging models (loss and fragility are inevitable; adaptation to changes via selection, optimization and compensation to maintain self-efficacy; successful aging; positive aging), media portrayals and cultural attitudes (anti-aging). 

When Dr. Yen went over “Why Aging is Tough,” I wondered how much of the physical changes are “tough” due to reactions from other people projecting fears of aging (pain; disconnection from self and other people; loss of function, independence, control, dignity) than one’s own adaptation to gradual changes?

For models, she offered 66-year-old Social Work Professor turned Accidental Icon Lyn Slater, and 98-year-old Iris Apfel, oldest person to be turned into a wrinkle-free Barbie doll and another Accidental Icon. 

Refreshingly, Dr. Yen did not reference #endageismsf, but used Australian Human Rights Commission’s upbeat “Power of Oldness” campaign.  She also used Meaningful Ageing Australia’s “See me, Know me” campaign with its 10 conversational starters to talk about “some” of who you are (likes, interests, beliefs, etc.).  She concluded, “Feel good, and be your authentic self.”

Dementia care

UCSF Mission Bay hosted its Memory and Aging Clinic’s Loving Dementia Care: Learn the Skills You Need.  UCSF resources include Care Ecosystem toolkit and free online Dementia Care Training for Lay Health Workers at http://canvas.instructure.com/enroll/R9B67G

Serggio Lanata, MD, presented Heartbeat of Dementia, discussing cerebral localization (predicting regions of brain damage based on patient’s clinical syndromes).

He also covered how the brain changes with aging, different neurodegenerative diseases of the brain causing dementia, and diagnostic process of person with cognitive impairment (neurological evaluation + neuropsychological testing + investigations + level of independence). 

Alejandra Sanchez-Lopez, MD, on Embracing Cognitive Evaluation, described how cognitive domains affect function and behavior.  She also reviewed tools for cognitive evaluation: screening tools include MMSE, MOCA, Mini-Cog, SLUMS; diagnostic neuropsych testing.  Simple strategies to assess cognition: orientation questions (person, place, time), knowledge of current events, perform task with more than one step, ask them to point to something (can they see it? Can they identify it by name?).

Julio Rojas, MD, on Getting to the Heart of Behaviors, because there is no cure for dementia, so treatment goals are to maintain quality of life, maximize function in daily activities, enhance cognition/mood/behavior, foster safe environment and promote social engagement.  

The vulnerable brain has lowered stress threshold.  Instead of "diagnose and adios," he offered 10 principles of behavioral management of dementia symptoms:

1.   Evaluate for medically treatable causes of symptoms, aka is your patient delirious?

2.   Use structured method to assess and manage behavioral symptoms: DICE = Describe, Investigate, Create, Evaluate 

3.   Non-pharmacological interventions should be implemented before pharmacological treatments: address underlying cause(s), provide cognitive accommodations, avoid triggers, reinforce desirable responses

4.   Savvy caregiver is most important ally, empower caregiver: educate, connect with resources, coach and reassure continuously

5.   Pay attention to communication style and content, tailor to accommodate for existing deficits (e.g. dementia stage)

6.   Use intervention hierarchy: nurse, social worker, OT/PT

7.   Person-centered care strategies should be prioritized because they promote strength of patients and honor their choice and values, stay creative: tailored activities program, validation therapy, reminiscence, music therapy

8.   Become structurally competent provider: know resources

9.   Systems-level and multidisciplinary approaches to coach families should be implemented when possible: care navigators, behavioral nursing clinic, support groups, task forces

10.If behavior poses high risk of harm to self or others, or causes severe disturbance to patient or caregiver, pharmacological approach should be implemented first

Nhat Bui, RN, AGNP-C, on Longitudinal Case of Compassionate Caregiving, discussed intervention strategies at each stage of dementia: education and support, counseling, community-based resources, home-based support resources, facility placement resources, legal and financial planning.

Family Caregiver Panel with Matthew (shared story about APS involvement to increase IHSS hours and adult day health care for mother-in-law dx CAA), Gayle (finding “right” caregiver for partner dx PCA and practicing meditation), and Pam (hiking with dogs and late husband dx Alzheimer’s to focus on what worked and not taking behaviors personally).

Mind-body health

At UCSF Parnassus, psychiatrist Descartes Li, MD, presented Cultural Factors in Psychiatric Care: Focus on Asian Mental Health.  He reviewed Cultural Formulation under DSM-5.  

·       Cultural identity: individual v. collective (family), acculturation (different levels around different issues), communication style (direct v. indirect, verbal v. nonverbal, include kinesics/haptics, proxemics, paralanguage), emotional expressivity (Confucian value of self-restraint), language proficiency (involve interpreters & translators)

·       Explanatory models of illness: idioms of distress (neurasthenia v. depression), cultural syndromes, definition of mental health (Western definition of mentally “healthy” person: ability to express feelings in words; high value on insight, understanding one’s emotions, highly individuated, ability to trust clinician), importance of patient’s perspective

·       Cultural stressors and supports: U.S. secularization (psychologization), community mental health/deinstitutionalization, biomedical paradigm; Chinese Confucianism (family, harmony/interdependence, golden mean, virtue), traditional Chinese (filial piety, “face,” love expressed by providing, self-restraint, humility)

·       Cultural elements of relationship with clinician: relationship to authority, informed consent, transference and conception of “self”

·       Overall assessment: impact of culture on assessment/diagnosis and treatment plan 

In 1980, American psychiatrist and medical anthropologist Arthur Kleinman went to Hunan, China, where he evaluated 100 patients who had been diagnosed with neurasthenia (characterized by fatigue after mental effort in ICD-10, dropped from DSM in 1980) and diagnosed 93% with depression and 71% with anxiety disorders.  Dr. Kleinman figured that older generation Chinese, influenced by Traditional Chinese Medicine and avoiding stigma of mental disorder, might experience mental distress as somatized distress, with physical symptoms such as fatigue (depletion of qi) and sleep disturbance.

Thought experiment: Could a Chinese psychiatrist come to the U.S., evaluate patients with a prior diagnosis of depression, and then re-diagnose them with neurasthenia? Are American psychiatrists misdiagnosing U.S. patients?

Three years later, Dr. Kleinman returned to China:

·       48 patients with “medical” perception, 33% decreased their medical utilization;

·       52 patients with new “psychological” understanding, 70% of patients decreased medical utilization

Oldness prevention?

Oldness does not happen when pedestrians are killed by drivers of motor vehicles.  Earlier this week, an 80-year-old man struck by a car in the Tenderloin became San Francisco’s first pedestrian fatality of the year.  San Francisco’s Vision Zero project is four years away towards its goal of zero traffic deaths by 2024. However, last year’s 29 traffic-related deaths, including 18 pedestrians, represent an increase from the previous two years (23 deaths in 2018, and 20 deaths in 2017).
Oldness also does not happen when people end their lives prematurely by suicide (and medical aid-in-dying).  In the U.S., suicide rates are highest among middle-age white men, with firearms accounting for more than half of all suicide deaths.  According to the Centers for Disease Control and Prevention (CDC), guns kill more Americans than motor vehicles, but CDC is reluctant to link “access to firearms” with suicide – though 60% of gun deaths are the result of suicides, not homicides.  Because 1996 Dickey Amendment prohibits CDC from using its funding to “advocate or promote gun control,” CDC’s suicide prevention message is “safe storage of lethal means” (keep gun locked and separate from ammunitions to decrease impulsive use) instead of “restricting access to guns.”

The suicide rate among veterans is 1.5 times greater than non-veterans, with over 6,000 veterans dying by suicide each year.  Veterans account for 13.5% of all suicide deaths, though just 7.9% of the U.S. population.  While VHA focuses on the growing number of younger veterans who have the highest rate of suicide among veterans, those 55 and older still represent the largest number of suicides.  Almost 70% of veteran suicides involved a gun, compared to about 48% of non-veteran suicides. 

At War Memorial Building, American Foundation for Suicide Prevention (AFSP) and San Francisco VA Health Care System partnered with National Shooting Sports Foundation (NSSF) to present all-day conference, Counseling Veterans at Risk for Suicide: Latest Advances in Preventive Strategies and Safe Storage of Firearms.  

(Left to right, in photo above) Joseph Simonetti, MD, MPH, Rocky Mountain Mental Illness Research, Education and Clinical Center for Suicide Prevention, VHA); Carolyn Colley, Disabled Air Force Veteran who lost two brothers, both veterans suffering PTSD, to suicide, and blamed "incompetent social worker"; Joy J. Ilem, Disabled American Veterans (DAV); Aimee C. Johnson, LCSW, VHA Office of Mental Health and Suicide Prevention; Matthew A. Miller, PhD, MPH, VHA Office of Mental Health and Suicide Prevention; M. Emmy Betz, MD, MPH, VHA); Jay Zimmerman, BA, CPSC, CRE, CPRP, Certified Peer Support Counselor, James H. Quillen VAMC; Matthew J. Miller, MD, MPH, ScD, Northeastern University; Doreen Marshall, PhD, AFSP; Joseph Bartozzi, NSSF; Megan McCarthy, PhD, AFSP Project 2025 (nationwide initiative to reduce annual suicide rate in U.S. 20% by 2025).

Like CDC, there was no mention of “gun control” but presenters used “lethal means safety.”  The presenter for firearms industry defended 2^nd amendment right to firearms, encouraging audience to reduce bias: “learn about gun owners, go out for a shoot.”  Peer support presenter explained “I shoot for relaxation, blow off steam… losing my hearing, but have fun bonding” with shooting pals. 

Matthew J. Miller stated the presence of firearm access matters in suicide.  His rationale for “means reduction”:  suicide acts are often impulsive for crises often fleeting; method used depends on availability; 90% likelihood of death with firearms; fewer than 10% of survivors go on to die by suicide.  Majority of guns used in suicides come from victims’ home.  People who live in homes with guns are neither depressed nor more suicidal than members of non-gun owning homes.  Availability of method affects suicide rates:  If not able to use preferred method, will not turn to other alternatives.  Population level restrictions on access to commonly used lethal methods of suicide saw profound fall in suicide rates, without any psychosocial intervention, after U.K. detoxed gas used in home ovens and Sri Lanka banned most toxic pesticides.  Israeli Defense Force cut its weekend suicide rate by 40% after requiring that soldiers leave weapons on base during weekend leaves.

Joseph Simonetti stated the presence of a gun in the home is strongly associated with suicide among adults, and U.S. veterans have greater firearm access than non-veterans: 47% of male veterans own a firearm versus 30% of male non-veterans; 24% of female veterans own a firearm versus 12% of female non-veterans. 1 in 3 firearm owners have a household firearm that is unsecured and loaded with ammunition.  Goal 6 of VA’s National Strategy for Preventing Veteran Suicide is to promote efforts to reduce access to lethal means of suicide among veterans with identified suicide risk.  Current efforts focus on Lethal Means Safety (LMS), including firearm safety device distribution program.  He explained messaging language matters: “safety is better than restriction.”  “Safety” means keeping firearms unloaded, secured with locking device, and separate from locked ammunition; removing firearms from home.  He also discussed need to expand suicide risk screening beyond risk groups with mental illness because nearly 30,000 VHA primary care patients died by suicide from 2000-14: 45% had no prior mental health or substance use diagnosis; those without diagnoses more likely to die by firearm injury.  LMS interventions should be different for female veterans, who use firearms for protection and safety (e.g. keeping loaded gun by nightstand), particularly if they've known sexual assault in the military. 

Oldness in museums

In recognition of the 75^th anniversary of the liberation of Auschwitz, War Memorial Veterans Gallery exhibited Violins of Hope: A Journey of Heroism, Healing and Humanity, a collection of over 20 violins once played by Holocaust prisoners and victims, exploring the power of music to heal, unite and protest. This exhibit made me think about TwoSet Violin Youtube duo who make old classical violin music so cool, accessible and relevant, and how can we do the same for Oldness? 

Social policies, based on compassionate ageism, that promote age-segregation do not help to make Oldness cool.  Adam Schachner’s short video, “The Old People Museum,” depicts this commodification and othering of older adults for visitors to observe and learn from Depression-era Old Man who talks about “what you used to be able to buy for a nickel.”  After the museum closes, Death Skeleton absconds with 104-year-old woman from her display case.  The end.

As part of its Soul of a Nation: Art in the Age of Black Power 1963-1983 exhibit, de Young Museum re-created the Black Panthers’ ground-breaking Oakland Community School with its Director (1973-1981) Ericka Huggins (both the first woman and first Black person to be appointed to the Alameda County Board of Education) facilitating a discussion about revolutionary child-centered education focused on serving children of color, each according to their ability and needs.  Critical thinking skills came from teachers and children posing questions and dialoguing for answers.  They were educated in subjects like math, science, language arts, history, current events, physical education (martial arts and yoga for mind-body connection), theater, dance, choir, gardening and environmental studies.  With “each one teach one” philosophy, everyone learned from one another. 

Contemporary Jewish Museum’s Levi Strauss: A History of American Style displayed never-before-exhibited Levi’s leather Cossack jacket worn by Albert Einstein during his early years in the U.S. when he arrived as a 54-year-old refugee from Nazi Germany.  Einstein makes Oldness cool!