Shut-ins

In contrast to my mostly homebound senior clients, I’m usually out and about so I’ve often considered taking a 30-day challenge to live like a shut-in so I could experience life like my clients.  As an introvert, I am inspired by shut-in clients who engage in creative arts like writing and publishing poetry, painting and selling artworks online, composing and performing music, etc.     

The Shut-Ins perform at fundraiser for Legal Assistance to the Elderly (LAE).  

LAE staff attorneys – Judy Hitchcock (elder abuse prevention; also Spanish bilingual), Christine Lau (public benefits; also Cantonese bilingual), Tom Drohan (housing; also bass player with The Shut-Ins) – have been with LAE for about 25 years each!  Paralegal Christy Nieves brought age diversity (and Spanish bilingual skills) after Bessie (who joined LAE in 1980 shortly after its founding) retired last year.  

Volunteer receptionist Tom Tallman (sandwiched between friend Richard and LAE Director Howard Levy, in photo above) has been with LAE for more than 25 years! 

Howard presented long-time LAE volunteer paralegal Sandra Fenix (Portuguese bilingual) with Volunteer Award. 

Howard announced his retirement by year-end after 28 years as LAE’s Executive Director.  Howard’s legacy is his role in fostering employee and volunteer retention (aging in workplace!), which seems remarkable for a non-profit serving older adults in San Francisco.  (Staff retention also helped by union membership in National Organization of Legal Services Workers.) 

LAE Board (not bored) member and journalist Tim Redmond noted that 14% of eviction defense cases in San Francisco are represented by LAE, winning each case to promote aging in place!  Woo-hoo! 

Get up and dance to music of The Shut-Ins!

Mental health 

Department of Aging & Adult Services (DAAS) Education Coordinator Rick Appleby introduced presenters at DAAS Community Training on Mental Health in Older Adults.  None of the presenters were psychiatrists, but it was refreshing to hear two geriatricians take a holistic (mind+body) approach rather than focus only on internal medicine diseases of older adults. 

Pei Chen, MD, UCSF Division of Geriatrics, presented on Depression, Suicide and Loneliness.  The risk factors for late on-set depression and loneliness seemed to describe my shut-in clients:

• Female
• Social isolation or low contact with friends or low quality relationships
• Widowed, divorced, separated marital status
• Lower socioeconomic class
• Comorbid medical conditions or worsening physical health

Dr. Chen shared screening tools for depression (PHQ-9), suicidality (P4), and loneliness (De Jong Gierveld 6-item).  Her recommendations: ask about mood/loneliness, be present and encourage interactions, connect with community resources.

While my shut-in clients seem receptive to contacting Friendship Line or friendly visitor programs, they are sometimes reluctant to seek services of mental health professionals due to stigma. 

Anna Chodos, MD, UCSF Division of Geriatrics, presented on Substance Abuse, a cohort issue with higher lifetime prevalence among baby boomers age 60-64. She also noted that 25% of older adults use psycho-active prescription drugs with potential for misuse/abuse:

• Opiates: morphine, oxycodone, methadone; 40-50% older adults in chronic pain
• Benzodiazepine: lorazepam, diazepam, etc.; avoid in older adults as these may cause decreased attention, memory, cognitive function, motor coordination lead to increased risk of falls/car crashes
• Medical marijuana: controversial (risk/benefit not clear); used for neuropathy, glaucoma, pain, anxiety

Screening for substance use disorders include TWEAK for alcohol use, and DAST-10 for other substance use.

Tobacco is the most common substance used by my clients.  As much as I want to support aging in place, there have been days when I’d come home smelling like an ashtray after home visits with clients who smoked like chimneys, and I’d think I’d be better off in a non-smoking institution like a nursing home!

Sonya Maeck, LCSW, Clinical Administrator and Program Director at Jewish Home, discussed her facility’s 12-bed acute geriatric psychiatry hospital that exclusively serves older adults who require short-term treatment (average 18-day stay) for psychiatric conditions like anxiety, depression, suicidal thoughts, etc.  Its staff has specialized training in the unique medical and psychiatric needs of older adults to evaluate physical conditions (e.g., infection) that can be underlying factors in mental disorders; after successful treatment, the goal is for the senior to return home.

Encourage interaction

My work with shut-ins is rewarding with opportunities to make a difference and the mutual appreciation for home visits.  While I wish I had more time with clients, I have a fairly tight schedule of 5 to 6 home visits per day plus travel time.  I often politely redirect clients who use questions to seque into long stories.  (See The Onion video report, “Census Visits Providing Shut-Ins Once-A-Decade Chance For Human Interaction,” featuring 87-year-old Helen DeAngelis who gives tips for trapping a census worker in your home for as long as possible.) 

For example, when I asked one client about her mobility, she replied that she used a cane to ambulate, and then she proceeded to recount her delightful story about getting the carpet in her studio apartment shampooed, which required her to leave home for 6 hours, so she took this opportunity to explore her neighborhood, which included visiting library to get a library card, then went to the movie theatre, etc.  Being out and about improved her disposition.

One way to reduce isolation of shut-ins is to fix broken doorbells, especially those who live in houses with outer gates preceding front doors so visitors need to ring doorbell or telephone: ding-dong-ding, how else can Jehovah’s Witnesses go door-to-door and reach isolated seniors who might welcome free home Bible studies?

Advance care planning 

San Francisco Village and Institute on Aging (IOA) hosted Talk to Me: Conversations that Matter about advance care planning and end-of-life options. IOA’s Patrick Arbore was a no-show due to illness, so SF Village Executive Director Kate Hoepke assumed role as moderator, opening up discussion by asking panelists what are the results of having these conversations?

• Sarah Hooper, Executive Director of the UCSF/UC Hastings Consortium on Law, Science & Health Policy, talked about how the process of documenting one’s legacy (in the form of advance health care directives, power of attorney for finance, wills, etc.) is empowering because law students care to ask and listen to clients about their goals and wishes, which are given the force of law—yet emphasizing the conversations are more important than the forms.

• Eric Widera, Clinician-Educator at UCSF Geriatrics, said “ditto” adding though it’s hard to predict future situations, conversations focus on what are important values—some people are known to appoint their bartender, who is someone they trust, they can have conversation and who is available to serve.

• Stefanie Elkins, California Medical Outreach Manager at Compassion & Choices, discussed California End of Life Option Act, which became effective June 9, 2016, authorizing medical aid in dying.

Because I have shut-in clients who cycle in and out of hospice care, I wonder about California End of Life Option Act applying to terminally ill adults with a “prognosis of six months or less to live” when it is difficult to predict when someone will die.