“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 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
2nd 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 75th 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!
