Oh, the places you’ll go!

A former client recently called to let me know that she has settled in San Antonio, where her niece provides home care that my client could not afford while living alone in San Francisco.  Now my client looks out into a garden, instead of the skyline from her former Tenderloin studio apartment.  Her new home is in a cul-de-sac with no sidewalks for wheelchair accessibility, but then she quickly added that it is too hot outside for her to leave her air-conditioned home anyway.  I mentioned that she missed the recent power outage caused by an electrical fire at PG&E substation in Tenderloin.  My client said she missed San Francisco, though she was mostly homebound except for outings to medical appointments.  

Last month, SF Main Library hosted a panel discussion, From Homelessness to Housing in San Francisco, moderated by San Francisco Chronicle Editor-In-Chief Audrey Cooper, and featured  BART Board Director Lateefah Simon, District 2 Supervisor Mark Farrell, San Francisco Chronicle Reporter Kevin Fagan, Department of Homelessness and Supportive Housing Director Jeff Kositsky, and Coalition on Homelessness Executive Director Jennifer Friedenbach.  Jeff proposed ending the home mortgage income tax deduction, which has been used by at least one-third of upper-income taxpayers; instead, he favored Germany’s model of tax incentives for rentals.  (Trump’s proposed tax plan to retain the mortgage tax deduction while doubling the standard deduction would likely further benefit higher-income taxpayers instead of broadening home ownership.) 

Several homebound clients, formerly homeless and now living in permanent supportive housing, appeared in a related exhibition, Everyone Deserves a Home, at SF Main Library. This exhibit showed photos of residents holding signs handwritten in response to “What does home mean to you?” and oral histories of their experiences of coming to San Francisco and their struggles (trauma, neglect, substance abuse, poverty, racism, etc.) that led them to their current home.

While home is important to age in place, the consequences of isolation and loneliness from being homebound and aging without community was the topic at the April 27, 2017 hearing before the U.S. Senate Special Committee on Aging. Experts testified on the negative mental, behavioral and physical health outcomes of isolation and loneliness, including the oft-quoted research finding that prolonged isolation is comparable to smoking 15 cigarettes a day!  (Effective April 1, 2017, California has imposed a $2 tax on tobacco products in an effort to discourage smoking, but it cannot legislate away social isolation and loneliness—though many smokers are already isolated.) 

Therefore, I encourage my homebound clients (especially if living alone and watching TV) to venture outside of their home (comfort zone) and into our communities, when possible.  And thanks to technology, I hope my blog can help bring the community (engagement, resources) to them!

SFSU Gerontology Program

SFSU Gerontology Program Coordinator Darlene Yee and College of Health & Social Sciences Dean Alvin Alvarez welcomed 160+ guests to SFSU Gerontology Program’s 30^th Anniversary Dinner held on campus. (SFSU Gerontology Program—the first and thus oldest graduate gerontology program in the California State University and University of California systems—is one of the educational trip offerings at this summer’s IAGG Congress!)

Serenaded by campus musicians 

Dinner plate 

Faculty table with Professor Brian de Vries, lecturer and California Advocates for Nursing Home Reform (CANHR) founder Pat Mc Ginnis, and Professor Annabelle Pelham

Classmates Ardath, Diane, Kay, Mary, Lois and Raenika 

Classmates May (holding up donation envelope) and Ardath 

Pat Mc Ginnis presented Distinguished Long-Term Care Advocate Award to Mark Leno, State Senator (2008-2016), for his advocacy of consumer protections for aged constituents: increase minimum wage and sick days for IHSS workers (SB 3), ban on admissions to RCFE if risk of harm (SB 1153), RCFE Eviction Protection Act (SB 897), etc.

Bayview Hunters Point Multi-Purpose Senior Services Director Cathy Davis and Aging Commission President and SFSU Gerontology alumna Edna James

Jewish Community Center of San Francisco 

I took vacation leave to attend worthwhile JCCSF’s 10^th Annual Art of Aging Gracefully Resource Fair: Stay Vital, Healthy and Fit, organized by Adult Programs Manager Shiva Schulz. 

Margaret Chesney, Director of Osher Center for Integrative Medicine at UCSF, presented “Outsmarting Stress, Enhancing Resilience & Optimizing Health in Today’s World.”  She recommended BREATHE strategy to enhance well-being:

Be present with self in the moment - slow down

Realistic goals - celebrate meeting them

Everyday events – notice positives and share with others

Acts of kindness – create positive events for others

Turn negatives around – reframe to find silver lining

Humor – smile

End each day with gratitude

Department of Aging and Adult Services (DAAS) Nutritionist Linda Lau at one of the busiest resource tables.  According to the most recent DAAS Needs Assessment, senior meals funding has shifted from congregate to home-delivered meals.  Does this reflect pattern of growing isolation of seniors at home? When clients tell me they are discouraged from eating at congregate meal sites because site staff/volunteers attempt to collect “suggested contribution,” I advise them to file complaint with DAAS!  

Health Librarian Janet Tom at SF Public Library table. I often refer homebound clients to Friends for Life to borrow books, DVDs, CDs, etc. by mail. SFPL also has its own youtube channel.

Office on Women’s Health hosted Women’s Health Leadership Institute, which I participated in almost 4 years ago, so always happy to reconnect with Regional Coordinator Kay Strawder (pictured at right) and Public Health Advisor Sheila James (not pictured at JCCSF because she was participating in Walk to Work Day).  Since women outlive men, the future is female …. but with attempts to repeal Obamacare, what is the future of women’s health?

                                  SF Public Library – Main Branch                                         

Filmmaker Felicia Lowe discussed genealogy research after a screening of her documentary, Chinese Couplets, exploring the life of her mother who assumed the identity of a paper daughter to immigrate to the U.S. during the Chinese Exclusion era.  Once settled in the U.S., Felicia’s mother reinvented herself several times through roles in her first marriage, motherhood, business, widowhood, etc. Near the end of life, Felicia's mother expressed contentment that she finally had financial security through remarriage to a wealthy man.

  

Contemporary Jewish Museum

Like Curious George Saves the Day: The Art of Margret and H.A. Rey (exhibit 5 years ago), I looked forward to this month’s opening of Roz Chast: Cartoon Memoirs – this time with the living artist in person!  

New Yorker cartoonist Roz Chast's memoir, Can’t We Talk About Something More Pleasant? is about an only child providing care for elderly parents until the end.

Exhibit included short film of Roz revealing that she wrote Can’t We Talk About Something More Pleasant? because “I didn’t want to forget how they talked, and I didn’t want to forget how they were …” 

Couch below speech balloons painted on wall provided photo opportunity

  

Lighthouse for the Blind and Visually Impaired

Frances Neer Visually Impaired Persons Forum presented Case Management with Tracy Moore and Cherie Golant of Institute on Aging.  Cherie described her case manager role as one who conducts an assessment, develops and implements a care plan, helps navigate systems and connect clients to resources.  As a private case manager, Cherie offers free 30-minute consultation by phone and then charges $135 per hour; services provided are limited to client’s ability to pay. A case manager can have different backgrounds and training (MSW, RN, LVN, PT OT, MA Gerontology).  The government also funds case management services through Multi-Purpose Senior Services (MPSS), Community Living Fund (CLF), various senior centers and non-profit agencies.

Ed Roberts Campus

 

Journalist Belva Davis moderated Alzheimer's Association 9^th Annual African American Caregiving and Wellness Forum at Ed Roberts Campus in Berkeley.

Rochelle Woods, MD, delivered keynote, “Self-Care While Caring for Someone with Dementia” reminding us that African-Americans are almost twice as likely to develop Alzheimer’s, and tend to take care of family to age-in-place.  African-Americans, especially women, have capacity to tolerate stresses, but are more susceptible to effects of taking care. She said caregivers need to put their mask on first (maintain mind-body-spirit, MBSR), educate about dementia (The 36-Hour Day) including support, have fun (old man dancing), be smart and savvy (advance directives, power of attorney, life care planning).

Heather Gray presented “Understanding and Responding to Dementia Behaviors” reminding us that people with Alzheimer’s still want independence and opportunities for participation/contribution, yet may not have language to express their needs.  Instead of stepping in and insisting something be done a certain way, let go if the person with Alzheimer’s can remain safe and content/engaged/involved.  It takes a village, so reach out to the community for support. 

“Ask the Experts Panel” Discussion, with presenters plus Rita Hartgrave, MD, addressed practical issues like when it’s time to go to nursing home, taking away car keys, bathing, etc. 

John Olichney, MD, presented “UC Davis’ Disparity in Brain Aging Research,” finding low levels of vitamin D is associated with cognitive decline.  Since the body makes vitamin D through sun exposure, many older adults (especially shut-ins) are low in vitamin D because they are not outside enough.  African-American and Hispanic subjects had lower levels of vitamin D than white subjects, as darker skin reduces the amount of sunlight absorbed. Overall, subjects with inadequate Vitamin D levels lost episodic memory and executive function more quickly. 

Cynthia Carter Perrilliat emphasized personal approaches to grief (process of healing from loss) in her talk, “Managing Grief and Loss While Caregiving.”

Asha Koshy, Program Manager at Bay Area Community Services Adult Day Health Care, presented “Connecting to Loved One Through Home-Based Activities.” She reminded us of 3 keys for failure-free activities that engage:

1. go with the flow
2. praise effort
3. acknowledge skill

Activities can include arts and crafts, music therapy, cooking, reminiscing and exercise.  Create a routine that is SPECIAL:

Schedule

Peace

Eliminate caffeine, especially at night

Cue what to expect

Include in activities

Activity

Lights

Intergenerational drumming at Berkeley Flea Market outside Ashby BART Station.

  

Black Cuisine in Bayview 

Last month, I volunteered at 37th Annual Black Cuisine Festival, fundraiser for Bayview Senior Services, at George W. Davis Senior Center.

Dance outdoors to Bobbie "Spider" Webb and make vitamin D!

Civic Center Plaza

April 15 Tax March protesters called on Chicken Don (30 foot inflatable made in China) to release his tax returns, as every U.S. President has done so for past 40 years.

"reject kleptocracy”

Dark Room Truck performs “Dump Trump Bump” protest song  

Earth Day “eye heart science” buttons 

March for Science posters 

Intergenerational March for Science from Ferry Building to City Hall

Sunday Streets

Now in its 9^th year, Livable City’s Sunday Streets Tenderloin offered live music, arts and crafts, information sharing by community non-profit and government agencies, etc.—opportunities to increase physical activity for all ages in a car-free environment! 

Curry Senior Center, providing medical and social services since 1972 to seniors who make up half of the population in the Tenderloin, gave away toothbrushes! Alisa Oberschelp, MD, and Angela Di Martino wear black Curry Senior Center T-shirts.

Central City SRO Collaborative organizes with SRO (single-room occupancy) tenants in San Francisco’s Central City neighborhoods including Tenderloin and South of Market communities. 

Permaculture is the answer

Butterfly effect: Be the change you want to see in the world! Artists transform 4 Corner Friday wall at Golden Gate and Hyde. 

“I’m at peace with myself” 

Normalization

In No Pity: People with Disabilities Forging a New Civil Rights Movement (1993), Joseph P. Shapiro noted that deinstitutionalization and the community living movement in the 1960s was driven by the rise of the concept of normalization.  This sociological (as opposed to medical) approach to disability has application to all who wish to age in place by normalizing aging and dying:  ask the elderly what matters in the end. Nothing about us without us!

“The normalization principle means making available to all people with disabilities patterns of life and conditions of everyday living which are as close as possible to the regular circumstances and ways of life or society.”

– Bengt Nirje on Normalization, which laid the groundwork for social inclusion and self-determination for people with disabilities

“Normalization demands …an entire spectrum of community living arrangements to serve all ages and age appropriate behavior levels, to address progress, integration and independence appropriate to a person's age and competencies.” – William G. Bronston, MD, on Concepts and Theory of Normalization 

Normalization means giving people with disabilities (including older adults) the same opportunities in life that others have.  The person is not the one being forced to be normal, but the environment is changed to give this person a chance to experience what is considered "normal." 

Senior & Disability Action staff presented Disability & Ableism Training, including skit on how to communicate and interact effectively with people with disabilities.

Nourishing the whole person

Normally eating can be a pleasurable activity, but can be challenging to those with dental problems (missing teeth, adjusting to dentures) or medical conditions (dry mouth, fatigue).  In my work with seniors, I routinely assess for nutritional risk asking, “Do you have tooth or mouth problems that make it hard for you to eat or chew?” When a client responds in the affirmative, my follow-up question is, “Would you like to change to a mechanical soft diet?”  Initially clients resist saying that they “don’t want any pureed baby food.”  Then I explain a mechanical soft diet includes a spectrum of different textures and consistencies (soft, liquid, blended, chopped, ground or minced) so it’s easier to chew and swallow.  The following are sample foods prepared by Meals On Wheels of San Francisco—so you see, these meals are age-appropriate for senior clients! 

Mechanical soft pork loin in sesame with peas & curried lentils: looks similar to kitfo (Ethiopian minced meat) or moo-shu (Chinese ground pork) moistened with sauce/gravy! 

Salisbury steak in mushroom sauce with broccoli, cauliflower & carrots

Dementia = Being present (tense)

At SFSU Counseling Student Association’s 5^th Annual Counseling Symposium, Nader Shabahangi and Sally Gelardin of AgeSong presented on 17 Things I Would Want, If I Get Forgetful (adapted from Rachel Wonderlin’s 16 Things I Would Want, If I Get Dementia).  Nader’s introduction raised the issue of labeling that separates humanity; for example, “disabilities” suggests being outside of the mainstream, rather than different functional abilities giving rise to possibilities.  Another example is “dementia” meaning “out of one’s mind” (from Latin), and this could suggest emptying the mind as in Zen enlightenment.  

Instead of the scientific view of dementia with its emphasis on cure, Nader talked about adopting an attitudinal shift towards a humanistic view of forgetfulness with an emphasis on care.  He noted that forgetfulness has a purpose to “let the mind go” of memories causing pain or embarrassment, to slowly work one’s way through death.  “If we view elders as our teachers, then forgetfulness as our teachers” that push us to learn wisdom and qualities like being present. 

  

Contemporary Jewish Museum’s Access Program hosted The Power of Art and Music: In the Lives of Those Living with Alzheimer’s seminar exploring research on creativity and the brain, and how arts and cultural experiences can enrich the lives of people living with Alzheimer’s or dementia.  The panelists included:

• Zachary Miller, MD Assistant Professor of Neurology, UCSF Memory and Aging Center – Neuroscience of Visual Art: lefty doc noted greater number of left handers in mental asylums & artistic behavior among mentally ill
• Lola  Fraknoi, founder of Ruth’s Table and Art Time Programs for a Creative Life  - Prompting to Make Art kit to release creativity in persons with moderate dementia
• Andrea Korsunsky, Coordinator for Center for Dementia Care, Seniors at Home, a program of Jewish Family and Children’s Services (JFCS) - Communication Strategies: use nonverbal body language to listen & be present, avoid word “remember”, ask for help & support in community
• Rachel Main, Family Support Coordinator, Ray Dolby Brain Health Center, Alzheimer’s Association – Why is Music and Art Important in Daily Life for People with Dementia? Engage both sides of brain to reduce 4 A’s (agitation, anxiety, apathy, aggression) & replace antipsychotics, focus on strengths that remain. 

Lola's examples of Prompting to Make Art: 1st slide (top left) shows beginning sketch of open image as visual cue for persons with Alzheimer’s to “think outside the box” and continue the drawing. 

Other resources:

·         TimeSlips 

·         Alzheimer’s Poetry Project 

·         NCCA Creative Caregiving 

Care giving/taking

At Ed Roberts Campus, UC Davis Alzheimer’s Disease Center and Alzheimer’s Association presented the 8th Annual African-American Caregiving and Wellness Forum: Focusing on Brain Health and Disease Management, which included a discussion moderated by Miranda Wilson of Smooth Jazz 98.1 FM:

·         Rita Hargrave, MD, geriatric psychiatrist at Veterans Administration

·         Yaisa Andrews-Zilling, PhD, who also presented on Recent Developments in Alzheimer’s Research: prevent and reduce risk by paying attention to heart health, exercise (African-Americans at highest risk of ethnic groups due to higher rates of cardiovascular disease, obesity & diabetes), brain stimulation/education/novelty, nutrition, social and emotional well-being

·         LoWanda Moore, MSW, who also presented on Taking Care of the Caregiver, demonstrated relaxation techniques like deep breathing and guided imagery

Elena Portacolone, PhD, of UCSF Institute for Health & Aging, is recruiting older adults age 65+ who are living alone with either Alzheimer’s disease or mild cognitive impairment for a research project, supported by National Institute on Aging and Alzheimer’s Association (which offers Dementia Capable Services & Supports, a free program to assist people living alone with dementia in San Mateo).  

Alzheimer’s Association Community Outreach Specialist Debbie Williams quit her job (supported by husband Lenny of Tower of Power) to care for her mother who was diagnosed with Alzheimer’s.  Though anyone with a brain is at risk, she emphasized that African-Americans are typically diagnosed in later stages of disease when they are more cognitively and physically impaired, needing more medical care yet less opportunity for input in long-term care and financial plans.

Treating Sickness & Death = Palliative & Hospice Care

Nearly half of all people with Alzheimer’s and other dementias are in hospice care at the time of their death, yet fewer than half of surveyed nursing homes have some sort of palliative care program.  Palliative Care and Hospice Education and Training Act (PCHETA) would increase palliative care and hospice training for health care professionals, launch a national campaign to inform patients and families about the benefits of palliative care, and enhance research on improving the delivery of palliative care. 

JFCS Seniors At Home launched a new Palliative Care Lecture Series, "Let's Keep Talking About..."  Psychotherapist Sylvia Boorstein and JFCS Director of Palliative Care Program Redwing Keyssar began the community conversation with “Let's Keep Talking About Old Age, Sickness, and Death - Liberating the Hard Questions from the Shadows.”

• Old Age:  Sylvia embraces old age by disclosing that she is 80 years old
• Sickness & Death:  Sylvia said if one gets cancer, one who thinks why me? suffers a lot; but one who thinks why not me? does not suffer so much.  Accept that death happens so don’t struggle with what can’t change.  Redwing expressed her disappointment reading Dr. Paul Kalanithi’s memoir, When Breath Becomes Air (2016), because the doctor dying of cancer only mentioned palliative care at the end, no mention of spiritual care but only medical treatment.

Redwing shared palliative care physician Ira Byock’s The Four Things That Matter Most: A Book About Living (2004) -- “Please forgive me,” “I forgive you,” “Thank you,” and “I love you” – the role of forgiveness as an opportunity to let go. 

At Books Inc., Pamela Skjolsvik read excerpts from her memoir Death Becomes Us (2015) about overcoming social anxiety disorder and fear of mortality.  Her use of humor to normalize death is similar to mortician Caitlin Doughty, author of Smoke Gets in Your Eyes & Other Lessons from the Crematory (2014) and founder of Order of the Good Death.

Aging policies

At Home With Growing Older hosted Brooke Hollister, Assistant Professor of Sociology in the Institute for Health & Aging at the University of California, San Francisco, for a discussion on Communicating Aging Issues At The Policy Level.

Congress finally passed legislation to reauthorize Older Americans Act (OAA), which President Obama signed into law this month—nearly five years after it expired  -- a symbolic act as funding remains flat for OAA programs like Meals On Wheels.  For example, government funding provides only 40% of the operating budget for Meals On Wheels of San Francisco (MOWSF), which fundraises the remainder; this month's MOWSF Star Chefs & Vintners Gala raised $3.3 million or 25% of its annual budget.  In contrast, Medicare expenditures doubled between 2005 and 2015, suggesting that unmet social needs are "medicalized" and delivered in higher-cost settings.

Booksmith hosted panel discussion on Marijuana in the Haight: From the 1967 Grateful Dead Bust to Legalization in 2016 with these movers and shakers: 

• Andy Clark, Assistant District Attorney
• Dennis McNally, The Grateful Dead’s publicist and historian
• Michael Stepanian, who formed the Haight-Ashbury Legal Organization (HALO) to defend the Grateful Dead who were busted for marijuana in 1967
• Marsha Rosenbaum, who made available free copies of Safety First release by Drug Policy Alliance
• Steven Heilig, San Francisco Medical Society and member of Lt. Governor Gavin Newsom’s Blue Ribbon Commission on Marijuana
• David Talbot, founder of Salon and author of Season of the Witch, a cultural history of San Francisco
• David Smith founded Haight Ashbury Free Clinic (HAFC) to care for young drug users and Rock Medicine to provide medical services at Bill Graham concerts.

Is medical marijuana as effective as opiates in treating pain?  Timely topic, especially following 57-year-old artist Prince’s death of possible opioid overdose.  In contrast to the epidemic of deaths from opioid overdose, the death rate from marijuana overdose remains zero.  And legalization of marijuana could generate tax revenue to fund senior services!

The New York Times' article, “U.S. Suicide Rate Surges to a 30-Year High,” (April 22, 2016) reported that from 1999 to 2014, suicide rates in the United States rose among most age groups:

• Men and women from 45 to 64 had a sharp increase
• Though suicide rates for older adults fell over the period of the study, men over 75 still have the highest suicide rate of any age group — 38.8 per 100,000 in 2014, compared with just 4 per 100,000 for their female counterparts.

Does Death With Dignity normalize suicide?

Stefano Bini, MD, UCSF Professor of Clinical Orthopaedics, highlights “Age is not a problem” during his presentation on Total Hip and Knee Replacement as a Treatment for Arthritis and New Developments.

DAAS Benefits & Resources Hub Grand Opening

San Francisco Department of Aging & Adult Services (DAAS) opened its Benefits and Resources Hub as a one-stop shop for the public to access in-person intake services (Adult Protective Services, In-Home Support Services & Home Care, Nutrition, Case Management, Information & Referral to Community Services), benefits (CalFresh, Medi-Cal), and Veterans Services.

Entrance to 2 Gough Street

Signs in English, Chinese, Spanish

Check-in with Greeter (gatekeeper) who asks for name & purpose of visit

Service counter

Waiting area