Anglonautes > English words - vocabulary - dictionary - encyclopedia > Life > Aging, Adulthood, Growing old / Getting older

BY the time he was 76, my father was frail. His balance was poor and he had trouble walking. He lived alone in Baltimore in a big house full of stairs, and watching him come tottering down those stairs was terrifying. Each time, I thought he might fall. He refused to make the house safer — no stair lifts, no grab rails (they would disfigure the house, he said) — and would not consider living anywhere else. When my brother and his wife invited my father to move in, the invitation was vigorously declined. And we lived in three different cities, far apart.

To try to cope better with this situation, my brother and I created a shared Google calendar — an online calendar in which we could both make entries from wherever we happened to be. Each time either of us spoke to our father, we marked it in the calendar — what time of day it was, how he sounded, what we spoke about. (If one of us called and he did not answer, we marked that, too. Yes, we both have an obsessive streak.)

For example, on Oct. 13, 2009, at 1:30, I telephoned home, spoke to my father and wrote in the calendar that he was “just off to see the new doctor, writing a list of his medications. Nothing else to report; leaves starting to turn and it’s starting to get cold.” Later that afternoon, he called my brother and said that he liked the new doctor (she was “slim, tall, pretty, and seemed very nice”), and that he had indeed discussed his medications with her.

The upshot was that we had an excellent record of how he was — whether he was getting out, if he was cheerful or feeling low, changes to his medicines, any falls he said he had had. The calendar also allowed us to make sure that one of us spoke to him just about every day. And if I couldn’t reach him, I didn’t have to wonder if he was lying hurt and helpless at the bottom of the stairs for days — I could look at the calendar and see that my brother had spoken to him a few hours ago.

We never told my father we did this — he probably would have been furious. There is, after all, something weird about the idea that people are taking notes on you, however loving their motives. It was our imperfect solution to an imperfect setup. And it helped us.

Just before his 79th birthday, my father started collapsing. First, he fell in the street. He thought he had tripped, but he wasn’t sure. Then he fell several times in the house (fortunately, not while on the stairs). The calendar provided a full record of it — and we could both see that there was something new, something abnormal. It turned out that his heart was stopping. My brother flew down and took him to a hospital, where he had a pacemaker put in.

But the calendar had other, more subtle effects, too. It was, in essence, a journal kept by two people who read each other’s entries, and so it gradually became a conversation between the two of us as well as a straight-up record of events. One day, he’s infuriating my brother with speculations about two friends’ having an inappropriate affair: “I said I thought he was being outrageous and that it was none of his business, even if his wild speculations were true. I hope he has the sense not to say anything to anyone else about his unfounded, wild, no evidence claims.” Another day, I’m remarking, “I’m worried by the extent to which he does not seem to cook for himself anymore.”

As you might expect, there are times when reading someone else’s journal entries is disquieting and revealing. I discovered aspects of my brother’s relationship with our father that I hadn’t appreciated. One of his entries said: “Asked about my accident (first time).” This was more than a year after my brother had been hit by a car and badly hurt. My heart cracked: I had not realized how inattentive my father had been.

Going back through the calendar now, more than 18 months after my father died, the entries chart a relentless physical decline — profound fatigue, sore hips and knees, aching wrists, swollen legs, inflamed teeth, increasing forgetfulness, the savage indignities of old age. One day, he took a bath but couldn’t get out of the tub. Luckily, the housekeeper arrived; she couldn’t get him out either, so she recruited the postman to help. My father thought this was hilarious: I admired his ability to laugh.

For through it all, there’s such courage. Yes, he’s just had a pacemaker installed and he’s feeling rotten, but he’s making strawberry jam. One day, “He sounded very low — lonely, old, and scared.” But another, he’s reading a history of some sinister French aristocrats and planning to install a wood stove in the fireplace. A beloved friend is coming to stay. He’s just learned a new poem.

At the time, I was glad we kept the calendar because it helped us to cope with a difficult situation. Now I’m glad for a different reason: it helps me remember small details about him, the little things that slip out of memory, that fade with time. Laughs, tears, worries, frustrations, joy and love — it’s all in the calendar.

Olivia Judson is a writer

and an evolutionary biologist.

The Last Calendar,
NYT,
22.1.2013,
https://www.nytimes.com/2013/01/23/
opinion/the-last-calendar.html

Life Goes On, and On ...

December 17, 2011

The New York Times

By JAMES ATLAS

A FRIEND calls from her car: “I’m on my way to Cape Cod to scatter my mother’s ashes in the bay, her favorite place.” Another, encountered on the street, mournfully reports that he’s just “planted” his mother. A third e-mails news of her mother’s death with a haunting phrase: “the sledgehammer of fatality.” It feels strange. Why are so many of our mothers dying all at once?

As an actuarial phenomenon, the reason isn’t hard to grasp. My friends are in their 60s now, some creeping up on 70; their mothers are in their 80s or 90s. Ray Kurzweil, the author of “The Singularity Is Near: When Humans Transcend Biology,” believes that we’re close to unlocking the key to immortality. Perhaps within this century, he prophesies, “software-based humans” will be able to survive indefinitely on the Web, “projecting bodies whenever they need or want them, including virtual bodies in diverse realms of virtual reality.” Neat, huh? But for now, it’s pretty much dust to dust, the way it’s always been — mothers included. (Most of our fathers are long gone, alas. Women live longer than men.)

It’s the ones who aren’t dead who should baffle us. My own mother, for instance, still goes to the Boston Symphony and attends a weekly current events class at Brookhaven, her “lifecare living” center (can’t we find a less technocratic word?) near Boston. She writes poems in iambic pentameter for every occasion. At 94, she’s hardly anomalous: there are plenty of nonagenarians at Brookhaven. Ninety is the new old age. As Dr. Muriel Gillick, a specialist in geriatrics and palliative care at Harvard Medical School, says, “If you’ve made it to 85 then you have a reasonable chance of making it to 90.” That number has nearly tripled in the last 30 years. And if you get that far... it’s been estimated that there will be eight million centenarians by 2050.

It won’t end there. Scientists are closing in on the mechanism of what are called “senescent cells,” which cause the tissue deterioration responsible for aging. Studies of mice suggest that targeting these cells can slow down the process. “Every component of cells gets damaged with age,” Leonard Guarente, a biology professor at M.I.T., explained to me. “It’s like an old car. You have to repair it.” We’re not talking about immortality, Professor Guarente cautions. Biotechnology has its limits. “We’re just extending the trend.” Extending the trend? I can hear it now: 110 is the new 100.

Is this a good thing or a bad thing? On the debit side, there’s the ... debit. The old-age safety net is already frayed. According to some estimates, Social Security benefits will run out by 2037; Medicare insurance is guaranteed only through 2024. These projected shortfalls are in part the unintended consequence of the American health fetish. The ad executives in “Mad Men” firing up Lucky Strikes and dosing themselves with Canadian Club didn’t have to worry. They’d be dead long before it was time to collect.

Then there’s the question of whether reaching 5 score and 10 is worth it — the quality-of-life question. Who wants to end up — as Jaques intones in “As You Like It” — “sans teeth, sans eyes, sans taste, sans everything”? You may live to be as old as Methuselah, who lasted 969 years, but chances are you’ll feel it.

Worse — it’s no longer a rare event — you can outlive your children. Reading the obituary of Christopher Ma, a Washington Post executive who had been a college classmate of mine, I was especially sad to see that Chris was survived by his wife, a daughter, a son, a brother, two sisters and “his mother, Margaret Ma of Menlo Park, Calif.” Can anything more tragic befall a parent than to be predeceased by a child?

These are the perils old people suffer. What about us, the boomers, now ourselves elderly children? One challenge my entitled generation faces is that many of our long-lived parents are running through their retirement money, which leaves the burden of supporting them to us. (To their credit, it’s a burden that often bothers our parents, too.) And the cost of end-stage health care is huge — a giant portion of all medical expenses in this country are incurred in the last months of life. Meanwhile, our prospects of retirement recede on the horizon.

Also, elder care is stressful and time consuming. The broken hips, the trips to the E.R., the bill paying and insurance paperwork demand patience. A paper titled “Personality Traits of Centenarians’ Offspring” suggests this cohort scores high marks “extraversion, openness, agreeableness and conscientiousness.” But even the well-adjusted find looking after old parents tough.

In the mid-’80s, when the idea of the “sandwich generation” was born — boomers saddled with the care of aging parents while raising their own children — it seemed like a problem we would eventually outgrow. Twenty-five years later, we’re still sandwiched, and some of those caught in the middle feel the squeeze.

So what’s the good part? Time spent with an elderly parent can offer an opportunity for the resolution of “unfinished business,” a chance to indulge in last-act candor. A college classmate writes in our 40th-reunion book of ministering to her chronically ill mother and being “moved by how the twists and turns of complicated health care have deepened our relationship.” I hear a lot about late-in-life bonding between parent and child.

My mother needs a minor operation. “I’ve outlasted my time,” she says as she’s wheeled into surgery. “Anyway, you’re too old to have a mother.” Thanks, Ma. What about Rupert Murdoch? His mother is 102. Also, if I’m too old to have a mother, why do I still feel like a child?

Two weeks later, Mom comes to Vermont to recuperate. My father, who died a decade ago at 87, is buried in the field behind our house (hope this is legal). His gravestone reads “Donald Herman Atlas 1913-2001,” and it has an epitaph from his favorite poet, T. S. Eliot, carved in italics: “I grow old ... I grow old .../ I shall wear the bottoms of my trousers rolled.” Mom likes to visit him there. Standing over Dad’s grave, she carries on a dialogue of one. “I thought I’d have joined you by now, Donny, but I’m a tough old bird.” As she heads back up to the house, she turns and waves. “À bientôt.” See you soon.

Not so fast, Mom. I still have issues.

James Atlas is the author

of “My Life in the Middle Ages: A Survivor’s Tale.”

Life Goes On, and On ...,
NYT,
17.12.2011,
http://www.nytimes.com/2011/12/18/
opinion/sunday/old-age-life-goes-on-and-on.html

Paying for Old Age

February 25, 2011

The New York Times

By HENRY T. C. HU

and TERRANCE ODEAN

LIFE expectancy at birth for Americans is about 78. But many Americans will die well before then, while others, like Eunice Sanborn, who died in Texas last month, will live to be 114.

Anyone planning for retirement must answer an impossible question: How long will I live? If you overestimate your longevity, you might scrimp unnecessarily. If you underestimate, you might outlive your savings.

This is hardly a new problem — and yet not a single financial product offers a satisfactory solution to this risk.

We believe that a new product — a federally issued, inflation-adjusted annuity — would make it possible for people to deal with this problem, with the bonus of contributing to the public coffers. By doing good for individuals, the federal government could actually do well for itself.

The insurance industry sells an inflation-adjusted annuity that goes part of the way toward helping people cope with the possibility of outliving their savings. During your working years or at the time of retirement, you can pay a premium to an insurance company in exchange for the promise that the company will pay you a fixed annual income, adjusted for inflation, until you die.

But in a world in which A.I.G. had an excellent rating only days before it became a ward of the state, how can someone — particularly a young person — know for sure which insurance companies will be solvent half a century from now? Annuities aren’t federally guaranteed. The only backstops are state-based systems, and the current protection ceilings are sometimes modest. If an insurance company goes under, the retiree may end up with nothing close to what was promised.

The federal government can offer a product that solves that problem. Individuals would face no more risk of default than that associated with Treasury bills and other obligations backed by the United States.

Here’s how it would work. Initially, people who wanted to buy this insurance would enroll through one of the qualified retirement savings plans already offered to the public, like a 401(k) plan, and could choose this annuity option instead of, or in addition to, investments in stocks, bonds or mutual funds.

How much the payouts would be could be based on a variety of factors, including interest rates on government bonds; mortality tables that, among other things, take into account that healthier people are more likely to buy annuities; and administrative costs. This new product wouldn’t cost the government a penny. In fact, the Treasury would benefit. It is only an incremental move beyond issuing inflation-adjusted bonds, which the Treasury already does. By allowing the government to tap a new class of investors, the cost of government borrowing over all would probably drop.

Moreover, by expanding the government’s base of domestic investors, the plan would help address overreliance on foreign lenders, who now own close to half of all outstanding federal debt — nearly 10 times the proportion in 1970. True, the government would be on the hook if a technological breakthrough caused an unanticipated increase in life expectancy. But that’s a risk that the government is already bearing implicitly: that is, a drastic enough increase could threaten the solvency of private issuers of annuities as well as the many retirees who don’t have annuities, creating pressure for government bailouts of insurers or individuals. Taking on the risk explicitly and pricing the fair cost of this risk into the annuities is a far preferable route.

There is also the concern that government-issued annuities would crowd out private annuity sales. To the contrary: they could spur growth in private annuities. Since the inflation-adjusted monthly payments on such risk-free government annuities would be low, many retirees may choose to supplement them with riskier, higher-paying annuities.

Furthermore, insurance companies could be allowed to package the government-issued annuities with their own products, creating appealing combinations that mix safety and the potential for higher returns.

Our proposal is a winner for everyone. The Treasury could lower borrowing costs and diversify its investor base while acknowledging and budgeting for risk that it already bears. Individuals could eliminate the risk of living too long. By looking at the promised rate of return on the annuities, individuals will have a better sense of how much they need to save. The Eunice Sanborns of the world, as well as all taxpayers, would rest a little easier at night.

Henry T. C. Hu is a professor

at the University of Texas School of Law.

Terrance Odean is a finance professor

at the University of California at Berkeley.

Paying for Old Age,
NYT,
25.2.2011,
http://www.nytimes.com/2011/02/26/
opinion/26Hu.html

Real Life Among the Old Old

December 30, 2010

The New York Times

By SUSAN JACOBY

I RECENTLY turned 65, just ahead of the millions in the baby boom generation who will begin to cross the same symbolically fraught threshold in the new year to a chorus of well-intended assurances that “age is just a number.” But my family album tells a different story. I am descended from a long line of women who lived into their 90s, and their last years suggest that my generation’s vision of an ageless old age bears about as much resemblance to real old age as our earlier idealization of painless childbirth without drugs did to real labor.

In the album is a snapshot of my mother and me, smiling in front of the Rockefeller Center Christmas tree when she was 75 and I was 50. She did seem ageless just 15 years ago. But now, as she prepares to turn 90 next week, she knows there will be no more holiday adventures in her future. Her mind is as acute as ever, but her body has failed. Chronic pain from a variety of age-related illnesses has turned the smallest errand into an excruciating effort.

On the next page is a photograph of my maternal grandmother and me, taken on a riverbank in 1998, a few months short of her 100th birthday. For one sunny afternoon, I had spirited her away from the nursing home where she spent the last three years of her life, largely confined to a wheelchair, with a bright mind — like my mother’s today — trapped in a body that would no longer do her bidding.

“It’s good to be among the living again,” Gran said, in a tone conveying not self-pity but her own realistic assessment that she had lived too long to live well.

Yet people my age and younger still pretend that old age will yield to what has long been our generational credo — that we can transform ourselves endlessly, even undo reality, if only we live right. “Age-defying” is a modifier that figures prominently in advertisements for everything from vitamins and beauty products to services for the most frail among the “old old,” as demographers classify those over 85. You haven’t experienced cognitive dissonance until you receive a brochure encouraging you to spend thousands of dollars a year for long-term care insurance as you prepare to “defy” old age.

“Deny” is the word the hucksters of longevity should be using. Nearly half of the old old — the fastest-growing segment of the over-65 population — will spend some time in a nursing home before they die, as a result of mental or physical disability.

Members of the “forever young” generation — who, unless a social catastrophe intervenes, will live even longer than their parents — prefer to think about aging as a controllable experience. Researchers who were part of a panel discussion titled “90 Is the New 50,” presented at the World Science Festival in 2008, spoke to a middle-aged, standing-room-only audience about imminent medical miracles. The one voice of caution about inflated expectations was that of Robert Butler, the pioneering gerontologist who was the first head of the National Institute on Aging in the 1970s and is generally credited with coining the term “ageism.”

Earlier this year, a few months before his death from leukemia at age 83, I asked Dr. Butler what he thought of the premise that 90 might become the new 50. “I’m a scientist,” he replied, “and a scientist always hopes for the big breakthrough. The trouble with expecting 90 to become the new 50 is it can stop rational discussion — on a societal as well as individual level — about how to make 90 a better 90. This fantasy is a lot like waiting for Prince Charming, in that it doesn’t distinguish between hope and reasonable expectation.”

The crucial nature of this distinction has become foremost in my thinking about what lies ahead.

My hope is that I will not live as long as my mother and grandmother. We all want to be the exceptions: Elliott Carter, an active composer when he walked onto the stage of Carnegie Hall for his centennial tribute in 2008; Betty White, a bravura comedian who wows audiences at 88; John Paul Stevens, the author of brilliant judicial opinions until the day he retired from the Supreme Court at 90. I, too, hope to go on being productive, writing long after the age when most people retire, in the twilight of the print culture that has nourished my life. Yet it is sobering for me — as it is for Americans in many businesses and professions that once seemed a sure thing — to see younger near contemporaries being downsized out of jobs long before they are emotionally or financially ready for retirement.

Furthermore, I am acutely aware — and this is the difference between hope and expectation — that my plans depend, above all, on whether I am lucky enough to retain a working brain. I haven’t mentioned, because I don’t like to think about it, that my paternal grandmother, who also lived into her 90s, died of Alzheimer’s disease. The risk of dementia, of which Alzheimer’s is the leading cause, doubles every five years after 65.

Contrary to what the baby boom generation prefers to believe, there is almost no scientifically reliable evidence that “living right” — whether that means exercising, eating a nutritious diet or continuing to work hard — significantly delays or prevents Alzheimer’s. This was the undeniable and undefiable conclusion in April of a major scientific review sponsored by the National Institutes of Health.

Good health habits and strenuous intellectual effort are beneficial in themselves, but they will not protect us from a silent, genetically influenced disaster that might already be unfolding in our brains. I do not have the slightest interest in those new brain scans or spinal fluid tests that can identify early-stage Alzheimer’s. What is the point of knowing that you’re doomed if there is no effective treatment or cure? As for imminent medical miracles, the most realistic hope is that any breakthrough will benefit the children or grandchildren of my generation, not me.

I would rather share the fate of my maternal forebears — old old age with an intact mind in a ravaged body — than the fate of my other grandmother. But the cosmos is indifferent to my preferences, and it is chilling to think about becoming helpless in a society that affords only the most minimal support for those who can no longer care for themselves. So I must plan, as best I can, for the unthinkable.

I have no children — a much more common phenomenon among boomers than among old people today. The man who was the love of my adult life died several years ago; now I must find someone else I trust to make medical decisions for me if I cannot make them myself. This is a difficult emotional task, and it does not surprise me, for all of the public debate about end-of-life care in recent years, that only 30 percent of Americans have living wills. Even fewer have actually appointed a legal representative, known as a health care proxy, to make life-and-death decisions.

I can see that the “90 is the new 50” crowd might object to my thinking more about worst-case scenarios than best-case ones. But if the best-case scenario emerges and I become one of those exceptional “ageless” old people so lauded by the media, I won’t have a problem. I can also take it if fate hands me a passionate late-in-life love affair, a financial bonanza or the energy to write more books in the next 25 years than I have in the past 25.

What I expect, though — if I do live as long as the other women in my family — is nothing less than an unremitting struggle, ideally laced with moments of grace. On that day by the riverbank — the last time we saw each other — Gran cast a lingering glance over the water and said, “It’s good to know that the beauty of the world will go on without me.”

If I can say that, in full knowledge of my rapidly approaching extinction, I will consider my life a success — even though I will have failed, as everyone ultimately does, to defy old age.

Susan Jacoby is the author,

most recently, of the forthcoming

“Never Say Die:

The Myth and Marketing of the New Old Age.”

Real Life Among the Old Old,
NYT,
30.12.2010,
http://www.nytimes.com/2010/12/31/
opinion/31jacoby.html

In Haven for Over-55 Set,

Age Police Hunt Violators

Who Shriek or Toddle

August 28, 2010

The New York Times

By MARC LACEY

SUN CITY, Ariz. — From behind the wheel of his minivan, Bill Szentmiklosi scours the streets of Sun City in search of zoning violations like unkempt yards and illegal storage sheds. Mostly, though, he is on the lookout for that most egregious of all infractions: children.

With a clipboard of alleged violations to investigate, he peers over fences and ambles into backyards of one of America’s pioneer retirement communities, a haven set aside exclusively for adults, where children are allowed to visit but not live.

Mr. Szentmiklosi, 60, a retired police officer who settled here four years ago, has remade himself as the chief of Sun City’s age police, the unit charged with ensuring that this age-restricted community of sexagenarians, septuagenarians and even older people does not become a refuge for the pacifier-sucking, ball-playing or pimple-faced.

One recent morning, as he slowly wheeled between ranch homes and palm trees, Mr. Szentmiklosi kept a sharp eye on the driveways and yards, surveying for any obvious signs of youth. It could be a stray ball, a misplaced pint-size flip-flop. In sniffing out children, he said, he relies on his three decades as an officer.

But it is when he strides up to a home, dressed in shorts, sandals and a polo shirt, and knocks on the door that his detective work really begins. He tells the suspected violator that a neighbor has complained and he asks gentle questions to get to the bottom of things, all the while peering around for signs of youthful activity. His work is helped by a simple reality: children are hard to hide.

They leave tracks and make unique sounds. Newborns bellow, toddlers shriek and teenagers play music that is not typical around Sun City.

Mr. Szentmiklosi and his fellow child-hunters have their work cut out for them. The number of age violations in Sun City, a town of more than 40,000 residents outside Phoenix, has been rising markedly over the years, from 33 in 2007 to 121 in 2008 to 331 last year, a reflection of a trend at many of the hundreds of age-restricted communities nationwide.

This year’s figures are expected to be even higher, said Mr. Szentmiklosi, who knows that despite his patrols Sun City is probably harboring more children that have not yet been detected. The economic crisis is aggravating the problem, he said, forcing families to take desperate measures to cut costs, even if it means surreptitiously moving into Grandma and Grandpa’s retirement bungalow.

The vigorous search for violators of Sun City’s age rules is about more than keeping loud, boisterous, graffiti-scrawling rug rats from spoiling residents’ golden years, although that is part of it. If Sun City does not police its population, it could lose its special status and be forced to open the floodgates to those years away from their first gray hair.

The end result would be the introduction of schools to Sun City, then higher taxes and, finally, an end to the Sun City that has drawn retirees here for the last half-century.

At 50, Sun City is not old by the standards of Sun City, where the average resident is in his or her early 70s.

To remain a restricted retirement community, at least 80 percent of Sun City’s housing units must have at least one occupant who is 55 or older, allowing for younger spouses or adult children. But the rules are clear on one thing: no one, absolutely no one, who is a teenager, an adolescent, a toddler, a newborn, any form of child, may call Sun City home.

“Visits are O.K. as long as they’re limited,” said Mr. Szentmiklosi, who describes himself as a doting grandfather and insists that he does not have an anti-child bone in his body. “You can have children visit for 90 days per year. That means if you have 10 grandchildren, each one can visit, but they can only stay nine days each.”

Mr. Szentmiklosi, the compliance manager for the Sun City Homeowners Association, said that although the city was scrupulous, it remained compassionate. For instance, it allowed a young woman with an infant who was renting a home without the association’s knowledge a year to move out.

But the association also plays hardball, issuing fines and threatening legal action to pressure youthful violators to leave. One reason Sun City is so vigorous is because of what happened on the other side of 111th Avenue, one of the main roads traversing the neighborhood.

Although Del Webb, who developed Sun City in 1960, gets credit for inventing the idea of a community of active retirees, the concept actually started years before on an adjacent tract in what was called Youngtown. But the developers there were not diligent in drawing up their legal paperwork. A challenge by the family of a teenage boy led the state to strip Youngtown of its age restrictions in 1998.

So on one side of the road, little people can be seen running around. On the other side, many people remember the Great Depression, and not from reading about it in a book.

“It was so much quieter before,” said Librado Martinez, 80, a retired machine operator who lives on the Youngtown side of the line and has to put up with children playing ball in the park in front of his house. “You heard no screams before.”

That peace is what Sun City residents want to keep. They rose up last month to block a charter school, which is not governed by the same rules as other public schools, from moving in.

“They were concerned about children roaming the streets and terrorizing things,” said Marsha Mandurraga, who works for the school’s founder.

To prevent future incursions, Sun City’s leaders are using their clout to urge state legislators to change the law to keep Sun City school-free.

“I’ve raised kids,” said Chris Merlav, 61, breathing through an oxygen tank and resting on the side of a Sun City pool designed for walking, not swimming. “After a while you get to the point where you don’t want to be bothered anymore.”

Mr. Merlav, who moved here from Rochester, had evidence at hand that he was not anti-child. His 20-year-old stepdaughter, Danielle Anastasia, was lounging in the pool with him. She understood the desire of Sun City residents to be with people their own age. “It’s like me hanging with my college friends,” she said.

Some of Sun City’s more hard-line anti-child activists can sound as though they somehow bypassed youth completely.

“There are people here who have never had children, don’t care for children and don’t particularly want children around,” said Jan Ek, who runs Sun City’s seven recreation centers, eight golf courses, two bowling centers and assorted other entertainment venues, some of which sometimes open up for child visitors.

At Sun City’s museum, the resident historian, Bill Pearson, 62, played a videotape used to lure retirees to the development in the 1960s.

The narrator said then what many residents still say now: “Of course we love them and enjoy their visits, but you deserve a little rest after raising your own.”

In Haven for Over-55 Set,
Age Police Hunt Violators Who Shriek or Toddle,
NYT,
28.8.2010,
http://www.nytimes.com/2010/08/29/us/29children.html

Jane Miller:

'I'm not sure I really will die'

In an extract from her new book Crazy Age,
the 77-year-old author takes a stark
– and very personal – look
at the realities of growing old in the 21st century

Thursday 26 August 2010
The Guardian
Jane Miller
This article appeared on p12
of the G2 section of the Guardian
on Thursday 26 August 2010.
It was published on guardian.co.uk at 07.00 BST
on Thursday 26 August 2010.
It was last modified at 10.10 BST
on Thursday 26 August 2010.

A statistic from nowhere, or nowhere I remember, but it has the ring of truth: if most of us can look forward to living for about 10 years longer than our parents, we can also expect to spend the equivalent of eight of those years in hospital or doctors' waiting-rooms. When, at nearly 80, Gore Vidal was asked to explain why he had left Italy for California, he spoke of his future as "the hospital years".

My local hospital is ugly on the outside and beautiful within, though both the outside and the inside seem differently determined to masquerade as something that is not a hospital. Its modern facade was meant to fit into the shops it sits among, and tucked into it are a post office, a cafe, a mobile phone shop and another shop that sells the unhealthiest snacks and fizzy drinks known to the western world. Desperate smokers – patients on crutches, in wheelchairs and dressing-gowns, nurses, doctors, visitors – cough and cluster outside.

Inside, however, there are constant and changing exhibitions of sculpture, pictures and mobiles. The building itself is curiously ship-like, constructed to seem open to the sky. There are wards from which you might gaze out across the roofs of London with a telescope to one eye, and walkways like gangplanks, and a chapel suspended in space, a kind of crow's nest from which to survey the turbulence below.

In this surprising building, I have now been in receipt of two new knees and weeks of physiotherapy in a hot pool and a gym. Twice a year I have my eyes tested for glaucoma and for mysterious "drusen" growths at the sides of my eyes, which must be stopped from putting pressure on the optic nerve. Also twice a year I go less happily through the endoscopy department to emerge bloated and suffering after a "procedure" I shall decently leave to the imagination. I have had x-rays of most bits of me and MRI scans, and tests for heart and lungs on a machine that simulates running uphill. I have been asked to count backwards in sevens and remember the name of the prime minister (part of a somewhat cursory test for Alzheimer's).

Only my teeth fail to interest anyone in this glorious NHS galleon, and for their sorry state I travel by three forms of public transport to north London, sometimes once a week. All that doesn't quite add up to four-fifths of my life, but it is mounting up.

I'm not sure this new familiarity with the inside of a large teaching hospital is especially cheering or enlightening, but it is intrinsic to contemporary experience. Philip Roth's book Everyman springs brilliantly out of the new knowingness – no doubt partial and amateurish, but full of relish for the language and the detail – that we all now exhibit about disease and treatment and dying. Here, for instance, is Roth's hero talking on the telephone to the wife of his old friend, who died suddenly at home while she was out to lunch: "Was it a stroke or was it a heart attack?" he asked.

"It was a myocardial infarct."

"Had he been feeling ill?"

"Well his blood pressure had been – well, he had a lot of trouble with his blood pressure. And then this past weekend he wasn't feeling so great. His blood pressure had gone up again."

"They couldn't control that with drugs?"

Roth's unnamed hero, his Everyman, is understandably interested in the manner of his friend's dying. He probably owns his own blood-pressure gauge too.

I should add that in general I am in remarkably good health. I hardly ever get colds or flu. I can now walk for miles with my new knees and stand for quite long stretches at bus stops or in exhibitions. I hardly ever sleep in the day (but don't sleep nearly enough in the night) and I eat and drink as much and as indiscriminately as I ever did.

My natural competitiveness let me down badly when I was assessed at the town hall for a temporary disability parking badge for my car. It was before I'd had my knees replaced, and I was having difficulty walking. There, in a tiny office, with an old-fashioned games teacher checking me for any tricks I might get up to, I found myself unable to resist showing her that I could still touch my toes, with my hands flat on the ground. Proving, I suppose, that I have long arms, short legs and little in the way of persuasive gifts. I was denied the badge.

Old people are often told they're "marvellous" for simply being there and not complaining much. As though our longevity or our susceptibility to disease were entirely up to us, were choices we make: pain and illness the outward signs of weakness, vacillation, lack of character; health the well-earned consequence of courage and the right amount of moral fibre. The man or woman who meekly submits to illness and death rather than "fighting" it, "putting up a struggle", is unlikely to figure gloriously in obituary columns.

What are we allowed to say about pain? The hardest aspect of it is the difficulty of describing it, measuring it, knowing if it is better or worse, more or less, than anyone else's or, indeed, our own on another day. When a doctor's report from the endoscopy department included the words "low pain threshold" I felt accused and slandered. How could he know that? How can any of us know? Perhaps the pain was beyond anyone's threshold. We'll never know.

This is all the more important now that the sinister word "triage" has been reintroduced into medical practice, reminiscent of Florence Nightingale and her nurses patrolling the tents in the Crimea in order to decide which of the wounded were worth treating, which should be attended to first and which were not worth bothering about because they were bound to die anyway. It may no longer be wise to show fortitude under stress if we want our ailments to be taken seriously.

I woke this morning with an ominous pain on the right side of my chest. There are some good things about new, sharp pains: they tend to blot out the older, more persistent ones. So, unusually, I had no cramp in my legs, nor could I feel the sharp agony and intractable stiffness in the small of my back that greets me on other mornings. The pains of old age are often undiagnosed and perhaps undiagnosable. Since they are usually produced by the gradual, or occasionally sudden, wearing out of bits of our minds and bodies, they are often less frightening than new and inexplicable pains were in one's youth, because for the most part they don't herald serious illness or catastrophe but simply remind us of our general and increasing debility. The bad thing about them, however, is that by and large they are going to get worse.

If I find it painful getting out of bed in the morning, I am likely to find it harder still in five years' time. Then you have to add that, though that is undoubtedly so, it is also quite possible that you won't be there in five years. And given that it's pain you're thinking about, you're faced with a dilemma. Do you really want to be there having a much worse version of the pain that's bothering you now? Might it possibly be a relief not to be there?

When Vidal talks of "the hospital years", he means his last years, not just a passing phase. And when we talk of our state of mind or health nowadays we probably aren't alluding to a temporary state, but to the present and the future and to a continuous, declining, but finite condition, and all of it hurtling along at great speed.

In his Nothing to Be Frightened Of, a meditation on his lifelong fear of dying, Julian Barnes divides people into those who fear death and those who fear the incapacities of old age, with subheadings for those who do or don't believe in God or an afterlife. "I'm sure my father feared death, and fairly certain my mother didn't: she feared incapacity and dependence more," Barnes writes. I don't think much about my own death or even fear it, I suppose because I am unable to imagine it. But I did catch myself hoping the other day that I might have most of my teeth when I'm dying, if only to spare the sensibility of an onlooker, should there be one. It is a hope all too likely to be thwarted, I'm sorry to say.

I can imagine all too easily, on the other hand, the stretch of life preceding death, and its potential for misery, weakness, dependence, though I don't think about that very much either, probably because I can't bear to. I am terrified of having nothing to do and no one to talk to. I avoid all articles and programmes advising me to insure myself now for dementia and other debilities, book a place in a home or negotiate a granny flat, let alone join EXIT or look into the fees, legality and conditions of death-delivering doctors in Switzerland.

I should come clean. I'm not sure that I really believe that I will be dead one day, any more than I entirely believe that I'm as old as I am. I would like to think that everyone has moments when they think of themselves as the exception to the rule. Writing about my own old age is a way of convincing myself that I really am old and that I really will die.

There are people who see old age as a time of peace, acceptance and the end of strong feeling. I do know old people who seem to have reached a plateau of that sort. They are amused, interested, calm, and they appear to have accepted the inevitability of their distance from a great deal of what goes on in the world. Yet in their desire both to live a good old age and to control the manner of their dying I doubt whether many of them would go quite as far as the old or ill adherents of Jainism in India sometimes do. William Dalrymple talked to a nun about the Jain custom of gently starving yourself to death, a process she firmly distinguishes from suicide.

"Sallekhana is a beautiful thing. There is no distress or cruelty. As nuns our lives are peaceful, and giving up the body should also be peaceful . . . First you fast one day a week, then you eat only on alternate days: one day you take food, the next you fast. One by one, you give up different types of foodstuffs. You give up rice, then fruits, then vegetables, then juice, then buttermilk. Finally you take only water, and then you have that only on alternate days. Eventually, when you are ready, you give up on that too. If you do it very gradually, there is no suffering at all. The body is cooled down, so that you can concentrate inside on the soul and on erasing all your bad karma."

There is an entirely different version of old age: the old person who is angry, impatient, full of regrets, nostalgia, distrust of the young; and there's a particular bitterness and resentment such a person may go in for, stored up from the past and sharpened now by powerlessness and by embarrassing and ineffectual efforts to garner and maintain dignity. Dylan Thomas was 37 when he wrote Do Not Go Gentle Into That Good Night with its injunction that "Old age should burn and rave at close of day." It was advice I approved of in those days, even though the poor fellow died two years later, when he was not yet 40. It would be hard for most of us to keep up all that burning and raving in our 70s.

My old friend Anne Wollheim had a really bad month or two at the end of her life and was known to wonder aloud, "Where is Dr Shipman now?" In fact, she had more than a year of knowing she was going to die and refusing to have the treatment which would probably not have lengthened her life by much. She filled that year with children and grandchildren and family and friends and travel, so that I find myself hoping that only the last two months or so were intolerable.

If it is true that we have 10 extra years of life nowadays, but that eight of them bear more than a shadow of decrepitude and the complicated moral choices inflicted on us by medical advances, we will need to work out how to get more control over the ways there may be of ending it all.

© Jane Miller 2010.
This is an edited extract from Crazy Age,
published by Virago at £14.99 on 2 September.
To order a copy for £11.99 with free UK p&p,
go to guardian.co.uk/bookshop or call 0330 333 6846

    Jane Miller: 'I'm not sure I really will die', G, 26?8.2010,
    http://www.guardian.co.uk/lifeandstyle/2010/aug/26/
    jane-miller-growing-old-ageing

Robert Butler,

Aging Expert,

Is Dead at 83

July 6, 2010
The New York Times
By DOUGLAS MARTIN

Dr. Robert N. Butler, a psychiatrist whose painful youthful realization that death is inevitable prompted him to challenge and ultimately reform the treatment of the elderly through research, public policy and a Pulitzer Prize-winning book, died Sunday in Manhattan. He was 83 and had worked until three days before his death.

The cause was acute leukemia, his daughter Christine Butler said.

Dr. Butler’s influence was apparent in the widely used word he coined to describe discrimination against the elderly: “ageism.” He defended as healthy the way many old people slip into old memories — even giving it a name, “life review.”

In speech after speech, he pounded home the message that longevity in the United States had increased by 30 years in the 20th century — greater than the gain during the preceding 5,000 years of human history — and that this had led to profound changes in every aspect of society, employment and politics among them.

Dr. Christine Cassel, president of the American Board of Internal Medicine, said in an interview that Dr. Butler had in effect “created an entire field of medicine.” She said he had helped change attitudes so that aging could be perceived “a positive thing.”

Dr. Butler was the founding director of the National Institute on Aging at the National Institutes of Health and advocated for the aging before Congress and the United Nations. He helped start and led the American Association for Geriatric Psychiatry, the Alzheimer’s Disease Association and the International Longevity Center. President Bill Clinton named him chairman of the 1995 White House Conference on Aging.

“He really put geriatrics on the map,” Dr. David B. Reuben, chief of the division of geriatrics at the University of California, Los Angeles, said in an interview.

Dr. Butler challenged long-held conceptions about aging, calling it “the neglected stepchild of the human life cycle.” He helped establish, for example, that senility is not inevitable with aging. When the Heinz Family Foundation presented him with an award in 2003, it called him “a prophetic visionary.”

The most noted exposition of his vision was the 1975 book that earned him his Pulitzer, “Why Survive? Being Old in America.” It went from a bleak explication of the elderly’s condition to prescriptions to improve it.

“Human beings need the freedom to live with change, to invent and reinvent themselves a number of times through their lives,” Dr. Butler wrote.

Dr. Butler’s mission emerged from his childhood, he wrote in his book. His parents had scarcely named him Robert Neil Butler before splitting up 11 months after his birth on Jan. 21, 1927, in Manhattan. He went to live with his maternal grandparents on a chicken farm in Vineland, N.J.

He came to revere his grandfather, with whom he cared for sick chickens in the “hospital” at one end of the chicken house. He loved the old man’s stories. But the grandfather disappeared when Robert was 7, and nobody would tell him why. He finally learned that he had died.

Robert found solace in his friendship with a physician he identified only as Dr. Rose. Dr. Rose had helped him through scarlet fever and took him on his rounds by horse and carriage. The boy decided he could have helped his grandfather survive had he been a doctor. He also concluded that he would have preferred that people had been honest with him about death.

From his grandmother, he learned about the strength and endurance of the elderly, he wrote. After losing the farm in the Depression, she and her grandson lived on government-surplus foods and lived in a cheap hotel. Robert sold newspapers. Then the hotel burned down, with all their possessions.

“What I remember even more than the hardships of those years was my grandmother’s triumphant spirit and determination,” he wrote. “Experiencing at first hand an older person’s struggle to survive, I was myself helped to survive as well.”

Dr. Butler served in the United States Maritime Service before entering Columbia University, where he earned his bachelor’s and medical degrees. During his internship in psychiatry at St. Luke’s Hospital, he had many elderly patients and realized how little he had been taught about treating them. He began reading about the biology of aging.

After his residency at the University of California, San Francisco, he worked at the National Institute of Mental Health as a research psychiatrist. He studied the central nervous system in elderly people, work that became part of a large study of aging. He also helped Ralph Nader investigate problems in nursing homes.

The book that emerged from his experiences proposed many specific reforms to help old people, including a national service corps that would enlist the elderly as community volunteers.

In 1975 he succeeded in creating a National Institute on Aging and was its head for six years.

“Nobody thought research on aging was a legitimate field until Bob came along and convinced them to create a separate institute,” Dr. Cassel said.

In 1982, the Mount Sinai School of Medicine in Manhattan asked Dr. Butler’s advice on whom to hire for a new geriatrics chair. He proposed instead that the school create a department devoted solely to gerontology. It did, and was one of the first to do so.

He wrote numerous articles and several books, including the bestseller “Sex after Sixty,” which he wrote with his second wife, Dr. Myrna I. Lewis, in 1976.

Dr. Butler’s first marriage, to Diane McLaughlin, ended in divorce. Dr. Lewis died in 2005. Besides his daughter Christine, he is survived by three other daughters, Carole Butler Hall, Cynthia Butler and Alexandra Butler; and six grandchildren.

Dr. Butler acknowledged in an interview two years ago with The Saturday Evening Post that his views on his own aging had changed: he feared death less.

“I feel less threatened by the end of life than I perhaps did when I was 35,” he said.

Robert Butler, Aging Expert, Is Dead at 83, NYT, 6.7.2010,
http://www.nytimes.com/2010/07/07/health/research/07butler.html

Hallucinations in Hospital

Pose Risk to Elderly

June 20, 2010
The New York Times
By PAM BELLUCK

No one who knows Justin Kaplan would ever have expected this. A Pulitzer Prize-winning historian with a razor intellect, Mr. Kaplan, 84, became profoundly delirious while hospitalized for pneumonia last year. For hours in the hospital, he said, he imagined despotic aliens, and he struck a nurse and threatened to kill his wife and daughter.

“Thousands of tiny little creatures,” he said, “some on horseback, waving arms, carrying weapons like some grand Renaissance battle,” were trying to turn people “into zombies.” Their leader was a woman “with no mouth but a very precisely cut hole in her throat.”

Attacking the group’s “television production studio,” Mr. Kaplan fell from his hospital bed, cutting himself and “sliding across the floor on my own blood,” he said. The hospital called security because “a nurse was trying to restrain me and I repaid her with a kick.”

Mr. Kaplan’s hallucinations lifted as doctors treated his pneumonia. But hospitals say many patients are experiencing such inexplicable disorienting episodes. Doctors call it “hospital delirium,” and are increasingly trying to prevent or treat it.

Disproportionately affecting older people, a rapidly growing share of patients, hospital delirium affects about one-third of patients over 70, and a greater percentage of intensive-care or postsurgical patients, the American Geriatrics Society estimates.

“A delirious patient happens almost every day,” said Dr. Manuel N. Pacheco, director of consultation and emergency services at Mount Auburn Hospital in Cambridge, Mass. He treated Mr. Kaplan, whom he described as “a very learned, acclaimed person,” for whom “this is not the kind of behavior that’s normal.” “People don’t talk about it, because it’s embarrassing,” Dr. Pacheco said. “They’re having sheer terror, like their worst nightmare.”

The cause of delirium is unclear, but there are many apparent triggers: infections, surgery, pneumonia, and procedures like catheter insertions, all of which can spur anxiety in frail, vulnerable patients. Some medications, difficult for older people to metabolize, seem associated with delirium.

Doctors once dismissed it as a “reversible transient phenomenon,” thinking “it’s O.K. for someone, if they’re elderly, to become confused in the hospital,” said Dr. Sharon Inouye, a Harvard Medical School professor. But new research shows significant negative effects.

Even short episodes can hinder recovery from patients’ initial conditions, extending hospitalizations, delaying scheduled procedures like surgery, requiring more time and attention from staff members and escalating health care costs. Afterward, patients are more often placed, whether temporarily or permanently, in nursing homes or rehabilitation centers. Older delirium sufferers are more likely to develop dementia later. And, Dr. Inouye found, 35 percent to 40 percent die within a year.

“It’s terrible, more dangerous than a fall,” said Dr. Malaz A. Boustani, a professor at the Indiana University Center for Aging Research, who found that elderly patients experiencing delirium were hospitalized six days longer, and placed in nursing homes 75 percent of the time, five times as often as those without delirium. Nearly one-tenth died within a month. Experts say delirium can contribute to death by weakening patients or leading to complications like pneumonia or blood clots.

Ethel Reynolds, 75, entered a Virginia hospital last July to have fluid drained that had been causing her feet to swell. She wound up hospitalized for weeks, sometimes so delirious that “she screamed constantly, writhed,” said her daughter, Susan Byrd. “I had to get in bed with her because she thought someone was coming and they were going to hurt us,” Ms. Byrd said.

Ms. Reynolds ended up needing dialysis and surgery after an infection, and she died in September.

“We got her death certificate, and the No. 1 cause of death was delirium,” said Ms. Byrd, an ophthalmology nurse. “I was just blown away. As a nurse, I was expecting a quote-unquote medical reason: kidneys, heart, lung, an organ that I could understand had failed, and it wasn’t. It was delirium.”

Other triggers involve disorienting changes: sleep interrupted for tests, isolation, changing rooms, being without eyeglasses or dentures. Medication triggers can include some antihistamines, sleeping pills, antidepressants and drugs for nausea and ulcers. Dr. Inouye said that many “doctors don’t know how to appropriately use meds in older people, in terms of dosing” and compatibility with other medications.

Earle Helton, 80, a retired chemist hospitalized after a stroke, ordered his family to “throw a rope over the hedge so he could escape,” said his daughter, Amanda. He tried removing his hospital gown, loudly sang “Lullaby and Goodnight,” and doctors had to tie down his hands to prevent him from leaving, said his wife, Ginnie. Only when Dr. Inouye stopped some medications that other doctors had prescribed did he become lucid.

Delirium is sometimes treated with antipsychotics, but doctors urge caution using such drugs.

Delirium can wax and wane, not always causing aggressive agitation.

“It is often the person quietly in bed,” and the condition can linger for weeks or months, landing patients back in the hospital, said Dr. Julie Moran, a geriatrician at Beth Israel Deaconess Medical Center in Boston. “We would have to build 100 more floors to keep everybody until they cleared their delirium. There are times when we could be working round the clock seeing patients with delirium.”

Frequently, geriatricians say, delirium is misdiagnosed, or described on patient charts as agitation, confusion or inappropriate behavior, so subsequent doctors might not realize the problem. One study found “delirium” used in only 7 percent of cases; “confusion” was most common. Another study of delirious older emergency-room patients found that the condition was missed in three-quarters of them.

People with dementia seem at greater risk for delirium, but many delirious patients have no dementia. For some of them, delirium increases the risk of later dementia. In such cases, it is unclear if delirium caused the dementia, or was simply a signal that the person would develop it later.

Some hospitals are adopting delirium-prevention programs, including one developed by Dr. Inouye, which adjusts schedules, light and noise to help patients sleep, ensures that patients have their eyeglasses and hearing aids, and has them walk, exercise and do cognitive activities like word games.

Dr. Moran’s hospital removes catheters, intravenous lines and other equipment whenever possible because they can make patients feel trapped, leading to delirium. She said nurses repeatedly assess cognitive function so patients “don’t have smoldering symptoms of delirium for days before they end up yelling and screaming.”

Mr. Kaplan, a biographer of Mark Twain and Walt Whitman, later jotted notes about his hallucinations, including being in a police helicopter “tracking fugitives with enormous light.”

“Exhilarating until I become one of the fugitives,” he wrote. “End up cold and naked in some sort of subway passage.”

His fall bruised his elbow, leg and wrist, said his wife, the writer Anne Bernays. The next day, “he was gaga till about noon,” and even “looked me in the eye and said ‘I’m going to kill you,’ ” she said. “He didn’t know where he was and didn’t recognize me.”

Fortunately, his delirium was discovered very quickly and he made a very good recovery, Dr. Pacheco said. “But,” he said, “delirium is very disruptive for the patient, family, hospital caregivers.”

As Mr. Kaplan understated later, “It was a lot of unpleasantness.”

Hallucinations in Hospital Pose Risk to Elderly, NYT, 20.6.2010,
http://www.nytimes.com/2010/06/21/science/21delirium.html

More Wander Off in Fog of Age

May 4, 2010
The New York Times
By KIRK JOHNSON

ASHBURN, Va. — For generations, the prototypical search-and-rescue case in America was Timmy in the well, with Lassie barking insistently to summon help. Lost children and adolescents — from the woods to the mall — generally outnumbered all others.

But last year for the first time, another type of search crossed into first place here in Virginia, marking a profound demographic shift that public safety officials say will increasingly define the future as the nation ages: wandering, confused dementia patients like Freda Machett.

Ms. Machett, 60, suffers from a form of dementia that attacks the brain like Alzheimer’s disease and imposes on many of its victims a restless urge to head out the door. Their journeys, shrouded in a fog of confusion and fragmented memory, are often dangerous and not infrequently fatal. About 6 in 10 dementia victims will wander at least once, health care statistics show, and the numbers are growing worldwide, fueled primarily by Alzheimer’s disease, which has no cure and affects about half of all people over 85.

“It started with five words — ‘I want to go home’ — even though this is her home,” said Ms. Machett’s husband, John, a retired engineer who now cares for his wife full time near Richmond. She has gone off dozens of times in the four years since receiving her diagnosis, three times requiring a police search. “It’s a cruel disease,” he said.

Rising numbers of searches are driving a need to retrain emergency workers, police officers and volunteers around the country who say they throw out just about every generally accepted idea when hunting for people who are, in many ways, lost from the inside out.

“You have to stop thinking logically, because the people you’re looking for are no longer capable of logic,” said Robert B. Schaefer, a retired F.B.I. agent who cared for his wife, Sarah, for 15 years at home through her journey into Alzheimer’s. He now leads two-day training sessions for the Virginia Department of Criminal Justice Services.

Mr. Schaefer told his class of mostly police officers here in northern Virginia that unlike the ordinary lost child or hiker, a dementia wanderer will sometimes take evasive action to avoid detection, especially if the disease has made them paranoid about authority figures.

“We’ve found them in attics and false ceilings, in locked closets — you name it,” said Gene Saunders, a retired police officer from Chesapeake, who started a nonprofit company called Project Lifesaver 11 years ago to help find wanderers or people with other cognitive impairments. The group’s technology, fitting patients with wristbands that can be tracked by police officers with radio devices, is in use in 45 states, but its widest use is here in Virginia.

Wanderers often follow fence or power lines, and tend to be drawn toward water, Virginia state rescue officials said, bound on a mission that only they — and sometimes perhaps not even they — can imagine. (A search trick: try to figure what door they exited from, then concentrate first in that direction. But don’t bother calling out the person’s name, which he or she has often forgotten.)

Searching for them often also means learning a patient’s life story as well, including what sort of work they did, where they went to school and whether they fought in war. Because Alzheimer’s disease, the leading cause of dementia, works backward, destroying the most recent memories first, wanderers are often traveling in time as well as space.

Some World War II veterans, for example, have gone huge distances believing they needed to report to base or the front lines. A man in Virginia was lost for days until searchers, in interviews with his family, learned he had long ago been a dairy farmer, rescue officials said. It turned out he had headed for a cow pasture not far from his home, believing it was time for the morning milking.

The all-too-human stories of exhausted family members caring for Alzheimer’s sufferers must be taken in account as well, searchers say. The son or daughter or spouse who nodded off or was briefly inattentive, allowing a loved one to slip out, might feel guilty, and so understate, sometimes by many hours, how long the person has been gone — a crucial variable because time on the run in turn hugely increases the potential size of the search area.

Meanwhile, cold cases are piling up.

In Arizona, James Langston, the state’s search and rescue coordinator at the Division of Emergency Management, is haunted by the stories of people who simply stride out into the desert in high summer and vanish. A few years ago, a 20,000-square-mile area was searched after an Alzheimer’s patient’s car was found on a dirt road at the desert’s edge, he said. No trace of the person was ever found.

Advanced age, meanwhile, can compound health risks of exposure.

“We’ve had them die in as little as seven hours because they just keep going and don’t recognize they’re getting dehydrated,” Mr. Langston said.

Many states do not collect or fully categorize local data on search-and-rescue cases, so it is impossible to gauge the full impact of dementia wandering on law enforcement. But in Oregon, for example, the number of searches for lost male Alzheimer’s patients nearly doubled just last year, to 26 from 14 in 2008, and has more than tripled since 2006, according to emergency management officials.

For many people involved in those searches — or in training rescuers for the demographic tsunami to come — the turbulent emotions and grief that swirl around Alzheimer’s disease and dementia are simply part of the terrain. In the middle of his training courses, Mr. Schaefer sometimes pauses, choked up by memories of his wife, who received her Alzheimer’s diagnosis at age 50. She died 17 years later, having forgotten how to swallow, he said, and then finally, even how to breathe.

On a recent afternoon at the Northern Virginia Criminal Justice Training Academy, Mr. Schaefer told his class about the day he asked her if she knew who he was. He had taken steps by then to keep Ms. Schaefer from wandering away, disguising their home’s doors, for one thing, covering them with posters that looked like bookshelves.

But now he could see the panic and horror in her eyes, he said, that she could not find the right answer to his question. Could she recognize her own husband?

“No,” she answered. “But you take very good care of me.”

For John McClelland, 57, a retired volunteer fire and rescue officer who now leads training courses in Colorado, the story is even more personal: He has a diagnosis of Alzheimer’s himself. The disease killed his grandfather and three other people on that side of the family. He said he has already lost the ability to remember the faces of new acquaintances, even a day after meeting them.

Knowing what is coming for him as the fatal disease takes its course has made his training work all the more important and urgent, he said.

“The mission I’m on is that I’m willing to talk about Alzheimer’s as long as I’m articulate,” he said. “The hell of the disease is that I know what’s coming.”

More Wander Off in Fog of Age, NYT, 4.5.2010,
http://www.nytimes.com/2010/05/05/us/05search.html

65 and Up and Looking for Work

October 24, 2009

The New York Times

By STEVEN GREENHOUSE

It is well known that during the nation’s gale-force recession, many older Americans who dreamed of retirement continued to work, often because their 401(k)’s had plunged in value.

In fact, there are more Americans 65 and older in the job market today than at any time in history, 6.6 million, compared with 4.1 million in 2001.

Less well known, though, is that nearly half a million workers 65 and older want to work but cannot find a job — more than five times the level early this decade and this group’s highest unemployment level since the Great Depression.

The situation is made more dire because of numerous recent trends: many people over 65 have lost their jobs as seniority protections have weakened, and like most other Americans, a higher percentage of them took on debt than in previous generations.

The expectation once was to pay off your 30-year mortgage before you retired, or come close. Instead, the level of indebtedness among older Americans has risen faster than in any other age group, partly because so many obtained second mortgages to take money out of their homes.

This financial squeeze is one reason President Obama has proposed giving a special $250 one-time payment to all Social Security recipients.

Many out-of-work older Americans complain that they face foreclosure or have had to give up their car.

“It’s a big deal for a lot of these people not to find a job,” said David Certner, legislative policy director for AARP. “That so many of them are still trying to find work shows how bad the economic situation is. A lot of people normally give up at that age.”

The unemployment rate for older Americans is still much better than for others — 6.7 percent compared with 9.8 percent in the general population. But 6.7 percent is more than double the level of two years ago — and far higher than the minuscule 1.9 percent rate early this decade.

And unemployed older workers stay out of work longer — 36.5 weeks on average, 40 percent longer than for the unemployed in general.

Patricia Warmhold, who has worked as a translator and telemarketer, would love to retire, but at age 67, she says that is out of the question.

Her mortgage payment is nearly $1,500 a month, and her car payments and auto insurance are another $350. She receives $1,071 a month in Social Security and $918 in pension.

“I have very little after the mortgage,” she said.

Ms. Warmhold, who speaks German, French and Creole, was laid off a year ago from her job as an interpreter for a law firm. “I’ve been looking for jobs ever since,” she said. “I applied to Nassau County and Suffolk County, and they don’t call back.”

A divorce worsened her financial situation, although her mother, who is in her 90s, helps by sometimes sending her $100.

“In a month’s time, I sent out 101 job applications,” she said, including more than 50 to school districts, to no avail.

The recession has battered young, middle-aged and old, although several modern trends have left older workers more vulnerable than in the past — for instance, the shift toward 401(k)’s and away from traditional pensions that give retirees a monthly stipend for life has pressured many Americans to continue working well past 60.

Another force pushing Americans to delay retirement is that the percentage of companies that provide health coverage to retirees is half what it was two decades ago. Moreover, the age to obtain full Social Security benefits has increased to at least 66 for people born after 1942, from its traditional 65.

The median income for those 65 and over was just $18,208 in 2008 — a quarter of them had incomes under $11,139, according to Patrick Purcell, an expert on older workers and pensions with the Congressional Research Service.

The average Social Security recipient age 65 and over receives just $12,437 in annual benefits, he said, and among individuals 65 and older who received income from financial assets, half received less than $1,542 last year.

While Social Security keeps most seniors above the poverty line, there are a substantial number near poverty “who are just getting by,” said Richard W. Johnson, a senior fellow at the Urban Institute. Many economists say it is good that Americans are working later in life — many are living longer and able to contribute longer.

Still, many older job seekers insist they are losing out because of age discrimination. Last year, nearly 25,000 workers filed age discrimination complaints, a 29 percent jump over 2007, according to the Equal Employment Opportunity Commission.

“I often get told that I’m overqualified,” said Barbara Brooks, 71, who retired in 2003 after 30 years as an administrative assistant at the University of California, Los Angeles. She said being told that is code language for “you’re too old.” But Ms. Brooks said she wanted to work — and needed to — citing her monthly mortgage of $1,500, which eats up half her monthly pension.

“I would like to be able to treat myself to a couple of dinners, maybe a movie,” Ms. Brooks said. “I think as long as people have excellent skills, and they can get around like a 40-year-old — I’ve been told I look 40 or 50 — why shouldn’t I work?”

For years, unemployment among older Americans was largely ignored because so few of them were jobless. But now more than a million Americans over age 60 are unemployed, two-and-a-half times the level two years ago.

And at least jobless workers 65 and over are guaranteed health coverage through Medicare. Workers laid off before that age often have to fend for themselves to obtain health insurance, which is often prohibitively expensive for those over 60.

One such worker is Michael Husar, 62, a former engineering manager who spent 38 years with General Motors and then its Delphi auto parts spinoff. Mr. Husar, a resident of Scottsdale, Ariz., retired in 2003 at age 56, but as a result of Delphi’s bankruptcy, he now has to purchase his own health insurance. He pays $1,600 a month, which translates to $19,200 a year.

Despite two engineering degrees, his search for consulting work has come up empty in recent months.

“There are two reasons I feel a need to continue working,” he said. “One, I still have a lot to offer, and two, I need the money.”

Alicia H. Munnell, director of the Center for Retirement Research at Boston College, says older workers have fared better by and large than younger workers in this recession. The percentage of workers ages 25 to 54 with jobs has fallen to 75 percent, from nearly 80 percent two years ago, while the percentage of older Americans with jobs has risen slightly, to 16.3 percent.

But that is fewer than the number who want to work.

Patricia Piazza, 66, who worked for Chrysler for 30 years as an analyst, knows that all too well.

She and her 72-year-old husband, a longtime employee at General Motors Acceptance Corporation, had planned to retire by now, but she is hunting for job, and he recently landed one with the local transit system.

Their home in Warren, Mich., has dropped $100,000 in value, Ms. Piazza said, while their pensions, as former nonunion employees, will be far less than anticipated because of the auto company bankruptcies.

Chrysler recently took away her life insurance policy and optical coverage, she said.

“It’s like the bottom fell out of everything” she said. “This isn’t the way we planned retirement.”

65 and Up and Looking for Work, NYT, 24.10.2009,
http://www.nytimes.com/2009/10/24/business/economy/24older.html

Online,

‘a Reason to Keep on Going’

June 2, 2009

The New York Times

By STEPHANIE CLIFFORD

Like many older people, Paula Rice of Island City, Ky., has grown isolated in recent years. Her four grown children live in other states, her two marriages ended in divorce, and her friends are scattered. Most days, she does not see another person.

But Ms. Rice, 73, is far from lonely. Housebound after suffering a heart attack two years ago, she began visiting the social networking sites Eons.com, an online community for aging baby boomers, and PoliceLink.com (she is a former police dispatcher). Now she spends up to 14 hours a day in online conversations.

“I was dying of boredom,” she said. “Eons, all by its lonesome, gave me a reason to keep on going.”

That more and more people in Ms. Rice’s generation are joining networks like Eons, Facebook and MySpace is hardly news. Among older people who went online last year, the number visiting social networks grew almost twice as fast as the overall rate of Internet use among that group, according to the media measurement company comScore. But now researchers who focus on aging are studying the phenomenon to see whether the networks can provide some of the benefits of a group of friends, while being much easier to assemble and maintain.

“One of the greatest challenges or losses that we face as older adults, frankly, is not about our health, but it’s actually about our social network deteriorating on us, because our friends get sick, our spouse passes away, friends pass away, or we move,” said Joseph F. Coughlin, director of the AgeLab at the Massachusetts Institute of Technology.

“The new future of old age is about staying in society, staying in the workplace and staying very connected,” he added. “And technology is going to be a very big part of that, because the new reality is, increasingly, a virtual reality. It provides a way to make new connections, new friends and new senses of purpose.”

About one-third of people 75 and older live alone, according to a 2009 study from AARP. In response to the growing number of older Americans, the National Institute on Aging is awarding at least $10 million in grants for researchers who examine social neuroscience and its effect on aging.

Online networks may offer older people “a place where they do feel empowered, because they can make these connections and they can talk to people without having to ask a friend or a family member for one more thing,” said Antonina Bambina, a sociologist at the University of Southern Indiana who wrote the book “Online Social Support” (Cambria, 2007).

For the family members of older people, online social networks can provide a bit of relief. Chris McWade of Franklin, Mass., the youngest member of a big family, recently helped his parents, his grandparents and his uncle move to retirement homes. He said he spent two or three years “just flying cross-country, holding a lot of hands” and seeing the isolation and depression that came with aging.

That sparked the idea for MyWay Village, a social network based in Quincy, Mass. Mr. McWade helped found it in 2006 and now sells it to retirement homes. It has just completed pilot programs in several nursing homes in Illinois and Massachusetts, and Mr. McWade says he has agreements to expand to several other homes.

Two and a half years ago, Howe Allen, a real estate broker in Boston, moved his parents to the River Bay Club, a retirement home in Quincy, Mass., that uses MyWay.

His mother died soon after, but his father, Carl, was able to start making friends and share stories on MyWay. The older man had never used a computer, but picked it up quickly; the software includes computer training sessions. And after he died last December, a memorial service at the home included photographs he had uploaded to MyWay, excerpts from memoirs he had posted and eulogies from friends he had made through the site.

“It was as moving a day as I can ever remember,” Howe Allen said. “It’s more than just the computer. It affected him in ways that are so far from the electronic age. It allowed this person to grow at an age where you assume most people stop growing.”

On a recent Monday, Neil Sullivan, a regional manager for MyWay, stood in front of a group of about 20 River Bay Club residents in the home’s library.

He came prepared with slides and speeches, but mostly the group just wanted to talk about their lives. When Mr. Sullivan showed a photograph of a 1950 Chevrolet, one resident said, “I had a ’57 Chevy,” and another responded, “Mine was a ’49 Chevy.” A man in a chartreuse sweater who had been quiet for some time added, “The best car I ever had was a Dodge Business Coupe.”

Sarah Hoit, a co-founder of MyWay and its chief executive, said that for older people, learning to get online was not an end in itself. “They want a vehicle to meet new people and share their lives,” she said. “They want to be stimulated.”

Outside of the weekly sessions, River Bay residents use the site to post stories like “My Life as a Nurse” or “I Worked at the Howard Johnson in Quincy.” Sunny Walker, 89, who refused to use an electric typewriter when she was a school secretary because she hated technology so much, now plays games and sends friends messages through the site.

“I’m telling you, it’s the best thing for seniors,” she said. “It challenges their mind, that’s what it does. It challenged mine.”

Some research suggests that loneliness can hasten dementia, and Dr. Nicholas A. Christakis, an internist and social scientist at Harvard, says he is considering research on whether online social connections can help delay dementia, as traditional ones have been found to do in some studies.

“Online social networks realize an ancient propensity we all have to connect with others,” he said.

The propensity may be ancient, but the means are not. Mollie Bourne, a golf course owner who lives in Puerto Vallarta, Mexico, half of the year, logs on to Facebook a few times a week. She likes to browse through her grandchildren’s posts and photos, even the ones taken at bars and parties that are hardly the sort that people expect their grandmothers to see.

“For heaven’s sakes, we all acted like that in college,” she said. “That’s one thing you get with your 76 years. I’ve been around. I’ve seen it all. It takes a lot to shock me.”

Online, ‘a Reason to Keep on Going’, NYT, 2.6.2009,
http://www.nytimes.com/2009/06/02/health/02face.html

Op-Ed Contributor

Growing Old With Autism

May 24, 2009
The New York Times
By KARL TARO GREENFELD

IN mid-2007, I set off to meet with geneticists, epidemiologists and doctors who specialize in researching and treating autism. I was seeking a novel therapy for my 42-year-old autistic younger brother Noah. I was also looking to discover how heightened awareness of autism — it is now among the most financially successful and mediagenic diseases ever, with hundreds of millions of dollars a year going to research, and regular press coverage — might have resulted in new and innovative programs for adult autistics like Noah.

Autism was already widely being described as an epidemic, affecting as many as 1 in 150 8-year-olds, according to the Centers for Disease Control and Prevention. We had come a long way since Noah got his diagnosis in the late ’60s, the so-called dark ages of autism, when many pediatricians believed they had never seen a case, and so-called refrigerator mothers were mistakenly blamed for their children’s withdrawn, antisocial condition.

But now, with autism described to me as “the disease of the decade” by Peter Bell, the executive vice president of programs and services for the advocacy group Autism Speaks, I thought perhaps there was hope, even for low-functioning adult autistics like Noah.

Noah has been my family’s focus for decades. As a baby, he had been very slow to turn over, crawl or walk, and each subsequent developmental milestone was even more delayed as he grew into adulthood. My parents did everything they could for him, moving us from New York to Los Angeles in the early 1970s to be closer to a pioneering autism program at the University of California at Los Angeles, opening their own day care center for the developmentally disabled, even creating a one-on-one assisted-living situation for Noah — years before this became common — so that they could delay institutionalizing him.

I toured those state hospital systems with my parents when we started looking for a place for a growing-up Noah. Those were terrifying visits: adult patients wearing helmets and restraints, howling and hitting themselves. This was during the ’70s when the scandals at state psychiatric hospitals like Letchworth Village in New York and Camarillo in California were making terrifying headlines. Clients at Camarillo were dying from neglect and improperly administered medications. We had to keep Noah out of that system for as long as we could.

Eventually, when he was 22, Noah had to leave home. He graduated from his special needs school on a bright, sunny Orange County day; he was beaming, handsome in his bright blue cap and gown.

But for the profoundly autistic, graduation is perhaps the saddest day in their lives. For those who cannot enter the work force, continue on to more education or find some sheltered workshop environment with adequate staffing, there are few options. Far too few programs and resources are allocated for adults with autism.

Noah has been in and out of sheltered workshops, but these are always under threat because of state budget deficits. Noah has been asked to leave some programs because he was too low-functioning. For several years, we have been trying to find a day program where he might interact with others and perhaps perform some simple, menial job. We have long since given up any hope that he might continue in adulthood the behavioral therapies that are now considered standard for autistics; unless the family is willing to pay the bulk of the cost, there is very little out there for men and women like Noah.

For purposes of fund-raising and awareness-raising, autism has been portrayed as a childhood disease. The federal Department of Health and Human Services has characterized it as a “disorder of childhood.” There are practical reasons for this: early intervention has been shown to be the most effective therapy. The trend in autism treatment has been to steadily lower the age at which intensive intervention commences — as early as five months, according to some experts. Yet autism is not a degenerative condition; the vast majority of those 1 in 150 children who are afflicted will survive to adulthood.

As I spoke with the experts, I began to see that the focus on children had influenced not only the marketing of autism, but also research and treatment. It seemed the majority were interested in children only, the younger the better.

“The best time to look is at the early ages, when autism is developing,” Sophia Calimaro, vice president of research at Autism Speaks, told me a few months ago, explaining that was also where there had been the most treatment success. “I’m not making excuses, but that’s really why more research into adults with autism hasn’t been done.”

Low-functioning adult autistics are viewed with sympathy but not much scientific inquiry. No one has broken down how many dollars are actually flowing to adult autistics, but at the International Meeting for Autism Research in Seattle in May 2007, I counted more than 450 papers and presentations and three dozen talks on autism given by academics and specialists; of those, only two dealt with low-functioning adults, and neither included a cohort large enough to be statistically relevant.

The careful measurements of brain function, or dysfunction, were almost all done on children. A few cognitive and emotional development studies dealt with adults, but these were overwhelmingly focused on high-functioning autistics and people with Asperger’s syndrome.

Autism Speaks, the major sponsor of autism research projects, has not broken down the proportion of funds that go to adult-oriented research, but Mr. Bell, whose teenage son is autistic, laments that “it’s low, too low. ... We have to change the paradigm for those of us who have kids who are going to grow up and need more and better services.”

That change can’t come soon enough. Even with state-of-the-art early intervention — eight hours a day, seven days a week — many autistics will need support throughout their lives. The reality is that very few, perhaps only 10 percent, of those as severely autistic as Noah benefit from the current interventions to the point where they become functioning members of society.

If the current C.D.C. estimation of prevalence is correct, then there will be an awful lot of adult autistics who need lifetime support and care. Noah’s life has been a grim study in how scarce those resources are. Without them, his behavior has regressed.

A recent “psychological and psychopharmacological” report by the California Department of Developmental Services said Noah exhibited a “failure to develop peer relationships, a lack of social or emotional reciprocity,” and it described some of his “maladaptive behaviors” like “banging his head against solid surfaces, pinching himself and grabbing others.”

“Noah may also,” it noted, “intentionally spit at others, pinch or scratch others, dig his fingernails into others, and/or pull others’ hair. He may bite, head-butt and hit others; throw objects at others, and hit/slap his head when he is highly agitated.” He is a handful.

Now, imagine a few hundred thousand Noahs.

Karl Taro Greenfeld is the author, most recently,

of “Boy Alone: A Brother’s Memoir.”

Growing Old With Autism, NYT, 24.5.2009,
http://www.nytimes.com/2009/05/24/opinion/24greenfeld.html

World's oldest person,

Edna Parker,

dies at 115

November 28, 2008
From Times Online
Hannah Strange

A great-great-grandmother who was the world's oldest person has died at the age of 115.

Indiana woman Edna Parker, who assumed the mantle more than a year ago, passed away on Wednesday at a nursing home in Shelbyville. She was 115 years, 220 days old.

Mrs Parker was born April 20, 1893, in central Indiana and had been recognised by Guinness as the world’s oldest person since the 2007 death of Japan's Yone Minagawa, who was four months her senior.

Dr Stephen Coles, the UCLA gerontologist who maintains a list of the world’s oldest people, said Mrs Parker was the 14th oldest validated super-centenarian in history. Maria de Jesus of Portugal, who was born September 10, 1893, is now the world’s oldest living person, according to the Gerontology Research Group.

Mrs Parker became a widow in 1939 - the year Judy Garland starred in The Wizard of Oz - when her husband, Earl Parker, died of a heart attack. She was 48. She remained alone in their farmhouse until age 100, when she moved into a son’s home and later to the Shelbyville nursing home.

Though she never drank alcohol or smoked and led an active lifestyle, she didn't credit this for her advanced years.

A teacher, her only advice to those who gathered to celebrate when she became the world's oldest person was to get “more education.”

Mrs Parker outlived both her sons, Clifford and Earl Jr. She also had five grandchildren, 13 great-grandchildren and 13 great-great-grandchildren.

Don Parker, 60, said his grandmother had a small frame and a mild temperament. She walked a lot and kept busy even after moving into the nursing home, he said.

“She kept active,” he said yesterday. “We used to go up there, and she would be pushing other patients in their wheelchairs.”

Indiana Governor Mitch Daniels, who celebrated with Mrs Parker on her 114th birthday, said it had been a "delight" to know her. She must have been a remarkable lady at any age, he added.

Mrs Parker graduated from the state's Franklin College in 1911 and went on to teach in a two-room school for several years.

She married Earl, her childhood sweetheart and neighbour, in 1913.

As was usual at the time, her career came to an end with her marriage and Mrs Parker became a farmer's wife, spending her days tending the home and preparing meals for the dozen men who worked on the farm.

Last year, she noted with pride that she and her husband were one of the first owners of an automobile in their rural area.

Coincidentally, Mrs Parker lived in the same nursing home as Sandy Allen, whom at 7ft 7¼ was officially the world's tallest woman until her death in August.

    World's oldest person, Edna Parker, dies at 115, Ts, 28.11.2008,
    http://www.timesonline.co.uk/tol/news/world/us_and_americas/
    article5250767.ece

In ‘Sweetie’ and ‘Dear,’

a Hurt for the Elderly

October 7, 2008
The New York Times
By JOHN LELAND

Professionals call it elderspeak, the sweetly belittling form of address that has always rankled older people: the doctor who talks to their child rather than to them about their health; the store clerk who assumes that an older person does not know how to work a computer, or needs to be addressed slowly or in a loud voice. Then there are those who address any elderly person as “dear.”

“People think they’re being nice,” said Elvira Nagle, 83, of Dublin, Calif., “but when I hear it, it raises my hackles.”

Now studies are finding that the insults can have health consequences, especially if people mutely accept the attitudes behind them, said Becca Levy, an associate professor of epidemiology and psychology at Yale University, who studies the health effects of such messages on elderly people.

“Those little insults can lead to more negative images of aging,” Dr. Levy said. “And those who have more negative images of aging have worse functional health over time, including lower rates of survival.”

In a long-term survey of 660 people over age 50 in a small Ohio town, published in 2002, Dr. Levy and her fellow researchers found that those who had positive perceptions of aging lived an average of 7.5 years longer, a bigger increase than that associated with exercising or not smoking. The findings held up even when the researchers controlled for differences in the participants’ health conditions.

In her forthcoming study, Dr. Levy found that older people exposed to negative images of aging, including words like “forgetful,” “feeble” and “shaky,” performed significantly worse on memory and balance tests; in previous experiments, they also showed higher levels of stress.

Despite such research, the worst offenders are often health care workers, said Kristine Williams, a nurse gerontologist and associate professor at the University of Kansas School of Nursing.

To study the effects of elderspeak on people with mild to moderate dementia, Dr. Williams and a team of researchers videotaped interactions in a nursing home between 20 residents and staff members. They found that when nurses used phrases like “good girl” or “How are we feeling?” patients were more aggressive and less cooperative or receptive to care. If addressed as infants, some showed their irritation by grimacing, screaming or refusing to do what staff members asked of them.

The researchers, who will publish their findings in The American Journal of Alzheimer’s Disease and Other Dementias, concluded that elderspeak sent a message that the patient was incompetent and “begins a negative downward spiral for older persons, who react with decreased self-esteem, depression, withdrawal and the assumption of dependent behaviors.”

Dr. Williams said health care workers often thought that using words like “dear” or “sweetie” conveyed that they cared and made them easier to understand. “But they don’t realize the implications,” she said, “that it’s also giving messages to older adults that they’re incompetent.”

“The main task for a person with Alzheimer’s is to maintain a sense of self or personhood,” Dr. Williams said. “If you know you’re losing your cognitive abilities and trying to maintain your personhood, and someone talks to you like a baby, it’s upsetting to you.”

She added that patients who reacted aggressively against elderspeak might receive less care.

For people without cognitive problems, elderspeak can sometimes make them livid. When Sarah Plummer’s pharmacy changed her monthly prescription for cancer drugs from a vial to a contraption she could not open, she said, the pharmacist explained that the packaging was intended to help her remember her daily dose.

“I exploded,” Ms. Plummer wrote to a New York Times blog, The New Old Age, which asked readers about how they were treated in their daily life.

“Who says I don’t take my medicine as prescribed?” wrote Ms. Plummer, 61, who lives in Champaign, Ill. “I am alive right now because I take these pills! What am I supposed to do? Hold it with vice grips and cut it with a hack saw?’”

She added, “I believed my dignity and integrity were being assaulted.”

Health care workers are often not trained to avoid elderspeak, said Vicki Rosebrook, the executive director of the Macklin Intergenerational Institute in Findlay, Ohio, a combined facility for elderly people and children that is part of a retirement community.

Dr. Rosebrook said that even in her facility, “we have 300 elders who are ‘sweetie’d’ here. Our kids talk to elders with more respect than some of our professional care providers.”

She said she considered elderspeak a form of bullying. “It’s talking down to them,” she said. “We do it to children so well. And it’s natural for the sandwich generation, since they address children that way.”

Not all older people object to being called sweetie or dear, and some, like Jan Rowell, 61, of West Linn, Ore., say they appreciate the underlying warmth. “We’re all reaching across the chasm,” Ms. Rowell said. “If someone calls us sweetie or honey, it’s not diminishing us; it’s just their way to connect, in a positive way.”

She added, “What would reinforce negative stereotypes is the idea that old people are filled with pet peeves, taking offense at innocent attempts to be friendly.”

But Ellen Kirschman, 68, a police psychologist in Northern California, said she objected to people calling her “young lady,” which she called “mocking and disingenuous.” She added: “As I get older, I don’t want to be recognized for my age. I want to be recognized for my accomplishments, for my wisdom.”

To avoid stereotyping, Ms. Kirschman said, she often sprinkles her conversation with profanities when she is among people who do not know her. “That makes them think, This is someone to be reckoned with,” she said. “A little sharpness seems to help.”

Bea Howard, 77, a retired teacher in Berkeley, Calif., said she objected less to the ways people addressed her than to their ignoring her altogether. At recent meals with a younger friend, Ms. Howard said, the restaurant’s staff spoke only to the friend.

“They ask my friend, ‘How are you; how are you feeling?’ just turning on the charm to my partner,” Ms. Howard said. “Then they ask for my order. I say: ‘I feel you’re ignoring me; I’m at this table, too.’ And they immediately deny it. They say, no, not at all. And they may not even know they’re doing it.”

Dr. Levy of Yale said that even among professionals, there appeared to be little movement to reduce elderspeak. Words like “dear,” she said, have a life of their own. “It’s harder to change,” Dr. Levy said, “because people spend so much of their lives observing it without having a stake in it, not realizing it’s belittling to call someone that.”

In the meantime, people who are offended might do well to follow the advice of Warren Cassell of Portland, Ore., who said it irritated him when “teenage store clerks and about 95 percent of the rest of society” called him by his first name. “It’s the faux familiarity,” said Mr. Cassell, 78.

But he mostly shrugs it off, he said. “I’m irked by it, but I can’t think about it that much,” he said. “There are too many more important things to think about.”

In ‘Sweetie’ and ‘Dear,’ a Hurt for the Elderly, NYT, 7.10.2008,
http://www.nytimes.com/2008/10/07/us/07aging.html

For the Elderly,

Being Heard About Life’s End

May 5, 2008
The New York Times
By JANE GROSS

HANOVER, N.H. — Edie Gieg, 85, strides ahead of people half her age and plays a fast-paced game of tennis. But when it comes to health care, she is a champion of “slow medicine,” an approach that encourages less aggressive — and less costly — care at the end of life.

Grounded in research at the Dartmouth Medical School, slow medicine encourages physicians to put on the brakes when considering care that may have high risks and limited rewards for the elderly, and it educates patients and families how to push back against emergency room trips and hospitalizations designed for those with treatable illnesses, not the inevitable erosion of advanced age.

Slow medicine, which shares with hospice care the goal of comfort rather than cure, is increasingly available in nursing homes, but for those living at home or in assisted living, a medical scare usually prompts a call to 911, with little opportunity to choose otherwise.

At the end of her husband’s life, Ms. Gieg was spared these extreme options because she lives in Kendal at Hanover, a retirement community affiliated with Dartmouth Medical School that has become a laboratory for the slow medicine movement. At Kendal, it is possible — even routine — for residents to say “No” to hospitalization, tests, surgery, medication or nutrition.

Charley Gieg, 86 at the time, was suffering from a heart problem, an intestinal disorder and the early stages of Alzheimer’s disease when doctors suspected he also had throat cancer.

A specialist outlined what he was facing: biopsies, anesthesia, surgery, radiation or chemotherapy. Ms. Gieg doubted he had the resilience to bounce back. She worried, instead, that such treatments would accelerate his downward trajectory, ushering in a prolonged period of decline and dependence. This is what the Giegs said they feared even more than dying, what some call “death by intensive care.”

Such fears are rarely shared among old people, health care professionals or family members, because etiquette discourages it. But at Kendal — which offers a continuum of care, from independent living apartments to a nursing home — death and dying is central to the conversation from Day 1.

So it was natural for Ms. Gieg to stay in touch with Joanne Sandberg-Cook, a nurse practitioner there, during her husband’s out-of-town consultation.

“I think that it is imperative that none of this be rushed!” Ms. Sandberg-Cook wrote in an e-mail message to Ms. Gieg. The doctor the Giegs had chosen, the nurse explained, “tends to be a ‘do-it-now’ kind of guy.” But the Giegs’ circumstances “demand the time to think about all the what-ifs.”

Ms. Sandberg-Cook asked whether Mr. Gieg would want treatment if he was found to have cancer. If not, why go through a biopsy, which might further weaken his voice? Or risk anesthesia, which could accelerate her husband’s dementia?

“Those are the very questions on my mind, too,” Ms. Gieg replied. The Giegs took their time, opted for no further tests or treatment, and Charley came back to the retirement community to die.

Such decisions are not made lightly, and not without debate, especially in an aging society.

Many in their 80s and 90s — and their boomer children — want to pull out all the stops to stay alive, and doctors get paid for doing a procedure, not discussing whether it should be done. The costliest patients — the elderly with chronic illnesses — are the only group with universal health coverage under Medicare, leading to huge federal expenditures that experts agree are unsustainable as boomers age.

Most of that money is spent at certain academic medical centers, which offer the most advanced tests, the newest remedies, the most renowned specialists. According to the Dartmouth Health Atlas, which ranks hospitals on the cost and quantity of medical care to elderly patients, New York University Medical Center in Manhattan, for instance, spends $105,000 on an elderly patient with multiple chronic conditions during the last two years of life; U.C.L.A. Medical Center spends $94,000. By contrast, the Mayo Clinic’s main teaching hospital in Rochester, Minn., spends $53, 432.

The chief medical officer at U.C.L.A., Dr. Tom Rosenthal, said that aggressive treatment for the elderly at acute care hospitals can be “inhumane,” and that once a patient and family were drawn into that system, “it’s really hard to pull back from it.”

“The culture has a built-in bias that everything that can be done will be done,” Dr. Rosenthal said, adding that the pace of a hospital also discourages “real heart-to-heart discussions.”

Beginning that conversation earlier, as they do at Kendal, he said, “sounds like fundamentally the right way to practice.”

That means explaining that elderly people are rarely saved from cardiac arrest by CPR, or advising women with broken hips that they may never walk again, with or without surgery, unless they can stand physical therapy.

“It’s almost an accident when someone gets what they want,” said Dr. Mark B. McClellan, a former administrator of Medicare and now at the Brookings Institution. “Personal control, quality of life and the opportunity to make good decisions is not automatic in our system. We have to do better.”

The term slow medicine was coined by Dr. Dennis McCullough, a Dartmouth geriatrician, Kendal’s founding medical director and author of “My Mother, Your Mother: Embracing Slow Medicine, the Compassionate Approach to Caring for Your Aging Loved One.”

Among the hard truths, he said, is that 9 of 10 people who live into their 80s will wind up unable to take care of themselves, either because of frailty or dementia. “Everyone thinks they’ll be the lucky one, but we can’t go along with that myth,” Dr. McCullough said.

Ms. Sandberg-Cook agrees. “If you’re never again going to live independently or face an indeterminate period in a disabled state, you may have to reorganize your thinking,” she said. “You need to understand what you face, what you most want to avoid and what you most want to happen.”

Kendal begins by asking newcomers whether they want to be resuscitated or go to the hospital and under what circumstances. “They give me an amazingly puzzled look, like ‘Why wouldn’t I?’ “ said Brenda Jordan, Kendal’s second nurse practitioner.

She replies with CPR survival statistics: A 2002 study, published in the journal Heart, found that fewer than 2 percent of people in their 80s and 90s who had been resuscitated for cardiac arrest at home lived for one month. “They about fall out of their chairs when they find out the extent to which we’ll go to let people choose,” Ms. Jordan said.

Kendal, where the average age is 84, is generally not a place where people want heroics. Dr. George Klabaugh, 88, a resident and retired internist, found himself at the center of controversy a few years back when he tried to revive a 93-year-old neighbor who had collapsed from cardiac arrest during a theatrical performance. Dr. Klabaugh, who was unaware that the man had a “Do Not Resuscitate” order, said he regretted his “automatic reaction,” a vestige of a professional training that predisposes most physicians to aggressive care.

Ms. Jordan surveyed Kendal residents and found only one that wanted CPR — Brad Dewey, 92, who dismissed the statistics. “I want them to try anyway,” he said. “Our daughter saved a man on a tennis court. Who’s to say I won’t recover?”

Some of the 400 residents, who pay $120,000 to $400,000 for an entry fee, and monthly rent from $2,000, which includes all health care, pursue no-holds-barred treatment longer than others. One woman, for example, arrived with cardiac and pulmonary disease but was still capable of living in her own apartment. First, she had cataract surgery that left her vision worse. Next, during surgery to replace a worn-out artificial hip, her thigh bone snapped. She spent a year in bed and wound up with blood clots. Then she broke the other leg.

Only then, Ms. Jordan said, did the woman decide to forgo further surgery or hospitalizations. The woman was too ill to be interviewed.

Some of those most in tune with slow medicine are the adult children who watch a parent’s daily decline. Suzanne Brian, for one, was grateful that her father, then 88 and debilitated by congestive heart failure, was able to stop medications to end his life.

“It wasn’t ‘Oh, you have to do this or do that,’ “ Ms. Brian said. “It was my father’s choice. He could have changed his mind at any time. They slowly weaned him from the meds and he was comfortable the whole time. All he wanted was honor and dignity, and that’s what he got.”

For the Elderly, Being Heard About Life’s End, NYT, 5.5.2008,
http://www.nytimes.com/2008/05/05/health/05slow.html

Barely Getting by

and Facing a Cold Maine Winter

November 24, 2007
The New York Times
By ERIK ECKHOLM

MILBRIDGE, Me. — They have worked since their teens in backbreaking seasonal jobs, extracting resources from the sea and the forest. Their yards are filled with peeling boats and broken lobster traps.

In sagging wood homes and aged trailers scattered across Washington County, many of Maine’s poorest and oldest shiver too much in the winter, eat far more biscuits and beans than meat and cannot afford the weekly bingo game at the V.F.W. hall.

In this long-depressed “down east” region, where the wild blueberry patches have turned a brilliant crimson, thousands of elderly residents live on crushingly meager incomes. This winter promises to be especially chilling, with fuel oil prices rising and fuel assistance expected to decline. But many assume that others are worse off than themselves and are too proud to ask for assistance, according to groups that run meal programs and provide aid for heating and weatherizing.

“One of our biggest problems is convincing people to take help,” said Eleanor West, director of services for the Washington Hancock Community Agency, a federally chartered nonprofit group. “I tell them, ‘You worked hard all your life and paid taxes and are getting back a little of what you paid in.’”

Over the last half century, Social Security, Medicare and private pensions have lifted most of the nation’s elderly. In 1960, one in three lived below the poverty line; now fewer than one in 10 do. But in Washington County, the poverty rate among those 65 and older is nearly one in five and many more live only a little above the federal subsistence standard in 2007 of $10,200 for a single person and $13,690 for two.

For thousands on fixed incomes, fuel assistance may decline while Social Security checks are scarcely rising.

Viola Brooks, 81, worked in fish and blueberry factories while her husband worked in textile and logging jobs. Now widowed, she gets $588 a month from Social Security, supplemented by $112 in food stamps and one-time fuel aid of more than $500 for the winter.

But this year, that fuel aid will not fill a single tank. The average house cost $1,800 to heat last year, and minimal comfort this winter may require closer to $3,000; trailers will require somewhat less. Electricity and rent already take up most of Ms. Brooks’s income.

“I’m broke every month, and the trailer needs storm windows,” she said. “I cook a lot of pea soup and baked beans and buy flour to make biscuits.”

“Some day I’d like to go to a hairdresser,” Ms. Brooks said of a dream deferred. Still she says she enjoys her lovebirds and cats, and points out that “some people have it worse.”

Jobs for the elderly, a growing trend nationwide, are virtually nonexistent in these hamlets. Many people survive with help from a range of programs including food stamps, Medicaid, disability and energy assistance; others suffer silently, long used to hardship and fiercely independent.

In a pattern still common, older people here often held a series of seasonal jobs, usually without benefits. They worked on lobster boats and dug clams or bloodworms (to sell for bait) from spring to fall, raked wild blueberries in August, harvested potatoes and then made Christmas wreaths for mail-order companies to mid-December. Wives often worked in sardine canneries or in blueberry processing.

“By their 50s, their bodies start breaking down,” said Tim King, director of the community agency at its headquarters in Milbridge, adding that high rates of smoking, obesity and diabetes also contributed to early aging. The aid programs define those as 60 and over as elderly.

Because of their irregular careers and payments into the system, many people get Social Security benefits far below the national average of more than $1,000 a month.

Velma L. Harmon, a 79-year-old widow, receives only $220 a month from Social Security and has a grand total of $85 to live on each month after she pays her subsidized rent and utilities at her apartment complex in Machias, one of a growing number of such federally aided facilities for the elderly.

She is grateful for free lunches provided by the Eastern Agency on Aging, another government-financed group, but too proud to apply for food stamps that would give her a bit more spending money. “Trying to buy Christmas presents, that’s the hardest thing,” said Ms. Harmon, who has a mangled finger from her years of snipping sardine heads in a canning factory.

The preoccupation right now is soaring fuel prices: cheaper natural gas is unavailable in this region, and wood heat is often impractical or insufficient. But because of limited federal money, average fuel assistance for the 46,000 low-income Maine families expected to apply will probably decline to $579 this year, from $688 last year, said Jo-Ann Choate of the Maine State Housing Agency.

“Low-income people aren’t even going to be able to fill up a single tank of fuel oil,” Ms. Choate said. “They already wrap themselves up in blankets during the winter. This year they’ll be colder.”

The disabled, and there are many, may have it hardest. Dolly Jordan of Milbridge has a history of two bad marriages, a bone-crushing auto accident and poor health, and looks and feels older than 61. With osteoporosis, arthritis, diabetes and obesity, she spends most of the day in a wheelchair and uses a combination of a gripper, a broom and a cane to make her bed or hang her laundry.

Come winter, she hangs a blanket over the front door of her little red wooden house, where she has lived alone the last 10 years and which sits on concrete blocks with no foundation. She turns the heat off at night to save fuel.

Her disability payment is $623 a month, plus she gets just $10 from the state and $74 in food stamps. After paying the housing tax and her utility bills, she said, she must watch every remaining penny. A daughter drives her to the distant town of Ellsworth for cheaper shopping.

Like many, she keeps a police scanner on as a diversion and, unable to afford cable, she watches the same videos over and over — her favorite is “On Golden Pond.”

“I wish for bedtime to come,” she said. “The days are so long.”

Easing down a ramp to her mailbox is a perilous 15-minute ordeal. Still, she said, “I wait for Fridays.”

“That’s junk-mail day, and I read all the ads. That’s my best day.”

She added, “There’s always older people out there who have it harder.”

Frederick and Kathleen Call, in Harrington, are in their 60s and live in a 1970s trailer with buckling walls. They live on his disability check — he has had six heart attacks — and food stamps and fuel assistance. Like many others in the region, they buy all their clothes at a church-run thrift shop. They spend their days playing board games and rummy and watching squirrels on their porch.

“We used to go to the food pantry for a free box,” Ms. Call said, “but I saw an old woman who looked like she really needed it. She was thin and cold. I gave her a blanket. We haven’t gone for free food for years.”

Some people here seem to have sunny outlooks no matter what. In the fishing village of Jonesport, Elizabeth Emerson, 87, is hard of hearing and has a titanium knee but is spry and irrepressively cheerful.

She lives in the tiny house her husband, a trucker, built in 1949, and has a view of the gravestone where her name is already etched next to his. Having a daughter nearby, and a total of 52 grand-, great-grand and great-great-grandchildren, whose pictures fill the walls and the refrigerator door, helps in ways practical and emotional.

Ms. Emerson said she “thoroughly enjoyed” the 25 years she spent working as an aide in a nursing home, and she demonstrated the yodeling she used to perform on command for one patient.

Each day she walks with her dog, Sabrina, down to the stony beach where her family once swam. “I saw moose tracks the other day,” she exulted. “Here is where I used to pick heather.”

With her Social Security payment of $683 a month, she refuses to feel impoverished.

“I was never a person to be extravagant,” Ms. Emerson said, adding, “I don’t play beano,” using the local term for bingo.

Besides, she said, she can still afford an indulgence here and there. “My greatest vice,” she added, “is Hershey bars.”

Barely Getting by and Facing a Cold Maine Winter, NYT, 24.11.2007,
http://www.nytimes.com/2007/11/24/us/24maine.html

Wealthy, healthy and aged 85:

the women living ever longer

October 25, 2007
From Times Online
Jill Sheerman, Whitehall editor

Life expectancy for professional women has shot up by 30 months to 85 years in only the last four years, while the gap between the top and bottom classes has widened.

Figures from the Office for National Statistics published yesterday show that females in high-status, well-paid jobs such as medicine, law and finance are living longer than ever. Their counterparts in clerical and manual jobs, however, are struggling to keep pace as their lifestyles and life expectancy emulate their male colleagues.

Diet, drinking and smoking are taking their toll on women in the lower social classes but health experts suggest that females at the top are in better shape than ever, have quicker access to healthcare, are no longer dying from breast cancer and can afford better holidays. Some epidemiologists also suggest that women get a psychological boost from a high-status job where they are largely in control.

The figures show that the life expectancy at birth for women in the top social class, or those who married into it, jumped from 82.6 years in 2001 to 85.1 years in 2005, an increase of 2.5years. This rise is at a much faster rate than the rest of the past 30 years where life expectancy has gone up about two years in every ten. During the same period the life expectancy for women in the lowest social class — unskilled workers and labourers — rose from 77.9 to 78.1 years, an increase of only ten weeks.

In male mortality, the opposite appears to be happening. Life expectancy in men has been catching up with women over the past 30 years, but since 2001 the increase has dropped slightly and the gap between the social classes has slightly narrowed.

Life expectancy for men in the professional classes rose from 79.5 years in 2001 to 80 years in 2005. At the same time the life span for unskilled workers rose from 71.5 to 72.7 years. A similar picture occurs in life expectancy from the age of 65. A women in Social Class 1 now aged 65 was expected to live to 85 in 2005, but is now expected to carry on to 87. However, the corresponding figures for women in Social Class 5 only rose from 81.9 to 82.7 years.

Eric Brunner, a reader in epidemiology at University College London, could not fully explain the acceleration in life expectancy for woman in the top social classes in the past four years. But he said that access to cash and high self-esteem has a big impact on health and longevity. “Money, wealth and resources, particularly psychological, mean that women feel more in control of their lives.”

Women are also categorised in Social Class 1 if they are married to men working in the professions, so many of them may be able to take on part-time jobs or not work at all.

Alcohol, smoking, poor diet and better health services in earlier life would all be factors in the widening gap between the social classes.

“There are different smoking patterns in men and women over the last 40 years,” said Dr Brunner. “The peak mortality rates for men with lung cancer was in the early 1970s while the peak rate for women was in the mid-1990s.”

In addition, there was a much greater class divide in obesity levels among women, with far more obese females in the lowest classes. There is no significant difference among men.

Professor Mel Bartley, a director of the Economic and Social Research Centre, said that women in the top social classes were more likely to get breast cancer but now less likely to die from it. Better screening techniques and drug treatments such as Tamoxifen had had a huge impact on mortality in recent years.

Brian Johnson, a statistician for the ONS, said that the figures for Social Class 1 and Social Class 5 had a higher level of variation than the other larger social classes so it was difficult to tell if the data marked a trend or a blip. The 2001 figures had shown a slight shift downwards in female life expectancy and this data had now reverted to the general trend of growing life expectancy, he suggested. He pointed to the narrowing of the gap between the manual classes and non-manual classes in males, particularly those over 65, which he said was more reliable.

The figures also show that between 1972 and 2005, men and women in non-manual occupations had a greater increase in life expectancy at birth and at age 65 than those classified by manual occupations.

For men, there was an eight-year increase in life expectancy at birth in non-manual workers, who range from clerks, cashiers and retail staff to doctors and lawyers, compared with a 6.8-year rise for those for manual workers, who range from labourers and cleaners to plumbers and electricians. But for women the corresponding figures were only 5.2 years and 4.8 years respectively.

Unskilled female workers aged 65 can now expect to live 17.7 years more, on average, than they did between 1972 and 1976, while women in the top social class now aged 65 are expected to outlive their mid-1970s predecessors by 22 years. An unskilled man now aged 65 can expect to live 14.1 years longer than his counterparts did in 1972-76 — to the same age as the professionals of the day. A 65-year-old high-status man is now expected to live 18.3 years longer than he would have done 30 years ago.

“There has been a longstanding difference in mortality in social classes, particularly between the highest and lowest classes,” said Mr Johnson. “But in women there is no evidence of further widening, and in men there is some tentative evidence of narrowing in the higher age groups.”

The definition

Life expectancy at birth for a particular social class and time period is an estimate of the number of years a newborn baby would survive if they experienced average mortality rates of that social class for that time period throughout their life

Source: Office for National Statistics

A divided society: how Britons fall into their seperate categories

1 This includes members of the top professions such as doctors, chartered accountants, lawyers, professionally qualified engineers and bankers who earn high salaries. Women who are married to men in these jobs will also be categorised in the top social class even if they do not work or work in a less skilled job.

2 This category covers managerial and technical jobs such as middle managers, journalists, school teachers, nurses, academics and computer technicians. They will earn less money and have more stressful jobs than those in the top social class. Women are more likely to be married and have children.

3 This group is split between skilled manual and non-manual. The latter category includes clerks, cashiers, call-centre operators, secretaries and retail staff who are on low salaries and generally have less control over their jobs. The former category of skilled manual workers includes plumbers, electricians, builders, drivers of goods vehicles and the supervisors of the above

4 These partly skilled workers include warehousemen, security guards, machine tool operators, care assistants, waiters and waitresses. They will typically be on low wages, work long hours and have little control over how or when they work.

5 This group of unskilled workers includes labourers, cleaners and messengers who will be earning not much more than the minimum wage. They and the group above them are much more likely to be heavy smokers and drinkers and prone to obesity and heart-related diseases. They will tend to be less capable of accessing quick health or social care.

Wealthy, healthy and aged 85: the women living ever longer, Ts, 25.10.2007,
http://www.timesonline.co.uk/tol/news/uk/health/article2731282.ece

Leading article:

Elderly people deserve

a far better deal from the state

Published: 11 October 2007
The Independent

It is not very clear what the Government is intending to do about funding long-term care for the elderly and disabled, which is shaping up to be one of the biggest political problems of the next decades. The King's Fund health think-tank claimed yesterday it had been briefed that Labour planned to scrap the current means-testing system, which requires old people to sell their homes to pay for residential care. But ministers were more circumspect, with the Chancellor, Alistair Darling, hinting only that reform is needed.

If he is unsure what that should be, then let us tell him. Our national failure to support frail and vulnerable people is one of the great unacknowledged scandals of our time. As the years pass, we have ever more old people and yet we do less and less for them. The same is true of families with disabled children, nearly half of whom receive no public support at all.

The situation will only get worse. Elderly people are living longer. Disabled people now expect to live full lives. Scotland has reached a distinct and admirable solution: the state will pay for residential care for the elderly, just as it does their hospital care. Helping someone go to the lavatory or wash – whether in hospital, residential care or their own home – is a form of nursing care, they argue, and should be provided free of charge, paid for through general taxation.

This flagship policy is expensive. At present 4 per cent of Scotland's elderly population live in a care home. Over the next two decades that number is set to double. Already the system is being squeezed; three-quarters of Scotland's councils have waiting lists of up to four months because the system is under-funded.

Government ministers said yesterday that they are open-minded about the outcome of the consultation they will be launching with a Green Paper. But they also made clear that the Scottish option is not on. In England and Wales, by 2050, according to last year's Wanless report, there will be twice as many people aged over 85 as there are now. (A potent argument, incidentally, for allowing more not less immigration at the present time.) We will then need to spend four times more on long-term care for older people. To make care homes free for all would, ministers claim, take up all the additional public spending now available.

But this is by no means self-evident. France and Germany spend more than double what we do on caring for older people. The fact is that the current means-testing system has caused misery to older people and their families. It is not at all clear how the kinds of "partnership model" ministers were floating yesterday – with a basic universal entitlement together with a top-up paid by individuals, or by the state in the case of the poor – get around this.

In any case there is more to the problem than how to fund care homes. The wider issue is how the state can help older people remain independent and active in their own homes, for as long as possible, in a way that offers them dignity and respect.

To do that, ministers must reverse the pernicious cuts that have been made in such services. They must provide more home-helps, not fewer. They need to reverse the preposterous cuts in services like chiropody which slowly render some old people immobile and eventually force them into care homes. They need to chastise the 150 local authorities who have so recast their definition of needs that even those who need help getting out of bed in the morning now find themselves excluded from services. State resources must be directed to where they can have the greatest impact on wellbeing – and where they support, rather than undermine, the dignity of those in the last age of life.

Leading article:
Elderly people deserve a far better deal from the state,
I,
11.10.2007,
http://comment.independent.co.uk/leading_articles/
article3047582.ece - broken link

Elderly hit

by soaring cost of home help

Many vulnerable people
now face eligibility tests for basic services
as councils tighten budgets

Sunday July 1, 2007
The Observer
Jo Revill, Whitehall editor

Councils have made it harder for the elderly to stay in their own homes by increasing charges for basic support services such as shopping and laundry.

New research reveals that budget restraints mean that thousands of pensioners who need help with cleaning or feeding are no longer receiving it free. They face a battery of tests to determine their 'eligibility' for care in spite of the fact that the vast majority have been paying council tax for years.

A survey to be published on Wednesday by the charity Counsel and Care will show that in the past year councils have raised the barriers even higher for those needing some domiciliary help.

As Britain has an ageing population, the survey shows that local authorities are providing a larger number of hospital services for a much smaller group of older people with the most complex needs. That means there is little or no support for those who are finding it hard to live independently but whose needs are relatively simple.

The Observer has had a huge response to its Dignity at Home campaign, which has highlighted how older people trying to access care and support services in their own homes face huge personal care bills or are forced to rely on over-stretched voluntary help. Even if the older person is eligible for means-tested services from their local authority, the charge for this care is increasing. Many struggle to afford to live at home or to pay the high cost of care home fees.

The survey, based on questions put to local authorities across England, showed that there was a 15 per cent increase in the number of councils that have restricted the eligibility criteria in the past 12 months. This will have affected thousands of people, although the exact numbers are not known.

Some older people are paying up to £320 a week towards domiciliary care costs, the survey says The price of meals-on-wheels also varies hugely, from £1.40 to £3.40 per meal. Even community transport, which gives older people a valuable opportunity to leave their home once a week, is being charged by some councils at up to £2.60 a trip.

Stephen Burke, chief executive of Counsel and Care, which runs an advice line for the elderly and their carers, said: 'There is a triple lottery for home care services: it's based on where someone lives, how their local authority applies the eligibility criteria for services and the charging policy of the local authority.'

The report will spell out that in a number of authorities there is now no service available at all for anyone with low or moderate needs.

Last year Sir Derek Wanless produced a report into the funding of social care for older people in which he pointed out that savings can be made by helping vulnerable people to stay at home. But local authorities say that they cannot afford to offer all the services to everyone.

Burke said: 'These figures show the social care problem will not solve itself. Without active intervention, the system is going to collapse as more and more people need to be cared for at home.'

'I'm 94 - but now I feel more like 24'

It is just after 11.30 on a Wednesday morning and Laetitia Dysart is tired and sore, but exhilarated after taking part in a fitness class. 'I'm 94 but after that I feel like I'm 24 or 25. I feel absolutely marvellous,' she says.

The woman everyone calls 'Lettie' has spent the last hour standing, bending, stretching and marching on the spot alongside 20 pensioners at the Healthy Living Centre in Worthing, West Sussex. The music has been strictly their generation: Glenn Miller and Frankie Vaughan.

'You work from the tips of your fingers to the tips of your toes, you use every muscle, although you do it gently, and it makes you feel that every part of your body is moving. It gives you the confidence to move around when many people my age just want to sit down all the time because they are in pain. People love the classes,' explains Lettie.

The Keeping Fit and Balanced session is just one of the centre's range of physical activity classes for the elderly including tai chi and seated exercises.

The centre also offers massage and beauty therapy. 'We want older people to look good and feel good about themselves and to be as healthy as possible. It's as much about their mental as their physical health, and their self-esteem', explains Jill Lancaster, manager of the centre, which is run by Guild Care, a local charity for elderly people. Everything at the centre is geared to helping older people stay in familiar surroundings as long, and as capably, as possible - happiness and dignity at home.

Elderly hit by soaring cost of home help,
O,
1.7.2007,
https://www.theguardian.com/society/2007/jul/01/
longtermcare.comment

The age revolution:

How to live to be 150

Experts believe that the first person to live half way
through their second century has already been born.

Jeremy Laurance, health editor,
reports on the stunning breakthroughs
that science promises,
while Sarah Harris outlines 10 ways
to extend your life

Published: 07 January 2007

The Independent on Sunday

For today's centenarians, living to be 100 is an achievement marked by a message from the Queen. Within two generations it could be as routine as collecting a bus pass.

The first person to live to 150 may already have been born, according to some scientists. Worldwide, life expectancy has more than doubled over the past 200 years and recent research suggests it has yet to reach a peak.

What will the world be like when people live long enough to see their great-grandchildren and great-great-grandchildren? Extending life by adding extra years of sickness and growing frailty holds little appeal. Increased longevity is one of the modern world's great successes, but long life without health is an empty prize. The aim is for humans to die young - as late as possible.

It is eight years since Jeanne Calment died peacefully in a nursing home in Arles, southern France in 1998. She was aged 122 years, five months and 14 days - and no one has yet challenged her title as the oldest person with an authenticated birth record to have lived. She attributed her longevity to a diet rich in olive oil, regular glasses of port and her ability to "keep smiling".

Destiny undoubtedly played a part, too. If you want to grow old, choose your parents carefully. The genetic determinants of long life are gradually being unravelled, In recent years at least 10 gene mutations have been identified that extend the lifespan of mice by up to half. The good news is that these super-geriatric mice are no more frail or sickly than their younger brethren.

In humans, several genetic variants have been linked with longevity. They include a family of genes dubbed the Sirtuins, which one Italian study found occurred more commonly in centenarian men than in the general population. Researchers at Harvard Medical School in the US, convinced they have discovered a "longevity gene", are now studying whether adding an extra copy of the gene extends the lives of mice. The long term aim is to find a way of manipulating the genes to add an extra decade or two to the human lifespan.

Other gene variants affect the production of growth hormone and insulin-like growth factor (IGF), both of which increase metabolism - organisms with higher metabolism tend to die sooner. Blocking receptors for growth hormone and IGF, so slowing metabolism, provide possible targets for anti-ageing drugs.

Also promising, but still far from yielding concrete results, are telomeres, which are present in every cell. Telomeres shorten with every cell division, like a burning fuse; when they can shorten no more, the cell dies. Inhibiting the enzyme telomerase to prevent the shortening of the telomeres in effect extends the lifespan of the cell, and, as we are comprised of millions of cells, could extend life.

Ageing cannot be reversed but it may, perhaps, be delayed. The emergence of the extremely old population has only happened in the past 50 years and is chiefly due to improvements in the health, lifestyle and environment of the elderly that started in the 1950s - how we eat and drink, where we live, what we do.

Ageing is an irresistible target for snake oil salesmen and the pharmaceutical industry. Several hundred medical compounds that can boost memory and learning ability are being investigated. Research teams are examining genes for Alzheimer's disease, mechanisms that cause cells to age and die, and brain interfaces that promise to pump new life into aged or diseased limbs. The aim here is to add life to years, as well as years to life, but ageing itself is taking over as the new target for therapeutic innovation.

One promising avenue of research is to increase the resistance of cells to the stresses caused by free radicals, unstable molecules that disrupt cellular processes. There is no evidence that the sort of anti-ageing compounds sold over the internet containing anti-oxidants that promise to tackle free radicals actually slow ageing. However, delivering antioxidant enzymes direct to the cell has been shown in mice to extend lifespan by 20 per cent - pointing the way to future research.

But the optimism comes with a warning - that the consistent increase in life expectancy we have enjoyed for the past 200 years could be about to go into reverse. Some Jeremiahs in the scientific community claim ours could be the first generation in which parents outlive their children. The greatest enemy of extending life further is growing obesity, they say. Its effects could rapidly approach and exceed those of heart disease and cancer. Calculations by US scientists suggest that life expectancy would already be up to a year longer but for obesity. As Jeannne Calment indicated, wisely if unexcitingly, on her 122nd birthday, those who live moderately live long.

Ten things you can do to help increase your life expectancy

Exercise regularly

Keeping fit is the elixir of youth. Even 30 minutes of regular gentle exercise three times per week, such as walking or swimming, can add years to your life expectancy.

Aerobic exercise preserves the heart, lungs and brain, elevates your mood, can help ward off breast and colon cancer and prevent atrophy of the muscles and bones.

Gareth Jones of the Canadian Centre for Activity and Ageing in London, found that for an over-50 who has never taken part in physical activity a brisk 30-minute walk three times a week can "basically reverse your physiological age by about 10 years." Not exercising can knock off five years.

A 1986 study at Stanford University found that death rates fell in direct proportion to the number of calories burned weekly.

Live dangerously

Mild sunburn, a glass of wine and some low-level radiation sounds like a recipe for disaster, but many researchers believe that small doses of "stressors" can reverse the ageing process.

While this "hormeosis", is not a licence to lie on a hot beach all day swigging vodka, mild exposure to certain harmful agents can trigger the body's natural repair mechanisms. The body is tricked into producing particular DNA-repair enzymes and heat shock proteins to fix the damage that has been caused. Sometimes the body's repair mechanisms overcompensate, treating unrelated damage - "rejuvenating" as well as repairing it. Hormeosis could stretch the average healthy life span to 90.

Live in a good area

It is not only how you live, but where you live that matters - and the residents of Okinawa in Japan seem to know the secret. These Japanese islands are home to the world's largest population of centenarians.

At 103, the daily routine of resident Seiryu Toguchi included stretching exercises, a diet of whole grain rice and vegetables, gardening and playing his three-stringed instrument, the sanshin.

The clean-living Seventh Day Adventists of Utah also do pretty well, living on average eight years longer than their fellow Americans.

Worst off are those living in poor, polluted urban areas such as Glasgow, where residents of the poorest suburbs have a life expectancy of only 54. Overcrowding, dirt and noise all contribute to high blood pressure, anxiety and depression, which reduce lifespan.

Be very successful

The more rich, privileged, successful and educated you are, the longer you will live. The Whitehall Studies, 1967-77, examined the health of male civil servants between the ages of 20 and 64, and found that men in the lowest-paid positions had a mortality rate three times higher than those at the top level.

The study proved that the more important a task a person is asked to perform, the longer they are likely to live; that the person at the top with the big office, shouting orders will have a more relaxed and pleasurable existence than his frustrated underlings. And it's not only civil servants: Canadian researchers found that Oscar-winners live longer than other actors because of am increased sense of self-worth and confidence.

And if you can't manage an Oscar, then only one extra year in education could increase your life expectancy by a year and a half.

Eat the right foods

Certain foods delay the ageing process and may increase life expectancy. Green leafy vegetables such as spinach and broccoli are rich in antioxidants and beta-carotene. Diets high in fruit, vegetables, fibre and omega-3 oils, and low in fat may prevent high blood pressure and heart disease.

In their low-fat diet of fruit, vegetables and rice, the long-living people of Okinawa also consume more soy than anyone on earth, and soy is linked to low cancer rates. Eating cooked tomato daily can slash your risk of heart disease by 30 per cent, found research at Harvard.

Challenge yourself

An active mind is as important as an active body. Studies show that you can boost your immune system and delay the onset of conditions from depression to dementia by keeping your brain engaged and stimulated.

Leonard Poon, director of the University of Georgia Gerontology Center found that people who reach three figures tend to have a high level of cognition, demonstrating skill in everyday problem-solving and learning. And Marian Diamond of the University of California, Berkley, found that rodents who were given problems to solve and toys to play with, lived 50 per cent longer.

Enjoy your life

Good relationships are the key to longevity. Social contact staves off depression, stress and boosts the development of the brain and immune system.

Most research shows that people with family, friends, partners or pets, live longer than those who don't. Marriage is also a good idea if you want to meet the 100-mark, adding an average of seven years to the life of a man, and two to a woman.

Indulgence, too, can be good for you. Chocolate can enhance endorphin levels and acts as a natural antidepressant, wine contains natural anti-oxidants, and laughing is good for your immunity.

Find God - or friends

It's official: having religion pays off - and not just in the after-life.

Nearly 1,000 studies have indicated that those who go to a place of worship are healthier than their faithless counterparts - and live an average seven years longer. One in 10 of the nuns of the convent of the School Sisters of Notre Dame in Minnesota have managed to reach their 100th birthday. But atheists should not despair: experts believe that a sense of community, and of belief in something larger than yourself, are vital ingredients in a long and happy life.

Jeff Levin, author of God, Faith, and Health: Exploring the Spirituality-Healing Connection, argues that a place of worship provides a social network and a source of comfort to the ageing, ill and needy.

Reduce your calories

One hundred years of hunger is what you can look forward to if you follow the Calorie Restriction philosophy. Practitioners of CR believe that by reducing your calorie intake (by between 10 and 60 per cent) you can extend life expectancy by lowering your metabolism and the production of harmful free radicals. It sounds like torture, but there is research to suggest that it works.

One study reported that participants who ate 25 per cent less for three months had lower levels of insulin in their blood, a reduced body temperature and less DNA damage. Brian Delaney, president of the California-based Calorie Restriction Society, is aiming to live to 122, and with a diet of barely 1,800 calories per day (2,500 is the normal for men).

Get your health checked

To last a century, stay ahead of life-threatening illnesses. It is possible with regular blood tests to detect the first signs of prostate cancer, one of the commonest causes of cancer deaths in men over 85.

If you're between 60 and 69 you can have free bowel cancer screening, cervical screening for women aged 24 to 64, and mammograms for women aged 50 to 70. Figures show that 95 per cent of women who had invasive breast cancer detected by screening are alive five years later.

The age revolution: How to live to be 150,
IoS,
7 January 2007,
https://www.independent.co.uk/life-style/health-and-families/
health-news/the-age-revolution-how-to-live-to-be-150-
431059.html

One for the Ages:

A Prescription

That May Extend Life

October 31, 2006

The New York Times

By MICHAEL MASON

How depressing, how utterly unjust, to be the one in your social circle who is aging least gracefully.

In a laboratory at the Wisconsin National Primate Research Center, Matthias is learning about time’s caprice the hard way. At 28, getting on for a rhesus monkey, Matthias is losing his hair, lugging a paunch and getting a face full of wrinkles.

Yet in the cage next to his, gleefully hooting at strangers, one of Matthias’s lab mates, Rudy, is the picture of monkey vitality, although he is slightly older. Thin and feisty, Rudy stops grooming his smooth coat just long enough to pirouette toward a proffered piece of fruit.

Tempted with the same treat, Matthias rises wearily and extends a frail hand. “You can really see the difference,” said Dr. Ricki Colman, an associate scientist at the center who cares for the animals.

What a visitor cannot see may be even more interesting. As a result of a simple lifestyle intervention, Rudy and primates like him seem poised to live very long, very vital lives.

This approach, called calorie restriction, involves eating about 30 percent fewer calories than normal while still getting adequate amounts of vitamins, minerals and other nutrients. Aside from direct genetic manipulation, calorie restriction is the only strategy known to extend life consistently in a variety of animal species.

How this drastic diet affects the body has been the subject of intense research. Recently, the effort has begun to bear fruit, producing a steady stream of studies indicating that the rate of aging is plastic, not fixed, and that it can be manipulated.

In the last year, calorie-restricted diets have been shown in various animals to affect molecular pathways likely to be involved in the progression of Alzheimer’s disease, diabetes, heart disease, Parkinson’s disease and cancer. Earlier this year, researchers studying dietary effects on humans went so far as to claim that calorie restriction may be more effective than exercise at preventing age-related diseases.

Monkeys like Rudy seem to be proving the thesis. Recent tests show that the animals on restricted diets, including Canto and Eeyore, two other rhesus monkeys at the primate research center, are in indisputably better health as they near old age than Matthias and other normally fed lab mates like Owen and Johann. The average lifespan for laboratory monkeys is 27.

The findings cast doubt on long-held scientific and cultural beliefs regarding the inevitability of the body’s decline. They also suggest that other interventions, which include new drugs, may retard aging even if the diet itself should prove ineffective in humans. One leading candidate, a newly synthesized form of resveratrol — an antioxidant present in large amounts in red wine — is already being tested in patients. It may eventually be the first of a new class of anti-aging drugs. Extrapolating from recent animal findings, Dr. Richard A. Miller, a pathologist at the University of Michigan, estimated that a pill mimicking the effects of calorie restriction might increase human life span to about 112 healthy years, with the occasional senior living until 140, though some experts view that projection as overly optimistic.

According to a report by the Rand Corporation, such a drug would be among the most cost-effective breakthroughs possible in medicine, providing Americans more healthy years at less expense (an estimated $8,800 a year) than new cancer vaccines or stroke treatments.

“The effects are global, so calorie restriction has the potential to help us identify anti-aging mechanisms throughout the body,” said Richard Weindruch, a gerontologist at the University of Wisconsin who directs research on the monkeys.

Many scientists regard the study of life extension, once just a reliable plotline in science fiction, as a national priority. The number of Americans 65 and older will double in the next 25 years to about 72 million, according to government census data. By then, seniors will account for nearly 20 percent of the population, up from just 12 percent in 2003.

Earlier this year, four prominent gerontologists, among them Dr. Miller, published a paper calling for the government to spend $3 billion annually in pursuit of a modest goal: delaying the onset of age-related diseases by seven years.

Doing so, the authors asserted, would lay the foundation for a healthier and wealthier country, a so-called longevity dividend.

“The demographic wave entering their 60s is enormous, and that is likely to greatly increase the prevalence of diseases like diabetes and heart disease,” said Dr. S. Jay Olshansky, an epidemiologist at the University of Illinois at Chicago, and one of the paper’s authors. “The simplest way to positively affect them all is to slow down aging.”

Science, of course, is still a long way from doing anything of the sort. Aging is a complicated phenomenon, the intersection of an array of biological processes set in motion by genetics, lifestyle, even evolution itself.

Still, in laboratories around the world, scientists are becoming adept at breeding animal Methuselahs, extraordinarily long lived and healthy worms, fish, mice and flies.

In 1935, Dr. Clive McCay, a nutritionist at Cornell University, discovered that mice that were fed 30 percent fewer calories lived about 40 percent longer than their free-grazing laboratory mates. The dieting mice were also more physically active and far less prone to the diseases of advanced age.

Dr. McCay’s experiment has been successfully duplicated in a variety of species. In almost every instance, the subjects on low-calorie diets have proven to be not just longer lived, but also more resistant to age-related ailments.

“In mice, calorie restriction doesn’t just extend life span,” said Leonard P. Guarente, professor of biology at the Massachusetts Institute of Technology. “It mitigates many diseases of aging: cancer, cardiovascular disease, neurodegenerative disease. The gain is just enormous.”

For years, scientists financed by the National Institute on Aging have closely monitored rhesus monkeys on restricted and normal-calorie diets. At the University of Wisconsin, where 50 animals survive from the original group of 76, the differences are just now becoming apparent in the older animals.

Those on normal diets, like Matthias, are beginning to show signs of advancing age similar to those seen in humans. Three of them, for instance, have developed diabetes, and a fourth has died of the disease. Five have died of cancer.

But Rudy and his colleagues on low-calorie meal plans are faring better. None have diabetes, and only three have died of cancer. It is too early to know if they will outlive their lab mates, but the dieters here and at the other labs also have lower blood pressure and lower blood levels of certain dangerous fats, glucose and insulin.

“The preliminary indicators are that we’re looking at a robust life extension in the restricted animals,” Dr. Weindruch said.

Despite widespread scientific enthusiasm, the evidence that calorie restriction works in humans is indirect at best. The practice was popularized in diet books by Dr. Roy Walford, a legendary pathologist at the University of California, Los Angeles, who spent much of the last 30 years of his life following a calorie-restricted regimen. He died of Lou Gehrig’s disease in 2004 at 79.

Largely as a result of his advocacy, several thousand people are now on calorie-restricted diets in the United States, says Brian M. Delaney, president of the Calorie Restriction Society.

Mike Linksvayer, a 36-year-old chief technology officer at a San Francisco nonprofit group, embarked on just such a diet six years ago. On an average day, he eats an apple or some cereal for breakfast, followed by a small vegan dish at lunch. Dinner is whatever his wife has cooked, excluding bread, rice, sugar and whatever else Mr. Linksvayer deems unhealthy (this often includes the entrée). On weekends, he occasionally fasts.

Mr. Linksvayer, 6 feet tall and 135 pounds, estimated that he gets by on about 2,000 to 2,100 calories a day, a low number for men of his age and activity level, and his blood pressure is a remarkably low 112 over 63. He said he has never been in better health.

“I don’t really get sick,” he said. “Mostly I do the diet to be healthier, but if it helps me live longer, hey, I’ll take that, too.”

Researchers at Washington University in St. Louis have been tracking the health of small groups of calorie-restricted dieters. Earlier this year, they reported that the dieters had better-functioning hearts and fewer signs of inflammation, which is a precursor to clogged arteries, than similar subjects on regular diets.

In previous studies, people in calorie-restricted groups were shown to have lower levels of LDL, the so-called bad cholesterol, and triglycerides. They also showed higher levels of HDL, the so-called good cholesterol, virtually no arterial blockage and, like Mr. Linksvayer, remarkably low blood pressure.

“Calorie restriction has a powerful, protective effect against diseases associated with aging,” said Dr. John O. Holloszy, a Washington University professor of medicine. “We don’t know how long each individual will end up living, but they certainly have a longer life expectancy than average.”

Researchers at Louisiana State University reported in April in The Journal of the American Medical Association that patients on an experimental low-calorie diet had lower insulin levels and body temperatures, both possible markers of longevity, and fewer signs of the chromosomal damage typically associated with aging.

These studies and others have led many scientists to believe they have stumbled onto a central determinant of natural life span. Animals on restricted diets seem particularly resistant to environmental stresses like oxidation and heat, perhaps even radiation. “It is a very deep, very important function,” Dr. Miller said. Experts theorize that limited access to energy alarms the body, so to speak, activating a cascade of biochemical signals that tell each cell to direct energy away from reproductive functions, toward repair and maintenance. The calorie-restricted organism is stronger, according to this hypothesis, because individual cells are more efficiently repairing mutations, using energy, defending themselves and mopping up harmful byproducts like free radicals.

“The stressed cell is really pulling out all the stops” to preserve itself, said Dr. Cynthia Kenyon, a molecular biologist at the University of California, San Francisco. “This system could have evolved as a way of letting animals take a timeout from reproduction when times are harsh.”

But many experts are unsettled by the prospect, however unlikely, of Americans adopting a draconian diet in hopes of living longer. Even the current epidemiological data, they note, do not consistently show that those who are thinnest live longest. After analyzing decades of national mortality statistics, federal researchers reported last year that exceptional thinness, a logical consequence of calorie restriction, was associated with an increased risk of death. This controversial study did not attempt to assess the number of calories the subjects had been consuming, or the quality of their diets, which may have had an effect on mortality rates.

Despite the initially promising results from studies of primates, some scientists doubt that calorie restriction can ever work effectively in humans. A mathematical model published last year by researchers at University of California, Los Angeles, and University of California, Irvine, predicted that the maximum life span gain from calorie restriction for humans would be just 7 percent. A more likely figure, the authors said, was 2 percent.

“Calorie restriction is doomed to fail, and will make people miserable in the process of attempting it,” said Dr. Jay Phelan, an evolutionary biologist at the University of California, Los Angeles, and a co-author of the paper. “We do see benefits, but not an increase in life span.”

Mice who must scratch for food for a couple of years would be analogous, in terms of natural selection, to humans who must survive 20-year famines, Dr. Phelan said. But nature seldom demands that humans endure such conditions.

Besides, he added, there is virtually no chance Americans will adopt such a severe menu plan in great numbers.

“Have you ever tried to go without food for a day?” Dr. Phelan asked. “I did it once, because I was curious about what the mice in my lab experienced, and I couldn’t even function at the end of the day.”

Even researchers who believe calorie restriction can extend life in humans concede that few Americans are likely to stick to such a restrained diet over a long period. The aging of the body is the aging of its cells, researchers like to say. While cell death is hardwired into every organism’s DNA, much of the infirmity that comes with advancing years is from an accumulation of molecular insults that, experts contend, may to some degree be prevented, even reversed.

“The goal is not just to make people live longer,” said Dr. David A. Sinclair, a molecular biologist at Harvard. “It’s to see eventually that an 80-year-old feels like a 50-year-old does today.”

In a series of studies, Dr. Kenyon, of the University of California, San Francisco, has created mutant roundworms that live six times longer than normal, largely because of a mutation in a single gene called daf-2. The gene encodes a receptor on the surface of cells similar to a receptor in humans that responds to two important hormones, insulin and the insulin-like growth factor 1 or IGF-1.

Insulin is necessary for the body to transport glucose into cells to fuel their operations. Dr. Kenyon and other researchers suggest that worm cells with mutated receptors may be “tricked” into sensing that nutrients are not available, even when they are. With its maintenance machinery thereby turned on high, each worm cell lives far longer — and so does the worm.

Many experts are now convinced that the energy-signaling pathways that employ insulin and IGF-1 are very involved in fixing an organism’s life span. Some researchers have even described Type 2 diabetes, which is marked by insensitivity to the hormone insulin, as simply an accelerated form of aging.

In yeast, scientists have discovered a gene similar to daf-2 called SIR2, that also helps to coordinate the cell’s defensive response once activated by calorie restriction or another external stressor. The genes encode proteins called sirtuins, which are found in both plants and animals.

A mammalian version of the SIR2 gene, called SIRT1, has been shown to regulate a number of processes necessary for long-term survival in calorie-restricted mice.

Scientists are now trying to develop synthetic compounds that affect the genes daf-2 and SIRT1.

Several candidate drugs designed to prevent age-related diseases, particularly diabetes, are on the drawing boards at biotech companies. Sirtris Pharmaceuticals, in Boston, already has begun testing a new drug in patients with Type 2 diabetes that acts on SIRT1 to improve the functioning of mitochondria, the cell’s energy factories.

While an anti-aging pill may be the next big blockbuster, some ethicists believe that the all-out determination to extend life span is veined with arrogance. As appointments with death are postponed, says Dr. Leon R. Kass, former chairman of the President’s Council on Bioethics, human lives may become less engaging, less meaningful, even less beautiful.

“Mortality makes life matter,” Dr. Kass recently wrote. “Immortality is a kind of oblivion — like death itself.”

That man’s time on this planet is limited, and rightfully so, is a cultural belief deeply held by many. But whether an increasing life span affords greater opportunity to find meaning or distracts from the pursuit, the prospect has become too great a temptation to ignore — least of all, for scientists.

“It’s a just big waste of talent and wisdom to have people die in their 60s and 70s,” said Dr. Sinclair of Harvard.

One for the Ages:
A Prescription That May Extend Life,
NYT,
31.10.2006,
http://www.nytimes.com/2006/10/31/
health/nutrition/31agin.html

Debate surrounds

end-of-life health care costs

Updated 10/19/2006

3:55 AM ET

USA Today

By Julie Appleby

If you are dying in Miami, the last six months of your life might well look like this: You'll see doctors, mostly specialists, 46 times; spend more than six days in an intensive care unit and stand a 27% chance of dying in a hospital ICU. The tab for your doctor and hospital care will run just over $23,000.

But spend those last six months in Portland, Ore., and you'll go to the doctor 18 times, half of those visits with your primary care doctor, spend one day in intensive care and stand a 13% chance of dying in an ICU. You'll likely die at home, with the support of a hospice program. Total tab: slightly more than $14,000.

Researchers at the Dartmouth Atlas Project, a program at the Dartmouth Medical School that evaluates variation in medical care, analyzed Medicare data on patients with chronic illnesses to develop those statistics, showing that it costs far more to die in some parts of the country than in others.

While researchers are able to show differences in costs, the real question remains how much of those additional hospitalizations, tests and doctor visits resulted in better care or better quality of life? Finding answers to that question is difficult and controversial, but health policy experts say doing so will become increasingly important as the U.S. seeks ways to slow the rapid rise in health care spending.

"There's a tremendous opportunity for both improving quality and enhancing efficiency in the care of people with very serious illnesses at the end of life," says geriatrician Joanne Lynn, who spent much of her career at think tank RAND studying end-of-life care.

She says substantial progress could be made in slowing rising costs if the U.S. health system could find better ways to reduce hospitalizations for people at the end of life, such as providing more in-home services.

Portland and Miami reflect that tremendous variation among regions. The most expensive city out of 309 hospital referral regions is Manhattan, at a cost of $35,838 for the last six months; the least expensive is Wichita Falls, Texas, at $10,913.

Estimates show that about 27% of Medicare's annual $327 billion budget goes to care for patients in their final year of life.

While that's not altogether surprising given Medicare's demographics — most patients are over 65 — researchers say it's important to find out if that is money well spent.

While not the major factor driving health care spending, costs involved in sustaining patients in their final days are likely to get a closer look by both Medicare and private insurers as health costs continue to spiral and the population ages.

Why costs vary

Why is it more expensive to die in some areas of the country than others?

The number of doctors and hospital beds is part of it: The more there are, the more care a person gets. Also playing roles: the expectations of patients and the practice patterns of doctors.

Portland has fewer ICU beds and specialists per person than Miami, which is also more multicultural, with a greater variety of views on end-of-life medical care.

But experts on the end-of-life care say one main reason for the vast difference between the two cities may be that in Oregon, doctors, or staff at hospitals and hospices, encourage patients with life-threatening illnesses to talk about the end of life, what kind of medical care they want and where they want to die. The state has a history of such debate: Oregon residents have long supported palliative care, a term usually used to describe medical care for the terminally ill that focuses more on comfort treatments than cures. And, in 1994, voters there became the first in the nation to approve doctor-assisted suicide, a referendum signed into law in 1998.

"We have fewer hospitals and ICU beds than Miami does and, yes, that's a factor. But making a plan and how everyone supports you to have that plan is what makes the difference," says Susan Tolle, a medical doctor and director of the Center for Ethics in Health Care at Oregon Health & Science University.

The ways people die in Portland and Miami illustrate the vast variation in what is done at the end of life in America.

Across the nation, some patients spend much of their final weeks seeing specialists, having tests, trying new drugs. Many die attached to machines, such as ventilators, in hospitals.

For some patients, that's exactly the right care. Doing everything that can be done to save an 18-year-old motorcycle-crash victim makes sense. But what about an 85-year-old with heart failure, diabetes and cancer? Do you continue aggressive chemotherapy?

Then the answers are not so clear-cut.

Complicating matters is that medicine often doesn't know what the most effective treatments are. And doctors are trained to save lives. As a result, some patients may be pushed into more than they want by a medical system that values doing something over doing nothing, even when futile.

"One of the things that frustrates us all is to see care being provided in an absolutely futile situation ... and doctors and hospitals are not accountable but are also being rewarded (financially) for that (futile care)," says John Santa, medical director for the Center for Evidence-Based Policy in Portland.

When not to treat

Not so long ago, Americans were felled by a bad infection or an accident or a sudden illness, such as a heart attack. Advances in medicine mean more of us are living longer, but often with disabilities.

"Many more of us make it to older age, and so there's much more we can do (medically)," says geriatrician Lynn.

But, increasingly, ethicists, economists and patient advocates are questioning whether the spending mentality is best for elderly patients or the long-term financial future of programs such as Medicare.

"We are going to double the number of people who are sick, old and frail in about 15 years," says Lynn. "It would be a good thing to try on some ways of thinking about how to live that well ... and at a cost the community can sustain."

She and others say there's not enough money to give everyone a treatment with a one-in-a-million chance of success. "None of us wants to bankrupt our community on desperate, long-shot treatments," Lynn says. "The question is, how do we build a sustainable health system?"

Those questions about what care to give and when to quit are deeply personal. A USA TODAY/Kaiser/ABC poll of 1,201 Americans taken by telephone in September found the public divided on the answers.

When asked if it is better to keep a terminally ill person alive as long as possible, regardless of the expense, or to make a judgment as to whether it's worth the expense, 48% said it's better to weigh the costs, compared with 40% who said to keep the person alive as long as possible, regardless of the cost.

Among those 65 and older, 60% said expense should be considered, compared with 28% who said cost should not enter the decision. The nationally representative poll has a margin of error of plus or minus 3 percentage points.

Improving quality of care

Still, not everyone agrees that slowing spending at the end of life is a panacea for rapidly rising health costs. Such costs are driven by a host of factors, of which the amount spent in the last six months of life is but a part. "There are so many things that would result in very substantial resources being saved, and (end-of-life care), on my list of things, is not at the top," says Santa.

Things closer to the top of his list include unnecessary back surgeries, hysterectomies and what he calls an over-reliance on some expensive brand-name drugs when generics would work just as well.

But Santa and other proponents of the Oregon model say its importance goes well beyond any cost savings that might result. Rather, they say it's a way to give patients more control over their own medical treatment and is changing a culture of medicine that has been reluctant to discuss dying.

Oregon's program allowing people to register their wishes on the single page Physician Order for Life Sustaining Treatments (POLST) form began in 1995 and is widely accepted in the medical community, although it took time to build.

On the forms, patients can say whether they want cardiopulmonary resuscitation, antibiotics or feeding tubes. Conversely, they can specify that they want full treatment, including breathing machines and feeding tubes. And for how long.

The forms differ from so-called advance directives, which are also called living wills, which name someone to speak on behalf of a patient and state patient wishes. Instead, the forms are doctor's orders, similar to directions written into medical charts, that are recognized and followed by medical personnel from technicians on ambulances to staff at hospitals and nursing homes.

Tolle says most of her patients want to talk about their care and the way they want to die, although the adult children of many are often more reticent.

"It's actually not that difficult to talk to approximately 80% of my patients for the first time about an advance plan," Tolle says. "What is horribly difficult is to talk to their children, who are not ready to talk about Mom and Dad dying."

She says younger people or those without life-threatening illnesses are encouraged to fill out legal documents for an advance directive, mainly to name a person who can make medical decisions for them if they are unable to make them for themselves.

The POLST forms in Oregon, which are printed on bright pink paper and can be transmitted electronically by hospitals and other medical providers, are "for the individual who is in life's last chapter," she says.

Robert Smith, a 79-year-old retired accountant in Portland, says he brought up the subject with his doctor and filled out the form as part of his overall estate planning, which includes a will, a designation of someone to speak for him if he is unable and funeral arrangements.

His form says he wants antibiotic treatment but does not want to be kept alive artificially. "If there's no hope of my continuing to live, I do not want a feeding tube," says Smith, who encourages others to write down their desires and talk with family and friends about them. "It's part of the care you have for your family, that you told them what to do," says Smith.

Tolle says the program's designers did not focus on whether it would save money. "A few individuals might want to spend more and want everything done," says Tolle. "And we would fight for them, too."

Debate surrounds end-of-life health care costs,
UT,
19.10.2006,
http://www.usatoday.com/money/industries/health/2006-10-18-
end-of-life-costs_x.htm - broken link

In Mystery of Reaching 104,

Mrs. Astor Is a Case Study

August 3, 2006

The New York Times

By JANNY SCOTT

One startling truth stands out among the accusations about the care of Brooke Astor in her old age: Mrs. Astor is not simply old, she is 104. That makes her a member of a most exclusive club, the exceptionally long lived. Route to admission? Mysterious. Benefits of membership? A blessing, though possibly a curse as well.

Mrs. Astor, the philanthropist and socialite, took her Dubonnet in moderation, practiced yoga, gave up smoking a lifetime ago. She swam laps all winter, walked with her dogs, had flocks of friends. She was disciplined, curious, flirtatious. She had a mission. She was resilient. She never let herself, she said, become depressed.

“It didn’t matter if we were at her apartment or the Knickerbocker or the Four Seasons,” said Graydon Carter, the editor of Vanity Fair and a frequent lunch companion of Mrs. Astor’s. “She would order a club sandwich or fish and a tall Campari and soda, which she would drink about a quarter of.”

She was always reading, Mr. Carter said, two books at a time.

Mrs. Astor also comes from a long-lived lineage. Her mother, Mabel H. Howard Russell, died at 88; her father, Maj. Gen. John Henry Russell, died at 74. Both grew up at a time when average life expectancy was in the 40’s. A grandfather, Rear Adm. John Henry Russell, born when John Quincy Adams was president, died at 69.

People who study exceptional longevity — the state of living to 100 or beyond — say factors like diet, exercise, health habits, social support and the ability to find meaning in life appear to play a role in getting people to, say, 85. But, some of them say, they suspect that genes play the dominant role in hitting 100 or above.

“I have no one that was exercising,” said Nir Barzilai, director of the Institute for Aging Research at the Albert Einstein College of Medicine, who is studying 400 centenarians. “I don’t have vegetarians. Nobody ate yogurt or anything like that. If you have longevity genes, well, lucky you. If you don’t, you know what to do.”

The gift of good genes is not without drawbacks, as the family struggle over the guardianship of Mrs. Astor suggests. The longer a person lives, the more generations take their place in line. Anecdotally, it appears to some that more opportunities arise for squabbling over care, expenses and who stands to inherit what.

“The longer the person lives, the more generations you have to deal with and the more your own future becomes an issue,” said Roberta Satow, a sociologist at Brooklyn College and the author of a book on caring for parents. “We have 70-year-olds taking care of their 90- and 100-year-old parents. Those 70-year-olds are worried about what they’re going to have if they’re spending the money on Mom and Dad.”

In Mrs. Astor’s case, a grandson, Philip Marshall, has gone to court asking that his father, Anthony D. Marshall, be replaced as her guardian. He has accused his father, Mrs. Astor’s only son, of neglect — failing to fill her prescriptions, cutting her staff, removing art, banishing her dogs to the pantry and forcing her to sleep on a couch.

Anthony Marshall, 82, a Broadway producer and former diplomat, has said the charges are untrue. He has said he has always taken good care of his mother, overseeing annual expenditures of more than $2.5 million “for her care and comfort alone.” He said she has a staff of eight to provide her with whatever she needs.

There is no up-to-date count of centenarians in New York City. But, according to the 2000 census, there were 1,253 women age 100 to 104 in the city at that time, and 104 women age 105 to 109. The numbers of men over 100 were slightly lower.

Why some people live to those ages is unclear, researchers say.

Ronald D. Adelman, co-chief of geriatrics at Weill Medical College of Cornell University in Manhattan, whose mother recently won a golf tournament at 91, believes the answer is a mix of genes and factors like diet, exercise, social networks and ability to handle stress.

But Dr. Barzilai, a professor of medicine and molecular genetics, said the answer might lie in mutations in three genes that have a role in cholesterol and lipoproteins.

“I have a 104-year-old lady who’s been smoking for 95 years,” he said. “Her response is, ‘Every doctor who told me to stop is now dead.’ ”

Mrs. Astor’s life has not been free of adversity. Her first marriage was unhappy; her second husband died in her arms. Her third husband, Vincent Astor, died five and a half years into their marriage, but left her with $62 million along with another $60 million for charity, which she helped parlay into $195 million and gave away over a 40-year period.

She ran the foundation into her late 90’s and remained a fixture on the social scene. “She had the zest for life and the zest for people,” said John Fairchild, a retired publisher of Women’s Wear Daily and a close friend. “She used to drink, I remember, a watered-down Scotch. Nothing was ever in excess. She’s a wonderful flirt. It kept her young.’’

Elizabeth Corbett, who worked as a dressmaker for Mrs. Astor, said Mrs. Astor used to advise her to take a vacation: “She said, ‘Elizabeth, you have to get to the shore, you have to get to the mountains, you have to get to four different places to stay alive. You have to refresh the body and the mind.’ ”

And did Miss Corbett take the advice? “Of course not,” she said. “I didn’t have the money or the time.”