New study rates elderly well-being high in Canada

A new study rates elderly well-being high in Canada. Just released by the United Nations, the study ranks the well-being of the elderly as being fifth best overall of the 91 nations studied.

See more in the Globe & Mail story: http://www.theglobeandmail.com/news/world/canada-ranks-fifth-in-well-being-of-elders-study/article14621721/

Taking to bed: an undercover problem

 

            Staying in bed is not a “normal” aspect of aging, other than for the occasional day or two which may occur as part of an underlying short-term illness. Most people want get out of bed and greet the day as soon as they can. So if an elderly loved one ‘takes to the bed’ and stays there, a full health evaluation and possibly intervention for depression, should be done.

Proper Assessment Is Essential

            The most important aspect of an in-home assessment is discovering any underlying medical problems that could cause someone to ‘take to bed.’ Clearly, any distinctive physical symptoms—such as pain or shortness of breath— that are relieved by staying in bed will need to be addressed.  In the absence of such fairly obvious physical symptoms, major depression ought to be considered.  Older men in particular have a significant risk of late onset depression, a condition that is easily overlooked, especially when the person denies feeling depressed.  Not every depressed person expresses negative or ‘blue’ thoughts, or mentions feelings of hopelessness or helplessness. Fortunately, treatment for depression, which might include medications or other therapies, is usually effective. 

What’s Wrong with Staying In Bed?

            When older people start taking to bed and refuse to get up, it makes perfect sense to them.  “I don’t have the energy or interest to get out of bed,” or “I just feel better being in bed,” are common explanations. But bed rest of more than a day or two very quickly becomes problematic, causing muscle tone and functional ability to deteriorate so that after a short period of being in bed, the person may indeed have difficulty performing everyday activities. Sometimes, physical condition can deteriorate seriously, leading to the need for hospitalization and urgent medical intervention. Family members often have a difficult time persuading their loved ones that staying in bed is bad for them. 

A Return to Meaningful Mornings and Engaging Days

            ‘Remaining in bed’ may not sound serious, but it can be symbolic of an important underlying condition which needs to be addressed and treated quickly and properly by the whole team of those who care for the older person. Sometimes, especially for the person who is living alone, moving to the more engaging and supportive environment of an assisted living facility may be worth considering. Ultimately, the ‘best decision’ is whatever helps the person look forward to getting out of bed and participating in the world around them. 

Elder care living choices: decisions are not easy

    It is a fairly common scenario: the daughter who was the primary care giver of her 84 year old mother was sitting together with her in my office. “I feel a lot better since that visit to the emergency room in the summer when they changed my medications. I have not had any more dizzy spells or falls.”  The daughter concurred and I confirmed from the discharge summary of the finding following a fall that was found to have blood pressure levels that fell when she stood up as well as a slow heartbeat.  It was believed to be the result of a combination of medications for her high blood pressure which were producing an excessive effect, leading to “postural hypotension” (an excessive fall in blood pressure when standing) 

The real issue beyond the medical care

    I was told that since the fall the mother was living in her daughter’s home; the mother’s apartment had suffered water damage during a rainstorm that required repairs. It was not yet certain if she would feel secure enough to return and live on her own, even though that was what she was appeared to prefer. The mother had mild cognitive impairment; but her every day and basic functioning was normal. She was able to care for herself in most ways despite being a bit repetitive. She expressed herself quite clearly and made reasonable sense about what was happening to her.

    The daughter asked quite bluntly after the assessment, “Do you think my mother should move into a retirement home rather than living with me? During the day she is alone in the house but we have checked it all for safety and she has an emergency call system which she knows how to use” I asked the patient and asked her how she felt about living in her daughter’s house. Other than musing that returning to her own home would be her preference she stated that she felt quite comfortable living with her daughter. The house was arranged in such a way that she could do everything she wanted to do and be comfortable on the modified ground floor.

Conflict between siblings

     The daughter continued, “My sister who lives in Toronto and brother (who lives in New York) feel she should in a retirement home for safety reasons. On their urging our mother tried one that seemed very nice and suitable but after three days she called and begged to be taken back to my house. They are now looking at others but my mother insists on staying at my house if she cannot return to her own apartment.”  

How such living decisions should be made

    Making elder care living choices is not easy. I explained to mother and daughter the principles according to ethics and the law, by which such living decisions should be made. The important point was the apparent ability of the mother to participate in such decisions.  I explained to the daughter and patient, “I think you and your siblings need a good discussion with someone who understands the process of personal decisions and how alternative housing arrangements should be made. Arrangements were therefore made for a family meeting with a social worker. The mother seemed very pleased that her wishes were being listened to and respected—that step and process is key to any such discussions. Being the daughter who in this case was the proverbial “It” in the middle of family discord is not easy.

 

Five key tips for interacting with your children about eldercare issues in the family

When you get busy helping your aging parents or other elderly loved ones, make sure you take the time to help your kids understand what’s going on and how you can do things together moving ahead.

Here are five key tips you may want to consider.

Don’t pressure.

Understand that no matter what their ages, your children sense and comprehend the pressures at play. The more you press them to be part of a caregiving team, the more they may well resist, especially as they reach adulthood.

Do explain.

Work hard to explain the situation, the medical prognosis and the timetable to likely events. Giving your children information helps them make their own decisions and take what the right actions are for them.

Ask a lot of questions.

Help your children construct and express their own feelings by asking a lot of questions about how they feel now, how they think they’ll feel when there is a death, how they think they’ll cope after a death and what it all means to them.

Share your feelings.
While it’s hard, share what’s on your mind and your own feelings about your parents’ health and decline, and how you’re dealing with their impending death. Let your children see and feel your emotions: they’ll respect you for it.

Be there for them.
As much as you may love your parents and work hard to help them, never for- get or short change your children: they need you, too. They need to feel and know that they’re also an important part of your life and that they have the comfort of your time and attention. 

More about music and elderly with dementia

We recently posted a blog about music; specifially, how I got my mother, with her advancing Alzheimer's, to get engaged with music that she seemed to remember from her younger years.

Today, CNN online carried the following story that underscores and amplifies my posting. Hope you will read this and find expanded interest in applying music and other active forms of involvement for your aging parent. He or she may have a host of limitations, but music can do so much, as can art, pets, kids… stimulates that engage the brain, regardless of its current state.

 

(CNN) — At 101, Frank Iacono still plays the violin. The concertmaster for the Providence Civic Orchestra of Senior Citizens in Rhode Island, he particularly enjoys playing polkas and jigs.

"It keeps my mind active, and it gives me a lot of pleasure," Iacono said.

The orchestra's executive director and co-founder, Vito Saritelli, said Iacono is extremely sharp for his age.

"Music has played a good part of his longevity," said his wife, Mary Iacono, 94. "We're blessed that we're both in good health."

Music meets medicineMusic meets medicine

 

As scientists race to figure out how to promote healthy aging of the brain, and prevent dementia, their preliminary advice for senior citizens has become a chorus of voices: "Stay active! Have hobbies! Be socially engaged!"

Playing music, for some people, is a natural answer to all of those recommendations. Frank Iacono, for instance, has been playing violin since he was 13 — just because he loves it.

But does music playing in particular stave off dementia? What about just listening to music? How many years do you need to engage in music before it benefits your brain?

Researchers are exploring these questions in the face of staggering statistics about the aging population. The number of Americans 65 and older with Alzheimer's is expected to triple nearly by 2050 — 13.8 million from 5 million now. The annual cost of dementia in the United States in 2050 will be $1.2 trillion, according to the Alzheimer's Association.

Early research suggests playing music may hold back dementia symptoms by about five years — which would be significant if it proves to be true, said Brenda Hanna-Pladdy, assistant professor of neurology at Emory University, who studies cognitive functioning among musicians.

"If you can delay the presentation (of dementia) by five years, then you add an extra five years of functioning to an individual at the end of the life span," she said. "In terms of fiscal cost and everything, that's actually quite a lot."

Being engaged

A large study using Sweden's twin registry is looking at intellectually and physically stimulating lifestyle factors that could help stave off cognitive decline. One component of this effort is exploring whether playing music protects against dementia. The results, discussed at the Interdisciplinary Society for Quantitative Research in Music and Medicine meeting in July, are not yet published.

Twin studies carry special importance in science. Usually, when people participate in a study, they each carry a different set of genetics and may have had different upbringings. Those factors could influence whatever researchers want to investigate. Fraternal twins, however, share about 50% of genes, and identical twins share almost all. Twins also likely grew up in the same environment.

"To me, the most intriguing aspect is, in a twin pair, if one becomes demented and the other doesn't, what did (one not do)? Or what did the one who did become demented do that might give you some clues about ways that other people can mitigate their risk?" asked Margaret Gatz, director of the Study of Dementia in Swedish Twins, and professor at the University of Southern California.

Researchers examining the broader twin data have found that, for women specifically, participating in intellectual and cultural activities was linked to lower dementia risk in one study. Activities such asexercise at midlife for both sexes are also protective against dementia, the study suggests.

"All of these kind of add up in suggesting that a more engaged lifestyle is a good thing for the aging brain," Gatz said.

Why would an "engaged lifestyle" help prevent dementia? The idea is that brain stimulation may counteract brain changes that occur because of cognitive decline so that a person can function for longer, Gatz said.

Music playing in particular is something that people can continue to enjoy for longer than their occupations, or strenuous physical activity, Gatz said. It also has cognitive, physical and potentially socially components, so it engages many brain networks.

Unfortunately the twin study has so far only looked at associations between lifestyle factors and dementia; it doesn't prove that music can protect you against cognitive decline. The study also doesn't include brain imaging or autopsies, so the precise mechanism — how engagement in activities would prevent dementia — is unknown.

Music therapy: When patients have 'music emergencies'

The brain's backup

There is other emerging evidence that playing music could help prevent dementia.

Hanna-Pladdy, the Emory neurologist, is interested in exploring the biological underpinnings further. Her theory agrees with Gatz's: Brain networks that have been strengthened by musical engagement compensate to delay the detrimental effects of aging, a process called cognitive reserve.

So far her research has demonstrated that extensive musical instrumental training, even in amateur musicians, provides a cognitive benefit that can last throughout a person's life. Her studies were published in 2011 in the journal Neuropsychology and in 2012 in the journal Frontiers in Human Neuroscience; they included instrumentalists, not singers.

Hanna-Pladdy and her colleagues found in their first study that even if participants did not continue playing music as they aged, they still performed better at tasks of object-naming, visuospatial memory and rapid mental processing and flexibility than those who didn't play at all — as long as they had played for at least 10 years. That's critical because as they age, people may lose motor skills or eyesight that prevents them from playing their instruments.

 

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The study also suggests the cognitive benefits of instrumental training can last a lifetime.

One of the study's participants said in an interview that he felt like having played for so long was akin to "an insurance policy," Hanna-Plady said.

The researcher's more recent study showed that musicians who began playing before age 9 had better verbal working memory functions than those who started later or didn't play at all.

This finding is consistent with verbal language acquisition — linguistics studies have shown that there is a critical period during which the brain is open to learning a language, and fluency becomes far more difficult after a certain age in childhood.

It also jives with the findings of a 1995 study that showed professional musicians who began training before age 7 had a thicker anterior corpus callosum, part of the pathway that links the right and left hemispheres of the brain.

And participants who continued to play their instruments at older ages tended to perform better on tasks of visuospatial judgment, "suggesting that there continues to be plasticity in advanced age," Hanna-Pladdy said.

"Finding a way to harness this plasticity is probably one of the biggest hopes we have for treating brain disorders or dealing with cognitive decline in advanced age," she said. "Similarly, continuing to play music in advanced age added a protective benefit to individuals with less education, which has previously been demonstrated (to be) one of the most robust ways to create cognitive reserve. Thus, musical training appears to be a viable model for cognitive stimulation, and can be conceptualized as an alternate form of education."

Should we start now?

Is it worth it then to teach an older person to play an instrument, perhaps one who already shows signs of cognitive decline? Recent research suggests it's harder, but still possible, to modify the brain in an older person. But no one has a definitive answer on whether teaching an elderly person a new instrument would lead to the same kinds of benefits that scientists have found in lifelong musicians.

"It would be pretty challenging, considering they're having a hard time remembering," Hanna-Pladdy said of dementia patients. "It may be beneficial to provide musical stimulation to individuals in the earlier phases (referred to as mild cognitive impairment) or to re-initiate musical practice in individuals who are no longer engaged."

Regardless, since people find music enjoyable, trying to learn an instrument won't hurt. But more research is needed over a long period of time to assess fully the benefits of music among elderly people, Hanna-Pladdy said.

Music: It's in your head, changing your brain

Evidence may continue to emerge that long-term music playing has a preventive effect against dementia, but that's not to say that nonmusicians are totally out of luck, Hanna-Pladdy said.

Music is becoming a hot area of study because it's easier to quantify the number of years that people play music than, for instance, the length of time reading or playing games.

"This is just meant to be a model for cognitive stimulation, and how cognitively stimulating activities can change your brain," Hanna-Pladdy said.

So music may be good for you, but so may other pastimes.

After all, violinist Frank Iacono and his wife, Mary — married for 66 years — play Scrabble together every night.

Tuning in

For patients who already have dementia, music can be used in a different way to help the mind.

The emotional response that people get from listening to music, and the brain chemicals associated with pleasure that get released in the process, are distinct from the structural changes in the brain that playing music over time may instigate, scientists said.

Dr. Sanford A. Shmerling, who has Alzheimer's, joined in drum circle activity recently at his nursing home in Atlanta.
Dr. Sanford A. Shmerling, who has Alzheimer's, joined in drum circle activity recently at his nursing home in Atlanta.

 

Trends emerging from research show that music exposure — whether through casual listening or more formalized music therapy — can help reduce the incidences of behavioral issues and generally calm dementia patients, said Beth Kallmyer, vice president for constituent services at the Alzheimer's Association.

"Anecdotally what we hear is that people can be upset, even a little agitated, and when they're listening to music, even in the late stages, people can appreciate music," Kallmyer said.

Family members should help caregivers choose music that is meaningful to a person with dementia, she said. "The most important thing is keeping your interventions person-centered as much as possible."

Naomi Ziv of the Academic College of Tel Aviv Yaffo in Israel and her colleagues showed in a Journal of Music Therapy study that background music is associated with an increase in positive behaviors — laughing, smiling, talking — a decrease in negative ones, including aggressiveness and crying.

Music attracts attention; it also enhances focus and affects emotion, Ziv told CNN in an e-mail.

"When we hear familiar and preferred music, we mentally follow it," she said. "It seems that whereas general memory deteriorates in dementia, memory for music remains relatively intact."

Familiar or preferred music evokes memories and influences mood, which is perhaps the underlying reason for these results, Ziv said.

Catherine Shmerling appreciates the effect that certain musical events have had on her father, Dr. Sanford A. Shmerling, 85. The elder Shmerling used to be the medical director of the William Breman Jewish Home in Atlanta; now, he lives there. He has Alzheimer's, and most of his speech is not comprehensible, his daughter said.

On a recent weekend, a swing band performed at the nursing home. At first the former medical director sat in his wheelchair staring into space, but soon his daughter noticed him clapping his feet. She started swinging his arm with the music, and after a few minutes he gave her "a cute little smile."

"It's gratifying," Catherine Shmerling said. "There is something about — I don't know, the music or the auditory or something — that does seem to get past whatever it is that's blocking their normal communication, and somehow it gets in there."

Science may not have all the answers, but Shmerling savors these small signs that her father is listening.

Yet new data about elder caring gaps, this for Canada

Here is the start of a Globe & Mail article the other day, and it totally supports our ealirer UK posting on this subject:

Sys­tem must fo­cus on se­nior care strat­egy
AN­DRÉ PI­CARD api­card@globe­and­mail.com
The Globe and Mail Metro (Ontario Edition)
19 August, 2013

Cana­di­ans have lit­tle con­fi­dence in the abil­ity of the health-care sys­tem to meet the needs of a bur­geon­ing num­ber of se­niors and they are look­ing to gov­ern­ment to shift their pri­or­i­ties and come up with a plan.

That’s the mes­sage that emerges from a new poll com­mis­sioned by the Cana­dian Med­i­cal As­so­ci­a­tion.

“The anx­i­ety Cana­di­ans have about health care in their so­called golden years is both real and well-founded,” said Anna Reid, out­go­ing pres­i­dent of the CMA.

Na­tion­wide, three in five re­spon­dents said they be­lieved there would not be suf­fi­cient hos­pi­tal beds, long-term care and home-care ser­vices to meet de­mand in their golden years.

How­ever, there are sig­nif­i­cant re­gional dif­fer­ences. In Que­bec, for ex­am­ple, 56 per cent of those polled said the health sys­tem is ready for the so-called grey tsunami, com­pared to 31 per cent in At­lantic Canada.

Where there is near-unan­i­mous agree­ment – 93 per cent – is around the idea that gov­ern­ments should unite to de­velop a com­pre­hen­sive se­niors’ strat­egy. A large num­ber of re­spon­dents, 78 per cent, said Ot­tawa should play a sig­nif­i­cant role in de­vel­op­ing the strat­egy, de­spite the fed­eral gov­ern­ment’s stand that health is strictly a pro­vin­cial mat­ter.

“Let there be no doubt that a na­tional strat­egy for se­niors’ health care should be a fed­eral pri­or­ity,” Dr. Reid said.

She added that the poll re­sults send a strong mes­sage that the pub­lic wants ac­tion.

The repeating key point is that the system can't deliver to meet our expectations about eldercare. We need to work harder than ever to plan ahead, to research needed resources, to define and enlist  the help of others… lots to do! And we can't start soon enough anymore. 

Care of the elderly a challenge that’s growing everywhere

Take a look at this short story on the BBC tonight: http://www.bbc.co.uk/news/health-23810109
 
It's an excellent example of the kinds of help and support shortages that will keep growing not just in England, but across Canada and the United States, too.
 
All the more reason to think about what kind of care our aging parents will need and likely when, and then plan now for how to get that help. 

Open, honest communication is essential

If one is a geriatrician, a good part of one’s practice is focused on individuals either living with dementia or concerned about having symptoms that might be dementia. It is often a frightening prospect, at times more so for the family members than for the person with the symptoms, depending on their awareness of the problem and insight into the implications.

As I looked through the health record, I saw the neuropsychological report that supported my initial clinical diagnosis of likely dementia. The symptoms suggested it was probably a type of Alzheimer’s type. There was a note that my secretary handed to me from the patient’s spouse which reminded me of many requests I have received over the years from family members accompanying a loved one to such a medical visit. She did not want me to share an adverse diagnosis with her husband

Years ago, families and physicians sometimes conspired to withhold the true nature of a patient’s condition. As a result, patients and families were denied the opportunity to honestly express their important thoughts and feelings to each other before the patient died.

Gaining trust

What should I do about this latest request? I looked again at the wife’s note and asked the couple to come into my office. I knew that I would have to gain the couple’s trust to ensure our future relationship would be productive. After our initial greetings, I turned to the issue of the neuropsychological report. “So how did that go?” I asked the patient. “I think pretty well. What was the result?” he replied.

I responded that the reason I sent him for the examination was because his wife and I had concerns about his memory, and that I suspected dementia. I could see the patient tense up when I used the term dementia. I continued, “You know that we use the term dementia to mean something is not right with the way the brain and its ability to remember things works. There are many disorders that can cause dementia…”

Breaking the news

The patient concentrated on my every word. I continued, “Fortunately, we now have medications and other treatments that can treat these conditions, including Alzheimer’s disease.”

I want to try one with you and start it now at a low dose to give you the best chance of tolerating it until I see you in a few weeks for follow- up. Is this OK with you?” I could see his wife with a bit of trepidation waiting for his response. “Sure…are there any side effects?” he asked. I replied, “Most people tolerate the medication well but I always start with a small dose just to make sure.” 

As he got up to leave with his prescription, I said that I looked forward to seeing him. I did not tell him or his wife what to expect so that there would be no pre-conceived ideas of his treatment. As she left the room, the wife said, “Thank you, I did not believe we could do this and we did.” I’ve learned through many years that open and honest communication between doctor and patient (and their family) is more helpful than avoiding the truth. It has to be done with sensitivity and sometimes over time rather than in one meeting.

Music can help with an aging loved one

A few years ago as my mother was sliding slowly but surely into her own mind’s dark spaces, engaging her become more and more difficult.

She’d more or less stopped talking in sentences and for periods of time barely spoke more than two or three connected words. She’d begun to eat less at most meals, and had stopped using utensils. When she fed herself at all, it was using her fingers.

Sleep was more often than not the activity of the day.

A few of my friends in the field of geriatrics suggested I play music for my mother. Figuring I had nothing to lose by trying, I bought a small CD player with a good quality headset. I remembered that she really used to like the Viennese waltzes and that she also liked the 1920s and 1930s musicals, which we used to play on an old ’78 record player when I was young.

Music made her day

The first time I showed her what I bought she shook her head, almost violently. So with great caution and very slowly and methodically, I organized the play and one of the CDs. I first put the headset on my ears to show her how it worked and that it was okay.

Then I applied the headset to her ears and hit the play button for the waltz CD. For about two minutes there was absolutely no reaction whatsoever. And then there was the hint of a little smile. A moment or two later, my mother’s eyes, which had be almost wildly open, slowly receded almost entirely from view as her eyelids became small slits.

She liked the music. She liked listening to the music.

What I discovered from a number of other like-minded children of aging parents at her nursing home was that indeed, soothing, known and liked music was calming and welcomed.

And the more I asked around, the more I found that the right kinds of music seemed to be just about as good as some of the prescription mood management drugs were… and with a lot less potential negative interactions with yet other drugs.

Even musicals and music shows on the communal television set seemed to make my mother more engaged.

Miss the music

One of the part time helpers I’d retained to spend time with my mother on weekends decided my mother actually didn’t really want to listen to music. It never registered on me until weeks later that when I’d go visit my mother on weekends she seemed more withdrawn and even more agitated.

I was baffled until one Saturday it dawned on me that there was no music. I asked the helper where the music was. She said my mother didn’t need it, that it made no difference. So I found the CD player, flipped in a CD, put the headset on my mother’s ears and upped the volume a bit. She liked the music.

That’s when I suggested to the helper that if she failed to ensure my mother had her music at least a couple of hours a day, she’d be looking for another job.

Diversions, distractions, pacifiers

The past years, I’ve spoken with many personal support workers, health care professionals and families; I’ve read reports and medical journal articles.

All suggest that music, pets, children, plants… whatever the diversion, distraction, pacifier might be… seem to help refocus the elderly, especially those with some form of dementia, to some kind of better, gentler, nicer personal place.

I suppose there are no guarantees, but there’s nothing to lose by trying the right kind of music or other mental pacifiers with your aging loved ones. Just remember, the first time may not work; it may take a few efforts before there is a benefit.

Aging parents, eldercare blog starting next week

In just days, we're starting to post blogs on a regular basis.

Our goal is to provide good counsel that  helps all those with aging parents and other loved ones better address the issues they face. We will be posting blogs on a regular basis.

As well, our newest Parenting Your Parents book will be in bookstores and available online as of September 21st. Pre-ordering can be done now.

We are looking forward to engaging you, offering sound insight into the issues we all face around eldercare in the family, and receiving your feedback.