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Slightly Dented Halos

Book Review
Slightly Dented Halos
Jackson, LA (2011). Slightly dented halos. Canada: ireadiwrite Publishing Edition. $3.99, ISBN eBook: 978-1-926760-51-3
Slightly Dented Halos is author LA Jackson’s real life account of about five and half years of her life after she invites her aging in-laws to move in with her family. Written in a tone that has been described as “a conversation with a friend over a cup of coffee,” Jackson conveys a series of anecdotes that are heartwarming, heartbreaking, and most often full of humor. In Jackson’s own words, “It wasn’t easy, much laughter and many tears, but I’d care for them again if given the opportunity.”
Without giving advice, Jackson’s novel brings to the forefront a number of questions for anyone who will have to face choices surrounding how to care for their parents or elder family members. After this read, the choice of having our in-laws move in, the help needed to care for them, the idea of nursing homes, and end of life care, will all be themes that you might glean with a new insight. Additionally, in-laws or parents, as well as aging seniors, are different from the other roommates we may have had in life as they bring twists to the cohabitation situation. How do we navigate this new relationship with a person who used to be in charge, but now is someone we hope will follow our rules? When do we intervene for safety’s sake if a parent’s driving is of concern to us? Jackson’s depictions of how she handles these and other difficult conversations and family situations will help you consider the actions that you might face with your own loved ones if they move in.
Not written in a chronological timeline, Slightly Dented Halos instead introduces us to a household that bridges three generations of family including Jackson’s beloved dogs through short “vignettes.” We meet Reed, Jackson’s husband with whom she relies on and also supports through the difficult choices as well as the everyday frustrations they face together. Jackson describes Reed as kind, sensitive, and having a special bond with his father. A bond we are fortunate to glimpse in ways that may bring a smile and often a tear. Conner is their teenage son who is trying his best to be supportive and helpful, but also is moving on to live his own life. This, of course, is another huge change Jackson must contend with. Betts, Reed’s Mom, is described as the kindest human being imaginable, but also someone who lacks any concept of organization. The scenes in which Jackson tries tactfully at first, then slowly describes how she looses her patience with Betts redecorating of her house are comical. Gus, Reed’s Dad, had a stroke at 29 which made mobility difficult for him. It becomes an increasing struggle in the story, but only second to Gus keeping his dignity. Included in the equation are Jackson and Reed’s beloved pets Hobbes, Zona, and Jameson. Jameson causes quite a stir when his love for Gus leads to his keeping needed help at bay. Finally we have Eleanor, the 89-year-old neighbor whose friendship and wisdom seem to help Jackson stay sane.
I would recommend this book to any reader, especially one that is open to challenging ethical dilemmas because Jackson’s book is addressing what is becoming clear and true of society today, the baby boomer generation is aging. One of the outcomes of the largest group of similarly aged people living at the same time is that it will also be the largest number of people approaching death at the same time; consequently, it will also be the largest number of people making the difficult end of life choices at the same time. Caregivers for this population will have unparalleled challenges they have never faced before, just ask Jackson. Just a few of hers were balancing career and family obligation, the strain on a relationship or marriage, medical tragedies, the reshaping of relationships with elders, and finding free time. These are essential to navigate if we hope to, as Jackson teaches us is most important of all, enjoy the journey and time spent together.
By not providing suggestions or answers and instead just telling her story, Jackson creates a dynamic with the reader in having them search their soul and questioning the decisions they might face with their loved ones. Jackson often describes situations and her reactions to them in this book that leave the impression she is conflicted with her own choices. Jackson seems to be questioning if she was doing the right thing. The book leads to an understanding that, often, we will be far from perfect in our words and actions, just like Jackson. At times we will make the right choice and the right choice will leave us feeling like terrible people. Jackson’s title tells me she has come to peace with her conscience. Remember, even slightly dented, it is still a halo.

The Right to Informed End of Life Decisions

 Voluntarily Stopping Eating and Drinking

 If a patient is in need of life-sustaining medical treatment such as dialysis or a ventilator they have a legal right to decline this care.  Suffering or not, this patient can legally choose to end their life.  Other patients nearing the end of life may not have this choice.  They may be suffering, or facing long declines that might be accompanied by severe symptoms including pain, lack of mobility, or growing dementia.   There is no life saving treatment to decline; having said that, there is a choice for these patients, a choice that has produced controversy.   Voluntarily stop eating and drinking (VSED) to accelerate the dying process is a proven evidenced based practice that produces what is labeled a good quality death.  A good quality death by definition is a death with as little pain as possible, on a patient’s own terms, and in a comfortable setting. The question before us becomes, what is the medical profession’s responsibility in this case?  Should patients be informed of all their end of life options, including aggressive treatment, foregoing life sustaining treatment, or VSED?   In the United States, physician assisted death is illegal.  VSED on the other hand is legal in every state since the physician is not assisting death; it is a choice made by the patient. VSED and information regarding this choice, however, is often withheld from patients.  The medical profession fears that it is suicide, illegal, or it is just unsure of the law.

While the idea of dying from hunger and dehydration can seem horrible, VSED is not the same thing. There are studies that show 94 percent of VSED deaths as “good deaths.”  The body naturally releases pain-relieving opioids in times of crisis.  It is believed that this same process can occur during VSED, and patients actually report improvement in their symptoms.  The normal dying process itself often includes discontinuing the consumption of food and liquids in the final days before death.  Palliative care, which is geared at relieving physical and emotional distress despite its inability to cure the affliction, should also be considered.  This can effectively accompany VSED and would insure as much comfort as possible.

Take the case of Armond and Dorothy Rudolph.  A couple both over 90 years old who were facing diminishing health. Mr. Rudolph had spinal stenosis, which causes chronic pain while Ms. Rudolph was losing her mobility; both faced early dementia.  The Rudolph’s believed they had enjoyed a satisfying life to this point and now they were scared of losing their independence.  Their son, Neil Rudolph remembers, “Their great fear was that they [would] end up in a nursing home.”  This fear became true for the Rudolph’s who entered an assisted living residence.  When the slow deterioration of their health seemed inevitable, the Rudolph’s put their plan into action.  They chose to voluntarily stop eating and drinking (VSED) which “hastened their dying” process.  The Rudolph’s, like others who make this choice, did so to avoid a slow decline in health, one likely accompanied by suffering.  By making this choice they took back control of their lives.  They had what they would have perceived to be a “good death.”

A similar positive account is provided in Joshua Segar’s death.  Mr. Segar chose VSED when Parkinson’s disease became a more unmanageable burden for him.  Mr. Segar’s family recounts his death as a weeklong process without pain.  They believe his decision of VSED provided Mr. Segar relief.  They viewed his death as “peaceful and . . . beautiful.”

If you are conflicted or bothered by these stories, you are not alone.  The assisted care home in which the Rudolph’s were living in demanded they leave upon realizing their intentions.  The Rudolph’s were forced to complete their plan in a private home, with the help of their family.   Mr. Rudolph died ten days later and Ms. Rudolph died the following day. In the Rudolph’s case “legal apprehension” is believed to have caused their eviction from the assisted living home.  Some doctor’s would call VSED suicide, viewing VSED as ethically wrong because by definition, suicide is “the act of hastening or causing one’s own death.”  Perhaps what needs to be considered is the way we perceive the act of death: whether it is correct to see death as “harm to the one who dies,” or that death can bring much awaited relief.

There is no clear side in this debate.  What is certain is that we each have values, ethics, spiritual beliefs, and life experiences that would impact our view of VSED.  What should be absolute is that the patient should be made aware and informed of all the possible end of life choices, including VSED. This assures that the patient can make the best-informed decision for themselves and their family.  In California advising the patients of end of life alternatives became law in 2008, removing the physician’s role in identifying what the patient might require. It would seem responsible for the rest of the country to follow this example and empower patients to make their own “informed health care and end of life decisions.”  Laws that allow these decisions to be carried out without legal complications should also be enacted.

Obesity in Senior America

“Human’s are Designed to Eat”

Jim Keller is a psychologist who helps obese people lose weight.  When beginning a relationship with a client he compassionately assures them that “humans are designed to eat.” Keller demonstrates empathy in understanding that “fat cells do not like to be shrunk.”  He does not deny “personal responsibility” plays a key role in weight management.  He believes mastering the “biology of the machine” that is the human body as the challenge of losing and keeping off weight. Keller concludes our body is a machine we can learn to fuel optimally by mastering “how the human machine works,” and the importance of “(making) this machine feel safe … well-fed, (and) well-hydrated.”

The baby boomer generation should take head to Keller, because baby boomers are in need of addressing the highest incidence of obesity seen in either the generation before or after it.  Obesity is defined through a tool called the Body Mass Index (BMI).  A BMI number is a measure of body fat in a person.  BMI incorporates weight and height into this measurement.  According to current BMI measures seventy-two percent of baby boomers are reported to be overweight, with half—36 percent—regarded as obese.  Comparatively, from either the previous or subsequent generations only 25 percent fall in this category.  This is a cause for alarm.

As a nation we have access to healthier food.   Health care has improved.  Levels of physical activity appear constant from one generation to the next.  The 2004 National Health Interview Survey found senior respondents aged 50 to 64 as identifying themselves with  “good” and “excellent” health in comparison to scores for seniors in the same study done in1994.  These health benefits, healthier food, and overall positive attitudes of health aside, it is clear that obesity in senior America must be addressed.  The main culprit in our society seems to be our increased  consumption of foods higher in fat.  Other risk factors for obesity include  our slowing metabolism once we reach age 40, meaning the same amount of calories now leads to weight gain.  Weakened senses of smell and taste also lead to increase in consumption of foods high in salt and often sugar.  Sugar equals more calories.  Medicines also impact appetite and taste, again creating an increase in consumption of high sugar.  Lifestyle changes, including retirement, death of a partner, or reduced social contacts can lead to loneliness or depression.  Overeating is often a symptom of these feelings.

Obesity alone is not the main danger.  Obesity is not considered a chronic disease.  The complication is that sixty-two percent of Americans 50-64 years of age present one or more obesity related health problems.  These include heart disease, cancer, arthritis, and high-cholesterol.  Obesity also impact levels of activity, and has shown a correlation to higher levels of depression.  Obesity also leads to higher rates of disabled seniors.  Women in their 50’s seem to have the highest incidence of obesity today.  Research by the Mayo Clinic has shown a connection between obesity and Alzheimer’s disease.

The combination of diet and exercise are proven to be the most effective tools to combat obesity.  To keep weight under control the first step is eating well. This includes lowering calorie consumption and improving the intake of nutrient rich foods.  Some suggestions incorporate a high fiber diet, containing whole grain breads; lean proteins like fish should be chosen when possible; calcium rich foods are also needed, these consist of dairy products like milk, but can be found in tofu and broccoli as well; all in addition to an abundance of fruits and vegetables.  With a healthy diet come benefits.  They boost energy, which helps us feel better.  Many also believe they look better, in turn raising self-esteem.  Physiologically our internal structures, including bones and organs are stronger over time.  Our ability to fight disease increases.  There are marked declines in the incidence of strokes, heart disease, high-blood pressure and diabetes.  We see a decline in cancer.  In terms of mental health, nutrients power the brain, and we see a decrease in Alzheimer’s.

Exercise is the next powerful step against obesity.  Simply walking 20-30 minutes a day has been shown to reduce the risk of diabetes by 60 percent and lowering cholesterol. The Mayo Clinic tells us that lack of energy is not “a result of age, but inactivity.”  Exercise returns this energy.  Other benefits are an increase in the efficiency of insulin, preventing or lowering the risk of type II diabetes.  When part of the exercise includes resistance or weight training, the benefits to healthy bone mass reduce the risk of osteoporosis.  More benefits include improved immune systems, and better circulation, and loss of fat which also proves to lower the risk of cancer.

Using Keller’s analogy of the body as a machine, the best weapons to combat obesity appear to be keeping the machine optimally fueled by choosing the right food in addition to exercising to keep the machine in top working condition.

 

 

 

Depression is Not a Byproduct of Old Age

Understanding and recognizing depression in our elders needs to become a priority.  According to the National Institute of Mental Health (NIHM) “studies show that many older adults who die by suicide — up to 75 percent — visited a physician within a month before death.”  This fact clearly demonstrates the need to better understand depression in older Americans.  NIMH reports that one of the reasons for this is that depression presents itself in conjunction with other severe “illnesses, such as heart disease, stroke, diabetes, cancer, and Parkinson’s disease.”  They conclude that because of this, the public, and health care professionals attribute the depression to a natural part of the aging process.  Depression becomes a secondary symptom.  However, NIHM clearly says, depression is “not a normal part of the aging process.”

The MAYO Clinic defines depression as “a variety of emotional and physical problems. You may have trouble doing normal day-to-day activities, and depression may make you feel as if life isn’t worth living.”  They warn that depression is a “chronic illness” that “requires treatment.”

The Mayo Clinic describes some of the symptoms of depression for older adults, echoing NIMH’s concern that we often ignore these signs and label them the reality of getting old.  They include “fatigue, loss of appetite, sleep problems or loss of interest in sex.”  NIMH says seniors chose to stay home rather than go out.   The American Association of Retired People (AARP) explains the words used by the elderly often minimize signs of depression.  “Older patients come in saying, ‘I can’t sleep, nothing tastes good, or my back hurts.” Expressions of suicide take on a different tone.  An example is how we interpret a senior who proclaims, “If God took me now, I wouldn’t mind.”  NIMH emphasizes awareness of language.  The words “dissatisfied…bored, helpless or worthless,” are cause for alarm.

NIHM believes that the risk for depression in elders rises with illness and with loss of functioning and mobility.  They highlight that major depression in older people in our country ranges from one to five percent, but that it goes up to 13.5 percent for those needing home care and as high as 11.5 percent for those that are hospitalized.  They report an additional five million seniors with identifiable symptoms of depression that fall short of meeting clinical criteria.

The National Alliance on Mental Illness (NAMI), says that depression in seniors is not caused by any one definitive factor.  They tell us that biologically genetics play a role.  With this hereditary predisposition in place, “stress, loss, or major life changes” can trigger depression.  For seniors this includes loss of loved ones, retirement, having to relocate, and losing their role as a caregiver.  Medications can also produce depression.  Substance abuse is another risk factor.   Women are at greater risk, up to “twice as likely” to have depression.  Hormonal changes can be a contributing factor.  Elderly women are more likely to provide care to the ill, a heavy burden.  Unmarried and widowed women share an elevated risk.  Finally NAMI reminds us that conditions like “heart attack, stroke, hip fracture or macular degeneration, and procedures such as bypass surgery are known to be associated with the development of depression.”

Heather Pollett’s literature review in June 2008 for the Canadian Mental Health Association discusses protective factors that insulate seniors from depression.  They include healthy self-esteem, having the ability and “flexibility” to cope with “illness and difficult life events,” as well as healthy social connections.

Suicide Awareness Voices of Education (SAVE) tells us that 90 percent of clinical depression can be treated.  The precursor for this is for the senior to get help.  With professional care the AARP reports that a number of interventions including counseling and medication can be effective.

By educating the public, we can increase the chance help arrives.  NIMH’s pamphlet on depression lists valuable steps that can help a senior with symptoms of depression.  The first step should be to visit a primary care provider or a mental health professional.  Depression requires professional care.   NIHM encourages “support, understanding patience and encouragement.”  They urge one to talk about the problem with the senior, and just as importantly to listen.  Comments about suicide should be taken seriously and reported to professional health care workers.  NIHM also advocate that we help the person get out for walks and other activities.  Helping the person remember that the treatment they may be undergoing does work is also valuable.  Remember, as NIHM says, depression is “not a normal part of the aging process.

Just Breath

“Just Breath”

Holistic Health Practices in Substance Abuse Treatment for Seniors

The Substance Abuse and Mental Health Service Administration (SAMHSA) in their publication, “Substance Abuse Among Older Adults, Treatment Improvement Protocol (TIP) Series 26” say the standard of care for older adults is motivational counseling that “meets people where they are at.”  In my experience as a behavioral health counselor, this has been a way of helping clients by acknowledging strengths, and these help the person heal.  I remember my training in motivational interviewing with Dee Dee Stout, a nationally recognized motivational interviewing trainer and a professor at City College of San Francisco’s Alcohol and Drug Studies Program.  She reminded us to “roll with resistance” in our classes.  My professional dilemma working with “motivational counseling” is just that, it relies on a minimum of ambivalence to be effective (D. Stout, personal communication, Fall semester 2007).  A person must be able to minimally acknowledge that they are contemplating a change for motivational counseling to be applied.  For some clients this will never be the case.  I have sat in clinical staff meetings and discussed what is getting in the way; was it culture, honesty, low self-esteem, or pride interfering with the process.  The problem remains, the client is struggling with talk therapy.  The solution always suggested by my supervisors has been to work with holistic health practices.

Marietta Arroyo a senior case manager at Asian American Recovery Services, Inc. Project ADAPT, an outpatient behavioral health program in San Francisco’s Panhandle district describes holistic health as a connection of mind, body, and spirit.  Ms. Arroyo believes that “not everything can be accomplished through a verbal process.” She explains that practices we might take for granted are vital in treatment.  “Just learning to breath” is something Ms. Arroyo teaches her clients.  She uses an example of a client speaking about the past, which brings not just emotional, but also physical symptoms. Reminding and helping a client to breath can settle their body and emotions (M. Arroyo, personal communication September 19, 2011).

Ms. Arroyo believes that community connection is vital in holistic treatment because people feel socially isolated through substance abuse and often as an impact of the aging process. Seniors in recovery carry shame and want to be able to provide value to others. By using the treatment community and having the members participate in roles such as cooking lunch for the community, working together on a project, or even cleaning the facility, clients can gain a sense of worth (M. Arroyo, personal communication September 19, 2011).

Garrett Chinn, an Instructor of Tai Chi Chuan, and a member of the Older Adults Department at City College of San Francisco has been working with seniors for 30 years.  For addiction, he talks about the need for balance.  Mr. Chinn cites research that shows 30 percent of seniors over 65 have at least one fall a year in emphasizing how physical balance affects emotional and spiritual balance.  He discusses the symbol of Ying and Yang, and says it is not two opposites, as he believes most people understand it, but the connection of both sides.  “A higher way” he says, is that “we can learn from both halves.”  In Chinese medicine the key is internal as well as external balance.  Mr. Chinn says, “Stress leads to relapse, …so physical balance may neutralize extreme emotions.” He talks about how clients go from tired to more positive feelings, including increased energy and relaxation by the end of his group.  He believes “more clarity upstairs will help resolve their issues (G. Chinn, personal communication September 16, 2011).”

Mr. Chinn sees Tai Chi as more appropriate for seniors than jumping jacks or pushups.  Additionally Tai Chi challenges their memory, as they must remember the movements.  He likens it to a “crossword puzzle.”  Tai Chi can be a “healthy habit, a substance free way to get high (G. Chinn, personal communication September 16, 2011).”

Cynthia Chang, Licensed Acupuncturist and the creator of the Tara Healing Center in San Francisco says that wellness is in us.  “We have a divine pattern of wholeness, a divine plan of perfection.”  She too describes holistic health as the connection of the mind, body, and spirit (C. Chang, personal communication September 19, 2011).

With substance abuse it is not about drugs, says Ms. Chang, but about why we use drugs.  Acupuncture helps clients listen to “your higher self-speak.”  This opens the door for forgiveness and healing.   Acupuncture helps the energy in our bodies flow.  Needlepoints are like “gates,” describes Ms. Chang.  When part of our energy is not flowing, it also keeps our thoughts from flowing.  Acupuncture lets you be in the present.  Being in the present brings clarity and allows us be “more fully ourselves (C. Chang, personal communication September 19, 2011).”

It was interesting that in my search for techniques aside from talk therapy I was brought back to them.  Ms. Chang says that if we have worked on the body and the illness continues, the question should be, “What is our core belief that causes this pain (C. Chang, personal communication September 19, 2011)?”

“The ability to be in the present will give you permission to follow your heart.” She too reminds us to breath, saying if people can breath easier, she believes they can work towards healing and the idea that “everything I need, I have,” in terms of the ability to heal (C. Chang, personal communication September 19, 2011).

 Substance Abuse Among the Elderly

“A Hidden National Epidemic”

Substance abuse among the elderly is a “hidden national epidemic” according to The New York State Office of Alcoholism and Substance Abuse Services (OASAS).  In a recent article titled “Elderly Alcohol and Substance Abuse” they describe that an estimated 10 percent of the total population of the United States abuses alcohol, yet up to as many as 17 percent of adults over 65 years of age are abusing alcohol.

Treatment Improvement Protocol (TIP) 26” from the Substance Abuse and Mental Health Services Administration (SAMSHA) in 1994 foreshadows what we see today in America.  They report that only recently the subject of substance abuse in the elderly has been discussed in literature.  The report warns that as the baby boomer generation in our country approaches the age of 65 this fact will no longer be avoidable. Christine L. Himes writes in “Elderly Americans” that United States census data from the year 2000 saw 35 million Americans over 65 in our total population, which is one out of every eight people. By 2030 that number is estimated to rise to one in five Americans.

In a Summary Report from 2005 titled “Substance Abuse Prevention and Treatment: Senior Forums” New York Sates OASAS cites a brief written by Cynthia Morley that is included in “Project 2015, The Future of Aging in New York State, Articles and Briefs for Discussion.” The article cites that five percent of those entering treatment for alcohol and other drug (AOD) problems in New York State are 55 or older.  The concern is a study done in 2000 showed that staff trained with the proper skills to recognize AOD problems at a hospital intake identified 20 percent of that age group screened with AOD problems.  The majority of the time these AOD issues had been undetected and more importantly untreated in these patients.

Studies are also showing the types AOD problems in this age demographic are changing. “The TEDS (Treatment Episode Data Set) Report” by SAMSHA cites data from 1992 till 2008 to show that the patterns for those 50 years of age and over are changing in regards to substance abuse in the United States.  For those 50 years of age and over admissions had risen from 6.6 percent in 1992 to 12.2 percent in 2008.  Admissions for alcohol dropped from 84.6 percent in 1992 to 59.9 percent in 2008.  Heroine use went from 7.2 percent in 1992 to 16 percent in 2008.  Poly substance use increased from 13.7 percent in 1992 to 39.7 percent by 2008.

The TEDS Report” goes on to say that the number of admissions that presented as beginning their abuse in the past five years was fairly constant, going from 3.2 to 3.8 percent from 1992 to 2008.  What did change was the drug of abuse for this group.  In 1992 alcohol was at 42.9 percent, in 2008 it dropped to 9.9 percent.  Methamphetamines rose from 1.3 to 8.6 percent in the time period.  Also prescription medication abuse went from 5.4 percent in 1992 to 25.8 percent in 2008.

There are a number of factors to consider when you look at drug abuse and why it is happening in the elderly.  Some have been abusers all their lives and they take this problem into their later years.  This is evidenced by the “The TEDS Report” data that just fewer than four percent began use in the last five years of their lives.  Other factors that often accompany aging also may play a role.  In their article “Elderly Alcohol and Substance Abuse” OASAS gives us insight into some risk factors in this population.  The reasons OASAS reports for the “late onset” of alcohol abuse are major life changes.  One big change is retirement.  Losing a loved one, perhaps a partner, a close friend, or even a beloved pet could have a tremendous impact.  Family conflict is also cited as a concern.  Health concerns and the challenges that they can present also create risk factors.  Nora Volkow, the director of The National Institute on Drugs and Alcohol (NIDA) writes in her article “Prescription Drugs, Abuse and Addiction” that the elderly are prescribed more medication than the younger population, leaving them at risk for abuse from the medication.

The evidence is clear and demonstrates substance abuse in the elderly warrants serious concern.  Further research in this area could be instrumental.  For example, finding information about gender, cultural, and class differences and how they impact the demographic of seniors who abuse drugs proved unsuccessful in researching this blog.  The impacts to individuals, families, health care, and the communities as a whole are all areas that will undoubtedly be touched by this epidemic.  We could all benefit, and perhaps help our elders, by raising our awareness to this “hidden national epidemic.”

 

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