THIS IS A SECRET LETTER.
I IMAGINE YOU WILL FIND IT AFTER I DIE.
I HOPE THAT MY FAMILY NEVER SEES IT.
To whom my life concerns:
I never imagined that I would come to this. I had loving parents. I went to shul. I studied hard. I became a teacher and married the love of my life. Together, we had three children, and every one of them made me proud. Yet now at 84, I live under house arrest. I have been sentenced to die.
My crime is living to an old age. I have outlived my husband and all but one of my dear friends. I have outlived my son, and that is a pain that no one should ever have to bear. And now, here I sit in my daughter Shelley’s grand home, hating her beige walls, her beige couches and my beige life.
I should be grateful, I know; I could be living in a nursing home. Instead, Shelley and my son-in-law have made me welcome, giving me a bedroom with windows that look out on their lovely back yard and on the weeping willow tree that I so delight in seeing. Sunlight fills my room and plays on the framed photos atop my dresser. I even have a private bath. And dear Mary cares for me every day as she keeps the house spotless, just like my daughter likes. She helps me ambulate with my walker, and sometimes she even talks to me as she makes me another tasteless meal without salt and without fat so that I can live another 20 years.
But I don’t complain, except here, anonymously. My daughter has enough tsuris, with two daughters of her own, a demanding part time job and volunteer responsibilities to boot. And Steve is always working, sometimes on the road. His own parents are struggling in Pittsburgh.
Shelley herself is not so young anymore. Is she 60 now? 61? I can’t remember. I do know, however, that she too has aches and pains, but she doesn’t complain. The apple doesn’t fall far.
The funny thing is that everyone thinks I’m happy, that I’m living the life in a Norman Rockwell painting. Every night is a Thanksgiving feast around the table. Hah!
I smile convincingly.
Yet the substance of most of my family communication, which is my only communication if truth be told, is about doctors’ appointments – setting them up, getting me there, getting me back, making certain that Medicare and insurance pay what they should, which is never enough. And the endless, “Where does it hurt? Did you take your pills? Are you watching your diet?” Of course, I am watching my diet! Shelley or Mary makes everything I eat. Because of my arthritis and that darned walker, I can’t do anything for myself, not even bathe.
I especially like to be Grandma, yet I am spared from my granddaughters’ talk about men and stress and menstrual cramps. Have I never known such things?
So we talk about doctors – my doctors. When I’m not seeing one specialist or another and I’m not busying myself by taking pills or getting to and from the bathroom, I watch TV. The news and Turner Classic Movies are my constant companions. I often nod off, but I make sure to tell Shelley at least one important news item each day lest she think that I have Alzheimer’s and send me to a place far less welcoming than this one.
Ah! – here she comes – so I must stop writing now. She’d want to know who I’m writing. Who indeed is there in my life with whom I could share precious memories and dreams? (Yes, I still do dream.)
Even from a distance, Shelley looks worn. She is probably worried about me: Is today the day Mom finally slips into senility?
But don’t you worry about me! I have memorized a news story for her and I will dutifully report it.
May you go from strength to strength.
May you never get old.
The Invisible Anne
The letter above is real, and it isn’t. It is an amalgam of what staff at JCA – the Jewish Council for the Aging – hears each day and knows in their hearts. The simple truth is that our community and our nation have done a pretty good job of helping people live longer. We’ve done less well at helping them live fulfilled and meaningful lives.
The American Psychological Association calls depression among the elderly a prevalent disorder and a pervasive problem. The U.S. Administration on Aging and the Substance Abuse and Mental Health Services Administration state, “An estimated 8,618 older Americans (ages 60+) died from suicide in 2010. Although the rate of suicide for women typically declines in older age, it increases with age among men. Older men die by suicide at a rate that is more than seven times higher than that of older women.”
Yet there are plenty of happy oldsters out there, too. From 2002 through 2004, Princeton Survey Research Associates International conducted studies for AARP to find out what baby boomers thought about their lives, hopes and expectations of the future. All told, the surveyed boomers were quite satisfied with their mental health, anticipating that their relationships with family and friends would at least modestly improve over the next five years. Most, however, weren’t nearly as satisfied with their physical health. Twenty-nine percent of the respondents in the 2004 report said that their physical health was worse than they expected it to be, and 19 percent said that this was the area they most wanted to change, second only to personal finances.
You can improve your physical and mental health – at least a little and perhaps a lot. This guide will tell you how to go about making choices that are right for you. Life is, after all, about making choices – those you make for yourself or those made for you. (Sometimes, people cede their independence because they fail to act at the opportune time. Don’t let that happen to you.)
Just as there are side effects to each and every medicine, there are side effects to life choices, too. Know them.
In Anne’s story, how effective is her in-home care? Would an adult day health center in which seniors interact with fellow seniors be a better option? Might Anne be happier in an assisted living community? Who has helped her and her family evaluate options? Has any one of the many specialists she’s seeing evaluated her mental health? Might her medications and sedentary lifestyle be contributing to her depression?
This guidebook presents questions and answers about health and aging. It deals with some tough stuff. Some of the questions have been asked of the JCA Senior HelpLine – an online and by-phone resource – or at workshops that the Jewish Council for the Aging conducts. Others are questions that staff wishes were asked but never were. To steal the thunder of what’s to come, here are two overarching principles to what you will read.
First: There are no easy answers. Every decision has a consequence. Not all consequences are clear.
Second: You – indeed, everyone – needs the advice of knowledgeable professionals. Make changes to diet, lifestyle or medication only with competent medical advice. Don’t stop taking a medication because you think it makes you sick; ask a professional. Don’t start a miracle tonic, a miracle diet or an exercise regime, simply because one friend or a hundred friends swear by it. And consult a geriatric care manager, geriatrician or other expert before changing your lifestyle or that of a loved one.
Our Jewish community is rich with resources! Start your search at the JCA Senior HelpLine by emailing them at [email protected] or by calling 301-255-4200 or 703-425-0999. Or utilize the senior services of the Jewish Social Service Agency at [email protected], 301-816-2633 or 703-896-7918.
Your life is yours to live, with or without a dash of salt.
HOW TO CONDUCT YOUR OWN MEDICAL RESEARCH
Q. My doctor just fired me. Oh, I know that’s not really the term for it, but it sure felt that way. Next month, Dr. G is becoming “a boutique doctor” – I think that’s what you call it –keeping only those patients who pay a hefty sum of money to stay with him. I can’t afford that, so after 20 years, I’m forced to find a new primary care physician. I don’t know where to start. He offered me suggestions, but I was so angry and upset that I didn’t want to hear them. Should I call him for a referral? Are recommendations from my own friends a better way to go?
A. Getting referrals from a trusted professional such as a physician you admire as well as from friends, neighbors and family members whose opinions you value is generally a wise thing to do. But don’t stop there. In the Greater D.C. area, we have a wonderful resource called the Washington Consumer Checkbook, which collects, analyzes and reports the data it collects from local consumers. The magazine is easy to use, but the companion online system is even easier because you can set it to search physicians by specialty and zip code. You can subscribe to the print and online editions at checkbook.org or access those resources via your local library.
Generally speaking, your primary care physician should be a geriatrician, internist, family practitioner or general practitioner. Or for women, a gynecologist might be a good choice.
Consider those particular fields when you use Checkbook or conduct research of your own.
To guide your interviews of family and friends, consider asking them about the key factors that Checkbook uses to rates physicians. Specifically: Rate the doctor by his or her willingness and ability to
• Listen to you and communicate with you;
• Treat you with courtesy, respect, sensitivity and friendliness;
• Spend sufficient time with you;
• Seek your input in making decisions;
• Coordinate your care;
• Give self-help advice;
• Be thorough, careful and demonstrate competence;
• Arrange to see you quickly when you need an appointment;
• Give timely, helpful advice by phone or email; and
• Keep down office waiting time.
And be sure to ask how your friends and family members would rate his or her overall quality.
Q. Is boutique medicine ever a good buy?
A. It’s not just patients who complain about poor medical care; physicians complain about it, too. At the end of the day, many say that they’re not only exhausted but also guilty about giving patients short shrift. The answer – maybe – is boutique medicine, though it’s only for patients willing and able to pay as much as $15,000 annually (though typically much less) for being one of few instead of one of many.
Boutique medicine, which is also called “concierge medicine” or “retainer-based medicine,” essentially reimburses the doctor for cutting his or her patient load.
According to Nissa Simon, writing for AARP:
Concierge medicine is not a substitute for health insurance. The retainer, no matter how steep, does not cover out-of-office visits to specialists, emergency room care, hospitalization, major surgery or high-tech diagnostic tests, such as CT scans and MRIs. The fee is not reimbursed by either private health insurance or Medicare, although patients’ health savings accounts may cover some of the cost.
Concierge medicine comes in nearly as many flavors as does ice cream. In some practices, patients pay an annual fee and also pay for office visits; in others the annual fee pays for all in-office care. In what’s called a hybrid practice, the doctor continues to see all patients but sets aside a few hours each day for patients who pay an extra fee.
Some practices bill for insurance reimbursement; others have gone off the insurance grid.
… There is no standard definition of concierge care, so before signing up you must be crystal clear on what you’ll get for the money.
Do you take insurance and will you file claims for me?
What services does the fee include?
Do you offer preventative care?
Do you admit your patients to the hospital yourself or do you use a hospital-based doctor?
Can I schedule same-day appointments?
Can I contact you by email or phone with routine questions?
Will you coordinate my care if I need one or more specialists?
Do you make house calls?
And perhaps most important of all, make sure you click with the physician.
To find a boutique doc convenient to you, search the free online directory at privatephysicians.com, a service of the American Academy of Private Physicians. Or call toll-free at 877-746-7301.
Q. Many hospitals aggressively advertise themselves. Inova Fairfax says that U.S. News named it as the Number One hospital in the D.C. metro area. At the same time, Virginia Hospital Center in Arlington says that Truven Health Analytics (an independent evaluator) named it one of America’s 100 Top Hospitals, and that it was one of only two hospitals in the entire Virginia/Washington, D.C./Baltimore region to be so named. And here’s the kicker: The other top scorer wasn’t Inova Fairfax; it was Inova Fair Oaks. What does it all mean?
A. Go to the source to better understand the listings. Visit health.usnews.com/best-hospitals/rankings to learn how U.S. News made its decisions. Visit 100tophospitals.com, a website of Truven Health Analytics, to understand the Truven approach.
The Guide to Choosing a Hospital by the Centers for Medicare and Medicaid Services is another good resource because it includes handy checklists as well as information about the free “Hospital Compare” web tool, which provides a wealth of evaluative data. Search for the Guide by title at medicare.gov.
The bottom line is that the quality of hospital care varies widely, especially by department or specialty. Choosing wisely can be important to your well-being.
SCREEN THE SCREENINGS
Q. For years, smart women got an annual Pap smear, smart men had a regular PSA test, and everyone had an annual physical. Now I hear (but not consistently) that these tests and others are often a waste of time and money or that they cause needless worry. Are insurance companies trying to scare us to use less services? Who and what should I believe?
A. A credible and growing body of research shows that many tests that physicians previously thought were essential simply aren’t. As a part of a national research and educational program called “Choosing Wisely,” the American Board of Internal Medicine Foundation asked societies of family doctors, cardiologists, oncologists and other specialties – more than 50 medical societies in all – to lists tests and treatments that they thought were unnecessary. In a March 2014 article in the AARP Bulletin, John Santa, the medical director of Consumer Reports (itself a partner of Choosing Wisely), noted that false-positive results can lead to unnecessary medications and even surgeries.
The AARP article listed 10 procedures to question unless you have telltale symptoms or risk factors. And here they are:
1. Nuclear stress tests, and other imaging tests, after heart procedures;
2. Yearly electrocardiogram or exercise stress test;
3. PSA to screen for prostate cancer;
4. PET scan to diagnose Alzheimer’s disease;
5. X-ray, CT scan or MRI for lower back pain;
6. Yearly Pap tests;
7. Bone density scan for women before age 65 and men before age 70;
8. Follow-up ultrasounds for small ovarian cysts;
9. Colonoscopy after age 75; and
10. Yearly physical.
If your healthcare professional suggests that you have one or more of these procedures, be a wise consumer. Ask why that procedure is important in your case and learn about the risks of a false positive as well as potential risks stemming from the test itself.
Q. My skin is dry and marked with what my dad used to call “liver spots.” I’m constantly scratching my arms and legs. Is this worth a visit to the doctor or are there some good creams or ointments to try? (There’s certainly no shortage of products at the drug store.)
A: Aged skin is often thin, dry, wrinkled and scaly, and it tends to be even more so for persons who have high stress, diabetes, kidney disease and certain other ailments. What’s more, old skin may itch and bruise easily.
Lotions, creams and other moisturizers can be soothing. Many physicians say that it’s a good idea to use them daily. But don’t add oil to your bath water because the slippery tub it creates can lead to serious accidents and injury.
If you find yourself picking or scratching your skin despite the use of moisturizers, see a dermatologist (a “skin doctor”) or other qualified health professional. The open wounds and bleeding that picking and scratching can cause can lead to infection.
Other tips: Be sure to drink enough liquids. Use sunscreen (or stay out of the sun). Try to avoid being in very dry environments. And do stop smoking.
A screening for skin cancer is generally a smart move, especially because the chance of skin cancer increases with age. While you’re at the doctor’s office, ask if your particular skin conditions are treatable.
To learn more, visit the website of the American Academy of Dermatology at aad.org and visit the National Library of Medicine at medlineplus.gov.
IN SIGHT AND ON BUDGET
Q. I just learned that my elderly neighbor hasn’t had an eye exam in years. I’m guessing she can’t afford one. Is there a program that could help her?
A. More than 6,000 volunteer ophthalmologists have helped nearly 1.8 million people get the eye care they need, and many are served without paying any out-of-pocket costs at all. To learn more, visit eyecareamerica.org and see the video there.
Encourage your neighbor to learn about other helping programs, too, by contacting the area agency on aging that serves her locale, visiting benefitscheckup.org, or contacting the JCA Senior HelpLine at [email protected], 301-255-4200 or 703-425-0999.
WHEN WARM MILK
Q. Until I turned 70, I never had trouble getting to sleep. Now, I need at least a couple nightcaps to get drowsy. Is that normal?
A. No. It may be a sign of alcohol dependency.
The National Institute on Alcohol Abuse and Alcoholism recommends that people age 65 and older limit themselves to seven drinks a week, and no more than three a day. And the definition of “a drink” is absolute. One drink equals a 12-ounce can of beer, a 5-ounce glass of wine, or a 1.5-ounce glass of hard liquor.
How do you stack up?
Alcoholism can mimic many of the symptoms of Alzheimer’s disease, damage the brain and liver, worsen diabetes and other ailments, mask the signs of a heart attack, compromise the immune system, lead to certain kinds of cancer, and exacerbate other problems including insomnia. Moreover, even small amounts of booze can interfere – sometimes dangerously – with the medications you take, including such over-the-counter meds as aspirin and acetaminophen.
Talk with your doctor if you have trouble sleeping or controlling a dependency on alcohol, and seek other help, too. There is plenty of help available!
To aid sleep, such simple lifestyle changes as changing the time or nature of your exercise or changing your just-before-bedtime routine can help enormously. For helpful tips, contact the National Sleep Foundation at sleepfoundation.org or 703-243-1697.
For information about alcoholism, visit the websites of the National Institute on Alcohol Abuse and Alcoholism at niaaa.nih.gov and the U.S. Substance Abuse and Mental Health Services Administration at samhsa.gov.
SADLY IN NEED OF HELP
Q. My sister has always been a glass-half-empty kind of person. Lately, however, her litany of complaints and worries has grown exponentially. No one wants to be around her. What’s more, she often talks about death. “Mark my words,” she says, “You won’t have me to kick around much longer!” I don’t understand that. She’s only 61 years old and, as far as I know, she’s never had a life-threatening condition. What should I do?
A. Your sister may be depressed, and depression is not a normal part of growing older. It is a treatable medical condition, and one that’s often misdiagnosed or overlooked
The Centers for Disease Control (CDC) defines depression as sadness or anxiety that lasts for weeks at a time, and the CDC notes the following 10 symptoms that sufferers may evidence:
• Feelings of hopelessness and/or pessimism;
• Feelings of guilt, worthlessness and/or helplessness;
• Irritability, restlessness;
• Loss of interest in activities or hobbies once pleasurable;
• Fatigue and decreased energy;
• Difficulty concentrating, remembering details and making decisions;
• Insomnia, early-morning wakefulness or excessive sleeping;
• Overeating or appetite loss;
• Thoughts of suicide, suicide attempts;
• Persistent aches or pains, headaches, cramps, or digestive problems that do not get better, even with treatment.
Older adults are at increased risk of depression, so you’re right to be concerned. Tell your sister how worried you are. Offer to accompany her when she visits her health-care provider. And know that anti-depression drugs, psychotherapy or a combination of both often results in marked improvement.
If you believe that your sister is in crisis, call 9-1-1, arrange for her transport to a nearby emergency department, or call the toll-free, 24-hour National Suicide Prevention Lifeline at 1-800-273-8255 or TTY 1-800-799-4TTY (4889), to talk to a trained counselor.
WHEN ARM AND FLOOR COLLIDE
Q. Last year, I fell twice, and the second fall was pretty bad; my right arm broke in two places. I’m scared of falling again, but short of living in a padded room, what can I do to protect myself? I feel fine, walk well and really have no idea why I fell in the first place.
A. The National Council on Aging (NCOA) has made falls prevention a top priority, and there’s good reason for them doing so. Below are NCOA’s 10 myths about falling and the ways that organization debunks them.
Myth 1: Falling happens to other people, not to me. Reality: …1 in 3 older adults – about 12 million – fall every year in the U.S.
Myth 2: Falling is something normal that happens as you get older. Reality: Falling is not a normal part of aging. Strength and balance exercises, managing your medications, having your vision checked and making your living environment safer are all steps you can take to prevent a fall.
Myth 3: If I limit my activity, I won’t fall. Reality: …Performing physical activities will actually help you stay independent, as your strength and range of motion benefit from remaining active.
Myth 4: As long as I stay at home, I can avoid falling. Reality: Over half of all falls take place at home. Inspect your home for fall risks. Fix simple but serious hazards such as clutter, throw rugs, and poor lighting. Make simple home modifications, such as adding grab bars in the bathroom, a second handrail on stairs, and non-slip paint on outdoor steps.
Myth 5: Muscle strength and flexibility can’t be regained. Reality: While we do lose muscle as we age, exercise can partially restore strength and flexibility….
Myth 6: Taking medication doesn’t increase my risk of falling. Reality: Taking any medication may increase your risk of falling. Medications affect people in many different ways and can sometimes make you dizzy or sleepy. Be careful when starting a new medication. Talk to your health-care provider about potential side effects or interactions of your medications.
Myth 7: I don’t need to get my vision checked every year. Reality: Vision is another key risk factor for falls…. People with vision problems are more than twice as likely to fall as those without visual impairment. Have your eyes checked at least once a year and update your eyeglasses.
Myth 8: Using a walker or cane will make me more dependent. Reality: Walking aids are very important in helping many older adults maintain or improve their mobility. However, make sure you use these devices safely. Have a physical therapist fit the walker or cane to you and instruct you in its safe use.
Myth 9: I don’t need to talk to family members or my health care provider if I’m concerned about my risk of falling. I don’t want to alarm them, and I want to keep my independence. Reality: Fall prevention is a team effort.
Myth 10: I don’t need to talk to my parent, spouse, or other older adult if I’m concerned about their risk of falling. It will hurt their feelings, and it’s none of my business. Reality: Let them know about your concerns and offer support…. There are many things you can do [together], including removing hazards in the home, finding a fall prevention program in the community, or setting up a vision exam.
FOR FEAR OF ALZHEIMER’S
Q. I am deathly afraid of getting Alzheimer’s disease. Is there anything I can do to reduce my chances of getting it?
A. Although scientists don’t know for certain what causes Alzheimer’s disease, it appears that genetics, environment and lifestyle all play a part. There’s nothing you can do about your parentage, but you can live healthier, and that includes tamping your fear of the disease.
Here’s a conundrum for you: Being highly anxious about Alzheimer’s disease (or anything else for that matter) produces stress. Stress can elevate blood pressure. And high blood pressure may increase the likelihood of Alzheimer’s.
An increasing body of evidence shows that what creates a healthy body creates a healthy brain. In other words, mom and grandma were probably right – you’ll live a longer, healthier life if you eat well, sleep well and are physically active, socially connected and mentally stimulated. Read more in JCA’s free guide entitled Staying Sharp: Tips for Brain Health, which is available for download from the Publications page of AccessJCA.org.
Q. My father has Alzheimer’s disease. We’ve traveled from specialist to specialist with little to show for our efforts; the medications he’s taking don’t seem to do much good. I see him slipping away, and I don’t want him to go. Might he benefit from new medications and therapies that are in development now? How are people selected for clinical trials?
A: The National Institute on Aging (NIA) supports research on the causes, diagnosis and management of Alzheimer’s disease. That research – ongoing and upcoming, too – needs subjects that include people with Alzheimer’s disease, people with mild cognitive impairments, people with a family history of Alzheimer’s, and healthy people with no memory problems and no family history of the disease.
There are benefits and risks to participation, however. The NIA lists these benefits:
You may get a new treatment for a disease before it is available to everyone.
You play a more active role in your own health care.
Researchers may provide you with medical care and more frequent health check-ups as part of your treatment.
You may have the chance to help others get a better treatment for their health problems in the future.
And NIA lists these risks:
The new treatment may cause serious side effects.
The new treatment may not work or it may not be better than the standard treatment.
You may NOT be part of the treatment group (or experimental group) that gets the new treatment – for example, a new drug or device. Instead, you may be part of the control group, which means you get the standard treatment or no treatment (a placebo).
The clinical trial could inconvenience you. For example, medical appointments could take a lot of time or you might be required to stay overnight or a few days in the hospital.
To find out more, talk to your health-care provider (or your dad’s provider), contact NIA’s Alzheimer’s Disease Education & Research (ADEAR) Center at 1-800-438-4380, or visit the ADEAR Center’s clinical trials database at ClinicalTrials.gov, where you can sign-up for alerts of new trials.
THE FINAL GIFT
Q. I think that I would like to be an organ donor, but I have two concerns. The first is a religious one. Under Jewish law, is it the right thing to do? The second is more practical. I am 90 years old, and I may surprise myself and my loved ones by living for another decade or more. Would anyone benefit by having a heart or kidney that’s 90 or 100 years old?
A. Judaism holds that life is sacred. It is precisely because of that belief that the issue of organ donation can be complex under Jewish law. Ask around; you’ll find plenty of opinions. Google unearthed 271,000 results (in .54 seconds, no less) when searching “organ donations Jewish law.”
Do discuss the issue with your rabbi because the U.S. Administration on Aging (AoA) states that people are never too old “to give the gift of life.” Moreover, says AoA, the donor needn’t be in good health. That’s because the condition of each organ, eye and tissue is evaluated at the time of death. The Organ Procurement and Transplant Network found that in 2011, 32 percent of all organ donors were over the age of 50.
The U.S. Health Resources and Services Administration says, “Right now, more than 110,000 people are waiting for an organ. More than 98 million people in the U.S. are aged 50 and older…. About 21 million of them think they’re too old to be donors.”
For additional information, visit organdonor.gov.
This guidebook was written by David Gamse, the chief executive officer of the Jewish Council for the Aging. A gerontologist, Gamse (as does everyone at JCA) works to help people age well.