Will guilt keep me from doing what is best for my Alzheimer spouse?

I met Vickie in Your Father’s Mustache, a sing-along place in Greenwich Village 46 years ago.  She had long dark hair and wore a poncho like Clint Eastwood in Fistful of Dollars. She was singing and swaying with such joy. She had the kind of face you could look at the rest of your life.  I noticed her eyes were different colors.  One was hazel and speckled with green, and the other a cloudy blue.  She asked me, “What do you do?”

“I’m a priest.”

She laughed uncontrollably.  That cinched it.  Continue reading…

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Robert Frost and the Decline of the Medical Profession

The title of this post is deliberately mysterious, but you’ll understand it at the end.

At my 50th medical school reunion in June, my classmates agreed that while the goals of medicine are as valid as ever, the profession itself is in decline. Here’s a quote from the Preface to our reunion book:

“A frequent refrain is our disappointment in the evolution of medicine in the 21st century…The art of medicine appears to have diminished in value.”

This isn’t just a reaction by grouchy old guys (my class, like other medical schools at the time, had relatively few women). In a recent survey of 13,575 physicians, 84% agreed that medicine is in decline, and 58% would not recommend medicine to young people. Continue reading…

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Dementia and the Goals of Care

Even though you think and behave perfectly normally, you might already have Alzheimer’s disease. In fact, you might warrant the label of “pre-clinical Alzheimer’s disease” for a full 20 years before graduating to the full-fledged condition. That according to the latest definition of Alzheimer’s put forward by the National Institute on Aging together with Alzheimer’s Association 3 years ago.

Heralded as a radical departure from earlier clinical diagnostic criteria, the new definition is in line with how we think about other chronic conditions such as cancer or heart disease. Normal cells often mutate into cancerous cells and proliferate for a long time before there are enough of them to produce symptoms—and a cancer diagnosis. Plaques may be deposited in the lining of coronary arteries long before they narrow blood vessels enough to impair blood flow to the heart resulting in chest pain. In all these cases, the hope is that we may be able to intervene during the pre-symptomatic phase, altering what is currently the inevitable trajectory of illness.

In the case of Alzheimer’s, detecting various “biomarkers” in the blood or cerebrospinal fluid would signal the need for some kind of biochemical intervention. The problem has been that we don’t as yet have any such intervention. Continue reading…

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A Retirement Community’s Private and Public Affairs

Our move from the Washington area to a retirement community in Baltimore called Roland Park Place came five ago when, I was 81 and my wife, Pat, was 80. It was concerns about our health and a concerted push from our seven children that propelled us to decide to move. It had become more noticeable that Pat might have Alzheimer’s. For me, Parkinson symptoms, dormant for a decade, had come alive.

At the beginning of our second year at Roland Park Place four falls in two days put Pat in a room in the health care center. I was able to move a second bed into her room and that is where I have slept for the past three years.

While caring for Pat is my main focus, I have become involved in discussion groups concerned with the world’s problems. Last year I became concerned about the morality of our government’s increased reliance on drones. For me it was a “distant mirror.” Continue reading…

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Aging with Purpose

Near the end of my clinical career as a psychiatrist, I, like so many other psychiatrists, was required to do more in less time. In order to use that precious time as best as possible, I wondered if there was anything else I could do to offset that limitation. Soon, I recalled the landmark book by the psychiatrist Viktor Frankl – Man’s Search For Meaning – which describes how even those in concentration camps were better able to cope if they had a sense of meaning in their lives there.

I then decided to ask each of my patients what gave them the most meaning in their lives. That way, I hoped, I might quickly know what was most important to them, then also be able to connect how the treatment could help them achieve those goals. Continue reading…

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Who’s Responsible for Granny?

On July 30, 1965, when President Lyndon B. Johnson signed the bill that created Medicare, he outlined an ethical vision for the nation’s obligations to its older citizens. “No longer will older Americans be denied the healing miracle of modern medicine,” he said. “No longer will illness crush and destroy the savings that they have carefully put away over a lifetime so that they might enjoy dignity in their later years. No longer will young families see their own incomes, and their own hopes, eaten away simply because they are carrying out their deep moral obligations to their parents, and their uncles, and their aunts.”

That was then. Remember that, in 1965, 19 million Americans 65 years and older were eligible for Medicare. Life expectancy for men was only 66.8 years and, for women, 73.7 years.

This is now. Almost 44 million people are 65 and older. Women who reach the age of 65 now have a life expectancy of 20.4 more years; for men, it’s 17.8 more. That’s a boon to the healthy and well-off, but a challenge for those who are sick and poor.  Continue reading…

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Overtreatment of elderly diabetics

The last time I was directly responsible for treating diabetes was fifty years ago, when I was an intern in medicine at UCLA. In my subsequent career as a psychiatrist I was not directly responsible for diabetes care, and as an individual, I don’t have the condition. As a result, I haven’t kept up on diabetes treatment, so a June 11 article on “Diabetes Overtreatment in Elderly Individuals: Risky Business in Need of Better Management” was news to me.

The opening two sentences of the American Diabetes Association’s article on “Tight Diabetes Control” make it sound as if “tight control” should be the goal of treatment:

“Keeping your blood glucose levels as close to normal as possible can be a lifesaver. Tight control can prevent or slow the progress of many complications of diabetes, giving you extra years of healthy, active life.”

In my uninformed state, that’s how I understood how diabetes should be managed, even for over 65ers. But I was wrong. Continue reading…

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Reluctance to use Hearing Aids

The classic cartoon picture of someone with hearing loss is a bent, old man with a giant ear horn held to his ear: not a pretty picture.  Things have come a long way.  Modern hearing aides are highly sophisticated electronic devices, some so small that they can fit into the ear canal and be virtually invisible.  Some have directional microphones that can help you sort out voices that you want to hear from background noise.

Yet, most people are reluctant to wear a hearing aid.  Some even buy them and don’t use them.  Why is that?  Continue reading…

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Healing from the Death of Loved Ones

This winter, three good friends and four admired colleagues died. As my generation winks out, there is plenty of time at funerals to think about grief and comforting the brokenhearted. It isn’t easy.

When death cuts down a life intertwined with mine, I’m depleted. Waves of pain and powerlessness wash over me and weigh me down. Premature, violent deaths are the hardest to bear. After 9/11, I went to the funeral of a young man last seen helping his coworkers down a fiery staircase. Patrick was mourned by his pregnant wife, two toddlers, parents, four siblings, and a sorrowful church full of friends and neighbors.

But even the hardest death blows can be healed – eventually. Continue reading…

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Arnold Relman: 1923 – 2014

Dr. Arnold (“Bud”) Relman died yesterday at 91. He was the most esteemed leader among those who have been dismayed by the commercialization, fragmentation, excessive cost, and relatively poor quality of the U.S. health “system.” In 1980, as editor of the New England Journal of Medicine, Bud sounded the alarm about a danger he fought against almost to the day of his death: “We should not allow the medical-industrial complex to distort our health care system to its own entrepreneurial ends…[Medicine must] serve patients first and stockholders second.”

Bud was a champion – perhaps the champion – on behalf of patient care values and ethical medical practice. But in this post I want to write about him as a model of aging for those of us who are over 65.

My contact with Bud was solely at meetings we attended together over the years. He was 16 years older than I, and as I joined him as a member of the over 65 set I increasingly admired him for his passionate commitment to his core values and the generative way in which he tried to support those who held the same commitments. I especially admired the way in which he could disagree with others in a respectful, friendly, humorous manner. To my eye he was a master of constructive debate and collaborative conflict.

I didn’t know Bud well enough to ask him the questions I posed to my beloved late father-in-law, who died at 91 sixteen years ago. I marveled at my father-in-law’s zest for learning about the fields his grandchildren were working in as journalist, psychologist, teacher, and environmental activist. When I asked him about the basis for his enthusiasm for new learning he seemed puzzled – “What else is there to be interested in but the future?”

I had a similar exchange with the grandmother of one of my daughters-in-law when she was 99. We discovered that we both wished we could return to earth in 500 years – not out of a wish for reincarnation but out of curiosity about how our species and the planet would evolve.

Some years ago when I was talking with a friend about my belief that a substantial number of over 65ers are worried about the impact of runaway Medicare costs on future generations, he responded with an aphorism I’ve treasured ever since: “The true meaning of life is to plant trees under whose shade you do not expect to sit.”

Bud Relman embodied this attitude for me. He didn’t expect to sit in the shade of a clinician-led, patient-oriented single payer system, but he worked tirelessly on behalf of that vision. I understood Bud to be following a “moral faith” that had the force of “religious faith.” Bud was a teacher to the end of his life, via both the content of his ideas and the example of his person.

[The aphorism comes from the title of a book that Wes Henderson (1928-2003), a third-generation Canadian, wrote about his father, Nelson. It's the advice Nelson gave Wes when Wes graduated from high school. For an extensive obituary for Dr. Relman, see here.]

Jim Sabin, M.D., 75, is an organizer of Over 65, a professor of population medicine and psychiatry at Harvard Medical School, and a Fellow of the Hastings Center.

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