Properly Estimating Older Friends and Colleagues

I learned, or perhaps relearned, something important today in relation to an older friend. He had been gaining weight and declining in his ambulatory status during the past 6 months or so. Yesterday I urged him not to walk to an overgrown area where I was walking because I felt that there were too many opportunities to trip and fall. However, today he chose to go there with me. He plodded a bit more than I, and he kept to the trails a little more, but he never seemed to be at risk for a fall.

There are lessons in at least two directions for this. One of course is that I was correct to look out for his welfare. The opposing lesson was that I should not legislate him away from taking a small risk. My friend is not frail. He can fall in a reasonable place and not get injured. And continuing to do the things that are important to him is very important in his continued viability in many dimensions. I have been thinking about continued challenge and exercise as one ages, and it appears to be even more important than I had thought. This is but one small example.

The Strength of Vigorous Aging

A friend of ours is a vigorous 88 and regularly plays tennis. She fell on her bicycle this August. She was going uphill, and those of us in the rolling hills of Massachusetts know how brutal that can be even for a college student. During the process her bike went slower and slower, and then she allowed the front wheel to turn and down she went. No ambulance. She got back up on her bicycle and proceeded home, a little hurt and a little shaken. We brought her some Arniflora, left over from fixing our child's pains when learning Tai Kwon Do. Our friend was sipping on an early cocktail when we came by. Some conversation and then we were off to our commitment. It is very good to have confirmed that not all falls, even from bicycles on the hard pavement of the street, are life threatening. They often do not even land a person under the care of a physician.

Single Payer Health Insurance

I was largely uninterested in this issue until recently, when a speaker at Harvard pointed out that the present health insurance system is broken. It is simple to see how it is broken: health insurance is for the most part attached to employers. This leads to huge liabilities for General Motors and other struggling or bankrupt companies. It also leads to expiration of coverage for individuals who lose their jobs. Now, I have worked closely with people at several Blue Cross/Blue Shield organizations, so I know the people and cannot accept that the source of the problem is corruption. However, it does appear that there is a problem, whatever the source.

The link here to BILL MOYERS JOURNAL on Single Payer Health Insurance will take you to one of the better discussions that I have heard about this topic. I am interested in your comments, and any other useful references on the topic.

Friends, Longevity, and Walking Revisited

I was talking with someone in his forties, a person who seems quite personable and outgoing. He told me that his wife and he are each others' best friends, and that each of them has about two good friends outside their marriage. It led me to think again about individual differences. I addressed personality and individual differences in my dissertation, so this will not come as a surprise to people who know my intellectual history. One key personality dimension is whether a person is a "reducer" or an "augmenter." Reducers are people who experience physical sensations less intensely than they really are. Augmenters are people who experience physical sensations more intensely than they really aer. Reducers tend to go into sports such as football, because it offers a means to feel they are really bumping up against the real world. Augmenters tend to go into activities that do not involve strong physical contact because it would hurt too much. Augmenters tend to achieve strongly in school, reducers less so. Reducers tend to have many friends, augmenters only a few. That being said, you can see where I am going with this.

It is unlikely that augmenters have a significantly shorter lifespan than do reducers. If you believe the life insurance companies, it may even be the reverse, because at least the last time I checked, they gave better rates for high school graduates who had strong academic records.

So this personality dimension also has to be taken into consideration when thinking about friend networks. The augmenters simply do not need or want as many friends. Reducers tend to have larger friend networks. So the material in my previous post has to be understood with a little more nuance than I first expressed it.

One way to think of it is in terms of augmenters who have relatively strong friend networks for augmenters, and reducers who have relatively strong friend networks for reducers. For each of these the observations might hold relative to those with weaker friend networks in each category. One might also argue that some augmenters do not need many friends, have very small friend networks, and so what! As long as they do not have an accident, they are just fine. But they are probably a pretty small part of the population. There are many more who would be better off for having a network of friends suitable for them.

A great research topic for somebody.

Friends, Longevity, and Walking

With the emergence of Girls from Ames, there is a newly acute awareness of the importance of social relations for health and longevity. We have known this about social relations within the family for a long time. I was personally introduced to this in the late 1970s by Stanley Krippner, an academic psychologist who studied cross cultural healing. One case example had particular impact on my thinking. This was about an elder woman from Central America who was near death. A native healer was called, and came to perform psychic healing. I recall that the healer claimed it was psychic surgery. This did not fool Dr. Krippner, who required that his graduate student study the art of magicians so that they could better understand sleight of hand. Stanley documented that indeed, the healer's performance was sleight of hand. Yet the elder recovered. So there must be some sort of dynamic. He concluded that it must have been the family members that the healer insisted bringing to the sick woman and the social interaction, the de-isolation, that led to the cure.

Now we have an article in the New York Times, http://www.nytimes.com/2009/04/21/health/21well.html?em=&pagewanted=print that presents some very compatible research results. A brief summary of research in the article identifies impacts of long term friendships on survival from breast cancer, reduced risk of heart attack and reduced fatalities from coronary heart disease, and reduced incidence of colds. One might ask whether this is alternatively a result of strong local relationships in addition to strong longterm relationship, that is, that people who have strong longterm relationships (at any geographical distance) also have strong local relationships, and it is really the local relationships that make the difference. The research is inconclusive, but the Times article seems to indicate that the longterm social relationships are actually more important than family relationships.

There is a line of unasked and unanswered questions that I pose about the question of whether such relationships extend to people's enduring capability to walk and run well. Frankly, I would bet that there is a relationship. Here is some introductory thinking about what the intermediate dynamics might be.

• People with good relationships would have a sense that life is worth living and in fact enjoyable, which would lead to continued physical vigor.
• People would enjoy and have fun walking in order to connect with their friends.
• People with friends would not give up, and thus would be better at recovering from injuries and problems.
• Such people would continue walking and maintaining themselves because they have something to live for. One of the problems of living into ones 90s is that many or all of one's friends pass away and one is left isolated. The solution to this is the development of new friendships, particularly with younger people. I have seen this occur when older people retain their mental aliveness and curiosity so that they are interesting to talk to. This again comes back to friendships.
• The ability to walk competently enables seniors to maintain relationships better and to continue to value them.
• Continued ambulation reduces the likelihood of depression and isolation, and these lead to continued ambulation. In some of what I have seen, loss of ambulatory competency results from not maintaining oneself. So friendships that reduce what leads to this will also reduce loss of ambulatory competency.
• In conclusion, lack of isolation, ambulatory competency, and linkage with friends are in many ways synonymous.

Possibly the most intriguing research finding in relation to this is summarized near the end of the Times article. Students wearing a heavy backpack were asked to estimate how steep a hill was in front of them. The students who stood beside a friend saw the steepness of the hill as being significantly less than those who stood alone in front of the hill. It would appear then that the task of walking up the hill, or for that matter, on a level surface if it is trying, is made more easy if one has the sense of the presence of friends. This would suggest strongly that friends make a difference for walking.

I am very interested in what others may have to say about this.

Calculator Gives Risk of Type 2 Diabetes

Type 2 diabetes poses a threat to the legs, and therefore a threat to walking. It is also associated with being overweight, which can also pose problems for walking. British scientists have recently found and published nine significant risk factors for Type 2 diabetes:

• age
• ethnicity
• body mass index
• smoking status
• socioeconomic level
• family history of diabetes
• diagnosis of cardiovascular disease
• hypertension
• use of steroid drugs.

They calculated the relative importance of each of these factors, and incorporated them into a web page algorithm, that quite accurately predicts the 10-year risk for Type 2 diabetes. Based on the British population, there is an interactive Web version of the algorithm at www.qdscore.org. Postal code and ethnicity applies only to Brits, but the results are good even without those two parameters.

See:
http://www.nytimes.com/2009/03/24/health/24awar0.html?src=linkedin

Electronic Monitoring

2/18/09: Last Friday there was a New York Times article about medical monitoring of seniors. It seemed to me that it reasonably summarized the current state of the art, although it left out some important names. I see our emerging technologies fitting right in with those discussed in the article. The point is to keep it simple and manageable for all involved, and to enable people to live out their lives as long as possible in their own homes. Here is a pointer to the article:

http://www.nytimes.com/2009/02/13/us/13senior.html

Medicare Independent Living Act

2/16/09: The Medicare Independent Living Act (H.R. 1809) was introduced ... The legislation would modify Medicare’s “in the home” restriction on mobility devices. It would significantly improve community access for Medicare beneficiaries with mobility impairments by removing a discriminatory restriction that bases the coverage of mobility devices solely on an individual’s mobility needs inside their home. The statutory “in the home” language was originally meant to define durable medical equipment (DME) as devices that were provided outside of a hospital or skilled nursing facility and, therefore, warranted separate reimbursement under Medicare Part B, rather than Part A. However, over time, Medicare has chosen to interpret this language in a way that restricts coverage of mobility devices to only those that are reasonable and necessary in the individual’s home.

Politics of Medical Research

2/16/09: Arlen Specter (R-PA)may not support everything, but he clearly does support health care research for medical cures, including those for cancer and heart disease. This article provides some detail about the political process for this in relation to the stimulus bill of February 2009. One thing worth noting is that this is clearly a one-senator special appropriation achieved in the horse trading process of legislation, but it is not an earmark.

http://www.nytimes.com/2009/02/14/health/policy/14specter.html

What is a "Fall"?

10/15/08: According to certain popular thought, when an elderly person falls it represents the beginning of the end, but when a younger person falls the threat is vastly less. Why is this? In the discussion below, I will share some of my thoughts. I hope you will respond by sharing some of your thoughts. (Note that except for my own personal experience, the identities of people mentioned have been changed to disguise them.)

The difference appears to have to do with the meaning of the fall in the overall cycle of life. A fall for a young person may lead to a broken wrist or a broken leg, but there is the sense that the break will heal. There is only temporary inconvenience and pain. There is a lack of a sense of fragility. For an elderly person the reverse is true. There is almost always the sense of vulnerability.

Part of this is the naivety of very young people about risk and death. It is young people who volunteer for the military, and who are sought after by the military, in part because they are naïve to the risks, believing that they will not die for a long time.

But let’s look at some examples of falls in my personal experience.

Two years ago I went cross country skiing on a day when the trails were icy. This is a problem with downhill skis. It is an even greater problem with cross country skis. I skied down a hill and started to bend to the left when my slight timidity on the ice was just enough to cause some instability, and I started to go down. I held myself up with mighty effort with my left ski pole. The pole broke about six inches below my hand, and I started going down. My feet were held in position by my skis, so that I could not twist to land on a fleshy part of my body. There was not much time, but there was enough so that the thought went through my head, “We’re going to find out how sturdy my hip bone is.” Well it was fine after the fall, but my left shoulder, the second point of impact, took a year to recover from the muscle and ligament trauma. It was a painful nuisance working with the shoulder while the muscles and ligaments gradually healed and then released their tension. However, it never offered even a hint of the beginning of the end of life. This was a hard fall, but it was not a “Fall.”

Patty is 94 and she falls regularly. Her caretaker stays up and listens for her to get up at night to go to the bathroom. At least once a month Patty will fall on her way to the bathroom, and her caretaker will come upstairs to help her. Staying up is wearing on the caretaker. Patty’s children are very worried and solicitous for her well-being. But Patty is very practical and matter-of-fact about her falling. She is not threatened by it, perhaps because she has never broken a bone by falling. She is stubbornly independent, and drove her car until just after her 90th birthday. These falls are certainly significant, and they do signify that the beginning of the endgame has started. However, none of them is a “Fall.” At the same time, everyone is watchful in the anticipation of a serious fall that will change things.

Mary is in her early 80s and suffered a serious fall in her apartment. She does not know what she tripped on, but she does know that she went unconscious for a matter of hours. A friend called her apartment, expecting her to be home, and found there was no answer. At that point the police came and rescued her. Mary knows that this fall was therefore life threatening. It was a “Fall” in that it changed her lifestyle. It also changed her lifestyle in the sense that she had to undergo therapy for more than a year afterwards, with anxiety about whether she would ever regain full dexterity in her affected limbs. Before she fully recovered she had another fall while walking on a poorly maintained sidewalk. She broke her hip, had hip replacement surgery, and went through therapy. She recovered rapidly in a physical sense, but this was a “Fall” psychologically for her, because of the threat and the difficulty of recovery. However, it was also not a “Fall,” in the sense that she mustered her resources and made a strong personal commitment to recover. It seems to me then, as I think about this, that the commitment of the person to recover is a key part of whether a fall is a “Fall.” If the person is committed to recovery, and likely to recover if she makes the effort, then there is a fall rather than a “Fall.”

Ann is well into her 90s, and was living with fierce independence in an apartment contiguous with her daughter’s house, when she fell and could not get up. She ended up in the hospital for a week or so, and then shifted to the medium term care facility. There was concern in the community that this strong, independent woman might be failing, and that she might spend the remainder of her lifetime in the medium care facility. However, it remained ambiguous just what kind of condition Ann was in. Those who visited her indicated that she still had plenty of pluck. A couple of months later, Ann fell while using her walker in the hall. She had immediate surgery for a broken hip. The interesting thing is that this did not seem to change her attitude or the community’s attitude toward her condition. Clearly the two falls were both “Falls,” but it remains unlikely that they signal her oncoming death, at least in the imminent future.

Contrast this with James, who fell off his bicycle when he was about 60. He was almost stationary at the time, and his feet were clipped in, so that his hip took the brunt of the fall and was smashed. His hip and femur were replaced with titanium versions, leading to extensive therapy on the associated muscles, which had ceased to know how to function. A few agonizing years later, he was back to normal. He died two years later as a result of a flu turning into pneumonia, and that becoming septic. Was the fall in any sense a “Fall?” I think not, because no matter how extreme the damage was, there was always the sense that he would recover from the fall, and he did. Further, his death was not related to the fall, even if it is perhaps interesting that it happened not so many years after the fall.

Consider Pat, a seventy year old woman who had misstepped at the top of her cellar stairs, and fallen hard to the cement floor, injuring herself. She, too, recovered, but she could be argued to have suffered a “Fall” in the sense that she was intimidated years later. She walked with special care and some asymmetries as a result of her fear of falling. She did this because she was extraordinarily anxious about another fall. Her Fall had led her to realize her vulnerability and the need for her to take great care, even though to my eye she was not actually frail, nor did she need to take that much care.

So what is a “Fall” as contrasted to a fall? It seems that some of the distinguishing factors are: • Whether the person has a sense of confidence about being able to recover. • Whether the person remains quite anxious about falling again. • Whether the person is near the end of his lifespan with or without the fall. • How frail or vulnerable the person seems to be during the time before and after the fall. • The degree to which the fall is purely accidental, or is caused by increasing physical disability. • How members of the community see the person in these same dimensions.

Thus when the therapeutic community uses the Dynamic Gait Index (DGI) to determine the risk of an elderly person falling, the fall if it happens for someone with a low DGI indicates that the person has been gradually failing and that the fall probably does not happen by accident. Such a fall marks a juncture in the elderly person’s life. There are interventions that can readily lead to a reversal of the decline. The person must make a decision about whether to invest the money and effort into those interventions. If the decision is not to attempt to reverse the decline, then the fall is truly a “Fall” and the endgame has truly begun.

Preventing Falls - I

6/12/08: Earlier this year my wife and I were at a Lydian Quartet concert at Shlosberg Auditorium at Brandeis. We have seats in the second row, center, which is a fabulous vantage point for us to watch the cellist. (We have learned to appreciate the others very much as well.) From the second row it is a long way back to the lobby, so we wait until many of the people sort themselves out, and then we start our trek up the stairs. Something was a little different this time: I wore my bifocals so that I could watch the players through the top part and the program through the bottom part. I should have taken them off for the intermission, but I did not. On the way up the steps slightly cramped with people I started around a cluster of people, and half-missed a step. I heard the audience gasp as I went down. Perhaps because it was a fall up the stairs, it was really a minor fall with not more than a hint of bodily distress, but a note to all of us that these things can happen anywhere, anytime, with outcomes that can be much more serious.

Not surprisingly, falls have become increasingly interesting to me. This interest has even more to do with our older circle of friends. Some are still playing tennis with us into their eighties. One is ninety-nine and clearly frail, but still driving her car in to town. Others have experienced their first serious falls and live in fear of the next fall. This has led to our considerable concern about how to prevent falls, and how to minimize the damage if and when a fall occurs.

Yesterday I visited the Fall Prevention class offered by the Weston Council for the Aging. The instructor, Leslie Worris had earned her MPH at Harvard after studying such disciplines as physical therapy at Boston University and yoga with yoga instructors. She knew her stuff, which was good, because I entered the room very skeptical about the classes I had seen, in which elderly people sit in a circle of chairs and perform light exercise. Yes, this was light exercise, but it was serious in the exertion level and serious in what it sought to accomplish. It was also adapted to the present level of each of the participants. Thus for example, I used a 5-lb weight in each hand for some of the exercises, while most others used a 1-lb or 2-lb weight.

Leslie emphasized that fall prevention is a program that involves every aspect of life. What I would say is that it involves continuing to live life fully, not shutting down, and continuing with the activity program that one has hopefully already established much earlier in ones lifetime. It involves exercise, stretching, attitude, having fun, diet, and many other things. I am going to see if I can share more details about this through involving Leslie in this forum.

What did I learn from the hour with the class? Many things. Dominant in my mind was seeing people making progress in their own terms as they pushed their bodies to perform the exercises. The woman next to me was able to lift her leg repetitively forward a few inches while standing on the other leg and holding on to the top of a chair. After several exercises, she laughed “I’m going to feel this tomorrow.” So the issue was not permanent physical restriction of her joints and body motions, but rather the strength and flexibility of her muscles. Leslie emphasized the importance of building a strong base in the abdominal and torso area, explaining that this area is the root of motions that keep one upright. As I have been mindfully watching my own motion over the past months, I have also noted that I trip quite a bit, and I fall when I am moving too fast for the circumstance. So it is partly a matter of tempo, and I can live safely at a faster tempo only if I am able to adjust quickly and effectively. This requires mental alertness, physical strength and suppleness. One take-home from the class was that just being elderly is no longer an excuse to not continue exercising our bodies. In doing this exercise gently and with awareness, we also become more aware of our bodies, how they function, and importantly, how they stay upright.

The basic idea is that falls result from many different causes. Again, the details can wait for a subsequent post, and for what the rest of you share. A major area of influence over falls is the adequate strength of the muscles used to stay upright, the suppleness of those muscles, and the awareness required to use those muscles to keep us in “good standing.” Thus, balancing exercises are important, and general physical and mental fitness is also important. I am reminded of the Harvard study with nonagenarians working out on Nautilus machines to develop muscle mass, particularly in the legs. The outcome was that the nonagenarians were more ambulatory than their children.

This is a deep and extensive subject area, about which much more can be shared, even about the experience of one fall prevention class. I look forward to people sharing their insights and experiences.

Getting Out for Exercise

7/19/08: I have just been reading Anne Morrow Lindberg's book, A Gift from the Sea, which addresses images of life in relation to objects from the sea. Among the images that she develops is that of the second half of life as a time of flowering in the dimensions that were set aside during the earlier part of life. In general, key visions for aging people also include (1) active, independent, healthy, involved lives as members of families, communities, and perhaps of the larger society along with (2) time and space alone or with a loved one in a more quiet or contemplative mode yet still safe through connection with others who care.

Technology done right can support all of these visions. There are many examples already of technologies that have been done “right enough” to achieve this. One of the recent Internet trends is people in their seventies and eighties using the Internet for extensive communicating with each other. Using the Internet at one’s computer at home also means that one need not drive (or be driven) to the library for information. (This in turn also saves gas and reduces global warming!) That is, inexpensive telephone and Internet communications leads to greater connectivity. Personal emergency response systems (PERS), although far from perfect, have fostered a greater sense of security among older people. Home-based monitoring leverages caregiver effort, provides more useful blood pressure measurements, and makes it easier for medical professionals to track the condition of elderly patients without their having to travel too often to the doctor’s office. Some Japanese companies are developing and marketing ever more sophisticated robots that perform simple caregiving tasks. Work is being done to make the robots seem as human as possible, even responding with appropriate “facial expressions,” so that elderly people can feel a degree of companionship from them.

In this forum, we can discuss our experiences and thoughts about each of these and many more approaches. Some of this may include critiques about what works, what doesn’t, and why. We can also share about how we would like to be living, how we would like to be using technology, and what might be useful in the future. Beyond information about the technology itself, I hope we will discuss, or perhaps even emphasize, the human dimensions.

Although technology is important for enablement, particularly in a world with a shortage of nurses and other caregivers, it is not the entire solution. It also needs to be molded and dominated by human concerns and human values. Technology is primarily useful to the extent that it addresses these human needs. Well-designed technology can enable us in what we want to do, where we want to explore and grow, in helping us to protect and provide for ourselves and others. It helps us to lead involved, productive lives while mitigating the negative effects of aging. It needs to be enabling, reliable, mostly unobtrusive. It needs to preserve independence, privacy, and dignity. Technology serves preferably in a supporting, not a primary role. Well designed technology can facilitate social interaction while minimizing alienation and isolation. It can enable people without confining them, provide support without getting in the way. What makes technology this way for you? What makes it not this way for you?

For my first contribution, I am thinking that I might write something about one of the following three areas of recent experience.
1. Riding a bicycle after age 60.
2. Dealing with winter cold, which is more tricky for the elderly than for the young.
3. Electronic devices to promote health and safety.
4. Using the Internet, a treasure trove of information and connectivity. I would appreciate your comments about which would be most interesting to you. Perhaps even more, I will be interested to read your own thoughts on these and other subjects of interest to you.

Senior Marathoner Runs 17 Miles Without Shirt in Winter

This continues my thread on human thermal response and performance, a topic of interest because it offers flexibility in dealing with thermal inflation, energy use, and global warming. It also relates to a man who continues to run marathons well into his 70s.

February 28, 2009. On the way riding my bicycle back from the library this morning, I happened to see a man running in runner's shorts and shoes, athletic socks, and gloves. His top and legs were exposed to the elements. After a brief consideration about whether to reach out to him, I caught up to him on the left side of Route 20 going in toward Boston, and rode along with him about a half mile.

At first he was a little reluctant to talk because, he said, a lot of people think he is nuts. I did not think he was nuts at all, and the conversation I had with him indicated he was certainly not nuts, unless all marathoners are nuts, which some might argue is true. Some might also envy those who run marathons, especially if those people have been around more than 65 years.

To me this is further validation of my theory about thermal inflation, a topic about which I posted earlier this year, and have written about since 1979. He explained that he was out on his "long route," 17 miles, in preparation for the Boston Marathon which is not so many weeks from now.

The other striking things about him were his age and the way he bent his knees to cushion his body from the shocks of running on pavement. He explained that he had started his experiment with temperature about 40 years ago. At first he had run during winter in heavy clothing and had sweat profusely. Then he realized that this did not make a lot of sense, so he started experimenting with varying levels of clothing, obviously less and less. What he had learned was that the body generates a lot of heat, which is a disadvantage in excess, and which is retained more if you do not start sweating.

He also learned, as he put it, that the pores in one's skin shut down if the skin is exposed to the cold. Much as I have found in my experiments, he found that one can "fool" oneself about how warm or cold one is, by focusing on the perceived temperature of one's skin. What counts is the internal temperature.

So after being something of a wimp about the cold when he was a boy, he had to work his way through his expectations and beliefs about his skin being cold. Those cold sensations are good rather than bad. Also an important factor is never to sweat, because when the sweating begins the skin temperature and body temperature become regulated in a very different way. This modifies the skin barrier between the elements and the core of the body. He commented that he had learned about a remarkable woman who swam competitively in cold bodies of water such as the English Channel, without a wet suit or grease to provide thermal insulation for her body. Her body had adapted by developing a layer of thick subcutaneous fat that serves as that layer of insulation. Indeed, the human body is able to adapt in all kinds of interesting ways, if we foster its doing so!

Then we got to the gloves. I explained that I live at 45-52 degrees, and that when I start to get cold, the first sign is that my hands get cold. He exclaimed, "Yes," the same thing happens for him. This is the reason that he runs with thick winter gloves on his hands. More later after I get the chance to interview this insightful man who has been willing to experiment for decades.