As some readers have already discovered, The Times is discontinuing publication of The New Old Age blog. I join many of you in disappointment — but, to paraphrase Mark Twain, reports of its death have
been exaggerated.
The blog, founded in 2008 by Jane Gross and anchored by me since 2009, has explored aging and caregiving from a variety of perspectives: medical decision-making, housing and long-term care, government policies,
the latest geriatrics research, end-of-life choices, the personal rewards and headaches of caring for aging loved ones.
Our posts, and those of other contributors, served as springboards for what really distinguished The New Old Age: people who had walked the walk chimed in to agree or debate with the writer, offered information
and suggestions (and the occasional jibe) to other readers, told their own stories. We have been a kind of online support group, one it has been a pleasure and an honor to facilitate.
You may have noticed the discreet way in which many nursing homes and assisted living places acknowledge a resident’s death: A bud vase on the mantle or at the reception desk. A single rose. A card announcing
the deceased’s name.
Death comes too frequently to these buildings to allow for memorial gatherings, several administrators have told me. Residents would become distressed, constantly reminded of loss. Instead, although people may
attend the funeral of someone they felt particularly close with, the homes commonly default to the vase, the flower and the tasteful card.
Photo
Staff members at the Hebrew Home singing at memorial service. From left, Larry Applewhite, Liisa Murray and Olivia Cohen.Credit The Hebrew Home at Riverdale
But when Faye Hellman died in November, at age 95, her neighbors and friends at the Hebrew Home at Riverdale assembled in a lounge for what it calls “A
Time to Remember.” With her family and the staff members who cared for her during the nine years she lived there, the group sang songs and said prayers and remembered Mrs. Hellman.
She loved casino trips and won $50 on her first try at a penny slot machine, a staff member reported. She knew all the Hebrew Home gossip and relished corned beef sandwiches with kosher pickles. A volunteer
recalled that when his wife died at the Hebrew Home late at night, Mrs. Hellman sat and cried with him.
“In a nursing home, death is expected — it happens on a regular basis,” said Charlotte Dell, the Hebrew Home’s director of social services. “The bed is filled shortly thereafter
without much discussion or dialogue.”
A few years back, Ms. Dell decided that was an inadequate response and started this custom.
Since then, each “neighborhood” of 40 or so residents in this big five-building complex decides when it’s time for an hourlong memorial, for one resident or several who recently died. The
gatherings typically take place once a month. With 845 residents, the Hebrew Home had 227 deaths in the past year.
“It brings the community together,” Ms. Dell said. “Despite all the losses, there’s tremendous comfort and support in sharing the experience.”
When last I wrote my will, I didn’t have a dog, a point that had begun to nag at me.
“When you’re dead, you’re dead,” I’d always told myself. “You’re childless, so what difference does it make who gets the money, if there’s any left, or
the sentimental treasures?” By which I mean my mother’s “sterling” silver, which turned out to be plate, and my flea market discoveries.
But my 10-year-old standard poodle was another story. Unmentioned in the existing document, Henry would be left alone after I died: unfed, unwalked, unloved. Would he die, too, only to be discovered by a neighbor
when he started to stink up the joint? I owed him better.
My elder care lawyer raised a skeptical eyebrow when I explained that the inspiration to update everything was my dog. I might as well review all the paperwork, I told him: the power of attorney, the health
care proxy, the living will, a codicil here and there, the list of friends’ children who had always been my beneficiaries.
But a full year went by while I looked guiltily at the file folder on my desk marked “new will.” That took me by surprise, as I’m not a procrastinator. Remember the hated kid in high school
who always had her papers done way in advance and went to the movies while everyone else was pulling an all-nighter? That was me.
But my lawyer, Gregg M. Weiss, was used to people starting the process and then disappearing. “That’s the No. 1 bane of my existence,” he said when I finally resurfaced, all papers ready
to be signed.
“Whatever is on anyone’s to-do pile, this typically goes to the bottom. It’s avoidance, not facing the reality of death. The 80-year-olds we see are different. They don’t dillydally.”
Elizabeth Youngstein, center, leads a diabetes prevention program in Wayne, N.J., with the participants Barbara Biazzo, left, and Marilyn Gerardi.Credit Asthaa Chaturvedi
What happens in Room 6 at the Y.M.C.A. in Wayne, N.J., on Wednesday mornings doesn’t look terribly dramatic. About a dozen people trickle in, step on a digital scale, show the program leader Elizabeth
Youngstein their logs — on iPads or smartphones or in paper notebooks — recording what they ate since last week and how much they exercised.
“We want 150 minutes per week,” Ms. Youngstein said. “So I track whether they’ve tracked.”
Then, as in any support group, members sit around a table and talk about what worked this week and what didn’t. Barbara Biazzo knows she’s not drinking enough water, “but at least I’m
moving.” Marilyn Gerardi enjoys using the treadmill, but it hurts her knees; Ms. Youngstein suggests a recumbent bike. Joe Venezia is substituting Greek yogurt with horseradish for mayonnaise.
Most participants here are in their late 50s and 60s, but Rosalie Scudellari is 84. “I somehow see your face when I think about another snack,” she tells Ms. Youngstein.
It’s Week 5 of the Diabetes Prevention Program, and however commonplace the conversation, the results can be impressive. In 2002, a large national clinical trial showed that among adults at risk for Type
2 diabetes, this “lifestyle modification program” and resulting weight loss reduced the incidence of the disease by 58 percent in 1,000 subjects participating in the program, compared with those who did not — and by an even more substantial 71 percent in those over age 60.
This may be the largest national health effort that most of us haven’t heard of, and one of the most important, especially for older adults.
Ann Albright, who directs the diabetes division at the C.D.C., estimates that in the first two years nearly 50,000 Americans have joined one of its recognized diabetes prevention programs, which are aimed at
people whose weight, blood glucose levels or other factors suggest they are at elevated risk for developing the disease.
“This is not a ‘diet,’ some sort of temporary thing,” Dr. Albright said. “This is intended to help people adopt new habits and to look at that as a way of life.”
Julianne Moore in a scene from "Still Alice."Credit Linda Kallerus/Sony
Pictures Classics, via Associated Press
Do casting directors insist on remarkable cheekbones when they’re lining up actors to play characters with dementia?
Think about it: Julie Christie in “Away From Her.” Genevieve Bujold in “Still
Mine.”
Meryl Streep as Margaret Thatcher.
And here’s one more: Julianne Moore in “Still Alice,” which had brief runs in New York and Los Angeles to qualify for Academy Award nominations and will open nationwide in January.
Dementia seems irresistible to dramatists, with its here-but-not-here characters and bewildered families already grieving for people who haven’t died. Yet these stories remain hard to sell to audiences,
along with aging narratives in general. So I suppose we can’t blame producers and directors for populating their films with actors who are, first, beautiful and, second, younger than their characters.
People in movies tend to be more beautiful than ordinary folks, period. (At least Emmanuelle Riva,
who deserved an Oscar for the unflinching “Amour” — and has the requisite cheekbones — was 85.)
“Still Alice” backs away even further from the usual characterizations, though, by giving its lovely protagonist a fairly rare form of dementia: early-onset Alzheimer’s disease, which afflicts
those younger than 65.
Prof. Alice Howland, seen running effortlessly through Riverside Park, is just 50 and enjoying an impressive academic career at Columbia when she starts forgetting words and getting lost in familiar places.
A few years back, a big clinical trial showed that certain nutritional supplements could slow the progression of macular degeneration and reduce the risk of vision loss. “There was great interest among
patients,” recalled Ingrid Scott, an ophthalmologist at the Penn State College of Medicine. “This was big news.”
Age-related macular degeneration is the leading cause of severe vision impairment and blindness in older Americans. For the great majority of those who have it, there’s no effective treatment. And it
generally worsens with time. “Patients with age-related macular degeneration are extremely motivated to do whatever they can,” Dr. Scott said.
The trial showed that one thing they could do was to take a specific formula of vitamins, minerals and other nutrients. Manufacturers quickly responded with a host of over-the-counter pills making a host of
claims. Now, my drugstore and supermarket — and yours — have shelves of products that supposedly help people with macular degeneration and other supplements that “promote” or
“maintain” or “protect” eye health.
Do they? Dr. Scott and her colleagues recently reviewed the ingredients and found reasons to proceed with caution.
The Commonwealth Fund has been publishing surveys comparing health care in industrialized countries since 1998, a continuing report card in which the United States has usually fared poorly because of its high
proportion of uninsured people.
But its latest report – an early anniversary tribute to Medicare, which turns 50 next year – focuses
on those over 65, the one segment of the American population with nearly universal coverage and access to care.
“It’s definitely a better picture than when we look at the U.S. population generally; that’s a pat on the back for Medicare,” said Robin Osborn, director of the fund’s International
Health Policy and Practice Innovations program and lead author of the study. Previous research has shown that “Medicare is more protective than all the different insurance plans people have under
age 65,” she said.
But as the survey of 15,617 respondents – published in Health Affairs – reveals, we still have mortifying lapses
and problems, despite spending more on health care than any other country in the world. Yet we do better than these 10 other countries on some measures, sometimes surprisingly. (You can read the fund’s
summaries here and here.)
The bad news first:
■ Our older population is sicker. We lead the list in the proportion of people over 65 who have two or more chronic diseases (68 percent report hypertension, heart disease, diabetes, cancer, etc.)
and who take four or more prescription drugs (53 percent). Only a third of seniors in the United Kingdom have multiple chronic conditions. (The survey didn’t include residents of nursing homes or
other care facilities.)
“One thing we know contributes to this is not having an ongoing, stable source of health insurance throughout your life,” Ms. Osborn said. Before they became Medicare-eligible, American seniors
may have forgone preventive treatments or let conditions worsen because they couldn’t afford care.
“Unmet needs,” a term gerontologists use, refers to care or help you require but don’t get. If, when you’re elderly or disabled, you aren’t able to shop or cook, you lack the
strength to go outside, you can’t keep track of your bank account or your medications — and no one assists you with those functions — you have unmet needs.
Older people who move into assisted living and other forms of supportive housing are primarily seeking ways to reduce unmet needs. Occasionally, someone moves because he feels lonely or she is trying not to
burden her children. But usually, people stay in their homes as long as they can until unmet needs pile up.
What I have frequently wondered – and I’m sure lots of you have, too – is how often those supposed solutions actually provide enough services to merit their very high price tags. When someone
is spending $3,500 a month for assisted living – the national median, according to Genworth’s annual survey – are there fewer activities the resident can’t manage? Does he or
she have fewer unmet needs?
The study uses data from the 2011 National Health and Aging Trends Study and pays particular attention to more than 4,000 Medicare beneficiaries over 65 who reported having difficulty with daily activities or
received help with them, but did not live in nursing homes.
The great majority (82 percent) still occupied “traditional community housing” (their own apartments, homes or condos), in line with national statistics. Almost 8 percent lived in retirement communities
or senior housing complexes that didn’t offer much in the way of services. Another 4.6 percent were in independent living facilities, and 5.8 percent in assisted living.
In interviews, “they were asked about things they had to go without in the past month, because they didn’t have the help they needed or it was too difficult to do those things on their own,”
said the co-author Vicki Freedman, research professor at the University of Michigan’s Institute for Social Research.
For starters, an older patient’s first visit with cardiologist Dr. John A. Dodson, the program’s director, takes a full hour. Beyond taking a complete history, Dr. Dodson looks for frailty by measuring
things like gait and grip strength and administers a short test of cognitive ability – things geriatricians routinely do and cardiologists mostly don’t.
“The No. 1 difference is time,” he told me in an interview. “To be able to spend an hour with a new patient is a gift.”
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Dr. John Dodson, director of the geriatric cardiology clinic at N.Y.U. Langone Medical Center.Credit Alishba Aslam
In January, when a pharmacist joins the program, Dr. Dodson will start asking patients to bring in all their prescription drug bottles for review. “They may be taking redundant medications or the wrong
medications,” he explained. “Where we can, we will peel away what’s not essential.”
The conversation expands to include less medical topics, too: the patient’s goals, the extent of family support, end-of-life preferences.
The N.Y.U. program is one of only a handful of geriatric cardiology programs that have sprouted up around the country, including the first (so far as we know) at Vanderbilt University Medical Center, in 2012,
and a similar program at the University of Pittsburgh Medical Center. More are likely to follow.
At Vanderbilt, “I talk about living wills and health care proxies and why they’re important,” said Dr. Susan Bell, a cardiologist and geriatrician the clinic director. “Is this the
person who wants quality of life or the person who wants to push for longevity as much as possible?”
This is mostly common sense – treating an individual, rather than an organ – but it is particularly crucial for older adults.
Dr. Dodson’s patients at N.Y.U. are mostly in their 80s; the oldest is 96. Whatever has gone wrong with their cardiovascular systems, they are usually also coping with several other chronic conditions
and disabilities, from diabetes to hearing loss. They take a raft of drugs. They may not cope well with procedures and regimens effective for younger patients.
Death and taxes have always been twinned in cliché for their unavoidable awfulness. But death only happens to each of us once, not annually. Wouldn’t our annual encounter with the Internal Revenue
Service be more aptly paired with the Medicare Part D open enrollment period, a yearly torture between mid-October and early December? Both take days out of our lives and leave us sitting in a heap of papers
with a splitting headache and residual worry that we got something wrong and will wind up in jail or the poorhouse.
It’s my third year of eligibility for Part D, the Medicare option, added in 2006, that provides coverage for prescription drugs. When I turned 65, I had nothing but good things to say about Medicare Parts
A and B, the 1964 hallmark legislation that covers hospital and outpatient medical care. That’s still mostly true, but for the growing numbers of doctors who have “opted out’’
of the government program because of inadequate reimbursement and onerous paper work. Part D, designed as a public/private hybrid, is another story. Forgive my cynicism, but any “benefit’’
that twins the insurance industry with Big Pharma can’t really have the public interest at heart.
My first experience choosing a drug plan was chronicled here, after a Fourth of July weekend that will live in memory as the worst I ever spent.
I should have expected as much, since my colleague Gina Kolata, a whiz at math, wrote of her effort to choose a plan for her father, testing if the Centers for Medicare and Medicaid Services website was
as simple as promised and found it an exasperating mess. Since my mathematical abilities are limited to counting on my fingers, and Gina
had struggled, I was braced for trouble. But not the trouble I found myself in.
Year two I had an excuse not to try, even when the booklet of changes for the coming year arrived from my insurance carrier and everything was more expensive by many multiples. In the midst of selling one home
and buying another, who could fault me for taking a slide? And how comforting to find out, and recount here, that a Kaiser Family Foundation study had found 87 percent of Part D policyholders between 2006 and 2010 made no change, even when they knew they were overpaying, because it was too hard. Kaiser went so far as to say that the Part D plans had observed and responded to this behavior, offering
reasonable rates one year and over-the-moon rates the next in a classic bait-and-switch.
It will not surprise people who spend time in nursing homes — who live or work there, who volunteer or visit family members — that residents can lash out at each other.
“Resident A is sitting in a wheelchair in a common area, yelling out,” said Karl Pillemer, a Cornell University gerontologist and researcher,
recounting an actual, and typical, example from his latest study. “Resident B goes over and says, ‘Be quiet, stop yelling.’ Resident A hits Resident B on the hand. The nursing aide separates
them, then sees someone else wandering and has to leave. When she does, Resident B kicks Resident A, and the cycle continues.”
It happens. Nursing facilities house people who are disinhibited, who have dementia, who
share close quarters with strangers, who may suffer pain or lose their ability to communicate in more acceptable ways.
On occasion, some will hit, kick, grab, bite and shove. Or threaten, bully and fling insults, including racial slurs. Or say and do things that are sexually inappropriate.
What may surprise people — and it certainly stunned Dr. Pillemer and his fellow researchers — is how often such incidents occur. Their five-year study, presented at the Gerontological Society of
America’s annual meeting in Washington earlier this month, found that 19.8 percent of nursing home residents had been involved in what the researchers call “resident-to-resident elder mistreatment”
— verbal, physical or sexual — in the previous month.
Saving money isn’t really the point of hospice care. Helping dying patients have the best possible remaining life, followed by a good death, is really the purpose.
But whether hospice care saves money has prompted debate for years. Most hospice patients die at home, which is what the great majority of Americans say they prefer, or in nursing homes. Wouldn’t that
save money compared with the cycle of 911 calls and hospitalizations that characterize so many American deaths?
Studies of this question have been small and have reported contradictory results. “There hasn’t been a lot of consensus,” said Dr. Ziad Obermeyer, an emergency physician and health policy
specialist at Harvard Medical School. “There are people in the policy establishment who are still skeptical about whether the costs are lower.”
He hopes the large study he and his colleagues at Brigham and Women’s Hospital in Boston published recently in JAMA will finally put that concern to rest. It matched two groups, each containing more than
18,000 older Americans with metastatic cancer, comparing patients who enrolled in hospice with those who had the same poor prognosis but didn’t use hospice. The researchers tracked participants in
both groups until their deaths.
The hospice patients had far fewer hospitalizations and less than half as many intensive care unit stays, their Medicare records showed. They endured half as many invasive procedures. They were five times less
likely to die in a hospital or nursing home.
And yes, care in the last year of their lives cost an average of about $8,700 less than for the nonhospice patients. Costs
for patients in the nonhospice group were $71,517 on average in the last year of life, compared with $62,819 for those in hospice. If extended nationwide, the difference could save Medicare billions of dollars.
Not once in the years I cared for my mother did any of her physicians ask me how I was doing. When was the last time I saw my own physician? Was I eating properly? Sleeping enough? Depressed?
What did I do for fun?
Frankly, I didn’t notice their apparent lack of concern, nor had I considered it since — until hearing a recent talk by Dr. Ronald D. Adelman, the co-chief of geriatrics and palliative medicine
at Weill Cornell Medical College in New York City.
The subject was caregiver burden and how physicians ought to be attending to the “invisible patient,” the one supporting an elderly family member with dementia or a heart condition or diabetes
— or all of the above. Given that there are currently 43.5 million people providing this kind of support to adults ages 50 and older, and that without them the long-term care system would collapse,
you’d think the proposition that somebody ought to be paying attention to them would be a no-brainer.
Sad to say, physicians often look right past caregivers. Earlier this year, Dr. Adelman published an article in JAMA detailing the problem,
along with recommendations for addressing the burdens of this group.
I ran into my father at a deli the other day. An undramatic encounter: I was waiting at the counter for a takeout order when I spotted him sitting at a corner table, yakking with friends from his senior residence,
their walkers and canes carefully folded or propped against the wall.
I was happy to see him, and we had a hug and a few words. I kibitzed with his buddies for a moment, too. Then we said goodbye and I went on my way without thinking much about it because, after all, we would
go out for lunch together on Saturday the way we usually did.
Photo
The author's father, Murray Span, at his 90th birthday party in 2012.Credit
Dad looked fine, except perhaps for a less-than-flattering white sweater he didn’t, in reality, own. In my dream — that’s what this was — I didn’t know that he had died.
He has been gone for nearly two years now, so I was glad to have this fleeting visit. I once dreamed of
my late mother, too: a hippie version of Ruth Span, standing on a hilltop in a gauzy flowered dress and long, windblown curls. (She actually wore polyester pantsuits and had sprayed hair that gales couldn’t
rearrange. Are people undergoing makeovers in the afterlife?) My sister has also occasionally dreamed about our parents.
Seeing Dad left me wondering how often deceased family members enter their survivors’ dreams and what we know about what — if anything — that means. So I called Alessandra Strada, a clinical
psychologist and director of integrative medicine and bereavement services at MJHS Hospice and Palliative Care in New York. She has listened to patients talk about their dreams for 20 years.
“Dreams are quite a prevalent component of the bereavement process,” Dr. Strada told me. In fact, a study recently published in The American Journal of Hospice and Palliative Care surveyed 278
caregivers (mean age: 63), nearly 60 percent of whom reported dreaming of relatives who had recently died in hospice care.
In July, Kathy Murphy received a letter from the Social Security Administration. “We are writing to tell you that you do not qualify for widow’s benefits,” it said. “You do not qualify
for the lump-sum death benefit because you are not Sara Elizabeth Barker’s widow or child.”
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Sara Baker, left, and Kathy Murphy in 2011. Credit Courtesy Kathy Murphy
Well. Not only had Ms. Murphy shared a modest ranch house in Austin, Tex., with Sara Barker for nearly 30 years, not only had she cared for Ms. Barker through two terrible final years of illness, but the two
were indeed legally married.
“We always hoped we’d be married in the state where we made a home,” Ms. Murphy, a native Texan, told me. “But Sara was diagnosed with cancer in 2010 and we didn’t have the
luxury of time any more.” So they flew to Boston, where they had met and first lived together, and were wed in a quiet, teary ceremony in a Unitarian Universalist chapel.
Had they remained in Massachusetts, things would be different. But the couple went home to Austin, where Ms. Barker died in early 2012. Social Security won’t approve spousal or survivors benefits for
same-sex spouses in Texas and the 16 other states (at the moment) that still don’t recognize their marriages.
“It’s like getting kicked when you’re down,” said Ms. Murphy, 62. “Somebody applying for survivors benefits has already suffered loss. The last thing you want is someone to
tell you your marriage isn’t legal and you’re not worthy.”
