Saturday, December 30, 2017

Atul Gawande on Care of Elderly Persons

My mother at Christmas 2007 (her last)

I am deeply moved by Atul Gawande's account of the changes in our brains and bodies as we age--if we are fortunate enough to age.

Many changes occur whether or not we acquire dementia as a result of a stroke or because of Alzheimer's Disease.

In Chapter 2 "Things Fall Apart," Dr. Gawande discusses the process of aging.

Here are some gems from his account:

**  "Remember that for most of our hundred-thousand year existence--all but the past couple hundred years--the average life span of human beings has been thirty years or less" (p. 32).

**  "Our bodies accumulate lipofuscin and oxygen free-radical damage and random DNA mutations and numerous other microcellular problems.  The process is gradual and unrelenting" (p. 35).

**  "Even our brains shrink: at the age of thirty, the brain is a three-pound organ that barely fits inside the skull; by our seventies, gray-matter loss leaves almost an inch of spare room...  The earliest portions to shrink are generally the frontal lobes, which govern judgment and planning, and the hippocampus, where memory is organized... By age eight-five, working memory and judgment are sufficiently impaired that 40 % of us have textbook dementia" (p. 31).

**  "In 1950 children under the age of five were 11% of the US population... those over 80 were 1%....  In thirty years, there will be as many people over eighty as there are under five" (p. 35-36).

**  "...a lot of doctors don't like taking care of the elderly" (p. 36).

**  "The single most serious threat [is]... falling.  Each year, about 350,000 Americans fall and break a hip.  Of those, 40% end up in a nursing home, and 20% are never able to walk again" (p. 40).

     Falling and breaking a hip was my mother's experience twice.  After her second fall at age 85, she had to be in a wheel chair.  Rehab with a walker was not successful.  

** Coughing when drinking water or eating occurs when "lordosis of your spine tips your head forward... Try to swallow while looking up: you'll choke once in a while" (p. 51).

     For my mother, coughing became a big problem in her last few months.  In the last few weeks, she couldn't drink water.  This was partly caused by ALZ-- the inability of her brain to control her swallowing muscles.

Because I will be turning 70 in 2018, I am thinking about aging and mortality.  This book by Gawande, a surgeon in Boston, is a road map for all of us who care for elderly relatives or are in our 60s or 70s or 80s ourselves. 

A year ago I was reading When Breath Becomes Air by Paul Kalanathi, who deeply respected this book by Gawande, but not until this week did I begin Being Mortal.

Monday, April 10, 2017

Stages of dying


Give up beauty.

Give up pride.

Give up walking.

Give up swallowing.

Give up calendars.

Give up memory.

Give up modesty.

Give up life.


Behold beauty.

Dwell in God's presence.

Embrace today.

Seek God's face.

These you will never lose. 

-- Psalm 27:4

Sunday, April 09, 2017

Holy Week, Holy Passing

My mother Evelyn and I in 2007

Today marks nine years since my mother died of Alzheimer's Disease.

This year the day falls on Palm Sunday, the day when Jesus returns to Jerusalem and the confrontations begin that will lead to his death.

This year my friend Kathleen is dying from cancer that began in her uterus and had metastasized to her lungs when discovered in June 2015.

I spent eight hours with her yesterday, from 11 am to 7 pm.  She's been in and out of the hospital since early February.  Her last hospitalization was toward the end of March, followed by a week in skilled nursing.

On March 30 she returned to an assisted living facility, Claremont Manor, and finally agreed to go on hospice.  Yesterday was her ninth day of hospice, and it's clear she only has a few days left to live.

Yesterday was also her birthday.  She turned 77.

How do you wish someone happy birthday as she dies?  It's difficult, but some 12-15 friends stopped by.  She was able to talk with them and enjoy their company briefly, but each visit was also tiring.

I just sat quietly in a chair at her bedside, leaving the room when she had visitors, getting things for her when she asked, listening when she spoke.

She monitored the oxygenation of her blood with a fingertip pulse oximeter.  Her oxygenation stayed around 90% except when she coughed and had to remove the oxygen tube from her nose.  When the pressure was set at 5, she felt a cold wind blowing past her ears.  Her caregiver would not turn the level down without permission from a nurse or doctor, so Kathleen asked me to turn it down to 3, sneakily, and I did.  Later her friend Margaret got the permission from one of her doctors.

We also figured out that where the tube splits into two, one for each nostril, it's important that the ends be pointing up, not down into the bottom of her nose.

Kathleen herself is a cardiologist.  Her heart beat was running about 112 beats per minute, according to the oximeter.  I expressed concern about that, but she waved it away, only following the oxygenation reports.

I realized that her heart was pumping so hard, trying to get oxygen and send it around through her blood.  It was the heart rate of an athlete exercising, running fast.  I knew the heart couldn't keep that up for day after day.

Kathleen had drunk a cup of tomato soup from Trader Joe's that morning.  She sipped water occasionally throughout the day.  When I suggested water, she was grateful, telling me that she forgets to drink.

"Remind me," she said.  I did.  She drank over half a cup of water during the time I was there, but I knew it wasn't enough.  She can't eat solid food or even pureed food.  It's difficult for her to swallow.  I didn't ask her why lung cancer would take away her ability to swallow.  She's also given up milk shakes and Ensure because they have milk in them, which causes congestion in her throat and lungs.

I realized that she's essentially fasting.  A body can't keep functioning without food for long, not when you have fourth-stage cancer and are barely drinking any liquid.  

When I was with her two weeks earlier, she said, "I'm on the way out."

"I'm so sorry," I said.

"It is what it is," she replied.  She says that at least once a day.

Yesterday when she said it, I replied, "But it's not good."

"It's interesting," she said, ever the doctor with a curious mind.

After some other guests had gone, she said, "Don't leave."

A doctor friend sent a birthday gift: fancy ocean-scented lotion and hand soap.  I opened it for her and showed them to her.  I helped her to text a thank you to the doctor.  Her fingers were barely warm enough to send a message when she tapped a letter.  Even knowing how to get names and phone numbers and change screens was becoming hard for her.

"Would you like lotion on your hands?" I asked.

I smoothed it on her long fingers and palm, then on the length of her arm.  I noticed her light brown skin had turned a bit jaundiced.  She only had one functioning kidney, and it was maybe shutting down.

"My skin is so dry," she said.

Later I realized we had enacted the scene where Mary in the Gospel of John, chapter 12, anoints Jesus's feet with costly nard.  "That's for the day of my burial," Jesus said, knowing that he was likely to be arrested and executed.

Light in the room was dimming at sunset.

"The day is so long," Kathleen said.  "And the nights are longer."

"That sounds like what Woody Allen said," I commented.  "'Eternity is so long, especially toward the end.'"  But I immediately wished I hadn't said it.  She was thoughtful, looking eternity in the face.

The whole day reminded me of my mother's death: her not being able to swallow or even drink toward the end, me postponing hospice until she had less than two weeks left-- but we never know how close to the end we are.

Kathleen (right) with Ivone Gebara
I thought my mother would live a week or two longer, so on a Tuesday I didn't visit her until the evening and then only briefly.  She died Wednesday morning, April 9.  Had I known, I would not have gone to teach my class and hold office hours that Tuesday.

I was also thinking of Pat Reif, who died on Palm Sunday of 2002.  I had spent time with her just before she left this earth, too early, with pancreatic cancer.  She was a nun, scholar, anti-war activist, feminist, with doctoral degrees in both philosophy and theology.

Like Kathleen, she had done much good in her life.  Both she and now Kathleen would die during  Holy Week.

At 7 pm I said goodbye to Kathleen.  "I'll come back Thursday," I said, thinking she might not make it to Saturday.  Maundy Thursday or Good Friday--fitting times for a near-saint to leave.

"Thank you for coming," she said.

Friday, April 07, 2017

Hip Replacement--or not?

Suppose your mother falls and breaks her hip, and she's in her 90s.  She's frail and thin.

Suppose she has mild dementia and can't always make her own decisions.  In a painful crisis, she may not be lucid enough to choose.

The doctor rules out surgery to repair the hip with pins because of osteoporosis.  She gives you two options: 

1) Give your mother a hip replacement--a serious surgery that she may not survive.

2)  Just put her into a skilled nursing facility (SNF) and drug her to the point where she doesn't feel the pain of being turned over or moved.  The survival rate after a broken hip is about a year in any case.

What do you do?  What do you do if you and your siblings are divided on this question?

Here's an article that gives you all some background for the decision.  Thank you to reporter Lisa Esposito and U.S. News & World Report (and to my friend Dana for finding the article).

Dr. Alexander Miric, an orthopedic surgeon at Kaiser Permanente in Los Angeles, stresses the seriousness of option two:
"...the mortality of broken hip without surgery is extremely, extremely high.”

Another sentence in the piece jumped out at me, a point made by Dr. Sharat Kusuma, director of adult reconstruction at Grant Medical Center in Columbus, Ohio:
"...Alzheimer’s-type dementia would rule out a patient" [for hip replacement].  

Catch 22:  Dementia cannot be definitively identified as Alzheimer's Disease until autopsy shows the tangles of plaque in the brain.  They thought my mother had Lewy Body Dementia, but it turned out to be ALZ.

Note to self: do not break your hip in your 90s if you get there.

Tuesday, March 28, 2017

Inheriting early-onset ALZ

Congratulations to Niki Kapsambelis for her new book on one family's coping with inherited Alzheimer's Disease.

The Inheritance is about the six children of Galen and Gail DeMoe; all six have a 50% chance 

Read this review and interview by John Williams in the New York Times today:

Friday, March 24, 2017

Trump & ALZ

If you search Twitter, you will find thousands of tweets by using the search terms "Trump dementia."

I first heard these reports in June of 2016.  

They began multiplying in January as the inauguration of Trump approached.

Many of these tweets cite articles on the question of whether the president has dementia.

One interesting and brief summary is "Linguistic Features Identify Alzheimer's in Narrative Speech" by Charles Moore, who reviews a study headed by Dr. Frank Rudzicz.

“Every caregiver knows that people with dementia have good days and bad days — we can tell this by talking to them, because speech is a rich source of information on the brain’s cognitive function,” says study co-author Dr. Jed Meltzer, a neurorehabilitation scientist with the Rotman Research Institute at Baycrest Health Sciences, a premier international center for the study of brain function. 

I've been noticing quite a few ALZ-like qualities in Trump's speech.  I'm familiar with this speech because of spending so much time with my mother in her last four years.

*  repetition -- Trump repeats statements so often in his speeches.  He repeats words like "very very very."

*  simple vocabulary --  Trump doesn't know how to praise a politician or diplomat or anyone else using complex, precise vocabulary.  All he does is repeat five simple words:  great, huge, terrific, amazing, big.  For those he doesn't like it's loser, sad, stupid, horrible, weak.  

* simple sentences -- Subject, verb, period.  There are very few sentences that begin with "Although, when, whether, if" or other subordinating conjunctions.  

* simple ideas and lack of detail in presenting them.

There are other signs of his dementia beyond speech:

  • his inability to remember what he has said or done earlier.

  • his grandiosity, a part of my mother's Alzheimer's.  During late 2007 and early 2008, she confused me with Hillary Clinton and thought I was running for president.  Then she thought my husband was running.

  • his lack of impulse control--like tweeting that President Obama had wiretapped Trump Tower.  His frontal lobes and temporal lobes are not functioning well.

These kinds of things convince me that Trump has dementia.  He lacks the 

The novelist described Trump as a speaker "wielding a vocabulary of seventy-seven words that is better called Jerkish than English.”

How to diagnose ALZ

Dr. Frank Rudzicz and team

There's now a way to diagnose Alzheimer's Disease with 80% accuracy.

Because science didn't have an accurate way to diagnose ALZ in 2004 through 2008, my mother's dementia wasn't correctly identified until after her death, when an autopsy was done.

Her physical, behavioral, and mental symptoms were tentatively diagnosed as Lewy Body Dementia, but instead of small hard Lewy bodies, her brain held the protein tangles of ALZ.

Developed by Dr. Frank Rudzicz at the University Health Network's Toronto Rehabilitation Institute, the new method was reported in the December 2015 issue of The Journal of Alzheimer's Disease.

"Linguistic Features Identify Alzheimer's Disease in Narrative Speech" is the title of the research report.

Speech samples were taken from 167 Alzheimer's patients and 97 control persons of similar ages and backgrounds.

The aspects of speech analyzed included 
lexical diversity, syntactic complexity, semantic content, and acoustics.

Now a start-up company called WinterLight Labs is working to commercialize the techology and make it available to the public. 

Wednesday, March 15, 2017

Signs of Alzheimer's Disease

People fifty years and older often put themselves down with the comment, "I'm having a senior moment."

I don't like to hear this when the thing misplaced or word forgotten is something that could happen at any age.

Let's know the difference between normal forgetfulness and early signs of Alzheimer's.

Go the the Alzheimer's Association website to learn the important differences.

In brief, they are:

  1. memory loss that disrupts daily life
  2. challenges in solving problems
  3. difficulty completing familiar tasks
  4. confusion with time or place
  5. trouble understanding visual images and spatial relationships
  6. new problems with words in speaking or writing
  7. misplacing things and losing the ability to retrace steps
  8. poor judgment
  9. withdrawal from work or social activities
  10. changes in mood and personality

Sunday, March 12, 2017

Thinking of Evelyn in 2017

My mother and I on Zuma Beach with Pt. Dume behind us

My mother would have turned 98 today.

Fortunately, she did not have to face that birthday.  She succumbed to Alzheimer's Disease at age 89 in 2008.  To live longer in her state of incapacitation would have been hard for her to bear... though she did feel a wistful sense of loss at leaving this earth.  

Her friend Janet Krause did turn 98 this year.  

Her Christmas card showed four generations:

  • herself
  • her daughter Karla,
  • her granddaughter Jenny, and
  • her greatgrandson Seth, age 3.

It's a beautiful photo.  

I appreciate knowing that a dear friend of my mother's is still alive and remembers Evelyn and their days together at Children's Hospital in Denver training to be nurses, graduating in 1941.  Out of the 28 who started in 1938, only 19 completed the program and became Registered Nurses.  Several of them went on to serve as military nurses in World War II.

Janet wrote me a lovely note, citing challenges as well as blessings:

"Some of the challenges include poor eyesight and issues with memory.  Some days can be more challenging than others.  Overall, though, my health is pretty good for a 9-year-old.

My many blessings include being a resident at Countryside Living Retirement and having so many wonderful friends.  My daughter retired in July, so she has been able to visit more often along with her husband Deen, granddaughter Jenny, and great-grandson Seth (3).  I am planning to go to Denver for Christmas so I will be able to visit most of my family at that time.  Other blessings include two very dear friends who come from out of town regularly to visit and help, Linda Ripley and Barb Schommer.

May God's blessings fill your heart this Christmas!

I do think of you, Anne--I am getting too old.  JK"  

The last line is hand-written.

What a blessing to have one's mental faculties at age 98.  

My mother inspires me to do all I can to slow or avoid my own development of Alzheimer's Disease.

The things I do include:

  • Trying to keep my weight down to about 150 pounds.

  • Trying to walk 10,000 steps per day as monitored by my Fitbit.

  • Taking occasional hikes.  I used to jog twice a week, but I have let that lapse.

  • Avoiding sugar except when it comes in natural forms with milk or whole fruit (not juice).

  • Learning Hebrew to keep my mind sharp.  (I'm not patient enough to do crossword puzzles.)

  • Getting 7-8 hours of sleep most nights.  I need to raise that to 8-9.

Saturday, February 11, 2017

Air Pollution and Dementia

We think of air pollution as a problem that impairs our lungs and our breathing, but there's new evidence that it may also affect our brains and even cause dementia.

See this article "Is there a Connection between Dementia and Dirty Air?" by Casey Kelly-Barton on

One specific culprit may be the magnetite particles found in dirty air.

Increased levels of magnetite have been found in the brains of persons with Alzheimer's disease.

I have a friend who died in 2012 from lung cancer--specifically, non small-cell lung cancer.  Her name was Katherine McTaggart.

She never smoked, so the change in her lung cells had to come from some other irritant, such as the polluted air in West Los Angeles, where we both live.  The 10 freeway starts at the beach and passes a few blocks from her house and from mine as it stretches east toward Texas and finally Florida.

Thus I am sure that the pollution surrounding my community is having effects on me and my friends.

Read the article above to find ways you can deal with particles in the air.  These methods include:

  • Avoid the outdoors and exercise on high-pollution days.
  • Wear a mask if you do need to go out on these days.
  • Use HVAC filters to remove irritants inside your home.

The Happy Side of Dementia

My mother with the chihuahua, Irie, in 2007
Dementia can be caused by several types of events, not just by Alzheimer's Disease.

Lewy Body Disease and Parkinson's are also associated with dementia.

Stroke is another frequent cause of impaired function of the brain, including the frontal temporal lobe, which is part of dementia.

Thank you to NPR this morning for the interview with Christine Hyung-Oak Lee, who had a stroke at age 33.

Her book is called Tell Me Everything You Don't Remember.

In the interview, Christine mentions "Depression is part of recovery from stroke," Christine says in the interview.  "It's grieving for the loss of one's former self."

On the other hand, in the initial stage when she had only 15 minutes of short-term memory, she reported being happy and at peace.

"It's actually quite pleasant," she said.  

That rang true for me.  When my mother was living on the Memory Care floor of an assisted living, I noticed her general calm and contentedness and that of most of the other residents.

She didn't remember that her brother had died a year before, nor that her mother had died twenty years earlier.  She had few expectations or worries.

She was more relaxed and happy than she had been during most of her former life, when she was married to my father, an alcoholic, and was working outside the home while raising four kids.

Of course, irritability is also part of ALZ to varying degrees and at different times of the day.  Waiting for meals or for help is difficult.  

My mother wanted to be at my house, not in a facility, and when I would leave after a two-hour visit, she didn't understand why she couldn't go with me. 

Another positive note: I was encouraged to hear that Christine regained much of her brain function with time.