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Useful Articles by the Home Not Alone Staff:

Eight Articles about Medical Conditions and Doctor Visits

Memory Loss and Forgetfullness: What is Normal? (part 1)

David Stephen, PhD

“When you think you think, you don’t really think…Thinking about thought is thoughtless thought...” –German proverb

We all do it.  You look up a phone number and forget it before dialing.  You walk purposefully from one room to another, pause, and mutter, “What did I come in here for?”  Memory lapses are common and memory changes as we age.  But when does forgetfulness become alarming?  How do we define the shady border between normal forgetfulness and memory impairment?

In his excellent book, “Somebody Tell Me Who I Am,” Dr. Richard Cairl explains the effects of aging on memory loss (Caremor Publications, 1995).   This article summarizes what is “normal” in decreased memory functions.  Let’s begin by defining memory.

“Put simply, memory is a process that involves learning, storing, and retrieving information.  It is a process that allows individuals to learn about, understand, and cope with the world around them,” writes Cairl.  Memory is a mechanism that allows us to orient ourselves to time, space, people, objects and events in our daily lives.  It is convenient to discuss two kinds of memory function, short term or primary memory, and long term or secondary memory. 

SHORT TERM MEMORY is like the “in-box” on your office desk.  It has limited capacity and is used as a temporary holding pen in the brain.  “Typically, information stored in short term memory is forgotten in less than thirty seconds,” explains Cairl, “unless the individual rehearses or repeats the information over and over again.”  That’s why, after looking up the phone number, you may have the unconscious (and effective) habit of repeating the number under your breath in hope of keeping the information available for immediate use, at least until you have finished dialing accurately. 

Not only is short-term memory data only briefly retained in the brain, the primary memory is only good for limited capacity.  The “in-box” on your brain’s desk can only hold a small amount of information, perhaps as little as seven words or numbers.  Retaining more information requires that you transfer the data to long-term memory through repetition or by coding the items so they are linked together or linked to existing information already resident in the long-term memory banks in your brain.  Without such links, the items are quickly lost.

LONG-TERM MEMORY is relatively permanent and has almost unlimited capacity.  Since we engage in so many complex tasks daily, this secondary memory bank is accessible in a way that makes these complex tasks seem almost “thoughtless.”  You do not even think that you think about all the steps required to brush your teeth, fix breakfast, dress, and drive to work.  We would go crazy if we had to transfer all this information to short term memory each time we began a task, and had to be fully conscious of each step.  The amount of information required would overwhelm the primary memory  “in-box.”

However, we all experience glitches in retrieving information from long-term memory.  If it is not properly coded and stored in some orderly way, access may be difficult.

AGING AFFECTS MEMORY FUNCTIONS and produces memory glitches that are normal.  Age does not normally affect short-term memory, although the amount of information stored in the primary memory may be reduced.  “Normal age related memory problems tend to occur in coding information for storage, or in remembering the cues necessary to retrieve information that has been stored” in long-term memory, Cairl explains.  “Older adults tend to be slower in processing information in short-term memory for storage in long-term memory, and in recalling all the specifics from information that has been stored in long-term memory.  Hence they may quite normally forget either the name of someone they recently met or a scheduled appointment.”

However, age also produces experience and creates habits that help abrogate these glitches.  We learn to get in the habit of making lists, referring to our date book or calendar, or devising mnemonic devices as strategies to compensate for diminished memory functions.  Older adults who consistently exercise their memory functions by staying mentally active seem to retain the attributes of a “youthful” memory.

This is good news!  These last observations support the assertion that older adults benefit by a rich, stimulating social life and by consistently engaging in challenging tasks that require mental acuity.  Isolation and idleness produce the equivalent of atrophy in brain muscles.  Intellectual engagement and cognitive exercise keep the memory in Olympian shape.  No one expects Grandpa to run a foot race as well as a youngster, but he may be able to beat the rest of the family at chess or Scrabble.  Even those afflicted with abnormal memory impairment seem to benefit from mental exercise.   Although mental functioning slows normally with age, brainpower seems to be more durable than physical prowess.

Memory and Forgetfullness: What is abnormal? (part 2)

David Stephen, PhD

“When you think you think, you don’t really think…

Thinking about thought is thoughtless thought...” –German proverb

We all do it.  You look up a phone number and forget it before dialing.  You walk purposefully from one room to another, pause, and mutter, “What did I come in here for?”  Memory lapses are common and memory changes as we age.  But when does forgetfulness become alarming?  How do we define the shady border between normal forgetfulness and memory impairment?

In his excellent book, “Somebody Tell Me Who I Am,” Dr. Richard Cairl explains the effects of aging on memory loss (Caremor Publications, 1995).   “Put simply, memory is a process that involves learning, storing, and retrieving information.  It is a process that allows individuals to learn about, understand, and cope with the world around them,” writes Cairl.   Memory is a mechanism that allows us to orient ourselves to time, space, people, objects and events in our daily lives.   It is convenient to discuss two kinds of memory function, short term or primary memory, and long term or secondary memory.  

Last month we defined short-term memory as a kind of “in-box” with a very limited storage capacity and very brief retention potential.   On the other hand, long-term memory has almost unlimited storage capacity and data stored there is almost permanent.  The trick is to code the information for retrieval from long-term memory.  You already know that the key to remembering something is linking that thought to other thoughts, which is why we so often say, “Hey, that reminds me…!”

Some memory functions are normally lost with aging.  Aging results in normal memory glitches because the processing of information often slows with aging.  Mental exercise helps keep memory nimble, but like muscles, if you don’t use it, you can lose it.  However, we need to know what constitutes abnormal memory loss, even given a reasonable amount of mental stimulation? 

ABNORMAL MEMORY LOSS can be manifested in either short-term or long-term memory dysfunction.  It is abnormal to consistently make mistakes in coding new information or to be incapable of retrieving properly coded information.  

Imagine this helpful analogy:   Your memory is like a tree with leaves on it.  Each leaf is a single piece of data and every time your brain gets new information to remember, it adds another individual leaf to the tree.   Names of relatives all go on one branch, recipes on another, birth dates on another, and so on.  The mental process of transporting the leaf to the branch is the job of short-term memory, and it is abnormal to misplace or lose the leaf before it gets attached to the right place in long-term memory.  

This is the first kind of abnormal memory loss, the consistent mis-coding or incapability of short-term memory to deliver retrievable information to long-term memory.  This may cause a person to read a magazine article over and over without grasping the meaning.  The information just doesn’t get processed beyond the short-term memory.  Remember that short-term memory is not made to contain much data or to hold onto it for long.  Distractions, like trying to concentrate in a noisy environment, can interrupt this process, and that is normal.  It is abnormal to consistently experience such an impediment when environmental or physical barriers are absent.

The second kind of abnormal memory loss involves retrieving information from long-term memory.   Returning to our tree analogy, not surprisingly, the leaves that were placed firmly on the tree years ago are easily memorable.  Those bits of information have been accessed many times and there seems to be a well-worn path to them that is easy to navigate.  Thus, “old” memories of childhood and events long past are the ones elders recall most readily.  But memories stored more recently may be abnormally difficult to access.  The brain may be unable to find, to read, or to meaningfully connect bits of individual information that are actually resident in long-term memory.

This gives us insights into what is occurring when an older adult has abnormal memory loss.  In the first case of abnormal memory loss, there is an abnormal inability to CREATE long-term memories; in the second case, there is an abnormal inability to RETRIEVE long-term memory data, especially memories that have been recently formed.

Not all abnormal memory problems are permanent.  Psychological or physical problems such as illness, stroke, accidents, or stress from emotion, fatigue or the physical environment may disguise themselves as age-related memory dysfunction.  These may be temporary conditions that can be solved, reversed or arrested.  For example, if Grandma finds it impossible to recall the name of a person she recently met, she may not be abnormally forgetful, she simply may not be hearing clearly.  Because the information she processed was clouded by interference, she did not process it properly.

Abnormal Memory Loss (part 3): Treatable Memory Loss

David W. Stephen, PhD

The ability to live at home, safely and securely, can be compromised by many issues. If you have a loved-one who seems to suffer from confusion or memory loss, she may forget medications, meals, or common tasks and you may believe that being old and being forgetful are normal and unavoidable. This may lead to the conclusion that remaining at home is not an option. The conclusion may not be accurate. Understanding the reasons for memory impairment is both comforting and crucial. Some memory losses can be treated and either reversed or arrested. All memory losses can be managed or coped with, if you understand the process and causes of memory impairment.

In the last two issues, we have explored memory loss, explained how long-term and short-term memory work together, and defined normal and abnormal memory loss. Last month we discussed some of the glitches in data storage and retrieval that explain why we sometimes fail to remember things and explain how the brain can fail to create the infrastructure for sorting, storing and retrieving information. (For copies of these previous articles, go to HomeNotAlone.com and click on “Caregiver Library.”)

In this installment, we look at physiological causes of abnormal memory impairment. Remember, it is NORMAL to expect that aging causes some decrease in cognitive functioning. It is also normal to successfully abrogate this tendency by exercising physical and mental “muscles.”  It is ABNORMAL to have a disease or medical condition that causes memory impairment.

First, let’s briefly list irreversible causes of abnormal memory loss. These include Alzheimer’s disease, other diseases that affect the brain, and stroke-like events.

Alzheimer’s – is the most common of the 50+ diseases classified as dementia that cause memory impairment. Alzheimer’s causes 1) a progressive memory loss, 2) impaired ability to think abstractly and to reason, 3) a gradual decrease in emotional and physical impulse control, and 4) a gradual decrease in the ability to use and understand language. Alzheimer’s causes abnormal, permanent, and irreversible memory loss.

MIDs & TIAs – A Multi-Infarct Dementia (MID) and a Transient Ischemic Attack (TIA) are both terms for hemorrhage or decreased blood supply. A severe stroke or multiple “mini” strokes  can cause 1) varying episodes of dementia and memory impairment, 2) altered moods and emotional responses, 3) physical tremors and motor dysfunction, and 4) language problems. MIDs & TIAs cause irreversible brain damage even though the damage may leave selected memory abilities unpredictably intact and may damage other functions unexpectedly, especially at the onset of the disease.

Other diseases – include dementia and memory loss caused by Parkinson’s,  Pick’s, and other maladies that permanently damage the brain.

However, if a loved-one seems to have memory loss, it is worth the effort to investigate other causes that are reversible or that can be arrested. Some of the treatable causes include the following:

Emotional disorders – such as depression may be characterized by mood swings, anxiety, irritability, withdrawal, sadness and crying, irrational fears and delusions, weight loss or gain, sleeping problems, slowed speech, etc. IMPORTANT – depression causes problems that are often diagnosed as dementia, when, in fact, it is only the symptoms that are similar. Some evidence indicates that untreated depression can actually lead to true dementia. A memory problem caused by depression is treatable and reversible.

Medications – can cause side effects that can result in a wide range of negative physical and emotional problems. The greater the number of medications a senior takes, the greater the possibility for deleterious effects. Likewise, the greater number of doctors the elder sees, the greater the chance for medication confusion. I have lost clients (thank God) when their medications were corrected and they regained normalcy.

Sensory deficits – such as deteriorating eyesight or hearing can cause disorientation and an inability to respond normally.  This is self evident. If Grandma doesn’t hear what you say or see your face clearly, then she can’t be expected to remember what she never heard or saw.  It may try everyone’s patience, but you need to give hearing and visual aids a persistent try because it often takes a long while to learn to adapt to these problem-solvers.

Nutritional deficiencies – (particularly B12, thiamine, iron, or folate) can cause confusion and abnormal memory problems.  A thorough physical and blood work-up can often help determine if a supplement will help improve cognitive functioning.

Metabolic disorders and acute medical conditions – cause unhealthful physical stress and stress can affect memory. Metabolic disorders include low blood sugar, low blood oxygen levels, low body temperature, decreased heartbeat, etc. Acute medical  problems, the after-effects of surgery or a hospital stay, or an illness such as a urinary tract infection or pneumonia can result in memory problems that can be resolved.

Memory problems should be examined carefully. Many are treatable.  For example, two new studies indicate that a 10 to 45 minute walk every 2 or 3 days can help maintain or regain  mental acuity. Seniors who live at home, alone, may need encouragement and companionship to do the activities that help keep memory loss at abeyance. Seniors need neither lose their minds nor their homes if memory loss problems are properly diagnosed and treated.

Old and Depressed: “Pseudo-Dementia”

Marc Ringel, M.D. & David Stephen, Ph.D.

In this article, Dr. Marc and Dr. Dave, long-time friends, team up to talk about “reversible dementia.”

Dr. Dave:  Let’s start with a definition. What is dementia?

Dr. Marc:  "Dementia" is a medical term that refers to mental impairment that results in confusion, forgetfulness and inability to function normally at mental tasks.

Dr. Dave:    But senile dementia is different than being occasionally forgetful. And there are some kinds of dementia – or abnormal memory loss and confusion – that are reversible.

Dr. Marc:  Yes, for some people all or a part of their dementia symptoms are reversible. There is a very long list of causes that a doctor needs to consider when an older person shows a decrease in mental function in the hope of uncovering something treatable. For instance, when the cause is an illness, the symptoms of dementia can often be relieved by treating the illness.

Dr. Dave:  That makes sense, Marc. Obviously, when we are ill, we are not operating at peak mental efficiency.

Dr. Marc:  Right. We are always  looking for treatable causes. In the elderly, the behaviors we associate with dementia, usually confusion and memory loss, can result from a cause as simple as a respiratory or urinary tract infection, low blood sugar, a vitamin deficiency, or stress.

Dr. Dave:  But these are not physical ailments specific to the elderly...

Dr. Marc:  No, David, but the elderly react differently to many illnesses than younger people do. They may have pneumonia without fever and appendicitis without pain. Depression may also look very different in older people. Sometimes it looks like senility. That’s why we call it "pseudo-dementia."

Dr. Dave:  You and I have both had first-hand experience with our own bouts of depression. Many people have. Depression can rob you of joy, make you irrationally irritable, cause lethargy or sleeplessness. Can depression cause dementia?

Dr. Marc:  Not so much cause but seem. Depression can seem like dementia. Here’s one of my favorite stories. Every doctor has a few patients who have changed his career. One of mine, long ago,  was a woman whose name I don't even remember. Her husband and daughter called her "Mom."

They explained that Mom had been "senile" for about ten years. Her spouse and her only child had devoted a good deal of their lives over the last decade to taking care of her.

Mom was 58 years old. She was a pleasant middle aged woman who could follow simple instructions during my examination. But her answers to my questions were either unrelated to what I had asked or unintelligible.

Something was not right. Forty-eight year olds do not become demented for no good reason. If they do, one expects them to deteriorate over the subsequent ten years. The woman I saw before me was sadly out of it but otherwise quite healthy. So I sent her to see a psychologist who interviewed Mom and performed some psychological tests. He told me he thought she was depressed.

I prescribed an antidepressant for Mom. Within a few weeks her daughter and husband said that they had "gotten her back."  After a decade's absence, she resumed her productive role in the family. When I saw her, Mom carried on a completely appropriate conversation with me. That gratifying result helped to make depression one of my favorite diseases to diagnose and treat.

Dr. Dave:  That’s an inspiring story, but not everyone is that passive when it comes to talking about depression. Unfortunately, there’s a negative social stigma attached to depression. Many people still feel that it is an embarrassing emotional problem and that makes it hard for people to admit.

Dr. Marc:  That’s quite true. But now we understand that depression can be caused by a chemical imbalance. So we treat it as we would, say, pneumonia. We don’t ask “Why do you have pneumonia,”  we just say, “That’s pneumonia. We know how to treat it,”  and we treat it.

Dr. Dave:  I have a client whose son suspects she is depressed and thinks that depression is the cause of her chronic fatigue. She took an antidepressant for about a week, had one good day, and said,  “I’m cured!”  So she stopped taking the medication. But she still seems fatigued all of the time.

Dr. Marc:  That’s unfortunate. You wouldn’t do that with blood pressure medication just because your blood pressure went down after a week. She should stay with the program her doctor prescribed. Depression can be chronic and should be treated for a while before attempting to wean (not suddenly quit) the medication.

Dr. Dave:  But how do you know which comes first, depression or the mental distress that people often think is an “emotional problem?”

Dr. Marc:  Depression, like most illnesses, has both an emotional and a biological side. Losses – of function, family and friends – can wreak emotional havoc on even the toughest older person. So that emotional distress can lead to emotional depression.

Dr. Dave:  Take away the stress and the depression goes away?  I mean, people sometimes “just get over it” when they have time to process the event, work through the grieving process, readjust to a change or loss.

Dr. Marc:  That can happen. But some of depression is explained by biological factors, namely an imbalance of neurotransmitters, the chemicals that allow the computer in our head to work by carrying messages between brain cells. Antidepressants change the balance of these neurotransmitters so that what comes out is a less depressed person.

Dr. Dave:  And a less depressed person may be a person whose dementia has been reversed. It’s ironic that people may be more wiling to accept an irreversible cause of dementia like Alzheimer’s disease than to admit to a potentially reversible cause of dementia like depression.

Dr. Marc:  Alzheimer's disease is the most common cause of dementia in the elderly. As anybody who has lived with an Alzheimer's patient knows, the level of impairment can range from trouble with the checkbook to not recognizing one's own spouse.

Unlike Alzheimer's type dementia, up to a third of dementias may be wholly or partially reversible. There are an enormous number of fixable things that can cause mental function to deteriorate, from low thyroid to overmedication. Depression is one of those things.

Dr. Dave:  So, how do you determine if the signs of dementia are caused by or related to depression?

Dr. Marc: Much of science is informed trial and error. You think you know the cause and treat that, and if the outcome is positive your diagnosis and treatment were probably right. If not, you go on to a new hypothesis based on what you knew previously and what you have learned did not work.

A depressed elderly person may, for all the world, look just plain demented. The medical workup, including physical exam, blood tests, and x-rays, may all be normal. If so, there is one more thing to try, antidepressants.

Dr. Dave: And that treatment might be as happily correct as the case of the woman you described who made such a remarkable recovery from “pseudo-dementia.”

Dr. Marc: We were all happy about that case. And that taught me to look for more causes for dementia than just being old. Remember that depression in an older person may look like senility. If you suspect that you or someone you care about is depressed, get help. Depression is treatable.

(SIDEBAR)

POTENTIALLY REVERSIBLE CAUSES OF DEMENTIA

•Stroke or heart attack (depending on brain damage and therapy)

•Low blood oxygen levels or low heart rate

•Respiratory or urinary tract infections

•Hypoglycemia (low blood sugar)

•Medication interactions or side effects

•Depression or stress

•Drug or alcohol abuse

•Vitamin deficiency (often B-12)

•Hypothyroidism

•Brain injuries (tumors, subdural hemorrhage & hematoma)

NOT REVERSIBLE

•Alzheimer’s disease

•AIDS

•Parkinson’s

•Stroke (resulting in permanent brain damage)

•Multiple Sclerosis

•Schitzophrenia

•Normal Pressure Hydrocephalus

•Other diseases (Pick’s, Huntington’s, Creutzfeldt-Jakob, Lewy Body, etc.)

(NOTE: Treatment can often lessen symptoms of dementia, even when the cause is non-reversible.)

How to get the most from your Doctor's Office Visit

David Stephen, Ph.D.

My head was spinning this morning as I left the doctor’s office. I had a bag of prescription samples, three new prescriptions to fill, new instructions for taking old medications, an appointment slip for a follow-up visit, and I was trying to remember the details of the instructions, signs, and symptoms the doctor had given me regarding a half a dozen important health issues.

How could so much have happened during a fifteen minute office visit? Did I forget to ask about something important? Did I understand everything I was told? 

If you accompany an elder to the doctor or if you are responsible for managing a loved-one’s care needs, here are some useful tips on how to get the most from your doctor’s office visit. The first rule is “Be Organized” and the following ideas will give you a good start.

BEFORE YOU LEAVE HOME

Drugs – Know which prescriptions need to be re-filled on this visit. Bring all the medicines that your loved-one takes, EVERY BOTTLE IN THE HOUSE. Organize them in two or three bags; prescriptions to be re-filled, old prescriptions, vitamins and supplements (especially herbs). Be sure to include over-the-counter medicines (aspirin, elixirs,  laxatives, digestive aids, ointments) because herbs, supplements and other non-prescription medicines may interact with prescription drugs or each other. Some vitamins and supplements can have side effects that affect the way your loved-one feels or behaves.

Foods – Make a general list that describes the elder’s normal diet. Include daily fluid intake, salt limitations, fresh fruits and vegetables, dairy products, cereals and fiber, fish, poultry, meats, sugar, etc. If the senior eats a lot of canned or prepared foods (canned soups, TV dinners), uses caffeine, tobacco or alcohol, let the doctor know. Provide a good estimate of how much and how often these foods and products are consumed, on a daily or weekly basis.

Names – Bring a list of other health care providers, including names, addresses and phone numbers. An easy way to do this is to simply collect business cards from the health care providers your loved-one is seeing. If the doctor needs to make a call to another health care provider, this can save valuable time. Have copies of medical records such as clinic notes, blood pressure and weight log, test results, and hospitalization records available for review by the doctor. It’s a good idea to create a loose-leaf notebook to contain this and other important information permanently.

Questions – Prepare your “Top Three Questions” or burning topics you wish to discuss with the doctor. Write these down in detail so you remember to mention all your concerns in an organized fashion. Be aware of time limitations and understand that only one or two issues may be dealt with fully, depending on the complexity of the problem.

IN THE WAITING ROOM

Paperwork – Arrive 15 minutes early to allow time for updating insurance records and filling out new forms. New federal privacy laws limit the doctor’s permission to share information with others. Be sure to ask, “Do we need to sign any release forms so you can send copies of these records to other clinics, caregivers and family members?”

Time – Of course, nobody likes to wait and the old joke is that we’ll all die of old age in the waiting room, but recognize that most doctors are scheduled to see a patient every 15 or 20 minutes. Unfortunately, the doctor may not be in control of how the clinic or hospital schedules appointments. If you are kept waiting beyond your appointment time, it may be that the doctor is taking extra time required to resolve another patient’s acute needs. Your time will come, both to see the doctor and to get extra time when you really need it.

WITH THE DOCTOR

Communication – What we think we hear may not be what was actually said. This goes for you as well as the doctor. Make sure the doctor understands what you are asking or saying. After the doctor tells you something you believe is important, repeat or summarize the information aloud to verify your understanding. At the end of the visit, summarize important points out loud again. Do not rely on memory. Ask the doctor to write down instructions for changes in medication, tests ordered, exercises, signs and symptoms to look for, and all other important information. Bring a note pad and pen into the consultation room. Before you leave the office, summarize what you have been told in writing and if you have questions, ask the nurse or receptionist for clarification.

Support staff – Good geriatric care is a team effort. Ask the doctor for names of support staff and resources your elder may need. For example, a social worker or case manager can help you understand changes in insurance regulations, coverage and co-payments. Here is a starter list of useful resource people: a social worker, case manager, nutritionist, occupational therapist, physical therapist, pharmacist, visiting nurse, home care provider, geriatric psychologist, assistive technology or medical supply company. Find out how to contact any of these people and remember to get copies of the records or information they may need.

BEFORE YOU LEAVE

Medical records – If the senior you are assisting has more than one doctor or consults other care providers, it may be useful to maintain a copy of their medical file. Ask for a copy of any new information that results from today’s consultation. It may expedite matters if you bring a self addressed, large manila envelope so the office can mail you copies of records that will be written-up after the consultation.

Legal forms – You may need help in arranging for advanced directives, a medical durable power of attorney, guardianship, or “Do Not Resuscitate” order. Ask the doctor, staff or hospital which specific forms that facility or state uses, where each document should be kept, who should know about the existence of the document, and how to complete the form. Only about a third of all people bother to complete these important forms even when they are furnished. Ask for names of people who can help you decide which directives you should have and how to address these crucial matters.

Being prepared and well organized can help assure that your elder loved-one gets the most out of the next doctor’s appointment. You should leave the office feeling confident and informed.

More Better Food for Skinny Seniors

David Stephen, PhD

One of the most common concerns in elder care is improving eating habits and increasing nutritional intake.  When a concerned family member calls me for help, about half the time one of the important issues is, “We don’t think she (or he) is eating regularly or eating well.”  Underweight or malnourished seniors are at risk because they have less functional reserve, a technical term for physical stamina, resistance, and physical resources for recovery.

There are many reasons for diminished appetite, besides obvious ones like inactivity.  For example, a stroke or accident can decrease or change the senses of taste and smell.  Here are some practical solutions for improving food intake for underweight or malnourished home-alone seniors.

“SINK EATING”  The social aspect of eating a meal is colossal.  When my wife or I are faced with eating lunch or dinner alone at home, we joke about grabbing whatever is handy and gobbling whatever we find over the sink.  We call this “Sinking It.”  No person I know (at any age) will habitually prepare a four or five course meal, light candles, open a bottle of vintage wine, and sit down to a leisurely, full meal without company.  Maybe the French do this in solitaire, but seniors I know who are home alone at meal times are apt to “sink it” or snack it or go without it.

One practical solution is to move the main meal of the day to a time when company is available.  We’ve had good luck moving the main meal to lunch time when a caregiver is present.  Company is good, but participation is even better.  Working together to  prepare  a simple but nutritious meal can increase the senior’s appetite, heighten the meal appeal, and increase the volume of intake.

“DANGER SIGNALS”  Look in the freezer, cupboard and trash.  Often, seniors resort to MREs (“Meals: Ready to Eat”, the current military appellation for GI field rations). The civilian version of this is TV dnners and canned foods.  The salt (sodium) content in canned soups, vegetables and frozen dinners could give a healthy polar bear high blood pressure enough to account for most of our global warming.

“THE MESS HALL” Good meals are often available outside the home.  One option is community meals at your local senor center, church or synagogue, or other gathering site.  Transportation resources are often part of such organized mealtimes.  For first timers, such a gathering may be daunting, so ask an activities coordinator or friend to be a meal buddy the first few times. 

A trick of the trade is the “gradual introduction” subterfuge.  Claiming that she had a short appointment with a staff member, one clever caregiver took Eileen (a skinny elderly client very reluctant to “eating with a bunch of strangers”) to our senior center at luncheon time.  She left Eileen in the lobby for a few minutes and when she returned from her “appointment” discovered Eileen chatting with a group of new acquaintances.  It took another visit before Dorothy felt comfortable enough to dine, but she now enjoys the luncheons as a semi regular participant.

“SMALL IS BEAUTIFUL” Old English wisdom says, “Eat like a King in the morning, a Prince at noon, and a Pauper in the evening.”  A heavy meal at night works for farm hands, but may be inappropriate for less active seniors.  Sometimes large portions turn the appetite off, so multiple small meals are the ticket for some elders with a diminished appetite. 

A balanced diet does not mean every single meal has to contain selections from each food group, although some combinations of foods compliment each other in taste.  For example, a couple of orange slices, a few nuts and a bit of chocolate can get the digestive juices flowing for a small sandwich and salad an hour or so later.  The body gives hunger signals, but good eating, such as a regimen of small but frequent meals, can be a learned habit.  Remember that breaking or making a habit can take six weeks or so.

“MAKE LESS MORE”

Finally, here are some tips for boosting calorie or protein intake.

•Finger food:  Eating with your fingers can increase appetite.  (Don’t try this with soup or jello.)

•Powdered milk:  Bump up the food value of liquid foods like desserts, gravy, soups and hot cereal with low-fat powdered milk.

•Enrich:  Sour cream, butter, whipped cream and other high calorie or fatty foods are tasty and calorific.

•Soft cheese: Cottage cheese and ricotta cheese go well with scrambled eggs, casseroles, and even some desserts.  Camembert and brie are tasty on fresh baguette or crackers.

•Hard cheese: Grated or thinly sliced cheese on toast and vegetables is nutritious and, like soft cheeses, can be a delightfully exotic taste treat.

•Super milk: Add high calorie, high protein liquid and powder supplements to milk shakes.  Instant breakfast powder on ice cream is tasty.

•Bake it:  Add wheat germ, nuts, and seeds to baked goods.

•Beat it:  Beat an egg into mashed or fried potatoes, cooked puddings and sauces.

•Mayo: Add extra mayonnaise to potato salad, egg salad, sandwiches and scrambled eggs.

•Sweeten it:  Honey is yummy on fruits, in yogurt, and various drinks.

Get creative!  One of my favorite childhood treats was “blue milk.”  A glass of milk, a teaspoon of sugar, a dash of vanilla extract and a few drops of blue food coloring won me at least one popularity contest among neighborhood playmates.  Having fun with food is a sensible, even silly way to increase appetite, nutritional intake, and morale.

Calling Grandma from the Brink: The Isolation of Hearing Loss

by David W. Stephen, PhD

Joan, 78, one of my home care clients, is on the brink of hospice care.  There’s no diagnosed disease that has caused her decline, she seems to have just given up the will to live.  From the first interview and assessment over three months ago, it was clear that she had begun to disengage from her environment, sinking into her own world and leaving her bedroom less and less.  Although she would not admit it, it was clear she had significant hearing loss.  Her apparent dementia was accelerating quickly.  This piqued my academic curiosity and I began to research the links between hearing impairment and dementia.

The good news is that hearing aids and other hearing health care can sometimes call Grandma back from the brink.  In this column, we have previously discussed “reversible dementia” and have identified ways to help elders who seem to suffer cognitive impairment regain their faculties or, at least, arrest the growth of dementia.  Today, we will examine how loss of hearing can contribute to serious decline. 

I never fully appreciated how much hearing loss can isolate a person from his or her environment  until I recently visited the office of an excellent hearing specialist.  In her high tech lab, she performed a demonstration that opened my eyes (and ears) to the effects of hearing loss.

First she played an audio recording  of a couple sitting outside, talking and drinking a soda.  The rattle of ice filling the glasses, the sound of the soda bottles spritzing open, and the fizzing sound of the poured beverages were all clear.  The quiet conversation was bright and crisp.  Birds chirped in the background.  The thirty second tone poem painted a Norman Rockwell picture of a snatch of robust, dynamic life.

Then the audiologist displayed a graph indicating the sound frequencies that a client with significant hearing loss experienced.  The sophisticated software allowed the audiologist to impose the restrictions of his poor hearing as she replayed the audio recording a second time, but this time simulating what the man heard.  This time the recording put his ears on me and placed me in a world far away, in a world of muted sounds.  It was as if someone had draped a gauzy, grey cloth over the environment.

No birds chirped.  No ice tinkled.  No bottle spritzed open.  No soda fizzed.  I heard only muffled, distant sounds.  Voices were so dull and thudding that I could not tell the difference between, “Let’s go to the store” and “I just closed the door.” 

Such a hearing impairment is not just an inconvenience, it can be one of the first steps on the road to dementia.  The person with hearing loss may become isolated from the sounds of the everyday environment, and begin to sink into a life divorced from reality.  Friends and family may misperceive the hearing loss as cognitive impairment, that is, dementia.

According to Dr. Max Chartrand, the effects of untreated hearing loss among elders can have powerful cognitive, communication and psychosocial detriments.  Hearing loss is not uncommon among seniors, and the fact that more seniors are living longer means that more seniors experience the isolation of hearing loss.  Unfortunately, undetected and untreated hearing loss is often mistaken for another brick in the wall attributed to dementia. In one study in Florida, he notes that 94% of seniors diagnosed with memory loss also suffered from a serious uncorrected hearing impairment. 

He concludes that the symptoms of uncorrected hearing loss often parallel the symptoms of dementia, “including depression, passivity, negativism, anxiety, social isolation, feelings of helplessness, loss of independence, and general cognitive decline.”

This is a good news, bad news story.  The good news is that hearing impairment can often be treated and can help bring Grandma back from the brink of dementia.  The bad news is that most hearing aid patients need 90-120 days to readjust and re-engage with their environment.  A senior with verified dementia plus hearing loss may take up to a year for noticeable effects to take place.  Unfortunately many hearing aid manufacturers have had policies of offering only a 30-day trial period. This has created a whole generation of seniors who may have tried hearing aids once and determined, after a month, that “hearing aids don’t work for me.”  Not true.  It’s more likely that the 30-day trial period is insufficient to determine effectiveness.

I discovered that research literature is replete with good evidence and conclusions that untreated hearing impairment increases the risk of other physical and psychological problems, including depression, hypertension, heart conditions, breakdown of familial bonds, denial, defensiveness... all symptoms that we associate with dementia.

Hearing loss can isolate an elder from his or her environment and can trigger other preventable problems.  If you suspect a family member is becoming hard of hearing, the sooner they receive treatment, the better.  And remember that if hearing aids are appropriate, it may take a few months or more for you to notice significant behavioral improvements.

Hearing aids and other treatments are not add-ons just to relieve the difficulties of having to shout at Grandma or relieving Grandma of straining to keep track of the conversation at the dinner table.  Untreated hearing loss can contribute to the development of life threatening conditions.  If only my client, Joan, had been fitted with hearing aids years ago, she might be in better health today, rather than on the brink of hospice care.

Health Care Checkup: Stop Treating Only Symptoms

by David W. Stephen, PhD

A good doctor treats your symptoms, but also looks for underlying causes in the hope of curing your illness. In this article, let’s look at what might cause Americans to be so concerned about affordable, even universal, health care.

Elections are over for another term but the presidential race did not focus on solutions to an issue of paramount importance to our society. Although health care concerns generated much rhetoric, no candidate I tuned into proffered a solution to the early deaths of seniors in the USA.

USA Today recently published a list of the top 50 countries in terms of life expectancy. The United States ranked third from the bottom. That's right. We're number 48. This year, Americans can expect a life span of 77.4 years, nearly four years behind the Japanese. The USA even lags behind counties that most USA citizens consider disadvantaged, developing Third World countries and nations with economies in transition from former Soviet rule.

The Institute for America’s Future asks, “How is it that the richest nation in the world can barely meet the health benchmarks set by former Soviet Union countries? According to Merrill Goozner, director of the Integrity in Science project at the Center for Science in the Public Interest, “It's all about averages...there's a huge race- and class-based health care disparity in the United States. And it's a problem that's going to take more than promises of universal health care to solve.”

The report continues: The United States spends more on health care than any country on earth—nearly 15 percent of its overall economy. That's nearly a half again as much as other countries and on a per capita basis, no one else is even close. Yet if one looks at the performance of our health care system, we're clearly not getting what we pay for.

Of course, our longevity has been rising every year by a small amount. But many countries that spend nowhere near our levels on doctors, hospital stays, drugs and sophisticated tests are clearly getting a lot more for their money.

“Take the oppressed citizens of the British isles, for instance,” says the Institute for America’s Future. “We're constantly told they are suffering under the yoke of an incompetent national health care system. Yet they live nearly a year longer on average than Americans. How about those beer-swilling, sausage-stuffing Germans? They live 14 months longer on average. Just over the border in Canada, the press constantly claims that our northern cousins are suffering endless waits for basic procedures that we take for granted. Surely they must be dying off at a faster clip. Uh-uh. They have two-and-a-half more years than the average American. Perhaps they spend it waiting on lines for their health care.

“Among large industrialized countries, the life expectancy leaders—all with an average life expectancy over 80 years—were Japan, Switzerland and Sweden. What do they have in common? They have national health care plans. But more importantly, they have a high degree of income and social equality across their societies—which, more than any other single factor, correlates with superior health outcomes.”

According to the Centers for Disease Control website, age-at-death disparities in the United States give a few clues about why our health care system performs so poorly despite outlandish costs. While the overall U.S. life expectancy rate is 77 years, the rate for blacks is about 72 years with black males at a Third World-level of 68 years. Infant mortality—a prime indicator of how well health care services are distributed in a society—is another area where the United States lags sadly behind its industrialized rivals. The CDC rankings of selected countries showed the United States at 28th out of 37 countries.

Who fell below us in safe and healthy childbirths and infant care through the first year of life? Virtually all the laggards (other than the United States) are countries of the former Soviet Union and Eastern Europe. How can it be that we are not much better off than Romania in this vital statistic? It's not middle-class moms in suburban hospitals losing babies. It's poor mothers without prenatal care. It's teenagers who hide their pregnancies, deliver low birth weight babies and have few support systems to help them care for their newborns.

The health effects of race and class and age are America's hidden health care story. Low-wage work leads to lousy diets because the foods that are plentiful and cheap happen to be the worst for you. Fear of unemployment and economic decline defines America's large lower middle class today and this produces tremendous psychic stress, an unreported epidemic. We spend billions on drugs to lower blood pressure, reduce cholesterol and treat diabetes, but almost nothing on social programs to offset the income-related lifestyles that lead to these conditions.

This election season featured much sound and fury about the 43 million Americans without health insurance. But when we begin peeling the onion we discover that we need health insurance because of ill health; many are in poor health because of unhealthful lifestyles; unhealthful lifestyles are strongly correlated with social inequality and economic distress, and these factors are at the root of the problem.

Simply put, life styles that put Americans at risk for early death have underlying causes that need to be addressed. Addressing the causes of ill health, including the social and economic disparities that are so strongly correlated with early death, is the ounce of prevention that can make universal health care a secondary consideration. Public policy or campaign rhetoric that does not note this, fails to consider the broader scope of why affordable and accessible health insurance coverage is such a concern.