Ask the Big Questions

I recently added a blue elephant to the décor of my office. It reminds me to ask questions that point out the key issues or controversial topics people may be avoiding because it is difficult or there is no foreseeable solution. The elephant in the room means there is something large and obvious happening, yet people choose to ignore it because it is uncomfortable. This is how I feel about the topic of aging policy in the United States.

The demographics of the United States are changing with the number of people age 65 and older more than doubling between 2010 and 2050. As we age, we often need more assistance with activities such as walking, eating, and bathing. We often have more health challenges and medical needs.  Our fragmented health system is not working well now. Imagine the increased medical needs that our population will have over the next thirty years. How will our system adapt to care for older adults?  Meanwhile, there is a growing lack of health care workers, increasing strain on family caregivers, as well as many other factors that make me concerned that we are not asking the big questions about aging policy.

Bob Blancato, aging policy expert, in a Next Avenue article, identified some of the big questions that are not being asked about aging during the Democratic debates. The aging policy questions missing from the debates are tough questions that make people uncomfortable because the solutions require comprehensive changes to an already broken system of medical and social care and support. Just a few of these questions include:

  • How will we address the approaching Alzheimer’s disease crisis?
  • How do we reduce isolation and loneliness to improve the health of older adults?
  • What can we do to make housing more affordable and transportation more accessible for older adults?
  • What can we do to help family caregivers?

As backward as it sounds, these questions will not be solved anytime soon at the national level. States are doing more to tackle these topics. The National Academy for State Health Policy, a nonpartisan forum of policymakers throughout state governments, is learning, leading and implementing innovative solutions to health policy challenges.  It conducts research and policy analyses, shares information on state programs and policies, and offers technical help to states. It has toolkits and other resources that support states in beginning to address these challenges. Local communities are also coming together to address these big questions in their community. MediCaring Communities is a concept of sustainable services so everyone in a community can live comfortably and meaningfully through disability and illness during the last years of life.

We need to discuss the elephant in the room and begin planning for our aging demographics. We need to ask the big questions and keep asking them until we find solutions.

Three things to learn about this week:

  1. 2020 Election: Where are the Debate Questions about Aging?
  2. Resources for State Health Policy
  3. MediCaring Communities

Photo by Emily Morter on Unsplash

Hitting Pause

It is hard for me to slow down, be quiet, and sit still. I feel a need to be constantly working on something, carrying out a task, or planning the next activity. If it is quiet, I listen to a podcast. It is difficult for me to let there be silence around me. And, it is challenging for me to quiet my mind and just be present. When I reflect on the last year, my mind quickly turns to plans for the upcoming year. I make lists, set goals, and set up tracking sheets. I sometimes focus on what I want to accomplish instead of being present for people who I love. Awareness and acknowledgement are the first steps in improving.

Across the world, many people are trying to learn to shift focus from doing to pausing and being present.  There are many resources, blogs, and guides. Meditation apps are available to download. The Fetzer Institute in Kalamazoo, Michigan supports programs that build a loving world where people realize they are part of one humanity. Its initiatives center around democracy, spiritual formation, and creating a more loving world. Its current blog is about the practice of pausing.

From the Fetzer Institute website you can move to the Spirituality and Practice website. On its Spiritual Practice of the Day page, there is more support for pausing and centering, reinforced by the quote: “In many other cultures, it is commonplace to retreat from everyday life for a prescribed time and get in touch with the aspect of ourselves that is not goal-directed and time-oriented, is not concerned with gaining or losing, but is boundless and infinite.” By Darlene Cohen in Finding a Joyful Life in the Heart of Pain.

Repatterning our thinking to growth and service, James Beck’s TedX Talk, describes a year of asking people, “How can I help you?” and only asking people to pay it forward in return. He felt his approach built stronger relationships and meaningful memories. His theory was that service helps people shift their mindset, thus creating a better world. Just imagine if we answered all our calls, texts, and emails with that question!

As we think about hitting pause and shifting our orientation, my hope is that we find ways to pause during our day and sit in silence for a few minutes. For me, I will be incorporating pause sessions at various times during the day. I will also work to integrate the habit of asking people “How can I help you?” This new orientation makes me excited for the year to come and for the positive difference we can make as friends, neighbors, and community members.

Three things to learn about this week:

  1. The Fetzer Institute
  2. Spiritual practice resources
  3. Pay-it-forward experiment

Photo by Matteo Di Iorio on Unsplash

2020 Here I Come

This is the time of year when many reflect on the past and consider goals for the upcoming year. Last year at this time, I was in the midst of my Health and Aging Fellows program, so I had a lot planned for the upcoming year. Now that I’ve completed the program, I’m left with a feeling of ‘what’s next?’. While planning to stay in my current position and location, I want to keep learning and sharing information with others to improve humanity, policy, and kindness. To that end, I plan to continue this blog and look for more opportunities to write, speak, and teach.

When I write about improving humanity, it is meant to focus on sharing information that helps us to improve the human condition through awareness, action, or advocacy. David Robson writes about us being in the intellectual golden age. Yet, rational thinking, social consideration, and deep wisdom are areas that we can expand upon. I hope to share more information, thoughts, and writing on these topics.

Policy drives so much of our day-to-day experiences. I’m most concern with improving health and aging policy. Almost daily, I observe and share the frustrations of individuals and their families who are navigating a national health system that is fragmented and often counter-intuitive. Health policies, payment models, and private industry shape it, frequently in ways that do not benefit individuals needing care. For our health system to successfully serve seriously ill individuals and our aging population, we must improve policies, payments, and oversight of private industry. Politics, the court system, and individual values and views have a significant impact on the future of quality and coordinated care in our communities. Reducing costs and increasing accesses and equity are priorities for policy makers in the upcoming year.

In our current political environment, I look for ways to promote kindness. Being friendly, generous, and considerate mean so much to people who are suffering. Individuals can feel isolated, unwelcomed, or undervalued. Ageism, as well as so many other ‘isms’, are rampant in our society. I hope to write in a kind and generous manner while being respectful to multiple perspectives. At the same time, I plan to share opportunities to advocate for improvements to our society, advancements in health and aging policy, and ways to take local action.

As we each seek to improve our world, I hope you will join me in learning three new things weekly to improve humanity, policy, and kindness. My hope is that we will make a positive difference as friends, neighbors, and community members.

Three things to learn about this week:

  1. Has Humanity Reached its Peak
  2. 2020 US Health Policy
  3. Make Kindness the Norm

Photo by Jamie Street on Unsplash

Medication Doesn’t Always Make You Better

When I was a child and as a young adult, I thought that medicines always helped and made you feel better. My culture and family experiences taught me this lesson repeatedly. As a professional working in hospice and palliative medicine, I learned that while drugs could be beneficial, they could also have adverse side effects when a person was nearing the end of their life. I also knew from my own experience that treatments such as chemotherapy and radiation had side effects that could reduce your quality of life. So, why was it such a surprise for me to learn that medications that can be helpful earlier in life may be harmful for older adults?

Older adults have the highest rates of medication-related issues, but many are avoidable. It may be that a person is prescribed an inappropriate drug that causes harmful side effects, a drug that interacts negatively with another diseases, a medication that has adverse effects on older adults, or a medication that must be dosed differently to not reduce renal function.[1] Often older adults have multiple conditions that improve with medications. But, when multiple drugs are prescribed, each focused on a singular condition, polypharmacy (use of multiple drugs) causes adverse events to be more common. [2]

The American Geriatrics Society (AGS) published a tool to reduce the rates of medication related issues for older adults. It is the AGS Beers Criteria for Potentially Inappropriate Medication Use in Older Adults, listing nearly 100 medications to use with caution or avoid as older adults. There are resources such as mobile apps and pocket reference cards to help healthcare providers use the prescribing recommendations. These are available at GeriatricsCareOnline.org. Tools for older adults and caregivers are available at no charge from HealthinAging.org.

As we age and seek treatments to help us continue to enjoy our lives, we need to be confident that our healthcare providers are aware of medications that may no longer be helpful and could cause us harm. Most medical professionals are not trained in geriatric medicine. Further training for healthcare providers, caregivers, and the general public is needed to better understand the positive and negative effects of medications.

Three things to learn about this week:

  1. AGS Beers Criteria 2019 Updates
  2. Why the Beers Criteria is Needed and Its Uses
  3. Adverse Drug Reactions in Older Adults

Photo by Laurynas Mereckas on Unsplash


[1] https://consultgeri.org/try-this/general-assessment/issue-16

[2] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4594722/

Genetics

This week I heard a futuristic presentation about genetics and precision medicine. When I was diagnosed with breast cancer in my early forties, I had genetic testing to see if I had the BRCA gene for breast cancer. Thankfully, I did not have this gene, but it has made me curious to learn about genetic testing and its role in preventive and proactive cancer care for my children.

A permanent change in one or more genes is called a genetic mutation. If an individual inherits a genetic mutation, it can cause certain diseases. Examples of these diseases are sickle cell anemia, cystic fibrosis, and early onset Alzheimer’s disease. In other situations, a genetic variant happens. This is when a single gene can have many variants. In some cases, the variance in the gene can cause diseases or play a role in increasing or decreasing a persons’ risk of developing a specific condition. Gene variances such as this are considered genetic risk factors.

Researcher are finding ways to find genetic variants and learn how to treat, prevent, and prepare for disease such as Alzheimer’s disease. This type of medicine is called precision medicine, but it also needs to take into consideration each person’s lifestyle and the environment. Precision medicine will enable researchers and physicians to predict the medical treatments and prevention plans for diseases.

I am excited about the possibilities to prevent diseases. As someone who has experienced a serious illness, I value ways to understand my genes, the likelihood of my daughter developing the same illnesses, and ways to prevent it. Funding, research, and learning about genetics and precision medicine are important to move this type of medicine forward. Learn more and advocate for these advancements in science.

Three things to learn about this week:

  1. Alzheimer’s Disease and Genetics
  2. Precision Medicine
  3. BRCA Gene Testing

Photo by Hush Naidoo on Unsplash

Age Friendly Times

I am becoming more and more excited about the designation of age-friendly. It seems to be gaining attention and momentum. There are age-friendly communities, cities, employers, health systems, and more. While each term describes a different location or institution, overall it has a reinforcing message of supporting and enabling older people. In a time when ageism is the norm in our culture, the age-friendly designation facilitates the much-needed inclusion and appreciation for older adults that is very much needed. It encourages people to think about what matters most to older adults and how to assist them in achieving their goals.

As someone who works in a health system and is passionate about quality care for older adults, I support the Age-Friendly Health Systems initiative of the Institute for Healthcare Improvement, The John A. Hartford Foundation, the American Hospital Association, and the Catholic Health Association of the United States. The purpose of Age-Friendly Health Systems is to ensure that older adults get the best care possible, experience no health-care related harms, and are satisfied with the health care they receive. The focus is on four M’s: medication, mentality, mobility, and what matters. Health systems across the country are working to improve their practices in these areas and share their learning with other systems.

Medication should not interfere with mental activity, mobility, or what matters, mobility, for older adults. Mentality emphasizes preventing, finding, treating, and managing dementia, depression, and delirium. Mobility ensures older adults move safely to keep their function and do what matters to them. What matters aligns care with each person’s individual goals and care preferences. Practically, this means that care teams learn what is important to the person they are caring for. Next, the care team addresses the medications, mobility, and mentality so the person can achieve what matters to them such as seeing a loved one, caring for a pet, and attending a wedding.

Older adults have approximately double the overnight stays in the hospital as people age 45 to 65. In 2015, overnight stays by people over 65 reached 7.1 million. Older adults deserve care that meets their needs and their goals. That is the purpose of Age-Friendly Health Systems. You can support this effort by asking your health system if they are involved in Age-Friendly Health Systems. Learn more and advocate for quality care.

Three things to learn about this week:

  1. Older Americans and Health Care
  2. Age-Friendly Health Systems
  3. What It Means to Be Age-Friendly

Photo by Kenny Luo on Unsplash

Understanding Quality of Life as we Age

This week I had the opportunity to speak on the topic of advance care planning with a colleague. The presentation was at a Continuing Care Retirement Community. I prepared in my usual way, outlining the benefits of advance care planning, how to choose an advocate, what to consider in your decision making, and how to complete an advance directive. In this case, the audience consisted of retired physicians, lawyers, and professionals. Nearly everyone had completed an advance directive. They already had the knowledge I was prepared to deliver to them. Instead, this group of older adults wanted to discuss how to define quality of life as they age.

Quality of life is a complex concept that has different meanings based on our current state, perspectives, values, experiences, culture, and beliefs. Individuals in the group expressed the desire to reflect upon what quality of life means, acknowledging that it changes over time and with changing circumstances. In this community, individuals see their friends and neighbors at various degrees of mobility, ability, and happiness. They watch people thriving as they age in their community, while seeing others struggle with their circumstances.

Quality of life as one ages can be difficult to measure and evaluate. Sometimes it helps to reflect on what a “good day” looks like versus a “bad day.” Consider how often a “good day” happens and what needs to be in place to make sure you have more “good days” than bad. Another way to reflect on quality of life is to consider how friends and family live. Without judgement, think about what aspects of how others live match your values and what would not be quality of life to you. Reflecting on quality of life is an ongoing process because our perspective may change as our life and circumstances change.

As we continue to improve our health care system, we need to remember that quality of life is one of the primary goals of older adults. We need to find ways to measure and evaluate if health care treatments are impacting the quality of life of people in positive ways, as defined by each individual. At the same time, quality of life is difficult to measure because it is so personal. Health care providers need to take time to learn what matters most to each person they treat. Health and wellness are factors of quality of life, but there are many other considerations such as positive relationships, meaningful activities, and sense of purpose. As a country and within our health care system, we need to bring quality of life for older adults to the forefront of our thinking.

Three things to learn about this week:

  1. Advance Care Planning
  2. What is Quality of Life
  3. Measuring and Improving Quality of Life

Photo by Zane Lee on Unsplash

We’re Forgetting About Dementia

Last week, I had the opportunity to experience what dementia might be like. I participated in a dementia simulation. I had inserts placed in my shoes, gloves that made it difficult to hold items, glasses that darkened my vision with blackened areas, and headphones with unfamiliar noises that made it difficult to hear and understand. I was led into a room and asked to do a series of tasks. I was confused, anxious, and unsure of myself. I felt unstable and isolated. I wandered, could not complete a task, and asked repeated questions. After less than ten minutes, I was led to another room to remove the headphones, glasses, gloves, and inserts. The experience was extremely impactful for me. It gave me insight into what someone with dementia might experience and how my actions could comfort them or scare them.

Alzheimer’s disease is the most common form of dementia. Currently, approximately 5.8 million Americans have this disease. This includes about 200,000 people who have earlier-onset Alzheimer’s disease along with the 5.6 million individuals age 65 and older. At this point, 10 percent of people age 65 and older has Alzheimer’s dementia. Nearly two-thirds are women. Older African American individuals are about twice as likely to have the disease.

This is a devastating disease for both the individual suffering from it and their family. The National Institute on Aging (NIA) supports research centers across the country to translate research into better diagnosis and care for people with Alzheimer’s disease. In addition to providing information, these centers offer support groups, aid with medical management, and offer the opportunity to take part in medical trials.

As individuals, communities, states, and as a nation, we need to support learning about dementia. Policies, research, and programs to support individuals and their caregivers are important. When you have the chance, please take the opportunity to experience what it might be like to have this disease so that you can be even more compassionate to those in our lives who experience this dementia.

Three things to learn about this week:

  1. Virtual Dementia Tour Experience
  2. Dementia Facts and Figures
  3. Alzheimer’s Research Centers

Photo by Hans-Peter Gauster on Unsplash

Advocates Work to Improve Hospice

My experiences and work have created my passion to improve the quality of life for people with a serious illness and their families. Care for this population is often fragmented and difficult to navigate. This can people especially true for people who live in rural areas and have additional barriers to access care. Our government creates health laws, policies, and regulations to solve problems. Unfortunately, sometimes these interventions are flawed or end up doing something that was unintended. At times, we need law makers to create new legislation to improve conditions and inequities. Advocacy groups work to harness the voice of policy advocates to gain the support of policy makers. One example of this is the Hospice Action Network (HAN). This group is dedicated to preserving and expanding access to hospice care in America. This week, September 9 – 13, 2019 the group is leading a Virtual Hill Week to encourage people to be the voice for those facing serious illness and their families.

Hospice advocates support the legislation, Rural Access to Hospice Act (S. 1190), which will help increase access to high-quality end-of-life care. The bill would allow Medicare beneficiaries, who elect hospice care, to keep their primary care doctor during this extremely vulnerable period. Under federal law, Medicare patients may choose a doctor to take care of them in hospice. But doctors who work at Rural Health Centers (RHC) and Federal Qualified Health Centers (FQHC) cannot serve as attending physicians unless they volunteer their time free of charge. As a result, many rural patients, who would like to take advantages of hospice care, decide to forego this care to keep access to their preferred doctor.

The Rural Access to Hospice Act is a solution to a flawed policy that harms patients and limits access to the physical, emotional, and spiritual benefits of professional hospice care. In Michigan, this legislation will improve the care for people who live in rural and underserved communities. Senator Debbie Stabenow (D-MI) supported this bill and I urge all of our state’s Congressional Representatives to follow her lead and support the Rural Access to Hospice Act. If you agree, you can urge your representatives to support it as well.

Three things to learn about this week:

  1. Hospice Action Network
  2. The Rural Access to Hospice Act
  3. Ways You Can Take Action

Photo by Tomasz Filipek on Unsplash

The Unseen Side of Caregiving

Over the Labor Day Weekend, I took a few extra days off from my work schedule. My husband and I visited some of our children and met with friends in Northern Michigan. We disconnected from our responsibilities, enjoyed the outdoors, our friends and family, and each other. What a luxury to take time off, relax, and refresh! It made me reflect upon family caregivers who may never get time away from their responsibilities. Family caregivers are often unpaid, economically affected by their responsibilities, and in need of training and support.

According to the Nation Alliance for Caregiving and AARP, approximately 34 million Americans served as unpaid caregivers to an older adult in the last year. Generally, the caregiver is caring for one adult but about 18% are caring for two or more older adults. Nearly half of the caregivers are caring for someone with dementia. Family caregivers have responsibilities such as shopping, meal preparation, cleaning, laundry, and transportation. Often they also assist with giving medication, feeding, dressing, and bathing. Many feel caregiving is their personal responsibility and believe that no one else could or would provide the care.

AARP has researched the value of family caregiving to be an estimated $470 billion in donated care and support. In 2016, they added a new study estimating that family caregivers use approximately $7,000 of their own money for caregiving. To cover this cost, many caregivers have to reduce their spending, vacations, eating out, and other luxuries. The economic impact is even greater for Hispanic/Latino and African American caregivers.

As a nation, we need policies to help family caregivers. In 2018, Congress passed The RAISE Family Caregivers Act that requires the U.S. Secretary of Health and Human Services (HHS) to develop, maintain, and update an integrated national strategy to support family caregivers. HHC will develop a national family caregiver strategy by creating a public advisory council of federal agencies, family caregivers, health care providers, employers, and state and local officials. The council will meet and make recommendations. States and health insurers can support caregivers by increasing access to support and training, extending caregiver leave from work, and paying caregivers. Individually, we can look for ways to help our friends and neighbors who are caring for others.

Three things to learn about this week:

  1. Family Caregiver Statistics
  2. Financial Impact on Family Caregivers
  3. RAISE Family Caregiving Advisory Council