Dr James Campbell, he suggested that I simply say on the way over, he is well prepared for this lecture I need not give you a long introduction, trust me I am his mother. Good afternoon. All right, can the people over there in the porch really hear me? Yes, okay. That's amazing, that's wonderful. Thank you very, very, very much for coming out on this delightful afternoon to enjoy some social company and to do a very rapid discussion on the topic that I find most interesting. The tour of Palestine Park is apparently been replaced by an ark building workshop. Anybody who would like to attend is free to leave the lecture early but you have to leave in twos. So I am a Geriatrician, all right. What's a geriatrician? A person who basically is decided to take some specialized training in the care of older people. Now people would say why would you want to do that? Well, there is couple of choices. Some people would say why you do it for the money? Don't think that's true, it's actually the lowest paid medical specialty there is. We don't want to analyze what that means about American society. On the other hand there was an article in the Annals of internal medicine approximately two and a half years ago, that rated every specialty in medicine in terms of the quality of life and job satisfaction. Any guesses on which specialty had the highest job satisfaction? Geriatrics, all right and you can look at the aging imperative and see whatever you want to see. The breaking of the bank of the Medicare system in approximately seven years and four months, the breaking of the bank of the social security system in slightly less than 20 years. I look at the aging imperative when I see job security. We are going to talk about a whole series of topics and if I don't get to them all I apologize. I want to start to give you a sense of how the week is going to go though, because we are going to have the Lorraine Mion a PhD nurse researcher speaking with you tomorrow. Bill Thomas who wrote the book lessons "Learning from Hannah". As well as the book, "What are Old People For?" speaking on Wednesday Dr. David Lipschitz who is the head of the program in geriatrics, one of the largest programs in the country in Little Rock Arkansas, will be here Thursday. And then my personal favorite which is actually return of a panel we did approximately three years ago where we bring 90 year old and above successful individuals from Cleveland and as many successful 90 and above people are joined from people who live here in Chautauqua for an open panel discussion. Were any of you here three years ago? All right, it was a wonderful time. We are going to talk about definitions of aging, a little bit about demographics, a concept of health, physical fitness, mental fitness, role and purpose and of course I don't think I can get off a department of religion lecture without a significant discussion of the spirituality and aging. And we will end with the end of life. Aging and the question is what's the definition of an old person? All right, for those of you who have got the old fashion definition, it's anybody who is 10 years older than I am. Which is clearly the answer from teenage children? The older individual has virtue, a particularly beneficial advantage or an inherent quality that is admirable. We have to understand that despite the fact that American society may not universally see that, hear that or behave that way. That's the reality that's out there and that's what makes my job wonderful. Some of the statistics that are just enjoyable are if you take all the people in the history of humankind who have ever been over the age of 65 half of those people are alive today. Between the times Kennedy was assassinated and 2003 the population over the age of 65 doubled. By 2030 the population of 65 will grow by another 30 percent, but more importantly the population over the age of 85 will grow by a 100 percent. We have to have a short moment on statistics and explain the different concept; there is life expectancy and life's span. The life span of human beings has really not changed. The life span being approximately 110 to 114 years, which is the maximum the oldest human can live to be. And we all remember the women who lived to be, but she lived to be in France about a 118, and she was asked what did she attribute her old ages. Does anybody remember the answer? She said "I think god forgot I was here". And on the other hand life expectancy is the percentage of people who are making it to old age that's what is been changing dramatically the number of people who are making it to advanced ages which is totally changed every reality of American society and definitely every reality of American medicine. The other piece of the puzzle that people forget to mention is if between 2000 and 2030 the number of people over 65 is going to up by 30 percent and the number people over 85 are going to go up a 100 percent. The number of people under the age of 18 is going to down by eight percent. So the society has aging in both respects. It's important to remember that by and large aging is a female phenomenon. The vast majority, 61 percent of the people over the age of 65 are women. If you live to be a 100 gentlemen in the room, there are five women for every man. There is still hope. The other one that I think is important and this may be important to me because I have two children going off to college between last week and this week. The average American now has more parents than children. And we need to talk a little bit about the centurions, the people over the age of a hundred. One in five people over the age of a hundred has no disability at all. More than half the people over the age of a hundred live outside of nursing homes. In 1956 how many people over hundred were there, about 2,500, by 1986 that was 25,000, by 2050 we could have as many as four million people in the United States over the age of a hundred. Now we live in a politically correct world, and we have to come up with names for groups, we used to call them seniors or grey panthers or elders but in a politically correct world we now to refer to them as chronologically gifted. Where the population over hundred as the severely chronologically gifted. The diseases that were dealing with number one Arthritis, number two Vision impairment, number three Hearing impairment. And you all hear from Dr. Thomas about the plagues of old age afford him and loneliness. So how do we define health? Because we have to be very careful as we define health that we do not insert ageist assumptions. If you define health on biophysical parameters, by definition you are in sort of speaking against the value of old age. By and large there are only two changes that we can identify that our universal as a result of aging. The first of those changes is that barring one major cosmetic industry. Everybody's hair does turn grey. The second is that everybody does lose their baby teeth and have them replaced with permanent teeth. Every single other change that occurs is a combination of aging, environment and disease. But if we define health in much broader terms, in terms of not only physical or as we in geriatrics refer to it to as functional health. But also emotional and psychological, intellectual and cognitive, social and family, practical and spiritual and existential. At that point, you start to understand there are many parameters of health that which younger people don't even have a chance of being as healthy as older individuals. We need to talk about how do you measure health. And of course as doctors we find its surprising that the single best measure of how healthy someone is is how healthy they feel. Sort of makes all those expensive tests seems a little bit excessive. But I have a lot of friends in radiology and they all need you know send their children to college as well. Self reported health is a good predictor of mortality even when corrected for all the confounders of smoking and age and race and gender; if correlated well with function and it's the single best indicator of how much health care resource utilization the average person uses. Physical fitness will go over briefly because physical fitness is the one you hear about the most. Physical fitness is essential. However, what people make complex is not. The simplest most effective exercise is walking. The important piece to remember about walking; "If you walk 20 minutes a day that gives you a certain quantity of cardiovascular advantage. If you walk 30 minutes instead of 20 minutes, you get twice as much advantage". That's pretty good math. But more important they took a set of 90 year old's, put them in standardized walking program and their ability to have prolonged endurance doubled even at the age 90 and above. We want to talk about mental fitness, because mental fitness is a very helpful concept. There is a myth about the ageing brain that the brain goes into steep decline as we age simply not true. That the cells in the brain are steadily dying and not being replaced. That's also been shown to be not true. Even when I was in Medical School not that long ago, we were told that if the brain cell died that was it; there was no replacement. We now know that to be inaccurate. And most importantly the myth of the aging brain is unable to adapt. Again, not true. The usual advice of crossword puzzles keeping notes to yourself, making lists, keeping items in the same place, repeating information and planning to remember is all good advice. But there is a wonderful book called "Neurobics" by Dr. Katz that talks about how to improve your memory and preserve your memory by doing certain activities, unique brain exercises that are deceptively simple. The brain naturally produces neurotrophines, the growth hormones that help to keep the cells healthy and regenerating. Those cells can be encouraged to continue to grow and continue to be active. Neurobics will help to improve those neurotrophines and those chemicals. We need to do a short neuro-physiology discussion. I promise I will try to keep this as short as possible. Since there was another one those challenging courses in Medical School that send me over the edge. Every neuron has its self receptors and its synapse and its delivery point across. And its not really appropriate to think about its dying, it's appropriate to think of that is a system that's needs to be continuously regenerated. The cerebral cortex which is the outer part of the brain that we know the best is where you get sensory processing and the new information that come in is seen and interpreted and put together. There is then the hippocampus which is the deeper part of the brain that's the part of the brain you hear about the most in sort of early Alzheimer's disease, that's the part of the brain that is in charge of mapping and retrieval so that it basically designs the systems of how do you get to the different pieces of in formation that exist in the different part of the cortex and how do you integrate that information and use that information for useful purpose. The brain receives and organizes this information and the problems with growing older the people associate with forgetfulness, not feeling sharp or having difficulty learning new things can involve either one of the systems, either in interpretation side on the cerebral cortex or as we talked about earlier if the two out of the three most common ailments of old age are impairment in hearing or an impairment in vision, the ability to understand and lay down new memory. But more importantly the hippocampus which is sort of your central processing unit for the computer people in the room, which I don't claim to be one, so if I am using bad analogies forgive me. Can also be involved what are the information there but you can't access it and process it in a helpful way. If you do PET scanning which is Positron Emission Tomography, where you measure the brain not only as a static picture, CAT scans are an interesting development in technology where instead of a standard X-ray whether they would look from the front to the back and take one picture, the CAT scans would actually be able to take a whole series of pictures and essentially give you a cross sectional picture of what was going on in any part of your body. The Positron Emission Tomography combines that circular element of the CAT scan with an additional element of measuring how much function is going on. And you can actually look and see when somebody goes through a novel learning experience there is certain part s of the brain that are highly firing. When people do things as they teach us in sort of baseball practice or softball practice off of muscle memory. There is far less firing in the brain there is actually a fairly simple Hippocampal triad and its going through the hippocampus out to the cortex and back, that's producing that down rote activity that occurs on a very simplistic basis, and the whole basis of Neurobics is to try to take new activities to expose yourself to new learning, and in that way to reinvigorate the parts of the brain and to start to get and you going to actually show this on PET scanning that you can reshow that the higher levels of activity are occurring in those new areas. And so a change is the reality the people believe that it is not possible to learn new things, not possible to lay down new memories, not possible to improve brain function. To being Neurobic it must involve one or more your senses preferably more. The traditional thinking is that the single best way to preserve neurologic function and cognitive function would be the learning of a musical instrument, because it has tactile elements, it has auditory elements and it has potential for new learning. It must engage your attentions and your emotions and the activity must have some meaning for you. Meaningless activity is not that helpful, it must be a break in routine doing something unexpected or doing something in an innovative way. This has to be something more than for example using a pen instead of a pencil to do the crossword puzzle. All right, on the other hand and this is your home work assignment fro tomorrow morning at the beginning of this weeks lecture, try brushing your teeth tomorrow morning with your non dominant hand. You will find it some what frustrating but actually your brain will be invigorating. Trust me on this one. All right, you can change your morning routine, expose yourself to different smells, try getting dressed without opening your eyes or as I often do if I'm waking up before my wife try getting dressed without turning the lights on. There is certain hazard may that comes with it, vary from the order of your routine. Walk from lecture to lecture along at different path, not the same path, eat something different, listen to a different television program. How many of you come to this lecture on a regular basis? How many of you sit or stand in approximately the same place every time you come? All right you are the people who are going to work that okay. In a way when you're back here tomorrow than next time I want you all in different places. All right, I think I went to all of college and all of medical schools sitting in right back hand corner of every lecture I ever went to. Use aromatic soaps in the bath or shower, read the paper out loud to your spouse or to someone else instead of reading it to yourself. Open the windows listen or smell, be social and you got to understand any lecture of ageing, successful ageing, any of that type of lecture and you do a lecture like at Chautauqua, you are cheating okay just like preaching to the choir. Its just too easy okay okay get on walk or that I will let you have cars. Experience a new sensory experience like being soaking wet you know, but most importantly learn new things, meet new people brainstorm my personal favorite take your family pictures in your house and turn them upside down and see how long you takes for people to notice. Sit in a different pew when you go to church or my personal other favorite, change the place you sit at the dinner table. How many of you sat at the same place for in the dinner table for more than ten years? Clearly we have some work to do. All right, eat something that rekindles the memory, a pot roast wiith okra. Change where you eat or what you eat, spice up the setting. So to review the mental fitness exercises is the Neurobics involve one or more of your senses, engage your attentions, your emotions and have meaning to you, take a break, do something unexpected. It's important to talk about ageing in the context of why? At this point the average person in America spends one third of their lifespan aging. There is nothing more absurd then the American belief that we can somehow define the needs of the aged. I don't think we would define any other third of our lifespan and say somehow we are going to be able to mush of these people all together and say they all need the same things. It just doesn't make a whole out of sense. People who are ageing need the same thing that every one else does. They need a purpose, they need a reason, they need a goal, maintaining quality relationships with other. It's important to remember that the fact that we don't have employment for older people and this was actually a great observation from Jimmy Carter. Is partially because of the way we define employment. If we define employment strictly by do you get a W2, do you get a pay check. Then a blackjack dealer in Las Vegas is employed and someone who is taking care of two demented elderly relatives is not, and I can tell you which one of those is working harder and potentially which one of those has more purpose in their life. We need to talk about care giving as one of the purposes, because there was a real problem with the geriatric literature up until about 13 or 14 years ago, the care giving was viewed as essentially universal negative. Oh, the burden of care giving, the stress of care giving care giver burn out. And then people started to say wait a second, maybe care giving is a role defining experience. Maybe care giving is what makes life worth while. We of course ran into that repeatedly in the office because we do have a delightful person in our office, the care giver would be there with them and the care giver would tell us all about how hard the care giving was. And you can walk away from that, and make two conclusions. One, they are complaining and they want you to change it. Or two, they want you to say, thank you, good job, that's a wonderful thing you have done. And the Aha moment for me, was the number of times we would have somebody in that situation, the person they were taking care of would die and within a six months, I would have a patient in my office with a very familiar face sitting next to them. And I would say, I know you but you don't fit this picture. Oh, I used to take care of her. Uh- huh, it gave them purpose. And the community knew they were good at it. They got a new assignment and sure enough, they are doing a great job. Volunteerism, again tremendously under valued in our society, I have gentleman who I saw in the office last week, I live in Cleveland. Nice guy, healthy guy, and he is about 78 years old. I love him dearly because his wife in the last year who was also 78 has had Appendicitis and a torn knee from trying to turn first base. If I was 78, and getting young people diseases, I am going to be really happy. But this gentleman has 26 visits planned between now and Christmas to different prisons in Ohio. And I start to look around, I realized I had four people in my little practice in Cleveland Ohio of people who are going to the prisons. One of them is going there to do substance abused counseling, one of them is going there to do religious counseling, and another one of them is just going to help out. And my favorite is the Short-Order cook, who is going to actually teach the inmates how to be Short-Ordered cook. So they had and he is my favorite because he also makes the best cheese cake you ever want to imagine. it's one of those cheesecakes that could substitute or it could stop a small semi because it weighs about. All right, the kinds of words you use to describe older individuals are also important. Volunteer, care givers that a favorite word that I think is most descriptive for older individuals is explorer. They are searching the frontier of this millennium. As we search the western part of the United States or in the 60s we tried to land on the moon. They are the people who are answering the question what is going on in the future. Where are we going to be? Realize that 70 percent of all people over the age of 65 are care givers for some one. And I did promise that I would talk about spirituality and I do have some time now. So life is good. All right, there is been a lot of studies on spirituality and health and particularly spirituality and health in older individuals. You have to make one important differentiation and it's between two concepts. One is the concept of spirituality and the other is the concept of religiosity. This was first broken down into two separate concepts in the Israeli heart study in approximately 1975. When they basically said, heart disease by and large was less likely in a population that it had large amounts of spirituality. What they did find is actually the religiosity was by and large independent of any measures of mortality. And that's been shown to be true again and again in older individuals. A number of studies did show religiosity to have some relationship to health, but when you actually added in the other variables about whether people could get out of the house, get around and do those things, the question of religiosity fell away as an important variable in health. But whether or not people have some sense of spirituality and this is a very ecumenical sense of spirituality. They have an ability to survive that is - and in order of magnitude the same as whether or not you smoke or whether or not you are diabetic. That's the kind of impact we are talking about. Interestingly in one study, 77 percent of patients wanted their physicians to ask them about their spirituality and their spiritual beliefs. Just for my interest, how many of you have had your physician ask you about your spiritual beliefs? Well, little below 77 percent. How many of you would want your physician to ask you about your spiritual or health beliefs. A fair number. A different study actually indicated 68 percent of patients would like their physician to pray with them. And I know at the hospital I am at which is a county hospital by definition a non denominational hospital, I can tell you of at least four physicians who regularly do pray with their patients. There are the spiritual tasks of reconciliation and spiritual discovery. Many people say "the older individual is more spiritual because they are closer to actually knowing the answers all right. or potentially the answers are sort of more directly relevant and necessary to figure out. I wanted to talk briefly about simple recipes that are out there for successful aging. And then encourage it to ask the panel on Friday, what they do and how they have got into to be over the age of 90. Don't smoke, maintain a reasonable body weight and exercise, minimize fats and cholesterol, drink only in moderation if at all, wear seat belts. The eighth leading cause of death in older individuals is trauma. With the growing number of older individuals riding motorcycles, remove hand guns from your home, and then of course interestingly the last one on the list screening medical exams. Screening medical exam all right, other studies have look in sort of what's important the level of education achieved that is a marker for not only life long learning its also a fairly strong predictor of all other sorts of social economic status. Amount of physical activity and more importantly the degree of control we feel over our own destiny. The most important part for that discussion now is this the amount of control we feel we have. We may or may not really have it, but if we think we do we do better. And even if we do and we think we don't we do poorly. On going engagement with life, conceive of important goals, this is again there was a delightful women, I wont name her but my mother set me up to go chat with her on the porch, one of the nice porches over there, she was ninety two or three at the time she gave me a wonderful discussion of Geriatirics that has stayed with me ever since, and she had that sort of uniquely geriatric humor that I love, because she proceeds to give me a fairly concise insightful discussion of healthcare financing in older individuals. Now this is a challenge for anybody at any age, and then she tells me about her geriatric experience and this lady who understood health care financing better than probably I do said and then they recommended I play bingo. I paid attention to that ever since, focus on the things that we can control, focus on fixing one problem at a time dividing long term goals in manageable steps and being satisfied with small steps. On a public policies stand point the recipe for aging was the 2005 white house conference on aging where they described reauthorizing the older Americans act, coming up with a long term care strategy which I don't think has been done providing transportation improving medicaid and Medicare, again. I don't think that's been done. Improving the availability of Non Institutional Long Term Care support Geriatric Education and Training. We don't want to go into how badly people support Geriatric Education and Training. We did have one recent victory which is titled seven which supported all the Geriatric education and a lot of other medical education for unreserved populations was essentially wiped out; that was restored approximately six months ago. But it's important to realize that if you take the entire national budget that has been put into Geriatric Education and Training, you could fund the Iraq War for 23 minutes. Improve the diagnosis, treatment and assessment of mental illness in older individuals. Improve the number of Health Care Professionals educated in the care of older people, and improve state and local integration of care systems. There is very few care systems that actually can even figure out how to integrate the Federal dollars and the State dollars. And very too often, the care suffers. Because every body spends all their time trying to shift the cost. Or like put you here then will go in the State budget; the Fed's will be happier. If I put you there, it will go in the Federal budget and the State's will be happier. I wanted to make a couple of comments and then we will talk a little bit about end of life as the appropriate way to end any talk. I wanted to talk about risk. Now at the risk of having a minister who is related to me behind me, I will loosely quote Ecclesiastes; "Whoever watches the wind will not plant and whoever looks at the clouds will not reap." I am still standing, the lightening hasn't started so we are okay. All right. One other things we forget is the importance of taking risk. The importance of getting out there and doing, all right. My favorite analysis that we go through repeatedly is we get a very well meaning older child who says, "My mother needs to be in a nursing home". Why does your mother need to be in a nursing home? Well, she could fall. That's true. What would happen if she fell? Well, she could break her hip. Also true. What would happen if she broke her hip? She can end up in a nursing home. I think we have sort of covered that. All right. If we look at a brief summery and again I am stealing from Jimmy Carter on the transcending goals. In Christians, the emulation of the life of Christ; in Judaism and ethical choice based on the covenant relationship with God; in Muslim, to comprehend the Koran growth and self awareness, compatibility with the world around us; Confucianism, contemplation, self evaluation, good living in every stage of existence, self disciplined and beneficence. And in the Japanese culture, improving ones ability to do your duty and achieve inner tranquility. When you look at that list of goals, can any young person have a chance? All right. That's so we got to remember. There are goals and there are goals. And there are certain goals that only older individuals are ready and available and up to the challenge of meeting. We need to talk a little bit about the end of life. And I refer you to Richard Grove's book on "The American Book of Dying" He was one of the people I wanted to get for this week and I got gypped by the fac that he was already in Oregon. The contextual factors and people's individual journey through life is most important in the end of life. Perceptions and concerns over their internal experiences and response to illness and adaptations and coping. The issues they are dealing with in old age at the end of life the number one issue identified is burden. I don't want to be dependent. I don't want to be a burden on my family. Again the overwhelming reality that even at this age even at the end of life, it's an altruistic goal that there after. Suffering, the actual anguish and dying from the dying process. One of the overwhelming issues at the end of life is hope. Hope in continued meaning and purpose. Dignity, the individual self concept or self esteem, respect, wellbeing and pride. And the one that is the most important when you are speaking with your children or your grand-children, decision making. I cannot tell you how many times when I see a patient in consultation and another group of paid doctors has been involved. The first thing the patient says to me, "You are the first doctor who talked to me. Every body else keeps asking them." All right. I had this one delightful woman that there are all delightful woman which is about this tall, right?. And her daughter was a very prominent individual in our community. And her daughter was there during the initial interview and then the daughter was excused as we continued the interview under the excuse, well I have to do the physical exam. That's always a great excuse, if you want to get the extraneous people out of the room. Then this little woman just looked to me and she said, "Doctor, lets get one thing straight. You talk to me and not to her got it?" And so let me put that down in the chart, yes. All right, Control on autonomy are also critical at the end of life. Confucius said the goal at the end of life is the avoidance of avarice and the avoidance of trying to cling to those things that we have had including clinging to life. So for older people, as they rank the important tasks that they are going through, they rank number one their goal of independence. Number two, time with family and friends. Number three, control of medical issues and symptoms. I always want to close with what I think is the most important piece of some of this discussion which is the question of "Where do we set our goals?" If we set our goals in the wrong place, we don't have buy in from the people we are working with. How many of you have heard goals discussed of older individuals of? Well, I would like to be able to maintain this. Or I would like to be able to keep doing that. Or be good if I can do almost as much as I used to. All right. Is that an exciting goal? All right. As I am sending my daughters off to College, do I say, See, I hope you can do almost as good as last year. Okay. You got to look at if you put this into the larger picture of health, and just say, the goal is to excel in old age to express and understand your wisdom to share that wisdom with your family and with others to explore the spiritual and existential goals that you are going through to experience all the new part of life. At that point, I would like open it up to questions. And again, thank you for coming out in the rain.
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