Social Isolation and Depression - serious problems

Large cities can be isolating

In today’s day and age everybody is busy, rushed and doesn’t really have much time for anything. Even though big cities are full of people many elderly feel isolated and alone.

Social Isolation leads to loneliness, which leads to sadness and may even lead to clinical depression. Depression is a serious illness that impacts not only quality of life but also affects your health and may possibly increase your risk of dying in certain circumstances. 

Social Isolation and Depression Haunt

Unfortunately, there is a vicious circle. Once people are depressed it becomes very difficult to think of fun things to do or to even enjoy simple pleasures. Additionally, depression affects energy level, motivation and may lead to increased pain perception – which in turn diminishes morale, energy and motivation even more. And there we are: even more social isolation and sadness.

Best is not to even get there. And if you did: Break the cycle! There is hope! 

I will come back to this topic of depression regularly, as it is relevant and important.

Today I want to encourage you to stay involved, active and to participate in meaningful activities. Check the internet for activities in your area. Ask around. If you really have no clue: find a senior center, a social worker or case manager to help you. (If you don’t know how to find those: ask your doctor).

In New York there is an amazing organization on the Upper West Side. It is called Dorot (click here for their website). They have a bunch of volunteers of all ages who are committed to spend time with elderly in the community. All different kind of activity can be arranged. They even have what they call “University without walls” a curriculum (click here to see it) of diverse classes that can be accessed from the comfort of your own home via the phone. Quite amazing!

I encourage you to look for resources like this in your community as well. Ask around. There will always be lovely people who are willing to give their time in order to enrich someone else’s life!

If you feel terribly depressed, and you cannot concentrate on simple tasks or even live your daily life anymore:

Speak to your physician!

There is hope!

This is a serious problem and it is not your fault! There is an imbalance in the chemistry of your brain and we have options how to treat these. For the most severe cases you may even need a psychiatrist. Don’t shy away from it.

Nobody likes to be ill but the first step for getting better always includes facing reality.

I wish you well.

And remember: you are not alone! 

Dr. B

Wear sunscreen – encore

Based on several questions that came up after the "wear sunscreen" article I wanted to write a few small additional note:

• The amount of SPF in makeup is not sufficient to cover you properly

• Even in the winter you should wear sunscreen on your face, neck, and hands

• There are special formulations for the face, these "milks" absorb much faster and feel nicer on the skin (I like Neutrogena: click here)

• Use high SPF on face, hand, neck (at least 55 SPF) all year round

• Even on a cloudy day you are not protected from UV radiation without sunscreen

• Sprays can be difficult to handle:

1. You inhale much of it while spraying
2. They are greasy and make your skin feel sweaty
3. When you spray them indoors they leave a film on your carpet, hardwood floors or tiles
4. The film on the tiles or hardwood floor can get dangerously slippery and you may fall on it (this almost happened to me)
5. You never know whether you applied the right amount of spray

When to use spray?

• It might be easier to use spray on small children rather than the lotion
• Outdoors or at the beach the spray falls into the sand rather than on your furniture
• If you don't have anybody to help you lotion your back you might be able to spray it yourself (might be tricky for some of you)

Otherwise, look for a lotion

• There are lighter formulations in lotions out there and I would really continue looking until you find what you like
• I would definitively use the highest SPF you can get for the days spent outside
• we usually don't apply the amount recommended (so we already lose SPF from that)
• after 45 min of sweating or in the water you cut your SPF in half

Example:   

• you start with 50 SPF lotion
• you put on too little: now you are at ~ 30 SPF
• after 45 min of sweating you are down to about 15 SPF
• You continue to lose half of that every 45 min without re-applying...
• So: Reapply, reapply, reapply

In the end of the day: Be a role model for others.

And don't get frustrated. I can't even get my own husband to use sunscreen regularly; but I won't give up!

Be well,

Dr. B

Wear Sunscreen

I am sure you have heard this over and over and yet I think it is so important that it cannot be said enough times:

Wear Sunscreen !!  

I attended a presentation by a dermatologist yesterday and got inspired to write to you today (I also went to CVS immediately after and restocked on highest SPF in the house!!)

Each time you get a sunburn you significantly increase your risk of getting melanoma. Melanomas are malignant cancer of the skin that can kill. These cancers don’t just stay confined to the skin but they can travel all over your body and seed in other organs like your brain or your lungs.

When you tan without burning you put yourself at acquiring other forms of skin cancers such as basal cell cancer – which is the most common cancer in humans.

It is true that the lighter you are the more susceptible you may be for burns and certain skin cancers, however, having dark skin does not protect you and you should still use sun screen.

What to do? 

• Use sunscreen every day even when you are not going to the beach (light or dark colored skin)
• Use sunscreen even when you wear clothing (a light white T-Shirt provides only about 15 SPF and next to none when wet)
• Use the highest SPF (sun protection factor) as it loses its protective factor when you sweat or get wet (after about an hour of sweating it may have lost half its SPF already)
• Reapply SPF frequently and use a “shot glass” amount on the whole body (a family of 4 at the beach should use one whole bottle of sun screen –scary, isn’t it? These bottles often last 2 summers!)
• Stay in the shade but beware: at the beach the sun will still reflect UVB radiation onto your skin and will still increase your skin cancer risk! So, even in the shadow: sun screen! 
• Wear a hat with a brim to protect your scalp

By the way, for the vain ones amongst us: one of the main factors contributing to the aging of our skin is UV radiation! So, the less exposure the younger you may look.

What about vitamin D?

You may have heard that it is necessary to be exposed to sunlight in order for the production of vitamin D to occur in your skin. This is true, however, 15 min per day are already enough for most of us. You don’t need to fry for hours!

There is a lot of information out there on the internet, check out this woman’s personal experience: click here.
Here some tips on sun screen brands by a dermatologist: click here.

And when in doubt: ask your doctor or see your dermatologist.

It probably is a good idea to see a dermatologist at some point and get the recommendation on how frequently you should return for follow ups.

Stay cool out there and remember:

Wear sun screen!

Dr. B

What is a MOLST form? Do I need it? Planning for end-of-life...

MOLST stands for “Medical Orders for Life­Sustaining Treatment”. 

It is a form filled out by a physician and it contains actual orders in regards to important end-of-life issues. Other health care professionals in different settings must follow these orders.

The Department of Health New York really promotes its use. It is recommended for persons with a serious illness or anybody who lives in a long­term care facility or requires long­term care services.

This form covers important topics that are relevant at the end of life. Here are these topics:

Pink Original MOLST form

• Resuscitation

• Framework for Treatment Guidelines: 

1. Comfort care
2. Limited medical interventions
3. No limitations on medical interventions

• Instructions on the use of breathing machines (intubation)

• Future Hospitalizations

• Use of artificial iv hydration and nutrition

• Antibiotic use

• Other instructions

The orders may entirely focus on avoiding any aggressive measures and making sure that the patient’s wishes of comfort care, no resuscitation, no use of antibiotics ne honored.

It is also possible to tailor these orders to an individual’s beliefs and values. Somebody may not want to be on breathing machines but they might still want workup for some of their symptoms (e.g. a CXR) and treatment with antibiotics.

A wonderful aspect of these orders is that they provide the option of “no hospitalization”. There are many people who would very much prefer not to go to the hospital and to stay in the home setting; event if it meant they’d die at home. (Of course, most of those should probably be on hospice – more about that in a future blog post)

By the way, the original MOLST form (in NY it is pink) always stays and travels with the patient from nursing home to hospital to rehab back to nursing home. The doctors and institutions keep copies only.

Not all states are using the MOLST form, some states even call it the POLST form. Talk to your doctor about what options you have. I would strongly encourage you to look into this.

Check out the MOLST form for New York State: Department of Health Website MOLST.

And remember, nothing is written in stone. You will always have the right to change your mind. Your doctor should periodically check in with you about your wishes to make sure that your MOLST is still up to date (there is a section the physician may sign).

This all may seem very scary but it shouldn’t be.

Planning for your future health care today ensures that you are able to voice all your concerns and make your own choices.

I wish you all the best for this endeavor,

Dr. B

PS: Check this article by elder lawyer Nancy Burner for more info on the MOLST form.

What is the most important document I need as a patient?

This is a very easy question.
Even though, there are many things that may be important, there is one that trumps them all:

The health care proxy!

Why is that?

The health care proxy is a person that you trust to speak with the doctors on your behalf when you are unable to do that yourself.

You might still be fit and very healthy and may think that you won’t need a Health Care Proxy any time soon – but beware!

What if you lose consciousness and cannot respond? You might recover from this, however, someone should be there assisting the doctors in making the right decisions.

What are the “right” decisions? 

These are things that you would decided the same way yourself.
It may not be what most people would choose for themselves but it is what YOU would want and that’s what makes it the “right” decision.

This is why it is crucial for you to be in constant communication with your health care proxy. This is the person who should know all your wishes and should have enough information about you to be able to guess what you would say in any given scenario.

Who can be a health care proxy? Does it have to be a relative?

Anyone above the age of 18 years can be your health care proxy.
You don’t have to be related.
Make sure to speak to this person about this, though.

He or she should be aware of this assignment and they should be willing to take on this important responsibility.

How to get started?

There is no easy way to talk about serious illness, disability and death.
Speak to your doctor about this if you have any further questions or require support or assistance. 

Also, check out this website: the conversation project 
There you will find a lot of resources on how to have these kinds of conversations.
They even offer a “starter kit” to help you jumpstart the conversation: Starter Kit.

By the way, you do not need a lawyer to fill out a health care proxy form (at least not in New York State). Ask your doctor about details as they might be different in the various States.

In New York State you would only have to fill out the form which you can find on the Department of Health Website: Health Care Proxy Form NY. You will need to have two adult witnesses to sign with you.

When you express yourself and you know that people are listening and willing to follow your wishes then you will have peace of mind. Also, you are relieving your loved ones from the burden and guilt. 

When they know your wishes they can be comforted by the assurance that the difficult decisions were yours not theirs. It is a gift you give to them as well as to yourself.

If you don’t already have a Health Care Proxy, make it a goal to sign one this month!

Be well,

Dr. B

Why is level of functioning important to a doctor?

We all understand intuitively how somebody is doing when we see through their eyes how they experience the world.

Dancing Janet! Tango

Janet

Imagine Janet. Janet is a lean, tall woman who is full of energy. Janet wakes up at 6:30AM to do an hour of Yoga, she eats fruits and yoghurt for breakfast. Then she is out the door and to the community center. She loves to volunteer and provide meaningful support to her community. In the afternoon she gets together with her friends for a coffee and they chitchat and lough. Tonight Janet takes a class in ballroom dancing.

Angela

Now let’s meet Angela. Angela has an aide who comes at 7AM and gets her washed and out of bed. The aide helps her with breakfast and then sits her in front of the TV. Angela sometimes thinks that it would be nice to go to the Park or meet her friends but she couldn’t really ask her aide to help her with that… at least she doesn’t dare to. The hours don’t seem to pass by, there is one game show after the other, one talk show after another… well, you know how irritating TV can be. And then tonight Angela goes back to bed with the help of her aide.

Who is doing better, health wise? How old is Janet? How old is Angela?

This is pretty obvious: Janet seems in great health. She is independent, energetic and very active. Angela on the other hand is probably seriously ill. Angela needs help with the some of the most basic activities of her daily life and might even be depressed.

What you might not expect is their ages: Janet is 92 years old! Angela is only 63, she could be Janet’s daughter.

And that is why we don’t look at a number when we treat a patient. Numbers play a role but not the biggest. We want to see the whole person. And that is when we evaluate their functional status. How dependent is someone in his or her “activities of daily living” (=ADL)? These are some ADLs: transferring out of bed, dressing, washing, toileting, feeding. And then there are the more advanced activities: instrumental ADLs (iADLs) such as managing the household, the medications, finances, and transportation. When we know which of these are done independently and which require assistance (and how much) then we have a much better understanding of the person as a whole and of this person’s needs.

Believe it or not: someone’s functional status may sometimes be one of the most important factors to be considered by the physicians when estimating whether a patient is a candidate for a procedure, a surgery, or even chemotherapy. Functional status really matters and helps to keep the big picture “vivid”.

Can you do something to improve functional status?

This really depends on the underlying cause of your impairment. A person with dementia will over time become worse and worse without much hope of significant improvement. Somebody healthy who broke a hip may benefit from rehabilitation and may recover a very high level of functioning.

 

Staying active is key. You may do this on your own (even taking regular brisk walks 30 min. three times a week is already great!) or you may require the help of a physical therapist – this depends on your situation and you should ask your doctor.

There are several great physical therapist and physical therapy clinics out there. I like to work with Fox Rehab (check out their blog: http://blog.foxrehab.org ). They are a “mobile” outpatient clinic and come to your house for 50 min one-on-one intense physical, occupational, speech and cognitive therapy. And what I like best: they have extensive experience with the older patient generation – which the geriatrician in me loves!

I hope this helped.

Have a great day and stay active,

Dr. B

Do I need a Geriatrician?

We all understand why there are pediatricians and why we need them. Children are a challenge, they often cannot express themselves, they are frightened of doctors and they don’t always understand the concept that something may be painful today and yet necessary.

What many people are not so aware of is why it is that we need geriatricians. Aren’t the elderly just “old adults”? Haven’t “regular internists” handled the older patients well enough? And who really wants to be considered old? Does going to a geriatrician mean that I have to admit that I am old, weak and maybe unwanted? How old do I have to be to see a geriatrician, anyway?

All these are legitimate questions.

Yes, of course, most internists are doing a great job managing the elderly – as a matter of fact geriatricians are internists themselves. However, the geriatricians have decided to focus on the care of the elderly and to understand the special needs of this population.

Now, what is OLD? Is 65 old? 85? 100? Well, I guess, we can all agree that 100 is pretty old. Nowadays, we consider people 65-74 the “young old”, 75 to 84 the “middle old” and above 85 the “oldest old”. Overall, we are moving away from looking at the number alone. A number may just be a number. There are 93 year-olds out there that are highly active in their communities, involved with friends and families and even enjoy a healthy sexual relationship with their partner. I know it; I have met them.

Ok then, back to our question: do I need to see a Geriatrician? What benefit do I get from that?

Internists know about the issues surrounding the care of elderly, however, they are often very limited in their time and may not be able to address certain topics with you.

Aside from the typical “medical stuff” a geriatrician will explore some of the following:

•        What is your level of functioning?
•        Are you supported in your home?
•        Is your home safe?
•        Are you able to get around?
•        Have you fallen? Are you afraid of falling?
•        Has your vision and hearing been checked lately?
•        Do you have problems holding your urine?
•        Do you suffer from subtle or obvious depression?
•        Are you taking too many medications? Can we reduce some of your medications? Should you not take certain medications?
•        How is your memory? Is it still “normal” for your age or may you suffer from dementia?
•        Have you thought about the end of your life? Do you have certain hopes and wishes? How can these wishes be respected?

These are just some of the things.

Do they need a Geriatrician?

In this blog I want to address these topics and others that might interest you (please, feel free to ask questions and suggest topics you would like discussed).

If you ask me, it is a great idea to see a geriatrician. You may be pleasantly surprised. You may also continue to see your internist as your primary care physician and a geriatrician for a consultation. Anything goes.

I thank you for your attention and I am hoping to have you come back to this site again soon.

Be well,

Dr. B