May 12, 2020

And another year older. I completed my 58th orbit of the sun yesterday and today start into my 59th year. 58 is an odd age to be. There’s nothing terribly interesting about the number. You’re not yet on the cusp, it’s late in an undistinguished decade, it’s not even a prime. But that’s the way the world and our mathematical system works with its arbitrary divisions determined by the natural cycles of the seasons and the motion of celestial bodies. It wasn’t a terribly interesting day either. Monday is my double clinic day at UAB Geriatrics and so it was pretty much work work work followed by a zoom board meeting. There was carrot cake though, not once but twice. Once at lunch provided by my clinic staff and once again for dinner provided by the friends who are my packers and movers.

Yesterday was also the first big packing day in the slow process of relocating. Covid Corners has been rejected as an appropriate name for the new condo. I’m now leaning towards Clearview as it has a view of downtown from its perch on the side of Red Mountain and I purchased it in 2020. My other thought, and another ophthalmalogical pun, is Hindsight. Most of the stuff in the house will be packed by the end of the week and then it’s just a matter of getting the new space ready to receive it all. That’s going a bit slower than anyone would like due to issues with the supply chain delivering replacement items like sinks but, once it’s fixed and the paint is dry, I shall be ready to send the stuff over. Of course, I won’t be able to find anything for about the next six weeks. It’s a good thing theater is out of production and no one is looking for props or costume pieces.

I’m trying to decide where to go next with Andy’s accidental plague diaries (10,000 cases in Alabama now with over 1,000 in Jefferson County). I keep having brilliant ideas for tangential subjects to mull over but by the time I get home, get settled and start to write, I can’t remember what any of them were. I’ll have to start jotting them down during the day and sticking them in my back pocket for later reference. Some days, as I start writing, it just comes to me and flows. Other days, it’s the pulling of proverbial hens teeth and I’m quite certain what I’ve laid out is complete garbage and no one will be interested. And then I see a comment from someone about how much they liked it or that it helped clarify something that had been on their mind and I feel like maybe these musings are worth while after all and I decide I’ll go ahead and write another one or two after all.

I do ask for readers to make suggestions about what I should write and someone brought up the subject of depression in aging. How do older people, who recognize that their physical and cognitive faculties are going cope with that downhill slide? Do they get depressed by this? Does debility and dementia cause depression or does depression worsen debility and dementia? What does any of this have to do with Covid 19? (I think I have an idea about how it all ties together – let me keep writing and we’ll see if I get there.) I think the first thing we have to consider is that an older person and a younger person are not the same being.

I’ve brought up evolutionary theory before. I do it because one of my big aha moments when I got into geriatrics was an understanding that it applied enormously to aging. Niche theory is the idea that all species fill an ecological niche in a vast puzzle and that, as the environment and other species change, the species must change to always fit into its niche or head towards extinction. Older people are like a species, existing in equlibrium with their niche of a life they’ve spent decades building. It’s multidimensional and consists of family, physical environment, finances, social connections, and myriad other factors but it works for them and they hum along. Then, slowly, they start to change. Maybe it’s arthritis making the stairs more difficult. Maybe it’s increasing living expenses eating away at a fixed income. Maybe it’s memory lapses. Maybe it’s eyesight changes creating problems with night vision and driving. Some of these problems can be fixed, some can’t. If they can’t be fixed, the person can try to live an unaltered life but, as their physical reality no longer fits key in lock with their life niche, things start to go wrong and disease will result. Or, if they can’t change themselves, they can change their lives and adapt to new circumstance. Move to a home without stairs, do some sort of cohousing to reduce expenses, use Uber after dark. The person who recognizes life is change and accepts and embraces it and keeps themselves in balance with their individual aging process usually does well and rarely becomes seriously depressed. The person who tries to live in a fossilized reality created by their younger self often does become depressed by seeing the growing mismatch between who they are and who they want to be and having a life that no longer really supports who they are. Studies of those who have broken the century mark show that they all have only one thing in common, a sense of optimism and looking forward rather than a sense of regret and dwelling in the past.

When lecturing about basic aging theory, I have a five box model which lays out these ideas in graphic form – I can see students and residents have that same aha moment I had as they get this basic concept. I published it eons ago in a book chapter I did back in my UC Davis days but no one has ever picked it up and named it the Duxbury model of aging or anything. I suppose not enough people are reading obscure titles on health and wellness published in the mid 90s. Where did I learn it? From my mother. She taught junior college sciences from the time I was in middle school until her retirement and, amongst her many routine courses, was basic biology. I remember her grading papers at the kitchen table when I was in high school with Helene Curtis’s biology text at her elbow and talking to her about the ideas she was looking for in essay answers and niche theory was nearly always on the test. I guess I absorbed it and it came out again years later in a somewhat different way.

I’ll talk a lot more about dementia later; it’s much too complex a subject to dispense with in a paragraph or two but I want to dispense with a basic definition. Dementia is a syndrome, a collection of signs and symptoms, not a disease. It’s the syndrome that presents in an adult when a previously functional brain stops working in the way it used to when that individual was a younger adult. There are hundreds of possible causes of dementia, a whole panapoly of diseases. The most common is Alzheimer’s disease. It is a specific disease process that creates easily identifiable physical changes to the brain but these changes are microscopic and not easily observed in a living person, although newer scanning techniques are starting to change that. We tend to, in society, use Alzheimer’s and dementia interchangably but they are not. Alzheimer’s is a specific subset of the dementing illnesses. It’s probably not a single disease; it’s probably a number of different processes with common final pathways leading to similar pathologic brain changes. We’re just not smart enough yet to separate them all out from each other or understand them as different entities.

People with dementia do get depressed. Sometimes they have difficulty accpeting or adjusting to the inevitable change and regret lost funciton. This can be treated medically and, in early stages with psychotherapy. It’s not inevitable. I know plenty of very demented people who have been serenely unaware of their own declines and perfectly happy through the process. We don’t know why some people get depressed and some don’t. I have a feeling personality structure plays a role, as does heredity and individual neurochemistry. Some people develop change in the frontal lobe that keeps them from self initiating. They don’t do. They can take care of themselves and their body but they lose all interest in formerly pleasurable activities and just sit on the couch doing plenty of nothing. Families usually interpret this as depression, but it’s not and usually not amenable to antidepressant treatment. Adjustments usually have to be made but not by the patients as much as by their loved ones.

In general keeping people looking forward, keeping their sense of adult self and dignity intact as much as possible, and slowly helping them change their lives to keep them in line with their abilities does more to prevent and alleviate depression with dementia than anything in pill form. The pills are occasionally necessary. They can help prevent friction in family life as much as they help the individual and when a demented person is at home, you have to treat the family as a unit, not the individual in isolation. And this is where Covid 19 comes in and why I am both angered and saddened by the yahoos bound and determined to open society up before we have a good handle on the virus. It’s placing barriers between elders and their family members for fear of infecting a vulnerable person. Baby time with grandchildren and great granchildren (especially valuable for demented elderly women) is restricted. Family that would meet and eat together for Sunday dinner now drop off a bag of groceries on the front porch and go. Older people who fall ill and must be admitted to the hospital are forbidden visitors and become delirious with no recognized faces or comforting presence. Those whose needs are beyond what a family can provide and live in a facility don’t necessarily understand why no one comes to see them anymore or, if they do, realize that a FaceTime chat isn’t the same as a hug and a healing touch. Instead, they’re locked down with underpaid and overworked staff who love their charges but who simply don’t have the resources to help them maintain good mental health and those with a dementing process already in place are likely to sink deeper more quickly. So think about the men and women who won World War II who are still with us. They’re mainly over the age of 93 but they’re still around and weigh your wish for dinner at Applebee’s against what it may cost them.

I’m still staying in.