Monday, December 18, 2017

Getting Older

My father once told his grand daughter, my niece that he was not really old, he was just older.

We are all getting older.  I celebrated my 60th birthday this summer.  This was a quiet celebration as have been most of the previous 59.  That is what happens when you have a summer birthday.  I did take a lot of time off this summer and went on two fabulous bike tours, so I guess I did have a nice birthday.

My parents are also getting older.  My father is 93 and my mother 88.   My father retired at 61 although he did some consulting after.  My parents had a very active retirement (although my mother as a housewife may not have noticed any retirement).  They traveled quite a bit; driving all over BC, Alberta and the Western US.  They also visited us quite a few times when we lived on the East Coast.  They toured Europe and Britain.   My father kept on gardening and with the extra time on his hands his garden became more elaborate.

They were however getting older.  One by one their siblings died until I have only one surviving aunt.  My father started to develop all the health problems, prostate cancer, atrial fibrillation (diagnosed by his urologist, most likely a publishable event), cataracts and an abdominal aneurysm repaired electively.  He also developed significant osteoarthritis in his knees which for some reason his family doctor didn't want to refer him to ortho for.  By the time I did the doctor thing and got an orthopod I knew to see him, all the above problems had presented and the orthopod prudently declined to operate.  My mother however remained in fairly good health and was with it.  While her mother died of TB in the 1930s, she had aunts on both sides who lived well into their 90s so I was anticipating a long life for her.  As my father became more and more crippled by his osteoarthritis, she became more and more his legs.

My parents continued to live in the house that they had lived in since 1960,  This was a single story house with a finished basement.  My mother cooked as cleaned as she had all their marriage, my father worked in his garden and did the yard work.  A few years ago, my mother disclosed to me that she wasn't sure that they could handle the house but that my father loved his garden and didn't want to move.  The garden was becoming smaller and less elaborate and shortly after his 90th birthday my father decided that this was his last garden.  They were getting a little help thru homecare and through Veterans Affairs.

Meanwhile my mother who suffered from macular degeneration, developed what might have been retinal detachments (I don't know for sure, the opthamologist wouldn't return my calls).  Last spring she told me, she could no longer read.  My mother loved to read as do I.  I felt very bad for her.

I had started visiting my parents every couple of months a few years ago.  I no longer had all the weekend sports and it didn't seem that expensive to fly to Victoria any more.  It was a nice trip, I would stay in a hotel and visit all my favourite places.  We would go out for dinner and my mother usually cooked lunch and occasionally dinner if I was leaving later on Sunday.

Last June (2016) I visited my parents and had a very nice visit.  My mother made us lunch and on Sunday because I had a later flight, she made a nice Sunday dinner.  She was at that time having the vision problems but the house was clean and they were nicely dressed.

I came back in August.  Again everything seemed okay.  I arrived mid morning, we had tea and then my mother made lunch.  We went out for dinner on Saturday.  Sunday I drove them out in the country and we went to a nice restaurant for lunch.  I was flying home around supper and told them I would eat at the airport on the way home.

So it was that around 1500, having tea my mother said to me, "you know if you had more education, you could get a better job".  Hey I know I'm just an anaesthesiologist.  She then asked me where I lived and who I was married too.  Thinking back over the weekend, I began to suspect she had not known who I was all weekend.  I left feeling somewhat shattered.

Monday I phoned home hoping to talk to my father. My mother answered the phone, recognized my voice and we talked for a few minutes before I was able to talk to my father.  He confirmed that she had been acting like that for some time now.  I contacted my brothers and one of them who had visited earlier in August, confirmed that she had been acting like that when he visited.  He also revealed that she had been falling over as well.

Concerned about (but secretly hoping it was) a subdural, I phoned her family doctor, got a locum told her the story and the locum was able to arrange a CT scan in uncommon speed for a GP.  This was normal except for atrophy.

A family meeting was convened with two of my brothers and me.  My parents or rather my father agreed that it was time to move to some type of facility.  My father has a good pension and they had considerable assets so a private facility was available for them
I am not going to go in detail all of what has gone down in the last year except that it was about 10 months that I never again want to experience.   My mother now lives in a "reminiscence unit", which is a locked ward for patients with dementia and a tendency to wander.  Reminiscence is a nice euphemism for a place inhabited by people who can remember events from the 1930s but can't remember the names of their children or what you told them 5 minutes ago.  My father as of a couple of weeks ago lives in the same building on  a different floor.  He is allowed to visit my mom but can't take her off the unit.

As it happened just over 6 months ago, we got a phone call that my mother in law was in the emergency with back and leg pain and not really able to walk.  Again not going into all the nuts and bolts of what went down but she is now in a nice facility in Burnaby having moved out of her condo.

Life as my father or maybe it was somebody else observed doesn't come with a users manual and I have learned more about getting older than I ever wanted to.  In no particular order.:

Seniors care is very expensive and somebody is making a lot of money off it.

My parents are currently spending between $10 and $20K a month for the rather nice place they are currently living.  My mother in law who had much less assets was after some time eligible for subsidized care.  However when we first placed her in her first assisted living facility she had to pay a significant extra amount of money to have someone dispense her medications and bath her.  This is despite the fact that the person providing the service is probably getting paid the minimum wage for the time spent providing the service.  This is also the case for the nice people who look after my parents.  There is a RN in their building but I suspect she is getting less than she would be getting by working in a hospital.a

Not all nursing homes are created equal.

I of course should have known that that.  We found a nice seniors home for my parents in their neighbourhood with a room available within 6 weeks.  My wife, then I suddenly realized that this was totally not the right place for my mom but the wheels were in motion and so that was where my parents went.  We told the administration right up front my mother's mental state realizing we might sabotage the move and to their credit they were very accommodating especially for a for-profit facility. 

There are in fact multiple levels of care, which overlap and some are available in the same building some are not.  Researching this was very complex.  This may mean divorce by nursing home.

There are of course public and private facilities to consider as well.  It is interesting that in Canada, everybody gets treated equally in the healthcare system (not really) but that where and how live as senior is so dependent on your income or what programs you are eligible for.

Staying in your home might be important but a lot of people can't do it.

The mantra since I was in medical school has been to keep seniors in their homes and we go to elaborate lengths to do this, not necessarily sometimes in the best interest of the elder or their support people.  My father really wanted badly to stay in his house which complicated things incredibly and my brothers and I (most me) tried to figure out scenarios where both my parents could stay in their home.  My parents are quite well off, money would not have been an object; however on thinking things over there was no way they could have possibly stayed in their home, even with the best of help.  This did not stop me from feeling like I had let the team down.
My mother in law on the other hand was an inpatient and it became clear that she could not go back to her condo.  She was eligible for subsidized care, however when we approached people about that we were advised that she could not go directly to subsidized care from hospital; she would have to go home first, fail her trial of home care and then go to subsidized care.  We had the means to put her in a non-subsidized care facility from which she was able to apply to the lovely subsidized care facility she currently lives in.  Had she not had the means to go into a private facility, however she might still be involved in a Mexican standoff where they say she has to go to her home but she can't possibly go to her home.  I am pretty sure that scenario is being played out in lots of hospitalized seniors.

Rather than being pro-active the system is set up for seniors to fail.

Even 30+ years ago when I came out in practice, they were talking about the silver tsunami although they may not have had such a catchy name.

In Canada we have socialized medicine, every person has a health care number, almost every person has some contact with the health care system, every person pays income tax or receives some form of government assistance, a great deal of seniors pay property tax.  In other words there is a huge repository of demographic information available.

So why are we  so surprised every time we have a senior with failure to thrive?  Why do we wait for seniors to end up in an acute care bed or the ER.  Why aren't we proactive?  It is quite likely for example that if I hadn't visited my parents that particular month, nobody would have realized just how far my mother had declined.  Sure, you can say the family should have some responsibility.  This ignores the reality that living in the same city you grew up in is the exception not the rule and that the children of seniors are mature adults who have jobs, look after their own kids and not infrequently have health issues of their own.

When I was department head, I had to attend Medical Advisory Committee meetings.  Most of those meetings involved various members of the administration telling us about the crisis of seniors in the ER or on the hospital wards.  Once I piped up, something to the effect that why don't we look upstream and try and prevent these people from ending up in a place they and we don't want them to go to.  Nice idea, said someone in a suit and we went on to the next topic.

What about geriatricians.  Geriatricians exist.  The problem is they largely work in hospitals where they see people who have already failed the system or in hospital clinics where after being on a long wait list you can get assessed.  Not out in the community putting out fires like they should be. 

Family docs?  Both my parents had pretty good family docs.  The problem is that it is very difficult providing the type of care seniors need in a fee for service system, while looking after the rest of your sick and not so sick patients.

Not everybody ages at the same rate.

I sort of knew this but visiting my parents in two different seniors' home brought it home to me.  The seniors' population is a heterogenous group with very different needs.  Closer to home, this means that a couple may not age at the same rate.  My mother for example doesn't recognize  me, my father's mind is still as sharp as every.  This leads to the phenomena of divorce by nursing home where because of different care needs a couple cannot stay in the same facility.  My parents are lucky enough to now live in the same building but in different rooms on different floors.

Even individuals don't age at the same rate.  I was astonished by the precipitous decline in my mother's mentation even though she may have been hiding it well.  The swift decline form a fully functioning individual to something way less than that, constant catches family and the healthcare system off guard.  It shouldn't.

A week or so ago, a pain clinic patient asked me if I was going to retire.  "Not right now", I said, "but I just turned 60 and things can change in a hurry."

Have I  learned anything from this?

My parents' generation largely didn't deal with this because people died at younger ages from infections or from heart disease or cancer for which there were fewer treatment options.  Therefore faced with their own fragile longevity they have no idea what to do because they never had to deal with elders in the same predicament when they were young.

I am starting to learn and hopefully plan my own senescence. 

Firstly, I  assume that at some point I will not be able to drive.  By that time I  will probably lack the insight into this so it is better to quit well before I am forced to.  This also means living in a place where the services are within walking distance (which  also might be a problem) or that there is good public transport. 

I am  going to need medical services.  I have a good family doctor.   For the rest of you, this means if you don't have a family doctor, you better get one who is a lot younger than you.  Preferably one who isn't an idiot and who works more than 3 days a week.  When choosing what town I am  going to live in, I now have to factor in what medical services are available locally.  This is important if I want to retire overseas as I often threaten to do.

There is of course planning my  home and will I be able to live in it in the future.  Better figure out how you are going to climb those stairs when you have generalized osteoarthritis or heart disease.  The necessary renovations are going to cost money and despite what my financial advisor tells me, I know I am going to have less of that in retirement.  I joked when visiting seniors homes about, "see you in 10 years" but maybe it is more realistic to go into a home when you want to, not when you have to.

There is of course the whole advanced directive thing.  I am pretty health right now and barring metastatic cancer or something like ALS I would probably like a little CPR.  Problem is that by the time I shouldn't be getting a little CPR or the related trimmings, I may not have the insight.  Better discuss this with somebody sensible now.  Make sure they are prepared to advocate for you because there are quite a few doctors out there who are prepared aggressively treat you, based on their religious belief, hospital policies or the irrational fear of  being sued.

In closing

As my parents started to push 90, believing that longevity is genetic, I rejoiced in my potential long life. 

Not so sure about that now.