RAM ROTARY SPEECH 4/26/2022
Years ago, I gave a talk on safe travel to the third world. There was a way to structure what you need to attend to and it was as follows:
Pack your kit—get organized about your needs before leaving.
Don’t get bit—Mostly about mosquito control but with an eye on snakes, dogs, etc in mind.
Don’t eat shit—think about your water supply and which foods are most likely contaminated.
Don’t do “it.”—-Think twice about taking risks in the third world.
Going to the third world………
Sigh………….
I decided to use the structure of that talk and reflect on aging with you, my target audience in mind. Only 10% or so of this Rotary is eligible for Medicare so how does one achieve such eligibility with not only longevity in mind, but with the all important quality of life?
How does one “age gracefully?"
I will start with “don’t do ‘it’.”
Anyone over 50 knows that energy levels, strength, coordination, and range of movement of your arms, legs, and spine are not what they used to be. Your thinking brain knows this —I can’t run as far (if I can run at all), I can’t touch my toes, I need a special pillow for my neck when I sleep—but your risk taking/judgement brain-- what is used “in the moment” operates on the patterns you developed as a 20 year old.. I tell my over 65 year old men to stop getting on ladders. In this case, do as I say, not as I do. Both doctors and non medical people know the stories about old men falling off ladders. Bottom line for aging gracefully is DON’T FALL! FORGET LADDERS—One in three adults over 50 who suffer a hip fracture from a fall die within a year. If you are a skinny woman over 70 and you fall and break your hip, the odds you will die in the next 2 years are nearly 50:50. Why is this? Falls cause medical problems to snowball sometimes unpredictably. If you survive, the recovery time is always longer than you think it should be. Corollaries …………Don’t drink and drive or text and drive…….If you got away with it in the past, aging will only help you get caught with what can go wrong doing it.
Part of third world advice about this risk taking is to suggest not having sex with locals in the third world. Peace Corps volunteers serving in Africa during the early years of the AIDS epidemic were instructed to not have unprotected sex with local people. Their teen-aged brains kicked in with the patterns learned when young. Fully a third of them, after years of service, admitted on a survey that they had had unprotected intercourse with locals. If you have been divorced, widowed, separated - whatever- and it has been five to ten years since you had sex and the opportunity comes up, and if you think everything is going to work like it did before, consider having a discussion with your doctor/nurse practitioner/PA or other knowledgeable source—you likely need a little “fluffing and dusting” not to mention a discussion with your potential partner. By this, I mean erectile dysfunction, performance anxiety, Peyronie’s disease, and the effects of menopause all have to be sorted for a successful outcome. Remember, we are talking about aging gracefully! People, both young and old, aren’t typically forthcoming about their sexual history, so starting over, like a young adult, you have to consider STD’s and all that goes with that. I had a 70 yo woman present with primary herpes of the vulva once……. It did not kill her but definitely got in the way of aging gracefully.
Don’t get bit
Infections are no longer top of the list for life ending events for the old. Before antibiotics, pneumonia was, “the old man’s friend” because it allowed for a relatively quick and kind end of life. For someone getting old with infections in mind, I would put vaccinations as an important tool. The world of covid evolves and vaccines hold a practical value but without focussing on covid, knowing the majority of deaths from it were in the Medicare eligible crowd, consider the vaccines you will be offered during preventive visits with your doctor: pneumonias, shingles, flu, boosters for tetanus,/pertusis/diptheria. These are simple time-proven ways to minimize the toll of common infections. Do you know the Chinese characters used for pertussis? “The cough of a 100 days." Pertussis rarely kills a person but even with treatment, the symptoms never seem to end. I know, I have had it.
While infections were our great grandparent’s concern with aging, for us, more likely is getting “bit” by the common diseases of aging. Stroke and Heart Attack symptoms seem straightforward when you study them but the range of symptoms is great and not uncommonly hard for a patient (this means YOU). They are not all that uncommon starting in the fifty year age group. Your problem given the brain relying on past personal experience is not recognizing this new thing with a resulting delay getting care. "If I just rest or go home or ignore it, it will go away.” This is the thinking of a teenager and we are hardwired to go there unless we use our brains. I have met people unable to move an arm or leg or both who had to be dragged to the Emergency Room against their will because the patient did not recognize that something was very wrong. “If I just rest for awhile, I will be fine….. It’s no big deal.” You may not recognize your problem when others do—pay attention and follow their advice. The worse that can happen is a few hours wasted in an ER and the best that can happen, well, let me tell you about Richard Thompson. Does anyone know who that is? He is the best guitarist you have never heard of. He is the Neil Young of Great Britain. I saw him playing this winter and my wife asked what ever happened to his ex-wife Linda. I did not know. She googled it and showed me in the concert, as I watched him playing world class guitar, her tweet from two years before when he was paralyzed on his right side from a stroke. She got him to a hospital that could provide medication to reverse the stroke before permanent damage occurred. Richard is aging gracefully because he did what his wife said!!! World class treatment for strokes is available inour local hospital.
Many doctors will routinely throw in a few questions about depression when it has nothing to do with the point of your visit. Why do they do this? Because you, the patient, will often be the last to know that you are depressed. Your family will know. Your friends will know. STRANGERS YOU MEET WILL KNOW. Your doctor otherwise focussed --on what you told a receptionist about why you needed to be seen-- will only know if they ask and dive into responses that suggest the possibility. Depression causes great pain both for you and those around you. The pain of addressing it is not easy but always well worth it.
Lastly: Get Screened for cancer —for women, this is mostly about mammography and if young enough, pap smears. For men, it is at least a discussion of pros and cons for prostate cancer screening. For either sex, if you have had sun exposure, skin exams, and if you smoked, a low dose periodic chest CT. For both sexes, colon cancer screening is important—it is the number two cancer killer (Lung cancer remains #1) in our country.
Don’t eat Shit
Covid stats were often focussed on deaths. Statistically this makes sense as there is little controversy about if you are alive or dead. For me, this was annoying because as those not very excited about Covid pointed out, we are all going to die and lots of things are out there to kill us. One can argue endlessly on what a covid death is. My focus on aging is less about avoiding death—ultimately a futile exercise-- and more about grace with a good life lived in mind. Long Covid is not living gracefully—- If you survive covid (or any other medical catastrophe) after a month in the ICU and you are 65 years old, you have a long road ahead of you and your quality of life is not going to be what you planned for. When the national news would show the old guy on oxygen being wheeled out of the hospital and rows of nurses clapping for him after the thirty day admission, it made me sad. This person was never going to be the same and the mountain they had to climb over the next year incredibly steep. My most-feared effect of aging lies in the risk of dementia. If you want to avoid that “living death,” consider what you can do to prevent dementia. Prevention is important because the medications for dementia once it is in play are notoriously ineffective long term. High on the list is treating the concurrent conditions of aging in our society: Hypertension, Diabetes, Elevated Cholesterol—all these relate to diet or genetics. Avoid smoking and minimize alcohol use—don’t drink shit, if you will. If you have bad luck, lifestyle adjustment may not be enough—medication is critical. The most important preventive variable I can find for reducing dementia risk is not about eating—it is about exercise, so this is in the category of “Do do it!” Regular aerobic exercise as a lifestyle starting now, no matter how old you are is the only clear cut variable correlated with reduced dementia scores. Walking counts! Twenty, thirty, forty minutes a day, whatever you can accommodate.
In this category I would include “don’t put up with bad sleep”. By that I mean too much/too little. If you have a sleep disturbance, get to a specialist. Implications are profound for mental health, productive thinking (focus), your immune system, and yes, your memory. How much memory can you spare to lose?
Pack your Kit
With age, you will develop medical conditions and likely take medications. It is really important that you be able to explain in your own words what those medications are and why you have them. It is important that you know why you take medications and what they are for. It is a good idea to periodically go over this with your doctor to see if you still need them all or if there are alternatives. It is really easy— over decades to be on medications all prescribed in good faith —and to find that you have interactions or treatments or simply don’t need them any more. Less is more as you age. Simplify with an eye on the prize: what do you want out of your medical planning and treatments? Aging gracefully? Living the longest of all your friends?
It is human nature to think the pattern of your life is going to continue: I have climbed ladders all my life, why change? I can safely drive a car after drinking two beers, why change? I have had 90 year olds express genuine surprise to realize they are dying. What is that about? We know better but our brains trick us into believing or at least not seeing what is right in front of us.
Think about your expectations regarding health--and death. If you have had a serious scare--a cancer diagnosis, a heart attack, a car accident-- you likely have already done this. Let others know of your experience and conclusions.
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Talk to your kids, casually about your expectations; If you make it too serious, I promise, THEY will cut the conversation short—“Why are you being so morbid? You look fine! You are fine! We don’t need to talk about this!”
My nightmare: Dad is dying, we can try to prolong life with treatments that have little chance for a meaningful outcome or we can go into hospice. Mom is too sad to weigh in. Daughter A says, do everyone and daughter B says, Hospice. My response, “If your healthy dad was in the corner and could give us advice, what would he say?" Your kids and your spouse will make up the answer to that if you have not had a conversation about your expectations and wishes. The legal niceties are helpful to the doctor and to the hospital but for you and yours, it is all about the conversation(s). Do it! Yearly! Mention it to your doctor who may or may not bring it up themselves. TV shows, movies, stories from your friends are all opportunities to weigh in. “If I get Covid next year and am not doing well and they want to intubate me, I want them to do X."
"I would rather die that be in that situation.” This might be said if there is something you feel passionate about that has occurred to a friend or family member. Comments like this are remembered.
A famous Hospice doctor had a father undergoing very serious spinal surgery and the risk of both death and the risk of being paralyzed quite real. She left feeling like she and her dad were on the same page and then she realized, she was not so sure. She returned. What turned her when questions came up was this: “If I am not able to be the way I am now, but can enjoy a bowl of ice cream and enjoy the football playoffs on TV, I would be OK with that!” That helped her in a way that hours of conversation had not.
Say what is important to you and and explain why. A hospital admission will find the staff, typically a nurse asking you about resuscitation orders. They are obliged to when you are Medicare age but it is worth getting it out there even now—with those who will speak for you if you cannot, no matter how old you are.
You never know what tomorrow may bring.
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