(9/8/05)- The following is a response to an email that we at therubins received re "coping" and the elderly.

We assume that you have looked at our web site and we hope it has provided you with some information on aging issues. Please continue to read our web
pages for current information and tell friends and colleagues about our pages.

Your question about seniors coping with change is so general that it is hard to answer, but we will try. In general, change is a stressful activity
because it upsets the stability that has been established. The necessary but sufficient factor that makes change possible is flexibility and is related
to anxiety about change. Many seniors learn to cope with change but because of increased information processing latency, it takes longer to adapt to
change. How they handle this latency time factor is a key to adapting to change. Accepting ones limitations is a challenge that all seniors face. How
they cope with this, not the change itself is an indication of how they will accept change. If you every read "Tuesday With Morrie", you will see an
example of an individual whose personality (optimistic attitude, a trait of the individual) made change acceptable, but not necessarily likeable.

Seniors are constantly going through changes, which runs against the homeostatic struggle to prevent change. Patterns are laid down internally
throughout our lives. We develop schemas to handle events. Many seniors like things to be in a certain place, have routines that they follow etc.
Disruption of these routines creates anxiety which make it harder to adapt to change. Again, much of the capacity to adapt to change depends on their
personality/temperament, a trait issue as opposed to the state of aging. Traits make it hard to adapt to change. Cognitive behavioral therapy
addresses these issues trying to create a more wholesome attitude toward change.

In general, seniors who have lived in the same place for most of their lives, have well established daily routines etc. have more difficulty
adapting to change. On the other hand, these individuals may have established a firewall protecting themselves (conserving energy) against the
expenditure of energy that is draining to seniors. Others who have had frequent changes in their lives may also have an easier time with change
because they have systematically learned methods to handle change, thus exerting less energy when change is needed. This energy is expressed in the
form of anxiety, not only from the senior making the change, but also from those around the individual.

All this may boil down to a factor that one can call "stresses loading". The greater the imagined stress loading, the more the individual has trouble
with change. We all handle change in our lives, sometimes adequately, sometimes poorly, leading to more difficulties. It is why some therapists
are now looking into concepts called stress inoculation (as far as we know, this concept was developed by Donald Meichenbaum).

Another factor that may prove important is spirituality. Here they are talkiing about a more generic concept, than a specific religious belief.

The Institute of Mental Health web site has the following "hints" on handling change:

"It's been said that the only thing constant in life is change. People change, circumstances change, things change. Change can be small, big,
subtle or sudden. Sometimes it's a breeze, other times it's a painful process. Change may be a choice we make, or it may be imposed on us. A new
job, getting married, starting a family, moving house - these are examples of life changes we may experience. Some people view change as a positive
challenge, others fret and agonize over the consequences of new situations. Few of us deal with change without feeling unruffled, so here are some tips
to help deal with it more effectively.

(8/3/03)-The following is a response from Harold Rubin to an email sent to us from

Dear Ms. Warfield:
Thank you for your comments. It is comments like the one you sent that makes it rewarding to write the articles on our web site.

We at www.therubins.com could not in anyway disagree with what you state in your email to us. We in fact have made some of the same points clear to those who will have care of us if anything happens. This, however, does not mean that it is the correct thing to do for all debilitated seniors.

Our site is an attempt to provide information to people interested in issues related to the elderly. We try to supply factual information, without giving advice to others

Failure to thrive is a not uncommon disorder in the elderly (originally it was described in babies) which is not clearly understood. Depression is in the picture, possible esophageal difficulties, other medical conditions as well as the attitude of the person suffering this condition.

Your email addresses an important issue, the quality of life. This is what we think is the deciding factor in allowing an individual to die without heroic measures. It does not negate taking measures to ensure a pain free quality of life, allowing the person to die with dignity.

Interestingly, in our mother's case, she was hospitalized weighing under 70 pounds and was put on a feeding tube and assessed as not qualified for physical therapy by professionals in the hospital. My brother and I provided the therapy including physical and eating. After 39 days in the hospital, she was able to walk into a nursing home, where she remained for over 4 years. Within that setting she thrived, gained weight, stated she had more people visit her than if she were at home etc. She always presented to us that she liked the home and found the staff wonderful. We would visit her every day and on weekends, when weather was nice would take her on walks outside the home in a wheelchair. She enjoyed the local sights. These quality of life factors is what made this nursing home a comfortable place for her to pass her final years.

At the end of our mother's life, when the quality of her life took a downward turn, my brother and I made the decision to allow her to starve to death. Before this decision was implemented, she died. We understood that there was little that our mother could look forward to in her life and that what would follow is just more downward spiral. Yes, there is reason to allow an individual to die and it may prove a healthy thing to do.

The way you present the situation indicates that your mother's situation is different. You have irreversible physical damage and is on medication for depression. Loss of appetite is a symptom of depression. Medication for depression is intended to relieve the symptoms. However, symptom relief is not linear thing, nor do symptoms alleviate at the same time.

Thank you for your comments

Harold Rubin
Coeditor
www.therubins.com

The Science section of the NY Times on Tuesday June 11, 2002 carried an article entitled "Abundance of "Cures" Brings Ills" by W. David McCoy. The author told of his "skeletal, feeble, disoriented, delusional and agitated" 94-year-old mother who slept "fitfully" and seemed in her declining days. She had been put on morphine to ease her dying days. The son, acting as an advocate, stopped the antipsychotiuc, antidepressant, diuretic and potassium supplement. Two weeks after she was withdrawn from her medications, "her mental condition and energy level were essentially normal for the first time in years. He postulated that his mother had gone from a "bright, happy, energetic, elderly women" to her debilitating state because of the medications she was taking.

He goes on to state what he learned from this experience: "That it is dangerous to grow old. Problems that would be cause great concern if exhibited by a younger person may be dismissed or ignored in the elderly". We had a similar experience with our mother, when the hospital she entered and stayed for 39 days felt that she was "failing to thrive" and there was no therapy they could give to her. As those who have read our article on "Selecting a Nursing Home" know she lived a good life for the next four years because of the social support system around her. Her sons provided the physical therapy and behavioral conditioning associated with eating.

We have now come to understand that the term "failure to thrive" is vague nomenclature attribute to elderly individuals who have begun a downward spiral of physical or cognitive decline including an inability to care for themselves and are now dependent on others for their basic survival. Other terms commonly used are "wasting away" and the metaphorical "sundown syndrome". Failure to thrive appears to have been borrowed from pediatrics. The problem with this syndrome is that there has been very little research into the causes, treatment or progress of the syndrome.

Sarkisian and Lachs include in their general description of the syndrome the following: undernourishment and weight loss, functional decline, cognitive impairment and depression and decreased social isolation. The attempt was to divide causes into categories including medical, psychological, functional and social problems. Once the syndrome is attributed to a person, there is a sense of hopelessness and helplessness on part of the patient, the family and the health care professionals responsible for the care of the patient.

Medically, there are usually signs of anemia, suppressed lymphocyte count, low albumin and cholesterol. As we understand it, these may be signs of malnutrition and immune system compromise. Some of the studies suggest about one-third of these patients have cancer, with infection being the second most common diagnosis. Only 13% of these patients survived over a year, with 50% of those without cancer alive one year after diagnosis. In hip fracture patients, 10% failed to thrive after the hip operation. While there appears to be no way to predict who will develop the syndrome of failure to thrive, certain risk factors increase the chances for expression of failure to thrive, with poor prognosis. These are diabetes, decreased muscle mass and dehydration.

Malnutrition in the elderly can be a complex issue consisting of a number of etiological factors including difficulty in swallowing, loss of sense of taste, cognitive impairment, social isolation, medication adverse effects, changes in insulinlike growth factors and their binding proteins. Huang et. al. suggests that alpha melanocyte-stimulating hormone, a melanocortine found in the hypothalamus, may have a role in anorexia and energy utilization. It is also known that when people are depressed, they tend to not eat.

Depression, a not so uncommon symptom in failure to thrive, involves interplay between vulnerability and external causes. Most depressions have a diurnal rhythm, with thoughts of never feeling better. The isolation of the elderly and thoughts of not having a "good death" contribute to the expression of depression. The loss of strength may be related to age-related changes such as declining levels of growth hormone and bone mass loss, as well as failing cardiovascular fitness.

These changes usually call for visits to doctor’s offices. With the elderly, many well-meaning physicians attend to the problems specific to their specialty, not venturing beyond their area of expertise. What appears to be needed is a physician who can act like a conductor of an orchestra, seeing that the multiple treating resources are coordinated and thus provide the proper management of the elderly.

There are indications of a growth of a geriatric specialty that may be a move in this direction. We cannot allow "failure to thrive" to become a wastebasket term resulting in sloppy thinking by professionals or a biased dismissal of a challenging patient. It is not difficult to realize that not many patients will have the same outcome as our and W. David McCoy’s mother, nor do some doctors feel it is worth the effort.

McCoy states: "with their typically large caseloads, even excellent doctors may simply prescribe new medication for symptoms rather than take the time to investigate the other possibilities. There may not be enough communication among multiple doctors about what drugs are being prescribed". Frailty does not mean consigning people to painful wasting death. There is no question that someone has to be an advocate for the patient in this process.

References:

Sarkisian CA & Lachs MS. "Failure to thrive" in older adults. Ann Inter Med 1996; 124:1072-1078. (Suggest that depression is a core component of failure to thrive.)

Huang Q., Hruby VJ., Tatro JB. Role of central melanocortines in endotoxin-induced anorexia. Am J Physiol 1999; 276:R864-871. (An attempt to explain some forms of malnutrition.)

Please also see "Suicide Risk Among the Elderly 

FOR AN INFORMATIVE AND PERSONAL ARTICLE ON PRACTICAL SUGGESTIONS WHEN SELECTING A NURSING HOME SEE OUR ARTICLE "How to Select a Nursing Home"

Harold Rubin, MS, ABD, CRC, Guest Lecturer
updated September 8, 2005

http://www.therubins.com

To e-mail: hrubin12@nyc.rr.com or rubin@brainlink.com

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