Denver Hospice

Wednesday was Bridge Day for my mom. Two weeks ago, however, her bridge group found her doubled over in pain and unable to express what was wrong. They called me at work, and as I sped to her house down I-25, I pondered what I would find and what I would do.

My mother's express wish for some time now has been to pass up 911 and ERs and any sort of diagnostic tests. Yet if she was in pain, if she was having a stroke, how could I just keep her at home and keep her comfortable?

Fortunately, the episode that day was not the big one, just one in a series of more or less transient little ones. She recovered her speech, and lord only knows what the abdominal pain was about. The entire episode, however, was a wake-up call as in wake-up and get a plan. This downward decline is a stepwise path to the end of the line, and we need help.

I called Denver Hospice at 1 p.m., and at 4 p.m. sharp their admissions nurse (a large and gentle man who looked like an ex-college linebacker) was at the door. Within an hour, we had a team in place--nurse, CNA, social worker, and chaplain.

Now I've got a replacement number to 911; I can call 303-321-2828 with our emergencies, we don't have to go this route alone.

Bad Brain Day

Or more correctly, bad brain daze. Now that my mother is firmly entrenched in this piecemeal loss of brain tissue, neuron by neuron, day by day, the events of the last several years make more sense.

Dr. Sherwin Nuland, author of How We Die, describes the cumulative effects of multiple tiny strokes:

Many strokes are so small that there are few or no immediate significant symptoms to indicate what has taken place. But with time, such little strokes accumulate, and the evidence of gradual deterioration becomes evident to even the most casual observer..The subtle process of infarcting brain may go on and on, accumulating irregular stepwise degenerations in cerebral function for as long as a decade or more...

He goes on to note that those elderly persons so affected are 'betrayed by their cerebral circulation.'

Dr. Nuland and pathologist Dr. Walker Smith reviewed autopsy results on 23 old ladies and men with an average age of 88 at death. While 7 of the subjects officially had heart attacks as their final exit line and only 4 had strokes listed on their death certificates, 'Every one of these twenty-three people had advanced atheromatous in the vessels of the heart or the brain, and almost all had it in both.'

In retrospect, on a host of days in the past few years when my mom's been dizzy or tired, she was having a 'bad brain day,' sending a few more neurons into oblivion.

Postural confusion

Turns out that an old heart has trouble perfusing an old brain through upstream corroded blood vessels when the old owner gets out of bed. I just figured out that why my mom has transient ischemic attacks or TIAs every mid-morning. At that point of the day, she's been up in a chair for an hour or so, and those narrowed cerebral blood vessels just shut down as her blood pressure falls.

Great. By then, she's too confused and weak to remember to lie down.

Imploding into eternity

...we die of old age because we've been worn and torn and programmed to cave in. The very old do not succumb to disease--they implode their way into eternity.
Sherwin Nuland, MD, "How We Die"

As my 87 year old mother implodes her way piecemeal towards the end, one neuron at a time, I was most comforted by Dr. Nuland's book, particularly the chapter "Doors to Death of the Aged." The inevitability of death for the aged supports our decision to mark this passage for Mom in her home with no ERs, no 911, no tests, no hospitalizations.

Nevertheless, it's rough.

We've come a long way...

Here's a backpacking metaphor for the Boomer's aging transition.

Our generation was the first to strap on baby, throwing Junior into a Snugli and heading out wherever we needed to go. Junior, fortunately and at last, is out the door and on his own (well perhaps not financially, but at least no longer on site). Now the makers of Snuglis bring us AirLift so we can strap on our oxygen tanks and step out, somewhat more slowly, wherever we care to step.

Pristiq: Non-hormonal rx for hot flashes

Wyeth is working hard to bring new products into the menopausal market after losing their leading edge when Premarin got such bad press out of the Women's Health Initiative.

Investigators recently reported that desvenlafaxine, a metabolite of Effexor that will be dubbed Pristiq had a significant effect on hot flashes and sleep disturbances associated with dwindling estrogen levels during the transition into menopause. Dr. Margery Gass called it "a major breakthrough for women: the first nonhormonal therapy for menopausal symptoms."

The results of these studies presumably will soon be presented to the FDA as Wyeth seeks approval to bring Pristiq to pharmacy shelves.

Coffee a lifesaver?

Well sure, coffee in the a.m. is a bit of a lifesaver. But in elderly persons with normal blood pressure, research suggests that it may be the real deal.

Researchers worked over the data from the National Health and Nutrition Examination Study (NHANESI), checking out who checked out with cardiovascular disease as correlated with their coffee-drinking habits. Those persons 65 and over without severe hypertension who knocked back 4 or more cups of coffee each day were nearly 50% less likely to end up dead from heart disease compared with the decaff gaffers.

So what's the explanation? Investigators aren't sure but speculate that coffee's pressor effect (i.e. its ability to raise blood pressure) may protect old quaffers from the harmful hypotensive effects of eating. This drop in blood pressure after a big meal has been linked to heart attacks and death.

So drink up, and brew a cup after dinner for your old mum as well. That caffeine buzz may keep your tickers ticking.

If Barbara Hillary...

can make it to the North Pole on skis...at age 75...after winning a battle with lung cancer at 67...you can make it to the gym today!

Beans, beans, good for your heart...

I suppose we could live without part 2 of that childhood ditty, but just know that line 1 is scientifically proven.

Epidemiologists sorted through the health and dietary records of nearly 10,000 participants in the First National Health and Nutrition Examination Survey (NHANES I), correlating the incidence of heart disease over 19 years of follow-up with the intake of beans.

Their conclusion?

Legume consumption was significantly and inversely associated with risk of coronary heart disease after adjustment for established cardiovascular risk factors.

You eat beans four or more times per week and you fall out with heart disease 22% less often than the underbeaned.

For those of you who have bean there but don't particularly like to go there often, here's a recipe for a bean smoothie that's mighty good. Actually, it's more a bean soup, but still provides that easy intake of nutrients without all that tedious chewing. This recipe is a done deal in 5 minutes, and heated up in another 5, but careful, the ingredients fill a standard-sized blender to about 1/18 of an inch from the top:

Chickpea Soup with Garam Masala and Cilantro*

2 16-ounce cans chickpeas, drained
1 14-ounce can light coconut milk
1 cup low-sodium chicken broth
1/2 cup prepared salsa
1 1/2 tsps. garam masala (blend of Indian spices, McCormick brand or other)
1 tsp. ginger
2 Tbs. frozen apple juice concentrate
1/4 cup packed cilantrol leaves
Garnish with plain yogurt and/or thinly sliced green onions
Blend it all but garnishes, heat up in large saucepan, simmer 4-5 minutes, drink to your heart's content.

*Recipe from Parade Magazine

Aspirin or not?

I take one before bed every night. It takes away my little aches and itches that get in the way of becoming one with the bed. And the long-term use of aspirin may (or may not depending on what you read) be associated with a decreased risk of cancer.

How much and how often you pop the pain reliever seems to be an important issue as to whether or not aspirin use will relieve your cancer risk as well as your pain. Itty bitty heart-disease preventing doses do not seem to help per the women of Iowa. The nurses of the Nurses Health Study, however, proved that if a little won't help, a bit more may do.

Over twenty years of follow-up, the dedicated health professional subjects of the NHS faithfully reported their aspirin use to investigators every 2 years. Those who took two or more regular strength (325 mg) aspirins per week for at least 10 years enjoyed a 33% reduced risk of colon cancer. Just last month, nearly 150,000 participants in the Cancer Prevention Study II Nutrition Cohort (dubbed a "relatively elderly population") confirmed that same 1/3 risk reduction for colon cancer with the regular use of aspirin.

So why wouldn't we all just do it, just down a daily Bayer? Consider a couple of stories from my practice before you conclude that aspirin does not cause stomach problems. Remember that each of these patients had no history of gastric distress.

Years ago, a thirty-something patient of mine called me in the middle of the night vomiting blood. She took aspirin on a regular basis for neck pain. Call an ambulance, head for the ER! Can't, said she, nothing to do with her young son, no one to care for him. The obvious solution? She got in a cab, dropped young son off at my house to spend the night until his dad could come get him, then she proceeded to the hospital where she was treated for bleeding from an aspirin-induced stomach ulcer.

Patient number 2 walked unsteadily into my office more recently, white as a sheet and dizzy after days of passing black stools (digested blood from the upper intestine emerges black out the back end). His problem? Blood loss from a gastric ulcer caused by daily use of low-dose aspirin for prevention of heart attack. No warning, no pain, just loss of half his blood volume down the toilet.

So aspirin or no? Like all the things we do for health, this one's a weighted decision.

D problem with aging brains

Higher intakes of calcium and vitamin D have been promoted in recent years as a way to prevent bone loss with aging. We are concerned that some of this extra calcium may end up in the blood vessel walls rather than the bone.
--Dr. Martha Payne, Duke University

Dang, if it's not one thing, it's another. Just the other day, as I explained that calcifications seen on CT scans of coronary arteries were markers for significant coronary disease, a patient asked me if it was a problem then to take extra calcium. Oh no, I assured her, the calcifications were an injury response, not a result of dietary intake.

So now Dr. Payne and colleagues have studied the correlation between intake of calcium and vitamin D in a group of elderly subjects with the appearance of brain lesions on MRI scans. These lesions are believed to represent areas of atherosclerosis in small blood vessels causing an interruption of blood flow to the white matter in the brain.

Not only did they find a significant relationship between the intake of these two bone supportive nutrients, but the relationship remained when they statistically controlled for the effects of age, hypertension, diabetes, and heart disease. Further analysis suggested that the total volume of screwed-up brain areas was significantly associated only with D intake.

Too much of a good thing, perhaps.