Good genetic news for geezers

https://i2.wp.com/upload.wikimedia.org/wikipedia/commons/1/1a/The_Triumph_of_Death%2C_or_The_Three_Fates.jpg

The Three Fates, Flemish tapestry (probably Brussels ca 1510-1520) Victoria and Albert Musem, London. (WikiMedia)

 

Live longer, get smarter? We wish.

And this wish could some day come true, thanks to the gene variant KL-VS, whose friendlier name is the klotho gene. The klotho gene was already known to be associated with longer life. But a team of scientists at UCSF and the Gladstone Institutes, found that it also seems to make people smarter.

One in five of us has the klotho gene. As this writer is definitely older I had hoped to get in on the smarter, although I never cancelled the dementia provision of my advance directives. But in an interview with San Francisco Chronicle health writer Erin Allday Dr. Lennart Mucke, director of neurological research at Gladstone, said, “Klotho increases cognition but doesn’t replace aging-related decline. You’re just coming down from a higher level.” So much for immediate — or personal — optimism.

UCSF Assistant Professor of Neurology Dena Dubal was lead author of the study, findings of which were published recently in the journal Cell Reports. Dubal and Mucke say more studies are needed, but the  hope is that eventually klotho could help old brains — old human brains; so far we’re talking about mouse brains — function better.

This writer, having an old brain far too right-brained to follow neurological research very far, did at least complete several years of Greek at Randolph-Macon Woman’s College some years before Dena Dubal was born. But as my class notes are not handy I turned to Theoi.com, an online encyclopedia of Greek mythology, to find more about Klotho. (For the record, her name is more commonly spelled Clotho in classical texts, but most of all this pre-dates Spellcheck.)

Klotho and her sisters Lakhesis and Atropos where the daughters of Zeus and Themis, and in Greek mythology one couldn’t ask for better parentage. They were known as “The Fates,” or “The Moirai,” the goddesses who determined everyone’s destiny. According to Theoi, “They assigned to every person his or her fate or share in the scheme of things.” Clotho (on the right in the tapestry above) was “the Spinner,” who spun the thread of life. Lakhesis (in the center)  measured the thread of life and Atropos (on the left) cut the thread. Presumably they are arising from Themis; birthing in mythology was somewhat less complicated than today.

(It’s tempting to speculate on what it would mean to have too many Atropos gene variants, but that is going too far with all this.)

No amount of Googling turns up the scientist who named the KL-VS gene variant after Klotho, but he or she had an appropriate understanding of Greek mythology. If Klotho can indeed eventually lead to reactivating old brains, she will have spun us all a golden thread.

 

On being treated to death – Part II

Is there a fate worse than death? Yes. In the U.S., often it is the fate of dying slowly: aggressively treated, over-treated and worn down by the system until that fate has made death truly a blessed relief.

Deborah Wright, an ordained Presbyterian minister and writer now working in secular fields while simultaneously serving as personal pastor to many, forwarded an article that proves out the fate-worse-than-death highlighted in this and recent other articles (see June 25 post below.) The fact that stands out, she comments, is that “the length of time we use palliative care services is growing shorter — because we start it too late.”

We start palliative care too late, we treat too aggressively and too long. The opening story in AP writer Marilynn Marchione’s thoughtful, poignant article just published in Daily Finance serves as a classic example:

The doctors finally let Rosaria Vandenberg go home.

For the first time in months, she was able to touch her 2-year-old daughter who had been afraid of the tubes and machines in the hospital. The little girl climbed up onto her mother’s bed, surrounded by family photos, toys and the comfort of home. They shared one last tender moment together before Vandenberg slipped back into unconsciousness.

Vandenberg, 32, died the next day.

That precious time at home could have come sooner if the family had known how to talk about alternatives to aggressive treatment, said Vandenberg’s sister-in-law, Alexandra Drane.

Instead, Vandenberg, a pharmacist in Franklin, Mass., had endured two surgeries, chemotherapy and radiation for an incurable brain tumor before she died in July 2004.

“We would have had a very different discussion about that second surgery and chemotherapy. We might have just taken her home and stuck her in a beautiful chair outside under the sun and let her gorgeous little daughter play around her — not just torture her” in the hospital, Drane said.

Marchione tells other stories of patients who might have had far more peaceful final days — and of patients who chose extensive, aggressive or experimental treatment for a variety of reasons. It should be the individual’s choice. But the reality is that discussion of palliative care or hospice care (there is a difference: hospice involves declining further treatment; with the newer “palliative care” concept some therapies may be continued) simply doesn’t happen until too late. If it happened sooner, many of us — likely including Rosaria Vandenberg — would choose hospice care over aggressive end-of-life treatment.  But physicians are too busy talking treatment, and patients have not considered their other choices. Comfort and peace lose to the system.

An article posted today on the website of the National Hospice and Palliative Care Organization points the finger in the right direction, right at you and me. If we took the time and energy to write our advance directives, and talk them over with family and friends, millions of days of suffering and millions of wasted dollars would be saved.

Recent media coverage on the challenges patients and families face with overtreatment of a life-limiting illness brings the issues of hospice and palliative care and advance care planning to public attention.

“It’s important to remember that quality of life and a patient’s personal wishes, beliefs and values must be a factor when making care decisions brought about by a serious or terminal illness,” said J. Donald Schumacher, president and CEO of the National Hospice and Palliative Care Organization.

“Discussions helping patients and families understand the many benefits of hospice and palliative care must be more common and held long before a family faces a medical crisis,” Schumacher added.

Advance care planning—which includes completing a living will and appointing a healthcare proxy—is somewhat like planning a road trip to an unfamiliar destination.  Very few people would expect to get to a destination safely and comfortably without having a well-thought-out map in hand.   Yet, it’s estimated that 70 percent of Americans have not completed a living will.

  • A living will charts the course for your healthcare, letting your family and health care providers know what procedures and treatments you would want provided to you—and under what conditions.
  • A healthcare proxy or healthcare power of attorney form, allows you to choose someone you trust to take charge of your healthcare decisions in case you are unable to make those decisions yourself.
  • Advance directives can be changed as an individual’s situation or wishes change.

Still, you and I put it off. Or you may be putting it off, at least, and if so you are taking an absurdly unnecessary risk. You could, instead, download free forms, fill them out and avoid that risk.

Deborah Wright has shepherded countless friends and family members through their final days, and knows what a blessing hospice and palliative care can be. Problem is, though, “we start it too late.”

Americans are treated, and overtreated, to death – DailyFinance.

Dementia: stories and sources

The post about dementia sufferers and their tendency to wander (May 6) evoked a host of stories about temporarily lost parents, grandparents, friends and relations. Almost everyone, it seems, has such a story — and unfortunately, those who haven’t may collect one or two in the future.  Reader Cathy Jensen sent a poignant tale of a friend who went wandering in his pajamas during the pre-dawn hours, but was found by the garbage collectors and brought home on the back of their truck. And reader Tom McAfee, en route to see his own mom and hopefully jog memories of children and grandchildren with photos, sent a link to a podcast aired on WNYC in March.

An offbeat idea, the WNYC piece explains, turned out to be a good solution for a nursing home in Germany from which residents were wandering off. Administrators created a bus stop in front of the home, complete with bench and a painted sign for a bus that never came. It provided a place where many wanderers could sit and wait until the urge to go back home, or elsewhere, melted away. Might not work everywhere, but it worked in Dusseldorf.

And reader JTMcKay4 sent, in case you missed them in the comments section, links to the Alzheimer’s Association’s “Safe Return” program and to a source for a long list of related documents. State-specific advance directive forms can also be downloaded, free, from the “Caring Connections” site maintained by the National Hospice and Palliative Care Association site, and this space remains committed to the support of the nonprofit Compassion and Choices, from which forms can also be downloaded.

There is no guarantee against winding up in a memory unit. But a little preparation can go a long way toward helping if the time comes.

More on mortality: living strong, dying well

It’s hard to think about the death of my sister Jane (below) without thinking of another death we faced together.

Our father, in his 90th year on the planet and his 20th year of widowhood, started putting the pressure on Jane and me to come to see him one Thanksgiving. As we were in different states and had families and other things needing attention, getting to Virginia required some doing. Our dad had two daughters in between Jane and me, but she was the executor of his estate and I was the one who brought comfort because I closely resemble my mother. We four daughters usually visited at different times in order to stretch out the audiences for his story-telling and generally keep an eye on him. This time he was adamant. He wanted the two of us there together.

In mid-January we got it worked out. Jane and I met in Atlanta, having to spend the night there because the Richmond airport was snowed in. We managed to get on the first plane to land in Richmond the next morning. After picking up a rental car for the drive to Dad’s home in Ashland we took him to lunch at the only place open in town. He was impatient to get back home. Once there he did his traditional monologue about his 12 flawless grandchildren, a reassurance, of sorts, of his posterity. Then he shuffled off to his room for a nap.

And that’s where we found him when he didn’t answer a call to dinner. Keeled over, on his knees at the head of his bed, where he had said his prayers for 90 years. Having  departed this realm in the midst of a conversation with God, all arrangements complete. He and God had long maintained a strong, conversational relationship.

Not all of us can engineer our departures so efficiently — you had to know my father. Or so gently as Jane’s closing days with her family around, singing hymns. But there are millions of such stories (some of which are in the book, Dying Unafraid, that was motivated by the first story above, if you’ll pardon a little blatant self-promotion here; it’s still in print.) The great majority of those stories happen not because the central character had an unshakable faith in some deity or other (although that does tend to help matters) or because he or she had mystical powers or superhuman strength and determination, but because the central character accepted his or her mortality. We’re born, we live, we die. The facing of, and preparation for, its eventual end often makes dying better and always makes life richer.

That’s the lesson of these two stories. Dying unafraid tends to happen to people who live unafraid. And who talk to their families and friends, and complete their advance directives, and make it clear what their choices are. This is equally true for the young and the old, the fit and the infirm.

What are you waiting for?

End-of-year look at end-of-life issues

Two end-of-year stories offer stark insights into end-of-life issues in the U.S., one from a purely financial perspective, the other purely about compassion. Between the two, the conflicted American way of dying comes into focus.

First the finance. The Wall Street Journal of December 30 features a front page story by Laura Saunders about wealthy families coming to grips with the disappearance, thanks to a quirk of Congress, of the estate tax beginning January 1, 2010. It will only disappear for a year, and in 2011 it will return at a higher rate with lower exemption. For those approximately 5,500 super-rich taxpayers to whom this tax applies, a lot of money is at stake. Presumably if a member of one of these families is now near death every possible measure will be taken to keep him or her alive into the new year and presumably that will be done for the best of reasons. But imagine the struggles involved if someone is near death this time next year, and his or her heirs stand to benefit in the millions if that death happens before January 1st rather than soon after. An altogether new meaning will have to be added to “letting go.” Not something one really wants to think through.

But the last two sentences of the WSJ article demonstrate how extensively the scenario is indeed being thought through, not from the heir’s point of view but from the soon-to-be-departed:

The situation is causing at least one person to add the prospect of euthanasia to his estate-planning mix, according to Mr. (Andrew) Katzenstein (a lawyer with) Proskauer Rose (LLP in Los Angeles.) An elderly, infirm client of his recently asked whether undergoing euthanasia next year in Holland, where it’s legal, might allow his estate to dodge the tax.

His answer: Yes.

However hard we might try to eliminate costs (and cost/benefit ratios) from considerations of end-of-life care and decision-making, they are here to stay and sure to remain complex. Another complexity — and this one should not be as difficult as it continues to be — surrounds the subject of palliative care. Palliative care is simply comfort care. It means, do everything possible to insure that a dying person might go about his or her dying with as little pain and anguish as humanly, medically possible.  A long, careful look into the issue is in the New York Times most recent “Months to Live” series article, “Hard Choice for a Comfortable Death” by health writer Anemona Hartocollis.

In almost every room people were sleeping, but not like babies. This was not the carefree sleep that would restore them to rise and shine for another day. It was the sleep before — and sometimes until — death.

In some of the rooms in the hospice unit at Franklin Hospital, in Valley Stream on Long Island, the patients were sleeping because their organs were shutting down, the natural process of death by disease. But at least one patient had been rendered unconscious by strong drugs.

The patient, Leo Oltzik, an 88-year-old man with dementia, congestive heart failure and kidney problems, was brought from home by his wife and son, who were distressed to see him agitated, jumping out of bed and ripping off his clothes. Now he was sleeping soundly with his mouth wide open.

“Obviously, he’s much different than he was when he came in,” Dr. Edward Halbridge, the hospice medical director, told Mr. Oltzik’s wife. “He’s calm, he’s quiet.”

Mr. Oltzik’s life would end not with a bang, but with the drip, drip, drip of an IV drug that put him into a slumber from which he would never awaken. That drug, lorazepam, is a strong sedative. Mr. Oltzik was also receiving morphine, to kill pain. This combination can slow breathing and heart rate, and may make it impossible for the patient to eat or drink. In so doing, it can hasten death.

Mr. Oltzik received what some doctors call palliative sedation and others less euphemistically call terminal sedation. While the national health coverage debate has been roiled by questions of whether the government should be paying for end-of-life counseling, physicians like Dr. Halbridge, in consultations with patients or their families, are routinely making tough decisions about the best way to die.

Writer Hartocollis covers in thoughtful detail the long, sometimes conflicted process through which the medical team and the patient’s family arrived at his eventual, peaceful death. The article looks at the multiplicity of issues that cry out for reasoned public dialogue — palliative care, physician aid in dying, end-of-life choice, family decision-making — that have been raised on this page in recent months and will be back again. It’s a story worth reading in full.

And meanwhile, the beginning of the year is a fine time to get your advance directives and other documents completed and to have those conversations with friends and loved ones that keep you from becoming another Terri Schiavo. Getting this done is one great way to put dying behind you and go about the business of living for a happy new year.

Months to Live – Hard Choice for a Comfortable Death – Sedation – Series – NYTimes.com.

Watching Idols and Icons Die

An article in yesterday’s New York Times chronicled the recent “funereal season” that has seen the passage of such players on the national stage as Walter Cronkite, Les Paul, Farrah Fawcett, Michael Jackson, Ted Kennedy and Patrick Swayze. Add to that the death this week of singer Mary (“Peter, Paul and Mary”) Travers. Although Times writer Sarah Kershaw noted that no more celebrities died this summer than in summers past, a couple of other elements are in play: the particular folks who departed the stage in recent months did so just as Baby Boomers are hitting retirement age, and they were the people who “defined (the Boomers) as a tribe, bequeathing through music, culture, news and politics as a kind of generational badge that has begun to fray.”

Generational badge-fraying is not necessarily a bad thing. As long as one wears the badge lightly on the pocket and occasionally notices which threads are coming loose, in fact, I maintain it is downright healthy. Contemplation of our terminal condition could do most of us a lot of good.

(Specifically, a few of those Boomers who have been putting off getting their advance directives done (OK, I see your eyes glazing over, but stick with me here) will start thinking about doing so. Or at the very least, have a little talk with their significant others about how long they’d like to be kept on life support if they have a stroke tomorrow. Getting this done today leaves tomorrow for enjoying everything else. Plus, it encourages calm; see below.)

Walter Cronkite wound up a long and happy life at 93. But Ted Kennedy was 77, one year older than yours truly. Farrah Fawcett was 62. Patrick Swayze, 57; Michael Jackson, 50. DJ AM Adam Goldstein was 36. The reality is that we’re all terminal; most of us terminate before we’re quite ready but it does happen. Acknowledging that fact can be ridiculously freeing.

The Boomers are reportedly worried not only about the finiteness of their lives, but also about their legacy. The Times article quoted a survey of 1,000 Americans age 44 to 79 conducted by AARP, which found that 55 percent believed they would leave the world worse off than they found it. That prospect can turn you gray in a hurry. But these near-retirees are not planning just to sit around getting gray.

Loss of their legends, according to Marc Freedman, author of “Prime Time: How Baby Boomers Will Revolutionize Retirement and Transform America, has created in this generation a sense of both the “expansion and compression of time,” and they are looking toward second careers doing good. “I think this is the first time so many have simultaneously had an awareness of death and the prospect of a whole new act,” Mr. Freedman says. Many of those new acts may turn the above expectation around, so the world might be left a little better off than they found it.

To which the post-Boomers say, Go Boomers.

More on Health Care: Where the Costs Are

A few interesting factoids were dropped into the health reform debate by New York Times writer Amanda Cox Tuesday:

In 2006, health care expenses among half the United States population totaled less than $800 per individual, according to the federal Agency for Healthcare Research and Quality.

For openers, that seems entirely reasonable. Would that we could actually care for the citizenry at $800 a pop. Keep reading.

But the expenditures were not uniformly distributed throughout the overall population. Spending was far higher among the elderly, the obese and people who identified themselves as unhealthy. Median spending in those groups totaled $2,300 per individual. Although these patients represent just one-third of the population, they accounted for almost 60 percent of health care spending.

I hate to stomp this nearly dead — oops, bad metaphor — horse even further into its grave, but a lot of us, given the chance to talk to our doctors about aggressive, invasive, often futile end-of-life treatments that are going to make our ends horrific might choose to go home and spend our remaining time with palliative care, at peace. A nifty way to cut that $2,300 back down to $800. But Senator Grassley and others think we should now allow those conversations.

The truth may be too obscured by the cleverly promoted lies, but the issue is about choice. Compassion. Comfort. Peace. Sanity. If anyone could get this truth across to seniors, that one critical segment of reform might still survive. And personally, I’d like to have the option of saving the rest of you taxpayers my $1,500.

via Making Sense of the Health Care Debate – Prescriptions Blog – NYTimes.com.