Aging and Positive Psychology

 

“Greenhouse” Alternatives to Nursing Homes
Beth Baker

Bio:
Beth Baker is an award winning journalist and author whose books include With a Little Help From Our Friends: Creating Community as We Grow Older and Old Age in a New Age: The Promise of Transformative Nursing Homes.

Notes:

• Common characteristics of Greenhouse homes include private bedrooms (as opposed to double occupancy), home cooking (with residents participating in meal planning, grocery shopping, and cooking if interested and able), communal meals, pets, plants, and staff roles more like family than caretakers. Usually, homes have cottages with about ten residents per cottage.
• While building costs are higher than traditional nursing homes, operational costs are comparable due in part to much lower staff turnover in Greenhouse homes and possibly less wastage of food.
• In the early 1990s geriatric physician William H Thomas (born 1959) created the Eden Alternative, a philosophy for deinstitutionalizing nursing homes. He later developed the Greenhouse Project, which advocated for and helped create small homelike facilities. In 2005 the Robert Wood Johnson Foundation contributed $10 million to launch the development of Greenhouse homes in all fifty states. In 2008 Thomas lead at team of experts at the Erickson School (University of Maryland) in developing the first elder friendly hospital emergency department. Dr. Thomas describes himself as a nursing home abolitionist. His first of several books was What Are Old People For?: How Elders Will Save the World (2004).
• Several terms to describe the approach include: person-centered, resident centered, resident directed, and relationship directed.
• While not discussed in the interview, another interesting development is that some universities have senior housing and assisted living (especially with alumni in mind) on or near campus. The residents can attend sporting and arts events, audit classes, and socialize with students.

 

A Visionary Redefines Aging and Retirement
John Erickson, Founder and first CEO of Erickson Living, The Erickson Foundation, and Erickson Healthcare.

Bio:
John Erickson is a visionary who has been reinventing aging and retirement. He turned an abandoned college campus in Maryland into a vibrant retirement community. Now Erickson Living has 18 communities serving 24,000 residents. Erickson Living has been on Forbes magazine’s list of the 100 Best Companies to Work for. Unhappy with medical services, Erickson developed Erickson Healthcare in which Erickson residents have half hour visits and unlimited access to their onsite primary care doctor. Erickson Healthcare records are fully electronic and often integrated with local hospitals. In 1998, he established the Erickson Foundation to fund research on healthcare and healthy aging for seniors. In 2004 Erickson helped establish and donated $5 million to the Erickson School of Aging, Management, and Policy at the University of Maryland. Unhappy with what television offers seniors, in 2006 Erickson invested $100 million dollars in developing a television network for seniors, Retirement Living TV. The financial crash of 2008 left him overextended financially and led to bankruptcy in 2009. The communities were sold and reorganized as Erickson Living. There have been lawsuits claiming that family members misused funds.

Notes:

• Itch phase – eager to try things always wanted to do, perhaps travel.
• Maintenance phase – day-to-day logistics become more difficult and require more energy. Thus, the issue becomes how to make a fulfilling life still doable.

The concept of retirement in the 1970s was take it easy, don’t overdo it. The concept now is use it or lose it.

Residential philosophy in the ’80s was to build a community of cottages so everyone had their own detached home in a community no larger than a few hundred residents. The problem was people often stayed home, especially in inclement weather. Erickson built communities with about 1,000-2,000 residents and had all the apartments and facilities attached. He believes there is no limit to the size of the communities, as long as they are near a city, as many residents want to be close to their families.

The downside of seniors living in their home in maintenance phase living:

• Social isolation
• Driving safety
• Unable to do their own maintenance

He divides adult developmental stages into:

• Education years
• Family years
• Career years
• Accumulation years
• Freedom years, to express what you lived your life for, a time for renewal and fun

Erickson is working to get Medicare to make all Medicare records electronic and to get the state of Maryland to have all medical records electronic. The advantages include:

• Having baseline and follow-up data, e.g., charting changes in lab tests
• Better sharing of data among primary care doctors, specialists, and hospitals
• Providing research data to generate better protocols
• Preventing repetitive testing and data collection
• Preventing overmedication
• Preventing problematic medication interactions
• Reducing errors
• Faster sharing of data, resulting in more timely care
• Eventually saving money

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Evidence-based Medicine and Common Harmful Medical Practices and Treatments
Alan Zelicoff, MD

Bio:
Alan Zelicoff, MD is a Board Certified internist and a physicist whose career has included research, teaching and international consulting. His expertise includes risk and hazard analysis in hospitals and office-based practices, systems for improving responsiveness, and countering biological terrorism. His advocacy hasn’t been limited to medical procedures. In 2003 he said he said he was forced to resign from his senior scientist/national security expert position with Sandia National Laboratories because of his outspoken criticism about the inappropriateness and ineffectiveness of polygraph tests in national security (https://antipolygraph.org/articles/article-006.shtml and http://www.nature.com/nature/journal/v428/n6980/full/428243b.html). He is the author of Microbe: Are We Ready for the Next Plague?  and More Harm Than Good: What Your Doctor May Not Tell You About Common Treatments and Procedures.

Notes:
Through the lens of evidence based medicine, many of the most commonly performed medical procedures are ill advised and can do more harm than good. We go to our physicians and expect surgery or pills for our ills. Our physicians feel pressured to try to fulfill our expectations. Financial incentives provide little compensation for patient education, but often richly reward performing procedures. Patients and physicians often don’t fully appreciate the statistics behind using evidence based medicine for choosing the best course of treatment. Dr. Zelicoff pulls no punches in discussing what the research says works, doesn’t work, and what often does more harm than good.

His findings included:

Diabetes
• For overweight adults, insulin medications contribute to blood vessel disease (atherosclerosis) and microvascular damage in the retina and kidneys.
• For overweight adults, insulin medications, which are anabolic hormones, can cause an increase in adipose (fat) tissue.
• Thus, the best approach to healthy blood sugar levels include exercise, nutrition (e.g., limiting calories, cholesterol, and heavy fats) weight loss, and using medications that increase the sensitivity to insulin.
• Even mild exercise, e.g., walking 15 minutes a day, has a profound effect on blood sugar levels, even if there is no weight loss.
• When family doctors use an ophthalmoscope to screen for vision problems, they cannot see the outer portion of the retina very well (where proliferative retinopathy starts). Consequently, diabetes patients should receive annual ophthalmologist eye exams. These exams can catch protein leakage (which usually precedes bleeding) and the doctor can then seal the areas where leakage occurs. Fewer than half of people at risk are getting annual exams.

Annual physical exams and cardiac tests
• The US Preventive Services Task Force recommends annual blood pressure tests but doesn’t recommend full annual physical exams.
• There is little evidence that full annual physical exams are cost effective.
• Annual Electrocardiograms (EKGs) and chest X-rays in the absence of symptoms or risk factors often lead to a cascade of unnecessary and increasingly invasive tests.
• There is no justification for cardiac stress tests in the absence of symptoms or risk factors as the test often has false positives that typically prompt even more tests (e.g., an MRI scan) or invasive procedures (e.g., an angiogram – i.e., threading a catheter into a vein to the heart).
• For people with a cardiovascular history, low dose aspirin is enormously helpful in preventing heart attacks but most Medicare patients with cardiovascular problems probably don’t receive a prescription for it.

Cancer
• For mammograms, the data don’t support the belief that squeezing breasts during the procedure risks metastasis.
• With prostrate tests, there are many false positives and this usually prompts an invasive biopsy. When there is a positive biopsy, for the vast majority of men, not treating it won’t result in pain or death from the prostate cancer.
• For all men over 65, 3-4% will die from metastatic prostate cancer.
• For those with high risk of prostate cancer, gene studies are starting to give guidance for whom to treat and whom not to treat.
• A family history of metastatic prostate cancer greatly increases the risk.

Surgeries
• There is no support for the vast majority of arthroscopic knee surgeries.
• Likewise, there is little support for the vast majority of arthroscopic shoulder surgeries.
• Most knee replacements in Medicare patients are justified.
• The number of neck surgeries has increased dramatically. In the absence of nerve damage these surgeries are rarely justified. Fusing neck vertebrae causes accelerated degeneration of the discs above and below the fused vertebrae

Arthritis
• Advances in treatment for rheumatoid arthritis have usually made it possible to stop the progression.

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Baby Boomer Life Transitions
Psychologist Jeff Johnson, Ph.D. and Sociologist Paula Forman, Ph.D.

Bio:
Psychologist Jeff Johnson, Ph.D. did research for the New York State Office of Aging and at Fordham University. He then worked for top-ten advertising agencies. More recently he has been doing consulting and writing with a focus on Baby Boomers. Sociologist Paula Forman, Ph.D. has been an Executive Vice President at Saatchi & Saatchi (advertising agency) and Worldwide Account Director for Procter & Gamble. She then became adjunct professor of sociology at The City University of New York. She is now with NDW Communications in Raleigh, North Carolina. Together they wrote The Hourglass Solution.

Notes:
How does a once narcissistic generation that was determined to reshape the world deal with career crashes, job burnout, divorce, empty nests, aging parents, and deciding whether to retire? Psychologist Dr. Jeff Johnson and Sociologist Dr. Paula Forman’s research focused on what is unique about Boomers and how to generatively handle their life transitions.

Johnson and Forman see many Boomers hitting a period of malaise in which they feel locked in by previous choices (career, marriage, children, financial) and feel limited or trapped by those choices. They use the metaphor of feeling funneled into the narrow part of an hourglass. They believe the key to this stage is appreciating the options and having the courage to choose options that are likely to work better. Johnson and Forman’s forte is looking to other Boomers for role models and success stories for getting unstuck and seeing options. It may take courage to make the changes, but the ensuing renewed sense of purpose usually proves worth the risk.

They see Baby Boomers as still destined to change the world – because of their size, values, ideals, never grow old and never retire attitudes, and their sense of entitlement. They were also clear that most Boomers find traditional retirement unsatisfying. That is because most Boomers get bored with retirement and because so much of their identity derives from what they do vocationally or avocationally. It is time to retire the word retirement and have a new vision for Greater Adulthood.

Often discussion about Boomers is just nostalgia and trivia. I found it fascinating to explore how the Boomer experience is evolving over time. In particular, I was fascinated by their image of Boomers having a very strong sense of entitlement, very broad boundaries, and a willingness to take on all responsibilities including careers, micromanaging their kids and caring for their parents. The downside can be difficulty prioritizing and difficulty in trying to do everything.

 

 
A Fulfilling Sex Life for Boomers and Seniors
Sexologist Robert Birch, Ph.D., ACS

Bio:
Robert Birch, Ph.D. has been a pioneer in sex therapy and has specialized in sex therapy for more than 40 years. He has been an American Congress of Sexologists Certified Sexologist and Adult Sexuality Educator, Adjunct Professor at The Ohio State University, and presenter at many seminars and workshops. While he has retired from his clinical practice as a psychologist, he is still writing sex education books and erotic novels. A complete list of his many currently available books can be found at https://www.amazon.com/Robert-W.-Birch/e/B000AR86AE/ref=sr_tc_2_0?qid=1489071965&sr=1-2-ent.

He noted that:
• In his 40 years of research and clinical experience he finds a lot of middle aged men avoiding sex for fear that they won’t perform well. The shift to a mindset of a playful trip means there is no grade.
• Most swingers have very clear rules.
• Most people in open marriages eventually end up either closing the relationship, that is making it exclusive (or getting a divorce). Why? Sex and relationships require trust and it’s hard to have trust without rules.

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What Research Says About Being Happy
Sonja Lyubomirsky, Ph.D.

Bio:
Sonja Lyubomirsky, Ph.D. is a Psychology Professor at the University of California – Riverside. Her research focuses on happiness. She is the author of The Myths of Happiness: What Should Make You Happy, But Doesn’t, What Shouldn’t Make You Happy But Does (2014), The Myths of Happiness (2013), The How of Happiness (2008) (which has been translated in 22 languages), and many professional journal articles.

Notes:
“The science of happiness deserves to be more than a fad. Striving to be happy is a serious, legitimate, and worthy aim. Unfortunately, most people have quite distorted ideas about what will make them happier and what they can do to be happier. Fortunately, we have a lot of high quality research that provides a lot of guidance. While our genetics create a ‘set point’ that determines 50% of our happiness, research supports dozens of strategies that can raise or override the set point.” ~Sonja Lyubomirsky, Ph.D.

Dr. Lyubomirsky’s formula is that happiness is roughly

• 50% genetic
• 40% what you do and how you think
• 10% life circumstances

Behavioral genetics finds that while several genes may contribute to depression, one in particular seems to be turned on by very stressful or traumatic events.

Genetics contribute to a set point or set range for happiness. Those who are born with a high set point for happiness don’t have to make as much effort to be happy. Using the strategies Dr. Lyubomirsky recommends helps to “override” the set point.

Hedonic adaptation describes how:

• People in cold climates become used to the cold weather and are as happy as those who live in idyllic climates.
• Increased income or wining the lottery often results in a temporary increase in happiness, but these people usually return to their previous level of happiness.

Myths about happiness:

• I will be happy when…
• Finding happiness (as opposed to happiness being a process)

Research on happiness and money finds that

• For people whose basic needs are not met, money helps a lot with happiness
• Once basic needs are met, the correlation ranges from small to none
• Experiments find that spending money on others is more likely to make one happy than spending the money on oneself

Smile lines:

• An experiment that used Botox to erase frown lines helped alleviate depression. This may be due to people in turn responding to them more positively and to the facial feedback hypothesis.
• The facial feedback hypothesis posits that smiling sends feedback to the brain that prompts feeling happier (even if the smile was fake). Conversely, frowning sends negative feedback that prompts unhappy feelings.

Dr. Lyubomirsky has the research on what we can do with the 40% that involves choice. Her solutions include:

• Expressing gratitude
• Cultivating optimism
• Avoiding overthinking
• Practicing acts of kindness
• Nurturing social relationships
• Developing strategies for coping
• Learning to forgive
• Increasing flow experiences
• Savoring life’s joys
• Practicing religion or spirituality
• Taking care of your body (meditation)
• Taking care of your body (physical activity)
• Acting like a happy person

She recommends starting with an assessment to help focus on what is most important. An assessment also allows for periodic follow-up assessments to measure progress.

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The Longevity Project: What an 80-year Longitudinal Research Project Found About Lifestyle and Longevity
Leslie Martin, Ph.D.

Bio:
Dr. Martin is a psychology professor at La Sierra University in Riverside California and a research associate of Howard Friedman, Ph.D. They are co-authors of The Longevity Project: Surprising Discoveries for Health and Long Life from the Landmark Eight-Decade Study (http://www.howardsfriedman.com/longevityproject/). She is also a co-author of the books Health Behavior Change and Treatment Adherence: Evidence-based Guidelines for Improving Healthcare and Health Psychology, and The Oxford Handbook of Health Communication, Behavior Change, and Treatment Adherence.

Notes:

• The study began in 1921 with Stanford University professor Lewis Terman studying 1500 intellectually above average ten year olds. Follow-up studies were every five or ten years and often included data from parents, teachers, and spouses.
• The Longevity Project continued following his students until they died and even probed beyond death certificate information to find the causes of death.
• One surprising finding was that the most cheerful, optimistic children had shorter life spans, apparently due to more risk taking (smoking, drinking, risky hobbies) and less conscientiousness about planning ahead.
• Conscientiousness, sometimes called neuroticism on tests and personality traits, was the strongest personality trait associated with living longer. Conscientious people were seen as being more organized, prudent, stable, and likely to plan ahead. They were more persistent and methodological. They were less impulsive and often selected jobs that they found interesting.
• While scientists were less social than business people, their longevity was about the same. Scientists tended to be stable, have good job satisfaction, and avoid jobs that placed them at risk of harm.
• While consistently being physically and mentally active were important for longevity, athleticism and athletic interests were not. Few of the longest living individuals engaged in formal exercise programs.
• The Longevity Project comprehensively studied other research to validate that its findings were valid and results still applied despite cultural changes.
• While a moderate amount of anxiety and worry was often helpful, “catastrophizers” were at greater risk of death from accidents, injuries, and suicides.
• Breastfeeding did not correlate with longevity.
• Children who started formal school early or skipped grades had higher mortality rates. This may have been due to needing more unstructured free play time as children and/or being out of synch with peers (and thus not fitting in socially and perhaps being teased or bullied).
• (Keeping in mind that the study participants were intellectually above average) the study found that educational achievement only had a very small effect on longevity.
• Parental divorce had a big influence on longevity. Children of divorce were at greater risk for abuse of alcohol and drugs, promiscuity, and having their own marriages end in divorce.
• Divorce is a bigger risk factor for men than women, apparently because women have bigger social networks.
• A surprising finding was that that husband’s happiness was more important that the wife’ happiness in their longevities.
• Religion was more important for longevity for women than men.
• Religion’s biggest benefits appeared to be in social connections and altruistic pursuits. People who were not religious but active in their communities and altruistic had similar benefits.
• Having a pet was not associated with longevity.
• While the cost and persistence required makes longevity research difficult, many types of data, particularly health data, have become easier to collect because of technological advances.

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Counseling Patients with Dementia
Marc Agronin, MD

Bio:
Dr. Agronin is Vice-president of Behavioral Health and Clinical at Miami Jewish Health Systems. He is a board certified geriatric psychiatrist and the author of several books for professional and lay readers including The Dementia Caregiver: A Guide to Caring for Someone with Alzheimer’s Disease and Other Neurocognitive Disorders and Therapy with Older Clients and Principles and Practice of Geriatric Psychiatry. This interview focuses on his book, How We Age: A Doctor’s Journey into the Heart of Growing Old. His website is www.MarcAgronin.com.

To summarize and elaborate on some of the points in the interview with Dr. Marc Agronin:

• Dr. Agronin is very impressed with neo-Freudian psychiatrist and stage theorist Erik Erickson. He was especially impressed with Erickson’s philosophy that out of the changes and crises in each stage there is always the potential for something better to emerge. He appreciates Erickson’s optimism, nuance, balance, and holistic perspective
• Agronin believes that unfortunately many medical and mental health professionals tend to take one-dimensional views of clients, e.g., just seeing their health problem, or recent loss.
• The case history of 98-year-old “Emma” illustrates how early Ericksonian developmental stages can apply to one’s life and how events such as a new sense of purpose (helping her sister-in-law who moved to the nursing home) can profoundly affect depression.
• Even people with severe memory loss can give and receive kindness and experience it in the moment. He sees this as a strength we maintain despite memory loss and those who don’t appreciate it lose an important opportunity to connect.
• He references Sophie Freud’s (Freud’s granddaughter) book, Living in the Shadow of the Freud Family, and how writing about her family’s troubled history helped her.
• He finds that taking a person’s history (reminiscence or life review) is one of the most therapeutic things a therapist can do – both for the client and the therapist.
• One of his favorite questions is, Please tell me about your most precious memory. An example was the woman who went from agitated to enraptured talking about how she once danced with Fred Astaire.
• For higher functioning clients therapy is often about integration and perspective on past memories. For lower functioning clients it may be focusing on some particular memories to make a connection and help them feel valued.
• He finds that elderly clients often make more changes in therapy than younger patients (contrary to what most therapists probably believe).
• One of his favorite sources of inspiration is Rabbi Abraham Joshua Heschel who said for example “just to be is a blessing” and “just to live is holy.” These beliefs have a big influence on perspective and how one approaches elderly clients.
• Agronin also has a belief of never giving up and sees this as like the Hippocratic Oath for therapists.
• In George Vaillant’s longitudinal Harvard Study of Adult Development, Vaillant concludes that the relationships we have are more important than the events in our lives. (The most recent book on the subject was Vaillant’s 2012 book, Triumphs of Experience: The Men of the Harvard Grant Study.)
• In talking about stories, Brickey pointed out that one therapy technique is telling the story back to the client in a more optimist frame and how clients subsequently may use that more optimistic or positive frame when telling the story in the future. This fits with memories not being “written in stone,” but changing with varying context, motivations, etc.
• He discussed Erik Erickson’s and Ronald Reagan’s dementia.
• Gene Cohen, a pioneer of geriatric psychiatry who died in 2009 at the young age of 65, built on Erickson’s theory by emphasizing that aging isn’t just a wrapping up, but also about being energetic and creative and doing new things. Cohen also wrote about our “social portfolio,” i.e., our social skills and resources and creativity.
• While not covered in the interview, Gene Cohen’s stage theory included:
• liberation phase 50s –70s new pursuits
• summing up phase 60s-90s
• encore phase late 70+ personal reflection, reaffirmation, celebration

 

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