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For those of us who are planners, it seems perfectly natural to anticipate the possibilities of the future and try to take steps to either avoid bad outcomes or implement steps to mitigate deleterious outcomes. My late father, an engineer whose expertise was motor vehicles, drummed into me the importance of timely oil changes—which I do to this day: it is an almost obsession with me. I constantly have to remind my children to keep up the schedule and over time they are getting better at it as I give them visual images of burned out engines, and the need for early retirement due to expensive maintenance costs of their cars.

For those like me who attend to elders as patients, with the usual accompaniment of their spouses and/or children, beyond clinical care, much of my time and effort focuses on planning for the future. Because my clearly defined domain is medicine, that is always the first level of interaction of clinical relationships. However within a short period of time depending on the length and duration of our relationship I try to focus on future planning—in all domains (what is often called advance care planning) and more recently on documentation of all the necessary information that makes it easier for families to cope with the challenging life events including severe illness or death.

During the past few years I have experienced on a personal level and extended family level the risks, benefits and barriers to planning for the unexpected and although foreseen theoretically always seems to be projected well into the future. One has often heard the phrase "Nothing focuses the mind like a hanging", attributed to the 18th century, poet, writer and critic, Samuel Johnson. Some people deal with the knowledge of a new and potentially debilitating or even eventually fatal illness with disbelief or the quest for an alternative diagnosis or as postulated by the Swiss Psychiatrist Elisabeth Kubler-Ross which in the original form included:

The stages, popularly known by the acronym DABDA, (from Wikipedia July 12, 2017):

1. Denial—The first reaction is denial. In this stage individuals believe the diagnosis is somehow mistaken, and cling to a false, preferable reality.
2. Anger—When the individual recognizes that denial cannot continue, they become frustrated, especially at proximate individuals. Certain psychological responses of a person undergoing this phase would be: "Why me? It's not fair!"; "How can this happen to me?"; "Who is to blame?"; "Why would this happen?"
3. Bargaining—The third stage involves the hope that the individual can avoid a cause of grief. Usually, the negotiation for an extended life is made in exchange for a reformed lifestyle. People facing less serious trauma can bargain or seek compromise. For instance: "I'd give anything to have him back." Or: "If only he'd come back to life, I'd promise to be a better person!"
4. Depression—"I'm so sad, why bother with anything?"; "I'm going to die soon, so what's the point?"; "I miss my loved one, why go on?"
   During the fourth stage, the individual despairs at the recognition of their mortality. In this state, the individual may become silent, refuse visitors and spend much of the time mournful and sullen.
5. Acceptance—"It's going to be okay."; "I can't fight it; I may as well prepare for it."
   In this last stage, individuals embrace mortality or inevitable future, or that of a loved one, or other tragic event. People dying may precede the survivors in this state, which typically comes with a calm, retrospective view for the individual, and a stable condition of emotions.

What is missing from this time honored construct of the stages of dealing with serious illness or impending death is what plans one undertakes to make sure everything is in place no matter the outcome. Like an impending hanging—one should focus one's mind on the often ordinary and mundane plans to make sure that one's family is not left to struggle with the emotional challenge of loss and have it compounded by incomplete and scattered financial and estate plans without clear direction as to whom one should contact to do what?

Anyone who has been through this process either as the person diagnosed with a serious disease or has witnessed the occurrence in a close family member or friend is likely to recognize the common failures when it comes to proper preparation. One approach that I have found useful when explaining to my patients and their families the importance of such planning is to go through the major steps that are involved, using as plain language as possible. Having a check list guide is another way of making sure that the important issues are addressed and documented.

Although it may seem self-evident, the first step is often dealt with as a crises rather than a well-planned process:

Arranging for the funeral and burial:
I became a convert to the pre-arranged and pre-paid funeral many years ago after I arranged it for myself—as a way of avoiding my family having to deal with such an emotionally fraught process in the time of crises and mourning. I found through the process I went through that the funeral home was very organized, dealt with all the issues and at the end provided me with the necessary documentation and contact numbers so that when necessary one phone call and the account number would assure the process would take place as I had wished it, not under the duress of making decisions such as type and expense of the casket. As an aside, pre-paying results in a financial saving as the payment is in current dollars not an inflated price in the future. If the person in question travels a lot it is worth paying the slight premium for return of the body to one's home town from anywhere in the world which could potentially cost a great deal.

Contacting critical people:
Aside from contacting close family members the critical people I am referring to: One's lawyer; financial advisor(s); insurance agent; bank manager; wills executor and accountant. With the help of this team, most if not all if the issues related to death and the issue of interpretation of the will, procedures around the release and distribution of assets can be undertaken in the most time efficient and non-emotional fashion. One should discuss the important points with the spouse or children who would be survivors to make sure everyone who should be in the loop of decision-making is properly prepared and informed. Arrangements for immediate cash-flow should have been anticipated and arranged so that there is no problem with paying necessary expenses while awaiting the final distribution of assets.

Making necessary documents readily and clearly available:
This is one of the most important steps in the estate planning process, one of the most difficult and tedious and the one which if not done well can leave one's loved one's high and dry or at least spending lots of trying to find important documents. Of the necessary documents that must be found as soon as possible during the latter days of a loved one's illness and after the death of a loved one is:

1. Powers of Attorney for personal care and for finance and any evidence of preferred wishes for the end of life period.
2. After death:
   a. Funeral arrangements: funeral home and burial site, will and name and address of Lawyer (who will usually have an original copy of last will). It is often worth considering taking on that lawyer in at least an advisory capacity to work through the nuances and facts of the will as the lawyer is likely to have had conversations with the deceased as to priority wishes prior to death. Sometimes there may be an estate document that explains some of the preferences and wishes to the executer to try and steer him/her in the right direction as the details of the will are implemented
   b. Name of bank(s) and accounts in which loved one is primary (even if joint accounts)—and check books so that co-owner of account can readily access money during the period after death
   c. Insurance agent to make sure insurance policies that will be in force will be acted upon with the insurance company
   d. Accountant to make sure final tax return will be done properly and in a timely fashion
   e. Investment advisor(s) to make sure necessary accounts can be dealt with and estate implementation can begin for the surviving family and estate planning if they do not have their own estate manager and account manager(s)
   f. Trust arrangements if they exist
   g. Charitable donation arrangements that might be ongoing after death and their parameters
   Some of the processes may take a longer time than might have been anticipated so that it is important to make sure that what amount(s) of available money is documented and where it may be situated and what organizations or agencies have to be notified as to death so that regular payments can continue or be cancelled or changed in terms of payer.

Practical tips:
Gathering all of the pertinent documents into one binder or file would the usual way of gathering and making available this information. Putting it into an Excel spread sheet would be another way and keeping that file readily available would be more contemporary way of doing it. Using one of the many commercial products available to facilitate a digital record might make the task easier and allow for easy editing and updating and if done properly make it hard to hack or disrupt the record that may be kept in a digital format.

One product among others I am impressed with is LifeBank™. There are a number of apps for IOS and Android and on line portals for keeping a record of medical reports, etc. There are what are called ehealth Wallets—a la Microsoft's HealthVault, Apple Health and Google Fit. There a variety of apps like myPHR, WebMD and Humana. Each suffers from a deficiency in one way or another. Clearly being on line via the cloud exposes all one's medical info to the "world" of hacking—now so widespread and pervasive. Many of the apps are also focused on fitness. Others, like the Humana, concentrate on a record of claims made.

LifeBank™—whose tag is Collect and Protect—can be used as a data key, totally off the cloud, or retained on one's computer or laptop. Either way, it contains a suite of forms providing a complete record from A to Z of all aspects of one's life. One significant and noteworthy feature of LifeBank is that one can scan into it—or via a cut and paste—all manner of documents including all of one's health-related records. Inter-activity with one's hospital or clinician is immediately enhanced! Leaving aside the value and security of being armed with all the information about oneself 24/7 in the event of an emergency, medical or otherwise, one's nearest and dearest—or an appointed trusted person like one's lawyer or accountant—can also be provided with a copy data key (for safe-keeping) or know where to access it should it become necessary. LifeBank is structured as a formatted document which reminds the user of the categories that need to be documented.

Conclusion
End of life planning is difficult enough although once undertaken most people can express their wishes and preferences to their loved ones and those who will be their substitute decision makers. Having the final medical preferences, documents such as the advance directives (living wills) and the estate planned information readily available will make the emotionally difficult task of implementing all the components of an estate plan will help make sure it goes as smoothly as possible.

When you enter a car showroom, a salesperson may identify you as a small-car buyer or a second-hand car buyer, or, if you're known to the dealership, perhaps as a solid every-three-year leaser. With a label in mind, the salesperson will approach you in a particular way. The same can be said of the barista who knows which customer is a "decaf latte" and who is a "dark roast with two creams"—or, in my case at my local Tim Hortons, a medium with two milks in a refill, often with a "good morning" that includes my name. (It's only at the drive-thru window does anything beyond my coffee preference enter the conversation, because I know some of the other servers and will ask them how they're doing in school.)

It's not uncommon to see the same dynamic in medicine—perhaps less so in emergency rooms or ambulatory clinics, but especially on medical wards where one begins what could become an ongoing relationship between physician and patient.

It's understandable that physicians and nurses are primarily concerned with the medical conditions they're responsible for treating. We develop languages that help us identify these conditions, and our shorthand often turns a person with an illness and personal worries and concerns into an organ system with deficiencies that require repair. It's easy to understand the dynamic that leads to the old-fashioned and much-criticized characterization of "the gallbladder in room 203."
So how does one get around the pressure to focus on the illness affecting a person rather than the person who happens to have an illness?

Part of the answer might lie in the long training of health-care providers, when a focus on the humanities should supersede, for a substantial period of time, the focus on what is in essence the scientific underpinning of medicine. Along those lines, I have read a definition of medicine that resonates with me. To paraphrase, it says medicine is a human, interactive and dedicated profession that's informed by science. In some ways, this contrasts with more standard understandings of medicine as the science of preventing, curing and treating diseases.

Whichever approach one takes, it's important to never forget Emily Dickinson's poem about surgeons: "Surgeons must be very careful, when they take the knife! Underneath their fine incisions, stirs the Culprit—Life! "

Another key reason why the patient's identity is so important is that it strongly affects how and why they may respond to medical interventions and the people providing their care.

As well, individual stories of lives lived make medicine a most wonderful profession. The multiple stories are part of the woven and sometimes miraculous fabric of this healing profession.

The dictum I use when teaching medical trainees dealing with a patient who is unknown to them, which I have found works wonders (other than in extreme situations when no time can be spent on anything other than immediate medical intervention), is to start an interview with, "So who are you?" rather than the usual "How are you?" This allows the often-surprised patient to tell the physician a bit about their life and values through their own personal narrative.

It can also cement the personal relationship between patient and doctor (and family, when they're part of the initial discussion). After adequate time is taken to develop a personal rapport, the business of "medical science" can take place on a platform of personal identity and valued personhood.

It's vital to good medical care.

This article was originally published online at http://www.cjnews.com/

I have often talked about how important stories are when it comes to medical care. We must, of course, use the best available medical knowledge to benefit our patients, but I believe it is also important to find the humanistic aspects of care and build on them, in order to foster human relationships.The importance of learning the patient’s personal story is key to achieving this goal.

Instead of asking a new patient, “How are you?” I recommend asking, “Who are you?”—meaning, “What is your story?” Recently, before meeting a new patient, I tried to see if his name would tell me anything about who he is. Having spent many years travelling, I can often relate to people if I get a clue as to their background or nationality—which, for people with European backgrounds, is reasonably easy for me at this point in my career.

I looked at his name and could not be sure of his origins, but I thought it might be close to Greek, or at least Mediterranean. To my surprise, his wife, who appeared initially to be more outspoken, said, “we are Egyptian.” With my knowledge of Egypt, I felt comfortable enough to ask, “Are you Coptic or Jewish? The name does not appear Muslim.” The patient seemed surprised that I actually knew about the various ethnic groups in Egypt. I told him that I had lived in Israel for a number of years, so knowing about Egypt was important for many reasons.

Their eyes lit up and he said, “We are Egyptian Jews.” After I inquired further, they said that they left the country just as Gamal Abdel Nasser came to power in the 1950s and began expelling most of the country’s remaining Jewish population.

“There are only few remaining Jews in Cairo, with members of one family being responsible for maintaining the main synagogue. We knew the family, the name of which is Haroun, and the elder sister died recently so the younger one is the primary caretaker of the synagogue, along with a half a dozen or so other Jewish women—there are no Jewish men left in Cairo,” he said.

When I mentioned that some of my friends and colleagues are Coptic, he said that they were very close to the Coptic community, both being minorities and beleaguered communities in a predominately Muslim country, but had managed well for centuries, prior to the explosion of pan-Arabic nationalism.

When I retold this fascinating story to one of my Coptic medical colleagues, she said she would mention the story to her parents, without naming my patient, but but would inquire about the Haroun family.

The next morning, I received a text saying that her mother knew the Haroun family and went to school with the remaining sister. As it turns out, Magda Haroun is still involved in keeping the local synagogue active (an interview with her, titled Closing the door: the last Jews of Cairo, can be found on YouTube).

When I mentioned the follow-up to the story to one of my Coptic friends, he mentioned that he too knew the family and told me that there are in fact eight remaining Jewish women in Cairo and that Magda Haroun is the community leader.

The story reminded me that there are often only a few degrees of separation between us, and that a little searching can bring out wonderful stories (elders are often the repository of such stories). We must find these stories whenever we can, as they are our collective human legacy.

This article was originally published online at http://www.cjnews.com/

It happens a few times a month: I get a request for a meeting with a family struggling whether or not to provide a do not resuscitate (DNR) order for a frail and aged family member. Often the patient has dementia, and, therefore, the decision falls to the formal substitute decision maker (SDM), in keeping with the Health Care Consent Act in Ontario (and comparable legislation elsewhere). It's an enormous burden for many families, and the decision to comply with the request for a DNR order is often fraught with great emotional pain and reluctance.

As a health care provider and ethicist involved in conversations with families, I often hear the refrain, "I just can't bear the thought that I am responsible for my father's death. He was such a fighter. He survived the Holocaust and now this, giving up like this. I just can't bring myself to do it." There may be more than one child, and sometimes they share responsibility of being the SDM, which means both parties (or more) must agree, which could lead to family conflict and strife.

The ultimate question for families is what does CPR actually offer to their loved ones, and does withholding such intervention through a DNR order make the children (assuming they provide the order) complicit in the death of their loved ones, which is a heavy burden to carry.

Many may not realize that the development of CPR in the 1960s was meant for a very select group of cardiac arrest victims who were otherwise usually well and whose hearts suddenly stopped, but had the wherewithal and cardiac reserve to withstand CPR, which, if successful, returns an otherwise relatively healthy heart to its intended pumping function.

Over time, the criteria for implementing CPR expanded to less-well individuals, with some occasional successes. But studies of various populations found that frail elderly individuals—those who fulfilled in most jurisdictions the criteria for residence in nursing homes—did not have the heart or bodily reserve to withstand the rigours of CPR. Rather than having a "cardiac arrest"—the sudden, unexpected cessation of heartbeat in an otherwise medically intact person—what occurred was in fact death, rather than an "arrest."
What does this mean for frail elders in nursing homes, since immortality is not part of the medical repertoire? One is going to die from a combination of age and all the physical and neurological conditions that afflict those who live long enough, which often include dementia. It's not that dementia itself is the barrier to successful resuscitation. It's that dementia in the frail elderly is usually a marker for a collection of problems that make it most unlikely for someone at the end of life to survive and recover from what is in many ways a trying and almost assaultive intervention whose outcomes are in most cases very bleak.

The other concern about all the attention given to CPR and the emotional turmoil about deciding on a DNR order is the elimination of the very human activities that might otherwise occur when death without CPR is expected and anticipated. The intrusion of CPR is often accompanied by the transfer from a nursing home to a general hospital. This disrupts the potentially peaceful passing of a loved one, which is sometimes associated with prayers and other rituals, depending on cultural or religious practice. Holding hands and personal expressions of love are replaced by the often traumatic intervention of strangers and technologies that distract from the humanity of what in most cases will be the death of the person in any event. CPR creates a medically focused event that sacrifices what may be the last chance for a family's expression of humanity and love.

This article was originally published in the December 22, 2016 issue of the CJN.

Further Reading

1. Gordon M. Assault as Treatment: Mythology of CPR in End-of-Life Dementia Care. Annals of Long-Term Care: Clinical Care and Aging. 2011;19(5):31-32.
2. Schafer A. Deciding when life ends. The Ottawa Citizen. February 8, 2008. www.canada.com/ottawacitizen/news/story.html?id=6af86b76-32ba-4c41-b11c-...<redir.aspx?REF=LbTtdqvjyWGkMsaVANVz8Hs_unV55CS3e5aUspFEIwWSW4D-sTnUCAFodHRwOi8vd3d3LmNhbmFkYS5jb20vb3R0YXdhY2l0aXplbi9uZXdzL3N0b3J5Lmh0bWw_aWQ9NmFmODZiNzYtMzJiYS00YzQxLWIxMWMtMjJkZjc3NGQ3NGQ0> [3]. Accessed January 13, 2011.
3. Gordon M. In long-term care, the "R" in CPR is not for resurrection. Ann R Coll Physicians Surg Can. 2001;34(7):441-443.
4. Ehlenbach WJ, Barnato AE, Curtis JR, et al. Epidemiologic study of in-hospital cardiopulmonary resuscitation in the elderly. N Engl J Med. 2009;36(1):22-31.
5. http://www.rmmj.org.il/userimages/408/1/PublishFiles/418Article.pdf

Reunions are unusual and sometimes bizarre phenomena. It is curious that people seem to be drawn to meeting over periods of many years or even decades with people that they may or may not have been close to during some period of their formative years of education. Think about the likelihood that at a high school reunion, you might meet more than a few people of significance in your life or with whom you have even the remotest interest in knowing what they have done during the intervening years. For university or post-university reunions one might imagine there might be a greater chance of congruence of life experiences and the possibility of a more compelling reason to know what life has done to the group individually and collectively.

I recently attended my “50th” medical school reunion in Dundee Scotland. Though born American I decided to “study abroad” as a means to satisfy my desire to travel—something I recognized from a 6 month stint as a university student wandering through Europe in my “junior–3rd year”. That 6 month stint stirred my determination to study overseas and as it turned out I was fortunate enough to be accepted into an English language first quality medical school in Dundee Scotland, which at the time was the clinical training resource to the renowned University of St. Andrews. It subsequently separated from its “mother ship” and became the University of Dundee that is the home of what has become a highly regarded medical school.

I have not missed any reunions, which started with the 10th and have continued every five years since then. At the 10th our guest speaker was our chief of medicine—Sir Ian W. Hill who was at that time the physician to the royal family when they were in Scotland that usually occurred at one of their favourite retreats, Balmoral Castle, with its beautiful surrounding hills and woodlands. Sir Ian, who was one of the greatest lecturers I have ever encountered—able to mesmerize a lecture hall full of medical students with his stories of illness and disease--cautioned us to stop meeting after 50 years as there might be few participants because of death and illness.

The reunion was a treat—it was in Dundee rather than as previously in St. Andrews; my youngest daughter joined me, having been at one about 15 years earlier and it fulfilled what reunions do—reminded us of our roots, of our history and gave each of us (we were only 25 classmates out of a class of 70—plus in many cases spouses)—a chance to reminisce about our lives and what seems to be the core of the attraction of reunions, to recount our recalled and shared experiences.

Even though many of the same stories were shared at previous reunions, recounting the stories of escapades, travel, parties, shared flats, our idols and failures as teachers and sadly our classmates who had died in the interim period—the whole experience was a mixture of rollicking fun, uplifting narratives and sad recall of dear classmates who had left us—with this reunion having lost three classmates in the previous 6 months—ones with whom I was especially close.

Like many things in life that we do, there is no compelling explanation or objective benefit in a reunion—but since it seems to be almost universal among so many people, it must resonate with those of us who wish to and usually attend. Reliving and sharing our past, confirming our recollections and in some ways fulfilling the curiosity about “what happened to …..?”Although Sir Ian counseled us against going beyond 50—as we were preparing to leave, a small group of us, including myself, planted the seeds for perhaps the next—55th reunion—I hope so and hope I can attend.

This article will be published online in January 2017 at http://www.cjnews.com/

One always hopes that as medical practitioners, we will be able to focus our attention on the medical issues faced by seniors and help families cope with the fears, disappointments and tragedies that are faced by loved ones in the midst of what are often life-altering illnesses.

Throughout our initial medical training, and most often during post-graduate training programs, the primary focus in general is: what is the "best of medicine" and what does "evidence-based medicine" tell us about treatment decisions and their ultimate impact on health, well-being and, often, the likelihood of death? This is particularly the case in the care of the older adult—whether in geriatric medicine or eldercare.

What is often surprising and baffling, especially to younger physicians, is the situation where the core of what appears to be the challenge in care provision is negatively tinged by what might be called family "strife." At times, however, a more appropriate term would be venomous, hateful actions—actions that ultimately will be destructive to the family fabric.

This should not be surprising to anyone who has even a modest understanding and familiarity with the world of literature—whether limited to English works, or more broadly including European or other literature.

Those medical trainees who have worked with me have in all likelihood heard me either seriously or humorously say, "If I were king, all first degrees would be in English literature." Or when there is a complex family dynamic playing out, I might say, "It's King Lear—if you have not read it ever or lately, read it or read it again—it's all there."
Sometimes I feel like that great American comic Jimmy Durante, who was quoted as saying, "I have a million of them, a million of them," referring to his often delectable jokes. According to an online biographical history, it has been said that "I've got a million of 'em" is what Durante (1893-1980) often said after telling a corny joke. Durante was credited with "I've got a million of 'em" in a 1929 newspaper story.

I say this when referring to complex family situations in which what appears to be the worst in human interactions seems to be playing out. Often the issue is related to money (or property), and if one is in a position to hear the story from all the parties, it often becomes clear that, for whatever reason, the pot has come to a boil at this juncture of life. This is usually because the flame heating the water that's not boiling has been on for what appears to have been many years.

Most of us know of such stories, hopefully not in our own families, but it is unlikely that there is a family who is not familiar with a "Lear-like" scenario in someone close to them. Greed, jealousy, hurtful memories, mean-spirited personalities, events that occurred—sometimes decades earlier—that were never resolved or left indelible scars are often the reasons cited for the enmity.

I have had the good fortune to observe that, on some occasions, especially when a parent, in particular, is dying, though it could be another relative, there is the possibility of repairing longheld animosities and bringing long-estranged family members back together. It does not always succeed, but I have witnessed the monumental efforts of health-care staff—especially those in social work, nursing and medicine, although any and all of the health-care staff can be key—in bridging the emotional moat that often separates family members.

It may not always work, but I believe it is always worth the effort. Living with the result of lifelong family strife is often disabling, and the scars that occur and that are left can have long-lasting negative effects on people's lives and their own abilities to have meaningful and binding relationships with their siblings and offspring.

This article was originally published online at http://www.cjnews.com/perspectives/opinions/dealing-family-strife

Physicians usually become adept at choosing medications for the complaints and illnesses that patients bring to their attention. Doctors have to become familiar with the common medications that are indicated for the most prevalent illnesses they see, and there are many resources available to keep physicians as up to date as possible on the most effective drugs and what the medical evidence says about indications, side effects, drug interactions and priorities of care at various points in the progression of a patient’s illness. In the elderly, there are often a number of illnesses competing for possible medical attention and intervention.

Dementia is the umbrella term used commonly to describe the cognitive decline that affects many older individuals. It may be due to a number of recognized conditions of which Alzheimer’s is the most commonly recognized, but the effects of blood vessel (vascular) disease are also very common factors in the aging population.

There are some medications for these conditions that affect memory, judgment and behaviour, the symptoms of which may cause great strife in the individuals affected as well as their families. The symptoms often cause immense challenges when it comes to the use of possibly helpful medications. The pharmaceutical products available for improvement of memory and judgment are often helpful in some individuals, but even when they are effective, they do not “cure” the cognitive impairment. They may, however, provide some improvement in certain aspects of cognition and especially socialization and interactive abilities.

Most challenging are the medications available for what are called behavioural manifestations of dementia, so much so that decisions to transfer to protective living environments such as nursing homes may be the result of such behavioural processes. These events may occur periodically and in what appear to be unpredictable outbursts. Although there are medications that are often used under such circumstances, which may be effective in decreasing the intensity of the disturbing symptoms, they—as do all medications—have potentially bothersome side-effects that may limit their efficacy.

During the past few years, the medical and non-medical health-care professionals involved in such care decisions have discovered that a number of non-medication interventions may be very effective and helpful without the risk of medication side-effects. Probably the most well-acknowledged and studied has been the use of individualized music, which has been shown to quell some of the agitations and disruptive behaviour associated with dementia. There are programs through the Alzheimer societies that provide personalized music on small iPods that can be used during episodes of behavioural outbursts.

In addition, there has been an expanding experience of using a range of alternative treatments such as pet therapy and doll therapy. In the latter, agitation, primarily in women, can be calmed by providing a life-like infant doll that brings out the calming and nurturing reactions many older women experienced during their earlier maternal days. Massage therapy and aroma therapy have also been used with good results in certain individuals.

The importance of these alternative therapies is that, unlike medications, they usually do not have side effects that might limit their effectiveness. They often tap into aspects of the person’s residual abilities that bring out what might otherwise be hidden aspects of his or her personality. Of greatest benefit is that these therapies are often provided by concerned and loving family members or dedicated health-care professionals, thus enhancing the social aspects of care that have been identified as being important through the course of conditions responsible for cognitive impairment.

Just imagine listening to one’s favourite music with an affectionate cat on one’s lap, while someone who cares enough provides a hand massage, rather than a dose of a medication that may cause drowsiness, increase the risk of falls and impair the person’s ability to walk securely. It may not always work, but it is always worth a try. So it’s important to be persistent and see what might work.

This article was originally published online at http://www.cjnews.com/perspectives/opinions/beyond-medications-dementia

Many older patients of mine have metal implants in their limbs following some form of reconstructive surgery. It is the age of the bionic person.

With so many "snowbirds" and with security metal detectors almost everywhere, there is often an expressed concern about whether having a metal implant in the hip or knee might delay you or lead to problems when you pass through airport or cruise security metal detectors.

I recently had a comparable experience when flying, which I do quite often. I had acquired a MedicAlert bracelet, which also is a common accoutrement of many older patients. As I passed through the security arch having already removed all my usual triggers (phone, wallet, belt, watch), the alarm went off—I realized that the Medic-Alert bracelet, whose clasp is such that it is very difficult to open, clearly for safety reasons, was the culprit. I mentioned it to the agent—who took his wand and clearly identified the source of the alarm, and when he finished the rest of the scan, he let me through without any problems.

I was curious and perused the medical literature on the subject, given the high prevalence of seniors with metal in their bodies—part of the contemporary miracle of modern medicine. I recall a time when severe knee and hip arthritis left seniors either completely immobilized or chronically racked by significant, often life-altering pain.
It is not that the surgery is "easy," and it's not always successful, but for many, it can have a dramatic and long-lasting beneficial effect. No less important than the surgery itself is that there seems to be a very flexible ceiling on age—with some very elderly individuals found suitable for surgery—depending on what other medical conditions exist.
Many of the articles that discuss the issue remark on a practice in the past, when patients with metal hardware in their bodies often provided the security agents with letters or cards attesting to their condition. However, it is now felt that these are not needed nor heeded, as there is no way of verifying the veracity of the author—and the backup metal detector or full body scan will do the trick more effectively and assuredly.

What most of the articles on the subject suggest is that the traveller should alert the security agent right up front about the issue rather than waiting for the detector to go off. I thought of having the clasp on my MedicAlert bracelet changed to one that could be more readily opened and closed but decided that the security of a bracelet that could not readily inadvertently fall off was more important than the minor inconvenience of a manual security scan.

Some things, we often say, just "come with the territory." Travel has become more complicated because of issues of security. There is no doubt that the recent tragic bombing of a passenger plane in the Middle East will result in either more intense scrutiny of travellers or some new directives on screening—just when things seemed to be easing up in North American airports.

Medicine has become more complicated because of novel treatments that, although life enhancing or life saving (such an internal heart pacemaker which also has metal wires), may cause some modicum of inconvenience at the security gate when people travel.

This seems to be a small price to pay to achieve both desirable ends—being able to walk unattended through a security gate after restorative surgery, and making sure that fellow travellers are safe in their travels.

Still, during those years when I was studying medicine all this would have been in the realm of wild imagination.

This article was originally published online at http://www.cjnews.com/living-jewish/travel/do-metal-implants-hinder-your-ability-to-travel

I was sitting in a coffee shop next to table with 5 older women. I could hear one of them say to the group, "I am cutting bacon out of my diet—but I do love it once in a while". "Why are you doing that, one of the woman replied?" "I just read that bacon and salami and hamburgers can cause cancer—didn't you see the paper yesterday—it was also on the news last night—it is almost as bad as smoking cigarettes—who would know—I hope it isn't too late as I have bacon at least once a week on the weekends when we go out for breakfast."

It always amazes me how when something is reported in the media, the response ranges from hyperbolic concern by reporters and the public to complete lack of concern by others. It can be very hard for the public, and at times the medical profession to decipher the real implications of the many reports that focus on public health threats from the world around us. I have watched as items such as eggs, coffee, various fats and oils, alcohol, different types of exercise and where we live and what we breathe become the focus of notices to the public to either "beware," "take heed," "change practice" or "just stop what you are doing".

Some public health warnings are real and immediate and often due to the finding or some food item that is being eaten or prepared in "real time" that poses an immediate threat to consumers. A recent example is the warning and resultant steps taken by the restaurant chain Chipotle where at the time of writing, "More than 40 people have fallen ill with E. coli food poisoning after eating at Chipotle Mexican Grill restaurants in six different states…the outbreak expanded with new Chipotle-linked E. coli cases reported in California, Ohio, New York and Minnesota, the U.S. Centers for Disease Control and Prevention said."

This type of warning is reminiscent of those that are propagated by public health agencies during BBQ season reminding consumers to BBQ their chicken and hamburgers particularly well because of risks of E-Coli outbreaks—a ubiquitous bacteria that can be destroyed by proper cooking but may linger in undercooked or rapidly cooked meet where the necessary bacterial-killing inside temperature is not reached. In 1993 there was a serious outbreak in the Jack in the Box chain of fast-food outlets in the United States that resulted in hundreds of illnesses some of which resulted in chronic and serious illnesses—it had a profound impact on new standards for food preparation in the fast-food industry.

These warnings are different from public health warnings about eating habits—having watched the potential harmful effects of coffee come and go over the years, I was forever grateful that the final estimation of this almost universally consumed drink, is that it probably has more beneficial effects on health parameters than negative ones—for me coffeeophile a public health blessing: yet the European Union recently recommended against drinking more than four cups of coffee a day based on caffeine consumption. In contrast is the recent report that," Hold on tight to that cup of Joe—because it could save your life. New research out of the Harvard School of Public Health says lifelong coffee lovers could be at less risk of dying from type two diabetes, suicide, cardiovascular and neurological diseases. "We found people who drank three to five cups of coffee per day had about a 15 percent lower [risk of premature] mortality compared to people who didn't drink coffee," one of the authors of the study, Walter Willett, told NPR.

So what about the bacon, hot dogs, corned beef and pastrami? What about the BBQ steaks and hamburgers? Does everyone who is not an life-long vegetarian or subscribe to the Mediterranean diet run the risk of sudden death from a BLT or hot dog at their favorite ball game? That a recent study in the US reveals that 57% of American Jews eat pork in one form or another (http://www.pewforum.org/files/2015/11/201.11.03_RLS_II_full_report.pdf)—should not necessarily be interpreted as a sure sign of anti-religious drift or impending doom, but rather the way surrounding cultures and practices influence people of all ethnic and religious backgrounds.

The final message should be: Most things can be eaten in a moderate and balanced fashion, unless there are specific health-related concerns for an individual—more important than how much bacon, meat and pastrami one eats, is that the portions are in keeping with one's individual nutritional needs, that they are balanced with other non-meat foods, including vegetables and fruits and that they are prepared and cooked well Food is one of the most enjoyable aspects of life—we should not make ourselves obsessively concerned every time a new "warning" comes out about the dangers of life and what we eat—hang in there—likely the recommendation will change over time—take it all in stride- with a dollop of mustard.

This article was originally published online at http://www.cjnews.com/perspectives/ideas/wheres-the-beef