Counting Each Day by Making Each Day Count

It was the 60s folk-rock band The Byrds that made the immortal words of Ecclesiastes sing to us through the music composed by Pete Seeger: “There is a time for everything, and a season for every activity under the heavens: a time to be born and a time to die, a time to plant and a time to uproot, a time to kill and a time to heal, a time to tear down and a time to build up, a time to weep and a time to laugh, a time to mourn and a time to dance…” (Ecclesiastes 3:1-4). In essence, the biblical author of these lyrics teaches us to appreciate the moment at hand for it passes so quickly. Instead of dwelling in the past or wishing away the present in the hopes of some unattainable future, Ecclesiastes beckons us to live in the present, the here and now, and appreciate the wonder of this moment right now.

The same can be said about life in general. We need to hold onto the preciousness of life by enjoying each day, maximizing its potential and learning its lessons. Indeed, a meditation on the prayer announcing the new month proclaims: “Teach us to number our days that we may use each precious moment wisely.” It is not a matter of mere longevity, of counting the days as they pass one by one that is important, but how we make each day count.  Quality of life is as important—if not more so—than quantity of life. It is a special blessing to have both quantity and quality of life.

In order to get the most out of our lives, both in times of challenge as well as in times of blessing, the Spiritual Care Department has created Spiritual Care Resource Centres on every residential floor of the Apotex and every patient floor of the hospital as well as on the main level of the Terraces. These Spiritual Care Resource Centres are display racks stocked with various LifeLight booklets written from a uniquely Jewish spiritual perspective to provide comfort, advice and additional resources for help. These LifeLights booklets are inspirational information brochures about challenges to our emotional and spiritual lives and how to deal with them. They are written by wise and caring souls, who know the inner territory of grief, doubt, confusion and longing. Each seeks to lighten a dark and difficult path down which we may be travelling in the hope of offering a way through that darkness into the light of personal meaning and wholeness. Each seeks to help us make the most of every day. I invite you to pick up a copy of those booklets that speak to your circumstances and find solace and direction from its contents.

Currently we are in the period of the Jewish calendar known as Sefirat HaOmer (Counting of the Omer). Jews mark each day from Passover to Shavuot, from slavery to freedom, from persecution to redemption, from spiritual darkness to revelation on Mt. Sinai, by counting an Omer. The Omer was a measure of barley grain brought to the Jerusalem Temple as an offering of thanksgiving for the annual harvest of grain. It symbolized the people’s overcoming of the growing season’s uncertainties and hope for a fruitful future. In many ways, this spiritual journey of our ancestors mirrors our own lives with their triumphs, disappointments and hopes. Indeed, just as we count the days in the ritual life of our people, so may we mark the significant moments in our own lives with perseverance in times of difficulty, appreciation in times of bounty and hope in what lies ahead. Amen.

Bill's Journal for April 17, 2013

Over the past number of weeks, the issues of brain health and the importance of investing in scientific research have become major topics of conversation among social policy commentators. It's not that the issues are new, but several notable connections to brain health and research have dominated the headlines, stimulating renewed discussion and debate.

The deaths of British Prime Minister Margaret Thatcher and former Alberta Premier Ralph Klein, afflicted with Alzheimer's Disease and frontotemporal dementia, respectively, have shone a light on the tragic implications of these particular aging associated brain illnesses. Jonathan Kay, the Comments Page Editor of the National Post, mused about how much richer our world of ideas might have been had Thatcher remained of sound mind during the last five years of her life.

And a call by US President Barack Obama to invest in a massive project to map the human brain as a way of understanding diseases such as Alzheimer's has gained international attention for what some call its vision, and others call its audacity. What few are disputing is the importance of learning more about how our brain works, why it often weakens as we age, and how we can strengthen it—with the goal of extending our cognitive abilities and supporting our emotional well-being for as long as possible.

If ever Baycrest Health Sciences needed validation that its mission and vision are important, this is it. Kay wrote that "no other challenge or threat—not fiscal collapse, not global warming, not terrorism—takes a greater toll in ruined lives" than conditions that affect the brain. He asserts that a cure for Alzheimer's would be the medical equivalent of smallpox and polio vaccines combined.

Baycrest is on the vanguard of a global race to understand the aging process of the human brain, and to find ways to support and strengthen brains that do not age well. Already, a number of our research projects show immense promise for future breakthroughs. President Obama's proposed brain mapping project has strong convergence with our own Virtual Brain Project, which is already well underway in development with global collaborators and is expected to be rolled out to clinicians for further beta testing later this year. A consumer-focused application that allows users to test their own cognitive abilities—fully informed by Baycrest science, and the first of its kind to be scientifically validated--will also be unveiled to the public later this year by our spin-out company, Cogniciti. These are just two examples among many that are positioning Baycrest as a world-leader in aging and brain health.

By taking our groundbreaking research from bench to bedside, we will transform aging for seniors, both here on Bathurst Street and around the world. We will uniquely contribute to creating a "new, old age." We know brain failure is not inevitable with aging, and we know our work will help preserve and extend the cognition and emotional well-being of older adults. Our goals, like President Obama's plan, are perhaps both visionary and audacious. But they are worthwhile and they are achievable.

Dr. William E. Reichman
President and Chief Executive Officer
Baycrest Health Sciences

Rabbinic Reflections by Rabbi Geoff

In a bizarre UK news report recently, police revealed that a man, who had been missing for three years, had in fact been living in a department store. The department store was one famous for not having clear exit signs and many suggest it was a ploy to keep shoppers shopping.

Three years trapped and wandering in a department store seems like nothing when compared with 430 years of captivity and 40 more years of wandering in the desert, but for the Jewish people, that was their experience while in Egypt long ago. Enslaved by Pharaohs and enduring all manner of hardship, God—through God’s servant Moshe—frees the Jewish people by punishing the Egyptian taskmasters with 10 plagues. God then commands the Jewish People to celebrate the Passover in thanksgiving.

Passover commemorates our freedom from slavery and oppression, but it also leads us to Shavuot and the giving of Torah on Mt. Sinai. This teaches us that freedom from slavery must lead to a life of civil and religious commitment. Often, in our past, we have been denied both and now that we enjoy civil liberties we should also commit ourselves to maintaining our fidelity to Jewish spiritual life. Too often, in fleeing from the shackles of past restrictions, we abandon our religious identity in favour of assimilating into the mainstream at the cost of losing our Jewish heritage, values and identity.

Although we have much to celebrate with the freedom we enjoy here in Canada, we must never forget our unique heritage and the mores it teaches. Other countries throughout our Jewish history looked at us with derision and disgust, denying us basic human dignities as well as rights and freedoms. Not so in Canada. Although faced with times of hardship and anti-Semitism, we never experienced Inquisition, pogrom or Holocaust within these borders. The Charter of Rights and Freedoms guarantees our ability to celebrate Judaism free from shame, persecution or pressure to assimilate and disappear as a distinct culture or peoplehood.

The best way we can thank Canada for the freedoms we enjoy, is to honour our heritage, celebrate the unique contributions we have made to Canadian life as Jews and inspire the next generation by bringing our unique values, perspectives and insights to the marketplace of ideas with pride. This is especially true as Baycrest Health Sciences becomes a global player in healthcare provision and brain research. Let us not wander aimlessly in a desert of lost pride commitment or identity, but instead march proudly to the promised land of continued commitment to Jewish life and contribution to bettering the world in which we live.

May you and your dear ones enjoy a kosher and joyous Passover! With all good wishes, from home to home,

Rabbi Dr. Geoffrey Haber
Director, Spiritual Care
Baycrest Health Sciences

Offering patients more choices about end-of-life care

A National Post story (Nov. 8) reported that New Brunswick was the latest province to move in the direction of offering patients more choices about end-of life-care, beyond the standard “do or do not resuscitate” policies.

Fast on the heels of this article was a story in The New York Times (NYT) on Nov. 24 about end-of-life care. The NYT reported that when advance care planning is done well “there is good evidence that…it can greatly increase the likelihood that patients will get the care they really want. And, as a secondary benefit, their choices may help reduce the cost of health care as well.”

What I found surprising about the National Post article was that one would think after reading it that offering dying patients more choices in their end-of-life care was a novel idea. As the NYT article pointed out, the history of so-called advance care planning dates back several decades. Canada has played a strong role historically in the development of the idea of the “living will” – a document used for the process of stating one`s wishes and values for end-of-life care, which can be expressed verbally or in writing. In Ontario it is supported legislatively through the province`s Health Care Consent Act.

The NYT story states, “Many people sign living wills that specify the care they want as death nears and powers of attorney that authorize relatives or trusted surrogates to make decisions if they become incapacitated”. As part of a nation-wide American project, Physician Orders for Life Sustaining Treatment have been created to ensure that a patient’s wishes are followed and not misplaced or too vague for family members to be sure what a comatose patient would want. According to the NYT article: “With these physician orders, the doctor, or in some states a nurse practitioner or physician assistant, leads conversations with patients, family members and surrogates to determine whether a patient with advanced illness wants aggressive life-sustaining treatment, a limited intervention or simply palliative or hospice care.”

With the shift toward giving patients more choices about their end-of-life care beyond do or do not resuscitate, we need to be careful of the real risk of developing a quick and cheap fix – that is, relying on a simple form in which people select from a menu of categories of choices for their final phase of care. This process has been shown by many in the field of ethics and end-of-life care to be too minimalist to capture the nuances and emotional complexities of expressing end-of-life wishes. Many would say the important part of the process is not a “form” that is filled out, but a robust conversation with those that you depend on to respect your values and wishes and interpret the potential treatments offered when the time comes to agree to or reject a treatment.

Pre-planning one’s future is never easy and can lead to unexpected and unwanted consequences if not done with careful thought and planning. The importance of the National Post and NYT stories is that they support the importance of having the conversation with close family members or those you might expect or appoint formally to carry out your wishes when you are no longer able to do so. This personal responsibility must be supported by public policy initiatives that promote education and training of those who ultimately will be responsible for assisting individuals and their families in tackling this challenge.

Dr. Michael Gordon is the medical program director of Palliative Care at Baycrest Health Sciences, co-director of their ethics program and a professor of Medicine at the University of Toronto. A prolific writer, his latest book is Late-Stage Dementia: Promoting Comfort, Compassion, and Care.

Holocaust Survivors share concerns about troubling trend

Shoshana Yaakobi and
Elaine Kohn

The New York Times and CBC Radio have reported on a controversial trend among some children and grandchildren of Holocaust Survivors who are tattooing their parent/grandparent’s concentration camp number on their own arms.

Those who are doing this, from their perspective, believe that they are honoring their survivor relative. For them, the tattoo is not only a symbol of the horrors of the Holocaust and a tribute to their memory of their Survivor relative, but also an act of remembrance, a reminder that they will never forget their relative’s Holocaust nightmare, and a mark of respect.

As social workers who run a support group for Holocaust Survivors at Baycrest Health Sciences, we recently discussed this issue with our clients. Although they understand and accept that this particular act is meant to express their children’s/grandchildren’s love and respect towards them, group members expressed great concern over this trend.

In their minds, not only is the act of tattooing one’s body a violation of the principles of Judaism, but the tattoo for many survivors is a graphic constant reminder of the dehumanization and barbaric cruelty of the Nazi regime. Holocaust Survivors and particularly those Survivors who were interned in concentration camps were subjected to the most severe and horrific experiences one cannot even imagine. As Survivors struggled to rebuild their lives and raise families following the Holocaust, their main concern was not to “scar” their children with their horrifying experiences. Survivors from our support group told us they wanted to protect their children and ensure that the trauma they had lived through would not knowingly be transmitted to their children. Their greatest wish, they told us, is not to upset and emotionally damage their children.

Consequently, this growing trend of seemingly honoring Holocaust Survivors with camp number tattoos actually negates and is contrary to what many Survivors hope for, said those in our group.  For Survivors, their greatest accomplishment is their grandchildren, a constant reminder that Hitler did not succeed.  To see a grandchild with their own concentration camp tattoo number on their arm feels like a reminder of Hitler and his quest for the extermination of Jews.  Frequently seeing such a tattoo would only trigger painful memories of their Holocaust experience.

For any children or grandchildren of Survivors who are contemplating replicating their relative’s concentration camp tattoo on their own arm, it is critical that they have a discussion with their Survivor relative and other family members before doing something that may serve only to cause panic, alarm and terror in those they are paying tribute to.

Shoshana Yaakobi and Elaine Kohn co-lead a support group for aging Holocaust Survivors in the Apotex Centre, Jewish Home for the Aged at Baycrest Health Sciences.

Are we prepared for cognitive decline in the workplace?

Marcia Sokolowski, PhD, Co-Director of Ethics, Baycrest

Recent news reports of a Canadian senator taking a leave of absence from her Senate job due to cognitive health problems sparked quite a reaction from the media, politicians and the public at large – some of it very cruel.  As an ethicist for Baycrest, I was invited by CBC Radio’s The Current to participate in a panel discussion about the ethical issues this situation raises, particularly when cognitive impairment is witnessed within the workplace environment.  I made a number of points that I wanted to share with you all again. 

Our population is aging and the existence of cognitive impairment in the workplace is an ever-growing reality that we are going to have to face up to, especially as more of us choose to work beyond the traditional retirement age of 65. The ethical issues are complex and deserving of much thought and attention.

A person with a diagnosis of early-stage Alzheimer’s, for example, may lack capacity in certain areas of decision making, but be perfectly capable in many other aspects of life. We need to think of cognitive capacity as fluid – it waxes and wanes; it is highly nuanced, and not black and white.  I prefer to think of it as existing on a continuum, not rendered to be all or nothing. There are many realms of decision-making, such as financial, social and emotional abilities.  Dementia does not affect every single aspect of one’s existence all at once and we cannot predict the timing of the trajectory of changes.  If one lives with dementia long enough, there is the possibility of becoming incompetent in every way; but the road to the end is not a straight line.

There are no federal or provincial strategies in place yet to address cognitive health in the workplace and employee and employer rights, but I would think we need to move on this sooner rather than later as our population ages.  We require an ethical foundation that will steer us in making morally justifiable decisions and this foundation needs to be based upon moral principles.  There must be trust that the individual’s privacy, under normal circumstances, will not be breached.  We must ensure that the person feels safe to confront his/her fears and to seek help from their physician and Employee Assistance Program without fear of losing their job right away.  We have to fight against the stigma associated with dementia and our North American focus on cognitive prowess being the supreme definer of our identities.

If an employee needs to leave the workplace due to cognitive decline, HR departments have a role to play in helping the individual transition out of the workplace in a humane way while preserving their dignity, and ensuring attention is placed upon the employee’s strengths and capabilities, not on what is “lost”. It is important to respect the trauma and devastation that accompanies this diagnosis and whenever possible allow for a job transition strategy that is not abrupt but rather a process of transition over a period of time with counseling support. The aim is to help the person and their family prepare for what can be a considerable life change; but one in which they feel  empowered and informed as to potential cognitive rehabilitation treatments and lifestyle strategies that can help maintain dignity and quality of life to the greatest extent possible.

Marcia Sokolowski, PhD, is Co-Director of Ethics at Baycrest Health Sciences, a Member of the Joint Centre for Bioethics, and Assistant Professor, Department of Medicine, University of Toronto.

Warning: Distracted Pedestrians Ahead

John Anderson, PhD student, Rotman Research Institute, Baycrest

I read stories in the media recently about a new public awareness campaign the Toronto police have launched, called Heads Up! Distraction Can Be Fatal. It's aimed at a new risk group - distracted pedestrians. It's a common a sight to see people walking on busy streets and other public spaces while thoroughly engrossed in their electronic devices. The growing number of pedestrians injured or killed while texting, talking, checking emails, or listening to music with their earbuds, underscores a finding that psychologists and neuroscientists have known for decades - people cannot manage simultaneous challenging tasks effectively.

When it comes to multitasking, there are two main theories dominating attention literature. An early theory suggested that people can split their attention and devote an equal share to each task.  This has since been replaced by the "task-switching" perspective which suggests one task dominates a person's attention almost completely until they "switch" to another. One might think of attention in this case as being a powerful beam of light that jumps back and forth between two objects, each of which can be illuminated separately, but not together. There are, of course, exceptions to every rule. Some people born without a connection between the two halves of their brain have shown a remarkable ability to process the right and left side of their visual fields separately. One such individual, the savant Kim Peek, was reputed to be able to read two pages from a book simultaneously with each of his eyes independently scanning a single page. Most of us, however, are not capable of this.

It is true that certain tasks, such as walking, can become "automatic" and not require as much effortful attention once started. This explains why people can walk, talk and text simultaneously - most times without incident. Walking is generally not that demanding on our attention system.  This is well and good unless unforeseen obstacles suddenly appear in our path that cannot be handled automatically.

When startled, most mammals (including humans) activate what is known as the orienting reflex.  Their entire bodies shift to alert them to the perceived threat. This reflex is designed to provide enough time (albeit a second or two) to avoid danger. Unfortunately we have become desensitized to cars, bicycles and other potential pitfalls in our cityscapes and they no longer register as potentially dangerous stimuli. This means that when pedestrians finally switch their attention from their electronics and realize their predicament - the pot hole ahead, the car racing through a yellow light - it may well be too late. Ironically, distraction may have a silver lining for some. The people with the greatest risk for distraction (for example seniors or those with attention deficit disorder), are the least likely to be fully engrossed by any one task and most likely to notice potential danger!

John Anderson is a PhD student at Baycrest's Rotman Research Institute (RRI) and the University of Toronto, and is co-supervised by RRI senior scientists Drs. Cheryl Grady and Lynn Hasher. His research with these scientists includes the cognitive control of attention (and distraction) and how time of day and circadian preference affects cognition and brain networks.

Improving physician communication skills in end-of-life care

Dr. Michael Gordon
Medical Program Director
Palliative Care, Baycrest

The July 15th, 2012 article in The Globe and Mail, Go gentle into that good night highlighted the importance of educating physicians at all levels of training and practice as to the challenges and satisfaction in communicating successfully with patients and families when end-of-life issues are looming. Although the focus was in the venue of intensive care, the principles are universal.

The current stage of my working life has focused on a combination of palliative and end-of-life care, with a special emphasis on dementia combined with an important interface with medical ethics. After three decades in geriatric medicine, and just prior to my retirement as Vice President of Medical Services and Head of Geriatrics at Baycrest, I agreed to "cover" the palliative care unit administratively for a limited period. That "limited" period lasted more than a year, and then as I retired from my "chief" positions I accepted the administrative supervisory role on the palliative care unit at Baycrest where I currently work. I had completed my masters in Ethics at the University of Toronto and began to shift the focus of my clinical practice to dementia. Those changes resulted in an emphasis on end-of-life discussions with patients and families which became a core part of my activities. I realized that the necessary skills and attitudes required to carry out this role were often inadequately addressed in medical education.

The Globe story highlighted a unique communications program that is helping to fill this gap, offered at Toronto General Hospital for doctors-in-training. Baycrest will also be hosting an educational workshop in this area later this fall. As a physician, I want to help families deal with the emotional tragedy and distress of knowing they are going to lose a loved one. I have tried to enhance the communication process by writing my latest book, Late Stage Dementia: Promoting Compassion, Comfort and Care, so that health care professionals as well as family members of ill loved ones understand there are many factors to consider when trying to achieve the goal of successful palliative care. I also encourage everyone who has an interest in this area to read the Globe article (linked above) by Carly Weeks.

Dr. Michael Gordon is a medical professor, ethicist and one of Canada’s best known geriatricians. His work to advance the understanding of aging and end-of-life care is valued by both public and professional audiences. Dr. Gordon explores and addresses the difficult questions of caring for the elderly with late-stage dementia in his latest book.

Viral video of bullied grandmother sparks rush of philanthropy – and reminds us to live with integrity

Corinne Rusch-Drutz
Director, Digital & Emerging Platforms, Baycrest

The astonishing story of Karen Klein – the school bus monitor who grabbed the Internet’s attention last week after shocking video was uploaded to YouTube of her being bullied by a group of kids – has struck a collective chord for good reason.  The video has created a tidal wave of support and emotional outpouring for the 68-year-old widow.  The story caught the attention of a Reddit user who put out a call to action, asking people to support her. The post resulted in donations exceeding $660,000 (and counting), the majority from total strangers who saw the video and were struck by Klein’s ability to continue to do her job in the face of such abuse.

In less than a week after the incident became public, Klein’s story has become more than just a narrative of goodwill triumphing over hate.  It is a remarkable example of viral fundraising – that is to say, a campaign that sparks an immediate human interest and is shared and spread by individuals via social media recommendations. A random individual touched by the video made a simple request:  to give the aggrieved bus monitor a vacation. He set a goal of raising $5,000, and within days raised well over one hundred times “the ask”.

There are several clear reasons for the success of the campaign. People saw an untouched video of a real-time incident and were sickened by the behaviour of the children on the bus. Bullying at any age strikes a chord because somewhere each of us has experienced disenfranchisement and hurt and it’s ugly. Finally, Klein was able to keep her cool in the face of the brutality, despite being touched inappropriately, threatened with being stabbed, and having her house ransacked, among other injuries and insults. 

Klein’s story is being watched closely by fundraisers around the world and can teach us some important lessons about the value of a social media campaign in raising both awareness and funds.

• Begin with an authentic message. Klein’s story is about as real as it comes, offering a brutal glimpse into real-life school-age bullying.
• Keep “the ask” straightforward, here a vacation of a lifetime.
• Spread the word. There’s a reason they call videos viral when they spread like germs far and wide. The same is true for viral awareness-raising for any cause.

The lessons are ones we are paying close attention to at Baycrest, as we consider the best ways to raise awareness about innovations in aging and brain health, where social media is an integral part of how we get our messages across.

How a campaign goes viral is the stuff marketing dreams are made of.  In this case, the story touched the hearts of millions while tapping into a dark cultural zeitgeist – bullying at any age. But in this brutal moment, Karen Klein herself offers all of us some valuable insights. Written on the side of her purse is the saying, “Live with integrity.”  Despite being taunted for carrying the purse in the first place, in the video Klein reminds us to make the right choices, live with the consequences and be proud of our actions. “Be remarkable,” reads another saying on the same purse. And indeed she is, as are the lessons her story has taught us.

We are listening.

Corinne Rusch-Drutz is Director, Digital & Emerging Platforms, at the Baycrest Foundation.

Investing in our bodies for a rainy day

The National Post (May 15, 2012) recently reported on scientific evidence showing that strength training with weights not only benefits the aging body but also the aging brain. There’s no doubt in my mind that exercise is the best form of investment for a rainy day as one gets older.

Judy Chu, certified kinesiologist, Baycrest

My 82-year-old father is a great example of wisely investing in his body. He has maintained a regular fitness regimen for many years – and it paid off for him when he was faced with a serious health crisis recently, a diagnosis of colon cancer. He had his surgery in December of 2011 and made a terrific recovery in just six weeks. He was able to return to his regular daily routine of exercise and social activities. His surgeon had predicted at least three months of recovery time. My father believes two things saved his life: a wonderful surgeon, and most importantly the time he invested in regular exercising.

My father has always valued exercise as a form of protection. I remember questioning him when I was a kid about how he could possibly go for a workout prior to starting work each day. He owned and managed a restaurant business for over 55 years. It was a seven-day-a-week business and the hours were long. He had only one day off during the week. I can still remember his words: the restaurant business is very hard on the body, the dishes are heavy and there is a great deal of running around – greeting customers, clearing dishes, and picking up the phone.

My father felt that his regular visits to the downtown YMCA were critically important for maintaining his body and energy level for the type of physical work he did. His routine at the Y consisted of running the track for a least a mile, lifting weights for his upper and lower body, and swimming one-to-two miles in the pool. After his workout, he would to tell me: “I feel great. This membership is worth every cent and more”.

In addition to going to the Y, he also played tennis from spring to late fall outdoors. His tennis partner was a man in his early 60s. I remember my father taking a broom with him to the neighbourhood tennis courts to sweep off leaves or rain water. Now reflecting back, I truly admire the man for his love for exercise. And by default, all his time devoted to exercise may have actually saved his life.

Judy Chu is a Certified Kinesiologist at the Wagman Centre, Terraces of Baycrest.

Protecting our seniors

In March the Canadian government introduced Bill C-36 to amend the Criminal Code to impose harsher sentences for those who commit elder abuse. This action made news headlines and prompted editorials.

Elder abuse is defined as any action by someone in a relationship of trust that results in harm or distress to an older person. It can be physical, psychological, financial or sexual. Active and passive neglect of the caregiver to carry out their caregiving responsibilities is also abuse. Financial abuse is the most common type of abuse experienced by seniors. Most abusers are known to the victim and can be a family member, paid caregiver, or professional who is in a position of trust with the senior.

Bev Adler, Baycrest social worker

A recent Statistics Canada Report noted that seven percent of Canadian seniors have likely experienced some form of elder abuse. That percentage may, in fact, be low because many seniors fail to report abuse. There are many reasons for non-reporting – the victim may not even recognize that they are being abused; fear reprisals by the abuser if they try to seek help; worry about being removed from their home and ending up in a long term care facility; or, if the abuse is coming from within the family, the victim may feel reluctant to lay charges against a family member.

It is important to learn about elder abuse because it occurs across all socio-economic groups. Public awareness campaigns are helpful for putting the spotlight on different types of elder abuse, the circumstances under which it can occur, and the warning signs. This is crucial for helping us all be more alert to this abuse – in the interests of our family members, our clients and customers whom we serve, our neighbours and friends, and ourselves. Making sure victims of elder abuse know where to turn to for help – whether confiding in a close friend or healthcare professional or neighbour, or calling a seniors’ hotline number –is essential. The Ontario Network for the Prevention of Elder Abuse (ONPEA) provides helpful information and a toll-free senior safety hotline – 1-866-299-1011. The ONPEA website is www.onpea.org.

As a social worker, I take the time to listen to my senior clients tell their story. I pay close attention to their reaction and interpretation of the incident they experienced because it may differ from my own reaction and interpretation. Most seniors who have experienced abuse are still mentally competent. We must be careful not to make decisions for them, but instead provide support and guidance to help them think through the situation they are in and come to the right decision. Imposing a decision which we think is best could have devastating and irreversible consequences, particularly if it involves separation from a family member.

We must also appreciate that what works for one person does not necessarily work for another. Each of us has our own wishes and thresholds for risk, from which options for a plan to address elder abuse will emerge.

Bill C-36 is a step in the right direction for punishing the worst offenders. However, few cases of elder abuse are ever brought to trial, and harsh penalties are not always effective deterrents to this behavior. More emphasis needs to be put on educational initiatives that reveal the many manifestations of elder abuse, and how to empathize with and support those who are coping with this reality so they may understand the resources available to them to help stop the abuse.

Bev Adler is a social worker at Baycrest.

Helping older drivers prolong their ability to drive safely

Dr. Gary Naglie, Chief of Medicine and RRI scientist, Baycrest

The Toronto Star published a major investigative series in February that questioned whether enough is being done to identify elderly drivers who are no longer capable of driving safely on the roads. Ontario Transportation Minister Bob Chiarelli promised that new initiatives will be implemented to address this issue.

As a geriatrician, few topics that I discuss with my patients and their family members elicit as much emotion as the topic of driving safety. As a researcher, a main interest of mine is driving safety in older adult drivers. I am a member of Candrive, a national inter-disciplinary health research program that aims to improve the health, safety and quality of life of Canada’s older drivers.

With an aging population, there is a rapidly rising number of older drivers with dementia who may not be safe to drive. The challenge for medical professionals is to accurately distinguish which older drivers are unsafe. It has been estimated that the current number of drivers in Ontario with dementia is about 50,000 and that this will double to about 100,000 by 2028. Physicians are required by law to report their older patients who may be unsafe to drive, but no validated tools exist to assist physicians to identify unfit drivers. Although guidelines state that people with moderate and severe dementia are unsafe to drive, they indicate that some people with mild dementia may still be safe to drive. Establishing which people with mild dementia are safe to drive is not clear cut, as is the case with older drivers with other chronic illnesses. As pointed out in the Star articles, the Ontario Ministry of Transportation’s mandatory testing for drivers who reach age 80, and then every two years after that, does not include cognitive testing or on-road testing. Specialized driving tests for older drivers that include cognitive and on-road assessments are very expensive ($500 or more) and are not available in every community.

The Candrive research team is at the midway point of conducting a national five-year study of almost 1,000 drivers, aged 70 and older, with the objective of developing the first comprehensive science-based tool to help identify older drivers at risk for a crash. This study includes yearly in-depth assessments of sensory, physical and cognitive function, as well as driving habits and behaviours, using a GPS system to monitor actual driving. The results from this study will hopefully lead to the creation of an office-based assessment tool that will help physicians make more accurate decisions about the driving fitness of their patients.

But with all the focus on “weeding out” and “putting the brakes” on unfit drivers, what are we doing to help senior drivers extend their safe driving abilities longer in the lifespan?

Currently, physicians have little to offer their patients with mild cognitive impairment to improve their driving performance. To address this gap, I am working with a group of researchers at Baycrest (Drs. Brian Levine, Deirdre Dawson, Morris Freedman and Malcolm Bins), other researchers from across the city (Drs. Tom Schweizer, Sandra Black, David Tang-Wai, Nathan Herrmann and Corinne Fischer), and Candrive colleagues (Michel Bédard and Nicol Korner-Bitensky). We are launching a study to evaluate an intervention for seniors with mild cognitive impairment that aims to improve their ability to sustain attention and consequently their ability to drive. We hope the results from this study will show that we can prolong the time that older drivers with mild cognitive impairment can continue to drive safely.

Dr. Gary Naglie is Chief of Medicine at Baycrest, an affiliated scientist at Baycrest’s Rotman Research Institute, and a member of Candrive (www.candrive.ca)

Want a brain boost? Try cybercycling!

Dr. Susan Vandermorris, psychologist, Baycrest

We've long known that physical exercise is good for our hearts. Now, a growing body of research shows that regular physical exercise may improve memory ability, promote new brain cell growth, and reduce the risk of dementia.

Along with this emerging evidence, more and more studies are showing that cognitive engagement – participating in activities that require active learning, thinking, and/or problem-solving – is also associated with better memory performance and reduced risk of dementia.

If both physical exercise and cognitive engagement are good for brain health, which is more important? Should I be adding a vigorous walk to my morning routine, or taking bridge lessons?

A recent study published in the American Journal of Preventative Medicine, and highlighted in Time magazine (Jan. 17, 2012), adds to growing evidence that doing physical exercise in combination with cognitive engagement can enhance brain health.

Led by scientist Cay Anderson-Hanley at Union College, the research team randomly assigned older adults to one of two different physical exercise groups. In the first group, participants completed an exercise program on a traditional stationary bicycle. In the second group, participants completed a similar exercise program using a "cybercycle," a stationary bicycle with an interactive computer-based simulation program displayed on a screen. On a typical cybercycle, your actions on the bike direct your on-screen character to do things like ride around obstacles, go up and down hills, or race a computer-based competitor.

After three months, both groups showed improvement on tests of brain function (i.e. thinking speed and working memory). The interesting result was that the participants in the cybercycle group, who combined exercise with the cognitively challenging computer program, showed equal physical exertion compared to the traditional group, with greater gains in tests of brain function.

So, to answer the question of physical exercise versus cognitive engagement – it seems that both are great, and combining the two may be even better. Intrigued by the cybercycle? Find a local gym and give it a try. But don’t be put off by the fancy equipment. You can marry physical and cognitive engagement without machinery in any number of ways. The next time you go for a brisk walk, find a partner and enjoy some stimulating conversation. Practice your rusty French skills in your mind when you next carry home your groceries. Sign up for that dance class you always wanted to take and learn some new moves.

References: Exergaming and older adult cognition: a cluster randomized clinical trial. Anderson-Hanley C, Arciero PJ, Brickman AM, Nimon JP, Okuma N, Westen SC, Merz ME, Pence BD, Woods JA, Kramer AF, Zimmerman EA. Am J Prev Med. 2012 Feb;42(2):109-19. PMID:22261206

Dr. Susan Vandermorris is a psychologist in the Neuropsychology and Cognitive Health Program at Baycrest and a postdoctoral fellow at Baycrest’s Rotman Research Institute. Her clinical and research activities focus on normal and atypical cognitive changes in aging. She currently runs the Memory and Aging Program at Baycrest, a five-week education and intervention program for older adults interested in learning more about what memory is, how it changes with age, and how to improve it. For more information about this program – contact 416.785.2500, ext. 2445 or click on www.baycrest.org/care-programs-43.php

Gabrielle Giffords and her husband face a life changed forever

Ruth Brickman, MSW, RSW, is a Social Worker with the Memory-Link program in the Neuropsychology and Cognitive Health Program at Baycrest.

Like so many others, I have been extremely moved by the remarkable recovery of U.S. Congresswoman Gabrielle Giffords since she was shot in the head by a gunman, suffering a devastating traumatic brain injury. The grace and courage demonstrated by her and her husband, retired American astronaut Mark Kelly, has been extraordinary.

During recent media attention of Giffords’ first anniversary since the shooting, Kelly hinted at the loss he and his wife have both endured. “We’ve had new realities to live with – the reality of letting go of the past,” he told The New York Times.

My perspective on their situation is influenced by the work I do as the social worker in the Memory-Link program here at Baycrest. In fact, one of the integral aspects of my role is to facilitate an ongoing support group for the spouses of our amnestic clients.

Amnesia is the permanent disruption of memory that sometimes accompanies a neurological event or illness. The most disabling aspects of amnesia involve prospective memory (the capacity to perform a task in the future) and episodic memory (the capacity to consciously recollect an event from the past). Memory changes of this sort can rob an individual of his or her independence and create stress and burden for families.

Memory-Link is a unique outpatient service established to assess, train, and support adults with amnesia. Our multidisciplinary team works with the person with amnesia, as well as that person’s immediate family and other members of their support system.

We all know that maintaining a solid marriage can take much effort during the best of times, and that not all marriages survive the complications and issues of day-to-day life. For some couples, after one partner suffers a brain injury the challenges prove too difficult and the marriage does not survive.

Many other couples persevere and sometimes even grow stronger after a devastating brain injury. I have been privileged to witness many such relationships, and have learned a great deal about the struggles and issues involved.

The initial relief one feels when a spouse has survived a traumatic event can slowly evolve into a realization that the spouse has been irrevocably changed. Partners in this situation have described feeling a grief that never ends. They cannot help feeling that the person they married is gone forever. One woman described that it’s like "living with a ghost" – she sees her husband in front of her, but he’s not really there. Our clients have become resigned to this “new normal” and have wondered, “Is this it then? Is this all I have to look forward to?”

Spouses describe feelings of utter exhaustion, now having to fulfil the roles of both partners in the marriage. These can include parenting, household chores and tasks, errands, planning and managing finances. And those injured are often in the prime of their lives, decades before their spouse might have expected to take on these additional roles.

Partners of those with amnesia feel guilty for sometimes getting angry or impatient with their spouse, when, for instance, they’ve asked the same question for the tenth time in an hour. This is similar to the experience of a caregiver when their spouse has a progressive dementia, such as Alzheimer’s disease or frontotemporal dementia (FTD). What’s unique about acquired brain injury is the early and sudden onset and the “invisible” nature of the condition. This is one of the reasons it is vital that these spouses have counselling and support available to them.

Spouses who attend the ongoing Spousal Support Group at Memory-Link tell us they derive enormous benefit from having a safe place to express their feelings about this experience. They know that when they’re sitting with other Memory-Link spouses, they can speak about anything, and the other participants “get it.” The transformative power of attending a support group and feeling genuinely understood is remarkable. And helping others through their experience adds to feelings of competence and strength for those spouses a little bit further along on the journey.

So how do these marriages survive, and sometimes even thrive? It’s often with the same ingredients present in any successful marriage: mutual respect and love, the pursuit of shared and individual interests, a supportive network and a good sense of humour. I’m privileged to witness grace and courage every day.

Ruth Brickman, MSW, RSW, is a Social Worker with the Memory-Link program in the Neuropsychology and Cognitive Health Program at Baycrest.  She has worked in other areas of the centre, including Baycrest’s Apotex Centre, Jewish Home for the Aged and the Community Day Centre for Seniors, and at other community agencies working with older adults.

Delaying retirement has benefits beyond the paycheque!

Suzanne Cook is a postdoctoral fellow at Baycrest's Rotman Research Institute and member of the BRAVO project.

Volunteering may also be good for your health.

Last December, The Globe & Mail ran a story about the surging employment levels of older women (Dec. 12, 2011, front page).

With increases in life expectancy, we can look forward to a second stage of adulthood, after age 55, that can last 30 years or longer. Finding meaningful paid and unpaid work for the mature labour force will become increasingly urgent.

As a gerontologist who studies aging, I am interested in the reasons behind the choice to pursue paid and unpaid work in the later years and the health and psychosocial impact of doing so. In my research, I see lots of incredibly accomplished older women who are educated, skilled and experienced. They want to continue to work and they recognize that they have something special to offer employers, potential employers and nonprofit organizations. They are inspiring as role models for healthy, successful and positive aging.

The most common reasons older women stay in the workforce, rejoin or enter the workforce for the first time - they need the money, want to stay mentally active, engaged and challenged, utilize their skills, like the social contact.  It's also interesting that women experience different career paths compared to their male counterparts.

• Women may not have worked as many years as men and they are generally paid less.
• They tend to be employed in the service and healthcare industries in part-time positions without benefits.
• Their employers likely did not offer a pension plan.  
• If they have a pension, the fact that women make less than the average man means that their pensions tend to be smaller.
• Mature women may be divorced or widowed and thus be the main source of support for themselves and any children living in the household.

Over the past two weeks, I've been paying particular attention to who is behind the counter during my errands and shopping. I've noticed that I'm often being served by older women over age 55. This has been the case not only at the department store at my local mall, but at a variety of retail stores - from the book store to the drug store, and from the grocer to the jewellery store and post office. In every case, these mature women have demonstrated excellent interpersonal skills and were nurturing and wise. They gave me exceptional service and treated me well, thus ensuring that I will be a repeat customer.

I hope more employers will see the value in providing mature women employees with on-going training and development as well as promotion and advancement opportunities. Some of these mature women would make excellent mentors to younger generations in the workplace and they would likely embrace this kind of challenge.

The talented and skilled mature women quoted in the Globe article reminded me of the individuals who are volunteering and participating in the BRAVO research project at Baycrest. Led by a cognitive scientist at Baycrest's world-class Rotman Research Institute, this cutting edge study is scientifically measuring the physical, psychosocial and cognitive benefits of engaging in volunteer work at the centre. Can specific volunteering activities actually improve older adults' cognitive functions, such as memory and attention? This research aims to answer that question. The BRAVO study may interest those who are ready for retirement but want to remain active, engaged and give back to the community.

If you or someone you know is not currently volunteering and may be interested in participating in BRAVO, please contact Syrelle Bernstein, Director of Volunteer Services at Baycrest, 416-785-2500, ext. 2575 or by email: sbernstein@baycrest.org.

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Suzanne Cook is a gerontologist, adult educator, and a life course, developmental researcher. She is an advocate for healthy, successful and positive aging. Her research interests are in lifelong learning, adult development and aging, and adult career development. Suzanne is a postdoctoral fellow at Baycrest's Rotman Research Institute where she is working on the BRAVO Project with scientist Nicole Anderson and the BRAVO Team. She recently completed her PhD in adult education and community development at OISE at the University of Toronto.

Helping seniors overcome ‘fear’ of falling

Aysha Bandali, Advanced Practice Leader – Nurse, Residential and Aging in Place Program at Baycrest

A story that appeared in the Saturday Star last month – “After the fall” (Nov. 19, 2011) – really resonated with me. I have a grandfather who fell about five years ago and suffered a hip fracture for which he had to undergo a total hip replacement. My grandfather was one of the lucky ones in that he was able to regain functioning and still manage to live independently in an apartment with his wife. But since then, the one difference I have noticed about him is his lack of confidence and his fear of falling. I don't think we fully appreciate the negative impact just the fear of falling can have on a person's psyche and quality of life. My grandfather has stopped exercising (an activity he used to enjoy), deliberately limits his fluid intake so he doesn't have to walk to the bathroom as much, and avoids going to crowed places or family gatherings.

Extreme fear of falling can cause seniors to limit their participation in physical and social activities, so that they become physically deconditioned, socially isolated, and likely depressed. Hearing about the downward spiral of seniors after having a fall and suffering serious injury is an all too familiar story among our elderly population. However, it doesn't have to be that way. At Baycrest, we recognize the importance of having a Falls Prevention Program that is built on the premise of group therapy, mutual support, adult education, evidence-based risk management, empowerment, and an exercise program tailored for older adults. Falls are often the result of many contributing factors, and thus falls prevention interventions must be tailored to include multiple strategies. Baycrest provides an outpatient education and exercise program for older adults living in the community who have experienced one or more falls and/or near misses, or have a fear of falling. The large variety of educational sessions, which are informative and interactive, are facilitated by Occupational Therapy, Physiotherapy, Social Work, and Nursing.  Exercise sessions are offered through both our Therapeutic Recreationist, who does a seated exercise program and a Physiotherapist, who conducts both seated and standing exercises using the bars. The program is held twice weekly for eight weeks, on Mondays and Wednesdays from 9:00 a.m. – 11:30 a.m. There are four programs per year and the cost of the program is covered by OHIP.

Clients in the program get the opportunity to share, connect, and learn from each others' experiences and life stories, all while engaging in balance, flexibility and strengthening exercises. My grandfather, who has always been the backbone and decision-maker of the family, doesn't always follow his physician's advice. He may be more inclined, however, to take advice from a fellow program member who has a similar story to his, and who also fears falling. The combination of mutual support, education and group therapy promotes a support system, social activation and increased fitness –all of which are important components of falls prevention.

If you are interested, or know of someone who could benefit from the Falls Prevention Program at Baycrest, here are the admission requirements:

• 65 years of age or older
• medically and cognitively well enough to participate in group activities
• able to walk 25 metres with or without a walking aid
• able to arrange their own transportation
• reside within the program's catchment area (between Steeles and St. Clair avenues, and Keele and Yonge streets)
• physician referral

For more information, call 416-785-2500 Ext. 2588

Aysha Bandali is an Advanced Practice Leader – Nurse for the Residential and Aging in Place Program at Baycrest. She is responsible for supporting clinical care, research, education, leadership, consultation and collaboration, utilizing an academic approach targeted to the patient, family and organizational needs.

Mindfulness meditation – a stress buster for kids and seniors

Dr. Norm Farb, Women of Baycrest Postdoctoral Fellow, Rotman Research Institute and Janet Murchison, Occupational Therapist.

In an article published Nov. 11, 2011 in The Globe and Mail, we learned about the promise of mindfulness meditation for children and teenagers. In an increasingly fast-paced and distracting world, it seems there are substantial benefits for teaching kids to relax and take the time to clear their minds, particularly in stressful situations such as taking tests or in heated discussions with parents. In some cases, mindfulness training has helped children to overcome clinical disorders such as ADHD and anxiety. It may also help parents and children to reconnect by learning to listen to each other before responding. The article also highlighted one of the common and liberating insights offered by mindfulness meditation – that “thoughts are not facts.” Mark Twain understood this to be true when he famously stated: “I am an old man and have known a great many troubles, but most of them never happened.”

All too often we are distracted by thoughts about the past or focused on what we want to or need to do in the future, reacting to imagined situations as though they were really happening. These preoccupations draw us away from being aware of what is going on right now. The irony is that while we are worrying about or planning our lives, we are missing the very moment in which we live life, this present moment, right now!

We all have the innate capacity to pay attention, but generally this is not something we have actively cultivated. Mindfulness meditation provides us with this opportunity. It involves systematic training in paying attention to present moment experience with an attitude of curiosity and acceptance. Through this practice, people can become empowered to try out different perspectives and explore their ways of reacting, often with powerful benefits to their sense of well-being.

Here at Baycrest, we have begun looking at mindfulness training for seniors, who face their own challenges and anxieties often related to the losses and life transitions that are an inherent part of aging. Possible changes in health, ability to manage day- to-day life, roles, responsibilities and social circumstances, raise real and valid concerns for the aging population. The problem is, at some point all of these concerns and worries can themselves become the biggest contributor to a person’s stress!

In our work as mindfulness instructors, we have begun to explore these issues in a pilot research program through the Mood and Related Disorders clinic. We are delighted to find that these mindfulness practices seem to hold a great deal of promise for helping seniors to deal with the stressors they encounter. Many of the participants reported benefits such as feeling less worried, less rushed and better able to cope. One participant commented: “The program was a gift. I never knew that daily life could be therapeutic.”

It is never too late to come to the present moment with greater kindness and acceptance, and learn to let go of one’s stress. It does however take diligent practice – the participants had to do meditations everyday over the eight-week course, meeting once a week for group sessions – but the reward may just be a calmer more enjoyable life.

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This blog was co-written by Janet Murchison and Dr. Norm Farb. Ms. Murchison is an Occupational Therapist in Neuropsychology and Cognitive Health and the Brain Health Centre - Mood and Related Disorders Clinic. Dr. Farb is the Women of Baycrest Postdoctoral Fellow, Rotman Research Institute at Baycrest.

Senior's body suit sensitizes youth to aging reality

Michael Kesterton’s “Social Studies” column in The Globe and Mail on Nov. 3 described AGNES, a full-body suit developed at the Massachusetts Institute of Technology that sensitizes the wearer to the physical challenges that come with aging. AGNES is short for Age Gain Now Empathy System. Put on the suit and you will experience instantly what it’s like to walk in a frail elderly person’s body. Plastic bands restrict movement, bulky shoes make your gait unsteady, foggy glasses impair your vision, harnesses make your body hunch over, and gloves impair dexterity in your hands and fingers.

In my role as coordinator of Volunteer Services at Toronto’s Baycrest, I oversee an orientation day that helps to sensitize our youth volunteers to the physical challenges many seniors experience. It’s just one component of a vibrant youth volunteer program Baycrest offers every summer for those 13 to 24 years of age. In the “Sensory Deprivation” module, volunteers put on different types of low tech gear, including shoe boxes over their shoes, safety goggles with obstructive tape on them mimicking visual impairment, and gardening gloves to simulate what it feels like to perform common daily living activities with arthritic hands. This latter experience hits home when they are asked to fasten a button shirt while wearing the cumbersome gloves. The volunteers walk approximately seven metres in their restrictive gear to a table with a phone on it, try to read a phone number and then attempt to push the numeric key pad. They also experience what it’s like to have hearing loss by trying to decipher information being broadcast to them through a muffled speaker system.

It is an enlightening experience for the young generation! At first there is a lot of giggling until they realize that these physical restrictions are a permanent reality for many seniors. Kelly Rose, a recreationist for Baycrest who developed the workshop, watches the young volunteers become frustrated when they can’t do the tasks as quickly as they are used to.

The youth say that a highpoint of their orientation day is watching a presentation by the “Voices of Baycrest”, a theatrical troupe made up of seniors who live at the Terraces of Baycrest. Shawn Fremeth, a social worker, helps the troupe write, direct and act in their own skits. The vignettes highlight the social challenges seniors face when moving into a retirement residence. Many go through the same “new kid on the block” unease that teens experience when moving to a new school. It often takes time to make new friends and feel comfortable in their new environment. Not surprisingly, there is a very spirited discussion after the skits between the young audience and senior actors, and a wonderful camaraderie develops between the two generations.

If you are interested in enrolling as a summer youth volunteer at Baycrest, please contact me (Janis Sternhill) at 416-785-2500, ext.2575.

Is a dementia diagnosis grounds for divorce?

This was the provocative headline on a Globe & Mail blog on Sept. 15. Television evangelist Pat Robertson had made international headlines earlier in the month for suggesting that it is morally justifiable for a spouse to look elsewhere for companionship after a partner has been diagnosed with Alzheimer’s disease, because the disease is a “kind of death” and therefore is in keeping with the marriage vow, “until death do us part”.

In reflecting on Robertson’s controversial remarks, I reviewed comments posted on the Internet. Most people abhorred his views. As a social worker who provides counseling and support to caregivers looking after a spouse afflicted with dementia, leaving an ill spouse is not often considered an option or a preference. This is not to say that many caregivers are not extremely stressed and may “want to run away” in the figurative sense from the demanding, life changing, and sometimes lonely and sad experience of being a caregiver to a partner with dementia.

Along with the changes in their partner’s personality, behavior, judgment and memory, the spouse is grieving the loss of companionship. When a spousal caregiver expresses a desire to find companionship outside of the marriage, we should never be quick to judge. We must consider the larger context and complexity of many relationships. For example, it may not have been a happy marriage to begin with. This distressing or unhappy situation can be compounded when dementia enters the picture and, sadly, may be a tipping point that prompts the spousal caregiver to want out of the marriage.

Many caregivers try to adjust to their changing relationship with a partner in their “new normal” by accessing help from professionals and other agencies, attending support groups and reaching out to family and friends. As a professional, I acknowledge and validate the losses and the conflicting emotions a spousal caregiver may feel, but I also seek to help these family members reflect on the benefits and positive experiences of caregiving. In the support group I co-facilitate for spouses, there was a discussion about Robertson’s comments. One gentleman remarked, “It would not be so terrible to go out for dinner with a male or female friend for companionship”. Another gentleman replied, “I think he (Robertson) means more than dinner”. The first gentleman responded with a smile, “At my age I am not talking about anything more than dinner”. This elicited laughs from the group members but underlined an important theme – the desire and need for companionship.

Robertson’s comments, if anything, have validated the challenges that caregivers experience with dementia in a partner. He has brought into the open a tender subject that no one really likes to talk about – i.e. the feeling of loneliness and a longing for companionship. Robertson may have ‘stirred the pot’ with his comments, perhaps to encourage partners to share their views and values about caregiving with one another before there is a diagnosis of dementia or other health crisis.

Jack Layton’s last letter to Canadians

With the recent passing of Canadian politician Jack Layton who left behind such an eloquent message, direction, and expression of feelings for Canadians, I am reminded of many of the clients I have worked with at end-of-life on the inpatient palliative care unit at Baycrest. I am a music therapist, who specializes in older adults and those suffering from a terminal illness. My doctoral research was focused on relationship completion through music in end-of-life care.

On a daily basis I see the importance of dying persons’ need to express sentiments and final thoughts to loved ones. This often involves the expression of key sentiments such as “I love you” and “thank you”. One might not think that these words are difficult to express but they can be, and music is one way that helps patients to express these emotions while also providing them with an avenue to leave behind a legacy gift such as a song or CD for their family and friends.

I use music in many ways at the end-of-life. For example, I had a 40-year-old client who wanted to create a scrapbook for her two small children but she did not have the energy in her last weeks to do this project. Together we wrote a song for her children. I recorded that song for them and we shared it at a family music therapy session together before she died. The song became very important to her family and they played it at her funeral and it is the theme song on her tribute website.

Another client I worked with wanted to express her sincere gratitude to her husband for the care and support he provided to her in her last months of life. She knew he understood she loved him, but it was important for her to express this gratitude and love in a unique way that he could treasure. Together over several weeks, we selected songs and wrote songs to express gratitude for their life journey together. We performed these songs for her husband at a “mini-concert” in her hospital room. Her husband was so moved that his wife had written songs for him. I recorded these songs and gave them to her husband after she passed away.

Music is powerful, and at the end-of-life it not only comforts but holds the ability to express, heal and transform. Music is a wonderful way for all of us to lift our mood and reduce our stress on a daily basis.

Amy Clements-Cortes, PhD, MusM, MTA

Ontario aims to expand care for ‘difficult’ dementia patients

Last month, The Globe and Mail reported on the Ontario Government’s revamping of the Behavioural Support Systems framework. The program aims to enhance care for patients with Alzheimer’s and other dementias who suffer from aggression and other challenging behaviours related to their neurological condition. This is an important initiative that tackles a very common, but often neglected problem encountered in patients suffering from dementia.

It is estimated that over half of all patients with dementia will suffer significant changes in behaviour as part of their illness. The medical term for these changes is Behavioural and Psychological Symptoms of Dementia (BPSD). Up to 40% of patients with BPSD will unfortunately suffer from aggression and agitation.

The overarching principle of the government’s Behavioural Support Systems framework is to deliver person and caregiver directed care. The six supporting principles include: 1) the idea that behaviour is a communication by patients, 2) taking into account patient diversity, 3) providing collaborative care, 4) promoting safety, 5) system coordination and integration, and 6) accountability and sustainability.

In April 2011, the government announced that they would be hiring 75 full-time nurses specialized in behavioural management throughout all of Ontario’s Local Health Integration Networks. This is a very positive and much needed step forward.

The government’s plan recognizes that training and education will play a vital role in further developing this framework – and opportunities for such education must be rapidly developed. I couldn’t agree more, and Baycrest could play an important role in assisting the provincial government in this work.

Baycrest is highly regarded for its expertise in treating patients with BPSD. Baycrest’s Behavioural Neurology Unit has over 25 years of experience in this area. This expertise extends to managing outpatients with dementia in its Sam and Ida Ross Memory Clinic. Efforts were initially pioneered by the clinic’s current medical director Dr. Morris Freedman, one of Canada’s leading clinicians in the diagnosis and treatment of some of the most difficult-to-diagnose dementias. Dr. Freedman has made a considerable effort to share his knowledge and experience by training several Behavioural Neurology Fellows over the years, such as myself. Other physicians have since come to join in this important work. In addition, multidisciplinary teams have come together, with the support of Baycrest, for both outpatient and inpatient care.

In the Globe article, I was quoted as saying that the hiring of more healthcare workers for behavioural support, should not be viewed as a panacea. To clarify, it is an important first step by the government. Liberating funds to hire more healthcare workers is essential. Instituting training programs for those workers will be a vital second step. In the long run, much more research is needed on what those training programs should entail, and on the best interventions needed.

Now that this important problem is getting more press, there is hope that progress will continue in this research, in training, and ultimately will result in improved outcomes for patients.

For information on the Ontario Government’s Behavioural Support Systems framework, go to the website: http://www.akeresourcecentre.org/BSS.

Grandpa’s little helpers

“Grandpa’s little helpers” was a very interesting article recently printed in the Globe and Mail. It describes how savvy marketers are now targeting the Baby Boom generation for their pocket-sized energy drinks. According to the article, companies are claiming that “those who drink them will be amped up for hours… (it is) the youthful tonic when coffee just isn’t enough.”

But are these drinks really safe for older adults? Well, there are several points to consider. First of all, large amounts of caffeine (even from natural sources such as yerba mate and guarana primarily used in these drinks) can cause problematic side effects such as restlessness, anxiety, nervousness, insomnia and gastrointestinal disturbances. In fact, Health Canada recommends that adults limit their caffeine intake to no more than 400mg per day for this very reason.

How much caffeine is in a typical energy drink? Well, it’s difficult to know exactly. Labelling for energy drinks is not the same as it is for foods and beverages in Canada. You won’t find a “Nutrition Facts” section on the label because it is classified by Health Canada as a “Natural Health Product.” Manufacturers simply have to declare that there is a source of caffeine in the product but do not have to declare how much. It is said that on average, there is approximately 200mg per bottle. When you consider that 63 percent of Canadians already consume most of their daily caffeine allowance in coffee, exceeding 400mg per day would be very easy to do.

Another issue with these drinks is that they can often contain amino acids, herbal supplements or vitamins. These may have unknown effects on an individual or could possibly even result in a potentially harmful medication interactions.

So based on the current evidence, the old adage of everything in moderation may apply but buyer beware…until labelling regulations become more specific about the amount of caffeine in the product and until there is more research available on the herbal supplements, vitamins and amino acids added to these drinks, it may not be worth the risk to your health.

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References – All reference information taken from Dietitians of Canada “Practice Based Evidence” website. Detailed reference list as follows:

Statistics Canada. Beverage consumption of Canadian adults. 2008 [cited 2010 5 Aug]. Available from: http://www.statcan.gc.ca/pub/82-003-x/2008004/article/6500240-eng.htm

Nawrot, P, Jordan S, Eastwood J, Rotstein J, Hugenholtz A, Feeley M. Effects of caffeine on human health. Food Addit Contam. 2003 [cited 2010 5 Aug]:20(1):1-30. Abstract available from: http://www.ncbi.nlm.nih.gov/pubmed/12519715

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Higdon JV, Frei B. Coffee and health: a review of recent human research. Crit Rev Food Sci Nutr. 2006 [cited 2010 5 Aug];46(2):101-23. Abstract available from: http://www.ncbi.nlm.nih.gov/pubmed/16507475

Ker K, Edwards PJ, Felix LM, Blackhall K, Roberts I. Caffeine for the prevention of injuries and errors in shift workers. Cochrane Database System Rev. 2010 [cited 2010 5 Aug],Issue 5. Art. No.: CD008508. DOI: 10.1002/14651858. Abstract available from: – http://www.ncbi.nlm.nih.gov/pubmed/20464765

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Wyatt JK, Cajochen C, Ritz-De Cecco A, Czeisler CA, Dijk DJ. Low-dose repeated caffeine administration for circadian-phase-dependent performance degradation during extended wakefulness. Sleep. 2004 [cited 2010 5 Aug];1;27(3):374-81. Abstract available from: http://www.ncbi.nlm.nih.gov/pubmed/15164887

The Canadian Tea and Coffee Industry [cited 2010 5 Aug]. Available from:. http://www4.agr.gc.ca/AAFC-AAC/display-afficher.do?id=1172237152079&lang=eng

Roehrs T, Roth T. Caffeine: sleep and daytime sleepiness. Sleep Med Rev. 2008 Apr [cited 21 2010 Apr];12(2):153-62. Available from: http://www.ncbi.nlm.nih.gov/pubmed/17950009

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A silver lining for wandering seniors

Renee Climans blogs:

In May, the Hamilton Spectator and Toronto Star reported that the Ontario Government will introduce the Silver Advisory system to help find missing seniors faster.

As a mom, I remember the terror and panic on the few occasions when my young and curious children briefly wandered away. But more recently I remember holding my breath when dropping my 94-year-old father off for his medical appointment and leaving him to go up to the doctor’s office on his own while I quickly parked the car.

In my professional role as a senior social worker who co-leads the Alzheimer’s Support Group for Spouses at Baycrest, I have listened to many caregivers tell their own frightening stories. Here are a few of the scenarios they’ve described:

A wife had just returned from a doctor’s appointment with her husband and dropped him off in front of their condo so that she could go to the pharmacy to fill prescriptions. When she returned home a half hour later, her husband was not there. “I was in a state of panic,” she recalled. This gentleman is registered with the Safely Home Registry through the Alzheimer’s Society. He wears an identification bracelet and carries a card in his wallet / pocket, and the police have his description in a central database for cognitively-impaired individuals who are at risk of wandering. In this particular case the police weren’t contacted as this gentleman returned to his condo about 30 minutes after his wife had arrived home. When asked where he had gone, he responded, “I decided to go for a walk.” For his worried partner, 30 minutes felt like “forever.”

The second story involves a couple who went to the symphony by subway on a winter evening. The wife recounts her terror at seeing her husband enter the subway train and the doors close before she was able to get on with him. She headed to Roy Thompson Hall praying that her husband would find his way there. She called her son who contacted the police. She recalled that the police sat with her and were wonderful. Her husband eventually showed up at the venue covered with snow. “He was fine, but I was terribly worried,” she said.

These stories had happy endings, but this was not the case last January when a 66-year-old woman with dementia wandered out of her Scarborough home during the night and her cries of distress went unanswered. She was discovered frozen to death hours later.

The Amber Alert Program for missing children has helped Canadians to become aware of the important role we can all play in being vigilant when a child goes missing. Might the proposed Silver Advisory serve the same role – informing members of the community to be on guard for older adults who are most vulnerable?

Social workers and other professionals at Baycrest often work with families before a clinical diagnosis of dementia has been made for their loved one. This ensures that safety measures are in place to reduce the risk of a frail family member wandering away from familiar surroundings and becoming lost.

Many of the spouses and other family caregivers with whom I counsel often ask about the usefulness of devices such as a GPS system for their relative, walkie talkies, and even microchips that are implanted under the skin similar to those used to track pets. These strategies will not work in isolation. We live in communities. The Silver Advisory will enhance the safety net we have for older persons with dementia – but only if we all work together as a community of watchful, vigilant and caring citizens.

Here is a checklist for families to consider:

1. Register your loved one with the Safely Home Program through the Alzheimer’s Society (there is a small fee).

2. Enlist the support of others, including family, friends and formal supports.

3. Connect with agencies (Community Care Access Centre, Family Caregiver Connections) and Baycrest’s services (Seniors Counselling and Referral), or speak to team members associated with your loved one’s specialist at Baycrest or in the community.

4. Minimize risks in your home environment and arrange for a Home Safety Assessment with an occupational therapist. Special door locks and coded entry systems might be suggested.

5. Don’t hesitate to consult with your family doctor or specialist when you have concerns. Wandering behaviour may be part of a larger spectrum of behaviours related to dementia, such as agitation and restlessness. Adjustment of medications may help settle the person and reduce confusion.

6. Engage your loved one in meaningful activities, such as the Community Day Centre for Seniors, the Wagman Centre at Baycrest, or other social programs in the community.

The crucial task of fall proofing the home

Nira Rittenberg blogs:

I was pleased to see the topic of seniors and falls so well explored in two recent Globe & Mail stories – “Falling Seniors: preventable problem a huge health burden” (May 30); and “The crucial task of fall proofing the home” (June 1).

I agree that the impact of falls on healthcare costs is significant and worrisome, but that is not what motivates me as a clinician when I work with clients and their families in the community.

As an occupational therapist, I help aging clients to maximize their daily functioning and I make recommendations regarding the safety of older adults in their homes. My professional experience with falls feels a lot more personal. I don’t see statistics, I see the person who has fallen and lost their independence to get out of bed. I see the “sandwich generation” family who is struggling to care for their aging parent between work and getting their kids to school. I monitor clients as they transition from their home to the hospital, and through the rehab process. If these approaches are not successful in helping restore functional independence, a nursing home bed may need to be considered – and this is never an easy topic to discuss with clients and their family.

The emotional, psychological and physical burden of falls for clients and their families is huge. Sadly, these falls are often preventable. I see the important work professionals in healthcare and community agencies do to reduce the risk of falls for frail seniors. I know that my work with clients will help reduce falls and related costs to the health system, but try telling a client or their family about the system impact. For them it is deeply personal – it is about pain and loss of quality of life.

Helping seniors stay safe and independent in their own homes is what motivates me every day in my job. I encourage anyone who has concerns about their relative being at risk of falls to contact their family doctor, an occupational therapist or other healthcare professional to discuss interventions to reduce the risk.

Here’s a quick falls risk checklist that I use as an OT when I visit a senior client for the first time in their home.

• Does the client have eyesight problems?
  
• Has the client had other falls in the past?
  
• Do they have conditions that affect walking or balance?
  
• Trouble getting to the washroom?
  
• Are there loose carpets, unsafe stairways or objects on the floor that pose hazards when walking?
  
• Slippery floors or areas that can’t be easily seen?
  
• Medication issues (over the counter and prescription)?
  
• Footwear that is improper?
  
• Is there a need for assistive devices such as a walker?
  

Grief not a mental illness, doctor warns colleagues

Dr. Grief blogs:

A recent headline and story from the Montreal Gazette – “Grief not a mental illness, doctor warns colleagues” – has triggered a storm of protest by angry readers.

Dr. Cindy Grief is a psychiatrist at Baycrest, who specializes in treating the complications of bereavement.

Here are my thoughts. The Gazette story reports on a proposal by psychiatric experts to shorten the delay period – from two months to two weeks – for doctors to diagnose clinical depression in a patient grieving the loss of a loved one. The change could be implemented in the next edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM), a classification system for diagnoses used by psychiatrists and other practitioners.

Critics of the proposed change have expressed concern that normal grief is being medicalized, and that there will be a surge in unnecessary prescriptions for antidepressants.

As a psychiatrist who specializes in treating the complications of bereavement, I would react similarly if the proposal were to change how normal grief – a universal human experience – is viewed. However, I believe the intention of the experts is to make it easier for clinicians to disentangle clinical depression from normal grief. While depression in the context of grief is understandable, as is a fever arising in response to infection, it is often something that benefits from treatment.

Depression in the aftermath of loss is common. Untreated depressive symptoms are associated with more severe depressions, poor medical health, and even death. In my experience, depression is all too often under-diagnosed. The DSM is not meant to be used mechanically without thought, nor can it ever replace balanced, non-judgmental clinical decision-making.

The ultimate goal for users of this manual is to work together with bereaved individuals to find the best way to ease their distress and alleviate suffering.

Expansion of the definition of dementia – good or bad?

Dr. Gordon blogs:

Dr. Michael Gordon, one of the longest serving geriatricians in Canada, and currently medical program director of Palliative Care at Baycrest, weighs in on the new U.S. guidelines. Dr. Gordon is co-author with other Canadian scholars on a paper that addresses the new guidelines, to be published in the journal, Alzheimer’s and Dementia.

American dementia experts have decided to expand the “dementia” definition to include a “pre-clinical” stage. This new definition is not without controversy. It’s based on the best estimates of dementia’s causative mechanisms and the tools that we currently have to identify individuals with the defined “biomarkers” such as specific structural findings on special imaging procedures of the brain and proteins in the cerebrospinal fluid (the fluid that surrounds and protects the brain). These biomarkers might indicate a higher likelihood of going from an apparently “normal” state of health to one in which early and then full-blown dementia will likely develop.

The idea is aligned with efforts to identify as early as possible those at higher risk for developing dementia and then determine which early interventions might postpone or prevent its progress. The model mimics that used for cardiovascular disease (CVD) in which, over the years, the field of medicine has accumulated sufficient knowledge to identify “risk factors” (e.g. hypertension, elevated blood lipids, sedentary life style, smoking) and then determine the impact of interventions such as exercise, diet, discontinuation of smoking, and medications to control, for example, hypertension and elevated lipids. This approach has significantly reduced the number of people afflicted with CVD — a testament to the beneficial effects of such interventions.

Whether a comparable pre-clinical diagnostic approach for dementia will be beneficial is the million dollar question. Can we detect those at risk of developing dementia (before symptoms) and then decrease their risk through various research-based experimental interventions?

A Canadian Task force has explored some of the potentially negative ramifications of the pre-clinical approach. The report will be published in the May issue of the journal Alzheimer’s and Dementia. Among the concerns noted in the report: the psychological result of labeling someone as being at risk of developing dementia; the implications for insurability for health care, travel, disability and long-term care insurance; the impact on the stability of family relationships and the exposure of people potentially at risk, but not certain to get the disease; and the implications of starting various interventions that might include potent and potentially toxic medications.

Although the potential for research to collect evidence-based data on the efficacy of pre-clinical interventions is very appealing, the potential for harm to the screened population might be serious. I strongly recommend that the risks be weighed very carefully before large-scale screening and labeling is undertaken by practicing physicians and researchers.