A broken hip can have a major impact on an older person's health and ability to live independently. But researcher Kathy McGilton doesn't believe it has to be this way — and improving the situation will require reshaping the beliefs of health care professionals.
A professor in U of T's Lawrence S. Bloomberg Faculty of Nursing and the Graduate Department of Rehabilitation Sciences, McGilton is also a senior scientist at Toronto Rehab. So she fully appreciates how a practitioner's outlook can ultimately affect an older patient's outcome.
"Nobody wants to get old," McGilton says. "Our society is so focused on staying young that this thinking infiltrates our attitudes as health professionals and undermines our clinical practice."
The result, she says, is a system in which seniors may be denied access to vital services that support healthy aging. As proof, McGilton points to hip-fracture patients. Following surgery, if patients show symptoms of cognitive impairment, such as agitation and confusion, they may be moved to a long-term care facility instead of a rehabilitation centre. While in a nursing home, patients may not receive appropriate rehabilitation, making it unlikely they will regain their previous level of physical functioning. Her study is trying to provide empirical evidence that people with cognitive impairment, if given the chance at rehabilitation, can go home.
The key, McGilton believes, is to teach nurses how to differentiate dementia and delirium. The former has a slow onset, while the latter comes on quickly. Delirium also has a variety of causes, including dehydration, post-surgical pain and an electrolyte imbalance — all of which are treatable.
McGilton says that missing the signs of delirium among older adults indicates a larger problem in the health care system: a limited grasp of gerontology. Encompassing more than physical health, gerontology considers the complete spectrum of an older person's life, including his or her support system and mental and emotional well-being. In a health care setting, nurses can bring the study of gerontology to life by, for instance, speaking directly to patients, focusing on their pre-morbid functioning and their abilities, getting them up out of bed, managing their pain and learning more about their personal lives.That said, McGilton has under-taken several initiatives to enhance nurses' knowledge of gerontology. "Older adults are our core business," she says. "They make up 60 per cent of medical-surgical patients and 50 per cent of patients on intensive care units. We need to increase our awareness of real issues in the hospitals." To that end, McGilton and her colleagues have helped add more gerontology-related content and case studies to the nursing curriculum at U of T. For example, a new undergraduate elective course ("Complex Issues in Gerontology") has been introduced, as has a graduate- level course on best practices in caring for the elderly. In addition, to increase professors' expertise, information sessions have been offered to faculty members in nursing, social work and medicine. "Caring for the elderly isn't up to nurses alone," McGilton says. "Many health care professionals play a role in decisions that affect older patients' lives, and we need to have better attitudes, assessment skills and knowledge of best care for older people. We need to change the way we care."
Does volunteering benefit older adults?
What happens when you live longer than you expected? So much longer, that three decades have passed since you retired, and you're still alive and well late into your 90s? That question first occurred to Dr. Suzanne Cook while she was teaching a gerontology course at the University of Guelph and observed the high number of seniors who were volunteering at the same community organizations as her placement students.
It became more personal when she spoke to her own 98-year-old grandfather, who confided that he'd never expected his own retirement to last so long. Cook was captivated when she considered the onslaught of baby boomers set to begin leaving the workplace, and wondered what this highly educated and motivated generation would do with all its energy and experience.
"So I was thinking, if they've been the generation to finish high school, go on to college and university in such high numbers and do continuing education in the workplace," she says, "then they were going to be looking for learning opportunities in retirement."
Cook, currently a post-doctoral fellow at the University of Toronto-affiliated Baycrest, one of U of T's nine partner hospitals, pursued her hunch as part of her doctoral research at U of T's Ontario Institute for Studies in Education. She wanted to know how the quest for lifelong learning continued in retirement, particularly as it applied to those ages 55 and older, who volunteered in a formal, structured way for a non-profit organization. Her findings confirmed that for many of her respondents, volunteering did indeed feed an important intellectual need, whether they were making use of skills they'd acquired during their working years, or learning new ones — such as the nuts and bolts of building a house with Habitat for Humanity.
Cook says her conclusions raised another question. "I was wondering if organizations should be paying more attention to this, to creating opportunities for lifelong learning, and are they creating them?" Specifically, she wondered whether developing more targeted, challenging roles for older volunteers would bolster recruitment and retention, just as it does in the paid workplace. That's something Cook is currently exploring as part of her post-doctoral work at Baycrest's Rotman Research Institute, where she is involved in a four- year study known as BRAVO — Baycrest Research About Volunteering Among Older Adults.
The BRAVO team — led by senior scientist Nicole Anderson (who is also a U of T associate professor in the Departments of Psychiatry and Psychology) and managed by a group of retired volunteers — is looking at a host of potential physical, cognitive and psychosocial health benefits related to volunteering. Subjects, aged 55 and older, are recruited to volunteer at Baycrest for a year, during which time they are followed and reassessed at six month intervals. Cook is working on the qualitative side, leading the team of volunteers that's conducting the interviews, and coding and analyzing the data.
In addition to testing the healthy-aging hypothesis, it's expected the study will give Baycrest and other non-profits some important clues about attracting volunteers and keeping them engaged and mentally stimulated. Cook predicts that could have a big impact on social policy, as Canada grapples with an aging, increasingly educated population and mounting healthcare costs.
"I think society needs to encourage and cultivate opportunities for later life learning," she says. "That includes the need for non-profits to consider the learning that can occur through volunteer activities, and to make it a priority in volunteers' roles."
Reframing the story of Alzheimer's disease
When we talk about Alzheimer's disease, what kind of story are we telling?
A horror story, at least here in contemporary North America, says Marlene Goldman.
"The media's take on Alzheimer's is very Gothic and apocaplytic," she says, a story of the slow loss of mind and self. "The typical presentation is: we have a huge baby boomer population and they'll be turning 65. In the media's view, they'll be zombies. And we'll have to pay for them."
The English professor at the University of Toronto Scarborough doesn't discount the suffering associated with Alzheimer's disease, but she wants us to realize that the way we talk about it matters. She is working with a group of scholars in humanities, medicine and social science through U of T's Jackman Humanities Institute and recently co-organized an international conference called Aging, Old Age, Memory and Aesthetics.
As a literary critic — someone who studies and interprets literature — Goldman is interested in the intersections between medicine and storytelling. "I think we make a mistake when we assume that a disease is like a table, an unchanging thing that's here in front of us. Our understanding of diseases has evolved throughout history."
It's hard to imagine a different version of the story we tell ourselves about Alzheimer's disease because we're so embedded in our own culture. But, says Goldman, "A literary analysis opens up the possibility of seeing things from a different angle."
We're accustomed to thinking of fiction as "not true." But fiction, Goldman says, can "show us an illness from the mind of a sufferer." In a medical setting, a clinician might take a case history, but it's always filtered through that clinician's perspective. Fiction, on the other hand, lets us see what Alzheimer's might be like from the inside.
In other words, Goldman wants us to know that we have a choice about how we tell the story: "We can see Alzheimer's as a Gothic, tragic story," as the mainstream media presents it, or we can look for alternative perspectives.
She gives the example of Alice Munro's short story "The Bear Came Over the Mountain," which Canadian director Sarah Polley made into the film Away From Her. In it, Grant, a self-confessed philanderer, witnesses his wife Fiona's rapid decline. Knowing her condition will worsen, Fiona checks herself into an institution. When Grant visits, he is shocked to discover that Fiona has formed a passionate attachment to another resident. Grant wonders if Fiona is playing an elaborate trick on him — he doesn't know whether Fiona's feelings spring from her illness or are a purposeful commentary on his past infidelities. "As in other Alzheimer's narratives such as Michael Redhill's Goodness and Mordecai Richler's Barney's Version," says Goldman, "the presence of an ironic trickster figure undercuts the dominant media and biomedical discourses of Alzheimer's."
"I don't want to diminish or make light of the real suffering associated with memory loss. But I do think it's helpful to have as much information as possible when looking at life-changing illnesses."
"We're all aging," says Goldman. "That's an inevitability. I don't like the idea that we have to live in fear of any sign of aging, that the story has to be solely one of decline."
Dementia, osteoporosis, diabetes. These are diseases of aging, right?
Wrong, according to new understanding of how we travel through life on developmental trajectories that are established in our earliest years — and even in utero. Though symptoms may not manifest themselves until later in life, it's increasingly clear that the foundation for health and well-being is laid long before most of us start to worry about RRSPs.
U of T is poised to become a global leader in the study of these developmental trajectories with the establishment of the Institute for Human Development. A group of researchers, led by Stephen Lye of Obstetrics and Gynaecology and Physiology, is set to launch the institute with a $1 million grant from U of T's Connaught Fund.
Lye is also senior scientist and associate director of research at Mount Sinai Hospital's Samuel Lunenfeld Research Institute. He is a world leader in the field of women's and infants' health. The Connaught Global Challenge Award will enable him and collaborators across campus to launch an ambitious research program aimed at understanding the relationship between children's earliest experiences and well-being throughout the life course.
When asked about aging, Lye thinks about pregnancy. "You start with a fertilized egg. A single cell. Over the course of just 40 weeks, that cell develops into a perfectly functioning human being. Think about it: the cells have to decide whether they're going to form a placenta or whether they're going to form the embryo itself. Then that collection of cells has to implant into the uterus. The organs have to form. Then all the nerves and the blood system have to connect up everything. Everything is kept between tightly-controlled levels — our hormones and blood sugar have to stay within the appropriate range. If there was ever a use for the term ‘miracle,' that's got to be it."
It doesn't stop there. In the few years after a baby is born, a staggering amount of brain development must occur.
So how does this all relate to aging well?
Historically, science has believed that genetics is destiny. Scientists are, however, increasingly coming to understand that it is the interaction between genes and environment that is important. Still, these interactions are not well understood.
Lye offers an example. Past research has discovered a particular gene linked to obesity. "There are two variants of this gene, an adverse variant associated with high body mass index (BMI) and a normal variant. We're looking at the impact of this variant throughout fetal life and after birth." It would seem that babies with the adverse variant are destined to become obese, but that's not necessarily the case. Lye and his colleagues found that those babies with the adverse variant who were exclusively breastfed for the first six months of life grew up to have lower BMIs than they otherwise would have. In this case, breastfeeding acted as an environmental influence that mitigated the potential negative effect of the adverse genetic variant.
There are potentially thousands of other environmental interventions that can affect the expression of our genes. Lye stresses that the new institute won't focus solely on health. Similar work will examine the impact of development on children's ability to learn and on how they form relationships as children and adults.
"The essence of this project is to discover how trajectories are set early in life and how they impact health, potential for learning and social functioning. And we believe the way to do our investigation most effectively is by looking at the trajectories from a multitude of perspectives."
A team of co-senior investigators from a broad range of disciplines is working with Lye on this project. They include Carl Corter of Human Development and Applied Psychology at the Ontario Institute for Studies in Education (OISE), Alison Fleming of Psychology at the University of Toronto Mississauga (UTM), Jennifer Jenkins of Human Development and Applied Psychology at OISE, Stephen Matthews of Physiology and Marla Sokolowski of Biology at UTM.
The group is planning to go beyond just understanding the trajectories we set ourselves on. "We're going to ask what we can do to modify these trajectories," says Lye. "We don't just want to study this. We want to have outcomes. We want to focus on how we can optimize the full potential of our children."
Healthy aging isn't only a concern for us, it seems. It's something we can help our kids prepare for now.
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