Thursday, October 16, 2014

Twist Your Way to Better Health

Yoga is being touted as a way to ease a whole host of health conditions, including preventing osteoporosis, improving sleep and increasing immunity. Yoga classes are available almost everywhere these days, but you can also do a few simple poses at home.

Before taking yoga classes, Bunny Grossinger, 87, had serious back problems that limited her mobility. But after the New York City resident started working with a yoga instructor, she found that her life was changed physically and mentally. Though doctors had told her she would need a walker soon, she can now walk again on her own, she told the New York Daily News.

After seeing Grossinger’s experience, the yoga instructor started a yoga studio aimed at those over 65. For older adults, yoga has many benefits, including increased bone density and increased flexibility at a time when we feel more stiff and creaky.

If you’re just starting out or haven’t done yoga for a while, don’t get turned away from yoga classes by the young athletic types wearing their skintight yoga pants and shirts, able to do Downward-facing Dog without thinking about it. Don’t be discouraged if you have a hard time doing the Warrior pose, because your body won’t bend over that far. It can take a while to limber up and stretch the muscles. Experts advise starting slowly and finding a beginner class, preferably one for older adults.
When we were younger, yoga was considered a strange esoteric practice done by people wearing white turbans. Now it’s become accepted, a regular fixture of recreation centers, health clubs, senior centers and assisted living residences. Some health plans offer to pay for yoga classes to keep their clients healthy and fit.

Multitude of Benefits

While ancient yoga practitioners promised a reversal of the aging process, research hasn’t yet been able to back up that claim. Still, studies have documented an amazing array of benefits from this 5,000-year-old form of exercise (see sidebar, “What Is Yoga?”).

Increases strength and flexibility. As we get older, our range of motion becomes limited, which makes us more vulnerable to bad falls. Yoga stretches all parts of the body, including the spine, which is often not affected by other exercises, such as walking. Yoga’s poses stretch muscles, ligaments and tendons and lubricates joints. By repeating the poses, we improve balance and increase strength.

Improves bone health. A gentle yoga practice may can be effective in increasing bone density.In one pilot study involving adults with an average age of 68, who practiced yoga for 10 minutes each day researchers found subjects gained bone density.
Aging women have an increased potential for developing osteoporosis, a disease that causes bones to become brittle and prone to breaking. Because yoga’s postures are weight-bearing and involve balance, they can help women reduce the possibility of bone fractures by maintaining bone strength and promoting joint agility.

Relieves stress. Numerous studies have shown that yoga can help reduce stress and anxiety. Because you concentrate on the poses and breathing deeply, yoga centers you in ways that most exercise can’t. At the same time, yoga can enhance your mood and overall sense of well-being.

Decreases migraines. Research shows that migraine sufferers have fewer and less painful migraines after three months of yoga practice. It’s not clear why but it could be that yoga works to relieve both mental stress and physical misalignment that cause migraines and other issues.

Improves sleep. Harvard researchers found that eight weeks of daily yoga significantly improved sleep quality for people with insomnia who participated in this study. Another study found that twice-weekly yoga sessions are associated with better sleep and less fatigue for cancer survivors. These results may be due to exercise’s physical benefits plus yoga’s breathing and relaxation techniques, although the reasons have yet to be determined.

Lessens chronic pain. A Harbor-UCLA Medical Center study reported participants needed less pain medication after only four weeks of yoga. Other studies report a decrease in arthritis pain among the participants.

Manages chronic conditions. Yoga can reduce risk factors for chronic diseases, such as heart disease and high blood pressure. According to a report to the National Institutes of Health, some evidence suggests yoga may be helpful when used with conventional medical treatment to help relieve some of the symptoms linked to cancer, asthma, diabetes, drug addiction, high blood pressure, heart disease and migraine headaches. In a study by the Yale University School of Medicine, researchers found that adding three days of yoga and meditation to your weekly routine may reduce your risk of heart disease.

Reduces blood pressure. Several studies have shown yoga can reduce high blood pressure because of its calming techniques and physical activity, which both help to lower blood pressure. In a study at the University of Pennsylvania, 58 men and women, aged 38 to 62, were divided into three groups: a diet and weight reduction and walking program; a yoga practice of two to three times per week for 24 weeks; and a combo program consisting of both yoga and dietary intervention. The research team found that only the yoga group experienced the biggest drop in their blood pressure (“Yoga Can Help Lower Blood Pressure,” June 2013, Medical News Today).
Eases depression: Researchers from Boston University School of Medicine found that yoga may be superior to other forms of exercise in its positive effect on mood and anxiety. The researchers contrasted GABA levels in the brain, which are associated with depression and other widespread anxiety disorders, of yoga practitioners and walkers over a 12-week period. One group practiced yoga three times a week for one hour, while the remaining subjects walked for the same period of time. Not only did the yoga practitioners’ brains show higher levels of GABA, but they reported less anxiety and a better mood. (From “New Study Finds New Connection Between Yoga And Mood,” June 2013, Medical News Today).

In addition to these listed benefits, other reports state that yoga can increase hand-grip strength in rheumatoid arthritis patients, control or decrease weight, reduce breathing difficulties in bronchial asthmatics and relieve menopausal discomfort.

Simple Exercises

Although yoga is generally considered safe for most healthy people when practiced under the guidance of a trained instructor, see your health care provider before you begin yoga if you have any of the following conditions or situations (from “Yoga Precautions,” Mayo Clinic):

  • A herniated disk
  • A risk of blood clots
  • Eye conditions, including glaucoma
  • Hyperthyroidism
  • Pregnancy
  • Severe balance problems
  • Severe osteoporosis
  • Uncontrolled blood pressure
Taking a yoga class can help beginners, especially, because trained instructors can work with their physical issues (bad knees, stiff back, etc.), and a class can provide the social benefit of interacting with others. You can also do some simple exercises at home (from “10 Yoga Exercises for Seniors,” How Stuff Works).

The One-legged Wind Releasing pose is a good, gentle stretch for the mid- to low-back and hips because it stretches all of the muscles in those areas, which helps resolve low back pain.

  1. Lie down on your back with your knees bent and your feet on the floor.
  2. Hug your right thigh to your chest, using a strap or belt to assist you, if necessary.
  3. Straighten your left leg along the floor, keeping your foot flexed.
  4. Keep your pelvis and right buttock on the floor (or, if you're unable, keep your left leg slightly bent).
  5. Breathe deeply until you feel the muscles relax, and then stay a few breaths longer.
  6. Repeat on the other side.

The Staff pose helps strengthen the muscles in the mid-back, improving posture. It also strengthens the quadriceps to help stabilize the knees.

  1. Sit on the floor with your legs stretched out in front. It may help to sit with your shoulder blades against a wall with a small rolled-up towel between the wall and your lower back.
  2. Pull in your belly and sit up tall.
  3. Place your hands on the floor next to your hips, fingers pointing toward your toes.
  4. Without hardening your abdomen, flex your thigh muscles while pressing them down toward the floor, rotating them inward and drawing your groin muscles toward your tailbone.
  5. Flex your ankles, pointing your toes toward your body.
  6. Imagine your spine is a staff pressing into the floor, and try to hold this position for two to 10 deep breaths.
  7. Relax.

The Seated Forward Bend pose can help reduce blood pressure. Use a chair to avoid overtaxing your back.

  1. Sit on a chair, keeping your knees together and your feet flat on the floor.
  2. Inhale.
  3. As you exhale, bend forward, rounding your shoulders and bending your back forward one vertebra at a time.
  4. Let your arms hang by your sides.
  5. Hold this pose for three breaths.

As you do this pose, your chest should make contact with your thighs, with your forehead near your knees.

For flexibility in your legs, try the Legs in V pose:

  1. Sit on the floor with your legs comfortably spread apart in a V shape. It doesn't matter if the V isn't that wide to begin with; it's more important to stretch comfortably.
  2. Grab a bunch of firm pillows and place them in front of you.
  3. Lean forward, keeping your neck long, and use the pillows to support your upper body. Breathe six times, allowing yourself to hang and feel the stretch along your legs.


“5 Surprising Health Benefits Of Yoga,” Feb. 12, 2014, Huffington Post

“10 Yoga Exercises for Seniors,” How Stuff Works

“NYC Yoga Class Caters To Seniors,” June 26, 2012, Sunrise Senior Living

“Seniors Can Find Confidence and Flow in Yoga Practice,” Aging Care

“Yoga for the 50+,” Senior Fitness

Twist Your Way to Better Health was featured in the  September 2014 Senior Spirit newsletter.

Blog posting provided by Society of Certified Senior Advisors

Tuesday, October 7, 2014

Finding the Right Words at a Bad Time

In difficult situations, where we encounter a friend who lost a spouse or the neighbor who has cancer, we often don’t know what to say. Experts and cancer patients provide advice and wisdom for those times when we want to offer comfort but aren’t sure exactly how to do so.

We’ve likely been in this situation, in one way or another. A friend’s husband has died or a family member just found out he has cancer. We don’t know what to say, so we blurt out the first thing that comes to our minds. When standing in front of an open casket, we exclaim, “Gosh, he looks great.”

Charles Puchta, founder of Care Ministry in Loveland, Ohio, recalls the story of one woman who had cancer. While walking through her small town, she saw a friend who was approaching her on the sidewalk cross the street to avoid her and then cross back after she passed by.

Puchta, a Certified Senior Advisor®, emphasizes treating someone who’s been marked by some kind of illness or tragedy as another human being. “Oftentimes, we don’t see them as people. If we don’t see them by their personhood, we define by their disease.” For example, because the idea of cancer may be threatening and make us want to turn away, Puchta suggests “renaming” the cancer something less upsetting, such as a broken leg.

In that way, the disease becomes less threatening, and, in turn, we become more comfortable approaching the person who has the disease. Puchta advises: “Ask, ‘How you are you doing?’ Don’t ignore it. Say what you would normally say. See them for who they are.”

Experts remind us to remember that the situation is not about us. Instead of worrying about ourselves, we should focus on the one who is grieving or suffering. Most of the time, the situation simply calls for an expression of compassion, even just a hug or a hand on the shoulder.

Offering Support

When we hear about friends who are suffering, either from the loss of a loved one or from a serious illness, we want to fix the situation. Or perhaps our friend’s situation brings up our own concerns about illness or death, and we react out of fear.

Sometimes, we try to say something profound, some bit of wisdom gleaned from a book or website, but such forced words often drop with a thud. Other times, we fall back on commonly used words of sympathy, many of which may sound insensitive to the suffering individual. The following sentiments mean well but may cause more pain than comfort:

“You're So Strong"

The recipient of these words might not feel strong at all. In fact, they may be experiencing feelings of helplessness, despair and fear about the future. Telling them how brave they are could make them feel worse, because they think you’re implying they’re not coping as well as they should or that they are taking too long to get over a loved one’s death.

Ann Silberman, who has breast cancer, writes on her blog about someone telling her that she’s so brave: “You are referring to me showing up on time for doctor’s appointments? . . . It’s nice to be called brave, but we cancer patients all know we aren’t. Brave is a word best reserved for people who deliberately put themselves in harm’s way. Trust me, if I could get out of this, I would. . . . The truth is, I have no choice but to put one foot in front of the other and do what my doctors say” ( Instead, give your friend permission to feel sad, scared and a little needy. Just hearing those words might be enough for her to feel she doesn’t have to shoulder the loss on her own or put on a brave face.

“She Lived a Full Life”

Phrases like “He is in a better place” or “God wanted her to be with him” may trivialize the person’s pain. Other unhelpful remarks include: "Time heals all wounds" and "Things always work out for the best." Unless you know and share the other person's religious beliefs, statements like "It was God's will" could be offensive or, at the very least, meaningless.

In a column entitled “What Can I Say That's Actually Helpful in Times of Grief?,” one commenter stated, ”If I believed what a lot of people say about the deceased, that God had His reasons, etc., then my only sane reaction if the people I love most died would be commit suicide and go try to kill God. Obviously that's not sane, so I ignore those oafs” (Lifehacker).

More than anything, the bereaved want to have their loss and pain recognized. A simple “I’m so sorry for your loss” acknowledges their pain rather than aims to make them feel better, which is probably not going to happen for a while.

Mourners may find comfort when you celebrate a deceased person’s life with your memories. “Share a brief story,” advises Puchta. “Connect with a person’s heart: ‘Barb your dad was so amazing‘ or ‘Your parents were our neighbors; they were always so friendly.’”

“I Know How You Feel”

Every person experiences grief and pain differently. Just because your aunt had liver cancer doesn’t mean you know how your friend feels after learning she has breast cancer. It’s better to acknowledge the person’s pain, without trying to make it similar to yours or minimizing it. Experts advise stepping out of our own shoes and imagining someone else’s turmoil and sadness.

The process of grief is complicated and involves many feelings: sadness, anger, anxiety and guilt, just to name a few. So, while you may be experiencing sadness over a loved one’s death, someone else may be feeling anger.

Cancer patient Silberman, reacting to someone saying “I know how you feel,” writes sarcastically, “Oh fantastic, let’s talk about the best way to relieve chemo-induced constipation without bringing on diarrhea! What’s your tip?” (

Instead, ask “How are you feeling?” or "I can't imagine what you're going through." This allows the person to talk about her anger, sadness or despair, rather than turning the conversation to your own feelings.

Maybe someone who is suffering is not ready to talk. In trying to comfort a loved one, “Follow their lead,” says Puchta. “Either they want to avoid or delve into it.”

“Have You Tried This Treatment?”

When trying to help others, we have an innate desire to fix the problem. It’s especially tempting to tell someone who is seriously ill about a new miracle or non-traditional cure you read about on a website: “Have you tried yoga? Shots of Vitamin K? Meditation?”

Chances are good that your friend has already read or thought about alternative treatments, and doctors warn that cancer is complicated and what works for one type won’t work for another. Just as important, your friend likely doesn’t need to be burdened with more options and information when she already has a lot on her mind.

Similarly, trying to tell someone to think positively can be offensive.

Says Silberman: “Don’t worry, I’m so busy concentrating on controlling the rivers of diarrhea without needing a diaper, my blood levels being so low I can get infected if my dog sneezes and vacuuming up the peeling skin on my hands and feet that I’m too busy to think negatively.

“It’s awful to tell somebody to think positively. Do you think all those cancer patients who are now dead thought negatively? It’s not a good thing to put the burden of our disease on us” (

“Let Me Know if I Can Do Anything”

Few people undergoing extreme grief or turmoil are going to take the time and energy to figure out what they need done. Or they may think that you are just being polite and saying something that makes you feel better. This passive expression of sympathy actually puts the burden on the person who is suffering to figure out what to ask you to do.

“Having to think of something I or we may need immediately sends my sleep-deprived and emotionally drained brain into the blankest of modes,” writes Silberman (

It’s much better, experts say, to offer to do a specific task. For example, call an ill friend and ask what you can pick them up at the grocery store. Bring a widow some prepared food, take them out for coffee, treat them to a movie or invite them to go on a walk. Stop by to check on an ill family member or find a chore that needs doing and do it.

“Pick up the phone and order a day of housecleaning service,” suggests Silberman. “Send over a fruit basket. Knock on the door and drop off a casserole. Come over and scrub the tub. . . . Bring a DVD of a funny movie and some chocolate. Stay with her in the hospital so she will get good nursing care. . . . Do something, don’t just talk about it. Just help, and don’t ask permission first.”

Doing Nothing

One of the worst things you can do is ignore someone who is suffering. People who have cancer or a terminal disease or who have just lost a loved one often feel very alone. Ignoring them just compounds the feelings of isolation.

“Yes, cancer is scary and yes, it’s hard to know what to say,” writes another cancer patient. “But when a loved one responds to ‘I have cancer’ with silence, that conjures up a special kind of pain. Overwhelmed by a friend or family member’s diagnosis? Don’t focus on the cancer; focus instead on the person you love and what you can do for them” (Fred Hutchinson Cancer Research Center).

You don’t even have to say anything. Many times people just want to be heard. Writes a parent: “My son died about four years ago. The worst part for me was/is that people are afraid to talk about him, like they'll reopen an old wound or something. I'm sure it's different for everyone, but my wife and I want to talk about him and remember the good times with him. . . . But you will probably see some tears, and that makes people feel like they're hurting you” (from Lifehacker).


“8 Things NOT To Say When Your Friend Is Grieving,” September 2012, Prevention

“10 Best Things to Say to Someone in Grief,” Heal Your Life

“Say what? 8 things you shouldn’t – and should – say to a cancer patient,” Oct. 30, 2013, Fred Hutchinson Cancer Research Center

“Timely insight on cancer topics from the experts of the American Cancer Society,” American Cancer Society

“Cancer caregiver advice on what to say and how to help,” April 11, 2013, MD Anderson Cancer Center

“What Can I Say That's Actually Helpful in Times of Grief?,” Lifehacker

“What do you say to a person who has cancer?” Dec. 6, 2011,

“What to say to someone with cancer/thoughts on how to be a friend to someone with a serious illness,” April 5, 2013 Lisa Boncheck Adams website

Finding the Right Words at a Bad Time was featured in the  August 2014 Senior Spirit newsletter.

Blog posting provided by Society of Certified Senior Advisors

Monday, September 29, 2014

Cognitive Impairment and Normative Aging

Most people believe that memory decline is a normal part of aging, but this is a myth. Memory tends to slow with age like other functions, but decline in the ability to remember things is not a normal part of the aging process. It’s important to understand and recognize the difference.

One of the most common questions health professionals face when working with aging
populations and hearing complaints of memory loss, forgetting names, and having difficulty finding words is, “Is this normal?” As people get older, these experiences become frightening. Americans worry that these are signs of one of the greatest fears that they face as they age: losing their mental capacity (Charlton Research Company 2005).

The prevalence of dementia in North America is expected to rise by 35 percent from 2007 to 2050 (Brookmeyer, Johnson, Ziegler-Graham, and Arrighi 2007). Projections have health professionals and research organizations working hard to develop methods of assessment and early interventions, designed to detect and slow the progression of cognitive decline and diminished functional ability. The question remains: Is memory loss, difficulty concentrating, or other noticed change normal?

Understanding Cognition
To understand cognitive decline, it is first important to understand cognition. Cognition is a singular term for a broad range of overarching concepts. These include our abilities in domains, such as: 
  • Language (the ability to speak and understand spoken communication); 
  • Visual-spatial construction (the ability to understand the world around us and our place in relation to it);
  • Non-verbal reasoning (the ability to use things like remote controls, drive, and complete other more visually dependent mechanical tasks);
  • Attention, concentration and, tracking (the ability to focus on information);
  • Memory and learning (the ability to remember both in the short and long term, and our ability to acquire and keep new information);
  • Executive functioning—commonly known as higher functioning (the ability to sort and categorize information, and problem solve).
What is “Normal” Aging? 
The normative process of the aging mind is something of debate in the medical profession. But there is a foundational understanding of what are normative cognitive changes and what are warning signs of greater decline to come. The truth is, most of us do not experience cognitive impairment as we age—we experience cognitive slowing. As people age, there are detectable changes in the brain. Its weight declines by 10 percent by age eighty, blood flow diminishes, nerve conduction slows, and nerves experience cell death (Patel and Holland 2012). Cognitive abilities decline gradually with these changes, but tend not to affect overall function or activities of daily living. 

Studies have shown that even with gradual decline,the majority of cognitive abilities remain within a normal range (one standard deviation from the mean) throughout most of the lifetime (Hedden and Gabrieli 2004). What falls below this range as we get older
(late seventies and early eighties) is our ability to think quickly (processing speed), and our numeric ability such as paying bills and calculating tips (Hedden and Gabrieli 2004).

Most people believe that memory decline is a normal part of aging, but this is a myth. Memory tends to slow with age like other functions, but decline in the ability to remember things is not a normal part of the aging process. It takes us longer to retrieve the information we are looking for. The same is true of learning. While we could acquire information relatively quickly and retain it well when we were younger, it takes more effort to process, store, and retrieve information as we age. To summarize, as we age, we
can expect to take more time to think things through, spend more effort learning, and occasionally have difficulty remembering something, but eventually these tasks are completed.

What is Cognitive Impairment?
Impairment in whole domains of cognition, even with adequate time and assistance—such as being unable to remember familiar things, having difficulty with planning or problem solving, not being able to communicate or understand words—is not normative aging. Impairment in these domains however does not necessarily mean the person is experiencing a degenerative disorder. The severity of the impairment (mild or severe), the onset, rate, and precipitating factors all play a significant role in diagnosis and treatment. 

Diagnosis of cognitive impairment. With the transition from the Diagnostic and Statistical Manual of Mental Disorders, fourth edition-text revision, to the Manual’s fifth edition (DSM-5; APA 2013), cognitive decline has been streamlined into mild and major neurocognitive disorders. These diagnoses come with subtype categories that include impairments consistent with the neurodegenerative diseases, such as vascular dementia and dementia of the Alzheimer’s type, as well as impairments consistent with other diagnoses, such as traumatic brain injury, and substance/medication-induced neurocognitive disorders.

Diagnosis is based on the severity and domains of cognitive deficits, interference with functional ability, and behavioral disturbances (APA 2013). Even if these aspects of a diagnosis are present, the decline is not necessarily permanent, especially in the case of delirium or substance-induced neurocognitive disorders. With diagnoses of mild neurocognitive impairment, although some patients progress to dementia, others remain
stable, or even improve (Patel and Holland 2012). 

Cognitive Screeners 
When assessing for specific diagnosis, medical professionals often use cognitive screeners that assess functioning in most of the cognitive domains mentioned. These types of screeners could include the Mini Mental Status Exam (MMSE) or the Montreal Cognitive Assessment (MoCA). These are “normed” tests, meaning they have been applied to a wide range of the population and have a particular cutoff point that demonstrates impairment greater than what we would expect from age-related decline. Although these screeners assess a range of domains, they give a global score for overall cognition. For example, an overall score of twenty-five or lower on the MoCA is concerning, because the vast majority of people score a twenty-six or above (unless they have an education below eighth-grade level). Depending on the level of impairment and corroborating information, a diagnosis may be made based on a screener, or additional, more comprehensive testing may be necessary.

Cognitive screeners have the same limitations as other screeners in the medical community. Where they may have sensitivity to a particular diagnosis (they will demonstrate cognitive impairment when it is present), they do not necessarily have specificity (the ability to accurately diagnose a specific problem, like dementia). Even when a score suggests impairment, it does not necessarily indicate the diagnosis or prognosis. Dementia is known to significantly impact executive functioning, language, working (immediate) memory, visual-spatial ability, and verbal memory (UCSF Memory and Aging Center 2014), but many other diagnoses and developmental components of the lifespan do as well. These include depression, delirium, traumatic brain injury, cerbrovascular accident (CVA) such as a stroke, transient ischemic attack (TIA)—often
known as “mini strokes”—learning disability, and lack of education, to name a few. Cognitive complaints are also a common side effect of many medications and whole treatment protocols, like chemotherapy.

If clients of CSAs or other professional advisors express concern about cognitive impairment, it is important to encourage them to seek medical consultation. It is not necessarily a dementia. Despite its expected increase in prevalence by the year 2050
(Brookmeyer et al. 2007), dementia’s current prevalence rates are lower than most people expect (18.9 percent of the population aged seventy-one to seventy-nine, 37.4 percent of the population aged ninety and older) (Plassman et al. 2007).

When seeking consultation with medical providers on cognitive complaints, patients as well as their care providers (spouses, children, concerned friends) should provide information on the onset (timing) of complaints, recent stressors, historical and recent injuries,current medications, lifetime substance use, family history of cognitive impairment, and any functional complaints (problems driving, paying bills, or preparing food). It is sometimes helpful to write these down before meeting with a medical professional. If a screener is administered, it is important to know that it may detect cognitive impairment, which clients may have already detected themselves. But it cannot provide the diagnosis by itself. As mentioned before, many different diagnoses can result in cognitive impairments that are not dementia and may fully resolve, improve, or at least remain stable.

Franklin D. Roosevelt famously said in his inaugural speech, “We have nothing to fear but fear itself.” In the realm of cognitive impairment, this is not an absolute truth, but it is a relative one. The fear of cognitive decline is often more significant than the decline itself, and more intense than the resulting diagnosis. •CSA


Carilyn Ellis is a psychology intern at the Salt Lake VA Medical Center, specializing in Palliative Care,Geriatric Home-Based Primary Care, Outpatient Mental Health and Neuropsychology. She has a master’s degree in clinical psychology and is a Psy.D. (doctor of psychology) candidate at George Fox University in Newberg, OR. She can be reached at

Cognitive Impairment and Normative Aging was recently published in the Spring 2014 edition of the CSA Journal.

Blog posting provided by Society of Certified Senior Advisors

Monday, September 22, 2014

Write Your Living Will Now to Ease Burdens Later

A living will is a legal document that indicates what medical treatments and life-sustaining measures you want or don't want. If the time comes when you can’t make your own decisions, a living will can be valuable for your family and doctor and help ensure your preferences are honored.
Approximately 80 percent of Americans fail to share their wishes for their end-of-life care, leaving family members and doctors to decide what life-saving measures to perform. Not only can this result in family quarrels, but you may receive care that is more aggressive than you desire. For example, CPR (cardiopulmonary resuscitation), which has a low success rate, can be violent and leave patients in worse condition. Not only does it make sense to write a living will as you get older and become increasingly prone to chronic illness, but it is also wise to understand the treatment options and their risks. A living will is a legal document that indicates the types of medical treatments and life-sustaining measures you want or don’t want, such as cardiopulmonary resuscitation (CPR), feeding tube, and mechanical breathing (respiration and ventilation). In addition to a living will, people are also encouraged to have an advance directive known as a medical power of attorney (POA). (See “Assigning Medical Power of Attorney is Both Difficult and Easy,” October 2012, Senior Spirit).

A medical POA is a legal document that designates an individual—referred to as your health care agent or proxy—to make medical decisions on your behalf if you’re unable to do so. Like the POA, the living will becomes a tool to help your family and medical staff determine the life sustaining measures and medical treatments to pursue at the end of your life if you are unconscious or not capable of deciding on your own.

In addition to executing a living will and medical POA, it’s important to discuss your beliefs and wishes with family members and your doctor. If they know beforehand what measures you want taken—and, just as important, why—when the time comes, the process can be easier and less stressful for everyone. (For where to find forms, see sidebar.

Important Questions to Ask

When writing your living will, give serious consideration to the kind of treatments you want. Questions to ask yourself include:

  • How important is it to be independent and self-sufficient?
  • What would make me feel that my life was not worth living?
  • Do I want treatment to extend life in any situation?
  • Or only if a cure is possible?
  • How might my decision about life-sustaining treatment be different if I was 50, 70 or 90 years old?
  • Would the treatment lessen my suffering?
  • What kind of burdens and side effects will the proposed treatment impose?
  • What are the potential benefits and risks associated with CPR, a feeding tube, ventilation, etc.?

(Adapted from Mayo Clinic and American Hospice.)
Weighing CPR

When a person stops breathing or the heart stops beating, medical personnel administer CPR, which can consist of two stages: chest compressions (forceful pressing on the chest to stimulate the heart) and artificial respiration (mouth-to-mouth rescue breathing). In addition, personnel may use electric stimulation and special medicines to resuscitate a stopped heart. CPR can help keep oxygenated blood circulating through the body, which can help prevent brain and organ damage. Without CPR, a person is likely to become unconscious almost immediately and will die in 5-10 minutes.

However, when a patient has an advanced life-threatening illness (such as late stages of cancer) and is dying, CPR may not provide any benefits (Family Doctor). Additionally, the survival rate after CPR is only 15 percent, but it decreases to 2 percent for the frail and elderly (Allina Health). If successfully, CPR may result in a sore chest, broken ribs or a collapsed lung, especially in elderly patients with fragile bones. Though they may survive, those especially who are older and/or frail may have a drastically reduced quality of life, suffer from brain damage or other health complications, and may require ongoing medical support (e.g., ventilator).

Other Treatment Considerations

Other treatment considerations to consider when executing a living will include (adapted from the Mayo Clinic and American Hospice):

Mechanical ventilation. A person who is unable to breathe sufficiently may need to have a tube inserted down the nose or throat (referred to as intubated), or surgically through the neck, into the trachea. This connects to a ventilator (breathing machine), which breathes for the patient. However, for those with certain lung and heart diseases, the likelihood of resuming normal functioning after removal from the ventilator is low. Intubated patients can’t talk and may need medicine to keep them comfortable. Some patients who survive may need to be on a breathing machine in the intensive care unit (ICU) for a while. Bacteria in the tubing can result in pneumonia, and patient immobility can lead to psychosis, skin breakdown and progressive weakness.

Nutrition and hydration assistance. To keep a patient alive, medical professionals will automatically supply the body with nutrients and fluids intravenously or via a feeding tube. If you are seriously ill or close to death, life-sustaining treatment will not be stopped unless spelled out in your advance directives. Permanently unconscious patients can sometimes live for years with artificial feeding and hydration. If food and water are removed, death will occur in a relatively short time due to dehydration, rather than starvation. Such a course of action generally includes a plan of medication to keep the patient comfortable.

Admission to the ICU. The ICU is generally meant for a person who is reversibly critically ill and who desires full resuscitation should cardiorespiratory arrest occur. But patients can suffer from isolation, as visitors are restricted, and immobilization, as well as disruption by light, noise, diagnostic tests and therapeutic interventions, which are uncomfortable and potentially painful. A frail patient is prone to develop ICU psychosis.
Additional Considerations

 Including a do-not-resuscitate (DNR) order in your living will may only prevent CPR, not other life-saving measures. Some people add a DNI—do not intubate. An alternative that is gaining popularity is AND—allow natural death. An AND advises doctors to offer only comfort measures, because any other aggressive treatment, such as intubation, may only prolong suffering. AND also conveys a positive, and perhaps gentler, message to those who must decide whether to continue life-saving measures for their loved one.

If your illness is terminal, you can also request in your living will that you want palliative care, which focuses on quality of life and dignity by helping a patient remain comfortable and free from pain until life ends naturally.

Some living wills encompass more than just DNR or DNI requests by spelling out your thoughts about dying, which can be more helpful to your doctors, friends and family when deciding what kind of end-of-life care you want. One of the more well known is Five Wishes, which goes beyond medical issues to deal with personal, emotional and spiritual concerns. The downloadable form includes questions about how comfortable you want to be, how you want people around you to treat you and what you want your loved ones to know when you’re facing the end of your life.

Five Wishes was written by Jim Towey, who worked with Mother Teresa and was inspired by her care and concern for others. His organization, Aging with Dignity, is a national nonprofit that aims to affirm and safeguard the human dignity of individuals as they age and to promote better care for those near the end of life. He introduced the Five Wishes will in Florida in 1997, and a year later, to the nation. Today, Five Wishes meets the legal requirements in 42 states, and millions have used the form to specify their desires.


“Advance Health Care Directives and Living Wills,” Help Guide

“Advance medical directive facts,” Medicine Net

“Cardiopulmonary Resuscitation (CPR),” Family Doctor

“CPR and Advance Care Planning: What You Need to Know,” Allina Health\

“Download Your State’s Advance Directives,”
“How Misconceptions Among Elderly Patients Regarding Survival Outcomes of Inpatient Cardiopulmonary Resuscitation Affect Do-Not-Resuscitate Orders,” Journal of American Osteopathic Association

“Living wills and advance directives for medical decisions,” Consumer Health, Mayo Clinic

“Medical Issues to Be Considered in Advance Care Planning,” American Hospice Foundation 

“What Do a Living Will and Power of Attorney for Health Care Cover?” Nolo (Law for All) 

“What is a Living Will?” All Law

Write Your Living Will Now to Ease Burdens Later was featured in the  August 2014 Senior Spirit newsletter.

Blog posting provided by Society of Certified Senior Advisors 

Monday, September 15, 2014

Cognitive Impairment and Normative Aging: Understanding the Differences

Family fights over the care, legal, and financial issues of aging relatives, can have disastrous results. Using a skilled mediator can make all the difference in achieving peace, harmony, and resolutions.
Family disputes can be among the most painful of all. People who are related by blood or
marriage may have such close ties that they fully understand not only how to do the right
thing for each other, but also how to hurt each other. When caregiving is involved and financial issues come up, it can bring out either the best or the worst in families.
Emotion is deep and old resentments can surface. Some families turn to dispute resolution with an outside professional to assist them when they get so mired in conflict they cannot find their way out.

The following two examples of actual cases (names changed) illustrate how families deal with these distressing conflicts. Mediation was a successful alternative for one family, enabling them to resolve their differences for the sake of an aging parent. Note the
choices each family made and the effect on the outcome of the conflict.

The Case of the Three Brothers

Three brothers are engaged in battle over their mother, Margaret’s, living situation. She has severe dementia and can’t care for herself independently. She has run out of money. Her only remaining asset is her home and she wants to stay there.

The oldest brother, James, seized power over her finances from the middle brother, Paul. James convinced his mother to appoint him the power of attorney and the agent on the healthcare directive, and displaced Paul, who had always been on both documents. Margaret wasn’t competent to sign anything when James made this move, but he didn’t seem to care. That infuriated Paul. Little brother Joe was somewhat passive, but sided with Paul. The three never got along very well, even as children, and their communication did not improve as they grew up. They largely avoided one another until now.

Without communicating with his brothers, James decided to move Margaret to an assisted living facility that cared for people with dementia. It would be in her neighborhood, she would have her own room, and her house would be sold to pay for it. A deposit was paid and the move was set.

When Paul heard of this, he became enraged, told Joe, and they both threatened to sue James. In response, James found a lawyer and began guardianship proceedings. There was no money in their mother’s checking account to pay the lawyer, so James promised
the attorney that she would get paid when the house was sold.

Margaret’s long-time estate attorney, not the guardianship lawyer, suggested mediation. She urged the siblings to stop upsetting their mother and each other by using a neutral person—a mediator—to help them try to reach some agreements.

This sounded like a good solution. With the mediator’s guidance, they could figure out a way to be more civil to each other and work toward a less aggravating future while caring for their mother. However, James refused to go to mediation. The guardianship case continues to move through the courts. Thousands of dollars will be needlessly wasted
on litigation that pits brother against brother. No one is likely to come out a winner, regardless of what happens in the case.

Who’s In Charge of Dad?

Three sisters were embroiled in a conflict over their father’s care. He was frail, needed help at home, was easily confused, and thought he was somewhere else most of the time. One of the sisters lived nearby and the other two sisters lived far away. They didn’t trust the sister nearest their father, and had reached the point of not speaking to one another. A professional handling their day-to-day finances understood the conflict among the siblings and she suggested mediation.

Surprisingly, all three sisters agreed to mediation. Four sessions took place over the phone, as all were distant.

The sisters gradually worked out their disputes. Each one had a point of view. Mistrust had dominated their communications for months and they had become hostile with one another. With discussion, each was able to ask questions, get information, and begin
to clear up misunderstandings. They made rules with the mediator’s help, and when they started to follow them, the trust they needed was re-established. They came to many agreements about how to best take care came to many agreements about how to best take care of their father, and finally reached a level of peace that had not been present in their dealings with each other for years. Their underlying mistrust, some of it going back to childhood, was not addressed, as mediation is not therapy, but they were able to work together to make the quality of their father’s life better.

Their father was well off financially so the family hired a nurse care manager and good home-care workers. The nearby sister was the liaison for everyone. She texted her siblings daily on their father’s situation. A few months later, their father died suddenly. But
now the daughters could look back on the time they cared for him during what turned out to be his last months, and knew that they had done their best for him. Mediation had enabled them to work together for their father’s benefit and for theirs as well.

Families at War
Family conflict is not at all uncommon when it comes to dealing with aging loved ones. Their old hurts, resentment, and emotional dysfunction emerge when they have to come together over the care or finances of an aging parent. Sometimes, they cope with not getting along by avoiding each other completely. This can go on for years. When a crisis happens, such as hospitalization of a parent, they are forced to not only see each other but make decisions together.
Being forced to make decisions as a group is even more difficult when the older adults in the family have not signed an advance healthcare directive (power of attorney for healthcare decisions), or a durable power of attorney for finances. However, even with these documents in place, as with James’ case, manipulation and influence over his vulnerable mother could undo what she had done when she was competent to sign
the documents.
In James’ case, he failed to communicate altogether, acted alone, and caused a fresh set of conflicts and resentments that could have been avoided. Conflicts over how to spend an aging parent’s assets are common. What needs to be examined closely is how to
avoid having the situation escalate to a legal fight. Unfortunately, litigation seldom works to benefit families in conflicts like this. Often, people engaged in these battles do irreparable harm to each other in the process. It’s a lose-lose ending.

In other situations, such as the three sisters, families choose to use an outside person to help them do what they have been unable to do by themselves. As you can tell from the outcomes of both of these true behavioral patterns, the choice families make affects
 their relationships with each other in the long term. Mediation won’t fix every fight, but according to, it’s statistically at least 80 percent effective in bringing people in dispute to agreements. Families that do not get along should be advised to
consider mediation as an option to make things better for everyone. An objective, neutral outsider can do a great deal to help family members reach agreements and resolve issues.'

The Mediation Process

Mediation is a voluntary process involving a trained, neutral mediator, and at least two parties in dispute. The parties meet, whether in person, by phone, or Skype. Mediation is a lot more than just talking things over. Mediator training is extensive, covering both the art and science of how the process works. A minimum of forty hours of training with both dispute resolution theory and mock mediation sessions is standard in the field. Mediators must have a basic understanding of how conflict works, how to de-escalate it, and how to ensure that all participants in mediation are heard. Mediators develop skills in drawing out the underlying emotions associated with conflict. They also use creative approaches to help the parties in conflict devise ways to resolve their disputes.

Many mediators have much more than forty hours of training. Some states certify mediators, but in most states there are no formal licensing requirements.

During mediation, the parties describe what they want to accomplish and the mediator takes on the task of making sure that every party at mediation has a chance to suggest possible solutions. The mediator leads the discussion and asks questions. The parties make their own decisions. The end result of a successful mediation is a written agreement or a set of agreements. Each person present has a voice in what happens. People do not have to like each other to reach agreement, but they often have to give up something to get something.

The mediator does not judge who is right or wrong or what the parties should decide. Rather, the mediator is a guide, referee, source of suggestions, and creative neutral party who finds common ground. The mediation agreement is a contract that all parties sign, and it is enforceable in court.  Apart from the written mediation agreement, all aspects of the process are confidential. What happens in mediation stays in mediation.

Finding a Qualified Mediator 

Mediators are usually independent, though some work in community-based organizations. Some are lawyers, though being a lawyer is not required. The best mediator for any dispute is a person who is experienced with the issues at hand. For example, a mediator
who works with older adults should have solid working knowledge of common areas of conflict concerning seniors and families, and know the community resources they can use to help solve their problems. Legal, healthcare, and emotional health issues may come up and it is important to find a mediator with expertise in one or more of these fields.

Some mediators work in a team approach, called co-mediation. Especially for larger groups, this can be very effective. Two mediators can see more problems from more angles and offer better suggestions than a single mediator can. and are independent resources for finding a mediator in your area. Other sources are dispute resolution services in local organizations, courts, or legal services groups dealing with older adults. Some courts have sponsored
programs for mediation, and some offer low-cost mediation for parties who represent themselves. However, one does not have to have a court case to find a mediator. The field of mediation for family disputes about aging individuals is emerging as a separate specialty, and there are relatively few mediators experienced in this area as compared with general mediation. It is referred to as “elder mediation” in the legal and mediation


Community-based organizations may offer free or low-cost mediation of this kind of dispute by using volunteer mediators. The drawback is that the volunteers may be new mediators, or may lack expertise or subject matter experience in the issues in dispute. The amount of time a mediator can work with a family may also be limited. Outside of community mediation services or low cost clinics, mediators generally work
independently on a fee for service basis.

Private mediators charge by the hour, often at rates similar to an attorney’s fees. The cost can be high for several sessions of mediation in a complex matter. However, it is certain to be much lower than the cost of any litigation. If you think of it as a preventive strategy to avoid paying ongoing attorney’s fees and court costs, mediation is a clear winner with excellent chances of success.


Unfortunately, family conflicts are common. People are living longer, creating more issues about running out of money, who is going to care for them, and loss of independence. Dysfunctional family members have to make decisions about these matters, which brings
out underlying long-standing problems. Fortunately, mediation is emerging as an excellent way to address these issues. It can help people reach agreements about many of the problems families face. Those who feel the pain of a family conflict or who witness it, should consider using mediation as a way to relieve the anguish and find a path to a more peaceful outcome. If you are a professional or an advisor to families at war, you are
in an excellent position to suggest using mediation, a tried and true method to reach agreements. •CSA


Carolyn Rosenblatt has more than forty years of experience in her combined professions of nursing and legal practice. She has worked extensively in geriatric caregiving as well as legal problems of aging, and is co-founder of, a resource for families, located in San Rafael, California. She blogs weekly at Aging Parents on, and is the author of The Boomer’s Guide.

Mediation: Finding a Way to Resolve Family Conflicts was recently published in the Spring 2014 edition of the CSA Journal.

Blog posting provided by Society of Certified Senior Advisors